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The Emotional Stroop Effect in Anxiety Disorders General Emotionality Or Disorder Specificity?

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The Emotional Stroop Effect in Anxiety Disorders General Emotionality Or Disorder Specificity? Anxiety Disorders 15 Q2001) 147±159 The emotional Stroop effect in anxiety disorders General emotionality or disorder specificity? Eni S. Beckera,*, Mike Rincka, JuÈrgen Margraf a, Walton T. Rothb aTU, Dresden, Germany bVA Palo Alto Health Care System, Palo Alto, CA, USA Received 8 January 1999; received in revised form 22 April 1999; accepted 15 October 1999 Abstract Selective attentional biases, often documented with a modified Stroop task, are considered to play an important role in the etiology and maintenance of anxiety. Two competing explanations for these effects are selectivity for highly emotional words in general vs. selectivity for disorder-specific words. We tested these explanations in 32 patients with generalized anxiety disorder QGAD), 29 patients with social phobia QSP), and 31 non-anxious controls. Stimuli were of four kinds: GAD-related words, SP-related words, words with a neutral valence, and words with a positive valence. Different attentional biases were observed: GAD patients were slowed by all types of emotional words, while SP patients were distracted specifically by speech-related words. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Attention; Generalized anxiety disorder; Social phobia; Stroop task 1. Introduction Cognitive models of anxiety have received increasing empirical support over the past decade Qe.g., Barlow 1988; Beck, Emery, & Greenberg, 1985; 1992). * Corresponding author. Department of Clinical Psychology, Dresden University of Technology, D-01062 Dresden, Germany. E-mail address: [email protected] QE.S. Becker). 0887-6185/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S0887-6185Q01)00055-X 148 E.S. Becker et al. / Anxiety Disorders 15 F2001) 147±159 These models focus on attentional processes because one function of anxiety is the detection of threat, enabling the individual to react quickly. According to cognitive theories Qe.g., Bower, 1981, 1987; Williams, Watts, MacLeod, & Mathews, 1988, 1997), anxiety patients' attention should be biased selectively towards threatening stimuli. To understand cognitive biases of attention, psychological theories and clinical research have increasingly turned to infor- mation processing paradigms derived from experimental cognitive psychology. A classical paradigm adapted to this purpose was originally introduced by Stroop Q1935). The modified version of the Stroop task is the paradigm most frequently used to show attentional biases in anxiety patients. The general approach of this task is to demonstrate selectively biased attention by showing diminished performance in a task condition where threatening stimuli could cause distraction. Specifically, participants are asked to name the ink color of words, disregarding their content. The basic finding is that, compared to other words and other participants, patients with anxiety disorders take longer to name the color of threatening words. The modified Stroop task has been used successfully with a variety of anxiety patients, among them patients with panic disorder QEhlers, Margraf, Davies, & Roth, 1988; McNally, Riemann, & Kim, 1990; McNally, Riemann, Louro, Lukach, & Kim, 1992), obsessive±compulsive disorder QIlai, Shoyer, & Foa, 1991), specific phobia QLavy, van den Hout, & Arntz, 1993), social phobia QSP, Hope, Rapee, Heimberg, & Dombeck, 1990), and posttraumatic stress disorder QFoa, Feske, Murdock, Kozak, & McCarthy, 1991; Kaspi, McNally, & Amir, 1995). Furthermore, there are several studies of patients with generalized anxiety QMartin, Williams, & Clark, 1991; Mathews & MacLeod, 1985; Mogg, Mathews, & Weinman, 1989). Most of these studies found the expected specific distraction effect, i.e., patients were specifically slowed in naming the print color of threat- related words. This effect occurs both with word-by-word and card-by-card presentation of the words, although it seems to be stronger with the blocked card- by-card format QHolle, Heimberg, & Neely, 1997; McNally, Amir, & Lipke, 1996). The color-naming interference does not seem to be due to inter-item priming, repetition of the items, or even more critically, on conscious attention. Four studies QMacLeod & Hagan, 1992; MacLeod & Rutherford, 1992; Mogg, Bradley, Williams, & Mathews, 1993; Mogg, Kentish, & Bradley, 1993) could demonstrate distraction by threatening stimuli presented subliminally. Hence, the interference seems to be a genuine bias of anxiety patients. Mathews and MacLeod Q1985) conducted one of the first studies using the modified Stroop task with anxiety patients. They found highly specific effects: patients who worried mostly about physical harm were particularly slow in naming the color of physical threat words, whereas patients worrying about social threat were especially slow in naming social threat words. Similarly, Hope et al. Q1990) reported that panic patients were slowed by physical threat cues, but not social threat cues, whereas the opposite held for social phobics. Specific, albeit slightly different, effects were also reported by Mogg et al. Q1989). Martin et al. E.S. Becker et al. / Anxiety Disorders 15 F2001) 147±159 149 Q1991), however, criticized earlier studies for confounding emotionality and threat. They presented evidence that anxiety patients were distracted by emo- tional words generally, regardless of their specific content. Thus, there are two competing explanations for the attentional biases observed in the emotional Stroop task: general emotionality Qpositive or negative) vs. schema congruency or specificity. If emotionality is responsible for the interference, then the schema theories proposing that anxious patients have increased accessibility only to threat information are wrong. However, Mathews and Klug Q1993), using threat-related negative and threat-related positive words Qantonyms of the threat-related negative ones, e.g., safe), and negative and positive words unrelated to threat, found evidence against the emotionality hypothesis: In their experiment, patients were slowed by all words related to their fears, regardless of the valence of the words. Furthermore, a study by MacLeod and Rutherford Q1992) found that specificity of effects depended on the level of processing. In their review, Williams, Mathews, and MacLeod Q1996) conclude that the Stroop effect is not due to emotionality per se, but rather to the degree to which words are semantically related to the schema. Furthermore, comparing interference indices over a variety of studies, they find that although ``current concern'' accounts for much Stroop inter- ference, it does not explain all the interference in patient groups. Besides relatedness, the negativity of the material is important in determining how much color naming will be disrupted. The present study employed the modified emotional Stroop task to further clarify the role of current concerns, emotionality, and specificity in color-naming interference. In addition to a group of non-anxious control participants, two different groups of anxiety patients participated in the studies, namely patients with generalized anxiety disorder QGAD) and patients with SP, most of whom were afraid of giving speeches. These anxiety disorders were chosen for two reasons: First, they involve anxiety schemata of differing widths, i.e., a rather broad schema QGAD) vs. a very narrow one QSP). GAD patients typically worry about a wide range of topics, while fears of SP patients in this study concentrated on giving speeches. Thus, GAD patients could be expected to have an attentional bias towards a broader range of stimuli Qmaybe even emotional stimuli in general) than SP patients. The GAD-related words chosen as stimuli were either connected to worry topics or to anxiety symptoms. The SP-related words were connected with giving a speech. 2. Method 2.1. Participants A total of 32 GAD patients, 29 SP patients, and 31 control participants without a history of any psychiatric disorder participated. GAD patients were invited to 150 E.S. Becker et al. / Anxiety Disorders 15 F2001) 147±159 participate in a drug-treatment study conducted by the fourth author at a VA Palo Alto Health Care System Hospital, Palo Alto, CA; patients with SP volunteered for a behavior therapy study at the same place. All patients completed the experiments reported here before receiving treatment. Control participants were paid a modest fee for their participation. All participants were recruited by advertisements in local newspapers. After an initial telephone screening, potential participants were given the ``Structural Clinical Interview for DSM-III-R, UpJohn Version'' QSCID-UP, Spitzer, Williams, & Gibbon, 1987) by trained interviewers. Several potential participants were excluded due to medical illness, substance abuse, and past or current psychotic episodes. Patients with both GAD and SP were excluded, as were patients with both GAD and panic disorder. Comorbidity was low in all participant groups: Four GAD patients, eight SP patients, and three control participants suffered from specific phobia, and one SP patient from panic disorder. The three groups were equated with regard to age, gender, and level of education Qsee Table 2). 2.2. Stroop cards A modified Stroop color-naming task similar to that of Mathews and MacLeod Q1985) was used. Participants were asked to name the ink color of the words on five cards. One card contained only GAD-related words, one contained only speech-related words, one neutral words, and one positive words. The words were selected
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