Gamification of cognitive bias modification for interpretations in anxiety increases training engagement and enjoyment

Mental imagery abilities in different modalities moderate the efficacy of cognitive bias modification for interpretation bias in social anxiety

OBJECTIVES

Cognitive bias modification for interpretation bias (CBM-I) is an effective low-intensity intervention that targets interpretation biases associated with the development and maintenance of social anxiety. Few studies to-date have examined the extent to which individual mental imagery ability affects the efficacy of CBM-I.

METHODS

A total of 666 individuals were screened. Seventy-two participants with high levels of social anxiety and elevated baseline interpretation bias were randomly assigned to either CBM-I (n = 36) or control groups (n = 36). They completed 5-day internet-delivered training in modifying their interpretation bias associated with ambiguous social scenarios (CBM-I) or reading neutral text passages (control).

RESULTS

Intent-to-treat analyses revealed that participants in the CBM-I group had a significant reduction in their interpretation bias compared to the controls. They had a reduction of 11 %-18 % on the social anxiety measures. Participants' mental imagery ability was significantly associated with the reduction of interpretation bias and social anxiety symptoms in the CBM-I group. Specifically, participants with higher mental imagery ability in emotional feelings benefited the most from the intervention.

CONCLUSIONS

CBM-I is an efficacious intervention for modulating social anxiety-related biases and symptoms. Mental imagery ability facilitated the efficacy of CBM-I.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Attentional bias to pain-related information has been implicated in pain chronicity. To date, research investigating attentional bias modification training (ABMT) procedures in people with chronic pain has found variable success, perhaps because training paradigms are typically repetitive and monotonous, which could negatively affect engagement and adherence. Increasing engagement through the gamification (ie, the use of game elements) of ABMT may provide the opportunity to overcome some of these barriers. However, ABMT studies applied to the chronic pain field have not yet incorporated gamification elements.

OBJECTIVE

This study aimed to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

METHODS

A final sample of 129 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, were included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants were randomly assigned to complete 6 web-based sessions of nongamified standard ABMT (n=43), gamified ABMT (n=41), or a control condition (nongamified sham ABMT; n=45) over a period of 3 weeks. Active ABMT conditions trained attention away from pain-related words. The gamified task included a combination of 5 game elements. Participant outcomes were assessed before training, during training, immediately after training, and at 1-month follow-up. Primary outcomes included self-reported and behavioral engagement, pain intensity, and pain interference. Secondary outcomes included anxiety, depression, cognitive biases, and perceived improvement.

RESULTS

Results of the linear mixed model analyses suggest that across all conditions, there was an overall small to medium decline in self-reported task-related engagement between sessions 1 and 2 (P<.001; Cohen d=0.257; 95% CI 0.13-0.39), sessions 1 and 3 (P<.001; Cohen d=0.368; 95% CI 0.23-0.50), sessions 1 and 4 (P<.001; Cohen d=0.473; 95% CI 0.34-0.61), sessions 1 and 5 (P<.001; Cohen d=0.488; 95% CI 0.35-0.63), and sessions 1 and 6 (P<.001; Cohen d=0.596; 95% CI 0.46-0.73). There was also an overall small decrease in depressive symptoms from baseline to posttraining assessment (P=.007; Cohen d=0.180; 95% CI 0.05-0.31) and in pain intensity (P=.008; Cohen d=0.180; 95% CI 0.05-0.31) and pain interference (P<.001; Cohen d=0.237; 95% CI 0.10-0.37) from baseline to follow-up assessment. However, no differential effects were observed over time between the 3 conditions on measures of engagement, pain intensity, pain interference, attentional bias, anxiety, depression, interpretation bias, or perceived improvement (all P values>.05).

CONCLUSIONS

These findings suggest that gamification, in this context, was not effective at enhancing engagement, and they do not support the widespread clinical use of web-delivered ABMT in treating individuals with chronic musculoskeletal pain. The implications of these findings are discussed, and future directions for research are suggested.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32359.

A mobile intervention to reduce anxiety among university students, faculty, and staff: Mixed methods study on users' experiences

Anxiety is highly prevalent among college communities, with significant numbers of students, faculty, and staff experiencing severe anxiety symptoms. Digital mental health interventions (DMHIs), including Cognitive Bias Modification for Interpretation (CBM-I), offer promising solutions to enhance access to mental health care, yet there is a critical need to evaluate user experience and acceptability of DMHIs. CBM-I training targets cognitive biases in threat perception, aiming to increase cognitive flexibility by reducing rigid negative thought patterns and encouraging more benign interpretations of ambiguous situations. This study used questionnaire and interview data to gather feedback from users of a mobile application called "Hoos Think Calmly" (HTC), which offers brief CBM-I training doses in response to stressors commonly experienced by students, faculty, and staff at a large public university. Mixed methods were used for triangulation to enhance the validity of the findings. Qualitative data was collected through semi-structured interviews from a subset of participants (n = 22) and analyzed thematically using an inductive framework, revealing five main themes: Effectiveness of the Training Program; Feedback on Training Sessions; Barriers to Using the App; Use Patterns; and Suggestions for Improvement. Additionally, biweekly user experience questionnaires sent to all participants in the active treatment condition (n = 134) during the parent trial showed the most commonly endorsed response (by 43.30% of participants) was that the program was somewhat helpful in reducing or managing their anxiety or stress. There was overall agreement between the quantitative and qualitative findings, indicating that graduate students found it the most effective and relatable, with results being moderately positive but somewhat more mixed for undergraduate students and staff, and least positive for faculty. Findings point to clear avenues to enhance the relatability and acceptability of DMHIs across diverse demographics through increased customization and personalization, which may help guide development of future DMHIs.

The role of acute stress recovery in emotional resilience

Background

Resilience refers to the process of demonstrating better outcomes than would be expected based on the adversity one experienced. Resilience is increasingly measured using a residual approach, which typically assesses adversity and mental health outcomes over a longitudinal timeframe. It remains unknown to what extent such a residual-based measurement of resilience is sensitive to variation in acute stress resilience, a candidate resilience factor.

Methods

Fifty-seven emerging adults enrolled in tertiary education completed measures of adversity and emotional experiences. To assess stress recovery, participants were exposed to a lab-based adverse event from which a Laboratory Stress Resilience Index was derived.

Results

We derived a residual-based measure of emotional resilience from regressing emotional experience scores onto adversity scores. This residual-based measure of emotional resilience predicted variance in the Laboratory Stress Resilience Index over and above that predicted by both a traditional resilience measure and the emotional experiences measure. These findings suggest that acute stress resilience may be a factor underpinning variation in emotional resilience, and that the residual-based approach to measuring resilience is sensitive to such variation in stress resilience.

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Efficacy of a smartphone-based Cognitive Bias Modification program for emotion regulation: A randomized-controlled crossover trial

Previous research has identified maladaptive emotion regulation as a key factor in psychopathology. Thus, addressing emotion regulation via scalable, low-threshold digital interventions - such as smartphone-based Cognitive Bias Modification (CBM) - holds important therapeutic potential. Using a randomized-controlled crossover trial, we tested the efficacy of an integrated CBM module within the Affect Regulation Training (ART, i.e., CBM-ART) that targeted emotion regulation through elements of appraisal-based and approach avoidance training. Undergraduate students reporting elevated stress were randomized to a one-week active intervention (Mindgames; including psychoeducation, a quiz, and CBM-ART; n = 40), active control training (Emo Shape; including placebo psychoeducation, a quiz, and a placebo swiping task; n = 36) or waitlist (n = 25). Before and after the intervention, we assessed emotion regulation, interpretation bias, stress and depression. We further tested post-training stress reactivity using an anagram task. Results indicated that the active intervention improved negative (OR = 0.35) and positive (OR = 2.40) interpretation biases and symptom measures (d = 0.52-0.87). However, active control training showed attenuated concurrent pre-post changes on interpretation biases (i.e., OR = 0.53 for negative, and OR = 1.49 for positive interpretations) and symptom measures (d = 0.26-0.91). The active intervention was rated positively in terms of acceptability and usability. These findings provide initial evidence for the efficacy and acceptability of an integrated app-based CBM intervention for emotion regulation in reducing interpretation biases and psychopathological symptoms, including stress. However, future studies should disentangle specific mechanisms underlying interventional effects.

Cognitive bias modification of interpretations for anxiety and depression in children and adolescents: A meta-analysis

Background

Evidence suggests that cognitive bias modification of interpretations (CBM-I) is effective in modifying interpretation biases and has a small effect on reducing anxiety in children and adolescents. However, most evidence to date is based on studies which report anxiety or general distress using ad-hoc Likert-type or Visual Analogue Scales, which are useful but do not reliably index symptoms of clinical importance. This meta-analysis aimed to establish the effects of CBM-I for children and adolescents on both anxiety and depression using psychometrically validated symptom measures, as well as state negative affect and negative and positive interpretation bias.

Methods

We identified studies through a systematic search. To be eligible for inclusion, studies needed to target interpretation biases, not combine CBM-I with another intervention, randomly allocate participants to CBM-I or a control condition, assess a mental health outcome (i.e., anxiety or depression symptoms using validated measures or state measures of negative affect) and/or interpretation bias and have a mean age less than 18 years.

Results

We identified 36 studies for inclusion in the meta-analysis. CBM-I had a small and non-significant unadjusted effect on anxiety symptoms (g = 0.16), no effect on depression symptoms (g = -0.03), and small and non-significant unadjusted effects on state negative affect both at post-training (g = 0.16) and following a stressor task (g = 0.23). In line with previous findings, CBM-I had moderate to large unadjusted effects on negative and positive interpretations (g = 0.78 and g = 0.52). No significant moderators were identified.

Conclusions

CBM-I is effective at modifying interpretation bias, however there were no effects on mental health outcomes. The substantial variability across studies and paucity of studies using validated symptom measures highlight the need to establish randomized controlled trial protocols that evaluate CBM-I in clinical youth samples to determine its future as a clinical intervention.

Web-Based Cognitive Bias Modification Program for Young People With Social Anxiety and Hazardous Alcohol Use: Feasibility, Acceptability, and Preliminary Efficacy Study

BACKGROUND

Interpretation bias modification (IBM) and approach bias modification (ApBM) cognitive retraining interventions can be efficacious adjunctive treatments for improving social anxiety and alcohol use problems. However, previous trials have not examined the combination of these interventions in a young, comorbid sample.

OBJECTIVE

This study aims to describe the feasibility, acceptability, and preliminary efficacy of a web-based IBM+ApBM program for young adults with social anxiety and hazardous alcohol use ("Re-Train Your Brain") when delivered in conjunction with treatment as usual (TAU).

METHODS

The study involved a 3-arm randomized controlled pilot trial in which treatment-seeking young adults (aged 18-30 y) with co-occurring social anxiety and hazardous alcohol use were randomized to receive (1) the "integrated" Re-Train Your Brain program, where each session included both IBM and ApBM (50:50 ratio), plus TAU (35/100, 35%); (2) the "alternating" Re-Train Your Brain program, where each session focused on IBM or ApBM in an alternating pattern, plus TAU (32/100, 32%); or (3) TAU only (33/100, 33%). Primary outcomes included feasibility and acceptability, and secondary efficacy outcomes included changes in cognitive biases, social anxiety symptoms, and alcohol use. Assessments were conducted at baseline, after the intervention period (6 weeks after baseline), and 12 weeks after baseline.

RESULTS

Both Re-Train Your Brain program formats were feasible and acceptable for young adults. When coupled with TAU, both integrated and alternating programs resulted in greater self-reported improvements than TAU only in anxiety interpretation biases (at the 6-week follow-up; Cohen d=0.80 and Cohen d=0.89) and comorbid interpretation biases (at the 12-week follow-up; Cohen d=1.53 and Cohen d=1.67). In addition, the alternating group reported larger improvements over the control group in generalized social anxiety symptoms (at the 12-week follow-up; Cohen d=0.83) and alcohol cravings (at the 6-week follow-up; Cohen d=0.81). There were null effects on all other variables and no differences between the intervention groups in efficacy outcomes.

CONCLUSIONS

Should these findings be replicated in a larger randomized controlled trial, Re-Train Your Brain has the potential to be a scalable, low-cost, and non-labor-intensive adjunct intervention for targeting interpretation and comorbidity biases as well as generalized anxiety and alcohol-related outcomes in the real world.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620001273976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/28667.

Effects of Training Body-Related Interpretations on Panic-Related Cognitions and Symptoms

Background

Interpretation biases (IBs) are central in panic disorder, and there is rich evidence showing that these are correlated with and predictive of panic-relevant symptomatology. However, experimental studies are needed to examine the potential causal effects of IBs, as predicted by cognitive models.

Methods

Panic-related IBs were manipulated via a sentence-completion Cognitive Bias Modification-Interpretation (CBM-I) training. The sample included N = 112 healthy participants reporting moderate levels of fear of bodily sensations. Participants were randomly allocated to a positive, negative, or control CBM-I condition. To test the trainings' effect on panic-relevant cognitive processing, IBs were assessed via proximal and distal measures. Symptom provocation tasks were applied to test transfer to panic-relevant symptomatology.

Results

Results on the proximal measure showed that positive CBM-I led to more positive IBs compared to negative, and control training. Further, positive CBM-I led to more positive IBs on the distal measure as compared to negative CBM-I. However, there were no differential training effects on panic-related symptomatology triggered via the provocation tasks.

Conclusion

The findings indicate a limited generalization of the effects of CBM-I on IBs and panic-related symptoms. Potential means to improve generalization, such as applying more nuanced measures and combining CBM-I with psychoeducation are discussed.

A systematic review of the literature on interpretation bias and its physiological correlates

An important, yet under-explored area of interpretation bias research concerns the examination of potential physiological correlates and sequalae of this bias. Developing a better understanding of the physiological processes that underpin interpretation biases will extend current theoretical frameworks underlying interpretation bias, as well as optimising the efficacy of cognitive bias modification for interpretation (CBM-I) interventions aimed at improving symptoms of emotional disorders. To this end, systematic searches were conducted across the Web of Science, PsycInfo and Pubmed databases to identify physiological markers of interpretation bias. In addition, grey literature database searches were conducted to compliment peer-reviewed research and to counter publication bias. From a combined initial total of 898 records, 15 studies were included in qualitative synthesis (1 of which obtained from the grey literature). Eligible studies were assessed using a quality assessment tool adapted from the Quality Checklist for Healthcare Intervention Studies. The searches revealed seven psychophysiological markers of interpretation bias, namely event-related potentials, heart rate and heart rate variability, respiratory sinus arrythmia, skin conductance response, pupillometry, and electromyography. The respective theoretical and practical implications of the research are discussed, followed by recommendations for future research.