Using Attentional Bias Modification to Address Trauma Symptoms
Condition: Posttraumatic Stress Disorder
MeSH terms: Stress Disorders, Post-Traumatic
Study type: Interventional

Summary: 
      Threat-related attentional biases have been identified as a possible precursor to the onset
      and maintenance of posttraumatic stress disorder (PTSD). As a result, protocols such as
      Attention Bias Modification (ABM) have been developed and utilized to treat these attentional
      biases in adults diagnosed with PTSD. However, to-date, ABM protocols have not been examined
      for use specifically among victims of sexual assaults. Participants are 20 undergraduate
      women enrolled in a Midwest university. The efficacy of ABM in this population will be
      assessed, as will the relationship between ABM and PTSD symptom clusters and outcome
      variables such as anxiety and depression scores.
    

Detailed description: 
      A relatively new intervention designed to reduce attention toward (or minimize disengagement
      from) threat-related information is attention bias modification (ABM). ABM is a novel
      treatment that may address several limitations posed by the use of CPT and PE. ABM is
      typically administered via computer, involving brief 20-minute sessions in which participants
      are trained to disengage from the threat cues to which they are naturally attuned. ABM
      addresses attentional biases in a similar, though more direct, manner as does CBT through the
      use of uninterrupted, repetitive exposure to feared threat cues or words in order to allow
      the patient to interpret that feared objects and situations are safe. In particular, ABM's
      effectiveness arises through the intent to normalize both attentional biases towards and away
      from threats such that the intended outcome is the non-existence of any bias surrounding
      threat cues. ABM addresses the specific bias in attention through targeting implicit,
      sub-cortical processes that focus on perturbed neural circuitry function. It trains
      individuals to remove any attention to or avoidance of threat cues by training brains to
      focus equally on threat and non-threat cues. Therefore, ABM further extends work implicating
      threat-related attention bias in anxiety disorders.

      ABM has successfully improved or alleviated symptoms of many disorders, including anxiety
      disorders, depression, obsessive-compulsive disorder, and chronic pain. In addition, ABM has
      been successfully implemented in many populations such as inpatient active duty U.S. military
      members, Israeli Defense Force soldiers, pediatrics, and outpatients with chronic PTSD.
      Despite these findings, ABM has never been applied to individuals with current, lifetime, or
      chronic PTSD resulting from sexual assaults. Furthermore, studies assessing the use of ABM
      have found consistent benefits from ABM control groups, although this effect has been smaller
      than those in the ABM treatment groups. Authors contend that the reason that ABM control
      groups may have experienced a decrease in symptoms may be that the use of training
      (regardless of treatment or control status) improves the relationship between emotional
      stimuli and the response required by participants in order to learn to exert attentional
      control.

      If ABM proves to be effective in addressing attentional biases associated with PTSD and its
      associated symptom clusters, it is a unique treatment that has the potential to address many
      of the limitations or concerns faced by those who rely exclusively on CPT or PE; benefits of
      ABM include that the treatment (1) is a relatively simple and brief intervention, (2) may be
      administered electronically and remotely at a patient's home or at locations beyond a typical
      clinical office, and (3) has the potential to be mass-administered. As ABM is a relatively
      new treatment with many implications for utilization, its full potential has not yet been
      explored; in particular, there are several ways with which ABM may interact with empirically
      supported treatments (ESTs) as CPT and PE.

      Firstly, it is important to recognize that CPT and PE have both been criticized for their
      role in requiring participants to immediately "dwell in the past", frequently resulting in
      clients reporting distress. This is particularly true in individuals who may have potentially
      been coping with or managing their trauma reaction through the use of intense avoidance.
      Thus, as a prelude to integrating individuals into CPT or PE, ABM has the potential to be a
      useful transition prior to ESTs to increase tolerance and prepare individuals to transition
      and integrate into these more provocative types of treatments. Starting with a treatment such
      as ABM, which introduces individuals to non-specific trauma content, might serve to help
      people to be more amenable to other ESTs such as CPT or PE, ultimately increasing willingness
      to start and stay in therapy, decreasing attrition, and improving retention.

      Secondly, ABM interventions have been shown in several populations to result in at least a
      mild reduction of symptoms. Even mild reductions of symptoms may open the door to allowing an
      individual to make larger improvements through more other evidence-based interventions.
      Studies show that individuals with more severe pretreatment trauma-related cognitions have
      slightly worse PE outcomes than do individuals beginning treatment with more moderate
      symptoms. In applying ABM prior to CPT or PE, it is likely that the mild reduction of
      symptoms beforehand may ultimately increase the effectiveness and efficiency of ESTs.

      Current Study Despite recent focus on attention training in PTSD, researchers have not yet
      examined whether training procedures such as ABM are capable of modifying attentional biases
      in individuals whose most disturbing and impactful trauma is a sexual assault. Thus, in this
      current study, the investigators aimed to examine the effect of ABM in a sample of women who
      have previously experienced an adult sexual assault. The aims of this study are three-fold:
      first and foremost, as this is the first study of its kind to assess the efficacy of ABM
      treatment in a sample of sexual assault victims, the investigators will be examining the
      effect of ABM in reducing PTSD symptoms within this trauma type. Secondly, investigators are
      exploring what PTSD symptoms or symptom clusters predict treatment outcomes and attentional
      variability. Finally, investigators expect to quantify and document attention variability in
      this population, and will explore whether variability is predictive of treatment outcomes.

      Regarding this study's aims, investigators hypothesize that (1) both the ABM treatment and
      control groups will experience decreased PTSD, depressive, and anxiety symptoms, but with a
      greater decrease from baseline in the treatment condition. Secondly, investigators
      hypothesize that (2) there will be a relationship between heightened symptom clusters as
      expressed by the individuals and their attentional biases, such that individuals high in
      avoidance symptoms (Criterion C on the Clinician-Administered PTSD Scale, CAPS-5) will
      demonstrate decreased response times to threat cues on measures of executive functioning with
      low variability, while those high in hyperarousal symptoms (Criterion E on the CAPS-5) will
      demonstrate increased response times and low variability. In contrast, investigators expect
      those high in both symptom clusters (hyperarousal and avoidance) will demonstrate high
      variability in reaction times, and those low in both symptom clusters will demonstrate low
      variability. Finally, investigators hypothesize that (3) increased attention variability will
      be associated with higher PTSD, depressive, and anxiety symptoms, but greater changes in
      attention variability across the study will be associated with greater improvements on PTSD,
      depressive, and anxiety symptoms. More specifically, investigators hypothesize that as a
      result of treatment, those participants who have the greatest decreases in variability over
      the course of treatment will be higher in hyperarousal and/or avoidance over those who are
      low in both symptom clusters.
    

Intervention name(s): Attention Bias Modification
Intervention type(s): Behavioral
Intervention description(s): comparison of treatment versus control
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment