Elsevier

Clinical Psychology Review

Volume 40, August 2015, Pages 76-90
Clinical Psychology Review

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

https://doi.org/10.1016/j.cpr.2015.06.001Get rights and content

Highlights

  • We examined the effects of attention bias modification (ABM) for social anxiety (SA).

  • ABM had small effects on SA symptoms, attentional bias, and reactivity to speech challenge.

  • ABM's characteristics, study design, and trait anxiety moderated effect sizes.

  • Effects on secondary symptoms and SA symptoms at 4-month follow-up were nonsignificant.

  • The quality of the studies was substandard and wedged the effect sizes.

Abstract

Research on attention bias modification (ABM) for social anxiety disorder (SAD) is inconclusive, with some studies finding clear positive effects and other studies finding no significant benefit relative to control training procedures. In this meta-analysis, we assessed the efficacy of ABM for SAD on symptoms, reactivity to speech challenge, attentional bias (AB) toward threat, and secondary symptoms at posttraining as well as SAD symptoms at 4-month follow-up. A systematic search in bibliographical databases uncovered 15 randomized studies involving 1043 individuals that compared ABM to a control training procedure. Data were extracted independently by two raters. The Q statistic was used to assess homogeneity across trials. All analyses were conducted on intent-to-treat data. ABM produced a small but significant reduction in SAD symptoms (g = 0.27), reactivity to speech challenge (g = 0.46), and AB (g = 0.30). These effects were moderated by characteristics of the ABM procedure, the design of the study, and trait anxiety at baseline. However, effects on secondary symptoms (g = 0.09) and SAD symptoms at 4-month follow-up (g = 0.09) were not significant. Although there was no indication of significant publication bias, the quality of the studies was substandard and wedged the effect sizes. From a clinical point of view, these findings imply that ABM is not yet ready for wide-scale dissemination as a treatment for SAD in routine care. Theoretical implications for the integration of AB in the conceptualization of SAD are discussed.

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.

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    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.

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