As predicted, attention training successfully facilitated attention disengagement from threat from pre- to post-assessment, as well as reduced symptoms of social anxiety in individuals diagnosed with GSP. At post-treatment, independent assessor and participant ratings converged in demonstrating that participants completing the AMP were significantly less socially anxious and less functionally impaired than the ACC group. Finally, 50% of participants in the AMP group no longer met DSM-IV criteria for GSP after training, compared to 14% of participants in the control condition. Considered together, the present findings are consistent with earlier work using attention training procedures to modify emotional vulnerabilities in the context of laboratory stressors (Amir et al., 2008
; MacLeod et al., 2002
), and support the utility of using computerized attention modification programs with clinically anxious populations.
The current study adds to a small but growing empirical literature demonstrating the efficacy of computerized attention training procedures in reducing clinical symptoms in individuals meeting diagnostic criteria for an anxiety disorder (Amir et al., 2009
; Schmidt et al., 2009
). The finding that similar treatment outcomes were obtained within the current study at separate sites with differing demographic profiles, as well as in an independent laboratory (Schmidt et al.), supports the generalizability of the attention modification program across settings. Moreover, the robustness of the attention training procedure is bolstered by the extension of earlier findings in analogue samples of socially anxious students during brief training procedures (e.g., Amir et al., 2008
; Li et al., 2008
) to treatment-seeking samples presenting with greater severity of symptoms and functional impairment. Although the training stimuli used in the current study comprised faces conveying signs of disgust, there is evidence to suggest that disgust-relevant stimuli activate brain regions also implicated in the processing of other emotional stimuli such as fear (e.g., Stark et al., 2007
). Research is needed to establish whether the current treatment effects are unique to disgust stimuli, or generalize to other types of emotional training stimuli. Furthermore, assessments completed approximately four-months after completion of the post-assessment revealed that participants maintained symptom reduction after completing the training, suggesting that the beneficial effects of the AMP were enduring (see also Schmidt et al.). However, follow-up data should be interpreted with caution because assessors and participants were no longer blind to condition. Future research should investigate the long-term impact of the attention training procedure, including an assessment of symptoms as well as attention bias.
Participants in the current study had clinical characteristics and symptom severity scores in the range of previous treatment studies (e.g., Clark et al., 2006
; Davidson et al., 2004
; Heimberg et al., 1998
). Moreover, the controlled post-assessment between-group effect sizes for the current study (LSAS, d
= 1.59; SPAI, d
= .69) are comparable to those reported in previous studies, suggesting that the AMP may be an effective intervention for reducing symptoms of social anxiety. These findings speak to the utility of the AMP, given the brevity of the intervention (eight sessions over four weeks, 20 minutes each) and absence of therapist contact. Although empirically supported treatments for SP already exist, many people do not have access to therapists trained in CBT, while others opt not to take medication for their symptoms (e.g., Huppert, Franklin, Foa, & Davidson, 2003
). The ease of delivery of the current intervention suggests that the AMP may serve as a transportable and widely accessible treatment for individuals with SP who are unable to or choose not to access existing treatments.
Although accumulating evidence suggests that computerized attention training procedures are efficacious in reducing symptoms of anxiety in treatment-seeking samples, little is known about the attentional mechanisms underlying clinical improvement. Because previous studies either have not employed a measure of attention bias (Schmidt et al., 2009
) or have assessed change in attention using the same task as employed during training (Amir et al., 2009
), they have not been able to identify attention mechanisms underlying the observed treatment effects (see Weierich et al., 2008
). The current study extended previous research by including an independent assessment of attention that comprised a different task and stimuli, as well as a distinct attention process (i.e., covert attention allocation) relative to that used in training. The results suggested that the AMP facilitated participants’ ability to disengage their attention from social threat cues from pre- to post-training. Although participants as a whole did not differ at pre-assessment in their response latencies on invalid social threat compared to invalid neutral trials, the AMP group became faster to identify probes following invalidly cued threat words at post-assessment, making their responses closer to the performance that non-anxious individuals have been shown to display in previous research using this task (see Amir et al., 2003
). Moreover, change in attention bias from pre- to post-assessment was associated with change in clinician-reported social anxiety symptoms. These results mirror those reported in Amir et al. (2008)
using an identical attention modification program in an analogue sample during a single-session training procedure in the context of a laboratory social stressor. The results of the mediation analysis, however, should be interpreted with caution, given that change in the putative mediator (attention bias) and change in social anxiety symptoms were assessed at the same time, and temporal precedence was therefore not established. Thus, although causal inferences can be made about change in attention resulting from the AMP, we cannot make such claims about the relationship between change in attention and symptom change. Future research should administer assessments of attention at multiple points during the course of treatment to better address these issues.
Several explanations may account for the reduction in social anxiety associated with attention training. Previous research indicates that socially anxious individuals preferentially process negative social information (see Bögels & Mansell, 2004
). To the extent that attention biases toward threat are causally involved in the maintenance of anxiety (e.g., Clarke et al., 2008
; MacLeod et al., 2002
), then any procedure that normalizes this bias would be expected to also reduce anxiety symptoms. Consistent with this hypothesis, participants in the AMP group displayed a reduction in attention bias to threat-relevant cues over the course of training. In keeping with findings from previous work, it may be that the attention training procedure reduced participants’ emotional vulnerability in the context of real-life social encounters (e.g., Amir et al., 2008
; MacLeod et al., 2002
If attention acts as an initial filter on the processing of environmental cues, then reducing selective attention to threat would be expected to allow for increased processing of other types of social information, or may alter the perception of threat early in the appraisal process (e.g., Gross, 2002
) before the cascade of maladaptive cognitive, behavioral, and emotional events associated with anxiety is fully activated. Previous research suggests that the attention bias characteristic of anxious individuals may be moderated by individual differences in attentional control, such that anxious participants with poor attentional control remained slow in disengaging from threat, whereas those with good attentional control were better in shifting away from threat (Derryberry & Reed, 2002
). The enhanced disengagement evident in anxious people with good attentional control may limit the buildup of anxiety elicited by threatening stimuli, while allowing those individuals to access other information related to safety or the absence of the feared outcome, and facilitate more effective coping (e.g., Eysenck, Derakshan, Santos, & Calvo, 2007
). As a result of our training, participants in the AMP group may have come to view external social situations as less threatening. In turn, diminished threat appraisals may lead to fewer avoidance behaviors, and may have provided AMP participants with greater opportunities to practice social skills and more objectively evaluate social situations, resulting in reductions in anxiety symptoms. Future studies should examine the cognitive and behavioral sequelae of attention training in naturalistic settings over time.
A large body of research suggests that cognitive and behavioral therapies (CBT) are effective in treating a range of anxiety-related conditions, including SP (e.g., Clark et al., 2006
; Heimberg et al., 1998
). A central component of these treatments is repeated exposure to fear-provoking stimuli designed to facilitate emotional processing of threat information in order to allow the individual to experience a reduction in anxiety (i.e., habituate) and test the hypothesis that the feared stimuli may not be as threatening as initially predicted (e.g., Foa, Huppert, & Cahill, 2006
). Contrary to this model of anxiety reduction, our training directed participants’ attention away from threatening cues. One might argue that this approach, through encouraging attentional avoidance of threatening stimuli, would stand in contrast to the goal of exposure by interfering with elaborative processing of emotional material thought to be necessary for symptom reduction.
A review of the extant empirical literature, however, paints a more complex picture. Although some studies have found that attentional focus during exposure facilitated fear reduction (e.g., Grayson, Foa, & Steketee, 1982
), others have found that distraction produced greater fear reduction (e.g., Oliver & Page, 2008
). These results suggest that not all forms of attentional avoidance are anti-therapeutic, and suggest that a more precise understanding of the distinct mechanisms involved in attentional avoidance is needed (see Craske et al., 2008
; Rachman, Radomsky, & Shafran, 2008
for reviews). As proposed by Weierich et al. (2008)
, different subcomponents of attention may influence emotional processing in distinctive ways. Thus, it may be that focusing away from threat stimuli under some conditions is beneficial, while avoidance of threat stimuli is detrimental in other cases. This issue is of considerable theoretical and clinical importance, and requires greater empirical attention.
Our study has limitations. First, our sample size was small. This provided limited power to conduct mediational analysis, and prevented an examination of moderators of treatment response (e.g., comorbidity). Second, we did not collect data regarding interviewers’ or experimental assistants’ guess regarding group assignment, and therefore cannot definitively establish that interviewers and assistants remained blind to participant condition in all cases. However, it is unlikely that awareness of group assignment accounted for our results for the following reasons. First, experimental assistants were not aware of the participant’s condition assignment, and did not view any of the computerized trials. Second, interviewers met with participants exclusively during pre-, post-, and follow-up interviews and had little to no contact with participants during the computerized training sessions. Further, inter-rater reliability was conducted using ratings from judges who were blind to condition and corroborated the results. It is also notable that data collected from participants suggested they did not systematically predict their condition assignment, and the pattern and magnitude of treatment effects were consistent across participant and interviewer measures. Nonetheless, future research should include an assessment of assessors’ prediction about group assignment.
We also did not include an assessment of significant others, or a behavioral assessment (e.g., social stressor, see Amir et al., 2008
). These additional sources of data would increase our confidence in the generalizability of the current results beyond indices of symptom reduction and impairment. We also did not assess change in attention using the same probe detection task used during training, which limits comparability to some previous studies (e.g., Amir et al., 2009
). Research is needed to examine the effects of the AMP on change in different subcomponents of attention hypothesized to be involved in the pathophysiology of GSP, as well as use more ecologically valid tests of attention. Finally, it should be noted that significant Group X Time interaction effects were obtained only on measures of social anxiety symptoms, whereas the two groups did not respond differentially on measures of general emotional distress. These results suggest that the training was more specific to social anxiety symptoms, consistent with other placebo-controlled clinical trials in SP (e.g., Heimberg et al., 1998
; Schmidt et al., 2009
). Although the AMP group displayed significant reductions in these symptom domains, the ACC group also exhibited similar, and in some cases, large treatment effects from pre- to post-assessment. Although treatment effects of this magnitude are not entirely inconsistent with previous treatment studies in SAD using credible placebo-controlled comparison conditions (e.g., Davidson et al., 2004
), it is nonetheless important to consider possible explanations for the placebo effects exhibited by the ACC group in this study. One possibility is that any procedure involving repeated attention focusing, particularly in the presence of threatening stimuli, may have some therapeutic benefit (see also Wells, 2000
). It is also possible that the scheduling demands of the current study (i.e., attending sessions twice weekly) served as a form of behavioral activation. Future research is needed to clarify the effect of similar attention bias modification procedures on anxious and depressed mood, and to explore the use of alternate attention control conditions in anxious populations.
In summary, the results of the present work suggest that the translation of basic psychopathology research to address a clinical condition may prove useful in developing new interventions. Moreover, these procedures may help identify the mechanisms that are involved in the pathogenesis of psychiatric conditions. The current findings are promising considering the short duration of the intervention and absence of therapist contact, and suggest that this type of attention training procedure may show promise as an efficacious and portable intervention for social anxiety. Future studies should examine the additive and/or interactive effects of attention training and currently efficacious interventions, as well as the combination of other types of information-processing training (e.g., interpretation training, see Beard & Amir, 2008