Anxiety sensitivity: The role of conscious awareness and selective attentional bias to physical threat

"Warning-This Content May Trigger Temporary Discomfort, Which Is Expected and Manageable": The Effect of Modified Trigger-Warning Language on Reactions to Emotionally Provocative Content

A growing body of research suggests that trigger warnings do not actually reduce distress in those viewing emotionally provocative stimuli and may at times even worsen it. However, little is known regarding the potential benefits of modifying trigger-warning language so that it employs therapeutically consistent messaging to encourage adaptive coping. The current study explored whether a modified trigger warning might be more effective than a traditional trigger warning in reducing participants' negative affect (NA) when exposed to distressing content. University students (N = 606) participated in an online study and were randomly assigned to one of three conditions: traditional trigger warning, modified trigger warning, or a no-warning control group. NA was measured before and after display of two emotionally provocative stimuli (one article and one video). Anxiety sensitivity (AS) and posttraumatic stress symptoms (PTSS) were also measured to assess whether these preexisting individual vulnerabilities might moderate participants' responses to the different messages. Although the carefully pilot-tested stimuli were successful in increasing NA, there was no significant effect of trigger-warning condition, despite ample statistical power. AS and PTSS were associated with higher overall levels of NA but did not interact with study condition. These results add to the growing body of literature suggesting trigger warnings (whether traditional or modified) do not succeed in their goal of reducing the distress elicited by emotionally provocative content, including among vulnerable individuals. Alternative approaches to traditional trigger warnings are considered that may help individuals cope adaptively with potentially distressing material.

A cross-sectional analysis of the relationships between anxiety sensitivity and youth irritability: the mediated roles of insomnia and selective attention for threat

BACKGROUND

Irritability is common in multiple psychiatric disorders and is hallmark of disruptive mood dysregulation disorder. Child irritability is associated with higher risk of suicide and adulthood mental health problems. However, the psychological mechanisms of irritability are understudied. This study examined the relationship between anxiety sensitivity and irritability among youth, and further explored three possible mediated factors: selective attention for threat, delayed reward discounting, and insomnia.

METHODS

Participants were 1417 students (51.7% male; mean age 13.83 years, SD = 1.48) recruited from one high school in Hunan province, China. Self-report questionnaires were used to measure irritability (The Affective Reactivity Index and The Brief Irritability Test), anxiety sensitivity (The Childhood Anxiety Sensitivity Index), selective attention for threat (The Davos Assessment of Cognitive Biases Scale-attention for threat bias subscale), insomnia (The Youth Self-Rating Insomnia Scale), and delayed reward discounting (The 27-item Monetary Choice Questionnaire). Structural equation modal (SEM) was performed to examine mediated relations.

RESULTS

Anxiety sensitivity was modestly related to irritability and insomnia (r from 0.25 to 0.54) and slightly correlated with selective attention for threat (r from 0.12 to 0.28). However, there is no significant relationship of delayed rewards discounting with anxiety sensitivity and irritability. The results of SEM showed that selective attention for threat (indirect effect estimate = 0.04) and insomnia (indirect effect estimate = 0.20) partially mediate the relationship between anxiety sensitivity and irritability, which explained 34% variation.

CONCLUSIONS

Anxiety sensitivity is an important susceptibility factor for irritability. Selective attention for threat and insomnia are two mediated mechanisms to understand the relationship between anxiety sensitivity and irritability.

Comparing the Effects of Thought Suppression and Focused Distraction on Pain-Related Attentional Biases in Men and Women

Increasing attentional focus away from pain can affect pain experience, suggesting that cognitive strategies that move attentional allocation may be a moderator of pain. In a pre-post-design, the present study examined the effects of 2 cognitive strategies used in pain contexts, thought suppression and focused distraction, on subsequent pain-related attention. Thought suppression was hypothesized to increase pain-related attention, whereas focused distraction was expected to reduce it. Influences of both anxiety and sex were also considered, as secondary questions. 139 (86 women, 53 men) healthy, pain-free participants were randomly assigned to use either thought suppression or focused distraction during a mild cold pressor test (CPT). Pain-related attention was examined using a dot-probe and an attentional blink task, pre-and post-CPT. Questionnaires about relevant cognitive and emotional aspects, demographics, and pain were completed. Results showed no difference in the effect of the 2 pain inhibition strategies on pain-related attention. The hypothesized rebound effect in thought suppression on pain-related attention did not emerge. However, thought suppression showed a short-term benefit in comparison to focused distraction regarding reported pain and perceived threat during the cold pressor test. Few sex differences were found. Thus, the cognitive strategies affected pain outcomes, but did not influence pain-related attention. PERSPECTIVE: Cognitive strategies could help with pain through changing attention allocation. In this study, the effects of the 2 cognitive strategies thought suppression and focused distraction on pain-related attention in men and women were examined. Elucidating mechanisms that lie behind pain strategies that focus on changing attention may help improve treatments.

The roles of disgust sensitivity and anxiety sensitivity in attentional bias in dental anxiety

Individuals with dental anxiety show biased attentional processing of threat- and dental-related information. Disgust sensitivity and anxiety sensitivity are both associated with dental fears and attentional biases. Whereas disgust sensitivity is generally associated with attentional avoidance (Armstrong et al., 2014), anxiety sensitivity may be associated with attentional engagement (Keogh et al., 2001a). Elucidating the role of these constructs in dental anxiety-relevant attentional biases could inform theoretical models and/or intervention recommendations. Participants (N = 51) with high dental anxiety completed a Posner paradigm to assess attentional biases to dental versus neutral stimuli. We examined whether disgust sensitivity and anxiety sensitivity moderated degree of attentional bias. Results indicated that both disgust sensitivity (mutilation subscale) and anxiety sensitivity (physical concerns subscale) statistically moderated degree of attentional bias at trend level, and in opposite directions. Simple effects analyses further indicated that disgust sensitivity regarding mutilation was associated with less attentional bias toward dental relative to neutral stimuli, potentially indicating attentional avoidance, and remained so when adjusting for anxiety sensitivity. In contrast, simple effects analysis indicated that anxiety sensitivity regarding physical concerns was not associated with magnitude of attentional bias. If replicated, findings highlight the potential role of disgust in dental anxiety.

Psychological Distress and Physical Health Symptoms in the Latinx Population During the COVID-19 Pandemic: Exploring the Role of Anxiety Sensitivity

Objective

The outbreak of the novel 2019 SARS2-Coronavirus disease (COVID-19) has led to substantial physical and mental health consequences. Rates of mortality and hospitalization are highest among those of racial and ethnic minority persons, including Latinx persons. Further, Latinx persons have been experiencing elevated mental health problems in response to the pandemic compared to non-Latinx Whites. The current study examined whether individual differences in anxiety sensitivity (AS) related to more severe emotional distress associated with social distancing, financial strain, fear of COVID-19, and physical health symptoms stemming from the COVID-19 pandemic among Latinx adults.

Methods

Participants included 188 Latinx persons (31.4% female, M_age = 34.1 years, SD = 8.16) recruited via an online survey panel program.

Results

Results indicated that AS significantly contributed to increased severity of the emotional stress response associated with social distancing (ΔR² = 0.15, p < 0.001), financial strain (ΔR² = 0.15, p < 0.001), physical health symptoms (ΔR² = 0.03, p = 0.006), and fear of COVID-19 (ΔR² = 0.15, p < 0.001). These effects were evident over and above the variance accounted for by gender, years living in the United States, education, and work and home life COVID-19-related stress.

Conclusions

These cross-sectional findings suggest AS may be an important individual difference factor for better understanding mental health among Latinx persons in the context of the COVID-19 pandemic.

Anxiety sensitivity and bodily kinematics

Anxiety sensitivity (AS) is an individual difference factor reflecting the fear of anxiety-related sensations and is one of the best researched risk factors for psychopathology. Decades of research have focused on exploring the relations between AS and clinical symptoms and disorders, although most of the research has employed self-report or interview-based methodologies to index primary dependent measures. No past research has sought to characterize the explanatory relevance of AS from a body kinematics perspective. The present study explored AS in relation to body kinematics to AS-specific images using a dual-task attentional control paradigm (i.e., approach versus avoidance) that employs AS-specific stimuli and motion-tracking technology. Participants included 108 young adults (58.3% female, M age = 25.3) who took part in a ball catching game to index their measures of behavioral engagement with the AS-specific and neutral stimuli presented at either side of the game environment. After adjusting for age, gender, race, handedness, physical functioning, and negative affectivity, self-reported AS was significantly associated with biokinematically-driven behavioral engagement with the AS-specific stimuli. The present study provides novel empirical evidence that AS is related to anxiety-related bodily kinematics. Future work is needed to extend the current results to clinical samples.

Sex, Gender, and Orofacial Pain

This review examines gender prevalence in orofacial pain to elucidate underlying factors that can explain such differences. This review highlights how gender affects (1) the association of hormonal factors and pain modulation; (2) the genetic aspects influencing pain sensitivity and pain perception; (3) the role of resting blood pressure and pain threshold; and (4) the impact of sociocultural, environmental, and psychological factors on pain.

Anxiety sensitivity is associated with attentional bias for pain-related information in healthy children and adolescents

This investigation explored the association between anxiety sensitivity and attentional bias for threatening information in children and adolescents ( N = 40). Participants completed a pictorial version of the visual-probe task, featuring pain-related, health-threat and general-threat images presented for 500 and 1250 ms. Regression analyses revealed significant associations between anxiety sensitivity and attentional bias towards pain-related images presented for 500 ms and between state anxiety and attentional bias towards general-threat images presented for 1250 ms. These results suggest that in children and adolescents, anxiety sensitivity is associated with attentional bias for negative information of personal relevance.

Neural correlates of individual differences in anxiety sensitivity: an fMRI study using semantic priming

Individuals with high anxiety sensitivity (AS) have an increased risk of developing anxiety disorders and are more biased in how they process fear-related stimuli. This study investigates the neural correlates of fear-related words and word associations in high- and low-AS individuals. We used a semantic priming paradigm during functional magnetic resonance imaging in which three types of target words (fear symptoms, e.g. 'dizziness'; neutral, e.g. 'drink'; and pseudowords, e.g. 'salkom') were preceded by two types of prime words (fear-triggers, e.g. 'elevator'; and neutral, e.g. 'bottle'). Subjects with high AS rated fear-symptom words (vs neutral words) as more unpleasant than low-AS individuals; they also related these words more strongly to fear-triggers and showed prolonged reaction times. During the processing of fear-symptom words, greater activation in the left anterior insula was observed in high-AS subjects than in low-AS subjects. Lower activation in the left inferior frontal gyrus, angular gyrus, fusiform gyrus and bilateral amygdalae was found in high-AS subjects when fear-symptom words were preceded by fear-trigger words. The findings suggest that cognitive biases and the anterior insula play a crucial role in high-AS individuals. Furthermore, semantic processes may contribute to high AS and the risk of developing anxiety disorders.

Reward devaluation: Dot-probe meta-analytic evidence of avoidance of positive information in depressed persons

Cognitive theories of depression and anxiety have traditionally emphasized the role of attentional biases in the processing of negative information. The dot-probe task has been widely used to study this phenomenon. Recent findings suggest that biased processing of positive information might also be an important aspect of developing psychopathological symptoms. However, despite some evidence suggesting persons with symptoms of depression and anxiety may avoid positive information, many dot-probe studies have produced null findings. The present review used conventional and novel meta-analytic methods to evaluate dot-probe attentional biases away from positive information and, for comparison, toward negative information, in depressed and anxious individuals. Results indicated that avoidance of positive information is a real effect exhibiting substantial evidential value among persons experiencing psychopathology, with individuals evidencing primary symptoms of depression clearly demonstrating this effect. Different theoretical explanations for these findings are evaluated, including those positing threat-processing structures, even-handedness, self-regulation, and reward devaluation, with the novel theory of reward devaluation emphasized and expanded. These novel findings and theory suggest that avoidance of prospective reward helps to explain the cause and sustainability of depressed states. Suggestions for future research and methodological advances are discussed.

Anxiety sensitivity and the anticipation of predictable and unpredictable threat: Evidence from the startle response and event-related potentials

There is growing evidence that heightened sensitivity to unpredictable threat is a core mechanism of dysfunction in anxiety disorders. However, it is unclear whether anxiety sensitivity is also associated with sensitivity to unpredictable threat. In the present study, 131 participants completed the Anxiety Sensitivity Index-3, which includes physical concerns (PC), social concerns (SC), and cognitive concerns (CC) subscales, and a predictable vs. unpredictable threat-of-shock task. Startle eyeblink and ERP responses (N100, P300) to the acoustic startle probes were measured during the task. PC and CC were associated with heightened and attenuated, respectively, startle for the unpredictable (but not predictable) condition. CC were also associated with attenuated probe N100 for the unpredictable condition only, and PC were associated with increased P300 suppression across the predictable and unpredictable conditions. This study provides novel evidence that the different anxiety sensitivity dimensions demonstrate unique relationships with the RDoC domains "acute" and "potential" threat.

Health threat increases attentional bias for negative stimuli

BACKGROUND AND OBJECTIVES

Although there is some evidence that health anxiety is associated with attentional bias, relatively little research has examined the role of situational threat on bias. This study examined the effect of health threat on attentional bias for negative health words.

METHODS

Participants completed questionnaires and were then randomized to receive either threatening or reassuring health-related feedback. Following randomization, participants completed the emotional Stroop and dot-probe tasks in a counter-balanced order.

RESULTS

On the emotional Stroop task, all participants took longer to name the colour of negative words, as compared to positive and neutral words. However on the dot probe task, differences in attentional bias emerged based on feedback condition. Those receiving reassuring feedback displayed a bias away from negative words while those receiving threatening feedback did not display a bias either towards or away from negative words. Following reassuring feedback only, metacognitions were negatively correlated with attention towards positive health-related stimuli, suggesting another avenue for future research.

CONCLUSIONS

Health threats lead to an increase in the processing of negative information, and the effect of metacognitions on processing appears to be apparent only in the absence of health threat.

Does anxiety sensitivity correlate with startle habituation? An examination in two independent samples

Individuals with anxiety disorders have previously demonstrated abnormal habituation to aversiveness over time. As anxiety sensitivity (AS), or an individuals' propensity to fear of anxiety-related sensations, has been shown to be a risk factor for anxiety disorders (particularly panic disorder), the present study examined whether AS was also associated with abnormal habituation. This association was examined in two independent samples of undergraduates (Ntotal=178). Habituation was operationalised as the reduction in startle response to multiple startle probes presented over 2.5 minutes and three definitions of this reduction were employed. Results indicated that individuals with higher levels of AS evidenced deficits in startle habituation, but the strength of this relationship was somewhat dependent on the definition of startle habituation, with the most robust definition being an analysis of participants' individual slopes across all nine blinks. The present findings suggest that startle habituation is a key mechanism underlying AS, and may help elucidate the role this risk factor plays in the pathogenesis of anxiety disorders.

Subliminal food images compromise superior working memory performance in women with restricting anorexia nervosa

Prefrontal cortex (PFC) is dysregulated in women with restricting anorexia nervosa (RAN). It is not known whether appetitive non-conscious stimuli bias cognitive responses in those with RAN. Thirteen women with RAN and 20 healthy controls (HC) completed a dorsolateral PFC (DLPFC) working memory task and an anterior cingulate cortex (ACC) conflict task, while masked subliminal food, aversive and neutral images were presented. During the DLPFC task, accuracy was higher in the RAN compared to the HC group, but superior performance was compromised when subliminal food stimuli were presented: errors positively correlated with self-reported trait anxiety in the RAN group. These effects were not observed in the ACC task. Appetitive activation is intact and anxiogenic in women with RAN, and non-consciously interacts with working memory processes associated with the DLPFC. This interaction mechanism may underlie cognitive inhibition of appetitive processes that are anxiety inducing, in people with AN.

The Benefits of Mindfulness Meditation: Changes in Emotional States of Depression, Anxiety, and Stress

The research investigated the effect of mindfulness meditation on the emotional states of depression, anxiety, and stress. Additionally, we explored whether people with varying severity of depression, anxiety, and stress responded differently to mindfulness training. In order to investigate these questions, participants (n = 50) completed the Depression Anxiety and Stress Scale, 21-item version (DASS-21) before and after a 10-week mindfulness meditation program. As predicted, the severity levels of all affective measures have decreased by the end of the meditation course. Participants with severe emotional difficulties at the time of commencing the meditation course demonstrated the most notable improvement over time. These results suggest that mindfulness training is beneficial in reducing the symptoms of subclinical depression and anxiety and can substantially reduce stress. Attentional retraining and self-management aspects of mindfulness meditation, as well as relevant methodological issues are discussed.

Health anxiety and attentional bias: the time course of vigilance and avoidance in light of pictorial illness information

Cognitive-behavioral models of health anxiety stress the importance of selective attention not only towards internal but also towards external health threat related stimuli. Yet, little is known about the time course of this attentional bias. The current study investigates threat related attentional bias in participants with varying degrees of health anxiety. Attentional bias was assessed using a visual dot-probe task with health-threat and neutral pictures at two exposure durations, 175ms and 500ms. A baseline condition was added to the dot-probe task to dissociate indices of vigilance towards threat and difficulties to disengage from threat. Substantial positive correlations of health anxiety, anxiety sensitivity, and absorption with difficulties to disengage from threat were detected at 500ms exposure time. At an early stage (i.e., at 175ms exposure time), we found significant positive correlations of health anxiety and absorption with orientation towards threat. Results suggest a vigilance avoidance pattern of selective attention associated with pictorial illness related stimuli in health anxiety.

Temperament, attentional processes, and anxiety: diverging links between adolescents with and without anxiety disorders?

The present study first examined the links between reactive temperament (negative affectivity), regulative temperament (effortful control [EC]) and internalizing problems in adolescents (12-18 years) with anxiety disorders (ANX; N = 39) and without anxiety disorders (nANX; N = 35). Links differed between ANX and nANX participants. Negative affectivity predicted internalizing problems, with almost no role of EC in nANX, but a protective role of EC was found in ANX youth. Second, we investigated the role of attentional bias as a mediator between temperament and internalizing problems. Strategic threat-related bias was predicted by initial attention and EC, but these relations differed in both groups. In nANX participants, higher initial bias scores were predictive for lower strategic bias scores and higher levels of EC were associated with higher bias scores. In ANX participants, there was almost no effect of initial bias or EC on strategic attention. Internalizing problems were predicted by strategic attention, but again differently in ANX and nANX participants. High strategic bias scores were associated with an increase in anxiety in ANX and a decrease in anxiety in nANX participants.

Attentional bias to pain and social threat in pediatric patients with functional abdominal pain and pain-free youth before and after performance evaluation

This study investigated attentional biases for pain and social threat versus neutral stimuli in 54 youth with functional abdominal pain (FAP) and 53 healthy control subjects (ages 10 to 16 years). We assessed attentional bias using a visual probe detection task (PDT) that presented pain and social threat words in comparison to neutral words at conscious (1250 ms) and preconscious (20 ms) presentation rates. We administered the PDT before and after random assignment of participants to a laboratory stressor--failure versus success feedback regarding their performance on a challenging computer game. All analyses controlled for trait anxiety. At the conscious rate of stimulus presentation, FAP patients exhibited preferential attention toward pain compared with neutral stimuli and compared with the control group. FAP patients maintained preferential attention toward conscious pain stimuli after performance feedback in both failure and success conditions. At the preconscious rate of stimulus presentation, FAP patients' attention was neutral at baseline but increased significantly toward pain stimuli after performance feedback in both failure and success conditions. FAP patients' somatic symptoms increased in both failure and success conditions; control youth's somatic symptoms only increased after failure. Regarding social threat, neither FAP nor control youth exhibited attentional bias toward social threat compared with neutral stimuli at baseline, but both FAP and control youth in the failure condition significantly increased attention away from social threat after failure feedback. Results suggest that FAP patients preferentially attend to pain stimuli in conscious awareness. Moreover, performance evaluation may activate their preconscious attention to pain stimuli.

A meta-analytic review of the association between anxiety sensitivity and pain

In recent years, anxiety sensitivity (AS) has demonstrated applicability across a wide range of conditions. An area of particular interest has been the association between AS and pain. This study aimed to provide an accounting of the magnitude of this effect across studies of both clinical and nonclinical pain. Forty-one studies (14 clinical and 27 nonclinical pain) were evaluated in this meta-analytic review and represented the study of 5,908 participants (2,093 for clinical and 3,815 for nonclinical pain studies). Results indicate that AS was strongly associated with fearful appraisals of pain, with more modest results for measures of pain tolerance/threshold and pain-related disability. Implications of these results for the treatment of chronic pain are discussed.

An examination of recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample

Both non-clinical panic attacks and panic disorder (PD) have been found to be associated with generalized anxiety disorder (GAD). This study examined a proxy risk factor model of the relationship between non-clinical panic attacks, PD, and GAD. Specifically, it was proposed that non-clinical panic attacks and PD predict GAD only due to their shared association with anxiety sensitivity (AS) and difficulties in emotion regulation. Results demonstrated that emotion regulation difficulties reliably predicted GAD above and beyond the experience of non-clinical panic attacks and PD. However, although PD lost strength as a predictor, it remained significantly associated with GAD in the full model, providing only partial support for the proposed proxy risk factor model. Findings speak to the underlying role of emotion regulation difficulties in GAD, and suggest that it may be the shared relationship of these difficulties with both PD and GAD that partially explain the association of these disorders.

Examining content specificity of negative interpretation biases with the Body Sensations Interpretation Questionnaire (BSIQ)

Cognitive biases have been suggested to act as latent vulnerability factors for the onset and maintenance of affective and emotional disorders. Additionally, several global and specific personality constructs are known to influence the course of psychopathology (e.g., trait anxiety, optimism, anxiety sensitivity (AS), injury/illness sensitivity (IS), fear of negative evaluation (FNE)). The current study examined the specificity of the relation between these constructs and a negative interpretation bias. One hundred and fifty-four healthy participants completed the Body Sensations Interpretation Questionnaire (BSIQ) [Clark, D. A., Salkovskis, P. M., Breitholtz, E., Westling, B. E., Ost, L.-G., Koehler, K. A., et al. (1997). Misinterpretation of body sensations in panic disorder. Journal of Consulting and Clinical Psychology, 65, 203-213], measuring negative interpretations on four domains. A confirmatory factor analysis offered support for four factors in the BSIQ. Multiple linear regression analyses demonstrated that optimism is predictive of less negative interpretations. AS, IS, and FNE are specifically predictive of negative interpretations on the panic, other bodily symptoms, and social situations subscale, respectively. In addition, specific pain-related constructs were found most predictive of the other bodily sensations subscale. It is concluded that individual variability in global and specific psychological constructs is associated with a content-specific negative interpretation bias.

Preattentive processing of heart cues and the perception of heart symptoms in congenital heart disease

The present study was aimed at clarifying whether preattentive processing of heart cues results in biased perception of heart sensations in patients with congenital heart disease (ConHD) who are also highly trait anxious. Twenty-six patients with ConHD and 22 healthy participants categorized heart-related (heart rate) or neutral sensations (constant vibration) as either heart or neutral. Both sensations were evoked using a bass speaker that was attached on the chest of the participant. Before each physical sensation, a subliminal heart-related or neutral prime was presented. Biased perception of heart-sensations would become evident by a delayed categorization of the heart-related sensations. In line with the prediction, a combination of high trait anxiety and ConHD resulted in slower responses after a heart-related sensation that was preceded by a subliminal heart cue. Preattentive processing of harmless heart cues may easily elicit overperception of heart symptoms in highly trait anxious patients with ConHD.

Anxiety sensitivity, conscious awareness and selective attentional biases in children

The current study investigated whether physical anxiety sensitivity (AS) is associated with selective attentional biases to affective stimuli in children. The dot-probe paradigm was used to examine the deployment of attention towards words pertaining to anxiety symptomatology, socially threatening words, and positive words, in samples of 8-10-year-old children. Word pairs were presented under both masked and unmasked conditions. Irrespective of masking, children high in physical AS displayed an attentional vigilance for emotional words relative to neutral words, whereas those low in physical AS displayed a relative avoidance of such material. The results of this study are interesting as they not only suggest the presence of automatic AS-related biases in childhood, but that this is a general emotionality bias rather than one related to specific anxiety-related stimuli.