Randomized controlled trial of computerized approach/avoidance training in social anxiety disorder: Neural and symptom outcomes

From social effort to social behavior: An integrated neural model for social motivation

As humans rely on social groups for survival, social motivation is central to behavior and well-being. Here we define social motivation as the effort that initiates and directs behavior towards social outcomes, with the goal of satisfying our fundamental need for connection. We propose an integrated framework of social motivation which emphasizes the maintenance of optimal connection levels through effort exertion, regulating social approach and avoidance, which allow interpersonal synchrony. Together, these behaviors serve as basic building blocks of social behavior, and give rise to behaviors critical for collective living such as cooperation and empathy. We describe a neural model according to which social connection levels are monitored by the hypothalamus, while the anterior cingulate cortex and anterior insula respond to detected social deficiency. As adjustment is required, the social effort system - comprised of the thalamus and striatum - is activated. This system directs neural networks that permit interpersonal synchrony or, conversely, desynchronization, aiming to restore and maintain optimal connection by preventing isolation on the one hand, and exaggerated social closeness on the other hand. The proposed framework offers insights into disorders characterized by aberrant social motivation, potentially identifying neural dysfunctions that may inform novel interventions.

The medial prefrontal cortex as a proposed regulatory structure in the relationship between anxiety and perceived social support: a review

Perceived social support is recognized as a critical protective factor against the development of mental health disorders. Anxiety disorders are the most common group of mental health disorders and have a substantial impact on individuals' well-being. Despite extensive research on anxiety and perceived social support, a significant gap exists in our understanding of the neural mechanisms linking these two phenomena. While several brain regions, including the amygdala, hippocampus, and insula, have been implicated in anxiety regulation and social support processing, the medial prefrontal cortex (mPFC) emerges as a particularly intriguing structure due to its central role in emotional regulation and social processing.Here, we hypothesize that the mPFC serves as a potential neural substrate mediating the relationship between anxiety and perceived social support. To support our hypothesis, we conducted a literature search in the PubMed database using a systematic Boolean search strategy. In total, 43 articles met our inclusion criteria. The reviewed studies suggest that the mPFC may play an essential role in regulating the effect of perceived social support on anxiety levels. The evidence indicates that individuals with higher levels of perceived social support may exhibit enhanced regulatory control over anxiety-related processes, with the mPFC mediating this effect.Understanding the neural mechanisms that underpin the relationship between anxiety and social support is crucial for devising targeted interventions. Further investigation into mPFC's role as a candidate structure in this domain could provide invaluable insights and aid in the development of new therapeutic strategies for the management of anxiety.

Social threat avoidance depends on action-outcome predictability

Avoiding threatening individuals is pivotal for adaptation to our social environment. Yet, it remains unclear whether social threat avoidance is subtended by goal-directed processes, in addition to stimulus-response associations. To test this, we manipulated outcome predictability during spontaneous approach/avoidance decisions from avatars displaying angry facial expressions. Across three virtual reality experiments, we showed that participants avoided more often when they could predict the outcome of their actions, indicating goal-directed processes. However, above-chance avoidance rate when facing unpredictable outcomes suggested that stimulus-response associations also played a role. We identified two latent classes of participants: the "goal-directed class" showed above-chance avoidance only in the predictable condition, while the "stimulus-response class" showed no credible difference between conditions but had a higher overall avoidance rate. The goal-directed class exhibited greater cardiac deceleration in the predictable condition, associated with better value integration in decision-making. Computationally, this class had an increased drift-rate in the predictable condition, reflecting increased value estimation of threat avoidance. In contrast, the stimulus-response class showed higher responsiveness to threat, indicated by increased drift-rate for avoidance and increased muscular activity at response time. These results support the central role of goal-directed processes in social threat avoidance and reveal its physiological and computational correlates.

Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward

Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.

Comparison of two reaction-time-based and one foraging-based behavioral approach-avoidance tasks in relation to interindividual differences and their reliability

Approaching rewards and avoiding punishments is a fundamental aspect of behavior, yet individuals differ in the extent of these behavioral tendencies. One popular method to assess differences in approach-avoidance tendencies and even modify them, is using behavioral tasks in which spontaneous responses to differently valenced stimuli are assessed (e.g., the visual joystick and the manikin task). Understanding whether these reaction-time-based tasks map onto the same underlying constructs, how they predict interindividual differences in theoretically related constructs and how reliable they are, seems vital to make informed judgements about current findings and future studies. In this preregistered study, 168 participants (81 self-identified men, 87 women) completed emotional face versions of these tasks as well as an alternative, foraging-based paradigm, the approach-avoidance-conflict task, and answered self-report questionnaires regarding anxiety, aggression, depressive symptoms, behavioral inhibition and activation. Importantly, approach-avoidance outcome measures of the two reaction-time-based tasks were unrelated with each other, showed little relation to self-reported interindividual differences and had subpar internal consistencies. In contrast, the approach-avoidance-conflict task was related to behavioral inhibition and aggression, and had good internal consistencies. Our study highlights the need for more research into optimizing behavioral approach-avoidance measures when using task-based approach-avoidance measures to assess interindividual differences.

Approach avoidance training versus Sham in veterans with alcohol use disorder: protocol for a randomized controlled trial

BACKGROUND

Alcohol use disorder (AUD) is highly prevalent and commonly co-occurs with other psychiatric disorders among Veterans. Provisional evidence supports the use of Approach Avoidance Training (AAT) - a form of computer-delivered cognitive bias modification designed to target implicit approach bias for alcohol-related cues - as an adjunctive program to treat AUD. However, the extent to which AAT is effective for improving AUD recovery outcomes in outpatient Veteran samples and those with psychiatric comorbidities has been understudied to date. Here we describe a double-blind randomized controlled trial of AAT versus a comparison condition (Sham) being conducted in Veterans with comorbid psychiatric conditions completing outpatient standard care.

METHODS

One hundred thirty-six Veterans currently receiving outpatient treatment for AUD will be recruited for this randomized controlled trial with parallel group assignment. Participants will be randomized to either 6 weeks of AAT (n = 68) or Sham (n = 68) training in conjunction with usual care. Assessments will occur at baseline and 6 weeks, 3 months, and 6 months post-baseline. Primary outcome variables will include functional consequences of drinking. Secondary outcome variables will include alcohol consumption, and behavioral indicators of alcohol approach bias. A subset of participants (n = 51) will also complete functional magnetic resonance imaging (fMRI) to assess neural response during an alcohol approach bias assessment.

DISCUSSION

This study is the first randomized controlled trial of AAT administered as an adjunctive treatment to standard care in Veterans with AUD and comorbid psychiatric disorders. Additionally, behavioral and neuroimaging data will be used to determine the extent to which AAT targets approach bias for alcohol cues. If effective, AAT may be a promising low-cost adjunctive treatment option for individuals with AUD.

REGISTRY NAME

AAT for Alcohol Use Disorder in Veterans.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05372029; Date of Registration: 5/9/2022.