Attention Bias Modification Training Via Smartphone to Reduce Social Anxiety: A Randomized, Controlled Multi-Session Experiment
- 2.3k Downloads
Testing feasibility and efficacy of psychological treatment via mobile devices is important, given its potential benefits for high-dosage treatment delivery, widespread and inexpensive dissemination, and efficient research methods. We conducted the first randomized controlled trial of attention bias modification training delivered via smartphones, comparing this training to control training in a double-blind design, also including a waitlist condition. All participants performed a variant of dot-probe training involving faces with neutral and disgust (representative of social threat) expressions in brief sessions three times daily over 4 weeks on their own smartphones, at home or anywhere they chose. Attention bias modification, also known as cognitive bias modification of attention, training included a contingency to induce attentional deployment away from disgust faces, whereas the control training included no contingency. Participants completed weekly Internet-based self-report symptom assessments as well as smartphone-delivered dot-probe attention bias assessments, whose reliability findings supported the viability of using smartphones for reaction-time based assessments. The between-groups training effect on attention bias scores was small, showing statistical significance in some analyses and not in others. On measures of social anxiety, intention-to-treat analyses (n = 326) revealed significant pre–post treatment declines with medium to large effect sizes in both training groups, whereas small declines in a waitlist group were nonsignificant. Both training groups showed greater reductions in social anxiety than did waitlist; however, the benefits under these two training conditions were statistically indistinguishable. Improvements in the two training conditions beyond those of waitlist could be attributable to any factors common to them, but not to the contingency training specific to active attention bias modification training.
KeywordsCognitive bias modification Attentional bias Attention training Social anxiety Mobile app treatment
The authors thank Imke Vonk, Linh Vu, and Jennifer Yu for their assistance, primarily in data collection.
Conflict of Interest
Philip M. Enock, Stefan G. Hofmann and Richard J. McNally declare that they have no conflict of interest.
All participants signed up through the website, which described the study in an easy-to-read format (Online Supplement 1). They electronically provided consent after going through these pages and a detailed consent form. All procedures were approved by Harvard’s Committee on the Use of Human Subjects in Research.
No animal studies were carried out by the authors for this article.
- Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J., Burns, M., et al. (2009b). Attention training in individuals with generalized social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 77(5), 961–973. doi: 10.1037/a0016685.PubMedCentralPubMedCrossRefGoogle Scholar
- Amir, N., Weber, G., Beard, C., Bomyea, J., & Taylor, C. T. (2008). The effect of a single-session attention modification program on response to a public-speaking challenge in socially anxious individuals. Journal of Abnormal Psychology, 117(4), 860–868. doi: 10.1037/a0013445.PubMedCentralPubMedCrossRefGoogle Scholar
- Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176–181. doi: 10.1037/1040-35184.108.40.206.CrossRefGoogle Scholar
- Barlow, D. H., Nock, M. K., & Hersen, M. (2009). Single case experimental designs: Strategies for studying behavior change (3rd ed.). Boston, MA: Allyn and Bacon.Google Scholar
- Boettcher, J., Leek, L., Matson, L., Holmes, E., Browning, M., MacLeod, C., et al. (2013). Internet-based attention bias modification for social anxiety: A randomised controlled comparison of training towards negative and training towards positive cues. PLoS ONE, 8(9), e71760. doi: 10.1371/journal.pone.0071760.PubMedCentralPubMedCrossRefGoogle Scholar
- Browning, M., Grol, M., Ly, V., Goodwin, G. M., Holmes, E. A., & Harmer, C. J. (2011). Using an experimental medicine model to explore combination effects of pharmacological and cognitive interventions for depression and anxiety. Neuropsychopharmacology, 36(13), 2689–2697. doi: 10.1038/npp.2011.159.PubMedCentralPubMedCrossRefGoogle Scholar
- Bunnell, B. E., Beidel, D. C., & Mesa, F. (2013). A randomized trial of attention training for generalized social phobia: Does attention training change social behavior? Behavior Therapy. doi: 10.1016/j.beth.2013.04.010.
- Carlbring, P., Apelstrand, M., Sehlin, H., Amir, N., Rousseau, A., Hofmann, S., et al. (2012). Internet-delivered attention bias modification training in individuals with social anxiety disorder—a double blind randomized controlled trial. BMC Psychiatry, 12(1), 66. doi: 10.1186/1471-244X-12-66.PubMedCentralPubMedCrossRefGoogle Scholar
- Eldar, S., Apter, A., Lotan, D., Edgar, K. P., Fox, N. A., Pine, D. S., et al. (2012). Attention bias modification treatment for pediatric anxiety disorders: A randomized controlled trial. The American Journal of Psychiatry, 15, 213–220. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491316/.
- Enock, P. M., & McNally, R. J. (2010). Feasibility and efficacy of attention bias modification via iPhone and other handheld devices to reduce social anxiety and worry. Unpublished manuscript. Department of Psychology, Harvard University, Cambridge, MA.Google Scholar
- Enock, P. M., & McNally, R. J. (2013). How mobile apps and other web-based interventions can transform psychological treatment and the treatment development cycle. The Behavior Therapist, 36(3), 56, 58, 60, 62–66. Retrieved from http://www.abct.org/docs/PastIssue/36n3.pdf.
- Enock, P. M., Robinaugh, D. J., Reese, H. E., & McNally, R. J. (2012). Improved reliability estimation and psychometrics of the dot-probe paradigm on smartphones and PC. Poster session presented at the meeting of The Association of Behavioral and Cognitive Therapies, National Harbor, MD.Google Scholar
- Fresco, D. M., Coles, M. E., Heimberg, R. G., Leibowitz, M. R., Hami, S., Stein, M. B., et al. (2001). The Liebowitz Social Anxiety Scale: A comparison of the psychometric properties of self-report and clinician-administered formats. Psychological Medicine, 31(6), 1025–1035. doi: 10.1017/S0033291701004056.PubMedCrossRefGoogle Scholar
- Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Turk, C. L. (2003). Using the Penn State Worry Questionnaire to identify individuals with generalized anxiety disorder: A receiver operating characteristic analysis. Journal of Behavior Therapy and Experimental Psychiatry, 34(3–4), 283–291. doi: 10.1016/j.jbtep.2003.09.001.PubMedCrossRefGoogle Scholar
- Gee, A. (2011). Therapist-free therapy: Cognitive-bias modification may put the psychiatrist’s couch out of business. The Economist. Retrieved from http://www.economist.com/node/18276234.
- Gelman, A., & Hill, J. (2007). Data analysis using regression and multilevel/hierarchical models (p. 648). New York: Cambridge University Press. Retrieved from http://www.amazon.com/Analysis-Regression-Multilevel-Hierarchical-Models/dp/052168689X.
- Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., et al. (2010). Attention bias modification treatment: A meta-analysis toward the establishment of novel treatment for anxiety. Biological Psychiatry. doi: 10.1016/j.biopsych.2010.07.021.
- Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., et al. (2012). Erratum: Attention bias modification treatment: A meta-analysis toward the establishment of novel treatment for anxiety. Biological Psychiatry, 72(5), 429. doi: 10.1016/j.biopsych.2012.07.015.CrossRefGoogle Scholar
- Hedman, E., Ljótsson, B., Rück, C., Furmark, T., Carlbring, P., Lindefors, N., et al. (2010). Internet administration of self-report measures commonly used in research on social anxiety disorder: A psychometric evaluation. Computers in Human Behavior, 26(4), 736–740. doi: 10.1016/j.chb.2010.01.010.CrossRefGoogle Scholar
- Heeren, A., Reese, H. E., McNally, R. J., & Philippot, P. (2012). Attention training toward and away from threat in social phobia: Effects on subjective, behavioral, and physiological measures of anxiety. Behaviour Research and Therapy, 50(1), 30–39. doi: 10.1016/j.brat.2011.10.005.PubMedCrossRefGoogle Scholar
- Heimberg, R. G., Mueller, G. P., Holt, C. S., Hope, D. A., & Liebowitz, M. R. (1992). Assessment of anxiety in social interaction and being observed by others: The social interaction anxiety scale and the Social Phobia Scale. Behavior Therapy, 23(1), 53–73. doi: 10.1016/S0005-7894(05)80308-9.CrossRefGoogle Scholar
- Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales (2nd ed.). Sydney: Psychology Foundation.Google Scholar
- MacLeod, C. (1995). Training selective attention: A cognitive-experimental technique for reducing anxiety vulnerability? In World congress of behavioural and cognitive therapies (p. 118).Google Scholar
- MacLeod, C., Rutherford, E., Campbell, L. W., Ebsworthy, G., & Holker, L. (2002). Selective attention and emotional vulnerability: Assessing the causal basis of their association through the experimental manipulation of attentional bias. Journal of Abnormal Psychology, 111(1), 107–123. doi: 10.1037/0021-843X.111.1.107.PubMedCrossRefGoogle Scholar
- MacLeod, C., Soong, L. Y., Rutherford, E. M., & Campbell, L. W. (2007). Internet-delivered assessment and manipulation of anxiety-linked attentional bias: Validation of a free-access attentional probe software package. Behavior Research Methods, 39(3), 533–538. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17958165.Google Scholar
- Matsumoto, D., & Ekman, P. (1988). Japanese and Caucasian Facial Expressions of Emotion (JACFEE) and Neutral Faces (JACNeuF). San Francisco, CA: Intercultural and Emotion Research Laboratory, Department of Psychology, San Francisco State University.Google Scholar
- Neubauer, K., von Auer, M., Murray, E., Petermann, F., Helbig-Lang, S., & Gerlach, A. L. (2013). Internet-delivered attention modification training as a treatment for social phobia: A randomized controlled trial. Behaviour Research and Therapy, 51(2), 87–97. doi: 10.1016/j.brat.2012.10.006.PubMedCrossRefGoogle Scholar
- Pinheiro, J., Bates, D., DebRoy, S., & Sarkar, D. (2010). nlme: Linear and nonlinear mixed effects models. Vienna: R Foundation for Statistical Computing. Retrieved from http://cran.r-project.org/web/packages/nlme.
- R Development Core Team. (2012). R: A language and environment for statistical computing. Vienna. Retrieved from http://www.r-project.org/.
- Sawyer, A. T., Whitfield-Gabrieli, S., Gabrieli, J. D. E., Amir, N., Fang, A., Richey, A., et al. (2012). Attention retraining in SAD: Treatment outcome and neurobiological correlates. In A. Asnaani & A. T. Sawyer (Chairs), Modifying cognitive biases: Emerging data on applications and effects on clinical disorders. Symposium conducted at the meeting of The Association of Behavioral and Cognitive Therapies, National Harbor, MD.Google Scholar
- SPSS Inc. (2009). PASW Statistics for Windows, Version 18.0. Chicago: SPSS Inc. http://www-01.ibm.com/support/docview.wss?uid=swg21476197
- Staugaard, S. R. (2009). Reliability of two versions of the dot-probe task using photographic faces. Psychology Science Quarterly, 51(3), 339–350.Google Scholar
- Waechter, S., Nelson, A. L., Wright, C., Hyatt, A., & Oakman, J. (2013). Measuring attentional bias to threat: Reliability of dot probe and eye movement indices. Cognitive Therapy and Research. doi: 10.1007/s10608-013-9588-2.