Neural Mechanisms of Imaginal and in Vivo Exposure

Neural Mechanisms of Imaginal and in Vivo Exposure: Exploring the Differences Between Imaginal and in Vivo Exposure, Using fMRI and Psychophysiology

Imaginal exposure is a widely used and effective psychological treatment technique. Recent research suggests that neural activations and emotional responses during imaginal exposure are similar to those elicited during in vivo exposure. However, to the investigators knowledge, no direct comparison between in vivo and imaginal exposure has been performed during neuroimaging. This study compares neural activations and emotional responses during imaginal and in vivo exposure. This study also explores the generalizability of fear reduction achieved through imaginal exposure to fear responses elicited by in vivo stimuli, and vice versa, in a follow-up session approximately one week later. A better understanding of the mechanisms behind both types of exposure could have significant clinical utility, as well as elucidate the differences between fear created from outward stimuli and fear created from inward stimuli, such as mental imagery.

Study Overview

• Status: Recruiting
• Conditions: Fear of Spiders
• Intervention / Treatment: Behavioral: Imaginal exposure; Behavioral: Exposure; Behavioral: Approach-avoidance conflict; Behavioral: In vivo exposure

Detailed Description

The study includes participants fearful of spiders and entails two experimental sessions, roughly one week apart. The first session includes brain imaging using functional magnetic resonance imaging (fMRI). During the first session, participants will be randomized into one of two conditions - in vivo exposure or imaginal exposure. In the in vivo exposure condition, participants will be shown video clips of spiders (fearful stimuli) and leaves (neutral stimuli) in different situations. In the imaginal exposure condition, participants will be instructed to produce mental imagery of the corresponding stimuli used for in vivo exposure.

Previous research found that the brief exposure procedure used during session 1 produced a fear reduction when the procedure was repeated one week later. Thus, in order to conceptually replicate this finding, and to examine the generalizability of fear reduction, participants return roughly one week later for a follow-up session. In the follow-up session, participants undergo a similar exposure procedure as used in session 1, but with half of the stimuli in vivo and the other half of the stimuli as mental imagery. In this way, it can be studied whether fear reduction generalize from exposure modality to another. The effects of imaginal and in vivo exposure on avoidance behavior towards fear-provoking stimuli (spiders) will also be assessed using an approach-avoidance conflict paradigm, using pictures of spiders to probe spider fear.

The current study will also explore the impact of mental imagery vividness during imaginal exposure on fear reduction. Additionally, the study will assess if vividness level can predict the generalizability of the effects of imaginal exposure to fear-provoking stimuli (mental imagery of a spider) on subsequent fear responses to to in vivo stimuli (film clip of a spider) one week later.

Functional magnetic resonance imaging (7T) is used to measure neural activations (session 1). Skin conductance is used to measure arousal response (session 1 & 2). Subjective fear and mental imagery vividness ratings will also be collected.

• Study Type: Interventional
• Enrollment (Anticipated): 80
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Thomas Ågren, PhD; Phone Number: +46(0)184712124; Email: thomas.agren@psyk.uu.se
• Study Contact Backup: Name: Johannes Björkstrand, PhD; Email: johannes.bjorkstrand@psy.lu.se

Study Locations

• Sweden
  • Lund, Sweden, 22242
    • Recruiting
    • The Swedish 7T facility
    • Contact: Karin Markenroth Bloch, PhD; Email: karin.markenroth@med.lu.se

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Willing and able to provide informed consent and complete study procedures
• Fear of spiders

Exclusion Criteria:

• Current psychiatric disorder other than spider phobia
• Current use of psychotropic medication
• Current neurological conditions
• MRI-contraindications (i.e metal implants in skull)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Imaginal exposure; Exposure to mental imagery including a fearful stimulus (spider) and corresponding scenes including a neutral stimulus (leaf)	Behavioral: Imaginal exposure; Session 1 (Day 1): Participants receive repeated exposure to mental imagery of fear-provoking stimuli (spiders) and neutral stimuli (leaves) while undergoing brain imaging med fMRI.; Behavioral: Exposure; Session 2 (Ca one week): Participants receive both imaginal and in vivo exposure to fear-provoking stimuli and neutral stimuli (both arms are exposed to both video clips (in vivo exposure) and mental imagery (imaginal exposure). Session 2 is conducted in the laboratory, i.e., no brain imaging.; Behavioral: Approach-avoidance conflict; Session 2 (Ca one week): Spider fear is probed by an approach-avoidance conflict task. Participants can receive varying small rewards for watching pictures of spiders, or avoid the spider pictures at the cost of not receiving a reward (neutral pictures are shown instead).
Experimental: In vivo exposure; Exposure to video clips including a fearful stimulus (spider) and corresponding clips including a neutral stimulus (leaf)	Behavioral: Exposure; Session 2 (Ca one week): Participants receive both imaginal and in vivo exposure to fear-provoking stimuli and neutral stimuli (both arms are exposed to both video clips (in vivo exposure) and mental imagery (imaginal exposure). Session 2 is conducted in the laboratory, i.e., no brain imaging.; Behavioral: Approach-avoidance conflict; Session 2 (Ca one week): Spider fear is probed by an approach-avoidance conflict task. Participants can receive varying small rewards for watching pictures of spiders, or avoid the spider pictures at the cost of not receiving a reward (neutral pictures are shown instead).; Behavioral: In vivo exposure; Session 1 (Day 1): in vivo exposure. Participants receive repeated exposure to film clips of fear-provoking stimuli (spiders) and neutral stimuli (leaves) while undergoing brain imaging med fMRI.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Blood oxygen level dependent contrast (BOLD-signal) during exposure to fearful stimuli (in vivo or imaginal).	BOLD-signal is assessed using functional magnetic resonance imaging.	Day 1
Physiological arousal response during exposure (in vivo or imaginal).	Skin-conductance responses are used as a measure of physiological arousal response, i.e. event-related rise in electrodermal activity as a response to stimulus. Unit of measure is microSiemens.	Day 1
Physiological arousal response during follow-up exposure	Skin-conductance responses are used as a measure of physiological arousal response, i.e. event-related rise in electrodermal activity as a response to stimulus. Unit of measure is microSiemens.	One week after Day 1
Ratings of subjective fear experienced during exposure to fearful stimuli and neutral stimuli	Scale 0-100; no fear at all - extreme fear	Day1
Ratings of subjective fear experienced during exposure to fearful stimuli and neutral stimuli	Scale 0-100; no fear at all - extreme fear	One week after Day 1

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Ratings of subjective fear participants expect to experience during exposure to fearful stimuli	Scale 0-100; no fear at all - extreme fear	Day 1 & one week after Day 1
Number of approach-avoidance decisions during an approach-avoidance behaviour task using fearful stimuli (spiders)	Number of participants' decisions to avoid looking at a fearful stimuli, or to look at them and be compensated with at small amount.	One week after Day 1
Task-specific mental imagery vividness ratings to fearful and neutral stimuli during imaginal exposure, and follow-up exposure (not applicable during in vivo exposure).	Vividness of Imagery (scale: 1-5; no image at all - image as clear and vivid as real life)	Day 1 & one week after Day 1
Spielberger State-Trait Anxiety Inventory (STAI-T)	STAI-T is a self-rated questionnaire which assess trait anxiety. Scale: 20-80 in the participants where higher scores represent higher levels of trait anxiety	One week after Day 1
Vividness of visual imagery Questionnaire (VVIQ)	VVIQ is used to measure individual differences in Vividness of Visual mental Imagery; scale: 16-80 where higher scores represent a higher ability for visual imagery.	One week after Day 1
Amount of watching film clips (not applicable during imaginal exposure).	Assessment of avoidance when watching film clips. "To what extent did you watch the film clips (i.e. not close your eyes)?" Scale 0-100% of film clips.	Day 1 & one week after Day 1

Collaborators and Investigators

• Sponsor: Uppsala University
• Investigators: Principal Investigator: Thomas Ågren, PhD, Uppsala University

Publications and helpful links

General Publications

• Hoppe JM, Holmes EA, Agren T. Exploring the neural basis of fear produced by mental imagery: imaginal exposure in individuals fearful of spiders. Philos Trans R Soc Lond B Biol Sci. 2021 Feb;376(1817):20190690. doi: 10.1098/rstb.2019.0690. Epub 2020 Dec 14.

Study record dates

Study Major Dates

• Study Start (Actual): April 7, 2022
• Primary Completion (Anticipated): December 1, 2022
• Study Completion (Anticipated): December 1, 2022

Study Registration Dates

• First Submitted: December 9, 2021
• First Submitted That Met QC Criteria: January 2, 2022
• First Posted (Actual): January 14, 2022

Study Record Updates

• Last Update Posted (Actual): April 11, 2022
• Last Update Submitted That Met QC Criteria: April 8, 2022
• Last Verified: April 1, 2022

More Information

Terms related to this study

• Keywords: Exposure; Mental Imagery; Imaginal exposure
• Other Study ID Numbers: 2020-06930a

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We plan to share anonymous behavioural and brain imaging data, training material, Statistical Analysis plan, and informed consent form on the project site on Open Science Framework (https://osf.io/vmrpw/).
• IPD Sharing Time Frame: Data will be available from completion of analysis and publication, and onwards.
• IPD Sharing Access Criteria: Anonymous behavioural and brain imaging data, training material, Statistical Analysis plan, and informed consent form will be made public on the project site on Open Science Framework (https://osf.io/vmrpw/).
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No