The Role of Alexithymia in the Face in The Crowd –
Visual Search Task
Bachelorthesis Clinical Developmental Psychology
Jeanine Baartmans (10633456)
University of Amsterdam
Amount of words thesis: 3.778 Amount of words abstract: 108
Supervised by:
Dr. Bram Van Bockstaele Dr. Kiki Nikolaou
Abstract
Alexithymia, also described as emotional illiteracy, is an emotional disorder that often co-occurs with social anxiety. This study investigated whether individuals with varying levels of alexithymia differ in their attentional biases on two conditions of a Visual Search Task (VST) with faces. 61 participants filled a questionnaire to measure alexithymia and completed a Feature Relevant- and Feature Irrelevant-VST as part of a bigger study. There was found no significant interaction between alexithymia and the difference between attentional bias scores on the two conditions of the VST. However, difficulties with identifying feelings, a specific symptom of alexithymia, was found as a confounding variable. Implications for future research are discussed.
The role of Alexithymia in the Face in the Crowd – Visual Search Task
Social anxiety is a fear of one or more social or performance situations in which a person is exposed to unfamiliar people or to possible scrutiny by others. A socially anxious individual fears that he or she will act in a way that will be embarrassing and humiliating (American Psychiatric Association, 2013). At least 13% of the population will meet the diagnostic criteria for a social anxiety disorder (SAD) in their lives (Kessler et al., 1994) and up to 40% of the general population describes themselves as shy (Zimbardo, Pilkonis & Norwood, 1974). These numbers suggest that social anxiety is a problem for many people. Furthermore, interference of social anxiety with daily functioning may be severe (Rapee, 1995; Schneier et al., 1994). People with high levels of social anxiety often show high levels of comorbidity with other disorders (Rapee & Heimberg, 1997).
Several theories assume that cognitive biases, such as attentional biases, underlie the etiology and maintenance of social anxiety. Attentional biases are influenced perceptions by individuals’ implicit or explicit cognitions (Beck, 1976; Eysenck, 1992). The relation between attentional biases and anxiety is best described as a bidirectional, maintaining, or mutually reinforcing relation (Van Bockstaele, 2014). The attentional system of socially anxious individuals may be more sensitive and biased towards social threat related stimuli (Clark & McManus, 2002; Heinrichs & Hofman, 2001; Musa & Lepine, 2000). A way to measure attentional biases in individuals is by using computer tasks. These Attentional Bias-tasks (AB-tasks) use repetitive methods to determine average response times as a measure of the
attentional bias in an individual (Pine, Helfinstein, Bar-Haim, Nelson, & Fox, 2009). The most frequently used measure for attentional biases in social anxiety is the dot-probe task (MacLeod, Mathews, & Tata, 1986). In this task a non-emotional dot-probe, for example a letter or symbol, appears on one of two spatial locations on the computer screen. Subjects have to identify as fast as possible in which of the two locations the probe appears by
pressing a corresponding key. Before the probe appears, a threatening and a non-threatening social stimulus appear simultaneously at the two spatial locations. The computer task
measures the difference in response time for identifying the location of the non-emotional probe after a threatening or a non-threating stimulus as a measure of the attentional bias toward threat-related stimuli (Hakamata et al., 2010). Asmundson and Stein (1994) used the dot-probe task in their study and found that individuals with social phobia responded faster to probes that followed social threat cues than probes that followed neutral cues. In control participants, the difference in response time between the cues was not observed. Furthermore, Pishyar, Harris, and Mezies (2004) found that individuals with low social anxiety had lower response times for indicating happy faces and higher for threatening faces on the dot-probe task. In individuals with high levels of social anxiety, the findings were the other way around. These results show that people with high levels of social anxiety show an attentional bias towards threatening faces on the dot-probe task. Mogg, Philippot, and Bradley (2004) used the dot-probe task in a clinical sample of social anxiety. In this study is was also found that individuals with social phobia have an enhances vigilance for angry face, compared to happy and neutral faces. In addition, Chen, Ehlers, Clark, and Mansell (2002) found an attentional preference with the dot-probe task in socially anxious individuals threatening social cues compared to control participants. In line with these studies Sposari and Rapee (2007) showed with the dot-probe task that socially anxious individuals have a preference towards social cues of threat. Thus, these studies that used the dot-probe task all supported the hypotheses that social anxiety in individuals is related to attentional biases towards social threat stimuli.
Besides the knowledge about attentional biases in socially anxious individuals, some studies have shown that anxious individuals not only have high attention for threat-related stimuli, but they experience also difficulties with disengaging their attention from threat (e.g. Fox, Russo, Bowles, & Dutton, 2001; Yiend & Mathews, 2001). In this theory it is assumed
that individuals with high levels of anxiety have lower attentional control (Eysenck,
Derakshan, Santos, & Calvo, 2007). This theory was supported by the study of Amir, Elias, Klumpp, and Przeworski (2003), in which the hypotheses of lower attentional control on individuals with social anxiety were tested. Amir et al. (2003) used a computer task in which a social threat cue, a neutral cue or a positive cue appeared on one of two spatial locations on the screen. After the cue disappeared, participants had to identify the place where a non-emotional probe appeared. It was found that all participants were slower in identifying the place of the probe when it was presented at the other spatial location than the cue (invalid cues) than when it was presented at the same location (valid cues). Only the individuals with high levels of social anxiety showed even longer response times when the invalid cues were social threat words. These findings support the hypotheses that individuals with high levels of social anxiety experience difficulties with disengaging their attention from socially
threatening stimuli.
A task that was developed to measure attentional biases in social anxiety and takes the attentional control into account is the Visual Search Task (VST) (e.g. Öhman, Flykt, & Esteves, 2001). In a VST for social anxiety, also named Face in the Crowd task, individuals are required to find a certain stimulus in a grid of distracters. For example, individuals have to search for an angry face in a grid of happy faces, or for a happy face in a grid of angry faces. By measuring the difference in response time between these two trial types, the degree of attentional bias can be determined. When individuals have a higher average response time on the trials with finding the happy face in the grid of angry faces, it can be concluded that the individual has an attentional bias towards angry faces (e.g. De Voogd, Wiers, Prins, & Salemink, 2014). Byrne and Eysenck (1995) found in their study using a VST that highly anxious individuals are faster in detecting threatening environmental stimuli than less anxious individuals. Eastwood and colleagues (2005) showed individuals with social phobia were
biased to become aware of negative faces faster than to become aware of positive faces on the VST. Juth and colleagues (2005) stated with their VST-study that high socially anxious individuals showed more effective detection of angry than happy faces. In addition, previous studies indicated that individuals with social anxiety disorder, compared to control
participants, had an attentional bias for angry faces in a neutral crowd. All in all these studies using the VST indicated that individuals with high levels of social anxiety have an attentional bias towards angry faces. Moreover, research suggests that highly social anxious participants were slower in detecting happy faces in a grid of angry faces compared to control participants (Gilboa-Schechtman, Foa & Amir, 1999; Suslow et al., 2004). Thus individuals with high levels of social anxiety seem to be unable to ignore images with negative emotions.
The VST for measuring biases in social anxiety described in the previous paragraph is a Feature Relevant VST (FR-VST). This means that participants have to focus explicitly on the faces in the task, and the faces are also used to measure the attentional bias (e.g.
Franconeri & Simons, 2003). A possible limitation of the FR-VST could be that the control and the active conditions of the task are identical; the target and the control stimuli are both the faces. Therefore, another version of the VST was created, the Feature Irrelevant VST (FI-VST). In this VST, the faces are presented on the background of distractors, which separates the control and active conditions in this task. This makes it possible to differentiate the effect of the attentional bias without the need of a control task.
Another psychological disorder that frequently co-occurs with other disorders is alexithymia (Fukushini, Sei, Morita, & Rahe, 1999). Moreover, Cox, Swinson, Shulman, and Bourdeau (1995) found that the prevalence of alexithymia in individuals with a social anxiety disorder was 28.3%. Alexithymia is a cognitive affective syndrome, which could be described as emotional illiteracy (Gündel, Ceballos-Baumann, & Rad, 2000). Individuals with
feelings, to describe their feelings and they show a rather external oriented thinking style (Schaible et al., 2002). In previous studies it was found that individuals with alexithymia characteristics were less able to recognize affective states in facial expressions (Mann, Wise, Trinidad, & Kohanski, 1994), that the difficulty to describe feelings is negatively related to the ability to detect expressions of negative emotions when they are presented rapidly (Parker, Prkachin, & Prkachin, 2005), and that alexithymia is linked to difficulties in detecting facial expressions (Grynberg et al., 2012). Furthermore, some studies showed that individuals with high levels of alexithymia are more impaired in being able to recognize angry faces than to recognize happy faces (Prkachin, Casey, & Prkachin, 2009; Vermeulen, Luminet, & Cogneille, 2006). These findings could be explained by the possibility that alexithymia mainly impairs the processing of negative facial information, which in healthy individuals is normally detected easier among other faces (Hansen & Hansen, 1988; Öhman et al., 2001).
Given the fact that alexithymia and social anxiety disorder have a high comorbidity rate, it is important to know that studies measuring social anxiety related processes are not confounded by differing levels of alexithymia. As described above, the VST’s for measuring attentional biases in social anxiety use faces with varying emotions. In the FR-VST, an individual should be able to discriminate between the angry and happy emotions on the faces to indicate the target stimulus. Based on previous findings about a bigger impairment in the processing of angry faces than in happy face in individuals with high levels of alexithymia, it could be that these individuals are more likely to show a attentional avoidance bias for angry faces on the FR-VST. In the FI-VST, individuals have to find a target stimulus while not being distracted by faces with emotional expressions. Individuals with high levels of
alexithymia should possibly not respond differently on trials with a background of positive or negative faces in the FI-VST, which results in attentional bias scores close to zero.
attentional biases in social anxiety with faces as stimuli may confound their findings if participants that are included have high levels of alexithymia. More specifically, this study focused on the question whether individuals with varying levels of alexithymia differ in their responses in the two conditions of the VST. It was hypothesized that individuals with high levels of alexithymia would indeed differ in their attentional biases measures by the two conditions of the VST’s as a result of the use of faces in the FR-VST both as target and distracting stimuli and in the FI-VST only as distracting stimuli.
Methods Participants
The participants of the current study were 61 Dutch bachelor students from the
University of Amsterdam. Among the participants were 25 males. All participants subscribed themselves for the study through an online research system of the university. After their participation all students received one research credit point or received ten euros. Materials
Toronto Alexithymia Scale (TAS-20): The TAS-20 is a questionnaire for measuring alexithymia in adults. The TAS-20 consists of twenty statements, for which the participants have to indicate on a five point Likert scale how much he or she relates to the statement. The questionnaire has three subscales: the ‘Difficulty Describing Feelings’ (DCD) -subscale, the ‘Difficulty Identifying Feeling’ (DIF) -subscale and the ‘Externally-Oriented Thinking’-(EOT) -subscale. An example of a statement from the DCD-scale is ‘I’m unsure of which words to use when describing my feelings’, an example from the DIF-scale is ‘When asked which emotion I’m feeling, I frequently don’t know the answer’ and an example from the EOT-scale is ‘I prefer doing physical activities with friends rather than discussing each other’s’ emotional experiences. There are five negatively keyed items. High scores on the TAS-20 correspond with high levels of alexithymia (Bagby, Parker, & Taylor, 1994). The
TAS-20 has a good internal consistency and a good test-retest reliability (Parker, Taylor, & Bagby, 2003). Furthermore, the TAS-20 has good concurrent validity (Bagby et al., 1994).
Social anxiety FR-VST: The social anxiety FR-VST was used as a measure of
attentional biases for social anxiety. The FR-VST is a computer task where participants were presented with a 4x4 grid of faces. Participants had to click using the mouse on the location of a target face as quickly and as accurately as possible . The task consisted of 2 blocks of 36 trials. In one block the participants had to indicate the happy target face among the angry faces, and in the other block the participants had to indicate the angry face among the happy faces. The faces were randomly located in the grid. The presentation of the blocks was counterbalanced across participants and stratified by gender. The task was preceded by six practice trials, in which the participant received feedback on their responses and had to continue until they performed the trial correctly. During the rest of the task every grid was presented until the participant responded by a mouse click. All pictures used in the VST-task came from the Karolinska Directed Emotional Face database (Lundqvist, Flykt, & Öhman, 1998). The attentional bias in the social anxiety FR-VST was measured by subtracting the average response times of trials where the participants had to find an angry face in the crowd of happy faces (negative trials) from the average response times of trials where they had to find a happy face in the crowd of angry faces (positive trials). Negative scores indicate attentional avoidance of angry faces, while positive scores indicate an attentional bias for angry faces.
Social anxiety FI-VST: The social anxiety FI-VST was used as a measure of
attentional biases for social anxiety. The FI-VST is a computer task where participants were presented with a 4x4 grid of faces. The presented faces were also selected from the
Karolinska Directed Emotional Face database (Lundqvist, Flykt, & Öhman, 1998). In the FI-VST neutral stimuli were presented on top of the faces. The neutral stimuli used in the current
FI-VST were the letters ‘b’, ‘d’ , ‘p’ and ‘q’. The participants had to indicate as fast as possible on which place in the 4x4 grid the ‘b’ was presented. The task consisted of two blocks of 36 trials. In each trial the participants were either presented with a grid consisting of only happy faces, or with a grid consisting of only angry faces. Both forms of grids were presented were presented in random order through the entire task. However, there were as much trials with happy faces as trials with angry faces. The task was preceded by six practice trials, in which the participant received feedback on their answered and had to continue until they performed the trial correctly. During the rest of the task every grid was presented until the participant responded by a mouse click. The attentional bias in the social anxiety FI-VST was measured by subtracting the average response times of trials where the participants had to indicate the target stimulus on top of the happy faces (positive trials) from trials where the participants had to indicate the target stimulus on top of the angry faces (negative trials). Design / Procedure
The current study was part of a bigger validation study about VST’s for social anxiety and alcohol addiction. All participants who signed up for the study came to the psychology labs at the University of Amsterdam. Every participant was brought to the computer testing room, where they received an informed consent and had the opportunity to ask questions before the computer tests started.
First, the participants had to fill in five questionnaires on the computer. After completing the questionnaires the participants had to go through the VST-tasks. The first presented VST was the control task with the flowers. Next, the FR-VST and the FI-VST were presented in counterbalanced order. After the VST’s the participants had to do a social threat Implicit Association Task (IAT). Finally, the participants were asked to fill in the TAS-20. After the participants had completed all computer tests and the questionnaires, they received a debriefing and their research credit point or ten euros.
Results
Among all participants, 60 of them completed the VST-tasks. However, on the TAS-20 only 37 responses were obtained. This was due to forgetting to ask the participants to fill out the last questionnaire on paper after the computer tasks.
Before computing the average response times of the trials, the data were cleaned. In the first phase of the cleaning process, all items in which the respondent indicated the wrong stimulus were removed. In total, 38 trials on the FR-VST were answered incorrectly and 37 trials on the FI-VST. Secondly, all responses that deviated more than three standard
deviations from the mean of all responses were removed. In the final phase of the cleaning all responses that deviated more than three standard deviations from the mean of each participant were removed.
After cleaning the data from the VST, the attentional bias measures were computed. The mean attentional bias score on the FR-VST was -173 (SD = 666) and was 12 (SD = 461) on the FI-VST. The mean score on the TAS-20 was 42.11 (SD = 10.37). Next, to find out whether or not the individuals with varying levels of alexithymia differ in their responses on the two conditions of the VST a Repeated Measures-ANOVA has been used. The attentional bias scores on the FR- and FI-VST were used as within-subject factors and the score on the TAS-20 was used as a covariate. The analyses showed no significant difference between the two conditions of the VST as a main effect, F(1,35) = .007. Furthermore, there was also no significant difference between the two conditions on the VST when there was controlled for alexithymia, F(1,35) = .071. Subsequently, the analyses were repeated with the three
different subscales of the TAS-20 as covariates. It was found that the interaction between the difference in attentional bias scores in interaction with the DDF-subscale was not significant,
F(1,33) = 3.704, neither was the interaction with the EOT-subscale, F(1,33) = 1.507.
DIF-subscale was significant, F(1,33) = 5.141, p < .05). This significant effect is presented in figure 1.
Finally, to test whether individuals with high or low levels of DIF did also differ their attentional bias score on each conditions of the VST separately two independent sample t-tests have been used. The between subject factors in these analyses were the below average, and above average group on DIF. The dependent variable scores was the attentional bias score on the FR-VST in the first t-test, and the attentional bias score on the FI-VST in the second t-test. Both t-test were not significant, t(35) = -.787 and t(35) = .006.
Figure 1. The interaction between the attentional bias scores on the VST’s and the Difficulty
Identifying feelings scores as a covariate
AB-FI * DIF AB-FR * DIF
Discussion
The purpose of the current study was to investigate whether individuals with varying levels of alexithymia differ in their attentional biases on the FR- and FI-VST. It was found that individuals with different levels of alexithymia measures by the TAS-20 did not differ in their attentional bias scores on the FR- and FI-VST. However, there was a difference between the two conditions of the VST for individuals with varying levels of difficulties with
identifying feelings, a symptom of alexithymia. In conclusion, the current research showed that studies identifying attentional biases in social anxiety with faces as stimuli could be confounded by individuals that have difficulties identifying emotional states of others. These finding were not completely in line with the expectations. It was namely expected that overall scores on alexithymia would interact with the difference in attentional bias scores between the two conditions of the VST. However, for indicating the target stimulus on the FR-VST, the possible impairment in the ability to identify emotions seems most relevant of the symptoms of alexithymia, which could explain the results.
The findings of the current study cannot be explained by assumption that individuals with high levels of alexithymia show an attentional avoidance bias on the FR-VST for angry faces compared to individuals with low levels of alexithymia. Besides, the attentional bias scores on the FI-VST for individuals with high levels of alexithymia was close to zero, but did not differ from the scores of individuals with low levels of alexithymia. Therefore, to get a better understanding of the interaction with difficulty to identify emotions and attentional bias scores on the VST, more research ne needed.
Some limitations have arisen in the current study. First, not all the participants filled in the alexithymia questionnaire. This can possibly have caused a power problem on this scale, which could explain why the overall scale of alexithymia showed no significant differences between the two conditions of the VST’s. In future research it would be good to include a
bigger sample of participants that fill in the alexithymia questionnaires.
Another limitation of the current study was that there were no explicit measure of social anxiety. These explicit measures could have made it possible to investigate whether a relation with alexithymia scores would have been the same on the questionnaires and attentional bias measures. Moreover, additional explicit measures are needed to find out if alexithymia could be a confounding variable between measuring explicit measures of social anxiety and attentional bias scores.
A final possible limitation of the current study could have been that there were no specific measures included for attentional control. The literature suggest that both individuals who are score high on (social) anxiety and individuals with high levels of alexithymia have lower attentional or effortful control (Eysenck et al., 2007; Amir et al., 2003; Gu, Liu, Guise, Fossella, Wang, & Fan, 2008). Though the VST take attentional control into account, it is not clear whether this also works in interaction with alexithymia. Therefore, it would be good to control for these variables in future research.
This thesis suggests that the difficulty with identifying emotions, which co-occurs frequently with social anxiety, can be a confounding variable in measuring attentional biases with faces with emotional expressions. More research is necessary to gain more knowledge about the relation between alexithymia, implicit measures and explicit measures of social anxiety.
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