Attentional retraining

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Attentional retraining is the retraining of automatic attentional processes. The method of retraining varies but has typically employed computerized training programs. [1] [2] The term originally indicated retraining of attention to rehabilitate individuals after a brain injury who had neurological disorders of attention including hemineglect, perseveration, limited attention span, and even ADHD. However, in more recent research and clinical applications attentional retraining has also been applied as a type of cognitive bias modification. [3] In this application, attentional retraining refers to the retraining of automatic attentional biases that have been observed in high levels of anxiety.

Contents

Neuropsychological rehabilitation applications

Computerized approaches to cognitive rehabilitation rose out of the recreational use of video games in the 1970s and the rise of the personal computer in the 1980s. The increased availability of personal computers and accessible programming languages allowed for researchers and clinicians to begin experimenting with computerized cognitive training. [4] Most tasks consisted of simple and repetitive training tasks that would increase in difficulty over time. In one such task participants must sit and observe on screen randomly presented numbers and push a buzzer when they see a specific digit – say, 3. [5] Similar tasks were developed and administered to individuals demonstrating neuropsychological impairment in areas of attentional processing. The theorized mechanism of action in this approach to cognitive retraining rests on the ability of the generally trained task (recognizing and responding to numbers presented on screen) to generalize to attentional processes employed in everyday life.

Effectiveness in brain injury

In a 2001 meta-analysis of outcomes in attention rehabilitation after brain injury, the authors surveyed 30 studies with 359 patients. In this most recent meta-analysis of outcomes the authors found that there were significant and large effect sizes (d statistic) from pre-training to post-training. However, this large effect size was only found for studies without a control group. When the authors analyzed those pre/post studies with a control group the authors found much smaller effect sizes. [6] This finding may reflect the natural improvement seen over time after brain injury.

Cognitive bias modification applications

Attention training for anxiety is a form of applied cognitive processing therapy (ACPT) and is also referred to in the scientific literature as cognitive bias modification therapy for attention. CBM therapies (CBMT) also include applied cognitive processing therapies for attention bias, interpretation bias and imagery.

Attention bias

The attentional bias [7] is the tendency of certain salient cues in a person's environment to preferentially draw and/or hold the person's attention. For example, individuals with anxiety disorders demonstrate an automatic attentional bias towards threatening cues in their environment and drug users and addicts demonstrate an automatic attentional bias towards drug related cues in their environment. [8] [9]

Although there is not yet clinical evidence that CBM works on handheld devices, this image illustrates what a CBM task might look like: Diagram of sequence of events in a single VP trial. 1) The fixation cross is presented for 500ms, 2) the two pictures - one smoking and one neutral- are displayed, and 3) the probe to which the participant must respond is presented. Visual Probe Task on a PDA.jpg
Although there is not yet clinical evidence that CBM works on handheld devices, this image illustrates what a CBM task might look like: Diagram of sequence of events in a single VP trial. 1) The fixation cross is presented for 500ms, 2) the two pictures – one smoking and one neutral- are displayed, and 3) the probe to which the participant must respond is presented.

The rise of research in cognitive bias modification has led to the recent publication of a special issue of the Journal of Abnormal Psychology focusing on the methods and technologies used for cognitive bias modification in psychopathology. [10] Attentional retraining as cognitive bias modification is predicated on the observed attentional bias evident in psychopathology. The most common task used to retrain attention in anxiety is the dot-probe task developed originally by Macleod et al. (1986). In this task two stimuli are briefly presented on screen. One of the stimuli is emotionally salient (a drug cue or threat cue) and the other is neutral. Stimuli (usually words or images) are presented for about 500 milliseconds and then one of the stimuli is replaced by a probe to which the participant must respond. Required responses are usually to indicate what side of the screen the probe is on or to indicate which direction the probe (an arrow in this case) is pointing. The attentional bias is indicated by the difference in reaction time to the probe after it replaces a salient cue versus the reaction time to respond to a cue that replaces the neutral cue. Usually, the anxious participant will be faster in responding to probes replacing salient stimuli than those replacing neutral stimuli. This suggests their attention was drawn preferentially by the previously presented salient stimuli.

Attentional retraining attempts to retrain this automatic attentional process by using the dot-probe task and having the probe replace the neutral stimuli 100% of the time. Thus, the participant learns an implicit if-then rule: if both salient and neutral stimuli are present, then attend preferentially to the neutral stimuli. [11] Therefore, if attentional biases have a causal role on the maintenance of anxiety or drug addictions then lowering the attentional biases should therefore lower feelings of anxiety amongst the anxious and craving amongst the drug addicted and promote abstinence amongst them as well.

Effectiveness of CBMT for anxiety

Effectiveness of attentional retraining has varied in both the anxiety and addictions literature.

In anxiety, cognitive bias modification therapy results have been much more promising and clear with several studies showing reductions in anxiety amongst the experimental group compared to control. [12] [13] [14] [15] Studies have thus far shown a greater effect of CBMT on anxiety when trials are conducted in a clinic [16] than when conducted at home. [17] According to a recent meta-analysis focusing on the clinical impact of Attention bias Modification (ABM) for alleviating Social Anxiety Disorder (SAD), [18] ABM produces a small but significant reduction in SAD symptoms (g = 0.27), reactivity to speech challenge (g = 0.46), and attentional bias for threat (g = 0.30). These effects were moderated by characteristics of the ABM procedure, the design of the study, and trait anxiety at baseline. However, effects on secondary symptoms (g = 0.09) and SAD symptoms at 4-month follow-up (g = 0.09) were not significant. Although there was no indication of significant publication bias, the authors identified that quality of the studies was substandard and wedged the effect sizes. From a clinical point of view, these findings imply that ABM is not yet ready for wide-scale dissemination as a treatment for SAD in routine care.

It has been found that attention training works through an improvement in the ability to disengage attention from threatening cues. [19] [20] Moreover, it has also been evidenced that attention bias modification is related to changes in activation of the prefrontal cortex to emotional stimuli. [21] Accordingly, a recent study [22] demonstrated that attentional bias for threat among individuals with anxiety disorders may be reduced via the application of neuromodulation techniques, such as transcranial direct-current stimulation over the dorsolateral part of the left prefrontal cortex.

Cognitive bias modification in addiction

Two large scale recent studies have shown that CBM training with an approach/avoid task in alcohol dependent individuals can reduce relapse rates at one year up to 10%. [23]

In an earlier study of attentional retraining in alcohol drinking attentional retraining altered attentional biases and altered the amount of alcohol subsequently consumed after training compared to a control group. [24]

Related Research Articles

<span class="mw-page-title-main">Cognitive bias</span> Systematic pattern of deviation from norm or rationality in judgment

A cognitive bias is a systematic pattern of deviation from norm or rationality in judgment. Individuals create their own "subjective reality" from their perception of the input. An individual's construction of reality, not the objective input, may dictate their behavior in the world. Thus, cognitive biases may sometimes lead to perceptual distortion, inaccurate judgment, illogical interpretation, and irrationality.

<span class="mw-page-title-main">Attention</span> Psychological process of selectively perceiving and prioritising discrete aspects of information

Attention is the concentration of awareness on some phenomenon to the exclusion of other stimuli. It is a process of selectively concentrating on a discrete aspect of information, whether considered subjective or objective. William James (1890) wrote that "Attention is the taking possession by the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought. Focalization, concentration, of consciousness are of its essence." Attention has also been described as the allocation of limited cognitive processing resources. Attention is manifested by an attentional bottleneck, in terms of the amount of data the brain can process each second; for example, in human vision, only less than 1% of the visual input data can enter the bottleneck, leading to inattentional blindness.

Metacognition is an awareness of one's thought processes and an understanding of the patterns behind them. The term comes from the root word meta, meaning "beyond", or "on top of". Metacognition can take many forms, such as reflecting on one's ways of thinking and knowing when and how to use particular strategies for problem-solving. There are generally two components of metacognition: (1) knowledge about cognition and (2) regulation of cognition. A metacognitive model differs from other scientific models in that the creator of the model is per definition also enclosed within it. Scientific models are often prone to distancing the observer from the object or field of study whereas a metacognitive model in general tries to include the observer in the model.

Depressive realism is the hypothesis developed by Lauren Alloy and Lyn Yvonne Abramson that depressed individuals make more realistic inferences than non-depressed individuals. Although depressed individuals are thought to have a negative cognitive bias that results in recurrent, negative automatic thoughts, maladaptive behaviors, and dysfunctional world beliefs, depressive realism argues not only that this negativity may reflect a more accurate appraisal of the world but also that non-depressed individuals' appraisals are positively biased.

Affective neuroscience is the study of how the brain processes emotions. This field combines neuroscience with the psychological study of personality, emotion, and mood. The basis of emotions and what emotions are remains an issue of debate within the field of affective neuroscience.

Salience is that property by which some thing stands out. Salient events are an attentional mechanism by which organisms learn and survive; those organisms can focus their limited perceptual and cognitive resources on the pertinent subset of the sensory data available to them.

The dot-probe paradigm is a test used by cognitive psychologists to assess selective attention.

Attentional bias refers to how a person's perception is affected by selective factors in their attention. Attentional biases may explain an individual's failure to consider alternative possibilities when occupied with an existing train of thought. For example, cigarette smokers have been shown to possess an attentional bias for smoking-related cues around them, due to their brain's altered reward sensitivity. Attentional bias has also been associated with clinically relevant symptoms such as anxiety and depression.

Test anxiety is a combination of physiological over-arousal, tension and somatic symptoms, along with worry, dread, fear of failure, and catastrophizing, that occur before or during test situations. It is a psychological condition in which people experience extreme stress, anxiety, and discomfort during and/or before taking a test. This anxiety creates significant barriers to learning and performance. Research suggests that high levels of emotional distress have a direct correlation to reduced academic performance and higher overall student drop-out rates. Test anxiety can have broader consequences, negatively affecting a student's social, emotional and behavioural development, as well as their feelings about themselves and school.

Alcohol myopia is a cognitive-physiological theory on alcohol use disorder in which many of alcohol's social and stress-reducing effects, which may underlie its addictive capacity, are explained as a consequence of alcohol's narrowing of perceptual and cognitive functioning. The alcohol myopia model posits that rather than disinhibit, alcohol produces a myopia effect that causes users to pay more attention to salient environmental cues and less attention to less salient cues. Therefore, alcohol's myopic effects cause intoxicated people to respond almost exclusively to their immediate environment. This "nearsightedness" limits their ability to consider future consequences of their actions as well as regulate their reactive impulses.

Social anxiety is the anxiety and fear specifically linked to being in social settings. Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life; however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

<span class="mw-page-title-main">Rumination (psychology)</span> Focused attention

Rumination is the focused attention on the symptoms of one's mental distress, and on its possible causes and consequences, as opposed to its solutions, according to the Response Styles Theory proposed by Nolen-Hoeksema in 1998.

<span class="mw-page-title-main">Cognitive bias modification</span>

Cognitive bias modification (CBM) refers to procedures used in psychology that aim to directly change biases in cognitive processes, such as biased attention toward threat stimuli and biased interpretation of ambiguous stimuli as threatening. The procedures are designed to modify information processing via cognitive tasks that use basic learning principles and repeated practice to encourage a healthier thinking style in line with the training contingency.

<span class="mw-page-title-main">Attentional control</span> Individuals capacity to choose what they pay attention to and what they ignore

Attentional control, colloquially referred to as concentration, refers to an individual's capacity to choose what they pay attention to and what they ignore. It is also known as endogenous attention or executive attention. In lay terms, attentional control can be described as an individual's ability to concentrate. Primarily mediated by the frontal areas of the brain including the anterior cingulate cortex, attentional control is thought to be closely related to other executive functions such as working memory.

<span class="mw-page-title-main">Richard McNally</span> Professor of psychology

Richard McNally is an American psychologist and director of clinical training at Harvard University's department of psychology. As a clinical psychologist and experimental psycho-pathologist, McNally studies anxiety disorders and related syndromes, such as post-traumatic stress disorder, obsessive–compulsive disorder, and complicated grief.

A cognitive vulnerability in cognitive psychology is an erroneous belief, cognitive bias, or pattern of thought that predisposes an individual to psychological problems. The vulnerability exists before the symptoms of a psychological disorder appear. After the individual encounters a stressful experience, the cognitive vulnerability shapes a maladaptive response that increases the likelihood of a psychological disorder.

Emotion perception refers to the capacities and abilities of recognizing and identifying emotions in others, in addition to biological and physiological processes involved. Emotions are typically viewed as having three components: subjective experience, physical changes, and cognitive appraisal; emotion perception is the ability to make accurate decisions about another's subjective experience by interpreting their physical changes through sensory systems responsible for converting these observed changes into mental representations. The ability to perceive emotion is believed to be both innate and subject to environmental influence and is also a critical component in social interactions. How emotion is experienced and interpreted depends on how it is perceived. Likewise, how emotion is perceived is dependent on past experiences and interpretations. Emotion can be accurately perceived in humans. Emotions can be perceived visually, audibly, through smell and also through bodily sensations and this process is believed to be different from the perception of non-emotional material.

Cognitive behavioral training (CBTraining), sometimes referred to as structured cognitive behavioral training, (SCBT) is an organized process that uses systematic, highly-structured tasks designed to improve cognitive functions. Functions such as working memory, decision making, and attention are thought to inform whether a person defaults to an impulsive behavior or a premeditated behavior. The aim of CBTraining is to affect a person's decision-making process and cause them to choose the premeditated behavior over the impulsive behavior in their everyday life. Through scheduled trainings that may be up to a few hours long and may be weekly or daily over a specific set of time, the goal of CBTraining is to show that focusing on repetitive, increasingly difficult cognitive tasks can transfer those skills to other cognitive processes in your brain, leading to behavioral change. There has been a recent resurgence of interest in this field with the invention of new technologies and a greater understanding of cognition in general.

Interpretive bias or interpretation bias is an information-processing bias, the tendency to inappropriately analyze ambiguous stimuli, scenarios and events. One type of interpretive bias is hostile attribution bias, wherein individuals perceive benign or ambiguous behaviors as hostile. For example, a situation in which one friend walks past another without acknowledgement. The individual may interpret this behavior to mean that their friend is angry with them.

Affect labeling is an implicit emotional regulation strategy that can be simply described as "putting feelings into words". Specifically, it refers to the idea that explicitly labeling one's, typically negative, emotional state results in a reduction of the conscious experience, physiological response, and/or behavior resulting from that emotional state. For example, writing about a negative experience in one's journal may improve one's mood. Some other examples of affect labeling include discussing one's feelings with a therapist, complaining to friends about a negative experience, posting one's feelings on social media or acknowledging the scary aspects of a situation.

References

  1. ↑ Macleod, C.; Soong, L.; Rutherford, E. M.; Campbell, L. W. (2007). "Internet-delivered assessment and manipulation of anxiety-linked attentional bias: Validation of a free-access attentional probe software package". Behavior Research Methods. 39 (3): 533–538. doi: 10.3758/BF03193023 . PMID   17958165.
  2. ↑ Gray, J.; Robertson, I.; Pentland, B.; Anderson, S. (1992). "Microcomputer-based attentional retraining after brain damage: A randomised group controlled trial". Neuropsychological Rehabilitation. 2 (2): 97–115. doi:10.1080/09602019208401399.
  3. ↑ Hakamata, Y.; Lissek, S.; Bar-Haim, Y.; Britton, J. C.; Fox, N. A.; Leibenluft, E.; Pine, D. S. (2010). "Attention bias modification treatment: a meta-analysis toward the establishment of novel treatment for anxiety". Biol Psychiatry. 68 (11): 982–990. doi:10.1016/j.biopsych.2010.07.021. PMC   3296778 . PMID   20887977.
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  10. ↑ Journal of Abnormal Psychology (2009), 118(1)
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  13. ↑ See, J.; MacLeod, C.; Bridle, R. (2009). "The reduction of vulnerability through the modification of attentional bias: A real world study using a home-based cognitive bias modification procedure". Journal of Abnormal Psychology. 118 (1): 65–75. doi:10.1037/a0014377. PMID   19222315.
  14. ↑ Amir, N.; Beard, C.; Burns, M.; Bomyea, J. (2009). "Attention modification program in individuals with generalized anxiety disorder". Journal of Abnormal Psychology. 118 (1): 28–33. doi:10.1037/a0012589. PMC   2645540 . PMID   19222311.
  15. ↑ Heeren, A.; Reese, H. E.; McNally, R. J.; Philippot, P. (2012). "Attention training toward and away from treat in social phobia: Effects on behavioural, subjective, and physiological measures of anxiety". Behaviour Research and Therapy. 50 (1): 30–39. doi:10.1016/j.brat.2011.10.005. PMID   22055280. S2CID   21750268.
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  17. ↑ Boettcher J, Leek L, Matson L, Holmes, E. A., Browning M, MacLeod C, . . . P, C. Internet-based attention modification for social anxiety: a randomised controlled comparison of training towards negative and training towards positive cues (SUBMITTED).
  18. ↑ Heeren, A; Mogoaşe C; Philippot P; McNally RJ (2015). "Attention bias modification for social anxiety: A systematic review and meta-analysis". Clinical Psychology Review. 4 (2): 76–90. doi:10.1016/j.cpr.2015.06.001. PMID   26080314.
  19. ↑ Heeren, A.; Lievens, L.; Philippot, P. (2011). "How does attention training work in social phobia: Disengagement from threat or reengagement to non-threat?". Journal of Anxiety Disorders. 25 (8): 1108–1115. doi:10.1016/j.janxdis.2011.08.001. PMID   21907539.
  20. ↑ Amir, N.; Weber, G.; Beard, C.; Bomyea, J.; Taylor, C. T. (2008). "The effects of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals". Journal of Abnormal Psychology. 117 (4): 860–868. doi:10.1037/a0013445. PMC   3569035 . PMID   19025232.
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  22. ↑ Heeren, A; Billieux B; Philippot P; de Raedt R; Baeken C; de Timary P; Maurage P; Vanderhasselt M-A (2016). "Impact of Transcranial Direct Current Stimulation on Attentional Bias for Threat: a Proof-of-Concept Study among Individuals with Social Anxiety Disorder". Social Cognitive and Affective Neuroscience. 12 (2): 251–260. doi:10.1093/scan/nsw119. PMC   5390730 . PMID   27531388.
  23. ↑ Eberl, C.; Wiers, R. W.; Pawelczack, S.; Rinck, M.; Becker, E. S.; Lindenmeyer, J. (2013). "Approach bias modification in alcohol dependence: Do clinical effects replicate and for whom does it work best?". Developmental Cognitive Neuroscience. 4: 38–51. doi: 10.1016/j.dcn.2012.11.002 . PMC   6987692 . PMID   23218805.
  24. ↑ Schoenmakers, T.; Wiers, R. W.; Jones, B. T.; Bruce, G.; Jansen, A. T. M. (2007). "Attentional re-training decreases attentional bias in heavy drinkers without generalization" (PDF). Addiction. 102 (3): 399–405. doi:10.1111/j.1360-0443.2006.01718.x. PMID   17298647.
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