Elsevier

Journal of Anxiety Disorders

Volume 25, Issue 8, December 2011, Pages 1108-1115
Journal of Anxiety Disorders

How does attention training work in social phobia: Disengagement from threat or re-engagement to non-threat?

https://doi.org/10.1016/j.janxdis.2011.08.001Get rights and content

Abstract

Social phobics exhibit an attentional bias for threat in probe detection paradigms. Attention training, whereby probes always replace non-threat in a display presenting both threat and non-threat, reduces attentional bias for threat and social anxiety. However, it remains unclear whether therapeutic benefits result from learning to disengage attention from threat or learning to orient attention towards non-threat. In this experiment, social phobics were randomly assigned to one of four training conditions: (1) disengagement from threat, (2) engagement towards non-threat, (3) disengagement from threat and re-engagement towards non-threat, and (4) a control condition. Effects were examined on subjective and behavioral responses to a subsequent stressor. Data revealed that training to disengage from threat reduces behavioral indices of anxiety. Engagement towards non-threat faces did not have effects in itself. These results support that the difficulty in disengaging attention from threat is a critical process in maintenance of the disorder.

Highlights

► A single session of attention training reduced behavioral and subjective anxiety in social phobics. ► Different training conditions targeted different attention components. ► Data showed that the critical process was training disengagement from threat. ► Training to preferentially allocate attention to non-threat did not prove to be effective.

Introduction

Most cognitive models of anxiety propose that selective attention to threat cues contributes to development and maintenance of emotional disorders (e.g., Mathews & MacLeod, 1994). For people with social phobia, these cues include threatening facial expressions displaying anger or disgust, and words signifying social threat (e.g., humiliation). In probe detection and probe discrimination tasks, individuals with social anxiety or social phobia respond faster to probes replacing these cues than to probes replacing neutral cues, thereby exhibiting an attentional bias for threat that is absent in nonanxious control individuals (e.g., Mogg et al., 2004, Pishyar et al., 2004).

Recent studies have attempted to dismantle this bias to identify which attention component underlies it. Most of these studies used the modified Posner (1980) spatial cueing task, in which a threat (or non-threat) cue appears on either the left or right side of a computer screen, followed by a probe that either replaces the cue or appears on the other side of the screen (e.g., Amir et al., 2003, Fox et al., 2001). These studies showed that anxious participants are no faster to respond to probes replacing threat than non-threat cues, but they are slower to respond to probes that appear opposite to threat cues relative to non-threat ones. This pattern of results suggests that anxious participants have difficulty disengaging attention from threat (e.g., Amir et al., 2003), rather than being faster to engage attention to threat.

Attentional bias for threat has clinical consequences. Its re-emergence predicts return of anxiety at follow-up among patients treated for generalized anxiety (Mogg, Bradley, Millar, & White, 1995) and social phobia (Lundh & Öst, 2001). Moreover, threat-related bias causally influences vulnerability to anxiety (MacLeod, Rutherford, Campbell, Ebsworthy, and Holker (2002). Using a dot-probe detection task, MacLeod and colleagues trained non-anxious participants to attend either to neutral or to threatening stimuli. The task comprised 672 trials in which pairs of words (one threatening and one neutral) appeared on a computer screen. In the attend-to-threat condition, probes replaced threat words, whereas in the attend-to-neutral condition, probes replaced neutral words. Participants pushed a button as soon as they detected the probe. Relative to those trained to attend to neutral material, participants trained to attend to threat material reported more anxiety and negative mood after performing a stressful anagram task. This study provides causal evidence that selective attention to negative information increases anxiety reactivity to an experimental stressor.

Regarding social anxiety, Li, Tan, Qian, and Liu (2008) have observed that 7-days of attention training towards positive faces diminished attentional bias for negative faces. Moreover, such training reduced self-reported fear of social interaction. Similarly, Amir, Weber, Beard, Bomyea, and Taylor (2008) trained, in a single-session, socially phobic individuals either to attend to neutral faces or to a control task in which there were no contingency between probe and cues. As compared to the latter condition, the former reduced anxiety in response to an impromptu speech. Blind raters judged the speeches of those in the non-threat attention training group more positively than those of the control group. Further, using a modified Posner paradigm after attention training, these authors observed that improvement in the ability to disengage attention from threat mediated the effects of the training on anxiety reactivity, and that this decrease in anxiety, in turn, improved speech performance. Recently, Heeren, Reese, McNally, & Philippot (submitted for publication) have fully replicated these observations and extended these findings to sympathetic activation to stressors occurring after the training. They reported that change in attentional bias occurring after attention training mediated changes in skin conductance reactivity to an impromptu speech. Likewise, Schmidt, Richey, Buckner, and Timpano (2009) have observed that training individuals with social phobia to attend to neutral faces led to a significant reduction in social anxiety and trait anxiety, in comparison to a control group. At a 4-month follow-up, the treatment group had improved further on measures of anxiety. Amir et al. (2009) have replicated these results.

These studies suggest that reducing attentional bias for threat in social phobia diminishes emotional vulnerability to subsequent social stressors. However, uncertainty remains regarding the mechanisms that mediate the reduction of emotional vulnerability via attention training. According to Amir et al. (2008), the improvement in the ability to disengage attention from threatening stimuli mediates the reduction of emotional reactivity to stressors (disengagement hypothesis). As mentioned above, studies show that anxious participants are no faster to respond to probes replacing threat as compared to non-threat cues. However, they are slower to respond to probes that appear opposite to threat cues as compared to non-threat cues, implying difficulties in disengaging attention from threat (e.g., Amir et al., 2003, Fox et al., 2001). Hence, disengagement difficulty would be the underlying process mediating attentional bias for threat in the probe detection and probe discrimination paradigms.

An alternative account is based on results of MacLeod et al. (2002) and Li et al. (2008). According to this explanation (the counter-bias hypothesis), the development of a counter-bias during training, in which attention is trained to be oriented towards non-threat cues, constitutes an alternative explanation. For instance, Li et al. (2008) have observed that training socially anxious individuals to focus more on positive faces reduces bias towards threatening faces but increases attentional bias towards non-threat cues. The therapeutic benefits of attention training would thus result from orienting attention towards non-threat cues. In other words, the critical component of attentional training would be the reallocation of attention towards non-threat rather than the disengagement from threat.

Finally, one cannot exclude the possibility that both processes (disengagement from threat and attention allocation to non-threat) are necessary for attentional training to be effective. Indeed, it could be argued that attention allocation to non-threat is only possible if one can disengage from threat.

However, to date, paradigms used do not allow us to determine the process of change. The present double-blind experiment addresses this question by crossing the presence/absence of disengagement from threat and allocation to non-threat in four different attention training conditions. Participants diagnosed as having generalized social phobia were randomly assigned to one of four attention training conditions: (1) disengaging attention from threat cues, (2) only attending to non-threat cues, (3) disengaging attention from threat cues and re-engaging it to non-threat cues, or (4) control condition (i.e., no contingencies between cues and probes).

If the disengagement hypothesis is true, participants who are trained to disengage their attention from threat cues, and those trained to disengage it from threat cues and re-engage it to non-threat cues, should show more reduction in anxiety than the two other groups. Indeed, these two conditions share the same process: attentional disengagement from threat cues. In contrast, if the counter-bias hypothesis is true, participants who are trained to engage attention to non-threat and those trained to disengage it from threat cues and re-engage it to non-threat cues should show more reduction in anxiety than the two other groups. Indeed, these two conditions share the same process: engagement of attention to non-threat cues. Finally, if attention training involves both disengagement from threat cues and the re-engagement to non-threat cues, we expect a significant decrease of anxiety for participants in this condition only.

Section snippets

Participants

We recruited 79 individuals with a primary DSM-IV (American Psychiatric Association, 1994) diagnosis of Generalized Social Anxiety Disorder from the Université catholique de Louvain community. A total of 398 volunteers responded to our invitation to take part in an investigation of the mechanisms underlying social interaction among shy people. Eighty-nine individuals met the initial eligibility criteria assessed via a screening questionnaire (i.e., Liebowitz Social Anxiety scale, Liebowitz, 1987

Group equivalence

Preliminary analyses indicated no differences among the groups at baseline on STAI-trait, F(3, 78) = 1.38, p > .26, ηp2 = .05, BDI-II, F(3, 78) = 1.34, p > .27, ηp2 = .05, and LSAS, F(3, 78) = 1.72, p > .17, ηp2 = .06. All groups were similar in terms of age F(3, 78) = .27, p > .76, gender, χ2 (3, N = 79) = 5.17, p > .16, and years of education, F(3, 78) = 1.59, p > .19, ηp2 = .06.

Compliance monitoring of the training task

Performance in the training task was investigated to check compliance with instructions (errors and outliers). Participants made very few errors on the

Discussion

The primary purpose of this study was to investigate the critical processes in attention training for social phobia. At this end, participants were randomized to either attention training to disengage from threat, engage towards non-threat, both disengage from threat and engage towards non-threat, or a control training. Consistent with the disengagement hypothesis, training benefits were observed only for participants trained to disengage attention from threat cues and those trained to

Acknowledgements

This work was supported by a grant from the Belgian National Fund for Scientific Research, awarded to Alexandre Heeren (1.1.315.09.F), and by a Joined Research Grant (ARC 06/11-337) from the Belgian French Community, awarded to Pierre Philippot. We thank Nathalie Vrielynck and François Maurage for their help in the inter-rater agreement. The authors also appreciate helpful comments of Betty Chang on earlier drafts of this paper.

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