بررسی رابطه بین اجتناب عاطفی مثبت و منفی و شدت علائم اضطراب: نقش تعدیل کننده کنترل توجه

Abstract Background and objectives Emotional avoidance has been found to be associated with higher levels of anxiety. However, no research to date has differentiated between the avoidance of positive and negative emotions in relation to anxiety. Additionally, no studies have examined the extent to which attentional control moderates the relation between the avoidance of emotions and anxiety. Thus, the purpose of this study was to (a) clarify relations between both positive and negative emotional avoidance and anxiety, and (b) examine attentional control as a moderator of the relations between both positive and negative emotional avoidance and anxiety. Methods A community sample of adults (N = 93) completed a series of questionnaires, as well as a laboratory-based measure of attentional control. Results Greater avoidance of both positive and negative emotions was associated with higher levels of anxiety. Additionally, attentional control moderated the relationship between negative (but not positive) emotional avoidance and anxiety. Specifically, the avoidance of negative emotions was associated with higher levels of anxiety for those with lower attentional control. Limitations Limitations include a cross-sectional design, use of self-report measures, and the examination of hypotheses within a non-clinical sample. Conclusion Findings are consistent with a growing body of research demonstrating the moderating role of attentional control in the relation between risk factors and negative outcomes. Findings also suggest that empirically-based treatment approaches that contain attention-based components may be beneficial for emotionally avoidant individuals with poor attentional control abilities

Introduction According to the National Comorbidity Survey Replication, anxiety disorders are the most commonly occurring psychiatric disorders in the United States, affecting approximately 18% of the general population in a given year (Kessler, Chiu, Demler, & Walters, 2005). In addition to the high level of psychological distress associated with severe levels of anxiety, anxiety disorders result in substantial impairment in social, occupational, and family functioning, as well as poorer physical health and an overall reduced quality of life (Hoffman, Dukes, & Wittchen, 2008). Moreover, the economic burden (e.g., treatment costs, work performance costs) of anxiety disorders is estimated to be over forty-two billion dollars per year, or more than 1/3 of the total yearly mental health bill of the United States (Kessler & Greenberg, 2002). Given the substantial burden associated with anxiety, considerable effort has been directed toward identifying risk and resiliency factors for the development and maintenance of anxiety pathology. One factor that has received increasing attention for its role in the development of anxiety is the tendency to avoid emotions (Campbell-Sills and Barlow, 2007 and Salters-Pedneault et al., 2004; see also Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Although the vast majority of the research in this area has focused exclusively on the avoidance of negative emotions, theoretical and empirical literature suggests that the avoidance of both positive and negative emotions may contribute to anxiety pathology. For example, it has been suggested that individuals at high risk for problems with anxiety (e.g., individuals high in anxiety sensitivity) may view any internal experience associated with heightened physiological arousal as aversive, including both positive and negative emotions. As a result, these individuals may learn to fear these emotions and be motivated to avoid them (Tull and Roemer, 2007 and Williams et al., 1997). Further, although the avoidance of emotions may result in temporary relief, it tends to have paradoxical effects in the long-term, increasing physiological arousal, worsening emotional distress, and motivating future avoidance (e.g., Campbell-Sills et al., 2006 and Levitt et al., 2004). Moreover, the chronic reliance on emotional avoidance as a regulation strategy may interfere with adaptive cognitive and emotional processing, contributing to the maintenance or worsening of anxiety (Foa & Kozak, 1986). Consistent with this literature (and in support of the relevance of positive emotional avoidance to anxiety as well), Tull and Roemer (2007) found that individuals who had experienced an uncued panic attack within the past year reported greater use of emotionally-avoidant regulation strategies in response to a positive emotion-inducing film clip, relative to individuals with no history of panic attacks. Likewise, Roemer, Litz, Orsillo, and Wagner (2001) found that combat Veterans with (vs. without) posttraumatic stress disorder reported the suppression of both positive and negative emotions. Finally, several studies have demonstrated that the combined avoidance of both positive and negative emotions is associated with anxiety-related pathology (including PTSD symptoms and general anxiety symptoms) in both clinical and nonclinical samples (Naifeh et al., 2012, Tull et al., 2011 and Wildes et al., 2010). Despite increasing support for the role of positive emotional avoidance in anxiety-related pathology, additional research is needed to explore the separate (and potentially unique) roles of positive and negative emotional avoidance in anxiety. Furthermore, additional research is needed that examines factors that may moderate the relation between positive and negative emotional avoidance and anxiety. One factor that may hold promise in this regard is attentional control (i.e., the skilled control of higher-order executive attention to regulate, or override, more automatic dominant response tendencies). In Gross's (1998) process model of emotion regulation, the ability to flexibly control attention is considered essential for maintaining psychological well-being, with attention deployment theorized to be the gatekeeper of emotion regulation. Indeed, research provides support for attentional control as a protective factor for psychopathology, with lower attentional control associated with negative emotionality, poor social adaptation, and externalizing behaviors (Derryberry and Reed, 2002 and Eisenberg et al., 2000) and higher attentional control associated with positive emotionality and faster mood recovery following exposure to a trauma cue (Bardeen and Read, 2010 and Derryberry and Reed, 2002). Consistent with Gross' process model, empirical research has shown that anxiety may be maintained and exacerbated through prolonged attentional engagement with threat information (Constans, 2005 and Elzinga and Bremner, 2002), and that the flexible use of attentional control to disengage and shift attention away from threat-related stimuli may reduce distress (Bardeen and Orcutt, 2011 and Bardeen and Read, 2010). As a result, greater attentional control may allow one to remain in a threatening or anxiety-provoking environment, facilitating habituation rather than the deployment of less adaptive secondary regulation strategies, such as emotional avoidance. Consistent with this premise, recent research provides support for the protective role of attentional control in the relation between putative risk factors for anxiety and anxiety-related pathology. For example, studies have found that attentional control protects against (a) higher levels of anxiety among individuals prone to using maladaptive and avoidance-oriented coping behaviors (Fergus, Bardeen, & Orcutt, 2012), (b) decrements in speech performance among those with public-speaking anxiety (Jones, Fazio, & Vasey, 2012), and (c) fearful responding to a CO2 challenge among those with higher levels of trait anxiety (Richey, Keough, & Schmidt, 2012). Despite increasing support for the moderating role of attentional control in psychopathology, one limitation of the extant research in this area is the primary reliance on self-report measures of attentional control (i.e., Attentional Control Scale; Derryberry & Reed, 2002). Some researchers have suggested that the Attentional Control Scale may measure beliefs about attentional control rather than providing an index of actual attentional control abilities (Spada, Georgiou, & Wells, 2010). Moreover, research has shown that the moderating effect of attentional control processes can take place in as little as 150 ms (Bardeen & Orcutt, 2011); thus, it may be especially difficult for individuals to report on cognitive processes that occur so rapidly. As such, the use of more objective measures of attentional control, such as laboratory-based behavioral tasks, may be an important next step in advancing this line of research. Extending past research in this area, the goals of the present study were to a) differentiate between the avoidance of positive emotions and negative emotions in relation to anxiety symptom severity and b) examine the moderating role of attentional control (assessed in the laboratory) in these relations. We predicted that both positive and negative emotional avoidance would be uniquely positively associated with anxiety. In addition, we expected that attentional control would moderate the relations between positive and negative emotional avoidance and anxiety, with emotional avoidance evidencing a significant association with anxiety symptoms only among individuals with lower (vs. higher) attentional control.

3. Results An examination of bivariate correlations revealed only two significant associations among the primary study variables (i.e., DASS-Anxiety, EAQ-Positive, EAQ-Negative, and ANT-Attentional Control). Specifically, DASS-Anxiety was significantly positively associated with both EAQ-Negative (r = .29, p = .005) and EAQ-Positive (r = .28, p = .007). Of note, EAQ-Positive and EAQ-Negative were not significantly associated with one another (r = −.08, p = .48), thus allaying concerns regarding the potential for multicollinearity in the regression analysis. Results of a hierarchical regression analysis revealed that both EAQ-Positive and EAQ-Negative were significantly positively associated with DASS-Anxiety in Step 1 of the model (see Table 1). Moreover, the interaction of EAQ-Negative and ANT-Attentional Control was significant in Step 2 of the model. The interaction effect was small to medium in size (Cohen's f2 = .08; Aiken & West, 1991), accounting for approximately 7% of the variance in anxiety symptoms. As shown in Fig. 1, results of the simple slopes analysis revealed a significant positive association between EAQ-Negative and DASS-Anxiety among participants with low attentional control (indicated by higher scores on this ANT subscale; B = .56, β = .59, p < .001); among participants with high attentional control, however, EAQ-Negative was not significantly associated with DASS-Anxiety (B = .07, β = .07, p = .63). Table 1. Hierarchical multiple regression analysis predicting DASS-21-Anxiety Scale (N = 93). Predictor B β ΔR2 Step 1 .18*** ANT-AC −.01 −.05 EAQ-Negative .31 .32*** EAQ-Positive .33 .30** Step 2 .07* ANT-AC −.01 −.09 EAQ-Negative .31 .33*** EAQ-Positive .28 .26** EAQ-Negative × ANT-AC .01 .25* EAQ-Positive × ANT-AC −.00 −.14 Note. DASS-21 = Depression, Anxiety, Stress Scales; ANT-AC = Attention Network Test-Attentional Control Scale; EAQ = Emotional Avoidance Questionnaire; EAQ-Negative = EAQ scale assessing avoidance of negative emotions; EAQ-Positive = EAQ scale assessing avoidance of positive emotions. ***p < .001, **p < .01, *p < .05. Table options Interaction effect (EAQ-Negative × Attentional Control) was a significant ... Fig. 1. Interaction effect (EAQ-Negative × Attentional Control) was a significant predictor of anxiety (i.e., DASS-21-Anxiety Scale), β = .25, p < .05. Simple slopes analysis revealed that, among participants with lower attentional control, those with higher avoidance of negative emotions reported significantly higher levels of anxiety than those with lower avoidance of negative emotions. There was not a significant association between avoidance of negative emotions and anxiety for those with higher attentional control.