Patrick J. F. Clarke

Absence of evidence or evidence of absence: reflecting on therapeutic implementations of attentional bias modification

Attentional bias modification (ABM) represents one of a number of cognitive bias modification techniques which are beginning to show promise as therapeutic interventions for emotional pathology. Numerous studies with both clinical and non-clinical populations have now demonstrated that ABM can reduce emotional vulnerability. However, some recent studies have failed to achieve change in either selective attention or emotional vulnerability using ABM methodologies, including a recent randomised controlled trial by Carlbring et al. Some have sought to represent such absence of evidence as a sound basis not to further pursue ABM as an online intervention. While these findings obviously raise questions about the specific conditions under which ABM procedures will produce therapeutic benefits, we suggest that the failure of some studies to modify selective attention does not challenge the theoretical and empirical basis of ABM. The present paper seeks to put these ABM failures in perspective within the broader context of attentional bias modification research. In doing so it is apparent that the current findings and future prospects of ABM are in fact very promising, suggesting that more research in this area is warranted, not less.

The Attentional Bias Modification Approach to Anxiety Intervention

Anxiety vulnerability and dysfunction are characterized by an attentional bias to threat. Cognitive training procedures designed to modify selective attentional responding to threat originally were developed to test the hypothesis that this attentional bias causally contributes to anxious disposition. The capacity of attentional bias modification (ABM) training to alleviate dysfunctional anxiety has since attracted growing interest, and the present article reviews studies that have evaluated this therapeutic potential. When intended ABM training has successfully reduced attention to threat, it also has reduced anxiety vulnerability and symptomatology with a high degree of reliability. When the delivery of intended ABM training has not resulted in such anxiety reduction, this typically has reflected the failure to successfully modify attentional selectivity as required. We discuss ways in which ABM training procedures may be refined to optimize their capacity to reduce attentional bias to threat, to improve delivery of the resulting anxiolytic benefits.

Assessing the role of spatial engagement and disengagement of attention in anxiety-linked attentional bias: a critique of current paradigms and suggestions for future research directions.

Abstract A considerable volume of research has demonstrated an anxiety-linked attentional bias characterized by selective processing of threat stimuli. The last decade has seen growing interest in identifying the precise attentional mechanisms which underlie such selective processing to advance both theoretical and etiological models of anxiety. This research has particularly focused on the roles of spatial engagement and disengagement of attention. The relative contribution of these attentional components to selective processing of threat in anxious individuals remains unclear however. Moreover, we argue here that many of the tasks employed to examine these mechanisms, may not be capable of indexing the attentional processes that they claim to measure. In this article, we provide a methodological review, critically evaluating the adequacy of previous tasks employed to measure biased attentional engagement and disengagement. Based on a number of concerns raised about the ability of such tasks to differentiate these component attentional processes, we detail three task criteria that we believe are essential to be confident that a task will accurately index biased attentional engagement with, and disengagement from threat in anxious participants.

Biased Attentional Processing of Positive Stimuli in Social Anxiety Disorder: An Eye Movement Study

Despite the established relationship between social anxiety and attentional bias towards threat, a growing base of evidence suggests that social anxiety is additionally maintained by a deficit in the attentional processing of positive information. However, it remains unclear which component of attention is implicated in this deficit. Using eye movement-based measures and a novel attentional cuing methodology, the present study sought to investigate the presence of anxiety-linked bias in attentional engagement with, attentional disengagement from, and total fixation time to, socially relevant emotional stimuli in individuals diagnosed with social anxiety disorder, relative to non-socially anxious controls. Socially anxious individuals were found to exhibit faster attentional disengagement from positive stimuli, and reduced total fixation time to all emotional stimuli, relative to controls. Additionally for socially anxious individuals, lower total fixation times to positive stimuli were associated with higher levels of state anxiety. No differential pattern of engagement was evident between groups. We conclude that social anxiety is maintained in part by the aberrant processing of positive social stimuli.

Prepared for the Worst: Readiness to Acquire Threat Bias and Susceptibility to Elevate Trait Anxiety

Although people differ in their susceptibility to elevate trait anxiety in response to extended stress, little is known about the cognitive substrate of this particular individual difference. We report three studies designed to evaluate the hypothesis that individual differences in readiness to acquire an attentional bias toward threat cues, in response to a contingency that makes the acquisition of such a bias adaptive, underlie individual differences in susceptibility to elevate trait anxiety in response to extended stress. Our findings confirm that the ease with which such a threat bias can be transiently evoked by experimental conditions that encourage its acquisition predicts the degree to which trait anxiety later becomes elevated by extended exposure to a mild stressor. Furthermore, this reflects the fact that such early measures of attentional bias plasticity predict the later naturalistic acquisition of attentional bias in response to subsequent stress, which in turn is associated with a consequent increase in trait anxiety level. These findings are consistent with our proposed account of individual differences in susceptibility to elevate trait anxiety in response to stress.

Validation of a novel attentional bias modification task: The future may be in the cards

Attentional bias modification (ABM) is a promising therapeutic tool aimed at changing patterns of attentional selectivity associated with heightened anxiety. A number of studies have successfully implemented ABM using the modified dot-probe task. However others have not achieved the attentional change required to achieve emotional benefits, highlighting the need for new ABM methods. The current study compared the effectiveness of a newly developed ABM task against the traditional dot-probe ABM task. The new person-identity-matching (PIM) task presented participants with virtual cards, each depicting a happy and angry person. The task encourages selective attention toward or away from threat by requiring participants to make matching judgements between two cards, based either on the identities of the happy faces, or of the angry faces. Change in attentional bias achieved by both ABM tasks was measured by a dot-probe assessment task. Their impact on emotional vulnerability was assessed by measuring negative emotional reactions to a video stressor. The PIM task succeeded in modifying attentional bias, and exerting an impact on emotional reactivity, whereas this was not the case for the dot-probe task. These results are considered in relation to the potential clinical utility of the current task in comparison to traditional ABM methodologies.

Attentional bias modification facilitates attentional control mechanisms : evidence from eye tracking

Social anxiety is thought to be maintained by biased attentional processing towards threatening information. Research has further shown that the experimental attenuation of this bias, through the implementation of attentional bias modification (ABM), may serve to reduce social anxiety vulnerability. However, the mechanisms underlying ABM remain unclear. The present study examined whether inhibitory attentional control was associated with ABM. A non-clinical sample of participants was randomly assigned to receive either ABM or a placebo task. To assess pre-post changes in attentional control, participants were additionally administered an emotional antisaccade task. ABM participants exhibited a subsequent shift in attentional bias away from threat as expected. ABM participants further showed a subsequent decrease in antisaccade cost, indicating a general facilitation of inhibitory attentional control. Mediational analysis revealed that the shift in attentional bias following ABM was independent to the change in attentional control. The findings suggest that the mechanisms of ABM are multifaceted.

Simply imagining sunshine, lollipops and rainbows will not budge the bias: The role of ambiguity in interpretive bias modification

Imagery-based interpretive bias modification (CBM-I) involves repeatedly imagining scenarios that are initially ambiguous before being resolved as either positive or negative in the last word/s. While the presence of such ambiguity is assumed to be important to achieve change in selective interpretation, it is also possible that the act of repeatedly imagining positive or negative events could produce such change in the absence of ambiguity. The present study sought to examine whether the ambiguity in imagery-based CBM-I is necessary to elicit change in interpretive bias, or, if the emotional content of the imagined scenarios is sufficient to produce such change. An imagery-based CBM-I task was delivered to participants in one of four conditions, where the valence of imagined scenarios were either positive or negative, and the ambiguity of the scenario was either present (until the last word/s) or the ambiguity was absent (emotional valence was evident from the start). Results indicate that only those who received scenarios in which the ambiguity was present acquired an interpretive bias consistent with the emotional valence of the scenarios, suggesting that the act of imagining positive or negative events will only influence patterns of interpretation when the emotional ambiguity is a consistent feature.

Assessing the Therapeutic Potential of Targeted Attentional Bias Modification for Insomnia Using Smartphone Delivery

Creation of experimental word stimuli Research assessing the presence of attentional bias in insomnia has consistently employed paired word stimuli that contain a threatening member, which communicates a meaning relevant to the concerns of those with sleep disturbance, and an emotionally neutral stimulus member (see [1]). In line with this, we included 48 threatening sleeprelated words characteristic of pre-sleep worry thoughts, paired with neutral words matched for length and spoken frequency [2] for the purpose of modification and assessment of attentional bias. The threat words were selected from an initial pool of 96 candidate words. These words were generated on the basis of three factors identified by Wicklow and Espie [3] as core themes relevant to presleep worry consistently reported by individuals with insomnia: active problem solving (e.g. thoughts about the negative consequences of poor sleep), present-state monitoring (e.g. thoughts about bodily functions), and reactivity to external stimuli (e.g. thoughts about environmental factors disturbing sleep). All 96 candidate words were rated by 12 independent judges using a 7-point scale on emotional valence, from 1 (Very negative) to 7 (Very positive) and relatedness to sleep concerns, from 1 (Not at all) to 7 (Extremely). The final selected threat words were rated to be strongest in negative valence (M = 2.35, SD = 0.78) and most relevant to sleep concerns (M = 4.67, SD = 0.93). The word pairs were randomised and divided into two separate stimulus subsets (Subset A and Subset B). For half the participants in each condition Subset A was used in the training/control component and Subset B was used in the assessment component of the task, while the remaining participants received the reverse allocation. The use of different stimuli in the training and assessment components ensures that any change in attentional bias can be attributed to the class of stimulus and not to specific stimuli themselves. These stimuli are provided in Supplementary Table 1.

The Potential Benefits of Targeted Attentional Bias Modification on Cognitive Arousal and Sleep Quality in Worry-Related Sleep Disturbance

Attentional bias for sleep-related negative information is believed to contribute to symptoms of insomnia by elevating arousal during the presleep period. In the present study, we examined whether the delivery of an attentional bias modification (ABM) procedure in the presleep period could produce transient benefits for sleep-disturbed individuals by reducing presleep cognitive arousal and improving ease of sleep onset. In a counterbalanced repeated A-B design, participants alternated completing an ABM training task and a nontraining control task across six nights and reported on presleep cognitive arousal and sleep onset latency. Significant reductions in presleep cognitive arousal and sleep onset latency were observed on nights where the ABM task was completed relative to nights where the control task was completed. These results suggest that delivery of ABM can attenuate cognitive arousal and sleep onset latency and highlights the possibility that targeted delivery of ABM could deliver real-world benefits for sleep-disturbed individuals.