Research Article

DEPRESSION AND ANXIETY 28 : 349–353 (2011)

VIGILANT AND AVOIDANT ATTENTION BIASES ASPREDICTORS OF RESPONSE TO COGNITIVEBEHAVIORAL THERAPY FOR SOCIAL PHOBIA

Matthew Price, M.A., Erin B. Tone, Ph.D., and Page L. Anderson, Ph.D.�

Background: Attention bias for socially threatening information, an empiri-cally supported phenomenon, figures prominently in models of social phobia.However, all published studies examining this topic to date have relied on groupmeans to describe attention bias patterns; research has yet to examine potentialsubgroups of attention bias among individuals with social phobia (e.g., vigilantor avoidant). Furthermore, almost no research has examined how attentionbiases in either direction may predict change in symptoms as a result oftreatment. Methods: This study (N 5 24) compared responses to cognitivebehavioral therapy (CBT) for social phobia between individuals with avoidantand vigilant biases for threatening faces at pretreatment. Results: Participantswith avoidant biases reported significantly and clinically higher symptom levelsat posttreatment than did those with vigilant biases. Conclusions: Thesefindings suggest that an avoidant attention bias may be associated with reducedresponse to CBT for social phobia. Depression and Anxiety 28:349–353, 2011.rr 2011 Wiley-Liss, Inc.

Key words: attention biases; social phobia; treatment response

INTRODUCTIONVarious theoretical models of social phobia suggestthat attention biases help maintain the disorder byenhancing the processing of negative information insocial situations.[1–3] Such enhanced processing notonly results in increased anxiety for the current eventand negative expectations for future events, but alsocontributes to maladaptive beliefs about the individual’ssocial performance. Most research to date has foundsocially phobic samples to show increased vigilance or abias to attend toward threatening information.[4–7]

Such biases, however, seem to be malleable. Recentstudies have found that cognitive behavioral therapy(CBT)[6,8] or attention retraining[9,10] can reducevigilance biases, along with other social phobiasymptoms, in clinical samples. Indeed, individualswho received attention retraining not only disengagedsignificantly faster from social threat cues after treat-ment, but they also reported greater declines in anxietysymptoms and functional impairment as compared to aplacebo treatment.[9] This provides preliminary evi-dence that decreased attentional vigilance towardthreat may serve as an important component of overalltreatment response for social phobia.

However, some research has also found evidence ofattentional avoidance or a bias away from threateninginformation in socially phobic individuals,[2,11,12]

raising questions about the uniformity of attentionalbiases in this population. A variety of factors couldcontribute to the inconsistent pattern of findings acrossstudies. First, these inconsistencies may reflect meth-odological differences (e.g., variations in stimuluspresentation duration or task type–Stroop versus dotprobe) among studies.[13,14] Indeed, unlike studies thatfound evidence of vigilant biases, the two studies thatshow avoidant biases in socially phobic samples used a

Published online 9 February 2011 in Wiley Online Library (wiley

onlinelibrary.com).

DOI 10.1002/da.20791

Received for publication 22 October 2010; Revised 27 December

2010; Accepted 29 December 2010

�Correspondence to: Page L. Anderson, Psychology Department,

Georgia State University, 140 East Decatur St, Atlanta, GA 30303.

E-mail: Panderson@gsu.edu

The authors report they have no financial relationships within the

past 3 years to disclose.

Georgia State University, Atlanta, Georgia

rr 2011 Wiley-Liss, Inc.

dot probe task that paired socially threatening faceimages with pictures of household objects, rather thanimages of neutral faces.[11,12] Second, consistent with atwo-stage model that proposes initial attentionalvigilance followed by attentional avoidance,[13] studiesmay have tapped attention at different stages, yieldingvariable results. A third possible explanation for themixed findings is individual differences in attentionbias. Specifically, subtypes of attentional bias (vigilant,avoidant) may exist within the broad diagnosticcategory of social phobia. This latter possibility is ofparticular interest, because it holds the potential tounite theoretical models of the disorder that emphasizedifferent types of attention bias: selective attention tocues of negative evaluation[3] versus directed attentionaway from external threat cues.[2] Limited research todate has explored individual differences in attentionbias patterns among individuals with social phobia;indeed, the exclusive use of group means to describeattention bias in prior research would have obscuredevidence of subgroups.

Understanding individual differences in attentionbias patterns in social phobia is important becauseaffected individuals with vigilant versus avoidantattentional styles could show distinctive patterns ofresponse to varied treatments. For example, individualswho are attentionally vigilant before treatment may bemore likely than pretreatment attentional avoiders torespond well to exposure-based therapies, given thatoptimal treatment response is thought to occur whenparticipants are fully present and aware of theexposures.[15,16] Furthermore, prior research showsthat distraction, which can be conceptualized asfacilitating avoidance, may inhibit extinction learning.[17,18]

Whether an avoidant attentional bias similarly inter-feres with adaptive responding to exposure therapy isunknown. To examine this possibility, this study testedthe hypothesis that pretreatment attentional vigilancefor and avoidance of threat cues would differentiallypredict treatment response to exposure-based CBT forsocial phobia. It was predicted that individuals whoshowed a pretreatment avoidant bias would have apoorer treatment response.

METHODS

PARTICIPANTS

Participants were recruited via two outcome studies. The first(N 5 75) was a randomized clinical trial comparing the effectivenessof virtual reality exposure therapy (VRE), Cognitive BehavioralGroup Therapy, and a waitlist control as a treatment for socialphobia. The second study (N 5 10) examined amygdala activity as apredictor of treatment response to VRE in the context of anuncontrolled clinical trial. The attention bias task was introducedtoward the end of the first study and was included from the beginningof the second study. Across these two studies, all participants whocompleted the attention bias task and received VRE were included(Study 1, n 5 14; Study 2, n 5 10). Recruitment procedures, treat-ment, and assessment protocols were identical across the two studies,

with the exception that individuals in the second study completed anfMRI scan at pre- and posttreatment.

Participants comprised 24 individuals diagnosed with socialphobia, with almost one third (n 5 9) meeting criteria for thegeneralized subtype. The sample was predominantly male (71%,n 5 17) with an average age of M 5 41.38, SD 5 11.26. Participantsself-identified as European American (46%, n 5 11), African Amer-ican (25%, n 5 6), Latino (8%, n 5 2), and Asian American (8%,n 5 2). The remaining (13%, n 5 3) participants reported theirethnicity as ‘‘Other.’’ The sample was well educated, with 71%having completed college; 58% reported being married. Most weremiddle class; 58% had an annual income of $50,000 or more.Informed consent was obtained from all participants before enroll-ment in the study.

MATERIALS

Social phobia symptoms were assessed with the Liebowitz SocialAnxiety Scale [LSAS[19]]. The LSAS is a 24-item self-reportinstrument that measures fear and avoidance experienced in a varietyof social and performance situations. Participants rate expected levelsof fear and avoidance for the situations (e.g., ‘‘going to a party’’ or‘‘speaking up at a meeting’’) on four-point Likert scales (0 5 no fear/avoidance, to 3 5 severe fear/avoidance). Scores range from 0 to 144.The self-report version of the LSAS is comparable to the originalclinician-administered version. It demonstrates good internal con-sistency among socially anxious individuals (a5 .95), as well as strongconvergent and discriminant validity.[20] Internal consistency for themeasure in this sample was excellent, with Cronbach’s that rangedfrom .92 to .97. Social phobia diagnoses were made with theStructured Diagnostic Interview for the DSM-IV [SCID;[21]] bytrained research assistants.

Attention bias was measured with a widely used dot probe taskdeveloped and described in detail by Bradley et al.[22] Consistent withBradley et al.[22] during each of 80 randomly ordered trials, after a500 ms fixation cross in the center of the screen, two images of anindividual’s face appeared for 500 ms (32 trials paired happy/neutralfaces, 32 paired angry/neutral faces, and 16 paired neutral/neutralfaces). After the offset of the face pair, a target probe (an asterisk)replaced one face for 1,100 ms; participants pressed computer keys toindicate as quickly as possible where on the screen (left or right side)each probe appeared. The probe appeared on the same side of thescreen as the emotionally valenced faces during half of the emotional-neutral pair trials and, appeared on the left or the right an equalnumber of times for each trial type (happy-neutral, angry-neutral,neutral-neutral).

To calculate threat bias scores, mean response time for the 16threat–neutral trials with threat–congruent probes (asterisks thatreplaced angry faces) was subtracted from the mean response time forthe 16 trials with threat-incongruent probes (asterisks that replacedneutral faces) for each participant. Positive scores indicated a bias todirect attention toward angry faces; negative scores indicated a bias todirect attention away from angry faces. Happy bias scores weresimilarly calculated, based on response times to congruent andincongruent happy-neutral trials. Findings from prior researchsuggest that the measure validly discriminates between anxious andnonanxious adults and youth.[13,22–24]

PROCEDURE

Eligibility was determined through a two-stage process. First,participants completed a telephone screen to identify exclusion criteria(active suicidal ideation, active substance abuse, current enrollment intherapy for social phobia, history of mania, and psychotropicmedication initiation or dosage change within the past 3 months).

350 Price et al.

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Second, during an in-person assessment, candidates completed theanxiety, mood, and substance abuse portions of the StructuredDiagnostic Interview for the DSM-IV [SCID[21]] to determine if thepotential participant met criteria for a primary diagnosis of socialphobia. The SCID was administered by a doctoral student in clinicalpsychology, supervised by a licensed psychologist. An independentassessor and licensed psychologist reviewed 10% of the videotapedSCID assessments and showed 100% agreement with the originalinterviewer for the primary diagnosis. Participants also completed theLSAS and the dot probe task before beginning treatment.

VRE consisted of eight sessions of CBT that targeted severalprocesses shown to maintain social phobia, including self-focusedattention, negative perceptions of self and others, perceptions of lackemotional control, rumination, and realistic goal setting for socialsituations. Treatment was administered according to a manualizedprotocol.[25] The virtual reality scenarios included (1) a conferenceroom, (2) a classroom, and (3) a large auditorium. These scenarioswere presented via a head-mounted display that consisted of a helmetwith headphones and goggles. At the conclusion of treatment,participants completed the LSAS.

RESULTSParticipants were divided into vigilant (n 5 15) and

avoidant (n 5 9) groups, based on their pretreatmentattention bias scores for threatening faces (vigilant:score40; avoidant: scoreo0) (see Table 1 for descrip-tive statistics). The threat bias scores of the two groupsdiffered significantly, (t(23) 5 4.13, Po.01; avoidant:M 5�7.09, SD 5 2.22; vigilant: M 5 18.99, SD 54.71). Threat bias scores for each group also differedsignificantly from 0 (Vigilant: t(14) 5 5.22, Po.01;Avoidant: t(8) 5�2.97, Po.01). However, there wereno pretreatment differences between groups on mea-sures of social anxiety, demographic variables, or biasscores for threatening or happy faces. Furthermore,there was no evidence that threat bias type wasassociated with drop-out status (w2 5 .12, P 5.73) orthat bias scores differed between those who droppedout of treatment and those who completed treatment(F (1, 30) 5 .03, P 5.86).

First, an ANCOVA was used to determine if threatbias category, avoidant or vigilant, accounted forpretreatment to posttreatment change in LSAS scores.The results indicated that after controlling for pre-treatment social anxiety, those with an avoidant threatbias (M 5 36.88, SD 5 13.66) had significantly higherposttreatment anxiety than those with a vigilant threatbias (M 5 24.29, SD 5 14.92), F (1, 19) 5 4.72, Po.05,partial Z2 5 .16 (Fig. 1). To more fully describe theassociation between attention bias type and treatmentresponse, a regression analysis using bias score as acontinuous variable was also conducted. However, thisyielded null results (b5�.09, P 5.66, R2

D 5 .01). Uponcloser inspection of the data, it appeared that the nullresult was due to a nonlinear association between biasscores and LSAS scores. Specifically, the associationbetween bias score and posttreatment LSAS scores(while controlling for pretreatment LSAS scores)varied by threat bias type (avoidant or vigilant)

(Fig. 1). To further explore this association with anappropriately powered analysis, separate regressionswere conducted for each bias type (Table 2). Forvigilant biases, bias scores predicted outcome such thatgreater vigilance bias was associated with greaterposttreatmnet social anxiety (b5 .52, Po.05,R2D 5 .27). For the group with avoidant biases, there

was no association between bias scores and posttreat-ment anxiety (b5�.22, P 5.41, R2

D 5 .04). Thesefindings suggest that participants with avoidant biasdid not benefit from treatment (MD 5 10.85) as muchas those with a vigilant bias (MD 5 23.04). Further-more, although vigilant bias scores were positivelyrelated to treatment response, no such association wasfound for avoidant bias scores.

DISCUSSIONThese findings provide preliminary support for the

hypothesis that the direction of attention bias (avoidantor vigilant) at the start of treatment would be associatedwith different patterns of response to VRE inindividuals with social phobia. Specifically, an avoidantbias for threatening faces at pretreatment was asso-ciated with a weaker treatment response (MD 5 10.85)

TABLE 1. Descriptive statistics

M SD

Avoidant (n 5 9)Attention bias score �7.09 2.22Pretreatment LSAS total score 47.73 14.95Posttreatment LSAS total score 36.88 13.66

Vigilant (n 5 15)Attention bias score 18.99 4.71Pretreatment LSAS total score 47.33 24.74Posttreatment LSAS total score 24.29 14.92

LSAS, Liebowitz Social Anxiety Scale.

Figure 1. Association between posttreatment LSAS scores andbias scores across bias subtypes.

351Research Article: Attention Biases as Predictors of Treatment Response

Depression and Anxiety

as shown by change in LSAS score than was a vigilantbias (MD 5 23.04). A potential theoretical explanationfor these findings comes from evidence that suggestsdistraction from a feared stimulus results in poorertreatment outcomes.[18] Although the attentionalavoidance measured in this study (e.g., reaction timesto faces) differs from the behavioral avoidance thatfunctions to distract an individual from a fearedstimulus (e.g., not making eye contact), future researchcould test whether such ‘‘automatic’’ forms of atten-tional avoidance limit engagement with exposure andacquisition of extinction learning.

These findings are the first to suggest that indivi-duals with social phobia may show one of two distinctattention bias subtypes. Given the small sample size ofthis study, our results are necessarily preliminary. Evenso, the findings are notable because most research onbiased attention to threat has focused on mean scores,thus potentially obscuring evidence of individualdifferences among adults with social phobia. Addition-ally, the dot probe task variant used in this study (pairthreatening and neutral faces) has historically yieldedevidence of mean vigilance biases; these findingssuggest that this task variant, such as a variant thatpaired threatening faces and pictures of householdobjects,[11,12] can also elicit avoidant biases in sociallyanxious individuals. Further research is needed todetermine whether attention bias subtypes can bereplicated in larger samples and to examine the utilityof attention bias subtypes in advancing knowledgeregarding social anxiety and its treatment.

If these findings are replicated, there may be implica-tions for treatments that directly address attention bias.For example, recent work has shown that attentionretraining alters attention biases and reduces socialphobia symptoms in a group presenting with a vigilancebias for socially threatening information.[9,10] An atten-tion retraining program may or may not be beneficial forindividuals with an avoidant bias, given that thetreatment focuses on disengaging attention from fearedstimuli. Alternatively, attention retraining may reduceavoidance biases and prepare such individuals to engagewith and benefit from traditional exposure therapy.

This study has several limitations. First, the samplesize was small, which may have increased our risk of

error and limited the scope of statistical analysis for thestudy. Furthermore, the majority of the sample did notmeet criteria for the generalized subtype of socialphobia, which may have contributed to relativelyrestricted threat bias scores. Additional research inlarger samples with generalized social phobia wouldpermit the selection of groups with extreme vigilant andavoidant biases, which would, in turn, provide a strongertest of differential effects of varying bias types. Allparticipants received VRE, and although VRE has beenshown to be equivalent to in vivo exposure for specificphobia,[26–28] it is unclear whether these results wouldgeneralize to studies that use other forms of CBT totreat social phobia. Furthermore, given that prior workhas indicated that attention biases can change during thecourse of treatment,[6,8] our use of cross-sectionalpretreatment attention bias measures may have obscureddynamic associations between attention bias and treat-ment response. Repeated measurement of attention biasbefore, during, and after treatment could shed light onmore complex interactions between attention bias andsocial phobia symptoms. Additionally, although atten-tion biases have been shown to fluctuate based on thepresence of a social threat,[29,30] this study did notinclude a social threat condition. How attention biasesfluctuate as a function of social threat and how thesechanges may influence social phobia and treatmentresponse warrant examination. Such research may beparticularly relevant with regard to CBT response;because CBT involves consistent presentation of sociallythreatening situations, attention biases that are observedunder social threat conditions may be a better indicatorof treatment response. Finally, even though the dotprobe task is widely considered to be a robust measureof attention bias, scholars have raised issues related to itsreliability[31] and ecological validity.[32]

Despite these limitations, we hope the results of thisstudy will stimulate further research on the existence ofsubtypes of attention bias and to examine its potentialutility in better understanding and treating social anxiety.Future research might also examine the neural substratesof attentional vigilance for and avoidance of threat inanxious samples; neuroimaging work to date, usingattention bias tasks in healthy adults, have yielded evidencethat avoidance may relate to increased occipitotemporal

TABLE 2. Hierarchical regression with attention bias score as predictor of outcome as measured by the LSAS

Variable R2D b b

Vigilance bias (n 5 15)Step 1 Pretreatment LSAS .04� .11 (.16) .20Step 2 Pretreatment LSAS .27� .09 (.15) .16

Attention bias .42� (.21) .52�

Avoidant bias (n 5 9)Step 1 Pretreatment LSAS .68� .96� (.27) .82�

Step 2 Pretreatment LSAS .04� .90� (.28) .77�

Attention bias �.42 (.47) �.22

�5 Po.05. LSAS, Liebowitz Social Anxiety Scale.

352 Price et al.

Depression and Anxiety

activation[33] and that vigilance may be associated withincreased activity in temporoparietal and prefrontalcortical (PFC) regions.[34] Increased activity in selectPFC regions, particularly the right dorsolateral PFC,during trials that reflect attention bias toward anger,has also been found in youths with anxiety disorders.[35]

None of these studies, however, have comparedpatterns of neural activation between individuals withavoidant and vigilant biases, which could show distinctpatterns of neural function, as well as behavior.

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