Training Less Threatening Interpretations Over the Internet: Impact of Priming Anxious Imagery and Using a Neutral Control Condition

Adapting cognitive bias modification to train healthy prospection

Prospection, the mental simulation of future events, has been theoretically linked to physical and mental health. Prior studies have found that prospection is malleable; however, no research to our knowledge has tested whether a scalable intervention explicitly targeting the simulation of positive future outcomes can lead to more generalized positive prospection, and enhance positive outlook and reduce distress. The current study tested a novel, web-based cognitive bias modification for interpretation (CBM-I) program designed to shift prospective bias towards more positive (as opposed to negative) representations of future outcomes among 172 participants selected for having a relatively negative baseline expectancy bias. Results showed that following CBM-I, participants in active training conditions exhibited more positive expectations about the future, and increased self-efficacy and growth mindset. Also, optimism increased and depression and anxiety symptoms decreased following active training, but this also occurred for the control condition. Analyses did not suggest that changes in positive expectations mediated changes in positive outlook outcomes. Results suggest that an online prospection intervention can lead to more positive expectations about future events and improve positive outlook, though open questions remain about what accounts for the training effects.

Efficacy of cognitive bias modification interventions in anxiety and depressive disorders: a systematic review and network meta-analysis

BACKGROUND

Cognitive bias modification (CBM) therapies, including attention bias modification, interpretation bias modification, or approach and avoidance training, are prototypical examples of mechanistically derived treatments, but their effectiveness is contentious. We aimed to assess the relative effectiveness of various CBM interventions for anxious and depressive symptomatology.

METHODS

For this systematic review and network meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane Central Register from database inception up until Feb 7, 2020. We included randomised controlled trials of CBM versus control conditions or other forms of CBM for adults aged 18 years and older with clinical or subclinical anxiety or depression measured with a diagnostic interview or a validated clinical scale. We excluded studies comparing CBM with a non-CBM active intervention. Two researchers independently selected studies and evaluated risk of bias with the Cochrane Collaboration tool. Primary outcomes encompassed anxiety and depressive symptoms measured with validated clinical scales. We computed standardised mean differences (SMDs) with a restricted maximum likelihood random effects model. This study is registered with PROSPERO, CRD42018086113.

FINDINGS

From 2125 records we selected 85 trials, 65 (n=3897) on anxiety and 20 (n=1116) on depression. In a well connected network of anxiety trials, interpretation bias modification outperformed waitlist (SMD -0·55, 95% CI -0·91 to -0·19) and sham training (SMD -0·30, -0·50 to -0·10) for the primary outcome. Attention bias modification showed benefits only in post-hoc sensitivity analyses excluding post-traumatic stress disorder trials. Prediction intervals for all findings were large, including an SMD of 0. Networks of depression trials displayed evidence of inconsistency. Only four randomised controlled trials had low risk of bias on all six domains assessed.

INTERPRETATION

CBM interventions showed consistent but small benefits; however heterogeneity and risk of bias undermine the reliability of these findings. Larger, definitive trials for interpretation bias modification for anxiety might be warranted, but insufficient evidence precludes conclusions for depression.

FUNDING

Romanian Ministry of Research and Innovation, The National Council for Scientific Research-The Executive Agency for Higher Education, Research, Development and Innovation Funding.

A randomised controlled trial of computerised interpretation bias modification for health anxiety

BACKGROUND AND OBJECTIVES

Health anxiety is characterised by a tendency to interpret benign bodily sensations as a sign of serious illness. This study aimed to examine whether computerised cognitive bias modification (CBM-I) training to facilitate benign interpretations of bodily symptoms could reduce these negative interpretations of bodily symptoms, health anxiety and comorbid symptoms.

METHODS

Participants (N = 89) with clinical levels of health anxiety (Short Health Anxiety Inventory [SHAI] scores ≥20) were randomised to receive two internet-delivered 30-min sessions of either CBM-I interpretation training (Intervention) or control CBM-I training over 1-week. Participants were assessed at pre-treatment, post-treatment and 2-weeks follow-up on self-reported health anxiety, cognitions and attributions of bodily symptoms, and comorbid symptoms (e.g., depression).

RESULTS

Results showed significantly reduced catastrophic attributions, health anxiety and related symptoms at post-treatment in both groups, which were maintained at 2-week follow-up. Although there were no significant group differences at post-treatment or follow-up, we found small non-significant effect sizes in favour of the CBM-I Intervention group on health anxiety and cognitions (Cohen's d's between-group effect sizes of 0.28 at post-treatment and d = 0.35 at follow-up on the 18-item Short Health Anxiety Inventory).

LIMITATIONS

The study was conducted online, limiting control over the setting in which participants completed training. Additionally, training was not tailored to the specific symptoms or diseases that participants feared.

CONCLUSIONS

This study is the first to evaluate the effect of internet-delivered CBM-I training targeting benign interpretations of bodily symptoms on health anxiety. Further research is needed before this intervention is disseminated.