A randomized controlled trial of attention modification for social anxiety disorder

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.

Evaluating the efficacy of an attention modification program for patients with fibromyalgia: a randomized controlled trial

Persons with chronic musculoskeletal pain may be hypervigilant for pain-related cues which, paradoxically, may be maintaining their pain. Several randomized controlled trials have assessed whether a modified dot-probe protocol (ie, attention bias modification [ABM]) reduces chronic pain- and pain-related symptoms in persons with several diagnoses, including fibromyalgia. Scalability and economic efficiency potentiates the appeal of ABM protocols; however, research results have been mixed, with only some studies evidencing significant symptom gains from ABM and some evidencing gains for the control group. The current randomized controlled trial sought to replicate and extend previous ABM research using idiosyncratic word stimuli and a 1-month follow-up. Participants included treatment-seeking adult women (n = 117) with fibromyalgia who were randomly assigned to a standard (ie, control) or active (ie, ABM) condition. The protocol was delivered online and involved twice-weekly 15-minute sessions, for 4 weeks, with questionnaires completed at baseline, posttreatment, and 1-month follow-up. Symptom reports were analysed with mixed hierarchical modelling. There was no evidence of differences between the control and ABM groups. Both groups had small significant (Ps < 0.05) improvements in pain experiences at posttreatment, but not at follow-up (Ps > 0.05). There were no significant changes for either group on measures of anxiety sensitivity, illness/injury sensitivity, pain-related fear, pain-related anxiety, or attentional biases (Ps > 0.05). The current findings add to the emerging and mixed literature regarding ABM for pain by demonstrating that ABM produces no substantive improvements in pain or pain-related constructs in a large sample of patients with fibromyalgia.

Threat-of-shock decreases emotional interference on affective stroop performance in healthy controls and anxiety patients

Patients with anxiety disorders suffer from impaired concentration, potentially as a result of stronger emotional interference on attention. Studies using behavioural measures provide conflicting support for this hypothesis. Elevated state anxiety may be necessary to reliably document differences in emotional interference in patients versus healthy controls. The present study examines the effect of experimentally induced state anxiety (threat-of-shock) on attention interference by emotional stimuli. Anxiety patients (n = 36) and healthy controls (n = 32) completed a modified affective Stroop task during periods of safety and threat-of-shock. Results indicated that in both patients and controls, threat decreased negative, but not positive or neutral, emotional interference on attention (both p < .001). This finding supports a threat-related narrowing of attention whereby a certain level of anxiety decreases task-irrelevant processing.

Web-Based Cognitive Bias Intervention for Psychiatric Disorders: Protocol for a Systematic Review

Background

Traditional psychological therapies focus mainly on modification of individuals’ conscious decision-making process. Unconscious processes, such as cognitive biases, have been found accountable for various psychiatric psychopathologies, and advances in technologies have transformed how bias modification programs are being delivered.

Objective

The primary aim of this review is to synthesize evidence of Web-based cognitive bias modification intervention for bias reduction. The secondary aim is to determine the change in symptoms for individual psychiatric disorders following bias modification.

Methods

A systematic review will be conducted including only randomized trials. There will be no restrictions on participants included in the study. A search will be conducted on the respective databases until 2017. Selection of studies will be by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA-P) guidelines. Quality assessment of included studies will be conducted using the Cochrane Risk of Bias tool. A narrative synthesis of identified articles will then be conducted. A meta-analysis will be considered only if there are sufficient articles in a domain for statistical analysis. Ethical approval for this protocol and the planned systematic review was not required.

Results

We expect that the review will be completed 12 months from publication of this protocol.

Conclusions

This review is of importance given how technology has transformed delivery of conventional therapies. Findings from this review will guide future research involving technology and cognitive bias modification interventions.

Trial Registration

International Prospective Register for Systematic Reviews (PROSPERO): 2017 CRD42017074754; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=74754 (Archived by WebCite at http://www.webcitation.org/ 71AvSgZGn)

Registered Report Identifier

RR1-10.2196/10427

Does attention bias modification training impact on task performance in the context of pain: An experimental study in healthy participants

Attention has been theorized to play a key role in the experience of pain and associated task interference. Training attention away from pain via attention bias modification (ABM) training techniques has been proposed to improve pain-related outcomes, but evidence is inconsistent. In an experimental study, we investigated the impact of a single session ABM training -using a visual probe paradigm with idiosyncratic pain words- on cold pressor test (CPT) pain experience and task interference by pain. Fifty-eight healthy volunteers were randomly assigned to an ABM training group (N = 28; attending away from pain) and a sham training group (N = 30; no training direction). At pre-training, participants performed a baseline Random-Interval-Repetition (RIR) task and the CPT. Participants reported on sensations they experienced during the baseline CPT. Relevant descriptors were integrated in the visual probe paradigm during the training phase. At post-training, participants completed the RIR task again while experiencing CPT pain. Participants also reported on the extent they attended to the pain and the intensity/unpleasantness of the pain. Results indicated that, in contrast with our hypotheses, ABM training did also not reduce task interference due to CPT pain. Furthermore, ABM training did not change self-reported attending to CPT pain. Finally, ABM training did not reduce CPT pain intensity or pain unpleasantness. Overall, the current study provides no support for the effectiveness of a single session ABM training in improving pain-related outcomes. Future research addressing the conditions under which ABM training improves or fails to improve pain-related outcomes is warranted.

Insula activation is modulated by attention shifting in social anxiety disorder

Social anxiety disorder (SAD) is characterized by exaggerated reactivity to social threat, often documented by biased attention to threatening information, and increased activation in brain regions involved in salience/threat processing. Attention training has been developed to ameliorate the attention bias documented in individuals with SAD, with mixed results. We investigated patterns of brain activation underlying acute attention modulation in 41 participants (29 with SAD and 12 health controls). We then investigated how brain activation changed over time in both groups in response to a 4-session attention training protocol (toward threat, away from threat, no-training control). Results revealed diminished pre-training deactivation in the insula in SAD participants during attention modulation. SAD participants also demonstrated an increase in insula deactivation over time, suggestive of an improvement in attention modulation of emotion, and this was associated with a decrease in symptom severity. Attention training did not, itself, lead to clinical improvement, though there was a trend level effect of training toward threat on increased insula deactivation over time. While deficits in attentional control and emotion modulation are documented in individuals with SAD, current attention training protocols are not robustly effective in ameliorating aberrant functioning. Pursuit of training protocols that have more robust impacts on the relevant neural circuitry may have some value.

Attention Bias Modification (ABM): Review of Effects of Multisession ABM Training on Anxiety and Threat-Related Attention in High-Anxious Individuals

Attention bias modification (ABM) aims to reduce anxiety by reducing attention bias (AB) to threat; however, effects on anxiety and AB are variable. This review examines 34 studies assessing effects of multisession-ABM on both anxiety and AB in high-anxious individuals. Methods include ABM-threat-avoidance (promoting attention-orienting away from threat), ABM-positive-search (promoting explicit, goal-directed attention-search for positive/nonthreat targets among negative/threat distractors), and comparison conditions (e.g., control-attention training combining threat-cue exposure and attention-task practice without AB-modification). Findings indicate anxiety reduction often occurs during both ABM-threat-avoidance and control-attention training; anxiety reduction is not consistently accompanied by AB reduction; anxious individuals often show no pretraining AB in orienting toward threat; and ABM-positive-search training appears promising in reducing anxiety. Methodological and theoretical issues are discussed concerning ABM paradigms, comparison conditions, and AB assessment. ABM methods combining explicit goal-directed attention-search for nonthreat/positive information and effortful threat-distractor inhibition (promoting top-down cognitive control during threat-cue exposure) warrant further evaluation.

Effects of cognitive bias modification on social anxiety: A meta-analysis

Background

Cognitive bias modification (CBM), a set of techniques for modifying bias in information processing—is considered a novel intervention for social anxiety disorder (SAD), which has drawn considerable interest from researchers. However, the effects of CBM on SAD are not consistent. Some studies have demonstrated significant positive effects compared to control groups, while others have found no such effects.

Aims

We conducted a meta-analysis aimed at quantitatively assessing the effects of CBM on SAD at post-test.

Method

Through a systematic literature search by two independent raters, 34 articles (36 randomized studies) including 2,550 participants were identified. A multilevel modeling approach was employed to assess the effects of CBM on SAD, and to explore the potentially crucial procedures and sample characteristics that enhance the effectiveness of benign training.

Results

In general, there were small but significant effects of CBM on the primary symptoms of SAD (g = 0.17), cognitive bias (CB) toward threat (g = 0.32), and reactivity in stressful situations (g = 0.25), but non-significant effects on secondary symptoms. However, the interpretation modification program was more effective than was attentional bias modification in reducing SAD primary symptoms and negative CB. Laboratory training procedures produced larger primary symptom reductions compared to Internet-based training, whereas the percentage of contingency and feedback about training performance boosted cognitive effects only. Finally, the following groups were more likely to benefit from CBM: younger participants (primary symptoms and cognitive effects), women (primary symptom effects), and samples with stronger CB (stressor effects). The quality of the randomized controlled trials was less than desirable, as there was some indication of publication bias in our study.

Conclusions

Current findings broadly supported cognitive theories of SAD that consider a bidirectional or mutually reinforcing relationship between symptoms and CBs. However, the small therapeutic effect observed here indicates that it is necessary to develop more reliable and efficient CBM interventions that are specific to SAD.

Online visual search attentional bias modification for adolescents with heightened anxiety and depressive symptoms: A randomized controlled trial

Anxiety and depression, which are highly prevalent in adolescence, are both characterized by a negative attentional bias. As Attentional Bias Modification (ABM) can reduce such a bias, and might also affect emotional reactivity, it could be a promising early intervention. However, a growing number of studies also report comparable improvements in both active and placebo groups. The current study investigated the effects of eight online sessions of visual search (VS) ABM compared to both a VS placebo-training and a no-training control group in adolescents with heightened symptoms of anxiety and/or depression (n = 108). Attention bias, interpretation bias, and stress-reactivity were assessed pre- and post-training. Primary outcomes of anxiety and depressive symptoms, and secondary measures of emotional resilience were assessed pre- and post-training and at three and six months follow-up. Results revealed that VS training reduced attentional bias compared to both control groups, with stronger effects for participants who completed more training sessions. Irrespective of training condition, an overall reduction in symptoms of anxiety and depression and an increase in emotional resilience were observed up to six months later. The training was evaluated relatively negatively. Results suggest that online ABM as employed in the current study has no added value as an early intervention in adolescents with heightened symptoms.

Cognitive bias modification of interpretation in children with social anxiety disorder

Negative (or a lack of positive) interpretation of ambiguous social situations has been hypothesised to maintain social anxiety disorder in children, yet there is currently limited evidence to support this. Cognitive Bias Modification of Interpretation (CBM-I) provides a means to explore the causal influence of interpretation bias on social anxiety disorder, and has been associated with a reduction in social anxiety symptoms in adults. Seven to twelve year old children with a diagnosis of social anxiety disorder completed CBM-I training, adapted from materials designed for socially anxious children in the community, or no training. Effects on interpretation bias and social anxiety were assessed. The adapted CBM-I training was not associated with significant changes in benign or negative interpretation. Unsurprisingly given the lack of successful interpretation training, there were no significant changes in child or parent reported social anxiety symptoms, clinician-rated severity or diagnoses and change in interpretation was not significantly associated with change in social anxiety. These findings contrast with some studies with community populations although it is possible that more intensive CBM-I training is required to fully test this hypothesis among clinical groups.

Online attention modification for social anxiety disorder: replication of a randomized controlled trial

Social anxiety disorder (SAD) models posit vigilance for external social threat cues and exacerbated self-focused attention as key in disorder development and maintenance. Evidence indicates a modified dot-probe protocol may reduce symptoms of SAD; however, the efficacy when compared to a standard protocol and long-term maintenance of treatment gains remains unclear. Furthermore, the efficacy of such protocols on SAD-related constructs remains relatively unknown. The current investigation clarified these associations using a randomized control trial replicating and extending previous research. Participants with SAD (n = 113; 71% women) were randomized to complete a standard (i.e. control) or modified (i.e. active) dot-probe protocol consisting of 15-min sessions twice weekly for four weeks. Self-reported symptoms were measured at baseline, post-treatment, and 4-month and 8-month follow-ups. Hierarchical linear modeling indicated significant self-reported reductions in symptoms of social anxiety, fear of negative evaluation, trait anxiety, and depression, but no such reductions in fear of positive evaluation. Symptom changes did not differ based on condition and were maintained at 8-month follow-up. Attentional biases during the dot-probe task were not related to symptom change. Overall, our results replicate support for the efficacy of both protocols in reducing symptoms of SAD and specific related constructs, and suggest a role of exposure, expectancy, or practice effects, rather than attention modification, in effecting such reductions. The current results also support distinct relationships between fears of negative and positive evaluation and social anxiety. Further research focused on identifying the mechanisms of change in attention modification protocols appears warranted.

An integrative network approach to social anxiety disorder: The complex dynamic interplay among attentional bias for threat, attentional control, and symptoms

Cognitive models posit that social anxiety disorder (SAD) is associated with and maintained by biased attention allocation vis-à-vis social threat. However, over the last decade, there has been intense debate regarding whether AB in SAD results from preferential engagement with or difficulty in disengaging from social threat. Further, recent evidence suggests that AB may merely result from top-down attentional impairments vis-à-vis non-emotional material. Consequently, uncertainty still abounds regarding both the relative importance and the mutual interactions of these different processes and SAD symptoms. Inspired by novel network approaches to psychopathology that conceptualize symptoms as complex dynamic systems of mutually interacting variables, we computed weighted directed networks to investigate potential causal relations among laboratory measures of attentional components and symptoms of social anxiety disorder. Global and local connectivity of network structures revealed that the three most central variables were the orienting component of attention as well as both avoidance and fear of social situations. Neither preferential attention engagement with threat nor difficulty disengaging from threat exhibited high relative importance as predictors of symptoms in the network. Together, these findings suggest the value of extending the network approach beyond self-reported clinical symptoms to incorporate process-level measures from laboratory tasks to gain new insight into the mechanisms of SAD.

Meta-analysis of technology-assisted interventions for social anxiety disorder

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g=0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g=0.38) and VRET showed comparable effects (p>0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g=0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.

The role of pain intensity and smoking expectancies on smoking urge and behavior following experimental pain induction

INTRODUCTION

Contemporary models of pain and smoking posit a cyclical relationship wherein smoking reduces pain in the short term but, ultimately, serves to exacerbate it in the long term. Such models were influenced by initial experimental findings suggesting situational pain is sufficient to increase smoking-urge and behavior. The initial experimental findings have not yet been replicated and potential mediating smoking motives and anxiety variables have not been explored.

METHODS

The current investigation was designed with the aims of exploring whether (a) electrical heat-pain is sufficient to increase smoking-urge, (b) pain intensity, anxiety sensitivity, and smoking expectancies for pain relief account for variance in post-pain smoking-urge, and (c) individuals are more likely to smoke following a pain experience.

RESULTS

Participants in the heat-pain condition (n=16) reported greater smoking-urge than those in the no-pain control condition (n=16). In the heat-pain condition, approximately 31% of variance in smoking-urge was accounted for by the belief that smoking would help with pain coping or relief. Anxiety sensitivity and pain intensity ratings were not significant predictors of smoking-urge. Significantly more individuals in the heat-pain condition attempted to smoke (100%) after the pain manipulation than those in the no-pain control condition (62.5%).

CONCLUSIONS

Acute heat-pain increases smoking-urge and behavior, especially for individuals with expectancies that smoking will help with pain coping. Pain and pain-related smoking expectancies may serve as barriers to smoking cessation for those experiencing pain. Findings provide support for smoking cessation interventions strategies aimed at pain management and challenging smoking expectancies for pain coping/relief.

Does attention redirection contribute to the effectiveness of attention bias modification on social anxiety?

Attention bias modification (ABM) is designed to modify threat-related attention bias and thus alleviate anxiety. The current research examined whether consistently directing attention towards targeted goals per se contributes to ABM efficacy. We randomly assigned 68 non-clinical college students with elevated social anxiety to non-valence-specific attend-to-geometrics (AGC), attention modification (AMC), or attention control (ACC) conditions. We assessed subjective, behavioral, and physiological reactivity to a speech task and self-reported social anxiety symptoms. After training, participants in the AMC exhibited an attention avoidance from threat, and those in the AGC responded more rapidly toward targeted geometrics. There was a significant pre- to post-reduction in subjective speech distress across groups, but behavioral and physiological reactivity to speech, as well as self-report social anxiety symptoms, remained unchanged. These results lead to questions concerning effectiveness of ABM training for reducing social anxiety. Further examination of the current ABM protocol is required.