ABCT in Philadelphia – Maximizing the Effects of Attention Bias Modification for Anxiety: How and for Whom

Maximizing the Effects of Attention Bias Modification for Anxiety: How and for Whom

J. M. Kuckertz¹; N. Amir¹; Y. Bar-Haim²; C. Beard^{3, 4}; R. Montana^{4, 5}; J. M. Kuckertz¹; C. Warren⁶; J. W. Boffa⁶; S. Rindt⁷; S. Norman⁸; N. Amir¹; P. Carlbring⁹; J. M. Kuckertz¹; E. Gildebrant¹⁰; O. Bodlund¹⁰; T. Stenlund¹⁰; S. G. Hofmann¹¹; G. Andersson¹²; N. Amir¹; A. Heeren^{13, 14}; C. Baeken¹⁴; M. Vanderhasselt¹⁴; P. Philippot¹³; R. De Raedt¹⁴
1. Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, San Diego, CA, United States.
2. Tel Aviv University, Tel Aviv, Israel.
3. Harvard Medical School, Boston, MA, United States.
4. McLean Hospital, Belmont, MA, United States.
5. Brandeis University, Belmont, MA, United States.
6. San Diego State University, San Diego, CA, United States.
7. Aurora Behavioral Health Care, San Diego, CA, United States.
8. Center for Stress and Mental Health and University of California, San Diego, San Diego, CA, United States.
9. Stockholm University, Stockholm, Sweden.
10. Umea University, Umea, Sweden.
11. Boston University, Boston, MA, United States.
12. Linkoping University, Linkoping, Sweden.
13. Universite Catholique de Louvain, Louvain-la-Nueve, Belgium.
14. Ghent University, Ghent, Belgium.

• Described factors that predict which individuals will respond to attention bias modification treatments
• Explained mechanisms underlying change and maintenance of symptoms following attention bias modification trials
• Discussed methods of enhancing attention bias change within the context of attention bias modification treatments

A large body of literature suggests that individuals with anxiety disorders are characterized by an attention bias for threat-relevant information (Bar-Haim et al., 2007). Moreover, such biases have been implicated in the maintenance of anxiety, with meta-analyses supporting the use of attention bias modification (ABM) as a treatment for anxiety disorders (Hakamata et al., 2010; Beard et al., 2012; Hallion & Ruscio, 2011). Despite meta-analytic promise, a number of recent ABM trials have failed to demonstrate differential symptom improvements between active and control conditions (e.g., Boettcher et al., 2012; Neubaurer et al., 2013; Schoorl et al., 2013). Discrepant findings have highlighted the need to place emphasis beyond solely whether or not symptoms are reduced as a result of ABM, but rather, for whom and for what reasons symptoms change (Clarke et al., 2014; Kuckertz et al., 2014). The current symposium represents data from four presenters examining novel perspectives on addressing these questions. Beard and Montana discuss predictors and moderators of symptom change in a trial combining ABM and interpretation modification for social anxiety disorder. Beard will present results suggesting that both attentional as well as demographic factors moderate outcome. Specifically, attentional control, but not attention bias, moderates treatment response. Moreover, results indicate that higher treatment credibility ratings predict improved response, thus offering implications for how ABM treatments are presented to patients. In an effort to examine questions of mechanism, Kuckertz and colleagues will present findings suggesting that ABM produces symptom reductions in post-traumatic stress disorder by manipulating the extent to which individuals demonstrate changes in attention bias within training sessions, rather than changes in average attention bias over the course of treatment. Such analyses represent a new method of examining change in attentional processes as mediating ABM treatment. Carlbring and colleagues will present data suggesting that ABM is successful in treating social anxiety only under conditions in which individuals both present with an attentional bias at pre-treatment and experience significant reductions in bias over the course of treatment. Such results beg the question of how attention bias is most effectively modified. In attempt to address this question, Carlbring will compare the results of two ABM trials, which suggest that attentional bias is best manipulated when individuals are instructed to activate their social anxiety fears prior to each ABM session. Heeren and colleagues will further examine this question by discussing a study in which they directly modulated the biological underpinnings of attention through the use of ABM paired with trancranial direct current stimulation (tDCS). The results of Heeren and colleagues suggest that anodal tDCS with ABM facilitates attentional disengagement from threat, thus offering promise for maximizing the effects of ABM. Together, data from these presenters advance an improved understanding of the role of ABM in treating anxiety, and represent a response to questions from a growing body of literature calling for closer attention to moderators and mediators of ABM.

Cognitive Bias Modification for Social Anxiety: Predictors and Moderators of Change

Cognitive Bias Modification (CBM) is an efficacious treatment for Social Anxiety Disorder (SAD) when delivered in a research lab or clinical setting. However, effect sizes vary and recent attempts to extend CBM to on-line delivery have failed. Thus, more data is needed regarding predictors and moderators of CBM’s effects. Such research is crucial to inform refinement of CBM protocols, as well as to determine subgroups for whom CBM may be particularly helpful or not. Thus, we examined predictors or treatment response in a randomized, double-blind placebo-controlled trial (n=32) of a CBM treatment called Attention and Interpretation Modification (AIM) for SAD. AIM comprised eight, twice weekly computer sessions designed to improve attention and interpretation biases. Treatment credibility ratings made at baseline were significantly correlated with change in social anxiety symptoms (r = .52, p = .02). Three- way interactions among Time X Treatment Condition X Age and Gender significantly moderated response, such that males and younger participants seemed to respond more strongly to the treatment (ps < .05). Baseline
levels of self-reported attentional control moderated response such that participants high in attentional control and in the treatment group had the largest reduction in symptoms. Baseline levels of social anxiety severity, attention bias, and interpretation bias did not moderate outcome. Results warrant further examination of these variables in future, larger trials. We will discuss treatment implications, such as enhancing treatment credibility, predicting which individuals may benefit from existing CBM protocols, and how future protocols may need personalization for specific subgroups. We will also present data on predictors of response from an ongoing randomized controlled trial of CBM as an adjunctive treatment for depression in a partial hospital setting.

Effects of an Attention Modification Program as an Adjunctive Treatment for PTSD

Attention bias modification (ABM) may be an effective treatment for anxiety disorders (Beard et al., 2012). As individuals with PTSD possess an attentional bias for threat-relevant information (Buckley et al., 2000; Thomas et al., 2013), ABM may prove to be effective in reducing anxiety symptoms in PTSD. To our knowledge, only one published study has examined the effects of ABM for PTSD (Schoorl et al., 2013), with results indicating no differences between active ABM and control conditions, and no change in attentional bias. Extant research suggests that changes in attentional biases mediate treatment outcomes in ABM (e.g., Amir et al., 2009; Kuckertz et al., 2014). To date, no ABM study has been able to successfully manipulate attentional processes in PTSD and examine subsequent changes in symptoms. Moreover, recent research suggests that variability of attentional bias within session is more strongly related to PTSD symptoms than is average attentional bias (Iacoviello et al., in press). Based on this research, we examined the role of attentional bias within-session trainability in accounting for the effects of attention training. In the current study, we report the results of a trial testing the efficacy of ABM in conjunction to prolonged exposure therapy and medication in a community inpatient facility unit for military personnel diagnosed with PTSD. Participants were randomized to either an ABM condition or to an attention control condition (ACC). Participants in the ABM group experienced significantly fewer PTSD and depressive symptoms at post-treatment when compared to the ACC group. Moreover, change in attentional bias trainability mediated this change in symptoms. These results suggest that ABM may be an effective adjunct treatment for PTSD, however, successful manipulation of attentional processing is a prerequisite for symptom change.

Internet-Delivered Attention Training for SAD: Who Responds and Why

While attention modification programs (AMP) have shown promise as laboratory-based treatments for social anxiety disorder, trials of internet-delivered AMP have not yielded significant differences between active and control conditions. To address these inconsistencies, we examined the moderational and mediational role of attention bias in the efficacy of attention training. We compared data reported by Carlbring et al. (2012) to an identical AMP condition, with the exception that participants were instructed to activate social anxiety fears prior to each attention training session (AMP+FACT; n=39). We also compared all attention training groups to an internet-delivered cognitive-behavioral therapy (iCBT) condition (n=40). Participants in the AMP+FACT group experienced greater reductions in social anxiety symptoms than both active (n=40) and control (n=39) groups reported by Carlbring et al., and did not differ in symptom reductions from the iCBT group. Higher attention bias predicted greater symptom reductions for participants who completed AMP, but not for the control group. Moreover, change in attention bias mediated the relationship between AMP group (active condition reported by Carlbring et al. versus AMP+FACT) and change in social anxiety symptoms. These results suggest the importance of interpreting findings related to symptom change in attention training studies in the context of bias effects.

Impact of Transcranial Direct Current Stimulation Over the Left Dorsolateral Prefontral Cortex During Attention Bias Modification: An Eye-Tracking Study

People with anxiety disorders exhibit an attentional bias for threat (AB). Attention Bias Modification (ABM) procedure may reduce this bias. At a fundamental level, however, uncertainty still abounds regarding the nature of the processes that mediate this effect. One explanation suggests that ABM requires the modification of attention control, driven by the recruitment of the dorsolateral prefrontal cortex (DLPFC). In the present double-blind study, we examined whether modifying AB requires the activation of the left DLPFC. We used transcranial current direct stimulation (tDCS) in order to directly modulate cortical excitability of the left DLPFC during ABM. We randomly assigned highly trait-anxious individuals to one of three conditions: 1) ABM combined with cathodal tDCS, 2) ABM combined with anodal tDCS, or 3) ABM combined with sham tDCS. We assessed the effects of these manipulations on both reaction times and eye-movements on a task indexing AB. Results indicate that combining ABM and anodal tDCS over the left DLPFC reduces the total duration of time that participants’ gaze remained fixated on threat assessed using eye-tracking measurement. As the difficulty to disengage attention from threat is known to play an important role in the maintenance of anxiety, this suggest that anodal tDCS over the left DLPFC may be considered as a promising tool to reduce the inability to effectively disengage attention from threat.