Anxiety-linked attentional bias and its modification: Illustrating the importance of distinguishing processes and procedures in experimental psychopathology research

Cognitive bias modification: A review of meta-analyses

BACKGROUND

Cognitive bias modification (CBM) is a novel, but controversial intervention with considerable divergence amongst conclusions in individual studies and reviews. This systematic review synthesizes meta-analyses of CBM to determine whether CBM is effective, and what parameters most reliably evoke the process of CBM.

METHODS

A systematic literature search resulted in twelve meta-analyses in total, from which the published effect sizes were extracted.

RESULTS

Attention bias modification (ABM) shifted targeted biases in adults (ES = 0.24-1.16), was effective as a buffer to stressor vulnerability (ES = 0.33-0.77) and in symptom control (ES = 0.16-0.41). Cognitive bias modification for interpretation (CBM-I) modified targeted biases (ES = 0.52-0.81) but did not reliably reduce stressor vulnerability (ES = 0.01-0.24, p > .05). CBM consistently reduced anxiety symptoms, but effects on depressive symptomatology were less compelling. The long-term efficacy of CBM was only supported in addiction studies.

LIMITATIONS

The review included a single CBM-I only meta-analysis, and two meta-analyses with pooled reporting on ABM and CBM-I outcomes.

CONCLUSIONS

Overall, this synthesis shows CBM is effective in the short-term for anxiety in adults, and highlights some conditions under which CBM is most efficacious. Rather than debating the efficacy of CBM, future research should focus on developing procedures that more reliably induce bias modification and determining the most efficacious clinical applications.

Core Mechanisms of Cognitive Behavioral Therapy for Anxiety and Depression: A Review

This article reviews the extant literature on mediators of change in cognitive behavioral therapy (CBT) for anxiety and depression. The authors briefly discuss the efficacy of CBT for anxiety and depression and methods of mediation analysis and detection. Then the authors discuss fear extinction in anxiety treatment and cognitive change in depression treatment.

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.

The Effects of Training Contingency Awareness During Attention Bias Modification on Learning and Stress Reactivity

Current attention bias modification (ABM) procedures are designed to implicitly train attention away from threatening stimuli with the hope of reducing stress reactivity and anxiety symptoms. However, the mechanisms underlying effective ABM delivery are not well understood, with awareness of the training contingency suggested as one possible factor contributing to ABM efficacy. Here, 45 high-anxious participants were trained to divert attention away from threat in two ABM sessions. They were randomly assigned to one of three training protocols: an implicit protocol, comprising two standard implicit ABM training sessions; an explicit protocol, comprising two sessions with explicit instruction as to the attention training contingency; and an implicit-explicit protocol, in which participants were not informed of the training contingency in the first ABM session and informed of it at the start of the second session. We examined learning processes and stress reactivity following a stress-induction task. Results indicate that relative to implicit instructions, explicit instructions led to stronger learning during the first training session. Following rest, the explicit and implicit groups exhibited consolidation-related improvement in performance, whereas no such improvement was noted for the implicit-explicit group. Finally, although stress reactivity was reduced after training, contingency awareness did not yield a differential effect on stress reactivity measured using both self-reports and skin conductance, within and across sessions. These results suggest that explicit ABM administration leads to greater initial learning during the training protocol while not differing from standard implicit administration in terms of off-line learning and stress reactivity.

Internet-based attentional bias modification training as add-on to regular treatment in alcohol and cannabis dependent outpatients: a study protocol of a randomized control trial

BACKGROUND

The automatic tendency to attend to and focus on substance-related cues in the environment (attentional bias), has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, contribute to treatment outcome and the reduction of relapse rates. Based on some promising research findings, we designed a study to test the clinical relevance of ABM as an add-on component of regular intervention for alcohol and cannabis patients.

DESIGN/METHODS

The current protocol describes a study which will investigate the effectiveness and cost-effectiveness of a newly developed home-delivered, multi-session, internet-based ABM (iABM) intervention as an add-on to treatment as usual (TAU). TAU consists of cognitive behavioural therapy-based treatment according to the Dutch guidelines for the treatment of addiction. Participants (N = 213) will be outpatients from specialized addiction care institutions diagnosed with alcohol or cannabis dependency who will be randomly assigned to one of three conditions: TAU + iABM; TAU + placebo condition; TAU-only. Primary outcome measures are substance use, craving, and rates of relapse. Changes in attentional bias will be measured to investigate whether changes in primary outcome measures can be attributed to the modification of attentional bias. Indices of cost-effectiveness and secondary physical and psychological complaints (depression, anxiety, and stress) are assessed as secondary outcome measures.

DISCUSSION

This randomized control trial will be the first to investigate whether a home-delivered, multi-session iABM intervention is (cost-) effective in reducing relapse rates in alcohol and cannabis dependency as an add-on to TAU, compared with an active and a waiting list control group. If proven effective, this ABM intervention could be easily implemented as a home-delivered component of current TAU.

TRIAL REGISTRATION

Netherlands Trial Register, NTR5497 , registered on 18th September 2015.

Gender Differences in the Difficulty in Disengaging from Threat among Children and Adolescents With Social Anxiety

There is some research showing that social anxiety is related with attentional bias to threat. However, others fail to find this relationship and propose that gender differences may play a role. The aim of this study was to investigate the gender differences in the subcomponents of attentional bias to threat (hypervigilance and difficulty in disengaging) among children and adolescents with social anxiety. Overall, 181 youngsters aged between 10 and 14 participated in the current study. Images of disgusted faces were used as threat stimuli in an Exogenous Cueing Task was used to measure the subcomponents of attentional bias. Additionally, the Social Anxiety Scale for Children was used to measure social anxiety. The repeated measures ANOVA showed that male participants with high social anxiety showed difficulty in disengaging from threat, but this was not the case for female participants. Our results indicated that social anxiety is more related with attentional bias to threat among male children and adolescents than females. These findings suggested that developing gender-specific treatments for social anxiety may improve treatment effects.

Current forms of inhibitory training produce no greater reduction in drinking than simple assessment: A preliminary study

BACKGROUND

Disinhibition is apparent in users of many substances, including heavy drinkers. Previous research has shown that brief training to improve inhibitory control is associated with reduced alcohol consumption. We investigated whether a new form of inhibitory training would produce greater reductions, relative to a carefully designed control condition and a proven method of reducing consumption, the Brief Alcohol Intervention (BAI).

METHODS

One hundred and fourteen regular drinkers were assigned randomly to one of five training conditions: Control (no inhibitory training); Beer-NoGo (inhibit responses linked to task-irrelevant pictures of beer); Restrained-Stop (requiring more urgent inhibition but without pictures of beer); Combined (a previously untested form of training requiring urgent inhibition to pictures of beer); or BAI. The outcome measures were alcohol consumption in the week before and after training, and in a bogus taste test administered immediately post-training.

RESULTS

Participation in the study, regardless of condition, was associated with reductions in weekly consumption. However, only the BAI produced a greater reduction relative to the Control condition. The training tasks were not associated with reductions in taste test consumption.

CONCLUSIONS

Although concerns about low power limit confidence, the current study suggests that three forms of inhibitory training do not have a substantial effect on drinking beyond the effect of simple assessment, in comparison to a control task which does not promote impulsive responding. Future research needs to establish a training protocol that produces greater reductions in consumption not only relative to the effect of assessment but also relative to a BAI.

Online visual search attentional bias modification for adolescents with heightened anxiety and depressive symptoms: A randomized controlled trial

Anxiety and depression, which are highly prevalent in adolescence, are both characterized by a negative attentional bias. As Attentional Bias Modification (ABM) can reduce such a bias, and might also affect emotional reactivity, it could be a promising early intervention. However, a growing number of studies also report comparable improvements in both active and placebo groups. The current study investigated the effects of eight online sessions of visual search (VS) ABM compared to both a VS placebo-training and a no-training control group in adolescents with heightened symptoms of anxiety and/or depression (n = 108). Attention bias, interpretation bias, and stress-reactivity were assessed pre- and post-training. Primary outcomes of anxiety and depressive symptoms, and secondary measures of emotional resilience were assessed pre- and post-training and at three and six months follow-up. Results revealed that VS training reduced attentional bias compared to both control groups, with stronger effects for participants who completed more training sessions. Irrespective of training condition, an overall reduction in symptoms of anxiety and depression and an increase in emotional resilience were observed up to six months later. The training was evaluated relatively negatively. Results suggest that online ABM as employed in the current study has no added value as an early intervention in adolescents with heightened symptoms.

Autobiographical episodic memory-based training for the treatment of mood, anxiety and stress-related disorders: A systematic review and meta-analysis

We review evidence for training programmes that manipulate autobiographical processing in order to treat mood, anxiety, and stress-related disorders, using the GRADE criteria to judge evidence quality. We also position the current status of this research within the UK Medical Research Council's (2000, 2008) framework for the development of novel interventions. A literature search according to PRISMA guidelines identified 15 studies that compared an autobiographical episodic memory-based training (AET) programme to a control condition, in samples with a clinician-derived diagnosis. Identified AET programmes included Memory Specificity Training (Raes, Williams, & Hermans, 2009), concreteness training (Watkins, Baeyens, & Read, 2009), Competitive Memory Training (Korrelboom, van der Weele, Gjaltema, & Hoogstraten, 2009), imagery-based training of future autobiographical episodes (Blackwell & Holmes, 2010), and life review/reminiscence therapy (Arean et al., 1993). Cohen's d was calculated for between-group differences in symptom change from pre- to post-intervention and to follow-up. We also completed meta-analyses for programmes evaluated across multiple studies, and for the overall effect of AET as a treatment approach. Results demonstrated promising evidence for AET in the treatment of depression (d=0.32), however effect sizes varied substantially (from -0.18 to 1.91) across the different training protocols. Currently, research on AET for the treatment of anxiety and stress-related disorders is not yet at a stage to draw firm conclusions regarding efficacy as there were only a very small number of studies which met inclusion criteria. AET offers a potential avenue through which low-intensity treatment for affective disturbance might be offered.

Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias

Computer-based approaches, such as Attention Bias Modification (ABM), could help improve access to care for anxiety. Study-level meta-analyses of ABM have produced conflicting findings and leave critical questions unresolved regarding ABM's mechanisms of action and clinical potential. We pooled patient-level datasets from randomized controlled trials of children and adults with high-anxiety. Attentional bias (AB) towards threat, the target mechanism of ABM, was tested as an outcome and a mechanistic mediator and moderator of anxiety reduction. Diagnostic remission and Liebowitz Social Anxiety Scale (LSAS) were clinical outcomes available in enough studies to enable pooling. Per-patient data were obtained on at least one outcome from 13/16 eligible studies [86% of eligible participants; n=778]. Significant main effects of ABM on diagnostic remission (ABM-22.6%, control-10.8%; OR=2.57; p=0.006) and AB (β* (95%CI)=-0.63 (-0.83, -0.42); p<0.00005) were observed. There was no main effect of ABM on LSAS. However, moderator analyses suggested ABM was effective for patients who were younger (≤37y), trained in the lab, and/or assessed by clinicians. Under the same conditions where ABM was effective, mechanistic links between AB and anxiety reduction were supported. Under these specific circumstances, ABM reduces anxiety and acts through its target mechanism, supporting ABM's theoretical basis while simultaneously suggesting clinical indications and refinements to improve its currently limited clinical potential.