Lack of evidence for predictive utility from resting state fMRI data for individual exposure-based cognitive behavioral therapy outcomes: A machine learning study in two large multi-site samples in anxiety disorders.

Data-based predictions of individual Cognitive Behavioral Therapy (CBT) treatment response are a fundamental step towards precision medicine. Past studies demonstrated only moderate prediction accuracy (i.e. ability to discriminate between responders and non-responders of a given treatment) when using clinical routine data such as demographic and questionnaire data, while neuroimaging data achieved superior prediction accuracy. However, these studies may be considerably biased due to very limited sample sizes and bias-prone methodology. Adequately powered and cross-validated samples are a prerequisite to evaluate predictive performance and to identify the most promising predictors. We therefore analyzed resting state functional magnet resonance imaging (rs-fMRI) data from two large clinical trials to test whether functional neuroimaging data continues to provide good prediction accuracy in much larger samples. Data came from two distinct German multicenter studies on exposure-based CBT for anxiety disorders, the Protect-AD and SpiderVR studies. We separately and independently preprocessed baseline rs-fMRI data from n = 220 patients (Protect-AD) and n = 190 patients (SpiderVR) and extracted a variety of features, including ROI-to-ROI and edge-functional connectivity, sliding-windows, and graph measures. Including these features in sophisticated machine learning pipelines, we found that predictions of individual outcomes never significantly differed from chance level, even when conducting a range of exploratory post-hoc analyses. Moreover, resting state data never provided prediction accuracy beyond the sociodemographic and clinical data. The analyses were independent of each other in terms of selecting methods to process resting state data for prediction input as well as in the used parameters of the machine learning pipelines, corroborating the external validity of the results. These similar findings in two independent studies, analyzed separately, urge caution regarding the interpretation of promising prediction results based on neuroimaging data from small samples and emphasizes that some of the prediction accuracies from previous studies may result from overestimation due to homogeneous data and weak cross-validation schemes. The promise of resting-state neuroimaging data to play an important role in the prediction of CBT treatment outcomes in patients with anxiety disorders remains yet to be delivered.

More than fear? Brain activation patterns of dental phobic patients before and after an exposure-based treatment.

Hyperactivation of brain networks conferring defensive mobilization is assumed to underlie inappropriate defensive-preparation in patients with Specific Phobia. However, studies targeting Dental Phobia (DP) yielded quite heterogeneous results and research concerning the effects of exposure treatments on phobic brain activation so far is missing. This functional Magnetic Resonance Imaging (fMRI) study aimed to investigate activation patterns in DP patients during exposure to phobia-related stimuli and the effects of an exposure-based fear treatment on phobia-related activation. Seventeen patients with DP and seventeen non-phobic, healthy controls participated in this fMRI experiment presenting dental-related and neutral auditory and visual stimuli. After completing a short exposure-based CBT program, patients were scanned a second time to illustrate treatment-related changes in brain activation patterns. Pre-treatment fMRI results demonstrate enhanced activation in DP-patients mainly in the precuneus and lateral parietal cortex. Moreover, a small activation focus was observed in the amygdala and anterior cingulate cortex (ACC) as parts of classically fear-related structures. Activation in all these clusters decreased significantly from pre- to post-treatment assessment and in the case of the ACC was correlated with dental fear reduction. Activation changes in the precuneus and lateral parietal cortex suggest a pronounced first-person perspective memory processing including a vivid recall of contextual information from an egocentric perspective triggered by exposure to phobia-related stimuli. Besides a treatment-sensitive hyperactivity of fear-sensitive structures, DP may also be characterized by a disturbed memory retrieval that can be reorganized by successful exposure treatment.

How Do Adherence to COVID-19 Mitigation Measures and Its Predictors Change between 2020 and 2021? An Explorative Investigation in Eight European Union and Non-European Union Countries.

INTRODUCTION: Adherence to COVID-19 mitigation measures is an important vehicle that has contributed to the fight against the pandemic. The present study investigated potential changes of the level of adherence and its predictors between 2020 and 2021 in eight countries. METHODS: Adherence to COVID-19 measures and its potential predictors (perception of usefulness of the measures, rating of the governmental COVID-19 communication, mental health variables, COVID-19 burden) were compared between representative population samples from European Union countries (France, Germany, Poland, Spain, Sweden) and non-European Union countries (Russia, UK, USA) assessed in 2020 (N = 7,658) and 2021 (N = 8,244). RESULTS: In the overall sample, multiple analyses of variance revealed significantly higher levels of adherence to the measures, their perception as useful, positive mental health, and feelings of being well supported and well informed by governments in 2020 than in 2021. In contrast, feelings of being left alone and symptoms of depression, anxiety, and stress were significantly higher in 2021 than in 2020. In France, Poland, Spain, and the UK, the adherence level was significantly higher in 2020 than in 2021. In European Union countries, ratings of governmental communication were less positive, and levels of mental health were lower in 2021 than in 2020. In non-European countries, an opposite result pattern was found. CONCLUSION: The current results indicate a decrease in adherence to the mitigation measures and factors that could foster it. Potential ways how governments and authorities could enhance the population's trust in COVID-19 mitigation measures are discussed.

The Relationship between Reasons for Smartphone Use, Addictive Use Tendencies, Fear of Missing Out, Depression, and Life Satisfaction: A Qualitative and Quantitative Analysis.

INTRODUCTION: In the present cross-sectional study, we investigated whether reasons for smartphone use are similar to those of social media use. Also, we explored links between reasons of smartphone use and mental health variables (problematic smartphone use, FOMO, depression symptoms, and life satisfaction) in Germany during the COVID-19 lockdown period. METHODS: Overall, 571 smartphone users (Mage = 31.60, SDage = 12.73) provided their reasons for smartphone use. The reasons were assigned to six categories by an inductive qualitative content analysis. RESULTS: Five of six reasons were similar to those of social media described by previous research. "Search for social interaction" goes along with less problematic smartphone use and depression symptoms and more life satisfaction. "Search for positive feelings" is associated with lower life satisfaction. More depressed people, those with problematic smartphone use tendencies, higher FOMO, and lower life satisfaction tend to "escape from negative emotions." DISCUSSION: Our results help to understand the relationships between reasons for smartphone use and mental health variables.

Love yourself as a therapist, doubt yourself as an institution? Therapist and institution effects on outcome, treatment length, and dropout.

OBJECTIVE: Research suggests that some therapists achieve better outcomes than others. However, an overlooked area of study is how institution differences impact patient outcomes independent of therapist variance. This study aimed to examine the role of institution and therapist differences in adult outpatient psychotherapy. METHOD: The study included 1428 patients who were treated by 196 therapists at 10 clinics. Two- and three-level hierarchical linear regression models were employed to investigate the effects of therapists and institutions on three dependent patient variables: (1) symptom change, (2) treatment duration, and (3) dropout. Level three explanatory variables were tested. RESULTS: The results showed that therapist effects (TE) were significant for all three types of treatment outcome (7.8%-18.2%). When a third level (institution) was added to the model, the differences between therapists decreased, and significant institution effects (IE) were found: 6.3% for symptom change, 10.6% for treatment duration, and 6.5% for dropout. The exploratory analyses found no predictors able to explain the systematic variation at the institution level. DISCUSSION: TE on psychotherapy outcomes remain a relevant factor but may have been overestimated in previous studies due to not properly distinguishing them from differences at the institution level.

Positive mental imagery and mental health amongst university students in Pakistan.

Mental health problems amongst university students pose a major public health challenge, and this is particularly the case in Pakistan. Alongside broader societal and cultural pressures, cognitive factors likely also play a role in the development of and resilience to mental health problems and may provide a feasible target for interventions. The current study built on previous research in primarily European samples investigating the relationship between one cognitive factor, positive future-oriented mental imagery, and mental health, extending this to a sample of university students in Pakistan (N = 1838). In a cross-sectional design, higher vividness of positive future-oriented mental imagery was associated with lower levels of depressive symptoms and higher levels of positive mental health amongst participants completing questionnaire measures on paper (N = 1430) or online (N = 408). In the sample completing the measures on paper, these relationships remained statistically significant even when controlling for socio-demographic and mental health-related variables. The results provide a foundation for further investigating positive mental imagery as a potential mechanism of mental health and intervention target amongst university students in Pakistan.

Demonstration of a 'leapfrog' randomized controlled trial as a method to accelerate the development and optimization of psychological interventions.

BACKGROUND: The scale of the global mental health burden indicates the inadequacy not only of current treatment options, but also the pace of the standard treatment development process. The 'leapfrog' trial design is a newly-developed simple Bayesian adaptive trial design with potential to accelerate treatment development. A first leapfrog trial was conducted to provide a demonstration and test feasibility, applying the method to a low-intensity internet-delivered intervention targeting anhedonia. METHODS: At the start of this online, single-blind leapfrog trial, participants self-reporting depression were randomized to an initial control arm comprising four weeks of weekly questionnaires, or one of two versions of a four-week cognitive training intervention, imagery cognitive bias modification (imagery CBM). Intervention arms were compared to control on an ongoing basis via sequential Bayesian analyses, based on a primary outcome of anhedonia at post-intervention. Results were used to eliminate and replace arms, or to promote them to become the control condition based on pre-specified Bayes factor and sample size thresholds. Two further intervention arms (variants of imagery CBM) were added into the trial as it progressed. RESULTS: N = 188 participants were randomized across the five trial arms. The leapfrog methodology was successfully implemented to identify a 'winning' version of the imagery CBM, i.e. the version most successful in reducing anhedonia, following sequential elimination of the other arms. CONCLUSIONS: The study demonstrates feasibility of the leapfrog design and provides a foundation for its adoption as a method to accelerate treatment development in mental health. Registration: clinicaltrials.gov, NCT04791137.

Subjective effects and perceived mechanisms of change of cognitive behavioral and mindfulness-based online interventions for low sexual desire in women.

Cognitive-behavioral (CBT) and mindfulness-based therapy (MBT) are effective treatments for Hypoactive Sexual Desire Dysfunction (HSDD) in women. To date, evidence regarding the mechanisms of these treatments for improving low sexual desire is still lacking. To gain comprehensive information on the subjective effects and perceived mechanisms of change of CBT and MBT for HSDD, semi-structured qualitative interviews were conducted with 51 cis-women who participated in a trial investigating internet-based CBT and MBT for HSDD. Data were analyzed with deductive and inductive content analysis. Subjective treatment effects included increased desire, improved communication, and greater self-acceptance. Different mechanisms of change for CBT and MBT were endorsed by participants. This study provides tangible evidence of the different pathways through which CBT and MBT can improve women's sexual desire.

Calibrating your own fears: Feasibility of a remote fear conditioning paradigm with semi-subjective stimulus calibration and differences in fear learning.

Fear conditioning studies have occurred mostly in the laboratory, but recently researchers have started to adapt fear conditioning procedures for remote application. Standardization of aversive stimulus material not causing unnecessarily strong discomfort remains an issue especially relevant to research without experimental supervision. The present study introduces a novel semi-subjective method to calibrate aversive sounds in a remotely conducted fear conditioning paradigm. To demonstrate feasibility and proof of concept, 165 participants completed the paradigm, calibrating the loudness of an aversive sound without the guidance of an experimental instructor. This study also aimed to replicate existing findings of participant groups that differed in their early CS-UCS contingency awareness. Participants were classified as Accurate (UCS more likely after the CS+ than CS-), Poor (UCS more likely after the CS- than CS+, or UCS unlikely after either CS), and Threat Biased (UCS equally likely after the CS+ and CS-). Results indicated both the feasibility and efficacy of the paradigm, with participants showing typical patterns of fear learning. Threat Biased participants showed significantly higher uncertainty towards safety signals. There were no differences between the groups in terms of personality traits, thus questioning whether these attributes mediate differences in fear learning and the emergence of anxiety disorders. Using semi-subjective sound calibration appears to be functional, and future studies may consider implementing the new method when remotely administering fear conditioning paradigms.

Positive Emotions Training (PoET) as an online intervention to improve mental health: a feasibility study.

BACKGROUND: Positive psychology interventions are known to have an impact on mental health as well as on a number of beneficial characteristics like optimism, gratitude and self-efficacy. The Positive Emotions Training (PoET) is one of the first holistic training programs covering eleven positive psychology constructs. The goal of this study was to test PoET's feasibility in the general population and to assess possible effects on positive and negative mental health factors. Additionally, possible effects on optimism, gratitude, happiness, resilience, and self-efficacy were examined. METHODS: The sample (n = 101) was not randomized. Participants were allocated to PoET (n = 55) or control group (n = 46) that did not receive treatment initially. The PoET group completed two training sessions (3.5 h each) that were conducted in an online format with groups of about 30 people. All participants completed positive and negative mental health measures at the beginning of the first training session and at the beginning of the second one as well as 30 days after the second session. Two-factorial repeated measures ANOVAs were conducted to test for possible effects of PoET on mental health. RESULTS: The results showed that the contents were comprehensible and that the conduction of the training was feasible overall. In addition, a significant decrease of depression and anxiety symptoms as well as a significant increase of optimism were found in the PoET group. No significant changes were found in the control group. CONCLUSIONS: Results indicate that PoET is an applicable intervention for improving mental health in the general population. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov on 21/02/2023 (Identifier/Trial registration number: NCT05737251).

Repetitive negative thinking mediates the relationship between addictive Facebook use and suicide-related outcomes: A longitudinal study.

Repetitive negative thinking (RNT) and addictive Facebook use have been shown to be associated with suicide ideation and suicidal behavior. The present longitudinal study aimed to investigate whether the association between addictive Facebook use and suicide-related outcomes is mediated by RNT. Data of 191 German Facebook users (M age = 26.17, SD age = 6.63) were assessed at two measurement time points over a one-year period (first measurement = T1, second measurement = T2) via online surveys. The significant positive association between addictive Facebook use (T1) and suicide-related outcomes (T2) was significantly mediated by RNT (T1). In contrast, a check test that included RNT (T1) as predictor and addictive Facebook use (T1) as mediator revealed no significant mediation effect. The current results demonstrate that if addictive Facebook use leads to RNT suicide ideation and attempts become likely. Therefore, RNT and addictive Facebook use should be taken into account when assessing individuals for risk of suicide.

It's all about control: Sense of control mediates the relationship between physical activity and mental health during the COVID-19 pandemic in Germany.

COVID-19-related burden has a significant impact on mental health and has led to an increase of depression, anxiety, and stress symptoms. Physical activity has been suggested to mitigate the negative effects of the pandemic and to foster mental health. The present study aimed to investigate, whether sense of control might mediate the supposed beneficial effects of physical activity on positive (PMH) and negative mental health (NMH) in unpredictable extraordinary situations. Data were assessed in a sample of 568 students (Mage = 19.90, SDage = 4.52) from Germany via an online survey in fall 2020. Mediation analyses revealed that sense of control mediated the relation between physical activity and PMH as well as depression, anxiety, and stress symptoms, respectively. The findings indicate that physical activity may be a promising strategy for fostering sense of control and thus mental health. Due to its practical implications and practicability, engagement in physical activity could be an effective way to reduce the NMH consequences of the current COVID-19 situation, and therefore should be addressed in actions for long-term prevention and intervention.

Psychometric evaluation of the Positive Mental Health (PMH) scale using item response theory.

BACKGROUND: The investigation of patient-reported outcomes and psycho-oncological interventions mainly focuses on psychological distress or psychopathology. However, the recognition of the equal importance of positive mental health (PMH) has increased lately. The PMH-scale is a brief questionnaire allowing to assess well-being in individuals in the general population and in patients. Previous studies evaluated the psychometric properties of the PMH-scale using classical test theory (CTT). This study is the first to investigate the PMH-scale in patients with cancer using item analysis according to the Rasch model. METHODS: In total, N = 357 cancer patients participated in the study. A Rasch analysis of the PMH-scale was conducted including testing of unidimensionality, local independence, homogeneity and differential item functioning (DIF) with regard to age, gender, type of cancer, the presence of metastases, psycho-oncological support, and duration of disease. Additionally, the ordering of the item thresholds as well as the targeting of the scale were investigated. RESULTS: After excluding one misfitting item and accounting for local dependence by forming superitems, a satisfactory overall fit to the Rasch model was established (χ2 = 30.34, p = 0.21). The new PMH-8 scale proved to be unidimensional, and homogeneity of the scale could be inferred. All items showed ordered thresholds, there was no further item misfit. DIF was found for age, but as the impact of DIF was not substantial, no adjustment related to the age-DIF had to be made. The Person Separation Index (PSI = 0.89) was excellent, indicating excellent discriminatory power between different levels of positive mental health. Overall, the targeting of the PMH-8 was good for the majority of the present sample. However, at both ends of the scale item thresholds are missing as indicated by a slight floor effect (1.4%) and a considerable ceiling effect (9.8%). CONCLUSIONS: Overall, the results of the analysis according to the Rasch model support the use of the revised PMH-scale in a psycho-oncological context.

Suicidal ideation in university students in Lithuania amid the COVID-19 pandemic: A prospective study with pre-pandemic measures.

We aimed to identify patterns of changes in suicidal ideation among university students six months after the COVID-19 outbreak, in comparison to the pre-pandemic suicidal ideation. Furthermore, we explored the links among these patterns and mental health indicators. 474 university students participated in the study in October-December 2019 and October-December 2020. The latent class change analysis revealed four groups: no-ideation (68.1%), stable low ideation (16.2%), increased ideation (8.9%), and decreased ideation (6.8%). Increased, in comparison to decreased ideation, was positively linked to changes in depression, stress, and anxiety. More loneliness during the pandemic was related to higher suicidal ideation.

Patients' self-perceived strengths increase during treatment and predict outcome in outpatient cognitive behavioral therapy.

OBJECTIVE: Modern conceptualizations suggest the independence of positive and negative mental health constructs. Research of positive constructs in psychotherapy is scarce. This study analyzed the development of patients' strengths during psychotherapy and whether pre-therapy strengths incrementally predict treatment outcome. METHODS: Two hundred and two patients (56.44% female, mean age = 42.49) treated by 54 therapists underwent cognitive behavioral therapy. Patients' strengths in different contexts as well as psychopathology, interpersonal problems, and self-esteem were assessed at the beginning and end of therapy. RESULTS: Strengths increased in the contexts of everyday life (EvdayS; d = 0.44, p < 0.001) and current problems (ProbS; d = 0.70, p < 0.001). Strengths in the context of previous crises that were managed successfully (CrisesS) did not change. However, baseline scores of CrisesS were a significant incremental predictor of all outcomes. CONCLUSION: A differentiated assessment of positive constructs is useful for outcome prediction and the implementation of strength-based interventions.

Addictive social media use during Covid-19 outbreak: Validation of the Bergen Social Media Addiction Scale (BSMAS) and investigation of protective factors in nine countries.

Since the Covid-19 outbreak, addictive social media use increased in many countries. To better understand this development, a universal instrument for the assessment of addictive social media use is required. Against this background, we examined the psychometric properties of the Bergen Social Media Addiction Scale (BSMAS) in representative population samples in nine countries (N = 9418, age range: "18 to 24 years" (youngest group), "55 years and older" (oldest group): China, France, Germany, Poland, Russia, Spain, Sweden, U.K., U.S.). Furthermore, we investigated potential factors and mechanisms that could be associated with addictive social media use. Our cross-national findings show that the BSMAS is a unidimensional reliable and valid instrument. Moreover, they reveal that the negative association between positive mental health and addictive social media use is mediated by sense of control in seven of the nine countries (exception: China, Russia). Thus, it can be hypothesized that activities which increase positive mental health could indirectly contribute to the decrease of addictive social media use. We identified conscious engagement in physical activity and a regular sleep rhythm during the pandemic as such potential activities. The fostering of both by governmental programs could enhance positive mental health and reduce addictive social media use.

The relationship between social media use, anxiety and burden caused by coronavirus (COVID-19) in Spain.

The outbreak of COVID-19 and national restrictions to slow down its spread have significantly changed people's everyday lives. Many people engage in intensive social media use (SMU) to stay up-to-date about the pandemic. The present study investigated the extent of SMU as source of COVID-19 information, and its relationship with anxiety and the experienced burden caused by the pandemic in Spain. Of the 221 participants, 52.5% reported to frequently use SM as information source. The use of other information sources such as print and online newspaper reports, television reports, and official governmental online sites was not associated with anxiety and burden caused by the current COVID-19 situation. However, SMU was significantly positively linked to both variables. Moreover, anxiety significantly mediated the relationship between SMU and the experienced burden. The findings show the potential negative effect of SMU on individual emotional state and behavior during the pandemic. They emphasize the significance of an accurate and conscious use of SM specifically during extraordinary circumstances such as the COVID-19 outbreak.

Neural adaptation of cingulate and insular activity during delayed fear extinction: A replicable pattern across assessment sites and repeated measurements.

Adapting threat-related memories towards changing environments is a fundamental ability of organisms. One central process of fear reduction is suggested to be extinction learning, experimentally modeled by extinction training that is repeated exposure to a previously conditioned stimulus (CS) without providing the expected negative consequence (unconditioned stimulus, US). Although extinction training is well investigated, evidence regarding process-related changes in neural activation over time is still missing. Using optimized delayed extinction training in a multicentric trial we tested whether: 1) extinction training elicited decreasing CS-specific neural activation and subjective ratings, 2) extinguished conditioned fear would return after presentation of the US (reinstatement), and 3) results are comparable across different assessment sites and repeated measures. We included 100 healthy subjects (measured twice, 13-week-interval) from six sites. 24 h after fear acquisition training, extinction training, including a reinstatement test, was applied during fMRI. Alongside, participants had to rate subjective US-expectancy, arousal and valence. In the course of the extinction training, we found decreasing neural activation in the insula and cingulate cortex as well as decreasing US-expectancy, arousal and negative valence towards CS+. Re-exposure to the US after extinction training was associated with a temporary increase in neural activation in the anterior cingulate cortex (exploratory analysis) and changes in US-expectancy and arousal ratings. While ICCs-values were low, findings from small groups suggest highly consistent effects across time-points and sites. Therefore, this delayed extinction fMRI-paradigm provides a solid basis for the investigation of differences in neural fear-related mechanisms as a function of anxiety-pathology and exposure-based treatment.

Psychometric Properties of a Self-Report Version of the Sexual Interest and Desire Inventory-Female (SIDI-F-SR).

BACKGROUND: The Sexual Interest and Desire Inventory-Female (SIDI-F) is a clinician-administered scale that allows for a comprehensive assessment of symptoms related to Hypoactive Sexual Desire Dysfunction (HSDD). As self-report questionnaires may facilitate less socially desirable responding and as time and resources are scarce in many clinical and research settings, a self-report version was developed (Sexual Interest and Desire Inventory- Female Self-Report; SIDI-F-SR). AIM: To assess the psychometric properties of the SIDI-F-SR and to investigate the agreement between the SIDI-F and SIDI-F-SR. METHODS: A total of 170 women (Mage = 37, SD = 11, range = 20-69) with HSDD answered the SIDI-F, administered by a clinical psychologist via telephone, first, followed by the SIDI-F-SR, delivered as an Internet-based questionnaire. A subset of 19 women answered the SIDI-F-SR twice over a period of 14 weeks. OUTCOMES: Convergent validity of the SIDI-F-SR was assessed via correlations with the desire subscale of the Female Sexual Function Index and the Female Sexual Distress Scale Revised. Internal consistency and test-retest reliability as well as intraclass correlation and predictors of absolute agreement between SIDI-F and SIDI-F-SR were examined. RESULTS: Test-retest-reliability was good (r = 0.74). Convergent validity was low but comparable between SIDI-F and SIDI-F-SR. Internal consistency of the SIDI-F-SR was acceptable (α = 0.76) and comparable to the SIDI-F (α = 0.74). When corrections for the restriction of range were applied, internal consistency of the SIDI-F-SR increased to 0.91. There was high agreement between SIDI-F and SIDI-F-SR (ICC = 0.86). On average, women scored about one point higher (indicated more desire) in the self-report vs the clinician-administered scale. CLINICAL IMPLICATIONS: The SIDI-F-SR can be used in settings where time and resources are limited. Whether the clinical cutoff point for the SIDI-F is adequate for the SIDI-F-SR has yet to be determined. STRENGTHS AND LIMITATIONS: Large sample of diverse women with HSDD. Lack of control groups (ie, healthy controls, women with other sexual dysfunctions). CONCLUSION: The SIDI-F-SR showed promising psychometric properties in a sample of women with HSDD. Velten J, Hirschfeld G, Meyers M, et al. Psychometric Properties of a Self-Report Version of the Sexual Interest and Desire Inventory-Female (SIDI-F-SR). J Sex Med 2021;18:990-995.

Visual Attention to Sexual Stimuli in Women With Clinical, Subclinical, and Normal Sexual Functioning: An Eye-Tracking Study.

BACKGROUND: Visual attention to sexual stimuli is an important means to facilitate sexual arousal and is thereby relevant for healthy sexual functioning. Experimental studies suggest that sexual dysfunction is associated with less attention toward sexual stimuli. AIM: The goal of this study was to use an eye-tracking-based free-viewing paradigm to investigate whether women in the clinical range of sexual function attend to a genital area in visual sexual stimuli differently than women with subclinical sexual function or those with normal sexual functioning. METHODS: Toward this goal, 69 women (Mage = 27.77, SD = 8.00, range = 19-54) with clinical (n = 30), subclinical (n = 23), and normal (n = 16) levels of sexual functioning watched a series of 10 pictures depicting heterosexual couples during vaginal intercourse while their eye movements were recorded. Each picture was presented twice-once with a distracting object (eg, a to-do list or household appliance) present in the picture and once without-for 8 seconds, each. OUTCOMES: 5 eye-tracking measures indicative of different aspects of initial and sustained attention were analyzed. RESULTS: As hypothesized, 3 out of 5 eye-tracking measures (ie, first fixation duration, number of first fixations, and total fixation duration) indicated that women in the clinical group attended less to the genital area in the pictures than women with normal sexual functioning. For 2 indices (ie, first fixation duration and total fixation duration), women with subclinical (vs normal) sexual functioning also attended less to the genital area. In contrast to our hypothesis, the presence of a distracting object did not influence attention to the genital area in either of the sexual function groups. CLINICAL IMPLICATIONS: This study provides further evidence of the role of attentional biases in sexual dysfunction in women. STRENGTHS AND LIMITATIONS: Eye-tracking methodology allows for a continuous measurement of visual attention; this is one of the first studies using this methodology to assess differences in visual attention in women with and without sexual dysfunction. However, the cross-sectional nature of this study prevents causal interpretation of findings. CONCLUSION: Future studies should use experimental paradigms to determine the causal role of visual attention for the development or maintenance of sexual dysfunction. Velten J, Milani S, Margraf J, et al. Visual Attention to Sexual Stimuli in Women With Clinical, Subclinical, and Normal Sexual Functioning: An Eye-Tracking Study. J Sex Med 2021;18:144-155.