# A really simple SA treatment - attentional training



## LostPancake (Apr 8, 2009)

Note: There's a study on this that you can participate in - see this thread http://www.socialanxietysupport.com...-worry-via-handheld-training-study-at-111018/.

If you do so it might be better to not read this thread in case it affects the results.

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"Amazingly, the authors found that, at termination, 72% of individuals in the treatment conditions no longer met criteria for SAD compared to 11% of individuals in the control condition. Additionally, these benefits were maintained at 4-month follow-up."

What is this treatment? Basically, it's this computer program that teaches you to look away from threat cues, like a picture of someone looking disgusted. It's based on the idea that people with SAD have an attentional bias towards threat cues, ie they're always subconsciously looking for negative reactions from people.

One thing I learned in intro to neuroscience is that being on the lookout for something actually primes those neurons to fire more easily. So we wind up seeing more negative things from the environment than other people, which just reinforces social anxiety.

"Perhaps even more impressive than the magnitude of these findings was the amount of time it took to attain them. Treatment consisted of eight 15-minute sessions, typically twice per week."

I first read about this on here last year, then promptly forgot about it. Then stumbled across that same thread a few months ago, surprised to find that I had commented in it. Then promptly forgot about it again. And yeah_yeah_yeah, a member on here who overcame SAD, mentioned using attentional training as part of his CBT treatment, and even wrote a document about it, which I downloaded but never read. Then I just came across an article about it on another website, and figured I should make another thread about it.

http://www.psychotherapybrownbag.co...a-novel-computerbased-treatment-approach.html

The original paper appeared in February 2009, and there have been 34 papers that cite it since then - I haven't looked at any of those yet. 
http://www.ncbi.nlm.nih.gov/pubmed/19222309

But this was a year and a half ago - we should all have this program available to us by now! It's apparently really simple, just showing pictures and letters in different places on a screen. You could probably even make something like it into a video on YouTube.


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## Belshazzar (Apr 12, 2010)

Interesting stuff. It's kind of like the opposite of exposure therapy. The very high success rate makes me suspicious that the experiment wasn't 100% controlled, i.e. were the subjects also undergoing other treatments for SA while they ran this trial? Did the subjects have more generalized or specific forms of SA? How severe was their SA?

This technique does seem promising, though, especially in conjunction with other treatments. Is there replication in the works?


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## LostPancake (Apr 8, 2009)

Actually, the times I did exposure exercises in CBT, I wound up having to force myself to change where I put my attention, in order to avoid anxiety. Like, instead of constantly thinking of what these people must think of me, I had to just think okay, I did my part, I said hello, now whatever reaction they have is out of my hands. I just kept my attention on what I had done and said, not on what their reactions were. It really did help.

But at some point, I started obsessing again about what people thought of me, how they were reacting to me. It's sort of like looking down when you're climbing a mountain - it's paralyzing.

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On the study, yeah, the sample size was pretty small, so there could be other things contributing to the results.

"The sample consisted of *36 outpatients* presenting for assessment and/or treatment at a university-affiliated community outpatient mental health clinic and research center that specializes in anxiety disorders. Diagnostic assessment was based on an initial telephone screening interview, followed by in-person administration of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-Patient Edition (SCID; First, Spitzer, Gibbon, & Williams, 2001). Eligible participants met the following criteria: (a) principal DSM-IV (APA, 1994) Axis I *diagnosis of SAD-generalized type*, (b) no evidence of suicidal intent, (c) no evidence of current substance dependence, and (d) no evidence of current or past schizophrenia, bipolar disorder, or organic mental disorder. In the case of co-occurring diagnoses, the designation of primary diagnosis was based on the condition that created the most distress and impairment for the individual. Groupwise analyses of all measures at baseline (described below) revealed no significant differences between groups at pretreatment.

randomization was conducted with a computerized random number generator with odd numbered participant cases assigned to AT and even numbered participant cases assigned to PC.

At the conclusion of the study, before participants were told which treatment condition they had received, they were asked which condition they believed they had received. *Only 1 participant correctly believed that he had been assigned to the AT [attentional training] condition. *The remaining participants believed they had been in the PC condition. Thus, it appears unlikely that participant's beliefs regarding their group assignment can account for any difference found between the two conditions."

Both groups had Liebowitz scores of about 81+/-5. The control group was at 75 at follow up (4 months later), while the treatment group was down to 56. They used some other measures as well.

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A slightly larger study done at another university, published Oct 2009 - 50% in the treatment group had SA at the end vs 14% in the control group.

"The authors conducted a randomized, double-blind placebo-controlled trial to examine the efficacy of an attention training procedure in reducing symptoms of social anxiety in *44 individuals* diagnosed with *generalized social phobia (GSP)*. Attention training comprised a probe detection task in which pictures of faces with either a threatening or neutral emotional expression cued different locations on the computer screen. In the attention modification program (AMP), participants responded to a probe that always followed neutral faces when paired with a threatening face, thereby directing attention away from threat. In the attention control condition (ACC), the probe appeared with equal frequency in the position of the threatening and neutral faces. Results revealed that the AMP facilitated attention disengagement from threat from pre- to postassessment and reduced clinician- and self-reported symptoms of social anxiety relative to the ACC. The percentage of participants no longer meeting Diagnostic and Statistical Manual (4th ed.) criteria for GSP at postassessment was 50% in the AMP and 14% in the ACC. Symptom reduction in the AMP group was maintained during 4-month follow-up assessment. These results suggest that computerized attention training procedures may be beneficial for treating social phobia."

http://www.ncbi.nlm.nih.gov/pubmed/19803575


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## leonardess (Jun 30, 2009)

interesting. sounds like a variation of EMDR which works with where a person looks as they reprocess memories. There is a pattern of working with sight amongst various therapies.


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## g0t Anxiety (May 16, 2010)

"Even more astoundingly, only one participant in the treatment condition correctly guessed that he or she was receiving treatment. In other words, every person in the study except one believed that they were in the no-treatment condition, so the belief that they were being treated can not account for these effects." 

- I wonder if there would be a different out come if the the participants knew it was a real test and had a mind set of (this test cant possibly help me) instead of instead of being completely ignorant.


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## Sunshine009 (Sep 21, 2008)

but seeing the negative is important to survival. I've also read nervous people are "quick to percieve, but poor to interpret". It's in the interpretation I feel. A glaring stranger means they have a problem not you. Also then looking for positive things and people around in the environment also positive things you can do despite the negative you see. While the study proves some facts, that thing is not therpeutic because we are more complex than that.


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## Belshazzar (Apr 12, 2010)

LostPancake said:


> Snip


Thanks for indulging my nerdishness.  It seems pretty well-designed. 36 subjects is still a decent sample size for a study like this.


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## HTSR (Jan 10, 2011)

*This treatment is freely available in my study*

Hi, please forgive me for promoting my study, but it's non-commercial, and since I saw this discussion, I thought I would tell you that this treatment is available through the research study I'm conducting right now.

We modeled the training we use on the exact study you mention, and it uses the same face images. The main difference is that we're the first study to do this on handheld devices. You need an iPhone, iPod Touch, or Android phone to participate.

My study doesn't cost anything to participants. The drawback is that you have a 50% chance of getting the placebo version. Almost anyone with a device can participate, anywhere in the world, and we're especially grateful to participants in the Boston area who can visit the lab. The treatment is actually also sold by another researcher on another website for $140.

To "g0t Anxiety": While we don't have too much data on whether it works for participants who are aware of how the treatment works, there was a single-session study (Krebs, Hirsch, & Mathews, 2010) where it seemed to go well. You can still participate, and just mention that you know how it works so that we're aware.

You can learn more and sign up at our recruiting site:
http://handheldtrainingstudy.com/

I can answer questions about the study, though I prefer not to describe all aspects of how it works, so we keep the highest chances of its working. I assure you, it has nothing to do with EMDR, and I've never seen an EMDR paper cited in an attention bias modification paper or conference talk.

Thank you,

Phil Enock
---
Phil Enock
Graduate Student
Department of Psychology
Harvard University
mcnallylab.com
handheldtrainingstudy.com


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## AlekParker (Oct 31, 2006)

LostPancake said:


> A slightly larger study done at another university, published Oct 2009 - 50% in the treatment group had SA at the end vs 14% in the control group.


Thanks lostpancake, but for clarity, I think you mean't 14% of the treatment group had SA and 50% of the control had SA at the end

Very interesting concept, I am going to try this as well. I wonder though are they screening for other outside factors. Like are the participants in the study taking medication, or seeking other therapies like CBT or seeing a therapist?

I mean if the person is willing to partake in a study that person is obviously trying to overcome there SA, and is perhaps more active than someone who wouldn't even attempt to do a study because their SA is so severe or they have just given up on trying to get over it.

Another possible problem though is that I think that people with social anxiety disorder AVOID focusing on negative facial expressions already. Like I would assume that someone who truly had SAD would automatically look towards the smiling or neutral face. In this case the attention training would just reinforce that person's avoidance of negative reactions.

If one could be unaffected by the negative face or reaction that would be more beneficial i would predict. I dunno. Either way it's good that researchers are attempting alternative therapies. I hope this works...


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## LostPancake (Apr 8, 2009)

AlekParker said:


> Thanks lostpancake, but for clarity, I think you mean't 14% of the treatment group had SA and 50% of the control had SA at the end


Doh!



> Very interesting concept, I am going to try this as well. I wonder though are they screening for other outside factors. Like are the participants in the study taking medication, or seeking other therapies like CBT or seeing a therapist?
> 
> I mean if the person is willing to partake in a study that person is obviously trying to overcome there SA, and is perhaps more active than someone who wouldn't even attempt to do a study because their SA is so severe or they have just given up on trying to get over it.


Yeah, I guess it's possible it wouldn't work as well on people who just didn't expect or think they could get better - the nocebo effect?

I'd join the study too, but I don't have a smartphone.



> Another possible problem though is that I think that people with social anxiety disorder AVOID focusing on negative facial expressions already. Like I would assume that someone who truly had SAD would automatically look towards the smiling or neutral face. In this case the attention training would just reinforce that person's avoidance of negative reactions.
> 
> If one could be unaffected by the negative face or reaction that would be more beneficial i would predict. I dunno. Either way it's good that researchers are attempting alternative therapies. I hope this works...


(I guess if you're doing the study, you shouldn't read this - it's all speculative anyway...)

I think this research is based on Clark & Well's theory of social anxiety, which goes back to the early 90's, and it's been demonstrated by experiments. For instance, if you were shown images of crowds and asked to hit a buzzer when you see a scowling face, people with social anxiety would see them faster. It's because the brain is actively looking for threat cues in the environment, like angry faces.

In evolutionary psychology terms, it's there to keep us safe and alive - if we feel we have a tenuous membership in the social group (which was essential for survival in our evolutionary history), we'd want to be really careful about pissing off the members of the group, and be quick to appease them.

So, the program seems to train you to reduce the subconscious threat-seeking, by getting you to actively look away from threat cues (if I'm understanding it correctly).

And threat-detection in itself causes anxiety, because it's happening in the lower levels of the brain, which act quickly on partial information, and err on the side of caution. So if you have some partial information, and it looks a bit like a social threat, your brain sees it as a threat, just to be on the safe side. So you end up living in this distorted reality, full of anxiety. And I guess anxiety ramps up these threat-seeking systems, so your brain gets stuck in this negative feedback loop.

So it's interesting that there is this attentional approach to reducing anxiety, in addition to the cognitive approach.

Anyway, I hope the study goes well - I'm looking forward to these programs being more widely available.


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## mhpp (Feb 25, 2006)

HTSR said:


> Hi, please forgive me for promoting my study, but it's non-commercial, and since I saw this discussion, I thought I would tell you that this treatment is available through the research study I'm conducting right now.
> 
> We modeled the training we use on the exact study you mention, and it uses the same face images. The main difference is that we're the first study to do this on handheld devices. You need an iPhone, iPod Touch, or Android phone to participate.
> 
> ...


Hello, do you have a link to the $140 version?


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## millenniumman75 (Feb 4, 2005)

It goes along with the taking of initial thought and rolling with it instead of saying "wait a minute - what is _really_ going on here?" , and then assessing the real issue. This ties into that. If he take the first thought and turn it even into the slightest bit of panic, that leaves us wide open for more panic attacks :afr.


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## popeet (Dec 8, 2005)

How interesting. Thanks LostPankake.


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## mhpp (Feb 25, 2006)

It looks like the $140 thing is this http://www.managingyouranxiety.com/

Kind of shocking they would ask for that kind of money for such a simple program. A high school / college computer student could develop this in a couple weeks max. The most expensive part might be getting the peoples head shots expressing happiness/disgust.. but then again the sad faces must be "medical grade" .


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## LostPancake (Apr 8, 2009)

^ Ah, cool, you found it - I was wondering where it was also.

Yeah $140 does sound like a lot, but I guess it's going to the guys who developed it, which is good, and it's cheap compared to therapy. They should offer a trial version or something though.

Oh wait, it's $140 for 90 days of use. Wha??



> After the first 90 days of unlimited use, the program can be renewed for an additional 90 day period at the discounted price of $99.99.
> 
> Attention Retraining is protected by patent rights held by San Diego State University and can only be used by purchasing Attention Retraining on this web site or by receiving written permission from Cognitive Retraining Technologies, LLC.


Dang. I'm torn on this - I definitely think they should be rewarded for developing the idea, but also wish they would make it freely available, or donationware, because so many people could benefit from it, from the sounds of it.



> Research has shown that individuals with a fear of public speaking or contamination concerns can be helped in one-ten minute session of Attention Retraining. These individuals displayed immediate benefits by performing better and being less anxious in challenging situations such as giving a speech or being asked to approach things they felt were dirty.
> 
> Research has also shown that individuals suffering from social anxiety disorder or generalized anxiety disorder can be helped by doing Attention Retraining for two-ten minute sessions per week for only four weeks. In the total time it takes to watch a movie or attend two traditional therapy sessions, people were able to start to gain control over their anxiety and their lives. Most importantly, these results have been found to be maintained for at least one year.
> 
> In both studies, 50% of participants no longer met the diagnostic criteria for their anxiety disorder after using Attention Retraining for just 8 sessions.


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## popeet (Dec 8, 2005)

Yah thanks for finding that mhpp. Lol medical grade headshots. I guess the free photos at stock xchange are low potency and cut with other stuff. 

I'm really interested in this.


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## fredbloggs02 (Dec 14, 2009)

This makes a lot of sense! I've done my own sort of field test. I get incredibly anxious walking through a crowds keeping my eyes at eye level. Turn them to the sky and I'm not anxious anymore.


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## eek a mouse (Apr 14, 2010)

I think $140 is very relative. If this can reduce say anxiety by 50% than 140 is a cheap price to pay for such a benefit. If it reduces it by 2% then its overpriced bs....


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## LostPancake (Apr 8, 2009)

LaRibbon said:


> But this confuses me because don't a lot of people with SA already avoid eye contact? So why don't they get better with that alone?


I'm not sure, maybe because with SA even if you avoid looking at people you're still living in a world where everyone is glaring at you, because that's what you see in your imagination? (that's my experience anyway)

I haven't looked at the papers yet - maybe they have some better explanations.

Here's a report from Fox News on it, with someone with social anxiety - it does look like a really simple program.


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## LostPancake (Apr 8, 2009)

irma said:


> you don't avoid focusing on the negative image. you notice changing images, but keep focus on the external problem. the $140 "Attention Retraining" program seems to be a basic version of the Attention Training Technique developed to aid MCT.


Is that meta cognitive therapy? I don't know much about that, except the idea of actually focusing on the external environment, instead of what you're feeling inside, or inferring about the environment. I've tried that a bit and it's hard to do - it's hard to not overlay some inference about what people are thinking about you. Maybe I wasn't doing it right though.

I think this is a bit different though, as you don't have to consciously direct your attention to different things - the program seems to train your attention automatically to react to threat cues differently.


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## sprinter (Nov 22, 2003)

There was another thread on this type of thing here... http://www.socialanxietysupport.com/forum/f43/novel-therapy-83933/

Unfortunately it appears the thread starter deleted his posts. This sounds interesting but I'm still pretty skeptical. I participated in a study that seems to have been based on these theories. It was only a one time thing though. I guess it was more geared toward testing how people with SAD read the faces. I'm not really sure I don't remember too much except it involved faces on a computer screen and at least one thing involved wearing some type of tracking gear.

One thing I can imagine is if a child grew up around a parent or other guardian who was volitle when in a bad mood then that would lead to the child be hypervigilant as to reading such a parents face to determine his or her mood and this could lead to transference of this hyper-vigilance in reading others faces in general.


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## LostPancake (Apr 8, 2009)

sprinter said:


> There was another thread on this type of thing here... http://www.socialanxietysupport.com/forum/f43/novel-therapy-83933/
> 
> Unfortunately it appears the thread starter deleted his posts.


Oh, yeah, and someone seemed to have read some papers on it - http://www.socialanxietysupport.com/forum/f43/novel-therapy-83933/#post1299328



> I actually just was reading some more about this. How the program works is the following. It shows you pictures of two faces on a screen. The trials are varied, but many of them will contain a neutral face and an angry face. These pictures are flashed together on the screen very briefly. After they are removed, the letter E or F appears on the screen where one of the two pictures used to be. The goal of the game is to determine whether or not the letter is an E or an F and hit the corresponding key as quickly as possible. You are given feedback on your speed so you can try to get better at it as you go through successive trials.
> 
> So, how does this retrain your brain you're probably wondering. * The program is designed so that the letters are most likely to appear where the neutral face was (or in other words, not where the angry face was on the screen). So, your brain subconsciously picks up on the fact that it can be more successful at the game by looking away from the angry face and towards the neutral face.* This is because if you do that you will be looking at the spot where the E or F will appear, and thereby be able to more quickly hit the E or F key. The idea then is that not only do you get better at the game but *you get an attentional bias away from negative faces. * It makes sense to me, since I often find myself looking at people's faces trying to detect some kind of disapproval.
> 
> Anyways, I hope that made sense. It's a fairly simple concept once you get the idea. The papers I am reading on this show pretty impressive results for something so simple.





> This sounds interesting but I'm still pretty skeptical. I participated in a study that seems to have been based on these theories. It was only a one time thing though. I guess it was more geared toward testing how people with SAD read the faces. I'm not really sure I don't remember too much except it involved faces on a computer screen and at least one thing involved wearing some type of tracking gear.


Did they tell you whether you had been in the control group or the real one? If you were in the control group then you wouldn't have gotten any benefit from it.

They've done several studies showing that it does reduce anxiety for a lot of people, and they only went commercial after doing the studies.



> One thing I can imagine is if a child grew up around a parent or other guardian who was volitle when in a bad mood then that would lead to the child be hypervigilant as to reading such a parents face to determine his or her mood and this could lead to transference of this hyper-vigilance in reading others faces in general.


Yeah, we actually have built in angry face detectors, because you have to be able to notice such things, lest you get killed by some angry male. Especially as children - even babies react negatively to angry faces. So if your parent shows a lot of anger all the time, it's bound to affect your anxiety levels - it would just be setting off all these alarms in your nervous system.


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## sprinter (Nov 22, 2003)

LostPancake said:


> Did they tell you whether you had been in the control group or the real one? If you were in the control group then you wouldn't have gotten any benefit from it.


I found a paper that explained the purpose of the study I participated in. It was to "learn more about how people with social phobia process emotional faces compared to non-anxious controls....This project investigates how anxious versus non-anxious participants attend to social cues. Specifically, we are testing whether anxious individuals have a tendency to direct their attention towards negative social cues(e.g., angry faces) compared to non-anxious individuals. In this study we measured how people direct their attention by measuring their eye movements...."


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## wxolue (Nov 26, 2008)

I participated in the Harvard study testing a handheld version of this program. I found out I was a control for the study (after it was over of course) and will get free access to the actual program soon. I'm excited to see if it works and will post my results here


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