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Wall Street Journal: For better talk therapy, try taking a nap

Doctors are finding creative ways to make cognitive behavioral therapy more effective

The Wall Street Journal has covered the latest research of SMU clinical psychologist Alicia Meuret, quoting her as an expert source.

The article, “For better talk therapy, try taking a nap,” published Nov. 28.

Meuret is director of the Anxiety and Depression Research Center at SMU, with expertise in discussing the differences between fear and anxiety and when each is helpful and adaptive and when they are harmful and interfere with our lives.

An associate professor in the Clinical Psychology Division at the SMU Department of Psychology, Meuret received her Ph.D. in Clinical Psychology from the University of Hamburg based on her doctoral work conducted at the Department of Psychiatry and Behavioral Sciences at Stanford University. She completed postdoctoral fellowships at the Center for Anxiety and Related Disorders at Boston University and the Affective Neuroscience Laboratory in the Department of Psychology at Harvard University.

Her research program focuses on novel treatment approaches for anxiety and mood disorders, biomarkers in anxiety disorders and chronic disease, fear extinction mechanisms of exposure therapy, and mediators and moderators in individuals with affective dysregulations, including non-suicidal self-injury.

The article “For better talk therapy, try taking a nap,” cites new findings from Meuret’s research, which found patients undergoing exposure therapy for anxiety fared better when sessions were held in the morning when levels of the helpful natural hormone cortisone are higher in the brain.

Read the full story.


By Andrea Petersen
Wall Street Journal

New tweaks are improving the age-old practice of talk therapy.

Doing therapy in the morning, taking a nap afterward or adding a medication that enhances learning are just a few of the methods scientists are discovering that can make cognitive behavioral therapy work better.

CBT, which involves changing dysfunctional patterns of thoughts and behaviors, is one of the most well-researched and effective treatments for a range of mental health issues, including anxiety disorders, depression and eating disorders.

But about a quarter to half of people with depression and anxiety don’t get significant relief after a course of CBT, which usually consists of about 12 to 15 weekly sessions. Some patients find the treatment time-consuming and difficult. Anywhere from 15% to 30% of people who begin it don’t finish, says David H. Barlow, founder of the Center for Anxiety and Related Disorders at Boston University. “There’s still plenty of room for improvement,” he says.

A study published in September in the journal Psychoneuroendocrinology that involved 24 patients with anxiety disorders found that therapy appointments earlier in the day were more effective than those later in the day.

In the study, subjects—who all had panic disorder with agoraphobia (fear of situations where escape may be difficult)—were treated with exposure therapy, a common component of CBT: They repeatedly confronted situations they feared, such as being in elevators or crowds. Subjects with sessions early in the day reported less severe anxiety symptoms at their next session than those who had sessions later in the day.

The researchers found that higher levels of the stress hormone cortisol that naturally occur in the morning were responsible for at least part of the benefit of the earlier sessions. “Acute boosts of cortisol can actually facilitate learning,” says Alicia E. Meuret, associate professor of psychology at Southern Methodist University and lead author of the study.

Read the full story.

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Psychotherapy sessions are best in the morning when levels of helpful hormone are high

New study found patients with anxiety, phobias and fears showed greater improvement from therapy that was scheduled in the morning, when levels of cortisol — a naturally occurring hormone — test higher.

Patients make more progress toward overcoming anxiety, fears and phobias when their therapy sessions are scheduled in the morning, new research suggests.

The study found that morning sessions helped psychotherapy patients overcome their panic and anxiety and phobic avoidance better, in part, because levels of cortisol — a naturally occurring hormone — are at their highest then, said clinical psychologist Alicia E. Meuret, Southern Methodist University, Dallas.

“The hormone cortisol is thought to facilitate fear extinction in certain therapeutic situations,” said Meuret, lead author on the research. “Drugs to enhance fear extinction are being investigated, but they can be difficult to administer and have yielded mixed results. The findings of our study promote taking advantage of two simple and naturally occurring agents – our own cortisol and time of day.”

The findings were reported in the article “Timing matters: Endogenous cortisol mediates benefits from early-day psychotherapy” in the journal Psychoneuroendocrinology.

Co-authors from the SMU Department of Psychology are David Rosenfield, Lavanya Bhaskara and Thomas Ritz. Co-authors from the Department of Psychiatry at the University of Michigan are Richard Auchus, Israel Liberzon, and James L. Abelson.

The study taps into research that anxiety and phobias are best treated by learning corrective information. Patients with anxiety and phobic disorders will overestimate the threat that a sensation or situation can cause. But by direct exposure, a patient learns that the likelihood of an expected catastrophe is very low.

“For example, a patient may think that standing in an elevator could cause him or her to lose control or faint, suffocate, or may create physical symptoms that would be intolerable,” Meuret said. “By having them stand in an elevator for a prolonged time, the patient learns that their feared outcome does not occur, despite high levels of anxiety. We call this corrective learning.”

However, since not all patients benefit equally from exposure therapy, researchers seek to identify ways to enhance corrective learning. To date, no simple way to augment fear extinction has been established.

The hormone cortisol is thought to help the extinction of fear. It appears to suppress the fear memory established by earlier distressing encounters while at the same time helping a patient better absorb and remember the new corrective information.

“In a prior study, we have shown that higher levels of cortisol during and in anticipation of exposure facilitate corrective learning,” said Meuret, an associate professor in the SMU Psychology Department and director of the SMU Anxiety and Depression Research Center in the Clinical Psychology Division of the department. “We also know that cortisol is higher early in the day. But we did not know whether cortisol would act as a mediator between time of day and therapeutic gains. This is what our study investigated.”

Exposure therapy in general resulted in significant improvements
Participants in the study were 24 people diagnosed with panic disorder and agoraphobia, which is a fear of public places where a person feels panicked, trapped or helpless.

For the study, participants underwent a standard psychotherapeutic treatment of “exposure therapy,” in which patients are exposed to situations that can typically induce their panic or fear with the goal that repeated exposure can help diminish a disabling fear response over time.

Patients received weekly sessions over three weeks, each lasting, on average, 40 minutes. Exposure situations included tall buildings, highways and overpasses, enclosed places such as elevators, supermarkets, movie theaters, and public transportation such as subways and intercity trains and boats. In addition, levels of cortisol were measured at various times during each exposure session by swabbing inside the mouth for saliva.

In the session following exposure, the researchers measured patients’ appraisals of the threats, their avoidance behavior, how much control they perceived themselves as having, and the severity of their panic symptoms.

Assessing the results from those measurements, the researchers found the exposure therapy in general resulted in significant improvements in all measures over all time periods.

Biggest gains after sessions that started earlier in the day
However, patients made the biggest gains in overcoming their fears after the sessions that started earlier in the day. At the next session, patients reported less severe symptoms for threat misappraisal, avoidance behaviors and panic symptom severity. They also perceived greater control over their panic symptoms.

“Notably, higher cortisol was related to greater reductions in threat appraisal, perceived control and panic symptom severity at the next session,” Meuret said, “and that was the case over-and-above the effects of time-of-day, with large effect sizes.”

That finding suggests that cortisol accounts for some of the therapeutic effects associated with time-of-day, she said.

Because cortisol levels are generally higher in the morning, the authors speculate that higher cortisol levels may aid extinction learning, and contribute to enhanced early-day benefits of exposure sessions through such a mechanism.

However, Meuret cautioned that the precise mechanism by which cortisol enhances the effectiveness of morning exposure sessions remains unclear and can’t be directly addressed from the data in this study. The sample size of the study was small and findings need to be confirmed independently in larger studies, she said.

Meuret and her team suspect additional mechanisms are at play to explain the time-of-day effect. Other factors could include memory and learning and the body’s natural circadian rhythm, quantity and quality of sleep, attention control, and interactions between those factors and others. — Margaret Allen, SMU

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$2 million NIH grant to help team from SMU and U-Maryland develop pediatric asthma monitor

Goal is to create wearable device that helps pediatric patients avoid asthma attacks

Two SMU psychology professors working with University of Maryland engineers have been awarded a National Institutes of Health grant in October that will bring nearly $2 million to their joint project to create a wearable device for pediatric asthma patients that helps them avoid asthma triggers.

The asthma device will monitor air quality (including pollen levels and temperature), carbon dioxide levels in the blood, physical activity, breathing, emotional states and other stimuli to identify each patient’s individual asthma triggers and alert them when conditions are ripe for an attack. The concept is similar to the glucose monitor that alerts diabetes patients when their blood sugar is low, but it also includes much more complex monitoring of the patients’ environment.

The device’s current iteration is a portable unit, but the Maryland team is miniaturizing it so that it can be worn as a vest.

SMU psychology professors Alicia E. Meuret and Thomas Ritz, have teamed up with University of Maryland Center for Advanced Sensor Technology professors Yordan Kostov, Xudong Ge and Govind Rao, which provides a natural extension of each team’s research.

“Most of my early research has been developing a treatment that addresses hyperventilation using portable CO2 measurement devices, and teaching patients who suffer from panic disorders to normalize their CO2 levels and stop hyperventilating,” said Meuret, an associate professor in SMU’s Department of Psychology. “The colleagues at University of Maryland contacted me because they wanted to use one of the refined devices as a therapeutic measure, and the partnership grew from there.”

One eventual goal for the academic partnership is for the device to provide Meuret’s treatment instructions to patients during an attack so they can more quickly recover.

How patients perceive asthma triggers and how they can better manage them has been Ritz’ major research interest. He says 25 percent to 30 percent of patients have asthma symptoms triggered by emotional stimuli, which can be demonstrated by experiments with mood induction.

“That percentage is clinically significant,” Ritz says. “It’s a large endeavor with researchers from across the United States working on it and exchanging experience to develop their projects further.”

While the Maryland team works on the hardware for the project — and other research teams across the country work on the software — SMU’s Ritz and Meuret are working on the psychology and the clinical testing of the device with patients. Starting in January, the pair will conduct tests where students wearing the sensors change their breathing systematically or watch mood-inducing stimuli, such as sad, frightening or joyful movie clips.

Other tests of the environmental sensors will be done with adolescent asthma patients’ daily life. This will generate the data that will make the device’s components eventually run smoothly.

The SMU allotment of the NIH grant’s funds is $540,737. The University of Maryland team also includes environmental engineering researchers Chris Hennigan and electrical engineering researchers Ryan Robucci and Nilanjan Banerjee. — Kenny Ryan

Follow on twitter at @smuresearch.

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.

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Asthma patients reduce symptoms, improve lung function with shallow breaths, more CO2

New study finds taking deep breaths doesn’t work; sufferers pairing biofeedback with shallow breaths increased carbon dioxide and improved long-term lung health

Asthma patients taught to habitually resist the urge to take deep breaths when experiencing symptoms were rewarded with fewer symptoms and healthier lung function, according to a new study from Southern Methodist University, Dallas.

The findings are from a large clinical trial funded with a grant from the National Institutes of Health’s National Heart, Lung, and Blood Institute.

The results suggest asthma patients using behavioral therapy in conjunction with their daily asthma medicine can improve their lung health over the long-term, said principal investigators Thomas Ritz and Alicia E. Meuret, both SMU clinical psychologists.

Also, sufferers may potentially reduce their dependence on emergency medication, such as rescue inhalers, the researchers said.

SMU behavioral psychologist Dr. Alicia Meuret helps a patient learn shallow breathing with biofeedback to relieve symptoms of air hunger. (Photo: SMU)
SMU clinical psychologist Dr. Alicia Meuret helps a patient learn shallow breathing with biofeedback to relieve symptoms of air hunger. (Photo: SMU)

Asthma can be a life-threatening disease if not managed properly, according to the American Lung Association. Nearly 26 million Americans have asthma, says ALA.

One of the most common chronic disorders in childhood, asthma is the third leading cause of hospitalization among children under 15, ALA says.

Asthma attacks typically provoke sufferers to gulp air and take deep breaths to relieve the frightening fear of asphyxiation, said Ritz and Meuret. In addition, asthma sufferers tend to breathe too much even when not experiencing symptoms.

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But Ritz, Meuret and their co-authors found with their research that deep breathing is exactly the wrong thing to do.

For their study, one group of asthma patients used biofeedback to monitor their breathing for reassurance they were getting sufficient oxygen. The patients practiced shallower, shorter breaths to increase their intake of carbon dioxide, CO2. A second group also practiced slower breathing, but without biofeedback.

“This study goes to the heart of hyperventilation — which is deep, rapid breathing that causes a drop in CO2 gas in the blood. That makes a person feel dizzy and short of breath,” Ritz said. “Patients in our study increased CO2 and reduced their symptoms. And over a six-month period we saw in the biofeedback group an actual improvement in the physiology of their lungs.”

The researchers reported their findings in the pulmonology medical journal Chest, “Controlling asthma by training of capnometry-assisted hypoventilation vs. slow breathing.” Ritz is a professor and Mueret an associate professor in the Department of Psychology in SMU’s Dedman College.

Shallow breathing method is counterintuitive
“When people hyperventilate, there is something very strange happening,” Meuret said. “In essence they are taking in too much air. But the sensation that they get is shortness of breath, choking, air hunger, as if they’re not getting enough air. It’s almost like a biological system error.”

Onlookers commonly give the advice, “Take a deep breath.” But that’s just the opposite of what a struggling breather should do.

“They don’t need any more oxygen,” Meuret said. “But consciously or not, people start to take deeper breaths — and that makes the symptoms worse.”

Among the study’s 120 patients who used the brief, four-week biofeedback therapy to boost their CO2, the researchers found that of 21 clinical indices of pathology more than 80 percent resulted in significant reductions. The researchers saw improvement in asthma symptoms and control, better lung function, reduced oversensitivity of the airways and less use of reliever medication, as well as improvement in physiology and the pathology of the airways.

Biofeedback method tested against tough scientific control group
The biological-behavioral treatment method, called Capnometry-Assisted Breathing Training, or CART for short, was developed by Meuret. Previous randomized controlled studies by Meuret found CART reduced symptoms of panic and hyperventilation in patients with panic and anxiety.

The handheld capnometer, equipped with a digital readout, enables patients via biofeedback to track changes in their CO2 when they alter their breathing during breathing training exercises and instruction sessions. Capnometers are medical devices that can only be purchased by a health care provider.

For the current SMU study, CART patients were compared to a randomized control group that also received a breathing treatment — specifically, slower breathing, or SLOW for short.

Patients in the SLOW group used the CART device also for their home exercises to validate they were breathing slower. The only difference between the CART and SLOW groups was that CART patients received biofeedback about their CO2.

“We tested CART against the toughest scientific control we could devise — another breathing treatment, where patients receive the same amount of attention from their therapist, use equipment to help them alter their breathing, are primed to pay attention to their own asthma management, and receive encouragement to take their medicine more regularly,” Ritz said.

CART and SLOW patients both improved, but CART benefits were long-lasting
Patients in the study were from the Dallas-Fort Worth area, all of them medically diagnosed with asthma. Each patient’s asthma diagnosis was independently validated at Baylor University Medical Center at Dallas by a methacholine airways stress test, a stringent diagnostic procedure to confirm patients met the criteria for asthma.

After four weeks of CART and SLOW training, asthma symptoms for both groups had improved, even when controlling for any change in medication intake.

However at follow up six months later, asthma symptoms for the SLOW control group had returned to higher levels.

“The follow-up period is often viewed as the moment of truth of how effective a treatment is,” said Meuret. “Once a patient doesn’t have to come to treatment, does the treatment continue to be beneficial? After four weeks, both treatments were beneficial, but CART was superior — and showed even greater improvements beyond that.”

CART patients also became less distressed about the methacholine test, indicating higher distress tolerance to their symptoms, Ritz said.

In addition, during treatment, the airways of CART patients widened during treatment in the lab, according to measurements taken by a forced oscillation technique. That was a positive development that allowed patients to breathe easier. Airways in the SLOW group actually narrowed a bit, said Ritz. Nevertheless, SLOW resulted in significant improvement also.

“The long-term goal of the CART research is to test whether we can achieve the same improvements with occasional intervals of capnometer feedback training, or ideally test whether shallow breathing in itself will achieve the same stable increases in CO2,” said the researchers.

CART not a relaxation technique
CART is not relaxation training. Quite the opposite.

“It’s actually very, very, very unrelaxing when patients start,” Meuret said.

For patients with low CO2 in particular, the process of breathing slow and shallow to increase the CO2 level — even just slightly — tends to trigger extreme air hunger.

“Only by reassuring themselves that the symptoms are caused by low CO2 and not low oxygen, they can keep on going,” Meuret said. “And that’s even more difficult for asthmatics than anxious patients who have a normal lung function.”

Patients initially want to take a deep breath, she said. “But I reassure them not to, telling them to ‘Look at the CART device, look at their oxygen, it’s at 100 percent, it can’t get any higher.’”

CART therapy can improve quality of life, reduce health dangers
“The goal is to reduce the need of the emergency medication,” Ritz said. “It’s a quality of life issue.”

Patients with asthma symptoms miss out on sports, limit their physical activity, or are kept out of school P.E. and other activities. They can also become depressed and anxious, and get over-sensitive to sensations.

“The more you can reduce these symptoms the more the person can take part in daily life like a normal person,” Ritz said.

Physiologically, symptoms are also an indicator the asthma patient may have more inflammation and constriction.

While there’s always the risk an attack may be fatal, Ritz said, lesser outcomes are serious also. It’s recommended to intervene in asthma early, ideally during childhood, because the airways become reshaped.

“The longer they’re inflamed, the thicker the tissue of the airways get and the narrower the airways and the less they can relax,” he said.

Other co-authors on the study were SMU psychologist David Rosenfield, graduate student Ashton M. Steele, and physician Mark W. Millard, Baylor University Medical Center Dallas. — Margaret Allen

Follow on twitter at @smuresearch.

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.

Health & Medicine Mind & Brain Researcher news SMU In The News Stress Myths — Debunked!

Health journalist Corrie Pikul wrote about the groundbreaking panic and anxiety research of SMU psychologists Dr. Alicia Meuret and Dr. Thomas Ritz in a Jan. 7 post on

The article, “Stress Myths—Debunked!,” cites the startling findings of Meuret’s anxiety research, which has found that the standard advice to “take a deep breath” actually makes such situations worse.

Read the full post.


By Corrie Pikul

[ … ] “Taking deep, slow breaths can help you calm down when you’re feeling panicked and overwhelmed.”

It makes sense that when you’re short of breath, you should try to compensate with a little extra oxygen, right? The problem is that when you are experiencing an intensely trying situation—waiting to hear the results of a serious medical test, during severe turbulence on an airplane, or when you slice your thumb with a bread knife just as your brunch guests pull into the driveway—you’re probably already taking in too much oxygen and could be at risk of hyperventilating, says Alicia Esperanza Meuret, PhD, associate professor of psychology at Southern Methodist University in Dallas. In her research on patients who suffer from panic disorders and asthma, Meuret has found that a more effective way to calm down is to take shallow, regular and slow breaths through the nose (not the mouth, which makes it too easy to suck more air than you actually need). “Imagine a beach where the water is sliding in and out in time with your breath,” she says. This may feel slightly uncomfortable at first, as you battle the impulse to fill your lungs, but Meuret says you should start to feel more relaxed after practicing a few times.

Read the full post.

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For more information,

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.