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Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial

  • I. Wald (a1), E. Fruchter (a2), K. Ginat (a2), E. Stolin (a2), D. Dagan (a2), P. D. Bliese (a3), P. J. Quartana (a4), M. L. Sipos (a4), D. S. Pine (a5) and Y. Bar-Haim (a1) (a6)...



Efficacy of pre-trauma prevention for post-traumatic stress disorder (PTSD) has not yet been established in a randomized controlled trial. Attention bias modification training (ABMT), a computerized intervention, is thought to mitigate stress-related symptoms by targeting disruptions in threat monitoring. We examined the efficacy of ABMT delivered before combat in mitigating risk for PTSD following combat.


We conducted a double-blind, four-arm randomized controlled trial of 719 infantry soldiers to compare the efficacy of eight sessions of ABMT (n = 179), four sessions of ABMT (n = 184), four sessions of attention control training (ACT; n = 180), or no-training control (n = 176). Outcome symptoms were measured at baseline, 6-month follow-up, 10 days following combat exposure, and 4 months following combat. Primary outcome was PTSD prevalence 4 months post-combat determined in a clinical interview using the Clinician-Administered PTSD Scale. Secondary outcomes were self-reported PTSD and depression symptoms, collected at all four assessments.


PTSD prevalence 4 months post-combat was 7.8% in the no-training control group, 6.7% with eight-session ABMT, 2.6% with four-session ABMT, and 5% with ACT. Four sessions of ABMT reduced risk for PTSD relative to the no-training condition (odds ratio 3.13, 95% confidence interval 1.01–9.22, p < 0.05, number needed to treat = 19.2). No other between-group differences were found. The results were consistent across a variety of analytic techniques and data imputation approaches.


Four sessions of ABMT, delivered prior to combat deployment, mitigated PTSD risk following combat exposure. Given its low cost and high scalability potential, and observed number needed to treat, research into larger-scale applications is warranted. The identifier is NCT01723215.


Corresponding author

*Address for correspondence: I. Wald, Ph.D., School of Psychological Sciences, Tel Aviv University, Tel Aviv 69978, Israel. (Email:


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Abend, R, Pine, DS, Fox, NA, Bar-Haim, Y (2014). Learning and memory consolidation processes of attention bias modification in anxious and non-anxious individuals. Clinical Psychological Science 2, 620627.
Adler, AB, Bliese, PD, McGurk, D, Hoge, CW, Castro, CA (2009). Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: randomization by platoon. Journal of Consulting and Clinical Psychology 77, 928940.
Agorastos, A, Marmar, CR, Otte, C (2011). Immediate and early behavioral interventions for the prevention of acute and posttraumatic stress disorder. Current Opinion in Psychiatry 24, 526532.
Badura-Brack, AS, Naim, R, Ryan, TJ, Levy, O, Abend, R, Khanna, MM, McDermott, TJ, Pine, DS, Bar-Haim, Y (2015). Effect of attention training on attention bias variability and PTSD symptoms: randomized controlled trials in Israeli and US combat veterans. American Journal of Psychiatry 172, 12331241.
Beevers, CG, Lee, HJ, Wells, TT, Ellis, AJ, Telch, MJ (2011). Eye gaze bias for emotion stimuli prospectively predicts PTSD and depression symptoms among soldiers deployed in Iraq. American Journal of Psychiatry 168, 735741.
Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Gusman, FD, Charney, DS, Keane, TM (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress 8, 7590.
Blanchard, EB, Jones-Alexander, J, Buckley, TC, Forneris, CA (1996). Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy 34, 669673.
Bradley, R, Greene, J, Russ, E, Dutra, L, Westen, D (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 162, 214227.
Britton, JC, Suway, JG, Clementi, MA, Fox, NA, Pine, DS, Bar-Haim, Y (2015). Neural changes associated with attention bias modification (ABM): implications for anxiety disorders. Social Cognitive and Affective Neuroscience 10, 913920.
Browning, M, Holmes, EA, Murphy, SE, Goodwin, GM, Harmer, CJ (2010). Lateral prefrontal cortex mediates the cognitive modification of attentional bias. Biological Psychiatry 67, 919925.
Eldar, S, Bar-Haim, Y (2010). Neural plasticity in response to attention training in anxiety. Psychological Medicine 40, 667677.
Feldner, MT, Monson, CM, Friedman, MJ (2007). A critical analysis of approaches to targeted PTSD prevention – current status and theoretically derived future directions. Behavior Modification 31, 80116.
Forneris, CA, Gartlehner, G, Brownley, KA, Gaynes, BN, Sonis, J, Coker-Schwimmer, E, Jonas, DE, Greenblatt, A, Wilkins, TM, Woodell, CL, Lohr, KN (2013). Interventions to prevent post-traumatic stress disorder: a systematic review. American Journal of Preventive Medicine 44, 635650.
Hoge, CW, Castro, CA, Messer, SC, McGurk, D, Cotting, DI, Koffman, RL (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351, 1322.
Iacoviello, BM, Wu, G, Abend, R, Murrough, JW, Feder, A, Fruchter, E, Levinstein, Y, Wald, I, Bailey, CR, Pine, DS, Neumeister, A, Bar-Haim, Y, Charney, DS (2014). Attention bias variability and symptoms of posttraumatic stress disorder. Journal of Traumatic Stress 27, 232239.
Kliem, S, Kroger, C (2013). Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling. Behaviour Research and Therapy 51, 753761.
Kroenke, K, Spitzer, RL, Williams, JB (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16, 606613.
Kuckertz, JM, Amir, N, Boffa, JW, Warren, CK, Rindt, SE, Norman, S, Ram, V, Ziajko, L, Webb-Murphy, J, McLay, R (2014). The effectiveness of an attention bias modification program as an adjunctive treatment for post-traumatic stress disorder. Behaviour Research and Therapy 63, 2535.
Ledoux, JE (2000). Emotion circuits in the brain. Annual Review of Neuroscience 23, 155184.
Linetzky, M, Pergamin-Hight, L, Pine, DS, Bar-Haim, Y (2015). Quantitative evaluation of the clinical efficacy of attention bias modification treatment for anxiety disorders. Depression and Anxiety 32, 383391.
MacLeod, C, Clarke, PJF (2015). The attentional bias modification approach to anxiety intervention. Clinical Psychological Science 3, 5878.
MacLeod, C, Grafton, B (2014). Regulation of emotion through modification of attention. In Handbook of Emotion Regulation, 2nd edn (ed. Gross, JJ), pp. 508528. Guilford Press: New York.
Monk, CS, Telzer, EH, Mogg, K, Bradley, BP, Mai, X, Louro, HM, Chen, G, McClure-Tone, EB, Ernst, M, Pine, DS (2008). Amygdala and ventrolateral prefrontal cortext activation to masked angry faces in children and adolescents with generalized anxiety disorder. Archives of General Psychiatry 65, 568576.
Naim, R, Abend, R, Wald, I, Eldar, S, Levi, O, Fruchter, E, Ginat, K, Halpern, P, Sipos, ML, Adler, AB (2015). Threat-related attention bias variability and posttraumatic stress. American Journal of Psychiatry 172, 12421250.
Pine, DS, Helfinstein, SM, Bar-Haim, Y, Nelson, E, Fox, NA (2009). Challenges in developing novel treatments for childhood disorders: lessons from research on anxiety. Neuropsychopharmacology 34, 213228.
Sipos, ML, Bar-HAIM, Y, Abend, R, Adler, AB, 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.
Skeffington, PM, Rees, CS, Kane, R (2013). The primary prevention of PTSD: a systematic review. Journal of Trauma and Dissociation 14, 404422.
Steenkamp, MM, Litz, BT (2013). Psychotherapy for military-related posttraumatic stress disorder: review of the evidence. Clinical Psychology Review 33, 4553.
Thomas, JL, Wilk, JE, Riviere, LA, Mcgurk, D, Castro, CA, Hoge, CW (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry 67, 614623.
Urbaniak, GC, Plous, S (2013). Research Randomizer (version 4.0) ( Accessed June 2013.
Wald, I, Bitton, S, Levi, O, Zusmanovich, S, Fruchter, E, Ginat, K, Charney, DS, Pine, DS, Bar-Haim, Y (2016). Acute delivery of attention bias modification training (ABMT) moderates the association between combat exposure and posttraumatic symptoms: a feasibility study. Biological Psychology. Published online 15 January 2016. doi:10.1016/j.biopsycho.2016.01.005.
Wald, I, Degnan, KA, Gorodetsky, E, Charney, DS, Fox, NA, Fruchter, E, Goldman, D, Lubin, G, Pine, DS, Bar-Haim, Y (2013). Attention to threats and combat-related posttraumatic stress symptoms: prospective associations and moderation by the serotonin transporter gene. JAMA Psychiatry 70, 401408.
Wald, I, Lubin, G, Holoshitz, Y, Muller, D, Fruchter, E, Pine, D, Charney, D, Bar-Haim, Y (2011). Battlefield-like stress following simulated combat and suppression of attention bias to threat. Psychological Medicine 41, 699707.
Weathers, FW, Ruscio, AM, Keane, TM (1999). Psychometric properties of nine scoring rules for the clinician-administered posttraumatic stress disorder scale. Psychological Assessment 11, 124133.
Zeger, SL, Liang, KY, Albert, PS (1988). Models for longitudinal data – a generalized estimating equation approach. Biometrics 44, 10491060.


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