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BACKGROUND: A key vulnerability factor in mental health problems is chronic stress. There is a need for easy-to-disseminate and effective interventions to advance the prevention of stress-related illnesses. App-based stress management trainings can fulfill this need. As subjectively experienced stress may be influenced by dysfunctional beliefs, modifying their evaluations might reduce subjective stress. Approach-avoidance modification trainings (AAMT) can be used to modify stimulus evaluations and are promising candidates for a mobile stress intervention. As the standard training reactions of the AAMT (swiping and joystick motion) have little valence, emotions could be incorporated as approach and avoidance reactions to enhance the effectiveness of AAMTs. OBJECTIVE: We aimed to evaluate the feasibility of a mobile emotion-enhanced AAMT that engages users to display sadness to move stress-enhancing beliefs away and display positive emotions to move stress-reducing beliefs toward themselves (emotion-based AAMT using sadness and positive emotions [eAAMT-SP]). We explored the clinical efficacy of this novel intervention. METHODS: We allocated 30 adult individuals with elevated stress randomly to 1 of 3 conditions (eAAMT-SP, a swipe control condition, and an inactive control condition). We evaluated the feasibility of the intervention (technical problems, adherence, usability, and acceptability). To explore the clinical efficacy of the intervention, we compared pretest-posttest differences in perceived stress (primary clinical outcome) and 3 secondary clinical outcomes (agreement with and perceived helpfulness of dysfunctional beliefs, emotion regulation, and depressive symptoms) among the conditions. RESULTS: The predetermined benchmarks of 50% for intervention completion and 75% for feasibility of the study design (completion of the study design) were met, whereas the cutoff for technical feasibility of the study design (95% of trials without technical errors) was not met. Effect sizes for usability and acceptability were in favor of the eAAMT-SP condition (compared with the swipe control condition; intelligibility of the instructions: g=-0.86, distancing from dysfunctional beliefs: g=0.22, and approaching functional beliefs: g=0.55). Regarding clinical efficacy, the pretest-posttest effect sizes for changes in perceived stress were g=0.80 for the comparison between the eAAMT-SP and inactive control conditions and g=0.76 for the comparison between the eAAMT-SP and swipe control conditions. Effect sizes for the secondary clinical outcomes indicated greater pretest-posttest changes in the eAAMT-SP condition than in the inactive control condition and comparable changes in the swipe control condition. CONCLUSIONS: The findings regarding the feasibility of the intervention were satisfactory except for the technical feasibility of the intervention, which should be improved. The effect sizes for the clinical outcomes provide preliminary evidence for the therapeutic potential of the intervention. The findings suggest that extending the AAMT paradigm through the use of emotions may increase its efficacy. Future research should evaluate the eAAMT-SP in sufficiently powered randomized controlled trials. TRIAL REGISTRATION: German Clinical Trials Registry DRKS00023007; https://drks.de/search/en/trial/DRKS00023007.

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BACKGROUND: Stress levels and thus the risk of developing related physical and mental health conditions are rising worldwide. Dysfunctional beliefs contribute to the development of stress. Potentially, such beliefs can be modified with approach-avoidance modification trainings (AAMT). As previous research indicates that effects of AAMTs are small, there is a need for innovative ways of increasing the efficacy of these interventions. For this purpose, we aim to evaluate the feasibility of the intervention and study design and explore the efficacy of an innovative emotion-based AAMT version (eAAMT) that uses the display of emotions to move stress-inducing beliefs away from and draw stress-reducing beliefs towards oneself. METHODS: We will conduct a parallel randomized controlled pilot study at the Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany. Individuals with elevated stress levels will be randomized to one of eight study conditions (n = 10 per condition) - one of six variants of the eAAMT, an active control intervention (swipe-based AAMT), or an inactive control condition. Participants in the intervention groups will engage in four sessions of 20-30 min (e)AAMT training on consecutive days. Participants in the inactive control condition will complete the assessments via an online tool. Non-blinded assessments will be taken directly before and after the training and 1 week after training completion. The primary outcome will be perceived stress. Secondary outcomes will be dysfunctional beliefs, symptoms of depression, emotion regulation skills, and physiological stress measures. We will compute effect sizes and conduct mixed ANOVAs to explore differences in change in outcomes between the eAAMT and control conditions. DISCUSSION: The study will provide valuable information to improve the intervention and study design. Moreover, if shown to be effective, the approach can be used as an automated smartphone-based intervention. Future research needs to identify target groups benefitting from this intervention utilized either as stand-alone treatment or an add-on intervention that is combined with other evidence-based treatments. TRIAL REGISTRATION: The trial has been registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS00023007 ; September 7, 2020).

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Introduction. Pregnancy is a unique time in a woman's life that can be both exciting and challenging. It is also a period that can be associated with significant stress, anxiety, and depression, which can have negative consequences for both the mother and the baby. Mindfulness interventions are known to be a well-suited treatment and prevention method for psychiatric symptoms in pregnancy, and web-based applications have been explored. We here present an up-to-date systematic review and meta-analysis of randomized-controlled trials to investigate the effect of digital-based mindfulness interventions on depressive, anxiety, and stress symptoms during pregnancy. Methods. The systematic literature search and data extraction was performed by two independent raters. It resulted in 13 eligible studies overall comprising 1373 participants. We conducted random-effects meta-analyses for depressive, anxiety, and stress symptoms after completion of a digital mindfulness intervention (compared to a control group). Results. Digital mindfulness intervention methods were significantly able to reduce depression (g = -0.47, 95% CI [-0.9; -0.09]) and anxiety symptoms (g = -0.41, 95% CI [-0.77; -0.05]), but not stress symptoms. These effects were moderated by the attrition rate (ßDepression = 0.025, pDepression < 0.01; ßAnxiety = 0.022, pAnxiety < 0.01; ßStress = 0.022, pStress < 0.01). Primiparity also had a significant influence on the intervention effect regarding depression symptoms (ß = 0.033, p = 0.024). Conclusions. Digital mindfulness interventions are a promising method to reduce mental health symptoms in pregnant women. We identified certain parameters moderating this effect, for example, primiparity and the attrition rate.

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Listening to trauma reports can lead to the development of symptoms associated with secondary traumatization. This is particularly relevant for psychotherapists in practice, where psychologists need to estabilish effective strategies for processing and coping with such emotionally challenging events. This explorative study investigated adaptive reframing strategies for future therapists listening to trauma stories compared to feeling empathy for the client. In a mixed design, 42 postgraduate psychology students were randomly instructed to objectively distance themselves, reappraise, or feel empathetic while watching a video of a presumed trauma patient reporting a single violent act. An overall ANOVA did not reveal a difference between the reframing groups and the empathy group (between subjects manipulated) in their skin conductance level and heart rate variability during the video, as well as their change in state depression and state anxiety over the three measurements (before the video, after the video, and 2 days later). Nevertheless, an explorative t-test showed a significantly weaker rise in state depression and state anxiety from before the video to after the video in the reframing groups compared to the empathy group. This supports the suggestion that reframing strategies can be discussed as a protective factor against health issues such as secondary traumatization in therapists and should be examined in further studies in more detail.

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During the COVID-19 pandemic several behavioral measures have been implemented to reduce viral transmission. While these measures reduce the risk of infections, they may also increase risk behavior. Here, we experimentally investigate the influence of face masks on physical distancing. Eighty-four participants with or without face masks passed virtual agents in a supermarket environment to reach a target while interpersonal distance was recorded. Agents differed in wearing face masks and age (young, elderly). In addition, situational constraints varied in whether keeping a distance of 1.5 m required an effortful detour or not. Wearing face masks (both self and other) reduced physical distancing. This reduction was most prominent when keeping the recommended distance was effortful, suggesting an influence of situational constraints. Similarly, increased distances to elderly were only observed when keeping a recommended distance was effortless. These findings highlight contextual constraints in compensation behavior and have important implications for safety policies.

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OBJECTIVE: Burnout describes a syndrome of exhaustion resulting from insufficient coping with work-related distress. We investigated if patients that are being clinically treated for burnout show insecure and unresolved attachment representation more often compared with healthy controls. METHODS: 50 out of 60 consecutive burnout patients participated in the study. Mental representation of attachment was measured by using the Adult Attachment Interview. Additionally, we administered the Self Report Questionnaire to Assess Emotional Experience and Emotion Regulation and several burnout specific questionnaires. A population sample was used as control group. RESULTS: Burnout patients were classified as insecurely attached significantly more often than controls. Unresolved attachment status concerning loss or trauma was found significantly more often within the burnout sample. Patients with insecure attachment representation reported a lower subjective significance of work. Patients with avoidant insecure attachment showed more depersonalisation. Patients with unresolved loss/trauma reported less social support. They showed more passive-negative emotion experience and emotion regulation characterized by externalization. CONCLUSION: The results of the study suggest that an insecure or unresolved attachment representation might constitute an intrapersonal risk factor for the development of burnout syndrome.

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Fear of negative evaluation, such as negative social performance feedback, is the core symptom of social anxiety. The present study investigated the neural correlates of anticipation and perception of social performance feedback in social anxiety. High (HSA) and low (LSA) socially anxious individuals were asked to give a speech on a personally relevant topic and received standardized but appropriate expert performance feedback in a succeeding experimental session in which neural activity was measured during anticipation and presentation of negative and positive performance feedback concerning the speech performance, or a neutral feedback-unrelated control condition. HSA compared to LSA subjects reported greater anxiety during anticipation of negative feedback. Functional magnetic resonance imaging results showed deactivation of medial prefrontal brain areas during anticipation of negative feedback relative to the control and the positive condition, and medial prefrontal and insular hyperactivation during presentation of negative as well as positive feedback in HSA compared to LSA subjects. The results indicate distinct processes underlying feedback processing during anticipation and presentation of feedback in HSA as compared to LSA individuals. In line with the role of the medial prefrontal cortex in self-referential information processing and the insula in interoception, social anxiety seems to be associated with lower self-monitoring during feedback anticipation, and an increased self-focus and interoception during feedback presentation, regardless of feedback valence.

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