Investigating the Neural Correlates of the Attention Training Technique Using a Novel fMRI Paradigm for Measuring Attentional Control

The Attention Training Technique (ATT) was developed with the aim of reducing self-focused attention and increasing executive control as part of metacognitive therapy. So far there is a paucity of data on the neurophysiological effects of ATT. In the present study we tested for specific effects to determine if attention control components of ATT elicit a specific signature that is different from passive listening. Thirty-six healthy volunteers were randomized to an active (follow instructions) or control (ignore instructions) condition. Resting state EEG was recorded for 3 min with eyes open and eyes closed before and after exposure to training, and the power of the theta, alpha, and beta-bands were analyzed in frontal, midline, and posterior electrodes. The active ATT condition enhanced alpha and beta-band activity during eyes-open, and frontal alpha during eyes-closed (p < 0.005). Frontoparietal changes in Alpha were generally accompanied by changes in Beta in the same brain regions of interest. However, these associations were largely significant in the active ATT rather than the control condition. No between-group differences were observed in the Theta-band. These results suggest a single dose of attention training increases alpha and beta-oscillations in frontoparietal networks. These networks are associated with top-down attentional or executive control.

Background: The Attention Training Technique (ATT) as part of Metacognitive Therapy (MCT) has shown to be a promising treatment element for several psychiatric disorders such as depression and anxiety. ATT predicts improvements of the ability to shift attention away from internal and non-relevant stimuli (e.g., ruminative thoughts) toward the relevant stimuli and aims to increase attentional flexibility and control. The current study investigated the impact of the Attention Training Technique on attentional performance.Methods: Eighty-five healthy participants (29 in two doses ATT, 28 in four doses ATT and 28 in the control group; 18–37 years of age) were administered a test battery for attentional performance before and after an intervention of two doses ATT (23 min duration) vs. four doses of ATT (46 min duration) vs. a control condition (non-intervention audio file via headphones. The test battery measured selective attention, inhibition, working memory, and attentional disengagement and comprised the following tasks: dichotic listening, attentional bias, attentional network, stroop, 2-back and a 3-back.Results: After ATT (both two and four doses), reaction time during dichotic listening was significantly faster compared to the control condition. Furthermore, reaction time to neutral stimuli in the attentional bias task was faster after four-doses ATT compared to two doses ATT and the control condition. We found a trend toward a reduced stroop effect for both ATT conditions compared to control group. There were no effects of ATT with regard to the attentional network task, the 2-back or the 3-back task.Conclusion: This first empirical evidence suggests that ATT promotes specific attentional flexibility in healthy participants. Based on the same mechanism, ATT may have beneficial effects on attentional performance in clinical populations and might be a promising tool in both healthy and clinical participants.

Neurophysiological correlates of the attention training technique: A component study

Clinically significant symptoms of depression and anxiety in coronary heart disease (CHD) patients are common and associated with adverse outcomes. Psychological treatments have shown limited effectiveness and more effective treatments have been requested. Attention training technique (ATT), a component of metacognitive therapy, can potentially be effective as a stand-alone treatment for anxiety and depression. In an open study, ATT delivered face-to-face in a group format was feasible and potentially effective for improving depression and anxiety symptoms in CHD patients. The next progressive step is to test the effectiveness of ATT in a randomized controlled trial. This paper describes the methodology of this trial. ATT-CHD is a randomized wait-list (WL) controlled study. Eligible CHD patients from two hospitals with Hospital Anxiety and Depression Scale (HADS)-Anxiety and/or HADS-Depression subscales scores ≥8 will be randomized into ATT (n = 32) or WL control (n = 32). After 6-8 weeks, WL patients will be allocated to ATT. Participants will be evaluated pre-, mid- and post-treatment, and at 6-months follow-up using changes in HADS as primary outcome. Secondary outcomes will be changes in psychiatric disorders, rumination, worry, type D-personality, metacognitions, insomnia, quality of life, and C-Reactive protein (CRP). To our knowledge, this will be the first WL-controlled randomized study testing the effectiveness of group-based ATT as treatment of symptoms of anxiety and depression in CHD patients. It will also explore correlations between changes in psychological distress and CRP. A qualitative analysis will reveal patients' experience with ATT including processes that may facilitate or serve as barriers to effectiveness. Recruitment into the study commenced in December 2022. The Regional Committees for Medical and Health Research Ethics (REK), Norway has granted approval for the study (ID 52002). The trial results will be published in peer-reviewed journals. According to Norwegian legislation, the Norwegian Data Protection Authority, and the Committee of Ethics, we are not allowed to share original study data publicly. ClinicalTrials.gov, identifier NCT05621408 pre-inclusion. There were no significant changes of methods or outcomes after study start.

Funding Acknowledgements Type of funding sources: None. Background Significant symptoms of anxiety and depression are prevalent (30-40%) in coronary heart disease (CHD) patients and these are associated with a greater risk of death, recurrent cardiovascular events, poorer quality of life, and more frequent use of healthcare services compared to those without this heart condition. To date, only a few psychological treatments have shown limited effectiveness on symptoms of anxiety and depression in CHD patients. Therefore, it is essential to develop and evaluate more effective treatments for depression and anxiety in CHD patients. Metacognitive therapy (MCT) is effective in reducing significant symptoms of anxiety and depression. A key component of MCT is the attention training technique (ATT), which is based on the self-regulatory executive function model. According to the MCT treatment manual, ATT is brief and does not require extensive training to be delivered by health care personnel in routine care. A review of the empirical evidence shows that ATT can be as effective as full MCT in alleviating anxiety and depressive symptoms. However, ATT has not yet been used as a stand-alone intervention in treating symptoms of anxiety and depression in CHD patients. Purpose To evaluate the feasibility of implementing group ATT in CHD patients with significant symptoms of anxiety and depression and describe changes in these symptoms. Methods Five consecutively referred CHD patients with significant anxiety and depressive symptoms, as assessed by the Hospital Anxiety and Depression Scale (HADS)-Anxiety or Depression subscale score &amp;gt; 8, were included in the study. They received six weekly group sessions of ATT in an open trial. Outcomes included symptoms measured by HADS at baseline, post-treatment and at six months follow-up. We also assessed psychiatric diagnoses and specific psychological factors (type D personality, insomnia, worry and rumination) as secondary measures. Results The sample comprised of five men between 52 and 65 years of age, with a mean age of 59.9 years. Four of the patients attended all six sessions, and one patient attended all but one session. The mean HADS-A scores at baseline, post-treatment, and follow up were 9.4 (SD 3.0), 4.2 (SD 3.0) and 4.0 (SD 2.5), and for HADS-D 8.6 (SD 3.3), 3.0 (3.7) and 1.6 (SD 1.5), respectively. The results showed clinically significant changes in anxiety, depression, psychiatric disorders, insomnia, worry, and rumination. Wilcoxon Signed Rank Tests revealed a significant change in outcome from pre- to post-treatment for HADS-A and worry, which was maintained at 6-months follow-up, and HADS-D significantly decreased from pre-treatment to 6-months follow up. Conclusions ATT in a group format appears to be a feasible stand-alone metacognitive treatment for CHD patients with significant symptoms of anxiety or depression. Based on these preliminary results, we believe that an adequately powered randomised controlled trial is now warranted.

The attention training technique (ATT) component of metacognitive therapy seeks to reduce anxiety and strengthen executive attention. ATT has the potential to expand mental health service delivery, with researchers labeling ATT as a possible form of eHealth. However, the only known published study to examine ATT in that delivery capacity was not supportive of its use. The current pilot study examined a new 4-week eHealth-based protocol of ATT among a small mixed sample of patients with anxiety disorders (N = 16). Patients attended a single in-person session to practice ATT and then practiced ATT remotely by accessing a standardized recording of ATT through the Internet for 4 weeks. There was no attrition and over 80% of patients achieved the practice benchmark. Improvements were noted across clinician-rated, patient-rated, and performance-based outcomes. Results support further examination of ATT as a possible eHealth treatment for anxiety disorders. Recommendations for future research are discussed.

The Attention Training Technique (ATT) is a psychotherapeutic intervention in Metacogntive Therapy (MCT) and aims at reducing maladaptive processes by strengthening attentional flexibility. ATT has demonstrated efficacy in treating depression on a clinical level. Here, we evaluated ATT at the neural level. We examined functional connectivity (FC) of the default mode network (DMN). 48 individuals diagnosed with Major Depressive Disorder (MDD) and 51 healthy controls (HC) participated in a resting-state (rs) functional magnetic resonance imaging (fMRI) experiment. The participants received either one week of ATT or a sham intervention. Rs-fMRI scans before and after treatment were compared using seed-to-voxel analysis. The 2x2x2 analysis did not reach significance. Nevertheless, a resting-state connectivity effect was found on the basis of a posttest at the second measurement time point in MDD. After one week, MDD patients who had received ATT intervention presented lower functional connectivity between the left posterior cingulate cortex (PCC) and the bilateral middle frontal gyrus (MFG) as well as between the right PCC and the left MFG compared to the MDD patients in the sham group. In HC we observed higher rsFC in spatially close but not the same brain regions under the same experimental condition. We found a first hint of a change at the neural level on the basis of ATT. Whether the changes in rsFC found here indicate an improvement in the flexible shift of attentional focus due to ATT needs to be investigated in further research paradigms. Further experiments have to show whether this change in functional connectivity can be used as a specific outcome measure of ATT treatment.

BackgroundThis study tested whether the combination of BATD and Attention Training Technique (ATT) is effective to reduce depressive symptomatology and investigate the mechanisms of action underlying the effectiveness of treatment with a multiple N-of-1 trials.MethodsNine adults with depressive symptoms were randomly included in three different combinations of BATD and ATT, concurrent in Condition 1 and sequential in Conditions 2 and 3 (ATT followed by BATD and BATD followed by ATT, respectively). The sequential components allow investigating the specific changes that occur during the two distinct treatment phases. Multiple self-report and pre–post-assessments were conducted on generic mental health measures (depressive symptoms, life functioning, mood, and well-being) and intervention-specific measures (behavioral activation, behavioral avoidance, self-focused attention, cognitive control and rumination), with two-week and three-month follow-up assessments. We also measured treatment adherence with treatment attendance, homework compliance and a clinical interview.ResultsParticipants’ attendance, homework compliance and satisfaction were acceptable in the three conditions, with higher adherence in Condition 1 and Condition 3. Eight participants out of nine reported a reduction in depressive symptomatology and five an improvement in well-being. Most of their progress was maintained 2 weeks after the intervention but not 3 months later. Conditions 1 and 2 seemed to be associated with a higher response to generic mental health measures in comparison with Condition 3. The three conditions were not associated with consistent changes in intervention-specific measures, except for rumination with five participants out of nine reporting an improvement in rumination immediately after the intervention and eight participants 2 weeks after the intervention. The concurrent format was associated with a better improvement in rumination immediately after the intervention. No specific changes of self-focused attention and rumination characterized ATT, and no specific changes of behavioral activation, behavioral avoidance and rumination characterized BATD.ConclusionOur three interventions were judged acceptable and showed positive short-term benefit for generic mental health measures and rumination maintained 2 weeks later, but not 3 months later. Results suggest that five sessions of concurrent treatment could be a better option than sequential formats. However, our data did not support the specificity of ATT and BATD treatments.Clinical Trial Registration: This trial was previously registered with the ClinicalTrials.gov NCT04595539 registration number and the title “Does Attention Training Technique Enhance the Effectiveness of Behavioral Activation Treatment for Depression: A Multiple Baseline Study.”

Metacognitive therapy and one of its treatment components, the attention training technique, are increasingly being delivered to improve mental health. We examined the efficacy of metacognitive therapy and/or attention training technique on mental health outcomes from single-case studies. A total of 14 studies (53 patients) were included. We used the d-statistic for multiple baseline data and the percentage change index to compute the effect sizes. Metacognitive therapy has a large effect on depression, anxiety, other psychopathological symptoms, and all outcomes together. Effect sizes were significantly moderated by the number of sessions, the severity and duration of symptoms, and patient gender, but not by study quality or attention training technique when used as a stand-alone treatment. At the follow-up, 77.36% of the individuals were considered recovered or had maintained improvement. Metacognitive therapy and attention training technique strongly contribute to improving mental health outcomes. This study effectively informs evidence-based practice in the clinical milieu.

A 41-year-old female with schizo-affective disorder presenting with an eight-year history of auditory hallucinations participated in a single case treatment study (A-B-A-B-A-C-B) of the effects of the Attention Training Technique (ATT). No antipsychotic medication was prescribed in this case following a serious adverse reaction in the past. The aim of the study was to test the impact of ATT on the frequency and duration of hallucinations using a repeated return to baseline followed by an alternating treatment design. The alternative intervention consisted of autogenic relaxation instructions. The patient monitored the frequency, duration, and her distress over the voices on a daily basis during baseline and intervention phases across a study period of 80 weeks. Visual analysis of the data showed that ATT when introduced at three phases following baselines or control conditions was associated with a reduction in auditory hallucination frequency and duration compared to the other phases. This contrasted with the autogenic relaxation intervention that was associated with an increase in duration and frequency of voices. The perceived benefits of ATT were maintained for varying periods of time.

Affective Network Hyperconnectivity and Hypoconnectivity of Cognitive Control and Ventral Attention Networks in Adults with High Neuroticism Scores

The metacognitive model and recent preliminary research suggests that metacognitive beliefs (i.e., beliefs about thinking) may be particularly important for understanding the pathogenesis of posttraumatic stress (PTS). The metacognitive model also suggests that deficits in executive control (i.e., metacognitive control) may increase the impact of metacognitive beliefs on PTS symptoms. Trauma-exposed adult participants (N = 469), recruited through an online crowdsourcing website, completed a battery of measures assessing the constructs of interest. As predicted, deficits in executive control strengthened the positive association between metacognitive beliefs and PTS symptoms. This effect was found in relation to positive (e.g., “Worrying will keep me safe”), but not negative (e.g., “My thoughts are uncontrollable”), metacognitive beliefs. Supplemental analyses, indicated that the interaction between positive metacognitive beliefs and executive control significantly predicted all PTS cluster scores (i.e., Intrusion, Cognition, Arousal, Avoidance). Taken together, results support the proposal that executive control deficits potentiate the effect of metacognitive beliefs on PTS symptoms. Intervention strategies designed to strengthen executive control (e.g., the attention training technique) may be useful in treating individuals with PTS.

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A randomized experimental analysis of the attention training technique: Effects on worry and relevant processes in individuals with probable generalized anxiety disorder