Despite the existence of many theories, there is still no clear and universal definition of the concept of care. However, what is known with absolute certainty is that this basic cognitive process is of paramount importance in the origin and maintenance of mental disorders and, in particular, anxiety disorders.

In the following lines we will present the repercussion that the technique of Attention Bias Modification is having, a new psychological attention technique designed for the treatment of social anxiety disorder or social phobia.

Care and treatment of mental disorders

As Shechner et al (2012) point out, attention is a basic process that encompasses different cognitive functions that allow the brain to prioritize the processing of certain information. The fact of paying attention or not to certain stimuli or information can affect a person’s development, since attention is the basis of memory and learning . You can only learn and memorize experiences that you are paying attention to.

According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), social phobia is characterized by “intense fear or anxiety in one or more social situations in which the individual is exposed to possible examination by other people.

The person is afraid to behave in a certain way that may be negatively valued by those around him/her. That is, is afraid of being judged by others and of being rejected for her/his performance in a situation involving several people. These situations can range from giving a talk to a large audience, to having a simple conversation with someone you know.

Najmi, Kuckertz and Amir (2011), showed that people with anxiety selectively attend to elements of the environment that they consider threatening, leaving aside the rest of the environment, in which they could find neutral or positive elements. This attentional bias often leads to misjudgments that result in increased anxiety and the long-term persistence of the disorder.

For example, if a person with social anxiety disorder was giving an oral presentation to an audience of 20 people, even though 16 people were paying attention and showing interest, if one person was yawning, another was playing with his or her cell phone, and two others were talking to each other, the speaker would only look at these latter actions, interpreting their execution as being catastrophic and boring, leading to increased anxiety and therefore an increased probability of making mistakes and worsening their actual execution, accompanied by a greater persistence of fear of public speaking in the future.

Conversely, if the person did not suffer from social anxiety, the behavior of these four individuals would likely go unnoticed, and would be interpreted as a lack of sleep and/or interest in the subject of those particular individuals rather than their own execution.

Modification of the attentional bias

In this context, Amir et al. (2009) created a virtual technique in order to correct this attentional bias . The patient is instructed to stand in front of a computer and determine the appearance of the letters “e” or “f” as quickly as possible and try not to make a mistake using the mouse (“e” left button, “f” right button) during multiple trials.

The key is that, during all attempts, before the appearance of the letter, two images of faces are presented : a face with a neutral expression and a face with an expression of disgust or rejection. In 80% of the attempts, the letter “e” or “f” always appears where moments before the neutral face was located. In this way, even if no explicit order is given about not paying attention to the rejection faces, the person learns unconsciously not to pay attention to the stimuli he or she fears.

Despite the simplicity of the technique, these authors managed, in 8 20-minute sessions over 4 weeks, to have 50% of the patients with social phobia reduce their symptoms to such an extent that they could not be diagnosed according to DSM criteria. Other authors such as Boettcher et al. (2013) and Schmidt et al. (2009) obtained similar results in their experiments .

This technique is not without controversy

According to Amir, Elias, Klumpp and Przeworski (2003), the real bias in anxiety disorders, and specifically social anxiety, is not to be hypervigilant in the face of threatening stimuli (rejection faces) – since detecting those things that can potentially harm us is a bias that all humans share and that has helped us survive for thousands of years – but rather once these threats are detected, they cannot be ignored by the person .

Therefore, the bias that causes the persistence of the disorder is the impossibility of “unhooking” attention from the threat, and modifying the attentional bias would act to eliminate this impossibility.

However, recent evidence suggests that the picture is much more complicated than it might at first appear . Klump and Amir (2010) found that designing the task to cater to threatening rather than neutral faces also produces a decrease in anxiety. Yao, Yu, Qian and Li (2015) performed the same experiment, but using geometric figures instead of emotional stimuli and also observed a decrease in participants’ subjective distress.

Cudeiro (2016), tried to measure attentional engagement bias through an experimental paradigm of eye movements and did not obtain conclusive evidence that the bias really existed or could at least be measured empirically.

In short, it is still not clear what the underlying mechanism(s) of action of this technique are . Future research will have to aim at replicating the efficacy studies and determining these possible mechanisms of action.

Bibliographic references:

  • Amir, N., Elias, J., Klumpp, H. and Przeworski, A. (2003). Attentional bias to threat in social phobia: facilitated processing of threat or difficulty disengaging attention from threat? Behaviour research and therapy, 41(11), 1325-1335.
  • Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J., Burns, M. and Chen, X. (2009). Attention training in individuals with generalized social phobia: A randomized controlled trial. Journal of consulting and clinical psychology, 77(5), 961-973.
  • Boettcher, J., Leek, L., Matson, L., Holmes, E. A., Browning, M., MacLeod, C., … and Carlbring, P. (2013). Internet-based attention bias modification for social anxiety: a randomised controlled comparison of training towards negative and training towards positive cues. PLoS One, 8(9), e71760. doi: 10.1371/journal.pone.0071760.
  • Cudeiro González, J. A. (2016). Modification of the attentional bias in anxiety disorders: an approach to the explanatory mechanisms. Minerva, 1-40
  • Klumpp, H. and Amir, N. (2010). Preliminary study of attention training to threat and neutral faces on anxious reactivity to a social stressor in social anxiety. Cognitive Therapy and Research, 34(3), 263-271.
  • Schmidt, N. B., Richey, J. A., Buckner, J. D. y Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of abnormal psychology, 118(1), 5-14.
  • Shechner, T., Britton, J. C., Pérez-Edgar, K., Bar-Haim, Y., Ernst, M., Fox, N. A., … y Pine, D. S. (2012). Sesgos de atención, ansiedad y desarrollo: ¿hacia o lejos de amenazas o recompensas?. Depresión y ansiedad, 29(4), 282-294.