Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20

Attentional avoidant biases as mediators in the

association between experiential avoidance and
blood pressure in dementia family caregivers

María Márquez-González, Isabel Cabrera, Andrés Losada & Bob G. Knight

To cite this article: María Márquez-González, Isabel Cabrera, Andrés Losada & Bob G. Knight
(2017): Attentional avoidant biases as mediators in the association between experiential avoidance
and blood pressure in dementia family caregivers, Aging & Mental Health

To link to this article: http://dx.doi.org/10.1080/13607863.2017.1293003

Published online: 02 Mar 2017.

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AGING & MENTAL HEALTH, 2017
http://dx.doi.org/10.1080/13607863.2017.1293003

Attentional avoidant biases as mediators in the association between experiential

avoidance and blood pressure in dementia family caregivers
Mar
ıa M
arquez-Gonz
alez a
, Isabel Cabrera a
, Andr
es Losada b
and Bob G. Knightc
a
Department of Biological and Health Psychology, Universidad Aut
onoma de Madrid, Madrid, Spain; bDepartment of Psychology, Universidad Rey
Juan Carlos, Madrid, Spain; cSchool of Psychology and Counselling, University of Southern Queensland, Toowoomba, Australia

ABSTRACT ARTICLE HISTORY

Objectives: Experiential avoidance in caregiving (EAC) has been found to be related with dementia Received 31 May 2016
family caregivers
distress and blood pressure (BP). The association between EAC and avoidant Accepted 5 February 2017
attentional biases to emotional stimuli in dementia caregivers, and the potential mediating role of KEYWORDS
these attentional biases in the association between EAC and increased BP are explored. Experiential avoidance;
Method: Seventy nine dementia family caregivers performed a dot-probe task with emotional pictures attentional biases; dementia
(distressing and positive) varying in content (general vs. caregiving-related (CR)) and time of exposure caregivers; blood pressure;
(100 vs. 500 ms). They also completed measures of EAC, anxiety, depression, alexithymia and dot probe task
rumination, and their BP was measured.
Results: EAC was associated with avoidant attentional biases to CR emotional pictures and negative
pictures in general at 100 ms. Experiential Avoidance in Caregiving Questionnaire (EACQ) ‘avoidant
behaviors’ and EACQ ‘intolerance of negativity’ factors were associated with diastolic and systolic BP,
respectively, with attentional avoidance of CR emotional pictures (distressing and positive,
respectively) mediating this association.
Conclusion: Attentional avoidance of CR emotional stimuli may be the link between EAC and
increased BP, as it prevents emotional processing and facilitates the maintenance of physiological
activation. EAC may pose a risk for cardiovascular disease in dementia caregivers.

Introduction Some studies find an anxiety-related pattern of vigilance-

Dementia caregiving represents a prototypical example of
chronic stress that can lead to impairments in caregivers

physical health, due to the numerous physical and psychoso-
cial demands they have to face during a long period of time
(3–15 years) (Shahly et al., 2013; Vitaliano, Zhang, & Scanlan,
2003). Caregivers
distress have been found to be associated
with high blood pressure (BP) (Chattillion et al., 2013;
Mausbach, Patterson, Rabinowitz, Grant, & Schulz, 2007), which
is a risk factor for cardiovascular disease (Roepke et al., 2011).
Experiential avoidance
Experiential avoidance (EA) is the tendency to ignore or avoid
aversive internal experiences (emotions, thoughts or sensa-
tions) and the circumstances which trigger them (Hayes, Stro-
sahl, & Wilson, 2012). EA has been shown to be associated
with different psychological problems, such as depression
and anxiety disorders, with physical health problems, and dys-
functional psychological variables such as alexithymia and
rumination (Cribb, Moulds, & Carter, 2006; Tull, Gratz, Salters,
& Roemer, 2004; Venta, Hart, & Sharp, 2013).
EA may be associated with attentional avoidance of dis-
tressing stimuli as seen in laboratory studies of attention and
emotion using paradigms such as the dot probe task
(MacLeod, Mathews, & Tata, 1986). Attentional biases have
been studied in clinically anxious and non-clinically high anx-
ious people, who have been found to show initial attentional
bias towards distressing stimuli (Bar-Haim, Lamy,
Pargamin, Bakermans-Kranenburg, & van Ijzendoorn, 2007).
avoidance: attention is initially oriented to threatening stimuli
(e.g. at 100 ms), but subsequently directed away from them
(e.g. at 500 ms) (Koster, Crombez, Vershuere, Van Damme, &
Wiersema, 2006; Lee & Knight, 2009), probably reflecting
people
s attempts to regulate their negative emotion via dis-
traction (Cisler & Koster, 2010).
Experiential avoidance in dementia caregiving
EA in caregiving (EAC) occurs when the caregiver is unwilling to
remain in contact with particular negative experiences associ-
ated to care and takes steps to escape from or to avoid them,
trying to alter the form or frequency of these thoughts and feel-
ings and the contexts that occasion them (M
arquez-Gonz
alez,
Romero-Moreno, & Losada, 2010). EA has been identified as a
correlate of dementia caregivers
distress by the only two studies,
to our knowledge, which have analyzed this variable in demen-
tia caregivers using self-report methods (Losada, M
arquez-
Gonz
alez, Romero-Moreno, & Lo
pez, 2014; Spira et al., 2007).
Losada et al. (2014) identified three dimensions of EAC, as
assessed with the Experiential Avoidance in Caregiving Ques-
tionnaire (EACQ): (a) Factor 1: active avoidant behaviors (e.g. ‘I
tend to ignore the negative thoughts that come to me about
my relative’); (b) Factor 2: intolerance of negative thoughts and
emotions towards the relative (e.g. ‘One shouldn’t feel rejection
or other unpleasant emotions about the person you’re caring
for’); and (c) Factor 3: apprehension concerning negative inter-
nal experiences related to caregiving (e.g. ‘I’m scared by the
emotions and thoughts I have about my relative’).

CONTACT Mar
ıa M
arquez-Gonz
alez maria.marquez@uam.es

© 2017 Informa UK Limited, trading as Taylor & Francis Group
2

M. MARQUEZ-GONZ

ALEZ ET AL.

Experiential avoidance in caregiving, blood pressure and tasks (Obisesan, 2009), and there is evidence that hyperten-
attentional biases sion may impair performance in tasks involving executive
functions, such as the dot probe task used in this study
In their study, Losada et al. (2014) found a positive correlation
(Harrington, Saxby, McKeith, Wesnes, & Ford, 2000; Raz,
between EACQ Factor 2 and mean arterial pressure, but
Rodrigue, & Acker, 2003). Five participants were excluded due
potential psychological or physiological mechanisms explain-
to their high error rate in the attentional task (see Results).
ing this association were not addressed. Several studies sup-
The final sample was composed of 79 caregivers (77.22%
port the association between avoidance-related traits and
women) with a mean age of 58.42 years old (SD = 13.56).
strategies such as avoidant and defensive coping style, denial
or suppression, and cardiovascular diseases in the general
population (Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Procedure
Low, Stanton, & Bower, 2008), and in stressful situations such
The variables included in this study were collected as part of
as caregiving (Billings, Folkman, Acree, & Moskowitz, 2000).
an assessment protocol for a wider intervention study (Losada
Although the specific physiological mechanisms linking the
et al., 2015). Given that the measurement of attentional biases
avoidance of negative emotions and thoughts with poorer
was not included in all the stages of the study, the sample
health are not yet fully understood, it has been associated
included in the present study is a subsample of the one
with increased neuroendocrine reactivity, implying increased
included in the Losada et al. (2014) article, which describes
sympathetic nervous system activity (Gross & John, 2003), and
the development and initial validation of the EACQ but does
an increased physiological threat reactivity (Mendes, Reis,
not analyze caregivers
attentional biases.
Seery, & Blascovich, 2003). These physiological reactions, in
Assessment interviews took place in the Health and Social
turn, have cumulative adverse effects potentially leading to
Services Centers. First, participants read and signed an
health problems such as increased BP (Matthews et al., 2004).
informed consent form, and then BP was measured. After BP
Self-reported EAC may be associated with attentional
measurement, sociodemographic, health and stress variables,
biases involving the avoidance of the processing of distress-
alexithymia, rumination and EA were assessed. Then, BP was
ing emotional stimuli (Lo
pez et al., 2010; Pickett & Kurby,
measured again and, after that, participants performed the
2010), which can be captured with a dot probe attentional
attentional task and anxiety and depression were measured,
task. This EAC-related pattern of attentional avoidance may
followed by the third and last BP measurement.
prevent the emergence of uncomfortable emotions and
All procedures contributing to this work comply with the
thoughts in caregivers and may contribute to explain the con-
ethical standards of the relevant national and institutional
nection between EAC and increased BP which has been found
committees on human experimentation and with the Helsinki
in previous studies (Losada et al., 2014).
Declaration of 1975, as revised in 2008.
The aims of the present study are: (1) to explore the atten-
tional correlates of EAC in a sample of dementia caregivers;
(2) to test the potential mediating role of avoidant attentional Materials
biases in the relationship between EA and BP; and (3) to ana-
Questionnaires
lyze the associations between EAC and other relevant varia-
Contextual, health and stress variables. Caregivers
age and
bles in the understanding of caregivers
distress: anxiety,
number of daily hours of sleep were assessed in the interview.
depression, alexithymia and rumination.
Disruptive behaviors of the care recipient were assessed with
Drawing upon the stress and coping model adapted to care-
the 8-items Disruptive Behaviors subscale of the Revised
giving (Knight & Sayegh, 2010), and integrating the EA literature
Memory and Behavioural Problems Checklist (RMBPC) (Teri
described above, three hypothesis were formulated according
et al., 1992).
to which: (a) EAC will be associated with attentional biases
Experiential Avoidance in Caregiving Questionnaire (Losada
reflecting avoidance of caregiving-related (CR) distressing emo-
et al., 2014). The EACQ was developed to measure the specific
tional stimuli; specifically, a pattern of vigilance-avoidance will
manifestations of EA most prevalent in caregivers. It consists
be observed, with attentional vigilance of these stimuli at a
of 15 items and presents a three-factor structure: (1) Factor 1:
short exposure time (100 ms) and attentional avoidance of
avoidant behaviors; (2) Factor 2: intolerance of negativity
those stimuli at a longer exposure time (500 ms); (b) avoidant
(negative thoughts and emotions towards the relative); and
attentional biases will mediate the association between EAC
(3) Factor 3: apprehension of negativity (negative internal
and caregivers
BP; and (c) EAC will be positively associated with
experiences related to caregiving).
emotion-regulation variables (alexithymia and rumination) and
Depressive symptomatology. The Center for Epidemiological
with caregivers
distress (anxiety and depression).
Studies-Depression Scale (CES-D) (Radloff, 1977) was used. It
consists of 20 items assessing depressive symptoms that care-
Method givers’ might have felt over the last week.
Anxiety. Anxiety symptomatology was measured via the 9-
Participants
item tension-anxiety subscale from the profile of mood states
Participants were 102 dementia family caregivers (74.51% (POMS) (McNair, Lorr, & Droppleman, 1971).
women) recruited through Health and Social Services Centers Alexithymia. This variable was assessed with the factor ‘dif-
(e.g. day-care centers). Caregivers were required to be at least ficulty identifying and describing feelings’ of the Toronto
18 years old, to identify themselves as the main source of Alexithymia Scale (TAS-20) (M€ uller, B€
uhner, & Ellgring, 2003),
help for their relative, to report devoting more than one daily which measures difficulty identifying feelings and distinguish-
hour to caregiving duties and that they had been providing ing between feelings and the bodily sensations of emotional
care for more than three consecutive months. Hypertensive arousal.
caregivers (n = 18) were excluded, as the use of medication Rumination. This variable was measured with the Rumina-
for their condition may affect their performance on cognitive tive Responses Scale (RRS-Brief Version) (Jackson & Nolen-

Hoeksema, 1998), which assesses the frequency of appear-
ance of ruminative thoughts.
Blood pressure. Systolic blood pressure (SBP) and diastolic
(DBP) blood pressure were measured at three different points
during the interview (see Procedure). No significant differen-
ces were found between these three measures (for SBP: F(2,77)
= 1.26; p = .29; for DBP: F(2,77) = 0.33, p = .72). Global scores for
SBP and DBP were calculated by obtaining the mean between
the three measurements taken during the interview. The BP
readings were obtained using a noninvasive monitor (OMRON
M7) validated according to the British Hypertension Society
Protocol (Coleman, Steel, Freeman, de Greeff, & Shennan,
2008), following the recommendations for its measurement
(O’Brien et al., 2003).
Attentional task
The dot probe task (MacLeod et al., 1986) was used to mea-
sure attentional biases. This task consists of the simultaneous
presentation of two stimuli (e.g. faces) for a brief duration in a
separate location on the computer screen (e.g. left/right). On
the critical trials, one stimulus is emotionally neutral and the
other is emotional (negative or positive). After the stimuli pair
disappears, a neutral probe (e.g. dot) appears in the same
screen location of one of the stimuli. Participants are then
asked to identify the probe as quickly as possible by pressing
a response key. Responses are most rapid in trials where the
probe appears in the spatial location where the participant is
already attending.
Trial types and timing trials. The task consisted of 16 practice,
320 experimental trials and 80 filler trials which were pre-
sented in a new random order for each participant. There
were 160 trials with general emotional pictures (80 distressing
and 80 positive), 160 trials with CR emotional pictures (80 dis-
tressing and 80 positive) and 80 trials with neutral pictures
(filler trials). Each trial began with a central fixation cross for
500 ms. All experimental trials consisted of a pair of pictures,
an emotional and a neutral one. One of the pictures was dis-
played on the left of the screen and the other on the right
and remained for 100 or 500 ms. Immediately following the
display of the picture pair, the probe stimulus was presented
in the location of one of the pictures, and participants were
required to press one of two keys in a response pad (one
located at the left and one at the right) to indicate the type of
probe (: or ..). The probe remained displayed until a response
was made. The next trial commenced 1000 ms later. Experi-
mental trials were balanced for the position of the emotional
picture and the target to be detected, for the exposure time
and for the type of probe.
Experimental stimuli. In order to explore the specificity of
avoidance effects, emotional stimuli both general and specifi-
cally related to dementia caregiving were used. Pictures with
general content were selected from images collected in the
International Affective Picture System (IAPS) (Lang, Bradley, &
Cuthbert, 1999). Three types of pictures were selected,
according to its emotional valence as classified in the IAPS: (a)
negative (e.g. scenes of persons with expressions of negative
emotions and/or in emotionally impacting situations); (b) pos-
itive (e.g. people laughing); and (c) neutral (e.g. a car).
Pictures with CR content were selected both from the IAPS
and other sources in Internet, as the range of pictures with
this type of content in the IAPS fell short for the purposes of
AGING & MENTAL HEALTH 3
the study. These pictures were of two types: (a) negative:
scenes of frail, dependent, ill or distressed (e.g. sad, scared,
etc.) older adults in a caregiving context (e.g. a sad old
woman with dementia sat on a wheelchair); and (b) positive:
frail elderly people in harmonious and happy scenes with
their relatives, with positive facial expressions (e.g. a smiling
frail old man hugged by his son). An initial pool of 257 pic-
tures with CR content was created by the members of the
research team. Nine independent people were asked to make
two judgments for each picture: (a) What is the emotional
valence? (positive, distressing or neutral); (b) Is the picture
related to the context of caregiving and older adults
depend-
ency? (yes/no). Only those pictures in which all nine judges
agreed that its content was caregiving related were selected:
80 pictures which were judged by all judges as ‘distressing’
and 80 as ‘positive’.
Data analysis
Reaction time data (RT) from the dot probe task were analyzed.
Attentional bias scores for each emotional picture content
(general/CR) and valence of pictures (distressing/positive) at
both exposure times (100 and 500 ms) were calculated for
each participant, by subtracting the mean RT when probes
appeared in the same location as the emotional picture, from
the mean RT when probes occurred in the opposite location
(e.g. Mogg, Millar, & Bradley, 2000). The following attentional
bias scores were obtained: attentional biases towards general
distressing pictures at 100 ms (AB-GD-100) and at 500 ms (AB-
GD-500); towards CR distressing pictures at 100 ms (AB-CRD-
100) and at 500 ms (AB-CRD-500); towards positive general pic-
tures at 100 ms (AB-GP-100) and at 500 ms (AB-GP-500); and
towards CR positive pictures at 100 ms (AB-CRP-100) and at
500 ms (AB-CRP-500). Positive values of attentional bias scores
indicate vigilance for the emotional picture and negative val-
ues reflect attentional avoidance.
Participants were divided into a high or low EAC group on
the basis of a median split carried out on their scores on the
EACQ. In order to explore the avoidant attentional correlates
of EAC, a 2 £ 2 £ 2 £ 2 mixed design ANOVA of attentional
bias scores was carried out. The between-subjects variable
was the EAC group (low/high in EACQ). The within-subject
variables were emotional valence of pictures (distressing/posi-
tive), picture content (general/CR) and exposure time (100/
500 ms). Omega squared (v2) effect sizes were calculated.
In order to test the mediating role of attentional biases in
the association between EAC and BP, two path models were
estimated to predict SBP and DBP (through the AMOS 21 soft-
ware). Following the suggestions by McDonald and Ho (2002),
an analysis of the correlations between the variables included
in the study was performed prior to the performance of path
analysis. Indices of model fit included the chi-square (x2) sta-
tistic; the chi-square value divided by the degrees of freedom
(x2/df), with values under or near three indicating good
model fit (Bollen, 1989); the root-mean-square error of
approximation (RMSEA), with values under .06 indicating
good fit, the comparative fit index (CFI) and the Tucker-Lewis
index (TLI), with values over .95 indicating good fit for the
latter two (Hu & Bentler, 1998). Mediation was analyzed fol-
lowing Preacher and Hayes (Preacher & Hayes, 2004) recom-
mended bootstrapping approach.
4

M. MARQUEZ-GONZ

ALEZ ET AL.

Results interaction effect was found, F(1,78) = 7.762, p = .007, v2 =

Participants with more than 25% of trials with errors in the dot
probe task (n = 5) were excluded from the analyses. First, RT
data from trials with errors were discarded (1.49% of data).
Second, we verified that there were not any RTs lower than
250 ms. Third, RTs of more than 1.96 SDs (p < .05) below or
above each participant’s mean in each trial type were
excluded in order to reduce the influence of outliers (Heerena,
Mogoas, McNallyc, Schmitz, & Philippot, 2015). This resulted in
the elimination of 5.01% of the trials.
Analysis of the results in the dot probe task: ANOVA
There were no significant main effects, but two significant
three way-interaction effects were found. First, EAC x picture
valence x exposure time, F(1,77) = 6.272, p = .014, v2 = .016. To
break down this interaction, data were examined for 100
and 500 ms separately and a 2 £ 2 mixed design ANOVA of
attentional bias scores were carried out for each exposure
time. The between-subjects variable was the EAC (low/high in
EACQ). The within-subject variables were the picture valence
(distressing /positive). There were no significant main or inter-
action effects at 500 ms. However, at 100 ms a significant
.041. Participants with high levels of EAC avoided distressing
pictures and attended to positive pictures at 100 ms, whereas
those with low levels avoided positive pictures at 100 ms
(Figure 1).
The second significant three-way interaction effects was
EAC x picture content x exposure time, F(1,77) = 6.587, p = .012,
v2 = .017. To break down this interaction data were also
examined for 100 and 500 ms separately and a 2 £ 2 mixed
design ANOVA of attentional bias scores were carried out for
each exposure time. The between-subjects variable was the
EAC (low/high in EACQ). The within-subject variables were the
picture content (general/CR). There were no significant main
or interaction effects at 500 ms. However, at 100 ms a signifi-
cant interaction effect was found, F(1,77) = 5.004, p = .028, v2 =
.024. Participants with high levels of EAC avoided CR pictures
and attended to general pictures at 100 ms, whereas those
with low levels avoided general pictures and attended CR
information at 100 ms (Figure 2).
Path analyses
Drawing on the stress and coping model adapted to caregiving
(Knight & Sayegh, 2010), and on the basis of the correlation

10
Mean attentional biases (ms) at 100

2
ms

Positive
-2
Negative

-6

-10
Low High
Experiential avoidance in caregiving
Figure 1. Mean attentional biases (ms) at 100 ms for positive and distressing pictures in low and high EAC caregivers.

10
Mean attentional biases (ms) at 100

-2
ms

General

-6 Caregiving

-10

-14
Low High
Experiential avoidance in caregiving
Figure 2. Mean attentional biases (ms) at 100 ms for general and CR pictures in low and high EAC caregivers.
 AGING & MENTAL HEALTH 5

Table 1. Correlations between the variables of the study.

EACQ Factor 1: EACQ Factor 2: EACQ Factor 3: EACQ
Avoidant Intolerance of Apprehension of Total
behaviors negativity negativity score SBP DBP Alexithymia Rumination Anxiety Depression
AB-GD-100 ¡.06 .12 ¡.05 .02 ¡.19 ¡.17 .03 .24 ¡.08 ¡.19
AB-GD-500 .10 ¡.04 .01 .04 .08 ¡.01 .02 .14 ¡.01 ¡.10

AB-CRD-100 ¡.26 ¡.08 ¡.11 ¡.24 ¡.21 ¡.26
¡.01 ¡.14 ¡.14 ¡.08
AB-CRD-500 ¡.06 ¡.03 ¡.15 ¡.11 ¡.00 ¡.17 ¡.17 .05 .01 .08
AB-GP-100 .18 .44 .05 .38 .07 .04 .07 .12 ¡.08 ¡.06
AB-GP-500 ¡.24 ¡.06 ¡.22 ¡.25 ¡.05 ¡.09 ¡.16 ¡.20 ¡.03 ¡.01
AB-CRP-100 .11 ¡.16 .37 .11 ¡.28 ¡.13 .14 ¡.14 ¡.01 ¡.02
AB-CRP-500 .01 ¡.23 .09 ¡.10 ¡.30 ¡.24 .01 ¡.20 ¡.29 ¡.27
SBP .08 .22 ¡.13 .12 ¡ .77 ¡.15 .04 .17 .19
DBP .23 .15 ¡.11 .18 .77 ¡ .03 .14 .26 .18
Alexithymia .46 ¡.06 .36 .38 ¡.15 .03 ¡ .38
.33
.23
Rumination .37 ¡.07 .16 .24 .04 .14 .38 ¡ .61 .51
Anxiety .17 .01 .05 .12 .17 .26 .33 .61 ¡ .66
Depression .08 ¡.11 ¡.05 ¡.03 .20 .17 .23 .51 .66 ¡
Disruptive behaviors .02 .06 .17 .04 .03 .01 .08 .26 .31 .23
of care recipient
Sleep hours ¡.12 .06 ¡.08 ¡.07 ¡.16 ¡.14 .24 .17 .41 ¡.21
Caregiver
s age ¡.15 .05 ¡.15 ¡.12 .38 .13 ¡.14 ¡.12 ¡.11 .14
Caregiver
s gender ¡.11 .17 .03 .03 .15 ¡.01 ¡.14 ¡.24 ¡.20 ¡.19
Note: AB-GD-100 = attentional bias towards general distressing pictures at 100 ms; AB-GD-500 = attentional bias towards general distressing pictures at 500 ms;
AB-CRD-100 = attentional bias towards CR distressing pictures at 100 m; AB-CRD-500 = attentional bias towards CR distressing pictures at 500 ms; AB-GP-100
= attentional bias towards positive general pictures at 100 ms; AB-GP-500 = attentional bias towards positive gGeneral pictures at 500 ms; AB-CRP-100 =
attentional bias towards CR positive pictures at 100 ms; AB-CRP-500 = attentional bias towards CR positive pictures 500 ms; Gender: 0 = female, 1 = male.

p .05.

p  .01.

p .001.

analysis (Table 1), separate models for SBP and DBP were gen-
erated. Mean SBP was 11.87 (SD = 1.75; range = 8.60–16.30)
and mean DBP was 7.70 (SD = 0.99; range = 5.60–10.10).
Contextual and health variables (caregivers’ age, gender and
hours of sleep) and caregiving stressors (care recipient’s disrup-
tive behaviors) were included in both models. Besides these
variables, emotion-regulation variables and attentional biases
which had shown to be significantly associated with either EAC
(EACQ ‘Avoidant Behaviors’ and ‘Intolerance of Negativity’) or
BP (SBP or DBP) were included in the models.
The SBP model included the following variables: (a) EACQ-
intolerance of negativity factor (Factor 2) and AB-CRP-500, as
they correlated significantly with SBP; and (b) AB-GP-100, due
to its significant correlation with EACQ-intolerance of negativ-
ity (Factor 2). In the DBP model, the following variables were
included: (a) EACQ-avoidant behaviors factor (Factor 1), AB-
CRD-100 and anxiety, as they had shown significant associa-
tions with DBP; (b) AB-GP-500, alexithymia and rumination,
because they were significantly associated with EACQ-avoi-
dant behaviors factor (Factor 1).
Initially, all paths reflecting the significant associations
showed in the correlation matrix were tested. However, fol-
lowing a model generating strategy (Joreskog, 1993), only
those associations that remained significant (p  .05) once all
the considered variables were included were retained in the
final model. Figures 3 and 4 show the final models for SBP
and DBP, respectively.
The obtained model for SBP (Figure 3) explained 19% of
the variance in caregivers’ SBP. The obtained fit indices (x2 =
6.54; p = .37; x2/df = 1.09; CFI = .985; TLI = .976 and RMSEA =
.034) suggest an adequate fit of the model to the data. The
results of the bootstrap analysis for testing mediation suggest
that the indirect effect of EACQ-Intolerance of negativity
(Factor 2) on SBP through the attentional bias AB-CRP-500 is
significant (standardized indirect effect = .06; p = .04; SE = .04;
95% CI = 0.03–0.16).
Regarding DBP (Figure 4), the obtained model explained
11% of the variance of caregivers DBP. The obtained fit
indexes also suggest a good fit of the model to the data (x2 =
27.68; p = .43; x2/df = 1.03; CFI = .993; TLI = .991, and RMSEA

Attentional bias towards

General Positive
Pictures at 100 ms
.45
(AB-GP-100)
Experiential avoidance
“Intolerance of negativity”
Attentional bias towards
-.23 Care-Related Positive
Pictures at 500 ms
-.26
(AB-CRP-500)
.19
Caregivers´ age Systolic BP
.36

Figure 3. Model with SBP as the outcome variable.

Note: All paths significant at the p < .05 level. Standardized coefficients are displayed.Errors have been omitted to improve clarity.
6

M. MARQUEZ-GONZ

ALEZ ET AL.
Alexithymia
.47
Experiential
avoidance
“Avoidant Behaviors”
.28
Problem behaviors Rumination
in CR .26
.57
Hours of sleep -.38
Anxiety
Figure 4. Model with DBP as the outcome variable.
Note: All paths significant at the p < .05 level. Standardized coefficients are displayed.Errors have been omitted to improve clarity.
= .018). The bootstrap analysis for testing mediation suggest
that the indirect effect of EACQ-avoidant behaviors (Factor 1)
on DBP through the attentional bias AB-CRD-100 is significant
(standardized indirect effect = .06; p = .04; SE = .04; 95% CI =
0.02–0.16). This model also confirms the significant associa-
tions between anxiety and DBP, as well as between EACQ-
avoidant behaviors and the emotion regulation variables
(alexithymia and rumination).
In both models, the associations between BP and the
mediating attentional biases are negative, which suggests
that increased BP is associated with either less attentional vig-
ilance or more avoidance of the emotional stimuli addressed
by the bias. To clarify the direction of this association, inde-
pendent t-test were performed, comparing caregivers with BP
scores in the lower and upper tertiles with regard to the mag-
nitude of the associated attentional biases (AB-CRP-500 for
SBP and AB-CRD-100 for DBP). This analysis revealed that high
SBP caregivers displayed an avoidant bias for CR positive pic-
tures (M = ¡9.9; SD = 59.8) which significantly differed (t50 =
2.1, p = .043) from the vigilant attentional bias towards these
pictures showed by low SBP caregivers (M = 19.9; SD = 42.6).
In a similar way, high DBP caregivers showed an avoidant bias
for CR distressing pictures (M = ¡18.7; SD = 42.7), which was
significantly different (t50 = 2.2, p = .031) from the vigilant bias
showed by low SBP caregivers (M = 8.7; SD = 47.3).
Discussion
In the following sections, the main findings of the study are
discussed.
Experiential avoidance and avoidant attentional biases
The ANOVA reveals that EAC is associated with avoidance of:
(a) distressing emotional pictures; and (b) CR emotional pic-
tures. These biases have been detected at 100 ms, which sug-
gest that they operate very early in the processing of
emotional information. Assuming that, in order to avoid
attending a stimulus, it has to be previously processed at
some level, these results suggest that EAC may be associated
with a heightened sensitivity to detect potential distressing
stimuli, which may operate at a very early stage of informa-
€
tion processing or even preattentively (Ohman & Soares,
1993). Previous studies have detected preattentive biases in
anxious subjects using very short exposure times (e.g. 14 or
Attentional Bias
towards Care-Related
-.24 Distressing pictures at
100 (AB-CRD-100)
-.26 Attentional Bias
towards Care-Related
Distressing pictures at -.23
100 (AB-CRD-100) .11
Diastolic BP
.57
30 ms) (Lee & Knight, 2009; Mogg, Bradley, & Williams, 1995).
Interestingly, the pattern of very rapid vigilance of threaten-
ing cues has been found in repressors (Derakshan, Eysenck, &
Myers, 2007). Future studies using shorter, even subliminal,
exposure times in the attentional task are needed to explore
the hypothesis of an EAC-related early vigilance. Also, studies
using eye-tracking methodology may allow the measurement
of gaze and focus of visual attention.
Attentional biases as mediators of the association
between EAC and blood pressure
The results of this study confirm previous findings regarding
the significant association between EAC and BP (Losada et al.,
2014). In this study, EACQ ‘Avoidant Behaviors’ (Factor 1) and
EACQ ‘Intolerance of Negativity’ (Factor 2) have been found
to be associated, respectively, with DBP and SBP. Further-
more, these relationships are mediated by attentional biases.
The association between EACQ ‘Avoidant Behaviors’ and DBP
is mediated by the atentional bias towards CR Distressing pic-
tures at 100 ms, while the association between EACQ ‘Intoler-
ance of Negativity’ and SBP is mediated by the attentional
bias towards CR Positive pictures at 500 ms. In both cases, the
association between attentional biases and BP is inverse and
reflects that increased BP is associated with more avoidance
of caregiving-related emotional pictures (CR distressing pic-
tures at 100 ms for DBP, and CR positive pictures at 500 ms
for SBP). These results suggest that EAC-attentional avoidance
is not limited to negatively valenced stimuli, and that the
overgeneralization of attentional avoidance to positive
aspects of caregiving may be associated with physiological
stress.
Attentional avoidance of CR emotional stimuli may prevent
emotional processing to be completed and conscious emo-
tional experience to arise, while also facilitating the mainte-
nance of the physiological activation which has been already
generated by the preattentive processing of these stimuli
(Derakshan et al., 2007). This heightened physiological activa-
tion could contribute to explain the association found in this
study between EAC and increased BP. Furthermore, EAC-
related attentional avoidance of CR emotional stimuli may
interfere with caregivers
appropriate coping with caregiving
problems or situations, hampering the identification of com-
ponents of problematic situations or care-recipient behaviors

which could be essential for their resolution (e.g. contextual
factors, care recipient’s facial expressions).
Experiential avoidance, emotion regulation and distress
This study supports previous findings showing that the EACQ
‘Avoidant Behaviors’ factor (Factor 1) is related to alexithymia
and rumination, emotion regulation variables which have
shown to be relevant in the explanation of caregiving stress
and coping (Losada et al., 2014). Alexithymic caregivers
diffi-
culty to appropriately identify and describe negative emotions
may contribute to make them distressing, and thus may facili-
tate avoiding experiencing them. The association between EAC
and rumination provide support to EA conceptualizations of
rumination (Giorgio et al., 2010), according to which it may
serve an avoidant function whereby the focus on recursive cog-
nition facilitates the avoidance of difficult emotions.
However, contrary to what was expected, no significant
associations have been found between EAC and anxious and
depressive symptomatology. The association of EAC with alex-
ithymia may contribute to explain these findings: the difficulty
for identifying and describing emotions may interfere with
caregivers
awareness and expression of emotional distress. In
fact, the construct of EAC itself, as measured with the EACQ,
involves subtle forms of avoidance, such as denial of negative
emotions and lack of awareness of one’s own negative emo-
tions, potentially close to repression strategies (Myers, 2010).
The differential associations found between EACQ factors and
the rest of variables analyzed in this study confirm the multi-
dimensionality and complexity of EA found in previous stud-
ies (G
amez, Chmielewski, Kotov, Ruggero, & Watson, 2011),
which should be further explored by future research.
Clinical implications
The negative health implications of EAC and attentional
avoidance of CR emotional stimuli found in this study suggest
the potential health benefits of acceptance and mindfulness
techniques to enhance the ability of caregivers with high
EAC to attend and process their disturbing emotions, which is
a requisite for their appropriate regulation, and for taking
advantage of their informative value (Oatley, 2010). According
to the guidelines for intervention on cardiovascular problems,
training caregivers in stress management techniques may be
an important secondary prevention intervention (e.g. Leon
et al., 2005), as presenting high levels of BP (prehypertension)
is considered to be a risk factor for hypertension (e.g. Julius
et al., 2006). Acceptance and mindfulness techniques are
stress management techniques which represent essential
tools of acceptance and commitment therapy (Hayes et al.,
2012), which has recently been found to be an effective ther-
apy for dementia caregivers (Losada et al., 2015), and mindful-
ness-based interventions such as mindfulness-based stress
reduction programs (MBSR; Kabat-Zinn, 1990) and mindful-
ness-based cognitive therapy (MBCT). Some intervention
studies raise empirical evidence supporting the capacity of
these therapies to reduce BP (Berman, Morton, & Hegel, 2016;
Hughes et al., 2013; Rosenzweig et al., 2009).
Limitations
Some limitations of this study should be acknowledged. The
used sample is composed of dementia caregivers who
AGING & MENTAL HEALTH 7
volunteered to participate in the study. This characteristic lim-
its the generalizability of the results to dementia caregivers
who are less prone to participate in this type of studies.
Life style factors and health variables known to be associated
with BP (e.g. Body Mass Index, smoking, etc.) were not assessed
and, consequently, were not controlled as potential confound-
ers. However, given the preliminary nature of this study, we
believe that, despite these limitations, it provides interesting
findings which can guide future research studies which can
control these important biological variables.
Concluding remarks
The present study is, to our knowledge, the first one analyzing
the association between EA and avoidant attentional biases
using the dot probe paradigm. EAC-related avoidant atten-
tional biases have a mediating role in the association between
EAC and increased BP. This study represents a significant
advance with regard to the study by Losada et al. (2014) on
EAC, as it explores a potential mechanism explaining the asso-
ciation between EAC and BP, providing evidence suggesting
that attentional biases in the processing of emotional infor-
mation may be important mediators in this relationship. Spe-
cifically, the results of the study suggest that attentional
avoidance of CR emotional stimuli might be the link between
EAC and increased BP, as it inhibits the conscious experience
of negative emotion; this inhibition, in turn, may facilitate the
maintenance of physiological activation, which can eventually
lead to a chronic elevation in BP.
The relationships identified in this study between EA,
attentional biases and BP are preliminary, and future studies
are needed to confirm them and to further clarify the poten-
tial links between these variables.
Acknowledgments
We thank all the caregivers for their participation in the study and also the
following centers for collaborating with us in the project: Fundaci
on Cien,
Fundaci
on Mar
ıa Wolff, Centros de d
ıa Vitalia, Centro de Salud General
Ricardos, Centro de Salud Garc
ıa Noblejas, Centro de Salud Benita de


Avila, Centro de Salud Vicente Muzas, Centro Reina Sof
ıa de Cruz Roja,
Unidad de Memoria de Cantoblanco, Servicio de Neurolog
ıa del Hospital
La Paz, Asociaci
on de Familiares de Alzheimer de Alcorc
on, Instituto de
familia de la Universidad CEU San Pablo, Centro de Psicolog
ıa Aplicada de
la Universidad Aut
onoma de Madrid, and Servicios Sociales de Getafe.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The Spanish Ministry of Economy and Competitiveness [grant number
PSI2015-65152-C2-2-R]; the Spanish Ministry of Science and Innovation
[grant number PSI2009-08132].
ORCID
Mar
ıa M
arquez-Gonz

alez http://orcid.org/0000-0001-6572-8949
Isabel Cabrera http://orcid.org/0000-0001-8362-764X
Andr
es Losada http://orcid.org/0000-0002-3134-7133
8

M. MARQUEZ-GONZ

ALEZ ET AL.
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