Anxiety and related disorders Case 3
How to improve exposure therapy?
Problem statement: “What is exposure therapy and how to improve it?”
Learning goals:
I. What is the information processing theory?
a. What cognitive biases are there? (Attention, information, and memory bias)
II. What is the cognitive theory?
a. What are the basic principles of cognitive theory?
III. What are safety behaviors and with is its impact on anxiety?
IV. What are the components of cognitive therapy?
What is the information processing theory?1
The basic assumption of the information-processing models of anxiety disorders (ADs) is that
processing biases aren’t symptoms but play a vital role in the maintenance and causation of ADs.
Cognitive biases
Attentional bias (AB)
Characteristics
AD-patients tend to prioritize the processing of threat-related stimuli before neutral stimuli.
→ Early stages of threat processing are characterized by increased attention to threat, whereas
later stages are characterized by attentional avoidance of threat.
Measurement:
Eye movement studies/gaze-duration studies.
Color Stroop: they are shown 4 cards; 1 practice card and 3 cards with panic, positive or
neutral words.
o The meaning of words is processed automatically which interference with the
reaction-speed to tell the color of the word.
→ The naming of words with emotion meaning is more difficult: slower RT.
Dot probe task:
o Words pairs from 3 categories
▪ 5 social-threatening/neutral pairs (e.g., bread-blush; beds-stare)
▪ 5 harm/neutral pairs (e.g. paralyzed-bathtub; disabled-periods)
▪ 5 neutral/neutral pairs (e.g., grape-soap; towels-closet)
o Faster reaction time (RT) on congruent trials (dot replaces target/feared word) than
to incongruent trials (dot replaces neutral word) shows attentional bias.
Underlying mechanism
Different components that are functionally and structurally independent but work cooperatively.
Three major components:
1. Alerting – maintaining an appropriate sensitivity level to perceive and process relevant stimuli.
AD-patients show an enhanced sensitivity to perceive and process threatening stimuli.
o The attentional system preferentially selects threat over safe/control signals.
o Even in the attentional blink interval, phobia-relevant stimuli are frequently
detected by AD-patients
1
De Jong (2014). Information processing.
, ▪
This indicates that phobic stimuli receive prioritized access to limited
cognitive resources.
Attentional bias may obstruct detecting safe/helpful/reassuring stimuli that occur close
to the threat stimuli.
2. Orienting – selection of pertinent information; relevant for the focus on concern-relevant stimuli.
Measured with the dot-probe task.
They respond faster to probes that replace a briefly presented threat, which is evidence
for a facilitated spatial orientation toward threat.
Test for orienting system regarding threat-stimuli (Valid = probe on same side as threat-
stimulus; Invalid = probe on opposite side of threat-stimulus)
o Facilitated attention is reflected in relatively fast responses on valid-threat trials
compared to valid-neutral trials.
o Difficulty to disengage is reflected in relatively slow responses on invalid-threat
trials compared to invalid-neutral trials.
So, facilitated attention would be most relevant during the early stages of processing,
whereas disengagement difficulties become increasingly important during the later
stages of stimulus processing.
3. Executive control – conflict resolution and voluntary action control.
→ The conflict: the motivational relevance of threat-related stimuli and the urge to
avoid that stimulus.
Deficiencies in executive control will enhance individuals’ sensitivity to threat stimuli will
lead to the difficulty to disengage from threat.
o They have an inability to inhibit automatic threat alerts from being processed.
Prognostic value and causal status
Influence of CBT on AB:
→ Tendency to direct attention towards threatening words and angry faces bias away from
threat-stimuli.
→ Tendency to direct attention away from positive words and happy faces positive approach
Cognitive Bias Modification (CBM) primarily targeted the later components of AB related to
engagement difficulties.
Self-focused attention2
People with a social anxiety are excessively focused on themselves and their own performance = self-
focused attention (= internal attention bias)
→ Their attention shifts from observation of others (external attention bias) to detailed self-
monitoring and -observation (internal attentional bias), which leads to misleading
interoceptive information used as evidence for their negative impression.
o This maintains social anxiety by preventing access to external information that could
disconfirm patients’ negative beliefs.
→ Excessive self-focused attention leads to dysfunctional effects: intensifying emotional states,
reducing effortful coping, and impairing task performance.
→ High speech anxious individuals direct their attention towards internal information and away
from external information when expecting to be socially evaluated during a speech.
2 Mansell (2003). Internal versus external attention in social anxiety.
How to improve exposure therapy?
Problem statement: “What is exposure therapy and how to improve it?”
Learning goals:
I. What is the information processing theory?
a. What cognitive biases are there? (Attention, information, and memory bias)
II. What is the cognitive theory?
a. What are the basic principles of cognitive theory?
III. What are safety behaviors and with is its impact on anxiety?
IV. What are the components of cognitive therapy?
What is the information processing theory?1
The basic assumption of the information-processing models of anxiety disorders (ADs) is that
processing biases aren’t symptoms but play a vital role in the maintenance and causation of ADs.
Cognitive biases
Attentional bias (AB)
Characteristics
AD-patients tend to prioritize the processing of threat-related stimuli before neutral stimuli.
→ Early stages of threat processing are characterized by increased attention to threat, whereas
later stages are characterized by attentional avoidance of threat.
Measurement:
Eye movement studies/gaze-duration studies.
Color Stroop: they are shown 4 cards; 1 practice card and 3 cards with panic, positive or
neutral words.
o The meaning of words is processed automatically which interference with the
reaction-speed to tell the color of the word.
→ The naming of words with emotion meaning is more difficult: slower RT.
Dot probe task:
o Words pairs from 3 categories
▪ 5 social-threatening/neutral pairs (e.g., bread-blush; beds-stare)
▪ 5 harm/neutral pairs (e.g. paralyzed-bathtub; disabled-periods)
▪ 5 neutral/neutral pairs (e.g., grape-soap; towels-closet)
o Faster reaction time (RT) on congruent trials (dot replaces target/feared word) than
to incongruent trials (dot replaces neutral word) shows attentional bias.
Underlying mechanism
Different components that are functionally and structurally independent but work cooperatively.
Three major components:
1. Alerting – maintaining an appropriate sensitivity level to perceive and process relevant stimuli.
AD-patients show an enhanced sensitivity to perceive and process threatening stimuli.
o The attentional system preferentially selects threat over safe/control signals.
o Even in the attentional blink interval, phobia-relevant stimuli are frequently
detected by AD-patients
1
De Jong (2014). Information processing.
, ▪
This indicates that phobic stimuli receive prioritized access to limited
cognitive resources.
Attentional bias may obstruct detecting safe/helpful/reassuring stimuli that occur close
to the threat stimuli.
2. Orienting – selection of pertinent information; relevant for the focus on concern-relevant stimuli.
Measured with the dot-probe task.
They respond faster to probes that replace a briefly presented threat, which is evidence
for a facilitated spatial orientation toward threat.
Test for orienting system regarding threat-stimuli (Valid = probe on same side as threat-
stimulus; Invalid = probe on opposite side of threat-stimulus)
o Facilitated attention is reflected in relatively fast responses on valid-threat trials
compared to valid-neutral trials.
o Difficulty to disengage is reflected in relatively slow responses on invalid-threat
trials compared to invalid-neutral trials.
So, facilitated attention would be most relevant during the early stages of processing,
whereas disengagement difficulties become increasingly important during the later
stages of stimulus processing.
3. Executive control – conflict resolution and voluntary action control.
→ The conflict: the motivational relevance of threat-related stimuli and the urge to
avoid that stimulus.
Deficiencies in executive control will enhance individuals’ sensitivity to threat stimuli will
lead to the difficulty to disengage from threat.
o They have an inability to inhibit automatic threat alerts from being processed.
Prognostic value and causal status
Influence of CBT on AB:
→ Tendency to direct attention towards threatening words and angry faces bias away from
threat-stimuli.
→ Tendency to direct attention away from positive words and happy faces positive approach
Cognitive Bias Modification (CBM) primarily targeted the later components of AB related to
engagement difficulties.
Self-focused attention2
People with a social anxiety are excessively focused on themselves and their own performance = self-
focused attention (= internal attention bias)
→ Their attention shifts from observation of others (external attention bias) to detailed self-
monitoring and -observation (internal attentional bias), which leads to misleading
interoceptive information used as evidence for their negative impression.
o This maintains social anxiety by preventing access to external information that could
disconfirm patients’ negative beliefs.
→ Excessive self-focused attention leads to dysfunctional effects: intensifying emotional states,
reducing effortful coping, and impairing task performance.
→ High speech anxious individuals direct their attention towards internal information and away
from external information when expecting to be socially evaluated during a speech.
2 Mansell (2003). Internal versus external attention in social anxiety.
