When Ignorance is Bliss: Explicit Instruction and the Efficacy of CBM-A for Anxiety

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.

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.

The effectiveness of cognitive bias modification in reducing substance use in detained juveniles: An RCT

BACKGROUND AND OBJECTIVE

Young offenders show high levels of substance use. Treatment programs within detention settings are less effective. Cognitive bias modification (CBM) is a promising supplement to substance use treatment. This study tests the effectiveness of CBM in young offenders to reduce cannabis and alcohol use, and delinquent recidivism.

METHOD

A randomized controlled trial added CBM to treatment as usual (TAU), among 181 youth in juvenile detention centers. In a factorial design, participants were randomly assigned to either active- or sham-training for two varieties of CBM, targeting attentional-bias (AtB) and approach-bias (ApB) for their most used substance. Substance use was measured with the Alcohol and Cannabis Use Disorder Identification Tests. Delinquent recidivism was measured with the International Self-Report Delinquency (ISRD) survey.

RESULTS

At pretest, participants showed AtB but no ApB for both substances. For alcohol, a decrease was found in AtB in the active-training group. For cannabis, a decrease was found in AtB for both active- and sham-training groups. Regardless of condition, no effects were found on substance use or ISRD scores at follow-up.

LIMITATIONS

The sample is judicial, not clinical, as is the setting. TAU and participant goals are not necessarily substance related.

CONCLUSIONS

Young offenders show a significant attentional-bias towards substance cues. CBM changed attentional-biases but not substance use. Combining CBM with a motivational intervention is advised. Follow-up research should better integrate CBM with running treatment programs. New developments regarding CBM task design could be used that link training better to treatment.

The influence of single-session reward-based attentional bias modification on attentional biases towards threat as measured by the N2pc component

Attentional biases toward threatening faces have repeatedly been studied in the context of social anxiety, with etiological theories suggesting exacerbated biases as a possible cause for the latter. To counteract these postulated effects, research has focused on the concept of attentional bias manipulation (ABM), in which spatial contingencies between succeeding stimuli are traditionally employed in training paradigms designed to deliberately shift automatic attention processes away from threat-related stimuli. The ABM research field has been faced with various methodological challenges, such as inconsistent results, low reliabilities of dependent variables and a high susceptibility to moderating factors. We aimed to combine several recent approaches to address these issues. Drawing upon theories of value-driven attention, we explored reward-based contingencies in a Dot Probe task to improve the training's efficacy, combined with neurophysiological measures for greater reliability compared to reaction times, while evaluating the moderating effect of explicitness in the instruction. In a healthy sample (N = 60) and within a single session, we found a general attentional bias toward angry faces present across all conditions as indicated by the N2pc, which was, however, marked by large intrinsic lateralization effects, with submeasures exhibiting opposing polarities. This prompted us to explore an alternative, intrahemispheric calculation method. The new N2pc variant showed the attentional bias to have disappeared at the end of the training session within the explicit instruction group. Reliabilities of the main dependent variables were varied from excellent to questionable, which, together with the exploratory nature of the analysis, leaves this result as preliminary.

Doubting the double-blind: Introducing a questionnaire for awareness of experimental purposes in neurofeedback studies

Double-blinding subjects to the experiment's purpose is an important standard in neurofeedback studies. However, it is difficult to provide evidence that humans are entirely unaware of certain information. This study used insights from consciousness studies and neurophenomenology to develop a contingency awareness questionnaire for neurofeedback. We assessed whether participants had an awareness of experimental purposes to manipulate their attention and multisensory perception. A subset of subjects (5 out of 20) gained a degree of awareness of experimental purposes as evidenced by their correct guess about the purposes of the experiment to affect their attention and multisensory perceptions specific to their double-blinded group assignment. The results warrant replication before they are applied to clinical neurofeedback studies, given the considerable time taken to perform the questionnaire (∼25 min). We discuss the strengths and limitations of our contingency awareness questionnaire and the growing appeal of the double-blinded standard in clinical neurofeedback studies.

Classroom Concordancing and Second Language Motivational Self-System: A Data-Driven Learning Approach

Research shows that exploring language corpora through data-driven learning (DDL) plays a significant role in language learning. Nevertheless, it is not clear if using concordancing as an application of DDL affects the learners’ second language motivation. To address this gap, the current study adopted a triangulation design, validating quantitative data model, and a quasi-experimental (comparison group, pretest-posttest) design. Ninety English-major university students with an intermediate level of English language proficiency, divided into control and experimental groups, took part in the study. Drawing on a second language motivational self-system questionnaire, the findings of the study did not result in any statistically significant differences between the students in their second language motivational self-system. Altogether, the students found learning English through a DDL approach with concordancing less motivating than receiving explicit instruction. The study has implications for language teaching and learning.

Behavioral modification decreases approach bias in young adults with internet gaming disorder

BACKGROUND

One of the key symptoms of Internet gaming disorder is the impulsive pursuit of Internet games, which causes individuals with this disorder to have a tendency to approach gaming cues. Dual processing theory states that this approach bias is caused by the suppression of reflective processing and the hyperactivity of impulsive processing. Therefore, reverse modification training for approach bias can suppress impulsive processing, thereby reducing or treating the disorder.

METHOD

In this study, 48 individuals with Internet gaming disorder were selected and randomly assigned to the following two groups: the experimental group and the control group. The 24 participants in the experimental group received a 4-day stimulus-response compatibility (SRC) approach bias modification treatment, whereas the 24 participants in the control group received a corresponding SRC pseudomodification training.

RESULTS

The approach response time of both groups to the gaming cues was significantly shorter than that to the neutral cues at baseline. After the modification, the response time of the experimental group to the gaming cues significantly increased, whereas the scores for Internet gaming disorder severity, anxiety level and craving significantly decreased. However, the control group subjects did not show these effects.

CONCLUSION

The current results imply that individuals with Internet gaming disorder show approach bias toward Internet gaming cues, and SRC reverse modification training can significantly correct this bias and therefore have therapeutic effects to some extent.

Individualized Web-Based Attention Training With Evidence-Based Counseling to Address HIV Treatment Adherence and Psychological Distress: Exploratory Cohort Study

BACKGROUND

The prevalence of mood, trauma, and stressor-related disorders is disproportionately higher among people living with HIV than among individuals without the virus. Poor adherence to HIV treatment and heightened psychological distress have been linked to symptoms associated with these disorders.

OBJECTIVE

The objective of this exploratory pilot study was to develop and implement an intervention that combined individualized web-based attention training with evidence-based counseling to promote HIV treatment adherence and reduce psychological distress among people living with HIV. The study targeted African American and Latino young men who have sex with men, two population groups in the US that continue to experience disparities in HIV treatment outcomes.

METHODS

Study participants with elevated symptoms of depression and suboptimal adherence to antiretroviral therapy were recruited primarily through referrals from Los Angeles health and social service providers as well as postings on social media. Participants enrolled in the 4-week intervention received weekly counseling for adherence and daily access to web-based attention training via their personal mobile devices or computers.

RESULTS

Of the 14 participants who began the intervention, 12 (86%) completed all sessions and study procedures. Using a pretest-posttest design, findings indicate significant improvements in adherence, depressive symptoms, and attention processing. Overall, the proportion of participants reporting low adherence to antiretroviral therapy declined from 42% at baseline to 25% at intervention completion (P=.02, phi=0.68). Mean depressive symptoms measured by the 9 item Patient Health Questionnaire (PHQ-9) showed a substantial reduction of 36% (P=.002, Cohen d=1.2). In addition, participants' attentional processing speeds for all types of stimuli pairings presented during attention training improved significantly (P=.01 and P=.02) and were accompanied by large effect sizes ranging from 0.78 to 1.0.

CONCLUSIONS

Our findings support the feasibility of web-based attention training combined with counseling to improve antiretroviral therapy adherence among patients with psychological distress. Future research should include a larger sample, a control group, and longer-term follow-up.

Cognitive bias modification to prevent depression (COPE): results of a randomised controlled trial

BACKGROUND

Although efficacious treatments for major depression are available, efficacy is suboptimal and recurrence is common. Effective preventive strategies could reduce disability associated with the disorder, but current options are limited. Cognitive bias modification (CBM) is a novel and safe intervention that attenuates biases associated with depression. This study investigated whether the delivery of a CBM programme designed to attenuate negative cognitive biases over a period of 1 year would decrease the incidence of major depression among adults with subthreshold symptoms of depression.

METHODS

Randomised double-blind controlled trial delivered an active CBM intervention or a control intervention over 52 weeks. Two hundred and two community-dwelling adults who reported subthreshold levels of depression were randomised (100 intervention, 102 control). The primary outcome of interest was the incidence of major depressive episode assessed at 11, 27 and 52 weeks. Secondary outcomes included onset of clinically significant symptoms of depression, change in severity of depression symptoms and change in cognitive biases.

RESULTS

Adherence to the interventions was modest though did not differ between conditions. Incidence of major depressive episodes was low. Conditions did not differ in the incidence of major depressive episodes. Likewise, conditions did not differ in the incidence of clinically significant levels of depression, change in the severity of depression symptoms or change in cognitive biases.

CONCLUSIONS

Active CBM intervention did not decrease the incidence of major depressive episodes as compared to a control intervention. However, adherence to the intervention programme was modest and the programme failed to modify the expected mechanism of action.

A randomized controlled trial of a virtual reality based, approach-avoidance training program for alcohol use disorder: a study protocol

BACKGROUND

The approach-avoidance training program (AATP) has shown preliminary promise as an add-on to standard treatment for alcohol dependence. However, knowledge is lacking as to whether the effectiveness of AATP can be enhanced further when performed in a typical drinking situation. The main aim of this study is to investigate whether approach-avoidance training implemented in a virtual reality bar environment is superior to the classical joystick PC-version of the AATP.

METHODS

The study will be implemented as a randomized controlled trial. A total of 204consecutively enrolled alcohol use disorder (AUD) patients, recruited from alcohol inpatient clinics in Germany, Poland and Denmark, will be randomized into one of three groups at the start of standard alcohol treatment: group A) stimuli-relevant AATP + treatment as usual (TAU); group B) stimuli-relevant AATP in virtual reality + TAU, and group C) TAU only (control group). Treatment outcomes will be assessed at pre-treatment, post-treatment and 3-month follow-up. Repeated-measures ANOVA will be applied to compare the trajectories of the groups over time on drinking, craving and impulsiveness outcomes. It is hypothesized that the two experimental groups will achieve better treatment outcomes compared to group C and that group B will achieve better outcomes than group A.

DISCUSSION

This study is the first trial examining the effectiveness of stimuli-relevant AATP delivered in a VR environment. The use of VR has shown promise in enhancing the effectiveness of other psychological treatments and since AATP has already been shown effective as add-on treatment, it is of interest to investigate whether these effects can be further enhanced by implementing the program in more ecologically valid environments. If proven effective, the AATP-VR can, like the AATP, be implemented easily and cheaply as add-on treatment or continued care to enhance the effectiveness of current evidence-based treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04283305 Registration date: 24.02.20.

Pilot study: Improving attention bias modification of alcohol cues through concealed gaze-contingent feedback in alcohol dependence

In an attempt to improve attention bias modification (ABM), we tested whether an attentional training protocol which featured monetary operant conditioning of eye-gaze to avoid alcohol stimuli in alcohol-dependent patients could reduce attention, craving and relapse to alcohol. We employed a pilot randomized control trial (RCT) with 21 detoxified alcohol dependent patients (48.9 ± 10 years of age, 9 male) from an inpatient and outpatient treatment centre. The novel concealed operant conditioning paradigm provided monetary reinforcements or punishments respective to eye-gaze patterns towards neutral or towards alcohol stimuli along with an 80% probability of a to-be-detected probe appearing following neutral stimuli (ET-ABM group). Patients in the control-group received random monetary feedback and a 50/50 ABM contingency. We compared AB on trained and untrained stimuli and addiction severity measures of obsessive thoughts and desires to alcohol following training. We further assessed addiction severity and relapse outcome at a 3-month follow-up. Results indicate that this attentional retraining only worked for the trained stimuli and did not generalize to untrained stimuli or to addiction severity measures or relapse outcome. Potential explanations for lack of generalization include the low sample size and imbalances on important prognostic variables between the active-group and control-group. We discuss progress and challenges for further research on cognitive training using gaze-contingent feedback.

Linear Ballistic Accumulator Modeling of Attentional Bias Modification Revealed Disturbed Evidence Accumulation of Negative Information by Explicit Instruction

In recent years, several attentional bias modification (ABM) studies have been conducted. Previous studies have suggested that explicit instruction (i.e., informing participants of the contingency of stimuli) enhances the effect of ABM. However, the specific working mechanism has not been identified. This is partly because reaction time (RT) data are typically reduced to an attention bias score, which is a mere difference of RT between experimental and control conditions. This data reduction causes a loss of information, as RT reflects various cognitive processes at play while making a response or decision. To overcome this issue, the present study applied linear ballistic accumulator (LBA) modeling to the outcomes (RT measures) of explicitly guided (compared to standard) ABM. This computational modeling approach allowed us to dissociate RTs into distinct components that can be relevant for attentional bias, such as efficiency of information processing or prior knowledge of the task; this provides an understanding of the mechanism of action underlying explicitly guided ABM. The analyzed data were RT-observed in the dot-probe task, which was administered before and after 3-days of ABM training. Our main focus was on the changes in LBA components that would be induced by the training. Additionally, we analyzed in-session performances over the 3 days of training. The LBA analysis revealed a significant reduction in processing efficiency (i.e., drift rate) in the congruent condition, where the target probe is presented in the same location as a negative stimulus. This explains the reduction in the overall attentional bias score, suggesting that explicit ABM suppresses processing of negative stimuli. Moreover, the results suggest that explicitly guided ABM may influence prior knowledge of the target location in the training task and make participants prepared to respond to the task. These findings highlight the usefulness of LBA-based analysis to explore the underlying cognitive mechanisms in ABM, and indeed our analyses revealed the differences between the explicit and the standard ABM that could not be identified by traditional RT analysis or attentional bias scores.

Investigating the Effects of Inhibition Training on Attentional Bias Change: A Simple Bayesian Approach

Attention bias modification (ABM), in which participants are trained to direct attention away from negative information, has been shown to reduce anxiety. However, such findings have been inconsistent. Changes in attentional bias are often absent, suggesting need for further investigation of the underlying mechanisms of ABM, as well as better statistical methods to analyze ABM data in order to reduce inferential error. In this study, we (a) compared inhibition control training to standard ABM training conditions, and (b) demonstrated the benefits of using simple Bayesian analyses to analyze ABM data. We recruited 116 participants and assessed their attentional bias prior to and after training, which involved practice avoiding negative stimuli, attending to negative stimuli, or avoiding a non-emotional, exogenous attentional cue (inhibitory control training). Our results suggested no impact of any of the training conditions on attentional bias. We further demonstrate Bayesian analyses may help control for both Type I and Type II error relative to a frequentist approach.

Cognitive Bias Modification for Behavior Change in Alcohol and Smoking Addiction: Bayesian Meta-Analysis of Individual Participant Data

Cognitive Bias Modification (CBM) refers to a family of interventions targeting substance-related cognitive biases, which have been found to play a role in the maintenance of addictive behaviors. In this study, we conducted a Bayesian meta-analysis of individual patient data from studies investigating the effects of CBM as a behavior change intervention for the treatment of alcohol and tobacco use disorders, in individuals aware of the behavior change goal of the studies. Main outcomes included reduction in the targeted cognitive biases after the intervention and in substance use or relapse rate at the short-to-long term follow-up. Additional moderators, both at the study-level (type of addiction and CBM training) and at the participant-level (amount of completed training trials, severity of substance use), were progressively included in a series of hierarchical mixed-effects models. We included 14 studies involving 2435 participants. CBM appeared to have a small effect on cognitive bias (0.23, 95% credible interval = 0.06–0.41) and relapse rate (−0.27, 95% credible interval = −0.68 – 0.22), but not on reduction of substance use. Increased training practice showed a paradoxical moderation effect on relapse, with a relatively lower chance of relapse in the control condition with increased practice, compared to the training condition. All effects were associated with extremely wide 95% credible intervals, which indicate the absence of enough evidence in favor or against a reliable effect of CBM on cognitive bias and relapse rate in alcohol and tobacco use disorders. Besides the need for a larger body of evidence, research on the topic would benefit from a stronger adherence to the current methodological standards in randomized controlled trial design and the systematic investigation of shared protocols of CBM.

Statistical learning as a predictor of attention bias modification outcome: A preliminary study among socially anxious patients

Attention bias modification (ABM) is a novel therapy designed to modulate attentional biases towards threat typically observed among anxious individuals. Bias modification is allegedly achieved via extraction of a statistical regularity embedded within the treatment task. However, no prior study examined prediction of ABM therapeutic response in relation to patients' capacity to extract statistical properties from the environment, a capacity known as "statistical learning". Here, 30 treatment-seeking patients with social anxiety disorder completed a gold-standard statistical learning task at baseline and then received six sessions of ABM therapy. Results indicate that baseline statistical learning capacity predicts treatment outcome: the better patients' statistical learning capacity, the greater their reduction in clinician-rated and self-reported social anxiety symptoms. Restricted capacities for statistical learning could account for the moderate effect sizes of ABM therapy in clinical trials. Poor response may occur in patients who fail to extract the underlying contingency embedded in ABM.

Attention bias modification training under working memory load increases the magnitude of change in attentional bias

BACKGROUND AND OBJECTIVES

Attention bias modification (ABM) procedures have shown promise as a therapeutic intervention, however current ABM procedures have proven inconsistent in their ability to reliably achieve the requisite change in attentional bias needed to produce emotional benefits. This highlights the need to better understand the precise task conditions that facilitate the intended change in attention bias in order to realise the therapeutic potential of ABM procedures. Based on the observation that change in attentional bias occurs largely outside conscious awareness, the aim of the current study was to determine if an ABM procedure delivered under conditions likely to preclude explicit awareness of the experimental contingency, via the addition of a working memory load, would contribute to greater change in attentional bias.

METHODS

Bias change was assessed among 122 participants in response to one of four ABM tasks given by the two experimental factors of ABM training procedure delivered either with or without working memory load, and training direction of either attend-negative or avoid-negative.

RESULTS

Findings revealed that avoid-negative ABM procedure under working memory load resulted in significantly greater reductions in attentional bias compared to the equivalent no-load condition.

LIMITATIONS

The current findings will require replication with clinical samples to determine the utility of the current task for achieving emotional benefits.

CONCLUSIONS

These present findings are consistent with the position that the addition of a working memory load may facilitate change in attentional bias in response to an ABM training procedure.

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.

Attention Bias Modification (ABM): Review of Effects of Multisession ABM Training on Anxiety and Threat-Related Attention in High-Anxious Individuals

Attention bias modification (ABM) aims to reduce anxiety by reducing attention bias (AB) to threat; however, effects on anxiety and AB are variable. This review examines 34 studies assessing effects of multisession-ABM on both anxiety and AB in high-anxious individuals. Methods include ABM-threat-avoidance (promoting attention-orienting away from threat), ABM-positive-search (promoting explicit, goal-directed attention-search for positive/nonthreat targets among negative/threat distractors), and comparison conditions (e.g., control-attention training combining threat-cue exposure and attention-task practice without AB-modification). Findings indicate anxiety reduction often occurs during both ABM-threat-avoidance and control-attention training; anxiety reduction is not consistently accompanied by AB reduction; anxious individuals often show no pretraining AB in orienting toward threat; and ABM-positive-search training appears promising in reducing anxiety. Methodological and theoretical issues are discussed concerning ABM paradigms, comparison conditions, and AB assessment. ABM methods combining explicit goal-directed attention-search for nonthreat/positive information and effortful threat-distractor inhibition (promoting top-down cognitive control during threat-cue exposure) warrant further evaluation.

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.

Cognitive bias modification of interpretation in children with social anxiety disorder

Negative (or a lack of positive) interpretation of ambiguous social situations has been hypothesised to maintain social anxiety disorder in children, yet there is currently limited evidence to support this. Cognitive Bias Modification of Interpretation (CBM-I) provides a means to explore the causal influence of interpretation bias on social anxiety disorder, and has been associated with a reduction in social anxiety symptoms in adults. Seven to twelve year old children with a diagnosis of social anxiety disorder completed CBM-I training, adapted from materials designed for socially anxious children in the community, or no training. Effects on interpretation bias and social anxiety were assessed. The adapted CBM-I training was not associated with significant changes in benign or negative interpretation. Unsurprisingly given the lack of successful interpretation training, there were no significant changes in child or parent reported social anxiety symptoms, clinician-rated severity or diagnoses and change in interpretation was not significantly associated with change in social anxiety. These findings contrast with some studies with community populations although it is possible that more intensive CBM-I training is required to fully test this hypothesis among clinical groups.

An open trial evaluating an attention bias modification program for overweight adults who binge eat

BACKGROUND AND OBJECTIVES

Binge eating is prevalent and is associated with significant psychiatric and medical comorbidities. To date, the most effective psychological treatments for individuals who binge eat are not effective for all patients and they do not result in significant weight loss. Dual process theories suggest that implicit factors, such as attention bias, may influence behavior, even when the behavior is in opposition to long-term goals. Attention bias modification programs have been tested in other areas of psychopathology, and could be utilized to improve outcomes for people who binge eat. Thus, the aim of this open trial was to conduct a preliminary evaluation of an attention bias modification program (ABM-Food) designed to train attention away from food cues.

METHODS

Adults who binge eat and were overweight or obese enrolled in an 8-week ABM-Food program, which consisted of one session in the lab each week and two training sessions at home. Nine participants completed the ABM-Food training program and the post-treatment assessment, and 8 completed the 3-month post-treatment assessment.

RESULTS

Results showed that the ABM-Food program is a feasible and acceptable treatment for adults who binge eat. Initial effectiveness data showed decreases in weight, eating disorder symptoms, binge eating, loss of control and responsivity to food in the environment, as well as changes in attention bias. The majority of these effects remained at the 3-month follow-up time point.

LIMITATIONS

This study is limited by the single-group open label trial, and the small sample size.

CONCLUSIONS

This open trial provides initial evidence for the feasibility, acceptability and effectiveness of ABM-Food for individuals who binge eat and are overweight or obese.

Refilling the half-empty glass--Investigating the potential role of the Interpretation Modification Paradigm for Depression (IMP-D)

BACKGROUND AND OBJECTIVES

Cognitive biases are known to cause and maintain depression. However, little research has been done on techniques targeting interpretation tendencies found in depression, despite the promising findings of anxiety studies. This paper presents two experiments, investigating the suitability of an Interpretation Modification Paradigm for Depression (IMP-D) in healthy individuals, which has already proven its effectiveness in anxiety (Beard & Amir, 2008). Different from other paradigms, the IMP-D aims at modifying an interpretation bias on response- and on a more implicit reaction time-level, making this task less susceptible to demand effects.

METHODS

The Word-Sentence Association Paradigm for Depression (Hindash & Amir, 2011) was modified and administered in healthy volunteers (experiment I: N = 81; experiment II: N = 105). To enhance a positive interpretation bias, endorsing benign and rejecting negative interpretations of ambiguous scenarios was reinforced through feedback. This intervention was compared to the opposite training (both experiments) and a control training (experiment II only).

RESULTS

Both experiments revealed a significant increase in bias towards benign interpretations on the level of overt decisions, while only in the first experiment a change was found on a reaction time level. These modifications are not reflected in group-differences in emotional vulnerability.

LIMITATIONS

Possible limitations regarding the reliability of inter-dependent response and reaction time measures are discussed.

CONCLUSIONS

The IMP-D is able to modify interpretation biases, but adaptations are required to maximize its beneficial effects.

Manipulating Attention to Nonemotional Distractors Influences State Anxiety: A Proof-of-Concept Study in Low- and High-Anxious College Students

Anxious individuals have difficulty inhibiting attention to salient, but nonemotional, distracting stimuli. The exact nature of this relationship remains unclear, however. In the present study, we tested the hypothesis that increasing attention to salient, but nonemotional, distracting stimuli would lead to increases in state anxiety by manipulating attentional strategies during a visual search task. We randomly assigned students low and high in trait anxiety to either a 1-session singleton detection training group or a feature search group. Singleton detection training increases distraction by salient, nonemotional stimuli whereas feature search training protects attention against distracting stimuli. Findings revealed that singleton detection training not only increased distraction by salient, nonemotional stimuli but also increased state anxiety. Moreover, this increase in state anxiety was most pronounced among high trait-anxious individuals. In contrast, feature search training protected attention against distracting stimuli and against increases in state anxiety, particularly in the high trait-anxious individuals. Together, the current findings provide initial support for the notion that distraction by salient, nonemotional stimuli can increase state anxiety levels. Furthermore, these results suggest that individuals already vulnerable to experience anxiety are most likely to be affected by distraction by salient, nonemotional stimuli, and that training anxious individuals to focus on specific shape features may be a viable attention modification intervention.