Do not think about pain: Neural correlates of attention guiding during visual symptom provocation in dental phobia—An fMRI study

•fMRI study on attention focusing in dental phobia.•Patients and controls viewed phobic and nonphobic pictures.•They conducted 3 tasks: distraction, classification, and attention to pain.•Dental phobics displayed enhanced OFC activation during attention to pain.

Patients undergoing dental treatment employ different attentional strategies. In order to investigate associated neuronal correlates, we exposed 20 women suffering from dental phobia and 20 non-anxious women to disorder-related and unrelated pictures. They were asked to either direct their attention to a foreground stimulus in the image (distraction), to classify the content, or to judge whether the picture elicited fear of pain. The patients rated the majority of dental pictures as pain-relevant (84%) in contrast to the control group (12%). Observed group differences were restricted to the pain condition with enhanced orbitofrontal cortex (OFC) activation displayed by the patients. For the controls, OFC and amygdala activity were positively correlated with self-reported dental anxiety during attention to pain. Across both groups, pain focusing provoked increased amygdala recruitment. As the OFC and amygdala are central for the evaluation of threat signals, the mere thinking about the possible pain relevance of stimuli seems to be dysfunctional.