Cognitive Therapy and Research

, Volume 42, Issue 2, pp 121–134 | Cite as

Increased Attention Regulation from Emotion Regulation Therapy for Generalized Anxiety Disorder

  • Megan E. Renna
  • Saren H. Seeley
  • Richard G. Heimberg
  • Amit Etkin
  • David M. Fresco
  • Douglas S. Mennin
Original Article


Dysfunction in the ability to sustain, shift and broaden attention has been proposed as a mechanism of normative emotion regulation that is a common target of cognitive-behavioral therapies. Attention regulation deficits are central to generalized anxiety disorder (GAD) and may contribute to a generally rigid, avoidant, response style that produces substantial decrements in well-being and functioning. Emotion Regulation Therapy draws upon mindfulness-based regulatory skills to facilitate attentional change during an initial phase of treatment. Two studies examined task-based changes in flexibly shifting attention in response to conflicting emotional contexts and sustaining attention despite distressing emotional contexts. In Study 1, at pre-treatment, patients with GAD, as compared to controls performed significantly more poorly on an emotional conflict adaptation task (i.e., less ability to flexibly shift attention) and improved in conflict adaptation by mid-treatment (when attention regulation skills were being trained). This task-related change predicted increases in mindful observing abilities over the course of acute treatment but was not directly associated with clinical outcomes. In Study 2, a choice reaction time (RT) task was utilized to measure the ability to sustain attention by discriminating between two tones while overcoming the interference of aversive visual stimuli. At pre-treatment, participants with GAD demonstrated slower RTs (i.e., more difficulty sustaining attention on the tonal prompt) compared to controls and demonstrated more rapid RTs from pre- to mid-treatment. This improved task performance was related to clinical improvement and decreased functional impairment. RT change was also associated with greater nonreactivity towards experiences. Overall, these findings suggest that targeting mindful regulation skills improve attention regulation in individuals with GAD and may partially account for efficacious clinical outcomes throughout treatment.


Emotion regulation therapy Generalized anxiety disorder Emotional interference Attention regulation Mindfulness Conflict adaptation Emotional Stroop 


The ability to sustain and flexibly shift attention is a crucial component of adaptive emotion regulation and goal-directed behavior (Tang et al. 2015). However, this quality of attention is often lacking in individuals suffering from generalized anxiety disorder (GAD; Mogg and Bradley 2005; Stefanopoulou et al. 2014) and may be partially responsible for their tendency to react strongly, rigidly, and negatively to their emotional experiences (Bargh and Williams 2007). GAD is characterized by excessive and uncontrollable worry for most of the day, nearly every day, for a period of at least 6 months (American Psychiatric Association 2013). Reliance on pathological worry to regulate emotions may play an integral role in the development and maintenance of GAD (Mennin and Fresco 2013), and poorer ability to flexibly shift attention away from threat may subsequently underlie the uncontrollable nature of this worry (Hirsch et al. 2011). By targeting attention regulation, it may be possible to decrease reliance on pathological worry through increasing the ability to engage in more efficient (i.e., antecedent-focused; Gross 1998) emotion regulation strategies. Consistent with the dual-mechanisms framework of cognitive control (Braver 2012), greater attention regulation would therefore combat the need to resort to resource-intensive, reactively-focused attempts to alter emotions (e.g. worry, rumination; see Borkovec et al. 2004; Nolen-Hoeksema et al. 2008) after they have fully unfolded as a way to regulate intense emotions.

Attention regulation is considered to be one mechanism underlying the impact of mindfulness (Hölzel et al. 2011), and mindfulness meditation practices enhance more automatic components of attentional deployment (Moore and Malinowski 2009) by strengthening inhibitory control (Lee and Chao 2012). This increase in inhibitory control, in turn, supports the ability to employ explicit emotion regulation strategies, such as reappraisal, and engage in goal-oriented behavior (Koole 2009; Wadlinger and Isaacowitz 2011). The inclusion of such practices appear to modulate early processing of stimuli, resulting in greater capacity to distribute attentional resources in a manner that supports cognitive and emotional regulation. Indeed, attention regulation is positively associated with increased mindfulness, and meditators, compared to those without experience meditating, perform better on behavioral measures of attention (Moore and Malinowski 2009). Mindfulness training in a group of healthy novice meditators has also improved attention regulation, measured both by response to a classic Stroop task and self-reports (Moore et al. 2012). Therefore, by invoking executive functions such as attentional shifting and sustaining attention, intentional mindfulness practice is proposed to strengthen the regulatory mechanisms needed to effectively pursue goals and respond to one’s environment (Lee and Chao 2012; Moore and Malinowski 2009).

Considering that disorders such as GAD are characterized by dysregulation in response to heightened negative affect and deficits in positive affect, promoting regulatory skills including attentional abilities may reflect an optimal treatment target (e.g., Hofmann et al. 2012). Addressing the attentional deficits present in emotional disorders such as GAD reflects a common change principle of both traditional and contemporary cognitive behavioral therapies (CBTs; Mennin et al. 2013). Given the encouraging findings that mindfulness practices have shown in training attention, coupled with the relatively modest effect sizes produced by traditional CBTs (Borkovec and Ruscio 2001), mindfulness-based treatment (MBTs) approaches have emerged for a variety of psychopathology over the past several decades (Segal et al. 2002; Witkiewitz et al. 2005) and appear efficacious in the treatment of mood and anxiety disorders, including GAD (Hofmann et al. 2010; Hoge et al. 2014). In particular, an important goal of these treatments is for patients to be able to deploy, flexibly shift (i.e., lead attention to various aspects of an experience; Szymura et al. 2007), and sustain (i.e., maintain attention on a specific stimulus; Posner and Rothbart 1992) attention in a manner that promotes attention regulation in service of decreasing symptoms and increasing functional behavior. Therefore, training these less elaborative regulatory skills through interventions to increase attention regulation appears to be a promising avenue for circumventing the tendency to engage in prolonged metacognitive processing of emotions and events via worry, which has been shown to maintain and even amplify negative emotional states (e.g., Ehring and Watkins 2008).

Emotion Regulation Therapy (ERT) was developed as a theoretically-derived treatment integrating principles from traditional and contemporary CBTs with basic and translational findings from affect science so as to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding regulatory characteristics of individuals with distress disorders such as GAD and major depressive disorder (MDD). Mindful emotion regulation skills (including both attention and meta-cognitive regulatory skills) are taught throughout ERT and combined with more traditional techniques including cue detection, in session exposure exercises, and between session behavioral experiments to help clients gain clarity about their motivations and take more effective, values-based actions. Preliminary findings support the efficacy of ERT (Mennin et al. 2015). Mindfulness-based regulatory skills are incorporated throughout ERT but are specifically emphasized during the first half, prior to exercises for experiential exposure in the latter half of treatment. Thus, the development of attention regulation in the early sessions of ERT may aid in the effectiveness of the other components of the treatment to reduce symptoms of GAD, such as excessive worry, and to improve social functioning and overall quality of life.

In summary, GAD reflects a condition that can be treated effectively with traditional CBT, but comparatively, the effect sizes and treatment durability lags behind other disorders (Borkovec and Ruscio 2001). One possible explanation for the somewhat more modest effect sizes might be that traditional CBT fails to effectively target deficits in flexible and sustained attention. Given the findings that training in mindfulness meditation, can enhance attention regulation, mindfulness enriched treatments have emerged with increasing evidence of efficacy in treating conditions like GAD (Hayes-Skelton et al. 2013; Wells et al. 2010). However, mindfulness based interventions alone also seem to fall short of effectively resolving the symptoms, impairment, and suffering caused by GAD (Craigie et al. 2008). ERT is a relative newcomer to the family of evidence based treatments and has demonstrated promising treatment efficacy (Mennin et al. 2015) possibly because it combines elements of traditional CBT with mindfulness meditation practices that explicitly target attention regulation. Building on this record of treatment efficacy, the current study sought to examine whether ERT does explicitly target attention regulation and whether changes in attention regulation are associated with clinical improvement.

In two studies, we examined tasks related to sustaining and flexibly shifting attention assessed during the course of ERT (pre-, mid-, and post-acute treatment). Early on in the first half of treatment, ERT emphasizes less elaborative attention regulation techniques (such as training in mindful awareness, interoceptive cue detection, and self-monitoring) to reduce reliance on maladaptive verbally-mediated efforts, followed by the introduction of strategies that strengthen metacognitive abilities (e.g., decentering, reappraisal). Given this early emphasis on attention regulation training, we expected that the greatest change in our behavioral indices of attentional regulation change would occur between pre- and mid-treatment, rather than between mid- and post-treatment. We also expected that the magnitude of pre-to-mid-treatment changes in attention regulation as measured by two behavioral tasks reflecting the ability to flexibly shift (Study 1) or sustain (Study 2) would be associated with pre-to-post-treatment self-reported improvements in less elaborative facets of mindfulness (i.e., attentional components; observing and non-reactivity to inner experience; Baer et al. 2008) as well as positive treatment effects on clinical outcomes (anxiety symptoms, depression symptoms, functional impairment, and quality of life).

Study 1

This study examined the ability to shift attention, one aspect of attention regulation, among individuals with GAD and healthy controls and also whether treatment with ERT was associated with improvements in shifting attention. An attentional shifting process that occurs within the context of emotional processing, in which patients with GAD have previously shown decrements, is emotional conflict adaptation (Etkin et al. 2010; Etkin and Schatzberg 2011). In this task, individuals experience an emotional conflict between facial expression (the target; i.e. a fearful face) and an emotional distracter word (i.e. “happy”). Adaptation in this paradigm involves the improvement in conflict regulation after experiencing an emotional conflict, such that an incongruent stimulus that followed an incongruent trial will create less behavioral conflict (measured as reaction time slowing) than an incongruent trial that followed a congruent trial. Efficient conflict adaptation requires the capacity to exert automatic control to inhibit limbic reactivity that could threaten goal-directed cognition (Etkin et al. 2006), a process requiring activity in the pregenual anterior cingulate cortex (Maier and Di Pellegrino 2012). Impaired conflict adaptation may be associated with emotional dysregulation, as patients with GAD (with and without comorbid MDD) display inferior emotional conflict adaptation (Etkin et al. 2010; Etkin and Schatzberg 2011).

The present study utilized the emotional conflict adaptation task (Etkin et al. 2006) to examine attentional change over the course of ERT. We hypothesized that participants with GAD would exhibit greater difficulties with conflict adaptation prior to treatment compared to a healthy control group. Additionally, we hypothesized that there would be a significant change in conflict adaptation from pre- to mid- treatment when attentional regulation is specifically targeted. We also were interested in examining how any observed change in task performance during the first half of ERT might relate to self-reported improvements in anxiety and depression symptoms, social disability, and quality of life at post-treatment. Additionally, we hypothesized that conflict adaptation would be associated with improvements in attention-based mindfulness abilities, including non-reactivity to inner experience and observing emotions.



Treatment-seeking individuals (N = 17) were recruited from the community to participate in trials of ERT offered at two different clinics in the northeastern United States.1 These received treatment with ERT and completed the conflict adaptation task at pre-, mid-, and post-treatment in association with larger parent trials (Mennin et al. 2015). All participants in the current study completed all 20 sessions of ERT (see description below). Inclusion criteria were a principal diagnosis of GAD based on DSM-IV-TR criteria (American Psychiatric Association 2000), being over the age of 18, and being able to fluently speak and write in English. Exclusion criteria included a principal DSM-IV-TR diagnosis other than GAD, prominent active suicidal ideation/intent, DSM-IV-TR diagnosis of substance abuse or dependence within the previous 6 months, a current DSM-IV-TR diagnosis of organic mental disorder; schizophrenia, psychotic disorder, bipolar I disorder, or dementia, or, an unwillingness to terminate or suspend concurrent psychotherapy throughout their participation in ERT.

Control participants were 44 individuals from the community over 18 years of age, fluent in English, and who did not endorse any clinically significant symptoms consistent with a current or lifetime DSM-IV-TR diagnosis. Control participants underwent the same diagnostic assessment as participants in the GAD group (described below).

Diagnostic Assessment

Participants received a semi-structured diagnostic interview with research staff to determine eligibility and suitability for the ERT trial. Clinic 1 participants were assessed with the Structured Clinical Interview for the DSM-IV (SCID; First et al. 2002) with the addition of CSR ratings; clinic 2 participants were assessed with the Anxiety Disorders Interview Schedule for DSM-IV (ADIS; DiNardo et al. 1994). Patients at both clinics were assigned a clinical severity rating (CSR) from 0 to 8 based on criteria outlined in the ADIS for each disorder for which participants met at least partial criteria. A CSR of four indicates clinical threshold for a given disorder, with higher scores indicating greater severity. Research staffs at both clinics were trained on diagnostic assessment by either the principal investigators or senior-level graduate students and were required to demonstrate strong inter-rater reliability with a more experienced interviewer before conducting assessments independently, as indicated by consistently concordant diagnoses and CSRs. Inter-rater reliability in diagnosing GAD was 100% in the current study.

Emotion Regulation Therapy

ERT consisted of 20 weekly sessions, each session lasting 60 min with the exception of sessions 11–16, which were 90 min long. The first half of ERT focuses on teaching emotion regulation skills that facilitate more intentional responding through mindful attending to somatic and emotional cues (i.e., attention regulation such as sustaining attention) and more elaborative emotion regulation skills (i.e., meta-cognitive regulation such as reappraisal). In the second half of ERT, participants work to engage contexts that simultaneously invoke both elevated reward and threat motivations via in-session, values-based, exposure exercises. In the final sessions, the focus shifts to consolidating treatment gains and terminating the therapeutic relationship (Fresco et al. 2013). Clinicians were experienced doctoral students in clinical psychology who administered ERT within the university-based anxiety clinics. These student clinicians were trained and received weekly group supervision by two licensed clinical psychologists (the fourth and fifth authors). Weekly sessions were video recorded to assess clinician adherence to the treatment protocol (Renna et al. 2017).

Clinical Self-Reported Indicators

The Mood and Anxiety Symptom Questionnaire-Short Form (MASQ; Watson and Clark 1991) assesses of anxiety and depression. For the current analysis, the MASQ General Distress Anxiety (MASQ-GDA) and MASQ General Distress Depression (MASQ-GDD) subscales were used to assess general symptoms of anxiety and depression. Cronbach’s α in the present sample was .76 for the MASQ-GDA subscale and .91 for the MASQ-GDD subscale.

The Quality of Life Inventory (QOLI; Frisch et al. 1992) assesses multiple life domains (such as relationships, environment, work, and play) for importance and satisfaction, as a measure of well-being. Cronbach’s alpha in the current sample of .74.

The Sheehan Disability Scale (SDS; Sheehan 1983) assesses level of disability within the domains of work/school, social life, and family life/home responsibilities. Consistent with previous research (Hambrick et al. 2004), the Cronbach’s alpha for the SDS in the current study was low at .169.

Trait Mindful Attention Self-Report Measure

The Five-Factor Mindfulness Questionnaire (FFMQ; Baer et al. 2006) measures five purported constructs of trait mindfulness: acting with awareness, non-judgment of inner experience, non-reactivity to inner experience, observing, and describing. The current analysis examined the observing (α = .58) and non-reactivity (α = .80) subscales, as they both represent less elaborative mindfulness strategies.

Conflict Adaptation Task

The conflict adaptation task developed by Etkin et al. (2006) served as our behavioral measure of the ability to flexibly shift attention. Based on the classic emotional Stroop paradigm (e.g., Stroop 1935), this task presented fearful or happy facial expressions from the set by Ekman and Friesen (1975), overlaid with either the word “FEAR” or “HAPPY” in large red text. The word and facial expression may be either incongruent (e.g., “FEAR” presented with a happy expression) or congruent (e.g., “FEAR” with a fearful expression). Incongruent trials preceded by a congruent trial are considered high-conflict trials; incongruent trials that are preceded by an incongruent trial are considered low-conflict trials (Egner 2007). There are 148 trials in all, pseudorandomized and counterbalanced across trial types for facial expression, word, response button, and gender (Etkin et al. 2006). Stimuli are presented for 1 s, with a varying interstimulus interval (ISI) of either 3, 4 or 5 s while a fixation cross is centered on the screen. Participants are instructed to indicate whether the facial expression is “fear” or “happy” as quickly and accurately as possible via key press while ignoring the word. Accuracy and mean RT were examined separately for: all trials, all incongruent trials (INCON), all congruent trials (CON), post-congruent congruent trials (cC), post-congruent incongruent trials (cI), post-incongruent congruent trials (iC), and post-incongruent incongruent trials (iI). Key variables consisted of overall conflict (computed as INCON minus CON trials), and emotional conflict adaptation (computed as low-conflict [iI] minus high-conflict [cI] trials). For the latter, higher values indicate lesser or absent RT facilitation on low-conflict trials, i.e., poorer conflict adaptation. The emotional conflict task is described in greater detail in Etkin et al. (2006).

Due to a programming error, a version of the task used early in the study failed to record any responses during the ISI. Data loss was minimal for the majority of participants as evidenced by response rates (see below). However, this error resulted in a restriction in the range of the behavioral data by inadvertently imposing a 1-s upper threshold on reaction time (RT). The error was detected and fixed later in the study, so only a portion of our sample were affected, but rather than further reduce an already small sample size in the patient group, we chose to examine all participants’ behavioral data using a 1-s cutoff.


Healthy control participants completed the emotional conflict task along with other study measures at one visit. ERT patients completed the emotional conflict task along with two other behavioral tasks in counterbalanced order along with the battery of self-report measures at three assessment points during the course of treatment. Stimuli were presented electronically using E-Prime 2.0 software (Psychology Software Tools, Pittsburgh, PA) on a desktop computer with a standard keyboard for responding. A research assistant provided instructions and administered brief practice versions beforehand. All participants were compensated $20 per assessment. The study was approved by each clinic’s corresponding Institutional Review Board.


Sample Demographics

As seen in Table 1, participants did not differ significantly between the two study clinics in terms of baseline characteristics including age, gender, race, ethnicity, or education, and were therefore combined in our final analysis.

Table 1

Study 1 sample demographics


GAD (n = 17)

Controls (n = 44)

Age (M, SD)

40.9 (13.8)

37.6 (13.6)

Female (n, %)

12 (70.6%)

32 (74.4%)

Caucasian (n, %)

14 (82.4%)

34 (77.3%)

Hispanic (n, %)

2 (11.8%)

4 (9.3%)

M mean, SD standard deviation, n number of participants, % percentage of participants

Consistent with other findings (Nutt et al. 2002), nearly half (n = 8) of the patient group received a diagnosis of MDD. Other diagnoses included dysthymia (n = 1), panic disorder (n = 3), social phobia (n = 4), post-traumatic stress disorder (n = 1), obsessive–compulsive disorder (n = 2), specific phobia (n = 1). Conflict adaptation did not differ significantly between participants with GAD versus patients with comorbid GAD and MDD at either pre (t(15) = .100, df = 15, p = .922), mid (t = .928, df = 15, p = .368), or post (t = .691, df = 10, p = .505). Similarly, the two patient groups did not differ significantly in terms of pre-mid conflict adaptation change (t = .647, df = 15, p = .527).

Response Rates & Reaction Times

Data from eight participants (47%) were affected by the programming error in the original version of the task. Of the 138 trials on which it was possible to make a response, on average participants responded on 124.59 trials at pre (SD = 15.11, range = 49) and 123.24 trials at mid (SD = 21.76, range = 67.0). In the subset of participants whose data was affected by the programming error, average response rates were similar at pre (M = 120.50, SD = 15.78, range = 45) and mid (M = 119.25, SD = 23.53, range = 62.0). Although we were unable to distinguish trials on which the recording failed as compared to trials on which the participant did not respond, it is likely that not all missed trials were due to the programming error. For instance, even when participants had the full 5 s for their response to be recorded, they still failed to provide responses on 100% of trials. Of the 148 trials, participants unaffected by the programming error failed to respond to approximately 14% of trials, while those impacted by the programmed error failed to respond on approximately 18% on trials.

Irrespective, response rates remained relatively high after applying a 1-s upper threshold to the RT data, and controls (M = .89, SD = .13) and patients (M pre  = .86, SD pre  = .10) were not significantly different, t(59) = .956, p = .343. In the patient group, response rates at mid (M mid  = .85, SD mid  = .15) and post (M post  = .89, SD post  = .19) were comparable to pre-treatment response rates.

Case Control Differences

Findings indicated that the control participants were well matched to GAD patients in terms of sample characteristics. For instance, the two groups did not differ in terms of age, t = − 0.85, df = 58, p = .397, gender (x 2 [1, N = 60] = 0.09, p = .762), race (x 2 [3, N = 60] = 0.66, p = .883), or ethnicity (x 2 [1, N = 60] = 0.08, p = .774). Multivariate analysis of variance (RT x Group: Patient, Control) revealed a significant effect of Group for conflict adaptation, F(1,59) = 8.04, p = .006, partial η2 = 0.12 such that GAD patients (M = 16.36, SD = 33.40) as compared to control participants (M = − 4.82, SD = 22.88) exhibited inferior conflict adaptation RT scores. There were no group differences on any other index of task performance, including overall RT (F[1,59] = 0.64, p = .427, partial η2 = 0.01), overall conflict (F[1,59] = 0.32, p = .572, partial η2 = 0.005), and overall accuracy (F[1,59] = 3.46, p = .068, partial η2 = 0.06).

Behavioral change over treatment

As predicted, paired-samples t tests indicated that conflict adaptation improved significantly between pre-treatment (M = 16.36, SD = 33.40) and mid-treatment (M = − 11.49, SD = 29.22), t(16) = 3.18, p = .006, Hedge’s g = 1.543. However, conflict adaptation did not change significantly between mid- and post-treatment (M = − .014, SD = 15.24), (t[11] = − 1.44, p = .18, Hedge’s g = 0.831).

Attention Regulation Change in relation to Treatment Outcomes

Previous ERT research has examined treatment outcomes in self-reported symptoms of anxiety and depression, mindfulness, quality of life, and social disability throughout the course of ERT using the above measures. Overall, findings indicated significant improvements in all measures surpassing traditional benchmarks for large effect sizes (e.g., Mennin et al. 2015).

To assess changes in task performance over the course of ERT, we calculated difference scores by subtracting mean RTs for both congruent and incongruent trials at one timepoint (mid- or post-treatment) from mean RTs at the previous timepoint (pre- or mid-treatment) to test whether pre-to-mid-treatment attention change was associated with less elaborative mindfulness and/or treatment outcomes, we used partial correlations to examine relationships between conflict adaptation and our selected self-reported measures, controlling for pre-treatment scores on those measures to account for baseline individual differences in severity. There were no significant relationships between conflict adaptation and MASQ GDA, MASQ GDD, QOLI, or SDS. These results are summarized in Table 2.

Table 2

Partial correlations between outcome variables (post-treatment scores controlling for pre- scores) and pre-mid change in conflict adaptation


conflict adaptation

Clinical indicators

 MASQ general distress anxiety subscale

− 0.15

 MASQ general distress depression subscale

− 0.05

 Quality of life inventory

− 0.10

 Sheehan disability scale

− 0.27

Trait mindful attention

 FFMQ observe subscale

− 0.64*

 FFMQ non-reactivity subscale


MASQ mood and anxiety symptom questionnaire, FFMQ five facet mindfulness questionnaire, **p < .001, *p < .05

Attention Change in relation to Trait Mindful Attention

Improved pre-to-mid-treatment conflict adaptation was associated with post-treatment scores (controlling for pre-treatment) of the FFMQ observing subscale (r = − .64, p = .025) but not the non-reactivity subscale, (r = .32, p = .308). These results are summarized in Table 3.

Table 3

Study 2 sample demographics


GAD (n = 14)

Controls (n = 43)

Age (M, SD)

44.8 (13.2)

38.0 (13.5)

Female (n, %)

12 (85.7%)

31 (72.1%)

Caucasian (n, %)

12 (85.7%)

33 (76.7%)

Hispanic (n, %)

2 (14.3%)

5 (11.6%)

M mean, SD standard deviation, n number of participants, % percentage of participants

Study 1: Summary

Prior to their participation in ERT, patients with GAD showed significantly less conflict adaptation relative to healthy controls (measured as reaction time facilitation on post-incongruent incongruent trials compared to post-congruent incongruent trials). In line with our predictions based on ERT’s phasic structure, task performance improved significantly between pre- and mid-ERT, but not mid- and post-ERT. Though not significantly related to our selected clinical outcome measures (quality of life; functional impairment; depression and anxiety symptoms; non-reactivity to inner experience), improved pre-to-mid-ERT conflict adaptation was associated with higher post-treatment scores on the FFMQ observing subscale, one of two subscales purportedly measuring less elaborative, attentional, facets of trait mindfulness.

Study 2

The ability to sustain attention despite the interference of emotional stimuli is another critical aspect of attention regulation that may be dysregulated among individuals with psychopathology. In Study 2, we predicted that treatment-seeking individuals with GAD would demonstrate poorer performance on a choice-reaction time (RT) task, which requires participants to identify and discriminate auditory tones despite introduction of evocative emotional stimuli. Longer RTs on trials with emotional stimuli are suggested to index ‘emotional interference’ (Buodo et al. 2002; Ortner et al. 2007). Individuals with GAD enrolled in ERT completed the task at three timepoints (pre-, mid-, and post-treatment).

In the current study, we hypothesized that individuals with GAD would demonstrate greater emotional interference, measured by the choice-RT behavioral task, compared to controls. Further, because mindfulness-based regulatory skills are a particular focus during the first half of ERT, we predicted that the greatest reduction in emotional interference, as an index of sustained attention regulation ability, would occur between pre- and mid-treatment when these skills were first being trained. We also predicted that improved task performance would be associated with improvements in self-reported indices of symptoms of anxiety and depression, functioning, quality of life, and attention-based, mindfulness skills, at post treatment.



The sample consisted of fourteen treatment-seeking patients with GAD (50% of whom were unique to Study 2 compared to Study 1) recruited for a treatment study of ERT offered through two university-affiliated mood and anxiety clinics.2 These individuals represent a subset of participants enrolled in trials of ERT who completed lab-based behavioral assessments, including the emotional interference task (EIT) reported here, at pre-, mid-, and post-treatment. All participants in the current study completed all 20 sessions of ERT. Participants in the control group (n = 43) were recruited from the general community surrounding both clinics. Inclusion and exclusion criteria for both groups were identical to that of Study 1. Control participants were from the same sample as Study 1 with the exception of one individual.

Diagnostic Assessment

Participants in the GAD group underwent the same diagnostic screening procedures as participants in Study 1. Consistent with diagnostic procedures in Study 1, participants in Study 2 were also assigned a CSR score based upon symptom severity, with a score ≥ 4 being consistent with a clinical diagnosis of a given disorder. Inter-rater reliability in diagnosing GAD reflected 100% agreement in the current study.

Clinical Indicators and Trait Mindfulness Self-Report Measures

Participants in the GAD and control groups completed the same battery of self-reported clinical indicators as participants in Study 1 to assess anxiety and depression symptoms (MASQ GDA, MASQ GDD), quality of life and functioning (SDS and QOLI). They also completed the FFMQ as a measure of trait self-reported mindful attention (FFMQ observing and non-reactivity subscales). Cronbach’s alpha for all self-report measures demonstrated strong reliability, indicated by values ranging from 0.68 to 0.92.

Emotional Interference Task

Participants completed a variant of the Emotional Interference Task (EIT; Buodo et al. 2002) before, during and after receiving ERT. This choice-RT task requires individuals to identify and discriminate auditory tones despite the earlier introduction of evocative emotional stimuli. Specifically, a negative or neutral image from the International Affective Picture System (IAPS; Lang et al. 2008) is presented for 6 s. At a 4-s stimulus onset asynchrony, a tone is played. Participants are instructed to identify the pitch of the tone as either low or high as rapidly as possible by pressing a button. The IAPS image, therefore, remains on the screen at the time of the tone onset and participant response. Faster RTs are thought to reflect better ability to inhibit task-irrelevant responses to emotional stimuli while sustaining attention to the identified task (i.e., identifying the tone).

Mean RT was calculated for each condition (i.e., negative or neutral). Trials with inaccurate responses or RTs under 150 or over 3000 ms were excluded from analysis. The minimum of 150 ms is in line with previous literature indicating that responses under this time likely represent errors rather than intentional responses (Thorpe et al. 1996). To address cross-modal influences (Miller et al. 2013), we established the relatively high upper limit. The progression of the EIT is presented in Fig. 1.

Fig. 1

Emotional interference task progression

Fourteen negatively valenced IAPS and 24 neutral IAPS were utilized in the current task3. Mean ratings for valence, arousal, and dominance were based on pre-established normed ratings for these images (Lang et al. 2008) and are presented in Table 4.

Table 4

Partial correlations between outcome variables (post-treatment scores controlling for pre- scores) and pre-mid change in emotional interference




Clinical indicators

 MASQ general distress anxiety subscale



 MASQ general distress depression subscale



 Quality of life inventory

− 0.21

− 0.15

 Sheehan disability scale



Trait mindful attention

 FFMQ observing subscale


− 0.21

 FFMQ non-reactivity subscale

− 0.58*


MASQ mood and anxiety symptom questionnaire, FFMQ five facet mindfulness questionnaire, **p < .001, *p < .05


The local InstitNutional Review Boards approved this study. Research staff conducted all research-related study visits, including the in-lab assessments in which participants in both groups completed the EIT. The EIT was administered at pre-, mid-, and post-treatment for the treatment group and only at a baseline assessment for those in the control group. All other study procedures were identical to Study 1.


Sample demographics

Participants with GAD did not differ significantly between the two study clinics in terms of baseline characteristics including age, gender, race, ethnicity, or education, and were therefore combined in our final analysis. Study demographics are presented in Table 3. In addition to a primary diagnosis of GAD, 50% (n = 7) had a diagnosis of MDD (n = 7). Other comorbidities included 21.4% panic disorder (n = 3), 7.1% post-traumatic stress disorder (n = 1), and 7.1% specific phobia (n = 1). An independent sample t test was conducted to examine differences in RT between patients with and without comorbid MDD. There were no significant differences in RT between these two groups for any valence/image onset time at pre-, mid-, or post-treatment.

Case control differences

Independent samples t tests demonstrated no significant differences between patients with GAD and controls in terms of age (t = − 1.64, df = 54, p = .107). Chi square tests determined that there were no significant differences between the two groups in sex (x 2 [1, N = 56] = 0.84, p = .36), race (x 2 [3, N = 56] = 0.53, p = .91), or ethnicity (x 2 [1, N = 56] = 0.25, p = .62). In terms of EIT performance, independent samples t tests demonstrated a significant difference between participants in the GAD and control group for negative images (M diff  = − 222.04, t = − 2.04, df = 55, p = .046, 95% C.I. = − 440.23, − 3.8448, hedge’s g = 0.545) and neutral images (M diff  = − 201.97, t = − 2.04, df = 55, p = .047, 95% C.I. = − 400.86, 03.0852, hedge’s g = 0.544), with participants with GAD demonstrating an overall slower reaction time for both image types compared to controls.

Behavioral Change Over Treatment

Mean reaction times were examined using a repeated measures analysis of variance (RM ANOVA) for time (pre-treatment, mid-treatment, post-treatment) × image valence (negative, neutral). We observed a significant within-subjects main effects of time (F [2, 26] = 11.38, p < .01, η p 2  = 0.467) and image valence (F [2, 26] = 8.08, p = .002, η p 2  = 0.383. Planned contrasts revealed significantly faster RTs at mid—than pre-treatment (F [1, 13] = 9.51, p = .009, η p 2  = 0.422) but not mid- than post-treatment (F [1, 13] = 1.56, p = .233, η p 2  = 0.107). Overall, RTs were significantly faster for tones following neutral images than negative images (F [1, 13] = 10.515, p = .006, η p 2  = 0.447). An examination of mean RTs demonstrated faster RTs for negative images at post treatment (M = 710.73, SD = 155.60) compared to mid (M = 778.91, SD = 215.03) and pre-treatment (M = 958.45, SD = 395.66). This pattern of faster RTs was the same for neutral images at post treatment (M = 710.56, SD = 198.08) compared to mid (M = 735.00, SD = 207.58) and pre-treatment (M = 897.41, SD = 303.78).

Attention Change in relation to Treatment outcomes

Clinical changes in all self-report measures from pre- to post- ERT surpassed conventions for large effect sizes (Mennin et al. 2015). To assess changes in task performance over the course of ERT, we calculated difference scores by subtracting mean RTs at one timepoint (mid- or post-treatment) from mean RTs at the previous timepoint (pre- or mid-treatment) in each condition. To test our hypothesis regarding the relationship between change in task performance and treatment response, we used partial correlations to examine the relationship between pre-mid RT change and post-treatment outcomes, controlling for baseline individual differences on the outcome measures. These results are summarized in Table 4.

Anxiety and Depression Symptoms

There was a strong significant correlation between pre-to-mid-treatment change in RT and a decrease in general anxiety symptoms (MASQ-GDA) and for negative images after controlling for pre-treatment MASQ-GDA (r = .755, p = .005). There were no significant associations between MASQ GDD at post-treatment and pre-to-mid-treatment RT change.

Functional Impairment and Well-Being

Partial correlations indicated a moderate significant correlation between pre-to-mid-treatment RT decrease for negative images and post-treatment (controlling for pre-treatment) scores on the SDS (r = .560, p = .047), but not quality of life at post-treatment as measured by the QOLI.

Attention Change in relation to Trait Mindful Attention

A statistically significant association was found between pre-to-mid-trNeatment negative image RT change and the FFMQ non-reactivity subscale but not the FFMQ observing subscale.

Study 2: Summary

The current study examined changes in the ability to sustain attention throughout ERT as measured by a behavioral task. Consistent with our hypotheses, there was a significant difference in task performance between people with GAD and healthy controls. Additionally, patients evidenced a significant improvement in task performance from pre-to-mid-treatment, but not from mid-to-post-treatment. This pattern of results may reflect the fact that attention regulation skills are specifically cultivated during the first half of ERT (the second half of treatment focuses largely on exposure), and correspondingly, increased ability to sustain attention is more pronounced. Additionally, we hypothesized that changes in RT on the emotional interference task would predict clinical change. Analyses indicated that this was the case for generalized distress symptoms of anxiety, functional impairment, but not for depression or quality of life. In terms of trait mindful awareness, analyses revealed an association between changes in sustaining attention between pre-mid treatment was associated with mindful non-reactivity to inner experience but not mindful observing. These findings offer evidence that an increased ability to sustain attention is associated with treatment-linked reductions in anxiety-related general distress.

General Discussion

The studies examined changes in the ability to flexibly shift and sustain attention throughout ERT as measured by two different behavioral tasks. Consistent with our hypotheses, findings from these studies demonstrated significant baseline differences between patients with GAD and healthy controls in terms of RTs in both studies, demonstrating a deficit in attention regulation in those with GAD consistent with prior investigations (Matthews and MacLeod 2005; Mogg and Bradley 2005). Patients treated with ERT evidenced significant changes in task performance from pre-to-mid-treatment, but not from mid-to-post-treatment in both studies. This finding might be expected given the priority placed in ERT on developing mindful attention skills during the first half of treatment. Additionally, we hypothesized that changes in RT on the conflict adaptation task and EIT would predict changes in clinical indicators of anxiety, depression, quality of life, and social disability. Findings from Study 1 indicated that changes in flexibly shifting attention as measured by the conflict adaptation task were not associated with any of the clinical measures. However, Study 2 analyses indicated that pre- to mid-treatment changes in sustaining attention as measured by the EIT did predict post-treatment outcomes in generalized distress symptoms of anxiety and functional impairment, although these relationships were not observed for symptoms of depression or quality of life. Taken together, these findings suggest that changes in the ability to sustain, rather than flexibly shift attention, improved through the cultivation of mindful emotion regulation skills throughout ERT, highlighting that an increased ability to sustain attention may be a stronger indicator of clinical improvement throughout treatment compared to flexibly shifting attention.

Previous research has suggested that deficits in attention regulation may also play a role in the functionally disabling nature of GAD, as poor attention regulation contributes to increased task-irrelevant processing (Derakshan and Eysenck 2009), which, in turn, promotes difficulty engaging in goal-directed behavior. Specifically, worry, the hallmark diagnostic characteristic of GAD, has been shown to inhibit the ability to shift attention among people with GAD compared to controls (Amir et al. 2009; Stefanopoulou et al. 2014). Independent of a GAD diagnosis, high worriers have shown greater attentional bias to threat compared to low worriers (Williams et al. 2014). Increases in the ability to sustain attention to a goal directed task following treatment with ERT were also associated with decreased social disability, but not increased quality of life, suggesting that sustaining attention contributes to an increased ability to function at work, in social situations, and within their family environments. Given that findings from Study 2 indicated that increased ability to sustain attention was correlated with reduced anxiety and not depression, these findings suggest that attention regulation may be more germane to improvements in chronic anxiety than depression. Prior findings have shown a greater relationship between attention and anxiety than depression (Mogg and Bradley 2005) but these findings extend that work by showing that treatment-related changes in these outcomes are differentially affected by attentional changes, as well.

Previous research has proposed mindfulness as a candidate mechanism crucial to adaptive emotion regulation among individuals with GAD (Hölzel et al. 2013). Much of the work on mindfulness in relation to emotion regulation to date has focused on explicit, or effortful and deliberate, forms of regulation compared to those that are relatively automatic or implicit (Bargh and Williams 2007; Mauss et al. 2007). Training attention strategies may therefore reduce the need to resort to resource-intensive, response-focused attempts to alter emotions after they have fully unfolded. Contrary to our hypotheses, not all aspects of the less elaborative, attentional, components of mindfulness measured in the current studies were related to changes in attention regulation throughout ERT. Non-reactivity to inner experience, rather than observing, seemed to be related to changes in attention regulation in Study 2 while the opposite was true for Study 1. Of note, however, the FFMQ demonstrated modest internal consistency in Study 1, which may have impacted the current findings. Both of these aspects of mindfulness are attentional and less elaborative than other components (e.g., describing) and were therefore expected to be associated with task performance change. However, these different aspects of mindfulness may operate in different ways.4 ERT provides patients with mindful emotion regulation skills aimed at both shifting and sustaining attention to decrease reliance on perseverative processes such as worry, rumination, and self-criticism that are central to GAD (Renna et al. 2017). This skills training allows patients to develop an ability to develop a repertoire of attention regulation skills, with the cultivation of sustaining attention potentially contributing to a higher degree of clinical improvements compared to shifting, which may operate more as a necessary but not sufficient attentional orienting skill.

Although a growing body of research has examined the relationship between mindfulness meditation and attention regulation (i.e., Chambers et al. 2008), future research may benefit from further honing the examination of specific less elaborative aspects of mindfulness and their relationship with attention regulation to establish greater specificity in our understanding of this relationship in both basic and applied research. Further, it may be important to address less elaborative attentional mechanisms in comparison to meta-cognitive mechanisms to determine if treatment changes are driven more by the former, the latter, or a combination of these mechanisms. To effectively determine this, it will be important to utilize a broader array of attention and metacognitive regulation measures and to make sure these measures are well specified to these constructs. Findings from these studies, bolstering previous research examining the relationship between increased mindfulness and stronger attention regulation, offer valuable insight into the importance of targeting the ability to shift and sustain attention as potential mechanisms in treatment as a way to improve symptoms associated with psychopathology. Study findings indicate that the ability to sustain attention may be a particularly worthwhile treatment target in interventions.

The findings from the present two studies are consistent with other interventions such as MBTs (Moore et al. 2012), as well as attention bias modification (ABM) interventions, which train individuals to shift their attention away from threatening stimuli and towards neutral stimuli through traditional and modified dot-probe task designs (Bar-Haim 2010). Although the findings across all anxiety disorders are mixed and occasionally fail to show good replicability ABM generally produces reductions in anxiety (Mogg et al. 2017). Considering ABM for GAD in particular, 58% of participants in the ABM condition, compared to a control condition, no longer met DSM-IV criteria for GAD following a 4-week, eight-session intervention (Amir et al. 2009). However, notably, a subgroup of individuals still maintained symptoms consistent with GAD, further demonstrating that shifting attention may be a necessary, but insufficient, treatment target to produce complete and lasting symptom reduction. Particularly, these trainings may help the client learn to effectively move their attention away from threat but they may still have difficulty sustaining their attention in the presence of aversive stimuli. For clients experiencing greater symptom severity, developing this form of attention regulation may be important for reducing anxiety symptoms and subsequently increasing functional behavior. The ability to target attention through a more comprehensive intervention package such as ERT therefore offers the potential for an increased ability to produce symptom change, as it may better address the complexity of attention-related dysfunction that characterizes GAD through targeting multiple mechanisms.

These studies have a number of limitations that should be taken into consideration. Given that ERT has several different components, we were unable to elucidate whether or not changes in attention regulation were specifically contributing to clinical outcomes, or if additional variables may have also contributed to these reductions in clinical changes and increased mindfulness at post-treatment. Future research should attempt to specify mechanisms that may be contributing to improvements in clinical outcomes at post-treatment by dismantling the different components of the treatment and comparing changes associated with each one of them. Doing so would allow us to isolate the specific contribution of attentional training on shifting outcomes in a way that is not possible to disentangle in the current studies.

Although a notable strength of the current study was the use of behavioral tasks instead of self-report measures to assess attention regulation, there were methodological differences between the two tasks that may have contributed to findings. Particularly, the conflict adaptation task utilized facial expression images while the EIT presented participants with images from the IAPS. Although these stimuli have promoted activation in similar neural areas (Britton et al. 2006), tasks that use the IAPS, a set of normatively rated images, exclusively, would promote a more equivalent methodology and better subsequent contextual comparison. Of note, a version of the conflict adaptation task failed to record responses that occurred post-stimulus offset, and we therefore opted to apply a 1-s upper threshold to all of our RT data to maximize the responses available to analyze. Though different from the scoring procedures by Etkin et al. (2006, 2010, 2011), response rates remained high, indicating that for most participants, the majority of their responses occurred within 1 s. The more conservative upper threshold also rules out the possibility that the observed behavioral effects were driven by outlying RTs, such for trials on which participants “spaced out” or were momentarily distracted. Further, although we were able to examine case control differences in the current study, control participants were not tracked throughout time, and therefore only baseline differences could be examined. Future research may benefit from measuring control participants throughout time in a similar manner to treatment participants to assess whether or not these differences in RT persist over time and if those with GAD are able to normalize in a way comparable to controls in terms of task performance as a result of treatment. In doing so, it will be important to consider the potential for practice effects in both groups, as one explanation for changes throughout treatment may be that individuals are habituating to the task. Further, an inert or comparison treatment group would allow us to further elucidate whether or not the treatment components presented within ERT specifically contributed to increases in attention regulation. Lastly, the sample sizes for these two studies were small and homogeneous, and therefore future studies should attempt to replicate these findings with a larger and more diverse sample.

Despite several limitations, these data suggest a promising line of inquiry that builds on ERT’s efficacy in treating individuals with GAD (Mennin et al. 2015). These findings add to the extant literature indicating a role for mindfulness-based attention training to reduce symptoms of GAD and enhance emotion regulation (e.g., Hoge et al. 2014). Consistent with the Research Domain Criteria (RDoC) efforts of the National Institute of Mental Health (Insel et al. 2010), which outlines several treatment targets as avenues for continued research, our findings suggest that training in attention regulatory ability (i.e., ability to shift and sustain attention)—one of the proposed RDoC constructs and proposed core mechanism common to the family of third-wave behavioral therapies (Mennin et al. 2013)—may aid in ameliorating regulatory deficits implicated in GAD psychopathology and further elucidate the necessary treatment components to promote optimal targeting of these deficits.


  1. 1.

    Independent sample t tests indicated that clinic site did not impact any study analyses.

  2. 2.

    Independent sample t tests indicated that clinic site did not impact any of the current study analyses.

  3. 3.

    Negative images utilized were IAPS numbers 2730, 3030, 3100, 3500, 5972, 6230, 6260, 6300, 6350, 6570.1, 6830, 9050, 9250, and 9921 (Mvalence = 2.41, SDvalence = 1.62; Marousal = 6.67, SDarousal = 2.06; Mdominance = 3.20, SDdominance = 2.20). Neutral IAPS images included numbers 2190, 2200, 2210, 2215, 2221, 2270, 2831, 2383, 2440, 2480, 2495, 2722, 2840, 2850, 2870, 2880, 2890, 5030, 5120, 5130, 5390, 5500, 5800, and 7002 (Mvalence = 5.02, SDvalence = 1.38; Marousal = 2.98, SDarousal = 1.96; Mdominance = 5.87, SDdominance = 2.05).

  4. 4.

    We conducted an exploratory post-hoc test of dependent correlations from Study 1 to examine if flexibly shifting attention is more strongly correlated with observing or non-reactivity. Results revealed no significant difference between the relationship of FFMQ Observing and FFMQ Non-Reactivity to conflict adaptation (Z = 1.43, p = .15, Hedge’s g = .73; Steiger 1980) but a large effect size, potentially due to the small sample size. Interestingly, an additional exploratory test of dependent correlations from Study 2 revealed that FFMQ Non-Reactivity was more strongly correlated than FFMQ Observing with sustaining attention (Z = 2.13, p = .03, Hedge’s g = 1.10) for negative images. For neutral images, a similar pattern emerged but the test of dependent correlations just missed significance (Z = 1.74, p = .08, Hedge’s g = .90), but demonstrated a large effect size as well. This pattern of findings may indicate that mindful non-reactivity may contribute to one’s ability to sustain attention regardless of emotional context.



This study was funded by the National Institute of Mental Health (NIMH; 1R34 MH070682).

Compliance with Ethical Standards

Conflict of interest

Megan E. Renna, Saren H. Seeley, Richard G. Heimberg, Amit Etkin, David M. Fresco, Douglas S. Mennin declares that they have no conflict of interest.

Ethical Approval

This study was approved by the IRB board of Yale University and Temple University.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Research Involving Human Participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


David M. Fresco was supported by National Heart, Lung, and Blood Institute Grant R01HL119977 and National Institute of Nursing Research Grant P30NR015326.


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Megan E. Renna
    • 1
  • Saren H. Seeley
    • 2
  • Richard G. Heimberg
    • 3
  • Amit Etkin
    • 4
    • 5
    • 6
  • David M. Fresco
    • 7
    • 8
  • Douglas S. Mennin
    • 1
  1. 1.Teachers CollegeColumbia UniversityNew YorkUSA
  2. 2.The University of ArizonaTucsonUSA
  3. 3.Temple UniversityPhiladelphiaUSA
  4. 4.Department of Psychiatry and Behavioral SciencesStanford Neuroscience InstituteStanfordUSA
  5. 5.Stanford UniversityStanfordUSA
  6. 6.Sierra Pacific Mental Illness Research Education and Clinical CenterPalo Alto VALivermoreUSA
  7. 7.Kent State UniversityKentUSA
  8. 8.Case Western Reserve Medical CenterClevelandUSA

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