Always Approach the Bright Side of Life: A General Positivity Training Reduces Stress Reactions in Vulnerable Individuals

Evaluation of a psychological readiness program and final clinical practicum among final year nursing students: A mixed methods study

BACKGROUND

Final year nursing students may experience higher levels of stress owing to the increasing complexity and expectations from their clinical practicums. Enhancing psychological readiness may be a potential strategy to enhance nursing students' transition to the clinical area.

OBJECTIVE

To evaluate the effects of a psychological readiness enhancement for transition to professional practice program and a 10-week clinical practicum on students' psychological wellbeing, resilience, practice readiness and confidence.

DESIGN

A sequential mixed-methods approach comprising of a single-group evaluation and descriptive qualitative study.

SETTING

Final year nursing students enrolled in an undergraduate nursing program from one autonomous university in Singapore was recruited.

PARTICIPANTS

148 final year nursing students participated in the single-group evaluation study. A total of 24 participants who completed the psychological readiness program were recruited in the qualitative study.

METHODS

This study included two phases. Phase I comprised of an evaluation of a blended psychological readiness program and clinical practicum. Data was collected across three waves to assess nursing students' psychological wellbeing, resilience, practice readiness and confidence. In Phase II, a qualitative study using individual semi-structured online interviews was conducted to examine students' experiences of the psychological readiness program and clinical practicum.

RESULTS

The psychological readiness program led to significant changes in students' anxiety and patient centeredness scores. The accumulated effects of the psychological readiness and clinical practicum showed significant improvements in students' practice readiness and confidence. Although there were no significant improvements in depression, stress and resilience scores, there were improvements in the trend across three waves. Students attributed these improvements to the psychological readiness program and sharing by the alumni.

CONCLUSIONS

The findings of this study laid the foundation for the development of psychological readiness programs. However, larger scale studies using randomized controlled trial designs should be used to confirm the effects of these interventions.

More organized white matter is associated with positivity bias in older adults

On average, healthy older adults prefer positive over neutral or negative stimuli. This positivity bias is related to memory and attention processes and is linked to the function and structure of several interconnected brain areas. However, the relationship between the positivity bias and white matter integrity remains elusive. The present study examines how white matter organization relates to the degree of the positivity bias among older adults. We collected imaging and behavioral data from 25 individuals (12 females, 13 males, and a mean age of 77.32). Based on a functional memory task, we calculated a Pos-Neg score, reflecting the memory for positively valenced information over negative information, and a Pos-Neu score, reflecting the memory for positively valenced information over neutral information. Diffusion-weighted magnetic resonance imaging data were processed using Tract-Based Spatial Statistics. We performed two non-parametric permutation tests to correlate whole brain white matter integrity and the Pos-Neg and Pos-Neu scores while controlling for age, sex, and years of education. We observed a statistically significant positive association between the Pos-Neu score and white matter integrity in multiple brain connections, mostly frontal. The results did not remain significant when including verbal episodic memory as an additional covariate. Our study indicates that the positivity bias in memory in older adults is associated with more organized white matter in the connections of the frontal brain. While these frontal areas are critical for memory and executive processes and have been related to pathological aging, more extensive studies are needed to fully understand their role in the positivity bias and the potential for therapeutic interventions.

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.

Sadness-Based Approach-Avoidance Modification Training for Subjective Stress in Adults: Pilot Randomized Controlled Trial

BACKGROUND

A key vulnerability factor in mental health problems is chronic stress. There is a need for easy-to-disseminate and effective interventions to advance the prevention of stress-related illnesses. App-based stress management trainings can fulfill this need. As subjectively experienced stress may be influenced by dysfunctional beliefs, modifying their evaluations might reduce subjective stress. Approach-avoidance modification trainings (AAMT) can be used to modify stimulus evaluations and are promising candidates for a mobile stress intervention. As the standard training reactions of the AAMT (swiping and joystick motion) have little valence, emotions could be incorporated as approach and avoidance reactions to enhance the effectiveness of AAMTs.

OBJECTIVE

We aimed to evaluate the feasibility of a mobile emotion-enhanced AAMT that engages users to display sadness to move stress-enhancing beliefs away and display positive emotions to move stress-reducing beliefs toward themselves (emotion-based AAMT using sadness and positive emotions [eAAMT-SP]). We explored the clinical efficacy of this novel intervention.

METHODS

We allocated 30 adult individuals with elevated stress randomly to 1 of 3 conditions (eAAMT-SP, a swipe control condition, and an inactive control condition). We evaluated the feasibility of the intervention (technical problems, adherence, usability, and acceptability). To explore the clinical efficacy of the intervention, we compared pretest-posttest differences in perceived stress (primary clinical outcome) and 3 secondary clinical outcomes (agreement with and perceived helpfulness of dysfunctional beliefs, emotion regulation, and depressive symptoms) among the conditions.

RESULTS

The predetermined benchmarks of 50% for intervention completion and 75% for feasibility of the study design (completion of the study design) were met, whereas the cutoff for technical feasibility of the study design (95% of trials without technical errors) was not met. Effect sizes for usability and acceptability were in favor of the eAAMT-SP condition (compared with the swipe control condition; intelligibility of the instructions: g=-0.86, distancing from dysfunctional beliefs: g=0.22, and approaching functional beliefs: g=0.55). Regarding clinical efficacy, the pretest-posttest effect sizes for changes in perceived stress were g=0.80 for the comparison between the eAAMT-SP and inactive control conditions and g=0.76 for the comparison between the eAAMT-SP and swipe control conditions. Effect sizes for the secondary clinical outcomes indicated greater pretest-posttest changes in the eAAMT-SP condition than in the inactive control condition and comparable changes in the swipe control condition.

CONCLUSIONS

The findings regarding the feasibility of the intervention were satisfactory except for the technical feasibility of the intervention, which should be improved. The effect sizes for the clinical outcomes provide preliminary evidence for the therapeutic potential of the intervention. The findings suggest that extending the AAMT paradigm through the use of emotions may increase its efficacy. Future research should evaluate the eAAMT-SP in sufficiently powered randomized controlled trials.

TRIAL REGISTRATION

German Clinical Trials Registry DRKS00023007; https://drks.de/search/en/trial/DRKS00023007.

The Role of Positivity on Depressive Symptoms in Women Seeking Help for Intimate Partner Violence

Intimate partner violence (IPV) is a complex and pervasive global phenomenon. Despite extensive research on physical and sexual violence, there has been a relative lack of investigation into the detrimental and distinctive consequences of psychological violence against women. This is surprising given the profound impact it has on the psychological well-being of victims, notably in the form of depression, which is commonly observed as an outcome in cases of psychological IPV victimization. The present study analyzes the impact of psychological IPV on depressive symptoms, considering the moderating influence of personal positivity, defined as positive self-perceptions, optimistic life perspectives, and a hopeful view of the future in a sample of 171 Italian women seeking assistance from anti-violence centers in different localities of Italy. The findings show that in line with the hypothesis, the association between psychological violence and depressive symptoms is moderated by the levels of perceived positivity, even when controlling for instances of physical violence. These results and implications for interventions are discussed within the framework of existing literature on positive psychology and psychological well-being in the context of IPV.

Evaluating the feasibility and exploring the efficacy of an emotion-based approach-avoidance modification training (eAAMT) in the context of perceived stress in an adult sample - protocol of a parallel randomized controlled pilot study

BACKGROUND

Stress levels and thus the risk of developing related physical and mental health conditions are rising worldwide. Dysfunctional beliefs contribute to the development of stress. Potentially, such beliefs can be modified with approach-avoidance modification trainings (AAMT). As previous research indicates that effects of AAMTs are small, there is a need for innovative ways of increasing the efficacy of these interventions. For this purpose, we aim to evaluate the feasibility of the intervention and study design and explore the efficacy of an innovative emotion-based AAMT version (eAAMT) that uses the display of emotions to move stress-inducing beliefs away from and draw stress-reducing beliefs towards oneself.

METHODS

We will conduct a parallel randomized controlled pilot study at the Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany. Individuals with elevated stress levels will be randomized to one of eight study conditions (n = 10 per condition) - one of six variants of the eAAMT, an active control intervention (swipe-based AAMT), or an inactive control condition. Participants in the intervention groups will engage in four sessions of 20-30 min (e)AAMT training on consecutive days. Participants in the inactive control condition will complete the assessments via an online tool. Non-blinded assessments will be taken directly before and after the training and 1 week after training completion. The primary outcome will be perceived stress. Secondary outcomes will be dysfunctional beliefs, symptoms of depression, emotion regulation skills, and physiological stress measures. We will compute effect sizes and conduct mixed ANOVAs to explore differences in change in outcomes between the eAAMT and control conditions.

DISCUSSION

The study will provide valuable information to improve the intervention and study design. Moreover, if shown to be effective, the approach can be used as an automated smartphone-based intervention. Future research needs to identify target groups benefitting from this intervention utilized either as stand-alone treatment or an add-on intervention that is combined with other evidence-based treatments.

TRIAL REGISTRATION

The trial has been registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS00023007 ; September 7, 2020).

Same same, but different: A psychometric examination of three frequently used experimental tasks for cognitive bias assessment in a sample of healthy young adults

Cognitive bias research draws upon the notion that altered information processing is key for understanding psychological functioning and well-being. However, little attention has been paid to the question of whether the frequently used experimental paradigms hold adequate psychometric properties. The present study examined the psychometric properties of three widely used cognitive bias tasks: the Approach-Avoidance Task (AAT), the visual dot-probe-task, and the Implicit Association Test (IAT). Approach, attentional, and association biases towards valenced stimuli were repeatedly measured at five different time points in a sample of 79 healthy young adults. Two different devices were used for assessment: a personal computer (PC) and a touchscreen-based tablet. Reliability estimates included internal consistency and temporal stability. Validity was inferred from convergence across different behavioral tasks and correlations between bias scores and self-reported psychological traits. Reliability ranged widely amongst tasks, assessment devices, and measurement time points. While the dot-probe-task appeared to be completely unreliable, bias scores obtained from the PC-based version of the AAT and both (PC and touchscreen) versions of the IAT showed moderate reliability. Almost no associations were found across information processing tasks or between implicit and explicit measures. Cognitive bias research should adopt a standard practice to routinely estimate and report psychometric properties of experimental paradigms, investigate feasible ways to develop more reliable tools, and use tasks that are suitable to answer the precise research question asked.

Biased information processing and anxiety coping: differences in attentional and approach patterns towards positive cues in repressors

Individual differences in emotional coping styles are likely to affect information processing on different stages. Repressive coping is assumed to be related to an attentional bias away from threatening information. Possible links to biases in later stages of information processing have not been investigated to date. In the current study, 82 participants completed the visual dot-probe task as a measure of attentional bias and the Approach-Avoidance Task (AAT) as a measure of approach/avoidance bias and classified into coping groups via the Mainz Coping Inventory (MCI). Prevalence of attention bias and approach/avoidance bias were compared between groups. Main results revealed a strong approach tendency toward positive stimuli for repressors and a strong avoidance tendency for sensitizers. No group differences were found for approach bias to negative stimuli or for attention bias. The present findings of strong preferential processing of positive stimuli in repressors may be part of broader information processing alterations, which may also be linked to alterations in emotion processing.

"Push it!" or "Hold it!"? A comparison of nicotine-avoidance training and nicotine-inhibition training in smokers motivated to quit

RATIONALE

Recently, experimental paradigms have been developed to strengthen automatic avoidance or inhibitory responses for smoking cues. However, these procedures have not yet been directly compared regarding their effectiveness and mechanisms of action.

OBJECTIVE

This study compared the effects of avoidance vs. inhibitory training as an add-on to a brief smoking cessation intervention. The standard Approach-Avoidance-Task (AAT) was adapted for both training types and control conditions.

METHODS

One hundred twenty-four smokers attended behavioral counseling for smoking cessation and were thereafter randomized to one of four training conditions: avoidance-AAT, sham-avoidance-AAT, inhibition-AAT, sham-inhibition-AAT. During a 2-week training period including five training sessions, smokers in the avoidance-AAT trained to implicitly avoid all smoking-related cues, while smokers in the inhibition-AAT trained to implicitly inhibit behavioral response to smoking cues. During sham training, no such contingencies appeared. Self-report and behavioral data were assessed before and after training. Cigarette smoking and nicotine dependence were also assessed at 4- and 12-week follow-ups.

RESULTS

At posttest, avoidance training was more effective in reducing daily smoking than inhibition training. However, this difference was no longer evident in follow-up assessments. All training conditions improved other smoking- and health-related outcomes. Neither training changed smoking-related approach biases or associations, but approach biases for smoking-unrelated pictures increased and Stroop interference decreased in all conditions. Smoking devaluation was also comparable in all groups.

CONCLUSIONS

Avoidance training might be slightly more effective in reducing smoking than inhibitory training. Overall, however, all four training types yielded equivalent therapy and training effects. Hence, a clear preference for one type of training remains premature.

Testing the Effects of a Virtual Reality Game for Aggressive Impulse Management: A Preliminary Randomized Controlled Trial among Forensic Psychiatric Outpatients

Prior laboratory experiments among healthy samples found that training avoidance movements to angry faces may lower anger and aggression, especially people high in trait anger. To enrich this training and make it more suitable for clinical applications, the present researchers developed it into a Virtual Reality Game for Aggressive Impulse Management (VR-GAIME). The current study examined the effects of this training in a randomized controlled trial among forensic psychiatric outpatients with aggression regulation problems (N = 30). In addition to the aggression replacement training, patients played either the VR-GAIME or a control game. Aggressive behavior was measured pre-, half-way, and post-treatment via self-report and clinicians ratings. No difference was found between the VR-GAIME and the control game. However, the participants reported gaining more insight into their own behavior and that of others. Future VR intervention tools in clinical settings may capitalize more on their benefits for self-reflection within interpersonal settings.

Approach bias retraining through virtual reality in smokers willing to quit smoking: A randomized-controlled study

Automatic approach biases toward smoking-related cues have been implicated in the development and maintenance of addictive behaviors. Studies aiming at modifying such biases have shown promise in changing maladaptive approach tendencies for smoking cues and reducing smoking behavior. However, training effects tend to be small and partly inconsistent. The present randomized-controlled trial incorporated virtual reality (VR) technology into Approach Bias Modification (ABM) to improve efficacy. One-hundred-eight smokers attended behavioral counseling for smoking cessation and were thereafter randomized to receive VR-ABM or VR-control training. During VR-ABM, participants trained to implicitly avoid smoking-related objects and to approach alternative objects, while no such contingency existed in the VR-control condition. Trainings were administered in six sessions within a two-week period. Assessments were conducted at baseline, post-intervention (three weeks after baseline), and at follow-up (seven weeks after baseline). VR-ABM did not change approach biases, nor other cognitive biases, but it was superior in reducing daily smoking. However, this effect was limited to the two-week training period. Both groups improved in other smoking- and health-related variables across time. Future work should continue to investigate working mechanisms of ABM, in particular crucial training ingredients. VR could prove valuable for public health as the potential of VR-based treatments is large and not fully explored.

Attentional bias modification with a new paradigm: The effect of the Detection Engagement and Savoring Positivity (DESP) task on eye-tracking of attention

BACKGROUND AND OBJECTIVES

We tested the effect of a new Attentional Bias Modification (ABM) task - the Detection Engagement and Savoring Positivity (DESP) task - on attentional biases. The DESP is innovative in that it involves a procedure of savoring the positivity of various pictures.

METHODS

Participants were randomly assigned to the DESP or to a placebo control condition (experiment 1; n = 38) or a condition controlling for savoring (experiment 2; n = 54) in a pre-post/training experimental design. During one week, the participants completed the DESP or the control task once a day between three and six times. We assessed the effects of the DESP task on various attentional biases (i.e. positive, negative and threat) by computing dwell time from an eye-tracking technology before and after the training, and also one week after the post-training session in experiment 2.

RESULTS

In both experiments, the attentional bias toward positive stimuli between the pre- and the post-training increased significantly more in the DESP task condition than in the control conditions. Negative and threat attentional biases were not significantly affected by the experimental manipulations. Experiment 2 revealed that the DESP task - including the savoring instruction - increased significantly more the positive attentional bias than a task excluding this step and that this effect remained significant one week after the post-training session.

LIMITATIONS

Our samples were mainly composed of women participants. This prevents generalization of the findings.

CONCLUSIONS

The DESP task offers promising perspectives for sustainably improving attention to positive information.

Combining cognitive bias modification training (CBM) and transcranial direct current stimulation (tDCS) to treat binge eating disorder: study protocol of a randomised controlled feasibility trial

INTRODUCTION

Binge eating disorder (BED) is a common mental disorder, closely associated with obesity. Existing treatments are only moderately effective with high relapse rates, necessitating novel interventions. This paper describes the rationale for, and protocol of, a feasibility randomised controlled trial (RCT), evaluating the combination of transcranial direct current stimulation (tDCS) and a computerised cognitive training, namely approach bias modification training (ABM), in patients with BED who are overweight or obese. The aim of this trial is to obtain information that will guide decision-making and protocol development in relation to a future large-scale RCT of combined tDCS+ABM treatment in this group of patients, and also to assess the preliminary efficacy of this intervention.

METHODS AND ANALYSIS

66 participants with Diagnostic and Statistical Manual-5 diagnosis of BED and a body mass index (BMI) of ≥25 kg/m2 will be randomly allocated to one of three groups: ABM+real tDCS; ABM+sham tDCS or a wait-list control group. Participants in both intervention groups will receive six sessions of ABM+real/sham tDCS over 3 weeks; engaging in the ABM task while simultaneously receiving bilateral tDCS to the dorsolateral prefrontal cortex. ABM is based on an implicit learning paradigm in which participants are trained to enact an avoidance behaviour in response to visual food cues. Assessments will be conducted at baseline, post-treatment (3 weeks) and follow-up (7 weeks post-randomisation). Feasibility outcomes assess recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments. Other outcomes include eating disorder psychopathology and related neurocognitive outcomes (ie, delay of gratification and inhibitory control), BMI, other psychopathology (ie, mood), approach bias towards food and surrogate endpoints (ie, food cue reactivity, trait food craving and food intake).

ETHICS AND DISSEMINATION

This study has been approved by the North West-Liverpool East Research Ethics Committee. Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN35717198.

Using the Actor-Partner Interdependence Model to assess maternal and infant contributions to mother-infant affective exchanges during the Still-Face Paradigm

This study describes maternal and infant contributions to dyadic affective exchanges during the Still-Face Paradigm (SFP) in an understudied mostly low-income sample. One hundred eleven mothers and their 7-month-old infants were videotaped during the SFP to analyze how a social stressor affects mother-infant positive and negative affective exchanges during interaction. The SFP includes 3 episodes: baseline, maternal still-face, and reunion. Maternal and infant positive and negative affect were scored by masked reliable coders. Data were analyzed using the Actor-Partner Interdependence Model to test the hypotheses that each partner's affectivity during the baseline episode would predict their own affectivity during the reunion episode (actor effects). We also expected that each partner's affectivity during the baseline episode would influence the other partner's affectivity during the reunion episodes (partner effects). After controlling for infant sex and maternal education, results provided evidence for actor effects for maternal and infant positive affect, and for partner effects for maternal baseline positive affect to infant positive affect during the reunion. One significant partner effect was observed for negative affect: Infant negativity during baseline predicted greater maternal negativity during reunion. Findings confirm that both mothers and infants contribute to dyadic affective processes during the SFP but specific findings vary depending on the affective valence in question. Clinical implications and future research are discussed.

Hypnotic Suggestions Can Induce Rapid Change in Implicit Attitudes

We sometimes evaluate our environment (e.g., persons, objects, situations) in an automatic fashion. These automatic or implicit evaluations are often considered to be based on qualitatively distinct mental processes compared with more controlled or explicit evaluations. Important evidence for this claim comes from studies showing that implicit evaluations do not change as the result of counterattitudinal information, in contrast to their explicit counterparts. We examined the impact of counterattitudinal information on implicit evaluations in two experiments (N = 60, N = 72) that included an innovative manipulation: hypnotic suggestions to participants that they would strongly process upcoming counterattitudinal information. Both experiments indicated that hypnotic suggestions facilitated effects of counterattitudinal information on implicit evaluations. These findings extend recent evidence for rapid revision of implicit evaluations on the basis of counterattitudinal information and support the controversial idea that belief-based processes underlie not only explicit but also implicit evaluations.

Approach bias modification training in bulimia nervosa and binge-eating disorder: A pilot randomized controlled trial

OBJECTIVE

Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with poorly controlled approach behavior toward food resulting in binge eating. Approach bias modification (ABM) may reduce these automatic action tendencies (i.e., approach bias) toward food and may thus decrease binge eating and related symptoms.

METHOD

A total of 56 patients with BN/BED participated in this double-blind, randomized controlled trial (RCT) comparing real and sham ABM. The real ABM condition adopted an implicit learning paradigm in which participants were trained to show avoidance behavior in response to food cues. Participants in the sham condition used a similar task but were not trained to avoid food cues. Both conditions comprised 10 training sessions within 4 weeks.

RESULTS

Participants in both groups experienced significant reductions in binge eating, eating disorder symptoms, trait food craving, and food cue reactivity. Real ABM tended to result in greater reductions in eating disorder symptoms than sham ABM. Food intake, approach bias, and attention bias toward food did not change.

DISCUSSION

This is the first RCT on ABM in eating disorders. The findings provide limited support for the efficacy of ABM in BN/BED and pose questions regarding its active ingredients and its usefulness as a stand-alone treatment for eating disorders.

Mechanisms linking childhood adversity with psychopathology: Learning as an intervention target

Exposure to childhood adversity is common and a powerful risk factor for many forms of psychopathology. In this opinion piece, we argue for greater translation of knowledge about the developmental processes that are influenced by childhood adversity into targeted interventions to prevent the onset of psychopathology. Existing evidence has consistently identified several neurodevelopmental pathways that serve as mechanisms linking adversity with psychopathology. We highlight three domains in which these mechanisms are well-established and point to clear targets for intervention: 1) threat-related social information processing biases; 2) heightened emotional reactivity and difficulties with emotion regulation; and 3) disruptions in reward processing. In contrast to these established pathways, knowledge of how childhood adversity influences emotional learning mechanisms, including fear and reward learning, is remarkably limited. We see the investigation of these mechanisms as a critical next step for the field that will not only advance understanding of developmental pathways linking childhood adversity with psychopathology, but also provide clear targets for behavioral interventions. Knowledge of the mechanisms linking childhood adversity with psychopathology has advanced rapidly, and the time has come to translate that knowledge into clinical interventions to prevent the onset of mental health problems in children who have experienced adversity.

Positivity-approach training for depressive symptoms: A randomized controlled trial

OBJECTIVE

Depression is highly comorbid and depressive symptoms are very common. Symptom severity adversely affects treatment outcome and later health status. Established interventions for depression leave ample room for improvement. Short interventions that target specific vulnerabilities emerge as plausible augmentation strategies. In this study, we tested the efficacy of a computerized general positivity-approach training and its effect on depressive symptoms.

METHODS

Patients (N = 240) with various diagnoses of mental disorders who received treatment-as-usual in an inpatient setting were randomly assigned to also receive either 4 sessions of a positivity-approach training or 4 sessions of sham training. Depression severity was assessed at baseline and post-treatment. Training data were analyzed for a subset of 111 patients.

RESULTS

Depressive symptoms were reduced more after positivity-approach training than after sham training. Initial depression symptom severity moderated the intervention effects, such that approach tendencies and depression symptoms were only affected positively among patients with higher levels of initial depression symptom severity.

CONCLUSIONS

The findings provide preliminary support for positivity-approach training as an add-on treatment option for depressive symptoms.

Combining attentional bias modification with dorsolateral prefrontal rTMS does not attenuate maladaptive attentional processing

High frequency repetitive Transcranial Magnetic Stimulation (rTMS) over the left dorsolateral prefrontal cortex (DLPFC) has been shown to reduce depressive symptoms and improve cognitive biases such as attentional bias. One promising technique that may complement rTMS treatment is attentional bias modification (ABM) training, given the similarity in modulating attentional bias and affecting neuronal activity. We tested whether the combination of rTMS treatment and ABM training in a single session would attenuate maladaptive attentional processing and improve mood in participants with subclinical depressive symptoms. To this end, 122 healthy participants were randomly assigned to one of four groups, receiving either a single rTMS treatment, a single ABM treatment, a combination of rTMS and ABM or a sham treatment. Of these 122 participants, 72 showed a heightened BDI-II score (between 9 and 25) and were included in our main analyses. In our subclinical (≥9 and ≤25 BDI-II) sample, a single combination treatment of rTMS and ABM training induced no significant changes in attentional bias, attentional control or mood, nor did rTMS alone affect attentional bias systematically. We discuss these null findings in light of the task specifics and relate them to the ongoing discussion on ABM training in depression.

Effects of induced appearance-related interpretation bias: A test of the cognitive-behavioral model of body dysmorphic disorder

BACKGROUND AND OBJECTIVES

Interpretation biases are hypothesized to maintain body dysmorphic disorder (BDD). Although their existence and malleability have been investigated in clinical studies, their causal status in the maintenance of BDD remains unclear. This study examined the effects of a single-session appearance-related interpretation bias training (CBM-I) on bias indices and stress reactivity (i.e., distress, appearance dissatisfaction, self-esteem, perceived physical attractiveness), exploring the causality predicted in cognitive-behavioral models.

METHODS

We used a modified version of the Word Sentence Association Paradigm (WSAP), assessing explicit (i.e., decision rates) and more implicit interpretation bias components (i.e., reaction times). Mentally healthy students (N = 112) were randomized to training conditions enhancing positive interpretation patterns (PT) vs. negative interpretation patterns (NT) vs. a no-feedback control condition (CC). Stress reactivity was assessed during the Cyberball Paradigm.

RESULTS

The PT showed a pre-post increase in adaptive bias patterns regarding decision and a differential pre-post decrease in reaction times for the rejection of negative interpretations, compared to the other groups. There were no condition-congruent post-training differences in stress reactivity. However, residual interpretation bias change was significantly correlated with state distress, self-esteem and appearance dissatisfaction during stressor exposure.

LIMITATIONS

Limitations pertaining to sample characteristics, training and assessment overlap, and stressor task design are discussed.

CONCLUSIONS

Findings suggest that appearance-related interpretation bias is modifiable both explicitly and more implicitly via CBM-I in a mentally healthy sample. The causal status of interpretation bias in BDD maintenance warrants further investigation.

Consequence-Based Approach-Avoidance Training: A New and Improved Method for Changing Behavior

The repeated performance of approach or avoidance actions in response to specific stimuli (e.g., alcoholic drinks) is often considered a most promising type of cognitive-bias modification that can reduce unwanted behavior (e.g., alcohol consumption). Unfortunately, approach-avoidance training sometimes fails to produce desired outcomes (e.g., in the context of unhealthy eating). We introduce a novel training task in which approach-avoidance actions are followed by affective consequences. Four experiments (total N = 1,547) found stronger changes in voluntary approach-avoidance behavior, implicit and explicit evaluations, and consumer choices for consequence-based approach-avoidance training in the food domain. Moreover, this novel type of training reduced self-reported unhealthy eating behavior after a 24-hr delay and unhealthy snacking in a taste test. Our results contrast with dominant (association-formation) accounts of the effects of approach-avoidance training and support an inferential explanation. They further suggest that consequence-based approach-avoidance training, and inference training more generally, holds promise for the treatment of clinical behavior.

Cognitive bias modification as an add-on treatment in clinical depression: Results from a placebo-controlled, single-blinded randomized control trial

BACKGROUND

Only 60% of depressed patients respond sufficiently to treatment, so there is a dire need for novel approaches to improve treatment effects. Cognitive Bias Modification (CBM) may be an effective and easily implemented computerized add-on to treatment-as-usual. Therefore, we investigated the effects of a positivity-attention training and a positivity-approach training compared to control trainings.

METHODS

In a blinded randomized-controlled design, 139 depressed inpatients received either the CBM Attention Dot-Probe Training (DPT) or the CBM Approach-Avoidance Training (AAT), next to treatment as usual. N = 121 finished all four training sessions. Both trainings had an active and a control condition. In both active conditions, patients were trained to preferentially process generally positive pictures over neutral pictures. Depressive symptom severity was assessed before and after CBM, and positivity bias was measured at the start and end of each session.

RESULTS

Clinician-rated depressive symptom severity decreased more in patients who received the active condition of the DPT or the AAT compared to patients in the control conditions. Significant change in positivity bias was found for the DPT (not the AAT), but did not mediate the effect of the training on depressive symptoms.

CONCLUSIONS

The results suggest that both types of CBM (i.e., DPT and AAT) may provide a fitting add-on treatment option for clinical depression. The working mechanisms and optimal dose of CBM trainings, plus their possible combination, should be examined in more detail.

How Do Actions Influence Attitudes? An Inferential Account of the Impact of Action Performance on Stimulus Evaluation

Over the past decade, an increasing number of studies have shown that the performance of specific actions (e.g., approach and avoidance) in response to a stimulus can lead to changes in how that stimulus is evaluated. In contrast to the reigning idea that these effects are mediated by the automatic formation and activation of associations in memory, we describe an inferential account that specifies the inferences underlying the effects and how these inferences are formed. We draw on predictive processing theories to explain the basic processes underlying inferential reasoning and their main characteristics. Our inferential account accommodates past findings, is supported by new findings, and leads to novel predictions as well as concrete recommendations for how action performance can be used to influence real-world behavior.

Working mechanisms of a general positivity approach-avoidance training: Effects on action tendencies as well as on subjective and physiological stress responses

BACKGROUND AND OBJECTIVES

The general positivity training, a Cognitive Bias Modification procedure modifying individuals' approach-avoidance tendencies to positively and negatively valenced pictures by means of a joystick task, has been proven effective in attenuating stress reactivity in dysphoric students. The present study explored which training component (pull positive pictures, push negative pictures, or both) is the active one in changing action tendencies and stress responses.

METHODS

Two-hundred-and-thirteen students completed one of four approach-avoidance trainings before being exposed to a stressful speech-task: The general positivity training (pull positive and push negative pictures), a training to approach positive pictures and avoid empty pictures (ApP), a training to avoid negative pictures and approach empty pictures (AvN), or a sham-training.

RESULTS

The pattern of results suggests that the groups trained to avoid negative pictures showed a stronger increase in positive approach-avoidance tendencies than the other two groups. However, only the positivity training induced significant within-group changes in positive bias. The groups further did not differ in self-report or cardiovascular measures of anxiety in response to the stress-task. Instead, the training affected mood directly: Exposure to negative pictures during the training increased state anxiety.

LIMITATIONS

Generalizability of the findings is limited by using an unselected student sample. Also, the use of empty pictures as neutral stimuli in the ApP and AvN could have weakened training effects in these groups.

CONCLUSIONS

Although our results hint at the importance of avoiding negative pictures for modifying an approach-avoidance bias, only the positivity training with both components may effectively induce a positive bias. Remarkably, we failed to replicate and extend previously reported effects of the training on stress-responses. Hence, it remains questionable whether the changes in bias reflect changes in underlying cognitive processing tendencies or task-specific learning effects.

[Internet-based resilience training and prevention of mental disorders]

BACKGROUND

Resilience is associated with a positive and resource-oriented perspective. Therefore, it seems especially attractive for health promotion and prevention. In recent years, interventions to foster resilience have been increasingly developed, which train resilience factors and are mainly conducted in a face to face group format.

OBJECTIVE

The question is raised what potential internet-based interventions (i-interventions) that train resilience factors have for health promotion and prevention.

MATERIAL AND METHODS

Based on a narrative overview, the possibilities for i‑interventions that train resilience factors for health promotion and prevention are investigated and the state of research is described.

RESULTS

The effects of the i‑interventions presented here, which aim at fostering resilience, on measures of mental health and well-being are heterogeneous and vary between low to high effects. Stronger evidence for the efficacy of these measures exists for more general i‑interventions that also train resilience factors but are conceptualized for the prevention of specific disorders, such as depression or for stress reduction.

DISCUSSION

Given the heterogeneous nature of intervention contents, theoretical foundations and therapeutic methods used, the heterogeneity of the evidence is discussed. In addition, perspectives for the further development of resource-oriented resilience interventions are outlined.

Automatic approach-avoidance tendencies as a candidate intermediate phenotype for depression: Associations with childhood trauma and the 5-HTTLPR transporter polymorphism

Depression risk genes in combination with childhood events have been associated with biased processing as an intermediate phenotype for depression. The aim of the present conceptual replication study was to investigate the role of biased automatic approach-avoidance tendencies as a candidate intermediate phenotype for depression, in the context of genes (5-HTTLPR polymorphism) and childhood trauma. A naturalistic remitted depressed patients sample (N = 209) performed an Approach-Avoidance Task (AAT) with facial expressions (angry, sad, happy and neutral). Childhood trauma was assessed with a questionnaire. Genotype groups were created based on allele frequency: L_aL_a versus S/L_g-carriers. The latter is associated with depression risk. We found that remitted S/L_g-carriers who experienced childhood trauma automatically avoided sad facial expressions relatively more than L_aL_a homozygotes with childhood trauma. Remitted L_aL_a-carriers who had not experienced childhood trauma, avoided sad faces relatively more than L_aL_a homozygotes with childhood trauma. We did not find a main effect of childhood trauma, nor differential avoidance of any of the other facial expressions. Although tentative, the results suggest that automatic approach-avoidance tendencies for disorder-congruent materials may be a fitting intermediate phenotype for depression. The specific pattern of tendencies, and the relation to depression, may depend on the genetic risk profile and childhood trauma, but replication is needed before firm conclusions can be drawn.

Eye-Tracking Based Attention Bias Modification (ET-ABM) Facilitates Disengagement from Negative Stimuli in Dysphoric Individuals

To address shortcomings of purely reaction-time based attention bias modification (ABM) paradigms, a novel eye-tracking based ABM training (ET-ABM) was developed. This training targets the late disengagement from negative stimuli and the lack of attention for positive information, which are characteristics of depression. In the present study, 75 dysphoric students (BDI ≥ 9) were randomly assigned to either this positive training (PT), or a sham-training (ST) that did not train any valence-specific gaze pattern (positive and negative pictures had to be disengaged from and attended to equally often). Results showed that the PT induced a positive attentional bias (longer fixations of positive than negative pictures). Although the ST group showed an increase in positive attentional bias as well, this increase was not as strong as in the PT group. Compared to the ST, the PT specifically induced faster disengagement from negative pictures. No differential training effects were found on stress responses or state rumination. These results show that the ET-ABM successfully modifies attentional processes, specifically late disengagement from negative stimuli, in dysphoric students, and hence might be a promising alternative to existing ABM paradigms.

The effect of combined avoidance and control training on implicit food evaluation and choice

BACKGROUND

Continual exposure to food cues in the environment contributes to unhealthy eating behaviour. According to dual-process models, such behaviour is partly determined by automatic processing of unhealthy food cues (e.g., approach bias), which fails to be regulated by controlled processing (e.g., inhibitory control). The current study aimed to investigate the effect of combined avoidance and control training on implicit evaluation (liking), choice, and consumption of unhealthy snack food.

METHOD

Participants were 240 undergraduate women who were randomly allocated to one of four experimental conditions of a 2 (avoidance training: training versus control) x 2 (control training: training versus control) between-subjects design.

RESULTS

The combined training group had a more negative implicit evaluation of unhealthy food than either of the two training conditions alone or the control condition. In addition, participants trained to avoid unhealthy food cues subsequently made fewer unhealthy snack food choices. No significant group differences were found for food intake.

LIMITATIONS

Participants were women generally of a healthy weight. Overweight or obese individuals may derive greater benefit from combined training.

CONCLUSIONS

Results lend support to the theoretical predictions of dual-process models, as the combined training reduced implicit liking of unhealthy food. At a practical level, the findings have implications for the effectiveness of interventions targeting unhealthy eating behaviour.

Approach bias modification training and consumption: A review of the literature

Recent theoretical perspectives and empirical evidence have suggested that biased cognitive processing is an important contributor to unhealthy behaviour. Approach bias modification is a novel intervention in which approach biases for appetitive cues are modified. The current review of the literature aimed to evaluate the effectiveness of modifying approach bias for harmful consumption behaviours, including alcohol use, cigarette smoking, and unhealthy eating. Relevant publications were identified through a search of four electronic databases (PsycINFO, Google Scholar, ScienceDirect and Scopus) that were conducted between October and December 2015. Eligibility criteria included the use of a human adult sample, at least one session of avoidance training, and an outcome measure related to the behaviour of interest. The fifteen identified publications (comprising 18 individual studies) were coded on a number of characteristics, including consumption behaviour, participants, task, training and control conditions, number of training sessions and trials, outcome measure, and results. The results generally showed positive effects of approach-avoidance training, including reduced consumption behaviour in the laboratory, lower relapse rates, and improvements in self-reported measures of behaviour. Importantly, all studies (with one exception) that reported favourable consumption outcomes also demonstrated successful reduction of the approach bias for appetitive cues. Thus, the current review concluded that approach bias modification is effective for reducing both approach bias and unhealthy consumption behaviour.

Investigating the (cost-) effectiveness of attention bias modification (ABM) for outpatients with major depressive disorder (MDD): a randomized controlled trial protocol

BACKGROUND

Despite the range of available, evidence-based treatment options for Major Depressive Disorder (MDD), the rather low response and remission rates suggest that treatment is not optimal, yet. Computerized attention bias modification (ABM) trainings may have the potential to be provided as cost-effective intervention as adjunct to usual care (UC), by speeding up recovery and bringing more patients into remission. Research suggests, that a selective attention for negative information contributes to development and maintenance of depression and that reducing this negative bias might be of therapeutic value. Previous ABM studies in depression, however, have been limited by small sample sizes, lack of long-term follow-up measures or focus on sub-clinical samples. This study aims at evaluating the long-term (cost-) effectiveness of internet-based ABM, as add-on treatment to UC in adult outpatients with MDD, in a specialized mental health care setting.

METHODS/DESIGN

This study presents a double-blind randomized controlled trial in two parallel groups with follow-ups at 1, 6, and 12 months, combined with an economic evaluation. One hundred twenty six patients, diagnosed with MDD, who are registered for specialized outpatient services at a mental health care organization in the Netherlands, are randomized into either a positive training (towards positive and away from negative stimuli) or a sham training, as control condition (continuous attentional bias assessment). Patients complete eight training sessions (seven at home) during a period of two weeks (four weekly sessions). Primary outcome measures are change in attentional bias (pre- to post-test), mood response to stress (at post-test) and long-term effects on depressive symptoms (up to 1-year follow-up). Secondary outcome measures include rumination, resilience, positive and negative affect, and transfer to other cognitive measures (i.e., attentional bias for verbal stimuli, cognitive control, positive mental imagery), as well as quality of life and costs.

DISCUSSION

This is the first study investigating the long-term effects of ABM in adult outpatients with MDD, alongside an economic evaluation. Next to exploring the mechanism underlying ABM effects, this study provides first insight into the effects of combining ABM and UC and the potential implementation of ABM in clinical practice.

TRIAL REGISTRATION

Trialregister.nl, NTR5285 . Registered 20 July 2015.

Can't Look Away: An Eye-Tracking Based Attentional Disengagement Training for Depression

To address shortcomings of purely reaction-time based attentional bias modification (ABM) paradigms, we developed an ABM task that is controlled by eye-tracking. This task allows to assess and train both disengagement from negative pictures and maintained attention to positive pictures. As a proof-of-principle study with an unselected student sample, this positive training (PT; N = 44) was compared to a negative training (NT; N = 42), which reinforced the opposite attentional pattern. Importantly, training trials were completed only if participants performed the correct gaze patterns. Results showed that higher depression levels were associated with slower disengagement from negative stimuli at baseline. As expected, the PT induced longer fixations on positive pictures and faster disengagement from negative pictures. The NT showed no changes in attentional processes. The groups did not differ in mood reactivity and recovery from a stressor. Advantages of using eye-tracking in ABM and potential applications of the training are discussed.