Heide Klumpp

Attention Training in Individuals with Generalized Social Phobia: A Randomized Controlled Trial

The authors conducted a randomized, double-blind placebo-controlled trial to examine the efficacy of an attention training procedure in reducing symptoms of social anxiety in 44 individuals diagnosed with generalized social phobia (GSP). Attention training comprised a probe detection task in which pictures of faces with either a threatening or neutral emotional expression cued different locations on the computer screen. In the attention modification program (AMP), participants responded to a probe that always followed neutral faces when paired with a threatening face, thereby directing attention away from threat. In the attention control condition (ACC), the probe appeared with equal frequency in the position of the threatening and neutral faces. Results revealed that the AMP facilitated attention disengagement from threat from pre- to postassessment and reduced clinician- and self-reported symptoms of social anxiety relative to the ACC. The percentage of participants no longer meeting Diagnostic and Statistical Manual (4th ed.) criteria for GSP at postassessment was 50% in the AMP and 14% in the ACC. Symptom reduction in the AMP group was maintained during 4-month follow-up assessment. These results suggest that computerized attention training procedures may be beneficial for treating social phobia.

Aberrant amygdala-frontal cortex connectivity during perception of fearful faces and at rest in generalized social anxiety disorder.

Generalized social anxiety disorder (gSAD) is characterized by exaggerated amygdala reactivity to social signals of threat, but if and how the amygdala interacts with functionally and anatomically connected prefrontal cortex (PFC) remains largely unknown. Recent evidence points to aberrant amygdala connectivity to medial PFC in gSAD at rest, but it is difficult to attribute functional relevance without the context of threat processing. Here, we address this by studying amygdala–frontal cortex connectivity during viewing of fearful faces and at rest in gSAD patients.

Preliminary Study of Attention Training to Threat and Neutral Faces on Anxious Reactivity to a Social Stressor in Social Anxiety

Cognitive theories of anxiety emphasize attentional bias to threat contributes to the maintenance of anxiety disorders (e.g., Williams et al. in Cognitive psychology and emotional disorders, 2nd edn. Wiley, Chichester, 1997). For example, anxiety may be the result of bias that interacts with vulnerability characteristics and stress (e.g., Mathews in Behav Res Ther 28:455–468, 1990; Mathews in The Psyochologist 6:493–499, 1993). Yet, few studies have experimentally directed attention towards threat to investigate its role in anxiety to stress. This study examined attention training effects on stress response in moderately socially anxious individuals. Participants were randomly assigned to one of three probe detection conditions: (1) attention training away from threat, (2) attention training to threat, or (3) attention randomly directed to threat and away from threat with equal frequency (control condition). Afterwards, participants completed a speech challenge and rated their anxiety level. Results indicate attention training to threat or away from threat, compared to no training, attenuated anxiety in response to a social stressor in socially anxious individuals.

Examination of vigilance and disengagement of threat in social anxiety with a probe detection task

Abstract Selective attention for threat faces in social anxiety is commonly measured with a probe detection task. Various studies that have used this task show socially anxious individuals exhibit selective attention for threat faces (Mogg & Bradley, 2002; Mogg, Philippot, & Bradley, 2004b; Pishyar, Harris, & Menzies, 2004). Selective attention for threat when measured with a probe detection task is interpreted as an attentional shift toward threat (“vigilance”). Yet, there is data that show socially anxious individuals may have difficulty in shifting their attention away from threat (“disengagement”; Amir, Elias, Klumpp, & Przeworski, 2003). A step toward clarifying the extent to which selective attention for threat comprises vigilance or disengagement effects is described by Koster, Crombez, Verschuere, and de Houwer (2004). We adapted their modified probe detection task to examine vigilance and disengagement effects for threat and happy faces in individuals with and without social anxiety. The results indicate that socially anxious individuals exhibit vigilance for threat faces, but not for happy faces, compared to individuals without social anxiety. Our study is consistent with cognitive theories of anxiety that propose vigilance for threat may contribute to the maintenance of anxiety disorders.

Anterior cingulate cortex and insula response during indirect and direct processing of emotional faces in generalized social anxiety disorder.

BackgroundGeneralized social anxiety disorder (gSAD) is associated with a heightened neural sensitivity to signals that convey threat, as evidenced by exaggerated amygdala and/or insula activation when processing face stimuli that express negative emotions. Less clear in the brain pathophysiology of gSAD are cortical top down control mechanisms that moderate reactivity in these subcortical emotion processing regions. This study evaluated amygdala, insula, and anterior cingulate cortex (ACC) activity in gSAD with a novel “Emotional Faces Shifting Attention Task” (EFSAT), an adaptation of perceptual assessment tasks well-known to elicit amygdala response. In healthy volunteers, the task has been shown to engage the amygdala when attention is directed to emotional faces and the ACC when attention is directed to shapes, away from emotional faces.MethodsDuring functional MRI, 29 participants with gSAD and 27 healthy controls viewed images comprising a trio of faces (angry, fear, or happy) alongside a trio of geometric shapes (circles, rectangles, or triangles) within the same field of view. Participants were instructed to match faces or match shapes, effectively directing attention towards or away from emotional information, respectively.ResultsParticipants with gSAD exhibited greater insula, but not amygdala, activation compared to controls when attending to emotional faces. In contrast, when attention was directed away from faces, controls exhibited ACC recruitment, which was not evident in gSAD. Across participants, greater ACC activation was associated with less insula activation.ConclusionsEvidence that individuals with gSAD exhibited exaggerated insula reactivity when attending to emotional faces in EFSAT is consistent with other studies suggesting that the neural basis of gSAD may involve insula hyper-reactivity. Furthermore, greater ACC response in controls than gSAD when sustained goal-directed attention is required to shift attention away from social signals, together with a negative relationship between ACC and bilateral insula activity, indicate the ACC may have served a regulatory role when the focus of attention was directed to shapes amidst emotional faces.

Amygdala reactivity to faces at varying intensities of threat in generalized social phobia: An event-related functional MRI study

Using functional magnetic resonance imaging, we measured amygdala reactivity to faces varying on threat intensity in patients with generalized social phobia (GSP) and healthy controls. GSP patients exhibited greater amygdala reactivity to threat faces at high and moderate intensities. More subtle displays of social threat are sufficient to evoke a fear-related neural response.

Review of brain functioning in depression for semantic processing and verbal fluency

Neurobiological models of depression point to brain regions that are proposed to be involved with both emotion regulation and language processing. This qualitative review focused on neurophysiological evidence for semantic processing and verbal fluency deficits associated with left frontal lobe and dorsolateral prefrontal cortex functioning in depression, respectively. Findings suggest that there are no behavioral or neurophysiological evidence of performance differences between depressed and healthy individuals for semantic processing of neutral information, arguing against generalized left frontal lobe deficits. However, the preponderance of evidence points to enhanced processing of negative information in both left and right frontal lobes and behavior. Studies of verbal fluency were limited to non-emotional information. The majority of studies evaluated phonemic verbal fluency in depression (e.g., producing words that begin with a particular letter) and results generally showed bilateral hypoactivation of the frontal lobe with no concomitant deficits in behavioral performance. Overall, semantic processing and verbal fluency studies did not provide substantive evidence of specific left frontal lobe deficits. Evidence that emotional information may differentially impact brain functioning relative to neutral information in depression suggests that examination of verbal fluency for emotional information may contribute to the elucidation of executive functioning processes associated with the dorsolateral prefrontal cortex in depression.

Age-related changes in amygdala–frontal connectivity during emotional face processing from childhood into young adulthood

The ability to process and respond to emotional facial expressions is a critical skill for healthy social and emotional development. There has been growing interest in understanding the neural circuitry underlying development of emotional processing, with previous research implicating functional connectivity between amygdala and frontal regions. However, existing work has focused on threatening emotional faces, raising questions regarding the extent to which these developmental patterns are specific to threat or to emotional face processing more broadly. In the current study, we examined age‐related changes in brain activity and amygdala functional connectivity during an fMRI emotional face matching task (including angry, fearful, and happy faces) in 61 healthy subjects aged 7–25 years. We found age‐related decreases in ventral medial prefrontal cortex activity in response to happy faces but not to angry or fearful faces, and an age‐related change (shifting from positive to negative correlation) in amygdala–anterior cingulate cortex/medial prefrontal cortex (ACC/mPFC) functional connectivity to all emotional faces. Specifically, positive correlations between amygdala and ACC/mPFC in children changed to negative correlations in adults, which may suggest early emergence of bottom‐up amygdala excitatory signaling to ACC/mPFC in children and later development of top‐down inhibitory control of ACC/mPFC over amygdala in adults. Age‐related changes in amygdala–ACC/mPFC connectivity did not vary for processing of different facial emotions, suggesting changes in amygdala–ACC/mPFC connectivity may underlie development of broad emotional processing, rather than threat‐specific processing. Hum Brain Mapp 37:1684–1695, 2016.

Beyond emotions: A meta-analysis of neural response within face processing system in social anxiety

Patients with social anxiety disorder (SAD) experience anxiety and avoidance in face-to-face interactions. We performed a meta-analysis of functional magnetic resonance imaging (fMRI) studies in SAD to provide a comprehensive understanding of the neural underpinnings of face perception in this disorder. To this purpose, we adopted an innovative approach, asking authors for unpublished data. This is a common procedure for behavioral meta-analyses, which, however has never been used in neuroimaging studies. We searched Pubmed with the key words “Social Anxiety AND faces” and “Social Phobia AND faces.” Then, we selected those fMRI studies for which we were able to obtain data for the comparison between SAD and healthy controls (HC) in a face perception task, either from the published papers or from the authors themselves. In this way, we obtained 23 studies (totaling 449 SAD and 424 HC individuals). We identified significant clusters in which faces evoked a higher response in SAD in bilateral amygdala, globus pallidus, superior temporal sulcus, visual cortex, and prefrontal cortex. We also found a higher activity for HC in the lingual gyrus and in the posterior cingulate. Our findings show that altered neural response to face in SAD is not limited to emotional structures but involves a complex network. These results may have implications for the understanding of SAD pathophysiology, as they suggest that a dysfunctional face perception process may bias patient person-to-person interactions.

Perceptual load modulates anterior cingulate cortex response to threat distractors in generalized social anxiety disorder

Generalized social anxiety disorder (gSAD) is associated with impoverished anterior cingulate cortex (ACC) engagement during attentional control. Attentional Control Theory proposes such deficiencies may be offset when demands on resources are increased to execute goals. To test the hypothesis attentional demands affect ACC response 23 patients with gSAD and 24 matched controls performed an fMRI task involving a target letter in a string of identical targets (low load) or a target letter in a mixed letter string (high load) superimposed on fearful, angry, and neutral face distractors. Regardless of load condition, groups were similar in accuracy and reaction time. Under low load gSAD patients showed deficient rostral ACC recruitment to fearful (vs. neutral) distractors. For high load, increased activation to fearful (vs. neutral) distractors was observed in gSAD suggesting a compensatory function. Results remained after controlling for group differences in depression level. Findings indicate perceptual demand modulates ACC in gSAD.