DEFICITS IN DISENGAGING ATTENTION FROM THREAT PREDICT IMPROVED RESPONSE TO COGNITIVE BEHAVIORAL THERAPY FOR ANXIETY

Attentional heterogeneity in social anxiety disorder: Evidence from Hidden Markov Models

There is some evidence for heterogeneity in attentional processes among individuals with social anxiety. However, there is limited work considering how attentional processes may differ as a mechanism in a naturalistic task-based context (e.g., public speaking). In this secondary analysis we tested attentional heterogeneity among individuals diagnosed with social anxiety disorder (N = 21) in the context of a virtual reality exposure treatment study. Participants completed a public speaking challenge in an immersive 360°-video virtual reality environment with eye tracking at pre-treatment, post-treatment, and at 1-week follow-up. Using a Hidden Markov Model (HMM) approach with clustering we tested whether there were distinct profiles of attention pre-treatment and whether there were changes following the intervention. As a secondary aim we tested whether the distinct attentional profiles at pre-treatment predicted differential treatment outcomes. We found two distinct attentional profiles pre-treatment that we characterized as audience-focused and audience-avoidant. However, by the 1-week follow-up the two profiles were no longer meaningfully different. We found a meaningful difference between HMM groups for fear of public speaking at post-treatment b = -8.54, 95% Highest Density Interval (HDI) [-16.00, -0.90], Bayes Factor (BF) = 8.31 but not at one-week follow-up b = -5.83, 95% HDI [-13.25, 1.81], BF = 2.28. These findings provide support for heterogeneity in attentional processes among socially anxious individuals, but our findings indicate that this may change following treatment. Moreover, our results offer preliminary mechanistic evidence that patterns of avoidance may be specifically related to poorer treatment outcomes for virtual reality exposure therapy.

The role of attentional shifting in the relation between error monitoring and anxiety in youth

The error-related negativity (ERN), a well-established neural marker of anxiety, reflects enhanced attention to internal threat signals. While attention to threat plays a crucial role in the development and maintenance of anxiety, it is unclear how attentional control influences the ERN-anxiety association. To address this, 37 youths (M_age = 10.89 years) completed self-report measures of attentional control and anxiety symptoms. To obtain ERN amplitude, youth completed a flanker task while simultaneous EEG was collected. Attentional control, specifically attentional shifting rather than focusing, moderated the relation between ERN amplitude and anxiety. Youth who displayed smaller neural responses to making an error and higher ability to shift attention experienced lower levels of anxiety, relative to those who exhibited larger neural responses to making an error or lower attention-shifting ability. These findings highlight that response magnitude to internal threat and ability to flexibly shift attention may jointly contribute to anxiety in youth.

Avoidance of mild threat observed in generalized anxiety disorder (GAD) using eye tracking

Attentional biases towards threat are assumed to be a causal factor in the development of anxiety disorders, including generalized anxiety disorder (GAD). However, findings have been inconsistent, and studies often examine single time-point bias during threat exposure, instead of across time. Attention to threat may shift throughout exposure (e.g., from initial engagement to avoidance), and research suggests that threat intensity and state anxiety influence attentional biases. No studies to our knowledge have examined biases across time and with varying threat intensity and state anxiety. Participants with GAD (n=38) and non-anxious controls (n=25) viewed emotional (high threat, mild threat, and positive) and neutral image pairs under calm and anxious mood states while their eye movements were tracked. Participants showed an initial orientation to emotional images, and, under the anxious mood induction, demonstrated a bias towards threatening images at first fixation and over time. Results suggest it may be normative to attend to threat cues over other stimuli while in an anxious state. Individuals with GAD uniquely showed a bias away from mild (but not high) threat images over time relative to controls. Implications for theories of attentional biases to threat and clinical implications for GAD and anxiety disorders broadly are discussed.

Effects of increased attention allocation to threat and safety stimuli on fear extinction and its recall

BACKGROUND AND OBJECTIVES

Attention plays an important role in the treatment of anxiety. Increased attention to threat has been shown to yield improved treatment outcomes in anxious patients following exposure-based therapy. This study examined whether increasing attention to learned stimuli during fear extinction, an experimental analogue for exposure-based treatments, could improve extinction learning and its maintenance.

METHODS

Sixty-five healthy adults were randomized into experimental or control conditions. All completed a differential fear conditioning task. During extinction, a subtle attentional manipulation was implemented in the experimental group, designed to increase participants' attention to both threat and safety cues. Three days later, an extinction recall test was conducted using the original cues and two perceptually similar morphs.

RESULTS

Fear conditioning was achieved in both behavioral and psychophysiological measures. In addition, between-group differences emerged during extinction. The experimental group exhibited increased attention to stimuli and lower fear responses in physiological measure than the control group. Similarly, during extinction recall, the experimental group exhibited lower startle responses than the control group. Last, across groups, attending to the safety cue during extinction was associated with lower self-reported risk of the two generalization morphs displayed during extinction recall.

LIMITATIONS

Skin conductance response (SCR) was not measured during extinction recall. Future research should include both SCR and additional generalization morphs so as to allow for the examination of more subtle individual differences.

CONCLUSIONS

Results indicate that the attentional manipulation increased attention allocation to stimuli during extinction; this, in turn, affected fear-related physiological response.

Posttraumatic stress disorder and the social brain: Affect-related disruption of the default and mirror networks

BACKGROUND

Social cognitive impairments, specifically in mentalizing and emotion recognition, are common and debilitating symptoms of posttraumatic stress disorder (PTSD). Despite this, little is known about the neurobiology of these impairments, as there are currently no published neuroimaging investigations of social inference in PTSD.

METHODS

Trauma-exposed veterans with and without PTSD (n = 20 each) performed the Why/How social inference task during functional magnetic resonance imaging (fMRI). Patients with PTSD had two fMRI sessions, between which they underwent affect labeling training. We probed the primary networks of the "social brain"-the default mode network (DMN) and mirror neuron system (MNS)-by examining neural activity evoked by mentalizing and action identification prompts, which were paired with emotional and nonemotional targets.

RESULTS

Hyperactivation to emotional stimuli differentiated PTSD patients from controls, correlated with symptom severity, and predicted training outcomes. Critically, these effects were nonsignificant or marginal for nonemotional stimuli. Results were generally consistent throughout DMN and MNS. Unexpectedly, effects were nonsignificant in core affect regions, but robust in regions that overlap with the dorsal attention, ventral attention, and frontoparietal control networks.

CONCLUSIONS

The array of social cognitive processes subserved by DMN and MNS appear to be inordinately selective for emotional stimuli in PTSD. However, core affective processes do not appear to be the primary instigators of such selectivity. Instead, we propose that affective attentional biases may instigate widespread affect-selectivity throughout the social brain. Affect labeling training may inhibit such biases. These accounts align with numerous reports of affect-biased attentional processes in PTSD.

The effect of Baduanjin qigong combined with CBT on physical fitness and psychological health of elderly housebound

BACKGROUND

To investigate the effectiveness of Baduanjin qigong combined with cognitive-behavior therapy (CBT) on the physical fitness and psychological health of elderly housebound.

MATERIALS AND METHODS

The 120 elderly housebound were randomly divided into 3 intervention groups: Baduanjin training, Baduanjin training combined with CBT, and CBT. The interventions were conducted by means of home visits over 6 months. Spirometry, SF-36 health survey of quality of life, and Lawton and Brody Instrumental Activities of Daily Living Scale (IADL) were used to collect physical health data, and self-evaluation of overall health status, self-evaluation of loneliness, and short-form geriatric depression scale (GDS-15) were used to collect mental health data at baseline, 3 months, and 6 months after intervention. Data was analyzed by repeated measures analysis of variance (rANOVA) and chi-squared test (χ test).

RESULTS

Forced vital capacity (FVC), maximum voluntary ventilation (MVV), quality of life (QOL), and self-reported health status were significantly increased (P < .05) in the group receiving joint Baduanjin and CBT intervention at 3 months and 6 months, as compared to the Baduanjin only group or the CBT only group. Activities of daily living (ADL), self-evaluated loneliness, and level of depression were significantly lowered (P < .05) in the group receiving joint Baduanjin and CBT intervention at 3 months and 6 months, as compared to the Baduanjin only group or the CBT only group.

CONCLUSIONS

Physical and psychological statuses of elderly housebound were significantly improved by Baduanjin training combined with CBT. The effect of the combined intervention exceeded that of CBT or Baduanjin alone.

State-of-the-art and future directions for extinction as a translational model for fear and anxiety

Through advances in both basic and clinical scientific research, Pavlovian fear conditioning and extinction have become an exemplary translational model for understanding and treating anxiety disorders. Discoveries in associative and neurobiological mechanisms underlying extinction have informed techniques for optimizing exposure therapy that enhance the formation of inhibitory associations and their consolidation and retrieval over time and context. Strategies that enhance formation include maximizing prediction-error correction by violating expectancies, deepened extinction, occasional reinforced extinction, attentional control and removal of safety signals/behaviours. Strategies that enhance consolidation include pharmacological agonists of NMDA (i.e. d-cycloserine) and mental rehearsal. Strategies that enhance retrieval include multiple contexts, retrieval cues, and pharmacological blockade of contextual encoding. Stimulus variability and positive affect are posited to influence the formation and the retrieval of inhibitory associations. Inhibitory regulation through affect labelling is considered a complement to extinction. The translational value of extinction will be increased by more investigation of elements central to extinction itself, such as extinction generalization, and interactions with other learning processes, such as instrumental avoidance reward learning, and with other clinically relevant cognitive-emotional processes, such as self-efficacy, threat appraisal and emotion regulation, will add translational value. Moreover, framing fear extinction and related processes within a developmental context will increase their clinical relevance.This article is part of a discussion meeting issue 'Of mice and mental health: facilitating dialogue between basic and clinical neuroscientists'.

Attentional Control and Fear Extinction in Subclinical Fear: An Exploratory Study

Attentional control (AC) and fear extinction learning are known to be involved in pathological anxiety. In this study we explored whether individual differences in non-emotional AC were associated with individual differences in the magnitude and gradient of fear extinction (learning and recall). In 50 individuals with fear of spiders, we collected measures of non-emotional AC by means of self-report and by assessing the functioning of the major attention networks (executive control, orienting, and alerting). The participants then underwent a paradigm assessing fear extinction learning and extinction recall. The two components of the orienting network functioning (costs and benefits) were significantly associated with fear extinction gradient over and above the effects of trait anxiety. Specifically, participants with enhanced orienting costs (i.e., difficulties in disengaging attention from cues not relevant for the task) showed faster extinction learning, while those with enhanced orienting benefits (i.e., attention facilitated by valid cues) exhibited faster extinction recall as measured by fear-potentiated startle and Unconditioned Stimulus expectancies, respectively. Our findings suggest that, in non-emotional conditions, the orienting component of attention may be predictive of fear extinction. They also show that the use of fear extinction gradients and the exploration of individual differences in non-emotional AC (using performance-based measures of attentional network functioning) can provide a better understanding of individual differences in fear learning. Our findings also may help to understand differences in exposure therapy outcomes.

New Developments in Cognitive-Behavioral Therapy for Social Anxiety Disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that causes considerable psychosocial impairment. This article reviews recent changes in the definition of SAD in DSM-5 and summarizes the current evidence for effective cognitive-behavioral treatments in adults, children, and adolescents. Current data suggests that cognitive-behavioral therapy (CBT) is efficacious in the treatment of this condition. Among different CBT approaches, individual cognitive therapy may be associated with the largest effect sizes. In this review, interventions targeting dysfunctional cognitive processes that contribute to the effective treatment of SAD are discussed. Some recent findings from neuroimaging research and studies on the augmentation of CBT using neuroenhancers indicate that changes in emotion regulation as well as fear extinction are important psychological mediators of positive outcome. Furthermore, internet-delivered CBT is a promising field of technological innovation that may improve access to effective treatments. Despite the availability of effective treatments, treatment-resistant SAD remains a common problem in clinical practice that requires more research efforts. Finally, potential areas for further development of CBT as well as its dissemination in health care are summarized.