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The pattern of findings suggests that both groups were equally aroused by the word-cues irrespective of valence. Both the valence and arousal findings are novel and the first to be demonstrated in an arrhythmia population. Given that both ICD and AF patients found the cardiac words highly arousing, it is possible that the words developed for this sample did not discriminate ICD related threat from AF related threat. Alternatively, the findings may suggest that recipients of ICDs and patients living with symptoms of AF are more similar with respect to levels of clinical hypervigilence than they are different. This is further evidence that the sample in this study may have been too affectively homogenous to clearly elucidate the specific affective attentional bias hypotheses.

–  –  –

The current study represented a first step in the application of principles and paradigms of cognitive neuroscience to the study of attentional processing in ICD recipients. Additionally it offered a unique perspective in merging mechanistic research with demonstrated psychosocial phenomena. Like many studies examining novel populations and paradigms, it ventured into uncharted territory and potential limitations must be addressed. A number of pragmatic and resource constraints may have affected the results.

The first limitation of the present study may have been with the study sample itself. The participants were highly selected and consisted mainly of Caucasian, highly educated arrhythmia patients, which may not be representative of the general cardiac/arrhythmia population in the United States. In addition, stringent criteria were used to control for medical and emotional health. As such, the patients in this sample were psychologically healthier than similar samples described in the ICD literature (Sears, 2003; Goodeman, 2004; Kuhl, 2006). Given that most of our hypotheses were based on the prediction of high anxiety, specifically shock-related anxiety, the lack of shock-specific anxiety in this cohort may have affected the results obtained.

Alternatively, it is possible that the ICD patients as well as AF controls were not anxious enough (given the low state/trait anxiety scores for both groups) for robust group effects to emerge.

Other similar studies have found individuals with higher STAI scores, specifically after experimental mood induction (Wilson & MacLeod, 2003; Fox et al, 2005) have biased attentional processing to emotionally-relevant information.

Another critical limitation that may have affected the ICD cohort in this study is the changing nature of the technology. More and more patients are being “paced” out of life threatening arrhythmias. That is, the ICD can detect an abnormally fast heart rhythm and as it prepares to fire, may terminate the rhythm before it becomes necessary to shock. The ICD group in this study had a low incidence of shock (63% had no shocks), as a result, they may not have been as anxious regarding their devices nor were they even familiar with post-shock psychological sequelae. Additionally, those who had been shocked at least once may have been educated about device acceptance and ICD shock and were therefore less concerned about the device. The ICD cohort at Shands hospital has been involved in numerous studies over the past 15 years specifically focusing on ICD education and device acceptance. Given the small number of clinics from which recruitment occurred, it is possible that oversampling of this population affected their responses on familiar measures of psychosocial effects and device knowledge.

Finally, the present study may have benefited from a post-task questionnaire as well as post-task ratings of state, trait and shock-related anxiety. Qualitative feedback from participants regarding their subjective experience during the task may have aided in clarifying inherent cohort specific problems with the task (e.g. too easy, unclear etc). Post-task anxiety questionnaires would have offered a data point to examine whether the task itself induced anxiety in our patients.

–  –  –

Future studies may improve on the present methodology by employing a “classic” dotprobe paradigm which uses word pairs as cues (McLeod, Mathews, & Tata, 1986). Additionally, given the low levels of anxiety in this cohort, ICD related mood induction may prove useful in clarifying effects of device specific anxiety on attentional bias. Mood induction is widely used in studies examining affective processing and is a powerful tool to induce an affective state (Compton, 2003). Use of the startle paradigm (e.g. eye-blink reflex) may provide more direct measurement of heightened threat relevant arousal and vigilance in arrhythmia patients.

Additionally, direct measures of physiological arousal such as skin conductance, heart rate, and blood pressure may also be useful in characterizing and differentiating VF and AF patients.

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