Anxiety-linked attentional bias and its modification: Illustrating the importance of distinguishing processes and procedures in experimental psychopathology research

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.

Shifting Episodic Prediction With Online Cognitive Bias Modification: A Randomized Controlled Trial

Negative future thinking pervades emotional disorders. This hybrid efficacy-effectiveness trial tested a four-session, scalable online cognitive bias modification program for training more positive episodic prediction. 958 adults (73.3% female, 86.5% White, 83.4% from United States) were randomized to positive conditions with ambiguous future scenarios that ended positively, 50/50 conditions that ended positively or negatively, or a control condition with neutral scenarios. As hypothesized (preregistration: https://osf.io/jrst6), positive training participants improved more than control participants in negative expectancy bias (d = -0.58), positive expectancy bias (d = 0.80), and self-efficacy (d = 0.29). Positive training was also superior to 50/50 training for expectancy bias and optimism (d = 0.31). Training gains attenuated yet remained by 1-month follow-up. Unexpectedly, participants across conditions improved comparably in anxiety and depression symptoms and growth mindset. Targeting a transdiagnostic process with a scalable program may improve bias and outlook; however, further validation of outcome measures is required.

Approach-Bias Retraining and Other Training Interventions as Add-On in the Treatment of AUD Patients

In the past two decades, a variety of cognitive training interventions have been developed to help people overcome their addictive behaviors. Conceptually, it is important to distinguish between programs in which reactions to addiction-relevant cues are trained (varieties of cognitive bias modification, CBM) and programs in which general abilities are trained such as working memory or mindfulness. CBM was first developed to study the hypothesized causal role in mental disorders: by directly manipulating the bias, it was investigated to what extent this influenced disorder-relevant behavior. In these proof-of-principle studies, the bias was temporarily modified in volunteers, either temporarily increased or decreased, with corresponding effects on behavior (e.g., beer consumption), in case the bias was successfully manipulated. In subsequent clinical randomized controlled trials (RCTs), training (away from the substance vs. sham training) was added to clinical treatment. These studies have demonstrated that CBM, as added to treatment, reduces relapse with a small effect of about 10% (similar effect size as for medication, with the strongest evidence for approach-bias modification). This has not been found for general ability training (e.g., working memory training), although effects on other psychological functions have been found (e.g., impulsivity). Mindfulness also has been found to help people overcome addictions, and different from CBM, also as stand-alone intervention. Research on (neuro-)cognitive mechanisms underlying approach-bias modification has pointed to a new perspective in which automatic inferences rather than associations are influenced by training, which has led to the development of a new variety of training: ABC training.

Same same, but different: A psychometric examination of three frequently used experimental tasks for cognitive bias assessment in a sample of healthy young adults

Cognitive bias research draws upon the notion that altered information processing is key for understanding psychological functioning and well-being. However, little attention has been paid to the question of whether the frequently used experimental paradigms hold adequate psychometric properties. The present study examined the psychometric properties of three widely used cognitive bias tasks: the Approach-Avoidance Task (AAT), the visual dot-probe-task, and the Implicit Association Test (IAT). Approach, attentional, and association biases towards valenced stimuli were repeatedly measured at five different time points in a sample of 79 healthy young adults. Two different devices were used for assessment: a personal computer (PC) and a touchscreen-based tablet. Reliability estimates included internal consistency and temporal stability. Validity was inferred from convergence across different behavioral tasks and correlations between bias scores and self-reported psychological traits. Reliability ranged widely amongst tasks, assessment devices, and measurement time points. While the dot-probe-task appeared to be completely unreliable, bias scores obtained from the PC-based version of the AAT and both (PC and touchscreen) versions of the IAT showed moderate reliability. Almost no associations were found across information processing tasks or between implicit and explicit measures. Cognitive bias research should adopt a standard practice to routinely estimate and report psychometric properties of experimental paradigms, investigate feasible ways to develop more reliable tools, and use tasks that are suitable to answer the precise research question asked.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression

Background

To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity.

Method

150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator.

Discussion

Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression.

Trial registration

The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

Scary in the eye of the beholder: Attentional bias and attentional retraining for social anxiety

Consistent with cognitive models of social anxiety, socially anxious individuals show cognitive biases that magnify their perceived level of threat in the environment.

OBJECTIVES

The first objective was to determine whether attentional bias for socially threatening stimuli occurs after concomitant depression has been controlled. The second objective was to test the effectiveness of the Attention Control Training Program for Social Anxiety (ACTP-SA) for reducing social anxiety attentional bias and improving therapeutic indices in people with social anxiety.

METHOD

In the first study, socially anxious (N = 30) and non-anxious individuals (N = 30) completed the Beck Depression Inventory-II, Spielberger's State-Trait Anxiety Inventory, Conner's Social Phobia Inventory, a social-anxiety Stroop test, and a clinical interview. In the second study, individuals with social anxiety (N = 30) were randomly assigned to an experimental group that received 4 sessions of ACTP-SA, or to a sham-intervention control condition. At the post-test and a 3-month follow-up, both groups completed the same measures as in Study 1.

RESULTS

In Study 1, socially anxious individuals showed higher attentional bias for threatening stimuli than the controls, after depression had been controlled for. In Study 2, participants in the experimental group, compared with the controls, showed greater reductions in attentional bias, social anxiety, and trait anxiety at post-test and follow-up.

CONCLUSIONS

The results underscore the importance of information processing biases in social anxiety and the benefits of attentional bias training as a complementary intervention for modifying symptoms of social anxiety.

Neurophysiological Correlates for Dynamic Variability Between Vigilance and Avoidance in Test Anxiety

Attention bias (ABs) to threat is essential in the etiology and maintenance of test anxiety. However, little is known about the attention pattern of ABs in test anxiety. The stimulus duration affects the attention pattern in anxiety. Thus, the present research combined the dot-probe paradigm and event-related potentials (ERPs) and varied the stimulus duration (100ms or 500ms) to test the ABs in test anxiety. Consequently, both groups showed a threat N2pc in 100ms and 500ms duration, suggesting that both groups allocated attention to the test-related threat. However, in the 100ms duration, the high test-anxious (HTA) group had smaller target-elicited P1 and greater target-elicited N2 in the threat-congruent condition than in the neutral condition. In the 500ms duration, an earlier threat N2pc and a threat PD followed a greater target P1, and smaller target N2 were pronounced in the HTA group. The current results provided electrophysiological evidence that the HTA group kept a dynamic attention pattern that fluctuated shift between vigilance and avoidance in the 100ms and 500ms duration. The HTA group was more vigilant than the LTA group in the 500ms duration when strategic attention was concerned, proposing that the vigilance in test anxiety was not an automatic process.

Personalized attention control therapy for PTSD: effectiveness and moderators of outcome in a randomized controlled trial

BACKGROUND

Previous randomized controlled trials (RCTs) suggest that attention control therapy (ACT), targeting aberrant fluctuations of attention toward and away from threats in patients with PTSD, may be effective in reducing symptoms. The current RCT examined whether the use of personalized-trauma stimuli enhances ACT efficacy in patients with PTSD. Additional moderators of treatment outcome were tested on an exploratory basis.

METHODS

Sixty patients with PTSD were randomly assigned to either personalized ACT, non-personalized ACT, or a control condition. Changes in symptoms were examined across pre-treatment, post-treatment, and a 3-month follow-up. Attentional interference was examined pre- and post-treatment. Baseline clinical and cognitive indices as well as the time elapsed since the trauma were tested as potential moderators of treatment outcome.

RESULTS

A significant reduction in clinical symptoms was noted for all three conditions with no between-group differences. Attention bias variability decreased following ACT treatment. Personalized ACT was more effective relative to the control condition when less time had elapsed since the trauma. Baseline clinical and cognitive indices did not moderate treatment outcome.

CONCLUSIONS

In this RCT of patients with PTSD, ACT was no more effective in reducing PTSD symptoms than a control condition. The data also suggest a potential benefit of personalized ACT for patients who experienced their trauma more recently.

Mobile Attention Bias Modification Training Is a Digital Health Solution for Managing Distress in Multiple Sclerosis: A Pilot Study in Pediatric Onset

Introduction: Emotional health is important dimension of care for patients living with pediatric onset multiple sclerosis (POMS), but few options are available for stress and anxiety reduction. The high burden of interventions requiring regular in person and onsite visits for treatment are less feasible. Attention bias modification training (ABMT) is effective for anxiety reduction in adult and adolescent populations. We tested the feasibility and preliminary efficacy of ABMT delivered through a mobile gamified version as a digital emotional health tool for patients with POMS.

Methods: Participants with POMS were consecutively recruited from the NYU Langone Pediatric MS Care Center and enrolled to complete a 1-month intervention with use of the Personal Zen ABMT app on their mobile personal device. Feasibility was evaluated by use of the 1-month intervention and efficacy was measured by changes in depression, anxiety, and affect.

Results: A total n = 35 patients with POMS were enrolled in the study (M_age = 17.7, SD = 2.2 years, range 14–23). Feasibility criteria were met with 74% completing the full intervention time, and 100% of the sample completing at least 50% of targeted intervention use. Initial efficacy was found for a reduction in negative affect from baseline to intervention end [M = 22.88, SD = 9.95 vs. M = 19.56, SD = 7.37; t₍₃₃₎ = 2.47, p = 0.019]. Anxiety also significantly decreased from pre to post-intervention in adults [M = 11.82, SD = 9.90 vs. M = 7.29, SD = 7.17; t₍₁₆₎ = 3.88, p = 0.001] and youth [M = 51.14, SD = 19.66 vs. M = 40.86, SD = 27.48; t₍₁₃₎ = 3.17, p = 0.007].

Conclusion: Mobile ABMT with the Personal Zen app is a feasible and accessible digital emotional health tool for patients with POMS and may have broader application for managing distress across chronic neurological conditions.

Effectiveness of attentional bias modification training as add-on to regular treatment in alcohol and cannabis use disorder: A multicenter randomized control trial

Background

Attentional bias for substance-relevant cues has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, increase positive treatment outcome and reduce relapse rates. The current study investigated the effectiveness of a newly developed home-delivered, multi-session, internet-based ABM intervention, the Bouncing Image Training Task (BITT), as an add-on to treatment as usual (TAU).

Methods

Participants (N = 169), diagnosed with alcohol or cannabis use disorder, were randomly assigned to one of two conditions: the experimental ABM group (50%; TAU+ABM); or the control group (50%; split in two subgroups the TAU+placebo group and TAU-only group, 25% each). Participants completed baseline, post-test, and 6 and 12 months follow-up measures of substance use and craving allowing to assess long-term treatment success and relapse rates. In addition, attentional bias (both engagement and disengagement), as well as secondary physical and psychological complaints (depression, anxiety, and stress) were assessed.

Results

No significant differences were found between conditions with regard to substance use, craving, relapse rates, attentional bias, or physical and psychological complaints.

Conclusions

The findings may reflect unsuccessful modification of attentional bias, the BITT not targeting the relevant process (engagement vs. disengagement bias), or may relate to the diverse treatment goals of the current sample (i.e., moderation or abstinence). The current findings provide no support for the efficacy of this ABM approach as an add-on to TAU in alcohol or cannabis use disorder. Future studies need to delineate the role of engagement and disengagement bias in the persistence of addiction, and the role of treatment goal in the effectiveness of ABM interventions.

Approach bias retraining through virtual reality in smokers willing to quit smoking: A randomized-controlled study

Automatic approach biases toward smoking-related cues have been implicated in the development and maintenance of addictive behaviors. Studies aiming at modifying such biases have shown promise in changing maladaptive approach tendencies for smoking cues and reducing smoking behavior. However, training effects tend to be small and partly inconsistent. The present randomized-controlled trial incorporated virtual reality (VR) technology into Approach Bias Modification (ABM) to improve efficacy. One-hundred-eight smokers attended behavioral counseling for smoking cessation and were thereafter randomized to receive VR-ABM or VR-control training. During VR-ABM, participants trained to implicitly avoid smoking-related objects and to approach alternative objects, while no such contingency existed in the VR-control condition. Trainings were administered in six sessions within a two-week period. Assessments were conducted at baseline, post-intervention (three weeks after baseline), and at follow-up (seven weeks after baseline). VR-ABM did not change approach biases, nor other cognitive biases, but it was superior in reducing daily smoking. However, this effect was limited to the two-week training period. Both groups improved in other smoking- and health-related variables across time. Future work should continue to investigate working mechanisms of ABM, in particular crucial training ingredients. VR could prove valuable for public health as the potential of VR-based treatments is large and not fully explored.

Attention control therapy for acute stress disorder: A randomized controlled trial

BACKGROUND

A subset of people exposed to traumatic events develop acute stress disorder (ASD), and approximately half of people with ASD develop posttraumatic stress disorder (PTSD). This randomized controlled trial examined the efficacy of internet-delivered attention control therapy (ACT), previously shown to reduce PTSD symptoms, as an adjuvant to treatment as usual in the community for patients with ASD.

METHODS

About 119 participants with ASD were randomly assigned to ACT or treatment as usual in the community within the first month following their traumatic event. PTSD symptoms and attention patterns were measured.

RESULTS

A significant reduction in stress-related symptoms was noted across participants with no difference between the two groups. Approximately half of the participants developed PTSD 2 months after the trauma. High attention bias variability was associated with elevated PTSD symptoms. However, attention bias variability did not change due to the therapy sessions.

CONCLUSIONS

Internet-delivered ACT was no more effective in reducing risk for PTSD in participants with ASD than treatment as usual in the community. Although elevated attention bias variability was detected in the patients with ASD, ACT failed to engage this cognitive target. Finally, ACT-based prevention research should proceed with caution given the possibility that this intervention might be associated with symptom worsening as indexed by the Clinical Global Impression scale.

Direct effects of cognitive therapy skill acquisition on cognitive therapy skill use, idiosyncratic dysfunctional beliefs and emotions in distressed individuals: An experimental study

Experimental studies that manipulate treatment procedures to investigate their direct effects on treatment processes and outcomes are necessary to find out the effective elements and improve the effects of cognitive behavioral therapy (CBT) for depression. The present study randomized mildly to severely depressed participants into a procedure focused on cognitive therapy skill acquisition (CTSA; n = 27) or a control procedure focused on being exposed to theories of automatic thinking (n = 25) and investigated the direct effects on cognitive therapy (CT) skill use, credibility of idiosyncratic dysfunctional beliefs and strength of emotions. After the procedure, participants were exposed to a sad mood induction and given an assignment to test their CT skills. Participants who received the CTSA procedure used more CT skills compared to participants that received the control procedure, but there were no differences between conditions in the decrease of the credibility of idiosyncratic dysfunctional beliefs and strength of emotions. However, in participants with mild levels of depression, those who underwent the CTSA procedure showed larger decrease in the credibility of their most malleable belief (i.e. mostly automatic negative thoughts) compared to those who received the control procedure, but the significance of these findings disappeared when controlling for differences in ratings of the procedures. Future experimental studies should focus on the effects of CT skill training in the long term, the dose of the procedure and individual patient differences to find out under what circumstances the use of CT skills can lead to a reduction in dysfunctional thinking and subsequent symptoms of depression.

Attentional Bias for Cues Signaling Punishment and Reward in Adolescents: Cross-Sectional and Prognostic Associations with Symptoms of Anxiety and Behavioral Disorders

Heightened reward sensitivity has been proposed as a risk factor for developing behavioral disorders whereas heightened punishment sensitivity has been related to the development of anxiety disorders in youth. Combining a cross-sectional (n = 696, mean age = 16.14) and prospective (n = 598, mean age = 20.20) approach, this study tested the hypotheses that an attentional bias for punishing cues is involved in the development of anxiety disorders and an attentional bias for rewarding cues in the development of behavioral disorders. A spatial orientation task was used to examine the relation between an attentional bias for punishing cues and an attentional bias for rewarding cues with anxiety and behavioral problems in a subsample of a large prospective population cohort study. Our study indicates that attentional biases to general cues of punishment and reward do not seem to be important risk factors for the development of anxiety or behavioral problems respectively. It might be that attentional biases play a role in the maintenance of psychological problems. This remains open for future research.

Sex Differences Linking Pain-Related Fear and Interoceptive Hypervigilance: Attentional Biases to Conditioned Threat and Safety Signals in a Visceral Pain Model

Although the broad role of fear and hypervigilance in conditions of the gut-brain axis like irritable bowel syndrome is supported by converging evidence, the underlying mechanisms remain incompletely understood. Even in healthy individuals, it remains unclear how pain-related fear may contribute to pain-related attentional biases for acute visceral pain. Building on our classical fear conditioning work in a clinically relevant model of visceral pain, we herein elucidated pain-related attentional biases shaped by associative learning in healthy women and men, aiming to elucidate possible sex differences and the role of psychological traits. To this end, we compared the impact of differentially conditioned pain-predictive cues on attentional biases in healthy women and men. Sixty-four volunteers accomplished a visual dot-probe task and subsequently underwent pain-related fear conditioning where one visual cue (CS⁺) was contingently paired with a painful rectal distention (US) while another cue remained unpaired (CS^-). During the following test phase, the dot-probe task was repeated to investigate changes in attentional biases in response to differentially valenced cues. While pain-related learning was comparable between groups, men revealed more pronounced attentional engagement with the CS⁺ and CS^- whereas women demonstrated stronger difficulties to disengage from the CS⁺ when presented with a neutral cue. However, when both CS⁺ and CS^- were presented together, women revealed stronger difficulties to disengage from the CS^-. Regression analyses revealed an interaction of sex, with negative affect predicting stronger avoidance of the CS⁺ and stronger difficulties to disengage attention from the CS^- in men. These results provide first evidence that pain-related fear conditioning may induce attentional biases differentially in healthy women and men. Hence, sex differences may play a role in attentional mechanisms underlying hypervigilance, and may be modulated by psychological vulnerability factors relevant to chronic visceral pain.

Attentional Bias Modification in Virtual Reality - A VR-Based Dot-Probe Task With 2D and 3D Stimuli

Background

Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias toward threatening information. The current study incorporated virtual reality (VR) technology and three-dimensional stimuli with a dot-probe task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

Methods

A total of 100 participants were randomized to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-months follow-up.

Results

Change in anxiety did not correlate with change in bias (p = 0.24). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM (p = 0.144), or between groups (p = 0.976). For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment (p < 0.001). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 9% of participants were classified as ‘recovered’ at 3-months follow-up.

Conclusion

A single session of VR-based ABM did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.

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.

Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial

BACKGROUND

Randomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD.

METHODS

Fifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment.

RESULTS

ACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment.

CONCLUSIONS

The current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.

Pinpointing mechanisms of a mechanistic treatment: Dissociable roles for overt and covert attentional processes in acute and long-term outcomes following Attention Bias Modification

Biased patterns of attention towards threat are implicated as key mechanisms in anxiety which can be modified through automated intervention (Attention Bias Modification; ABM). Intervention refinement and personalized dissemination efforts are substantially hindered by gaps in understanding the precise attentional components that underlie ABM's effects on symptoms-particularly with respect to longer-term outcomes. Seventy adults with transdiagnostic anxiety were randomized to receive 8 sessions of active ABM (n=49) or sham training (n=21). Reaction time and eyetracking data, collected at baseline, post-training, and 1-month follow-up, dissociated multiple core attentional processes, spanning overt and covert processes of engagement and disengagement. Self-reported symptoms were collected out to 1-year follow-up. Covert disengagement bias was specifically reduced by ABM, unlike all other indices. Overt disengagement bias at baseline predicted acute post-ABM outcomes, while covert engagement bias was non-specifically predictive of symptom trajectories out to 1-year follow-up. Results suggest unique and dissociable roles for each discrete mechanism.

Heterogeneity of the Anxiety-Related Attention Bias: A Review and Working Model for Future Research

The anxiety-related attention bias (AB) has been studied for several decades as a clinically-relevant output of the dynamic and complex threat detection-response system. Despite research enthusiasm for the construct of AB, current theories and measurement approaches cannot adequately account for the growing body of mixed, contradictory, and null findings. Drawing on clinical, neuroscience, and animal models, we argue that the apparent complexity and contradictions in the empirical literature can be attributed to the field's failure to clearly conceptualize AB heterogeneity and the dearth of studies in AB that consider additional cognitive mechanisms in anxiety, particularly disruptions in threat-safety discrimination and cognitive control. We review existing research and propose a working model of AB heterogeneity positing that AB may be best conceptualized as multiple subtypes of dysregulated processing of and attention to threat anchored in individual differences in threat-safety discrimination and cognitive control. We review evidence for this working model and discuss how it can be used to advance knowledge of AB mechanisms and inform personalized prevention and intervention approaches.

Anxiety-Linked Attentional Bias: Is It Reliable?

There is substantial evidence that heightened anxiety vulnerability is characterized by increased selective attention to threatening information. The reliability of this anxiety-linked attentional bias has become the focus of considerable recent interest. We distinguish between the potential inconsistency of anxiety-linked attentional bias and inconsistency potentially reflecting the psychometric properties of the assessment approaches used to measure it. Though groups with heightened anxiety vulnerability often exhibit, on average, elevated attention to threat, the evidence suggests that individuals are unlikely to each display a stable, invariant attentional bias to threat. Moreover, although existing assessment approaches can differentiate between groups, they do not exhibit the internal consistency or test-retest reliability necessary to classify individuals in terms of their characteristic pattern of attentional responding to threat. We discuss the appropriate uses of existing attentional bias assessment tasks and propose strategies for enhancing classification of individuals in terms of their tendency to display an attentional bias to threat.

Online Attention Bias Modification in Combination With Cognitive-Behavioural Therapy for Children and Adolescents With Anxiety Disorders: A Randomised Controlled Trial

Attention Bias Modification (ABM) targets attention bias (AB) towards threat, which is common in youth with anxiety disorders. Previous clinical trials showed inconsistent results regarding the efficacy of ABM, and few studies have examined the effect of online ABM and its augmented effect with cognitive behavioural therapy (CBT). The aim of the current study was to examine the efficacy of online ABM combined with CBT for children and adolescents with anxiety disorders in a randomised, double-blind, placebo-controlled trial. Children (aged 8–16 years) completed nine online sessions of ABM (n= 28) or online sessions of the Attention Control Condition (ACC;n= 27) over a period of 3 weeks (modified dot-probe task with anxiety disorder-congruent stimuli), followed by CBT. Primary outcomes were clinician-reported anxiety disorder status. Secondary outcomes were patient-reported anxiety and depression symptoms and AB. Results showed a continuous decrease across time in primary and secondary outcomes (ps < .001). However, no differences across time between the ABM and ACC group were found (ps > .50). Baseline AB and age did not moderate treatment effects. Online ABM combined with CBT does not show different efficacy compared with online ACC with CBT for children and adolescents with anxiety disorders.

Dispositional negativity, cognition, and anxiety disorders: An integrative translational neuroscience framework

When extreme, anxiety can become debilitating. Anxiety disorders, which often first emerge early in development, are common and challenging to treat, yet the underlying mechanisms have only recently begun to come into focus. Here, we review new insights into the nature and biological bases of dispositional negativity, a fundamental dimension of childhood temperament and adult personality and a prominent risk factor for the development of pediatric and adult anxiety disorders. Converging lines of epidemiological, neurobiological, and mechanistic evidence suggest that dispositional negativity increases the likelihood of psychopathology via specific neurocognitive mechanisms, including attentional biases to threat and deficits in executive control. Collectively, these observations provide an integrative translational framework for understanding the development and maintenance of anxiety disorders in adults and youth and set the stage for developing improved intervention strategies.

The effects of attentional bias modification on emotion regulation

BACKGROUND AND OBJECTIVES

In two experiments, we investigated the effects of Attentional Bias Modification (ABM) on emotion regulation, i.e. the manner in which people influence emotional experiences. We hypothesized that decreases in attentional bias to threat would impair upregulation and improve downregulation of negative emotions, while increases in attentional bias to threat would improve upregulation and impair downregulation of negative emotions.

METHODS

Using the emotion-in-motion paradigm (Experiment 1, N = 60) and the visual search task (Experiment 2, N = 58), we trained participants to attend to either threatening or positive stimuli and we assessed emotion intensity while observing, upregulating, and downregulating emotions in response to grids of mixed emotional pictures.

RESULTS

In Experiment 1, the attend positive group reported more positive emotions while merely watching grids of training pictures and the attend threat group showed impaired upregulation of negative affect. In Experiment 2, the attend threat group reported intensified negative emotions for all three instructions, while the attend positive group remained largely stable over time.

LIMITATIONS

We cannot unequivocally attribute these changes in emotion regulation to changes in attentional bias, as neither of the experiments yielded significant changes in attentional bias to threat.

CONCLUSIONS

By showing that attentional bias modification procedures affect the manner in which people deal with emotions, we add empirical weight to the conceptual overlap between attentional bias modification and emotion regulation.

A randomized controlled trial of inhibitory control training for the reduction of alcohol consumption in problem drinkers

OBJECTIVE

We conducted a randomized controlled trial to compare the effects of three types of Internet-delivered Inhibitory Control Training (ICT) with each other and with an active control intervention on alcohol consumption in a community sample of problem drinkers.

METHOD

Two hundred and 46 heavy drinkers, who were motivated to reduce their alcohol consumption (mean age 41.32, 130 female) self-monitored their alcohol consumption for 1 week before being randomized to receive 1 of 3 variants of ICT (Associative No-Go, Associative Stop Signal, General Inhibition) or an active control. Participants then completed up to 14 ICT/control sessions on the Internet over a 4-week period, while regularly recording their alcohol consumption.

RESULTS

There were significant reductions in alcohol consumption across all groups over the 4-week training period (main effect of time, F(2, 402) = 77.12, p < .01, ηp2 = .28, BF10 > 99), however there were no differences between ICT groups, or between ICT groups and the active control group (Group × Time interaction, F(6, 402) = 1.10, p = .36, ηp2 = .02, BF10 = 0.03). Contrary to hypotheses, there were no changes in general inhibitory control, the disinhibiting effects of alcohol cues, or alcohol affective associations after ICT.

CONCLUSIONS

In this study, which attempted to translate findings from proof-of-concept laboratory studies into a viable behavior change intervention, we found that multiple sessions of ICT delivered over the Internet did not help heavy drinkers to reduce their alcohol consumption beyond nonspecific effects associated with taking part in a trial. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study

Background

Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved.

Objective

This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability.

Methods

We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor.

Results

Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60).

Conclusions

Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback.

The effectiveness of attentional bias modification for substance use disorder symptoms in adults: a systematic review

BACKGROUND

Attentional bias modification (ABM) interventions have been developed to address addiction by reducing attentional bias for substance-related cues. This study provides a systematic review of the effectiveness of ABM interventions in decreasing symptoms of addictive behaviour, taking baseline levels of attentional bias and changes in attentional bias into account.

METHODS

We included randomised and non-randomised studies that investigated the effectiveness of ABM interventions in heavy-using adults and treatment-seeking individuals with symptoms of substance use disorder to manipulate attentional bias and to reduce substance use-related symptoms. We searched for relevant English peer-reviewed articles without any restriction for the year of publication using PsycINFO, PubMed, and ISI Web in August 2016. Study quality was assessed regarding reporting, external validity, internal validity, and power of the study.

RESULTS

Eighteen studies were included: nine studies reported on ABM intervention effects in alcohol use, six studies on nicotine use, and three studies on opiate use. The included studies differed with regard to type of ABM intervention (modified dot probe task n = 14; Alcohol Attention Control Training Programme n = 4), outcome measures, amount and length of provided sessions, and context (clinic versus laboratory versus home environment). The study quality mostly ranged from low average to high average (one study scored below the quality cut-off). Ten studies reported significant changes of symptoms of addictive behaviour, whereas eight studies found no effect of ABM interventions on symptoms. However, when restricted to multi-session ABM intervention studies, eight out of ten studies found effects on symptoms of addiction. Surprisingly, these effects on symptoms of addictive behaviour showed no straightforward relationship with baseline attentional bias and its change from baseline to post-test.

CONCLUSIONS

Despite a number of negative findings and the diversity of studies, multi-session ABM interventions, especially in the case of alcohol and when the Alcohol Attention Control Training Programme was used, appear to have positive effects on symptoms of addictive behaviour. However, more rigorous well-powered future research in clinical samples is needed before firm conclusions regarding the effectiveness of ABM interventions can be drawn.

SYSTEMATIC REVIEW REGISTRATION

Registration number PROSPERO: CRD42016046823.

A Clinical Trial with Combined Transcranial Direct Current Stimulation and Attentional Bias Modification in Alcohol-Dependent Patients

BACKGROUND

Modifying attentional processes with attentional bias modification (ABM) might be a relevant add-on to treatment in addiction. This study investigated whether influencing cortical plasticity with transcranial direct current stimulation (tDCS) could increase training effects. tDCS could also help alcohol-dependent patients to overcome craving and reduce relapse, independent of training. These approaches were combined to investigate effects in the treatment of alcoholism.

METHODS

Ninety-eight patients (analytical sample = 83) were randomly assigned to 4 groups in a 2-by-2 factorial design. Patients received 4 sessions of ABM (control or real training) combined with 2 mA tDCS (active: 20 minutes or sham: 30 seconds) over the left dorsolateral prefrontal cortex. Alcohol bias and craving were assessed, and treatment outcome was measured as relapse after 1 year.

RESULTS

Attentional bias scores indicated that during the training only the group with active tDCS and real ABM displayed an overall avoidance bias (p < 0.05). From pre- to postassessment, there were no main or interaction effects of tDCS and ABM on the bias scores, craving, or relapse (p > 0.2). However, effects on relapse after active tDCS were in the expected direction.

CONCLUSIONS

There was no evidence of a beneficial effect of tDCS or ABM or the combination. Whether the absence of effect was due to issues with the outcome measurements (e.g., lack of craving, high dropout, and unreliable measurements) or aspects of the intervention should be further investigated.

A pilot randomized clinical trial of cognitive behavioral therapy versus attentional bias modification for social anxiety disorder: An examination of outcomes and theory-based mechanisms

No studies have compared face-to-face cognitive-behavioral therapy (CBT) and attention bias modification (ABM) for social anxiety disorder (SAD) and their purported mechanisms. We asked: 1) Is CBT more effective than ABM? and 2) Are changes in attentional biases and cognitions temporally related to symptom change? Forty-three patients were randomly assigned to 8 sessions of ABM or up to 20 sessions of individual CBT. Intent-to-treat results revealed that CBT was superior to ABM in response rates and on symptom measures at endpoint, but not on other measures. No differences were found on measures in rates of change between CBT and ABM. Frequency of negative cognitions changed in both groups and negative beliefs changed only in CBT. Attentional bias did not change in either group. Cognitive changes bidirectionally correlated with symptom change in cross-lagged analyses in CBT, but not in ABM, suggesting a reciprocal relationship. Trial-level bias away from negative faces was simultaneously related to symptom change in ABM only. Results suggest that CBT is superior to ABM when administered at their typical doses, but raise questions given the similar rates of change. In addition, results support theories of cognitive change and raise questions about changes in attentional biases in CBT.

Trait anxiety and the alignment of attentional bias with controllability of danger

Attentional bias to threat cues is most adaptive when the dangers they signal can readily be controlled by timely action. This study examined whether heightened trait anxiety is associated with impaired alignment between attentional bias to threat and variation in the controllability of danger, and whether this is moderated by executive functioning. Participants completed a task in which threat cues signalled money loss and an aversive noise burst (the danger). In 'high control' blocks, attending to the threat cue offered a high chance of avoiding this danger. In 'low control' blocks, attending to the threat cue offered little control over the danger. The task yielded measures of attentional monitoring for threat, and attentional orienting to threat. Results indicated all participants showed greater attentional orienting to threat cues in high control relative to low control blocks (indicative of proper alignment), however, high trait-anxious participants showed no difference in attentional monitoring for threat between block types, whereas low trait-anxious participants did. This effect was moderated by N-Back scores. These results suggest heightened trait anxiety may be associated with impaired alignment of attentional monitoring for threat cues, and that such alignment deficit may be attenuated by high executive functioning.

A failure to show the efficacy of a dot-probe attentional training in dysphoria: Evidence from an eye-tracking study

OBJECTIVE

This study examines whether a 4-day dot-probe attentional training to orient attention toward positive words could lead participants with dysphoria to change selective attention to emotional faces. It was also explored whether this positive attentional bias training could lead to a decrease in depressive symptoms.

METHODS

Participants were randomly assigned to Positive Training Group (PTG) and No Training Group (NTG). PTG was composed of 16 subjects, whereas NTG was composed of 15 subjects. All participants were women with a mean age of 22.87 (SD = 3.21).

RESULTS

Results showed that dysphoric participants in the PTG did not show changes in attentional patterns to emotional faces. Furthermore, depressive symptoms did not significantly change after the 4-session training.

CONCLUSIONS

These results suggest that cognitive training procedures based on dot-probe paradigms are probably not adequate to modify attentional patterns in individuals with depressive symptoms. The theoretical and practical implications are discussed.

Post-earthquake Distress and Development of Emotional Expertise in Young Adults

After a natural disaster like an earthquake about 15% of the population experience a post-traumatic stress disorder (PTSD). However, even those without a diagnosis of PTSD can suffer from disorders of the affective sphere, including anxiety, depression and alteration of emotion recognition. The objective of this study was to investigate the neuropsychological and emotional profile of students living in the earthquake-affected areas of L'Aquila, Italy. A group of students living in L'Aquila at the time of the 2009 earthquake was recruited, and compared to a control group of students not living in any earthquake-affected areas. Participants were assessed by means of the Beck Depression Inventory (BDI) scale, the State-Trait Anxiety Inventory (STAI), the Insomnia Severity Index (ISI), the Intolerance of Uncertainty Scale Short Form, the Uncertainty Response Scale (URS), the Anxiety Sensitivity Index 3 (ASI-3), and the Eysenck Personality Questionnaire-Revised Short Form (EPQ-RS). Participants also took part in two behavioral experiments aimed at evaluating their ability to recognize facial expressions (by means of the Ekman and Friesen Pictures of Facial Affect) and to evaluate emotionally evocative scenes (by means of the International Affective Picture System (IAPS)). Results showed that students living in the earthquake-affected areas had a general increase of anxiety and anticipation of threats. Moreover, students living in the earthquake-affected areas showed a significantly higher overall accuracy in recognizing facial expressions as compared to controls. No significant differences between the two groups were detected in the evaluation of emotionally evocative scenes. The novel result lies in the greater accuracy of earthquake victims in recognizing facial expressions, despite the lack of differences from controls in evaluating affective evocative scenes. The trauma exposure may have increased vigilance for threats in earthquake victims, leading them to systematically pay attention to potential signs of approaching threats, such as emotional facial expressions, thus progressively developing particular "emotional expertise."

Cognitive dysfunction in major depressive disorder

PURPOSE OF REVIEW

The principal aim of this review is to highlight recent advances in our understanding of cognitive dysfunction in major depressive disorder (MDD). We review new assessment and treatment approaches, in which cognition and associated psychosocial dysfunction are considered primary outcomes.

RECENT FINDINGS

Current work suggests that cognitive dysfunction reduces occupational productivity, and interferes broadly with domains of day-to-day and social functioning. These findings imply that cognitive dysfunction interacts with emotional and social factors relevant to MDD. Recent advances in screening instruments enable standardized detection of cognitive symptoms in MDD. Clinical trials suggest that cognitive symptoms are suitable targets and primary outcomes of psychological and pharmacological treatments.

SUMMARY

A growing interest in cognitive dysfunction in MDD has improved our ability to assess and treat MDD. Future research will be strengthened by the use of consistent terminology, standardized cognitive screening, and treatments that target cognitive dysfunction in MDD. Integration of emotional and social treatment strategies may further advance clinical efficacy.

Attention bias modification training under working memory load increases the magnitude of change in attentional bias

BACKGROUND AND OBJECTIVES

Attention bias modification (ABM) procedures have shown promise as a therapeutic intervention, however current ABM procedures have proven inconsistent in their ability to reliably achieve the requisite change in attentional bias needed to produce emotional benefits. This highlights the need to better understand the precise task conditions that facilitate the intended change in attention bias in order to realise the therapeutic potential of ABM procedures. Based on the observation that change in attentional bias occurs largely outside conscious awareness, the aim of the current study was to determine if an ABM procedure delivered under conditions likely to preclude explicit awareness of the experimental contingency, via the addition of a working memory load, would contribute to greater change in attentional bias.

METHODS

Bias change was assessed among 122 participants in response to one of four ABM tasks given by the two experimental factors of ABM training procedure delivered either with or without working memory load, and training direction of either attend-negative or avoid-negative.

RESULTS

Findings revealed that avoid-negative ABM procedure under working memory load resulted in significantly greater reductions in attentional bias compared to the equivalent no-load condition.

LIMITATIONS

The current findings will require replication with clinical samples to determine the utility of the current task for achieving emotional benefits.

CONCLUSIONS

These present findings are consistent with the position that the addition of a working memory load may facilitate change in attentional bias in response to an ABM training procedure.

Cognitive bias modification: A review of meta-analyses

BACKGROUND

Cognitive bias modification (CBM) is a novel, but controversial intervention with considerable divergence amongst conclusions in individual studies and reviews. This systematic review synthesizes meta-analyses of CBM to determine whether CBM is effective, and what parameters most reliably evoke the process of CBM.

METHODS

A systematic literature search resulted in twelve meta-analyses in total, from which the published effect sizes were extracted.

RESULTS

Attention bias modification (ABM) shifted targeted biases in adults (ES = 0.24-1.16), was effective as a buffer to stressor vulnerability (ES = 0.33-0.77) and in symptom control (ES = 0.16-0.41). Cognitive bias modification for interpretation (CBM-I) modified targeted biases (ES = 0.52-0.81) but did not reliably reduce stressor vulnerability (ES = 0.01-0.24, p > .05). CBM consistently reduced anxiety symptoms, but effects on depressive symptomatology were less compelling. The long-term efficacy of CBM was only supported in addiction studies.

LIMITATIONS

The review included a single CBM-I only meta-analysis, and two meta-analyses with pooled reporting on ABM and CBM-I outcomes.

CONCLUSIONS

Overall, this synthesis shows CBM is effective in the short-term for anxiety in adults, and highlights some conditions under which CBM is most efficacious. Rather than debating the efficacy of CBM, future research should focus on developing procedures that more reliably induce bias modification and determining the most efficacious clinical applications.