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Attentional Bias Components in Anxiety and Depression: a Systematic Review

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Attentional Bias Components in Anxiety and Depression: a Systematic Review Attentional Bias Components in Anxiety and Depression: A Systematic Review Denise Rogersa, Edel Murphya, Sarah Jane Windersa & Ciara M. Greenea aSchool of Psychology, University College Dublin, Belfield, Dublin 4, Ireland Corresponding author: Associate Professor Ciara M. Greene Email: [email protected] Postal address: School of Psychology, University College Dublin, Belfield, Dublin 4, Ireland Tel: +353 1 7168334 1 Abstract Attentional biases have been identified as a transdiagnostic cognitive process that may underlie a range of psychological disorders. They comprise three measurable and observable components; facilitation (rapid detection of concern-related stimuli), difficulty in disengagement (slower attentional shifting away from concern-related stimuli) and attentional avoidance (allocation of attention away from concern-related stimuli). Attentional biases to negative stimuli are common in anxiety and depression; however, their shared (i.e. transdiagnostic) and distinct components have not yet been systematically investigated. Literature searches were conducted on the PsychINFO, Embase, PubMed and Web of Science databases, yielding 560 articles after duplicates were removed. Articles were subject to abstract and full-text screening against study eligibility criteria. Twenty-five articles were included in the extraction phase. Data regarding population, experimental paradigm and attentional bias components were extracted. Results are suggestive of facilitation as a transdiagnostic attentional process across anxiety, depression and those with co- occurring anxiety and depression. There was strong evidence of avoidance in depression, with weaker evidence in anxiety, while delayed disengagement was observed in anxiety, but not in depression. Critical gaps in the literature were also identified. These findings provide support for the transdisagnostic nature of attentional biases, shedding light on the commonalities observed across diagnostic categories. Keywords: Attentional bias; facilitation; avoidance; delayed disengagement; anxiety; depression Funding: This work was supported by a scholarship to DR from the Health Services Executive of Ireland Public significance: This systematic review suggests that attentional biases towards and away from concern-related stimuli are a feature of both anxiety and depression, and suggest considerable overlap in the cognitive processes underlying these two disorders. 2 Introduction Mental health conceptualisation, research and treatment is currently in the midst of a paradigm shift. Traditional nosological systems, such as the Diagnostic Statistical Manual Fifth Edition (DSM- 5; American Psychiatric Association, 2013) and the International Statistical Classification of Diseases and Related Health Problems Tenth Edition (ICD-10; World Health Organization, 1993), assume that mental health disorders are distinct and independent categorical entities (Krueger & Eaton, 2015). However, these systems have been heavily criticised for their lack of validity, over- specification, internal heterogeneity and high comorbidity rates (Hyman, 2007, 2010; Wakefield, 2016). Alternatively, the transdiagnostic approach posits that common cognitive, behavioural and psychophysiological processes predispose and maintain symptoms across diagnostic boundaries (Garland & Howard, 2014; Mansell, Harvey, Watkins, & Shafran, 2008). The transdiagnostic approach calls for a shift in focus from disorder-specific symptoms to cross-disorder processes (Harvey, Watkins, & Mansell, 2004). Attentional biases are an excellent example of a cognitive transdiagnostic process (Garland & Howard, 2014), as highlighted by the proliferation of attentional bias research over the past number of decades; reviews of this research have been conducted in relation to anxiety (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van Ijzendoorn, 2007), depression (Peckham, McHugh, & Otto, 2010), eating disorders (Dobson & Dozois, 2004), OCD (Muller & Roberts, 2005) and addictive disorders (Field & Cox, 2008). Attentional bias refers to the systematic tendency to preferentially attend to concern-related stimuli over non-concern-related stimuli (Mansell et al., 2008). The ability to flexibly allocate attention towards and away from salient environmental cues is arguably essential for adaptive functioning. Deficits or biases in this ability contribute to the onset and maintenance of many mental health difficulties, including anxiety and depression (Bar-Haim et al., 2007; Peckham et al., 2010). Anxiety and depression are two of the most prevalent mental health disorders world-wide and have a comorbidity rate of up to 50% (Goldberg, Krueger, Andrews, & Hobbs, 2009; Hirschfeld, 2001). Given the magnitude of these comorbidity rates, investigation into transdiagnostic processes such as attentional bias is warranted and may be fruitful in informing future transdiagnostic treatments such as attentional bias modification training (ABM; Craske, 2012). 3 Although there is a wealth of disorder-specific attentional bias research, few studies have taken a transdiagnostic perspective or focused upon the individual components of the attentional bias effect. Research has shown that attentional biases are comprised of three observable and measurable components; ‘facilitation’ (also referred to as vigilance, engagement and attentional orienting), ‘difficulty in disengagement’ and ‘attentional avoidance’ (Cisler, Bacon, & Williams, 2009; Cisler & Koster, 2010; Fox, Russo, Bowles, & Dutton, 2001). Facilitation refers to the process by which attention is drawn towards a threatening stimulus more quickly than a non-threatening stimulus (Cisler & Koster, 2010). Difficulty in disengagement describes the process by which attentional shifts away from a threatening stimulus are slower than attentional shifts away froma non-threatening stimulus. Attentional avoidance, in contrast, describes the process whereby attention is directed away from a threatening stimulus and strategically allocated to an alternative location. Theories Underlying Attentional Bias Components There are two main theories underlying the individual components of attentional bias; the vigilance-avoidance hypothesis and the delayed disengagement hypothesis. The vigilance- avoidance hypothesis has largely been investigated in anxious populations (Koster, Verschuere, Crombez, & Van Damme, 2005; Mogg, Bradley, Miles, & Dixon, 2004; Mogg, Bradley, De Bono, & Painter, 1997). The vigilance-avoidance hypothesis proposes that anxious individuals direct their attention towards threatening stimuli more quickly and more frequently during the early stages of processing (e.g. <500 milliseconds) and then direct their attention away from threatening stimuli during the later stages of processing (e.g. 1500 milliseconds; Mogg et al., 2004). The strategic re- direction of attention away from threatening stimuli alleviates distress in the short-term; however, persistent avoidance maintains distress overtime as it prevents habituation in the presence of threatening stimuli. Interestingly, research investigating the vigilance-avoidance hypothesis in depression is lacking. This may relate to the dominance of traditional models, such as Williams and colleagues’ (1988) model, which states that attentional biases in depression occur at later stages of processing only and are not detectable at shorter exposure durations. In contrast, the delayed disengagement hypothesis has been investigated in both anxious (Fox et al., 2001; Koster, Crombez, Verschuere, & De Houwer, 2004) and depressed populations (Goeleven, De Raedt, Baert, & Koster, 2006; Koster, De Raedt, Goeleven, Franck, & Crombez, 2005b). It suggests that anxiety and depression are maintained by impairments in inhibiting and shifting attention away from threatening or negative stimuli (Fox et al., 2001). Such difficulties in 4 disengagement result in sustained processing of negative stimuli rather than flexible re- engagement with other environmental stimuli. The delayed disengagement hypothesis has typically been measured at longer stimulus exposure durations (see Cisler & Koster, 2010 for a review). Attentional Bias Paradigms A number of experimental paradigms have been used to investigate the attentional bias effect. In order to elucidate the manner in which each paradigm investigates the attentional bias effect and how each paradigm differentiates between the different attentional bias components, a brief overview of the most commonly used tasks is provided below. In the Dot Probe Task (DPT; MacLeod, Mathews, & Tata, 1986), two stimuli (e.g. words, pictures or facial expressions) are presented simultaneously for a brief period. One stimulus is emotional in content and the other is neutral in content. After both stimuli disappear, a probe appears in one of the previously occupied locations. Participants are instructed to respond to the spatial location of the probe. Reaction times on congruent trials (i.e. trials where probes replace emotional stimuli) are subtracted from incongruent trials (i.e. trials where probes replace neutral stimuli) to calculate an attentional bias index score (MacLeod et al., 1986). A positive bias score is suggestive of an attentional bias towards emotional stimuli and a negative bias score is suggestive of an attentional bias away from emotional stimuli (i.e. attentional avoidance). Importantly, a positive bias score on the DPT may reflect either facilitated engagement with stimuli or difficulty in disengagement. These two attentional
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