Complementary Features of Attention Bias Modification Therapy and Cognitive-Behavioral Therapy in Pediatric Anxiety Disorders

Abstract

Objective: In the treatment of anxiety disorders, attention bias modification therapy (ABMT) and cognitive-behavioral therapy (CBT) may have complementary effects by targeting different aspects of perturbed threat responses and behaviors. ABMT may target rapid, implicit threat reactions, whereas CBT may target slowly deployed threat responses. The authors used amygdala-based connectivity during a threat-attention task and a randomized controlled trial design to evaluate potential complementary features of these treatments in pediatric anxiety disorders.

Method: Prior to treatment, youths (8-17 years old) with anxiety disorders (N=54), as well as healthy comparison youths (N=51), performed a threat-attention task during functional MRI acquisition. Task-related amygdala-based functional connectivity was assessed. Patients with and without imaging data (N=85) were then randomly assigned to receive CBT paired with either active or placebo ABMT. Clinical response was evaluated, and pretreatment amygdala-based connectivity profiles were compared among patients with varying levels of clinical response.

Results: Compared with the CBT plus placebo ABMT group, the CBT plus active ABMT group exhibited less severe anxiety after treatment. The patient and healthy comparison groups differed in amygdala-insula connectivity during the threat-attention task. Patients whose connectivity profiles were most different from those of the healthy comparison group exhibited the poorest response to treatment, particularly those who received CBT plus placebo ABMT.

Conclusions: The study provides evidence of enhanced clinical effects for patients receiving active ABMT. Moreover, ABMT appears to be most effective for patients with abnormal amygdala-insula connectivity. ABMT may target specific threat processes associated with dysfunctional amygdala-insula connectivity that are not targeted by CBT alone. This may explain the observation of enhanced clinical response to CBT plus active ABMT.

Trial registration: ClinicalTrials.gov NCT00018057.

Keywords: Adolescents; Anxiety Disorders; Attention Bias Modification; Child Psychiatry; Cognitive Neuroscience.

FIGURE 1.

The Dot-Probe Task

FIGURE 2.. Flow Diagram of Patients in a Study of Pediatric Anxiety^a

^a The diagram includes only the patient group, not the healthy comparison group (N=51).

FIGURE 3.. Anxiety Ratings in Youths With Pediatric Anxiety Receiving Cognitive-Behavioral Therapy Plus Active or Placebo Attention Bias Modification Therapy (ABMT)^a

^aPARS=Pediatric Anxiety Rating Scale. Significant difference between groups, p<0.05. Error bars indicate standard deviation.

FIGURE 4.. Amygdala-Insula Connectivity on a Dot-Probe Task in Youths With Pediatric Anxiety and Healthy Comparison Subjects^a

^a Whole brain random-effects analyses indicated a condition (congruent, incongruent, neutral)-by-anxiety group interaction for connectivity between the right amygdala and insula (panelA; the image is displayed in radiological convention[left=right]; cluster size=1,031mm3, peak activation=41,26, 14). Post hoc analyses were conducted (panel B) to examine group differences in connectivity on each task condition as well as on the difference between the incongruent and congruent conditions (i.e., attention bias contrast). PPI=psychophysiological interaction. Error bars indicate standard error. *p≤0.05. **p≤0.01.

FIGURE 5.. Amygdala-Insula Connectivity on a Dot-Probe Task Related to Overall Treatment Response in Youths With Pediatric Anxiety^a

^aWhole brain random-effects analyses controlling for baseline Pediatric Anxiety Rating Scale (PARS) ratings and attention bias modification therapy (ABMT) indicated a condition (congruent, incongruent, neutral)-by-posttreatment PARS ratings interaction for connectivity between the rightamygdala and insula (panel A; the image is displayed in radiological convention [left=right]) (cluster size=1,859 mm³, peak activation=54, 24, 9). To probe the interaction, correlations between posttreatment PARS ratings and conditionwere examined. Panels B–Dare scatterplots between posttreatment PARS rating and congruent (r=0.43, p<0.01), incongruent (r=−0.11, n.s.), and attention bias (incongruent – congruent; r=−0.48, p<0.01) conditions. PPI=psychophysiological interaction.

FIGURE 6.. Amygdala-Insula Connectivity on a Dot-Probe Task Related to ABMT-Specific Treatment Response in Youths With Pediatric Anxiety^a

^a Whole brain random-effects analyses controlling for baseline Pediatric Anxiety Rating Scale (PARS) ratings indicated anattention bias modification therapy (ABMT) group (active, placebo)-by-condition (congruent, incongruent, neutral)-by-posttreatment PARS ratings interaction for connectivity between the right amygdala and insula (panel A; the image is displayed in radiological convention [left=right]; cluster size=615 mm3, peak activation=45, 0, 24). To probe the interaction, correlations between posttreatment PARS ratings and the attention bias contrast (incongruent – congruent) were examined for each of the ABMT groups. The scatterplots in panels B and C show the association between posttreatment PARS rating and attention bias contrast for the placebo ABMTgroup (r=20.78, p,0.001) and the active ABMT group (r=0.15, n.s.). PPI=psychophysiological interaction