Attentional bias modification reduces clinical depression and enhances attention toward happiness

Affective processing in dysphoria: Evidence from startle probe modulation of ERPs

The hypoactivation of the appetitive and defensive motivational systems in the brain is a feature of depression and might also represent a vulnerability factor for the disorder. A measure that can be employed to investigate both motivational systems is the electroencephalographic response to an acoustic startle probe during affective processing. Particularly, the amplitude of auditory event-related potentials (ERPs) components to the startle probe is smaller when the emotional context is more arousing. Neural responses to an unattended startle probe during an emotional passive viewing task of pleasant, neutral, and unpleasant pictures was employed to assess the activation of the approach and defensive motivational systems in a sample of individuals with (n = 24, 23 females) vs. without (n = 24, 23 females) dysphoria. The group without dysphoria showed a reduced startle-elicited N200 only in the context of pleasant relative to neutral pictures, indicating that the affective processing of the appetitive context might reduce the attentional resources needed to orient attention toward unattended non-salient stimuli. Conversely, the N200 amplitude was not attenuated for pleasant relative to neutral and unpleasant contexts in the group with dysphoria. Moreover, no within- or between-group differences emerged in the P300 amplitude. Taken together, the results of this study showed that depression vulnerability is characterized by reduced attention to pleasant contexts, suggesting a blunted affective processing of appetitive emotional stimuli.

The impact of attention bias modification training on behavioral and physiological responses

Attention bias modification training aims to alter attentional deployment to symptom-relevant emotionally salient stimuli. Such training has therapeutic applications in the management of disorders including anxiety, depression, addiction and chronic pain. In emotional reactions, attentional biases interact with autonomically-mediated changes in bodily arousal putatively underpinning affective feeling states. Here we examined the impact of attention bias modification training on behavioral and autonomic reactivity. Fifty-eight participants were divided into two groups. A training group (TR) received attention bias modification training to enhance attention to pleasant visual information, while a control group (CT) performed a procedure that did not modify attentional bias. After training, participants performed an evaluation task in which pairs of emotional and neutral images (unpleasant-neutral, pleasant-neutral, neutral-neutral) were presented, while behavioral (eye movements) and autonomic (skin conductance; heart rate) responses were recorded. At the behavioral level, trained participants were faster to orientate attention to pleasant images, and slower to orientate to unpleasant images. At the autonomic level, trained participants showed attenuated skin conductance responses to unpleasant images, while stronger skin conductance responses were generally associated with higher anxiety. These data argue for the use of attentional training to address both the attentional and the physiological sides of emotional responses, appropriate for anxious and depressive symptomatology, characterized by atypical attentional deployment and autonomic reactivity.

The long-term effects of ABM on symptom severity in patients with recurrent depression: A randomized sham-controlled trial

BACKGROUND

The present study reports on long-term outcomes of ABM over one year in self-reported and clinician-rated depression symptoms, anxiety symptoms, and relapse rates.

METHODS

We conducted a double-blind randomized sham-controlled trial in 301 participants with recurrent major depression disorder between January 2015 and October 2016 (#NCT02658682). Participants were allocated to ABM or sham condition twice daily for 14 consecutive days. Long-term effects of ABM were assessed by BDI-II, HDRS and BAI at one-, six-, and 12-months follow-up. Relapse rates at 12-months follow-up were also assessed.

RESULTS

There was no long-term effect of ABM (as compared to sham) on clinician-rated depression symptoms, on anxiety symptoms, nor in relapse rates. By 12 months follow-up, there was a small effect on self-reported depression favoring ABM over sham.

LIMITATIONS

The lack of an assessment-only condition hinders comparison to natural trajectories of depression symptoms.

CONCLUSIONS

The overall long-term effect of ABM was limited, and currently there is no convincing evidence for implementing this as a viable treatment option in clinical populations. We speculate if the sham condition should be replaced by another control condition when investigating the clinical utility of ABM.

Mindfulness training modifies attentional bias to facial emotion and emotional symptoms

BACKGROUND

Mindfulness training has been shown to improve emotional symptoms such as anxiety and depressive symptoms. However, its cognitive-behavioral mechanism is still unclear. The present study aimed to investigate the effect of mindfulness training on attention to emotional faces and its role in the improvement in emotional symptoms.

METHODS

Eighty participants were recruited and randomly divided into a training group (n = 40) that received eight weeks of mindfulness training and a control group (n = 40) that attended a mindfulness lecture. Before training (T1), immediately after training (T2), and three months after training (T3), all participants were asked to complete the Self-Rating Depression Scale (SDS) and the Self-Rating Anxiety Scale (SAS) to assess their emotional symptoms and a modified dot-probe task to measure their attention to emotional faces.

RESULTS

Mindfulness training significantly reduced anxiety and depressive symptoms at both T2 and T3. After training, the attentional bias toward happy faces increased, while the attentional bias toward sad faces decreased in the training group compared with the control group. Mediation analysis showed that the improvement in attentional bias toward sad faces partially mediated the effect of mindfulness training on depression at T2.

LIMITATIONS

Our participants were not a clinical sample (i.e., were not diagnosed with emotional disorders), and the time course of attention components was difficult to examine in the present study.

CONCLUSIONS

Mindfulness training can stably reduce anxious and depressive symptoms. However, it may have a temporary effect on attentional bias toward facial emotions, which plays a limited role in improving emotional symptoms.

The effect of attention bias modification on depressive symptoms in a comorbid sample: a randomized controlled trial

BACKGROUND

Studies investigating the long-term effect of attention bias modification (ABM) in clinical samples are lacking. This study investigates the 6-months follow-up effect of ABM on depressive symptoms in participant with major depressive disorder with and without comorbid disorders.

METHODS

We conducted a double-blind randomized sham-controlled trial in 101 participants between 19 November 2019, and 17 August 2021. Follow-up ended 3 April 2022. Participants were allocated to ABM or sham condition twice daily for 14 consecutive days. Primary outcomes were the total score on the Beck Depression Inventory-II (BDI-II) at 6 months, mean Brief State Rumination Inventory (BSRI) score post-treatment and reduction in BSRI post-treatment. Secondary outcome was change in attentional bias (AB). The trial was preregistered in ClinicalTrials.gov (#NCT04137367).

RESULTS

A total of 118 patients aged 18-65 years were assessed for eligibility, and 101 were randomized and subjected to intention-to-treat analyses. At 6 months, ABM had no effect on depression and anxiety compared to a sham condition. While rumination decreased during the intervention, there was no effect of condition on rumination and AB. Predictor analysis did not reveal differences between participants with ongoing major depressive episode or comorbid anxiety.

CONCLUSION

Compared to sham training, there was no effect of ABM on depressive symptoms at 6-months follow-up. Since the intervention failed at modifying AB, it is unclear whether changes in AB are related to long-term outcomes.

Attention bias modification for depression: A systematic review and meta-analysis

Background

Depression is a mental health disorder characterized by affective, somatic, and cognitive symptoms. Attention bias modification (ABM) has been widely used to treat depression. However, the results seem inconsistent. We conducted a systematic review and meta-analysis to investigate the efficacy of ABM for depression and to explore the optimal protocol of ABM.

Methods

Seven databases were systematically searched from their inceptions to 5 October 2022 to include randomized controlled trials (RCTs) of ABM for depression. Two independent reviewers selected the eligible articles, extracted data, and evaluated the risk of bias using version 2 of the Cochrane risk-of-bias tool (ROB 2.0) for randomized trials. The primary outcome was the evaluation of depressive symptoms using widely accepted and validated scales. The secondary outcomes included rumination and attentional control. Meta-analysis was conducted by using RevMan (version 5.4) and Stata (version 12.0). Subgroup analyses and meta-regressions were performed to identify the source of heterogeneity. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Results

A total of 19 trials involving 20 datasets (1,262 participants) were included. The overall risk of bias in one study was rated as low risk of bias, three studies were considered as high, and the remaining studies were some concerns. Compared with attention control training (ACT), ABM had a greater effect in the improvement of depression (SMD = −0.48, 95% CI −0.80 to −0.17, I2 = 82%) and rumination (MD = −3.46, 95% CI −6.06 to −0.87, I2 = 0%). No significant differences were observed in the attentional control outcome between ABM and ACT (MD = 3.07, 95% CI −0.52 to 6.65, I2 = 0%). Subgroup analysis demonstrated that adults exhibited a greater decrease in depression scores than adolescents. ABM using the dot-probe task, training target stimulus presented by face, and training directions by left–right were associated with better antidepressant effects. ABM training delivered in the laboratory tended to yield a better effect than those conducted at home. Sensitivity analysis indicated that the results were robust. The certainty of the evidence for all outcomes was low or very low, and publication bias may exist.

Conclusion

Due to high heterogeneity and limited studies, not enough current evidence supported that ABM could be an effective intervention to relieve depressive symptoms. More rigorous RCTs are required to verify the benefits and to explore the optimal protocol of ABM training for depression.

Systematic Review Registration: [PROSPERO], identifier [No. CRD42021279163].

Attention bias modification add-on to inpatient treatment for young women with anorexia nervosa-A randomized controlled trial

Patients with anorexia nervosa (AN) display elevated anxiety and attention biases (ABs) in threat processing. Attention bias modification treatment (ABMT) is considered promising for anxiety disorders, but its potential for AN is limited. In this study, 154 young women hospitalised because of AN were assigned to ED-related and anxiety-related threat stimuli, or to a non-ABMT intervention control condition in a randomized control trial. Hundred-and-ten patients completed the study. ABMT was an add-on to the regular inpatient treatment. Research participants completed two pretreatment training sessions and eight biweekly sessions of ABMT. AB, ED-related symptoms, depression, anxiety and stress were assessed before and after ABMT in the research groups, and, similarly, 5 weeks apart, in the controls. We found that despite the different patterns of change in AB between the three groups following ABMT, the reduction in AB, or the between-group differences in AB-reduction, were not significant. While the severity of ED-symptoms, depression, anxiety and stress was reduced following ABMT, or control condition, in all groups, there were no between-group differences in these changes. Changes in AB were not correlated with baseline and pre-post-treatment changes in ED-related and comorbid symptomatology. Methodological and inpatient treatment-related considerations may explain our negative ABMT-related results.

Excitatory brain stimulation over the left dorsolateral prefrontal cortex enhances voluntary distraction in depressed patients

BACKGROUND

While implicit distraction could ameliorate negative feelings in patients with major depressive disorders (MDD), it remains unclear whether patients could benefit from explicit, voluntary distraction. Meanwhile, though the dorsolateral prefrontal cortex (DLPFC) is established as a crucial brain region involved in attentional control, the causal relationship between the DLPFC and voluntary distraction is unexplored in patients.

METHODS

Combing explicit distraction and transcranial magnetic stimulation (TMS), this study investigated whether TMS-activated DLPFC facilitates voluntary distraction in MDD patients. Eighty patients diagnosed with current MDD underwent either active (n = 40) or sham (n = 40) TMS sessions, followed by receiving negative social feedback from other patients, during which they were requied to use distraction strategy to down-regulate their painful feelings. Electroencephalogram was recorded during the task.

RESULTS

Both the subjective emotional rating and the amplitude of late positive potential showed that depressed patients successfully down-regulate their negative emotions via voluntary distraction, and the TMS-activated left DLPFC produced a larger benefit of emotion regulation compared to the sham TMS group. Results also revealed that while emotion regulation effect was negatively associated with depressive symptoms in the sham TMS group, this correlation was largely diminished when patients' left DLPFC was activated by TMS during the voluntary distraction.

CONCLUSIONS

These findings demonstrated that distraction is valuable for emotion regulation in MDD patients and they could be beneficial in voluntary distraction by activating their left DLPFC using neural modulation techniques. This study has valuable implications for clinical treatement of emotional dysregulation in MDD patients.

A review of attentional bias modification trainings for depression

Negative attentional bias is a basic character of depression. The attentional bias modification training (ABMT), being a highly promising and easy-to-use depression intervention technique, has attracted much attention to alleviate depressive symptoms in recent years. However, the effectiveness of ABMT programs was mixed across studies, since it remained unclear the underlying mechanisms of ABMT on alleviating depressive symptoms. We systematically analyzed the main ABMT paradigms to clarify possible mechanisms of effective training and reasons of ineffective training. Valid ABMT programs might alleviate depressive symptoms through regulating self-related rumination or two subcomponents of attentional bias: facilitated attention and impaired attentional disengagement. The reasons for the invalidity of ABMT mainly included the suboptimal design of training procedures, mixed effects of participants' personal characteristics, and the unclear relationship between attentional bias and depression. The ABMT is promising for alleviating depressive symptoms, but training procedures are required to be improved to obtain stable training effects.

The relationship between psychological resilience, neuroticism, attentional bias, and depressive symptoms in college Chinese students

In recent years, the incidence of depressive symptoms among Chinese college students has been increasing. Studies have shown that depressive symptoms are related to a variety of psychosocial factors, among which neuroticism, resilience, and attention bias are most notably related, but the correlation among the three is not clear. This study aimed to investigate the influence mechanisms of different degrees of resilience, attentional bias, and neuroticism in the formation of depressive symptoms. The college freshmen of this study were selected through stratified multi-stage cluster sampling. Students provided informed consent and then completed a general situation questionnaire and four scales: the Chinese version of the Connor–Davidson Resilience Scale, the Attention to Positive and Negative Information Scale, the Eysenck Personality Questionnaire, and the Zung Self-Rating Depressive Symptoms Scale. In total, 1,493 freshmen participated in the research group. Our results showed that low resilience, negative attention bias, and high neuroticism jointly increased the risk of depressive symptoms. There is a significant correlation between these three factors and depressive symptoms. Additionally, strength, tenacity, and attention bias all had more significant effects on the occurrence of depressive symptoms. These findings indicate that there may be an important psychological mechanism for the occurrence, development, and poor prognosis of depressive symptoms.

Disentangling emotional processing in dysphoria: An ERP and cardiac deceleration study

The present study aimed to investigate emotional processing in dysphoria. To this end, the amplitude of the Late Positive Potential (LPP) and cardiac deceleration were assessed during the passive viewing of affective (pleasant, neutral, and unpleasant) pictures in 26 individuals with dysphoria and in 25 non-depressed controls. The group with dysphoria revealed a smaller LPP amplitude than the group without dysphoria in response to pleasant and neutral, but not unpleasant, stimuli at centro-parieto-occipital sites. Interestingly, whereas both groups showed cardiac deceleration when viewing pleasant compared to neutral pictures (3-6 s time window), only individuals with dysphoria showed a prolonged cardiac deceleration in response to unpleasant stimuli as compared with neutral ones. This study suggests that dysphoria is characterized by reduced motivated attentional allocation to positive information and by sustained intake of unpleasant information. Overall, the present findings provide novel insights into the characterization of valence-specific attentional processes in dysphoria as potential vulnerability factors for clinically significant depression.

Promoting helpful attention and interpretation patterns to reduce anxiety and depression in young people: weaving scientific data with young peoples' lived experiences

BACKGROUND

Anxiety and depression are common, disabling and frequently start in youth, underscoring the need for effective, accessible early interventions. Empirical data and consultations with lived experience youth representatives suggest that maladaptive cognitive patterns contribute to and maintain anxiety and depression in daily life. Promoting adaptive cognitive patterns could therefore reflect "active ingredients" in the treatment and/or prevention of youth anxiety and depression. Here, we described and compared different therapeutic techniques that equipped young people with a more flexible capacity to use attention and/or promoted a tendency to positive/benign (over threatening/negative) interpretations of uncertain situations.

METHODS

We searched electronic databases (PubMed, PsycINFO, EMBASE, and PsycARTICLES) for studies containing words relating to: intervention; youth; anxiety and/or depression and attention and/or interpretation, and selected studies which sought to reduce self-reported anxiety/depression in youth by explicitly altering attention and/or interpretation patterns. Ten young people with lived experiences of anxiety and depression and from diverse backgrounds were consulted on the relevance of these strategies in managing emotions in their daily lives and also whether there were additional strategies that could be targeted to promote adaptive thinking styles.

RESULTS

Two sets of techniques, each targeting different levels of responding with different strengths and weaknesses were identified. Cognitive bias modification training (CBM) tasks were largely able to alter attention and interpretation biases but the effects of training on clinical symptoms was more mixed. In contrast, guided instructions that teach young people to regulate their attention or to evaluate alternative explanations of personally-salient events, reduced symptoms but there was little experimental data establishing the intervention mechanism. Lived experience representatives suggested that strategies such as deliberately recalling positive past experiences or positive aspects of oneself to counteract negative thinking.

DISCUSSION

CBM techniques target clear hypothesised mechanisms but require further co-design with young people to make them more engaging and augment their clinical effects. Guided instructions benefit from being embedded in clinical interventions, but lack empirical data to support their intervention mechanism, underscoring the need for more experimental work. Feedback from young people suggest that combining complimentary techniques within multi-pronged "toolboxes" to develop resilient thinking patterns in youth is empowering.

Cognitive and Neural Correlates of Loneliness and Wisdom during Emotional Bias

Loneliness and wisdom have opposing impacts on health and well-being, yet their neuro-cognitive bases have never been simultaneously investigated. In this study of 147 healthy human subjects sampled across the adult lifespan, we simultaneously studied the cognitive and neural correlates of loneliness and wisdom in the context of an emotion bias task. Aligned with the social threat framework of loneliness, we found that loneliness was associated with reduced speed of processing when angry emotional stimuli were presented to bias cognition. In contrast, we found that wisdom was associated with greater speed of processing when happy emotions biased cognition. Source models of electroencephalographic data showed that loneliness was specifically associated with enhanced angry stimulus-driven theta activity in the left transverse temporal region of interest, which is located in the area of the temporoparietal junction (TPJ), while wisdom was specifically related to increased TPJ theta activity during happy stimulus processing. Additionally, enhanced attentiveness to threatening stimuli for lonelier individuals was observed as greater beta activity in left superior parietal cortex, while wisdom significantly related to enhanced happy stimulus-evoked alpha activity in the left insula. Our results demonstrate emotion-context driven modulations in cognitive neural circuits by loneliness versus wisdom.

A Cross-sectional Study of Attention Bias for Facial Expression Stimulation in Patients with Stroke at the Convalescence Stage

BACKGROUND

Post-stroke depression increases the likelihood of adverse physical symptoms. Attentional bias (AB) for negative stimuli is important in depression onset, maintenance, and remission. Stroke is more likely in older adults, who can have reduced cognitive function. Individuals with mild cognitive impairment (MCI) can have delayed reaction times (RTs). We hypothesized that RT to select neutral facial expression is affected by depressive symptoms and cognitive function in patients with stroke.

METHODS

This study analyzed 61 patients with stroke. Beck Depression Inventory-Second Edition (BDI-II) and Profile of Mood States (short version) scores were determined. Task stimuli comprised eight pairs of facial expressions containing affective (angry) and neutral faces. AB was measured as the RT to select the neutral face in two simultaneously presented images using attention bias modification (ABM) software. Patients were grouped according to depressive symptoms using BDI-II scores. Between-subject factors of depressive symptoms and cognitive function were determined by ANCOVA.

RESULTS

No significant interaction was found between depressive symptoms and cognitive function on RT. There was a main effect of cognitive function, but not depressive symptoms. In patients with hemiparesis and depressive symptoms, RT was significantly shorter in patients without MCI compared with patients with MCI.

CONCLUSIONS

People with stroke and elevated depression symptoms with hemiparesis but without MCI quickly selected neutral facial expressions from neutral and aversive expressions, and thus do not need ABM to escape aversive stimuli. ABM in response to aversive stimuli may be useful in evaluating negative emotions in individuals with post-stroke depression without MCI.

Attention and affect in dysphoria: Insights from startle reflex modulation and cardiac deceleration

The present study investigated the interplay between attention and affective disposition during emotional processing in dysphoria. Attentional and affective startle modulation and cardiac deceleration were assessed during the viewing of emotional pictures in 38 individuals with dysphoria and in 52 controls. Startle probes during picture viewing were presented at 300, 1500, 3500, 4500 ms after picture onset. Whereas controls showed the expected startle potentiation to unpleasant stimuli as compared to neutral and pleasant ones, individuals with dysphoria did not show any significant increase in startle reflex amplitude in response to unpleasant stimuli. Of note, startle potentiation during the viewing of unpleasant stimuli was significantly attenuated in the group with dysphoria relative to controls. Conversely, no significant effect concerning attentional startle modulation was noted. However, whereas individuals with dysphoria showed a prolonged cardiac deceleration when viewing unpleasant compared to neutral stimuli, the same effect was observed in controls only in the initial stage of stimuli processing. This study suggests that dysphoria is characterized by underactivation of the defensive motivational system and by prolonged attentional allocation to unpleasant stimuli. The assessment of affective startle modulation and cardiac deceleration is a valuable paradigm for unraveling dysfunctions in affective disposition and attention in dysphoria.