Finding the Balance Between Safety and Threat May Hold the Key to Success When Treating PTSD

Abstract

Deployment stressors—most notably exposure to combat (1)—have profound effects on mental health (2). It is estimated that approximately 20% of military veterans develop posttraumatic stress disorder (PTSD) (3), while approximately 7%210% develop alcohol use disorders and 17% experience major depressive disorder (4). These mental health issues have profound effects on social functioning and the ability to work, and they increase utilization of health care services (5). Standardized behavioral treatments are helpful but have limited effect size (6), and exposurebased interventions seem best suited for combat-related PTSD (7). Yet a significant gap between treatment need and availability remains. Computerized treatment techniques might be able to address this gap. These methods are firmly rooted in cognitive science and provide a useful approach to specifically treat basic cognitive processing dysfunctions in PTSD. In this issue, Badura-Brack and colleagues (8) address a critical question, i.e., For individuals with PTSD, is it better to train paying attention to safe instead of threat stimuli or to increase control of attention to both safe and threat stimuli? and provide a provocative answer. The “classical” answer has been that it is better to train individuals with anxiety disorders to pay more attention to “safe” stimuli (9).YetPTSD isdifferent,withdifferent studies finding both increased and decreased bias toward threat, respectively.Moreover, PTSD individuals seem to fluctuate between a focus on threat and a focus away from threat (avoidance), which has been termed attention bias variability. Badura-Brack and colleagues conducted a randomized controlled trial using an attentional task to examine the efficacy of attention bias modification versus attention control training. In fact, Badura-Brack and colleagues (8) report on two randomized controlled trials with different number of sessions and different stimulus materials, which ultimately provided the same answer. Study 1 focused on 144 treatment-seeking individuals with combat-related PTSD from the Israel Defense Forces, of whom 52 were included in the study. Study 2 involved 76 veterans from Iraq and Afghanistan who had been screened for PTSD, of whom 46 participated in the study. For both studies, participants completed particular versions of the dot-probe task, one of which targeted attention bias to threat, while the other served as an attention control. To understand the findings, it is important to consider what the specific task demands are and how individuals are being trained on the dot-probe task. First, during the dotprobe task an individual is asked to focus on the center of a computer screen. Second, twowords (angry or neutral faces in study 2) are presented simultaneously above or below the center of the screen. Third, the person pushes a button as quickly as possible when he or she sees a target stimulus (letter E or F in study 1, “,” or “.” in study 2), which is presented in the same location as either the threat-relatedor neutral word (or face). If the person has no bias, then the reaction time should be the samewhether the target appears at the location of either word (or face). However, if the person’s brain is more engaged in processing the threatrelated word (or angry face) relative to the “safe” word (or neutral face), then the individual should be faster to respond to the target that appears in the same location as the threat word. Two measures provide an index of bias and variability. Threat-related attention bias is thedifference in reaction time followinga target at the threat versus the safe location. Attention bias variability is the variability of this measure across trials. The same dot-probe procedure described above is also used for training. However, for attention bias modification and unbeknownst to the individual, the target only appears at the location of the neutral word (neutral face). Thus, attentionbiasmodification implicitly trains individuals to focus their attentionmore toward theneutral (rather than the threat) stimulus. In comparison, during attention control training, individuals see the target at either the location of the threat word or the location of the safe word in a counterbalanced manner. The authors found that all groups got better (had fewer PTSD symptoms), but the individuals undergoing attentional control training were significantly better than those undergoing attention bias modification. This effect was specific to PTSD-related symptoms and did not extend to depression symptoms, although there was a small effect on a depression measure in study 2. Moreover, in both studies, the attention Computerized treatment techniques... are firmly rooted in cognitive science and provide a useful approach to specifically treat basic cognitive processing dysfunctions in PTSD.