A pilot study augmenting cognitive behavioral therapy for panic disorder with attention bias modification: Clinical and psychophysiological outcomes

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Highlights

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    Attention bias modification (ABM) enhanced CBT for panic disorder (PD).

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    Contrary to hypotheses, ABM did not significantly reduce attention bias scores.

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    Pre-to post-treatment changes in attention bias and panic symptoms were uncorrelated.

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    Across groups, response was associated with larger declines in resting heart rate.

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    Further research on efficacy and mechanisms of ABM and CBT for PD is indicated.

Abstract

Background and objectives

Studies show that attentional bias towards threat is a key maintenance factor for panic disorder (PD). Attentional bias may be an important mechanism of symptom reduction, and thus, a useful target for optimizing outcomes. The current study examined whether an attention bias modification (ABM) task enhanced CBT outcomes. Multiple methods for assessing PD were used, including physiological measurement and clinician-rated assessment.

Methods

Adults with panic disorder (N = 24) received seven sessions of CBT with either ABM or sham attention tasks. Psychophysiological reaction to a loud tones startle paradigm was assessed before and after treatment.

Results

Across both groups, panic symptom severity decreased with CBT. The ABM group showed greater reductions in PD symptoms compared to the placebo group. Notably, however, changes in attentional bias were not associated with symptom reductions across groups. No significant group differences on psychophysiological assessment were observed.

Limitations

This study is limited by the small sample size, which rendered our power to investigate mediators and moderators insufficient. More research is needed to validate the effect of attention bias modification on attentional bias to threat.

Conclusions

This pilot study suggests that future research should investigate attentional bias in conjunction with CBT. A larger sample would provide opportunity to further investigate the mechanisms through which ABM works, along with potential moderating factors and the use of psychophysiological measurements in panic disorder.

Section snippets

Participants

Randomized participants were 23 adults (M age = 32.40 years, SD = 10.32) with a primary diagnosis of PD with or without agoraphobia, as defined in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). Sample demographic and clinical characteristics are detailed in Table 1, with study flow in Fig. 1. Inclusion criteria included moderate to severe PD symptom severity as measured by the Clinical Global Impression-Severity Scale (≥4; Guy, 1976). Participants were willing and able to

Sample demographics and baseline characteristics

The sample (N = 23) was 52.6% female with an average age of 32.4 years, and primarily Caucasian (95%) (see Table 1 demographic and clinical characteristics). There were no significant differences in baseline panic severity (PDSS, t(20) = 0.54, p = .59, CGI- S, t(20)<0.0001, p = .5), or attention bias scores (t(19) = 1.00, p = .33) between the ABM and PBO groups.

Pre-treatment

During the loud-tone paradigm, higher pre-tone HR levels (r = 0.75, p < 0.001) and, as anticipated, larger HR responses to the loud

Discussion

The present pilot study aimed to address gaps in the literature regarding the efficacy of combining ABM with CBT to enhance treatment outcomes for individuals with PD, with initial promising clinical results. It is also a first step towards informing avenues for future research that can advance our understanding of how ABM enhances symptom gains (mediators) and for whom ABM is optimally indicated (moderators). Specifically, our study design was optimized with multi-modal measures of symptom

CRediT authorship contribution statement

A.W. Baker: Conceptualization, Investigation, Formal analysis, Writing - original draft, Writing - review & editing, Visualization, Supervision, Project administration. S.N. Hellberg: Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Visualization. R.J. Jacoby: Investigation, Writing - original draft, Writing - review & editing. O.M. Losiewicz: Formal analysis, Data curation, Writing - review & editing, Visualization. S. Orr: Methodology,

Declaration of competing interest

No disclosures to declare.

Acknowledgments

The Highland Street Foundation, Newton, MA.

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