Using Attentional Bias Modification to Address Trauma Symptoms

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.

Inclusion Criteria:

- Female, 19+, have experienced at least one adult sexual trauma, and must currently be
experiencing PTSD symptoms as a result of the sexual assault

Exclusion Criteria:

- male