Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment
Harvey, A., G., Watkins, E., Mansell, W., Shafran, R. (2004)
Chapter 2
Attention

What is selective attention?

Out experience at any one point is dominated by some stimuli at the expense of others.
Selective attention is a process by which specific stimuli, within the external and internal environment, are selected for further processing.
Further processing may be reasoning, thought, or the generation of a plan of action. These processes are not to be confused with selective attention itself.
Selective attention is the internal filtering of stimuli. S

Attentional bias: a systematic tendency to attend (or avoid attending) to a particular class of stimuli.

The processes of selective attention have been divided into

• Automatic processes
  The person is either unaware that their attention has been drawn to a particular stimulus, or they may feel that their attention is out of their own control.
• Controlled processes
  Consciously planning to attend a stimulus.

This might be a continuum.

Most everyday behaviours are triggered, and often maintained, in an automatic manner such that they free up resources and thereby maximize the efficiency with which we operate the world.

Self-focused attention

Self-focused attention is an awareness of self-referent, internally generated information that stands in contrast to an awareness of externally generated information derived through sensory receptors.
Self-focused attention includes awareness of

• Physical state
• Feelings
• Thoughts
• Emotions
• Memories

How is selective attention measured?

Self-report measures

Asking people.
Self-report measures index how much the individual reports attending to the stimulus identified.

Advantages

• Easy to use in clinical practice where other methods may not be available
• Attention to certain stimuli may be difficult to address in other ways

Drawbacks to self-report

• They tend to tap a broad range of processes other than attention
• Self-report scales are prone to biases and inaccuracies in memory because they are completed retrospectively
• They cannot provide information about automatic processes that are too quick or subtle for the person to notice

The emotional stroop task

It has been proposed that the participants’ selective attention to the content of the word interfered with their response to name the colour of the ink.

In 1980 the Stroop task was adapted by replacing the colour words with emotional words.
The typical design involved selecting emotional words that were relevant to the disorder of interest and comparing the time taken to colour-name neutral words, matched for word-length and frequency.
Positive words might also be included or words from a certain category.

The presentation of an emotional word can significantly interfere with one’s performance on a neutral task.
But it is not clear that this effect is actually a result of selective attention to the word.
Longer time taken to colour-name could be caused by other factors

• Threatening words may create an emotional reaction
• The emotional Stroop effect may be capturing ‘cognitive avoidance’
• The emotional Stroop effect may be reflecting mental pre-occupation with themes related to the emotional words

Detection tasks

If an individual selectively attends to a certain class of stimuli, then it follows that the person will be faster at detecting these stimuli.
Detection is assumed to provide an index of selective attention.

Visual search task.
The participant is presented an array of stimuli, and they must detect a target stimulus within this array as quickly as possible.

Dichotic listening task

In the dichotic listening task the participants wear a pair of headphones and they read out loud a story that is being played to them through one ear, and threat and non-threat words are played in the other ear.
At the same time, the participant engages in a visual reaction time task in which they are asked to press a button as fast as possible as soon as they detect the word ‘press’ on the computer screen in front of them.

Attentional bias to thread words is indexed by a slower response to the visual probe when a threat word is played in the un-attended channel, compared to the reaction time when a non-thread word is played in the unattended channel.

Dot-probe task

Selective attention is indexed by a shorter latency to respond.

The participant is first instructed to fix his/her eyes on a cross presented in the centre of a screen.
Next, the cross is replaced by two word stimuli.
The participant’s task is to read the top word out loud. Next, the pair of word is replaced by a dot that appears in the spatial location of one of the two words.
The participant’s task is to press the response button as fast as possible when s/he detects a dot on the computer screen.

The degree of selective attention to the emotional words is calculated by subtracting the time taken to respond to the dot-probes in the spatial location of the neutral words from the time taken to respond to the dot-probes in the spatial location of the emotional words.

Eye tracker (visual scanpath)

The eye tracker directly assesses where, in a presented picture, people focus they eye gaze over time.

To what kind of stimuli do people selectively attend?

There is a variety of stimuli (internal and external) to which people are more likely to attend

• Stimuli that are novel
• Stimuli that have certain physical properties
  • Bright visual stimuli
  • Moving stimuli
  • Intensely painful stimuli

Some stimuli are ‘prepared’ in the sense that we have an innate sensitivity to detect and respond to these stimuli.
People generally attend to prepared stimuli that are both rewarding and threatening.

People also attend to their current concerns either owing to their prepared nature, their acquired meaning, or both.

Do attentional processes play a causal role?

The existing evidence tentatively suggests a causal role for attention in psychological disorders.

Theoretical issues

People with psychological disorders selectively attend to internal and external stimuli that are related to their current concerns, including detecting and eliminating danger, pursuing reward, or detecting sources of safety.

There is evidence of substantial overlap across disorders in the content of the stimuli to which people attend.
One possible explanation is that although attentional bias may often be concern-specific, some disorders may overlap in the concerns that relate to them.

Three models have been proposed to explain the role of selective attention in psychological disorders.

• Mark Williams
  High levels of trait and state anxiety lead individuals to show an automatic attentional bias towards threatening stimuli
  • But this cannot fully account for the evidence
• Cognitive-motivational model
  Anxiety disorders are associated with an automatic attentional bias towards threat. People with low levels of anxiety avoid threatening stimuli.
  • The degree to which and individual attends to a stimulus will depend on their currently active goal and how they appraise the stimulus.
  • Avoidance of a threat may be a process involved in maintaining anxiety because it prevents the reappraisal of feared stimuli when they are not dangerous.
  • All motivational goals can lead to biases in selective attention
  • But, this model provides no explicit explanation for the convincing evidence of an attentional bias to internal cues
• Self-regulatory executive function model S-REF
  Composed of an executive system that engages in the controlled monitoring of ‘low-level processing units’ that are responsible for automatic processing.
  The monitoring behaviour is influenced directly by self-beliefs and procedural plans that are stored in long-term memory
  People with emotional disorders engage in excessive monitoring of relevant information
  • This process prevents attention to new information that may contradict negative beliefs, disrupts ongoing behaviour, and maintains the experience of distress
    It is also possible that enhanced distractability is caused by the operation of plans to scan the environment, even for neutral stimuli, because they are regarded as threatening
    The controlled process can become automatized with repeated rehearsal

None of the models can fully explain the processes of selective attention in psychological disorders.
None incorporate the possibility that people with certain psychological disorders may have an underlying deficit in controlling their attention
A fully comprehensible model would have to accept several features

• Motivational states other than anxiety can influence selective attention in patients with psychological disorders
• The appraisal of certain stimuli as threatening can lead them to capture attention automatically even without repeated rehearsal
• Avoidance of threat and attention to safety are associated with psychological disorders

Clinical implications

The attentional biases associated with psychological disorders are reduced following successful therapy.
It is not known whether these treatments work because attentional processes were modified directly or whether they change is a secondary effect of targeting other cognitive and behavioural processes.

Five possible ways in which selective attention may serve to maintain a psychological disorder

• People attend to information that is consistent with their concerns
  This make individuals miss information that could disconfirm his or her problematic beliefs
• Over time, selective attention to a limited range of concerns is likely to result in attention being directed away from other information in the internal and external environment that may be useful for learning skills, gaining knowledge, or improving social interactions.
  Biases in selective attention may lead to objective decrements
• Attention directed towards internal stimuli leads an individual to make more internal attributions to events
• Selective attention may lead to the encoding of specific information within memory, which may then affect subsequent cognitive processing.
• It is possible that the automatic nature of attentional biases may lead people to feel that their mind is not under their control which would lead to fears of going mad or acting impulsively

Implications for therapy

• The therapist must broaden the range of stimuli to which a patient attends
• The therapist needs to generate conditions that can reduce internally focused attention
• Attentional training may help improve attentional control

Attentional training is designed to modify the perseverative self-relevant processing that is characteristic of emotional disorders.
It is designed to promote the processing of disconfirmatory information and also to increase the voluntary, flexibly control of attention so that patients can effectively disengage their attention from the stimuli that automatically capture their attention.

Manipulation of attention during behavioural experiments is a technique that has been used successfully in the treatment of social phobia and specific phobia.
In behavioural experiments sometimes it is helpful to enrich the environment to facilitate the patient to direct their attention.

Mindfulness may target attention.
To train people to be able to focus and sustain attention on one facet of their internal or external environment.

The positive data log aims to explicitly correct biases in attention.
Automatic thoughts records may be helpful to identify, examine the evidence for and against them, and to generate and evaluate more functional thoughts.