Attentional Bias for Threat: Evidence for Delayed Disengagement from Emotional Faces

The present paper reports three new experiments suggesting that the valence of a face cue can influence attentional effects in a cueing paradigm. Moreover, heightened trait anxiety resulted in increased attentional dwell-time on emotional facial stimuli, relative to neutral faces. Experiment 1 presented a cueing task, in which the cue was either an "angry", "happy", or "neutral" facial expression. Targets could appear either in the same location as the face (valid trials) or in a different location to the face (invalid trials). Participants did not show significant variations across the different cue types (angry, happy, neutral) in responding to a target on valid trials. However, the valence of the face did affect response times on invalid trials. Specifically, participants took longer to respond to a target when the face cue was "angry" or "happy" relative to neutral. In Experiment 2, the cue-target stimulus onset asynchrony (SOA) was increased and an overall inhibition of return (IOR) effect was found (i.e., slower responses on valid trials). However, the "angry" face cue eliminated the IOR effect for both high and low trait anxious groups. In Experiment 3, threat-related and jumbled facial stimuli reduced the magnitude of IOR for high, but not for low, trait-anxious participants.These results suggest that: (i) attentional bias in anxiety may reflect a difficulty in disengaging from threat-related and emotional stimuli, and (ii) threat-related and ambiguous cues can influence the magnitude of the IOR effect.

Facial Expressions of Emotion: Are Angry Faces Detected More Efficiently?

The rapid detection of facial expressions of anger or threat has obvious adaptive value. In this study, we examined the efficiency of facial processing by means of a visual search task. Participants searched displays of schematic faces and were required to determine whether the faces displayed were all the same or whether one was different. Four main results were found: (1) When displays contained the same faces, people were slower in detecting the absence of a discrepant face when the faces displayed angry (or sad/angry) rather than happy expressions. (2) When displays contained a discrepant face people were faster in detecting this when the discrepant face displayed an angry rather than a happy expression. (3) Neither of these patterns for same and different displays was apparent when face displays were inverted, or when just the mouth was presented in isolation. (4) The search slopes for angry targets were significantly lower than for happy targets. These results suggest that detection of angry facial expressions is fast and efficient, although does not "pop-out" in the traditional sense.

Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many individuals involved with care of the dying advocate expanding access to hospice care for persons with advanced lung, heart, or liver disease. However, to be eligible, these patients generally must have a prognosis for survival of less than 6 months.

OBJECTIVE

To test the ability of currently available criteria to identify a population with a survival prognosis of 6 months or less among seriously ill hospitalized patients with 1 of 3 commonly fatal chronic diseases.

DESIGN

Validation study using data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) phase 1 (June 1989-June 1991) and phase 2 (January 1992-January 1994), with a 6-month follow-up.

SETTING AND PATIENTS

Consecutive sample of 2607 seriously ill patients from 5 US medical centers who were hospitalized with chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, and who survived to hospital discharge.

MAIN OUTCOME MEASURES

Descriptive and operating characteristics of 5 general and 2 disease-specific clinical criteria for identifying patients with a survival prognosis of 6 months or less, and 3 sets of combination criteria (broad, intermediate, and narrow inclusion) aimed at providing low, medium, and high thresholds for hospice eligibility based on National Hospice Organization guidelines.

RESULTS

Seventy-five percent of the sample survived more than 6 months after hospital discharge; 44% expressed a preference for palliative care. Broad inclusion criteria identified 923 patients eligible for hospice care, of whom 70% survived longer than 6 months. Intermediate inclusion criteria identified 300 patients, of whom 65% survived longer than 6 months. Narrow inclusion criteria identified 19 patients, of whom 53% survived longer than 6 months. Sensitivities and specificities of the combination criteria were 41.7% and 66.7% (broad inclusion), 16.2% and 90.1 % (intermediate inclusion), and 1.4% and 99.5% (narrow inclusion), respectively.

CONCLUSIONS

These data indicate that for seriously ill hospitalized patients with advanced chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, recommended clinical prediction criteria are not effective in identifying a population with a survival prognosis of 6 months or less.

Processing emotional facial expressions: the role of anxiety and awareness

In this paper, the role of self-reported anxiety and degree of conscious awareness as determinants of the selective processing of affective facial expressions is investigated. In two experiments, an attentional bias toward fearful facial expressions was observed, although this bias was apparent only for those reporting high levels of trait anxiety and only when the emotional face was presented in the left visual field. This pattern was especially strong when the participants were unaware of the presence of the facial stimuli. In Experiment 3, a patient with right-hemisphere brain damage and visual extinction was presented with photographs of faces and fruits on unilateral and bilateral trials. On bilateral trials, it was found that faces produced less extinction than did fruits. Moreover, faces portraying a fearful or a happy expression tended to produce less extinction than did neutral expressions. This suggests that emotional facial expressions may be less dependent on attention to achieve awareness. The implications of these results for understanding the relations between attention, emotion, and anxiety are discussed.

Mental health in UK Biobank - development, implementation and results from an online questionnaire completed by 157 366 participants: a reanalysis

BACKGROUND

UK Biobank is a well-characterised cohort of over 500 000 participants including genetics, environmental data and imaging. An online mental health questionnaire was designed for UK Biobank participants to expand its potential.

AIMS

Describe the development, implementation and results of this questionnaire.

METHOD

An expert working group designed the questionnaire, using established measures where possible, and consulting a patient group. Operational criteria were agreed for defining likely disorder and risk states, including lifetime depression, mania/hypomania, generalised anxiety disorder, unusual experiences and self-harm, and current post-traumatic stress and hazardous/harmful alcohol use.

RESULTS

A total of 157 366 completed online questionnaires were available by August 2017. Participants were aged 45-82 (53% were ≥65 years) and 57% women. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status. Lifetime depression was a common finding, with 24% (37 434) of participants meeting criteria and current hazardous/harmful alcohol use criteria were met by 21% (32 602), whereas other criteria were met by less than 8% of the participants. There was extensive comorbidity among the syndromes. Mental disorders were associated with a high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.

CONCLUSIONS

The UK Biobank questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed because of selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.

Alemtuzumab more effective than interferon β-1a at 5-year follow-up of CAMMS223 clinical trial

OBJECTIVE

To report the long-term safety and efficacy results from CAMMS223 comparing alemtuzumab with interferon β-1a in early, active relapsing-remitting multiple sclerosis (RRMS). What are the long-term effects of alemtuzumab treatment, received 36 to 48 months previously, on relapse and disability in early, active RRMS? This study provides evidence of the effectiveness of alemtuzumab in reducing the relapse rate and accumulation of disability compared with interferon β-1a (IFNβ-1a) through extended follow-up (up to 60 months from baseline).

METHODS

Of 334 patients originally randomized, 198 participated in the extension phase (151 [68%] alemtuzumab and 47 [42%] IFNβ-1a). Disability, relapses, and safety were assessed as in the original study period. Efficacy outcomes were analyzed from baseline of the original trial period to 60 months. Safety data extended beyond 60 months.

RESULTS

Over 5 years, alemtuzumab lowered the risk of sustained accumulation of disability by 72% and the rate of relapse by 69% compared with IFNβ-1a (both p < 0.0001). The annualized relapse rate from baseline to month 60 was 0.11 for alemtuzumab and 0.35 for IFNβ-1a. Complete safety follow-up reflected 988 and 376 person-years for alemtuzumab and IFNβ-1a patients, respectively. Serious infections were seen in 7% of alemtuzumab patients and 3% of IFNβ-1a patients, and thyroid disorders were seen in 30% of alemtuzumab patients vs 4% of IFNβ-1a patients. Immune thrombocytopenia occurred in 3% of alemtuzumab patients and 0.9% of IFNβ-1a patients during the initial study period; no additional events were reported during the extension phase. One alemtuzumab patient developed Goodpasture disease 39 months after the second annual cycle of alemtuzumab.

CONCLUSIONS

Through extended follow-up, alemtuzumab remained significantly more efficacious than IFNβ-1a, with a safety profile consistent with previous reports.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that alemtuzumab is more effective than interferon β-1a in reducing relapses and disability in patients with RRMS in a long-term follow-up of a rater-blinded, randomized clinical trial with 59.5% of patients participating in the extended follow-up period.

Introduction to the special section on cognitive bias modification in emotional disorders

Cognitive models of anxiety disorders and unipolar depression have postulated that selective information processing plays an important role in the development and maintenance of emotional psychopathology. Cognitive bias modification (CBM) procedures have recently been developed to test this theoretical claim. The purpose of this special section is to introduce the central ideas underlying CBM and to bring together the research that exemplifies the theoretical and clinical potential of the CBM approach.

Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project

OBJECTIVE

To determine the extent to which older or seriously ill inpatients would prefer to have their family and physician make resuscitation decisions for them rather than having their own stated preferences followed if they were unable to decide themselves.

DESIGN

Analysis of existing data from the Hospitalized Elderly Longitudinal Project (HELP) and the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT).

SETTING

Five teaching hospitals in the United States.

PARTICIPANTS

2203 seriously ill adult inpatients (SUPPORT) and 1226 older inpatients (HELP) who expressed preferences about resuscitation and about advance decision-making.

MEASURES

We used a logistic regression model to determine which factors predicted preferences for family and physician decision-making.

RESULTS

Of the 513 HELP patients in this analysis, 363 (70.8%) would prefer to have their family and physician make resuscitation decisions for them whereas 29.2% would prefer to have their own stated preferences followed if they were to lose decision-making capacity. Of the 646 SUPPORT patients, 504 (78.0%) would prefer to have their family and physician decide and 22.0% would prefer to have their advance preferences followed. Independent predictors of preference for family and physician decision-making included not wanting to be resuscitated and having a surrogate decision-maker.

CONCLUSIONS

Most inpatients who are older or have serious illnesses would not want their stated resuscitation preferences followed if they were to lose decision-making capacity. Most patients in both groups would prefer that their family and physician make resuscitation decisions for them. These results underscore the need to understand resuscitation preferences within a broader context of patient values.

NF1 plexiform neurofibroma growth rate by volumetric MRI: Relationship to age and body weight

OBJECTIVE

To longitudinally analyze changes in plexiform neurofibroma (PN) volume in relation to age and body growth in children and young adults with neurofibromatosis type 1 and inoperable, symptomatic, or progressive PNs, using a sensitive, automated method of volumetric MRI analysis.

METHODS

We included patients 25 years of age and younger with PNs entered in a natural history study or in treatment trials who had volumetric MRI over > or =16 months.

RESULTS

We studied 49 patients (median age 8.3 years) with 61 PNs and a median evaluation period of 34 months (range 18 to 70). The PN growth rates varied among patients, but were constant within patients. Thirty-four patients (69%) experienced > or =20% increase in PN volume during the observation period. PN volume increased more rapidly than body weight over time (p = 0.026). Younger patients had the most rapid PN growth rate.

CONCLUSIONS

Volume increase of plexiform neurofibromas is a realistic and meaningful trial endpoint. In most patients plexiform neurofibroma growth rate exceeded body growth rate. The youngest patients had the fastest plexiform neurofibroma growth rate, and clinical drug development should be directed toward this population. Age stratification for clinical trials for plexiform neurofibromas should be considered.

Looking on the bright side: biased attention and the human serotonin transporter gene

Humans differ in terms of biased attention for emotional stimuli and these biases can confer differential resilience and vulnerability to emotional disorders. Selective processing of positive emotional information, for example, is associated with enhanced sociability and well-being while a bias for negative material is associated with neuroticism and anxiety. A tendency to selectively avoid negative material might also be associated with mental health and well-being. The neurobiological mechanisms underlying these cognitive phenotypes are currently unknown. Here we show for the first time that allelic variation in the promotor region of the serotonin transporter gene (5-HTTLPR) is associated with differential biases for positive and negative affective pictures. Individuals homozygous for the long allele (LL) showed a marked bias to selectively process positive affective material alongside selective avoidance of negative affective material. This potentially protective pattern was absent among individuals carrying the short allele (S or SL). Thus, allelic variation on a common genetic polymorphism was associated with the tendency to selectively process positive or negative information. The current study is important in demonstrating a genotype-related alteration in a well-established processing bias, which is a known risk factor in determining both resilience and vulnerability to emotional disorders.

Incorporating palliative care into critical care education: principles, challenges, and opportunities

OBJECTIVE

To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU).

DATA SOURCES AND STUDY SELECTION

A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered.

DATA EXTRACTION

A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus.

DATA SYNTHESIS

In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU.

CONCLUSIONS

Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.

Anxiety and sensitivity to gaze direction in emotionally expressive faces

This study investigated the role of neutral, happy, fearful, and angry facial expressions in enhancing orienting to the direction of eye gaze. Photographs of faces with either direct or averted gaze were presented. A target letter (T or L) appeared unpredictably to the left or the right of the face, either 300 ms or 700 ms after gaze direction changed. Response times were faster in congruent conditions (i.e., when the eyes gazed toward the target) relative to incongruent conditions (when the eyes gazed away from the target letter). Facial expression did influence reaction times, but these effects were qualified by individual differences in self-reported anxiety. High trait-anxious participants showed an enhanced orienting to the eye gaze of faces with fearful expressions relative to all other expressions. In contrast, when the eyes stared straight ahead, trait anxiety was associated with slower responding when the facial expressions depicted anger. Thus, in anxiety-prone people attention is more likely to be held by an expression of anger, whereas attention is guided more potently by fearful facial expressions.

Focusing on fear: Attentional disengagement from emotional faces

Evidence suggests that anxiety is associated with a shift of visual attention toward threatening stimuli in the environment, such as facial expressions (Mogg & Bradley, 1999). More recent evidence, however, indicates that anxiety may be better characterized by a failure to rapidly disengage the visual attention system away from threat-related facial expressions (Fox, Russo, Bowles, & Dutton, 2001). The present study further investigates this delayed disengagement hypothesis. Results show that high trait-anxious individuals, in contrast to low trait-anxious individuals, take longer to classify peripheral target letters when fearful facial expressions were presented at fixation relative to sad, happy, or neutral expressions. These findings demonstrate a specific tendency to dwell on fear-relevant stimuli, as opposed to negative information in general. These findings are considered from an evolutionary perspective and the possible role of delayed disengagement from threat in the maintenance of anxiety states is also discussed.

The face of fear: Effects of eye gaze and emotion on visual attention

We investigated whether a fearful expression enhances the effect of another's gaze in directing the attention of an observer. Participants viewed photographs of faces whose gaze was directed ahead, to the left or to the right. Target letters then appeared unpredictably to the left or right. As expected, targets in the location indicated by gaze were detected more rapidly. In nonanxious volunteers the effects of fearful gaze did not differ from neutral gaze, but fearful expression had a more powerful influence in a selected high anxious group. Attention is thus more likely to be guided by the direction of fearful than neutral gaze, but only in anxiety-prone individuals.

Psychological Science Needs a Standard Practice of Reporting the Reliability of Cognitive-Behavioral Measurements

Psychological science relies on behavioral measures to assess cognitive processing; however, the field has not yet developed a tradition of routinely examining the reliability of these behavioral measures. Reliable measures are essential to draw robust inferences from statistical analyses, and subpar reliability has severe implications for measures’ validity and interpretation. Without examining and reporting the reliability of measurements used in an analysis, it is nearly impossible to ascertain whether results are robust or have arisen largely from measurement error. In this article, we propose that researchers adopt a standard practice of estimating and reporting the reliability of behavioral assessments of cognitive processing. We illustrate the need for this practice using an example from experimental psychopathology, the dot-probe task, although we argue that reporting reliability is relevant across fields (e.g., social cognition and cognitive psychology). We explore several implications of low measurement reliability and the detrimental impact that failure to assess measurement reliability has on interpretability and comparison of results and therefore research quality. We argue that researchers in the field of cognition need to report measurement reliability as routine practice so that more reliable assessment tools can be developed. To provide some guidance on estimating and reporting reliability, we describe the use of bootstrapped split-half estimation and intraclass correlation coefficients to estimate internal consistency and test-retest reliability, respectively. For future researchers to build upon current results, it is imperative that all researchers provide psychometric information sufficient for estimating the accuracy of inferences and informing further development of cognitive-behavioral assessments.

The eyes are sufficient to produce a threat superiority effect

The research described in this article used a visual search task and demonstrated that the eye region alone can produce a threat superiority effect. Indeed, the magnitude of the threat superiority effect did not increase with whole-face, relative to eye-region-only, stimuli. The authors conclude that the configuration of the eyes provides a key signal of threat, which can mediate the search advantage for threat-related facial expressions.

Anxiety modulates the degree of attentive resources required to process emotional faces

The present study contributes to the ongoing debate over the extent to which attentive resources are required for emotion perception. Although fearful facial expressions are strong competitors for attention, we predict that the magnitude of this effect may be modulated by anxiety. To test this hypothesis, healthy volunteers who varied in their self-reported levels of trait and state anxiety underwent an attentional blink task. Both fearful and happy facial expressions were subject to a strong attentional blink effect for low-anxious individuals. For those reporting high anxiety, a blink occurred for both fearful and happy facial expressions, but the magnitude of the attentional blink was significantly reduced for the fearful expressions. This supports the proposals that emotion perception is not fully automatic and that anxiety is related to a reduced ability to inhibit the processing of threat-related stimuli. Thus, individual differences in self-reported anxiety are an important determinant of the attentional control of emotional processing.

The role of perceptual load in negative priming

Negative priming (NP) effects from irrelevant distractors were assessed as a function of perceptual load in the processing of prime targets. Participants searched for a target letter among a varying number of nontarget letters in the center of the display and ignored an irrelevant peripheral distractor. NP from this distractor was found to depend on the relevant search set size, decreasing as this set size was increased. The authors conclude that exhausting attention in relevant processing reduces irrelevant processing (e.g., N. Lavie, 1995), leaving less distractor processing to produce NP. This conclusion is consistent with recent reactive inhibition views for NP (e.g., G. Houghton, S. P. Tipper, B. Weaver, & D. I. Shore, 1996).

The serotonin transporter gene alters sensitivity to attention bias modification: evidence for a plasticity gene

BACKGROUND

Attention bias modification (ABM) procedures have been shown to modify biased attention with important implications for emotional vulnerability and resilience. The use of ABM to reduce potentially toxic biases, for instance, is a newly emerging therapy for anxiety disorders. A separate line of gene-by-environment interaction research proposes that many so-called vulnerability genes or risk alleles are better seen as plasticity genes, as they seem to make individuals more susceptible to environmental influences for better and for worse.

METHODS

A standard ABM procedure was used with a sample of 116 healthy adults. Participants were randomly assigned to one of two training groups. One received an ABM procedure designed to induce a bias in attention toward negative material, while the other was trained toward positive pictures. Individuals with low- and high-expressing forms of the serotonin transporter gene (5-HTTLPR) were compared.

RESULTS

Those with a low-expression form (S/S, S/Lg, or Lg/Lg) of the 5-HTTLPR gene developed stronger biases for both negative and positive affective pictures relative to those with the high-expression (La/La) form of the gene.

CONCLUSIONS

Here, we report the first evidence that allelic variation in the promotor region of the 5-HTTLPR gene predicts different degrees of sensitivity to ABM. These results suggest a potential cognitive mechanism for the gene-by-environment interactions that have been found in relation to the serotonin transporter gene. Variation on this genotype may therefore determine who will benefit most (and least) from therapeutic interventions, adversity, and supportive environments.

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment

BACKGROUND

The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

OBJECTIVE

To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective.

DESIGN

This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.

RESULTS

Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.

CONCLUSIONS

SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Attentional bias in anxiety: selective or not?

Under certain circumstances, anxiety has been shown to be associated with a processing bias favouring threatening information. Much of the evidence has come from experiments utilising the modified Stroop colour-naming paradigm. However, the traditional Stroop stimuli does not allow for a good test of selective attention. The present study presented colour, neutral and threatening words in conditions where the distracting (word) and target (colour) information were presented: (i) together; or (ii) separately. High trait-anxious Ss took longer to colour-name threatening words than neutral words, even when the threatening material was presented outside the focus of attention. There were no differential responses to threat and neutral words for low trait-anxious Ss. High trait-anxious Ss were also distracted by separate colour words, which produced no interference for the low-anxious Ss. These results suggest that high-trait anxiety may be associated with a general inability to maintain attentional focus, rather than by an automatic attentional bias towards threatening information.