Training less threatening interpretations over the Internet: Does the number of missing letters matter?

Online cognitive bias modification for interpretation to reduce anxious thinking during the COVID-19 pandemic

Anxiety disorders are highly prevalent, and rates increased during the COVID-19 pandemic. However, most individuals with elevated anxiety do not access treatment due to barriers such as stigma, cost, and availability. Digital mental health programs, such as cognitive bias modification for interpretation (CBM-I), hold promise in increasing access to care. Before widely disseminating CBM-I, we must rigorously test its effectiveness and determine whom it is best positioned to benefit. The present study (which is a substudy of a parent trial) compared CBM-I against psychoeducation offered through the public website MindTrails, and also tested whether baseline anxiety tied to COVID-19 influenced the rate of change in anxiety and interpretation bias during and after each intervention. Adults with moderate-to-severe anxiety symptoms were randomly assigned to complete five sessions of either CBM-I or psychoeducation as part of a larger trial, and 608 enrolled in this substudy after Session 1. As predicted (https://osf.io/2dyzr), CBM-I was superior to psychoeducation at reducing anxiety symptoms (on the OASIS but not the DASS-21-AS: d = -0.31), reducing negative interpretation bias (d range = -0.34 to -0.43), and increasing positive interpretation bias (d = 0.79) by the end of treatment. Results also indicated that individuals higher (vs. lower) in baseline COVID-19 anxiety had stronger decreases in anxiety symptoms while receiving CBM-I but weaker decreases in anxiety symptoms (on the DASS-21-AS) while receiving psychoeducation. These findings suggest that CBM-I may be a useful anxiety-reduction tool for individuals experiencing higher anxiety tied to uncertain events such as the COVID-19 pandemic.

Web-Based Cognitive Bias Modification Program for Young People With Social Anxiety and Hazardous Alcohol Use: Feasibility, Acceptability, and Preliminary Efficacy Study

BACKGROUND

Interpretation bias modification (IBM) and approach bias modification (ApBM) cognitive retraining interventions can be efficacious adjunctive treatments for improving social anxiety and alcohol use problems. However, previous trials have not examined the combination of these interventions in a young, comorbid sample.

OBJECTIVE

This study aims to describe the feasibility, acceptability, and preliminary efficacy of a web-based IBM+ApBM program for young adults with social anxiety and hazardous alcohol use ("Re-Train Your Brain") when delivered in conjunction with treatment as usual (TAU).

METHODS

The study involved a 3-arm randomized controlled pilot trial in which treatment-seeking young adults (aged 18-30 y) with co-occurring social anxiety and hazardous alcohol use were randomized to receive (1) the "integrated" Re-Train Your Brain program, where each session included both IBM and ApBM (50:50 ratio), plus TAU (35/100, 35%); (2) the "alternating" Re-Train Your Brain program, where each session focused on IBM or ApBM in an alternating pattern, plus TAU (32/100, 32%); or (3) TAU only (33/100, 33%). Primary outcomes included feasibility and acceptability, and secondary efficacy outcomes included changes in cognitive biases, social anxiety symptoms, and alcohol use. Assessments were conducted at baseline, after the intervention period (6 weeks after baseline), and 12 weeks after baseline.

RESULTS

Both Re-Train Your Brain program formats were feasible and acceptable for young adults. When coupled with TAU, both integrated and alternating programs resulted in greater self-reported improvements than TAU only in anxiety interpretation biases (at the 6-week follow-up; Cohen d=0.80 and Cohen d=0.89) and comorbid interpretation biases (at the 12-week follow-up; Cohen d=1.53 and Cohen d=1.67). In addition, the alternating group reported larger improvements over the control group in generalized social anxiety symptoms (at the 12-week follow-up; Cohen d=0.83) and alcohol cravings (at the 6-week follow-up; Cohen d=0.81). There were null effects on all other variables and no differences between the intervention groups in efficacy outcomes.

CONCLUSIONS

Should these findings be replicated in a larger randomized controlled trial, Re-Train Your Brain has the potential to be a scalable, low-cost, and non-labor-intensive adjunct intervention for targeting interpretation and comorbidity biases as well as generalized anxiety and alcohol-related outcomes in the real world.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620001273976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/28667.

Multi-session online interpretation bias training for anxiety in a community sample

The present study assessed target engagement, preliminary efficacy, and feasibility as primary outcomes of a free multi-session online cognitive bias modification of interpretation (CBM-I) intervention for anxiety in a large community sample. High trait anxious participants (N = 807) were randomly assigned to a CBM-I condition: 1) Positive training (90% positive-10% negative); 2) 50% positive-50% negative training; or 3) no-training control. Further, half of each CBM-I condition was randomized to either an anxious imagery prime or a neutral imagery prime. Due to attrition, results from six out of eight sessions were analyzed using structural equation modeling of latent growth curves. Results for the intent-to-treat sample indicate that for target engagement, consistent with predictions, decreases in negative interpretations over time were significantly greater among those receiving positive CBM-I training compared to no-training or 50-50 training, and vice-versa for increases in positive interpretations. For intervention efficacy, the decrease in anxiety symptoms over time was significantly greater among those receiving positive CBM-I training compared to no-training. Interaction effects with imagery prime were more variable with a general pattern of stronger results for those completing the anxious imagery prime. Findings indicate that online CBM-I positive training is feasible and shows some promising results, although attrition rates were very high for later training sessions.

Which variations of a brief cognitive bias modification session for interpretations lead to the strongest effects?

Background

Brief computerized programs that train less threatening interpretations (termed Cognitive Bias Modification for Interpretations, or CBM-I) can shift interpretation biases and subsequent anxiety symptoms. However, results have been inconsistent, particularly for studies conducted over the Internet.

Methods

The current exploratory study tests 13 variations of a single brief session of CBM-I, a non-CBM-I cognitive flexibility condition, a neutral condition, and a no task control condition in an analogue sample with moderate to severe anxiety.

Results

Results suggest that all conditions, except the neutral scenarios condition and the alternative way to improve cognitive flexibility, led to changes in interpretations (when compared to the no task control condition). Only conditions geared toward increasing imagery during CBM-I and targeting flexibility related to emotional material differed from the no task control condition on other post-training measures.

Conclusions

Presenting valenced interpretations of ambiguous information during brief CBM-I, regardless of the format, can lead to changes in interpretation bias. However, most conditions did not differ from the no task control condition on other post-training assessments (and differences that did occur may be due to chance). Future trials should consider further testing of CBM-I that targets flexibility related to emotional material, and should include an increased number of sessions and trials.

Facilitating Episodic Simulation in Anxiety: Role of Sensory Scaffolding and Scenario Modality

Cognitive bias modification of interpretation style (CBM-I) is a family of cognitive training programs that seek to reduce anxious thinking by training people to assign relatively more positive meanings to ambiguous situations. CBM-I’s effects may be enhanced by encouraging more vivid imagery-based episodic simulation of events and by increasing engagement with the training materials. This study investigated the role of sensory scaffolding (whether pictures, or pictures + sound were added) and verbal scenario modality (whether scenarios were delivered visually or aurally) on episodic simulation (Vivid; Plausible; Changing Perspective ratings) and user engagement (Relatable, Comprehensible, Enjoyable ratings). Amazon Mechanical Turk workers (N = 187) with varied anxiety symptom severity read or listened to brief scenarios that varied by sensory scaffolding and verbal scenario modality. Results were somewhat mixed. Generally, picture scaffolding tended to facilitate both episodic simulation and user engagement (relative to no scaffolding), irrespective of scenario modality and anxiety level.

Threat and benign interpretation bias might not be a unidimensional construct

The tendency for individuals to interpret ambiguous information in a threatening way is theorised to maintain anxiety disorders. Recent findings suggest that positive and negative interpretation biases may have unique effects. This study tested the relationships between threat and benign biases with state and trait anxiety and quality of life, and whether individual differences moderate these relationships. N = 699 individuals with elevated trait anxiety symptoms completed web-based measures of interpretation bias, trait anxiety, state anxiety, and quality of life. Results demonstrated that threat interpretations predicted state anxiety, trait anxiety, and quality of life. Benign interpretations also predicted quality of life. However, benign interpretations only weakly (or not at all) predicted state and trait anxiety. Individual differences (e.g. gender, race, ethnicity, age) did not moderate findings. Results emphasise the need to consider benign and threat biases separately, both in cognitive models of anxiety and experimental designs.

Web-Based Cognitive Bias Modification Interventions for Psychiatric Disorders: Scoping Review

BACKGROUND

Cognitive biases refer to automatic attentional or interpretational tendencies, which result in individuals with addictive disorders to automatically attend to substance-related stimuli and those with anxiety disorders to attend to threatening stimuli. To date, several studies have examined the efficacy of cognitive bias modification, and meta-analytical studies have synthesized the evidence for overall efficacy. The clinical utility of cognitive bias modification interventions has previously been limited to the confines of a laboratory, but recent advances in Web technologies can change this.

OBJECTIVE

This scoping review aimed to determine the scope of Web-based cognitive bias interventions and highlight their effectiveness.

METHODS

Databases (PubMed and MEDLINE, EMBASE, PsycINFO, ScienceDirect, and Cochrane Central) were searched from inception to December 5, 2017. The following search terminologies were used: ("attention bias" OR "cognitive bias" OR "approach bias" OR "avoidance bias" OR "interpretative bias") AND ("Internet" OR "Web" OR "Online"). The methods for this scoping review are based on the previously published protocol. For the synthesis of the evidence, a narrative synthesis was undertaken, as a meta-analysis was not appropriate, given the lack of reported effect sizes and the heterogeneity in the outcomes reported.

RESULTS

Of the 2674 unique articles identified, we identified 22 randomized controlled studies that met our inclusion criteria: alcohol use disorder (n=2), tobacco use disorder (n=2), depressive disorder (n=3), anxiety and depressive symptoms in adolescents (n=3), obsessive-compulsive disorder (OCD; n=2), social anxiety disorder (n=9), and anxiety disorder (n=1). The sample sizes of these studies ranged from 16 to 434 participants. There is preliminary evidence to suggest that Web-based interventions could reduce biases among adolescents with heightened symptoms of anxiety and depression and among individuals with OCD.

CONCLUSIONS

This is the first scoping review that mapped out the scope of cognitive bias modification interventions for psychiatric disorders. Web-based interventions have been applied predominantly for social anxiety and addictive disorders. Larger cohorts must be used in future studies to better determine the effectiveness of Web-based cognitive bias interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/10427.

Web-Based Cognitive Bias Intervention for Psychiatric Disorders: Protocol for a Systematic Review

Background

Traditional psychological therapies focus mainly on modification of individuals’ conscious decision-making process. Unconscious processes, such as cognitive biases, have been found accountable for various psychiatric psychopathologies, and advances in technologies have transformed how bias modification programs are being delivered.

Objective

The primary aim of this review is to synthesize evidence of Web-based cognitive bias modification intervention for bias reduction. The secondary aim is to determine the change in symptoms for individual psychiatric disorders following bias modification.

Methods

A systematic review will be conducted including only randomized trials. There will be no restrictions on participants included in the study. A search will be conducted on the respective databases until 2017. Selection of studies will be by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA-P) guidelines. Quality assessment of included studies will be conducted using the Cochrane Risk of Bias tool. A narrative synthesis of identified articles will then be conducted. A meta-analysis will be considered only if there are sufficient articles in a domain for statistical analysis. Ethical approval for this protocol and the planned systematic review was not required.

Results

We expect that the review will be completed 12 months from publication of this protocol.

Conclusions

This review is of importance given how technology has transformed delivery of conventional therapies. Findings from this review will guide future research involving technology and cognitive bias modification interventions.

Trial Registration

International Prospective Register for Systematic Reviews (PROSPERO): 2017 CRD42017074754; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=74754 (Archived by WebCite at http://www.webcitation.org/ 71AvSgZGn)

Registered Report Identifier

RR1-10.2196/10427

Using Advances From Cognitive Behavioral Models of Anxiety to Guide Treatment for Social Anxiety Disorder

This case features an adult male with moderate social anxiety disorder and mild depressive symptoms who showed an initial positive response to an earlier experience of cognitive behavior therapy, but then relapsed when he started avoiding social situations again because of continuing beliefs that experiencing anxiety was unacceptable. His treatment at our clinic focused on shifting unhelpful thinking about the likelihood and consequences of becoming anxious and reengaging in avoided social situations so he could learn to tolerate negative affect and uncertainty. The treatment approach draws from cognitive behavioral models of social anxiety and highlights advances in clinical science, especially recent work on the causal role of interpretation biases (the tendency to assign negative or threatening meaning to ambiguous situations) in the maintenance and reduction of anxiety.

Introduction to the special issue on Cognitive bias modification: Taking a step back to move forward?

Cognitive bias modification (CBM) research holds important theoretical and clinical potential. CBM represents one of the most exciting translational developments in experimental psychopathology research in recent years. Despite theoretical and methodological advances in the past 15 years, the clinical efficacy of CBM, to-date, has been disappointing. However, it is important to remember that the CBM therapeutics literature is only in its early stages of scientific development. We argue that the potential for novel approaches to CBM to contribute to disseminable psychological interventions is strong and has yet to be realized. Accordingly, we propose 5 inter-related steps that may help advance the basic and clinical science of CBM: (1) Innovation and refinement of the methodology to modify information-processing bias; (2) Advancing understanding of the nature of processing biases in order to guide their modification; (3) Conceptualizing and studying the moderating and mediating mechanisms underlying the modification of information-processing bias and their effects on maladaptation; (4) Focus on augmenting existing validated treatments, by targeting psychobehavioral processes proximally linked to information-processing biases; (5) Encouraging publication of methodologically strong, mixed and unexpected findings. Finally, we introduce papers in the special issue with respect to each of these future directions. These papers provide important new conceptual and methodological perspectives to advance CBM research.

Attempted Training of Alcohol Approach and Drinking Identity Associations in US Undergraduate Drinkers: Null Results from Two Studies

There is preliminary evidence that approach avoid training can shift implicit alcohol associations and improve treatment outcomes. We sought to replicate and extend those findings in US undergraduate social drinkers (Study 1) and at-risk drinkers (Study 2). Three adaptations of the approach avoid task (AAT) were tested. The first adaptation – the approach avoid training – was a replication and targeted implicit alcohol approach associations. The remaining two adaptations – the general identity and personalized identity trainings – targeted implicit drinking identity associations, which are robust predictors of hazardous drinking in US undergraduates. Study 1 included 300 undergraduate social drinkers. They were randomly assigned to real or sham training conditions for one of the three training adaptations, and completed two training sessions, spaced one week apart. Study 2 included 288 undergraduates at risk for alcohol use disorders. The same training procedures were used, but the two training sessions occurred within a single week. Results were not as expected. Across both studies, the approach avoid training yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes. The general identity training also yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes with one exception; individuals who completed real training demonstrated no changes in drinking refusal self-efficacy whereas individuals who completed sham training had reductions in self-efficacy. Finally, across both studies, the personalized identity training yielded no evidence of training effects on implicit alcohol associations or alcohol outcomes. Despite having relatively large samples and using a well-validated training task, study results indicated all three training adaptations were ineffective at this dose in US undergraduates. These findings are important because training studies are costly and labor-intensive. Future research may benefit from focusing on more severe populations, pairing training with other interventions, increasing training dose, and increasing gamification of training tasks.