Anxiety and attention to threat: cognitive mechanisms and treatment with attention bias modification

Anxiety disorders are common and difficult to treat. Some cognitive models of anxiety propose that attention bias to threat causes and maintains anxiety. This view led to the development of a computer-delivered treatment: attention bias modification (ABM) which predominantly trains attention avoidance of threat. However, meta-analyses indicate disappointing effectiveness of ABM-threat-avoidance training in reducing anxiety. This article considers how ABM may be improved, based on a review of key ideas from models of anxiety, attention and cognitive control. These are combined into an integrative framework of cognitive functions which support automatic threat evaluation/detection and goal-directed thought and action, which reciprocally influence each other. It considers roles of bottom-up and top-down processes involved in threat-evaluation, orienting and inhibitory control in different manifestations of attention bias (initial orienting, attention maintenance, threat avoidance, threat-distractor interference) and different ABM methods (e.g., ABM-threat-avoidance, ABM-positive-search). The framework has implications for computer-delivered treatments for anxiety. ABM methods which encourage active goal-focused attention-search for positive/nonthreat information and flexible cognitive control across multiple processes (particularly inhibitory control, which supports a positive goal-engagement mode over processing of minor threat cues) may prove more effective in reducing anxiety than ABM-threat-avoidance training which targets a specific bias in spatial orienting to threat