Threat-related Attention Bias Research Articles

Attention Bias Modification Treatment Augmenting Effects on Cognitive Behavioral Therapy in Children With Anxiety: Randomized Controlled Trial

Attention bias modification treatment (ABMT) is a promising novel treatment for anxiety disorders, but clinical trials have focused largely on stand-alone formats among adults. This randomized controlled trial examined the augmenting effects of threat-based ABMT on cognitive behavioral therapy (CBT) in clinically anxious youth. Sixty-three treatment-seeking children with anxiety disorder were randomly assigned to 1 of the following 3 treatment groups: ABMT+ CBT; ABMT placebo+ CBT; and CBT-alone. Participants in the 2 ABMT conditions received repeated training on dot-probe tasks either designed to shift attention away from threats (active) or designed to induce no changes in attention patterns (placebo). Primary outcome measures were frequency and severity of anxiety symptoms as determined by a clinician using a semi-structured interview. Self- and parent-rated anxiety measures and threat-related attention bias scores were also measured before and after treatment. Both the active and placebo ABMT groups showed greater reductions in clinician-rated anxiety symptoms than the CBT-alone group. Furthermore, only the active ABMT group showed significant reduction in self- or parent-rated anxiety symptoms. Finally, all groups showed a shift in attention patterns across the study, starting with a bias toward threat at baseline and shifting attention away from threat after treatment. Active and placebo ABMT might augment the clinical response to CBT for anxiety. This effect could arise from benefits associated with performing computer-based paradigms such as the dot-probe task. Given the absence of group differences in attention-bias changes during treatment, possible mechanisms and methodological issues underlying the observed findings are discussed. Clinical trial registration information-Augmenting Effects of ABMT on CBT in Anxious Children: A Randomized Clinical Trial; http://clinicaltrials.gov/; NCT01730625.

POSTDEPLOYMENT THREAT-RELATED ATTENTION BIAS INTERACTS WITH COMBAT EXPOSURE TO ACCOUNT FOR PTSD AND ANXIETY SYMPTOMS IN SOLDIERS

Recent studies suggest that assessment of threat-related attention bias may be useful in identifying soldiers at risk for clinical symptoms. The present study assessed the degree to which soldiers experienced combat events and showed attentional threat avoidance affected their reported levels of post-traumatic stress disorder (PTSD) and anxiety symptoms. Four months after a combat deployment to Iraq, 63 US soldiers completed a survey assessing combat exposures and clinical symptoms as well as a dot-probe task assessing threat-related attention bias. Significant three-way interactions regressing threat reaction times (RTs), neutral RTs, and combat exposure on PTSD and anxiety symptoms were observed. Specifically, soldiers with high levels of combat exposure, who were more likely to demonstrate attentional bias away from threat, were also more symptomatic. These results demonstrate the potential of threat-related attention bias as a behavioral marker of PTSD and anxiety symptoms in a high-risk military occupational context.

Neural time course of threat-related attentional bias and interference in panic and obsessive–compulsive disorders

Attentional biases to threat are considered central to anxiety disorders, however physiological evidence of their nature and time course is lacking. Event-related potentials (ERPs) characterized sensory and cognitive changes while 20 outpatients with panic disorder (PD), 20 with obsessive–compulsive disorder (OCD), and 20 healthy controls (HCs) responded to the color (emotional Stroop task) or meaning of threatening and neutral stimuli. ERPs indicated larger P1 amplitude and longer N1 latency in OCD, and shorter P1 latency in PD, to threatening (versus neutral) stimuli, across instructions to attend to, or ignore, threat content. Emotional Stroop interference correlated with phobic anxiety and was significant in PD. Participants with emotional Stroop interference had augmented P1 and P3 amplitudes to threat (versus neutral) stimuli when color-naming. The results suggest early attentional biases to threat in both disorders, with disorder-specific characteristics. ERPs supported preferential early attentional capture and cognitive elaboration hypotheses of emotional Stroop interference.

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

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

Attention to Threats and Combat-Related Posttraumatic Stress Symptoms

Combat places soldiers at risk for posttraumatic stress disorder (PTSD). The excessive rates of PTSD and other adjustment disorders in soldiers returning home make it imperative to identify risk and resilience factors that could be targeted by novel therapeutic treatments. To investigate the interplay among attention to threat, combat exposure, and other risk factors for PTSD symptoms in soldiers deployed to combat. Longitudinal prospective study of Israeli Defense Force infantry soldiers carried out in 2008 through 2010. Repeated measurements during a 1-year period included baseline and predeployment data collected in training camps and deployment data collected in the combat theater. Infantry soldiers (1085 men; mean age, 18.8 years). Postcombat PTSD symptoms. RESULTS Soldiers developed threat vigilance during combat deployment, particularly when they were exposed to high-intensity combat, as indicated by faster response times to targets appearing at the location of threat relative to neutral stimuli (P < .001). Threat-related attention bias also interacted with combat exposure to predict risk for PTSD (P < .05). Bias toward threat at recruitment (P < .001) and bias away from threat just before deployment (P < .05) predicted postcombat PTSD symptoms. Moreover, these threat-related attention associations with PTSD were moderated by genetic and environmental factors, including serotonin transporter (5-HTTLPR) genotype. Combat exposure interacts with threat-related attention to place soldiers at risk for PTSD, and interactions with other risk factors account for considerable variance in PTSD vulnerability. Understanding these associations informs research on novel attention bias modification techniques and prevention of PTSD.

There’s more to anxiety than meets the eye: Isolating threat-related attentional engagement and disengagement biases.

Threat-related attentional biases represent a basic survival mechanism. These biases include an engagement bias involving rapid direction of attention toward threat and a disengagement bias involving slow direction of attention away from threat. The exact nature of these biases in healthy and anxious individuals remains controversial because of the challenges associated with accurately isolating each of these attentional biases. Combining a cognitive attentional task with classical conditioning using electric stimulation, we created a new paradigm that makes it possible to more clearly isolate these attentional biases. Utilizing this novel paradigm, we detected both types of attentional bias and differentiated between levels of trait anxiety, in which low- and high-trait anxiety individuals showed equal levels of engagement bias, but only high-trait anxiety individuals showed impaired disengagement from threat.

Subliminal attention bias modification training in socially anxious individuals

Anxious individuals demonstrate threat-related attention biases both when threat stimuli are presented within conscious awareness and when presented below awareness threshold. Nevertheless, attention bias modification (ABM) research has rarely utilized sub-awareness protocols in an attempt to modify attention patterns and reduce anxiety. Exploring the potential of subliminal ABM is of interest, as it may target attention processes related to anxiety that are distinct from those engaged by supraliminal ABM. Here we examined the effect of a subliminal ABM training protocol on levels of social anxiety and stress vulnerability. Fifty-one socially anxious students were randomly assigned to either ABM or placebo condition, and completed a pre-training assessment, four training sessions, a social stressor task, and a post-training assessment. Results indicate that the subliminal ABM used here did not induce detectable changes in threat-related attention from pre- to post-training as measured by two independent attention tasks. Furthermore, the ABM and placebo groups did not differ on either self-reported social anxiety post-training or state anxiety following stress induction. Post-hoc auxiliary analyses suggest that ABM may be associated with smaller elevations in state anxiety during the stressor task only for participants who demonstrate attention bias toward threat at baseline. Implications and future research directions are discussed.

Attentional bias toward personally relevant health-threat words

Conflicting findings have emerged regarding the presence of attentional biases (ABs) in health anxiety, probably due to methodological limitations in the stimuli used in cognitive tasks and the assessment of health anxiety-relevant factors. The current study sought to examine ABs toward health-related threats using idiographically chosen health-threat words in a non-clinical sample. A modified dot-probe task using idiographically selected health-threat words was administered to an undergraduate sample. Self-report measures were administered to assess somatic, cognitive, and behavioral aspects of health anxiety, in addition to assessing negative affect, anxiety sensitivity, and experience of actual medical conditions. Results showed that behavioral and somatic aspects of health anxiety were significantly associated with AB toward personally relevant threat words, even after controlling for negative affect, anxiety sensitivity, and experience of actual medical conditions. Additional analyses revealed that these biases reflected difficulty disengaging attention from threat rather than a facilitated detection of threat. In contrast, illness-related cognitions were found to be unrelated to ABs. These findings suggest an association between threat-related ABs and excessive health-care seeking efforts.

Threat bias in attention orienting: evidence of specificity in a large community-based study

Preliminary research implicates threat-related attention biases in paediatric anxiety disorders. However, major questions exist concerning diagnostic specificity, effects of symptom-severity levels, and threat-stimulus exposure durations in attention paradigms. This study examines these issues in a large, community school-based sample. Method A total of 2046 children (ages 6-12 years) were assessed using the Development and Well Being Assessment (DAWBA), Childhood Behavior Checklist (CBCL) and dot-probe tasks. Children were classified based on presence or absence of 'fear-related' disorders, 'distress-related' disorders, and behavioural disorders. Two dot-probe tasks, which differed in stimulus exposure, assessed attention biases for happy-face and threat-face cues. The main analysis included 1774 children. For attention bias scores, a three-way interaction emerged among face-cue emotional valence, diagnostic group, and internalizing symptom severity (F = 2.87, p < 0.05). This interaction reflected different associations between internalizing symptom severity and threat-related attention bias across diagnostic groups. In children with no diagnosis (n = 1411, mean difference = 11.03, s.e. = 3.47, df = 1, p < 0.001) and those with distress-related disorders (n = 66, mean difference = 10.63, s.e. = 5.24, df = 1, p < 0.05), high internalizing symptoms predicted vigilance towards threat. However, in children with fear-related disorders (n = 86, mean difference = -11.90, s.e. = 5.94, df = 1, p < 0.05), high internalizing symptoms predicted an opposite tendency, manifesting as greater bias away from threat. These associations did not emerge in the behaviour-disorder group (n = 211). The association between internalizing symptoms and biased orienting varies with the nature of developmental psychopathology. Both the form and severity of psychopathology moderates threat-related attention biases in children.

Saccadic latency is modulated by emotional content of spatially filtered face stimuli.

Models of attention and emotion assign a special status to the processing of threat. While evidence for threat-related attentional bias in highly anxious individuals is robust, effects in the normal population are mixed. An important explanation for the absence of threat-related attentional bias in nonanxious individuals may relate to the spatial frequency components of stimuli. Here we report behavioral data from two experiments examining the relationship between spatial frequency components of emotional and neutral faces and fast saccadic orienting behavior. In Experiment 1 participants had to saccade toward a single face, filtered to include mostly low, high or broad spatial frequencies (LSF, HSF or BSF), posing a fearful, happy or neutral expression presented for 20 ms in the periphery. At BSF a general emotional effect was found whereby saccadic responses were faster for fearful and happy faces relative to neutral, with no significant differences between fearful and happy faces. At LSF both fearful and happy faces had shorter saccadic latencies in comparison to neutral, demonstrating an emotional bias consistent with the BSF data. However, at LSF fearful faces resulted in significantly faster saccades than happy faces indicating that this bias was stronger for threat-related faces. There was no difference in saccadic responses between any emotions at HSF. Experiment 2 showed that the emotional bias diminished for inverted stimuli suggesting that the results were not attributable to low-level image properties. The findings suggest an overall advantage in the oculomotor system for orientation to emotional stimuli and at LSF in particular, a significantly faster localization of threat conveyed by the face stimuli in all individuals.

Anxiety-related attention biases in preschoolers: an investigation using the pictorial dot-probe task

The present study examined in preschool aged children the effects of threat-related attention biases on anxiety symptoms. In addition, we also measured reactive and regulative temperamental traits, given that it is believed that these temperamental traits might be related to both attention biases and anxiety symptoms. Results showed that attention biases were associated with higher levels of anxiety symptoms. Furthermore, a marginally significant interactive effect of attention biases towards happy faces and inhibitory control on anxiety symptoms was found. These data are some of the first providing support for the presence of anxiety-related attention biases early in the development.

Attention Bias Modification and the Serotonin Transporter: Personalized Treatment Implications of Gene Interactions with Learning

Threat-related attention biases play a role in the etiology and maintenance of anxiety (1). Initial evidence from a recent meta-analysis suggests that attention bias modification (ABM) procedures reduce anxiety by targeting threat biases (2). However, questions regarding the clinical applications of ABM procedures still exist. In particular, it remains unclear when attention retraining procedures are effective and translate into therapeutic benefit.

Early information processing biases in social anxiety

Considerable controversy persists regarding the nature of threat-related attention biases in social anxiety. Previous studies have not considered how variations in the temporal and energetic dimensions of affective stimulus delivery interact with anxiety-related individual differences to predict biased attention. We administered a visual dot-probe task, using faces that varied in affective intensity (mild, moderate, strong) and presentation rate (100, 500, 1,250 ms) to a selected sample. The high, compared to the low, socially anxious group showed vigilance towards angry faces and emotionally ambiguous faces more generally during rapid (100 ms) presentations. By 1,250 ms, there was only a non-specific motor slowing associated with angry faces in the high socially anxious group. Findings suggest the importance of considering both chronometric and energetic dimensions of affective stimuli when examining anxiety-related attention biases. Future studies should consider using designs that more closely replicate aspects of real-world interaction to study processing biases in socially anxious populations.

Training anxious children to disengage attention from threat: a randomized controlled trial

Threat-related attention biases have been implicated in the etiology and maintenance of anxiety disorders. As a result, attention bias modification (ABM) protocols have been employed as treatments for anxious adults. However, they have yet to emerge for children. A randomized, double-blind placebo-controlled trial was conducted to examine the efficacy of an ABM protocol designed to facilitate attention disengagement from threats, thereby reducing anxiety and stress vulnerability in children. Participants were 34 chronically high-anxious 10-year-olds. An emotional attention spatial cueing task was used. In the ABM condition (n=18), threat faces never cued the targets' locations, such that the valid-invalid ratio was 0%/100%, respectively. The valid-invalid ratio on neutral cue trials was 25%/75%, respectively. In the control condition, the valid-invalid ratio was 25%/75% for both neutral and threat faces. Anxiety and depression were measured pre- and post-training and pre- and post-stress induction. ABM facilitated attention disengagement from threat. In response to the stressor task, children in the ABM condition reported less state anxiety relative to controls. Computerized attention training procedures may be beneficial for reducing stress vulnerability in anxious children.

Battlefield-like stress following simulated combat and suppression of attention bias to threat

Acute stress disorder involves prominent symptoms of threat avoidance. Preliminary cross-sectional data suggest that such threat-avoidance symptoms may also manifest cognitively, as attentional threat avoidance. Confirming these findings in a longitudinal study might provide insights on risk prediction and anxiety prevention in traumatic exposures. Attention-threat bias and post-traumatic symptoms were assessed in soldiers at two points in time: early in basic training and 23 weeks later, during advanced combat training. Based on random assignment, the timing of the repeat assessment occurred in one of two schedules: for a combat simulation group, the repeat assessment occurred immediately following a battlefield simulation exercise, and for a control group, the assessment occurred shortly before this exercise. Both groups showed no threat-related attention bias at initial assessments. Following acute stress, the combat simulation group exhibited a shift in attention away from threat whereas the control group showed no change in attention bias. Stronger threat avoidance in the combat simulation group correlated with severity of post-traumatic symptoms. Such an association was not found in the control group. Acute stress may lead some individuals to shift their attention away from threats, perhaps to minimize stress exposure. This acute attention response may come at a psychological cost, given that it correlates with post-traumatic stress disorder (PTSD) symptoms. Further research is needed to determine how these associations relate to full-blown PTSD in soldier and civilian populations.

Research Review: attention bias modification (ABM): a novel treatment for anxiety disorders

Attention bias modification (ABM) is a newly emerging therapy for anxiety disorders that is rooted in current cognitive models of anxiety and in established experimental data on threat-related attentional biases in anxiety. This review describes the evidence indicating that ABM has the potential to become an enhancing tool for current psychological and pharmacological treatments for anxiety or even a novel standalone treatment. The review also outlines the gaps in need of bridging before ABM techniques could be routinely applied and incorporated into standard treatment protocols.

Stereotype threat as validity threat: The anxiety–sex–threat interaction

Stereotype threat has been invoked to explain underperformance on a variety of groups for whom the stereotypes allege inferior cognitive abilities. In math testing, stereotype threat has been used to explain sex differences in test performance. This paper describes an experimental study on a large sample ( n = 313), in which the role of anxiety and mental rotation on math sex-related differences under stereotype threat has been analyzed in the tradition of Aptitude–Treatment–Interaction (ATI) designs. Results show that the manipulation effects are evident only in interaction with anxiety, which suggests that the construct validity of stereotype threat is itself seriously threatened. The analogy with the validity threat known as reactivity to the experimental situation is elaborated, and a more promising approach (the study of threat-related attentional bias in anxious and non-anxious individuals) suggested.

Effects of threat cues on attentional shifting, disengagement and response slowing in anxious individuals

According to cognitive models of anxiety, attentional biases for threat may cause or maintain anxiety states. Previous research using spatial cueing tasks has been interpreted in terms of difficulty in disengaging attention from threat in anxious individuals, as indicated by contrasts of response times (RTs) from threat cue versus neutral cue trials. However, on spatial cueing tasks, differences in RT between threat cue and neutral cue trials may stem from a slowing effect of threat on RT, as well as effects on allocation of visuospatial attention. The present study examined the effects of threat cues on both attentional cueing and response slowing. High and low anxious individuals completed a central cue task, which assessed threat-related response slowing, and a spatial cueing task, which assessed attentional biases for angry, happy and neutral faces. Results indicated that interpretation of the anxiety-related bias for threat depended on whether the effect of response slowing was taken into account. The study illustrates an important problem in using the modified spatial cueing task to assess components of threat-related attentional bias. As this experimental method may reflect both threat-related attentional cueing and response slowing effects, it cannot be assumed to provide pure measures of shift or disengagement components of attention bias.

Threat-related attentional biases: an analysis of three attention systems

It is unclear how threat-related attentional biases affect multiple attention systems. This study used a new modification of a reaction time paradigm to examine whether inter-trial task-irrelevant fearful faces influenced the efficiency of alerting, orienting, and executive attention, and whether effects varied with level of state anxiety. Participants, 63 non-disordered adults (17 males and 46 females), reported on their subjective state anxiety and completed a modified version of the Attention Network Test in which fearful or neutral faces or control stimuli were presented briefly (50 ms) between trials of the task, but provided no task-relevant information. Across all participants, state anxiety was positively correlated with alerting, whereas fearful versus neutral faces were linked to decreased alerting efficiency. Contrasting high and low anxiety groups showed that fearful versus neutral faces reduced executive attention in the low state anxiety group only, suggesting decreased distraction by irrelevant stimuli in the high state anxiety group. Results document threat-related attentional biases that varied with attention system but failed to find enhanced bias effects among those with higher state anxiety in a typical range. This modification of the Attention Network Test, which added presentation of emotional distracters, provides a potentially useful new method for assessing the impact of task-irrelevant emotional stimuli on three aspects of attention performance.

Threat-related attentional bias in anxious and nonanxious individuals: A meta-analytic study.

This meta-analysis of 172 studies (N = 2,263 anxious,N = 1,768 nonanxious) examined the boundary conditions of threat-related attentional biases in anxiety. Overall, the results show that the bias is reliably demonstrated with different experimental paradigms and under a variety of experimental conditions, but that it is only an effect size of d = 0.45. Although processes requiring conscious perception of threat contribute to the bias, a significant bias is also observed with stimuli outside awareness. The bias is of comparable magnitude across different types of anxious populations (individuals with different clinical disorders, high-anxious nonclinical individuals, anxious children and adults) and is not observed in nonanxious individuals. Empirical and clinical implications as well as future directions for research are discussed.