Beruflich Dokumente
Kultur Dokumente
18 (2004) 609627
Received 15 October 2002; received in revised form 16 April 2003; accepted 4 August 2003
Abstract
Attentional bias towards threat reliably correlates with clinical anxiety status as well as
elevated trait anxiety. Although such findings have led many to posit a potential causative
or predictive role of threat-biased attentional processes on anxiety problems, little
informative research exists. The present investigation was designed to address the role
of threat-biased attentional processes on emotional/fearful responding. Eighty-seven
participants provided baseline measures of anxiety vulnerability (i.e., anxiety sensitivity;
unmasked/masked emotional Stroop task indices) and then underwent biological challenge
procedures (inhalations of 20% carbon dioxide (CO2)-enriched air). Following challenge,
participants completed measures of emotional response. Regression analyses indicated that
both unmasked and masked attentional bias indices significantly predicted emotional
responding above and beyond anxiety sensitivity. Exploratory analyses also revealed
a gender effect, with prediction of emotional response largely attributable to females.
$
This paper is based on the doctoral dissertation of the first author. Portions of this paper were
presented at the annual meeting of the Association for the Advancement of Behavior Therapy,
Philadelphia, PA, USA, 2001.
*
Corresponding author. Tel.: 1-301-594-9287; fax: 1-301-480-3610.
E-mail address: nayw@intra.nimh.nih.gov (W.T. Nay).
1
Present address: National Institute of Mental Health, Mood and Anxiety Disorders Program,
Building 1, Room 3B-20, Bethesda, MD 20892, USA.
0887-6185/$ see front matter # 2003 Elsevier Inc. All rights reserved.
doi:10.1016/j.janxdis.2003.08.003
610 W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627
These findings support attentional bias towards threat as a relatively independent factor
predictive of emotional responding.
# 2003 Elsevier Inc. All rights reserved.
Keywords: Selective attention; Cognitive bias; Anxiety; Fear; Gender differences; Biological challenge
Individuals suffering from anxiety disorders typically recognize that their fears
and consequent reactions to potential threats are out of proportion to reality, yet
they feel helpless in controlling these seemingly automatic responses (McNally,
1995; Ohman & Soares, 1994). Thus, many researchers have directed their efforts
towards consideration of automatic cognitive processes that may be at least partly
responsible for the dissociation between intentioned, verbal-cognitive control,
and fearful responding. Research efforts have been directed towards such
cognitive processes as interpretive, attentional, and memory biases (MacLeod
& Rutherford, 1998; McNally, 1994, 1995). These phenomena have been
investigated for their potential as markers, and as possible causes, of clinical
anxiety dysfunction (e.g., MacLeod, Rutherford, Campbell, Ebsworthy, &
Holker, 2002; Mathews & MacLeod, 2002). The present investigation focuses
specifically on the role of attentional bias towards threat in anxiety disturbance.
A characteristic tendency to disproportionately allocate attentional resources
towards potential threats is believed to contribute to a vicious anxiety cycle
(Williams, Mathews, & MacLeod, 1996). This hypothesis proposes that high trait
vulnerability to anxiety leads to a propensity to shift attention to personally
relevant threat stimuli. Such propensity, in turn, independently causes these stimuli
to be processed more often and to a greater degree of personal emotional
significance. Increased processing of these potential threats globally increases
anxiety. Finally, increased global anxiety may make threat stimuli more salient,
thus increasing the interpreted probability of harm. Thus, cognitive models
assume that attentional bias is not simply a by-product of the emotional disorder
but plays a vital role in its causation and maintenance (Williams et al., 1996, p. 3).
By means of the emotional Stroop task or variants thereof (see, MacLeod, 1991,
for a review), numerous studies have revealed reliable relations between clinical
anxiety disorder status and attentional bias to threat (e.g., GAD: Mathews &
MacLeod, 1985; social phobia: Mattia, Heimberg, & Hope, 1993; specific phobia
of spiders: Watts, McKenna, Sharrock, & Treazise, 1986; panic disorder: Ehlers,
Margraf, Davies, & Roth, 1988; PTSD: Kaspi, McNally, & Amir, 1995; OCD:
Lavy, van Oppen, & van den Hout, 1994). Furthermore, the bias appears to be most
strongly evident with stimuli relevant to the disorder in question (e.g., cata-
strophe in panic) versus generally negative stimuli. Within clinical populations,
attentional bias effects also are observed when the word stimuli are pattern
masked. Pattern masking involves rapidly replacing (usually on the order of
1430 ms) the experimental stimuli with meaningless ones to prevent or reduce
conscious awareness of the critical stimuli. Consistent evidence of attentional
W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627 611
biases to threat under masking conditions (in clinically anxious populations) has
supported arguments that these biases emerge automatically, in the sense that they
are unintended, do not require elaborate conscious processing, and yet affect
behavior (e.g., delayed reaction times on threat-related emotional Stroop tasks). It
remains uncertain, however, whether attentional bias effects observed under
masking conditions also are disorder content-specific. A number of studies, for
example, have found that bias effects under masked conditions are attuned
generally to stimuli of negative affective tone, and not specifically to stimuli
relevant to features of particular anxiety disorders (Lundh, Wikstrom, Westerlund,
& Ost, 1999; Mogg, Bradley, Williams, & Mathews, 1993).
Given the vicious cycle hypothesis, one of the most intriguing questions
regarding attentional bias in anxiety is whether the bias precedes, and whether it
possibly contributes to, the development of anxiety dysfunction (MacLeod &
Hagan, 1992; McNally, 1994; McNally, Hornig, Hoffman, & Han, 1999). Using a
conceptual variant of the emotional Stroop taskthe visual dot-probe task,
Broadbent and Broadbent (1988) found an interesting relationship between trait
anxiety and attentional bias towards threat cues among a sample of college
females (males were not assessed). Among those highest in trait anxiety, there
appeared to be a strong, positive, linear association with attentional bias. Lower
scores on a measure of trait anxiety, however, appeared to bear no definite
relationship with attentional bias. In total, the findings suggested that attentional
bias is a continuous anxiety-related factor observable in the general population.
However, this relationship is not apparent in anyone, but rather is observed only in
individuals with high levels of trait anxiety.
Until recently (e.g., MacLeod et al., 2002; Mathews & MacLeod, 2002), little
work had been undertaken to determine whether attentional bias per se has any
unique contributory influence on anxiety or other emotional dysfunction. This
recent laboratory research has provided preliminary evidence of a causal role for
attentional bias in anxiety disturbance (MacLeod et al., 2002; Mathews &
MacLeod, 2002). MacLeod and his coworkers manipulated attentional bias in
normal control populations by reinforcing threat-biased responses to multiple
visual dot-probe training trials (or, conversely, reinforcing neutral-biased
responses in comparison groups). The authors found that, although endorsement
of negative emotional states was comparable across groups after attentional
bias training trials, the groups differed in their emotional response to stress
subsequent to training (i.e., insoluble or difficult anagrams). Participants trained
to respond with a threat bias had greater negative emotional reactions to
subsequent stress. Having directly manipulated attentional biases, the authors
make a strong case for the causal influence of attentional bias on emotional
vulnerability. However, as the authors argued, that effect is not for attentional bias
to directly influence emotion, but rather it affects emotional reactivity to sub-
sequent stress.
To date, MacLeod and his coworkers (MacLeod et al., 2002; Mathews &
MacLeod, 2002) are the only researchers to provide experimentally sound
612 W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627
1. Method
1.2. Participants
Table 1
Means and standard deviations for demographic and baseline anxiety measures by completer status
Demographics
Age 21.4 (5.63) 23.31 (8.58) 20.70 (4.10) 1.58
Gender (% female) 58.6 69.0 55.2 1.71
Baseline measures
ASI 20.57 (9.25) 20.79 (8.27) 20.49 (9.59) 0.15
STAI-T 41.91 (9.92) 43.34 (9.63) 41.44 (10.02) 0.90
STAI-S 37.05 (9.19) 38.38 (9.77) 36.61 (9.01) 0.90
Unmasked threat 14.46 (67.50) 25.53 (79.62) 10.77 (63.04) 1.02
interference index
Masked threat 3.04 (35.65) 10.10 (44.83) 0.69 (31.98) 1.23
interference index
a
All values are non-significant (P > :05).
1.3. Materials
1.3.1.2. Profile of Mood States. The POMS (McNair, Lorr, & Droppleman, 1981)
is a 65-item self-report inventory designed to assess transient, fluctuating mood
states. The items are rated on a 04 Likert-type scale of current intensity, where 0
is not at all and 4 is extremely. The Tension-Anxiety (T/A) subscale, which
is being used in the current investigation, is composed of nine of the sixty-five
items (range of scores 036) and includes items describing somatic tension and
psychomotor agitation. Internal consistency for the T/A scale across two studies
with psychiatric outpatients averaged .91 and test-retest reliability was .70 over an
W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627 615
average of 20 days. Means for the T/A scale in a college population are 13.9
(S:D: 7:4) for females and 12.9 (S:D: 6:8) for males. Scores on the T/A
subscale of the POMS discriminates individuals with panic disorder and non-
clinical panickers (Norton, Dorward, & Cox, 1986) as well as high-anxiety
sensitive college students from low-anxiety sensitive college students (Donnell &
McNally, 1989; Holloway & McNally, 1987), both upon biological challenge.
1.3.1.3. Health Status Interview. A Health Status Interview was devised to probe
for medical issues that may contraindicate brief inhalations of 20% CO2-enriched
air. Because of the relative safety of this procedure, such medical screenings are
uncommon in the extant literature. However, we conservatively elected to dismiss
from the challenge task any participant who endorsed taking medications (other
than contraceptives or aspirin/analgesics), adult asthma or rhinitis (as evidenced
through current use of inhaler or oral medication), history of cardiac disease or
dysfunction, history of high blood pressure treated with medication, history of
regular fainting episodes, history of epilepsy, or that a physician recommended
that they do not exercise.
1.3.1.4. Anxiety Sensitivity Index. The ASI (Peterson & Reiss, 1992) is a 16-item
self-report inventory devised to assess the degree to which a person fears anxiety
sensations. Each item is scored on a 5-point Likert-type scale that ranges from 0
(very little) to 4 (very much), with a total score range of 064. The average
score on the ASI for normal samples is 19.01 (S:D: 9:11; Peterson & Reiss,
1992). Internal reliabilities (Cronbachs alpha) across both normal and patient
populations range between .8 and .9. Also, acceptable test-retest reliabilities have
been demonstrated in college students at 2-week intervals (r :75) and at 3-year
intervals (r :71).
1999). Split-half sets were created from each valence (panic-related and neutral
household words) from the item pool, creating four sets of 14 words each. Words
were matched between sets to equate for length and frequency of English usage
(Francis & Kucera, 1982).
Emotional Stroop tasks were run through a Dell Dimension XPS T500 Pentium
III mini-tower computer. Stimuli were presented on a 19 in. Dell P991 Super
VGA monitor, which was set at its lowest possible resolution for the purpose of
maximizing refresh rate. Vocal reaction times to the Stroop tasks were recorded
by the computer via a serial response box (Psychology Software Tools, Inc., 1999)
and a microphone. Stimulus and mask presentation was controlled by specialized
software.
1.4. Procedures
Once the participant had completed the Stroop assessment, the researcher
re-entered the room and provided the participant with mid-point self-report
assessments to be used for manipulation checks (POMS-T/A scale and
Symptom Checklist). After completion of the questionnaires, the second
consent procedure was undertaken. The second consent procedure explained
that participants might be administered dosages of CO2-enriched air. Further-
more, consent procedures informed participants that it would not be possible
for them to know when the CO2 could be administered. All participants,
regardless of their responses to the health status questionnaire, were given the
opportunity to accept or decline. Once the participant made his or her election,
the experimenter excused those who answered affirmatively to any of the
contraindicating conditions and/or who declined. Asking participants for their
assent without regard to eligibility was implemented so that it may be possible
later to statistically look at factors that may predict refusal of CO2 admin-
istration.
For those participants eligible and assenting to continue with the biological
challenge, the experimenter then fitted the participant with a respiratory mask.
After 60 s of rest/acclimation, the researcher opened the three-way valve to the
20% CO2-enriched air for 30 s. A 30-s period of breathing room air followed, and
then additional Stroop tasks were initiated. Half-way through the additional tasks
(matching the rest period in the middle of the initial Stroop procedures), the three-
way valve was once again opened to the 20% CO2-enriched air for 30 s. Following
completion of the experimental session, the participant was asked to complete a
second POMS-T/A subscale, a second Symptom Checklist, and a second STAI-S.
Upon completion of the questionnaires, each participant was debriefed and given
research credit.
Typical data reduction procedures used in the attentional bias literature were
employed (e.g., MacLeod & Hagan, 1992; Mogg et al., 1993). Mean scores were
calculated for each participant across the four critical Stroop epochs: unmasked
threat, unmasked neutral, masked threat, and masked neutral. Prior to calculating
these means, however, instances of no response or response artifacts were
eliminated. Instances of no response were evident as 3-s response times. Also,
responses shorter than 100 ms were eliminated as likely artifacts. At this point,
within-individual means and standard deviations per valence set (neutral words
vs. threat words) and per presentation type (unmasked vs. masked) were calcu-
lated. Data points beyond three standard deviations of these specific within-
individual means were eliminated.
For analytic purposes, data were reduced further. Attentional bias to threat
index scores were calculated. To accomplish this, individual mean scores for each
neutral set were subtracted from the individual mean score from the appropriate
threat set (Lundh et al., 1999; MacLeod & Hagan, 1992; Mogg et al., 1993). A
W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627 619
positive index score reflects some degree of bias towards threat. In all, each
participant provided one unmasked and one masked threat index.
2. Results
The questions to be addressed in this study are dependent on the assumption that
inhalation of CO2-enriched air will increase symptoms of fearful/anxious respond-
ing. Therefore, t-tests were conducted on baseline STAI-S compared to post-CO2
STAI-S anxiety, mid-point Symptom Checklist compared to post-CO2 Symptom
Checklist, and mid-point POMS-T/A subscale versus post-CO2 POMS-T/A sub-
scale. Use of the mid-point measures, where available, was considered a more
conservative test of symptom increase specifically due to CO2 than baseline
assessment of symptoms would have been. Specifically, it is arguable that the (first
set of) Stroop tasks may have increased symptoms compared to baseline due to the
stress of the procedure and/or the presentation of threat stimuli. Therefore, a more
direct argument can be made that any change in symptoms after the initial Stroop
tasks to post-CO2 should be due primarily to the effects of inhaling CO2-enriched air.
As predicted, Symptom Checklist and POMS scores significantly increased from
post-Stroop to post-CO2 inhalation (M 5:5 vs. M 11:7, t 8:69, P < :05;
M 8:2 vs. M 12:2, t 6:52, P < :05, respectively). Significant increases in
state anxiety also were observed from baseline to post-CO2 (M 36:6 vs.
M 47:0, t 8:07, P < :05). Results suggest that the two 30-s inhalations of
20% CO2-enriched air successfully increased fearful/anxious symptoms.
The overall zero-order correlation matrix for the predictors and dependent
variables can be found in Table 2. Inspection of the matrix reveals that all
predictors were significantly correlated with post-CO2 symptoms (i.e., Symptom
Checklist scores). Similarly, the post-CO2 POMS T/A subscale was significantly
correlated with all measures, except for the masked threat index. The Symptom
Checklist and POMS T/A subscale were highly correlated (r :75, P < :001),
suggesting that these measures assess largely the same construct. Therefore, to
reduce the likelihood of Type I error, only the Symptom Checklist was retained as
a primary dependent measure. This measure contains more panic-relevant items
and maps directly onto DSM-IV (American Psychiatric Association, 1994) panic
attack criteria.
Contrary to a priori expectations, association between the ASI and Symptom
Checklist was not statistically greater than for the STAI-T and the Symptom
Checklist (r :40 vs. r :32, respectively; Zdiff 0:60; P > :05). As the
620 W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627
Table 2
Zero-order correlation matrix for predictors/covariates and dependent variables
Measure 1 2 3 4 5
Predictor variables
ASI
Trait anxiety .58**
Unmasked index .12 .23*
Masked index .05 .24* .31**
Criterion variables
Symptoms Checklist .40** .32** .50** .24*
POMS-T/A .36** .37** .33** .18 .75**
n 87; n 86 for POMS T/A.
*
P < :01.
**
P < :001.
STAI-T and ASI were moderately correlated (r :58; P < :01), Symptom Check-
list scores were regressed onto ASI and STAI-T scores using stepwise procedures.
This analysis resulted in a final prediction model including only the ASI
(F 16:36; P < :01). Our finding suggests that any non-overlapping variance
accounted for by the STAI-T does not significantly add predictive power above and
beyond that accounted for by the ASI, despite the moderately strong zero-order
correlations held by both with respect to symptomatic response to CO2 inhalation.
Table 3
Summary of multiple regression analyses: unmasked and masked index in the prediction of Symptom
Checklist scores
Model 1a
Step 1
(Hierarchical) .16**
**
ASI .32 .08 .35
Step 2
(Forward stepping within block) .37** .21**
Unmasked index .00 .01 .46**
Model 2b
Step 1
(Hierarchical) .16**
**
ASI .32 .08 .35
Step 2
(Forward stepping within block) .21** .05*
Masked index .00 .03 .22*
a
Centered ASI unmasked index interaction did not enter significantly (P > :05).
b
Centered ASI masked index interaction did not enter significantly (P > :05).
*
P < :01.
**
P < :001.
Table 4
Zero-order correlation matrix for predictors and dependent variables: males (n 39)/females
(n 48)
1 2 3
Predictor variables
ASI
Unmasked index .05/.15
Masked index .01/.07 .35*/.29*
Criterion variable
Symptom Checklist .23/.48* .31/.59** .14/.29*
*
P < :01.
**
P < :001.
Table 5
Summary of multiple regression analyses: unmasked and masked index in the prediction of Symptom
Checklist scores (females only)
Model 1a
Step 1
Hierarchical .23**
**
ASI .34 .09 .40
Step 2
Forward stepping within block .50** .27**
Unmasked index .06 .01 .53**
Model 2b
Step 1
Hierarchical .23**
**
ASI .34 .09 .40
Step 2
Forward stepping within block .30** .07*
Masked index .06 .03 .26*
a
Centered ASI unmasked index interaction did not enter significantly (P > :025).
b
Centered ASI masked index interaction did not enter significantly (P > :025).
*
P < :01.
**
P < :001.
3. Discussion
indicate that these varying methods tap different levels of cognitive analysis (i.e.,
strategic versus automatic; post-attentive versus pre-attentive; see, Williams et al.,
1996, for a review). The current findings can be interpreted in at least two ways. One
interpretation is that, in fact, the two different procedures do tap different levels of
cognitive analysis. Another interpretation would be that the level of cognitive
processing involved is the same, but the effect is weakened by degraded or impeded
awareness. Unfortunately, the methods involved in the current investigation do not
allow a means to clarify which of these two hypotheses better accounts for the
findings. Regardless, the findings of the current investigation suggest that the
proportion of attentional resources allocated to even a procedurally masked threat
stimulus has a direct, linear effect on ones affective reactions.
Reanalysis of the regression models according to gender group status revealed
unexpected findings, given that gender differences have not been noted frequently
in the literature on attentional biases. In particular, it appears that the prediction of
symptomatic response by anxiety sensitivity and interference indices can largely
be attributed to effects observed among female participants. One caveat is offered
in considering the generalizability of the gender difference findings. Specifically,
the magnitude of symptom increase, although roughly the same for males and
females, was small in absolute terms. It is possible that true but less robust effects
in males were translated into non-significant findings. Further research on the
issue of gender differences in attentional bias is clearly warranted.
Given the possibility that attentional bias to threat represents a vulnerability
factor in anxiety disturbance, the speculation naturally arises that perhaps it is
possible to re-train or re-condition vulnerable individuals so that they no longer
disproportionately attend to threat. Recent studies hint at the possibility of
implementing laboratory procedures designed to train individuals in neutral or
positively skewed attentional allocation (MacLeod et al., 2002; Mathews &
MacLeod, 2002). Other practical applications of the current findings also are
evident, including the use of attentional bias paradigms as a method of anxiety
vulnerability assessment. Through the development of standardized procedures,
measures of attentional bias to threat may become valuable clinical tools in multi-
method assessment. Future research is needed, however, in addressing the
temporal stability and reliability of attentional bias assessments.
The current study contains a number of methodological limitations that can be
improved upon in future research. One such limitation is the lack of a subjective
awareness check on masked stimuli. This check was not conducted in the current
study for a number of reasons. First, the chosen interval between stimulus
presentation and mask presentation (25 ms) falls well in the range of stimulus
presentation duration found effective for blocking subjective awareness in
numerous previous studies (Esteves & Ohman, 1993; Lundh et al., 1999; Mogg
et al., 1993; Mogg, Kentish, & Bradley, 1993; Whalen et al., 1998). Second, a
logistical complication arises regarding where in the protocol to inject awareness
checks. If done anywhere in the middle of the protocol, these checks may affect
later trials. If awareness checks are conducted at the end of the trials, one has to
W.T. Nay et al. / Anxiety Disorders 18 (2004) 609627 625
consider the influence of both practice effects (or spreading cognitive activation)
and of having unmasked presentations of the same stimuli beforehand. Certainly,
many of these difficulties can be overcome or simply accepted as a complication
of conducting awareness checks. However, given the preliminary nature of the
current study and the additional burden the awareness checks would have put on
research participants, it was decided to limit discussion to the effects of pro-
cedural masking.
To maximize emotional responding, predictability, and control were important
considerations in the present experimental design. Nonetheless, future investiga-
tions could experimentally manipulate these factors in an attempt to examine the
ability of attentional biases to predict emotional responding when these factors
vary. One final consideration for the present study is that the pattern of results
observed may not apply to clinical samples. Future investigations could more
directly assess the relations among these variables within clinical samples to
determine whether similar patterns of association emerge.
Acknowledgments
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