注意方向與正念導向對改善高強迫傾向者注意偏誤的效應

Abstract

強迫性疾患（obsessive-compulsive disorders, OCD）易有注意偏誤現象，而導致其高估了威脅的可能性和嚴重性，並影響其對訊息處理的資源分配。傳統注意偏誤操弄訓練藉由注意中性刺激，以降低強迫症者對強迫相關威脅情境的敏感性，並增加對注意的控制能力，然而，研究結果並不一致。有別於傳統注意中性刺激的注意偏誤訓練，暴露於威脅刺激而不做出迴避行為，是暴露不反應療法產生療效的主要程序。另外，傳統注意中性刺激的注意偏誤訓練，為由下而上的歷程，易助長個體對威脅刺激的逃避，是負增強。而經由正念，個體覺察並控制注意歷程，可增進自上而下的情緒調節歷程，降低對威脅情境的敏感度。本研究的目的旨在探討注意方向與正念導向對改善高強迫傾向者注意偏誤的效應，並比較相對於傳統注意偏誤操弄訓練，注意威脅詞（強迫詞）與正念導向，此二新的取向對改善高強迫傾向者注意偏誤的效果，據以擬定臨床治療的可行策略。本研究以三個研究分別針對注意方向（注意中性詞/注意威脅詞/注意隨機詞）、指導語導向（正念導向/非正念導向），以及正念合併注意方向，探討此三研究對注意偏誤的效應。本研究以Koster（2004）所提的點偵測作業（dot-probe task）派典與注意偏誤指標（attentional bias index），即注意警覺指標與注意轉移困難指標，比較不同的注意偏誤操弄訓練方式對注意偏誤的兩個主要機制的效應。研究一的參與者共計90人，其中，高、低強迫傾向者各45人，依隨機方式每組中各有三分之一的參與者被分派至上述三種注意方向的注意偏誤操弄方式之一。研究二的參與者共計60人，其中，高、低強迫傾向者各30人，依隨機方式每組中各有二分之一的參與者被分派至上述二種指導語導向的指引方式之一。研究三的參與者共計60人，其中，高、低強迫傾向者各30人，依隨機分派，每組中各有二分之一的參與者被分派至正念導向合併注意中性字詞或正念導向合併注意強迫字詞的二種注意偏誤操弄方式之一。所有參與者須每3-4日進行一次的訓練，共五次，為期約二週半，並分別於第一次訓練前（前測），以及第五次訓練後（後測），檢驗注意偏誤操弄方式對注意偏誤的效應。研究一的結果顯示，注意威脅刺激的注意偏誤操弄可有效降低高強迫傾向者注意警覺指標與注意轉移困難指標，而傳統注意中性刺激的注意偏誤操弄僅能降低注意警覺指標，無法改變注意轉移困難指標。而此兩種注意方向的操弄均可提升正向情緒、正念狀態、自我效能，並降低負向情緒。研究二的結果顯示，正念可有效降低高強迫傾向者注意警覺指標與注意轉移困難指標，亦可提升正向情緒、正念狀態、自我效能，並可使負向情緒與壓抑衝動程度下降；而非正念導向介入則反之。研究三的結果顯示，在正念指引下，注意中性與注意威脅對注意警覺指標與注意轉移困難指標的改變效應相當。雖然兩者均能提升正向情緒、正念狀態與自我效能，並降低負向情緒與壓抑衝動程度。但是，正念合併注意威脅的效應大於正念合併注意中性。本研究亦發現，正念合併注意威脅在注意警覺與注意轉移困難上與單獨注意威脅無差異，但在提升正向情緒、正念狀態及降低負向情緒方面更具效果。正念合併注意威脅可提高注意偏誤操弄的依從性，減少高強迫傾向者面對威脅情境的害怕，降低治療中途退出的可能，故在臨床治療的選用上效果最佳。總體而言，本研究結果顯示，對於改善高強迫傾向者的注意偏誤，注意方向與正念導向皆扮演重要角色，為具有實證效益與潛能的治療方式。

Individuals with obsessive-compulsive disorders (OCD) tend to exhibit attentional biases, which lead them to overestimate the likelihood and severity of threat, thereby influencing how they allocate cognitive resources for information processing. Traditional attentional bias modification training (ABMT) aims to reduce sensitivity to threatening stimuli and enhance attentional control by training individuals to focus on neutral stimuli. However, its empirical results have been inconsistent. In contrast to traditional ABMT, exposure to threatening stimuli while preventing avoidance behaviors represents the core mechanism underlying the efficacy of exposure and response prevention therapy. Moreover, traditional ABMT relies primarily on bottom-up processes, which encourage avoidance of threatening stimuli and serve as negative reinforcers, and thereby maintain the pathology. In this context, mindfulness by fostering awareness and deliberately controlling attentional processes can enhance top-down emotional regulation, thereby reducing sensitivity to threat. This study examined the effects of attention focus and mindfulness on ABMT in individuals with high obsessive-compulsive tendencies. Specifically, it compared traditional ABMT with training attention toward threatening words and mindfulness instruction, in improving attentional biases, and accordingly, aimed to develop some feasible clinical treatment strategies. Three studies were conducted to assess the effects of attentional focus (neutral words / threatening words / random), instruction type (mindfulness / non-mindfulness), and mindfulness combined with attentional focus. The dot-probe task and attentional bias indices proposed by Koster (2004), the attentional vigilance index, and the disengagement difficulty index were used as outcome measures. Study 1 included 90 participants (45 high and 45 low obsessive-compulsive tendencies). They were randomly assigned to one of three attentional focus conditions. Study 2 included 60 participants (30 high and 30 low). They were randomly assigned to mindfulness or non-mindfulness instruction. Study 3 included 60 participants (30 high and 30 low). They were assigned to mindfulness combined with either neutral-focused or threat-focused attention. All participants completed five training sessions across approximately 2.5 weeks, with pre-test and post-test assessments. Results of Study 1 showed that threat-focused attention further reduced both vigilance and disengagement difficulty compared with neutral-focused attention, which only reduced vigilance. Both types of focused attention improved positive emotions, mindfulness, and self-efficacy and reduced negative emotions. Study 2 demonstrated that mindfulness significantly reduced vigilance and disengagement difficulty, improved positive emotions, mindfulness state, and self-efficacy, and reduced negative emotions and compulsive-urge suppression; non-mindfulness showed opposite effects. Study 3 found that, under mindfulness instruction, both neutral-focused and threat-focused attention improved vigilance and disengagement difficulty, but the threat-focused condition yielded greater improvements in positive emotions, mindfulness, and greater reductions in negative emotions as well. Mindfulness, combined with threat-focused attention, did not differ from threat-focused attention alone in terms of bias indices, but it did enhance more emotional and mindfulness outcomes. Combining mindfulness with threat-focused attention can enhance compliance with attention bias modification, reduce fear when individuals with high obsessive-compulsive tendencies face threatening situations, and lower the likelihood of dropping out during treatment; therefore, it is the most effective option in clinical practice. Overall, these findings indicate that attention focus and mindfulness-based approaches are empirically supported and effective methods for reducing attentional biases in individuals with high obsessive-compulsive tendencies, and may serve as promising strategies for clinical intervention.