A Preliminary Investigation of the Time Course of Attention Bias Variability in Posttraumatic Stress Disorder: The Moderating Role of Attentional Control

The effect of feedback in attention training on Attention Bias to Threat in individuals with Sluggish Cognitive Tempo

BACKGROUND AND OBJECTIVES

This study was conducted to identify the characteristics of attentional bias of individuals with Sluggish Cognitive Tempo (SCT) and how Attention Bias to Threat (ABT) changes when feedback was provided in attention training.

METHODS

First, a dot probe task was conducted to confirm the ABT of the SCT feedback group (N = 27) and SCT no feedback group (N = 25), and healthy control group (N = 30) before intervention. Thereafter, a VR-based attention training was conducted three times with feedback or no feedback. Finally, a dot probe task was executed again.

RESULTS

The SCT groups showed a higher ABT than the healthy control group. A result of the attention training, the reaction time of disengage was significantly reduced when provided feedback. In addition, it was confirmed that the ABT of the SCT group that received feedback, was significantly reduced.

LIMITATIONS

First, the only stimulus used to examine the ABT was the angry face, and the reaction time to other threatening facial expressions was not confirmed. Second, attention training was conducted three times, but further studies are needed on the effect of the duration of training on the magnitude of effect.

CONCLUSIONS

This study identified ABT associated with internalizing symptoms of SCT and suggests that attention training with immediate and continuous feedback is needed to reduce ABT.

Attentional bias modification and attention control training in PTSD: a systematic review and meta-analysis

Background

Cognitive models of post-traumatic stress disorder (PTSD) highlighted the effect of maladaptive cognitive processing in the development and maintenance of PTSD. PTSD is related to attentional bias (AB) toward threatening stimuli and greater attentional bias variability (ABV). Attentional bias modification (ABM) and attention control training (ACT) have demonstrated the effect of improving PTSD, but the results of randomized controlled trials (RCTs) are controversial.

Objectives

The current study aimed to evaluate the extent of evidence supporting the efficacy of ABM in the treatment of PTSD.

Design

Systematic review and meta-analysis.

Methods

We searched PUBMED, PsycINFO, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for articles published between 1980 and 2022. RCTs of ABM for adult participants with PTSD symptoms were identified. The primary outcome was changes in PTSD severity, and the second outcome was changes in AB and ABV. Trial quality was assessed using the Cochrane Risk of Bias Tool. Publication bias was assessed using the Doi plot and Luis Furuya-Kanamori (LFK) index.

Results

Eight RCTs comparing the effect of ABM to ACT were included in the review, and six studies were meta-analyzed. Meta-analysis favored ACT in improving PTSD symptoms and ABV, and the effect size was large. ABM and ACT demonstrated similar effects in improving AB.

Conclusion

ACT should not only be seen as a control training condition but also has therapeutic values. However, since the current meta-analysis only included a limited number of studies, further research was still needed to examine the clinical value of ACT in PTSD treatment.

Attentional Bias Toward Cigarette-Related Cues in Male Smokers is Modulated by Cognitive Control Mechanisms

Background: Many studies have found that smokers' attentional bias toward cigarette-related cues and cognitive control impairment significantly impacts their cigarette use. However, there is limited research on how the interaction between attentional bias and cognitive control may modulate smokers' cigarette-seeking behavior. Objectives: This study used a cigarette Stroop task to examine whether smokers with different attentional control ability had different levels of attentional bias toward cigarette-related cues. Methods: A total of 130 male smokers completed the Flanker task to measure their attentional control ability. The attentional control scores of all participants were ranked from low to high, with the top 27% placed in the high attentional control group and the bottom 27% in the low attentional control group. Subsequently, both groups completed the cigarette Stroop task to measure their attentional bias toward cigarette-related cues. Results: Smokers with low attentional control responded more slowly to cigarette-related cues than to neutral cues, while smokers with high attentional control showed no significant difference in their response time to either condition. Conclusions/Importance: Attentional control ability can regulate smokers' attentional bias toward cigarette-related cues. Smokers with low attentional control ability are more likely to have attentional bias toward cigarette-related cues, offering insights for targeted prevention of cigarette addiction.

Nightmares, interoceptive sensibility and nociception: An exploratory study in a general population

OBJECTIVE

Nightmares are dysphoric dreams present in both clinical and non-clinical populations. Physiological activity underlies their emotional reactivity. Therefore, the objective of this study was to investigate the role of interoceptive processes (interoceptive sensibility and nociception) in nightmares in the general population.

METHOD

542 French participants were recruited from the general population to complete an online survey. Interoceptive sensibility, nociception, nightmare frequency and nightmare distress were assessed through online scales and questionnaires. Network analysis, regression and mediation analyses were conducted to assess the relationship between these variables.

RESULTS

The results showed the existence of associations between certain dimensions of interoceptive sensibility, nociception, nightmare frequency and nightmare distress. The regression analysis highlighted the involvement of interoceptive dimensions in predicting the nightmare distress score. Mediation analysis highlighted that nociception was a mediating variable in the relationship between nightmare frequency and nightmare distress.

CONCLUSION

This study provides initial evidence in favour of the involvement of interoceptive processes in the understanding of nightmares. These results offer a new window of understanding the etiology of nightmares but also present the interest to target interoceptive processes in the management of nightmares.

Variability in caregiver attention bias to threat: A Goldilocks effect in infant emotional development?

Attention biases to threat are considered part of the etiology of anxiety disorders. Attention bias variability (ABV) quantifies intraindividual fluctuations in attention biases and may better capture the relation between attention biases and psychopathology risk versus mean levels of attention bias. ABV to threat has been associated with attentional control and emotion regulation, which may impact how caregivers interact with their child. In a relatively diverse sample of infants (50% White, 50.7% female), we asked how caregiver ABV to threat related to trajectories of infant negative affect across the first 2 years of life. Families were part of a multi-site longitudinal study, and data were collected from 4 to 24 months of age. Multilevel modeling examined the effect of average caregiver attention biases on changes in negative affect. We found a significant interaction between infant age and caregiver ABV to threat. Probing this interaction revealed that infants of caregivers with high ABV showed decreases in negative affect over time, while infants of caregivers with low-to-average ABV showed potentiated increases in negative affect. We discuss how both high and extreme patterns of ABV may relate to deviations in developmental trajectories.

A randomized controlled trial of supervised remotely-delivered attention bias modification for posttraumatic stress disorder

BACKGROUND

Many individuals with posttraumatic stress disorder (PTSD) have limited access to first-line treatments, warranting the development of remotely-delivered treatments. Attention bias modification (ABM), targeting perturbed threat-related attentional patterns, shows promise when delivered in-person. However, previous studies found ABM to be ineffective when delivered remotely. Randomized clinical trials usually applied two variations of ABM: ABM away from threat or attention control training (ACT) balancing attention between threat-related and neutral stimuli. We tested remotely-delivered ACT/ABM with tighter supervision and video-based interactions that resemble in-clinic protocols. We expected to replicate the results of in-clinic trials, in which ACT outperformed ABM for PTSD.

METHODS

In this double-blinded, parallel-group randomized controlled trial, 60 patients diagnosed with PTSD were randomized (ABM n = 30; ACT n = 30). Patients performed eight bi-weekly remotely-delivered supervised ABM/ACT sessions. Symptoms were assessed pre- and post-treatment with Clinician-Administered PTSD Scale 5 (CAPS-5) severity score and PTSD diagnosis as the primary outcomes. Current depressive episode, current anxiety-related comorbidity, and time elapsed since the trauma were examined as potential moderators of treatment outcome.

RESULTS

Significant decrease in CAPS-5 severity scores and PTSD diagnosis was observed following both ACT and ABM with no between-group difference. Patients without depression or whose trauma occurred more recently had greater symptom reduction in the ACT than the ABM group.

CONCLUSIONS

Contrary to our expectation, symptoms decreased similarly following ACT and ABM. Moderator analyses suggest advantage for ACT in non-depressed patients and patients whose trauma occurred more recently. Further refinements in remotely-delivered ABM/ACT may be needed.

Eye-tracking indices of attention allocation and attention bias variability are differently related to trauma exposure and PTSD

Amplified attention allocation to negative information in one's environment has been implicated in posttraumatic stress disorder (PTSD). Attention bias variability (ABV), the magnitude of attention fluctuation between negative and neutral cues, has also been found to be elevated in PTSD. While eye-tracking methodology has been used in research on attention allocation in PTSD, ABV was only explored using manual reaction-time-based indices. Thirty-seven participants with PTSD, 34 trauma-exposed healthy controls (TEHC), and 30 non-exposed healthy controls (HC) completed an eye-tracking free-viewing task in which matrices comprised of neutral and negatively-valenced faces were presented. Threat-related attention allocation was calculated as the proportion of dwell time (DT%) on negatively-valenced faces. Eye-tracking-based ABV was calculated as the standard deviation of DT% across matrices. DT% on negatively-valenced faces was greater in participants with PTSD compared to both TEHC (p = .036, d = 0.50) and HC (p < .001, d = 1.03), with TEHCs showing a greater attentional bias compared to HCs (p = .001, d = 0.84). Controlling for average fixation duration, ABV was higher in both the PTSD and TEHC groups relative to the HC group (p = .004, d = 0.40), with no difference between the two trauma-exposed groups. Biased attention allocation toward negative social information is related to PTSD pathology, whereas elevated ABV measured with eye-tracking appear to be related to trauma-exposure per-se.

Investigating the specific domains of the cognitive attentional syndrome that predict posttraumatic stress symptoms: The moderating effect of attentional control

The metacognitive model of posttraumatic stress disorder (PTSD) suggests that persistent use of the maladaptive self-regulation strategies that comprise the cognitive attentional syndrome (CAS) increases the likelihood of developing PTSD symptoms following trauma exposure. The metacognitive model also suggests that flexible regulation of attention might be protective against developing maladaptive outcomes that are associated with the CAS. The aims of this study were to (1) examine associations between all seven domains of the CAS and PTSD symptoms using a recently developed, multidimensional measure of the CAS, and (2) examine the moderating effect of self-reported attentional control on associations between the CAS and PTSD symptoms. Participants were trauma-exposed community adults (N = 237) who completed a battery of self-report measures. Results from linear regression analyses showed that worry, substance use, and internal threat monitoring accounted for unique variance in PTSD symptoms when all seven CAS domains were entered into the same model. Moderation analyses showed that attentional control dampened the effect of the CAS, specifically external threat monitoring, on PTSD symptoms. Study results support attentional control as a protective factor against the maladaptive effects of the CAS on PTSD symptoms.

Is attentional bias variability causally implicated in emotional vulnerability? A systematic review and meta-analysis

BACKGROUND

The aim of the present review was to determine whether attentional bias variability (ABV) is causally implicated in emotional vulnerability. We consider evidence examining whether ABV precedes and predicts later psychopathology, and whether modifying ABV leads to changes in psychological symptoms following an intervention.

METHODS

A systematic literature search located 15 studies that met the inclusion criteria (3 longitudinal, 12 intervention). Eligible intervention studies were also meta-analysed.

RESULTS

Preliminary evidence suggests that ABV predicts later post-traumatic stress symptomatology in interaction with number of traumatic events. The few interventions designed to reduce ABV suggest promise for improving PTSD symptoms. However, these interventions did not consistently change ABV, and where it was tested, change in ABV did not correspond to change in symptoms.

CONCLUSIONS

There is emerging evidence that ABV could represent a vulnerability factor for psychological symptoms, particularly for those exposed to trauma. This may indicate attentional control difficulties, although this remains to be tested. Conclusions regarding the causal status of ABV will depend on future high-quality randomised controlled trials.

Attentional bias variability and its association with psychological and health symptoms: A meta-analysis

The present meta-analysis sought to assess the association between an emerging neurocognitive marker of psychopathology in attentional bias variability (ABV) and key psychological and health outcomes. A comprehensive literature review yielded 53 studies in 43 manuscripts (N = 5428). Overall, clinical and sub-clinical samples exhibited greater ABV than control samples (g = 0.462). Trauma samples showed significantly greater ABV than control samples (g = 0.782, medium-large effect), whereas social anxiety samples did not (g = 0.147). Similarly, ABV was associated with degree of trauma symptoms (r = 0.21 - 0.25). ABV was associated with some symptoms of depression and anxiety, although these were small and inconsistent. These findings suggest a specific relationship between ABV and post-traumatic stress symptoms, with evidence equivocal for other psychological difficulties (although also less research). Key recommendations for future research include investigating mechanisms underlying ABV and the importance of controlling for non-attentional processes, such as reaction time variability, to ensure the validity of ABV measures.

Attentional bias in German Armed Forces veterans with and without posttraumatic stress symptoms - An eye-tracking investigation and group comparison

BACKGROUND AND OBJECTIVES

Most eye tracking based paradigms evidence patterns of sustained attention on threat coupled with low evidence for vigilance to or avoidance of threat in posttraumatic stress symptoms (PTSS). Still, eye tracking data on attention bias is particularly limited for military population. This eye tracking study investigated attentional bias in PTSS in a sample of German Armed Forces veterans.

METHODS

Veterans with deployment-related PTSS (N = 24), veterans with deployment-related traumatization without PTSS (N = 28), and never-deployed healthy veterans (N = 18) were presented with pairs of combat and neutral pictures, pairs of general threat and neutral pictures, and pairs of emotional and neutral faces. Their eye gazes were tracked during a free viewing task. 3 x 3 x 2 mixed general linear model analyses were conducted. Internal consistency of attention bias indicators was calculated for the entire sample and within groups.

RESULTS

Veterans with PTSS dwelled longer on general threat AOIs in contrast to non-exposed controls and shorter on general threat and combat associated neutral AOIs in contrast to both control groups. Veterans with PTSS entered faster to general threat AOIs than non-exposed controls. Veterans with PTSS showed circumscribed higher attention fluctuation in contrast to controls. Internal consistency varied across attention bias indicators.

LIMITATIONS

Statistical power was reduced due to recruitment difficulties.

CONCLUSIONS

Evidence is provided for the maintenance hypothesis in PTSS. No robust evidence is provided for hypervigilant behavior in PTSS. Findings on attention bias variability remain unclear, calling for more investigations in this field.

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.

Executive functioning deficits exacerbate posttraumatic stress symptoms: A longitudinal mediation model

Executive functioning (EF) consists of a set of related, but distinct, higher-level cognitive abilities that are used to organize and integrate lower-level processes in the service of engaging in goal-direct behavior. Evidence suggests that deficits in EF are a vulnerability factor for the development of posttraumatic stress (PTS) symptoms. Less understood, however, is the role that EF plays in symptom maintenance and exacerbation following trauma exposure. As such, the primary purpose of the present study was to determine whether EF deficits exacerbate PTS symptoms over the course of one year. A secondary aim of this study was to use a cross-lagged design to determine the directional relations among EF deficits and PTS. Trauma-exposed adults (N = 98) completed a clinical interview and self-report measures at an initial assessment session (Time 1 [T1]). Participants also completed self-report measures at 6- (Time 2 [T2]; n = 92) and 12-month (Time 3 [T3]; n = 91) follow-up sessions. As predicted, EF deficits at T2 mediated the relationship between PTS symptoms from T1 to T3, thus suggesting that EF deficits exacerbate PTS symptoms following trauma exposure. Results from a cross-lagged path analysis from T2 to T3 suggest that deficits in EF exert a stronger influence on the maintenance of PTS symptoms than vice versa. These results have implications for (a) identifying individuals that are at elevated risk for developing PTS symptoms, (b) developing precision medicine-based approaches for alleviating PTS symptoms, and (c) improving well-established PTSD treatments for those with relative deficits in EF.

Attentional Bias Toward Threat in Sexually Victimized Hispanic Women: A Dot Probe Study

The current study examined attentional bias toward threat in Hispanic college women exposed to lifetime sexual victimization in childhood, adulthood, and both childhood and adulthood. Response latencies and attention bias scores were compared between victimized and non-victimized individuals. Participants were 20 women exposed to adulthood sexual victimization (AS group), 15 exposed to childhood sexual victimization (CS group), 8 exposed to both childhood and adulthood sexual assault (revictimization: RV group), and 20 not endorsing sexual victimization (NS group). They were asked to complete the dot-probe task. The CS group and RV group were combined to create the CS-RV group. Among the AS and CS-RV groups, response latencies were faster when attention was engaged to threat than when attention was engaged to non-threat. The NS group did not demonstrate such differences. When response latencies were compared among the three groups, the CS-RV group had slower response latencies than the NS group. The CS-RV and AS groups revealed similarly significantly elevated bias scores toward threat words than the NS group. Hispanic college women exposed to lifetime sexual victimization display elevated levels of attention bias compared to non-victimized women. Further, the current findings align with an integrative cognitive model for explaining maladaptive informational processing in trauma victims.

The use of trial-level bias scores to examine attention bias and attention bias variability among people with and without social anxiety disorder

BACKGROUND

Cognitive models of anxiety propose that people with anxiety disorders show elevated levels of attention bias toward threat, but the most commonly used index of attention bias, which measures the construct with an aggregate score of multiple trials across an experimental session, shows poor test-retest reliability. Newer indices that measure attention bias dynamically on a trial-to-trial basis show good reliability and enable researchers to measure not only overall attention bias toward threat, but also attention bias variability.

METHODS

The current study tested the hypothesis that people diagnosed with social anxiety disorder would show higher attention bias variability and higher attention bias toward threat when calculated dynamically and when calculated using the traditional aggregate index. Participants diagnosed with social anxiety disorder (n = 47) and controls (n = 57) completed a 160-trial version of the dot-probe task using emotional and neutral images of faces as stimuli.

RESULTS

Relative to controls, participants diagnosed with social anxiety disorder showed higher mean bias toward threat, but only when calculated using trial-level bias scores. There were no differences between groups on attention bias variability.

DISCUSSION

This is the first study to examine differences in attention bias and attention bias variability between people with and without social anxiety disorder using trial-level bias scores. Results suggest that attention bias, but not attention bias variability, is a feature of social anxiety psychopathology and that trial-level bias scores may be more sensitive than aggregated mean scores to detect it. These findings have implications for clinical interventions such as attention bias modification programs, which require precise measures of attention bias to accurately assess treatment outcomes.

Increasing cognitive load attenuates the moderating effect of attentional inhibition on the relationship between posttraumatic stress symptoms and threat-related attention bias variability

Theory and empirical evidence suggest that those with higher posttraumatic stress (PTS) symptoms and better attentional control (i.e., the strategic control of higher-order executive attention in regulating bottom-up, stimulus driven responses to prepotent stimuli; Sarapas et al., 2017) can use that ability to disengage and shift attention away from threat stimuli and reduce threat-related attentional dysregulation (i.e., avoidance/overcontrollers). Those with relatively worse attentional control lack the requisite resources to do this, leading to prolonged attentional engagement with threat stimuli and threat-related attention dysregulation (i.e., maintenance/undercontrollers). Given that attentional control is a limited resource, strategic avoidance of threat information or reduced threat-related attention dysregulation may not be possible among those with relatively higher attentional control when cognitive load is relatively high. To test this hypothesis, the interaction between PTS symptoms, attentional control, and cognitive load was examined as a predictor of threat-related attentional bias and threat-related attention bias variability. Participants (N = 125 undergraduate students) were randomly assigned to high or low load conditions. Participants completed self-report measures of PTS symptoms, a behavioral measure of attentional control, and a novel task that assessed threat-related attentional bias via eye movements and threat-related attention bias variability via button press. The results of a series of hierarchical regressions showed that attentional control moderated the relationship between PTS symptoms and threat-related attention bias variability in the low, but not high, load condition. This moderation effect was not observed for threat-related attentional bias assessed via eye-tracking. Consistent with theory, under conditions of higher cognitive load, overcontrollers may not be able to use attentional control to consistently regulate threat-related attention. Study findings suggest that it may be important to consider contextual factors that increase cognitive load, as well as individual differences in attentional control, when developing attention bias modification interventions to reduce PTS symptomatology.

Early childhood experiences and cognitive risk factors for anxiety symptoms among college students

Data indicate that adverse childhood experiences (ACEs) are a risk factor for cognitive and attentional vulnerabilities. A vulnerability linked to these impairments is repetitive negative thinking (RNT), and data suggest that RNT and anxiety symptoms may be moderated by attentional control. The current study investigated the effect of these risk factors on symptoms of anxiety. Participants: College students (N = 376) were recruited from a university. Methods: Participants were administered questionnaires online to assess retrospective ACEs, current RNT, attentional control, and anxiety symptoms. Results: There was an indirect effect of ACEs on anxiety symptoms through RNT. High attentional control moderated the indirect effects, such that high compared to low attentional control was associated with an increased effect of RNT on anxiety symptoms. Conclusions: Increased ACEs may be a risk factor for RNT among college students. Combined with high attentional control, these may be risk factors for anxiety symptoms.

Attentional processes and contamination-related intrusion distress

Whilst people with high contamination fear may not experience a greater number of contamination-related intrusions than people with low contamination fear, they tend to experience heightened distress in response to such intrusions. The aim of the present study was to test the hypothesis that attentional bias to contamination-relevant information, and the variability of this attentional bias, moderates the degree to which high contamination fearful but not low contamination fearful individuals experience distress in response to contamination-related intrusions. Individuals with high (n = 31) or low (n = 44) contamination fear completed a lab-based session including questionnaires, a dot-probe measure of contamination-related attentional bias and attentional bias variability, and a contamination stressor video. Participants then completed a week-long contamination intrusions diary. There were significant differences in intrusion distress between those with low and high contamination fear in the anticipated direction, and attentional bias significantly moderated this relationship. Regardless of contamination fear level, greater attentional bias variability was associated with greater intrusion distress. These findings suggest that reducing attentional bias variability could potentially help to reduce distress elicited by contamination-related intrusions, while also highlighting the fact that attentional bias towards threat may protect against such distress in low contamination fearful individuals.

Attention allocation in posttraumatic stress disorder: an eye-tracking study

BACKGROUND

Eye-tracking-based attentional research implicates sustained attention to threat in posttraumatic stress disorder (PTSD). However, most of this research employed small stimuli set-sizes, small samples that did not include both trauma-exposed healthy participants and non-trauma-exposed participants, and generally failed to report the reliability of used tasks and attention indices. Here, using an established eye-tracking paradigm, we explore attention processes to different negatively-valenced cues in PTSD while addressing these limitations.

METHODS

PTSD patients (n = 37), trauma-exposed healthy controls (TEHC; n = 34), and healthy controls (HC; n = 30) freely viewed three blocks of 30 different matrices of faces, each presented for 6 s. Each block consisted of matrices depicting eight negatively-valenced faces (anger, fear, or sadness) and eight neutral faces. Gaze patterns on negative and neural areas of interest were compared. Internal consistency and test-retest reliability were evaluated for the entire sample and within groups.

RESULTS

The two trauma-exposed groups dwelled longer on negatively-valenced faces over neutral faces, while HC participants showed the opposite pattern. This attentional bias was more prominent in the PTSD than the TEHC group. Similar results emerged for first-fixation dwell time, but with no differences between the two trauma-exposed groups. No group differences emerged for first-fixation latency or location. Internal consistency and 1-week test-retest reliability were adequate, across and within groups.

CONCLUSIONS

Sustained attention on negatively-valenced stimuli emerges as a potential target for therapeutic intervention in PTSD designed to divert attention away from negatively-valenced stimuli and toward neutral ones.

The effects of left DLPFC tDCS on emotion regulation, biased attention, and emotional reactivity to negative content

The potentiation of neural activity in lateral prefrontal regions via transcranial direct current stimulation (tDCS) can reduce patterns of biased attention for threat and may facilitate intentional emotion regulation. The current study sought to determine whether left dorsolateral prefrontal cortex tDCS, in combination with intentional down-regulation of emotional responses would reduce negative appraisals of aversive content during emotional regulation (assessed during online tDCS), reduce patterns of biased attention and attention bias variability (assessed offline), and attenuate spontaneous (uninstructed) emotional reactivity to negative content (assessed offline) above tDCS or intentional down-regulation of emotions in isolation. Healthy participants (n = 116) were allocated to one of four experimental conditions involving either active or sham tDCS, combined with an either a down-regulate or maintain emotion regulation task. Attention bias/bias variability was assessed with an attentional probe task, and emotional reactivity was assessed in a negative video viewing task. tDCS did not affect the appraisals of negative stimuli during emotion regulation, and there were no effects on attention bias/bias variability. However, tDCS did attenuate emotional reactivity. Those receiving active stimulation showed smaller elevations in negative mood in response to viewing aversive video content compared with sham. The present findings are consistent with the potential of left frontal tDCS to attenuate negative emotional reactions to aversive content but provide no support for tDCS enhancement of emotion regulation, nor its impact on attention bias or attention bias variability.

What is attention bias variability? Examining the potential roles of attention control and response time variability in its relationship with anxiety

The present study examined the underlying role of attention control and response time variability in explaining the relationship between anxiety and two commonly computed measures of attention bias variability: 'moving average' and 'trial-level bias score' measures. Participants (final n = 195) completed measures of anxiety symptomatology, antisaccade performance (attention control), a stand-alone measure of response-time variability, and a probe task measure of attention bias. Average bias and moving average bias variability measures both recorded significant, but low split-half reliability. Both attention bias variability measures and average attention bias were associated with anxiety, and attention control. Both attention bias variability measures correlated with response time variability. Neither attention bias variability measure correlated with average attention bias. Attention control was the single significant mediator of the relationship between anxiety and the trial-level bias score measure of attention bias variability. Neither response time variability nor attention control significantly mediated the relationship between anxiety and the moving average measure of attention bias variability. No evidence was found for the mediating role of response time variability. The present findings suggest that the relationships observed between anxiety and the trial-level bias score measure of attention bias variability in particular may be attributable to the over-arching role of attention control.

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.

Individual differences in attentional control explain the differential expression of threat-related attentional bias among those with posttraumatic stress symptomatology and predict symptom maintenance up to one year later

Individual differences in attentional control may explain null findings and inconsistent patterns of threat-related attentional bias (ABT) that are common in the posttraumatic stress disorder (PTSD) literature. At Time 1 (T1), trauma-exposed community participants (N = 89) completed a clinical interview, self-report measures, and an eye-tracking task developed to assess ABT. Participants completed follow-up assessments online 6 (T2) and 12 (T3) months later. Those with higher PTSD symptoms and deficits in attentional control exhibited a pattern of undercontrol, characterized by attention maintenance on threat and increased arousal. In contrast, those with higher PTSD symptoms and relatively better attentional control exhibited a pattern of overcontrol, characterized by threat avoidance and reduced arousal. These effects were specific to threat stimuli. Among PTSD symptom clusters, symptoms of hyperarousal were of central importance to the observed effects. Results from the longitudinal analysis indicate that both of these patterns of ABT are maladaptive, resulting in symptom maintenance at T2 and T3. These results have implications for (a) reconciling tensions between disparate models of ABT (i.e., vigilance-avoidance vs. attention maintenance), (b) precision medicine based approaches to targeting PTSD-related ABT, and (c) understanding the transdiagnostic role that attentional control may play in influencing ABT expression.

The buffering effect of attentional control on the relationship between cognitive fusion and anxiety

Cognitive fusion has been identified as a risk factor for anxiety. Evidence suggests that those with better attentional control may be able to flexibly shift attention from an internal to external focus, thus reducing contact with negative self-referent thoughts. As such, attentional control was examined as a moderator of the relation between cognitive fusion and anxiety in this two-part study. Adult participants (N = 597) completed self-report measures in Study 1. In Study 2, adult student participants (N = 173) completed self-report measures of cognitive fusion and anxiety, as well as behavioral measures that assessed three specific attentional control processes (i.e., inhibition, shifting, working memory updating). As predicted, attentional control moderated the relation between cognitive fusion and anxiety such that the strength of the relation decreased as attentional control increased. The results of Study 2 suggest that inhibitory ability is the attentional control process that accounts for this effect. Taken together, results suggest the possibility that attentional control (especially inhibitory ability) may be a protective factor against the development of anxiety among those with higher levels of cognitive fusion. The use of experimental and longitudinal study designs will be an important next step in this line of research to further clarify the nature of relations among cognitive fusion, attentional control, and anxiety. Results from an exploratory analysis, in which depressive symptoms served as the outcome variable, will also be discussed.

Attention bias variability and posttraumatic stress symptoms: the mediating role of emotion regulation difficulties

Growing literature has linked attention bias variability (ABV) to the experience and treatment of posttraumatic stress disorder (PTSD). Unlike assessments of attention bias in only one direction, ABV captures dynamic fluctuations in attention toward and away from threat. While mechanisms underlying the ABV-PTSD relations are unclear, some research implicates emotion regulation difficulties. The current study examined in community women with varying PTSD symptom severity, the amount of variance in the association between ABV and PTSD accounted for by emotion regulation difficulties. The full sample (N = 74) was comprised of 59% community women with PTSD due to domestic and/or sexual violence, and 41% community women without PTSD. All participants completed self-report questionnaires including the Difficulties in Emotion Regulation Scale-16, which assessed emotion regulation. ABV was calculated following a computerised dot probe task. The indirect effect of ABV on PTSD symptom severity through emotion regulation difficulties was statistically significant, while the direct effect between ABV and PTSD symptom severity was not significant. Findings replicated after controlling for total trauma exposure. Clinical implications and literature suggesting how ABV may perpetuate emotion regulation difficulties associated with PTSD symptomology are discussed.

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.

Validity of Attention Bias Variability Indices for Posttraumatic Stress Disorder Research: Evidence From Patient Data

Although initial findings indicated that threat-related attention bias variability (ABV), an index designed to capture dynamic shifts in threat-related attention over time, was positively correlated with the severity of posttraumatic stress disorder (PTSD) symptoms, a recent study relying on simulated data has raised questions regarding the validity and empirical utility of ABV. Specifically, the simulations suggested that core features of reaction time data distinct from threat-related attention bias, such as the reaction time standard deviation and mean, could explicate the reported elevated ABV among samples with PTSD. In the present study, we evaluated these suggestions in 95 PTSD-diagnosed participants. The results showed that ABV significantly and uniquely predicted PTSD symptom severity beyond the predictive value of core reaction time features, ΔR² = .05-.23. Some of the predictions stemming from the simulated results were replicated, whereas others were not. Contrary to the conclusion drawn from the simulated data, the results from the current study suggest that ABV is a valid and replicable correlate of PTSD symptom severity.

Attention to threat in posttraumatic stress disorder as indexed by eye-tracking indices: a systematic review

BACKGROUND

Cognitive models of posttraumatic stress disorder (PTSD) implicate threat-related attentional biases in the etiology and phenomenology of the disorder. However, extant attentional research using reaction time (RT)-based paradigms and measures has yielded mixed results. Eye-tracking methodology has emerged in recent years to overcome several inherent drawbacks of RT-based tasks, striving to better delineate attentional processes.

METHODS

A systematic review of experimental studies examining threat-related attention biases in PTSD, using eye-tracking methodology and group-comparison designs, was conducted conforming to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were selected following a systematic search for publications between 1980 and December 2017 in PsycINFO, MEDLINE and the National Center for PTSD Research's Published International Literature on Traumatic Stress (PILOTS) database. Additional records were identified by employing the Similar Articles feature in PubMed, and the Cited Reference Search in ISI Web of Science. Reference sections of review articles, book chapters and studies selected for inclusion were searched for further studies. Ongoing studies were also sought through Clinicaltrials.gov.

RESULTS

A total of 11 studies (n = 456 participants in total) were included in the final review. Results indicated little support for enhanced threat detection, hypervigilance and attentional avoidance. However, consistent evidence emerged for sustained attention on threat (i.e. attention maintenance) in PTSD.

CONCLUSIONS

This review is the first to systematically evaluate extant findings in PTSD emanating from eye-tracking studies employing group-comparison designs. Results suggest that sustained attention on threat might serve as a potential target for therapeutic intervention.

Neurocognitive and Information Processing Biases in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

We review recent research addressing neurocognitive and information processing abnormalities in posttraumatic stress disorder (PTSD), including studies informing direction of causality. We additionally consider neurocognition in the context of co-morbid mild traumatic brain injury (TBI) and psychosocial treatments for PTSD.

RECENT FINDINGS

Learning, memory, attention, inhibitory functions, and information processing biases frequently accompany PTSD, reflecting potential bi-directional relationships with PTSD. Although mild TBI is associated with increased risk of PTSD development and maintenance, TBI does not typically contribute significantly to sustained neurocognitive deficits in individuals with PTSD. Whereas better learning and memory is associated with mildly enhanced response to psychosocial interventions, such interventions may also improve neurocognitive performance and can be effectively provided to patients with TBI history. PTSD is associated with cognitive abnormalities in processing both emotionally relevant and emotionally neutral information and, although mild, may underlie some PTSD symptom expression.

Temporal dynamics of anxiety-related attentional bias: is affective context a missing piece of the puzzle?

Previous research has demonstrated that anxious individuals attend to negative emotional information at the expense of other information. This is commonly referred to as attentional bias. The field has historically conceived of this process as relatively static; however, research by [Zvielli, A., Bernstein, A., & Koster, E. H. W. (2014). Dynamics of attentional bias to threat in anxious adults: Bias towards and/or away? PLoS ONE, 9(8), e104025; Zvielli, A., Bernstein, A., & Koster, E. H. W. (2015). Temporal dynamics of attentional bias. Clinical Psychological Science, 3(5), 772-788.], and others, challenges this assumption by demonstrating considerable temporal variability in attentional bias amongst anxious individuals. Still, the mechanisms driving these temporal dynamics are less well known. Using a modified dot-probe task, the present study examined the impact of two relevant contextual variables- affective valence and trial repetition. Affective context was instantiated by the presentation of negative versus neutral pictures before each trial, while repetition context was achieved via the presentation of the valenced pictures in either a blocked- or mixed-trial design. Results indicate that individuals with higher trait-anxiety levels were significantly more influenced by blocked presentations of negative affective information, leading to greater temporal fluctuations in attentional bias. Furthermore, our findings provide additional evidence that attentional bias is best conceptualised as dynamic and variable, and that an individual's affective experience is one factor that regulates attentional bias dynamics. Implications relating to theoretical and methodological factors are discussed.