Threat-Related Attention Bias in the Early Stages of Cognitive-Behavior Therapy Action for Panic Disorder

Abstract

Cognitive theories of anxiety propose that informationprocessing biases play a pivotal role in the etiology and maintenance of anxiety disorders (1). Along with the application of conditioning principles derived from learning theories, such cognitive models inspired the development of cognitive-behavioral therapy (CBT), now considered the first-line treatment for anxiety disorders (2,3). But although extensive evidence indicates that automatic attention is biased toward threatening information in anxious individuals (4), such threatrelated attention biases were typically thought to be outside the realm of the direct therapeutic effects of CBT, which focuses primarily on the modification of thoughts, interpretations, and beliefs (3). Although CBT is highly effective in reducing anxiety symptoms, the exact processes and dynamics underlying its therapeutic effect are still not fully understood. In particular, it is not clear whether low-level, automatic processes are indeed not directly engaged by CBT. Complex interactions between different levels of cognitive processing impose further difficulties on outlining the mechanisms of CBT action. For example, it has been shown that training individuals to attend toward threat led to increased interpretation of ambiguous information as threatening (5). Conversely, another study (6) demonstrated that inducing change in the interpretation of ambiguous information affected attentional threat bias. Taken together, such findings suggest that anxiety symptoms may potentially be reduced via different and interacting cognitive processes and pathways. Mapping the interplay between the different mechanisms mediating symptom reduction has substantial implications for the understanding of CBT as well as for the development and refinement of novel treatment approaches. In the current issue of Biological Psychiatry, Reinecke et al. (7) examine the role of threat-related attention bias in the early stages of CBT action, testing the possibility that CBT rapidly affects automatic emotional information processing, before later symptom reduction is reported. Twenty-eight panic disorder patients participated in the study, which took place on 2 consecutive days and a follow-up 4 weeks later. On each of the study days, patients completed self-report questionnaires of panic-related cognitions assessing explicit catastrophic beliefs, fear of physical symptoms, and severity of agoraphobic beliefs. On each day, patients also reported stress reactivity to a 5-minute, panic-inducing situation tailored to each participant’s individual panic trigger (stress test). At the end of the first day, patients were randomized to receive either a single-session CBT intervention (treatment group) or no intervention (control group). The intervention included a brief explanation of the cognitive mechanisms associated with panic disorder and its treatment and a 15-minute exposure to a panic-inducing situation while dropping safety behavior. Attention bias to emotion faces (happy and fearful) was measured once on the day following the intervention. Results indicated that the treatment and control groups did not differ in self-reported panic cognitions at baseline (first day, prior to intervention). On the following day, after half of the patients received the CBT session, the two groups still did not differ in panic cognitions, and a significant attentional bias toward masked fearful faces was found in the control group. At the 4-week follow-up, the treatment group reported lower fear of physical symptoms and lower severity of agoraphobic beliefs relative to controls. Finally, in the treatment group, fear bias correlated with a reduction in agoraphobic beliefs from baseline to follow-up. The present results provide potentially important insights into the therapeutic effect of CBT and the role that threatrelated attention bias plays in it. Because group differences in threat bias were evident one day following the intervention and