ContentslistsavailableatSciVerseScienceDirect
Journal
of
Anxiety
Disorders
Enhanced
anger
superiority
effect
in
generalized
anxiety
disorder
and
panic
disorder
Chris
Ashwin
a,∗,
Pawel
Holas
b,
Shanna
Broadhurst
a,
Andrzej
Kokoszka
b,
George
A.
Georgiou
c,
Elaine
Fox
a,∗∗aDepartmentofPsychology,UniversityofEssex,WivenhoePark,Colchester,UK
bIIDepartmentofPsychiatry,MedicalUniversityofWarsaw,Warsaw,Poland
cDept.ofPsychology,RoehamptonUniversity,London,UK
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received24January2011
Receivedinrevisedform
14November2011
Accepted20November2011
Keywords: Anxiety Threat
Generalizedanxietydisorder
Panicdisorder
Attentionbias
Visualsearch
a
b
s
t
r
a
c
t
Peoplearetypicallyfasterandmoreaccuratetodetectangrycomparedtohappyfaces,whichisknownas theangersuperiorityeffect.Manycognitivemodelsofanxietysuggestanxietydisordersinvolve atten-tionalbiasestowardsthreat,althoughthenatureofthesebiasesremainsunclear.Thepresentstudy usedaFace-in-the-Crowdtasktoinvestigatetheangersuperiorityeffectinacontrolgroupandpatients diagnosedwitheithergeneralizedanxietydisorder(GAD)orpanicdisorder(PD).Themainfindingwas thatbothanxietygroupsshowedanenhancedangersuperiorityeffectcomparedtocontrols,whichis consistentwithkeytheoriesofanxiety.Furthermore,bothanxietygroupsshowedadifferentialpattern ofenhancedbiastowardsthreatdependingonthecrowdinthedisplays.Thedifferentattentionalbias patternsbetweentheGADandPDgroupsmayberelatedtothediversesymptomsinthesedisorders. Thesefindingshaveimplicationsforthediagnosisandtreatmentofanxiety.
© 2011 Elsevier Ltd.
1. Introduction
Humans sensemore information in their environment than they can effectively process, so attention is necessary to filter out unnecessary information and to focus on relevant items. Manycognitivetheoriesofanxietyproposethatbiasesin atten-tionplayanimportantroleinthecausationandmaintenanceof anxietydisorders (Beck,1976; Eysenck, 1992; Mathews, 1990; Williams, Watts, MacLeod, & Mathews, 1988, 1997). There is nowmuchevidenceshowingthathigh-traitanxiouspeopleand patients with clinical diagnoses of anxiety display attentional biasestowardsthreateninginformation(forreviewssee:Bar-Haim, Lamy,Pergamin,Bakermans-Kranenburg,&vanIjzendoorn,2007; Mathews&MacLeod,2005;Mogg&Bradley,2004).
Muchoftheevidenceforattentionalbiasesinhighanxietyhas emergedfromasmallnumberofexperimentalparadigms, includ-ingtheStrooptask,dotprobeandFace-in-the-Crowdtests.Inthe
∗ Correspondingauthorat:Dept.ofPsychology,UniversityofBath,BathBA27AY,
UK.Tel.:+4401225383502;fax:+4401225386752.
∗∗ Correspondingauthor.Tel.:+4401225383502;fax:+4401225386752.
E-mailaddress:c.ashwin@bath.ac.uk(C.Ashwin).
modifiedStrooptaskpeoplehavetonamethecoloursofwords printed indifferent fonts,eitherin a listorpresented oneat a time.Findingshaverevealedthatanxiousindividualsshowgreater interferencewhencolour-namingthreateningwordscomparedto neutralwords(Williams,Mathews,&Macleod,1996).Thisis pro-posedtoreflectthatattentiontothenegativecontentindistracter wordsinterferes withperformanceonthecentraltaskof nam-ingtheinkcolour.Thiseffecthasalsobeenshownwhenwords aremaskedtorestrictawareness(MacLeod&Rutherford,1992; Mogg,Bradley,Williams,&Mathews,1993),andthereisevidence thattheStroopeffectinthesemodifieddesignsalsopredictsthe amountoflaterdistressexperiencedfromadisturbinglifeevent (MacLeod&Hagan,1992).However,ithasbeenarguedthe mecha-nismsunderlyingthiseffectmayactuallyreflectdisruptioncaused bytheemotionalvalence,ratherthanattentionaleffects(Mathews &MacLeod,2005).Inaddition,someproposethatwordstimulimay belimitedinanxietyresearchforanumberofreasons(Bradley, Mogg,White,Groom,&deBono,1999;Mogg&Bradley,2004).For example,wordscouldrepresentaweakerstimulusormighthave amoreindirectrelationshipwith‘real-world’dangers,compared topictorialrepresentationsofthreat.Thereisalsoapossible con-foundthatanxiouspeoplemaybemorefamiliarandexperienced withthreat-relatedwordscomparedtocontrols.Facialexpressions ofemotionmightrepresentamorepotentandecologicallyvalid
0887-6185 © 2011 Elsevier Ltd. doi:10.1016/j.janxdis.2011.11.010
Open access under CC BY license.
typeofstimuliforinvestigatingbiasestowardsthreatinanxiety research.
Otherexperimentalmethods,includingthedotprobeand Face-in-the-Crowdparadigms,haveutilisedimagesoffacialexpressions toinvestigateattentionalbiasesinanxiety.Dot-probeparadigms typicallyinvolvetwopicturesappearingbrieflyinadisplay, fol-lowedbyatargetprobeappearingbehindthelocationofoneof thepictures.Fasterresponsestoatargetareinferredtoshowthat attentionwaspreferentiallyallocatedtothepicturethatappeared initslocation.Anumberofdot-probestudieshavereportedthat peoplewithhigh traitanxietyand those diagnosed with clini-calanxietyshowanattentionalbiasforthreateninginformation, includingfacialexpressionsofemotion(Bradleyetal.,1999;Mogg &Bradley,1999,2002;Royetal.,2008;Waters,Mogg,Bradley,& Pine,2008).Forexample,usingadotprobeparadigm,Moggand Bradley(1998)showedthatpeoplewithhightraitanxietyattended moretothreateningfacespresentedat500msor1250ms com-paredtoacontrolgroupandpeoplewithdysphoria.
Another method used to study the detection of threat usingimagesofemotionalexpressionsistheFace-in-the-Crowd paradigm.HansenandHansen(1988)carriedouttheoriginalstudy involvinggroupsofphotographsshowingemotionalexpressions arrangedindisplays.Participantshadtosearchthedisplaysand decideifadiscrepantfacewaspresentornot.Theyreportedthat peopledetectedangryfacesfasterandmoreaccuratelythanhappy faces,andinterpretedthistoillustrateathreatsuperiority advan-tageforangryfacescomparedtofriendlyfaces.However,thestudy waslimitedafterdiscoveryoneofthephotographshadashadow init,whichmayhaveaffectedtheresults(Purcell,Stewart,&Skov, 1996).Furtherstudiesdevelopedcomputer-drawnschematicfaces insteadofphotographs,toavoidvisualconfoundsbetween stimu-lustypes.TheseversionsoftheFace-in-the-Crowdtaskhaveused schematizedangry,happyandneutralexpressionfacesarrangedin displaysonacomputerscreen.Participantsdecideifallthefacesin thedisplayarethesame,orifthereisonefacethatisdifferentthan therest.Anumberofstudieswithcontrolparticipantshaveused theFace-in-the-Crowdtaskwithschematicfacesandfoundthat angryfacesaredetectedfasterandmoreaccuratelythanfriendly faces,termedtheangersuperiorityeffect(Ashwin,Wheelwright, &Baron-Cohen,2006; Eastwood, Smilek,&Merikle, 2003; Fox, Lester,Russo,Bowles,Pichler,&Dutton,2000;Öhman,Lundqvist, &Esteves,2001).Thesefindingssupportideasofan evolutionar-ilydevelopedthreatdetectionmodulethatpreferentiallydetects stimuliintheenvironmentthatsignalthreatandallocates atten-tionalresourcestowardsthem(Öhman,1986;Öhman&Mineka, 2001;Öhmanetal.,2001).
Todate onlya small number of studieshave beenreported usingtheFace-in-the-Crowdtaskwithpeoplewhoarehigh anx-ietyordiagnosed withanxietydisorders.Mostof thesestudies haveincludedpeoplewithnon-clinicalhighanxietyorwith diag-nosesspecifictosocialanxiety.ByrneandEysenck(1995)usedthis paradigmwithphotographsofpeopleexpressingangryandhappy expressionsindisplaysandfoundthatindividualshighin subclin-icaltraitanxietywerefasterindetectingangryfacescomparedto lowtrait-anxiety.Gilboa-Schechtman,Foa,andAmir(1999)used a similarFace-in-the-Crowd design toByrne and Eysenck with photographsand reportedthat peoplewith social anxiety dis-ordershowedgreaterattentionalbiasesfor angryversushappy facescomparedtocontrols.AstudybyJuth,Lundqvist,Karlsson, andÖhman(2005)utilizedtheFace-in-the-Crowdparadigmwith schematicfaces,insteadofphotographs, and foundthatpeople withhighsocialanxietyshowedmoreeffectivedetectionofangry comparedtohappyfaces.AnotherFace-in-the-Crowdstudyusing schematicfacesanddifferentdisplaysizesfoundthatpeoplewith socialanxietydisorderhadshallowerslopesfordetectingangry facescomparedtohappyfaces(Eastwoodetal.,2005),illustrating
thatangryfacescaptureattentionmoreeasilythanhappyfacesin thosewithsocialanxiety.Theyfurtherreportedthatpeople diag-nosedwithPDalsohadagreaterattentionalbiastowardsangry faces,comparablewiththesocialanxietygroup.Ameta-analysis byBar-Haimetal.(2007)lookedat172differentstudiesmeasuring biastowardsthreatening informationin peoplewithand with-outhighanxietyusingavarietyofexperimentalparadigms.The authorsreportedarobustthreat-relatedbiaswithalowtomedium effectsizewasevidentinpeoplewhoarediagnosedwithanxiety disordersorhavehighsub-clinicalmeasuresoftraitanxiety.
Generalizedanxietydisorder(GAD)andpanicdisorder(PD)are bothclinicallydiagnosedanxietydisorders.GADischaracterized byheightenedanxietyandtensionalongsidedifficultyinrelaxing. PeoplewithGADhaveexcessiveandoftenirrationalworryabout aspectsofeverydaylife(APA,1994).Theirworryischaracterized byrepeatednegativethoughtsaboutpossiblethreat,whichmay emergefromattemptsatavoidanceorcoping(Borkovec&Roemer, 1995).Thispervasiveworryisbeyondthatnormallyexperienced ineverydaylife,andexpressesaschronicandexaggerated anxi-ety.Therefore,individualswithGADtendtoalwaysbeanticipating disasterandworryingaboutissuessuchashealth,money, fam-ily,friends,andwork.Incontrasttothechroniclow-levelanxiety foundinGAD,panicdisorder(PD)involvesunexpectedepisodes ofintensefearaccompaniedbyphysicalsymptoms,andpersistent apprehensionovertheirrecurrenceorconsequences(APA,1994). AstrongcomponentofPDisthefearofembarrassmentor humili-ationfromothers.Infact,individualsoftenreportadesiretoavoid orescapepublicplacesbecausetheywouldfeelembarrassedor humiliatediftheyhadapanicattackthere.Sincesocialelementsare animportantfactor,itisthoughtpeoplewithPDmightbebiased towardscuesofsocialevaluation,suchasemotionalexpressions (Eastwoodetal.,2005).
While GADand PDpresentwithdissimilar behavioural pro-files,thenatureofanydifferencesbetweenPDandGADintheir attentionalbiasestowardsthreatiscurrentlyunknown.Oneidea is there might be a commoncore threat-related attentionbias sharedbythevariousanxietydisorders, withattentional differ-encesbetweendisordersemergingfromotherfactors(Bar-Haim etal.,2007).Alternatively,distinctivepatternsofattentionalbiases relatedtobehaviouralsymptomsmightbeevidentacrossvarious anxietydisorders. While there is some initialevidence to sug-gestvariousanxietydisordersmightshowdifferencesinhowthey processthreateninginformation,thereisa lackofexperimental findingsinthisarea(Amiretal.,1996;Vrana,Roodman,&Beckham, 1995).Researchhasshowndifferencesbetweenanxietydisorders inthetimingofattentionalbiases,withsomedisordersshowing earlybiasestowardsthreatandlaterbiasesawayfromthreat(Mogg &Bradley,2004,2006).However,Eastwoodetal.(2005)reported thatsocialphobicsandthosewithPDhadsimilarlyenhanced atten-tiontowardsthreateningfaces.Therehavebeenanumberofmixed findingstodate,sofurtherresearchisneededtobetterunderstand thenatureofcognitivebiasesinanxietydisorders.
1.1. Experimentalaims
Themainaimofthepresentstudywastoinvestigate atten-tionalbiasestowardsangryfacesincontrolparticipantsandclinical patients diagnosed with either GAD or PD using the Face-in-the-Crowdtaskwithschematicfaces.Schematicfaceswereused becausetheyarehighlymatchedonlow-levelvisual characteris-tics,whichminimizespotentialvisualconfoundsthatcanoccur betweenexpressionsinrealphotographs(Foxetal.,2000;Öhman et al., 2001). We predicted that theGAD and PD would show enhancedangersuperiorityeffectscomparedtocontrols.SincePD is associatedwithheightened concernsabout sociallyobserved anxiety,wehypothesisedpeoplewithPDmightshowevengreater
angersuperiorityeffectscomparedtothosewithGAD,especially whencrowdscontainedemotionalfaces.
2. Materialsandmethods 2.1. Participants
ThestudywasconductedintheLaboratoryofSexologyand Psy-chotherapy,attheIIDepartmentofPsychiatry,MedicalUniversity ofWarsaw.66volunteerswererecruitedtotakepartinthestudy. Participantsincluded 18clinicalpatients(13 females)who had receivedadiagnosisofGAD,and17clinicalpatients(15females) whohadreceivedadiagnosisofPDbytrainedpsychiatristsatthe outpatientclinic.Patientswereinitiallyreferredtotheclinicbya psychiatristbasedonadiagnosisofanxietydisordersaccordingto internationalcriteria(WHO,1992).Diagnosisofthepatientswas thenconfirmedattheclinicusingeithertheofficialPolishversionof theMini-InternationalNeuropsychiatricInterview(MINI)version 5.0.0(Masiak&Przychoda-Masiak,2002;Sheehanetal.,1997)or furtherinternationalcriteria(APA,1994).Theselectioncriterionfor thepatientgroupsinthestudywasaprimarydiagnosisofGADor PD,withnoevidenceofpsychosisororganicbraindamage. Consen-sualdiagnosisbymembersoftheclinicalteamwasarequirement forselectiontotheresearch.Inaddition,31peoplewithno his-toryofpsychiatricdisorders(19females)wererecruitedfromthe communitytoserveascontrols.Allparticipantscompleted ques-tionnairemeasuresofstateandtraitanxiety,depression,worry andattentionalcontrol.Allparticipantshadnormalor corrected-to-normalvision,andgavewritteninformedconsenttotakepart. 2.2. Materials
TheFace-in-the-CrowdtaskwasrunonMacintoshPower PC G3witha15-in.LCDmonitorfordisplay.Thepresentationofthe experimentandresponsesoftheparticipantswerecontrolledby PsyScope(Cohen,MacWhinney,Flatt,&Provost,1993).Theface stimuliwereschematicfacesusedwithpermissionfrompreviously publishedresearch(Öhmanetal.,2001).Eachofthedisplays con-tainedfourschematicfacesarrangedina2×2matrix.Eachofthe targetsappearedequallyinallfourlocations.Eachfacetookup 3.9◦×3.9◦ofvisualangle.Theclosestdistancefromthecenterof thefacetothecentralfixationpointwas6.7◦ofvisualangleand theclosestdistancefromthecenterofonefacetoanotherfacewas 7.6◦ofvisualangle.
2.2.1. Questionnairemeasures
Fiveself-reportquestionnaireswerecompletedbefore partic-ipantsbeganthecomputerizedtasks.TheSpielbergerState-Trait AnxietyInventory(STAI:Spielberger,Gorsuch,Lushene, Vagg,& Jacobs,1983)isa40-itemself-reportmeasureofanxiety.Thefirst 20items(STAI-S)measurestateanxiety,orhowthesubjectfeels rightnow.Thesecond20items(STAI-T)assesstraitanxiety,orhow thesubjectgenerallyfeels.Eachitemisratedusingascalefrom0 (notatall)to3(verymuchso).Therangeofscoresonbothmeasures variesfrom0to60,withhigherscoresindicatinggreateranxiety.A numberofstudieshaveshownreliablepsychometricpropertiesfor theSTAI(e.g.Spielbergeretal.,1983).ThePolishversion(Parnowski &Jernajczyk,1977)oftheBeckDepressionInventory(BDI:Beck, Ward,Mendelson,Mock,&Erbaugh,1961)wasusedtoassessthe severityofdepression.TheBDIisa21itemquestionnairecomposed ofitemsrelatingtodepressionsymptoms,tomeasuretheseverity ofdepression.Ithasafour-pointscaleforeachitemrangingfrom 0to3,withscoresrangingfrom0to63.Higherscoresrepresent moreseveresymptomsofdepression.Ithasgoodinternal consis-tency,withaCronbach’salphacoefficientinadultsreportedtobe around0.85(e.g.Ambrosini,Metz,Bianchi,Rabinovich,&Undie,
1991).TheBeckAnxietyInventory(BAI:Beck&Steer,1990)isa 21itemquestionnairemeasuringthephysiologicalandcognitive aspectsofanxiety.Itconsistsofdescriptivestatementsofanxiety symptomswhichareratedona4-pointscale,from0(Notatall)to3 (Severely;Icouldbarelystandit).ThetotalscoreontheBAIranges from0and63,andithasgoodinternalconsistencywithCronbach’s alphareportedof.92–.94foradults(Beck&Steer,1990).Finally,the shortversionoftheAttentionalControlScale(ACS:Derryberry& Reed,2002)wasincluded,whichisa20itemquestionnaire mea-suringthedegreeofattentionalcontrolofparticipants.Itemsare scoredona4-pointscalefrom0(Never)to3(Always),withthe totalscorerangingfrom0to60.Higherscoresreflectgreaterlevels ofattentionalcontrol.Studieshaveshowngoodinternal reliabil-ityoftheACSinadults,reportingCronbach’salphaof.87(Muris, Meesters,&Rompelberg,2007).
2.3. Designandprocedure
Participantsfirstcompletedthequestionnairesatadeskina quietroom,followedbytheexperimentaltask. Eachtrialofthe visualsearchtaskbeganwiththepresentationofacrosshairfor 500ms,which wasfollowed by one of the displays containing fourfacesfor300ms.Thisdisplaytimewaschosentolimitthe number ofsaccadesparticipantscouldmake while viewingthe displays. Participants pressed a buttonon theresponse box to indicatewhetherallthefacesin thedisplaywerethesame,or whethertherewasonethatwasdifferentfromtherest.A trial endedwhentheparticipantrespondedorafter2000ms,thenit moved on to start the next trial after a 1000ms blank screen ITI.
Therewere96target-presenttrials,whereatargetappearedina crowdofdistracterfaces.Inhalfthetrials,theangryandhappyface targetsappearedincrowdsofemotionalfaces,i.e.angrytargetsin happycrowdsandhappytargetsinangrycrowds.Intheotherhalf ofthetrials,theangryandhappyfacetargetsappearedincrowdsof neutralfaces.Therewere24trialsofeachtarget–distracter combi-nationtype,creatingthetotalof96target-presenttrials.Therewere also96target-absenttrialswhereallthefaceswerethesametype (i.e.angry,happyorneutral),with32trialsofeachdisplaytype. Thisresultedinatotalof192trialsfortheexperiment.Theorderof presentationforthedifferenttrialtypeswasrandomized through-outtheexperiment.Therefore,participantsdidnotknowbefore thestartofeachtrialwhichtypeoftarget–distractercombination wasgoingtoappear.
2.4. Statisticaldesign
The various group characteristics were compared using independent-samplet-tests,andarereportedinTable1.The pri-mary measures of interest were mean response latencies and meanaccuracyscores,andforthetarget-presenttrialsthesewere analysedusingarepeatedmeasuresgenerallinearmodel(GLM) ANOVAwithTarget(Angryvs.Happy)andDistracter(Neutralvs. Emotional)asthewithin-subjectfactorsandGroup(Controlsvs. GADvs.PD)asthebetween-subjectfactor.Meanresponselatencies andmeanaccuracyscoresfortarget-absentdisplayswereanalysed usingaGLMANOVAhavingValence(Angryvs.Happyvs.Neutral) asthewithinsubjectsfactorandGroup(Controlsvs.GADvs.PD) asthebetween-subjectsfactor.
3. Results
Thegroupsdidnotdifferintermsofageorsex,howeverthe psy-chiatricgroupsdifferedfromthecontrolsonmeasuresofanxiety anddepressionasexpected(seeTable1).
Table1
MeandemographicandquestionnairemeasuresfortheGAD,PD,andControlgroups(standarddeviationsinparentheses).
Group
GAD(n=18) PD(n=17) Controls(n=31) Statistics
Age 32.06(10.2) 32.76(9.22) 29.26(9.20) F=.922,ns Sexratiom:f 5:13 2:15 12:19 X2=3.9,ns STAI-T 55.47a(9.23) 52.0b(9.30) 41.29(9.18) F=15.4,p<.001 STAI-S 50.08a(8.56) 44.41b(10.8) 34.81(10.9) F=13.5,p<.001 BDI 17.89a(7.76) 16.35b(9.06) 7.23(5.94) F=15.2,p<.001 BAI 22.01a(11.5) 23.18b(13.7) 7.65(8.71) F=15.4,p<.001 ACS 56.0a,c(8.93) 50.18(7.21) 45.52(11.0) F=6.58,p<.01
Note:STAI-T=TraitscaleoftheState-Traitanxietyinventory;STAI-S=StatescaleoftheState-Traitanxietyinventory;BDI=BeckDepressionInventory;BAI=BeckAnxiety
Inventory;ACS=AttentionControlScale.
aGAD>Controls(p<.01).
b PD>Controls(p<.01).
c GAD>PD(p>.05).
3.1. Target-presentdisplays
Themeasuresofinterestweremeanresponselatencyand accu-racyscores,whichwerebothanalysedusingarepeatedmeasures generallinearmodel(GLM)ANOVAwithTarget(Angryvs.Happy) andDistracter(Neutralvs.Emotional)asthewithin-subjectfactors andGroup(Controlsvs.GADvs.PD)asthebetween-subjectfactor. 3.1.1. Responselatencies
Results revealed there was no main effect of Group, F(2,63)=2.07,ns,2
p=.10,showingthatallgroupswere perform-ingthesameoverallfortheexperiment.Howevertherewasamain effectofTarget,F(1,63)=74.12,p<.001,2
p=.34,withangrytargets (942.6ms)beingdetectedfasterthanfriendlytargets(1034.0ms). TherewasalsoamaineffectofDistracter,F(1,63)=39.42,p<.001, 2
p=.53, with quicker response times when distracters were neutral (967.1.0ms) compared to when they were emotional (1009.5ms).
Importantly,therewasathree-wayinteractionbetweenTarget, DistracterandGroup,F(1,63)=6.25,p<.01,2
p=.21.Tointerrogate thisinteractionfurther,andtotestourmainhypothesisaboutan enhancedangersuperiorityeffectintheanxietygroups,wefirst cal-culated‘differencescores’foreachgroupbysubtractingtheRTsto angrytargetsfromRTstohappyacrossbothneutralandemotional distracterconditions.Wethencarriedoutindependentsample t-testsonthedifferencescoresbetweentheanxietygroupsandthe controlstotestourmainhypothesisaboutanenhancedanger supe-riorityeffectinanxiety.Resultsshowedthatthedifferencescore fortheGADgroupwassignificantlygreatercomparedtocontrols whencrowdswereneutral,t(47)=2.09,p<.05,d=.63,butnotwhen crowdswereemotional,t(47)=0.74,ns,d=.23.ThePDgrouphad asignificantlygreaterdifferencescorecomparedtocontrolswhen crowdswereemotional,t(46)=2.01,p<.05,d=.65,butnotwhen crowdswereneutral,t(46)=0.23,ns,d=.07(seeFig.1).
We then ran independent sample t-tests between the two anxietygroups totest ourthird aimaboutdifferencesin atten-tionalbiasbetweenanxietydisorders.TheGADgroupshoweda greaterdifference score thanthe PDgroup when crowdswere neutral, t(33)=2.07, p<.05, d=.70, while thePD groupshowed a greater differencescore than the GAD groupwith emotional crowds,t(33)=3.17,p<.01,d=1.07(seeFig.1).
3.1.2. Accuracydata
TheaccuracyscoreswereanalysedusinganANOVAwith Tar-get(Angryvs.Happy)andDistracter(Neutralvs.Emotional)asthe within-subjectfactorsandGroup(GADvs.PDvs.Controls)asthe between-subjectfactor.Therewasasignificantmaineffectof Tar-getF(1,63)=75.97,p<.001,2
p=.16,withangryfaces(87.2%)being detectedmoreaccurately thanhappy faces(75.3%)(see Fig.1).
TherewasalsoasignificantmaineffectofdistracterF(1,63)=17.05, p<.001,2
p=.52,showingthatpeopleweremoreaccuratewhen displayshad neutral (83.1%) compared toemotional distracters (79.4%)(seeFig.1).Therewerenosignificantmaineffectsor inter-actionsinvolvingGroup(allp>.05).
3.2. Target-absentdisplays 3.2.1. Responselatencies
Themeasuresofinterestweremeanresponselatencyand accu-racyscores,whichwerebothanalysedusingaGLMANOVAwith Valence(Angryvs.Happyvs.Neutral)asthewithin-subjectfactor andGroup(GADvs.PDvs.Controls)asthebetween-subjectfactor. Resultswithresponselatenciesshowedtherewasasignificant maineffectofValenceF(2,62)=92.66,p<.001,2
p=.76.Posthoc pairwisecomparisonsshowedthatresponsetimesforall-neutral displays(866.42ms) wereless thanboth theall-angry displays (1034.54ms),andtheall-happydisplays(1038.54ms),whilethere wasnodifferencebetweentheall-angryand theall-happy dis-plays(seeFig.2a).Therewasnomaineffectorinteractioninvolving Group(allp>.05).
3.2.2. Accuracydata
Results revealed a significant main effect of Valence, F(2,62)=26.14, p<.001, 2
p=.48 (see Fig. 2b). Post hoc pair-wisecomparisonsshowedthat participantsweremoreaccurate fortheall-neutraldisplays(93.5%)comparedtoboththeall-angry displays(80.7%),andtheall-happydisplays(82.7%).Therewasno differencein accuracybetweentheall-angry andthe all-happy displays.Therewasnosignificantmaineffectorinteractionwith Group(allp>.05).
4. Discussion
Thepresentstudyrevealedthatallthree groupsshowedthe typical anger superiority effect, withfaster and more accurate detectionofangryfacesversushappyfaces.Thisisconsistentwith theideaofanevolutionarilydevelopedthreatevaluationsystem thatpreferentiallydetectsstimuliintheenvironmentthatsignal threat(Öhman,1986;Öhman&Mineka,2001;Öhmanetal.,2001). Respondingrapidlyandsuccessfully tothreatiscritical for sur-vival,soit isadvantageous forthreat-related information tobe processedinahighlyefficientmannercomparedtoothertypes ofinformation.AccordingtoÖhmanandcolleagues(e.g.Öhman, 2002;Öhman&Mineka,2001),thereisanevolutionarilyshaped fearmodulesubservedbyneuralcircuitscentredontheamygdala, whichdetectsandcoordinatesresponsestothreatening informa-tion,suchasangryfaces.Perceivingthreateningstimuliinterrupts
Fig.1. Responselatencies(leftside)andaccuracyscores(rightside)inthetarget-presenttrialstodetectangryandhappyfacesacrossemotionalandneutraldistractersfor
theControlgroup(a),GADgroup(b),andPDgroup(c).
ongoingcognitionandthisinformationbecomesprioritized,which thenprovidesadditionalprocessingofthethreat.
Inhealthy individuals,a normalfunctioningthreatdetection systemwouldbeadaptiveforsurvival.However,differencesin sen-sitivityorthresholdofthisthreat-detectionmodulearethought toproduce enhanced threatprocessing biasesin anxiety disor-ders. The main clinicalfinding of interest in thepresent study wasthatboththeGADandPDgroupsshowedanenhancedanger
superiorityeffectcomparedtothecontrols.Thisresultisinline withcognitivemodelsofanxietyproposingagreaterbiastowards threateninginformationinthedevelopmentandmaintenanceof anxietydisorders(Williamsetal.,1988,1997),andanumberof previousstudiesreportingattentionalbiasestowardsthreatening facesinhighlyanxiouspeopleusingvariousparadigms(Bradley etal.,1999;Gilboa-Schechtmanetal.,1999;Mogg&Bradley,1999, 2002;Royetal.,2008;Waters etal.,2008).Ameta-analysisby
Fig.2.Responselatencies(a)andaccuracyscores(b)inthetarget-absenttrialstodetectall-angry,all-happy,andallneutraldisplaysfortheControl,GAD,andPDgroups.
Bar-Haimetal.(2007)including172differentempiricalstudies foundthereareconsistentandreliablefindingsofathreat-related biasinanxiety.Forexample,Eastwoodetal.(2005)useda sim-ilarFace-in-the-Crowdparadigmtothepresentstudyandfound enhanceddetection ofthreateningfacesin peoplewithPD and socialphobia.Theresultspresented herereplicatethisprevious findingof anattentional biastowardsanger in PD,and extend thefindings to also include GAD.The present findings suggest theamygdala-basedfearmodulemaybehypersensitiveinthose withhighanxiety(Öhman,2007).Indeedneuroimaging experi-mentshaveshownearlyandenhancedactivationoftheamygdala tonegative information in peoplewith anxietydisorders com-paredtocontrols(Evans,Wright,Wedig,Gold,Pollack,&Rauch, 2008;Larson,Schaefer,Siegle,Jackson,Anderle,&Davidson,2006; Schienle,Schafer,Walter,Stark,&Vaitl,2005;Stein,Goldin,Sareen, Zorrilla,&Brown,2002).
Thesecondmainclinicalfindingofinterestwasthatthetwo anxietygroupsinthepresentstudyshoweddifferentpatternsof enhancedbiastowardsanger,dependingonthetypeoffacesin thecrowds.ThePDgrouphadagreaterangersuperiorityeffect comparedtotheothergroupswhentargetsappearedincrowds withemotionalfaces,consistentwiththehypotheses.However, theGADgroupshowedenhancedangersuperiorityversustheother groupswhenthetargetsappearedwithincrowdsofneutralfaces. Thisshowsthatthesocialcontextisimportantfordeterminingthe natureandtypeofbiasfordifferentanxietydisorders.Measures takenofanxietyanddepressionduringtheexperimentalsession didnotdifferbetweentheanxietygroups.Therefore,thedistinct patternsofattentionalbiasesarelikelytorelatetootherimportant factorsratherthangeneralanxietystates.Thesenotonlyinclude thesocialcontextofthestimuliusedintheexperiment,butalso likelyinvolvedistinctionsinthebehaviouralcharacteristicsand social-evaluativefearsbetweenthesedisorders.Whileattentional biasesarecommontoallanxietydisorders,theprecisecontentof thebiastendstoberelatedtouniquefeaturesthataresignificant tospecificdisorders(Craske&Waters,2005;Williamsetal.,1988, 1997).
TheenhancedthreatdetectionbytheGADgroupoccurredwhile searchingthroughcrowdsofneutraldistracterfacesforangry tar-getfaces,with nofacilitationof threat detectionwhen crowds containedhappydistracterfaces.Thisisconsistentwithideasthat biasesaremostevidentforGADwhencomparingemotionaland neutral items withinthe same display (Mogg & Bradley, 1998, 1999). GADis characterizedby chronicand exaggeratedworry related to everyday events, such as work/school performance, health,money,family orfriends.Theanxiety-relatedsymptoms inGADarelessintensecomparedtootheranxietydisorderssuch
asPD,wherepeopleexperiencepanicattacksinvolvingextreme fear(Noyes&Hoehn-Saric,1998).Ineverydaylifeintense emo-tionaleventswherecrowdsofpeoplewithemotionalexpressions arealllookingtowardsyouarenotcommonplaceevents.Instead, peoplewithGADmay bemore attunedtoperceiving threatin contextsmoretypicalofeverydaylifewithlessemotionalarousal orsocialstress.Inthepresentstudy,searchingforanangryface withinaneutralcrowdmaybemorerelatedtothechronicworry abouteveryday lifeeventswhichpersonifiesGAD.Furthermore, there was not an enhanced bias for GAD when searching for angrytargetsamongstemotionaldistracters,which maybedue tothemperceivinghappyfaceswithinthesecrowds.Seeinghappy facesmayactuallyservetoalleviateworriesandhelpreduceany enhancedthreatdetectioninpeoplewithGAD,andmayaccount for whytheenhancement ofthreat detectionin GADwasonly seenwithintheneutraldistractercrowds.Therefore,the social-evaluativefearsinpeoplewithGADmaybemoretunedtoseeing threatwithinneutral-relatedcontexts,moreakintoeverydaylife events.
TheoppositepatternofbiasfindingswasseeninthePDgroup. Theyshowedenhancedthreatdetectionwhilesearchingforangry targetswithincrowdsofhappyfaces,butnoenhancementwhen searchingneutralcrowds.PDinvolvessuddenandintenseanxiety statesmorecloselylinkedtobodilysensationsandtheircontexts, andthefearofevaluationaboutthesebodilysensations.The social-evaluative fears in this disorder may be more associated with crowdsfeaturingallemotionalfaceslookingtowardsthem,asthese havehigheremotionalintensityandgreaterpotentialsignsofsocial evaluationcomparedtoneutralcrowddisplays.Ontheotherhand, thereducedemotionalintensityinthedisplayscontainingneutral facecrowdsmayactuallyhelptoalleviateanxietytosomedegree inthosewithPD,asthesecontainfeweremotional expressions and,therefore,potentialsignsofsocialevaluation.Panicattacks areusuallyrelatedtotriggerfactorswhicharesocial-emotionalin nature,whiletheincreaseofanxietyinGADismorelikelytooccur insituationsofdecreasedstimulation,passivity,anddecreasesin goal-orientedactivity.Thereissomeevidencetosupportthisidea fromastudylookingatphysiologicalreactivityinpeoplewithGAD versusPDintheformofrespirationmeasures(Wilhelm,Trabert,& Roth,2001).Theyfoundthetwodisorderscouldbedifferentiated fromeachotherbasedontheirphysiologicalbehaviour,interms ofrespirationinresponsetoemotionalstimuli.Morespecifically, thePDgroupshowedgreaterphysiologicalreactivitycomparedto GAD.Thisprovidesa‘bottom-up’interpretationofthedisparityin attentionalbiasesbetweenGADversusPD,involvingdifferences inphysiologicalreactivitythatmaybeinfluencedbytheaffective intensityofstimuli.
Anotherpossibleexplanationforthebiasdifferencesisamore ‘top-down’influenceofattentionalcontrol.Allthegroupsinthe presentstudydifferedfromeachotherontheirACSscores,with thecontrolgroupscoringthelowestcomparedtothetwoanxiety groups,andtheGADgrouphavinghigherattentionalcontrolthan thePDgroup.TheACSisproposedtomeasuretop-down mech-anismscontrollingattentionalresources,withhigherattentional controlrelating tovoluntarycoping strategieswhen processing informationperceivedasthreatening(Derryberry&Reed,2002). Attentionalcontrolisthoughttohelpregulateemotionalresponses and anxiety. Therefore, these findings may suggest differences betweentheanxietygroupsinhigherlevelvoluntarycontrolofthe attentionalprocessingofthreatwithindifferentcontexts. Inter-estingly, cognitive-behavioral therapy (CBT) of GADfocuses on restructuringdysfunctionalbeliefsandmeta-beliefs,whileCBTof PDfocusesmoreonthelearningofrelaxation,therecognitionof triggerfactors,andthemechanismsunderlyingtheexaggeration of threateningexperiences. Therefore, theCBT forGAD focuses onmentalprocesses,whileforPDitfocusesonemotional reac-tionsrelatedwithbodilyexperiencesandtheirsocialconsequences (Wells,1997).
Ourfindingscannotbeaccountedforbyaspeed-accuracy trade-offinrespondingtoangryfaces,wherepeoplemightbefasterbut alsomakingmoreerrors.Instead,participantsinthestudywere notonlyfasterinrespondingtoangrycomparedtohappyfaces, buttheywerealsomoreaccurateintheirdetectionofangryfaces. Thisrunscountertotheideaofaspeed-accuracytrade-off.Another possibleexplanationfortheresultsisthatpeopleintheanxiety groupswerenotactuallyfasterindetectingtheangryfacetargets, butinsteadmighthavebeenfasterinscanningthroughthe dis-tractercrowdsofhappyexpressionswhensearchingforangryface targetswithindisplays.However,differencesbetweenthegroups inscanningthedistractercrowdsdoesnothelpexplaintheresults, asnogroup differencesin response latenciesor accuracywere foundforrespondingtocrowdsofhappyversusangryfaceswhen notargetswerepresent.Thissuggeststheywereequallyfastin scanningthroughbothhappyandangrycrowdswhendetecting thetargets.Thepresentfindingsalsocannotbeexplainedby dif-ferencesindetectinglow-levelvisualcharacteristicsinthefaces, suchascurved or angledlines in thestimuli (Treisman, 1980). Theangryandhappyschematicfaceswereveryhighlymatched toeachotheronallvisualcharacteristics,which waswhy they werechosenasstimuli.Theonlydifferencebetweentheangryand happyfaceswastheorientationofkeyfeatureswhichproduced thecorrespondingemotionalexpressions.Therefore,wefeelthe bestexplanationforthepresentfindingsisanenhancedattentional biastowardsthreateninginformationinclinicalanxiety,consistent withpreviousexperimentalresultsandkeytheories.
Thepresentfindingshavepotentialimplicationsforthe assess-mentandtreatmentofanxietydisorders.Diagnosticdifferentiation betweendifferentanxietydisorderscanbedifficultwhenitisbased solelyonclinicalinterviews.Therefore,experimentalparadigms suchastheFace-in-the-Crowdtaskcouldbeusedtohelpaidin moreaccuratediagnosisbyobjectivelyrevealingabnormalbiases towardsthreateninginformationinpatients,aswellasthenature ofthebias.Runningtheexperimentaltaskbeforeandafter treat-mentcouldalsohelptorevealtheeffectivenessofinterventions, forexamplebyshowingwhethertreatmenthasbeensuccessfulin reducingthebiastowardsthreat.Ofcoursethisapplicationwould requirehighreliabilityandspecificityofthetasktoconsistently showenhancedbiasesinpeoplewithanxiety,andalsofor reveal-ingdifferentpatternsofbiasesbetweenvariousanxietydisorders. Thepresent studygenerallyhadmedium effectsizesfor differ-encesbetweengroups;howevermoreresearchisneededtotestthe reliabilityandconsistencyoffindingsacrossmanyclinicalstudies. Similarexperimentalparadigmscouldalsopotentiallybeusedto
helpreduceenhancedattentionalbiasesinthosewithhighanxiety. Fox,Ashwin,Zougkou,andBroadhurst(submitted)recentlyuseda dotprobeparadigmwithpeoplewhowerehighorlowinspider phobia,andmanipulatedthelocationofthetargettoalwaysbe awayfromspiderpicturesforthosehighinspiderfear.Theyfound that aftermany experimentaltrialsthere wasa reduced atten-tionalbiastowardsspidersinthosewithhighspiderphobia,and thereductioninbiaswasalsoaccompaniedbylessaversive rat-ingsofspider-relatedphotos.Thereisgrowingevidencethatsuch attentionaltraining,orcognitivebiasmodificationprocedures,can alleviateanxioussymptomatologyinavarietyofanxietydisorders (forreviewsseeBrowning,Holmes,&Harmer,2010;Hakamata etal.,2010;MacLeod,Koster&Fox,2009),includingGAD(Amir, Beard,Burns, &Bomyea,2009)Thesepotentialclinical applica-tionsofcognitiveexperimentalparadigmsareimportantbecause althoughCBTtreatmentsarereportedtobeeffectiveformany peo-plediagnosedwithanxietydisorders(Butler,Chapman,Forman,& Beck,2006),asmanyasonethirdofpatientsdonotreceive sig-nificanttreatmentbenefitsandfewpatientsactuallyachievefull recovery(Ballenger,1999).
While thesimplicityof theexperimentalparadigmmakesit well-suitedforpsychiatricresearch,onelimitationofthepresent studyisthatthedisplaysizeswerealwaysthesamethroughout. Thiswasduetotimeconstraintswiththeavailabilityofthe anx-ietyparticipantsduringtestingsessions.Havingdifferentdisplay sizeswouldhaveallowedfortheanalysisofdetectionslopesfor theangryand happytargets acrossthedifferentsizesfor each group(Eastwoodetal.,2005;Frischen,Eastwood,&Smilek,2008). Thisadditionalfactorwouldhavehelpedtorevealmorespecificity aboutwhetherpreorpostattentionalmechanismswereinvolved inthepresentfindings.Therefore,atpresentwecannotdetermine whetherenhancedeffectsbyGADandPDgroupsweredueto bet-terawarenessoftheemotionaltargetsorduetoresponsebiases once thetargets weredetected.We have been cautious in our interpretationsregardingthebiasesinvolvedandnotspeculated aboutwhethertheeffectsinvolvedpreorpostattentiveprocesses. Furtherstudiesofthistypeinanxietydisordersshouldinclude dif-ferentsizedisplays,tohelpdeterminemorespecificallythetype ofattentionalmechanismsinvolved.Furtherresearchshouldalso includegreaternumbersofclinicalpatients,astheparticipant num-bersinthepresentstudywerelimited.
Acknowledgements
ThisworkwassupportedbyaprojectgrantfromtheWellcome Trust(ref:076701/Z/05/Z)awardedtoElaineFox,andagrantfrom thePolishMinistryofScienceandHigherEducation(ref:NN402 269036)toPawelHolas.
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