Attention bias modification for social anxiety: A systematic review and meta-analysis

Testing a brief attention training protocol to prevent emotional distress from a fear induction procedure

BACKGROUND AND OBJECTIVES

Attentional hypervigilance to threat in posttraumatic stress disorder (PTSD) is an important topic to investigate. Efforts to leverage attention training to prevent PTSD have been promising but underlying mechanisms have not been fully elucidated. The current study tested whether Attention Bias Modification (ABM) prior to an emotion induction of fear could reduce self-reported fear and arousal compared to two control conditions.

METHODS

Participants (N = 86) were recruited from Amazon Mechanical Turk and randomized to receive either (1) ABM where they were directed towards fear related words on every trial; (2) Attention Control Training (ACT) where they were directed towards fear related words on 50% of trials; or (3) Neutral training where all words were neutral. Participants then completed a fear emotion induction (a 2-min video), reporting fear, arousal, and mood before and after the emotion induction.

RESULTS

Participants in the ABM condition had lower fear compared to the Neutral condition b = 11.43, 95% CI (1.20, 21.65), d = 0.48. Participants in the ABM condition did not have lower fear compared to the ACT condition b = 9.75, 95% CI (-0.64, 19.96), d = 0.41. Importantly, attentional avoidance at baseline moderated the effect of condition for both fear and arousal; higher avoidance at baseline for the ABM condition was associated with lower fear and arousal after the emotion induction compared to the Neutral condition.

LIMITATIONS

The sample size was relatively small and limited in diversity.

CONCLUSIONS

These findings are the first experimental evidence showing that the benefit of ABM prior to a fearful experience may be in its reduction of the target emotion. Additionally, ABM may work best for those that demonstrate the most avoidance at baseline in their attention towards fearful stimuli.

Distinct patterns of monocular advantage for facial emotions in social anxiety

Individuals with social anxiety often exhibit atypical processing of facial expressions. Previous research in social anxiety has primarily emphasized cognitive bias associated with face processing and the corresponding abnormalities in cortico-limbic circuitry, yet whether social anxiety influences early perceptual processing of emotional faces remains largely unknown. We used a psychophysical method to investigate the monocular advantage for face perception (i.e., face stimuli are better recognized when presented to the same eye compared to different eyes), an effect that is indicative of early, subcortical processing of face stimuli. We compared the monocular advantage for different emotional expressions (neutral, angry and sad) in three groups (N = 24 per group): individuals clinically diagnosed with social anxiety disorder (SAD), individuals with high social anxiety in subclinical populations (SSA), and a healthy control (HC) group of individuals matched for age and gender. Compared to SSA and HC groups, we found that individuals with SAD exhibited a greater monocular advantage when processing neutral and sad faces. While the magnitudes of monocular advantages were similar across three groups when processing angry faces, individuals with SAD performed better in this condition when the faces were presented to different eye. The former findings suggest that social anxiety leads to an enhanced role of subcortical structures in processing nonthreatening expressions. The latter findings, on the other hand, likely reflect an enhanced cortical processing of threatening expressions in SAD group. These distinct patterns of monocular advantage indicate that social anxiety altered representation of emotional faces at various stages of information processing, starting at an early stage of the visual system.

Beyond the modified dot-probe task: A meta-analysis of the efficacy of alternate attention bias modification tasks across domains

Attention biases towards disease-relevant cues have been implicated in numerous disorders and health conditions, such as anxiety, cancer, drug-use disorders, and chronic pain. Attention bias modification (ABM) has shown that changing attention biases can change related emotional processes. ABM most commonly uses a modified dot-probe task, which has received increasing criticism regarding its reliability and inconsistent findings. The purpose of the present review was thus to systematically review and meta-analyse alternative tasks used in ABM research. We sought to examine whether alternative tasks significantly changed attention biases and emotional outcomes, and critically examined whether relevant sample, task and intervention characteristics moderated each of these effect sizes. Seventy-four (completer n = 15,294) study level comparisons were included in the meta-analysis. Overall, alternative ABM designs had a medium effect on changing biases (g = 0.488), and a small, but significant effect on improving clinical outcomes (g = 0.117). We found this effect to be significantly larger for studies which successfully changed biases compared to those that did not. Across all tasks, it appeared that targeting engagement biases results in the largest change to attention biases. Importantly, we found tasks incorporating gaze-contingency - encouraging engagement with non-biased stimuli - show the most promise for improving emotional outcomes.

Pharmacotherapy and cognitive bias modification for the treatment of anxiety disorders

INTRODUCTION

Anxiety disorders are characterized by widespread and persistent anxiety or recurrent panic attacks. As a result of their high prevalence, chronicity, and comorbidity, patients' quality of life and functioning are severely compromised. However, several patients do not receive treatment.

AREAS COVERED

This review discusses the effectiveness, safety, and limitations of major medications and cognitive bias modification (CBM) for treating anxiety disorders. The possibility of combined treatment is also discussed in the literature. Furthermore, drawing on Chinese cultural perspectives, the authors suggest that anxiety can be recognized, measured, and coped with at three levels of skill (), vision (), and Tao ().

EXPERT OPINION

The combination of pharmacotherapy and CBM is possibly more effective in treating anxiety disorders than either treatment alone. However, clinicians and patients should participate in the joint decision-making process and consider comprehensive factors. Moderate anxiety has adaptive significance. In the coming years, by combining the downward analytical system of western culture with the upward integrative system of Chinese culture, a comprehensive understanding of anxiety and anxiety disorders should be established, rather than focusing only on their treatment.

Attentional bias modification and attention control training in PTSD: a systematic review and meta-analysis

Background

Cognitive models of post-traumatic stress disorder (PTSD) highlighted the effect of maladaptive cognitive processing in the development and maintenance of PTSD. PTSD is related to attentional bias (AB) toward threatening stimuli and greater attentional bias variability (ABV). Attentional bias modification (ABM) and attention control training (ACT) have demonstrated the effect of improving PTSD, but the results of randomized controlled trials (RCTs) are controversial.

Objectives

The current study aimed to evaluate the extent of evidence supporting the efficacy of ABM in the treatment of PTSD.

Design

Systematic review and meta-analysis.

Methods

We searched PUBMED, PsycINFO, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for articles published between 1980 and 2022. RCTs of ABM for adult participants with PTSD symptoms were identified. The primary outcome was changes in PTSD severity, and the second outcome was changes in AB and ABV. Trial quality was assessed using the Cochrane Risk of Bias Tool. Publication bias was assessed using the Doi plot and Luis Furuya-Kanamori (LFK) index.

Results

Eight RCTs comparing the effect of ABM to ACT were included in the review, and six studies were meta-analyzed. Meta-analysis favored ACT in improving PTSD symptoms and ABV, and the effect size was large. ABM and ACT demonstrated similar effects in improving AB.

Conclusion

ACT should not only be seen as a control training condition but also has therapeutic values. However, since the current meta-analysis only included a limited number of studies, further research was still needed to examine the clinical value of ACT in PTSD treatment.

Interpersonal sensitivity as a mediator linking interpersonal stressors and social anxiety: Longitudinal mediation analysis using parallel process latent growth curve modeling

BACKGROUND

Little is known about the mechanism between interpersonal stressors and social anxiety in college students. This study was to investigate the mediating effect of interpersonal sensitivity between interpersonal stressors and social anxiety.

METHODS

The data was taken from a large-scale health-related cohort among Chinese college students. This study used data from the first four waves, including 4191 participants. The latent growth curve mediation model was used to examine the potential mediating role of interpersonal sensitivity in the relationship between interpersonal stressors and social anxiety over time.

RESULTS

Both levels and changes in interpersonal stressors were positively associated with subsequent levels and changes in social anxiety. Mediation analysis showed that interpersonal sensitivity mediated the relationship between interpersonal stressors and social anxiety.

LIMITATION

All variables were collected based on self-report.

CONCLUSIONS

Interpersonal stressor is a significant risk factor for social anxiety, and this association appears to be mediated by interpersonal sensitivity. It is necessary to evaluate and intervene against interpersonal sensitivity related to interpersonal stressors for the prevention of social anxiety.

Normalization of Fronto-Parietal Activation by Cognitive-Behavioral Therapy in Unmedicated Pediatric Patients With Anxiety Disorders

OBJECTIVE

Anxiety disorders are prevalent among youths and are often highly impairing. Cognitive-behavioral therapy (CBT) is an effective first-line treatment. The authors investigated the brain mechanisms associated with symptom change following CBT.

METHODS

Unmedicated youths diagnosed with an anxiety disorder underwent 12 weeks of CBT as part of two randomized clinical trials testing the efficacy of adjunctive computerized cognitive training. Across both trials, participants completed a threat-processing task during functional MRI before and after treatment. Age-matched healthy comparison youths completed two scans over the same time span. The mean age of the samples was 13.20 years (SD=2.68); 41% were male (youths with anxiety disorders, N=69; healthy comparison youths, N=62). An additional sample including youths at temperamental risk for anxiety (N=87; mean age, 10.51 years [SD=0.43]; 41% male) was utilized to test the stability of anxiety-related neural differences in the absence of treatment. Whole-brain regional activation changes (thresholded at p<0.001) were examined using task-based blood-oxygen-level-dependent response.

RESULTS

Before treatment, patients with an anxiety disorder exhibited altered activation in fronto-parietal attention networks and limbic regions relative to healthy comparison children across all task conditions. Fronto-parietal hyperactivation normalized over the course of treatment, whereas limbic responses remained elevated after treatment. In the at-risk sample, overlapping clusters emerged between regions showing stable associations with anxiety over time and regions showing treatment-related changes.

CONCLUSIONS

Activation in fronto-parietal networks may normalize after CBT in unmedicated pediatric anxiety patients. Limbic regions may be less amenable to acute CBT effects. Findings from the at-risk sample suggest that treatment-related changes may not be attributed solely to the passage of time.

Memory persistence: from fundamental mechanisms to translational opportunities

Memory persistence is a double edge sword. Persistence of adaptive memories is essential for survival and even determines who we are. Neurodegenerative conditions with significant memory loss such as Alzheimer's disease, testify how defects of memory persistence have severe and irreversible effects on personality, among other symptoms. Yet, maintenance of overly strong maladaptive memories underlies highly debilitating psychiatric conditions including post-traumatic stress disorder, specific phobia, substance dependence and binge eating disorder. Here we review the neurobiological mechanisms supporting memory formation, persistence, inhibition and forgetting. We then shift the focus to how such mechanisms have been exploited to alter the persistence of laboratory-generated memories in human healthy volunteers as a proof of concept. Finally, we review the effect of behavioural and pharmacological interventions in anxiety and addiction disorder patients, highlighting key findings, gaps, and future directions for basic and translational research.

The impact of attention bias modification training on behavioral and physiological responses

Attention bias modification training aims to alter attentional deployment to symptom-relevant emotionally salient stimuli. Such training has therapeutic applications in the management of disorders including anxiety, depression, addiction and chronic pain. In emotional reactions, attentional biases interact with autonomically-mediated changes in bodily arousal putatively underpinning affective feeling states. Here we examined the impact of attention bias modification training on behavioral and autonomic reactivity. Fifty-eight participants were divided into two groups. A training group (TR) received attention bias modification training to enhance attention to pleasant visual information, while a control group (CT) performed a procedure that did not modify attentional bias. After training, participants performed an evaluation task in which pairs of emotional and neutral images (unpleasant-neutral, pleasant-neutral, neutral-neutral) were presented, while behavioral (eye movements) and autonomic (skin conductance; heart rate) responses were recorded. At the behavioral level, trained participants were faster to orientate attention to pleasant images, and slower to orientate to unpleasant images. At the autonomic level, trained participants showed attenuated skin conductance responses to unpleasant images, while stronger skin conductance responses were generally associated with higher anxiety. These data argue for the use of attentional training to address both the attentional and the physiological sides of emotional responses, appropriate for anxious and depressive symptomatology, characterized by atypical attentional deployment and autonomic reactivity.

Attentional heterogeneity in social anxiety disorder: Evidence from Hidden Markov Models

There is some evidence for heterogeneity in attentional processes among individuals with social anxiety. However, there is limited work considering how attentional processes may differ as a mechanism in a naturalistic task-based context (e.g., public speaking). In this secondary analysis we tested attentional heterogeneity among individuals diagnosed with social anxiety disorder (N = 21) in the context of a virtual reality exposure treatment study. Participants completed a public speaking challenge in an immersive 360°-video virtual reality environment with eye tracking at pre-treatment, post-treatment, and at 1-week follow-up. Using a Hidden Markov Model (HMM) approach with clustering we tested whether there were distinct profiles of attention pre-treatment and whether there were changes following the intervention. As a secondary aim we tested whether the distinct attentional profiles at pre-treatment predicted differential treatment outcomes. We found two distinct attentional profiles pre-treatment that we characterized as audience-focused and audience-avoidant. However, by the 1-week follow-up the two profiles were no longer meaningfully different. We found a meaningful difference between HMM groups for fear of public speaking at post-treatment b = -8.54, 95% Highest Density Interval (HDI) [-16.00, -0.90], Bayes Factor (BF) = 8.31 but not at one-week follow-up b = -5.83, 95% HDI [-13.25, 1.81], BF = 2.28. These findings provide support for heterogeneity in attentional processes among socially anxious individuals, but our findings indicate that this may change following treatment. Moreover, our results offer preliminary mechanistic evidence that patterns of avoidance may be specifically related to poorer treatment outcomes for virtual reality exposure therapy.

Attentional bias to threat is modulated by stimulus content: an fNIRS study

People are evolutionarily predisposed to associate threat relevant stimuli with fear or aversiveness and show an attentional bias toward threat. Attentional bias modification (ABM) has been shown to reduce threat biases, while quantitative reviews assessing the effectiveness of bias modification yielded inconsistent results. The current study examined the relationship between the training effect of attentional bias to threat and the type of threatening stimuli. Twenty-two participants performed a modified dot-probe task while undergoing functional near-infrared spectroscopy (fNIRS) imaging. Results indicated that there was a strong pattern of attentional avoidance among individuals in an animal but not human threat condition. Furthermore, findings from fNIRS confirmed that the influence from type of threatening stimulus would be modulated by cortical activation patterns, especially in the ventrolateral prefrontal cortices (vlPFC) and angular gyrus. Overall, these results suggest that stimulus-specific may play a major role in personalization of specific psychological interventions.

Knowledge of Threat Biases Perceptual Decision Making in Anxiety: Evidence From Signal Detection Theory and Drift Diffusion Modeling

Background

Threat biases are considered key factors in the development and maintenance of anxiety. However, these biases are poorly operationalized and remain unquantified. Furthermore, it is unclear whether and how prior knowledge of threat and its uncertainty induce these biases and how they manifest in anxiety.

Method

Participants (n = 55) used prestimulus cues to decide whether the subsequently presented stimuli were threatening or neutral. The cues either provided no information about the probability (high uncertainty) or indicated high probability (low uncertainty) of encountering threatening or neutral targets. We used signal detection theory and hierarchical drift diffusion modeling to quantify bias.

Results

High-uncertainty threat cues improved discrimination of subsequent threatening and neutral stimuli more than neutral cues. However, anxiety was associated with worse discrimination of threatening versus neutral stimuli following high-uncertainty threat cues. Using hierarchical drift diffusion modeling, we found that threat cues biased decision making not only by shifting the starting point of evidence accumulation toward the threat decision but also by increasing the efficiency with which sensory evidence was accumulated for both threat-related and neutral decisions. However, higher anxiety was associated with a greater shift of starting point toward the threat decision but not with the efficiency of evidence accumulation.

Conclusions

Using computational modeling, these results highlight the biases by which knowledge regarding uncertain threat improves perceptual decision making but impairs it in case of anxiety.

The influence of single-session reward-based attentional bias modification on attentional biases towards threat as measured by the N2pc component

Attentional biases toward threatening faces have repeatedly been studied in the context of social anxiety, with etiological theories suggesting exacerbated biases as a possible cause for the latter. To counteract these postulated effects, research has focused on the concept of attentional bias manipulation (ABM), in which spatial contingencies between succeeding stimuli are traditionally employed in training paradigms designed to deliberately shift automatic attention processes away from threat-related stimuli. The ABM research field has been faced with various methodological challenges, such as inconsistent results, low reliabilities of dependent variables and a high susceptibility to moderating factors. We aimed to combine several recent approaches to address these issues. Drawing upon theories of value-driven attention, we explored reward-based contingencies in a Dot Probe task to improve the training's efficacy, combined with neurophysiological measures for greater reliability compared to reaction times, while evaluating the moderating effect of explicitness in the instruction. In a healthy sample (N = 60) and within a single session, we found a general attentional bias toward angry faces present across all conditions as indicated by the N2pc, which was, however, marked by large intrinsic lateralization effects, with submeasures exhibiting opposing polarities. This prompted us to explore an alternative, intrahemispheric calculation method. The new N2pc variant showed the attentional bias to have disappeared at the end of the training session within the explicit instruction group. Reliabilities of the main dependent variables were varied from excellent to questionable, which, together with the exploratory nature of the analysis, leaves this result as preliminary.

Attention Bias and Anxiety: The Moderating Effect of Sociocultural Variables in Rural Latinx Youth

Attention bias confers risk for anxiety development, however, the influence of sociodemographic variables on the relationship between attention bias and anxiety remains unclear. We examined the association between attention bias and anxiety among rural Latinx youth and investigated potential moderators of this relationship. Clinical symptoms, demographic characteristics, and a performance-based measure of attention bias were collected from 66 rural Latinx youth with clinical levels of anxiety (33.3% female; Mage = 11.74; 92.4% Latinx, 7.6% Mixed Latinx). No moderating effects for age or gender were found. Youth below the poverty line displayed an attention bias away from threat in comparison to youth above the poverty line, who displayed an attention bias towards threat. Among youth below the poverty line, this bias away from threat was associated with increased anxiety. Findings highlight the importance of economic adversity in understanding the relationship between attention bias and anxiety.

Attentional Bias Modification Training Based on Virtual Reality and Eye Tracking in Anorexia Nervosa Patients

Anorexia nervosa (AN) patients exhibit attentional bias (AB) related to the body, which is the tendency to pay greater attention to weight-related body areas compared to non-weight-related ones. This phenomenon has been linked to elevated levels of body dissatisfaction (BD) and may potentially reduce the effectiveness of body exposure therapy. The purpose of this pilot study is to assess the efficacy of a single session of a new body-related AB modification task (ABMT) that combines virtual reality with eye tracking in patients with AN. The goals of the ABMT are to reduce body-related AB by balancing attention between weight and non-weight-related body areas and to reduce BD levels. Twenty-three adolescent patients with AN were embodied in a virtual avatar and immersed in a virtual environment where they completed the ABMT. Body-related AB measures and BD levels were assessed before and after the training. A paired samples t-test showed statistically significant differences between pre-assessment and post-assessment; the complete fixation time on weight-related body parts was reduced and BD levels decreased. The initial evidence of the efficacy of this ABMT has important clinical implications, since AB and BD are considered risk factors for developing and maintaining eating disorder symptomatology among patients with AN.

Neural evidence of face processing in social anxiety disorder: A systematic review with meta-analysis

Numerous previous studies have used event-related potentials (ERPs) to examine facial processing deficits in individuals with social anxiety disorder (SAD). However, researchers still need to determine whether the deficits are general or specific and what the dominant factors are behind different cognitive stages. Meta-analysis was performed to quantitatively identify face processing deficits in individuals with SAD. Ninety-seven results in 27 publications involving 1032 subjects were calculated using Hedges' g. The results suggest that the face itself elicits enlarged P1 amplitudes, threat-related facial expressions induce larger P2 amplitudes, and negative facial expressions lead to enhanced P3/LPP amplitudes in SAD individuals compared with controls. That is, there is face perception attentional bias in the early phase (P1), threat attentional bias in the mid-term phase (P2), and negative emotion attentional bias in the late phase (P3/LPP), which can be summarized into a three-phase SAD face processing deficit model. These findings provide an essential theoretical basis for cognitive behavioral therapy and have significant application value for the initial screening, intervention, and treatment of social anxiety.

The Effects of Repeated Attachment Security Priming on Social Anxiety and Attention Bias: A Randomized Controlled Trial

BACKGROUND

Although the clinical utility of attachment security priming has been suggested in recent years, the effect of attachment security priming on social anxiety and its core symptoms (i.e., attention bias) remains unspecified. Therefore, the present study explored the potential effectiveness of repeated attachment security priming in alleviating social anxiety and attention bias among Chinese college students.

METHODS

Fifty-six college students with high social anxiety were randomly assigned to the attachment security priming group (n = 30) or control group (n = 26). The priming group completed seven attachment security priming sessions over 2 weeks (every 2 days), and the control group was assigned to a waitlist for 2 weeks.

RESULTS

The results revealed that individuals in the priming group reported less social anxiety after 2 weeks of security attachment priming, and those in the control group did not change significantly. The results also showed that there was no significant change in the attention bias of individuals with social anxiety before and after the intervention.

CONCLUSIONS

Our findings indicate that attachment security priming is a promising alternative intervention option for social anxiety. The potential clinical implications of security attachment priming are discussed.

Resting state connectivity predictors of symptom change during gaze-contingent music reward therapy of social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is common, first-line treatments are often only partially effective, and reliable predictors of treatment response are lacking. Here, we assessed resting state functional connectivity (rsFC) at pre-treatment and during early treatment as a potential predictor of response to a novel attention bias modification procedure, gaze-contingent music reward therapy (GC-MRT).

METHODS

Thirty-two adults with SAD were treated with GC-MRT. rsFC was assessed with multi-voxel pattern analysis of fMRI at pre-treatment and after 2-3 weeks. For comparison, 20 healthy control (HC) participants without treatment were assessed twice for rsFC over the same time period. All SAD participants underwent clinical evaluation at pre-treatment, early-treatment (week 2-3), and post-treatment.

RESULTS

SAD and depressive symptoms improved significantly from pre-treatment to post-treatment. After 2-3 weeks of treatment, decreased connectivity between the executive control network (ECN) and salience network (SN), and increased connectivity within the ECN predicted improvement in SAD and depressive symptoms at week 8. Increased connectivity between the ECN and default mode network (DMN) predicted greater improvement in SAD but not depressive symptoms at week 8. Connectivity within the DMN decreased significantly after 2-3 weeks of treatment in the SAD group, while no changes were found in HC over the same time interval.

CONCLUSION

We identified early changes in rsFC during a course of GC-MRT for SAD that predicted symptom change. Connectivity changes within the ECN, ECN-DMN, and ECN-SN may be related to mechanisms underlying the clinical effects of GC-MRT and warrant further study in controlled trials.

A randomised controlled feasibility study of food-related computerised attention training versus mindfulness training and waiting-list control for adults with overweight or obesity: the FOCUS study

BACKGROUND

In a feasibility randomised controlled trial in people with overweight/obesity with and without binge eating disorder (BED) symptoms, we assessed eight weekly sessions of attention bias modification training (ABMT) and mindfulness training (MT) versus waiting list (WL) and explored potential mechanisms.

METHODS

45 participants were randomly allocated to one of three trial arms. Primary outcomes were recruitment, retention and treatment adherence rates. Secondary outcomes included measures of eating behaviour, mood, attention and treatment acceptability. Assessments were conducted at baseline, post-intervention (week 8), and follow-up (week 12).

RESULTS

Participant retention at follow-up was 84.5% across groups. Session completion rates in the laboratory were 87% for ABMT and 94% for MT, but home practice was much poorer for ABMT. Changes in BMI and body composition were small between groups and there was a medium size BMI reduction in the MT group at follow-up. Effect sizes of eating disorder symptom changes were not greater for either intervention group compared to WL, but favoured ABMT compared to MT. Hedonic hunger and mindful eating scores favoured MT compared to ABMT and WL. ABMT reduced attention biases towards high-calorie food cues, which correlated with lower objective binge eating days at post-intervention. No significant changes were observed in the MT, or WL conditions.

CONCLUSIONS

Both ABMT and MT have potential value as adjuncts in the treatment of obesity and BED, and a larger clinical trial appears feasible and indicated.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN15745838. Registered on 22 May 2018.

Attention bias modification for depression: A systematic review and meta-analysis

Background

Depression is a mental health disorder characterized by affective, somatic, and cognitive symptoms. Attention bias modification (ABM) has been widely used to treat depression. However, the results seem inconsistent. We conducted a systematic review and meta-analysis to investigate the efficacy of ABM for depression and to explore the optimal protocol of ABM.

Methods

Seven databases were systematically searched from their inceptions to 5 October 2022 to include randomized controlled trials (RCTs) of ABM for depression. Two independent reviewers selected the eligible articles, extracted data, and evaluated the risk of bias using version 2 of the Cochrane risk-of-bias tool (ROB 2.0) for randomized trials. The primary outcome was the evaluation of depressive symptoms using widely accepted and validated scales. The secondary outcomes included rumination and attentional control. Meta-analysis was conducted by using RevMan (version 5.4) and Stata (version 12.0). Subgroup analyses and meta-regressions were performed to identify the source of heterogeneity. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Results

A total of 19 trials involving 20 datasets (1,262 participants) were included. The overall risk of bias in one study was rated as low risk of bias, three studies were considered as high, and the remaining studies were some concerns. Compared with attention control training (ACT), ABM had a greater effect in the improvement of depression (SMD = −0.48, 95% CI −0.80 to −0.17, I2 = 82%) and rumination (MD = −3.46, 95% CI −6.06 to −0.87, I2 = 0%). No significant differences were observed in the attentional control outcome between ABM and ACT (MD = 3.07, 95% CI −0.52 to 6.65, I2 = 0%). Subgroup analysis demonstrated that adults exhibited a greater decrease in depression scores than adolescents. ABM using the dot-probe task, training target stimulus presented by face, and training directions by left–right were associated with better antidepressant effects. ABM training delivered in the laboratory tended to yield a better effect than those conducted at home. Sensitivity analysis indicated that the results were robust. The certainty of the evidence for all outcomes was low or very low, and publication bias may exist.

Conclusion

Due to high heterogeneity and limited studies, not enough current evidence supported that ABM could be an effective intervention to relieve depressive symptoms. More rigorous RCTs are required to verify the benefits and to explore the optimal protocol of ABM training for depression.

Systematic Review Registration: [PROSPERO], identifier [No. CRD42021279163].

Is attentional bias variability causally implicated in emotional vulnerability? A systematic review and meta-analysis

BACKGROUND

The aim of the present review was to determine whether attentional bias variability (ABV) is causally implicated in emotional vulnerability. We consider evidence examining whether ABV precedes and predicts later psychopathology, and whether modifying ABV leads to changes in psychological symptoms following an intervention.

METHODS

A systematic literature search located 15 studies that met the inclusion criteria (3 longitudinal, 12 intervention). Eligible intervention studies were also meta-analysed.

RESULTS

Preliminary evidence suggests that ABV predicts later post-traumatic stress symptomatology in interaction with number of traumatic events. The few interventions designed to reduce ABV suggest promise for improving PTSD symptoms. However, these interventions did not consistently change ABV, and where it was tested, change in ABV did not correspond to change in symptoms.

CONCLUSIONS

There is emerging evidence that ABV could represent a vulnerability factor for psychological symptoms, particularly for those exposed to trauma. This may indicate attentional control difficulties, although this remains to be tested. Conclusions regarding the causal status of ABV will depend on future high-quality randomised controlled trials.

Effects of attention bias modification for anxiety: Neurophysiological indices and moderation by symptom severity

OBJECTIVE

Attention bias modification (ABM) aims to decrease anxiety symptom severity through the reduction of threat-related attention bias (AB). Individual differences in treatment response and poor measurement reliability of AB have called its clinical promise into question. The current study examined whether individual differences in anxiety severity at baseline moderated treatment response, and employed both behavioral and neurophysiological metrics of AB.

METHODS

Participants (N = 99) were randomly assigned to four weeks of ABM or placebo control training (PT). Self-reported anxiety symptom severity, and AB metrics and ERPs generated during the dot probe task were collected at baseline (Time 1), one-week post-intervention (Time 5), and at a three-month follow-up (Time 6).

RESULTS

ABM, relative to PT, reduced ERPs indexing attention discrimination (N170) and increased ERPs indexing salience tracking (P3). Increases in P3 were associated with ABM-related reductions in anxiety. Anxiety severity was reduced following ABM, but only among those with higher baseline anxiety symptom severity.

CONCLUSIONS

ABM effectively reduced symptom severity among those with higher levels of anxiety, and modulated neurophysiological indices of AB.

SIGNIFICANCE

Results provide evidence for attention-relevant ERPs as outcomes of ABM treatment responsivity and suggest that ABM may be most beneficial for those with more severe anxiety symptoms.

Time course of attentional bias in social anxiety: Evidence from visuocortical dynamics

Threat-related attentional bias is thought to have a causal influence on the etiology of social anxiety. However, there is uncertainty on whether attention dwells on or diverts away from threats, and the measurements typically utilized to explore attentional bias cannot continuously quantify changes in attention. Here, we used steady-state visual evoked potentials (ssVEPs) as a continuous neurophysiological measure of visual attentional processing to examine the time course of attentional bias in social anxiety. Participants with high (n = 18) and low (n = 18) social anxiety passively viewed two faces flickering at 15 and 20 Hz frequency to evoke ssVEPs, and completed Attentional Control Scale. The results showed that angry faces, as compared to happy and neutral faces, elicited larger ssVEP amplitudes for the time window of 180-500 ms after facial stimuli onset only in the high socially anxious individuals, and the effect extended to the next two periods of 500-1000 ms and 1000-1500 ms. The ssVEP amplitudes differed most when individuals with high social anxiety viewed angry-neutral expression combinations. Additionally, attentional control was negatively correlated with social anxiety and threat-related attentional bias. The results suggested that individuals with social anxiety initially oriented attention toward the threat and subsequently exhibited difficulty in disengaging attention from it, possibly due to impaired attentional control.

Scary in the eye of the beholder: Attentional bias and attentional retraining for social anxiety

Consistent with cognitive models of social anxiety, socially anxious individuals show cognitive biases that magnify their perceived level of threat in the environment.

OBJECTIVES

The first objective was to determine whether attentional bias for socially threatening stimuli occurs after concomitant depression has been controlled. The second objective was to test the effectiveness of the Attention Control Training Program for Social Anxiety (ACTP-SA) for reducing social anxiety attentional bias and improving therapeutic indices in people with social anxiety.

METHOD

In the first study, socially anxious (N = 30) and non-anxious individuals (N = 30) completed the Beck Depression Inventory-II, Spielberger's State-Trait Anxiety Inventory, Conner's Social Phobia Inventory, a social-anxiety Stroop test, and a clinical interview. In the second study, individuals with social anxiety (N = 30) were randomly assigned to an experimental group that received 4 sessions of ACTP-SA, or to a sham-intervention control condition. At the post-test and a 3-month follow-up, both groups completed the same measures as in Study 1.

RESULTS

In Study 1, socially anxious individuals showed higher attentional bias for threatening stimuli than the controls, after depression had been controlled for. In Study 2, participants in the experimental group, compared with the controls, showed greater reductions in attentional bias, social anxiety, and trait anxiety at post-test and follow-up.

CONCLUSIONS

The results underscore the importance of information processing biases in social anxiety and the benefits of attentional bias training as a complementary intervention for modifying symptoms of social anxiety.

Reducing anxiety and attentional bias with reward association learning and attentional bias modification

The current study examined the effects of a reward associative learning procedure and the traditional threat-avoidance ABM paradigm on anxiety and attentional bias. In reward training, participants were given high rewards for correct responses to neutral target and low rewards for correct responses to negative target. In reward control training, participants received no cues of rewards after their responses. High trait anxious individuals (N = 76) first completed a session of reward training or reward control training, followed by four sessions of ABM training or ABM control training. Generalized anxiety disorder symptom (GAD-7) and attentional bias in a dot-probe task were assessed during pre-and post-training. Results indicated that the effect of ABM training on reducing anxiety was only obtained in the reward training condition. Participants who received reward training showed significantly less attentional bias compared with those receiving reward control training. There was no significant training effect of ABM on atttentiona bias. Results suggested that reward training reduced general anxiety and attentional bias. Traditional ABM training reduced anxiety only when combined with reward training. Attentional bias in anxiety are modifiable through reward training.

Emotional Threat Perception and Its Association with Neurocognition in Social Anxiety Disorder

BACKGROUND

The negative appraisal of emotional stimuli is a feature of social anxiety disorder (SAD). People with SAD demonstrate deficits in neurocognitive performance while performing tasks of attention. However, the relationship between attentional control, working memory, and threat perception in SAD has not been studied well. The present study aimed to identify patterns of threat perception in relation to performance on attention and visuospatial working memory tasks in individuals with SAD.

METHODS

Subjects with SAD (n = 27) and a healthy comparative (HC) group (n = 26) completed tasks of sustained and focused attention, visuospatial working memory, computerized emotion identification, and pictorial emotional Stroop.

RESULTS

The SAD group had decreased performance in the domains of sustained (P = 0.001) and focused attention (P = 0.04). They also had an enhanced threat perception as demonstrated by greater reaction time to anger (P = 0.03), lower emotion recognition accuracy (P = 0.05), and higher over-identification of the threat to neutral and nonthreatening faces. However, the Stroop effect was not demonstrated across the groups. No group difference was seen in the performance on the visuospatial working memory tasks. Lower focused attention was significantly correlated with higher emotional threat perception (ETP; P = 0.001) in the SAD group.

CONCLUSION

People with SAD have greater deficits in attention processing and ETP. The attention deficits were associated with enhanced ETP in social anxiety. The link between threat perception and cognitive functions would aid in a better understanding of SAD and in planning appropriate intervention.

Attentional biases in human anxiety

Across clinical and subclinical samples, anxiety has been associated with increased attentional capture by cues signaling danger. Various cognitive models attribute the onset and maintenance of anxiety symptoms to maladaptive selective information processing. In this brief review, we 1) describe the evidence for the relations between anxiety and attention bias toward threat, 2) discuss the neurobiology of anxiety-related differences in threat bias, 3) summarize work investigating the developmental origins of attention bias toward threat, and 4) examine efforts to translate threat bias research into clinical intervention. Future directions in each area are discussed, including the use of novel analytic approaches improving characterization of threat-processing-related brain networks, clarifying the role of cognitive control in the development of attention bias toward threat, and the need for larger, well-controlled randomized clinical trials examining moderators and mediators of treatment response. Ultimately, this work has important implications for understanding the etiology of and for intervening on anxiety difficulties among children and adults.

Therapeutic potential of brain stimulation techniques in the treatment of mental, psychiatric, and cognitive disorders

Treatment for brain diseases has been disappointing because available medications have failed to produce clinical response across all the patients. Many patients either do not respond or show partial and inconsistent effect, and even in patients who respond to the medications have high relapse rates. Brain stimulation has been seen as an alternative and effective remedy. As a result, brain stimulation has become one of the most valuable therapeutic tools for combating against brain diseases. In last decade, studies with the application of brain stimulation techniques not only have grown exponentially but also have expanded to wide range of brain disorders. Brain stimulation involves passing electric currents into the cortical and subcortical area brain cells with the use of noninvasive as well as invasive methods to amend brain functions. Over time, technological advancements have evolved into the development of precise devices; however, at present, most used noninvasive techniques are repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), whereas the most common invasive technique is deep brain stimulation (DBS). In the current review, we will provide an overview of the potential of noninvasive (rTMS and tDCS) and invasive (DBS) brain stimulation techniques focusing on the treatment of mental, psychiatric, and cognitive disorders.

Boosting psychological change: Combining non-invasive brain stimulation with psychotherapy

Mental health disorders and substance use disorders are a leading cause of morbidity and mortality worldwide, and one of the most important challenges for public health systems. While evidence-based psychotherapy is generally pursued to address mental health challenges, psychological change is often hampered by non-adherence to treatments, relapses, and practical barriers (e.g., time, cost). In recent decades, Non-invasive brain stimulation (NIBS) techniques have emerged as promising tools to directly target dysfunctional neural circuitry and promote long-lasting plastic changes. While the therapeutic efficacy of NIBS protocols for mental illnesses has been established, neuromodulatory interventions might also be employed to support the processes activated by psychotherapy. Indeed, combining psychotherapy with NIBS might help tailor the treatment to the patient's unique characteristics and therapeutic goal, and would allow more direct control of the neuronal changes induced by therapy. Herein, we overview emerging evidence on the use of NIBS to enhance the psychotherapeutic effect, while highlighting the next steps in advancing clinical and research methods toward personalized intervention approaches.

Attention guidance augmentation of virtual reality exposure therapy for social anxiety disorder: a pilot randomized controlled trial

Biased attention to social threats has been implicated in social anxiety disorder. Modifying visual attention during exposure therapy offers a direct test of this mechanism. We developed and tested a brief virtual reality exposure therapy (VRET) protocol using 360°-video and eye tracking. Participants (N = 21) were randomized to either standard VRET or VRET + attention guidance training (AGT). Multilevel Bayesian models were used to test (1) whether there was an effect of condition over time and (2) whether post-treatment changes in gaze patterns mediated the effect of condition at follow-up. There was a large overall effect of the intervention on symptoms of social anxiety, as well as an effect of the AGT augmentation on changes in visual attention to audience members. There was weak evidence against an effect of condition on fear of public speaking and weak evidence supporting a mediation effect, however these estimates were strongly influenced by model priors. Taken together, our findings suggest that attention can be modified within and during VRET and that modification of visual gaze avoidance may be casually linked to reductions in social anxiety. Replication with a larger sample size is needed.

Personalized attention control therapy for PTSD: effectiveness and moderators of outcome in a randomized controlled trial

BACKGROUND

Previous randomized controlled trials (RCTs) suggest that attention control therapy (ACT), targeting aberrant fluctuations of attention toward and away from threats in patients with PTSD, may be effective in reducing symptoms. The current RCT examined whether the use of personalized-trauma stimuli enhances ACT efficacy in patients with PTSD. Additional moderators of treatment outcome were tested on an exploratory basis.

METHODS

Sixty patients with PTSD were randomly assigned to either personalized ACT, non-personalized ACT, or a control condition. Changes in symptoms were examined across pre-treatment, post-treatment, and a 3-month follow-up. Attentional interference was examined pre- and post-treatment. Baseline clinical and cognitive indices as well as the time elapsed since the trauma were tested as potential moderators of treatment outcome.

RESULTS

A significant reduction in clinical symptoms was noted for all three conditions with no between-group differences. Attention bias variability decreased following ACT treatment. Personalized ACT was more effective relative to the control condition when less time had elapsed since the trauma. Baseline clinical and cognitive indices did not moderate treatment outcome.

CONCLUSIONS

In this RCT of patients with PTSD, ACT was no more effective in reducing PTSD symptoms than a control condition. The data also suggest a potential benefit of personalized ACT for patients who experienced their trauma more recently.

Is interpretation bias for threat content specific to youth anxiety symptoms/diagnoses? A systematic review and meta-analysis

Anxiety is the most common mental health problem in youth. Numerous studies have identified that youth anxiety is associated with interpretation bias or the attribution of threatening meaning to ambiguity. Interpretation bias has been proposed as a mechanism underlying the development and maintenance of pediatric anxiety. Theoretically, interpretation bias should be content-specific to individual youth anxiety symptom domains. However, extant studies have reported conflicting findings of whether interpretation bias is indeed content specific to youth anxiety symptoms or diagnoses. The present meta-analysis aimed to synthesize the literature and answer the question: is the relationship between interpretation bias and anxiety content specific? Search of PubMed and PsycINFO databases from January 1, 1960 through May 28, 2019 yielded 9967 citations, of which 19 studies with 20 comparisons and 2976 participants met eligibility criteria. Meta-analysis with random effects models was conducted to examine an overall effect (Pearson r) between anxiety domain and content-specific interpretation bias in single sample studies, and an overall effect size difference (Cohen's d) in studies comparing anxious to non-anxious youth. Results support a content specific correlation between interpretation bias and anxiety symptom domain in single sample studies (r = 0.18, p = 0.03). However, it is currently undetermined whether this relationship holds in studies that compare the relationship between content-specific interpretation bias and anxiety in anxious versus non-anxious youth. A variety of methodologic considerations across studies are discussed, with implications for further investigation of interpretation bias and youth anxiety.

Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms

This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I² = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I² = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.

The effect of immersive virtual reality-based attentional bias modification on anxiety mitigation in healthy population

The present study compared an immersive virtual reality-based attentional bias modification (immersive VR-ABM) with the desktop version of the VR-ABM and an immersive virtual reality-based game (immersive VR-game) to examine the possible effect of the immersive presence on self-reported emotional reactions to a stressful task. One hundred and twenty participants were randomly assigned into three groups, and each group received a three-turn induction-intervention training. Anxiety symptoms were assessed at pre-induction, post-induction, and post-training. Results showed that virtual reality-based anxiety was induced and alleviated successfully in all three groups, but only the immersive VR-ABM group showed an accumulated effect on self-reported anxiety across sessions. The attentional bias based on probe latencies indicated no significant change in either the immersive or desktop VR-ABM groups. The present findings support the hypothesized VR-ABM's effect on self-reported anxiety at the immersive presence. The practical implications of using immersive VR-ABM are discussed for obtaining ecological validity.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

Social Commerce Intention, Social Interaction, and Social Support

A higher number of socially anxious users were found as more users joined social network sites. Since social commerce has become an important issue, this study investigated the effect of social anxiety on online users’ social commerce intention. Online social interactions are hypothesized to influence social commerce intention directly or indirectly through online social support. 427 effective samples were collected from Facebook users, and the results confirmed most of the causal effects. The study also tested the moderating effect of social anxiety on the causal effects. Of the eight relationships, social anxiety significantly moderates six of them. The relationships between online social interaction and emotional support and between online social interaction and social commerce intention are stronger for users with higher social anxiety. For users with lower social anxiety, the relationship between social support and the receiving of social commerce intention is stronger. The research findings lead to significant theoretical contributions and managerial implications.

Attentional processes during emotional face perception in social anxiety disorder: A systematic review and meta-analysis of eye-tracking findings

Background In recent years, a growing body of eye-tracking research has investigated gaze behavior in individuals with social anxiety during the visual perception of emotional stimuli. The aim of this article was to review and synthesize studies examining attention orientation in patients with clinical social anxiety by means of eye-tracking methodology. Methods Through a systematic search, 30 articles were identified, including 11 studies in which single emotional faces were used as stimuli and seven eligible studies in which threatening faces were paired with neutral stimuli. Meta-analyses were conducted to compare prolonged eye-contact behavior and early attentional biases to threats in individuals with social anxiety disorder (SAD) and healthy controls. Results Moderate group differences were revealed for single face viewing studies, with SAD patients showing significantly reduced eye contact with negative (Hedges' g = -0.67) and positive emotional faces (g = -0.49) compared to that of healthy participants. Type of task and duration of stimulus presentation were (marginally) significant moderators of between-study variance in effect size. Small but significant group differences were found for early attentional biases toward angry faces versus neutral stimuli (g = 0.21) but not toward happy faces versus neutral stimuli (g = 0.05). Preliminary evidence for a hyperscanning strategy in SAD patients relative to healthy controls emerged (g = 0.42). Limitations The number of included studies with face pairings was low, and two studies were excluded due to unavailable data. Conclusions Our results suggest that eye contact avoidance with emotional faces is a prominent feature in SAD patients. Patients might benefit from guidance to learn to make adequate eye contact during therapeutic interventions, such as exposure therapy. SAD patients demonstrated slightly heightened attention allocation toward angry faces relative to that of healthy participants during early processing stages. Threat biases can be potential targets for attention modification training as an adjuvant to other treatments. Future research on early attentional processes may benefit from improved arrangements of paired stimuli to increase the psychometric properties of initial attention indices.

Neural correlates of attentional control in social anxiety disorder: the impact of early-life adversity and DNA methylation

BACKGROUND

Social anxiety disorder is characterized by intense fear and avoidance of social interactions and scrutiny by others. Although alterations in attentional control seem to play a central role in the psychopathology of social anxiety disorder, the neural underpinnings in prefrontal brain regions have not yet been fully clarified.

METHODS

The present study used functional MRI in participants (age 18-50 yr) with social anxiety disorder (n = 42, 31 female) and without (n = 58, 33 female). It investigated the interrelation of the effects of social anxiety disorder and early-life adversity (a main environmental risk factor of social anxiety disorder) on brain activity during an attentional control task. We applied DNA methylation analysis to determine whether epigenetic modulation in the gene encoding the glucocorticoid receptor, NR3C1, might play a mediating role in this process.

RESULTS

We identified 2 brain regions in the left and medial prefrontal cortex that exhibited an interaction effect of social anxiety disorder and early-life adversity. In participants with low levels of early-life adversity, neural activity in response to disorder-related stimuli was increased in association with social anxiety disorder. In participants with high levels of early-life adversity, neural activity was increased only in participants without social anxiety disorder. NR3C1 DNA methylation partly mediated the effect of social anxiety disorder on brain activity as a function of early-life adversity.

LIMITATIONS

The absence of behavioural correlates associated with social anxiety disorder limited functional interpretation of the results.

CONCLUSION

These findings demonstrate that the neurobiological processes that underlie social anxiety disorder might be fundamentally different depending on experiences of early-life adversity. Long-lasting effects of early-life adversity might be encoded in NR3C1 DNA methylation and entail alterations in social anxiety disorder-related activity patterns in the neural network of attentional control.

Look at the Audience? A Randomized Controlled Study of Shifting Attention From Self-Focus to Nonsocial vs. Social External Stimuli During Virtual Reality Exposure to Public Speaking in Social Anxiety

Background: Enhanced self-focused attention plays a central role in the maintenance and treatment of Social Anxiety and is targeted in contemporary cognitive behavioral therapy. Actual developments use Virtual Reality (VR) for behavioral training. However, no VR attention training combining exposure to public speaking with shifting attention from self-focus to external focus has been investigated, and no experimental evidence exists on different kinds of external cues as targets of attention. Therefore, we investigated the effects of an attention training during public speaking in VR and examined differential effects of an external focus on nonsocial vs. social stimuli. Methods: In this randomized controlled study, highly socially anxious participants were instructed to focus on either objects or the audience within a virtual speech task. We assessed the pre-post effects on affective reactions, self-perception, and attentional processes during public speaking as well as general Social Anxiety using subjective, physiological, and eye-tracking measures. Repeated-measures analyses of variance (ANOVAs) were calculated to detect changes from pretest to posttest over both groups, and time × group interaction effects. Results: Within the analysis sample (n = 41), anxiety during public speaking and fear of negative evaluation significantly decreased, with no significant differences between groups. No significant time effect, but a significant time × group effect, was found for the looking time proportion on the audience members' heads. Follow-up tests confirmed a significant increase in the social-focus group and a significant decrease in the nonsocial-focus group. For all other variables, except external focus and fear of public speaking, significant improvements were found over both groups. Further significant time x group effects were found for positive affect during public speaking, with a significant increase in the social focus, and no significant change in the nonsocial-focus group. Conclusion: Our findings suggest that attention training to reduce self-focus can be successfully conducted in VR. Both training versions showed positive short-term effects in the highly socially anxious, with particular advantages of an external social focus concerning eye contact to the audience and positive affect. Further research should investigate whether social focus is even more advantageous long term and if reinterpretations of dysfunctional beliefs could be achieved by not avoiding social cues.

A multifaceted study of interpersonal functioning and cognitive biases towards social stimuli in adolescents with eating disorders and healthy controls

BACKGROUND

Cognitive biases towards social stimuli have been identified as one of the putative modifiable mechanisms to remediate interpersonal difficulties in adolescents with mental disorders. However, evidence for these biases in adolescents with eating disorders is scarce.

METHODS

This study assessed interpersonal sensitivity, cognitive biases towards social stimuli, and quantity and quality of social group memberships in adolescents with eating disorders (n = 80), compared to healthy controls (n = 78), and examined whether a negative interpretation bias would mediate the relationship between interpersonal sensitivity, eating disorder symptoms and positive group memberships.

RESULTS

Adolescents with eating disorders displayed greater interpersonal awareness, negative interpretation biases of ambiguous social information and poorer quality relationships with their social groups compared to healthy controls. In a simple mediation model, interpersonal awareness predicted eating disorder symptoms, and this effect was partially mediated by a negative interpretation bias.

CONCLUSIONS

Psychological interventions which aim to reduce a negative interpretation bias might help to reduce the severity of eating disorder symptoms in adolescents with eating disorders.

Neurophysiological predictors of gaze-contingent music reward therapy among adults with social anxiety disorder

Social anxiety disorder (SAD) is associated with fear of negative evaluation and heightened performance monitoring. The best-established treatments help only a subset of patients, and there are no well-established predictors of treatment response. The current study investigated whether individual differences in processing errors might predict response to gaze-contingent music reward therapy (GC-MRT). At baseline, healthy control subjects (HC; n = 20) and adults with SAD (n = 29), ages 19-43 years, completed the Flanker Task while electroencephalography (EEG) data were recorded. SAD participants then received up to 12 sessions over 8 weeks of GC-MRT, designed to train participants' attention away from threatening and toward neutral faces. Clinical assessments were completed 9- (post-treatment) and 20-weeks (follow-up) after initiating the treatment. At baseline, compared to HC, SAD performed the task more accurately and exhibited increased error-related negativity (ERN) and delta power to error commission. After controlling for age and baseline symptoms, more negative ERN and increased frontal midline theta (FMT) predicted reduced self-reported social anxiety symptoms at post-treatment, and FMT also predicted clinician-rated and self-reported symptom reduction at the follow-up assessment. Hypervigilance to error is characteristic of SAD and warrants further research as a predictor of treatment response for GC-MRT.