Attention Bias Modification Treatment Research Articles

Attention Training Program May Improve Social Anxiety Symptoms

Attention Training Program May Improve Social Anxiety Symptoms

Attention Bias Modification Treatment Versus a Selective Serotonin Reuptake Inhibitor Or Waiting List Control for Social Anxiety Disorder: A Randomized Clinical Trial.

Social anxiety disorder is common and impairing. The efficacy of pharmacotherapy is moderate, highlighting the need for alternative therapies. This study compared the efficacy of gaze-contingent music reward therapy (GC-MRT), an eye-tracking-based attention bias modification treatment, with a selective serotonin reuptake inhibitor (SSRI) treatment or a waiting list control condition in reducing social anxiety disorder symptoms. Superior clinical effects of similar magnitude were expected for the active treatments relative to the control condition. Participants were 105 treatment-seeking adults with social anxiety disorder, randomly allocated to 12 weeks of GC-MRT, SSRI, or waiting list control. Mean changes in clinician-rated and self-reported social anxiety symptoms from baseline to mid- and posttreatment assessments were compared between groups using generalized estimating equations. Changes in attentional dwell time on threat were also examined. Analysis indicated a significant differential reduction in symptoms between groups. Patients in the GC-MRT and SSRI groups had lower social anxiety scores at the mid- and posttreatment assessments compared with patients in the waiting list group. The efficacy of the active treatments did not differ. Only patients in the GC-MRT group showed reduction in dwell time on threat from baseline to posttreatment assessment. Eye-tracking-based attention bias modification is an acceptable and effective treatment option for social anxiety disorder.

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.

Neuroplastic changes in anterior cingulate cortex gray matter volume and functional connectivity following attention bias modification in high trait anxious individuals

Attention bias modification (ABM) was developed to alleviate anxious symptoms by way of a reduction in anxiety-linked attentional bias to threat. Central to the rational of ABM is a learning-related reconfiguration of attentional biases. Yet, the neuroplastic changes in brain structure that underlie this learning are unresolved. The amygdala, anterior cingulate cortex, and lateral prefrontal cortex are part of a system linked to attentional bias to threat and its modification with ABM. We assessed the extent to which ABM modulates gray matter volume and resting-state functional connectivity. Sixty-one individuals selected for attentional bias to threat and heightened trait anxiety completed a 6-week multi-session ABM protocol with 7200 total training trials. Participants were assigned to either an ABM (n = 30) or a control (n = 31) condition. We found that participants’ levels of attentional bias and anxiety did not differ following ABM and control training interventions. However, the ABM group displayed greater levels of anterior cingulate cortex gray matter volume as well as greater superior frontal gyrus resting-state functional connectivity with the anterior cingulate cortex and insula. Changes in anterior cingulate cortex gray matter volume were linked to reduced anxious symptoms in the ABM, but not control, group. These findings suggest that ABM distinctively impacts structural and functional neural mechanisms associated with emotion reactivity and cognitive control processes.

Attention Bias Modification Treatment (ABM) vs Selective Serotonin Reuptake Inhibitors (SSRI) and Waitlist Control for Social Anxiety Disorder: A Randomized Clinical Trial

Attention Bias Modification Treatment (ABM) vs Selective Serotonin Reuptake Inhibitors (SSRI) and Waitlist Control for Social Anxiety Disorder: A Randomized Clinical Trial

Increasing cognitive load attenuates the moderating effect of attentional inhibition on the relationship between posttraumatic stress symptoms and threat-related attention bias variability

Theory and empirical evidence suggest that those with higher posttraumatic stress (PTS) symptoms and better attentional control (i.e., the strategic control of higher-order executive attention in regulating bottom-up, stimulus driven responses to prepotent stimuli; Sarapas et al., 2017) can use that ability to disengage and shift attention away from threat stimuli and reduce threat-related attentional dysregulation (i.e., avoidance/overcontrollers). Those with relatively worse attentional control lack the requisite resources to do this, leading to prolonged attentional engagement with threat stimuli and threat-related attention dysregulation (i.e., maintenance/undercontrollers). Given that attentional control is a limited resource, strategic avoidance of threat information or reduced threat-related attention dysregulation may not be possible among those with relatively higher attentional control when cognitive load is relatively high. To test this hypothesis, the interaction between PTS symptoms, attentional control, and cognitive load was examined as a predictor of threat-related attentional bias and threat-related attention bias variability. Participants (N = 125 undergraduate students) were randomly assigned to high or low load conditions. Participants completed self-report measures of PTS symptoms, a behavioral measure of attentional control, and a novel task that assessed threat-related attentional bias via eye movements and threat-related attention bias variability via button press. The results of a series of hierarchical regressions showed that attentional control moderated the relationship between PTS symptoms and threat-related attention bias variability in the low, but not high, load condition. This moderation effect was not observed for threat-related attentional bias assessed via eye-tracking. Consistent with theory, under conditions of higher cognitive load, overcontrollers may not be able to use attentional control to consistently regulate threat-related attention. Study findings suggest that it may be important to consider contextual factors that increase cognitive load, as well as individual differences in attentional control, when developing attention bias modification interventions to reduce PTS symptomatology.

Can compassion-focused imagery be used as an attention bias modification treatment?

Compassion focused-imagery (CFI), one of the psychological interventions of compassion-focused therapy, is receiving increasing attention. It is a therapeutic tool that targets the process of self-criticism by prompting individuals to imagine themselves as compassionate or to imagine receiving compassion from an ideal compassionate other. This research examines the role of self-criticism in the attentional processing of emotional stimuli, namely, critical and compassionate facial expressions. It is hypothesized that the activation of positive social emotions through CFI plays a role in broadening attention in the processing of emotional stimuli. The McEwan Faces stimulus set, which includes critical, neutral and compassionate faces, was used to create an attentional bias task called the dot probe task. The processing of emotional faces was assessed before and after exposure to either CFI or neutral imagery, controlling for the process of sensory integration (n = 80). A between-subject analysis was used to test the hypothesis. Before the imagery task, participants tended to look away from critical faces, and their level of self-criticism played a role. Both types of imagery significantly reduced the bias away from critical faces when the stimuli were presented for 1200 ms. This effect was reversed in the neutral condition for participants with high levels of self-criticism but not in the CFI condition. Interestingly, self-criticism impacts the attentional treatment of critical faces and the effect of imagery entailing sensory integration on this treatment. CFI seems to preserve this effect for participants with high levels of self-criticism, possibly due to the activation of positive social emotions.

Computational modelling of attentional bias towards threat in paediatric anxiety

Computational modelling can be used to precisely characterize the cognitive processes involved in attentional biases towards threat, yet so far has only been applied in the context of adult anxiety. Furthermore, studies investigating attentional biases in childhood anxiety have largely used tasks that conflate automatic and controlled attentional processes. By using a perceptual load paradigm, we separately investigate contributions from automatic and controlled processes to attentional biases towards negative stimuli and their association with paediatric anxiety. We also use computational modelling to investigate these mechanisms in children for the first time. In a sample of 60 children (aged 5‐11 years) we used a perceptual load task specifically adapted for children, in order to investigate attentional biases towards fearful (compared with happy and neutral) faces. Outcome measures were reaction time and percentage accuracy. We applied a drift diffusion model to investigate the precise cognitive mechanisms involved. The load effect was associated with significant differences in response time, accuracy and the diffusion modelling parameters drift rate and extra‐decisional time. Greater anxiety was associated with greater accuracy and the diffusion modelling parameter ‘drift rate’ on the fearful face trials. This was specific to the high load condition. These findings suggest that attentional biases towards fearful faces in childhood anxiety are driven by increased perceptual sensitivity towards fear in automatic attentional systems. Our findings from computational modelling suggest that current attention bias modification treatments should target perceptual encoding directly rather than processes occurring afterwards.

Time course of pupillary response to threat words before and after attention bias modification for transdiagnostic anxiety disorders: A randomized controlled trial.

IntroductionAltered attention to threatening stimuli at initial and sustained stages of processing may be dissociable dimensions that influence the development and maintenance of transdiagnostic symptoms of anxiety, such as vigilance, and possibly require distinct intervention. Attention bias modification (ABM) interventions were created to implicitly train attention away from threatening stimuli and have shown efficacy in treating anxiety. ABM alters neurocognitive functioning during initial stages of threat processing, but less is known regarding effects of ABM on neural indices of threat processing at sustained (i.e., intermediate and late) stages, or if ABM‐related neural changes relate to symptom response. The current study utilized pupillary response as a temporally sensitive and cost‐effective peripheral marker of neurocognitive response to ABM.Materials and MethodsIn a randomized controlled trial, 79 patients with transdiagnostic anxiety provided baseline data, 70 were randomized to receive eight sessions of twice‐weekly ABM (n = 49) or sham training (n = 21), and 65 completed their assigned treatment condition and returned for post‐training assessment.ResultsAmong ABM, but not sham, patients, pupillary response to threat words during initial and intermediate stages decreased from pre‐ to post‐training. Pre‐ to post‐training reductions in intermediate and late pupillary response to threat were positively correlated with reductions in patient‐reported vigilance among ABM, but not sham, patients.ConclusionsAll measured stages of threat processing had relevance in understanding the neural mechanisms of ABM, with overlapping yet dissociable roles exhibited within a single neurophysiological marker across an initial–intermediate–late time continuum. Pupillometry may be well suited to measure both target engagement and treatment outcome following ABM.

Time Course and Neural Underpinnings of Pupillary Response to Threat Words Before and After Attention Bias Modification for Transdiagnostic Anxiety Disorders: A Randomized Controlled Trial

Altered attention to threatening stimuli at initial and sustained stages of processing are thought to be dissociable dimensions that underlie anxiety disorders and possibly require distinct intervention. Attention Bias Modification (ABM) interventions implicitly train attention away from threatening stimuli and show efficacy in treating anxiety. ABM alters neurocognitive functioning during initial stages of threat processing, but less is known regarding ABM effects at sustained (i.e., intermediate and late) processing stages, or if ABM-related neural changes relate to symptom response.

What Drives Symptom Reduction in Attention Bias Modification Treatment? A Randomized Controlled Experiment in Clinically Anxious Youths

Attention-bias modification (ABM) is a novel treatment for anxiety disorders. We tested the contribution of two possible factors implicated in ABM’s efficacy: training of threat-related selective spatial attention and exposure to threat. We also measured general attention control to examine its potential role in treatment effects. A four-arm randomized controlled design was used, which dissociated spatial attention and threat exposure while equating treatment expectancies. One hundred clinically anxious youths were randomized and assessed at pretreatment, midtreatment, posttreatment, and 3-month follow-up. All four groups manifested large reductions in anxiety symptoms; there were no significant between-group differences. Level of change in anxiety symptoms significantly correlated with level of change in youths’ self-rated attention control. Findings did not support the role of either dissociated spatial attention or threat exposure as underlying mechanisms. Implications of the findings are discussed including possible roles of expectations and general attention control in ABM efficacy.

Gamified M-Health Attention Bias Modification Intervention for Individuals with Opioid Use Disorder: Protocol for a Pilot Randomised Study.

Introduction: Globally, there is an epidemic of opioid use disorders. Locally, in Singapore, there is an increase in the number of individuals abusing opioids. The advances in experimental psychology have highlighted the need to modify unconscious, automatic biases. These automatic, unconscious biases result in individuals having preferential attention to substance-related cues in their natural environment, thus leading to a slip or relapse back into their underlying addictive disorders. Prior studies have demonstrated not only the presence of robust attentional biases amongst individuals with opioid use disorder, even when maintained on methadone; and the effectiveness of bias modification amongst these individuals. There remains limited evaluation of attention bias modification amongst a treatment-seeking cohort of Asian individuals. The objective of this pilot is to ensure that the methods of the planned definitive randomized trial could be conducted. Methods and Analysis: A non-blinded pilot randomized trial will be conducted. A total of 30 participants will be randomized to receive either the conventional application or the newly designed co-designed application. In order to identify these 30 participants, 60 participants will be recruited and screened to determine if they have baseline biases. Participants will be recruited from the inpatient unit at the National Addictions Management Service (NAMS) Singapore. All participants who are enrolled into the trial will complete a baseline assessment task, and a bias modification assessment and modification task daily. They will have to complete a baseline demographic and clinical information questionnaire, as well as a cravings rating scale before and after the intervention daily. Perspectives—that of self-reported experiences—will be sought from the participants following their completion of three intervention tasks. Descriptive statistical analyses will be performed, and chi-square and ANOVA analyses will be performed. Qualitative analyses will be undertaken for the perspectives shared. Ethics and Dissemination: Ethical approval has been obtained from the National Healthcare Group’s Domain Specific Research Board (DSRB) (approval number that of 2019/00934). The findings arising from this study will be disseminated by means of conferences and publications.

Клинические случаи курсового применения транскраниальной микрополяризации как поддерживающей стратегии при терапии модификации искаженного внимания у подростков

This article presents the results of a case series to assess the feasibility, acceptability, and clinical promise of transcranial Direct Current Stimulation (tDCS) as an augmentation strategy in clinic referred adolescents. Attention Bias Modification Treatment (ABMT) is a computer-based attention-training protocol designed to reduce rapidly deployed attention orienting to threat and thereby reduce anxiety symptom severity. Studies of ABMT reveal overall small to medium effect sizes. Advances in the neural underpinnings of attention to threat and attention-training protocols suggest the potential of tDCS of the dorsolateral prefrontal cortex (dlPFC) as a novel augmentation strategy to enhance ABMT’s efficacy (ABMT + tDCS). However, tDCS has never been tested in a sample of adolescents with anxiety disorders. Six adolescents with a primary anxiety disorder completed all four ABMT + tDCS sessions. Adverse effects were mild and transient. Adolescents and parents independently reported fair to excellent levels of satisfaction. Impairment ratings of the primary anxiety disorder significantly decreased. Further, electrophysiological data recorded via electroencephalography (EEG) suggested decreases in neural resources allocated to threat. These findings support the feasibility, acceptability, and clinical promise of tDCS as an augmentation strategy in adolescents with anxiety disorders, and provide the impetus for further investigation using randomized controlled designs in larger samples.

Development of a co-designed gamified attention bias modification app for individuals with opioid use disorder.

The advances in experimental psychology in the last decade have led to a greater understanding of cognitive bias, and the investigation of cognitive bias modifications as a therapeutic option. Whilst conventionally such interventions are delivered in a laboratory, technological advances are changing the potential modes of delivery of these interventions. Whereas mobile delivery of interventions might seem to increase accessibility and encourage compliance, this might not be the case for cognitive bias modification interventions. To reduce boredom, researchers have investigated whether gamification of the task could help reduce repetitiveness, and the diminished motivation that participants had over time. In a prior review of cognitive bias modification interventions, a collaboration between academics and developers was recommended to ensure that the developed product is evidence-based. With the increased recognition of the importance of participatory action research, participants could better help conventional intervention to meet their needs. The aim of this article was to describe the iterative steps in the conceptualization of the co-designed gamified cognitive bias modification intervention for individuals with opioid use disorders. A multidisciplinary team worked through the differences in the perspectives offered by healthcare professionals and patient participants, and jointly worked with a developer to conceptualize a new co-designed gamified attention bias modification intervention. The methods shared in this article could be considered and applied to future conceptualization of co-designed interventions.

Making Sense of Negative Findings from Mobile Attention Bias Modification Interventions for Individuals with Addictive Disorders: Quantitative Feasibility Study.

BackgroundAdvances in experimental psychology have led to a better understanding of unconscious, automatic processes that result in individuals relapsing into their substance-using habits. While some reviews have demonstrated the effectiveness of bias retraining of these unconscious biases, there have been other reviews that have highlighted that bias retraining is not always effective. Other studies have revealed there was no baseline biases among some participants. An examination of mobile bias retraining interventions has also revealed mixed results, with some reporting effectiveness and others null findings. A recent feasibility and acceptability study, done by the authors, revealed that 53% of participants have had no baseline biases and 21% of those with positive baseline biases did not have a positive change in magnitude following intervention.ObjectiveThe aim of this paper was to explore potential variables (demographic and clinical) that could account for the negative baseline biases in the prior feasibility and acceptability study, and to discuss some of the factors that could account for the absence of baseline biases. We also explored potential reasons for why there was no reduction in the magnitude of attentional biases among individuals with baseline biases.MethodsParticipants who were in the rehabilitation phase of their treatment were invited to participate. During the study they had to complete a set of baseline questionnaires, and on each day that they were on the ward they had to complete an attention bias assessment and modification task and rate their cravings using a visual analogue scale. Attention bias was deemed to be present if individuals had a positive score.ResultsIn our study, 53% (16/30) of individuals did not present with baseline attentional biases, and among those with positive baseline biases a total of 21% (3/14) of participants did not have a reduction in the overall magnitude of attentional biases. Chi-square analyses undertaken to compare the demographic characteristics of participants with and without baseline biases did not reveal any significant findings. However, with respect to clinical characteristics, those who had positive baseline biases had experimented with more substances.ConclusionsOur study is one of the first to have explored negative findings in attention bias modification interventions for individuals with addictive disorders. We postulate that several factors could account for the absence of baseline biases and there being no changes following bias retraining. Future research ought to take into consideration these factors.

Co-designing a Mobile Gamified Attention Bias Modification Intervention for Substance Use Disorders: Participatory Research Study.

BackgroundAdvances in experimental psychology have highlighted the need to modify underlying automatic cognitive biases, such as attentional biases. The effectiveness of bias modification has been well studied for substance use disorders. With recent advances in technology, it is now possible to work outside the laboratory with Web-based and mobile-based attention bias interventions. Gamification technologies might also help diminish the repetitiveness of the task and increase the intrinsic motivation to train. The inconsistent findings of the impact of gaming on the effectiveness of mobile interventions call for further work to better understand the needs of patients (users) and health care professionals.ObjectiveThe aim of this study was to involve patients, together with health care professionals, in the design of a gamified mobile attention bias modification intervention for substance use disorders.MethodsThe participatory design research method adopted is that of a user-oriented design approach in the form of a future workshop. In the first phase of the workshop, participants shared their critique of an attention bias modification intervention. In the second phase of the workshop, participants were asked to brainstorm features. Participants were also shown gamification approaches and asked to consider if gaming elements could enhance the existing app. In the last phase, participants were asked to sketch a new prototype.ResultsThree co-design workshops were conducted with health care professionals, inpatients, and outpatients. There were 20 participants, consisting of 10 health care professionals and 10 patients. When asked to identify the limitations in the existing app, common issues identified were those of the design, visual probe task, and the included images. Outpatients were also concerned with the safety of administration of the intervention. In the brainstorming sessions, health care professionals made recommendations as to how the stimulus, the mechanism of responding, and the presentation of the scores could be enhanced. Inpatient participants recommended the addition of functionalities, such as information on the harms associated with the substance use, and for there to be enhancements in the design, images, and task. Outpatient participants perceived a need to improve the images and presentation of the results and recommended the inclusion of gaming features. There were differences in opinion on the inclusion of gaming features, as only health care professionals endorsed their inclusion. In the last phase of the workshop, participants were tasked with the conceptualization of prototypes, and the commonality in the design was for a gradual shortening of the interval for stimulus/image presentation.ConclusionsThe results from this research will guide the development of an app that meets the specific needs of patients and is still based on a pre-existing validated task paradigm.

Codesigning a mobile gamified attention bias modification intervention: research protocol

IntroductionAdvances in experimental psychology has highlighted the need to modify underlying automatic cognitive biases, such as attentional biases. While prior research has documented the effectiveness of cognitive bias modification, such...

A Smartphone Attention Bias App for Individuals With Addictive Disorders: Feasibility and Acceptability Study.

BackgroundConventional psychology therapies are unable to address automatic biases that result in individuals relapsing into their substance use disorder. Advances in experimental psychology have led to a better understanding of attention and approach biases and methods to modify these biases. Several studies have demonstrated the effectiveness of bias modification among clinical cohorts. The advances in mobile health technologies have allowed remote delivery of these interventions. To date, there is a lack of studies examining bias modification in a substance-using non-Western sample.ObjectiveThis study was designed to determine the feasibility of an attention bias modification intervention and an attention bias modification smartphone app for the reduction of attention biases among treatment-seeking individuals. The secondary aim is to determine the acceptability of the intervention.MethodsA feasibility study was conducted among inpatients who were in their rehabilitation phase at the National Addictions Management Service. Participants were to complete a set of baseline questionnaires, and on each day that they are in the study, undertake an attention bias assessment and modification task while completing a visual analogue scale to assess their craving. Feasibility was determined by the acceptance rate of participation and participants’ adherence to the interventions. Acceptability was assessed by a perception questionnaire. Descriptive statistical analyses were performed using SPSS version 22. A thematic analysis approach was used in the qualitative synthesis of users’ perceptions.ResultsOf the 40 participants invited to participate in the feasibility study, 10 declined, yielding an acceptance rate of 75%. Of the recruited participants, 6 participants were diagnosed with alcohol dependence; 17, with opioid dependence; 2, with cannabis dependence; and 5, with stimulant dependence. In addition, of the final 30 participants, 11 (37%) failed to complete all the planned interventions and 22 (73%) completed the perspective questionnaires; of these 22 participants, 100% rated the app as extremely and very easy, 77% rated it as extremely or very interactive, 54% rated it as extremely or very motivating, and 33% reported a change in their confidence levels.ConclusionsOur results highlight the feasibility of recruiting participants to undertake attention bias modification interventions. Participants generally accept use of a mobile version of such an intervention. Nevertheless, our acceptability data indicate that there could be improvements in the existing app, and a participatory design approach might be helpful in its future conceptualization.International Registered Report Identifier (IRRID)RR2-10.2196/11822

Attention Bias Modification Treatment for Young Adults With Major Depressive Disorder

Attention Bias Modification Treatment for Young Adults With Major Depressive Disorder

A Randomized Controlled Trial of Attention Bias Modification Treatment in Youth With Treatment-Resistant Anxiety Disorders.

Randomized clinical trials of augmentation strategies for youth with treatment-resistant anxiety disorders do not exist. This report presents findings from an efficacy trial of attention bias modification treatment (ABMT) as an augment for this population compared with attention control training (ACT). Sixty-four youths (34 boys; mean age 11.7 years) who continued to meet for anxiety diagnoses after completing cognitive-behavioral therapy were randomized to ABMT or ACT. ABMT and ACT consisted of dot-probe attention training trials presenting angry and neutral faces; probes appeared in the location of neutral faces on 100% of trials in ABMT and 50% of trials in ACT. Independent evaluators, youths, and parents completed ratings of youth anxiety severity, and youths completed measures of attention bias to threat and attention control at pretreatment, post-treatment, and 2-month follow-up. The 2 arms showed significant decreases in anxiety severity, with no differences between arms. Specifically, across informants, anxiety severity was significantly decreased at post-treatment and decreases were maintained at follow-up. Primary anxiety disorder diagnostic recovery combined across arms was 50% at post-treatment and 58% at follow-up. Attention control, but not attention bias to threat, was significantly improved at post-treatment in the 2 arms. This is the first study to show anxiety can be decreased in youth who did not respond to cognitive-behaviorial therapy, and that the anxiety-decreasing effect is found using these 2 attention training contingency schedules. These findings and increases in attention control in the 2 arms raise intriguing questions about mechanisms of decreasing anxiety in treatment-resistant youth with attention training that require further research. Attention Bias Modification Training for Child Anxiety CBT Nonresponders; https://clinicaltrials.gov/; NCT01819311.