Simply Imagining Sunshine, Lollipops and Rainbows Will Not Budge the Bias: The Role of Ambiguity in Interpretive Bias Modification

Shifting Episodic Prediction With Online Cognitive Bias Modification: A Randomized Controlled Trial

Negative future thinking pervades emotional disorders. This hybrid efficacy-effectiveness trial tested a four-session, scalable online cognitive bias modification program for training more positive episodic prediction. 958 adults (73.3% female, 86.5% White, 83.4% from United States) were randomized to positive conditions with ambiguous future scenarios that ended positively, 50/50 conditions that ended positively or negatively, or a control condition with neutral scenarios. As hypothesized (preregistration: https://osf.io/jrst6), positive training participants improved more than control participants in negative expectancy bias (d = -0.58), positive expectancy bias (d = 0.80), and self-efficacy (d = 0.29). Positive training was also superior to 50/50 training for expectancy bias and optimism (d = 0.31). Training gains attenuated yet remained by 1-month follow-up. Unexpectedly, participants across conditions improved comparably in anxiety and depression symptoms and growth mindset. Targeting a transdiagnostic process with a scalable program may improve bias and outlook; however, further validation of outcome measures is required.

Feasibility and Acceptability of Cognitive Bias Modification for Interpretation as an Adjunctive Treatment for OCD and Related Disorders: A Pilot Randomized Controlled Trial

Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs. We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation. Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation. This was the first study to evaluate CBM-I in naturalistic treatment for adults seeking IRT for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.

Neural correlates of cognitive bias modification for interpretation

The effectiveness of cognitive bias modification for interpretation (CBM-I), a treatment method employed to reduce social anxiety (SA), has been examined. However, the neural correlates of CBM-I remain unclear, and we aimed to elucidate brain activities during intervention and activity changes associated with CBM-I effectiveness in a pre–post intervention comparison. Healthy participants divided into two groups (CBM, control) were scanned before, during and after intervention using functional magnetic resonance imaging. Ambiguous social situations followed by positive outcomes were repeatedly imagined by the CBM group during intervention, while half of the outcomes in the control group were negative. Whole-brain analysis revealed that activation of the somatomotor and somatosensory areas, occipital lobe, fusiform gyrus and thalamus during intervention was significantly greater in the CBM than in the control group. Furthermore, altered activities in the somatomotor and somatosensory areas, occipital lobe and posterior cingulate gyrus during interpreting ambiguous social situations showed a significant group × change in SA interaction. Our result suggests that when facing ambiguous social situations, positive imagery instilled by CBM-I is recalled, and interpretations are modified to contain social reward. These findings may help to suggest an alternative manner of enhancing CBM-I effectiveness from a cognitive-neuroscience perspective.

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.

Positive imagery training increases positive self-referent cognition in depression

Depressed adults often show a bias towards negative self-referent processing at the expense of positive self-referent processing. The current study assessed whether a mental imagery intervention (Positive Self Reference Training-PSRT) delivered via the Internet could improve self-referent processing and depressive symptomatology among adults with moderate or greater depression symptoms. Participants were recruited via online methods and randomly assigned to one of two computerized interventions: active PSRT (n=44) or control training (NTC; n=43). The PSRT involved visualizing the self in response to different positive cues (e.g., an achievement) every other day for two weeks. The NTC provided neutral cues about objects. Self-referential processing of positive and negative adjectives and depression symptoms were measured at baseline, one week, and two weeks after initiating training. Over those two weeks, PSRT participants showed a greater increase in positive self-referent processing than did NTC participants. Negative self-referent processing and symptoms of depression declined comparably in both groups. Similarly, for both groups, increase in positive and decrease in negative self-referent processing was associated with a greater reduction in depression. These results indicate that mental imagery has the potential to improve self-referential processing, especially for positive stimuli, which may, in turn, help reduce depressive symptomatology.

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.

The effect of positive mood induction on reducing reinstatement fear: Relevance for long term outcomes of exposure therapy

While exposure therapy is effective in treating anxiety, fear can return after exposure. Return of fear can be understood through mechanisms of extinction learning. One form of return of fear is reinstatement, or, the fear that results from an unsignaled unconditional stimulus (US) presentation after extinction. Though the conditional response (CR; e.g., fear) typically reduces during extinction, the excitatory conditional stimulus (CS+) valence remains negative. The more negative the CS+ valence after the end of extinction, the greater the fear at reinstatement. The current study evaluated the degree to which positive mood induction (positive imagery training; PIT) compared to control (positive verbal training; PVT) before extinction a) decreased CS+ negative valence during extinction and b) reduced reinstatement fear. Compared to PVT, PIT a) increased positive affect, b) decreased post-extinction CS+ negative valence, and c) reduced reinstatement responding as measured by eye blink startle reflex (when shock was used at reinstatement) and self-report fear (regardless of reinstatement US type). Results suggest that increasing positive affect prior to exposure therapy could reduce relapse through reinstatement.

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Post-extinction CS+ valence is a known predictor of reinstatement CS+ fear.

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Pre-extinction positive mood induction increased post-extinction CS+ valence.

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Pre-extinction positive mood induction decreased reinstatement CS+ fear.

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Results suggest positive mood induction prior to exposure could reduce relapse in anxiety disorders.

Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): a randomized controlled trial

BACKGROUND

Accruing evidence suggests that positive imagery-based cognitive bias modification (CBM) could have potential as a standalone targeted intervention for depressive symptoms or as an adjunct to existing treatments. We sought to establish the benefit of this form of CBM when delivered prior to Internet cognitive behavioral therapy (iCBT) for depression

METHODS

A randomized controlled trial (RCT) of a 1-week Internet-delivered positive CBM vs. an active control condition for participants (N=75, 69% female, mean age=42) meeting diagnostic criteria for major depression; followed by a 10-week iCBT program for both groups.

RESULTS

Modified intent-to-treat marginal and mixed effect models demonstrated no significant difference between conditions following the CBM intervention or the iCBT program. In both conditions there were significant reductions (Cohen׳s d .57-1.58, 95% CI=.12-2.07) in primary measures of depression and interpretation bias (PHQ9, BDI-II, AST-D). Large effect size reductions (Cohen׳s d .81-1.32, 95% CI=.31-1.79) were observed for secondary measures of distress, disability, anxiety and repetitive negative thinking (K10, WHODAS, STAI, RTQ). Per protocol analyses conducted in the sample of participants who completed all seven sessions of CBM indicated between-group superiority of the positive over control group on depression symptoms (PHQ9, BDI-II) and psychological distress (K10) following CBM (Hedges g .55-.88, 95% CI=-.03-1.46) and following iCBT (PHQ9, K10). The majority (>70%) no longer met diagnostic criteria for depression at 3-month follow-up.

LIMITATIONS

The control condition contained many active components and therefore may have represented a smaller 'dose' of the positive condition.

CONCLUSIONS

Results provide preliminary support for the successful integration of imagery-based CBM into an existing Internet-based treatment for depression.

Practice makes perfect: Training the interpretation of emotional ambiguity

The interpretation of emotionally ambiguous words, sentences, or scenarios can be altered through training procedures that are collectively called cognitive bias modification for interpretation (CBM-I). In three experiments, we systematically manipulated the nature of the training in order to discriminate between emotional priming and ambiguity resolution accounts of training effects. In Experiment 1 participants completed word fragments that were consistently related to either a negative or benign interpretation of an ambiguous sentence. In a subsequent semantic priming task they demonstrated an interpretation bias, in that they were faster to identify relatedness of targets that were associated with the training-congruent meaning of an emotionally ambiguous homograph. We then manipulated the training sentences to show that interpretation bias was eliminated when participants simply completed valenced word fragments following unrelated sentences (Experiment 2), or completed fragments that were related to emotional but unambiguous sentences (Experiment 3). Only when participants were required to actively resolve emotionally ambiguous sentences during training did changes in interpretation emerge at test. Findings suggest that CBM-I achieves its effects by altering a production rule that aids the selection of meaning from emotionally ambiguous alternatives, in line with an ambiguity resolution account.

Positive Imagery-Based Cognitive Bias Modification as a Web-Based Treatment Tool for Depressed Adults: A Randomized Controlled Trial

Depression is a global health problem requiring treatment innovation. Targeting neglected cognitive aspects may provide a useful route. We tested a cognitive-training paradigm using positive mental imagery (imagery cognitive bias modification, imagery CBM), developed via experimental psychopathology studies, in a randomized controlled trial. Training was delivered via the Internet to 150 individuals with current major depression. Unexpectedly, there was no significant advantage for imagery CBM compared with a closely matched control for depression symptoms as a whole in the full sample. In exploratory analyses, compared with the control, imagery CBM significantly improved anhedonia over the intervention and improved depression symptoms as a whole for those participants with fewer than five episodes of depression and those who engaged to a threshold level of imagery. Results suggest avenues for improving imagery CBM to inform low-intensity treatment tools for depression. Anhedonia may be a useful treatment target for future work.

When we should worry more: using cognitive bias modification to drive adaptive health behaviour

A lack of behavioural engagement in health promotion or disease prevention is a problem across many health domains. In these cases where people face a genuine danger, a reduced focus on threat and low levels of anxiety or worry are maladaptive in terms of promoting protection or prevention behaviour. Therefore, it is possible that increasing the processing of threat will increase worry and thereby enhance engagement in adaptive behaviour. Laboratory studies have shown that cognitive bias modification (CBM) can increase or decrease anxiety and worry when increased versus decreased processing of threat is encouraged. In the current study, CBM for interpretation (CBM-I) is used to target engagement in sun protection behaviour. The goal was to investigate whether inducing a negative rather than a positive interpretation bias for physical threat information can enhance worry elicited when viewing a health campaign video (warning against melanoma skin cancer), and consequently lead to more adaptive behaviour (sun protection). Participants were successfully trained to either adopt a positive or negative interpretation bias using physical threat scenarios. However, contrary to expectations results showed that participants in the positive training condition reported higher levels of worry elicited by the melanoma video than participants in the negative training condition. Video elicited worry was, however, positively correlated with a measure of engagement in sun protection behaviour, suggesting that higher levels of worry do promote adaptive behaviour. These findings imply that more research is needed to determine under which conditions increased versus decreased processing of threat can drive adaptive worry. Various potential explanations for the current findings and suggestions for future research are discussed.

Optimizing the ingredients for imagery-based interpretation bias modification for depressed mood: is self-generation more effective than imagination alone?

Negative interpretation is thought to be crucial in the development and maintenance of depression. Recently developed cognitive bias modification paradigms, intending to change these biases towards a more optimistic interpretation tendency (CBM-I), seem to offer new promising implications for cognitive therapy innovation. This study aimed to increase our knowledge of the underlying mechanisms of action of imagery-based CBM-I in the context of depressed mood. We therefore compared the efficacy of CBM-I requiring participants to imagine standardized positive resolutions to a novel, more active training version that required participants to generate the positive interpretations themselves. Fifty-four participants were randomly allocated to (1) standardized CBM-I, (2) self-generation CBM-I or (3) a control group. Outcome measures included self-report mood measures and a depression-related interpretation bias measure. Both positive training variants significantly increased the tendency to interpret fresh ambiguous material in an optimistic manner. However, only the standardized imagery CBM-I paradigm positively influenced mood.