Attention Bias Modification With Eye Tracking May Be Effective Intervention for SAD

Treatment for social anxiety disorder using eye tracking was found to be an effective approach.

An eye-tracking-based attention bias modification intervention was found to be an acceptable and effective treatment for social anxiety disorder (SAD). These results of a study were published in the American Journal of Psychiatry.

Patients (N=105) with SAD who were seeking treatment were recruited for this randomized clinical trial at Tel Aviv University in Israel. Patients were randomly assigned in a 1:1:1 ratio to receive gaze-contingent music reward therapy (GC-MRT; n=35), selective serotonin reuptake inhibitors (SSRI; n=35), or waitlist (n=35). The GC-MRT intervention was a 12-week protocol comprising one 45-minute informational session followed by ten 20-minute intervention sessions in which a selected music track played when the patient focused their gaze on neutral faces and stopped when they focused on threatening faces. The SSRI intervention comprised 12-week flexible-dose escitalopram treatment starting at 5 mg/day and increased to an average maximum dose of 11.6 mg/day plus 4 visits with a psychiatrist. The waitlist group received the GC-MRT intervention after a 12-week waiting period. The primary outcome was a change in the clinician-rated severity score using the Liebowitz Social Anxiety Scale (LSAS) instrument.

The 3 groups had a mean age of 30.51 to 30.83 years, 54.29% to 62.86% were men, and 28.57% to 45.71% had comorbid mild depressive episodes.

A total of 33 patients completed the GC-MRT intervention, among whom 29 attended all treatment sessions. A total of 25 patients completed the SSRI intervention, among whom 24 attended all sessions with the psychiatrist and 96% reported SSRI adherence. The SSRI group had higher attrition rates than the waitlist (χ2, 4.63; P =.031) or GC-MRT (χ2, 6.44; P =.011) cohorts.

 GC-MRT presents low demands on patients, is short-term, and requires minimally trained professionals, making it a viable treatment option.

Among the waitlist group, LSAS scores remained relatively stable from baseline (mean, 81.49 points) to midtreatment (mean 75.97 points) and posttreatment (mean, 74.03 points) whereas LSAS scores decreased from 80.03 points at baseline to 60.86 and 54.70 points at mid- and posttreatment among SSRI recipients and from 76.83 points at baseline to 59.00 and 56.78 points at mid- and posttreatment among the GC-MRT group, respectively. Overall, the proportion of patients that clinicians rated as much or very much improved was higher in the active interventions compared with controls (χ2, 11.08; P =.004).

Similar trends in self-rated Social Phobia Inventory (SPIN) scores were observed.

The GC-MRT intervention was superior at decreasing the time spent dwelling on threatening faces from baseline to posttreatment (45.29% vs 35.45%) compared with the SSRI (47.34% vs 44.37%) or waitlist (46.93% vs 46.21%) recipients, respectively. The change in dwell time on threat faces had significant time (χ2, 19.33; P <.001), group (χ2, 9.86; P =.007), and group-by-time interaction (χ2, 14.40; P =.006) effects.

Both the GC-MRT and SSRI recipients reported a high level of satisfaction (mean, 3.08 vs 3.19) and found treatment to be credible (mean, 8.00 vs 7.74), respectively.

This study may have been limited as the investigators speculated whether being on a waitlist was an appropriate control condition for either active treatment.

Study authors concluded, “GC-MRT presents low demands on patients, is short-term, and requires minimally trained professionals, making it a viable treatment option. SSRIs and GC-MRT may engage different mechanisms to reduce social anxiety symptoms, consistent with differential effects on comorbid depression. Hence, the 2 therapies may possess additive therapeutic value for social anxiety.”


Arad G, Azriel O, Pine DS, et al. Attention bias modification treatment versus a selective serotonin reuptake inhibitor or waiting list control for social anxiety disorder: a randomized clinical trial. Am J Psychiatry. 2023;appiajp20220533. doi:10.1176/appi.ajp.20220533