Can attention bias modification augment the effect of CBT for anxiety disorders? A systematic review and meta-analysis

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

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.

Change in food choice during acute treatment and the effect on longer-term outcome in patients with anorexia nervosa

BACKGROUND

Restriction of food intake is a central pathological feature of anorexia nervosa (AN). Maladaptive eating behavior and, specifically, limited intake of calorie-dense foods are resistant to change and contribute to poor long-term outcomes. This study is a preliminary examination of whether change in food choices during inpatient treatment is related to longer-term clinical course.

METHODS

Individuals with AN completed a computerized Food Choice Task at the beginning and end of inpatient treatment to determine changes in high-fat and self-controlled food choices. Linear regression and longitudinal analyses tested whether change in task behavior predicted short-term outcome (body mass index [BMI] at discharge) and longer-term outcome (BMI and eating disorder psychopathology).

RESULTS

Among 88 patients with AN, BMI improved significantly with hospital treatment (p < 0.001), but Food Choice Task outcomes did not change significantly. Change in high-fat and self-controlled choices was not associated with BMI at discharge (r = 0.13, p = 0.22 and r = 0.10, p = 0.39, respectively). An increase in the proportion of high-fat foods selected (β = 0.91, p = 0.02) and a decrease in the use of self-control (β = -1.50, p = 0.001) predicted less decline in BMI over 3 years after discharge.

CONCLUSIONS

Short-term treatment is associated with improvement in BMI but with no significant change, on average, in choices made in a task known to predict actual eating. However, the degree to which individuals increased high-fat choices during treatment and decreased the use of self-control over food choice were associated with reduced weight loss over the following 3 years, underscoring the need to focus on changing eating behavior in treatment of AN.

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.

A novel probe of attentional bias for threat in specific phobia: Application of the "MouseView.js" approach

Although attentional bias for threat has been implicated in anxiety disorders, traditional attentional bias measures have been criticized for lack of reliability and validity, and eye tracking technologies can be cost-prohibitive. MouseView.js was recently developed to mimic eye tracking online by using the computer cursor as a proxy for gaze, and although it is equally reliable, MouseView.js' utility for capturing attentional bias for threat in anxiety-related disorders remains unclear. To fill this knowledge gap, snake phobic and non-phobic participants (N = 62) completed a behavioral avoidance task (BAT) and the MouseView.js task which consisted of 10-second exposures to blurred, side-by-side images of either pleasant-neutral or threat-neutral pairings and were instructed to freely move the mouse to reveal the images. Results demonstrated that snake phobic participants had significantly shorter average mouse dwell time on threat images than non-phobic individuals and showed a significant reduction in average dwell time on threat images following the first presentation of the threat-neutral pairing. Additionally, dwell time on threat images significantly mediated the group differences in steps completed on the BAT. Results highlight the utility of MouseView.js in capturing avoidant patterns of attentional bias for threat that may also partially drive avoidance in snake phobia. Implications for capturing attentional bias for threat in anxiety disorders more broadly are discussed.

Cognitive behavioral therapy (CBT) plus attention bias modification (ABM) reduces anxiety sensitivity and depressive symptoms in panic disorder: A pilot randomized trial

BACKGROUND

Cognitive bias theories propose that reducing threat hypervigilance in mental disorders can augment cognitive behavioral therapy (CBT) outcomes. However, no studies have tested whether adding attention bias modification (ABM) can effectively enhance CBT's effects on anxiety sensitivity (AS), electromyography (EMG), and skin conductance (SC) for panic disorder (PD). This pilot randomized controlled trial (RCT) thus aimed to evaluate the efficacy of CBT + ABM (vs. CBT plus attention training placebo; PBO) on those outcomes.

METHOD

This study is a secondary analysis (Baker et al., 2020). Adults with PD were randomized to receive CBT + ABM (n = 11) or CBT + PBO (n = 12). Before each of the first five CBT sessions, CBT + ABM and CBT + PBO participants completed a 15-min ABM task or attention training PBO, respectively. AS and depression severity as well as SC and EMG during habituation to a loud-tone startle paradigm were assessed. Hierarchical Bayesian analyses were conducted.

RESULTS

During pre-post-treatment and pre-follow-up, CBM + ABM (vs. CBT + PBO) led to a notably greater reduction in ASI-Physical (between-group d = -1.26 to -1.25), ASI-Cognitive (d = -1.16 to -1.10), and depression severity (d = -1.23 to -0.99). However, no between-group difference was observed for ASI-Social, EMG, or SC indices.

DISCUSSION

Adding a brief computerized ABM intervention to CBT for PD protocols may enhance therapeutic change.

Cognitive Remediation in Psychiatric Disorders: State of the Evidence, Future Perspectives, and Some Bold Ideas

Many people with psychiatric disorders experience impairments in cognition. These deficits have a significant impact on daily functioning and sometimes even on the further course of their disease. Cognitive remediation (CR) is used as an umbrella term for behavioral training interventions to ameliorate these deficits. In most but not all studies, CR has proven effective in improving cognition and enhancing everyday functional outcomes. In this paper, after quickly summarizing the empirical evidence, practical advice to optimize the effects of CR interventions is provided. We advocate that CR interventions should be as fun and motivating as possible, and therapists should at least consider using positively toned emotional stimuli instead of neutral stimuli. Participants should be screened for basic processing deficits, which should be trained before CR of higher-order cognitive domains. CR should stimulate metacognition and utilize natural settings to invoke social cognition. Wherever possible, CR tasks should link to tasks that participants face in their everyday life. Therapists should consider that participants might also benefit from positive side effects on symptomatology. Finally, the CR approach might even be utilized in settings where the treatment of cognitive impairments is not a primary target.