Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study

Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental... Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved. Objective: This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability. Methods: We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor. Results: Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60). Conclusions: Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback. (JMIR Serious Games 2018;6(4):e10993) doi: 10.2196/10993 KEYWORDS attentional bias; anxiety disorders; experimental games http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al focus on developing more effective procedures than the Introduction dot-probe task to modify attentional bias [27-29]. Moreover, researchers have raised concerns about the suitability of the Attentional Bias Modification in Anxiety conventional probe-based training task for use with clinical We operate in a complex and dynamic world in which we are cohorts because of its monotonous nature and low face validity continuously confronted with an ever-changing stream of [27]. perceptual information. The limited capacity of our cognitive Gamification of Attentional Bias Modification system means we can only attend to certain information, while other information is filtered out. Such filtering does not operate Paradigms in the same manner across all individuals; however, it has In recent years, some investigators sought to adapt existing become clear that there is a relationship between such attentional ABM procedures to make them more engaging by gamifying selectivity and individual differences in emotional vulnerability them. Gamification refers to the use of game design elements [1]. Specifically, research has shown that elevated anxiety in nongame contexts [30]. Several levels can be discerned in vulnerability, whether indicated by elevated levels of trait the gamification of ABM tasks, from simply adding game anxiety or the presence of anxiety pathology, is associated with elements to existing training tasks, to adding extrinsic rewards, an attentional bias that favors the processing of negative adding intrinsic motivators, adding a game shell, to using an information [2]. Moreover, studies that have manipulated existing off-the-shelf game [31]. It is thought that maintaining patterns of attentional bias (using attentional bias modification a close connection with validated ABM tasks and adding [ABM] procedures) have shown that attentional bias causally intrinsic motivation and a game shell may be optimal for ABM contributes to anxiety vulnerability, as a change in attentional gamification [31]. bias produces a consequent change in anxiety vulnerability Existing gamified training protocols have been variants of the [3,4-6]. original probe approach; however, all these protocols share in The observation that ABM tasks delivered in the laboratory can common the limitation that they seek to train attentional exert a beneficial impact on anxiety responses to stressor has selectivity using very simple static displays that typically present led a number of researchers to investigate whether extended only 1 or 2 stationary emotional stimuli [28,32-36]. This exposure to such ABM training can reduce anxiety dysfunction contrasts markedly with real-world settings, which generally in real-world settings. The most frequently used ABM procedure require individuals to engage in patterns of attentional scanning is based on the dot-probe task [7]. In this task, participants are and tracking within a complex and dynamic environment [37]. briefly exposed to stimulus pairs, comprising 1 negative and 1 In addition, these studies have been hampered by design non-negative stimulus, before a small visual probe is presented, limitations. In some cases, these studies have lacked a control which participants are required to identify. A contingency condition [33,34]. Moreover, most of these novel procedures between the position of the probes and the position of the have been delivered in studies that afford no opportunity to negative stimuli is introduced, whereby probes are either always compare their efficacy with that of the conventional probe-based presented in the location where the non-negative stimulus was ABM approach. Without such a comparison, it remains unknown just displayed (encouraging the adoption of an attentional bias whether a novel ABM task can achieve attentional bias change away from negative information) or else probes are always under conditions where the conventional probe-based ABM presented in the location where the negative stimulus was just task fails to do so or whether a novel task can produce change displayed (encouraging the adoption of an attentional bias in anxiety vulnerability when such change is not elicited by a toward negative information). There is now a substantial body conventional probe-based ABM approach. of evidence showing that such ABM tasks, configured to reduce These studies did, however, incorporate different gamification attentional bias to negative information, can attenuate the and other (nongame) elements to enhance engagement with the symptoms of social anxiety disorder [8,9], generalized anxiety tasks to improve their effectiveness in modifying attentional disorder [10,11], and subclinical obsessive-compulsive bias [36,38]. Some studies have included motivating feedback symptoms [12]. or goal metrics, in the form of real-time visual performance Although such encouraging findings highlight the potential feedback or points [32,35] or block-by-block feedback on clinical benefits of ABM procedures, it is important to recognize performance [28]. Others have implemented more elaborate that in a number of ABM studies, the intended attentional displays or a game-shell to increase intrinsic motivation training procedure has failed to affect emotional vulnerability [33,35,39-43]. Another element thought to increase intrinsic [13-16]. Overall, meta-analyses show that the clinical motivation is goals-directed learning, which directs players to effectiveness of the implementation of ABM procedures is small particular goals to increase targeted skills (eg, through but nonetheless significant [17-21]. However, careful instructing participants to attend to positive information) [44]. consideration of this literature suggests a clear pattern. In the However, despite inclusion of these gamification elements, the studies where the intended ABM procedure successfully changed majority of these studies continue to rely on either relatively attentional bias, this produced a medium-sized and significant sparse or mostly static stimulus displays. effect on emotional vulnerability. In contrast, in studies where This Study the intended ABM procedure did not change attentional bias, no significant impact on emotional vulnerability was observed The objective of this study was to develop and evaluate a novel [22-26]. These results indicate that future research efforts should candidate ABM procedure designed to modify attentional http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al selectivity within a task setting that, like most real-world training condition, (2) if both tasks prove capable of so contexts, requires participants to selectively distribute attention modifying attentional bias, whether the Emotion-in-Motion while processing a complex and dynamic emotional ABM task impacts attentional bias to an equal or greater degree environment. The task required participants to search for and than does the conventional probe-based ABM task, (3) whether track 1 particular target stimulus presented on screen among both the conventional probe-based ABM task and this new, multiple moving distractors, based on its emotional valence. complex, dynamic Emotion-in-Motion ABM task serve to This screen display thus realizes the elaborate display induce a group difference in anxiety vulnerability as a function gamification element, as it presents a large number of stimuli of allocated training condition, and (4) if both tasks prove that dynamically move across the whole screen. The task also capable of so influencing anxiety vulnerability, whether the incorporated the gamification elements of motivating feedback Emotion-in-Motion ABM task impacts anxiety vulnerability to through a game-by-game high score that participants were an equal or greater degree than does the conventional encouraged to try to beat as well as the element of goals-directed probe-based ABM task. learning, as participants were explicitly instructed to track 1 particular emotional expression. The task was built upon the Methods same principles as the original probe-based ABM task, in which Participants the training condition was designed to increase attentional bias toward positive information, and the task performance would A total of 129 undergraduate students at the University of be improved to the extent that participants adopted a more Western Australia completed the study. In line with previous positive attentional bias [6]. Similarly, in the corresponding research, participants who did not show an elevation in state training condition of the gamified task, performance will anxiety in response to the intended stressor were excluded before improve to the extent participants allocate attention to positive analyses [28]. This led to the exclusion of 19 participants, with stimuli. 110 participants remaining. Participant characteristics are shown in Table 1. Our primary aim was to evaluate the capacity of this new candidate ABM procedure, which we have labeled the Conventional Probe-Based Attentional Tasks Emotion-in-Motion task, to induce a group difference in Overall, 55 participants completed the conventional probe-based selective attentional responding to negatively and positively bias training and assessment tasks. These participants were valenced information and to causally impact anxiety randomly assigned to either an attend-positive or attend-negative vulnerability, as evidenced by the strength of state anxiety training condition. Participants assigned to these 2 conditions responses to a controlled laboratory stressor. We also delivered of the probe-based tasks did not differ significantly in age, trait the conventional probe-based ABM procedure to a separate anxiety scores, or gender (all P>.05). cohort of similar participants under equivalent laboratory conditions. This conventional probe-based ABM task does not Emotion-in-Motion Attentional Tasks include any of the gamification elements introduced in the Overall, 55 participants completed our novel Emotion-in-Motion Emotion-in-Motion task. Specifically, there is no elaborate bias training and assessment tasks. Participants were randomly display (only 2 static images are presented), no motivating assigned to either an attend-positive or attend-negative training feedback after each block (only trial-by-trial feedback), and no condition. Participants in these 2 conditions of the goals-directed learning (participants are simply instructed to Emotion-in-Motion tasks did not differ significantly in age or discriminate the identity of a probe). We chose to compare our trait anxiety scores (both P>.05). These 2 groups did differ novel Emotion-in-Motion task with the probe-based ABM task, significantly in gender ratio, P=.03, with a higher proportion as this is the procedure most commonly used in studies aiming of males in the attend-negative condition than in the to modify patterns of attentional bias [17,18,21]. attend-positive condition. Consequently, we considered gender ratio as a covariate in our analyses of the data, which provided This study design will enable us to determine (1) whether both reassurance that observed effects of this experimental the conventional probe-based ABM task and this new, complex, manipulation remained evident when this group difference in dynamic Emotion-in-Motion ABM task produce a group gender ratio was accounted for. difference in attentional bias in line with the allocated attentional Table 1. Age, gender, and trait anxiety scores (using the Spielberger Trait Anxiety Inventory) for participants completing the conventional probe-based and the Emotion-in-Motion attentional tasks in each of the 2 training conditions. Condition Age, mean (SD) Gender, female/male Trait anxiety, mean (SD) Conventional probe tasks Attend-negative condition (N=27) 19.33 (2.86) 14/13 38.44 (8.14) Attend-positive condition (N=28) 19.50 (2.60) 19/9 41.18 (11.08) Emotion-in-Motion tasks Attend-negative condition (N=28) 19.78 (3.62) 17/10 47.18 (8.18) Attend-positive condition (N=27) 18.50 (0.95) 23/3 43.22 (9.24) http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al At the start of a block, each face remained constant for the first Materials 2000 milliseconds. Thereafter, individual faces within a Attentional Tasks Stimuli rectangle switched to a different identity (but same expression) The face stimuli for the attentional tasks were selected from the randomly at any point between 1 and 2000 milliseconds Karolinska Directed Emotional Faces stimulus set [45]. These throughout the block. Within each block, the target rectangle images were cropped to show only the face and the neck. The switched (thus, an expression switch occurred) 60 times, at face stimuli for the training tasks were photos of 32 individuals, random intervals of 5 to 10 seconds. All 8 rectangles moved half of them were female and half were male. For the assessment with different randomly determined trajectories, at a randomly tasks, photos of 8 different individuals were selected, half of determined speed of between 30 and 50 pixels per 100 them were male and half were female. There were 2 photographs milliseconds. Thus, although the rectangles moved at different of each individual, 1 in which they depicted a happy expression speeds, each rectangle’s speed was constant within a game. The and 1 in which they depicted an angry expression. Each rectangles bounced off the screen edges and other stimuli they photograph was 258 pixels (width) by 323 pixels (height). The contacted at an angle of reflection that matched their angle of stimuli were the same size in the Emotion-in-Motion and incidence. The target rectangle was never indicated; however, probe-based tasks. For the Emotion-in-Motion training task, when the mouse cursor was correctly located in the position of the 32 identities were grouped into 8 stimulus subsets, each the current target rectangle, this cursor disappeared behind the containing the photos of 8 identities, 4 female and 4 male. Each rectangle (to not obscure the face presented within) and stimulus subset was used in 1 of the 8 blocks delivered in this remained hidden as long as the participant kept it on target. Emotion-in-Motion task. The onset of each block was preceded by a 3-second countdown Emotion-in-Motion Attentional Bias Modification Task presented in the center of the screen. At the end of each block, participants were presented with a tracking score (ie, the The aim of this task was to induce, in a complex and dynamic percentage of time during that game they were tracking the task environment, selective attending to angry or happy faces, target rectangle), a switching score (ie, the average speed with depending on the assigned training condition. To provide readers which the participant was able to shift their cursor to the next with a first-hand impression of this Emotion-in-Motion task, target rectangle), and a total score for that block (generated by the task can be viewed on the Web [46]. combining the tracking score and the switching score). The The Emotion-in-Motion ABM task consisted of 8 3.5 min blocks screen also displayed the participant’s highest prior (total) score. or games. During each block, 8 placeholder rectangles moved Participants were instructed that they would play several games dynamically around the screen over a black background. Each of this task and were encouraged to beat their current high score rectangle contained an image of a face, each with a different in each successive game. identity. At all times, the target rectangle displayed a face with Emotion-in-Motion Attentional Bias Assessment Task an emotional expression that differed from the emotional expressions displayed by the faces in all 7 other rectangles on The training contingency was removed from the screen, and participants were required to attend to and track this Emotion-in-Motion training task to create the assessment task rectangle. In the attend-negative condition, the target rectangle used to reveal the impact of this training on attentional displayed a face with an angry expression, whereas the other selectivity. Thus, participants were required to track a rectangle rectangles displayed faces with happy expressions. In the displaying a face with a happy expression (among 7 rectangles attend-positive condition, the target rectangle displayed a face displaying faces with angry expressions) on half of the blocks with a happy expression, whereas the other 7 rectangles and to track a rectangle displaying a face with an angry displayed faces with angry expressions. Participants were expression (among 7 rectangles displaying faces with happy instructed to find the target rectangle and track it using the expressions) on the other half of the blocks. This assessment mouse cursor. All the rectangles, including the target, constantly task delivered 12 short blocks, each of which contained 5 target switched faces. Participants were instructed to keep tracking switches, resulting in a total of 60 target switches across the the target rectangle (ie, depicting the single face with the assessment task. In 6 of these blocks, the target rectangle expression differing from that of the other 7 faces) even when displayed a face with an angry emotional expression, and in 6 the face presented within changed, as long as the emotional blocks, the target rectangle displayed a face with a happy expression of the face presented remained the same (ie, when emotional expression. The order of these block conditions was the face in the target rectangle switched to a different identity, randomly determined, with the constraint that a maximum of 2 participants were required to keep tracking the rectangle as long consecutive blocks could have a target with the same valence. as the emotional expression of the new face was the same as Each block started with a 5-second countdown. the emotional expression of the previous face). At random To obtain a measure of attentional bias to negative information, intervals, the emotional expression of a target face would change an attentional bias index (ABI) was computed by subtracting in addition to its identity, at which point this ceased to be the the average tracking score a participant obtained in blocks where target rectangle. At that same moment, 1 of the other rectangles targets were happy faces from the average tracking score the would assume a face depicting this emotion, and thus identifying participant obtained in blocks where targets were angry faces. it as the (new) target rectangle. At these points, participants had Therefore, a higher positive score on this index reflects greater to quickly find the new target rectangle and start tracking it. attention to negative information, as it represents more successful tracking of angry than of happy faces. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al Results showed neither a significant main effect of attentional Other Experimental Tasks assessment point, F <1, nor of training condition, F =2.246, 1,48 1,48 The Trait Anxiety Assessment, conventional probe-based ABM, P=.14. Most importantly, the critical interaction between and assessment tasks as well as the anxiety reactivity assessment attentional assessment point and training condition fell short of task are described in Multimedia Appendix 1. significance, F =3.018, P=.09, η =.059. 1,48 p Procedure Attentional Impact of Emotion-in-Motion Training Participants were tested individually in a sound-attenuated room. Once informed consent from participants had been obtained, Application of the outlier criteria led to the exclusion of 3 participants were instructed to sit at a comfortable viewing participants (1 in the attend-positive training condition). To distance from the computer screen (approximately 60 cm), were determine whether our novel Emotion-in-Motion attentional given instructions, and completed the first assessment task. training procedure was effective in modifying attentional After completion of the training task, they completed the original responding to negative information, the ABI scores obtained assessment task again. Next, participants completed the anxiety by participants who completed this task were subjected to a reactivity assessment task containing an anagram stressor task mixed-design 2x2 ANOVA that again considered the preceded and followed by a measure of state anxiety. At the within-group factor attentional assessment point (pretraining end of the session, participants were debriefed about the purpose assessment vs posttraining assessment) and the between-group of the study. The entire experimental session lasted about 1 factor training condition (attend-positive training vs hour. This study was approved by the University of Western attend-negative training). This analysis revealed a significant Australia’s Human Research Ethics Committee, protocol 2 main effect of training condition, F =4.602, P=.04, η =.084, 1,50 p RA415243. subsumed within a higher-order interaction of attentional assessment point x training condition, F =5.629, P=.02, 1,50 Results η =.101. At pretraining, there was no significant difference Impact of Attentional Training Procedure on between the ABI scores obtained by participants in the attend-positive training condition and participants in the Attentional Bias attend-negative training condition, F <1. In contrast, at 1,50 The criteria to identify outliers are described in Multimedia posttraining, participants in the attend-negative training Appendix 1. The ABI scores obtained before and after the condition showed significantly higher ABI scores as compared training task are shown in Table 2. with participants in the attend-positive condition, F =9.903, 1,50 Attentional Impact of Conventional Probe-Based P=.003, Cohen d=0.87. Although the change in attentional bias Training from pre- to posttraining fell short of significant for participants Application of the outlier criteria led to the exclusion of 4 in the attend-negative training condition, t =−1.162, P=.26, participants (2 in the attend-positive training condition). To Cohen d=0.229, there was a significant change from pre- to examine whether the conventional probe-based training task posttraining for participants in the attend-positive training was capable of modifying attentional bias, a mixed-methods condition, t =2.114, P=.045, Cohen d=0.415. Overall, this analysis of variance (ANOVA) was performed with the pattern of results confirms that the 2 training conditions exerted within-subjects factor attentional assessment point (pretraining a differential impact on attentional bias to negative information, assessment, posttraining assessment) and the between-subjects and the direction of the observed attentional training effects was factor training condition (attend-positive training, as expected. When controlling for the gender, by adding this as attend-negative training). The ABI scores obtained by a covariate, this interaction between attentional assessment point participants who completed this conventional probe-based and training condition remained significant, F =4.393, P=.04, 1,43 training task served as the dependent variable. η =.087. Table 2. Attentional bias index scores pre- and posttraining for participants who completed the conventional probe-based attentional bias training and assessment tasks or the Emotion-in-Motion attentional bias training and assessment tasks in either the attend-positive training condition or the attend-negative training condition. Assessment point Attend-positive condition, mean (SD) Attend-negative condition, mean (SD) Conventional probe training −5.669 (50.752) −3.116 (29.591) ABI pretraining ABI posttraining −15.101 (45.33) 11.002 (36.9) Emotion-in-Motion training ABI pretraining 0.449 (6.041) 1.011 (5.968) ABI posttraining −2.739 (6.545) 2.445 (5.261) ABI: attentional bias index. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al Table 3. State anxiety scores pre- and postanagram stressor for participants who previously completed the conventional probe-based attentional bias training task or the Emotion-in-Motion attentional bias training task in either the attend-positive training condition or the attend-negative training condition. Assessment point Attend-positive condition, mean (SD) Attend-negative condition, mean (SD) Conventional probe training State anxiety pretraining 30.680 (10.858) 26.200 (12.176) State anxiety posttraining 43.600 (9.734) 40.440 (11.623) Emotion-in-Motion training State anxiety pretraining 31.292 (10.149) 29.541 (11.699) State anxiety posttraining 39.458 (11.026) 41.458 (10.879) point and training condition remained significant, F =4.638, 1,43 Impact of Attentional Training Procedure on Anxiety P=.04, η =.097. Vulnerability The state anxiety scores obtained using the analog mood scale Follow-up t tests revealed that immediately following the given before and after the final anagram stressor are shown in attentional training procedure but before the anagram stressor Table 3. experience, participants who had received the 2 training conditions did not differ in their levels of state anxiety, F =.31, 1,46 Emotional Impact of Conventional Probe-Based P=.58, η =.01. Participants in each Emotion-in-Motion Training attentional training condition responded to this stress Application of the outlier criteria on participants included in manipulation by displaying an elevation in anxious mood state the attentional bias assessment analyses led to the additional (attend-positive training: F =55.84, P<.001, η =.71 vs 1,23 p exclusion of 1 participant (in the attend-positive condition). To examine whether the 2 training conditions had a differential attend-negative training: F =70.56, P<.001, η =.76). 1,23 p impact on anxiety reactivity, state anxiety scores were subjected However, the magnitude of the elevation in state anxiety evoked to a mixed-methods ANOVA with the within-subjects factor by this stressor was significantly attenuated in those participants state anxiety assessment point (prestressor assessment vs who had received the Emotion-in-Motion attend-positive poststressor assessment) and the between-subjects factor training attentional training compared with those participants who had condition (attend-positive training vs attend-negative training). received the Emotion-in Motion attend-negative attentional Results showed a significant main effect of state anxiety training condition (mean 8.17, SD 5.35 vs mean 11.92, SD 6.94; assessment point, F =159.991, P<.001, indicating that state 1,48 Cohen d=0.60). Thus, those participants who had been exposed anxiety increased from before the anagram stressor (mean to the Emotion-in-Motion task training contingency designed 28.440, SD 11.639) to after the anagram stressor (mean 42.020, to reduce attentional bias to negative information subsequently SD 10.729). However, neither the main effect of training came to display relatively attenuated elevations of anxious mood condition, F =1.664, P=.20, nor the critical interaction state in response to the anagram stressor experience compared 1,48 with participants who had been exposed to the training condition between state anxiety assessment point and training condition, designed to increase attentional bias to negative information. F =.378, P=.54, η =.008, were significant. 1,48 p In addition, the elevation in anxiety in the positive training Emotional Impact of Emotion-in-Motion Training condition of the Emotion-in-Motion task (mean 8.17, SD 5.35) was significantly smaller than the elevation in state anxiety in Application of the outlier criteria on participants included in the positive training condition of the conventional probe-based the attentional bias assessment analyses led to the additional training task (mean 12.92, SD 8.83), t =2.35, P=.02, Cohen exclusion of 4 participants (2 in the attend-positive training d=0.67. condition). The same 2x2 ANOVA as reported above was conducted on state anxiety scores to examine whether in Discussion participants who completed the Emotion-in-Motion training procedure, the 2 training conditions had a differential impact Principal Findings on anxiety reactivity. This analysis revealed a significant main effect of state anxiety assessment point, F =125.99, P<.001, The objective of this study was to develop and evaluate a novel 1,46 ABM procedure intended to systematically alter selective η =.73, again reflecting the fact that state anxiety increased attentional responding to emotional information in a complex from before the stressor (mean 30.58, SD 10.87) to after the and dynamic task environment. Our results showed that our stressor (mean 40.54, SD 10.88). This main effect was now novel Emotion-in-Motion training procedure succeeded in subsumed within a significant two-way interaction of state modifying patterns of attentional bias, as intended. Moreover, anxiety assessment point and training condition, F =4.39, 1,46 the participants who were allocated to the attend-positive P=.04, η =.09. When controlling gender, by adding gender as condition of the Emotion-in-Motion attentional training task a covariate, this interaction between state anxiety assessment showed reduced anxiety reactivity to the subsequent lab-based stressor as compared with participants who were allocated to http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al the attend-negative condition of this task. These results suggest next trial for 3 seconds, which may have elicited increased that our novel attentional training task appeared capable of negative mood. Block feedback of the type delivered in the modifying both patterns of attentional bias and causally Emotion-in-Motion task has been shown to enhance learning influencing anxiety vulnerability. in simple repetitive tasks [55], whereas negative mood has been shown to impair learning [56]. As such, this difference in A subsidiary aim was to permit comparison with the feedback may have also contributed to enhanced performance conventional probe-based attentional bias training procedure. in the Emotion-in-Motion task. Future research could further Under equivalent laboratory conditions, the conventional examine the contribution of enriched performance feedback to probe-based attentional training approach failed to induce the efficacy of ABM procedures by comparing conventional differential patterns of attentional bias, and the 2 probe-based probe-based training with and without such block feedback or training conditions did not lead to participant differences in by manipulating whether or not the presently provided block anxiety reactivity to the subsequent stressor. In recent years, feedback is delivered within the Emotion-in-Motion task. several studies (including 3 out of our lab) have reported similar failures of the conventional probe-based attentional training Moreover, in the conventional probe-based training task, images task to successfully modify patterns of attentional bias depicting different emotional expression of the same identity [28,47-51]; therefore, it is reasonable to conclude that the were paired, whereas in the Emotion-in-Motion task, each image probe-based ABM procedure may be a nonoptimal way of depicted a different identity. As such, participants performing achieving bias change. the probe-based training only needed to discriminate emotional expression on the same person, whereas participants performing Candidate Explanations for the Effectiveness of the the Emotion-in-Motion tasks needed to discriminate emotional Emotion-in-Motion Task expressions between different identities. There is some evidence In reflecting on the reasons for the capacity of our novel to suggest that emotion classifications are affected by variations Emotion-in-Motion paradigm to induce differential patterns of in identity [57]. It is, therefore, possible that this increased attentional bias, under conditions where the conventional demand on emotion classification contributed to the probe-based training did not, several candidate factors can be Emotion-in-Motion task being more challenging. The more considered. First, the Emotion-in-Motion task presents 8 stimuli challenging emotion classification, enhanced performance simultaneously, whereas the conventional probe task displays feedback, as well as the complex and dynamic nature of the task only 2 stimuli. There is some evidence that attentional bias is could have resulted in greater engagement with the more pronounced when assessed using visual displays that Emotion-in-Motion task, relative to the conventional probe task. contain more stimuli [52,53], but as yet, it is unknown whether Task engagement can be conceptualized as a combination of more robust ABM effects can be obtained using paradigms that energy, motivation, and concentration and can be measured present more stimuli. Although some training procedures that using self-report as well as through task performance indicators involve more complex stimulus displays already exist [41,54], [58]. In the Emotion-in-Motion task, we did not obtain so far no direct comparison between the effectiveness of training self-report measures of task engagement, and the difference in tasks using simple versus complex stimulus displays has been the nature of the tasks leaves us unable to compare performance made. In future research, the Emotion-in-Motion paradigm can indicators of engagement. However, future research may be easily be adapted to present simple displays (eg, 2 rectangles) usefully examine whether individuals show a difference in versus complex displays (eg, 8 rectangles), to enable such engagement with the Emotion-in-Motion task relative to the comparison. probe task and whether task engagement moderates the procedures’ impact on attentional bias and anxiety vulnerability A second candidate factor that could have contributed to the [36]. findings observed with the Emotion-in-Motion approach is the dynamic nature of the stimulus presentation. In the An additional difference between the 2 training procedures Emotion-in-Motion task, all stimuli move dynamically around concerns participants’ responses. The tracking response required the display, whereas in other attentional training paradigms, in the Emotion-in-Motion task is continuous, whereas the probe stimuli are presented in a static manner. It is possible that the task only requires a response every couple of seconds. It is likely dynamic nature of Emotion-in-Motion enhanced concentration that as a result, participants in the Emotion-in-Motion task spend and engagement with the task, thereby increasing its capacity more time attentionally engaged with the target valence (positive to deliver the intended attentional bias change. In future or negative, depending on training condition) as compared with research, the potential contribution of this dynamic component participants in the conventional probe task. However, it is also could be examined by contrasting task variants that employ the possible that this continuous response would be harder to sustain present dynamic approach with variants that instead present the over time as it is more motorically demanding. As such, future same number of stimuli in static grid. research may usefully examine the acceptability of this response format in multi-session training designs. It is also relevant to A third candidate reason for its efficacy may be the provision note that in the Emotion-in-Motion task, the mouse cursor only of enriched performance feedback in the Emotion-in-Motion disappears behind the target rectangle. As such, it is possible task compared with the rudimentary trial-by-trial error feedback that participants could ignore the content of the rectangle and given in the conventional probe-based attentional training task. simply see on which rectangle the mouse cursor would Moreover, block feedback in the Emotion-in-Motion task was disappear. Although given the speed and complexity of the task encouraging, whereas trial-by-trial feedback in the probe-based this strategy is unlikely to have occurred, importantly, this task penalized participants for making errors by delaying the http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al strategy would have reduced the efficacy of the attentional complex and dynamic nature of the Emotion-in-Motion task training. Future research could, therefore, evaluate whether can be expected to enhance face validity of and engagement in modification to the task (eg, making the cursor disappear behind the task, future research using clinical cohorts will be necessary every image) would further increase the effectiveness of the to determine whether this novel ABM task is more acceptable task. It will be important to establish, however, whether such to patients than the conventional probe-based training task. modifications that render participants’ awareness of the position It is also important to consider some potential limitations of of the cursor more uncertain cause unwanted frustration or using gamification for bias modification. Some of the potential disorientation in participants. drawbacks are discussed by Boendermaker et al [31]. These authors note that some gamification elements designed to Strengths and Limitations increase motivation (such as visible scores) may be distracting It is important to consider the potential limitations of this study. and impair training. Second, implementing intrinsic motivators One such limitation is that the capacity of the may be costly and difficult, and the intrinsically motivating Emotion-in-Motion training task and the capacity of the value of such elements may vary across individuals. In addition, conventional probe-based training task to modify attentional even if a game is intrinsically motivating, it may need to be bias were each established using a different method of assessing combined with a motivation to change in participants before attentional bias. For both training tasks, the assessment approach adherence to multi-session training is improved. Most involved delivering the same task but with the training importantly, however, given the strong link between change in contingency removed. This design critically allows for attentional bias and change in emotional vulnerability, it is comparable demonstration of near transfer across the 2 training important that in any gamified ABM procedure, the core tasks. However, it does preclude direct comparison of attentional mechanism underlying ABM (encouraging a change in bias change observed in response to each of these 2 candidate attentional bias) remains intact [24,59]. attentional training approaches. It is possible, for example, that the assessment version of the Emotion-in-Motion task is more Conclusions sensitive to individual differences in attentional bias than the In the meantime, we hope that the Emotion-in-Motion task, probe-based attentional bias assessment task (of potential which this study has shown to be capable of modifying relevance to this, note that the SDs for Emotion-in-Motion ABI attentional bias to emotional information and altering anxiety scores are smaller than those for the probe-based ABI scores). vulnerability as indicated by anxiety reactivity to a stressor, will If this is the case, then the results of this study could be be of interest and potential value to researchers investigating explained by the Emotion-in-Motion training task producing a the potential anxiolytic benefits of directly manipulating greater modification of attentional bias, the Emotion-in-Motion maladaptive patterns of attentional bias. To facilitate further assessment task more sensitively assessing group differences research using this task and to encourage independent replication in attentional bias, or both. Future research could circumvent of the findings of this study, we made our Emotion-in-Motion this limitation by employing the same attentional bias task software freely available [60]. While we look forward to assessment approaches for all ABM tasks under evaluation. the future evaluation of this novel ABM approach in other A second potential limitation is that this study was carried out cohorts and settings, we also encourage fellow researchers to on an undergraduate nonclinical participant sample. Although develop and refine new and innovative ABM paradigms that this design allowed us to examine whether the further enhance our capacity to modify the attentional bias to Emotion-in-Motion procedure can induce differential patterns negative information implicated in anxiety vulnerability and of attentional bias and consequently test the causal impact of dysfunction. Such continuous improvement in our ABM these differential patterns of attentional bias on anxiety approaches will optimize the prospect of developing future vulnerability, it does limit conclusion concerning either the ABM protocols that prove capable of delivering robust and acceptability or the efficacy of our novel Emotion-in-Motion reliable therapeutic benefits within the clinic. ABM approach when used with a clinical sample. Although the Acknowledgments LN is supported by the Australian Research Council under Grant DP140104448. CM is supported in part by a grant from the Romanian National Authority for Scientific Research, CNCS-UEFISCDI, project number PNII-ID-PCCE-2011-2-0045. PJFC was supported by Australian Research Council Grant DP140103713. BG is supported in part by Australian Research Council Grant DP170104533. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Conflicts of Interest None declared. Multimedia Appendix 1 Further detail on the methods and data handling. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al [PDF File (Adobe PDF File), 68KB-Multimedia Appendix 1] References 1. Van Bockstaele B, Verschuere B, Tibboel H, De Houwer J, Crombez G, Koster EH. A review of current evidence for the causal impact of attentional bias on fear and anxiety. Psychol Bull 2014 May;140(3):682-721. [doi: 10.1037/a0034834] [Medline: 24188418] 2. Bar-Haim Y, Lamy D, Pergamin L, Bakermans-Kranenburg MJ, van Ijzendoorn MH. Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychol Bull 2007 Jan;133(1):1-24. [doi: 10.1037/0033-2909.133.1.1] [Medline: 17201568] 3. Amir N, Weber G, Beard C, Bomyea J, Taylor CT. The effect of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals. J Abnorm Psychol 2008 Nov;117(4):860-868 [FREE Full text] [doi: 10.1037/a0013445] [Medline: 19025232] 4. Hazen RA, Vasey MW, Schmidt NB. Attentional retraining: a randomized clinical trial for pathological worry. J Psychiatr Res 2009 Mar;43(6):627-633. [doi: 10.1016/j.jpsychires.2008.07.004] [Medline: 18722627] 5. Heeren A, Reese HE, McNally RJ, Philippot P. Attention training toward and away from threat in social phobia: effects on subjective, behavioral, and physiological measures of anxiety. Behav Res Ther 2012 Jan;50(1):30-39. [doi: 10.1016/j.brat.2011.10.005] [Medline: 22055280] 6. MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias. J Abnorm Psychol 2002 Feb;111(1):107-123. [doi: 10.1037/0021-843X.111.1.107] [Medline: 11866165] 7. MacLeod C, Mathews A, Tata P. Attentional bias in emotional disorders. J Abnorm Psychol 1986 Feb;95(1):15-20. [doi: 10.1037/0021-843X.95.1.15] [Medline: 3700842] 8. Amir N, Beard C, Taylor CT, Klumpp H, Elias J, Burns M, et al. Attention training in individuals with generalized social phobia: a randomized controlled trial. J Consult Clin Psychol 2009 Oct;77(5):961-973 [FREE Full text] [doi: 10.1037/a0016685] [Medline: 19803575] 9. Schmidt NB, Richey JA, Buckner JD, Timpano KR. Attention training for generalized social anxiety disorder. J Abnorm Psychol 2009 Feb;118(1):5-14. [doi: 10.1037/a0013643] [Medline: 19222309] 10. Amir N, Beard C, Burns M, Bomyea J. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol 2009 Feb;118(1):28-33 [FREE Full text] [doi: 10.1037/a0012589] [Medline: 19222311] 11. Amir N, Taylor CT. Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy. Behav Ther 2012 Sep;43(3):546-559 [FREE Full text] [doi: 10.1016/j.beth.2010.12.008] [Medline: 22697443] 12. Najmi S, Amir N. The effect of attention training on a behavioral test of contamination fears in individuals with subclinical obsessive-compulsive symptoms. J Abnorm Psychol 2010 Feb;119(1):136-142 [FREE Full text] [doi: 10.1037/a0017549] [Medline: 20141250] 13. Carlbring P, Apelstrand M, Sehlin H, Amir N, Rousseau A, Hofmann SG, et al. Internet-delivered attention bias modification training in individuals with social anxiety disorder--a double blind randomized controlled trial. BMC Psychiatry 2012 Jun 25;12:66 [FREE Full text] [doi: 10.1186/1471-244X-12-66] [Medline: 22731889] 14. Julian K, Beard C, Schmidt NB, Powers MB, Smits JA. Attention training to reduce attention bias and social stressor reactivity: an attempt to replicate and extend previous findings. Behav Res Ther 2012 May;50(5):350-358 [FREE Full text] [doi: 10.1016/j.brat.2012.02.015] [Medline: 22466022] 15. McNally RJ, Enock PM, Tsai C, Tousian M. Attention bias modification for reducing speech anxiety. Behav Res Ther 2013 Dec;51(12):882-888. [doi: 10.1016/j.brat.2013.10.001] [Medline: 24211339] 16. Rapee RM, MacLeod C, Carpenter L, Gaston JE, Frei J, Peters L, et al. Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: a randomized controlled trial. Behav Res Ther 2013 May;51(4-5):207-215. [doi: 10.1016/j.brat.2013.01.005] [Medline: 23435121] 17. Cristea IA, Kok RN, Cuijpers P. Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. Br J Psychiatry 2015 Jan;206(1):7-16. [doi: 10.1192/bjp.bp.114.146761] [Medline: 25561486] 18. Heeren A, Mogoa e C, Philippot P, McNally RJ. Attention bias modification for social anxiety: a systematic review and meta-analysis. Clin Psychol Rev 2015 Aug;40:76-90. [doi: 10.1016/j.cpr.2015.06.001] [Medline: 26080314] 19. Mogoaşe C, David D, Koster EH. Clinical efficacy of attentional bias modification procedures: an updated meta-analysis. J Clin Psychol 2014 Dec;70(12):1133-1157. [doi: 10.1002/jclp.22081] [Medline: 24652823] 20. Linetzky M, Pergamin-Hight L, Pine DS, Bar-Haim Y. Quantitative evaluation of the clinical efficacy of attention bias modification treatment for anxiety disorders. Depress Anxiety 2015 Jun;32(6):383-391. [doi: 10.1002/da.22344] [Medline: 25708991] 21. Price RB, Wallace M, Kuckertz JM, Amir N, Graur S, Cummings L, et al. Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias. Clin Psychol Rev 2016 Dec;50:37-49 [FREE Full text] [doi: 10.1016/j.cpr.2016.09.009] [Medline: 27693664] http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al 22. MacLeod C, Clarke PJ. The attentional bias modification approach to anxiety intervention. Clin Psychol Sci 2015 Jan 06;3(1):58-78. [doi: 10.1177/2167702614560749] 23. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 24. Clarke PJ, Notebaert L, MacLeod C. Absence of evidence or evidence of absence: reflecting on therapeutic implementations of attentional bias modification. BMC Psychiatry 2014 Jan 15;14:8 [FREE Full text] [doi: 10.1186/1471-244X-14-8] [Medline: 24423043] 25. MacLeod C, Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research. Behav Res Ther 2016 Dec;86:68-86. [doi: 10.1016/j.brat.2016.07.005] [Medline: 27461003] 26. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 27. Beard C. Cognitive bias modification for anxiety: current evidence and future directions. Expert Rev Neurother 2011 Feb;11(2):299-311 [FREE Full text] [doi: 10.1586/ern.10.194] [Medline: 21306216] 28. Notebaert L, Clarke PJ, Grafton B, MacLeod C. Validation of a novel attentional bias modification task: the future may be in the cards. Behav Res Ther 2015 Feb;65:93-100. [doi: 10.1016/j.brat.2014.12.007] [Medline: 25594940] 29. Kuckertz JM, Amir N. Attention bias modification for anxiety and phobias: current status and future directions. Curr Psychiatry Rep 2015 Feb;17(2):9. [doi: 10.1007/s11920-014-0545-x] [Medline: 25620791] 30. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games 2013 Dec 12;1(1):e3 [FREE Full text] [doi: 10.2196/games.3139] [Medline: 25658754] 31. Boendermaker WJ, Prins PJ, Wiers RW. Cognitive bias modification for adolescents with substance use problems--can serious games help? J Behav Ther Exp Psychiatry 2015 Dec;49(Pt A):13-20 [FREE Full text] [doi: 10.1016/j.jbtep.2015.03.008] [Medline: 25843611] 32. Bernstein A, Zvielli A. Attention Feedback Awareness and Control Training (A-FACT): experimental test of a novel intervention paradigm targeting attentional bias. Behav Res Ther 2014 Apr;55:18-26. [doi: 10.1016/j.brat.2014.01.003] [Medline: 24562088] 33. Urech A, Krieger T, Chesham A, Mast FW, Berger T. Virtual reality-based attention bias modification training for social anxiety: a feasibility and proof of concept study. Front Psychiatry 2015;6:154 [FREE Full text] [doi: 10.3389/fpsyt.2015.00154] [Medline: 26578986] 34. Amir N, Kuckertz JM, Strege MV. A pilot study of an adaptive, idiographic, and multi-component attention bias modification program for social anxiety disorder. Cognit Ther Res 2016 Oct;40(5):661-671 [FREE Full text] [doi: 10.1007/s10608-016-9781-1] [Medline: 27795598] 35. Dennis-Tiwary TA, Egan LJ, Babkirk S, Denefrio S. For whom the bell tolls: neurocognitive individual differences in the acute stress-reduction effects of an attention bias modification game for anxiety. Behav Res Ther 2016 Feb;77:105-117 [FREE Full text] [doi: 10.1016/j.brat.2015.12.008] [Medline: 26745621] 36. Boendermaker J, Sanchez MS, Boffo M, Wiers RW. Attentional bias modification with serious game elements: evaluating the shots game. JMIR Serious Games 2016 Dec 06;4(2):e20 [FREE Full text] [doi: 10.2196/games.6464] [Medline: 27923780] 37. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munaf&ograve; MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11 [FREE Full text] [doi: 10.2196/games.5888] [Medline: 27421244] 38. Whyte EM, Smyth JM, Scherf KS. Designing serious game interventions for individuals with autism. J Autism Dev Disord 2015 Dec;45(12):3820-3831. [doi: 10.1007/s10803-014-2333-1] [Medline: 25488121] 39. Dennis TA, O'Toole L. Mental Health on the Go: effects of a gamified attention bias modification mobile application in trait anxious adults. Clin Psychol Sci 2014 Sep 01;2(5):576-590 [FREE Full text] [doi: 10.1177/2167702614522228] [Medline: 26029490] 40. De Voogd EL, Wiers RW, Prins PJ, Salemink E. Visual search attentional bias modification reduced social phobia in adolescents. J Behav Ther Exp Psychiatry 2014 Jun;45(2):252-259. [doi: 10.1016/j.jbtep.2013.11.006] [Medline: 24361543] 41. Dandeneau SD, Baldwin MW, Baccus JR, Sakellaropoulo M, Pruessner JC. Cutting stress off at the pass: reducing vigilance and responsiveness to social threat by manipulating attention. J Pers Soc Psychol 2007 Oct;93(4):651-666. [doi: 10.1037/0022-3514.93.4.651] [Medline: 17892337] 42. Waters AM, Pittaway M, Mogg K, Bradley BP, Pine DS. Attention training towards positive stimuli in clinically anxious children. Dev Cogn Neurosci 2013 Apr;4:77-84 [FREE Full text] [doi: 10.1016/j.dcn.2012.09.004] [Medline: 23063461] 43. Waters A, Zimmer-Gembeck MJ, Craske MG, Pine DS, Bradley BP, Mogg K. Look for good and never give up: a novel attention training treatment for childhood anxiety disorders. Behav Res Ther 2015 Oct;73:111-123. [doi: 10.1016/j.brat.2015.08.005] [Medline: 26310362] http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al 44. Johnson DR. Goal-directed attentional deployment to emotional faces and individual differences in emotional regulation. J Res Pers 2009 Feb;43(1):8-13. [doi: 10.1016/j.jrp.2008.09.006] 45. Lundqvist D, Flykt A, Ohman A. Emotionlab. 1998. The Karolinska Directed Emotional Faces&ndash;KDEF, CD ROM from Department of Clinical Neuroscience, Psychology section URL: http://www.emotionlab.se/kdef/ [accessed 2018-10-15] [WebCite Cache ID 73BDN1IqC] 46. Notebaert L. Youtube. 2018. Emotion-in-Motion viewing example URL: https://www.youtube.com/watch?v=PMUnimtCag0 [accessed 2018-05-08] [WebCite Cache ID 6zFh6RRSI] 47. Enock P, Hofmann SG, McNally RJ. Attention bias modification training via smartphone to reduce social anxiety: a randomized, controlled multi-session experiment. Cogn Ther Res 2014 Mar 4;38(2):200-216. [doi: 10.1007/s10608-014-9606-z] 48. Boettcher J, Hasselrot J, Sund E, Andersson G, Carlbring P. Combining attention training with internet-based cognitive-behavioural self-help for social anxiety: a randomised controlled trial. Cogn Behav Ther 2014;43(1):34-48 [FREE Full text] [doi: 10.1080/16506073.2013.809141] [Medline: 23898817] 49. Schoorl M, Putman P, Van Der Werff S, Van Der Does AJ. Attentional bias and attentional control in posttraumatic stress disorder. J Anxiety Disord 2014 Mar;28(2):203-210. [doi: 10.1016/j.janxdis.2013.10.001] [Medline: 24291395] 50. Clarke P, Branson S, Chen NT, Van Bockstaele B, Salemink E, MacLeod C, et al. Attention bias modification training under working memory load increases the magnitude of change in attentional bias. J Behav Ther Exp Psychiatry 2017 Dec;57:25-31. [doi: 10.1016/j.jbtep.2017.02.003] [Medline: 28257926] 51. Clarke P, Browning M, Hammond G, Notebaert L, MacLeod C. The causal role of the dorsolateral prefrontal cortex in the modification of attentional bias: evidence from transcranial direct current stimulation. Biol Psychiatry 2014 Dec 15;76(12):946-952. [doi: 10.1016/j.biopsych.2014.03.003] [Medline: 24690113] 52. Notebaert L, Crombez G, Van Damme S, De Houwer J, Theeuwes J. Signals of threat do not capture, but prioritize, attention: a conditioning approach. Emotion 2011 Feb;11(1):81-89. [doi: 10.1037/a0021286] [Medline: 21401228] 53. Eastwood JD, Smilek D, Merikle PM. Differential attentional guidance by unattended faces expressing positive and negative emotion. Percept Psychophys 2001 Aug;63(6):1004-1013. [doi: 10.3758/BF03194519] [Medline: 11578045] 54. Lazarov A, Pine DS, Bar-Haim Y. Gaze-contingent music reward therapy for social anxiety disorder: a randomized controlled trial. Am J Psychiatry 2017 Dec 01;174(7):649-656. [doi: 10.1176/appi.ajp.2016.16080894] [Medline: 28103714] 55. Liu J, Dosher B, Lu ZL. Modeling trial by trial and block feedback in perceptual learning. Vision Res 2014 Jun;99:46-56 [FREE Full text] [doi: 10.1016/j.visres.2014.01.001] [Medline: 24423783] 56. Brand S, Reimer T, Opwis K. How do we learn in a negative mood? Effects of a negative mood on transfer and learning. Learning and Instruction 2007 Feb;17(1):1-16. [doi: 10.1016/j.learninstruc.2006.11.002] 57. Schweinberger S, Burton AM, Kelly SW. Asymmetric dependencies in perceiving identity and emotion: experiments with morphed faces. Percept Psychophys 1999 Aug;61(6):1102-1115. [doi: 10.3758/BF03207617] [Medline: 10497431] 58. Matthews G, Campbell SE, Falconer S, Joyner LA, Huggins J, Gilliland K, et al. Fundamental dimensions of subjective state in performance settings: task engagement, distress, and worry. Emotion 2002 Dec;2(4):315-340. [doi: 10.1037/1528-3542.2.4.315] [Medline: 12899368] 59. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 60. Notebaert L, Macleod C, Grafton B. Emotion-in-Motion task material. The University of Western Australia 2018 [FREE Full text] [doi: 10.26182/5bbd5735031f6] Abbreviations ABI: attentional bias index ABM: attentional bias modification ANOVA: analysis of variance Edited by TR Soron; submitted 08.05.18; peer-reviewed by W Boendermaker, M Zhang; comments to author 14.08.18; revised version received 26.08.18; accepted 27.08.18; published 28.11.18 Please cite as: Notebaert L, Grafton B, Clarke PJF, Rudaizky D, Chen NTM, MacLeod C JMIR Serious Games 2018;6(4):e10993 URL: http://games.jmir.org/2018/4/e10993/ doi: 10.2196/10993 PMID: 30487121 http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al ©Lies Notebaert, Ben Grafton, Patrick JF Clarke, Daniel Rudaizky, Nigel TM Chen, Colin MacLeod. Originally published in JMIR Serious Games (http://games.jmir.org), 28.11.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 12 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study

Loading next page...
 
/lp/jmir-publications/emotion-in-motion-a-novel-approach-for-the-modification-of-attentional-0O0buKnsEF

References (63)

Publisher
JMIR Publications
Copyright
Copyright © The Author(s). Licensed under Creative Commons Attribution cc-by 4.0
ISSN
2291-9279
DOI
10.2196/10993
Publisher site
See Article on Publisher Site

Abstract

Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved. Objective: This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability. Methods: We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor. Results: Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60). Conclusions: Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback. (JMIR Serious Games 2018;6(4):e10993) doi: 10.2196/10993 KEYWORDS attentional bias; anxiety disorders; experimental games http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al focus on developing more effective procedures than the Introduction dot-probe task to modify attentional bias [27-29]. Moreover, researchers have raised concerns about the suitability of the Attentional Bias Modification in Anxiety conventional probe-based training task for use with clinical We operate in a complex and dynamic world in which we are cohorts because of its monotonous nature and low face validity continuously confronted with an ever-changing stream of [27]. perceptual information. The limited capacity of our cognitive Gamification of Attentional Bias Modification system means we can only attend to certain information, while other information is filtered out. Such filtering does not operate Paradigms in the same manner across all individuals; however, it has In recent years, some investigators sought to adapt existing become clear that there is a relationship between such attentional ABM procedures to make them more engaging by gamifying selectivity and individual differences in emotional vulnerability them. Gamification refers to the use of game design elements [1]. Specifically, research has shown that elevated anxiety in nongame contexts [30]. Several levels can be discerned in vulnerability, whether indicated by elevated levels of trait the gamification of ABM tasks, from simply adding game anxiety or the presence of anxiety pathology, is associated with elements to existing training tasks, to adding extrinsic rewards, an attentional bias that favors the processing of negative adding intrinsic motivators, adding a game shell, to using an information [2]. Moreover, studies that have manipulated existing off-the-shelf game [31]. It is thought that maintaining patterns of attentional bias (using attentional bias modification a close connection with validated ABM tasks and adding [ABM] procedures) have shown that attentional bias causally intrinsic motivation and a game shell may be optimal for ABM contributes to anxiety vulnerability, as a change in attentional gamification [31]. bias produces a consequent change in anxiety vulnerability Existing gamified training protocols have been variants of the [3,4-6]. original probe approach; however, all these protocols share in The observation that ABM tasks delivered in the laboratory can common the limitation that they seek to train attentional exert a beneficial impact on anxiety responses to stressor has selectivity using very simple static displays that typically present led a number of researchers to investigate whether extended only 1 or 2 stationary emotional stimuli [28,32-36]. This exposure to such ABM training can reduce anxiety dysfunction contrasts markedly with real-world settings, which generally in real-world settings. The most frequently used ABM procedure require individuals to engage in patterns of attentional scanning is based on the dot-probe task [7]. In this task, participants are and tracking within a complex and dynamic environment [37]. briefly exposed to stimulus pairs, comprising 1 negative and 1 In addition, these studies have been hampered by design non-negative stimulus, before a small visual probe is presented, limitations. In some cases, these studies have lacked a control which participants are required to identify. A contingency condition [33,34]. Moreover, most of these novel procedures between the position of the probes and the position of the have been delivered in studies that afford no opportunity to negative stimuli is introduced, whereby probes are either always compare their efficacy with that of the conventional probe-based presented in the location where the non-negative stimulus was ABM approach. Without such a comparison, it remains unknown just displayed (encouraging the adoption of an attentional bias whether a novel ABM task can achieve attentional bias change away from negative information) or else probes are always under conditions where the conventional probe-based ABM presented in the location where the negative stimulus was just task fails to do so or whether a novel task can produce change displayed (encouraging the adoption of an attentional bias in anxiety vulnerability when such change is not elicited by a toward negative information). There is now a substantial body conventional probe-based ABM approach. of evidence showing that such ABM tasks, configured to reduce These studies did, however, incorporate different gamification attentional bias to negative information, can attenuate the and other (nongame) elements to enhance engagement with the symptoms of social anxiety disorder [8,9], generalized anxiety tasks to improve their effectiveness in modifying attentional disorder [10,11], and subclinical obsessive-compulsive bias [36,38]. Some studies have included motivating feedback symptoms [12]. or goal metrics, in the form of real-time visual performance Although such encouraging findings highlight the potential feedback or points [32,35] or block-by-block feedback on clinical benefits of ABM procedures, it is important to recognize performance [28]. Others have implemented more elaborate that in a number of ABM studies, the intended attentional displays or a game-shell to increase intrinsic motivation training procedure has failed to affect emotional vulnerability [33,35,39-43]. Another element thought to increase intrinsic [13-16]. Overall, meta-analyses show that the clinical motivation is goals-directed learning, which directs players to effectiveness of the implementation of ABM procedures is small particular goals to increase targeted skills (eg, through but nonetheless significant [17-21]. However, careful instructing participants to attend to positive information) [44]. consideration of this literature suggests a clear pattern. In the However, despite inclusion of these gamification elements, the studies where the intended ABM procedure successfully changed majority of these studies continue to rely on either relatively attentional bias, this produced a medium-sized and significant sparse or mostly static stimulus displays. effect on emotional vulnerability. In contrast, in studies where This Study the intended ABM procedure did not change attentional bias, no significant impact on emotional vulnerability was observed The objective of this study was to develop and evaluate a novel [22-26]. These results indicate that future research efforts should candidate ABM procedure designed to modify attentional http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al selectivity within a task setting that, like most real-world training condition, (2) if both tasks prove capable of so contexts, requires participants to selectively distribute attention modifying attentional bias, whether the Emotion-in-Motion while processing a complex and dynamic emotional ABM task impacts attentional bias to an equal or greater degree environment. The task required participants to search for and than does the conventional probe-based ABM task, (3) whether track 1 particular target stimulus presented on screen among both the conventional probe-based ABM task and this new, multiple moving distractors, based on its emotional valence. complex, dynamic Emotion-in-Motion ABM task serve to This screen display thus realizes the elaborate display induce a group difference in anxiety vulnerability as a function gamification element, as it presents a large number of stimuli of allocated training condition, and (4) if both tasks prove that dynamically move across the whole screen. The task also capable of so influencing anxiety vulnerability, whether the incorporated the gamification elements of motivating feedback Emotion-in-Motion ABM task impacts anxiety vulnerability to through a game-by-game high score that participants were an equal or greater degree than does the conventional encouraged to try to beat as well as the element of goals-directed probe-based ABM task. learning, as participants were explicitly instructed to track 1 particular emotional expression. The task was built upon the Methods same principles as the original probe-based ABM task, in which Participants the training condition was designed to increase attentional bias toward positive information, and the task performance would A total of 129 undergraduate students at the University of be improved to the extent that participants adopted a more Western Australia completed the study. In line with previous positive attentional bias [6]. Similarly, in the corresponding research, participants who did not show an elevation in state training condition of the gamified task, performance will anxiety in response to the intended stressor were excluded before improve to the extent participants allocate attention to positive analyses [28]. This led to the exclusion of 19 participants, with stimuli. 110 participants remaining. Participant characteristics are shown in Table 1. Our primary aim was to evaluate the capacity of this new candidate ABM procedure, which we have labeled the Conventional Probe-Based Attentional Tasks Emotion-in-Motion task, to induce a group difference in Overall, 55 participants completed the conventional probe-based selective attentional responding to negatively and positively bias training and assessment tasks. These participants were valenced information and to causally impact anxiety randomly assigned to either an attend-positive or attend-negative vulnerability, as evidenced by the strength of state anxiety training condition. Participants assigned to these 2 conditions responses to a controlled laboratory stressor. We also delivered of the probe-based tasks did not differ significantly in age, trait the conventional probe-based ABM procedure to a separate anxiety scores, or gender (all P>.05). cohort of similar participants under equivalent laboratory conditions. This conventional probe-based ABM task does not Emotion-in-Motion Attentional Tasks include any of the gamification elements introduced in the Overall, 55 participants completed our novel Emotion-in-Motion Emotion-in-Motion task. Specifically, there is no elaborate bias training and assessment tasks. Participants were randomly display (only 2 static images are presented), no motivating assigned to either an attend-positive or attend-negative training feedback after each block (only trial-by-trial feedback), and no condition. Participants in these 2 conditions of the goals-directed learning (participants are simply instructed to Emotion-in-Motion tasks did not differ significantly in age or discriminate the identity of a probe). We chose to compare our trait anxiety scores (both P>.05). These 2 groups did differ novel Emotion-in-Motion task with the probe-based ABM task, significantly in gender ratio, P=.03, with a higher proportion as this is the procedure most commonly used in studies aiming of males in the attend-negative condition than in the to modify patterns of attentional bias [17,18,21]. attend-positive condition. Consequently, we considered gender ratio as a covariate in our analyses of the data, which provided This study design will enable us to determine (1) whether both reassurance that observed effects of this experimental the conventional probe-based ABM task and this new, complex, manipulation remained evident when this group difference in dynamic Emotion-in-Motion ABM task produce a group gender ratio was accounted for. difference in attentional bias in line with the allocated attentional Table 1. Age, gender, and trait anxiety scores (using the Spielberger Trait Anxiety Inventory) for participants completing the conventional probe-based and the Emotion-in-Motion attentional tasks in each of the 2 training conditions. Condition Age, mean (SD) Gender, female/male Trait anxiety, mean (SD) Conventional probe tasks Attend-negative condition (N=27) 19.33 (2.86) 14/13 38.44 (8.14) Attend-positive condition (N=28) 19.50 (2.60) 19/9 41.18 (11.08) Emotion-in-Motion tasks Attend-negative condition (N=28) 19.78 (3.62) 17/10 47.18 (8.18) Attend-positive condition (N=27) 18.50 (0.95) 23/3 43.22 (9.24) http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al At the start of a block, each face remained constant for the first Materials 2000 milliseconds. Thereafter, individual faces within a Attentional Tasks Stimuli rectangle switched to a different identity (but same expression) The face stimuli for the attentional tasks were selected from the randomly at any point between 1 and 2000 milliseconds Karolinska Directed Emotional Faces stimulus set [45]. These throughout the block. Within each block, the target rectangle images were cropped to show only the face and the neck. The switched (thus, an expression switch occurred) 60 times, at face stimuli for the training tasks were photos of 32 individuals, random intervals of 5 to 10 seconds. All 8 rectangles moved half of them were female and half were male. For the assessment with different randomly determined trajectories, at a randomly tasks, photos of 8 different individuals were selected, half of determined speed of between 30 and 50 pixels per 100 them were male and half were female. There were 2 photographs milliseconds. Thus, although the rectangles moved at different of each individual, 1 in which they depicted a happy expression speeds, each rectangle’s speed was constant within a game. The and 1 in which they depicted an angry expression. Each rectangles bounced off the screen edges and other stimuli they photograph was 258 pixels (width) by 323 pixels (height). The contacted at an angle of reflection that matched their angle of stimuli were the same size in the Emotion-in-Motion and incidence. The target rectangle was never indicated; however, probe-based tasks. For the Emotion-in-Motion training task, when the mouse cursor was correctly located in the position of the 32 identities were grouped into 8 stimulus subsets, each the current target rectangle, this cursor disappeared behind the containing the photos of 8 identities, 4 female and 4 male. Each rectangle (to not obscure the face presented within) and stimulus subset was used in 1 of the 8 blocks delivered in this remained hidden as long as the participant kept it on target. Emotion-in-Motion task. The onset of each block was preceded by a 3-second countdown Emotion-in-Motion Attentional Bias Modification Task presented in the center of the screen. At the end of each block, participants were presented with a tracking score (ie, the The aim of this task was to induce, in a complex and dynamic percentage of time during that game they were tracking the task environment, selective attending to angry or happy faces, target rectangle), a switching score (ie, the average speed with depending on the assigned training condition. To provide readers which the participant was able to shift their cursor to the next with a first-hand impression of this Emotion-in-Motion task, target rectangle), and a total score for that block (generated by the task can be viewed on the Web [46]. combining the tracking score and the switching score). The The Emotion-in-Motion ABM task consisted of 8 3.5 min blocks screen also displayed the participant’s highest prior (total) score. or games. During each block, 8 placeholder rectangles moved Participants were instructed that they would play several games dynamically around the screen over a black background. Each of this task and were encouraged to beat their current high score rectangle contained an image of a face, each with a different in each successive game. identity. At all times, the target rectangle displayed a face with Emotion-in-Motion Attentional Bias Assessment Task an emotional expression that differed from the emotional expressions displayed by the faces in all 7 other rectangles on The training contingency was removed from the screen, and participants were required to attend to and track this Emotion-in-Motion training task to create the assessment task rectangle. In the attend-negative condition, the target rectangle used to reveal the impact of this training on attentional displayed a face with an angry expression, whereas the other selectivity. Thus, participants were required to track a rectangle rectangles displayed faces with happy expressions. In the displaying a face with a happy expression (among 7 rectangles attend-positive condition, the target rectangle displayed a face displaying faces with angry expressions) on half of the blocks with a happy expression, whereas the other 7 rectangles and to track a rectangle displaying a face with an angry displayed faces with angry expressions. Participants were expression (among 7 rectangles displaying faces with happy instructed to find the target rectangle and track it using the expressions) on the other half of the blocks. This assessment mouse cursor. All the rectangles, including the target, constantly task delivered 12 short blocks, each of which contained 5 target switched faces. Participants were instructed to keep tracking switches, resulting in a total of 60 target switches across the the target rectangle (ie, depicting the single face with the assessment task. In 6 of these blocks, the target rectangle expression differing from that of the other 7 faces) even when displayed a face with an angry emotional expression, and in 6 the face presented within changed, as long as the emotional blocks, the target rectangle displayed a face with a happy expression of the face presented remained the same (ie, when emotional expression. The order of these block conditions was the face in the target rectangle switched to a different identity, randomly determined, with the constraint that a maximum of 2 participants were required to keep tracking the rectangle as long consecutive blocks could have a target with the same valence. as the emotional expression of the new face was the same as Each block started with a 5-second countdown. the emotional expression of the previous face). At random To obtain a measure of attentional bias to negative information, intervals, the emotional expression of a target face would change an attentional bias index (ABI) was computed by subtracting in addition to its identity, at which point this ceased to be the the average tracking score a participant obtained in blocks where target rectangle. At that same moment, 1 of the other rectangles targets were happy faces from the average tracking score the would assume a face depicting this emotion, and thus identifying participant obtained in blocks where targets were angry faces. it as the (new) target rectangle. At these points, participants had Therefore, a higher positive score on this index reflects greater to quickly find the new target rectangle and start tracking it. attention to negative information, as it represents more successful tracking of angry than of happy faces. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al Results showed neither a significant main effect of attentional Other Experimental Tasks assessment point, F <1, nor of training condition, F =2.246, 1,48 1,48 The Trait Anxiety Assessment, conventional probe-based ABM, P=.14. Most importantly, the critical interaction between and assessment tasks as well as the anxiety reactivity assessment attentional assessment point and training condition fell short of task are described in Multimedia Appendix 1. significance, F =3.018, P=.09, η =.059. 1,48 p Procedure Attentional Impact of Emotion-in-Motion Training Participants were tested individually in a sound-attenuated room. Once informed consent from participants had been obtained, Application of the outlier criteria led to the exclusion of 3 participants were instructed to sit at a comfortable viewing participants (1 in the attend-positive training condition). To distance from the computer screen (approximately 60 cm), were determine whether our novel Emotion-in-Motion attentional given instructions, and completed the first assessment task. training procedure was effective in modifying attentional After completion of the training task, they completed the original responding to negative information, the ABI scores obtained assessment task again. Next, participants completed the anxiety by participants who completed this task were subjected to a reactivity assessment task containing an anagram stressor task mixed-design 2x2 ANOVA that again considered the preceded and followed by a measure of state anxiety. At the within-group factor attentional assessment point (pretraining end of the session, participants were debriefed about the purpose assessment vs posttraining assessment) and the between-group of the study. The entire experimental session lasted about 1 factor training condition (attend-positive training vs hour. This study was approved by the University of Western attend-negative training). This analysis revealed a significant Australia’s Human Research Ethics Committee, protocol 2 main effect of training condition, F =4.602, P=.04, η =.084, 1,50 p RA415243. subsumed within a higher-order interaction of attentional assessment point x training condition, F =5.629, P=.02, 1,50 Results η =.101. At pretraining, there was no significant difference Impact of Attentional Training Procedure on between the ABI scores obtained by participants in the attend-positive training condition and participants in the Attentional Bias attend-negative training condition, F <1. In contrast, at 1,50 The criteria to identify outliers are described in Multimedia posttraining, participants in the attend-negative training Appendix 1. The ABI scores obtained before and after the condition showed significantly higher ABI scores as compared training task are shown in Table 2. with participants in the attend-positive condition, F =9.903, 1,50 Attentional Impact of Conventional Probe-Based P=.003, Cohen d=0.87. Although the change in attentional bias Training from pre- to posttraining fell short of significant for participants Application of the outlier criteria led to the exclusion of 4 in the attend-negative training condition, t =−1.162, P=.26, participants (2 in the attend-positive training condition). To Cohen d=0.229, there was a significant change from pre- to examine whether the conventional probe-based training task posttraining for participants in the attend-positive training was capable of modifying attentional bias, a mixed-methods condition, t =2.114, P=.045, Cohen d=0.415. Overall, this analysis of variance (ANOVA) was performed with the pattern of results confirms that the 2 training conditions exerted within-subjects factor attentional assessment point (pretraining a differential impact on attentional bias to negative information, assessment, posttraining assessment) and the between-subjects and the direction of the observed attentional training effects was factor training condition (attend-positive training, as expected. When controlling for the gender, by adding this as attend-negative training). The ABI scores obtained by a covariate, this interaction between attentional assessment point participants who completed this conventional probe-based and training condition remained significant, F =4.393, P=.04, 1,43 training task served as the dependent variable. η =.087. Table 2. Attentional bias index scores pre- and posttraining for participants who completed the conventional probe-based attentional bias training and assessment tasks or the Emotion-in-Motion attentional bias training and assessment tasks in either the attend-positive training condition or the attend-negative training condition. Assessment point Attend-positive condition, mean (SD) Attend-negative condition, mean (SD) Conventional probe training −5.669 (50.752) −3.116 (29.591) ABI pretraining ABI posttraining −15.101 (45.33) 11.002 (36.9) Emotion-in-Motion training ABI pretraining 0.449 (6.041) 1.011 (5.968) ABI posttraining −2.739 (6.545) 2.445 (5.261) ABI: attentional bias index. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al Table 3. State anxiety scores pre- and postanagram stressor for participants who previously completed the conventional probe-based attentional bias training task or the Emotion-in-Motion attentional bias training task in either the attend-positive training condition or the attend-negative training condition. Assessment point Attend-positive condition, mean (SD) Attend-negative condition, mean (SD) Conventional probe training State anxiety pretraining 30.680 (10.858) 26.200 (12.176) State anxiety posttraining 43.600 (9.734) 40.440 (11.623) Emotion-in-Motion training State anxiety pretraining 31.292 (10.149) 29.541 (11.699) State anxiety posttraining 39.458 (11.026) 41.458 (10.879) point and training condition remained significant, F =4.638, 1,43 Impact of Attentional Training Procedure on Anxiety P=.04, η =.097. Vulnerability The state anxiety scores obtained using the analog mood scale Follow-up t tests revealed that immediately following the given before and after the final anagram stressor are shown in attentional training procedure but before the anagram stressor Table 3. experience, participants who had received the 2 training conditions did not differ in their levels of state anxiety, F =.31, 1,46 Emotional Impact of Conventional Probe-Based P=.58, η =.01. Participants in each Emotion-in-Motion Training attentional training condition responded to this stress Application of the outlier criteria on participants included in manipulation by displaying an elevation in anxious mood state the attentional bias assessment analyses led to the additional (attend-positive training: F =55.84, P<.001, η =.71 vs 1,23 p exclusion of 1 participant (in the attend-positive condition). To examine whether the 2 training conditions had a differential attend-negative training: F =70.56, P<.001, η =.76). 1,23 p impact on anxiety reactivity, state anxiety scores were subjected However, the magnitude of the elevation in state anxiety evoked to a mixed-methods ANOVA with the within-subjects factor by this stressor was significantly attenuated in those participants state anxiety assessment point (prestressor assessment vs who had received the Emotion-in-Motion attend-positive poststressor assessment) and the between-subjects factor training attentional training compared with those participants who had condition (attend-positive training vs attend-negative training). received the Emotion-in Motion attend-negative attentional Results showed a significant main effect of state anxiety training condition (mean 8.17, SD 5.35 vs mean 11.92, SD 6.94; assessment point, F =159.991, P<.001, indicating that state 1,48 Cohen d=0.60). Thus, those participants who had been exposed anxiety increased from before the anagram stressor (mean to the Emotion-in-Motion task training contingency designed 28.440, SD 11.639) to after the anagram stressor (mean 42.020, to reduce attentional bias to negative information subsequently SD 10.729). However, neither the main effect of training came to display relatively attenuated elevations of anxious mood condition, F =1.664, P=.20, nor the critical interaction state in response to the anagram stressor experience compared 1,48 with participants who had been exposed to the training condition between state anxiety assessment point and training condition, designed to increase attentional bias to negative information. F =.378, P=.54, η =.008, were significant. 1,48 p In addition, the elevation in anxiety in the positive training Emotional Impact of Emotion-in-Motion Training condition of the Emotion-in-Motion task (mean 8.17, SD 5.35) was significantly smaller than the elevation in state anxiety in Application of the outlier criteria on participants included in the positive training condition of the conventional probe-based the attentional bias assessment analyses led to the additional training task (mean 12.92, SD 8.83), t =2.35, P=.02, Cohen exclusion of 4 participants (2 in the attend-positive training d=0.67. condition). The same 2x2 ANOVA as reported above was conducted on state anxiety scores to examine whether in Discussion participants who completed the Emotion-in-Motion training procedure, the 2 training conditions had a differential impact Principal Findings on anxiety reactivity. This analysis revealed a significant main effect of state anxiety assessment point, F =125.99, P<.001, The objective of this study was to develop and evaluate a novel 1,46 ABM procedure intended to systematically alter selective η =.73, again reflecting the fact that state anxiety increased attentional responding to emotional information in a complex from before the stressor (mean 30.58, SD 10.87) to after the and dynamic task environment. Our results showed that our stressor (mean 40.54, SD 10.88). This main effect was now novel Emotion-in-Motion training procedure succeeded in subsumed within a significant two-way interaction of state modifying patterns of attentional bias, as intended. Moreover, anxiety assessment point and training condition, F =4.39, 1,46 the participants who were allocated to the attend-positive P=.04, η =.09. When controlling gender, by adding gender as condition of the Emotion-in-Motion attentional training task a covariate, this interaction between state anxiety assessment showed reduced anxiety reactivity to the subsequent lab-based stressor as compared with participants who were allocated to http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al the attend-negative condition of this task. These results suggest next trial for 3 seconds, which may have elicited increased that our novel attentional training task appeared capable of negative mood. Block feedback of the type delivered in the modifying both patterns of attentional bias and causally Emotion-in-Motion task has been shown to enhance learning influencing anxiety vulnerability. in simple repetitive tasks [55], whereas negative mood has been shown to impair learning [56]. As such, this difference in A subsidiary aim was to permit comparison with the feedback may have also contributed to enhanced performance conventional probe-based attentional bias training procedure. in the Emotion-in-Motion task. Future research could further Under equivalent laboratory conditions, the conventional examine the contribution of enriched performance feedback to probe-based attentional training approach failed to induce the efficacy of ABM procedures by comparing conventional differential patterns of attentional bias, and the 2 probe-based probe-based training with and without such block feedback or training conditions did not lead to participant differences in by manipulating whether or not the presently provided block anxiety reactivity to the subsequent stressor. In recent years, feedback is delivered within the Emotion-in-Motion task. several studies (including 3 out of our lab) have reported similar failures of the conventional probe-based attentional training Moreover, in the conventional probe-based training task, images task to successfully modify patterns of attentional bias depicting different emotional expression of the same identity [28,47-51]; therefore, it is reasonable to conclude that the were paired, whereas in the Emotion-in-Motion task, each image probe-based ABM procedure may be a nonoptimal way of depicted a different identity. As such, participants performing achieving bias change. the probe-based training only needed to discriminate emotional expression on the same person, whereas participants performing Candidate Explanations for the Effectiveness of the the Emotion-in-Motion tasks needed to discriminate emotional Emotion-in-Motion Task expressions between different identities. There is some evidence In reflecting on the reasons for the capacity of our novel to suggest that emotion classifications are affected by variations Emotion-in-Motion paradigm to induce differential patterns of in identity [57]. It is, therefore, possible that this increased attentional bias, under conditions where the conventional demand on emotion classification contributed to the probe-based training did not, several candidate factors can be Emotion-in-Motion task being more challenging. The more considered. First, the Emotion-in-Motion task presents 8 stimuli challenging emotion classification, enhanced performance simultaneously, whereas the conventional probe task displays feedback, as well as the complex and dynamic nature of the task only 2 stimuli. There is some evidence that attentional bias is could have resulted in greater engagement with the more pronounced when assessed using visual displays that Emotion-in-Motion task, relative to the conventional probe task. contain more stimuli [52,53], but as yet, it is unknown whether Task engagement can be conceptualized as a combination of more robust ABM effects can be obtained using paradigms that energy, motivation, and concentration and can be measured present more stimuli. Although some training procedures that using self-report as well as through task performance indicators involve more complex stimulus displays already exist [41,54], [58]. In the Emotion-in-Motion task, we did not obtain so far no direct comparison between the effectiveness of training self-report measures of task engagement, and the difference in tasks using simple versus complex stimulus displays has been the nature of the tasks leaves us unable to compare performance made. In future research, the Emotion-in-Motion paradigm can indicators of engagement. However, future research may be easily be adapted to present simple displays (eg, 2 rectangles) usefully examine whether individuals show a difference in versus complex displays (eg, 8 rectangles), to enable such engagement with the Emotion-in-Motion task relative to the comparison. probe task and whether task engagement moderates the procedures’ impact on attentional bias and anxiety vulnerability A second candidate factor that could have contributed to the [36]. findings observed with the Emotion-in-Motion approach is the dynamic nature of the stimulus presentation. In the An additional difference between the 2 training procedures Emotion-in-Motion task, all stimuli move dynamically around concerns participants’ responses. The tracking response required the display, whereas in other attentional training paradigms, in the Emotion-in-Motion task is continuous, whereas the probe stimuli are presented in a static manner. It is possible that the task only requires a response every couple of seconds. It is likely dynamic nature of Emotion-in-Motion enhanced concentration that as a result, participants in the Emotion-in-Motion task spend and engagement with the task, thereby increasing its capacity more time attentionally engaged with the target valence (positive to deliver the intended attentional bias change. In future or negative, depending on training condition) as compared with research, the potential contribution of this dynamic component participants in the conventional probe task. However, it is also could be examined by contrasting task variants that employ the possible that this continuous response would be harder to sustain present dynamic approach with variants that instead present the over time as it is more motorically demanding. As such, future same number of stimuli in static grid. research may usefully examine the acceptability of this response format in multi-session training designs. It is also relevant to A third candidate reason for its efficacy may be the provision note that in the Emotion-in-Motion task, the mouse cursor only of enriched performance feedback in the Emotion-in-Motion disappears behind the target rectangle. As such, it is possible task compared with the rudimentary trial-by-trial error feedback that participants could ignore the content of the rectangle and given in the conventional probe-based attentional training task. simply see on which rectangle the mouse cursor would Moreover, block feedback in the Emotion-in-Motion task was disappear. Although given the speed and complexity of the task encouraging, whereas trial-by-trial feedback in the probe-based this strategy is unlikely to have occurred, importantly, this task penalized participants for making errors by delaying the http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al strategy would have reduced the efficacy of the attentional complex and dynamic nature of the Emotion-in-Motion task training. Future research could, therefore, evaluate whether can be expected to enhance face validity of and engagement in modification to the task (eg, making the cursor disappear behind the task, future research using clinical cohorts will be necessary every image) would further increase the effectiveness of the to determine whether this novel ABM task is more acceptable task. It will be important to establish, however, whether such to patients than the conventional probe-based training task. modifications that render participants’ awareness of the position It is also important to consider some potential limitations of of the cursor more uncertain cause unwanted frustration or using gamification for bias modification. Some of the potential disorientation in participants. drawbacks are discussed by Boendermaker et al [31]. These authors note that some gamification elements designed to Strengths and Limitations increase motivation (such as visible scores) may be distracting It is important to consider the potential limitations of this study. and impair training. Second, implementing intrinsic motivators One such limitation is that the capacity of the may be costly and difficult, and the intrinsically motivating Emotion-in-Motion training task and the capacity of the value of such elements may vary across individuals. In addition, conventional probe-based training task to modify attentional even if a game is intrinsically motivating, it may need to be bias were each established using a different method of assessing combined with a motivation to change in participants before attentional bias. For both training tasks, the assessment approach adherence to multi-session training is improved. Most involved delivering the same task but with the training importantly, however, given the strong link between change in contingency removed. This design critically allows for attentional bias and change in emotional vulnerability, it is comparable demonstration of near transfer across the 2 training important that in any gamified ABM procedure, the core tasks. However, it does preclude direct comparison of attentional mechanism underlying ABM (encouraging a change in bias change observed in response to each of these 2 candidate attentional bias) remains intact [24,59]. attentional training approaches. It is possible, for example, that the assessment version of the Emotion-in-Motion task is more Conclusions sensitive to individual differences in attentional bias than the In the meantime, we hope that the Emotion-in-Motion task, probe-based attentional bias assessment task (of potential which this study has shown to be capable of modifying relevance to this, note that the SDs for Emotion-in-Motion ABI attentional bias to emotional information and altering anxiety scores are smaller than those for the probe-based ABI scores). vulnerability as indicated by anxiety reactivity to a stressor, will If this is the case, then the results of this study could be be of interest and potential value to researchers investigating explained by the Emotion-in-Motion training task producing a the potential anxiolytic benefits of directly manipulating greater modification of attentional bias, the Emotion-in-Motion maladaptive patterns of attentional bias. To facilitate further assessment task more sensitively assessing group differences research using this task and to encourage independent replication in attentional bias, or both. Future research could circumvent of the findings of this study, we made our Emotion-in-Motion this limitation by employing the same attentional bias task software freely available [60]. While we look forward to assessment approaches for all ABM tasks under evaluation. the future evaluation of this novel ABM approach in other A second potential limitation is that this study was carried out cohorts and settings, we also encourage fellow researchers to on an undergraduate nonclinical participant sample. Although develop and refine new and innovative ABM paradigms that this design allowed us to examine whether the further enhance our capacity to modify the attentional bias to Emotion-in-Motion procedure can induce differential patterns negative information implicated in anxiety vulnerability and of attentional bias and consequently test the causal impact of dysfunction. Such continuous improvement in our ABM these differential patterns of attentional bias on anxiety approaches will optimize the prospect of developing future vulnerability, it does limit conclusion concerning either the ABM protocols that prove capable of delivering robust and acceptability or the efficacy of our novel Emotion-in-Motion reliable therapeutic benefits within the clinic. ABM approach when used with a clinical sample. Although the Acknowledgments LN is supported by the Australian Research Council under Grant DP140104448. CM is supported in part by a grant from the Romanian National Authority for Scientific Research, CNCS-UEFISCDI, project number PNII-ID-PCCE-2011-2-0045. PJFC was supported by Australian Research Council Grant DP140103713. BG is supported in part by Australian Research Council Grant DP170104533. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Conflicts of Interest None declared. Multimedia Appendix 1 Further detail on the methods and data handling. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al [PDF File (Adobe PDF File), 68KB-Multimedia Appendix 1] References 1. Van Bockstaele B, Verschuere B, Tibboel H, De Houwer J, Crombez G, Koster EH. A review of current evidence for the causal impact of attentional bias on fear and anxiety. Psychol Bull 2014 May;140(3):682-721. [doi: 10.1037/a0034834] [Medline: 24188418] 2. Bar-Haim Y, Lamy D, Pergamin L, Bakermans-Kranenburg MJ, van Ijzendoorn MH. Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychol Bull 2007 Jan;133(1):1-24. [doi: 10.1037/0033-2909.133.1.1] [Medline: 17201568] 3. Amir N, Weber G, Beard C, Bomyea J, Taylor CT. The effect of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals. J Abnorm Psychol 2008 Nov;117(4):860-868 [FREE Full text] [doi: 10.1037/a0013445] [Medline: 19025232] 4. Hazen RA, Vasey MW, Schmidt NB. Attentional retraining: a randomized clinical trial for pathological worry. J Psychiatr Res 2009 Mar;43(6):627-633. [doi: 10.1016/j.jpsychires.2008.07.004] [Medline: 18722627] 5. Heeren A, Reese HE, McNally RJ, Philippot P. Attention training toward and away from threat in social phobia: effects on subjective, behavioral, and physiological measures of anxiety. Behav Res Ther 2012 Jan;50(1):30-39. [doi: 10.1016/j.brat.2011.10.005] [Medline: 22055280] 6. MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias. J Abnorm Psychol 2002 Feb;111(1):107-123. [doi: 10.1037/0021-843X.111.1.107] [Medline: 11866165] 7. MacLeod C, Mathews A, Tata P. Attentional bias in emotional disorders. J Abnorm Psychol 1986 Feb;95(1):15-20. [doi: 10.1037/0021-843X.95.1.15] [Medline: 3700842] 8. Amir N, Beard C, Taylor CT, Klumpp H, Elias J, Burns M, et al. Attention training in individuals with generalized social phobia: a randomized controlled trial. J Consult Clin Psychol 2009 Oct;77(5):961-973 [FREE Full text] [doi: 10.1037/a0016685] [Medline: 19803575] 9. Schmidt NB, Richey JA, Buckner JD, Timpano KR. Attention training for generalized social anxiety disorder. J Abnorm Psychol 2009 Feb;118(1):5-14. [doi: 10.1037/a0013643] [Medline: 19222309] 10. Amir N, Beard C, Burns M, Bomyea J. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol 2009 Feb;118(1):28-33 [FREE Full text] [doi: 10.1037/a0012589] [Medline: 19222311] 11. Amir N, Taylor CT. Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy. Behav Ther 2012 Sep;43(3):546-559 [FREE Full text] [doi: 10.1016/j.beth.2010.12.008] [Medline: 22697443] 12. Najmi S, Amir N. The effect of attention training on a behavioral test of contamination fears in individuals with subclinical obsessive-compulsive symptoms. J Abnorm Psychol 2010 Feb;119(1):136-142 [FREE Full text] [doi: 10.1037/a0017549] [Medline: 20141250] 13. Carlbring P, Apelstrand M, Sehlin H, Amir N, Rousseau A, Hofmann SG, et al. Internet-delivered attention bias modification training in individuals with social anxiety disorder--a double blind randomized controlled trial. BMC Psychiatry 2012 Jun 25;12:66 [FREE Full text] [doi: 10.1186/1471-244X-12-66] [Medline: 22731889] 14. Julian K, Beard C, Schmidt NB, Powers MB, Smits JA. Attention training to reduce attention bias and social stressor reactivity: an attempt to replicate and extend previous findings. Behav Res Ther 2012 May;50(5):350-358 [FREE Full text] [doi: 10.1016/j.brat.2012.02.015] [Medline: 22466022] 15. McNally RJ, Enock PM, Tsai C, Tousian M. Attention bias modification for reducing speech anxiety. Behav Res Ther 2013 Dec;51(12):882-888. [doi: 10.1016/j.brat.2013.10.001] [Medline: 24211339] 16. Rapee RM, MacLeod C, Carpenter L, Gaston JE, Frei J, Peters L, et al. Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: a randomized controlled trial. Behav Res Ther 2013 May;51(4-5):207-215. [doi: 10.1016/j.brat.2013.01.005] [Medline: 23435121] 17. Cristea IA, Kok RN, Cuijpers P. Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. Br J Psychiatry 2015 Jan;206(1):7-16. [doi: 10.1192/bjp.bp.114.146761] [Medline: 25561486] 18. Heeren A, Mogoa e C, Philippot P, McNally RJ. Attention bias modification for social anxiety: a systematic review and meta-analysis. Clin Psychol Rev 2015 Aug;40:76-90. [doi: 10.1016/j.cpr.2015.06.001] [Medline: 26080314] 19. Mogoaşe C, David D, Koster EH. Clinical efficacy of attentional bias modification procedures: an updated meta-analysis. J Clin Psychol 2014 Dec;70(12):1133-1157. [doi: 10.1002/jclp.22081] [Medline: 24652823] 20. Linetzky M, Pergamin-Hight L, Pine DS, Bar-Haim Y. Quantitative evaluation of the clinical efficacy of attention bias modification treatment for anxiety disorders. Depress Anxiety 2015 Jun;32(6):383-391. [doi: 10.1002/da.22344] [Medline: 25708991] 21. Price RB, Wallace M, Kuckertz JM, Amir N, Graur S, Cummings L, et al. Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias. Clin Psychol Rev 2016 Dec;50:37-49 [FREE Full text] [doi: 10.1016/j.cpr.2016.09.009] [Medline: 27693664] http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al 22. MacLeod C, Clarke PJ. The attentional bias modification approach to anxiety intervention. Clin Psychol Sci 2015 Jan 06;3(1):58-78. [doi: 10.1177/2167702614560749] 23. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 24. Clarke PJ, Notebaert L, MacLeod C. Absence of evidence or evidence of absence: reflecting on therapeutic implementations of attentional bias modification. BMC Psychiatry 2014 Jan 15;14:8 [FREE Full text] [doi: 10.1186/1471-244X-14-8] [Medline: 24423043] 25. MacLeod C, Grafton B. Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research. Behav Res Ther 2016 Dec;86:68-86. [doi: 10.1016/j.brat.2016.07.005] [Medline: 27461003] 26. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 27. Beard C. Cognitive bias modification for anxiety: current evidence and future directions. Expert Rev Neurother 2011 Feb;11(2):299-311 [FREE Full text] [doi: 10.1586/ern.10.194] [Medline: 21306216] 28. Notebaert L, Clarke PJ, Grafton B, MacLeod C. Validation of a novel attentional bias modification task: the future may be in the cards. Behav Res Ther 2015 Feb;65:93-100. [doi: 10.1016/j.brat.2014.12.007] [Medline: 25594940] 29. Kuckertz JM, Amir N. Attention bias modification for anxiety and phobias: current status and future directions. Curr Psychiatry Rep 2015 Feb;17(2):9. [doi: 10.1007/s11920-014-0545-x] [Medline: 25620791] 30. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games 2013 Dec 12;1(1):e3 [FREE Full text] [doi: 10.2196/games.3139] [Medline: 25658754] 31. Boendermaker WJ, Prins PJ, Wiers RW. Cognitive bias modification for adolescents with substance use problems--can serious games help? J Behav Ther Exp Psychiatry 2015 Dec;49(Pt A):13-20 [FREE Full text] [doi: 10.1016/j.jbtep.2015.03.008] [Medline: 25843611] 32. Bernstein A, Zvielli A. Attention Feedback Awareness and Control Training (A-FACT): experimental test of a novel intervention paradigm targeting attentional bias. Behav Res Ther 2014 Apr;55:18-26. [doi: 10.1016/j.brat.2014.01.003] [Medline: 24562088] 33. Urech A, Krieger T, Chesham A, Mast FW, Berger T. Virtual reality-based attention bias modification training for social anxiety: a feasibility and proof of concept study. Front Psychiatry 2015;6:154 [FREE Full text] [doi: 10.3389/fpsyt.2015.00154] [Medline: 26578986] 34. Amir N, Kuckertz JM, Strege MV. A pilot study of an adaptive, idiographic, and multi-component attention bias modification program for social anxiety disorder. Cognit Ther Res 2016 Oct;40(5):661-671 [FREE Full text] [doi: 10.1007/s10608-016-9781-1] [Medline: 27795598] 35. Dennis-Tiwary TA, Egan LJ, Babkirk S, Denefrio S. For whom the bell tolls: neurocognitive individual differences in the acute stress-reduction effects of an attention bias modification game for anxiety. Behav Res Ther 2016 Feb;77:105-117 [FREE Full text] [doi: 10.1016/j.brat.2015.12.008] [Medline: 26745621] 36. Boendermaker J, Sanchez MS, Boffo M, Wiers RW. Attentional bias modification with serious game elements: evaluating the shots game. JMIR Serious Games 2016 Dec 06;4(2):e20 [FREE Full text] [doi: 10.2196/games.6464] [Medline: 27923780] 37. Lumsden J, Edwards EA, Lawrence NS, Coyle D, Munaf&ograve; MR. Gamification of cognitive assessment and cognitive training: a systematic review of applications and efficacy. JMIR Serious Games 2016 Jul 15;4(2):e11 [FREE Full text] [doi: 10.2196/games.5888] [Medline: 27421244] 38. Whyte EM, Smyth JM, Scherf KS. Designing serious game interventions for individuals with autism. J Autism Dev Disord 2015 Dec;45(12):3820-3831. [doi: 10.1007/s10803-014-2333-1] [Medline: 25488121] 39. Dennis TA, O'Toole L. Mental Health on the Go: effects of a gamified attention bias modification mobile application in trait anxious adults. Clin Psychol Sci 2014 Sep 01;2(5):576-590 [FREE Full text] [doi: 10.1177/2167702614522228] [Medline: 26029490] 40. De Voogd EL, Wiers RW, Prins PJ, Salemink E. Visual search attentional bias modification reduced social phobia in adolescents. J Behav Ther Exp Psychiatry 2014 Jun;45(2):252-259. [doi: 10.1016/j.jbtep.2013.11.006] [Medline: 24361543] 41. Dandeneau SD, Baldwin MW, Baccus JR, Sakellaropoulo M, Pruessner JC. Cutting stress off at the pass: reducing vigilance and responsiveness to social threat by manipulating attention. J Pers Soc Psychol 2007 Oct;93(4):651-666. [doi: 10.1037/0022-3514.93.4.651] [Medline: 17892337] 42. Waters AM, Pittaway M, Mogg K, Bradley BP, Pine DS. Attention training towards positive stimuli in clinically anxious children. Dev Cogn Neurosci 2013 Apr;4:77-84 [FREE Full text] [doi: 10.1016/j.dcn.2012.09.004] [Medline: 23063461] 43. Waters A, Zimmer-Gembeck MJ, Craske MG, Pine DS, Bradley BP, Mogg K. Look for good and never give up: a novel attention training treatment for childhood anxiety disorders. Behav Res Ther 2015 Oct;73:111-123. [doi: 10.1016/j.brat.2015.08.005] [Medline: 26310362] http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al 44. Johnson DR. Goal-directed attentional deployment to emotional faces and individual differences in emotional regulation. J Res Pers 2009 Feb;43(1):8-13. [doi: 10.1016/j.jrp.2008.09.006] 45. Lundqvist D, Flykt A, Ohman A. Emotionlab. 1998. The Karolinska Directed Emotional Faces&ndash;KDEF, CD ROM from Department of Clinical Neuroscience, Psychology section URL: http://www.emotionlab.se/kdef/ [accessed 2018-10-15] [WebCite Cache ID 73BDN1IqC] 46. Notebaert L. Youtube. 2018. Emotion-in-Motion viewing example URL: https://www.youtube.com/watch?v=PMUnimtCag0 [accessed 2018-05-08] [WebCite Cache ID 6zFh6RRSI] 47. Enock P, Hofmann SG, McNally RJ. Attention bias modification training via smartphone to reduce social anxiety: a randomized, controlled multi-session experiment. Cogn Ther Res 2014 Mar 4;38(2):200-216. [doi: 10.1007/s10608-014-9606-z] 48. Boettcher J, Hasselrot J, Sund E, Andersson G, Carlbring P. Combining attention training with internet-based cognitive-behavioural self-help for social anxiety: a randomised controlled trial. Cogn Behav Ther 2014;43(1):34-48 [FREE Full text] [doi: 10.1080/16506073.2013.809141] [Medline: 23898817] 49. Schoorl M, Putman P, Van Der Werff S, Van Der Does AJ. Attentional bias and attentional control in posttraumatic stress disorder. J Anxiety Disord 2014 Mar;28(2):203-210. [doi: 10.1016/j.janxdis.2013.10.001] [Medline: 24291395] 50. Clarke P, Branson S, Chen NT, Van Bockstaele B, Salemink E, MacLeod C, et al. Attention bias modification training under working memory load increases the magnitude of change in attentional bias. J Behav Ther Exp Psychiatry 2017 Dec;57:25-31. [doi: 10.1016/j.jbtep.2017.02.003] [Medline: 28257926] 51. Clarke P, Browning M, Hammond G, Notebaert L, MacLeod C. The causal role of the dorsolateral prefrontal cortex in the modification of attentional bias: evidence from transcranial direct current stimulation. Biol Psychiatry 2014 Dec 15;76(12):946-952. [doi: 10.1016/j.biopsych.2014.03.003] [Medline: 24690113] 52. Notebaert L, Crombez G, Van Damme S, De Houwer J, Theeuwes J. Signals of threat do not capture, but prioritize, attention: a conditioning approach. Emotion 2011 Feb;11(1):81-89. [doi: 10.1037/a0021286] [Medline: 21401228] 53. Eastwood JD, Smilek D, Merikle PM. Differential attentional guidance by unattended faces expressing positive and negative emotion. Percept Psychophys 2001 Aug;63(6):1004-1013. [doi: 10.3758/BF03194519] [Medline: 11578045] 54. Lazarov A, Pine DS, Bar-Haim Y. Gaze-contingent music reward therapy for social anxiety disorder: a randomized controlled trial. Am J Psychiatry 2017 Dec 01;174(7):649-656. [doi: 10.1176/appi.ajp.2016.16080894] [Medline: 28103714] 55. Liu J, Dosher B, Lu ZL. Modeling trial by trial and block feedback in perceptual learning. Vision Res 2014 Jun;99:46-56 [FREE Full text] [doi: 10.1016/j.visres.2014.01.001] [Medline: 24423783] 56. Brand S, Reimer T, Opwis K. How do we learn in a negative mood? Effects of a negative mood on transfer and learning. Learning and Instruction 2007 Feb;17(1):1-16. [doi: 10.1016/j.learninstruc.2006.11.002] 57. Schweinberger S, Burton AM, Kelly SW. Asymmetric dependencies in perceiving identity and emotion: experiments with morphed faces. Percept Psychophys 1999 Aug;61(6):1102-1115. [doi: 10.3758/BF03207617] [Medline: 10497431] 58. Matthews G, Campbell SE, Falconer S, Joyner LA, Huggins J, Gilliland K, et al. Fundamental dimensions of subjective state in performance settings: task engagement, distress, and worry. Emotion 2002 Dec;2(4):315-340. [doi: 10.1037/1528-3542.2.4.315] [Medline: 12899368] 59. Grafton B, MacLeod C, Rudaizky D, Holmes EA, Salemink E, Fox E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017 Nov;211(5):266-271. [doi: 10.1192/bjp.bp.115.176123] [Medline: 29092835] 60. Notebaert L, Macleod C, Grafton B. Emotion-in-Motion task material. The University of Western Australia 2018 [FREE Full text] [doi: 10.26182/5bbd5735031f6] Abbreviations ABI: attentional bias index ABM: attentional bias modification ANOVA: analysis of variance Edited by TR Soron; submitted 08.05.18; peer-reviewed by W Boendermaker, M Zhang; comments to author 14.08.18; revised version received 26.08.18; accepted 27.08.18; published 28.11.18 Please cite as: Notebaert L, Grafton B, Clarke PJF, Rudaizky D, Chen NTM, MacLeod C JMIR Serious Games 2018;6(4):e10993 URL: http://games.jmir.org/2018/4/e10993/ doi: 10.2196/10993 PMID: 30487121 http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Notebaert et al ©Lies Notebaert, Ben Grafton, Patrick JF Clarke, Daniel Rudaizky, Nigel TM Chen, Colin MacLeod. Originally published in JMIR Serious Games (http://games.jmir.org), 28.11.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/4/e10993/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10993 | p. 12 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious GamesJMIR Publications

Published: Nov 28, 2018

Keywords: attentional bias; anxiety disorders; experimental games

There are no references for this article.