«ATTENTIONAL BIAS IN PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATORS: EXAMINING MECHANISMS OF HYPERVIGILENCE AND ANXIETY By NEHA K. DIXIT A ...»
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.
Algom, D., Chajut, E. & Lev, S. (2004). A rational look at the emotional stroop phenomenon: a generic slowdown, not a stroop effect. Journal of Experimental Psychology, 133, (3), 323-338.
Amir, N., Elias, J., Klumpp, H., & Przeworski, A. (2003). Attentional bias to threat in social phobia: facilitated processing of threat or difficulty disengaging attention from threat?
Behaviour Research and Therapy, 41,1325-1335.
Armony, J.L., & LeDoux, J.E. (2000). How danger is encoded: Towards a systems, cellular and computational understanding of cognitive-emotional interactions in fear. In M.S.
Gazzaniga (Ed.), The new cognitive neurosciences (2nd Ed. pp1067-1079). Boston: MIT Press.
AVID Investigators. (1997). A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. New England Journal of Medicine, 337, 1576-1583.
Beck, A.T. (1976). Cognitive therapy and emotional disorders. New York: International Universities Press.
Beck, A., Steer, R., & Brown, G. (1996). Manual for Beck Depression Inventory-II (2nd ed.).
San Antonio, TX: Psychological Corporation.
Beck, J.G., Freeman, J.B., Shipherd, J.C., Hamblen, J.L., Lackner, J.M. (2001). Specificity of stroop interference in patients with pain and PTSD. Journal of Abnormal Psychology, 110 (4): 536-43.
Bishop, S., Duncan, J., Brett, M., & Lawrence, A.D. (2004). Prefrontal cortical function and anxiety: controlling attention to threat-related stimuli. Nature Neuroscience, 7(2), 184Bradley, M.M., & Lang, P.J. (1999). Affective norms for English words (ANEW): Stimuli, instruction manual and affective ratings. Technical report C-1, Gainesville, FL. The Center for Research in Psychophysiology, University of Florida Broomfield, N.M. & Turpin, G. (2005). Covert and overt attention in trait anxiety: a cognitive psychophysiological analysis. Biological Psychology, 68, 179-200.
Bush, G., Luu, P., & Posner, M.I. (2000). Cognitive and emotional influences in anterior cingulated cortex. Trends in Cognitive Sciences, 4 (6), 215-222.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, N.J.:
L. Erlbaum Associates.
Cohen, J. D., Botvinick, M., & Carter, C. S. (2000). Anterior cingualte and prefrontal cortex:
Who's in control? Nature Neuroscience, 3, 421-423.
Compton, R.J. (2003). The interface between emotion and attention: a review of evidence from psychology and neuroscience. Behavioral and Cognitive Neuroscience Reviews, 2 (2), 115-129.
Compton, R.J. & Banich, M.T. (2003). Paying attention to emotion: an fMRI investigation of cognitive and emotional stroop tasks. Cognitive, Affective, & Behavioral Neuroscience, 3 (2), 81-96.
Damasio, A. R. (1994). Descartes’ error. Emotion, reason, and the human brain. New York:
Deghani, M., Sharpe, L., & Nicholas, M.K. (2003). Selective attention to pain-related information in chronic musculoskeletal pain patients. Pain, 105, 37-46.
Derryberry, D., & Reed, M.A. (1994). Temperament and attention: orienting toward and away from positive and negative signals. Journal of Personality and Social Psychology, 66, 1128-1139.
Derryberry, D., & Reed, M.A. (2002). Anxiety-related attentional biases and their regulation by attentional control. Journal of Abnormal Psychology, 111 (2), 225-236.
Dolan, R. (2000). Emotional processing in the human bran revealed through functional neuroimaging. In M.S. Gazzaniga (Ed). The new cognitive neurosciences (2nd ed. pp.
701-710.) Cambridge, MA: MIT Press.
Dunbar, S.B., Kimble, L.P., Jenkins, L.S., Hawthorne, M., Dudley, W., Slemmons, M., et al.
(1999). Association of mood disturbance and arrhythmia events in patients after cardioverter defibrillator implantation. Depression and Anxiety, 9, 163-168.
Fox, E., Russo, R., Bowles, R., & Dutton, K. (2001). Do threatening stimuli draw or hold visual attention in subclinical anxiety? Journal of Experimental Psychology: General, 130 (4), 681-700.
Fox, E., Russo, R., & Dutton, K. (2002). Attentional bias for threat: Evidence for delayed disengagement from emotional faces. Cognition and Emotion, 16, 355-379.
Godemann, F., Aherns, B., Behrens, S, Berthold, R., Gandor, C., Lampe, F., Linden, M. (2001) Classic conditioning and dysfunctional congitions in patients with panic disorder and agoraphobia treated with implantable cardioverter/defibrillator. Psychosomatic Medicine, 63, 231-238.
Godemann, F., Butter, C., Lampe, F., Linden, M., Werner, S., & Behrens, S. (2004).
Determinants of the quality of life (QoL) in patients with an implantable cardioverter/defibrillator (ICD). Quality of Life Research, 13, 411-416.
Haywood, C. (1995). Psychiatric Illness and cardiovascular disease risk. Epidemiology Review, 17, 129-138.
Hegel, M.T., Griegel, L.E., Black, C., Goulden, L., & Ozahowski, T. (1997). Anxiety and depression in patients receiving implanted cardioverter-defibrillators: A longitudinal investigation. International Journal of Psychiatry in Medicine, 27, 57-69.
Herrman, C., von zur Muhen, F., Schaumann, A., Buss, U., Kemper, S., Wantzen, C., et al.
(1997). Standardized assessment of psychological well-being and quality-of-life in patients with implanted defibrillators. Pacing and Clinical Electrophysiology, 20, 95Irvine, J., Dorian, P., Baker, B., O’Brien, B.J., Roberts, R., Gent, M., Newman, D., & Connolly, S.J. (2002). Quality of life in the Canadian Implantable Defibrillator Study (CIDS).
American Heart Journal, 144, 282-289.
Kamphuis H.C., de Leeuw J.R., Derksen R., Hauer RN, Winnubst JA. (2003). Implantable cardioverter defibrillator recipients: quality of life in recipients with and without ICD shock delivery: a prospective study. Europace, 5, 381-389.
Kiernan, R., Mueller, J., Langston, W. & Van Dyke, C., (1987). The Neurobehavioral Cognitive Status Examination: A brief but differentiated approach to cognitive assessment. Annals of Internal Medicine 107, pp. 481–485 Kubzansky, L.D., Kawachi, I., Weiss, S.T., & Sparrow, D. (1998). Anxiety and coronary heart disease: a synthesis of epidemiological, psychological, and experimental evidence.
Annals of Behavioral Medicine, 20, 47-58.
Kohn, C.S., Pterucci, R.J., Baessler, C., Soto, D.M., & Movsowitz. C. (2000). The effect of psychological intervention on patients’ long-term adjustment to the ICD: A prospective study. PACE, 23, 450-456.
Koster, E.H.W, Crombez, G., VanDamme, S., Verscheuere, B., & De Houwer, J. (2004). Does imminent threat capture and hold attention?Emotion, 4, (3), 312-317.
Kroeze, S. & van den Hout, M.A. (2000). Selective attention for cardiac information in panic patients. Behaviour Research and Therapy, 38, 63-72.
Lemon J, Edelman S, Kirkness A. (2004). Avoidance behaviors in patients with implantable cardioverter defibrillators. Heart Lung, 33, 176-82.
Lane, R.D., Chua, P.M.-L. & Dolan, R.J. (1997). Neural activation during selective attention to subjective emotional responses. NeuroReport, 8, 3968-3972.
Lang, P.J., Bradley, M.M. & Cuthburt, B.N. (1997). Motivated attention: affect, activation and
action. In P.J. Lang, R.F. Simons, & M.T. Balaban (Eds), Attention and orienting:
sensory and motivational process (pp.97-135. Mahwah, NJ: Lawrence Earlbaum.
Lang, P.J., Davis, M., & Ohman A. (2000). Fear and anxiety: animal models and human cognitive psychophysiology. Journal of Affective Disorders, 61, 137-159.
Le Doux, J. (1996). The emotional brain. New York: Simon & Schuster.
Lazarus, R.S. (1966). Psychological Stress and the coping process. New York: McGraw Hill.
Mangun, G.R., Jha, A. Hopfinger, J.B. & Handy, T.C. (2000). The temporal dynamics and functional architechture of attentional processes in human extrastriate cortex. In M.S.
Gazzaniga (Ed). The new cognitive neurosciences (2nd ed. pp. 701-710.) Cambridge, MA:
MacLeod, C.M. & MacDonald, P.A. (2000). Interdimensional interference in the stroop effect:
uncovering the cognitive and neural anatomy of attention. Trends in Cognitive Sciences, 4 (10), 383-391.
MacLeod, C., Mathews, A. & Tata, P. (1986). Attentional bias in emotional disorder. Journal of Abnormal Psychology, 95, 15-20.
Mogg K & Bradley, B. (2002). Selective orienting to masked faces in social anxiety.
Behaviour Therapy and Research, 40 (12), 1403-1414.
Moss, A. J., Hall, W. J., Cannom, D. S., Daubert, J. P., Higgins, S. L., Klien, H., et al., for the Multicenter Automatic Defibrillator Implantation Trial Investigators. (1996). Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. New England Journal of Medicine, 335, 1933-1940.
Oatley, K. & Johnson-Laird, P.N. (1987). Towards a cognitive theory of emotions. Cognition and Emotion, 1, 29-50.
Ohman, A. (1997). As fast as the blink of an eye: evolutionary preparedness for preattentive processing of threat. In P.J. Lang, R.F. Simons, & M.T. Balaban (Eds), Attention and orienting: sensory and motivational process (pp.97-135. Mahwah, NJ: Lawrence Earlbaum.
O’Leary, C. J., & Jones, P. W. (2000). The left ventricular dysfunction questionnaire (LVD-36):
Reliability, validity, and responsiveness. Heart, 83, 634-640.
Pauli, P., Wiedemann, G., Dengler, W., Blaumann-Benninghoff, G., & Kuhlkemp, V. (1999).