Examination Stress Results in Attentional Bias and Altered Neural Reactivity in Test-Anxious Individuals

Anodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex improves attentional control in chronically stressed adults

Introduction

Chronic stress is a long-term condition that negatively affects cognitive ability and mental health. Individuals who experience chronic stress show poor attentional control. Transcranial direct current stimulation (tDCS) to the dorsolateral prefrontal cortex (DLPFC) modulates executive function domains. Therefore, it is beneficial to investigate whether tDCS of the DLPFC could improve attentional control and relieve stress in chronically stressed individuals.

Methods

We assess the event-related potentials (ERPs) associated with attentional control in individuals with chronic stress after the tDCS intervention. Forty individuals were randomly assigned to either the anodal tDCS group, which received 5 sessions of the 20 min tDCS over the DLPFC (2 mA; n = 20), or the sham tDCS (n = 20). Participants' stress levels, anxiety, depressive symptoms, and state affects were assessed and compared before and after the intervention. The ERP was collected through electroencephalography (EEG) technology during an attentional network test.

Results

After the anodal tDCS, we found a significant decrease in the perceived stress scale (PSS) scores (from an average score of 35.05 to 27.75), p = 0.01 as well as the State-Trait Anxiety Inventory (STAI) scores, p = 0.002. Better performance in the attentional network test, a significant reduction in the N2 amplitudes, and an enhancement in the P3 amplitudes (both cues and targets) were also found in the anodal tDCS group.

Discussion

Our study findings suggest that tDCS to the left DLPFC could effectively relieve chronic stress, potentially reflected by increased attentional control.

Electrophysiological and behavioral evidence for the attention capture and suppression failure of irrelevant singleton in test anxiety

Attention bias (ABs) and inhibition deficits play crucial roles in the development, maintenance, and recurrence of test anxiety. However, whether test-anxious individuals will show ABs and inhibition deficits of general task-irrelevant stimuli in a complex visual display is unclear. Thus, we used the additional singleton task (AST) and recorded event-related potentials (ERPs) indices of attentional selection (the N2 posterior contralateral, N2pc), suppression (distractor positivity, PD), and maintenance of working memory (the sustained posterior contralateral negativity, SPCN) to explore this issue. Twenty-eight participants in the high test-anxious (HTA) group and twenty-eight participants in the low test-anxious (LTA) group attended the experiment and were required to search for a target and synchronously ignore a singleton distractor on some trials. Consequently, HTA and LTA individuals had poorer accuracies and longer response times in the distractor-present condition than in the distractor-absent condition. The HTA group got larger interferences from singleton distractors than the LTA group. Electrophysiological results revealed a distractor N2pc and SPCN in the HTA group. Moreover, target N2pc and SPCN in the HTA group were larger when the singleton distractor and target were on the same side than on the opposite side. These results indicated that HTA individuals were captured attention by singleton distractors and failed to expel them from working memory. Accordingly, the present findings extended previous work by providing direct evidence that test anxiety could increase the effects of stimulus-driven attention systems and impair the function of goal-directed attention systems.

Interventional Strategies to Reduce Test Anxiety among Nursing Students: A Systematic Review

Nursing students are reported to have moderate to high test anxiety, leading to reduced academic performance, poor self-esteem, and failure to complete the program and practice nursing. This review aims to examine the interventions for test anxiety reduction in nursing students. Following the PRISMA guidelines, peer-reviewed experimental studies published in English between 2016 and 2021 from four databases, EBSCOhost, PubMed, Science Direct, and Scopus, were systematically searched. The findings were presented in tabular and narrative form. Among the 722 studies retrieved, 14 selected studies were critically appraised, guided by the Joanna Briggs checklist for Randomized Controlled Trials and the checklist for Quasi-Experimental Studies, resulting in 11 studies for inclusion in the systematic review. Test anxiety was assessed by different scales. Aromatherapy hand massage, aromatherapy using a diffuser in combination with music therapy, confidence training for test relaxation, coping program, music therapy, emotional freedom technique, animal-assisted intervention, and guided imagery were all found to be effective in reducing test anxiety. In conclusion, while numerous interventions to reduce test anxiety in nursing students were found to be effective, the quality of the studies investigating these interventions was varied with generally small sample sizes and limited follow-up. Future research should be conducted, and the same interventions should be carried out using a larger sample size to strengthen the body of evidence.

Effects of Expressive Writing on "Choking under Pressure" in High Test-Anxious Individuals

(1) Background: High test-anxious students often fail to perform at their actual level and are prone to choking under pressure (CUP). The aim of the present study was to investigate whether expressive writing (EW) can help high test-anxious individuals reduce the degree of the CUP effect, and whether the intervention effects were different in people with different working memory capacities. (2) Methods: High test-anxious participants wrote expressively (EW group) or neutrally (control group) according to guidance, and then completed a modular arithmetic (MA) task under a high-stress condition. (3) Results: The state anxiety score of the control group was significantly higher than that of the EW group in the high-pressure situation, indicating that the EW intervention was helpful to alleviate the state anxiety. Subjects with high working memory capacity in the control group performed the complex MA task significantly less accurately in the high-stress situation than in the low-stress situation, showing the CUP effect. There was no significant difference in complex MA task scores between high- and low-stress situations for subjects with high working memory capacity in the EW group, indicating that the EW intervention can reduce the degree of the CUP effect. (4) Conclusions: EW intervention was effective in reducing state anxiety levels and attenuating the detrimental effects of test stress on cognitive processing in test-anxious individuals with high working memory capacity.

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.

Evidence for dynamic attentional bias toward positive emotion-laden words: A behavioral and electrophysiological study

There has been no consensus on the neural dissociation between emotion-label and emotion-laden words, which remains one of the major concerns in affective neurolinguistics. The current study adopted dot-probe tasks to investigate the valence effect on attentional bias toward Chinese emotion-label and emotion-laden words. Behavioral data showed that emotional word type and valence interacted in attentional bias scores with an attentional bias toward positive emotion-laden words rather than positive emotion-label words and that this bias was derived from the disengagement difficulty in positive emotion-laden words. In addition, an attentional bias toward negative emotion-label words relative to positive emotion-label words was observed. The event-related potential (ERP) data demonstrated an interaction between emotional word type, valence, and hemisphere. A significant hemisphere effect was observed during the processing of positive emotion-laden word pairs rather than positive emotion-label, negative emotion-label, and negative emotion-laden word pairs, with positive emotion-laden word pairs eliciting an enhanced P1 in the right hemisphere as compared to the left hemisphere. Our results found a dynamic attentional bias toward positive emotion-laden words; individuals allocated more attention to positive emotion-laden words in the early processing stage and had difficulty disengaging attention from them in the late processing stage.

Randomized trial estimating effects of hypnosis versus progressive muscle relaxation on medical students' test anxiety and attentional bias

BACKGROUND

Test anxiety is prevalent among medical students and leads to impaired academic performance. Test-related attentional bias has been identified as an important maintaining factor in test-anxious individuals.

AIM

To evaluate whether hypnosis and progressive muscle relaxation (PMR) could modify medical college students' test anxiety and attentional bias.

METHODS

A total of 598 medical students were screened. The participants were divided into higher and lower test anxiety groups according to their scores on the test anxiety scale (TAS). Ninety medical college students with high TAS score were randomly assigned to a hypnosis or PMR group. Another 45 students with low TAS score were included, forming a baseline control group. The intervention was conducted weekly for 6 wk, and each session lasted approximately 30 min. The total intervention time and the number of intervention sessions for the hypnosis and PMR groups were equal. Data were collected at the pretest, posttest, and 2-mo follow-up.

RESULTS

Hypnosis group participants had a significantly lower TAS score at posttest (t = -21.827, P < 0.001) and at follow-up (t = -14.824, P < 0.001), compared to that at pretest. PMR group participants also had a significantly lower TAS score at posttest (t = -10.777, P < 0.001) and at follow-up (t = -7.444, P < 0.001), compared to that at pretest. At the posttest level, the hypnosis group had a significantly lower TAS score than the PMR group (t = -3.664, P < 0.001). At the follow-up level, the hypnosis group also had a significantly lower TAS score than the PMR group (t = -2.943, P = 0.004). Clinically significant improvement was found in both the hypnosis and PMR groups (hypnosis = 64.0%; PMR = 62.22%). Hypnosis was more effective than PMR in reducing test anxiety among medical college students. Hypnosis could modify attentional bias toward threatening stimuli, but PMR could not.

CONCLUSION

These results suggest that attentional bias plays an important role in test anxiety treatment.

A calming hug: Design and validation of a tactile aid to ease anxiety

Anxiety disorders affect approximately one third of people during their lifetimes and are the ninth leading cause of global disability. Current treatments focus on therapy and pharmacological interventions. However, therapy is costly and pharmacological interventions often have undesirable side-effects. Healthy people also regularly suffer periods of anxiety. Therefore, a non-pharmacological, intuitive, home intervention would be complementary to other treatments and beneficial for non-clinical groups. Existing at-home anxiety aids, such as guided meditations, typically employ visual and/or audio stimuli to guide the user into a calmer state. However, the tactile sense has the potential to be a more natural modality to target in an anxiety-calming device. The tactile domain is relatively under-explored, but we suggest that there are manifold physiological and affective qualities of touch that lend it to the task. In this study we demonstrate that haptic technology can offer an enjoyable, effective and widely accessible alternative for easing state anxiety. We describe a novel huggable haptic interface that pneumatically simulates slow breathing. We discuss the development of this interface through a focus group evaluating five prototypes with embedded behaviours (‘breathing’, ‘purring’, ‘heartbeat’ and ‘illumination’). Ratings indicated that the ‘breathing’ prototype was most pleasant to interact with and participants described this prototype as ‘calming’ and ‘soothing’, reminding them of a person breathing. This prototype was developed into an ergonomic huggable cushion containing a pneumatic chamber powered by an external pump allowing the cushion to ‘breathe’. A mixed-design experiment (n = 129) inducing anxiety through a group mathematics test found that the device was effective at reducing pre-test anxiety compared to a control (no intervention) condition and that this reduction in anxiety was indistinguishable from that of a guided meditation. Our findings highlight the efficacy of this interface, demonstrating that haptic technologies can be effective at easing anxiety. We suggest that the field should be explored in more depth to capture the nuances of different modalities in relation to specific situations and trait characteristics.

Autonomic Nervous System Response Patterns of Test-Anxious Individuals to Evaluative Stress

Test anxiety is a widespread and primarily detrimental emotion in learning and achievement settings. This research aimed to explore the autonomic nervous system (ANS) response patterns of test-anxious individuals in response to evaluative stress. By presenting a standard interview task, an evaluative scenario was effectively induced. Heart rate variability (HRV), a biomarker that can accurately reflect the ANS activity, was used to reflect the physiological responses of 48 high test-anxious subjects and 49 low test-anxious subjects. Results indicate that: (1) both groups show a significantly increased emotional arousal in the evaluative scenario; (2) high test-anxious individuals show a significantly decreased emotional pleasantness in the evaluative scenario, whereas low test-anxious individuals show no significant changes; (3) both groups show a significantly increased low-frequency HRV; (4) high test-anxious individuals show a significantly decreased high-frequency HRV and root mean square of successive heartbeat interval differences (RMSSD), whereas low test-anxious individuals remain stable. These findings suggest that high test-anxious individuals display an increased sympathetic nervous system (SNS) activity and a decreased parasympathetic nervous system (PNS) activity in response to evaluative stress, while low-anxious individuals display an increased SNS activity and a stable PNS activity in response to evaluative stress.

Numbers (but not words) make math anxious individuals sweat: Physiological evidence

The study aimed to determine the specificity of math anxiety by measuring physiological arousal to the presentation of numerical and non-numerical stimuli. It also investigated whether math and trait anxieties share similar behavioral and physiological manifestations. Fifty-two female university students performed an experimental task including simple or complex arithmetical equations and math-related or neutral words. Participants' electrodermal activity (skin conductance response) was monitored during the task. Math and trait anxieties were measured using common explicit questionnaires. Results showed math anxiety levels were significantly related to physiological arousal during the performance of complex numerical tasks. Importantly, math anxiety significantly mediated the links between trait anxiety and physiological arousal in complex numerical tasks. The findings support previous work finding relations between math and trait anxieties, but also show math anxiety is a unique phenomenon with specific behavioral and physiological manifestations, especially during the processing of complex numerical information.

Neural Processing of Cognitive Control in an Emotionally Neutral Context in Anxiety Patients

Impaired cognitive control plays a crucial role in anxiety disorders and is associated with deficient neural mechanisms in the fronto-parietal network. Usually, these deficits were found in tasks with an emotional context. The present study aimed at investigating electrophysiological and vascular signatures from event-related brain potentials (ERPs) and functional near-infrared spectroscopy (fNIRS) in anxiety patients versus healthy controls during an inhibition task integrated in an emotionally neutral context. Neural markers were acquired during the completion of a classical Eriksen flanker task. The focus of data analysis has been the ERPs N200 and P300 and fNIRS activations in addition to task performance. No behavioral or neural group differences were identified. ERP findings showed a larger N2pc and a delayed and reduced P300 for incongruent stimuli. The N2pc modulation suggests the reorienting of attention to salient stimuli, while the P300 indicates longer lasting stimulus evaluation processes due to increased task difficulty. FNIRS did not result in any significant activation potentially suggesting a contribution from deeper brain areas not measurable with fNIRS. The missing group difference in our non-emotional task indicates that no generalized cognitive control deficit but rather a more emotionally driven deficit is present in anxiety patients.

Impact of Chronic Stress on Attention Control: Evidence from Behavioral and Event-Related Potential Analyses

Chronic stress affects brain function, so assessing its hazards is important for mental health. To overcome the limitations of behavioral data, we combined behavioral and event-related potentials (ERPs) in an attention network task. This task allowed us to differentiate between three specific aspects of attention: alerting, orienting, and execution. Forty-one participants under chronic stress and 31 non-stressed participants were enrolled. On the performance level, the chronically stressed group showed a significantly slower task response and lower accuracy. Concerning ERP measures, smaller cue-N1, cue-N2, and larger cue-P3 amplitudes were found in the stressed group, indicating that this group was less able to assign attention to effective information, i.e., they made inefficient use of cues and had difficulty in maintaining alerting. In addition, the stressed group showed larger target-N2 amplitudes, indicating that this group needed to allocate more cognitive resources to deal with the conflict targets task. Subgroup analysis revealed lower target-P3 amplitudes in the stressed than in the non-stressed group. Group differences associated with the attention networks were found at the ERP level. In the stressed group, excessive depletion of resources led to changes in attention control. In this study, we examined the effects of chronic stress on individual executive function from a neurological perspective. The results may benefit the development of interventions to improve executive function in chronically stressed individuals.

The neural chronometry of threat-related attentional bias: Event-related potential (ERP) evidence for early and late stages of selective attentional processing

Rapid and accurate detection of threat is adaptive. Yet, threat-related attentional biases, including hypervigilance, avoidance, and attentional disengagement delays, may contribute to the etiology and maintenance of anxiety disorders. Behavioral measures of attentional bias generally indicate that threat demands more attentional resources; however, indices exploring differential allocation of attention using reaction time fail to clarify the time course by which attention is deployed under threatening circumstances in healthy and anxious populations. In this review, we conduct an interpretive synthesis of 28 attentional bias studies focusing on event-related potentials (ERPs) as a primary outcome to inform an ERP model of the neural chronometry of attentional bias in healthy and anxious populations. The model posits that both healthy and anxious populations display modulations of early ERP components, including the P1, N170, P2, and N2pc, in response to threatening and emotional stimuli, suggesting that both typical and abnormal patterns of attentional bias are characterized by enhanced allocation of attention to threat and emotion at earlier stages of processing. Compared to anxious populations, healthy populations more clearly demonstrate modulations of later components, such as the P3, indexing conscious and evaluative processing of threat and emotion and disengagement difficulties at later stages of processing. Findings from the interpretive synthesis, existing bias models, and extant neural literature on attentional systems are then integrated to inform a conceptual model of the processes and substrates underlying threat appraisal and resource allocation in healthy and anxious populations. To conclude, we discuss therapeutic interventions for attentional bias and future directions.