Amit Lazarov

Are obsessive–compulsive tendencies related to reliance on external proxies for internal states? Evidence from biofeedback-aided relaxation studies

This article presents two studies that examine the hypothesis that obsessive-compulsive (OC) tendencies are associated with a general deficiency in subjective conviction, which leads to seeking and reliance on external proxies to compensate for that deficiency. We examined this hypothesis using a biofeedback-aided relaxation procedure. In Study 1 low OC participants performed better on a relaxation task than high OC participants. More importantly, viewing the biofeedback monitor (an external proxy for the internal state of relaxation) had a different effect on the two groups: Whereas high OC participants performed better, low OC participants did not. In addition, when given the opportunity, high OC participants requested the biofeedback monitor more than did the low OC participants. In Study 2 high OC participants were more affected by false biofeedback when judging their level of relaxation compared to low OC participants. Real relaxation level differences between the two false biofeedback phases among the two groups were not found. These results provide preliminary support for the hypothesis that obsessive-compulsive disorder is associated with deficient subjective conviction in internal states and increased reliance on external proxies. Implications for the understanding of OCD-related rules and rituals as well as for cognitive therapy for OCD are discussed.

Obsessive-compulsive tendencies and undermined confidence are related to reliance on proxies for internal states in a false feedback paradigm

BACKGROUND AND OBJECTIVES We have previously hypothesized that obsessive-compulsive (OC) tendencies are associated with a general lack of subjective conviction regarding internal states, which leads to compensatory seeking of and reliance on more discernible substitutes (proxies) for these states (Lazarov, A., Dar, R., Oded, Y., & Liberman, N. (2010). Behaviour Research and Therapy, 48, 516-523). This article presents two studies designed to provide further support to this hypothesis by using false biofeedback as a proxy for internal states. METHODS In Study 1 we presented high and low OC participants with pre-programmed false feedback showing either increasing or decreasing levels of muscle tension. In Study 2 we presented similar false feedback on level of relaxation to non-selected participants, half of which received instructions that undermined their confidence in their ability to assess their own level of relaxation. RESULTS In Study 1, high OC participants were more affected by false biofeedback when judging their own level of muscle tension than were low OC participants. In Study 2, undermined confidence participants were more affected by false biofeedback when judging their own level of relaxation as compared to control participants. LIMITATIONS Our findings are based on a non-clinical, highly functioning, largely female student sample and their generalization to OCD requires replication with a sample of OCD patients. CONCLUSIONS These results provide converging evidence for our hypothesis by replicating and extending our previous findings. We discuss the implication of our hypothesis for the understanding and treatment of OCD and outline directions for future research.

Social anxiety is related to increased dwell time on socially threatening faces.

BACKGROUND Identification of reliable targets for therapeutic interventions is essential for developing evidence-based therapies. Threat-related attention bias has been implicated in the etiology and maintenance of social anxiety disorder. Extant response-time-based threat bias measures have demonstrated limited reliability and internal consistency. Here, we examined gaze patterns of socially anxious and nonanxious participants in relation to social threatening and neutral stimuli using an eye-tracking task, comprised of multiple threat and neutral stimuli, presented for an extended time-period. We tested the psychometric properties of this task with the hope to provide a solid stepping-stone for future treatment development. METHODS Eye gaze was tracked while participants freely viewed 60 different matrices comprised of eight disgusted and eight neutral facial expressions, presented for 6000ms each. Gaze patterns on threat and neutral areas of interest (AOIs) of participants with SAD, high socially anxious students and nonanxious students were compared. Internal consistency and test-retest reliability were evaluated. RESULTS Participants did not differ on first-fixation variables. However, overall, socially anxious students and participants with SAD dwelled significantly longer on threat faces compared with nonanxious participants, with no difference between the anxious groups. Groups did not differ in overall dwell time on neutral faces. Internal consistency of total dwell time on threat and neutral AOIs was high and one-week test-retest reliability was acceptable. LIMITATIONS Only disgusted facial expressions were used. Relative small sample size. CONCLUSION Social anxiety is associated with increased dwell time on socially threatening stimuli, presenting a potential target for therapeutic intervention.

Seeking proxies for internal states in obsessive–compulsive disorder.

Pervasive doubts are a central feature of obsessive-compulsive disorder (OCD). We have theorized that obsessive doubts can arise in relation to any internal state and lead to compensatory reliance on more discernible substitutes (proxies), including rules and rituals. Previous findings corroborated this hypothesis, but were based on students with high and low OCD tendencies and did not control for anxiety. The present study tested our hypothesis in OCD participants using both anxiety disorders and nonclinical controls. Twenty OCD participants, 20 anxiety disorders participants, and 20 nonclinical participants underwent 2 experimental procedures. In the first, participants had to produce specific levels of muscle tension with and without the aid of biofeedback. In the second, participants were asked to subjectively assess their own muscle tension after viewing preprogrammed false feedback showing either increasing or decreasing levels of muscle tension. As predicted, OCD participants were less accurate than anxiety disorder and nonclinical participants in producing designated levels of muscle tension when biofeedback was not available and more likely to request the biofeedback when given the opportunity to do so. In the false feedback procedure, OCD participants were more influenced by the false biofeedback when judging their own level of muscle tension compared with the 2 controls groups. In both procedures, anxiety disorder participants did not differ from the nonclinical controls. These results support the hypothesis that individuals with OCD have attenuated access to and reduced confidence in their internal states, and that this deficit is specific to OCD and not attributable to anxiety.

Body image in social anxiety disorder, obsessive-compulsive disorder, and panic disorder.

Body dysmorphic disorder falls under the category of obsessive-compulsive and related disorders, yet research has suggested it may also be highly associated with social anxiety disorder. The current study examined body image variables among 68 outpatients with primary obsessive-compulsive disorder (OCD; n=22), social anxiety disorder (SAD; n=25), and panic disorder (PD; n=21). Participants filled out self-report measures of body image disturbance, attitudes toward ones appearance, and anxiety. Body image disturbance and attitudes toward appearance did not significantly differ between the groups. However, SAD symptoms predicted body image disturbance, Appearance Evaluation and Body Areas Satisfaction, and OCD symptoms predicted Appearance Orientation. These findings suggest that SAD and OCD may be associated with different facets of body image. Implications for the treatment of anxiety disorders and for future research are discussed.

Exploring metacognitive components of confidence and control in individuals with obsessive-compulsive tendencies.

BACKGROUND AND OBJECTIVES Obsessive-compulsive (OC) patients typically display reduced metacognitive confidence, but findings regarding the scope of this phenomenon and factors that mediate it have been inconsistent. This study aimed to further the understanding of reduced metacognitive confidence in obsessive-compulsive disorder (OCD) by exploring the relationship between metacognitive processes and OC tendencies. METHODS High and low OC participants answered a general-knowledge questionnaire, rated their confidence in each answer, and decided whether or not to report each answer. RESULTS High and low OC participants did not differ either in their performance (general knowledge) or in their subjective estimations or confidence regarding their performance. The two groups also did not differ in the effectiveness of their metacognitive monitoring or in the relationship between monitoring and report-control decisions (control sensitivity). However, the two groups did differ in response criterion, with high OC participants less willing to report answers held with low-to-medium levels of subjective confidence. LIMITATIONS The study was conducted with non-clinical participants, which limits generalization to OCD. CONCLUSIONS These results suggest that conservative response criterion among OC individuals might be the critical factor underlying feelings of doubt and uncertainty endemic in OCD.

The Effects of Training Contingency Awareness During Attention Bias Modification on Learning and Stress Reactivity

Current attention bias modification (ABM) procedures are designed to implicitly train attention away from threatening stimuli with the hope of reducing stress reactivity and anxiety symptoms. However, the mechanisms underlying effective ABM delivery are not well understood, with awareness of the training contingency suggested as one possible factor contributing to ABM efficacy. Here, 45 high-anxious participants were trained to divert attention away from threat in two ABM sessions. They were randomly assigned to one of three training protocols: an implicit protocol, comprising two standard implicit ABM training sessions; an explicit protocol, comprising two sessions with explicit instruction as to the attention training contingency; and an implicit-explicit protocol, in which participants were not informed of the training contingency in the first ABM session and informed of it at the start of the second session. We examined learning processes and stress reactivity following a stress-induction task. Results indicate that relative to implicit instructions, explicit instructions led to stronger learning during the first training session. Following rest, the explicit and implicit groups exhibited consolidation-related improvement in performance, whereas no such improvement was noted for the implicit-explicit group. Finally, although stress reactivity was reduced after training, contingency awareness did not yield a differential effect on stress reactivity measured using both self-reports and skin conductance, within and across sessions. These results suggest that explicit ABM administration leads to greater initial learning during the training protocol while not differing from standard implicit administration in terms of off-line learning and stress reactivity.

Free viewing of sad and happy faces in depression: A potential target for attention bias modification

BACKGROUND Identification of reliable targets for therapeutic interventions is essential for developing evidence-based therapies. Attention biases toward negative-valenced information and lack of protective positive bias toward positive-valenced stimuli have been implicated in depression. However, extant research has typically used tasks with narrow stimuli arrays and unknown or poor psychometric properties. Here, we recorded eye-tracking data of depressed and non-depressed participants during a free viewing task to address these limitations. METHODS Patients with major depressive disorder (MDD; n = 20) and undergraduate students with high (n = 23) and low (n = 20) levels of depression freely viewed 60 different face-based matrices for six seconds each. Each matrix included eight sad and eight happy facial expressions. Gaze patterns on sad and happy areas of interest (AOIs) were explored. Internal consistency for the entire sample and one-week test-retest reliability in the student sub-sample were assessed. RESULTS Compared to undergraduates with low levels of depression, patients with MDD and students with high levels of depression dwelled significantly longer on sad faces. Results also showed a significantly longer dwell time on the happy AOI relative to the sad AOI only in the low depression group. The two depressed groups dwelled equally on the two AOIs. The task demonstrated high internal consistency and acceptable one-week test-retest reliability. LIMITATIONS Only sad and happy facial expressions were used. Relative small sample size. CONCLUSION Relative to non-depressed participants, depressed participants showed prolonged dwelling on sad faces and lack of bias toward happy faces. These biases present viable targets for gaze-contingent attention bias modification therapy.

Extraction of mean emotional tone from face arrays in social anxiety disorder

Social anxiety disorder (SAD) is characterized by intense fear when facing a crowd. Processing biases of crowd‐related information have been suggested as contributing to the etiology and maintenance of the disorder. Here we tested whether patients with SAD display aberrant patterns of extracting the mean emotional tone from sets of faces.

Attention Bias Modification Treatment Reduces Depression Symptoms in Youth.

ajor depression is a commonly occurring, serious, and recurrent disorder that often starts at a M young age. According to the World Health Organization, depression is ranked among the leading causes of disability worldwide. In 2013, an estimated 2.6 million adolescents 12 to 17 years old in the United States had at least 1 major depressive episode in the past year, representing 10.7% of the population in this age range. Efficacious treatments for major depression, including cognitive-behavioral therapies and pharmacotherapy, have been available for decades. However, the prevalence rates of major depression remain notably consistent, with fewer than 15% of potential patients receiving minimally adequate treatment. This observation has led to a call for interventions that take advantage of technology to increase patient access and lower cost through the use of computerbased procedures. One such intervention, attention bias modification treatment (ABMT), was originally designed to directly target a posited cognitive mechanism of anxiety, namely selective attention to threat stimuli. Recently, ABMT has been tested for depression. Cognitive theories of depression implicate attention biases in the processing of emotional information as a key factor in the etiology and maintenance of the disorder. Two types of attentional biases have been reported in major depression: increased attention allocation to negatively valenced stimuli compared with positive or neutral stimuli and a lack of attentional bias toward positive stimuli that typically characterizes healthy individuals. Therefore, computerized ABMT protocols have started to emerge that target these specific biases in adult patients with depression. ABMT protocols are typically designed to implicitly modify biased attentional patterns. For instance, in a dotprobe task, 2 stimuli, 1 related to threat and 1 neutral (e.g., threat and neutral words), are shown briefly at each trial, and their removal is followed by a small target probe in the location just occupied by one of the stimuli. Patients are required to discriminate as quickly as possible between 2 variants of the probe (e.g., 1 or 2 dots) without compromising accuracy. In the classic format of this task, designed to measure attention biases, targets appear with equal probability at the location of threat and neutral stimuli. Thus, attention bias toward threat is shown when participants are faster to respond to probes that replace threat-related stimuli rather than neutral stimuli. In attention training variants of the dot-probe task, target location is systematically manipulated to increase the proportion of targets appearing at the location of the intended training bias. It is assumed that because attending to such contingencies can assist in task