Attention Modification Program for the Treatment of Anxiety Disorders

By Sadia Najmi, PhD, & Nader Amir, PhD 

Over the past 20 years, researchers have shown that anxious individuals tend to focus their attention on negative information. For instance, if they are shown two words or two pictures, one with a negative meaning and one with a neutral meaning, people with anxiety are faster than non-anxious individuals to detect the negative word. We refer to this tendency as an attentional bias for threatening information. Over the past seven years, researchers have tried to use this knowledge to create computer programs that attempt to change this tendency, with the goal of reducing anxiety. For example, in a series of studies in our clinic we have shown that a simple computer task, done twice a week for about 20 minutes each for 8-10 sessions, can reduce symptoms of Generalized Anxiety Disorder as well as Social Anxiety Disorder.  These results are encouraging because the treatments require very little time and can be delivered in locations where patients may not have access to other forms of treatment.

How does the training of attention work? Most studies of attention training use a task first described in 2002 by Colin MacLeod and colleagues at the University of Western Australia. These tasks are similar to computer games in which letters, words and/or pictures show up on the screen and you are asked to press a mouse button in response to them. However, unlike a computer game, these tasks are designed specifically to draw your attention away from negative information. MacLeod and colleagues found that a single session of attention training resulted in less anxiety when participants were faced with a stressful challenge task.

A few years after that, across various labs, researchers compared the effects of a single-session Attention Modification Procedure (AMP) on responses to a public speaking challenge in a sample of individuals with subclinical social anxiety. Participants in the AMP condition – whose attention was trained away from pictures of threatening faces – were compared to participants in a placebo condition in which there was no relationship between the location of the probe and the location of the threatening pictures.  As predicted, these studies found that those in the AMP group experienced lower levels of anxiety in response to a public speaking task and were judged as having superior speech performance relative to participants in the placebo group. These results suggest that the modification of attentional bias may effectively improve behavioral performance in anxiety-inducing tasks in individuals with subclinical levels of anxiety.

Three studies have now demonstrated that a multi-session AMP – in which attention is trained away from threat – can reduce symptoms in clinical samples of patients diagnosed with anxiety disorders. In our lab we have shown that an eight-session AMP was effective in reducing symptoms of Generalized Anxiety Disorder and of Social Anxiety Disorder. Using our procedure, Schmidt and colleagues at Florida State University also showed significantly greater reductions in social anxiety in patients with social anxiety disorder compared to patients in the placebo condition.

Despite this research on attention training in anxiety, researchers have not yet examined whether training procedures such as AMP are capable of treating OCD. We recently examined the effect of a single AMP session on behavioral approach towards feared objects in individuals with subclinical obsessive-compulsive symptoms. Our investigation was limited to individuals with contamination-related obsessive-compulsive symptoms. We hypothesized that training attention away from a contamination-related threat would decrease attentional bias for that threat and that this decrease in bias would lead to a decrease in avoidance of threatening objects (i.e., feared contaminants).

For our study, participants were comprised of 52 individuals recruited from a pool of undergraduate students at our university with an advertisement for individuals who “have concerns about germs, dirt, or contamination.” Participants were further screened based on their score on the Cleaning subscale of the Maudsley Obsessive-Compulsive Inventory, a measure of various OCD symptoms. Participants first completed the AMP (or a placebo task), followed by a behavioral approach test (BAT).

We adapted the BAT from a study by Cougle and colleagues. We used three different BATs to assess avoidance of a variety of contaminants. The first BAT consisted of a pile of dirty underwear and other clothes. Participants were told that “some of these items may have been touched with bodily fluids.” The second BAT included a mixture of “dirt, dead insects, and cat hair.” This mixture was made of potting soil, dead crickets, and cat hair. The third BAT involved a toilet (with an open lid) that was made to look unclean with blotches of potting soil on the inside of the bowl. Each BAT comprised six steps in a graduated hierarchy. If participants were able to complete the first item, they were asked to complete the next one on the hierarchy and if they refused to perform an item, the experimenter terminated that BAT.

Our results demonstrated that, compared to the placebo condition, the AMP was successful in reducing attentional bias for contamination-related threat in individuals with contamination-related obsessive-compulsive symptoms. Moreover, participants who completed the AMP task completed significantly more steps on each of the three BATs than did participants in the placebo group.  Thus, consistent with our hypothesis, participants in the AMP group showed significantly greater approach towards a variety of feared contaminants than did participants in the placebo group.

In summary, attention training was effective in reducing attentional bias for threat and increasing behavioral approach towards feared objects in individuals with contamination-related fears. Our results provide support for the effectiveness of attention modification procedures in decreasing observable avoidance behaviors. We are currently in the process of examining a multi-session AMP treatment for patients diagnosed with OCD (any subtype). If replicated in a clinical sample of OCD patients, these findings may have promising implications for the treatment of OCD. The behavioral treatment of exposure with response prevention is considered the psychological treatment of choice for OCD, but a large percentage of patients are either resistant to this form of treatment or refuse it. Our preliminary results from the current study suggest that the behavioral approach required for exposure therapy may be facilitated by attentional bias modification procedures.

Sadia Najmi, PhD, is a post-doctoral fellow at the Center for Understanding and Treating Anxiety at San Diego State University. Her doctoral dissertation in Clinical Psychology at Harvard University was on techniques for managing intrusive thoughts in OCD, and she completed part of her pre-doctoral clinical internship at the OCD Institute at McLean Hospital. Dr. Najmi is currently involved primarily in the research and treatment of OCD.

Nader Amir, PhD, is the Director of the Center for Understanding and Treating Anxiety and Associate Professor of Psychology at San Diego State University.  He has authored over 60 empirical articles and book chapters related to anxiety disorders.  Dr. Amir’s research is funded by grants from the National Institutes of Health. He provides direct therapeutic services as well as supervises post-doctoral fellows and doctoral students in clinical psychology.