Skip to main content Accessibility help

Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial

  • Amit Lazarov (a1), Benjamin Suarez-Jimenez (a2), Rany Abend (a3), Reut Naim (a4), Erel Shvil (a5), Liat Helpman (a2), Xi Zhu (a2), Santiago Papini (a6), Ariel Duroski (a5), Rony Rom (a5), Franklin R. Schneier (a2), Daniel S. Pine (a3), Yair Bar-Haim (a7) and Yuval Neria (a2)...



Randomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD.


Fifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment.


ACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment.


The current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.


Corresponding author

Author for correspondence: Amit Lazarov, E-mail:


Hide All

This work reflects equal contribution of the first two authors.



Hide All
Amir, N, Taylor, CT and Donohue, MC (2011) Predictors of response to an attention modification program in generalized social phobia. Journal of Consulting and Clinical Psychology 79, 533541.
Aupperle, RL, Melrose, AJ, Stein, MB and Paulus, MP (2012) Executive function and PTSD: disengaging from trauma. Neuropharmacology 62, 686694.
Badura-Brack, AS, Naim, R, Ryan, TJ, Levy, O, Abend, R, Khanna, MM, McDermott, TJ, Pine, DS and Bar-Haim, Y (2015) Effect of attention training on attention bias variability and PTSD symptoms: randomized controlled trials in Israeli and U.S. Combat Veterans. American Journal of Psychiatry 172, 12331241.
Bardeen, JR and Orcutt, HK (2011) Attentional control as a moderator of the relationship between posttraumatic stress symptoms and attentional threat bias. Journal of Anxiety Disorders 25, 10081018.
Bardeen, JR, Tull, MT, Daniel, TA, Evenden, J and Stevens, EN (2016) A preliminary investigation of the time course of attention bias variability in posttraumatic stress disorder: the moderating role of attentional control. Behaviour Change 33, 94111.
Bar-Haim, Y (2010) Research review: attention bias modification (ABM): a novel treatment for anxiety disorders. Journal of Child Psychology and Psychiatry 51, 859870.
Bar-Haim, Y, Holoshitz, Y, Eldar, S, Frenkel, TI, Muller, D, Charney, DS, Pine, DS, Fox, NA and Wald, I (2010) Life-threatening danger and suppression of attention bias to threat. American Journal of Psychiatry 167, 694698.
Basanovic, J, Notebaert, L, Grafton, B, Hirsch, CR and Clarke, PJF (2017) Attentional control predicts change in bias in response to attentional bias modification. Behaviour Research and Therapy 99, 4756.
Beck, AT, Steer, RA and Brown, GK (1996) BDI-II Manual, 2nd Edn. San Antonio: Harcourt Brace & Company.
Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Gusman, FD, Charney, DS and Keane, TM (1995) The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress 8, 7590.
Blanchard, EB, Hickling, EJ, Devineni, T, Veazey, CH, Galovski, TE, Mundy, E, Malta, LS and Buckley, TC (2003) A controlled evaluation of cognitive behaviorial therapy for posttraumatic stress in motor vehicle accident survivors. Behaviour Research and Therapy 41, 7996.
Bradley, R, Greene, J, Russ, E, Dutra, L and Westen, D (2005) A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 162, 214227.
Brady, KT, Killeen, TK, Brewerton, T and Lucerini, S (2000) Comorbidity of psychiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry 61, 2232.
Brewin, CR and Holmes, EA (2003) Psychological theories of posttraumatic stress disorder. Clinical Psychology Review 23, 339376.
Bryant, RA and Harvey, AG (1997) Attentional bias in posttraumatic stress disorder. Journal of Traumatic Stress 10, 635644.
Buckley, TC, Blanchard, EB and Neill, WT (2000) Information processing and PTSD: a review of the empirical literature. Clinical Psychology Review 20, 10411065.
Chemtob, CM, Roitblat, HL, Hamada, RS, Carlson, JG and Twentyman, CT (1988) A cognitive action theory of Post-Traumatic Stress Disorder. Journal of Anxiety Disorders 2, 253275.
Clarke, PJF, Notebaert, L and MacLeod, C (2014) Absence of evidence or evidence of absence: reflecting on therapeutic implementations of attentional bias modification. BMC Psychiatry 14, 8.
Difede, J, Olden, M and Cukor, J (2014) Evidence-based treatment of post-traumatic stress disorder. Annual Review of Medicine 65, 319332.
Ehlers, A and Clark, DM (2000) A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38, 319345.
Eysenck, MW, Derakshan, N, Santos, R and Calvo, MG (2007) Anxiety and cognitive performance: attentional control theory. Emotion 7, 336353.
Fani, N, Bradley-Davino, B, Ressler, KJ and McClure-Tone, EB (2011) Attention bias in adult survivors of childhood maltreatment with and without posttraumatic stress disorder. Cognitive Therapy and Research 35, 5767.
First, MB, Spitzer, RL, Gibbon, M and Williams, JBW (1995) Structured Clinical Interview for DSM-IV Axis I Disorders. New York: New York State Psychiatric Institute.
Foa, EB and Rothbaum, BO (1998) Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. Treatment Manuals for Practitioners. New York: Guilford Press.
Foa, EB, Steketee, G and Rothbaum, BO (1989) Behavioral cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy 20, 155176.
Foa, EB, Feske, U, Murdock, TB, Kozak, MJ and Mccarthy, PR (1991) Processing of threat-related information in rape victims. Journal of Abnormal Psychology 100, 156162.
Hallion, LS and Ruscio, AM (2011) A meta-analysis of the effect of cognitive bias modification on anxiety and depression. Psychological Bulletin 137, 940958.
Hamilton, M (1960) A rating scale for depression. Journal of Neurology Neurosurgery and Psychiatry 23, 5662.
Hien, DA, Jiang, HP, Campbell, ANC, Hu, MC, Miele, GM, Cohen, LR, Brigham, GS, Capstick, C, Kulaga, A, Robinson, J, Suarez-Morales, L and Nunes, EV (2010) Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA's clinical trials network. American Journal of Psychiatry 167, 95101.
Imel, ZE, Laska, K, Jakupcak, M and Simpson, TL (2013) Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 81, 394404.
Krell, HV, Leuchter, AF, Morgan, M, Cook, IA and Abrams, M (2004) Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. The Journal of Clinical Psychiatry 65, 11741179.
Kuckertz, JM, Amir, N, Boffa, JW, Warren, CK, Rindt, SEM, Norman, S, Ram, V, Ziajko, L, Webb-Murphy, J and McLay, R (2014 a) The effectiveness of an attention bias modification program as an adjunctive treatment for post-traumatic stress disorder. Behaviour Research and Therapy 63, 2535.
Kuckertz, JM, Gildebrant, E, Liliequist, B, Karlstrom, P, Vappling, C, Bodlund, O, Stenlund, T, Hofmann, SG, Andersson, G, Amir, N and Carlbring, P (2014 b) Moderation and mediation of the effect of attention training in social anxiety disorder. Behaviour Research and Therapy 53, 3040.
Lazarov, A, Abend, R, Seidner, S, Pine, DS and Bar-Haim, Y (2017 a) The effects of training contingency awareness during attention bias modification on learning and stress reactivity. Behavior Therapy 48, 638650.
Lazarov, A, Marom, S, Yahalom, N, Pine, DS, Hermesh, H and Bar-Haim, Y (2017 b) Attention bias modification augments cognitive-behavioral group therapy for social anxiety disorder: a randomized controlled trial. Psychological Medicine 48, 21772185.
Linetzky, M, Pergamin-Hight, L, Pine, DS and Bar-Haim, Y (2015) Quantitative evaluation of the clinical efficacy of attention bias modification treatment for anxiety disorders. Depression and Anxiety 32, 383391.
Litz, BT and Keane, TM (1989) Information processing in anxiety disorders: application to the understanding of post-traumatic stress disorder. Clinical Psychology Review 9, 243257.
MacLeod, C and Clarke, PJF (2015) The attentional bias modification approach to anxiety intervention. Clinical Psychological Science 3, 5878.
MacLeod, C and Grafton, B (2016) Anxiety-linked attentional bias and its modification: illustrating the importance of distinguishing processes and procedures in experimental psychopathology research. Behaviour Research and Therapy 86, 6886.
MacLeod, C, Mathews, A and Tata, P (1986) Attentional bias in emotional disorders. Journal of Abnormal Psychology 95, 1520.
Meffert, SM, Metzler, TJ, Henn-Haase, C, McCaslin, S, Inslicht, S, Chemtob, C, Neylan, T and Marmar, CR (2008) A prospective study of trait anger and PTSD symptoms in police. Journal of Traumatic Stress 21, 410416.
Naim, R, Abend, R, Wald, I, Eldar, S, Levi, O, Fruchter, E, Ginat, K, Halpern, P, Sipos, ML, Adler, AB, Bliese, PD, Quartana, PJ, Pine, DS and Bar-Haim, Y (2015) Threat-related attention bias variability and posttraumatic stress. American Journal of Psychiatry 172, 12421250.
Ruggiero, KJ, Del Ben, K, Scotti, JR and Rabalais, AE (2003) Psychometric properties of the PTSD checklist – civilian version. Journal of Traumatic Stress 16, 495502.
Sarapas, C, Weinberg, A, Langenecker, SA and Shankman, SA (2017) Relationships among attention networks and physiological responding to threat. Brain and Cognition 111, 6372.
Schoorl, M, Putman, P and van Der Does, W (2013) Attentional bias modification in posttraumatic stress disorder: a randomized controlled trial. Psychotherapy and Psychosomatics 82, 99105.
Sipos, ML, Bar-Haim, Y, Abend, R, Adler, AB and Bliese, PD (2014) Postdeployment threat-related attention bias interacts with combat exposure to account for PTSD and anxiety symptoms in soldiers. Depression and Anxiety 31, 124129.
Sullivan, GM and Neria, Y (2009) Pharmacotherapy of PTSD: current status and controversies. Psychiatric Annals 39, 342347.
Tottenham, N, Tanaka, J, Leon, A, McCarry, T, Nurse, M, Hare, T, Marcus, D, Westerlund, A, Casey, BJ and Nelson, CB (2009) The NimStim set of facial expressions: judgments from untrained research participants. Psychiatry Research 168, 242249.
Van Etten, ML and Taylor, S (1998) Comparative efficacy of treatments for post-traumatic stress disorder: a meta-analysis. Clinical Psychology & Psychotherapy 5, 126144.
Vens, M and Ziegler, A (2012) Generalized estimating equations and regression diagnostics for longitudinal controlled clinical trials: a case study. Computational Statistics & Data Analysis 56, 12321242.
Weathers, F, Litz, BT, Huska, JA and Keane, TM (1991) The PTSD Checklist (PCL). Boston, VA: Medical Centre: Boston.
Weathers, FW, Keane, TM and Davidson, JRT (2001) Clinician-administered PTSD scale: a review of the first ten years of research. Depression and Anxiety 13, 132156.
Williams, JBW (1988) A structured interview guide for the Hamilton depression rating-scale. Archives of General Psychiatry 45, 742747.
Zeger, SL and Liang, KY (1986) Longitudinal data-analysis for discrete and continuous outcomes. Biometrics 42, 121130.
Zeger, SL, Liang, KY and Albert, PS (1988) Models for longitudinal data – a generalized estimating equation approach. Biometrics 44, 10491060.


Related content

Powered by UNSILO

Bias-contingent attention bias modification and attention control training in treatment of PTSD: a randomized control trial

  • Amit Lazarov (a1), Benjamin Suarez-Jimenez (a2), Rany Abend (a3), Reut Naim (a4), Erel Shvil (a5), Liat Helpman (a2), Xi Zhu (a2), Santiago Papini (a6), Ariel Duroski (a5), Rony Rom (a5), Franklin R. Schneier (a2), Daniel S. Pine (a3), Yair Bar-Haim (a7) and Yuval Neria (a2)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.