اثر حواس پرتی داخلی و خارجی و تمرکز در طول مواجهه با محرک های آسیب ناشی از تزریق خون

Abstract The present study examined the effects of attentional focus on fear reduction during exposure. Participants were randomly assigned to experimental conditions: exposure plus internal focus, exposure plus external focus, exposure plus internal distraction, exposure plus external distraction or exposure alone. Fifty blood-injury-injection fearful participants received 3 weekly exposure sessions. Participants in the distraction group reported the greatest fear reduction, with most notable reductions occurring for the external distraction condition. The distraction group also achieved a greater number of steps on a behavioral avoidance task at post-treatment, with the external distraction condition displaying greater approach behavior at follow-up. At follow-up the distraction group also displayed a greater increase in perceived control than the focusing group. Thus, distraction reduces fear within and between sessions and increases approach behavior in the longer-term, with exposure plus external distraction further facilitating this effect.

3. Results 3.1. Manipulation checks From the audio-taped recordings of all three exposure sessions for the four conditions, a 20 s passage was randomly selected and rated by an independent person to ascertain if the conversation in each condition was in the “correct category”. Forty of the 40 (100%) participants were judged as being in the correct category to which they were originally allocated. An objective measure of response latency (reaction time) was used to measure how closely participants were maintaining their visual focus on the stimulus display. Consistent with Oliver and Page (2003) and Penfold and Page (1999), there was an interaction between mean reaction times on correct trials by group membership, F(1, 36) = 4.67, η2 = .11, p < .05, with the focusing group taking significantly longer to respond to the white probes on the computer screen than the distraction group, t(38) = −2.20, p < .05. Considering that half of the participants in the focusing group were required to engage in conversation regarding details of the threatening stimuli, and may have had their attention diverted from the probes, the longer reaction time for this group seems reasonable. In contrast, all participants in the distraction group were engaged in conversation that was irrelevant to the feared stimuli so they were free to respond to the whole stimulus display. To ensure that participants were attending visually to the feared stimuli in each exposure trial, participants were asked to rate the percentage of time they spent focused on the photographs and syringe. There were no differences in the conditions in terms of the percentage of time participants spent attending to the stimuli across the three exposure trials, F(2, 72) = 1.42, η2 = .03, p = ns. The results indicate that both cognitive and visual attention were manipulated equivalently for each of the four conditions across the three exposure trials. Therefore, it was possible to examine the extent to which these manipulations affected fear reduction and perceived control. 3.2. Test of hypotheses For the sake of clarity the exposure alone condition was used as a baseline, with difference scores calculated so that scores in the other four conditions were examined relative to this condition. The more negative the score, the larger the improvement relative to exposure alone. Hence, the ANOVA used a 3(within-sessions) × 3(between-sessions) × 3(time:pre-treatment, post-treatment and follow-up) × 2(group:distraction or focus) × 2(direction of attention of conversation: internal or external). There were two groups, with two levels of direction of attention in each group. As can be seen in Fig. 1, the SUD ratings decreased significantly over time within each session relative to the control, as indicated by a significant linear, F(1, 36) = 30.31, η2 = .45, p < .05 trend. Furthermore, SUD ratings reduced at a decreasing rate between each exposure session, as reflected by significant linear, F(1, 36) = 59.35, η2 = .62, p < .05 and quadratic, F(1, 36) = 6.02, η2 = .14, p < .05 trends. These results imply that repeatedly exposing participants to the feared stimuli for 10-min durations was effective in reducing fear over time, both within and between exposure sessions. Of particular importance was the need to ascertain if there were any differences between the four conditions within each exposure session for trials 0, 5 and 10 min and between each of the three exposure sessions. The ANOVA yielded a significant within-session × between-session × group × direction of attention four-way interaction, F(1, 36) = 6.33, η2 = .15, p < .05. To understand these relationships it was necessary to break down this interaction by examining the within- and between-session effects for the focusing and distraction groups. Mean SUD scores (+S.E.) for exposure plus internal focus, exposure plus external ... Fig. 1. Mean SUD scores (+S.E.) for exposure plus internal focus, exposure plus external focus, exposure plus internal distraction and exposure plus external distraction conditions at the beginning (0 min), during (5 min) and conclusion (10 min) of exposure trials 1, 2 and 3. Figure options As can be seen in Fig. 1, there were no significant interactions for within-session × between-session × direction of attention, F(1, 18) = .77, η2 = .03, p = ns, for the focusing group. This indicates that there were no differences between exposure plus internal focus and exposure plus external focus conditions within and between exposure sessions. In contrast, there was a significant within-session × between-session × direction of attention interaction, F(1, 18) = 7.05, η2 = .28, p < .05, occurring for the two distraction groups. Further analyses were conducted using a series of independent t tests for each of the three within-session exposure trials for the distraction groups. As evident in Fig. 1, the exposure plus internal distraction and exposure plus external distraction conditions were not significantly different from each other at the beginning of session one, t(18) = 1.34, p = ns, or at 5 min, t(18) = 2.06, p = ns. However, participants in the exposure plus external distraction condition had less fear at the end of session one, t(18) = 2.45, p < .05, and sustained significance for every time point in the remaining exposure sessions (all ts < .05). To determine if the within- and between-session effects on fear reduction generalized to longer-term gains on other measures repeated measures ANOVAs were conducted for the MQ, ACQ and BAT (see Table 1). Analyses of the MQ revealed a significant improvement from pre-treatment to post-treatment, F(1, 36) = 10.58, η2 = .22, p < .05, but not from post-treatment to follow-up, F(1, 36) = .01, η2 = .00, p = ns. There were no significant interactions from pre-treatment to post-treatment, F(1, 36) = .24, η2 = .00, p = ns, or from post-treatment to follow-up, F(1, 36) = .00, η2 = .00, p = ns. This suggests that there was a reduction in fear for all conditions from pre-treatment to post-treatment but no further reductions in fear, thereafter, for any of the conditions. Table 1. Mean and standard deviation (S.D.) scores for the mutilation questionnaire and anxiety control questionnaire at pre-treatment, post-treatment and 1 month follow-up for participants in exposure plus internal focus, exposure plus external focus, exposure plus internal distraction, exposure plus external distraction, and control conditions Condition Anxiety control questionnaire Mutilation questionnaire Pre Post Follow-up Pre Post Follow-up Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Distraction internal 80.4 11.2 90.5 18.0 94.1 13.3 21.1 4.1 16.1 4.2 15.1 3.5 Distraction external 83.8 22.8 100.1 13.2 106.2 9.3 21.2 9.9 13.6 6.5 13.0 8.2 Focus internal 83.5 20.3 88.0 10.4 86.4 10.7 20.5 4.8 17.3 6.5 17.3 7.1 Focus external 83.6 21.7 87.3 16.5 85.1 9.0 23.2 6.0 20.1 7.3 20.8 6.9 Control 85.8 22.0 84.9 17.6 84.3 17.0 20.5 3.4 20.2 6.5 20.1 4.7 Table options On the ACQ there was a significant improvement from pre-treatment to post-treatment, F(1, 36) = 6.09, η2 = .14, p < .05, but not from post-treatment to follow-up, F(1, 36) = 2.83, η2 = .07, p = ns. Consistent with Oliver and Page (2003), an interaction occurred between time by group membership from post-treatment to follow-up, F(1, 36) = 7.50, η2 = .17, p < .05, with scores improving for the distraction groups. However, this was not affected by the direction of attention for the distraction conditions, F(1, 36) = .20, η2 = .01, p = ns. A series of one way ANOVAs revealed that at post-treatment there were no significant differences between the groups, F(1, 38) = 2.65, p = ns, although this changed at follow-up, F(1, 38) = 16.15, p < .05, with participants in the distraction group reporting a significantly greater increase in perceived control than the focusing group, t(38) = 4.02, p < .05. Analyses of the number of steps achieved when viewing the 30 negative content photographic slides in the BAT revealed a significant improvement from pre-treatment to post-treatment, F(1, 36) = 79.47, η2 = .68, p < .05, and from post-treatment to follow-up, F(1, 36) = 29.04, η2 = .44, p < .05, with a time × group × direction of attention interaction occurring from post-treatment to follow-up, F(1,36) = 6.75, η2 = .16, p < .05. A series of one way ANOVAs showed that there was a significant difference between the groups at post-treatment, F(1, 38) = 13.26, p < .05, and at follow-up, F(1, 38) = 11.80, p < .05. At post-treatment and follow-up, participants in the exposure plus external distraction condition were able to complete a greater number of steps on the BAT than the exposure plus internal focus condition (post-treatment: t(18) = −3.36, p < .05; follow-up: t(18) = −3.69, p < .05) and the exposure plus external focus condition (post-treatment: t(18) = −3.56, p < .05; follow-up: t(18) = −6.22, p < .05) who in turn were not significantly different from each other (post-treatment: t(18) = −.14, p = ns; follow-up: t(18) = .51, p = ns). There were no significant differences between the exposure plus internal distraction condition and either the exposure plus internal focus condition (post-treatment: t(18) = −1.73, p = ns; follow-up: t(18) = .73, p = ns) or the exposure plus external focus condition (post-treatment: t(18) = −1.88, p = ns; follow-up:, t(18) = −1.51, p = ns). While there were no differences between the exposure plus external distraction condition and the exposure plus internal distraction condition at post-treatment, t(18) = −1.19, p = ns, the exposure plus external distraction condition was able to achieve a greater number of steps than the exposure plus internal distraction condition at follow-up, t(18) = −3.19, p < .05. This suggests that overall, using distraction strategies increase the likelihood of approach behavior. Conversation directed towards the more non-threatening aspects of the external environment (exposure plus external distraction) further increases this behavior in the long-term.