The contextual goal dependent attentional flexibility (CoGoDAF) framework: A new approach to attention bias in depression

Successful adaptation to the environment requires attentional prioritization of emotional information relevant to the current situational demands. Accordingly, the presence of an attention bias (AB) for both positive and negative information may allow preferential processing of stimuli in line with the current situational goals. However, AB for negative information sometimes becomes maladaptive, being antithetical to the current adaptive needs and goals of an individual, such as in the case of affective disorders such as depression. Although difficulties in flexible shifting between emotional stimuli in depression have increasingly become a topic of discussion in the field, an integrative approach towards biased versus flexible emotional attentional processes remains absent. In the present paper, we advance a novel and integrative view of conceptualizing potentially aberrant affective attention patterns in depression as a function of the current contextual features. We propose that flexible emotional attention takes place as a result of attention prioritization towards goal-relevant emotional stimuli depending upon the current context of the individual. Specifically, the roles of context, distal and proximal goals, and approach and avoidance motivation processes are considered in a unified manner. The empirical, clinical, and interventional implications of this integrative framework provide a roadmap for future psychological and neurobiological experimental and translational research.

A Learning Theory Approach to Attachment Theory: Exploring Clinical Applications

Although clinicians typically acknowledge the importance of insecure attachment as one factor that can contribute to children's psychopathology, translating attachment theory into clinical practice has proved a challenge. By specifying some of the mechanisms through which the child's attachment develops and changes, learning theory can enhance attachment based approaches to therapy. Specifically, interventions building on operant (parent management training) and classical (exposure therapy) learning can be used to stimulate new learning that increases the child's security and confidence in the parent's availability and responsiveness. To explore the clinical application and utility of a Learning Theory of Attachment (LTA), we focus on two attachment-focused interventions: Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) and Middle Childhood Attachment-based Family Therapy (MCAT). VIPP-SD is an evidence-based parent management training designed to promote sensitive parenting and secure attachment in early childhood. MCAT is a recently developed intervention that uses exposure to stimulate secure attachment in middle childhood. LTA sheds light on the mechanisms set in train by VIPP-SD and MCAT facilitating the induction of professionals in clinical applications.

A Web-Based Cognitive Bias Modification Intervention (Re-train Your Brain) for Emerging Adults With Co-occurring Social Anxiety and Hazardous Alcohol Use: Protocol for a Multiarm Randomized Controlled Pilot Trial

BACKGROUND

Alcohol use and anxiety disorders commonly co-occur, resulting in a more severe clinical presentation and poorer response to treatment. Research has shown that approach bias modification (ApBM) and interpretation bias modification (IBM) cognitive retraining interventions can be efficacious adjunctive treatments that improve outcomes for alcohol use and social anxiety, respectively. However, the acceptability, feasibility, and clinical utility of combining ApBM and IBM programs to optimize treatments among comorbid samples are unknown. It is also unclear whether integrating ApBM and IBM within each training session or alternating them between each session is more acceptable and efficacious.

OBJECTIVE

This paper describes the protocol for a randomized controlled pilot trial investigating the feasibility, acceptability, and preliminary efficacy of the Re-train Your Brain intervention-an adjunct web-based ApBM+IBM program-among a clinical sample of emerging adults with hazardous alcohol use and social anxiety.

METHODS

The study involves a three-arm randomized controlled pilot trial in which treatment-seeking emerging adults (18-30 years) with co-occurring hazardous alcohol use and social anxiety will be individually randomized to receive the Re-train Your Brain integrated program, delivered with 10 biweekly sessions focusing on both social anxiety and alcohol each week, plus treatment as usual (TAU; ie, the model of care provided in accordance with standard practice at their service; n=30); the Re-train Your Brain alternating program, delivered with 10 biweekly sessions focusing on social anxiety one week and alcohol the next week, plus TAU (n=30); or TAU only (n=30). Primary outcomes include feasibility (uptake, follow-up rates, treatment adherence, attrition, and adverse events) and acceptability (system usability, client satisfaction, user experience, and training format preference). Secondary efficacy outcomes include changes in alcohol approach and interpretation biases, social anxiety, and alcohol use (eg, drinks per day, binge drinking, drinking motives, severity of dependence, and cravings). The primary end point will be posttreatment (6 weeks postbaseline), with a secondary end point at 3 months postbaseline. Descriptive statistics will be conducted for primary outcomes, whereas intention-to-treat, multilevel mixed effects analysis for repeated measures will be performed for secondary outcomes.

RESULTS

This study is funded from 2019 to 2023 by Australian Rotary Health. Recruitment is expected to be completed by mid-2022 to late 2022, with follow-ups completed by early 2023.

CONCLUSIONS

This study will be the first to evaluate whether an ApBM+IBM program is acceptable to treatment-seeking, emerging adults and whether it can be feasibly delivered via the web, in settings where it will ultimately be used (eg, at home). The findings will broaden our understanding of the types of programs that emerging adults will engage with and whether the program may be an efficacious treatment option for this comorbidity.

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)

PRR1-10.2196/28667.

Acceptability and Co-Development of an Online Cognitive Bias Modification Intervention for Emerging Adults With Hazardous Alcohol Use and Social Anxiety: A Mixed Methods Study

BACKGROUND

Approach bias modification (ApBM) and interpretation bias modification (IBM) are two promising adjunct treatments for alcohol use and social anxiety, respectively. However, the acceptability of combining ApBM and IBM into one program for people who experience both of these disorders is unknown. The present study describes the codevelopment of a new, hybrid ApBM + IBM program and provides insight into the perceptions of acceptability from service providers and emerging adults.

METHODS

Service providers (n = 14) and emerging adults aged 18 to 25 years with lived experience of hazardous alcohol use and heightened social anxiety (n = 15) were recruited via online advertisements and through existing networks. All participants were shown a beta version of the program and asked to complete qualitative and quantitative questions to ascertain feedback on the program's acceptability and suggestions for improvement.

RESULTS

Themes emerged relating to the ApBM + IBM program's quality and usefulness, appropriateness, motivation and engagement, and potential clinical value. The program was well received and deemed acceptable for the target age group. It was rated particularly highly with regard to the overall quality and ease of use. Emerging adults had fewer suggestions for how the intervention might be revised; however, there were suggestions from both groups regarding the need for a compelling rationale at the outset of treatment and a suggestion to include a motivational interviewing and psychoeducational-based module prior to the first training session, to increase user buy-in and engagement.

CONCLUSIONS

The current findings reflect positively on the acceptability of a hybrid ApBM + IBM for emerging adults with co-occurring hazardous alcohol use and social anxiety. Service providers and emerging adults identified a number of ways to improve the design and implementation of the program, which will likely improve adherence to, and outcomes of, the intervention when added as an adjunct to treatment as usual.

A Further Validation of the Cognitive Bias Modification Effect on Trust in Middle Childhood

Recent middle childhood research suggests that children's trust in maternal support can be manipulated using Cognitive Bias Modification (CBM) aimed at changing children's interpretation of ambiguous maternal support-related behavior. The current study with 60 children (40 girls, M_age = 10.62, SD_age = 1.20) aimed to replicate previous research and to test whether the CBM effect is specific to trust or generalizes to other child evaluations of maternal behavior. More specifically, CBM effects on children's evaluation of parenting behavior were tested. Trust and maternal parenting behaviors were assessed using children's self-report. Results largely replicated previous findings, including the positive effect of CBM on children's trust in maternal support. Suggesting that this effect was specific for trust, the CBM manipulation did not affect children's appraisal of maternal parenting behavior. This finding supports the validity of CBM effects.

Strengthening Attachment-Based Therapies: A Case for Cognitive Bias Modification?

A recent article published in the Journal describes the effectiveness of attachment-based family therapy in decreasing suicidal ideation and depressive symptoms in adolescents. ¹Because insecure attachment is a transdiagnostic risk factor in the development of psychological problems in children and adolescents, improving attachment relationships is an important therapeutic endeavor. In their article, Diamond et al. suggest that programs such as attachment-based family therapy might become more effective or "fortified by integrating more specific cognitive and emotional skills training." ¹In the current letter, we want to argue that such a claim is theoretically meaningful, how such fortification might be achieved, and which training components might be added. Most importantly, we want to plea for clinical research that puts this claim to a test.

A failure to show the efficacy of a dot-probe attentional training in dysphoria: Evidence from an eye-tracking study

OBJECTIVE

This study examines whether a 4-day dot-probe attentional training to orient attention toward positive words could lead participants with dysphoria to change selective attention to emotional faces. It was also explored whether this positive attentional bias training could lead to a decrease in depressive symptoms.

METHODS

Participants were randomly assigned to Positive Training Group (PTG) and No Training Group (NTG). PTG was composed of 16 subjects, whereas NTG was composed of 15 subjects. All participants were women with a mean age of 22.87 (SD = 3.21).

RESULTS

Results showed that dysphoric participants in the PTG did not show changes in attentional patterns to emotional faces. Furthermore, depressive symptoms did not significantly change after the 4-session training.

CONCLUSIONS

These results suggest that cognitive training procedures based on dot-probe paradigms are probably not adequate to modify attentional patterns in individuals with depressive symptoms. The theoretical and practical implications are discussed.

From neuroscience to evidence based psychological treatments - The promise and the challenge, ECNP March 2016, Nice, France

This ECNP meeting was designed to build bridges between different constituencies of mental illness treatment researchers from a range of backgrounds with a specific focus on enhancing the development of novel, evidence based, psychological treatments. In particular we wished to explore the potential for basic neuroscience to support the development of more effective psychological treatments, just as this approach is starting to illuminate the actions of drugs. To fulfil this aim, a selection of clinical psychologists, psychiatrists and neuroscientists were invited to sit at the same table. The starting point of the meeting was the proposition that we know certain psychological treatments work, but we have only an approximate understanding of why they work. The first task in developing a coherent mental health science would therefore be to uncover the mechanisms (at all levels of analysis) of effective psychological treatments. Delineating these mechanisms, a task that will require input from both the clinic and the laboratory, will provide a key foundation for the rational optimisation of psychological treatments. As reviewed in this paper, the speakers at the meeting reviewed recent advances in the understanding of clinical and cognitive psychology, neuroscience, experimental psychopathology, and treatment delivery technology focussed primarily on anxiety disorders and depression. We started by asking three rhetorical questions: What has psychology done for treatment? What has technology done for psychology? What has neuroscience done for psychology? We then addressed how research in five broad research areas could inform the future development of better treatments: Attention, Conditioning, Compulsions and addiction, Emotional Memory, and Reward and emotional bias. Research in all these areas (and more) can be harnessed to neuroscience since psychological therapies are a learning process with a biological basis in the brain. Because current treatment approaches are not fully satisfactory, there is an imperative to understand why not. And when psychological therapies do work we need to understand why this is the case, and how we can improve them. We may be able to improve accessibility to treatment without understanding mechanisms. But for treatment innovation and improvement, mechanistic insights may actually help. Applying neuroscience in this way will become an additional mission for ECNP.

Re-training automatic action tendencies to approach cigarettes among adolescent smokers: a pilot study

BACKGROUND

This pilot study conducted a preliminary examination of whether Cognitive Bias Modification (CBM), a computerized task to retrain cognitive-approach biases towards smoking stimuli (a) changed approach bias for cigarettes, and (b) improved smoking cessation outcomes in adolescent smokers.

METHODS

Sixty adolescent smokers received four weeks of Cognitive Behavioral Therapy (CBT) for smoking cessation, with CBM (90% avoidance/10% approach for smoking stimuli and 10% avoidance/90% approach for neutral stimuli) or sham (50% avoidance/50% approach for smoking and neutral stimuli) training in the Netherlands (n = 42) and the United States (n = 18).

RESULTS

While we did not observe changes in action tendencies related to CBM, adolescents with higher smoking approach biases at baseline had greater decreases in approach biases at follow-up, compared to adolescents with smoking avoidance biases, regardless of treatment condition (p = 0.01). Intent-to-treat (ITT) analyses showed that CBM, when compared with sham trended toward higher end-of-treatment, biochemically-confirmed, seven-day point prevalence abstinence, (17.2% vs. 3.2%, p = 0.071). ITT analysis also showed that regardless of treatment condition, cotinine level (p = 0.045) and average number of cigarette smoked (p ≤ 0.001) significantly decreased over the course of treatment.

CONCLUSIONS

The findings from this pilot study suggests that re-training approach biases toward cigarettes shows promise for smoking cessation among adolescent smokers. Future research should utilize larger samples and increased distinction between CBM and sham conditions, and examine mechanisms underlying the CBM approach.

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.

A preliminary investigation of a novel training to target cognitive biases towards negative social stimuli in Anorexia Nervosa

BACKGROUND

Patients with Anorexia Nervosa (AN) experience high levels of social difficulties and anxiety. These problems might be underpinned by negatively biased processing of social stimuli. The aim of this study was to examine the feasibility of using a novel Cognitive Bias Modification (CBM) training to target information processing biases in patients with AN.

METHODS

Twenty-eight patients with AN completed a baseline and end of intervention assessment of mood and social appraisals. The CBM training consisted of 5 sessions and included an attentional probe task to train attention towards positive social stimuli and an ambiguous scenarios task to train benign or neutral interpretations of ambiguous social scenarios.

RESULTS

At baseline patients displayed an attention and interpretation bias towards negative social stimuli. At the end of intervention there was a medium sized increase in attention to positive faces and fewer negative interpretations of ambiguous social stimuli. There were also lower levels of anxiety and higher levels of self-compassion in response to a judgemental video clip.

LIMITATIONS

The lack of a control group is the main limitation to this preliminary study as the changes obtained may have resulted from non-specific aspects of the inpatient treatment.

CONCLUSIONS

A novel CBM training is associated with more positive processing of social information in AN. It would be of interest to test the hypothesis that reducing cognitive biases towards social stimuli impacts on wider features of an eating disorder.

Augmentation of Treatment As Usual with online Cognitive Bias Modification of Interpretation training in adolescents with Obsessive Compulsive Disorder: A pilot study

BACKGROUND AND OBJECTIVES

Cognitive Behavioral Therapy for children and adolescents with Obsessive Compulsive Disorder (OCD) is effective. However, since almost half of patients remain symptomatic after treatment, there remains room for improvement. Cognitive Bias Modification training of Interpretations (CBM-I) is a promising new intervention, as it targets misinterpretation of intrusions, which is seen as an important characteristic in OCD. To date, there have been no published studies of CBM-I in adolescents with OCD. The aim of the current pilot study was to examine the added value of online CBM-I training as an adjunctive treatment to the Treatment As Usual (TAU; that included CBT and pharmacotherapy) in adolescents with OCD.

METHODS

Patients receiving TAU were randomly assigned to either an additional CBM-I training (n = 9), or to an additional placebo variant of this procedure (n = 7).

RESULTS

Immediate, on-line interpretations changed in response to the CBM-I training, while no such effects were observed on slower retrospective off-line interpretations. Patients in the CBM-I training condition reported fewer obsessive compulsive symptoms after training, and clinicians rated them as having fewer obsessive symptoms (corresponding to medium-large effect sizes). No such changes were observed in the placebo group.

LIMITATIONS

The small sample size precludes strong conclusions and replication is necessary to test the robustness of the findings.

CONCLUSIONS

This small randomized controlled trial is suggestive, although not conclusive, regarding the promising additive value of OC-related CBM-I training as an adjunctive intervention to TAU in an adolescent clinical population.

Children's Attentional Processing of Mother and Proximity Seeking

Attachment expectations regarding the availability of mother as a source for support are supposed to influence distressed children’s support seeking behavior. Because research is needed to better understand the mechanisms related to support seeking behavior, this study tested the hypothesis that the cognitive processing of mother-related information is linked to proximity and support seeking behavior. Uncertainty in maternal support has been shown to be characterized by a biased attentional encoding of mother, reducing the breadth of children’s attentional field around her. We investigated whether this attentional bias is related to how long distressed children wait before seeking their mother’s proximity. Thirty-three children (9-11 years) participated in this study that consisted of experimental tasks to measure attentional breadth and to observe proximity seeking behavior and of questionnaires to measure confidence in maternal support and experienced distress. Results suggested that distressed children with a more narrow attentional field around their mother wait longer to seek her proximity. Key Message: These findings provide a first support for the hypothesis that the attentional processing of mother is related to children’s attachment behavior.

(In)variability of Attachment in Middle Childhood: Secure Base Script Evidence in Diary Data

Secure attachment is characterised by a secure base script regarding the attachment figure as a source for support. Having such a cognitive script should affect the stability of state attachment. Specifically, incongruent attachment-related information should get assimilated to this secure base script, leading to state attachment scores that hardly fluctuate. For children without a script, state attachment should vary depending on the quality of attachment-related interactions. Two diary studies were carried out in 9- to 13-year-old children. Results suggested that with assimilation: (1) securely attached children fluctuated less in their daily attachment-related appraisals; (2) fluctuations were related to conflicts with mother; (3) this relation was stronger for less securely attached children. Consequently, these studies further support the secure base script hypothesis and provide insight into the interplay of trait and state components of attachment-related appraisals.

Cognitive processes and emotion regulation in depression

Sustained negative affect and diminished positive affect are hallmark features of Major Depressive Disorder (MDD). Difficulties in emotion regulation have been proposed to be at the core of these cardinal symptoms of MDD. It remains unclear, however, what underlies emotion regulation difficulties. Cognitive theories of depression have focused on cognitive processes and recent studies suggest that cognitive biases and deficits in cognitive control may help explain affective symptoms of this disorder. Specifically, it is proposed that cognitive biases and deficits affect emotion regulation ability thereby setting the stage for maintained negative affect and diminished levels of positive affect. The article reviews empirical studies that speak to these links and closes with a discussion of novel treatment approaches that are inspired by these ideas.

Internet-based cognitive bias modification of interpretations in patients with anxiety disorders: a randomised controlled trial

BACKGROUND AND OBJECTIVES

Previous research suggests that negative interpretation biases stimulate anxiety. As patients with an anxiety disorder tend to interpret ambiguous information negatively, it was hypothesised that training more positive interpretations reduces negative interpretation biases and emotional problems.

METHODS

In a randomised, double-blind placebo-controlled trial, patients with different anxiety disorders were trained online over eight days to either generate positive interpretations of ambiguous social scenarios (n = 18) or to generate 50% positive and 50% negative interpretations in the placebo control condition (n = 18) (Study 1).

RESULTS

Positively trained patients made more positive interpretations and less negative ones than control patients. This training was followed by a decrease in anxiety, depression, and general psychological distress, but this effect was also observed in the control group. To get a better understanding of these unexpected results, we tested a 100% neutral placebo control group (Study 2, n = 19); now the scenarios described neutral, non-emotional situations and no valenced interpretations were generated. The results from this neutral group were comparable to the effects from the other control group.

LIMITATIONS

An advantage, but potentially also a disadvantage of the study is that CBM-I training was performed online with less control over the procedures and setting. In addition, the scenarios were not matched to the specific concerns of each patient and the training sessions were performed in close proximity to one another.

CONCLUSIONS

Compared to both control conditions, CBM-I had superior effects on interpretations, but not on emotions. The current findings showed the boundary conditions for CBM-I.

Rumination mediates the relationship between impaired cognitive control for emotional information and depressive symptoms: A prospective study in remitted depressed adults

Impaired cognitive control may be an important vulnerability factor for depression. Moreover, impairments in cognitive control have been proposed as a crucial process underlying ruminative thinking. The present study investigates the influence of impaired cognitive control for emotional information on rumination and depressive symptoms in a prospective design with a 1 year follow up in a clinical sample. Thirty remitted depressed adults completed the Internal Shift Task (IST), a measure of cognitive control of emotional information, at baseline. Moreover, questionnaires measuring rumination (RRS) and depressive symptoms (BDI-II) were administered. One year later participants were contacted again and asked to complete the BDI-II and RRS. Mediation analyses showed a significant influence of impaired cognitive control for emotional information at baseline on depressive symptoms one year later, which was fully mediated by rumination. These findings underscore the importance of cognitive control abilities as a process underlying rumination and as a vulnerability factor for depression. They can stimulate translational research to improve the effectiveness of interventions that aim to decrease vulnerability by targeting cognitive control.

Cognitive bias modification procedures in the management of mental disorders

PURPOSE OF REVIEW

To review recent research on the therapeutic impact of cognitive bias modification (CBM) procedures, designed to train direct change in the patterns of attentional and interpretive bias known to characterize particular forms of psychopathology.

RECENT FINDINGS

CBM designed to change attentional selectivity has proven capable of modifying attentional biases associated with emotional dysfunction, pain disorders, eating disorders and addictions. CBM designed to change interpretive selectivity has proven capable of modifying the tendency to resolve ambiguity in a negative manner that is characteristic of emotional dysfunction. Recent research confirms that both forms of CBM can alter the severity of symptoms associated with psychopathology. Extended delivery of such CBM approaches now has been shown to yield therapeutic benefits for a range of anxiety disorders, and in the case of CBM-A has augmented the efficacy of treatment for alcohol dependence.

SUMMARY

CBM approaches have passed the proof-of-concept stage, and recent small-scale trials attest to their likely clinical value. There is a pressing need for large-scale randomized controlled trials, to compare the efficacy of CBM with that of alternative approaches, and to identify how CBM can most effectively be integrated into multimodal treatment programs.