A follow-up study of cognitive bias in generalized anxiety disorder

Nightmare experiences and perceived ethnic discrimination amongst female university students in the United Arab Emirates: a cross-sectional study

Perceived ethnic discrimination is known to be associated with anxiety and depression, and in turn, anxiety and depression are known to be associated with nightmare frequency and distress. This elicits a question: is perceived ethnic discrimination associated with nightmare frequency and distress? In this study, 179 female university students from the United Arab Emirates were assessed to answer that question. Results showed that while anxiety and depression were related to nightmare experiences, perceived ethnic discrimination was a stronger predictor of nightmare experiences. We posit two explanations for this finding: one based on psychoanalytical insights, and the other based on the Disposition-Stress model with neurobiological correlates. No significant differences were found across ethnicity when it comes to nightmare experiences or perceived ethnic discrimination. This is an encouraging sign of optimal societal integration in the United Arab Emirates.

Characteristics of attentional bias in adolescents with major depressive disorders: differentiating the impact of anxious distress specifier

Background

No consistent conclusion has been reached regarding the attentional bias characteristics of adolescents with major depressive disorders (MDD), and unexamined co-occurring anxiety distress may contribute to this inconsistency.

Methods

We enrolled 50 MDD adolescents with anxiety distress, 47 MDD adolescents without anxiety distress and 48 healthy adolescents. We measured attentional bias using a point-probe paradigm during a negative-neutral emotional face task. Reaction time, correct response rate and attentional bias value were measured.

Results

MDD adolescents did not show a negative attentional bias; MDD adolescents with anxiety distress exhibited longer reaction time for negative and neutral stimuli, lower correct response rate for negative stimuli. Hamilton Anxiety Scale scores were positively correlated with reaction time, negatively correlated with correct response rate, and not significantly correlated with attentional bias value.

Limitations

The cross-sectional design hinders causal attribution, and positive emotional faces were not included in our paradigm.

Conclusion

Negative attentional bias is not a stable cognitive trait in adolescents with MDD, and avoidance or difficulty in disengaging attention from negative emotional stimuli may be the attentional bias characteristic of MDD adolescents with anxiety distress.

Hydrocortisone as an adjunct to brief cognitive-behavioural therapy for specific fear: Endocrine and cognitive biomarkers as predictors of symptom improvement

BACKGROUND

Glucocorticoid (GC) administration prior to exposure-based cognitive-behavioural therapy (CBT) has emerged as a promising approach to facilitate treatment outcome in anxiety disorders. Further components relevant for improved CBT efficacy include raised endogenous GCs and reductions in information-processing biases to threat.

AIMS

To investigate hydrocortisone as an adjunct to CBT for spider fear and the modulating role of threat bias change and endogenous short-term and long-term GCs for treatment response.

METHODS

Spider-fearful individuals were randomized to receiving either 20 mg of hydrocortisone (n = 17) or placebo (n = 16) one hour prior to single-session predominantly computerised exposure-based CBT. Spider fear was assessed using self-report and behavioural approach measures at baseline, 1-day and 1-month follow-up. Threat processing was assessed at baseline and 1-day follow-up. Cortisol and cortisone were analysed from hair and saliva samples at baseline.

RESULTS/OUTCOMES

Self-report, behavioural and threat processing indices improved following CBT. Hydrocortisone augmentation resulted in greater improvement of self-report spider fear and stronger increase in speed when approaching a spider, but not on threat bias. Neither threat bias nor endogenous GCs predicted symptom change, and no interactive effects with hydrocortisone emerged. Preliminary evidence indicated higher hair cortisone as predictor of a stronger threat bias reduction.

CONCLUSIONS/INTERPRETATION

Our data extend earlier findings by suggesting that GC administration boosts the success of exposure therapy for specific fear even with a low-level therapist involvement. Future studies corroborating our result of a predictive hair GC relationship with threat bias change in larger clinical samples are needed.

D-cycloserine as adjunct to brief computerised CBT for spider fear: Effects on fear, behaviour, and cognitive biases

BACKGROUND AND OBJECTIVES

In anxiety disorders, cognitive behavioural therapy (CBT) improves information-processing biases such as implicit fear evaluations and avoidance tendencies, which predicts treatment response. Thus, these cognitive biases might constitute important treatment targets. This study investigated (i) whether information-processing biases could be changed following single-session computerised CBT for spider fear, and (ii) whether this effect could be augmented by administration of D-cycloserine (DCS).

METHODS

Spider-fearful individuals were randomized to receiving either 250 mg of DCS (n = 21) or placebo (n = 17). Three hours after drug administration, they received single-session computerized CBT, characterized by psychoeducation and exposure elements. Spider fear was assessed using self-report, behavioural, and information processing (Extrinsic Affective Simon Task & Approach Avoidance Task) measures at baseline (before drug administration), post-treatment, 1-day, and 1-month follow-up.

RESULTS

Linear mixed-effects analyses indicated significant improvements on self-report and behavioural spider fear indices following CBT, but not on cognitive bias measures. There was no evidence of an augmentation effect of DCS on any outcome. Cognitive bias measures at 1-day were not predictive of 1-month follow-up spider fear in adjusted linear regression analyses.

LIMITATIONS

Results might be biased by limited representativeness of the sample (high education and intelligence, largely Caucasian ethnicity, young age). The study was also only powered for detection of medium-sized DCS effects.

CONCLUSIONS

These findings do not provide evidence for information-processing biases relating to treatment outcome following computerised CBT for spider fear or augmentation with DCS.

Attention to Peer Feedback Through the Eyes of Adolescents with a History of Anxiety and Healthy Adolescents

During adolescence, youth may experience heightened attention bias to socially relevant stimuli; however, it is unclear if attention bias toward social threat may be exacerbated for adolescents with a history of anxiety. This study evaluated attentional bias during the Chatroom-Interact task with 25 adolescents with a history of anxiety (18F, Mage = 13.6) and 22 healthy adolescents (13F, Mage = 13.8). In this task, participants received feedback from fictional, virtual peers who either chose them (acceptance) or rejected them (rejection). Overall, participants were faster to orient toward and spent longer time dwelling on their own picture after both rejection and acceptance compared to non-feedback cues. Social feedback was associated with greater pupillary reactivity, an index of cognitive and emotional neural processing, compared to non-feedback cues. During acceptance feedback (but not during rejection feedback), anxious youth displayed greater pupil response compared to healthy youth, suggesting that positive feedback from peers may differentially influence youth with a history of an anxiety disorder.

Physical aggression and attentional bias to angry faces: An event related potential study

This study aimed to identify the neural correlates of aggression-related attentional selectivity to angry faces in physical aggression. Physical aggression in a non-clinical sample of young men (N = 36) was measured using an aggression questionnaire. Visual attentional bias to angry faces was assessed using a dot-probe task during which angry and neutral faces were presented simultaneously, and EEG was recorded. Median split and correlational analyses were conducted to assess the relationship between physical aggression and attentional bias. Behavioural results indicated that higher levels of physical aggression were associated with greater attentional bias to angry faces. ERP results revealed an interaction where males with higher physical aggression had undifferentiated P3 amplitudes to angry and neutral trials, whereas low physical aggression males exhibited greater P3 amplitude to angry than to neutral trials (effect of probe congruency). Increased levels of physical aggression were also significantly correlated with increased P3 amplitude to probes replacing neutral faces, relative to angry faces. It was concluded that the aggressive males selectively attend to angry faces, and that attentional bias is characterized by undifferentiated P3 amplitude. We propose that this results from an inferior ability to downregulate competing angry face distractors when responding to probes replacing neutral faces (as reflected by the P3 response). These findings indicate that attentional bias to angry faces in individuals with higher physical aggression is characterized by a distinctive ERP signature; this could inform the development of therapeutic interventions seeking to reduce aggression.

WITHDRAWN: Physical aggression and attentional bias to angry faces: An event related potential study

This article has been withdrawn at the request of the authors. The authors have opted to update their article and have resubmitted it to the journal as a new submission. The updated article has now been accepted and can be found here: https://doi.org/10.1016/j.brainres.2019.146387. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Generalized Anxiety Disorder, worry and attention to threat: A systematic review

Among anxious populations, attention has been demonstrated to be preferentially biased to threatening material compared to neutral or other valenced material. Individuals who have high levels of trait worry, such as those with Generalized Anxiety Disorder (GAD), may be biased to threat but research has produced equivocal findings. This review aimed to systematically review the extant experimental literature to establish the current evidence of attentional bias to threat among trait worriers compared to healthy controls and other clinical populations. Twenty-nine published articles were included in the final review. There was strong evidence of a bias to threat among GAD patients compared to other groups and this was found across most experimental paradigms. Few studies had investigated this bias in non-clinical trait worriers. Among GAD patients this bias to threat was most strongly evidenced when visual threat material was in a verbal-linguistic format (i.e., words) rather than when in pictorial form (i.e., images or faces). The bias was also found across several domains of negative material, supporting the general nature of worry. Further research should look to examine the specific components of the threat bias in GAD, as well as investigating the bias to threat in trait worriers.

Early Attention Processes and Anxiety in Children

It has been hypothesized that anxiety in children is associated with attentional bias in the early stages of information processing. Bias towards threat indicates the tendency of an individual to direct attention towards threatening information. The aim of the present study was to investigate whether high test-anxiety in a sample of nonreferred children is associated with attentional bias towards threat pictures, and if low test-anxiety is associated with attentional bias away from threat pictures. A probe-detection task was used with 44 10- to 13-yr.-old children. The overall analyses indicated the presence of an attentional bias away from threatening pictures in these nonreferred children. However, in relation to anxiety, the study did not confirm that high anxious children show an attentional bias towards threatening pictures or that low anxious children show an attentional bias away from threatening pictures. Yet, higher anxiety did seem to be associated with longer mean response times. These longer response times might originate from the interpretation of the nature of a stimulus as too threatening, compared to the actual threatening content, in the first stage of information processing. This finding could be useful to improve treatment methods aimed at anxiety symptoms during childhood.

Does anxiety-linked attentional bias to threatening information reflect bias in the setting of attentional goals, or bias in the execution of attentional goals?

Heightened anxiety vulnerability is characterised by an attentional bias that favours the processing of negative information. However, this anxiety-linked attentional bias is amenable to two quite different explanations. One possibility is that it reflects anxiety-linked bias in the setting of attentional goals that favours setting the goal of attending towards negative information over the alternative goal of attending away from such information. Another possibility is that it reflects anxiety-linked bias in the execution of attentional goals that enhances the execution of the former attentional goal compared to the latter. The present study introduces a novel methodology designed to discriminate the validity of these competing hypotheses, by examining anxiety-linked attentional bias under two conditions. One condition left attentional goals unconstrained. The other condition imposed the attentional goal of either attending towards more negative or more benign emotional stimuli. The finding that anxiety-linked attentional bias was observed only under the former condition supported the hypothesis that anxiety is characterised by a bias favouring the setting attentional goals involving vigilance rather than avoidance of negative information, while giving no support to the hypothesis that anxiety is characterised by a bias reflecting enhanced execution of the former attentional goal compared to the latter.

Attentional bias to respiratory- and anxiety-related threat in children with asthma

This study investigated attentional biases in children with asthma. The study aimed at testing whether children with asthma are vigilant to asthma and/or anxiety cues. Thirty-six children (18 with asthma and 18 healthy controls) aged 9-12 completed a computerised dot probe task designed to measure attentional bias to three different categories of words: asthma, anxiety symptom and general negative emotion. Main caregiver anxiety was also assessed, as was frequency of inhaler use for those with asthma. Children with asthma showed an attentional bias towards asthma words but not anxiety or general negative emotion words. Children without asthma showed no significant attentional biases to any word categories. Caregiver anxiety was correlated with asthma word attentional bias in the asthma group. The findings indicate that attentional bias is present in children with asthma. Further research is required to ascertain if this exacerbates or maintains health-related problems.

The effect of maternal psychopathology on parent-child agreement of child anxiety symptoms: A hierarchical linear modeling approach

The current study examined the effects of maternal anxiety, worry, depression, child age and gender on mother and child reports of child anxiety using hierarchical linear modeling. Participants were 73 mother-child dyads with children between the ages of 7 and 10 years. Reports of child anxiety symptoms, including symptoms of specific disorders (e.g., social phobia) were obtained using concordant versions of the Screen for Anxiety and Related Emotional Disorders (SCARED). Children reported significantly higher levels of anxiety symptoms relative to their mothers. Maternal worry and depression predicted for significantly lower levels of maternal-reported child anxiety and increasing discrepant reports. Maternal anxiety predicted for higher levels of maternal-reported child anxiety and decreasing discrepant reports. Maternal depression was associated with increased child-reported child anxiety symptoms. No significant effect of child age or gender was observed. Findings may inform inconsistencies in previous studies on reporter discrepancies. Implications and future directions are discussed.

Attention bias modification (ABM) as a treatment for child and adolescent anxiety: a systematic review

BACKGROUND

Attention Bias Modification (ABM) is a novel computer based treatment for anxiety disorders. It has been proposed as an efficient, accessible psychological therapy and is based on cognitive theories of attention. The present review sought to investigate the efficacy of ABM as a potential treatment for child and adolescent anxiety.

METHOD

A systematic literature review was conducted, using three main databases, PsycINFO, Embase and Medline, to identify original research articles which measured the effect of ABM on anxiety levels in children and/or adolescents.

RESULTS

Ten articles met the inclusion criteria and of these 10, three were randomised control trials. A lack of standardisation in relation to the treatment protocol was observed; nonetheless the identified studies generally provided evidence for the efficacy of ABM as an anxiety treatment.

LIMITATIONS

Due to the nature of the studies found, a statistical meta-analysis was not possible.

CONCLUSIONS

ABM seems to be a promising, novel treatment for child and/or adolescent anxiety disorders with merits over lengthier, talking based therapies. However, more rigorous research trials are needed to clarify the mechanisms behind ABM and establish effective, standardised treatment protocols.

Attention bias modification treatment augmenting effects on cognitive behavioral therapy in children with anxiety: randomized controlled trial

OBJECTIVE

Attention bias modification treatment (ABMT) is a promising novel treatment for anxiety disorders, but clinical trials have focused largely on stand-alone formats among adults. This randomized controlled trial examined the augmenting effects of threat-based ABMT on cognitive behavioral therapy (CBT) in clinically anxious youth.

METHOD

Sixty-three treatment-seeking children with anxiety disorder were randomly assigned to 1 of the following 3 treatment groups: ABMT + CBT; ABMT placebo + CBT; and CBT-alone. Participants in the 2 ABMT conditions received repeated training on dot-probe tasks either designed to shift attention away from threats (active) or designed to induce no changes in attention patterns (placebo). Primary outcome measures were frequency and severity of anxiety symptoms as determined by a clinician using a semi-structured interview. Self- and parent-rated anxiety measures and threat-related attention bias scores were also measured before and after treatment.

RESULTS

Both the active and placebo ABMT groups showed greater reductions in clinician-rated anxiety symptoms than the CBT-alone group. Furthermore, only the active ABMT group showed significant reduction in self- or parent-rated anxiety symptoms. Finally, all groups showed a shift in attention patterns across the study, starting with a bias toward threat at baseline and shifting attention away from threat after treatment.

CONCLUSIONS

Active and placebo ABMT might augment the clinical response to CBT for anxiety. This effect could arise from benefits associated with performing computer-based paradigms such as the dot-probe task. Given the absence of group differences in attention-bias changes during treatment, possible mechanisms and methodological issues underlying the observed findings are discussed. Clinical trial registration information-Augmenting Effects of ABMT on CBT in Anxious Children: A Randomized Clinical Trial; http://clinicaltrials.gov/; NCT01730625.

Information processing bias and pharmacotherapy outcome in older adults with generalized anxiety disorder

Information processing bias was evaluated in a sample of 25 older adults with generalized anxiety disorder (GAD) over the course of 12 weeks of escitalopram pharmacotherapy. Using the CANTAB Affective Go/No Go test, treatment response (as measured by the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, and Generalized Anxiety Disorder Severity Scale) was predicted from a bias score (i.e., difference score between response latencies for negative and positive words) using mixed-models regression. A more positive bias score across time predicted better response to treatment. Faster responses to positive words relative to negative words were associated with greater symptomatic improvement over time as reflected by scores on the GADSS. There was a trend toward significance for PSWQ scores and no significant effects related to HAMA outcomes. These preliminary findings offer further insights into the role of biased cognitive processing of emotional material in the manifestation of late-life anxiety symptoms.

Combining attention training with internet-based cognitive-behavioural self-help for social anxiety: a randomised controlled trial

Guided Internet-based cognitive-behavioural self-help (ICBT) has been proven to be effective for social anxiety disorder (SAD) by several independent research groups. However, as the proportion of clinical significant change has room for improvement, new treatments should be developed and investigated. A novel treatment is attention bias modification (ABM). This study aimed at evaluating the combination of ABM and ICBT. We compared two groups, one group receiving ICBT and ABM targeting attentional avoidance and the other group receiving ICBT and control training. ABM and control training tasks were both based on the dot-probe paradigm. A total of 133 participants, diagnosed with SAD, were randomised to these two groups. The attention training group (N = 66) received 2 weeks of daily attention training followed by 9 weeks of ICBT. The control group (N = 67) received 2 weeks of daily control training, also followed by 9 weeks of ICBT. Social anxiety measures as well as the attention bias were assessed at pre-assessment, at week 2, and at post-treatment. Results showed no significant differences between the attention training group and the control group. Both groups improved substantially on social anxiety symptoms from pre- to post-assessment (dwithin = 1.39-1.41), but showed no change in attention processes (dwithin = 0.10-0.17). In this trial, the attention modification training failed to induce differential change in attention bias. Results demonstrate that the applied ABM procedure with its focus on the reduction of attentional avoidance was ineffective in the Internet-based setting. The results do not suggest that adding ABM targeting attentional avoidance to ICBT results in better outcomes than ICBT alone.

Pregabalin for the treatment of generalized anxiety disorder: an update

A PREVIOUS REVIEW SUMMARIZED WHAT WAS THEN KNOWN ABOUT THE POTENTIAL ROLE OF PREGABALIN IN THE TREATMENT OF PATIENTS WITH GENERALIZED ANXIETY DISORDER (GAD): this review provides an update on its pharmacological properties and presumed mechanism of action, the liability for abuse, and efficacy and tolerability in patients with GAD. Pregabalin has a similar molecular structure to the inhibitory neurotransmitter gamma amino butyric acid (GABA) but its mechanism of action does not appear to be mediated through effects on GABA. Instead, its anxiolytic effects may arise through high-affinity binding to the alpha-2-delta sub-unit of the P/Q type voltage-gated calcium channel in "over-excited" presynaptic neurons, thereby reducing the release of excitatory neurotransmitters such as glutamate. The findings of randomized controlled trials and meta-analyses together indicate that pregabalin is efficacious in both acute treatment and relapse prevention in GAD, with some evidence of an early onset of effect, and broad efficacy in reducing the severity of psychological and physical symptoms of anxiety. It also has efficacy as an augmenting agent after non-response to antidepressant treatment in GAD. Continuing vigilance is needed in assessing its potential abuse liability but the tolerability profile of pregabalin may confer some advantages over other pharmacological treatments in the short term for treatment in patients with GAD.

Changes in automatic threat processing precede and predict clinical changes with exposure-based cognitive-behavior therapy for panic disorder

BACKGROUND

Cognitive behavioral therapy (CBT) is an effective treatment for emotional disorders such as anxiety or depression, but the mechanisms underlying successful intervention are far from understood. Although it has been a long-held view that psychopharmacological approaches work by directly targeting automatic emotional information processing in the brain, it is usually postulated that psychological treatments affect these processes only over time, through changes in more conscious thought cycles. This study explored the role of early changes in emotional information processing in CBT action.

METHODS

Twenty-eight untreated patients with panic disorder were randomized to a single session of exposure-based CBT or waiting group. Emotional information processing was measured on the day after intervention with an attentional visual probe task, and clinical symptoms were assessed on the day after intervention and at 4-week follow-up.

RESULTS

Vigilance for threat information was decreased in the treated group, compared with the waiting group, the day after intervention, before reductions in clinical symptoms. The magnitude of this early effect on threat vigilance predicted therapeutic response after 4 weeks.

CONCLUSIONS

Cognitive behavioral therapy rapidly affects automatic processing, and these early effects are predictive of later therapeutic change. Such results suggest very fast action on automatic processes mediating threat sensitivity, and they provide an early marker of treatment response. Furthermore, these findings challenge the notion that psychological treatments work directly on conscious thought processes before automatic information processing and imply a greater similarity between early effects of pharmacological and psychological treatments for anxiety than previously thought.

Does the vigilance-avoidance gazing behavior of children with separation anxiety disorder change after cognitive-behavioral therapy?

Cognitive biases are of interest in understanding the development of anxiety disorders. They also play a significant role during psychotherapy, where cognitive biases are modified in order to break the vicious cycle responsible for maintaining anxiety disorders. In a previous study, the vigilance-avoidance pattern was shown in children with separation anxiety disorder (In-Albon et al. Journal of Abnormal Child Psychology 38:225-235, 2010). The exhibited avoidance pattern may be essential for the maintenance of the anxiety disorder. Therefore, in the present study we used eye tracking methodology presenting disorder specific pictures to examine possible changes in the vigilance-avoidance pattern in 18 children with separation anxiety disorder after cognitive-behavioral treatment (CBT) and 13 healthy controls. Results indicated that following treatment, the vigilance pattern of children with separation anxiety disorder reduced significantly. Thus, the vigilance-avoidance pattern can be modified by CBT.

Evaluation of a novel translational task for assessing emotional biases in different species

Changes in the processing of emotional information are key features of affective disorders. Neuropsychological tests based on emotional faces or words are used to detect emotional/affective biases in humans, but these tests are not applicable to animal species. In the present study, we investigated whether a novel affective tone discrimination task (ATDT), developed to study emotion-related behaviour in rats, could also be used to quantify changes in affective states in humans. To date, the methods used in human neuropsychology have not been applicable to animal experiments. Participants completed a training session in which they learnt to discriminate specific tone frequencies and to correctly respond in order to gain emotionally valenced outcomes, to obtain rewards (money), or to avoid punishment (an aversive sound clip). During a subsequent test session, additional ambiguous probe tones were presented at frequencies intermediate between the reward and avoidance paired tones. At the end of the task, participants completed self-report questionnaires. All participants made more avoidance responses to the most ambiguous tone cues, suggesting a bias towards avoidance of punishment. Individual differences in the degrees of bias observed were correlated with anxiety measures, suggesting the task's sensitivity to differences in state anxiety within a healthy population. Further studies in clinical populations will be necessary to assess the task's sensitivity to pathological anxiety states. These data suggest that this affective tone discrimination task provides a novel method to study cognitive affective biases in different species, including humans, and offers a novel assessment to study anxiety.

Automaticity in anxiety disorders and major depressive disorder

In this paper we examine the nature of automatic cognitive processing in anxiety disorders and Major Depressive Disorder (MDD). Rather than viewing automaticity as a unitary construct, we follow a social cognition perspective (Bargh, 1994) that argues for four theoretically independent features of automaticity: unconscious (processing of emotional stimuli occurs outside awareness), efficient (processing emotional meaning uses minimal attentional resources), unintentional (no goal is needed to engage in processing emotional meaning), and uncontrollable (limited ability to avoid, alter or terminate processing emotional stimuli). Our review of the literature suggests that most anxiety disorders are characterized by uncontrollable, and likely also unconscious and unintentional, biased processing of threat-relevant information. In contrast, MDD is most clearly typified by uncontrollable, but not unconscious or unintentional, processing of negative information. For the anxiety disorders and for MDD, there is no sufficient evidence to draw firm conclusions about efficiency of processing, though early indications are that neither anxiety disorders nor MDD are characterized by this feature. Clinical and theoretical implications of these findings are discussed and directions for future research are offered. In particular, it is clear that paradigms that more directly delineate the different features of automaticity are required to gain a more comprehensive and systematic understanding of the importance of automatic processing in emotion dysregulation.

A cognitive model of pathological worry

We present an evidence-based model of pathological worry in which worry arises from an interaction between involuntary (bottom-up) processes, such as habitual biases in attention and interpretation favouring threat content, and voluntary (top-down) processes, such as attentional control. At a pre-conscious level, these processes influence the competition between mental representations when some correspond to the intended focus of attention and others to threat distracters. Processing biases influence the probability of threat representations initially intruding into awareness as negative thoughts. Worry in predominantly verbal form then develops, influenced by conscious processes such as attempts to resolve the perceived threat and the redirection of attentional control resources to worry content, as well as the continuing influence of habitual processing biases. After describing this model, we present evidence for each component process and for their causal role in pathological worry, together with implications for new directions in the treatment of pathological worry.

Direction of threat attention bias predicts treatment outcome in anxious children receiving cognitive-behavioural therapy

BACKGROUND

A bias to selectively direct attention to threat stimuli is a cognitive characteristic of anxiety disorders. Recent studies indicate that individual differences in pre-treatment threat attention bias predict treatment outcomes from cognitive-behavioural therapy (CBT) in anxious individuals. However, there have been inconsistent findings regarding whether attention bias towards threat predicts better or poorer treatment outcome.

METHOD

This longitudinal study examined treatment outcomes in 35 clinically-anxious children following a 10-week, group-based CBT program, as a function of whether children showed a pre-treatment attention bias towards or away from threat stimuli. The effect of CBT on attention bias was also assessed.

RESULTS

Both groups showed significant improvement after receiving CBT. However, anxious children with a pre-treatment attention bias towards threat showed greater reductions not only in anxiety symptom severity, but also in the likelihood of meeting diagnostic criteria for anxiety disorders at post-treatment assessment, in comparison with anxious children who showed a pre-treatment attention bias away from threat. Children who had a pre-treatment bias away from threat showed a reduction in this bias over the course of CBT.

CONCLUSIONS

Findings suggest that pre-existing differences in the direction of attention towards versus away from threat could have important implications for the treatment of anxious children.

Treatment sensitivity of implicit threat evaluation, avoidance tendency and visual working memory bias in specific phobia

Cognitive theories of anxiety postulate that negative processing biases play a causal role in the pathogenesis of a disorder, while a normalisation of bias drives recovery. To test these assumptions it is essential to investigate whether biases seen in anxiety are treatment-sensitive, or whether they instead represent enduring vulnerability factors. Twenty-nine spider fearfuls were tested before and after brief cognitive-behaviour therapy (CBT), with half of them additionally being tested before a waiting period to control for retest effects. Using three cognitive bias tasks, we measured implicit threat evaluation (Extrinsic Affective Simon Task), avoidance tendency (Approach-Avoidance Task), and working memory for threat. CBT significantly enhanced negative implicit evaluation and avoidance. This indicates that these cognitive biases are no stable risk factors and provides further evidence for their potential key role in the development and remission of anxiety.

Attentional biases to threat and serotonin transporter gene promoter (5-HTLPR) polymorphisms: Evidence from a probe discrimination task with endogenous cues

Recent studies have investigated the association between serotonin transporter gene promoter (5-HTTLPR) functional polymorphisms and attentional biases to threat, a cognitive mechanism that probably contributes to the development and maintenance of anxiety. The present study genotyped a sample of N = 141 healthy volunteers for an insertion/deletion polymorphism and the rs25531 single-nucleotide polymorphism in 5-HTTLPR. In order to investigate attentional biases to threat, we used a probe discrimination task in which the gaze direction of centrally presented fearful or neutral faces endogenously cued attention. The results indicated no significant differences in attentional biases to threat between 5-HTTLPR genotype groups. However, we found that carriers of two low-expressing alleles (i.e., S or LG) of 5-HTTLPR displayed a significant slowing of responses across trials with fearful compared to neutral faces. This effect may indicate that fearful faces triggered increased emotional arousal in these genotypes, which may have interfered with the processing of gaze direction and spatial cuing. These results suggest that using fearful faces as endogenous spatial cues may be problematic in genotypes associated with facilitated emotional arousal to these stimuli, and underscore the hypothesis that 5-HTTLPR specifically influences automatic rather than consciously-controlled processes of attention.

Emotional processing and antidepressant action

Negative affective schema and associated biases in information processing have long been associated with clinical depression. Such an approach has guided the development of successful psychological therapies for this and other emotional disorders. However, until quite recently, there has been a large chasm between the practitioners and scientists working with this approach and those working on the neurobiological basis of depression and its treatment. Recent research, however, has started to bridge this gap and our understanding of the neural processes underpinning these cognitive processes has progressed markedly over the past decade. Moreover, rather than representing separate targets for psychological and biological treatments, novel findings suggest that pharmacological interventions for depression also modify these psychological maintaining factors early in treatment and may be involved in the later emergence of clinically relevant change. Such findings offer the possibility of greater integration between psychological and pharmacological conceptualisations of psychiatric illness and provide an experimental medicine model to generate and test specific predictions. Such a model could be applied to improve treatment development, stratification and combination approaches for patients with depression and provide a framework for considering and overcoming treatment nonresponse.

How does attention training work in social phobia: disengagement from threat or re-engagement to non-threat?

Social phobics exhibit an attentional bias for threat in probe detection paradigms. Attention training, whereby probes always replace non-threat in a display presenting both threat and non-threat, reduces attentional bias for threat and social anxiety. However, it remains unclear whether therapeutic benefits result from learning to disengage attention from threat or learning to orient attention towards non-threat. In this experiment, social phobics were randomly assigned to one of four training conditions: (1) disengagement from threat, (2) engagement towards non-threat, (3) disengagement from threat and re-engagement towards non-threat, and (4) a control condition. Effects were examined on subjective and behavioral responses to a subsequent stressor. Data revealed that training to disengage from threat reduces behavioral indices of anxiety. Engagement towards non-threat faces did not have effects in itself. These results support that the difficulty in disengaging attention from threat is a critical process in maintenance of the disorder.

Preliminary findings: neural responses to feedback regarding betrayal and cooperation in adolescent anxiety disorders

We compared neural and behavioral responses to feedback received during interpersonal interactions within the Prisoner's Dilemma game between adolescents with anxiety disorders (n = 12) and healthy peers (n = 17). Groups differed significantly in neural activation in the medial prefrontal cortex (mPFC), anterior cingulate cortex (ACC), precuneus, insula, and temporoparietal junction (TPJ). Anxious adolescents were also more likely than controls to cooperate after co-player betrayal. Our findings provide evidence that social behavior and related neural activity differs between anxious and healthy adolescents. These findings constitute a step toward elucidating neural correlates of social impairment in anxious youths.

Gender difference of unconscious attentional bias in high trait anxiety individuals

By combining binocular suppression technique and a probe detection paradigm, we investigated attentional bias to invisible stimuli and its gender difference in both high trait anxiety (HTA) and low trait anxiety (LTA) individuals. As an attentional cue, happy or fearful face pictures were presented to HTAs and LTAs for 800 ms either consciously or unconsciously (through binocular suppression). Participants were asked to judge the orientation of a gabor patch following the face pictures. Their performance was used to measure attentional effect induced by the cue. We found gender differences of attentional effect only in the unconscious condition with HTAs. Female HTAs exhibited difficulty in disengaging attention from the location where fearful faces were presented, while male HTAs showed attentional avoidance of it. Our results suggested that the failure to find attentional avoidance of threatening stimuli in many previous studies might be attributed to consciously presented stimuli and data analysis regardless of participants' gender. These findings also contributed to our understanding of gender difference in anxiety disorder.

Attentional bias in untreated panic disorder

The role of attentional biases in panic disorder has been well characterised. However, recent studies suggest an important effect of antidepressant and anxiolytic drugs on cognitive bias and most studies have included medicated patients in their sample. This study therefore examined cognitive bias in an untreated sample of participants with panic disorder (PD). A sample of 23 untreated participants with panic disorder with or without agoraphobia (PPD) and 22 healthy controls (HC) were tested with a Facial Expression Recognition task featuring different emotional intensities, a Faces Dot Probe task, a Self Beliefs task and an Emotional Stroop task. PPD showed exaggerated attentional biases to negative face and word stimuli in two different paradigms and endorsed more panic-related and negative self-attributions. They also showed enhanced perception of facial expressions of sadness. These tasks are sensitive to cognitive bias in a community-based sample of untreated PD participants. Attentional biases in panic disorder cannot be explained by the use of medication in this group and may therefore play a critical role in the underlying pathogenesis of the disorder.

[Generalized anxiety disorder: recognizing it and understanding its impact on the cognitive functioning]

Since the appearance of Generalized Anxiety Disorder (GAD) in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the definition and the comprehension of this disorder have largely evolved. The present article is an overview of the principal aspects of GAD in the literature such as the history, the prevalence, the socioeconomic characteristics, the comorbidity, the differential diagnosis and its evolution, while considering the litigious questions concerning its classification. This article also presents a report of the recent studies about the cognitive profile of patients, from a perspective of cognitive experimental psychology and neuropsychology. The consequences on cognitive functioning are discussed in the second part of the article, as well as precautions relatively to functioning clinicians have to consider.

Attentional Bias in Anxiety Disorders Following Cognitive Behavioral Treatment

A substantive literature suggests that anxious people have an attentional bias toward threatening stimuli. To date, however, no systematic review has examined the effects of cognitive behavioral therapy (CBT) for anxiety on attentional bias. A better understanding of the extant literature on CBT and its effect on attentional bias can serve to bridge the gap between experimental research on cognitive bias and the implications for clinical treatment of anxiety disorders. The present review examined studies that measured the effects of CBT on attentional bias. Of the 13 studies reviewed, 10 demonstrated that attentional bias, as assessed by dichotic listening tasks, the emotional Stroop test, or probe detection tasks, was significantly reduced from pretreatment to posttreatment for obsessive-compulsive disorder, spider phobia, social phobia, and generalized anxiety disorder. Methodological issues are considered, and implications for cognitive behavioral treatments of anxiety are discussed.

Attention to social threat as a vulnerability to the development of comorbid social anxiety disorder and alcohol use disorders: an avoidance-coping cognitive model

Despite the frequent comorbidity of social anxiety disorder and alcohol use disorders, no theoretical model currently exists to explain the specific mechanisms underlying the comorbidity between these two disorders. An integration of existing theoretical models and empirical evidence across the social anxiety and alcohol use literatures is presented as the Avoidance-Coping Cognitive Model, which proposes that socially anxious individuals may be particularly vulnerable to the anxiolytic effects of alcohol through reductions in attention biases to social threat. The disproportionate reduction in anxiety may then make alcohol an attractive method of avoidance coping. Gaps in the empirical literature are reviewed in light of this model as future directions are suggested.

Cognitive theory and therapy of anxiety and depression: convergence with neurobiological findings

In this review paper a modified cognitive neurophysiological model of Aaron T. Beck's cognitive formulation of anxiety and depression is proposed that provides an elaborated account of the cognitive and neural mediational processes of cognitive therapy (CT). Empirical evidence consistent with this model is discussed that indicates the effectiveness of cognitive therapy could be associated with reduced activation of the amygdalohippocampal subcortical regions implicated in the generation of negative emotion and increased activation of higher-order frontal regions involved in cognitive control of negative emotion. Future cognitive neuroscience research is needed on the unique brain substrates affected by CT and their role in facilitating symptom change. This future research would have important implications for improving the efficiency and efficacy of this treatment approach.

The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients

OBJECTIVES

To assess the extent to which perceived pain and psychological factors explain levels of disability and health-related quality of life (HRQOL) in patients scheduled for lumbar fusion surgery, and to test the hypothesis that relationships between pain intensity, mental health, fear of movement/(re)injury, disability and HRQOL are mediated by cognitive beliefs and appraisals.

DESIGN

Cross-sectional, correlation study.

SETTING

Orthopaedic outpatient setting in a tertiary hospital.

PARTICIPANTS

One hundred and seven chronic back pain patients scheduled for lumbar fusion surgery.

MEASURES

Visual analogue scale for pain intensity, Short Form 36 mental health subscale, Tampa Scale for Kinesiophobia, Back Beliefs Questionnaire, Self-efficacy Scale, Coping Strategy Questionnaire, Oswestry Disability Index and European Quality of Life Questionnaire.

RESULTS

The group effect of multiple mediators significantly influenced the relationships between pain intensity and mental health, fear of movement/(re)injury, functional disability and HRQOL. Pain catastrophising significantly mediated the relationship between pain intensity and mental health, control over pain significantly mediated the relationship between mental health and functional disability, self-efficacy and pain outcome expectancy significantly mediated the relationship between mental health and HRQOL, and self-efficacy also significantly mediated the relationship between pain intensity, fear of movement/(re)jury and functional disability. The model explained 28, 30, 52 and 42% of the variation in mental health, fear of movement/(re)injury, functional disability and HRQOL, respectively.

CONCLUSIONS

This study highlights the strong influence and mediation roles of psychological factors on pain, mental health, fear of movement/(re)injury, disability and HRQOL in patients scheduled for lumber fusion. Future research should focus on screening as well as pre- and post-operative interventions based on these psychological factors for the potential improvement of lumber fusion surgery outcomes.

Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review

A wealth of research demonstrates attentional biases toward threat in the anxiety disorders. Several models have been advanced to explain these biases in anxiety, yet the mechanisms comprising and mediating the biases remain unclear. In the present article, we review evidence regarding the mechanisms of attentional biases through careful examination of the components of attentional bias, the mechanisms underlying these components, and the stage of information processing during which the biases occur. Facilitated attention, difficulty in disengagement, and attentional avoidance comprise the components of attentional bias. A threat detection mechanism likely underlies facilitated attention, a process that may be neurally centered around the amygdala. Attentional control ability likely underlies difficulty in disengagement, emotion regulation goals likely underlie attentional avoidance, and both of these processes may be neurally centered around prefrontal cortex functioning. The threat detection mechanism may be a mostly automatic process, attentional avoidance may be a mostly strategic process, and difficulty in disengagement may be a mixture of automatic and strategic processing. Recommendations for future research are discussed.

Is preattentive bias predictive of autonomic reactivity in response to a stressor?

Biased processing of threatening information may play a casual role in the development of anxiety disorders. Even though empirical evidence points to the fact that preattentive bias can predict subjectively experienced distress in response to a stressor, it is still unknown whether it could be useful in predicting the physiological reactivity in response to a stressor. In the present study, the emotional Stroop task was used to measure preattentive bias. Whereas Stroop interference for masked threat words (i.e., preattentive bias) was found to be positively associated with emotional distress (self-reported) in response to a laboratory stressor, this association was reversed when the autonomic reactivity (electrodermal activity) was used as a measure of emotional response to the very same stressor. Also, neither of these effects were a function of pre-existing anxiety levels. The negative association between preattentive bias and autonomic reactivity corresponds to the autonomic inflexibility seen in clinical anxiety (or very high scores of trait anxiety) when exposed to stressful events. Results were discussed in terms of an inability to automatically inhibit the processing of threatening cues that seems to be a vulnerability marker for anxiety.

Attentional retraining: a randomized clinical trial for pathological worry

OBJECTIVE

Research has consistently shown that highly anxious individuals tend to show an attentional bias in favor of threat cues (i.e., a threat bias). Further, recent evidence suggests that it is possible to modify patterns of attention allocation for such stimuli and the resulting changes in attention allocation alter affective responses to stress. However, to date such changes in patterns of attention have been shown only over brief time intervals and only in non-anxious individuals who lack a pre-existing attentional bias. In contrast, the present study tested the efficacy of such attentional training in a sample of severe worriers over an extended period of time using psychometrically validated measures of anxiety and depression.

METHOD

Twenty-four adult participants reporting severe worry were randomly assigned to receive five sessions of either computer-delivered attentional retraining or sham training. The study was conducted from January to August 2001 and June to August 2002.

RESULTS

Significant Treatment Group X Time interactions were found for both threat bias (p=001) and a composite measure of anxious and depressive symptoms (p=.002). Compared to sham-training, the active retraining program produced significant reductions in both threat bias and symptoms.

CONCLUSIONS

These data support the view that an attentional bias in favor of threat cues is an important causal factor in generalized anxiety and suggest that a computer-based attentional retraining procedure may be an effective component of treatment.