Anxiety and Threat-Related Attention: Cognitive-Motivational Framework and Treatment

Research in experimental psychopathology has led to the development of ABM training as a potential computer-delivered treatment for anxiety disorders. Conventional ABM threat-avoidance training encourages anxious individuals to orient attention away from threat, but has variable effects on anxiety and threat-related ABs. Differing explanations for mixed outcomes of ABM training, and theoretical controversy about the causes of anxiety and ABs, encourage the development of alternative novel ABM training methods. Development of effective attention-based treatments for anxiety would be advanced by better theoretical understanding of the cognitive processes underlying anxiety and ABs, and by using more refined and comprehensive assessments of threat-related attention and associated cognitive and neural functioning. Research in experimental psychopathology and cognitive theories of anxiety highlight threat-related attention biases (ABs) and underpin the development of a computer-delivered treatment for anxiety disorders: attention-bias modification (ABM) training. Variable effects of ABM training on anxiety and ABs generate conflicting research recommendations, novel ABM training procedures, and theoretical controversy. This article summarises an updated cognitive-motivational framework, integrating proposals from cognitive models of anxiety and attention, as well as evidence of ABs. Interactions between motivational salience-driven and goal-directed influences on multiple cognitive processes (e.g., stimulus evaluation, inhibition, switching, orienting) underlie anxiety and the variable manifestations of ABs (orienting towards and away from threat; threat-distractor interference). This theoretical analysis also considers ABM training as cognitive skill training, describes a conceptual framework for evaluating/developing novel ABM training procedures, and complements network-based research on reciprocal anxiety–cognition relationships. Research in experimental psychopathology and cognitive theories of anxiety highlight threat-related attention biases (ABs) and underpin the development of a computer-delivered treatment for anxiety disorders: attention-bias modification (ABM) training. Variable effects of ABM training on anxiety and ABs generate conflicting research recommendations, novel ABM training procedures, and theoretical controversy. This article summarises an updated cognitive-motivational framework, integrating proposals from cognitive models of anxiety and attention, as well as evidence of ABs. Interactions between motivational salience-driven and goal-directed influences on multiple cognitive processes (e.g., stimulus evaluation, inhibition, switching, orienting) underlie anxiety and the variable manifestations of ABs (orienting towards and away from threat; threat-distractor interference). This theoretical analysis also considers ABM training as cognitive skill training, describes a conceptual framework for evaluating/developing novel ABM training procedures, and complements network-based research on reciprocal anxiety–cognition relationships. Anxiety disorders are common mental-health problems that are burdensome for sufferers and health services [1Craske M.G. Stein M.B. Anxiety.Lancet. 2016; 388: 3048-3059Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar]. Treatments include medication and cognitive behavioural therapy (CBT); however, many anxiety sufferers fail to respond, or relapse [1Craske M.G. Stein M.B. Anxiety.Lancet. 2016; 388: 3048-3059Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 2Olatunji B.O. et al.Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings.Psychiatr. Clin. North Am. 2010; 33: 557-577Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar]. Consequently, there is need for additional treatment options which are effective, low-cost, and easily delivered. One potential computer-delivered treatment is attention-bias modification (ABM) training. ABM training arose from research in experimental psychopathology (see Glossary), and draws on theory and methods in experimental cognitive psychology to examine and modify attention processes in anxiety. The original version, ABM threat-avoidance training, is based on assumptions that anxious individuals have an enduring automatic tendency to attend preferentially to threat information [3Williams M. et al.Cognitive Psychology and Emotional Disorders.1st edn. Wiley, 1988Google Scholar], and reduction of this attention bias (AB) should reduce anxiety [4MacLeod C. et al.Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias.J. Abnorm. Psychol. 2002; 111: 107-123Crossref PubMed Google Scholar, 5MacLeod C. Clarke P.J.F. The attentional bias modification approach to anxiety intervention.Clin. Psychol. Sci. 2015; 3: 58-78Crossref Scopus (98) Google Scholar]. However, there is dispute about the clinical effectiveness of ABM training and the cognitive processes underlying anxiety and threat-related ABs. The purpose of this article is several-fold: to provide a brief overview of these issues, which builds on and extends our previous reviews [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar, 7Mogg K. et al.Attention bias modification (ABM): review of effects of multisession ABM training on anxiety and threat-related attention in high-anxious individuals.Clin. Psychol. Sci. 2017; 54: 698-717Crossref Scopus (3) Google Scholar]; to describe an updated cognitive-motivational model of anxiety and threat-related attention; to view ABM training as cognitive skill training; to apply the distinction between processes and procedures [8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar] to this updated perspective; to describe a conceptual framework for evaluating and developing novel ABM training procedures; and to encourage network-based research evaluating reciprocal anxiety–cognition relationships. The most widely used method, ABM threat-avoidance training, typically employs a modified visual probe task to train anxious individuals to direct attention away from threat [4MacLeod C. et al.Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias.J. Abnorm. Psychol. 2002; 111: 107-123Crossref PubMed Google Scholar]. Each trial presents a threat and nonthreat cue simultaneously in different locations of a computer screen, immediately followed by a probe (e.g., a dot) which replaces one of the cues (Figure 1). Participants respond as quickly as possible to the probe. In ABM threat-avoidance training, probes are unlikely to appear in locations just vacated by threat cues. Hence, training (many hundreds of trials) encourages orienting of attention away from the location of threat. Since its introduction about 15 years ago, over 30 studies have evaluated the effects of ABM threat-avoidance training on anxiety symptoms and AB in high-anxiety individuals. Despite initial promising results, many studies report disappointing outcomes [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar, 7Mogg K. et al.Attention bias modification (ABM): review of effects of multisession ABM training on anxiety and threat-related attention in high-anxious individuals.Clin. Psychol. Sci. 2017; 54: 698-717Crossref Scopus (3) Google Scholar, 8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 9Cristea I.A. et al.Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis.Br. J. Psychiatry. 2015; 206: 7-16Crossref PubMed Scopus (176) Google Scholar, 10Cristea I.A. et al.Practitioner review: cognitive bias modification for mental health problems in children and adolescents: a meta-analysis.J. Child Psychol. Psychiatry Allied Discip. 2015; 56: 723-734Crossref PubMed Scopus (23) Google Scholar, 11Heeren A. et al.Attention bias modification for social anxiety: a systematic review and meta-analysis.Clin. Psychol. Rev. 2015; 40: 76-90Crossref PubMed Scopus (90) Google Scholar, 12Van Bockstaele B. et al.A review of current evidence for the causal impact of attentional bias on fear and anxiety.Psychol. Bull. 2014; 140: 682-721Crossref PubMed Scopus (103) Google Scholar, 13Price R.B. et al.Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias.Clin. Psychol. Rev. 2016; 50: 37-49Crossref PubMed Scopus (36) Google Scholar, 14Mogoaşe C. et al.Clinical efficacy of attentional bias modification procedures: an updated meta-analysis.J. Clin. Psychol. 2014; 70: 1133-1157Crossref PubMed Scopus (146) Google Scholar, 15Liu H. et al.Effects of cognitive bias modification on social anxiety: a meta-analysis.PLoS One. 2017; 12: 1-24Google Scholar, 16Jones E.B. Sharpe L. Cognitive bias modification: a review of meta-analyses.J. Affect. Disord. 2017; 223: 175-183Crossref PubMed Scopus (24) Google Scholar]. ABM threat-avoidance training is often no more effective in reducing anxiety than control attention training (e.g., a visual probe task in which probes are equally likely to replace threat and nonthreat cues) which combines attention task practice and threat-cue exposure, but does not encourage threat-avoidant orienting. Recent reviews and meta-analyses conclude that conventional ABM threat-avoidance training has inconsistent effects on anxiety and AB [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar, 7Mogg K. et al.Attention bias modification (ABM): review of effects of multisession ABM training on anxiety and threat-related attention in high-anxious individuals.Clin. Psychol. Sci. 2017; 54: 698-717Crossref Scopus (3) Google Scholar, 8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 9Cristea I.A. et al.Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis.Br. J. Psychiatry. 2015; 206: 7-16Crossref PubMed Scopus (176) Google Scholar, 10Cristea I.A. et al.Practitioner review: cognitive bias modification for mental health problems in children and adolescents: a meta-analysis.J. Child Psychol. Psychiatry Allied Discip. 2015; 56: 723-734Crossref PubMed Scopus (23) Google Scholar, 11Heeren A. et al.Attention bias modification for social anxiety: a systematic review and meta-analysis.Clin. Psychol. Rev. 2015; 40: 76-90Crossref PubMed Scopus (90) Google Scholar, 12Van Bockstaele B. et al.A review of current evidence for the causal impact of attentional bias on fear and anxiety.Psychol. Bull. 2014; 140: 682-721Crossref PubMed Scopus (103) Google Scholar, 13Price R.B. et al.Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias.Clin. Psychol. Rev. 2016; 50: 37-49Crossref PubMed Scopus (36) Google Scholar, 14Mogoaşe C. et al.Clinical efficacy of attentional bias modification procedures: an updated meta-analysis.J. Clin. Psychol. 2014; 70: 1133-1157Crossref PubMed Scopus (146) Google Scholar, 15Liu H. et al.Effects of cognitive bias modification on social anxiety: a meta-analysis.PLoS One. 2017; 12: 1-24Google Scholar, 16Jones E.B. Sharpe L. Cognitive bias modification: a review of meta-analyses.J. Affect. Disord. 2017; 223: 175-183Crossref PubMed Scopus (24) Google Scholar], and is therefore unsuitable as a treatment for anxiety. Other ABM training methods (considered later) may be more effective, but outcome data are preliminary. Hence, ABM training research is at a turning point, with diverse recommendations: (i) research into ABM training as a treatment for anxiety should be abandoned [9Cristea I.A. et al.Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis.Br. J. Psychiatry. 2015; 206: 7-16Crossref PubMed Scopus (176) Google Scholar]. (ii) ABM training procedures should be improved to be more effective in training threat-avoidant attention-orienting [5MacLeod C. Clarke P.J.F. The attentional bias modification approach to anxiety intervention.Clin. Psychol. Sci. 2015; 3: 58-78Crossref Scopus (98) Google Scholar, 8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 17Grafton B. et al.Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability.Br. J. Psychiatry. 2017; 211: 266-271Crossref PubMed Scopus (1) Google Scholar]. (iii) The theoretical premise of ABM training should be reconsidered, and ABM training methods revised to target multiple processes underlying anxiety and ABs [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar, 7Mogg K. et al.Attention bias modification (ABM): review of effects of multisession ABM training on anxiety and threat-related attention in high-anxious individuals.Clin. Psychol. Sci. 2017; 54: 698-717Crossref Scopus (3) Google Scholar, 18Zvielli A. et al.Targeting biased emotional attention to threat as a dynamic process in time: Attention Feedback Awareness and Control Training (A-FACT).Clin. Psychol. Sci. 2016; 4: 287-298Crossref Scopus (6) Google Scholar, 19Amir I. et al.(De)Coupling of our eyes and our mind's eye: a dynamic process perspective on attentional bias.Emotion. 2016; 53: 1689-1699Google Scholar]. This article considers evidence-based cognitive perspectives of anxiety, threat-related attention, and cognitive skill training which may guide future research. To improve the efficacy of ABM training, it is helpful to consider why conventional ABM threat-avoidance training does not consistently reduce anxiety as expected. An important distinction is between target processes and training procedures [8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar]. Poor outcomes may be explained by deficient training procedures: if ABM threat-avoidance training fails to modify its target process (i.e., reduce pre-existing AB in orienting towards threat), this could explain its failure to reduce anxiety [5MacLeod C. Clarke P.J.F. The attentional bias modification approach to anxiety intervention.Clin. Psychol. Sci. 2015; 3: 58-78Crossref Scopus (98) Google Scholar, 8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 16Jones E.B. Sharpe L. Cognitive bias modification: a review of meta-analyses.J. Affect. Disord. 2017; 223: 175-183Crossref PubMed Scopus (24) Google Scholar, 17Grafton B. et al.Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability.Br. J. Psychiatry. 2017; 211: 266-271Crossref PubMed Scopus (1) Google Scholar]. For example, ABM threat-avoidance training is less effective when delivered at home than in laboratory/clinic settings, possibly because greater distractions at home impair learning [8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 13Price R.B. et al.Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias.Clin. Psychol. Rev. 2016; 50: 37-49Crossref PubMed Scopus (36) Google Scholar]. ABM threat-avoidance training is also repetitious and boring, which may reduce treatment compliance [20Dennis T.A. O'Toole L.J. Mental health on the go.Clin. Psychol. Sci. 2014; 2: 576-590Crossref PubMed Scopus (40) Google Scholar, 21Amir N. et al.A pilot study of an adaptive, idiographic, and multi-component attention bias modification program for social anxiety disorder.Cogn. Ther. Res. 2016; 40: 661-671Crossref PubMed Scopus (0) Google Scholar]. The implication would be to improve ABM threat-avoidance training procedures, for example by reducing distraction and by making training more engaging [8MacLeod C. Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research.Behav. Res. Ther. 2016; 86: 68-86Crossref PubMed Google Scholar, 20Dennis T.A. O'Toole L.J. Mental health on the go.Clin. Psychol. Sci. 2014; 2: 576-590Crossref PubMed Scopus (40) Google Scholar, 21Amir N. et al.A pilot study of an adaptive, idiographic, and multi-component attention bias modification program for social anxiety disorder.Cogn. Ther. Res. 2016; 40: 661-671Crossref PubMed Scopus (0) Google Scholar]. Another explanation for poor outcomes concerns the target process: if AB in orienting towards threat does not play a strong causal role in anxiety, this may explain the inconsistent effects of ABM threat-avoidance training [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar, 11Heeren A. et al.Attention bias modification for social anxiety: a systematic review and meta-analysis.Clin. Psychol. Rev. 2015; 40: 76-90Crossref PubMed Scopus (90) Google Scholar, 12Van Bockstaele B. et al.A review of current evidence for the causal impact of attentional bias on fear and anxiety.Psychol. Bull. 2014; 140: 682-721Crossref PubMed Scopus (103) Google Scholar, 18Zvielli A. et al.Targeting biased emotional attention to threat as a dynamic process in time: Attention Feedback Awareness and Control Training (A-FACT).Clin. Psychol. Sci. 2016; 4: 287-298Crossref Scopus (6) Google Scholar]. Other cognitive processes may underpin both anxiety and ABs to threat. If so, training procedures should be modified to target them. Numerous cognitive models of anxiety and threat-related ABs have emerged in the past 30 years (e.g., [3Williams M. et al.Cognitive Psychology and Emotional Disorders.1st edn. Wiley, 1988Google Scholar, 6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. 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Wiley, 1997Google Scholar, 32Waters A.M. Craske M.G. Towards a cognitive-learning formulation of youth anxiety: a narrative review of theory and evidence and implications for treatment.Clin. Psychol. Rev. 2016; 50: 50-66Crossref PubMed Scopus (3) Google Scholar]; reviewed in [6Mogg K. Bradley B.P. Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification.Behav. Res. Ther. 2016; 87: 76-108Crossref PubMed Scopus (44) Google Scholar]). We focus here on two perspectives with differing implications for ABM training: one perspective proposes that anxiety is caused by automatic AB towards threat, which can be targeted by conventional ABM threat-avoidance training; the other proposes that anxiety and ABs are caused by multiple cognitive processes, which can be targeted more effectively by multicomponent ABM training procedures. According to early cognitive views of anxiety, high-anxiety individuals have an enduring AB towards threat, whereas low-anxiety individuals are threat-avoidant [3Williams M. et al.Cognitive Psychology and Emotional Disorders.1st edn. Wiley, 1988Google Scholar]. AB towards threat is conceptualised as a stable trait-like characteristic which plays a causal role in anxiety; hence, interventions that reduce AB to threat should reduce anxiety [5MacLeod C. Clarke P.J.F. The attentional bias modification approach to anxiety intervention.Clin. Psychol. Sci. 2015; 3: 58-78Crossref Scopus (98) Google Scholar, 33Bar-Haim Y. Research review: attention bias modification (ABM): a novel treatment for anxiety disorders.J. Child Psychol. Psychiatry Allied Discip. 2010; 51: 859-870Crossref PubMed Scopus (239) Google Scholar]. Empirical research indicates that anxiety-related AB towards threat can operate automatically, outside awareness [6Mogg K. Bradley B.P. 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Thus, conventional ABM threat-avoidance training uses implicit training procedures (i.e., training without awareness of what is being taught) and relies on repeated practice on hundreds of trials to reduce automatic attention-orienting to threat (participants are typically not informed that the training goal is to induce threat avoidance) [5MacLeod C. Clarke P.J.F. The attentional bias modification approach to anxiety intervention.Clin. Psychol. Sci. 2015; 3: 58-78Crossref Scopus (98) Google Scholar, 33Bar-Haim Y. Research review: attention bias modification (ABM): a novel treatment for anxiety disorders.J. Child Psychol. Psychiatry Allied Discip. 2010; 51: 859-870Crossref PubMed Scopus (239) Google Scholar]. Empirical evidence increasingly indicates that anxious individuals do not consistently exhibit AB towards threat, and sometimes show no AB or threat avoidance [6Mogg K. Bradley B.P. 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