Attention bias modification for social anxiety: A systematic review and meta-analysis
Introduction
Social anxiety disorder (SAD) is the most common anxiety disorder with a lifetime prevalence of more than 12% (e.g., Stein & Stein, 2008). SAD is characterized by intense fear in social situations, causing considerable distress and impaired daily functioning. Although there are several empirically supported psychological (for a meta-analysis, see Acarturk, Cuijpers, van Straten, & de Graaf, 2009) and pharmacological treatments for SAD (for a meta-analysis, see Blanco et al., 2003), many patients with this condition do not access treatment for a number of reasons (e.g., inability to afford treatment, concern about what others might think, concern over side effects; Gunter and Whittal, 2010, Lovell and Richards, 2000, Olfson et al., 2000, Weisberg et al., 2007). Moreover, even when they inquire about treatment, only about 15% initiate it (e.g., Olfson et al., 2000). These findings highlight the importance of developing effective treatments that are widely accessible and acceptable for individuals with SAD.
Recently, a growing body of research has accumulated on a new treatment for reducing anxiety, called attention bias modification (ABM). ABM builds upon cognitive theories of psychopathology that implicate attentional bias for threat (AB) in the maintenance, and perhaps the etiology, of SAD (Morrison & Heimberg, 2013). The clinical purpose of ABM is to reduce AB, thereby diminishing anxiety proneness and symptoms (MacLeod & Mathews, 2012). The most common ABM procedure is a modification of the visual dot-probe task (MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002) based on the classic work of MacLeod, Mathews, and Tata (1986). In early versions of the dot-probe task (e.g., MacLeod et al., 1986), participants viewed two stimuli (e.g., a pair of threatening-neutral words or photographs) presented in two distinct locations (presented either horizontally or vertically) of a computer screen for a brief duration (usually 500 ms). Immediately thereafter, a dot appeared in the location previously occupied by one of the two stimuli. In different versions, participants had to indicate the location of the probe (right or left versus up or down) or to indicate its identity (e.g., “E” or “F”) as quickly as possible. An AB occurred when participants responded faster to the probe when it replaced a threatening stimulus than when it replaced a nonthreatening stimulus, indicating that their attention was directed to the location occupied by the threatening stimulus.
In ABM, researchers typically modify the original task so that the probe nearly always (e.g., 95% of the trials) replaces the neutral or positive stimulus, thereby redirecting subjects' attention to non-threatening cues. In the control condition, there is no contingency between cues and probes. Relative to the control condition, ABM often reduces symptoms in people with SAD (e.g., Amir et al., 2008, Amir et al., 2009, Heeren et al., 2012b, Li et al., 2008, Schmidt et al., 2009). These findings suggest that ABM could have important clinical potential for treating SAD, as it entails a very simple protocol, little effort and motivation from the patient, little contact with a mental health professional, and can be easily disseminated (e.g., Amir et al., 2011, Heeren et al., 2013). However, over the past two years, other studies have reported mixed findings (e.g., Boettcher et al., 2012, Boettcher et al., 2013, Carlbring et al., 2012, Heeren et al., 2011, Julian et al., 2012, McNally et al., 2013). More specifically, these studies have shown that ABM and the control condition did not differ significantly at posttraining in reducing AB or SAD symptoms. That is, although the AB condition often attenuated anxiety symptoms, the control condition performed just as well. These failures to replicate initial results with ABM have prompted a dismissive appraisal of ABM's prospects as a viable clinical intervention from some commentators (e.g., Emmelkamp, 2012).
Section snippets
Previous comprehensive evidence
Over the last four years, several systematic reviews have affirmed the clinical potential of ABM across a variety of clinical conditions. Indeed, to date, five meta-analyses have been published on the effects of ABM (Beard et al., 2012a, Cristea et al., 2015, Hakamata et al., 2010, Hallion and Ruscio, 2011, Mogoașe et al., 2014).
The first meta-analysis (Hakamata et al., 2010) summarized the findings of 12 studies that used ABM to reduce AB and anxiety (all anxiety disorders included). It
Overview of the present meta-analysis
Despite the five previous meta-analyses on the clinical efficacy of ABM, none focused on a single disorder. Moreover, this is especially unfortunate for SAD — the chief target in most studies and the disorder for whom ABM may be most appropriate as either a stand-alone treatment (e.g., Amir et al., 2011, Heeren et al., 2013) or as integrated into a standard cognitive-behavioral treatment package (e.g., Rapee et al., 2013).
Furthermore, only two meta-analyses included studies with negative
Literature search
We performed the meta-analysis in accordance with the PRISMA guidelines (Liberati et al., 2009; see Appendix A). Potentially relevant studies were identified following a systematic search of the Scopus, PubMed, and PsycInfo database through October 2014, using the following keywords: “attentional bias modification”, “attentional training”, “attentional retraining”, combined with “social anxiety”. We also systematically searched the references within the most recent articles (De Voogt et al.,
Characteristics of the studies
Table 2 summarizes the characteristics of the 15 studies. Study sample size ranged from 24 to 299 with a total of 1043 randomized participants (ABM = 537; Control = 506), 53.63% were women (range 36.75 to 74.45%), and the mean age was 28.47 (range of the means 19.01–39.54). The mean baseline of the LSAS total score was 71.09 (range of the means 39.90–81.81). Five studies included one training session, whereas ten had multiple sessions (mean numbers of sessions = 9.01; SD = 15.27). Six studies included
Discussion
This is the first meta-analysis to assess the efficacy of ABM for SAD on symptoms, reactivity to speech challenge, AB, and secondary symptoms at posttraining as well as on SAD symptoms at 4-month follow-up. We performed a systematic review and meta-analysis on 15 studies with a combined total sample size of 1043 participants. We first examined the degree to which ABM yields therapeutic benefits for the different categories of outcomes measurement depicted above. We then explored possible
Role of funding sources
This research was supported by a Grant (Grant # FC 78142) from the Belgian National Science Foundation “F.R.S.—FNRS.” (awarded to Alexandre Heeren) and by the Sectorial Operational Program for Human Resources Development 2007–2013 (“Young Successful Researchers”; Grant # POSDRU/159/1.5/S/132400) from the European Social Fund (awarded to Cristina Mogoaşe). This research also received the support from the Belgian Foundation for Vocation (“Vocatio”) and the Belgian French Community Grant for
Contributors
Alexandre Heeren and Richard J. McNally designed the study and wrote the protocol. Alexandre Heeren and Cristina Mogoașe conducted literature searches, provided summaries of previous research studies, and conducted the statistical analyses. Alexandre Heeren and Richard J. McNally wrote the first draft of the manuscript. All authors revised the manuscript critically and contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
References2 (99)
- et al.
Behaviour Research and Therapy
(2013) - et al.
Efficacy of attention bias modification using threat and appetitive stimuli: A meta-analytic review
Behavior Therapy
(2012) - et al.
Attention feedback awareness and control training (A-Fact): Experimental test of a novel intervention paradigm targeting attentional bias
Behaviour Research and Therapy
(2014) - et al.
Lateral prefrontal cortex mediates the cognitive modification of attentional bias
Biological Psychiatry
(2010) - et al.
Neuroimaging in social anxiety disorder: A meta-analytic review resulting in a new neurofunctional model
Neuroscience & Biobehavioral Reviews
(2014) - et al.
A randomized trial of attention training for Generalized Social Phobia: Does attention training change social behavior?
Behavior Therapy
(2013) - et al.
The causal role of the dorsolateral prefrontal cortex in the modification of attentional bias: Evidence from transcranial direct current stimulation
Biological Psychiatry
(2014) - et al.
The psychometric properties of the dot-probe paradigm when used in pain-related attentional bias research
Journal of Pain
(2011) - et al.
Disseminations of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patients access
Clinical Psychology Review
(2010) - et al.
Attention bias modification treatment: A meta-analysis toward the establishment of novel treatment for anxiety
Biological Psychiatry
(2010)
How does attention training work in social phobia: Disengagement from threat or reengagement to nonthreat?
Journal of Anxiety Disorders
Attention training toward and away from treat in social phobia: Effects on behavioural, subjective, and physiological measures of anxiety
Behaviour Research and Therapy
Information-processing bias in social phobia
Clinical Psychology Review
Attention training to reduce attention bias and social stressor reactivity: An attempt to replicate and extend previous findings
Behaviour Research & Therapy
Moderation and mediation of the effect of attention training in social anxiety disorder
Behaviour Research & Therapy
Continual training of attentional bias in social anxiety
Behaviour Research & Therapy
Does chocolate consumption really boost Nobel award chances? The peril of over-interpreting correlations in nutrition and health studies
The Journal of Nutrition
Attention bias modification for reducing speech anxiety
Behaviour Research and Therapy
Does quality of reports of randomized trials affect estimated of intervention efficacy reported in meta-analyses
The Lancet
Validation of a novel attention bias modification task: The future may be in the cards
Behaviour Research and Therapy
A cognitive-behavioral model of anxiety in social phobia
Behaviour Research and Therapy
Integrating cognitive bias modification into a standard cognitive behavioural treatment package for social phobia: A randomized controlled trial
Behaviour Research and Therapy
Social anxiety disorder
The Lancet
Psychological treatment of social anxiety disorder: A meta-analysis
Psychological Medicine
Diagnostic and statistical manual of mental disorders
Attention training in individuals with generalized social phobia: A randomized controlled trial
Journal of Consulting and Clinical Psychology
Predictors of response to an attention modification program in generalized social phobia
Journal of Consulting and Clinical Psychology
The effects of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals
Journal of Abnormal Psychology
Acetylcysteine in the prevention of contrast-induced nephropathy: A case study of the pitfalls in the evolution of evidence
Archives of Internal Medicine
Threat-related attentional bias in anxious and non-anxious individuals: A meta-analytic study
Psychological Bulletin
Socially anxious primary care patients' attitudes toward cognitive bias modification (CBM): A qualitative study
Behavioural and Cognitive Psychotherapy
Controlling the false discovery rate: A practical and powerful approach to multiple testing
Journal of the Royal Statistical Society
Internet-based guided self-help for several anxiety disorders: A randomized controlled trial comparing a tailored with a standardized disorder-specific approach
Psychotherapy
Trait anxiety and impoverished prefrontal control of attention
Nature Neuroscience
Pharmacological treatment of social anxiety disorder: A meta-analysis
Depression & Anxiety
Internet-based attention training for social anxiety: A randomized controlled trial
Cognitive Therapy and Research
Internet-based attention bias modification for social anxiety: A randomized controlled comparison of towards negative and training towards positive cues
PLoS ONE
Introduction to meta-analysis
Internet-delivered attention bias modification training in individuals with social anxiety disorder — A double blind randomized controlled trial
BMC Psychiatry
Absence of evidence or evidence of absence: Reflecting on therapeutic implementations of attentional bias modification
BMC Psychiatry
Statistical power analysis for the behavioral sciences
The handbook of research synthesis and meta-analysis
The efficacy of cognitive bias modification interventions in anxiety and depression: A meta-analysis
British Journal of Psychiatry
The effect of psychotherapy for adult depression are overestimated: A meta-analysis of study quality and effect size
Psychological Medicine
Visual search attentional bias modification reduces social phobia in adolescents
Journal of Behavior Therapy and Experimental Psychiatry
Mental health on the go: Effects of a gamified attention-bias modification mobile application in trait-anxious
Clinical Psychological Science
Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis
Biometrics
Bias in meta-analysis detected by a simple, graphical test
British Medical Journal
Attention bias modification: The Emperor's new suit?
BMC Medicine
Cited by (215)
Testing a brief attention training protocol to prevent emotional distress from a fear induction procedure
2024, Journal of Behavior Therapy and Experimental PsychiatryThe impact of attention bias modification training on behavioral and physiological responses
2024, Biological PsychologyAttentional heterogeneity in social anxiety disorder: Evidence from Hidden Markov Models
2024, Behaviour Research and TherapyAttention bias vs. attention control modification for social anxiety disorder: A randomized controlled trial
2024, Journal of Anxiety DisordersKnowledge of Threat Biases Perceptual Decision Making in Anxiety: Evidence From Signal Detection Theory and Drift Diffusion Modeling
2024, Biological Psychiatry Global Open Science
- 2
References marked with an asterisk indicate studies included in the meta-analysis. The in-text citations to studies selected for meta-analysis are not preceded by asterisks.