Modifying social anxiety related to a real-life stressor using online Cognitive Bias Modification for interpretation

Online cognitive bias modification for interpretation to reduce anxious thinking during the COVID-19 pandemic

Anxiety disorders are highly prevalent, and rates increased during the COVID-19 pandemic. However, most individuals with elevated anxiety do not access treatment due to barriers such as stigma, cost, and availability. Digital mental health programs, such as cognitive bias modification for interpretation (CBM-I), hold promise in increasing access to care. Before widely disseminating CBM-I, we must rigorously test its effectiveness and determine whom it is best positioned to benefit. The present study (which is a substudy of a parent trial) compared CBM-I against psychoeducation offered through the public website MindTrails, and also tested whether baseline anxiety tied to COVID-19 influenced the rate of change in anxiety and interpretation bias during and after each intervention. Adults with moderate-to-severe anxiety symptoms were randomly assigned to complete five sessions of either CBM-I or psychoeducation as part of a larger trial, and 608 enrolled in this substudy after Session 1. As predicted (https://osf.io/2dyzr), CBM-I was superior to psychoeducation at reducing anxiety symptoms (on the OASIS but not the DASS-21-AS: d = -0.31), reducing negative interpretation bias (d range = -0.34 to -0.43), and increasing positive interpretation bias (d = 0.79) by the end of treatment. Results also indicated that individuals higher (vs. lower) in baseline COVID-19 anxiety had stronger decreases in anxiety symptoms while receiving CBM-I but weaker decreases in anxiety symptoms (on the DASS-21-AS) while receiving psychoeducation. These findings suggest that CBM-I may be a useful anxiety-reduction tool for individuals experiencing higher anxiety tied to uncertain events such as the COVID-19 pandemic.

The role of interpretation biases and safety behaviours in social anxiety: an intensive longitudinal study

BACKGROUND

Interpretation bias and safety behaviours (Safe-B) have been proposed as factors perpetuating social anxiety (SA). However, longitudinal research on how they contribute to SA in everyday life is scarce.

AIM

The aim was to examine whether interpretation bias predicts daily Safe-B and SA. A mediated moderation was hypothesized, where the relationship between daily social stressors and Safe-B would be moderated by interpretation bias, and Safe-B, in turn, would mediate the association between stressors and SA levels. In addition, it was hypothesized that prior levels of SA would predict higher Safe-B use, especially in co-occurrence with stressors.

METHOD

An intensive longitudinal design was employed, with 138 vocational training students (51% men, mean age 20.15 years). They completed initial measures of SA and interpretation bias and 7-day diaries with measures of social stressors, Safe-B, and SA. They reported SA levels two months later.

RESULTS

Both stressors and interpretation bias in ambiguous situations predicted Safe-B, which in turn predicted daily SA levels. However, neither interpretation bias nor Safe-B predicted SA levels at the follow-up, and interpretation bias did not moderate the association between stressors and daily SA. In addition, the relationship between stressors and Safe-B was stronger in people with higher initial SA levels.

CONCLUSIONS

The results suggest that Safe-B are a mechanism through which earlier SA levels and interpretation bias contribute to higher SA levels in daily life.

The influence of outcome expectancy on interpretation bias training in social anxiety: an experimental pilot study

BACKGROUND

Cognitive bias modification for interpretation (CBM-I) trainings have shown positive effects on interpretation bias in both active interpretation bias training conditions and structurally similar control conditions. Outcome expectations have been suggested to contribute to these placebo effects. The goal of this pilot experimental study was to test the feasibility of positive expectancy induction, to gain preliminary insight into whether this has implications for the efficacy of CBM-I training, and to assess the feasibility of recruitment and the overall study design.

METHODS

Socially anxious individuals aged 18 years and older received a single session (approx. 45 min) of either CBM-I or placebo training preceded by either a positive expectancy induction or no expectancy induction. We first tested whether the expectancy induction had modified participants' expectations of training. We then explored the effects of CBM-I training and expectancy induction on interpretation bias. Finally, we assessed the feasibility of recruitment and further study procedures.

RESULTS

Due to pandemic-related difficulties, fewer participants were recruited than initially planned. Thirty-four (22 females and 12 males) participants were randomly assigned to one of four conditions (interpretation bias training + high expectancy = 10, interpretation bias training + no expectancy = 8, placebo training + high expectancy = 11, placebo training + no expectancy = 5). Participants in the positive expectancy condition had more positive expectations of the training (CBM-I or placebo) than participants in the no expectancy condition. We were unable to conduct the planned 2 × 2 × 2 analysis of interpretation bias due to the small sample size. When looking at these groups individually, we found that participants in the active training condition and participants in the high expectancy condition showed increases in positive interpretation bias and decreases in negative interpretation bias from pre- to post-training, while participants in the placebo and no expectancy conditions showed no change.

CONCLUSIONS

These findings suggest that the expectancy manipulation utilized in this study may be adopted by future studies which investigate outcome expectations as an unspecific mechanism of CBM-I. Preliminary analyses suggest that participants' expectations are likely to play a role in the effect of CBM-I training, although these effects require replication in a larger sample. Several observations about the study feasibility were made which could inform future trials.

TRIAL REGISTRATION

Retrospectively registered on the August 23, 2022, through the German Clinical Trials Register ( DRKS00029768 ).

The effects of challenge and threat states on coping flexibility: evidence from framing and exemplar priming

BACKGROUND AND OBJECTIVES

Challenge and threat states have divergent effects on cognitive, affective, and behavioral responses. The present research used two experiments to investigate whether challenge and threat states influence coping flexibility differently.

DESIGN

Study 1 (N = 93) used loss-framed and gain-framed task instructions to elicit situation-specific threat and challenge evaluations, respectively, with a Null condition as a control. Study 2 (N = 86) used an online single-session Cognitive Bias Modification for Interpretation (CBM-I) paradigm to present participants with exemplars related to either positive or negative resolutions of stressful situations to engender a stress-is-a-challenge or stress-is-a-threat mindset, with a mixed condition as a control.

RESULTS

Loss-framed task instruction generated situation-specific threat evaluation, debilitated effective attention, and reduced positive affect, without altering coping flexibility measured in other scenarios. CBM-I engendered a stress-is-a-challenge mindset and maintained positive affect and coping flexibility, whereas the negative and mixed groups decreased coping flexibility. A stress-is-a-challenge mindset was positively associated with coping flexibility prior to and after exemplar priming.

CONCLUSIONS

Findings enrich the literature on stress coping and shed light on future practice by illustrating the different effects of framing and CBM-I on challenge/threat situation-specific evaluation and stress mindset, and the positive relation of stress-is-a-challenge mindset to coping flexibility.

Positive Interpretation Bias Predicts Longitudinal Decreases in Social Anxiety

Theoretical models of social anxiety suggest that distorted interpretation processes contribute to its development and maintenance, although the pathways through which this occurs are not well understood. Therefore, the present longitudinal study sought to determine whether negative interpretation bias, positive interpretation bias, and interpretation inflexibility (the degree to which participants correctly revise initial interpretations) predict changes in social anxiety over time. In an important advance over prior studies, individual differences in working memory capacity (WMC) were accounted for, as WMC is thought to play a crucial role in the generation and maintenance of interpretation biases. Following a baseline assessment of social anxiety, interpretation biases, and WMC, participants completed follow-up assessments of social anxiety both 2 weeks (n = 106) and 4 weeks (n = 96) later. After controlling for baseline social anxiety and WMC, greater positive interpretation bias was found to predict lower social anxiety at both follow-ups. Neither negative interpretation bias nor interpretation inflexibility was significantly associated with follow-up social anxiety. These results provide support for greater positive interpretation bias as a facilitator of decreases in social anxiety and a potential target for clinical intervention.

Inhibition Predicts the Course of Depression and Anxiety Symptoms Among Adolescents: The Moderating Role of Familial Risk

ABSTRACT

Numerous theoretical models suggest that inhibition difficulties-the inability to moderate automatic responses-contribute to the onset and/or maintenance of internalizing symptoms. Inhibition deficits and internalizing disorders run in families and share overlapping genetic risk factors, suggesting that inhibition deficits may be particularly prognostic of internalizing symptoms in those with high familial risk. This study tested this hypothesis in a longitudinal sample during the transition from adolescence to early adulthood. As hypothesized, prospective associations between inhibition and anxiety and depressive symptoms 8 years later were moderated by familial risk for depression. Specifically, poorer inhibition prospectively predicted greater anxiety and depressive symptoms in those at high (but not low) familial risk for major depressive disorder. These findings provide preliminary support for impaired inhibition as an indicator of risk for later internalizing symptoms in those at high familial risk.

Attention and interpretation cognitive bias change: A systematic review and meta-analysis of bias modification paradigms

This systematic review and meta-analysis examines the effect of Cognitive Bias Modification for attention (CBM-A) and interpretation (CBM-I) on reducing the targeted biases and investigates moderators of each approach. PsycINFO, PsychArticles, and PubMED databases were searched for randomized-controlled studies published before March 2020 with pre- and post-CBM cognitive bias outcome measures, resulting in 91 CBM-A (n = 5914 individuals) and 70 CBM-I samples (n = 4802 individuals). Random-effects models and Hedge's g calculation showed significant medium overall effects of bias reduction with moderate to high heterogeneity (CBM-A g = 0.49 [0.36, 0.64], I² = 85.19%; CBM-I g = 0.58 [0.48, 0.68], I² = 70.92%). Effect sizes did not differ between approaches and remained significant after trim-and-fill adjustment for possible publication bias. Moderator variables were investigated with meta-regression and subgroup analyses. Participant age, symptom type, control condition and number of trials moderated CBM-A; student and clinical status moderated CBM-I effect size. Results support attention and interpretation modification in controlled laboratory and variable (online) training settings for non-clinical and clinical samples across various symptom types (anxiety, depression, substance use, eating disorders). Further empirical evidence is necessary to determine optimal sample and methodological combinations most strongly associated with adaptive behavioral outcomes.

The combined cognitive bias hypothesis in anxiety: A systematic review and meta-analysis

Cognitive theories have postulated the relational nature of different cognitive biases in the development and maintenance of anxiety disorders. To test this combined cognitive bias hypothesis, this review addressed the following questions: (i) whether different cognitive biases are associated with each other and (ii) whether one bias influences another bias. We identified 36 articles that studied the relationship between cognitive biases (attention, interpretation and memory bias). Of these, 31 studies were entered into two meta-analyses. Sixteen studies were included in the first meta-analysis of the correlation between cognitive bias indices. A further 15 studies were included in another meta-analysis to examine the transfer effects of cognitive bias modification (CBM) to another bias. Both meta-analyses yielded small but significant overall pooled effect sizes after the removal of outliers (r = 0.11 and g = 0.19 respectively). Moderator analyses revealed that the relationship between interpretation and memory bias was significantly stronger than other types of cognitive bias correlations and CBM is more potent in modifying biases when it was delivered in the laboratory compared with online. Our review quantifies the strength of the relationships between biases and transfer effects following CBM, which serves as a basis to further understand the mechanisms underlying biased information processing.

Pathways Linking the Big Five to Psychological Distress: Exploring the Mediating Roles of Stress Mindset and Coping Flexibility

Personality affects the vulnerability to the emotional symptoms of depression and anxiety. This study investigated whether stress mindset (general belief about the nature of stress) and coping flexibility (the ability to terminate ineffective coping strategies and adopt alternative ones) mediate the relations of the Big Five personality traits to psychological distress. A total of 260 undergraduate students (60.4% female) in Singapore completed self-reported questionnaires. A series of path analyses was performed. Firstly, a dual-pathway model of stress coping was established, which consisted of (a) a stress-threat-distress pathway where a stress-is-a-threat mindset mediated the association between stressful experiences and psychological distress and (b) a challenge-flexibility-enhancement pathway where coping flexibility mediated the relation of a stress-is-a-challenge mindset to a lower level of psychological distress, without being influenced by stressful experiences. Furthermore, Neuroticism was associated with the stress-threat-distress pathway, with stressful experiences and a stress-is-a-treat mindset mediating the relation of Neuroticism to psychological distress. Conscientiousness was associated with the challenge-flexibility-enhancement pathway, with a stress-is-a-challenge mindset and coping flexibility mediating the relation of Conscientiousness to less psychological distress. Extraversion, Agreeableness, and Openness were directly associated with greater coping flexibility. The findings enrich the literature on personality and stress coping and inform future interventions to promote mental health.

A multifaceted study of interpersonal functioning and cognitive biases towards social stimuli in adolescents with eating disorders and healthy controls

BACKGROUND

Cognitive biases towards social stimuli have been identified as one of the putative modifiable mechanisms to remediate interpersonal difficulties in adolescents with mental disorders. However, evidence for these biases in adolescents with eating disorders is scarce.

METHODS

This study assessed interpersonal sensitivity, cognitive biases towards social stimuli, and quantity and quality of social group memberships in adolescents with eating disorders (n = 80), compared to healthy controls (n = 78), and examined whether a negative interpretation bias would mediate the relationship between interpersonal sensitivity, eating disorder symptoms and positive group memberships.

RESULTS

Adolescents with eating disorders displayed greater interpersonal awareness, negative interpretation biases of ambiguous social information and poorer quality relationships with their social groups compared to healthy controls. In a simple mediation model, interpersonal awareness predicted eating disorder symptoms, and this effect was partially mediated by a negative interpretation bias.

CONCLUSIONS

Psychological interventions which aim to reduce a negative interpretation bias might help to reduce the severity of eating disorder symptoms in adolescents with eating disorders.

Promoting helpful attention and interpretation patterns to reduce anxiety and depression in young people: weaving scientific data with young peoples' lived experiences

BACKGROUND

Anxiety and depression are common, disabling and frequently start in youth, underscoring the need for effective, accessible early interventions. Empirical data and consultations with lived experience youth representatives suggest that maladaptive cognitive patterns contribute to and maintain anxiety and depression in daily life. Promoting adaptive cognitive patterns could therefore reflect "active ingredients" in the treatment and/or prevention of youth anxiety and depression. Here, we described and compared different therapeutic techniques that equipped young people with a more flexible capacity to use attention and/or promoted a tendency to positive/benign (over threatening/negative) interpretations of uncertain situations.

METHODS

We searched electronic databases (PubMed, PsycINFO, EMBASE, and PsycARTICLES) for studies containing words relating to: intervention; youth; anxiety and/or depression and attention and/or interpretation, and selected studies which sought to reduce self-reported anxiety/depression in youth by explicitly altering attention and/or interpretation patterns. Ten young people with lived experiences of anxiety and depression and from diverse backgrounds were consulted on the relevance of these strategies in managing emotions in their daily lives and also whether there were additional strategies that could be targeted to promote adaptive thinking styles.

RESULTS

Two sets of techniques, each targeting different levels of responding with different strengths and weaknesses were identified. Cognitive bias modification training (CBM) tasks were largely able to alter attention and interpretation biases but the effects of training on clinical symptoms was more mixed. In contrast, guided instructions that teach young people to regulate their attention or to evaluate alternative explanations of personally-salient events, reduced symptoms but there was little experimental data establishing the intervention mechanism. Lived experience representatives suggested that strategies such as deliberately recalling positive past experiences or positive aspects of oneself to counteract negative thinking.

DISCUSSION

CBM techniques target clear hypothesised mechanisms but require further co-design with young people to make them more engaging and augment their clinical effects. Guided instructions benefit from being embedded in clinical interventions, but lack empirical data to support their intervention mechanism, underscoring the need for more experimental work. Feedback from young people suggest that combining complimentary techniques within multi-pronged "toolboxes" to develop resilient thinking patterns in youth is empowering.

Multi-session online interpretation bias training for anxiety in a community sample

The present study assessed target engagement, preliminary efficacy, and feasibility as primary outcomes of a free multi-session online cognitive bias modification of interpretation (CBM-I) intervention for anxiety in a large community sample. High trait anxious participants (N = 807) were randomly assigned to a CBM-I condition: 1) Positive training (90% positive-10% negative); 2) 50% positive-50% negative training; or 3) no-training control. Further, half of each CBM-I condition was randomized to either an anxious imagery prime or a neutral imagery prime. Due to attrition, results from six out of eight sessions were analyzed using structural equation modeling of latent growth curves. Results for the intent-to-treat sample indicate that for target engagement, consistent with predictions, decreases in negative interpretations over time were significantly greater among those receiving positive CBM-I training compared to no-training or 50-50 training, and vice-versa for increases in positive interpretations. For intervention efficacy, the decrease in anxiety symptoms over time was significantly greater among those receiving positive CBM-I training compared to no-training. Interaction effects with imagery prime were more variable with a general pattern of stronger results for those completing the anxious imagery prime. Findings indicate that online CBM-I positive training is feasible and shows some promising results, although attrition rates were very high for later training sessions.

Biased interpretation in paranoia and its modification

BACKGROUND AND OBJECTIVES

Cognitive models of psychosis implicate interpretation biases as one of the mechanisms involved in the formation and maintenance of symptoms. First we measured the strength of association between interpretation biases and psychosis-relevant traits. Next we manipulated these biases and quantified the effects of doing so on psychosis-relevant outcomes.

METHODS

Experiment 1 used two measures of interpretation bias in a healthy sample (n = 70). Experiment 2 used a novel cognitive bias modification procedure (CMB-pa) in individuals with moderate trait paranoia (n = 60).

RESULTS

Experiment 1 revealed that over a third of the variance in interpretation bias could be explained by the combined effect of trait measures of paranoia/psychosis. In Experiment 2, CBM-pa produced training-congruent changes in the interpretation of new ambiguous information and influenced the interpretation, attribution and distress associated with a real-life social event.

LIMITATIONS

The potentially confounding effects of elevated anxiety and depression on interpretation bias and the restricted range of outcome measures to assess the wider effects of CBM-pa.

CONCLUSIONS

These studies are consistent with interpretation biases contributing to the maintenance of paranoia. CBM-pa could next be adapted and evaluated to test its efficacy as a therapeutic intervention.

Which variations of a brief cognitive bias modification session for interpretations lead to the strongest effects?

Background

Brief computerized programs that train less threatening interpretations (termed Cognitive Bias Modification for Interpretations, or CBM-I) can shift interpretation biases and subsequent anxiety symptoms. However, results have been inconsistent, particularly for studies conducted over the Internet.

Methods

The current exploratory study tests 13 variations of a single brief session of CBM-I, a non-CBM-I cognitive flexibility condition, a neutral condition, and a no task control condition in an analogue sample with moderate to severe anxiety.

Results

Results suggest that all conditions, except the neutral scenarios condition and the alternative way to improve cognitive flexibility, led to changes in interpretations (when compared to the no task control condition). Only conditions geared toward increasing imagery during CBM-I and targeting flexibility related to emotional material differed from the no task control condition on other post-training measures.

Conclusions

Presenting valenced interpretations of ambiguous information during brief CBM-I, regardless of the format, can lead to changes in interpretation bias. However, most conditions did not differ from the no task control condition on other post-training assessments (and differences that did occur may be due to chance). Future trials should consider further testing of CBM-I that targets flexibility related to emotional material, and should include an increased number of sessions and trials.

Internet-based interpretation bias modification for body dissatisfaction: A three-armed randomized controlled trial

OBJECTIVE

Appearance-related interpretation bias is postulated to play a role in the maintenance of body dissatisfaction (BD), a risk factor for body dysmorphic disorder (BDD), and eating disorders (ED). Cognitive bias modification for interpretation (CBM-I) has been shown to reduce maladaptive interpretation bias and symptoms in various emotional disorders. This study investigated the acceptability and efficacy of an easily disseminable, web-based CBM-I program for BD.

METHODS

Individuals with high BD (N = 318) were randomized to a multi-session CBM-I (Sentence Word Association Paradigm [SWAP] with feedback) vs. control (SWAP without feedback) versus waitlist condition. Interpretation bias, BD and associated symptoms were assessed at baseline and post-intervention. Symptoms were monitored up to 1-week and 4-week follow-up. We further investigated transference effects to stress reactivity, as predicted by cognitive-behavioral models, at post-intervention.

RESULTS

Appearance-related CBM-I led to a differential pre-post increase in adaptive interpretation patterns, particularly for appearance-related and social situations (d = 0.65-1.18). Both CBM-I and control training reduced BD, BDD symptom severity, and depression. However, CBM-I (vs. control and waitlist) improved appearance-related quality of life (d = 0.51), self-esteem (d = 0.52), and maladaptive appearance-related beliefs (d = 0.47). State stress reactivity was overall reduced in the CBM-I condition (vs. waitlist). Intervention effects largely held stable up to follow-ups. Treatment satisfaction was comparable to other CBM-I studies, with low rates of adverse reactions.

DISCUSSION

These findings support assumptions of cognitive-behavioral models for BD, BDD, and ED, and suggest that web-based CBM-I is an efficacious and acceptable intervention option.

Intrusive memories and voluntary memory of a trauma film: Differential effects of a cognitive interference task after encoding

Methods to reduce intrusive memories (e.g., of traumatic events) should ideally spare voluntary memory for the same event (e.g., to report on the event in court). Single-trace memory accounts assume that interfering with a trace should impact both its involuntary and voluntary expressions, whereas separate-trace accounts assume these two can dissociate, allowing for selective interference. This possibility was investigated in 3 experiments. Nonclinical participants viewed a trauma film followed by an interference task (Tetris game-play after reminder cues). Next, memory for the film was assessed with various measures. The interference task reduced the number of intrusive memories (diary-based, Experiments 1 and 2), but spared performance on well-matched measures of voluntary retrieval-free recall (Experiment 1) and recognition (Experiments 1 and 2)-challenging single-trace accounts. The interference task did not affect other measures of involuntary retrieval-perceptual priming (Experiment 1) or attentional bias (Experiment 2). However, the interference task did reduce the number of intrusive memories in a laboratory-based vigilance-intrusion task (Experiments 2 and 3), irrespective of concurrent working memory load during intrusion retrieval (Experiment 3). Collectively, results reveal a robust dissociation between intrusive and voluntary memories, having ruled out key methodological differences between how these two memory expressions are assessed, namely cue overlap (Experiment 1), attentional capture (Experiment 2), and retrieval load (Experiment 3). We argue that the inability of these retrieval factors to explain the selective interference is more compatible with separate-trace than single-trace accounts. Further theoretical developments are needed to account for this clinically important distinction between intrusive memories and their voluntary counterpart. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Digital Mental Health Interventions for Depression, Anxiety, and Enhancement of Psychological Well-Being Among College Students: Systematic Review

BACKGROUND

College students are increasingly reporting common mental health problems, such as depression and anxiety, and they frequently encounter barriers to seeking traditional mental health treatments. Digital mental health interventions, such as those delivered via the Web and apps, offer the potential to improve access to mental health treatment.

OBJECTIVE

This study aimed to review the literature on digital mental health interventions focused on depression, anxiety, and enhancement of psychological well-being among samples of college students to identify the effectiveness, usability, acceptability, uptake, and adoption of such programs.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092800), and the search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) from the date of inception to April 2019. Data were synthesized using a systematic narrative synthesis framework, and formal quality assessments were conducted to address the risk of bias.

RESULTS

A total of 89 studies met the inclusion criteria. The majority of interventions (71/89, 80%) were delivered via a website, and the most common intervention was internet-based cognitive behavioral therapy (28, 31%). Many programs (33, 37%) featured human support in the form of coaching. The majority of programs were either effective (42, 47%) or partially effective (30, 34%) in producing beneficial changes in the main psychological outcome variables. Approximately half of the studies (45, 51%) did not present any usability or acceptability outcomes, and few studies (4, 4%) examined a broad implementation of digital mental health interventions on college campuses. Quality assessments revealed a moderate-to-severe risk of bias in many of the studies.

CONCLUSIONS

Results suggest that digital mental health interventions can be effective for improving depression, anxiety, and psychological well-being among college students, but more rigorous studies are needed to ascertain the effective elements of these interventions. Continued research on improving the user experience of, and thus user engagement with, these programs appears vital for the sustainable implementation of digital mental health interventions on college campuses.

Enhancing the Efficacy of Cognitive Bias Modification for Social Anxiety

Cognitive bias modification for interpretation (CBM-I) is a promising treatment modality for social anxiety disorder, but effect sizes are relatively small across investigations (Hallion & Ruscio, 2011). Additionally, the extent to which CBM-I impacts other cognitive, emotional, and behavioral outcomes is unclear. This study investigated whether two empirically supported treatment components for anxiety disorders, imaginal exposure (IE) and relaxation, augment the effects of CBM-I and increase the extent to which the effects of CBM-I generalize to behavioral and affective outcomes. We randomly assigned 111 undergraduate students with social anxiety to undergo IE, relaxation, or neutral thinking prior to CBM-I, then measured their interpretation biases, as well as their speaking time, anxiety, and subjective evaluations of performance during a speech task. Results indicated that individuals who received IE prior to CBM-I evidenced more adaptive interpretation biases and less behavioral avoidance during the speech task than did individuals who engaged in relaxation or neutral thinking. However, they did not report differential anxiety, habituation, or evaluations of their performance on the speech task. These findings suggest that the combination of CBM-I with adjunct components that target behavioral, rather than cognitive, mechanisms can facilitate transfer of the effects of CBM-I to reducing behavioral avoidance.

Attention and interpretation bias modification treatment for social anxiety disorder: A randomized clinical trial of efficacy and synergy

BACKGROUND AND OBJECTIVES

Attention bias modification treatment (ABMT) and cognitive bias modification of interpretation (CBM-I) both have demonstrated efficacy in alleviating social anxiety, but how they compare with each other, their combination, and with a combined control condition has not been studied. We examined their relative and combined efficacy compared to control conditions in a randomized controlled trial (RCT).

METHODS

Ninety-five adults diagnosed with social anxiety disorder (SAD), were randomly allocated to 4 groups: ABMT + CBM-I control (hereafter ABMT; n = 23), CBM-I + ABMT control (hereafter CBM-I; n = 24), combined ABMT + CBM-I (n = 23), and combined control (n = 25). Treatment included eight sessions over four weeks. Clinician-rated and self-reported measures of social anxiety symptoms, functional impairment, and threat-related attention and interpretive biases were evaluated at baseline, post-treatment, and 3-month follow-up.

RESULTS

ABMT yielded greater symptom reduction as measured by both clinician-ratings (Cohen's ds = 0.57-0.70) and self-reports (ds = 0.70-0.85) compared with the CBM-I, the combined ABMT + CBM-I, and the combined control conditions. Neither of the other conditions demonstrated superior symptom change compared to the control condition. No group differences were found for functioning or cognitive biases measures.

LIMITATIONS

Limitations mainly include the mix of active and control treatments applied across the different groups. Therefore, the net effect of each of the treatments by itself could not be clearly tested.

CONCLUSIONS

Results suggest superiority of ABMT compared to CBM-I and their combination in terms of symptom reduction. Possible interpretations and methodological issues underlying the observed findings are discussed.

Attention and Cognitive Bias Modification Apps: Review of the Literature and of Commercially Available Apps

Background

Automatic processes, such as attentional biases or interpretative biases, have been purported to be responsible for several psychiatric disorders. Recent reviews have highlighted that cognitive biases may be modifiable. Advances in eHealth and mHealth have been harnessed for the delivery of cognitive bias modification. While several studies have evaluated mHealth-based bias modification intervention, no review, to our knowledge, has synthesized the evidence for it. In addition, no review has looked at commercial apps and their functionalities and methods of bias modification. A review is essential in determining whether scientifically validated apps are available commercially and the proportion of commercial apps that have been evaluated scientifically.

Objective

The objective of this review was primarily to determine the proportion of attention or cognitive bias modification apps that have been evaluated scientifically and secondarily to determine whether the scientifically evaluated apps were commercially available. We also sought to identify commercially available bias modification apps and determine the functionalities of these apps, the methods used for attention or cognitive bias modification, and whether these apps had been evaluated scientifically.

Methods

To identify apps in the published literature, we searched PubMed, MEDLINE, PsycINFO, and Scopus for studies published from 2000 to April 17, 2018. The search terms used were “attention bias” OR “cognitive bias” AND “smartphone” OR “smartphone application” OR “smartphone app” OR “mobile phones” OR “mobile application” OR mobile app” OR “personal digital assistant.” To identify commercial apps, we conducted a manual cross-sectional search between September 15 and 25, 2017 in the Apple iTunes and Google Play app stores. The search terms used to identify the apps were “attention bias” and “cognitive bias.” We also conducted a manual search on the apps with published evaluations.

Results

The effectiveness of bias modification was reported in 7 of 8 trials that we identified in the published literature. Only 1 of the 8 previously evaluated apps was commercially available. The 17 commercial apps we identified tended to use either an attention visual search or gamified task. Only 1 commercial app had been evaluated in the published literature.

Conclusions

This is perhaps the first review to synthesize the evidence for published mHealth attention bias apps. Our review demonstrated that evidence for mHealth attention bias apps is inconclusive, and quite a few commercial apps have not been validated scientifically.

A randomized controlled trial of multi-session online interpretation bias modification training: Short- and long-term effects on anxiety and depression in unselected adolescents

Introduction

Negatively biased interpretations play an important role in anxiety and depression, which are highly prevalent in adolescence, and changing such biases might thus reduce or prevent emotional disorders. We investigated the short- and long-term effects of an online interpretation bias modification training in unselected adolescents to explore its potential in preventing anxiety and depression.

Methods

Participants (N = 173) were randomly allocated to eight online sessions of interpretation or placebo training. Interpretation bias was assessed pre- and post-training. Primary outcomes of anxiety and depression, and secondary measures of emotional resilience were assessed pre- and post-training and at three, six, and twelve months follow-up.

Results

Compared to placebo, interpretation training marginally increased positive interpretations. Irrespective of training condition, symptoms of anxiety and depression showed a decline post-training and at follow-up, and indices of resilience showed an increase. Change in interpretation bias, baseline interpretation bias, stressful life events, or number of training sessions completed did not moderate the effects on anxiety or depression.

Conclusions

Results suggest that interpretation training as implemented in this study has no added value in reducing symptoms or enhancing resilience in unselected adolescents.

A Question of Control? Examining the Role of Control Conditions in Experimental Psychopathology using the Example of Cognitive Bias Modification Research

While control conditions are vitally important in research, selecting the optimal control condition can be challenging. Problems are likely to arise when the choice of control condition is not tightly guided by the specific question that a given study aims to address. Such problems have become increasingly apparent in experimental psychopathology research investigating the experimental modification of cognitive biases, particularly as the focus of this research has shifted from theoretical questions concerning mechanistic aspects of the association between cognitive bias and emotional vulnerability, to questions that instead concern the clinical efficacy of ‘cognitive bias modification’ (CBM) procedures. We discuss the kinds of control conditions that have typically been employed in CBM research, illustrating how difficulties can arise when changes in the types of research questions asked are not accompanied by changes in the control conditions employed. Crucially, claims made on the basis of comparing active and control conditions within CBM studies should be restricted to those conclusions allowed by the specific control condition employed. CBM studies aiming to establish clinical utility are likely to require quite different control conditions from CBM studies aiming to illuminate mechanisms. Further, conclusions concerning the clinical utility of CBM interventions cannot necessarily be drawn from studies in which the control condition has been chosen to answer questions concerning mechanisms. Appreciating the need to appropriately alter control conditions in the transition from basic mechanisms-focussed investigations to applied clinical research could greatly facilitate the translational process.

Emotion recognition training using composite faces generalises across identities but not all emotions

Many cognitive bias modification (CBM) tasks use facial expressions of emotion as stimuli. Some tasks use unique facial stimuli, while others use composite stimuli, given evidence that emotion is encoded prototypically. However, CBM using composite stimuli may be identity- or emotion-specific, and may not generalise to other stimuli. We investigated the generalisability of effects using composite faces in two experiments. Healthy adults in each study were randomised to one of four training conditions: two stimulus-congruent conditions, where same faces were used during all phases of the task, and two stimulus-incongruent conditions, where faces of the opposite sex (Experiment 1) or faces depicting another emotion (Experiment 2) were used after the modification phase. Our results suggested that training effects generalised across identities. However, our results indicated only partial generalisation across emotions. These findings suggest effects obtained using composite stimuli may extend beyond the stimuli used in the task but remain emotion-specific.

Imagine the bright side of life: A randomized controlled trial of two types of interpretation bias modification procedure targeting adolescent anxiety and depression

Introduction

Anxiety and depression are highly prevalent during adolescence and characterized by negative interpretation biases. Cognitive bias modification of interpretations (CBM-I) may reduce such biases and improve emotional functioning. However, as findings have been mixed and the traditional scenario training is experienced as relatively boring, a picture-based type of training might be more engaging and effective.

Methods

The current study investigated short- and long-term effects (up to 6 months) and users’ experience of two types of CBM-I procedure in adolescents with heightened symptoms of anxiety or depression (N = 119, aged 12–18 year). Participants were randomized to eight online sessions of text-based scenario training, picture-word imagery training, or neutral control training.

Results

No significant group differences were observed on primary or secondary emotional outcomes. A decrease in anxiety and depressive symptoms, and improvements in emotional resilience were observed, irrespective of condition. Scenario training marginally reduced negative interpretation bias on a closely matched assessment task, while no such effects were found on a different task, nor for the picture-word or control group. Subjective evaluations of all training paradigms were relatively negative and the imagery component appeared particularly difficult for adolescents with higher symptom levels.

Conclusions

The current results question the preventive efficacy and feasibility of both CBM-I procedures as implemented here in adolescents.

Effects of cognitive bias modification on social anxiety: A meta-analysis

Background

Cognitive bias modification (CBM), a set of techniques for modifying bias in information processing—is considered a novel intervention for social anxiety disorder (SAD), which has drawn considerable interest from researchers. However, the effects of CBM on SAD are not consistent. Some studies have demonstrated significant positive effects compared to control groups, while others have found no such effects.

Aims

We conducted a meta-analysis aimed at quantitatively assessing the effects of CBM on SAD at post-test.

Method

Through a systematic literature search by two independent raters, 34 articles (36 randomized studies) including 2,550 participants were identified. A multilevel modeling approach was employed to assess the effects of CBM on SAD, and to explore the potentially crucial procedures and sample characteristics that enhance the effectiveness of benign training.

Results

In general, there were small but significant effects of CBM on the primary symptoms of SAD (g = 0.17), cognitive bias (CB) toward threat (g = 0.32), and reactivity in stressful situations (g = 0.25), but non-significant effects on secondary symptoms. However, the interpretation modification program was more effective than was attentional bias modification in reducing SAD primary symptoms and negative CB. Laboratory training procedures produced larger primary symptom reductions compared to Internet-based training, whereas the percentage of contingency and feedback about training performance boosted cognitive effects only. Finally, the following groups were more likely to benefit from CBM: younger participants (primary symptoms and cognitive effects), women (primary symptom effects), and samples with stronger CB (stressor effects). The quality of the randomized controlled trials was less than desirable, as there was some indication of publication bias in our study.

Conclusions

Current findings broadly supported cognitive theories of SAD that consider a bidirectional or mutually reinforcing relationship between symptoms and CBs. However, the small therapeutic effect observed here indicates that it is necessary to develop more reliable and efficient CBM interventions that are specific to SAD.

Modifying interpretation biases: Effects on symptomatology, behavior, and physiological reactivity in social anxiety

BACKGROUND AND OBJECTIVES

The present study investigated the effects of computerized interpretation training and cognitive restructuring on symptomatology, behavior, and physiological reactivity in an analogue social anxiety sample.

METHODS

Seventy-two participants with elevated social anxiety scores were randomized to one session of computerized interpretation training (n = 24), cognitive restructuring (n = 24), or an active placebo control condition (n = 24). Participants completed self-report questionnaires focused on interpretation biases and social anxiety symptomatology at pre and posttraining and a speech task at posttraining during which subjective, behavioral, and physiological measures of anxiety were assessed.

RESULTS

Only participants in the interpretation training condition endorsed significantly more positive than negative interpretations of ambiguous social situations at posttraining. There was no evidence of generalizability of interpretation training effects to self-report measures of interpretation biases and symptomatology or the anxiety response during the posttraining speech task. Participants in the cognitive restructuring condition were rated as having higher quality speeches and showing fewer signs of anxiety during the posttraining speech task compared to participants in the interpretation training condition.

LIMITATIONS

The present study did not include baseline measures of speech performance or computer assessed interpretation biases.

CONCLUSIONS

The results of the present study bring into question the generalizability of computerized interpretation training as well as the effectiveness of a single session of cognitive restructuring in modifying the full anxiety response. Clinical and theoretical implications are discussed.