Prepared for the Best: Readiness To Modify Attentional Processing andReduction in Anxiety Vulnerability in Response to Therapy

Patrick J. F. Clarke, Nigel T. M. Chen, and Adam J. GuastellaUniversity of Sydney

Individuals differ in the extent to which their vulnerability to anxiety is reduced by psychological therapy.However, the cognitive basis for such individual differences is still poorly understood. To test a cognitiveaccount of differences in anxiety reduction in response to treatment, the present study examinedindividuals undergoing group therapy for social anxiety disorder. We assessed whether differences intheir readiness to adopt selective attentional processing in response to an experimental contingencypredicted positive changes in a range of anxiety measures in response to treatment. Findings wereconsistent with the position that readiness to alter attentional processing bias may underpin individualdifferences in the tendency to respond to positive experiential conditions, such as group therapy, byreducing anxiety vulnerability.

Keywords: anxiety, attention bias modification, cognitive bias, treatment response

It is now well established that individuals with high anxietyvulnerability, including those who are clinically anxious, displaybiased attentional processing of threatening information (cf. Bar–Haim, Lamy, Pergamin, Bakermans–Kranenburg, & van Ijzen-doorn, 2007; Cisler & Koster, 2010). One of the most consistentlyemployed methods of assessing selective attention in anxiety hasbeen the attentional probe task (MacLeod, Mathews, & Tata,1986). This experimental task involves the simultaneous presen-tation of threat and neutral stimuli for a brief duration, followed bya target probe which appears in the location vacated by one of thetwo words. Shorter latencies to discriminate probes appearing inthe location of threatening, relative to neutral stimuli, suggestselective processing of threat. Using this task, it has consistentlybeen demonstrated that members of the general population withhigh levels of anxiety vulnerability show biased attention for threatstimuli (Broadbent & Broadbent, 1988; MacLeod & Mathews,1988). This attentional selectivity for threat is also evident in thosewith anxiety pathology including social anxiety disorder (Musa,Lepine, Clark, Mansell, & Ehlers, 2003; Schultz & Heimberg,2008), generalized anxiety disorder (MacLeod et al., 1986; Mogg,Mathews, & Eysenck, 1992), posttraumatic stress disorder (Bryant& Harvey, 1997), panic disorder (Kroeze & van den Hout, 2000)and obsessive compulsive disorder (Tata, Leibowitz, Prunty, Cam-eron, & Pickering, 1996).

It has also been revealed that patterns of selective attention canbe acquired by exposure to contingencies that make the adoptionof such a bias adaptive (MacLeod, Rutherford, Campbell, Ebswor-thy, & Holker, 2002). To assess the impact of acquired attentionalbias MacLeod et al. (2002) modified the attentional probe assess-ment task by introducing a contingency between the location of thethreat word and the position of the probe. To encourage attentionalprocessing of threat stimuli, the probe would consistently appear inthe location vacated by the threat word over a number of trials.Alternatively, to encourage attentional processing away fromthreat, probes consistently appeared in the location opposite thethreat word over a number of trials. By delivering these alternativetask variants to different groups of participants, MacLeod et al.(2002) found that, on average, participants adopted an attentionalprocessing bias consistent with the assigned contingency. Theyalso revealed that the induction of this selective information pro-cessing bias led to a between-group difference in response to asubsequent stress task, whereby those who were exposed to thecontingency encouraging selective processing away from threatexhibited lower average state anxiety response, compared to thosewho received the reverse contingency. Similar findings have sincebeen revealed in a number of subsequent studies (Amir, Weber,Beard, Bomyea, & Taylor, 2008; Eldar, Ricon, & Bar-Haim, 2008;Mathews & MacLeod, 2002).

The task developed by MacLeod et al. (2002) creates an exper-imental condition where the acquisition of an attentional biasbecomes adaptive. That is, successful performance of the task isenhanced through the adoption of an attentional processing biasfavoring either threatening or neutral stimuli depending on thecontingency. Given the observation that the adoption of an atten-tional bias also causally affects anxiety vulnerability, Clarke,MacLeod and Shirazee, (2008) proposed that individual differ-ences in the susceptibility to elevate trait anxiety in response to acontinuous stressful environment, may be underpinned by thereadiness to acquire an attentional bias for threat. This hypothesissuggests that chronic exposure to even mildly stressful environ-

This article was published Online First October 3, 2011.Patrick J. F. Clarke, Nigel T. M. Chen, and Adam J. Guastella, Brain and

Mind Research Institute, University of Sydney, Sydney, New South Wales,Australia.

Patrick J. F. Clarke is now with the School of Psychology at theUniversity of Western Australia, Crawley, Western Australia, Australia.

Correspondence concerning this article should be addressed to PatrickJ. F. Clarke, School of Psychology, University of Western Australia,Crawley, Western Australia 6009, Australia. E-mail: patrick.clarke@uwa.edu.au

Emotion © 2011 American Psychological Association2012, Vol. 12, No. 3, 487–494 1528-3542/11/$12.00 DOI: 10.1037/a0025592

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ments will make it adaptive to selectively attend to threat cuesbecause these are likely to signal genuine danger. The early iden-tification of threat in such an environment will confer some ad-vantage in preparation for the impending danger, while also re-sulting in increased trait anxiety.

Based on this rationale, Clarke et al. (2008) proposed that thedegree to which individuals alter their information processingpriorities in response to a version of MacLeod et al.’s (2002)attentional training task (where the adoption of an attentional biasto threat is adaptive) will serve as an experimental proxy forrevealing the extent to which individuals adopt such a pattern ofattention in response to environmental conditions characterized byextended mild stress, and so increase trait anxiety. Those with thegreater readiness to acquire an attentional bias (RAAB) shouldtherefore be most likely to increase trait anxiety in response tosuch mildly stressful conditions. In two separate studies Clarke etal. (2008) demonstrated that measures of individual difference inRAAB obtained from commencing university students, predictedthe magnitude of increase in anxiety vulnerability across their firstuniversity semester, with greater RAAB predicting greater in-crease in anxiety vulnerability. This research also found that read-iness to acquire an attentional bias away from threat did not predictsubsequent changes in anxiety vulnerability.

The key aim of the present study was to build on the findings ofClarke et al. (2008) to examine whether RAAB is predictive ofindividual differences in anxiety reduction. Just as it is adaptive toacquire an attentional bias favoring threat under conditions wherethreat cues are likely to signal legitimate danger, it is also the casethat when these conditions remit, or are replaced by less stressfulconditions, adopting an alternative pattern of information process-ing will be adaptive and facilitate a reduction in anxiety vulnera-bility. It is entirely possible therefore that the readiness to adopt anattentional bias, under conditions where the acquisition of such abias is adaptive, will provide a critical marker of individual dif-ference in anxiety reduction in response to what we here term“positive experiential conditions.”

Indeed, just as the susceptibility to elevate trait anxiety inresponse to extended stress is subject to considerable individualdifference, so too is the tendency to reduce anxiety vulnerability inresponse to positive experiential conditions. While many differentexperiences may serve to reduce heightened anxiety vulnerability(e.g., caring relationships, stable employment), one of the mostthoroughly researched, is the psychological treatment for anxietypathology. Psychological therapy is specifically designed to reduceanxiety by targeting change in those factors implicated in thedevelopment and maintenance of dysfunctional anxiety.Cognitive–behavioral therapy (CBT) has consistently been shownto reduce anxiety symptoms in those suffering anxiety disorders(e.g., Herbert et al., 2009; Ladouceur et al., 2000). Despite theapparent effectiveness of CBT, there is considerable individualdifference in treatment response, with a significant proportion ofindividuals showing limited anxiety reduction in response to treat-ment (e.g., McEvoy, 2007). Identifying the facilitators and imped-iments to anxiety reduction in therapy has been the subject ofconsiderable attention. Such research has, however, tended tofocus on individual and therapy factors which may affect treatmentoutcome, such as dimensions of personality (Berger et al., 2004),pretherapy self-report symptom profiles (Chambless, Tran, &Glass, 1997), and expectancy of change and homework compli-

ance (Westra, Dozois, & Marcus, 2007). Here we examine aninformation processing account of individual difference in thetendency to reduce anxiety in response to positive experientialconditions.

To adequately assess variance in anxiety reduction in responseto positive experiential conditions it is necessary to examine indi-viduals with already elevated levels of anxiety, who will undergoa consistent experience that is likely to both reduce anxiety andpermit individual differences to emerge in such reduction. In thepresent study, we consider individual differences in anxiety reduc-tion among patients undergoing group therapy for social anxietydisorder (SAD). As per the requirements outlined above, individ-uals with SAD clearly constitute a group who exhibit elevatedanxiety vulnerability with respect to social situations, are likely toreduce such vulnerability in response to the therapy experience,and, are likely to differ in the extent to which this experienceserves to reduce their anxiety. The group therapy environmentfurther ensures that individuals are receiving similar positive ex-periential conditions; reducing the likelihood that variance in anx-iety reduction is due to differences in treatment content or delivery.

Based on the previous findings of Clarke et al. (2008) weidentify two distinct hypotheses concerning RAAB as a predictorof anxiety reduction in response to positive experiential conditions.The first states that RAAB reflects differences in attention-biasplasticity, where individuals respond to the presence or the absenceof environmental threat cues by altering information-processingpriorities toward or away from threat accordingly. Thus, a greaterpropensity to acquire an attentional threat bias when this is adap-tive would also signal a greater propensity to acquire the reversepattern of attentional processing when such an alternative biasbecomes adaptive. According to this account, individuals whodisplay greater RAAB, as revealed by an increased tendency totemporarily acquire an attentional bias in response to an experi-mental contingency, will also be most likely to respond to acorrective experience, such as group therapy, by altering theirinformation processing bias away from threat, and consequentlyshow increased anxiety reduction. This hypothesis we term thebias plasticity account of RAAB. The alternative hypothesis sug-gests that individual difference in RAAB represents a stable andenduring tendency to prioritize the identification of threat in theenvironment. Thus, a greater tendency to acquire an attentionalbias for threat when this is adaptive will signal a reduced propen-sity to acquire the reverse pattern of attentional processing underdifferent environmental conditions. According to this account,individuals who possess a specific tendency to adopt an attentionalbias favoring threat, as revealed by the transient acquisition of sucha bias in response to an experimental contingency, will be leastlikely to show readiness to acquire an alternative pattern of infor-mation processing in response to positive experiential conditionsprovided during therapy. According to this specific threat biasacquisition account of RAAB, those who demonstrate greaterRAAB will show the least response to therapy.

In the present study, we evaluated these alternative accounts byassessing the degree to which measures of RAAB serve to predictthe magnitude of reductions in anxiety vulnerability over thecourse of therapy for SAD. Whereas Clarke et al. (2008) includedonly a single measure of anxiety vulnerability, the present studybuilds on this research by incorporating measures of general anx-iety vulnerability, those more specific to social anxiety, and mea-

488 CLARKE, CHEN, AND GUASTELLA

sures of depression and general stress. The inclusion of theseadditional measures allow the present study to examine how con-sistently the measure of RAAB predicts different indicators ofanxiety reduction, and further, to establish if this cognitive char-acteristic is associated with change in anxiety vulnerability inparticular, or, with other measures of emotional vulnerability suchas current stress and depressed mood.

Method

Participants

Participants were 34 individuals who completed an 8-week CBTtreatment for social anxiety disorder (SAD). Acceptance into thetreatment program was conditional on having met the Diagnosticand statistical manual of mental disorders, Fourth Edition, TextRevision (DSM–IV–TR) criteria for a primary diagnosis of SAD(American Psychiatric Association, 2000). The participant samplecomprised 23 males and 11 females, with a mean (M) age of 26.03and standard deviation (SD) � 9.69 years.

Group CBT Program

Participants received an 8-session manualized CBT treatmentprogram. Session 1 of the program involves psychoeducationregarding social anxiety and general introduction to cognitivetherapy. Sessions 2 – 6 involve cognitive therapy (thought–feelingassociations, thought diary completion and cognitive restructuring)and the completion of both group and individualized in-sessionexposure tasks (e.g., public speaking, approaching strangers fordirections, and items from individual exposure hierarchies). Ses-sions 7 and 8 are devoted to examining the role of safety behaviorsin maintaining anxiety in social situations, identifying and chal-lenging core beliefs, goal planning, and relapse prevention.

Materials

Clinical Interview and Questionnaire Measures

Suitability for entry into the group treatment program wasdetermined via clinical interview using the Anxiety Disorder In-terview Schedule for the DSM–IV (ADIS-IV; Brown, Di Nardo, &Barlow, 1994). All clinical interviews were conducted by a clinicalpsychologist or clinical psychology intern trained and supervisedby the managing clinical psychologists (Patrick Clarke and AdamGuastella).

Questionnaire measures were administered prior to the com-mencement of therapy and at the end of the final session. Generalanxiety, stress, and depressive symptoms were assessed using theDepression Anxiety and Stress Scale (DASS-21; Lovibond &Lovibond, 1995). Symptoms of social anxiety were assessed usingthe Social Phobia Scale (SPS; Mattick & Clarke, 1998), andthe Social Interaction Anxiety Scale (SIAS; Mattick & Clarke,1998), Social Phobia and Anxiety Inventory-23 (SPAI-23, con-tains both social anxiety and agoraphobia subscales; Roberson–Nay, Strong, Nay, Beidel, & Turner, 2007), and the LeibowitzSocial Anxiety Scale (LSAS, contains fear and avoidance sub-scales; Leibowitz, 1987).

Word Stimuli

The experimental task employed 48 threat/neutral word pairsselected from the stimulus set used by MacLeod et al. (2002) tomodify selective attention, and subsequently by Clarke et al.(2008) to assess individual differences in RAAB. Threat wordsincluded items such as “discouraged,” “ignored,” and “worthless,”while their paired neutral words were items such as “connections,”“batteries,” and “lighted.” Each word pair was matched accordingto letter length and frequency of usage. The 48 word pairs weredivided into two stimulus subsets comprising 24 word pairs ineach.

Experimental Hardware

The experimental task was delivered using Inquisit 3.0.3.2 (Mil-lisecond Software, 2009). Stimuli were displayed on a high reso-lution monitor. Participant responses were registered with a two-button mouse labeled with a single dot and two dots on the left andright buttons respectively to indicate the appropriate response tothe corresponding probe types.

Experimental Task Structure

The RAAB assessment task comprised three blocks of trials.The first and last blocks of trials were designed to assess relativeattentional allocation to threat and neutral stimuli immediatelybefore and after exposure to a contingency designed to elicitattentional bias acquisition. These blocks will be referred to as thepre- and postcontingency bias assessment blocks respectively. Themiddle block of trials introduced the contingency between stimu-lus valence and probe location such that probes consistently re-placed threat words on each trial. The purpose of this block oftrials was to elicit selective attention favoring threat stimuli andwill be referred to as the attentional contingency block.

Characteristics of All Trials

Across all experimental blocks the basic trial structure wasidentical. All stimuli were presented against a black background.At the commencement of each trial a white central fixation crosswas presented for 500 ms. This was then replaced by a verticallyaligned word pair, presented in the center of the screen in 8-mmwhite block text. The stimulus centers were separated by 26 mm,vertically subtending approximately 2° visual angle at a viewingdistance of 70 cm. Word stimuli remained on the screen for 500ms. Following the termination of this display a single red dot ortwo small red dots then appeared in the location vacated by one ofthe two words. Participants were required to identify which ofthese two probes had appeared by pressing a corresponding mousekey. Immediately following the participant’s response, the displaywas cleared for 500 ms before the next trial began.

Structure of Bias Assessment Blocks

The structure of trials in the pre- and postcontingency biasassessment blocks was similar to traditional attentional probeassessment tasks whereby probes appear with equal frequency inthe location of either threatening or neutral stimuli on each trial.Each bias assessment block consisted of 48 trials. One was deliv-

489READINESS TO ACQUIRE ATTENTIONAL BIAS

ered before and one immediately after the attentional contingencyblock. Latency to discriminate probe type was recorded on eachtrial. Consistently shorter latencies to identify probes in the vicin-ity of threatening as compared with neutral words are taken tosuggest an attentional bias favoring threat.

Structure of Attentional Contingency Block

The purpose of the attentional contingency block was to elicitthe adoption of a pattern of attention that would facilitate probeidentification when a contingency is present between stimulusvalence and probe type. In choosing an appropriate contingencyfor inclusion we were guided by Clarke et al.’s (2008) previousfindings, demonstrating that individual differences in the tendencyto acquire an attentional bias toward threat was predictive ofsubsequent changes in anxiety, whereas the same measure derivedfrom the reverse contingency, encouraging attention away fromthreat, did not predict changes in anxiety. Therefore, during theattentional contingency block participants were presented with 288trials where probe position was fixed such that probes alwaysappeared in the location of the threat word. As performance onthese trials would be enhanced by the adoption of attentional biasfavoring threat, this contingency should encourage the emergenceof individual differences in the adoption of such a threat bias.

Allocation of Stimuli

The presentation of the two stimulus subsets were balanced suchthat a participant received a different stimulus subset used in theprecontingency bias assessment block to the postcontingency biasassessment block. For each participant, the stimulus subset used inthe precontingency bias assessment block was also employed inthe attentional contingency block. The use of different stimulussubsets in the pre- and postcontingency bias assessment blockswas designed to ensure that any change in attentional bias follow-ing exposure to the attentional contingency was related to stimulusvalence and not specific word stimuli.

Procedure

The experimental session assessing RAAB was conducted dur-ing a pregroup introductory session in the week prior to the

commencement of the group therapy program. During this sessionquestionnaire measures were returned or, if they had not alreadybeen completed, participants were provided these to completebefore attending the first group session. For completion of thecomputer task, participants were seated in a sound-attenuated roomapproximately 70 cm from the computer screen. Participants wereall provided the following instructions:

For this task a number of trials will be presented. At the start of each triala small cross will appear in the middle which you should attend to. Thiswill be followed by two words briefly presented, one above the other onthe screen, followed by either one or two red dots. Your task on eachtrial is to identify whether one or two dots were presented as quicklyand as accurately as possible. Press the left mouse key when one dotappears, and the right mouse key when two dots appear. Speed andaccuracy to identify the dots will be recorded on each trial.

Participants then completed 12 practice trials before the experimen-tal task began. The trials ran sequentially with nothing to signalboundaries between blocks. To assist in the extinction of any acquiredattentional bias, following the completion of the postcontingency biasassessment block participants completed an additional 48 trials whereno contingency was present. This experimental session took around20 min to complete. At no time during the completion of the CBTprogram were therapists made aware of participant results derivedfrom this pretherapy experimental session.

Participants completed questionnaire measures again in the finalgroup session, 8 weeks following the initial testing session. Mea-sures of anxiety reduction in response to the 8-week group pro-gram were calculated by subtracting each questionnaire scoretaken in the first session from the corresponding questionnairescore obtained in the final week. Negative scores on this indextherefore represent reductions in symptom severity.

Results

In order to assess individual differences in anxiety reduction, itwas necessary that the therapy program did indeed result in overalldecreases in measures of anxiety. Consistent with this requirement,the group treatment program resulted in significant reductions inall measures of anxiety vulnerability from the beginning to the endof therapy (see Table 1). The only exception was the Agoraphobia

Table 1Average Questionnaires Scores at Pre- and Posttherapy, and the Average, Minimum, Maximum, and Significance of Decrease FromPre- to Posttherapy

Questionnaire measure Pre Post

Symptom reduction pre-post t-score

Average Max Min (df � 33)

DASS – Depression 21.23 (10.35) 16.41 (11.07) �4.82 �34 14 2.97��

DASS – Anxiety 19.64 (8.06) 13.76 (8.01) �5.88 �24 6 5.13��

DASS – Stress 23.76 (9.18) 18.59 (10.07) �5.18 �22 10 3.74��

SIAS 60.56 (12.47) 49.79 (14.44) �10.76 �64 12 4.21��

LSAS 88.79 (25.06) 68.35 (30.12) �20.44 �79 19 5.08��

SPS 39.65 (17.06) 30.35 (17.36) �9.29 �38 19 4.01��

SPAI-23 - Social phobia 50.82 (8.86) 43.38 (11.12) �6.18 �20 10 5.14��

SPAI-23 - Agoraphobia 9.02 (7.23) 7.76 (6.47) �1.26 �11 9 1.51

Note. Standard deviations given in parentheses.� p � .05. �� p � .01.

490 CLARKE, CHEN, AND GUASTELLA

subscale of the SPAI-23. Given that agoraphobia was not anidentified problem, nor the target of curative change, the absenceof significant reduction on this measure could be considered un-surprising. Most important for the present study there was consid-erable variance in the magnitude of the change in these indicatorsof social anxiety and emotional vulnerability. As displayed inTable 1, participants showed considerable individual difference inthe size of symptom reduction across the course of treatment.

The average latency for participants to identify probes in theprecontingency bias assessment block was 516.46 ms (SD �75.50) for threat stimuli and 513.06 ms (SD � 71.56) for neutralstimuli, while the average latency for participants to identifyprobes in the postcontingency bias assessment block was 501.76ms (SD � 71.85) for threat stimuli and 509.13 ms (SD � 81.06)for neutral stimuli. To calculate indices of the degree to which anattentional bias was acquired by exposure to the task contingency,we employed a similar approach to Clarke et al. (2008). Thus, foreach participant an attentional bias index was first calculated forboth the pre and postcontingency bias assessment blocks by takingthe median latency to respond to probes appearing in the locationof threat words, from the median latency to respond to probesappearing in the vicinity of neutral words. A higher score on thisattentional bias index, therefore, represents speeding to attend toprobes in the vicinity of threat. The index of RAAB was achievedby subtracting the precontingency attentional bias score from thepostcontingency attentional bias score. The resulting RAAB indexrepresents the degree to which participants adopted the pattern ofinformation processing encouraged in the threat bias contingencyblock, via an increase in attentional bias for threat in the postcon-tingency bias assessment block, relative to the precontingency biasassessment block.

Consistent with the position that individuals will vary in thereadiness to acquire an attentional bias, the degree to which indi-viduals acquired an attentional bias as observed on the RAABindex (M � 9.41, SD � 43.10) was highly variable with scoresranging from a minimum of �51 to a maximum of 150. The factthat the attentional bias index in the precontingency bias assess-ment block did not serve to significantly predict the attentionalbias index in the postcontingency bias assessment block, r(28) �.003, ns, further suggests that there was considerable individualdifference in the degree to which participants adopted the patternof attention encouraged in the attentional contingency block.

To address the key hypotheses under scrutiny, we performedmultiple linear regression analyses to examine whether RAABassessed at the start of therapy served to positively or negativelypredict anxiety reduction in response to the treatment program.Within each individual analysis, the measure of RAAB was thesingle predictor variable and the measure of symptom changeserved as the dependent measure. According to the bias plasticityaccount, those who most readily adopt an attentional bias whenexposed to the experimental contingency will also be most likelyto respond to therapy by adopting an alternative information pro-cessing bias and thus reduce anxiety vulnerability. This accountpredicts that higher RAAB scores will be associated with greaterreductions in anxiety symptoms, resulting in a negative correlationbetween RAAB and the magnitude of reduction in anxiety vulner-ability measures pre to posttherapy. The specific threat bias acqui-sition account instead predicts that those who are most likely toacquire an attentional bias for threat in response to an experimental

contingency will also be least likely to respond to therapy byacquiring an alternative pattern of information processing. Thishypothesis states that higher RAAB scores will be associated withthe least reduction in anxiety vulnerability resulting in RAABpositively predicting reduction in anxiety vulnerability pre- toposttherapy.

The pattern of findings clearly supported the bias plasticityaccount, in that the RAAB index negatively predicted the magni-tude of reduction in measures of anxiety vulnerability. The RAABindex significant predicted change in; the Anxiety subscale of theDASS, F(1, 33) � 8.34, r � �.45, p � .01; the Social InteractionAnxiety Scale, F(1, 33) � 8.54, r � �.50, p � .01; the SocialPhobia Scale, F(1, 33) � 12.03, r � �.52, p � .01; the SocialPhobia subscale of the SPAI-23, F(1, 33) � 9.90, r � �.49, p �.01; and the Leibowitz Social Anxiety Scale, F(1, 33) � 5.46, r ��.38, p � .05.1 Furthermore, consistent with the position that theRAAB index will specifically predict change in anxiety vulnera-bility, this index was not associated with change in other measuresof emotional vulnerability such as the Depression subscale of theDASS, F(1, 33) � 2.29, r � �.26, ns; the Stress subscale of theDASS, F(1, 33) � 0.51, r � �.12, ns; and the Agoraphobiasubscale of the SPAI-23, F(1, 33) � 2.24, r � �.26, ns.

Although the pattern and consistency of the above correlationsprovide clear support for measures of RAAB as a predictor ofresponse to therapy, it is possible that such effects could bemediated by other variables. Subsidiary analyses were thereforeperformed to address some of these alternative possibilities. Onealternative account is that those who most readily acquire anattentional bias will experience the greatest reductions in anxietyvulnerability across the course of therapy because they also havethe highest initial anxiety vulnerability. To address this possibility,part correlations were examined to establish the unique contribu-tion of RAAB to predict measures of symptom reduction in re-sponse to treatment when controlling for the contribution of initialanxiety measures at the beginning of therapy. These analysesrevealed that the pattern and significance of the above results waslargely preserved when controlling for initial levels of these mea-sures. The RAAB index remained a significant predictor ofchanges in; the Anxiety subscale of the DASS, pr(34) � �.36, p �.05; the Social Interaction Anxiety Scale, pr(34) � �.33, p � .05;the Social Phobia Scale, pr(34) � �.42, p � .01; and the SocialPhobia subscale of the SPAI-23, pr(34) � �.46, p � .01; whereasthe correlation with the Leibowitz Social Anxiety Scale was re-duced to marginal significance, pr(34) � �.33, p � .06. Thispattern of findings clearly suggests that RAAB negatively predictschange in anxiety vulnerability in response to therapy independentof initial anxiety vulnerability.

Another alternative account of the observed findings concernsthe relative contribution of attentional bias observed before expo-sure to the contingency (the precontingency attentional bias score),versus after exposure to the contingency (the postcontingencyattentional bias score), in predicting symptom change across ther-apy. If attentional bias measured before exposure to the experi-mental contingency consistently predicts change in symptom se-

1 Examination of scatter plots demonstrating the relationship betweenRAAB and each measure of symptom change did not reveal any nonlin-earity or ceiling effects.

491READINESS TO ACQUIRE ATTENTIONAL BIAS

verity across therapy, while attentional bias measured afterexposure to the experimental contingency does not, then thiswould suggest that the “baseline” attentional bias (observed priorto contingency exposure) is more likely to be the critical mecha-nism than the attentional bias elicited in response to the contin-gency.

To examine this possibility we conducted separate linear regres-sion analyses using the precontingency attentional bias score andthe postcontingency attentional bias score as predictors of theanxiety symptom change measures. The precontingency atten-tional bias score did not significantly predict change in any of thesymptom measures pre- to posttherapy, DASS-Anxiety, F(1,33) � 0.60, r � .14, p � .44; Social Interaction Anxiety Scale,F(1, 33) � 0.02, r � .02, p � .89; Social Phobia Scale, F(1, 33) �3.17, r � .30, p � .09; Leibowitz Social Anxiety Scale, F(1, 33) �0.81, r � .16, p � .38; with the exception of the Social Phobiasubscale of the SPAI-23, F(1, 33) � 5.83, r � .39, p � .05.However, the attention bias index derived from the postcontin-gency bias assessment block was a consistent negative predictorof all anxiety measures of symptom change, DASS-Anxiety,F(1, 33) � 8.22, r � �.45, p � .01; Social Interaction AnxietyScale, F(1, 33) � 14.54, r � �.56, p � .01; Social PhobiaScale, F(1, 33) � 5.72, r � �.39, p � .05; Leibowitz SocialAnxiety Scale, F(1, 33) � 4.21, r � �.34, p � .05; again, withthe exception of the Social Phobia subscale of the SPAI-23,F(1, 33) � 2.30, r � �.26, p � .14. As the postcontingencyattentional bias score proved to be the most consistent predictor oftreatment response, these findings suggest that the pattern ofattentional bias elicited by exposure to the experimental contin-gency is most likely to be the critical mechanism underlying theprediction of change in symptom response, and not baseline atten-tional bias.2

Discussion

The findings of the present study revealed that individual dif-ferences in RAAB elicited by brief exposure to an experimentalcontingency serves to predict the extent to which individualssubsequently reduce anxiety in response to a therapeutic interven-tion. Our results revealed that this pattern of findings also re-mained intact when controlling for initial levels of anxiety symp-toms present at the beginning of therapy. Furthermore, thedirection of the correlations observed in this study provided un-ambiguous support for the bias plasticity account of attentionalbias acquisition, in that greater RAAB was associated with largerreductions in anxiety vulnerability across therapy. This pattern offindings is consistent with the notion that individual differences inreadiness to acquire an attentional bias are characterized by atten-tional bias malleability. According to this hypothesis, those withthe greatest readiness to acquire an attentional processing biasfavoring threat in response to an experimental contingency makinga threat bias adaptive, will also be most likely to adopt the reverseprocessing bias when exposed to environmental conditions (i.e.,group therapy) which make this adaptive and so reduce anxietyvulnerability. The present study provides the first experimentalevidence that RAAB serves to predict decreases in anxiety vul-nerability in response to positive experiential conditions. It is alsoonly the second that we are aware of to establish a link betweenindividual differences in this cognitive construct and change in

anxiety across time. We believe that these findings possess signif-icant theoretical and applied implications.

Although the current results are obviously encouraging, thepresent study is not, however, without limitations that should beacknowledged. One of these is highlighted by the absence ofcorrelations between RAAB and changes in depression, stress, orelements of anxiety unrelated to the treatment program. Thesefindings could suggest that RAAB specifically predicts reductionin elevated anxiety over time and not other more general indicatorsof emotional vulnerability. However, given that we assessed ananxiety-linked cognitive bias, within a treatment program aimed atreducing anxiety, the absence of associations with these othermeasures of emotional vulnerability may be somewhat unsurpris-ing. Our present findings must therefore be restricted to an anxiety-related cognitive bias assessed within a CBT protocol. We cannotsay with confidence whether a measure of RAAB will predictreductions in anxiety (or other measures of emotional vulnerabil-ity) under other conditions that would encourage such a change, orwhether this measure is relevant only for predicting change forthose undergoing CBT. Given that this measure has been shown topredict increases in anxiety in response to a mild stressor such asbeginning university for the first time (Clarke et al., 2008), it isentirely possible that measures of RAAB will predict reductions inanxiety in response to other more general environmental condi-tions characterized by the remittance of a stressor. Incorporatingthis assessment procedure into other treatments for anxiety, orother conditions that would encourage anxiety reductions, couldprovide a means of assessing whether this is indeed the case in thefuture.

The present study was deliberately designed to examine RAABand anxiety change in response to therapy. While this restricts ourfindings to this particular cognitive bias within anxiety, it isentirely possible that similar designs could be applied to otherestablished cognitive biases and aspects of emotion other thananxiety. The development of modification techniques for cognitivebias, such as facilitated forgetting of negative material in depres-sion for example (Joormann, Hertel, LeMoult, & Gotlib, 2009),could provide an avenue for future research to assess whetherindividual differences in the malleability of such biases also pre-dict subsequent change in associated emotional vulnerabilities, likedepression, in response to conditions designed to remediate suchemotional dysfunction.

While the present findings invite the conclusion that those whomost readily acquire an attentional threat bias will also acquire anattentional processing bias away from threat under conditionswhere this is adaptive, the absence of measures of readiness toacquire a nonthreat bias highlights a limitation of the presentresearch. The strength and consistency of the correlations observed

2 A final alternative possibility concerning whether level of participantengagement could potentially account for the observed findings was alsoaddressed in analyses. This was examined by using task indicators ofengagement (total accuracy and median response latency) as predictors ofchanges in anxiety across therapy. When accuracy and total median re-sponse latency were used as predictor variables in a linear regressionanalysis, they did not significantly predict change in any of the anxietymeasures (largest F � 0.25, largest p � 0.30), suggesting that level ofengagement is unlikely to account for the relationship between readiness toacquire attentional bias and treatment response.

492 CLARKE, CHEN, AND GUASTELLA

in the present study provide reassurance that the contingencyselected for inclusion in the experimental task was appropriate formeasuring this construct. It is entirely possible, however, thatindividual differences in the readiness to acquire an attentionalprocessing bias away from threat would similarly predict suchchanges in anxiety vulnerability. Examining relationships betweenreadiness to acquire an attentional processing bias toward versusaway from threat, and changes in anxiety vulnerability over timealso provides a clear avenue for future research.

In considering the implications of the present findings, and inparticular the bias plasticity account of RAAB, it interesting toconsider how this potentially relates to theories of attention control(Eysenck, Derakshan, Santos, & Calvo, 2007) and research on therole of learning in reducing anxiety (Myers & Davis, 2002). Theability to acquire new learning in relation to fear-relevant stimuliand the tendency to alter information processing priorities on thebasis of such learning could be critical mechanisms which influ-ence the relationship between RAAB and change in anxiety inresponse to therapy.

Variants of the attentional probe task which encourage theacquisition of an attentional bias either toward or away from threathave generally been considered in terms of “training” attention,though clearly the degree to which these tasks serve to modifyattention will depend on learning the association between stimulustype and probe location. Eysenck et al. (2007) suggest that atten-tion control is a top-down process with attentional bias for threatin anxiety being the result of a deficit in such top-down inhibitionof attention to threat. Given this understanding of selective atten-tion in anxiety, it is possible that the degree to which an attentionalbias is adopted in response to an experimental contingency willdepend on an individual’s ability to increase top-down attentionalcontrol to inhibit attentional deployment to the type of stimulusappearing opposite the probe, while allocating attention toward thecategory of stimulus consistently appearing in the location of theprobe. Consistent with this, the role of increasing attentionalinhibition during a probe training task has received empiricalsupport from recent functional magnetic resonance imaging re-search. Browning, Holmes, Murphy, Goodwin, and Harmer (2010)found that exposure to an attentional training contingency encour-aging the processing of threatening or neutral stimuli resulted inchanges in neural systems associated with attentional inhibition.Specifically, they revealed that, after completing an attentionaltraining procedure, participants showed increased lateral prefrontalcortex activity when presented with the class of stimulus (eitherthreat or neutral) that they were trained to attend away from. Thiswas taken to suggest that attentional change in response to atraining variant of the probe task occurs via increasing inhibition tothe class of stimulus that participants are trained to avoid. Theauthors go on to suggest that changes in attentional bias via suchinhibition pathways may be a critical mechanism involved inreducing anxiety vulnerability in psychological interventions suchas CBT.

Indeed, through exposure therapy, behavioral experiments,thought evaluation and other methods, CBT for anxiety provideslearning opportunities which allow individuals the opportunity toreevaluate the threat value of feared stimuli and situations. Assuggested by Browning et al. (2010), this process could readilycontribute to change in attentional processing priorities by increas-ing attentional control through inhibition for threat stimuli which

are no longer allocated high attentional priority. The degree towhich learning in therapy is translated to modification of atten-tional processing priorities could be critical to achieving therapeu-tic gains. Our own findings would tend to support such a mecha-nism of therapeutic change and further suggest that the degree towhich individuals will alter attentional processing priorities inresponse to environmental conditions which make such changesadaptive, may be a critical individual difference dimension indetermining how readily positive experiential conditions will con-tribute to reductions in anxiety symptoms.

The present findings also have implications for interventionswhich are designed to directly target dysfunctional patterns ofselective attention. Recently, attentional modification proceduresdesigned to remediate dysfunctional levels of anxiety by encour-age selective processing of away from threat have shown consid-erable promise as a therapeutic intervention. Procedures involvingexposure to attentional training contingencies over a period ofweeks have been successful in reducing symptoms for many,though not all, of those diagnosed with generalized anxiety disor-der (Amir, Beard, Burns, & Bomyea, 2009) and with social anxietydisorder (Amir, Beard, Taylor, Klumpp, Elias, Burns, & Chen,2009; Schmidt, Richey, Buckner, & Timpano, 2009). Given thecapacity of RAAB measures to predict treatment response to CBTin the current study, there is every reason to believe that such ameasure would predict treatment response to an intervention de-signed to directly modify selective attention. Indeed, it is entirelypossible that capacity of RAAB measures to predict treatmentoutcome would be even greater when the intervention itself isspecifically designed to alter attentional preference for threat.RAAB could therefore have significant potential to predict themagnitude of change in attentional processing in response to suchan intervention and so inform the likelihood that someone willbenefit from attentional bias modification as a treatment for anx-iety difficulties.

Further investigation will obviously be required to determinewhether such applications of this assessment task prove to be useful.Our present findings however, provide support for the functionalrole of RAAB as a predictor of the tendency to reduce anxietyduring therapy. More specifically they suggest that individualdifferences in RAAB in response to conditions that make such abias adaptive precedes and predicts subsequent reductions in anx-iety symptoms in response to positive experiential conditions.

References

Amir, N., Beard, C., Burns, M., & Bomyea, J. (2009). Attention modifi-cation program in individuals with generalized anxiety disorder. Journalof Abnormal Psychology, 118, 28–33. doi:10.1037/a0012589

Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J., Burns, M., &Chen, X. (2009). Attention training in individuals with generalizedsocial phobia: A randomized controlled trial. Journal of Consulting andClinical Psychology, 77, 961–973.

Amir, N., Weber, G., Beard, C., Bomyea, J., & Taylor, C. T. (2008). Theeffect of a single-session attention modification program on response toa public-speaking challenge in socially anxious individuals. Journal ofAbnormal Psychology, 117, 860–868. doi:10.1037/a0013445

American Psychiatric Association. (2000). Diagnostic and statistical man-ual of mental disorders. Fourth Edition, Text Revision. Washington DC:Author.

Bar–Haim, Y., Lamy, D., Pergamin, L., Bakermans–Kranenburg, M. J., &

493READINESS TO ACQUIRE ATTENTIONAL BIAS

van Ijzendoorn, M. H. (2007). Threat-related attentional bias in anxiousand nonanxious individuals: A meta-analytic study. Psychological Bul-letin, 133, 1–24. doi:10.1037/0033-2909.133.1.1

Berger, P., Sachs, G., Amering, M., Holzinger, A., Bankier, B., &Katschnig, H. (2004). Personality disorder and social anxiety predictdelayed response in drug and behavioral treatment of panic disorder.Journal of Affective Disorders, 80, 75–78. doi:10.1016/S0165-0327(03)00043-0

Broadbent, D., & Broadbent, M. (1988). Anxiety and attentional bias: Stateand trait. Cognition & Emotion, 2, 165–183. doi:10.1080/02699938808410922

Brown, T., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety DisordersInterview Schedule Adult Version (ADIS-IV). San Antonio, TX: Psycho-logical Corporation/Graywind Publications Incorporated.

Browning, M., Holmes, E. A., Murphy, S. E., Goodwin, G. M., & Harmer,C. J. (2010). Lateral prefrontal cortex mediates the cognitive modifica-tion of attentional bias. Biological Psychiatry, 67, 919 –925. doi:10.1016/j.biopsych.2009.10.031

Bryant, R. A., & Harvey, A. G. (1997). Attentional bias in posttraumaticstress disorder. Journal of Traumatic Stress, 10, 635–644. doi:10.1002/jts.2490100409

Chambless, D. L., Tran, G. Q., & Glass, C. R. (1997). Predictors ofresponse to cognitive-behavioral group therapy for social phobia. Jour-nal of Anxiety Disorders, 11, 221–240. doi:10.1016/S0887-6185(97)00008-X

Cisler, J. M., & Koster, E. H. (2010). Mechanisms of attentional biasestowards threat in anxiety disorders: An integrative review. ClinicalPsychology Review, 30, 203–216. doi:10.1016/j.cpr.2009.11.003

Clarke, P., MacLeod, C., & Shirazee, N. (2008). Prepared for the worst:Readiness to acquire threat bias and susceptibility to elevate trait anxi-ety. Emotion, 8, 47–57.

Eldar, S., Ricon, T., & Bar–Haim, Y. (2008). Plasticity in attention:Implications for stress response in children. Behaviour Research andTherapy, 46, 450–461. doi:10.1016/j.brat.2008.01.012

Eysenck, M. W., Derakshan, N., Santos, R., & Calvo, M. G. (2007).Anxiety and cognitive performance: Attentional control theory. Emo-tion, 7, 336–353. doi:10.1037/1528-3542.7.2.336

Herbert, J. D., Gaudiano, B. A., Rheingold, A. A., Moitra, E., Myers, V. H.,Dalrymple, K. L., & Brandsma, L. L. (2009). Cognitive behavior therapyfor generalized social anxiety disorder in adolescents: A randomizedcontrolled trial. Journal of Anxiety Disorders, 23, 167–177. doi:10.1016/j.janxdis.2008.06.004

Inquisit 3.0.3.2 (2009). Seattle, WA: Millisecond Software LLC.Joormann, J., Hertel, P. T., LeMoult, J., & Gotlib, I. H. (2009). Training

forgetting of negative material in depression. Journal of AbnormalPsychology, 118, 34–43. doi:10.1037/a0013794

Kroeze, S., & van den Hout, M. A. (2000). Selective attention for cardiacinformation in panic patients. Behaviour Research and Therapy, 38,63–72. doi:10.1016/S0005-7967(99)00023-6

Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, F., &Thibodeau, N. (2000). Efficacy of a cognitive-behavioral treatment forgeneralized anxiety disorder: Evaluation in a controlled clinical trial.Journal of Consulting and Clinical Psychology, 68, 957–964. doi:10.1037/0022-006X.68.6.957

Leibowitz, M. R. (1987). Social phobia. Modern Problems of Pharmaco-psychiatry, 22, 141–173.

Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative

emotional states: Comparison of the Depression Anxiety Stress Scales(DASS) with the Beck Depression and Anxiety Inventories. BehaviourResearch & Therapy, 33, 335–343. doi:10.1016/0005-7967(94)00075-U

MacLeod, C., & Mathews, A. (1988). Anxiety and the allocation ofattention to threat. Quarterly Journal of Experimental Psychology A, 40,653–670.

MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emo-tional disorders. Journal of Abnormal Psychology, 95, 15–20. doi:10.1037/0021-843X.95.1.15

MacLeod, C., Rutherford, E., Campbell, L., Ebsworthy, G., & Holker, L.(2002). Selective attention and emotional vulnerability: Assessing thecausal basis of their association through the experimental manipulationof attentional bias. Journal of Abnormal Psychology, 111, 107–123.doi:10.1037/0021-843X.111.1.107

Mathews, A., & MacLeod, C. (2002). Induced processing biases havecausal effects on anxiety. Cognition & Emotion, 16, 331–354. doi:10.1080/02699930143000518

Mattick, R. P., & Clarke, J. C. (1998). Development and validation ofmeasures of social phobia scrutiny fear and social interaction anxiety.Behaviour Research and Therapy, 36, 455–470. doi:10.1016/S0005-7967(97)10031–6

McEvoy, P. M. (2007). Effectiveness of cognitive behavioural grouptherapy for social phobia in a community clinic: A benchmarking study.Behaviour Research and Therapy, 45, 3030 –3040. doi:10.1016/j.brat.2007.08.002

Mogg, K., Mathews, A., & Eysenck, M. (1992). Attentional bias to threatin clinical anxiety states. Cognition & Emotion, 6, 149–159. doi:10.1080/02699939208411064

Musa, C., Lepine, J., Clark, D., Mansell, W., & Ehlers, A. (2003). Selectiveattention in social phobia and the moderating effect of a concurrentdepressive disorder. Behaviour Research and Therapy, 41, 1043–1054.doi:10.1016/S0005-7967(02)00212-7

Myers, K. M., & Davis, M. (2002). Behavioral and neural analysis ofextinction. Neuron, 36, 567–584. doi:10.1016/S0896-6273(02)01064-4

Roberson–Nay, R., Strong, D. R., Nay, W. T., Beidel, D. C., & Turner,S. M. (2007). Development of an abbreviated Social Phobia and AnxietyInventory (SPAI) using item response theory: The SPAI-23. Psycholog-ical Assessment, 19, 133–145. doi:10.1037/1040-3590.19.1.133

Schmidt, N. B., Richey, J., Buckner, J. D., & Timpano, K. R. (2009).Attention training for generalized social anxiety disorder. Journal ofAbnormal Psychology, 118, 5–14.

Schultz, L. T., & Heimberg, R. G. (2008). Attentional focus in socialanxiety disorder: Potential for interactive processes. Clinical PsychologyReview, 28, 1206–1221. doi:10.1016/j.cpr.2008.04.003

Tata, P. R., Leibowitz, J. A., Prunty, M. J., Cameron, M., & Pickering,A. D. (1996). Attentional bias in obsessional compulsive disorder.Behaviour Research and Therapy, 34, 53– 60. doi:10.1016/0005-7967(95)00041-U

Westra, H. A., Dozois, D. J., & Marcus, M. (2007). Expectancy, homeworkcompliance, and initial change in cognitive-behavioral therapy for anx-iety. Journal of Consulting and Clinical Psychology, 75, 363–373.doi:10.1037/0022-006X.75.3.363

Received April 6, 2011Revision received August 17, 2011

Accepted August 19, 2011 �

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