Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study

The role of acute stress recovery in emotional resilience

Background

Resilience refers to the process of demonstrating better outcomes than would be expected based on the adversity one experienced. Resilience is increasingly measured using a residual approach, which typically assesses adversity and mental health outcomes over a longitudinal timeframe. It remains unknown to what extent such a residual-based measurement of resilience is sensitive to variation in acute stress resilience, a candidate resilience factor.

Methods

Fifty-seven emerging adults enrolled in tertiary education completed measures of adversity and emotional experiences. To assess stress recovery, participants were exposed to a lab-based adverse event from which a Laboratory Stress Resilience Index was derived.

Results

We derived a residual-based measure of emotional resilience from regressing emotional experience scores onto adversity scores. This residual-based measure of emotional resilience predicted variance in the Laboratory Stress Resilience Index over and above that predicted by both a traditional resilience measure and the emotional experiences measure. These findings suggest that acute stress resilience may be a factor underpinning variation in emotional resilience, and that the residual-based approach to measuring resilience is sensitive to such variation in stress resilience.

Beyond the modified dot-probe task: A meta-analysis of the efficacy of alternate attention bias modification tasks across domains

Attention biases towards disease-relevant cues have been implicated in numerous disorders and health conditions, such as anxiety, cancer, drug-use disorders, and chronic pain. Attention bias modification (ABM) has shown that changing attention biases can change related emotional processes. ABM most commonly uses a modified dot-probe task, which has received increasing criticism regarding its reliability and inconsistent findings. The purpose of the present review was thus to systematically review and meta-analyse alternative tasks used in ABM research. We sought to examine whether alternative tasks significantly changed attention biases and emotional outcomes, and critically examined whether relevant sample, task and intervention characteristics moderated each of these effect sizes. Seventy-four (completer n = 15,294) study level comparisons were included in the meta-analysis. Overall, alternative ABM designs had a medium effect on changing biases (g = 0.488), and a small, but significant effect on improving clinical outcomes (g = 0.117). We found this effect to be significantly larger for studies which successfully changed biases compared to those that did not. Across all tasks, it appeared that targeting engagement biases results in the largest change to attention biases. Importantly, we found tasks incorporating gaze-contingency - encouraging engagement with non-biased stimuli - show the most promise for improving emotional outcomes.

Understanding the Role of Expectancy, Anticipatory Anxiety, and Attention Bias in Nocebo Hyperalgesia: A Gaze-Contingent Attention Bias Modification Study

Nocebo effects in pain (nocebo hyperalgesia) have been thoroughly researched, and negative expectancies have been proposed as a key factor in causing nocebo hyperalgesia. However, little is known about the psychological mechanisms by which expectations exacerbate the perception of pain. A potential mechanism that has been proposed within wider pain research is pain-related attention. The aim of the present study was thus to explore whether attention bias (AB) to pain influenced nocebo hyperalgesia. One-hundred and thirty-four healthy participants were randomized in a 2 (AB training: towards vs away from pain) × 2 (nocebo condition: nocebo vs control) design. Pain-related AB was manipulated through a novel, partially gaze-contingent dot-probe task. Participants then completed either a nocebo instruction and conditioning paradigm or a matched control condition. Primary outcomes were measures of expectancy, anticipatory anxiety, and pain intensity completed during a nocebo test phase. Results showed that the AB manipulation was unsuccessful in inducing ABs either toward or away from pain. The nocebo paradigm induced significantly greater expectancy, anticipatory anxiety, and pain intensity for the nocebo groups compared to the control groups. In a posthoc analysis of participants with correctly induced ABs, AB towards pain amplified nocebo hyperalgesia, expectancy, and anticipatory anxiety relative to AB away from pain. The results are consistent with the expectancy model of nocebo effects and additionally identify anticipatory anxiety as an additional factor. Regarding AB, research is needed to develop reliable means to change attention sample-wide to corroborate the present findings. PERSPECTIVE: This article explores the role of AB, expectancy, and anticipatory anxiety in nocebo hyperalgesia. The study shows that expectancy can trigger anticipatory anxiety that exacerbates nocebo hyperalgesia. Further, successful AB training towards pain heightens nocebo hyperalgesia. These findings identify candidate psychological factors to target in minimizing nocebo hyperalgesia.

Serious Games Based on Cognitive Bias Modification and Learned Helplessness Paradigms for the Treatment of Depression: Design and Acceptability Study

BACKGROUND

Depression is a debilitating mental health disorder, with a large treatment gap. Recent years have seen a surge in digital interventions to bridge this treatment gap. Most of these interventions are based on computerized cognitive behavioral therapy. Despite the efficacy of computerized cognitive behavioral therapy-based interventions, their uptake is low and dropout rates are high. Cognitive bias modification (CBM) paradigms provide a complementary approach to digital interventions for depression. However, interventions based on CBM paradigms have been reported to be repetitive and boring.

OBJECTIVE

In this paper, we described the conceptualization, design, and acceptability of serious games based on CBM paradigms and the learned helplessness paradigm.

METHODS

We searched the literature for CBM paradigms that were shown to be effective in reducing depressive symptoms. For each of the CBM paradigms, we ideated how to create a game so that the gameplay was engaging while the active therapeutic component remained unchanged.

RESULTS

We developed 5 serious games based on the CBM paradigms and the learned helplessness paradigm. The games include various core elements of gamification, such as goals, challenges, feedback, rewards, progress, and fun. Overall, the games received positive acceptability ratings from 15 users.

CONCLUSIONS

These games may help improve the effectiveness and engagement levels of computerized interventions for depression.

Attention bias modification for depression: A systematic review and meta-analysis

Background

Depression is a mental health disorder characterized by affective, somatic, and cognitive symptoms. Attention bias modification (ABM) has been widely used to treat depression. However, the results seem inconsistent. We conducted a systematic review and meta-analysis to investigate the efficacy of ABM for depression and to explore the optimal protocol of ABM.

Methods

Seven databases were systematically searched from their inceptions to 5 October 2022 to include randomized controlled trials (RCTs) of ABM for depression. Two independent reviewers selected the eligible articles, extracted data, and evaluated the risk of bias using version 2 of the Cochrane risk-of-bias tool (ROB 2.0) for randomized trials. The primary outcome was the evaluation of depressive symptoms using widely accepted and validated scales. The secondary outcomes included rumination and attentional control. Meta-analysis was conducted by using RevMan (version 5.4) and Stata (version 12.0). Subgroup analyses and meta-regressions were performed to identify the source of heterogeneity. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Results

A total of 19 trials involving 20 datasets (1,262 participants) were included. The overall risk of bias in one study was rated as low risk of bias, three studies were considered as high, and the remaining studies were some concerns. Compared with attention control training (ACT), ABM had a greater effect in the improvement of depression (SMD = −0.48, 95% CI −0.80 to −0.17, I2 = 82%) and rumination (MD = −3.46, 95% CI −6.06 to −0.87, I2 = 0%). No significant differences were observed in the attentional control outcome between ABM and ACT (MD = 3.07, 95% CI −0.52 to 6.65, I2 = 0%). Subgroup analysis demonstrated that adults exhibited a greater decrease in depression scores than adolescents. ABM using the dot-probe task, training target stimulus presented by face, and training directions by left–right were associated with better antidepressant effects. ABM training delivered in the laboratory tended to yield a better effect than those conducted at home. Sensitivity analysis indicated that the results were robust. The certainty of the evidence for all outcomes was low or very low, and publication bias may exist.

Conclusion

Due to high heterogeneity and limited studies, not enough current evidence supported that ABM could be an effective intervention to relieve depressive symptoms. More rigorous RCTs are required to verify the benefits and to explore the optimal protocol of ABM training for depression.

Systematic Review Registration: [PROSPERO], identifier [No. CRD42021279163].

The update of self-identity: Importance of assessing autobiographical memory in major depressive disorder

Major depressive disorder is a leading global cause of disability. There is a growing interest for memory in mood disorders since it might constitute an original tool for prevention, diagnosis, and treatment. MDD is associated with impaired autobiographical memory characterized by a tendency to overgeneral memory, rather than vivid episodic self-defining memory, which is mandatory for problem-solving and projection in the future. This memory bias is maintained by three mechanisms: ruminations, avoidance, and impaired executive control. If we adopt a broader and comprehensive perspective, we can hypothesize that all those alterations have the potential to impair self-identity updating. We posit that this update requires a double referencing process: (1) to internalized self-representation and (2) to an externalized framework dealing with the representation of the consequence of actions. Diagnostic and therapeutic implications are discussed in the light of this model and the importance of assessing autobiographical memory in MDD is highlighted. This article is categorized under: Psychology > Memory Psychology > Brain Function and Dysfunction Neuroscience > Clinical.

Cognitive bias modification training of attention and interpretation to reduce expectations of social rejection in adolescents with eating disorders: A small efficacy randomized controlled trial

OBJECTIVE

This study aimed to investigate whether a computerized cognitive bias modification training delivered remotely would reduce expectations of rejection in adolescents with eating disorders.

METHOD

Sixty-seven adolescents aged 12-18 (99.5% female) with an eating disorder diagnosis (94% anorexia nervosa) and receiving specialist treatment were recruited. Participants were randomized to an intervention condition (n = 37) which included treatment as usual (TAU) supplemented by nine sessions of online cognitive bias modification training for social stimuli (CBMT + TAU), or a control condition (n = 30), which included TAU only. Participants were invited to complete assessments at baseline and post-intervention.

RESULTS

In the intervention condition, 22/37 participants completed six or more training sessions and post-intervention measures, the pre-defined criteria to be considered "completers." In the control condition, 28/30 participants completed the post-intervention measures. Participants who completed the intervention displayed a significantly greater reduction in negative interpretations of ambiguous social scenarios, with a medium effect size (p = .048, ηp2 = .090), and eating disorder psychopathology, with a medium effect size (p = .027, ηp2 = .105), compared to participants in the control condition. No significant between-group differences were found on emotional response to criticism, and anxiety and depression symptoms post-intervention (ps > .05; small effect sizes).

DISCUSSION

Enhancing treatment as usual with CBMT targeting expectations of social rejection might be feasible and effective to reduce expectations of social rejection and eating disorder psychopathology in adolescents with eating disorders. Training adaptations might be necessary to impact on emotional processing and comorbid psychological distress.

PUBLIC SIGNIFICANCE

Adolescents with eating disorders who completed a brief (4-week) online cognitive training intervention, alongside their usual treatment, reported greater reductions in expectations of social rejection and eating disorder psychopathology after the intervention, compared to a separate group of patients who received their usual treatment only. This brief and accessible intervention may be a helpful treatment adjunct for adolescents with eating disorders.

Positive Attention Bias Trained during the Rethink Therapeutic Online Game and Related Improvements in Children and Adolescents' Mental Health

Attentional bias towards positive stimuli is considered a resilience factor for mental health and well-being. The aim of the present study was to analyze the effects of an attentional bias training for positive faces in a preventive therapeutic game for children and adolescents. The sample of 54, which consisted of children and adolescents aged between 10-16 years, played the REThink game, which included an attentional bias training level based on the visual search paradigm, where children had the task to quickly find the happy face among other angry faces. We measured mental health, and positive and negative emotions and analyzed their associations between changes in attention bias. Attentional bias indicators demonstrated acceptable reliability and results showed that increases in attentional bias towards positive faces were associated with improvements in children and adolescents' conduct problems, hyperactivity, and peer relationship problems. Overall, our results support the protective role of training attentional bias towards positive faces as part of a preventive therapeutic game for children and adolescents.

Gamification of cognitive bias modification for interpretations in anxiety increases training engagement and enjoyment

BACKGROUND AND OBJECTIVES

Interpretation bias plays a crucial role in anxiety. To test the causal role and potential clinical benefits, training procedures were developed to experimentally change interpretation bias. However, these procedures are monotonous and plain, which could negatively affect motivation and adherence. The aim of this study was to make the interpretation training more engaging and enjoyable, without compromising its effectiveness, through gamification.

METHODS

The training was gamified by including extrinsically and intrinsically motivating elements such as points, scores, time-pressure, fun and adaptive elements (training at an individually challenging level). A 2 (Type: Gamified vs. Standard) x 2 (Training Valence: Positive vs. Placebo) between-subjects design was used with random allocation of 79 above-average anxious individuals. Post-training, we assessed the liking and recommendation of the training task, interpretation bias (Recognition task and the Scrambled Sentence Task) and anxiety.

RESULTS

Participants experienced the gamified training tasks as more engaging and enjoyable than the standard tasks, although it was not recommend more to fellow-students. Both positive training conditions (gamified and standard) were successful in eliciting a positive interpretation bias when assessed with the Recognition task, while only the standard positive training impacted on interpretations when assessed with the Scrambled Sentence Task. No differential effects were observed on anxiety.

LIMITATIONS

The study involved only a single-session training and participants were selected for high trait (and not social) anxiety.

CONCLUSIONS

The gamified training was evaluated more positively by the participants, while maintaining the effectiveness of eliciting positive interpretations when assessed with the Recognition task. This suggests that gamification might be a promising new approach.

Enhanced capacity to switch but not to maintain: The basis of attentional bias to high calorie foods in restrained eaters

It has been argued that high restrained eaters (i.e., people who fluctuate between restrictive food intake and overeating) are characterised by a heightened attentional bias to high calorie foods. However, the validity of this hypothesis has not yet been convincingly established. The current study sought to empirically evaluate this hypothesis using two directional measures of attentional bias: the well-established dot probe bias assessment task and the more novel Chase the Food bias assessment task. The latter attentional assessment approach has the capacity to differentiate between attentional switching and attentional maintenance within a complex and dynamic food environment. Participants (61 high restrained eaters and 38 low restrained eaters) completed the dot probe task and the Chase the Food task. Findings obtained on the dot probe task did not reveal a group difference in terms of biased attentional responding towards high calorie vs. low calorie food. Conversely, the two groups were found to differ on one of the measures obtained on the Chase the Food task. Specifically, high restrained eaters, as compared to low restrained eaters, demonstrated speeded attentional switching to high calorie foods, rather than a greater ability to maintain attention on high calorie foods when required to do so. These novel findings imply that high restrained eaters are potentially characterised by facilitated attentional switching towards high calorie foods. Implications are discussed including the possibility of targeting biased attentional switching using training variants of the Chase the Food task in interventions designed to reduce maladaptive eating behaviours.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Effectiveness of attentional bias modification training as add-on to regular treatment in alcohol and cannabis use disorder: A multicenter randomized control trial

Background

Attentional bias for substance-relevant cues has been found to contribute to the persistence of addiction. Attentional bias modification (ABM) interventions might, therefore, increase positive treatment outcome and reduce relapse rates. The current study investigated the effectiveness of a newly developed home-delivered, multi-session, internet-based ABM intervention, the Bouncing Image Training Task (BITT), as an add-on to treatment as usual (TAU).

Methods

Participants (N = 169), diagnosed with alcohol or cannabis use disorder, were randomly assigned to one of two conditions: the experimental ABM group (50%; TAU+ABM); or the control group (50%; split in two subgroups the TAU+placebo group and TAU-only group, 25% each). Participants completed baseline, post-test, and 6 and 12 months follow-up measures of substance use and craving allowing to assess long-term treatment success and relapse rates. In addition, attentional bias (both engagement and disengagement), as well as secondary physical and psychological complaints (depression, anxiety, and stress) were assessed.

Results

No significant differences were found between conditions with regard to substance use, craving, relapse rates, attentional bias, or physical and psychological complaints.

Conclusions

The findings may reflect unsuccessful modification of attentional bias, the BITT not targeting the relevant process (engagement vs. disengagement bias), or may relate to the diverse treatment goals of the current sample (i.e., moderation or abstinence). The current findings provide no support for the efficacy of this ABM approach as an add-on to TAU in alcohol or cannabis use disorder. Future studies need to delineate the role of engagement and disengagement bias in the persistence of addiction, and the role of treatment goal in the effectiveness of ABM interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Editorial: Attention to Threat in Child Anxiety: Gazing Into the Future While Keeping Sight of the Past

Since the 1960s, cognitive theories of anxiety have prioritized attention to threat in the etiology and maintenance of anxiety and its disorders.¹ The development of computer-administered tasks in the 1980s, displaying threatening stimuli on the screen and relying on participants' clicking of keys or mouse buttons to measure reaction time, permitted experimental testing of the hypothesis that individuals with anxiety disorders show biased attention to threat.² Considerable data have since accumulated supporting this hypothesis, including in children and adolescents.^1,3 However, reaction times measured by mouse button clicks are indirect and imprecise measurements of attention.⁴ With the availability of eye-tracking in the last decade, researchers have been able to directly and precisely measure attention. Lisk et al.,⁵ in this issue of the Journal, provide a systematic review and meta-analysis of studies that used eye-tracking to measure attention to threat in children and adolescents.

A new approach to facilitating attentional disengagement from food cues in unsuccessful dieters: The bouncing image training task

This study tested the capacity of a modified Bouncing Image Training Task (BITT) to enhance unsuccessful dieters' attentional disengagement from food cues. Unsuccessful dieters were assigned to a training group performing daily BITT sessions for one week (n = 57) or a waitlist control group (n = 56). Change in attention was assessed using a visual search task and an odd-one-out task. Impact of the BITT on food craving and food intake were also assessed. Participants in the training group, compared to waitlist controls, showed reduced attention to food cues from pre-to post-training. Moreover, the reduction in AB to food cues exhibited by those who completed the BITT reflected the relative facilitation of attentional disengagement from food cues, rather than a reduction in attention engagement with food cues. The groups did not differ on food craving or intake post-training. It is concluded that the BITT is a promising procedure for directly manipulating individuals' attentional disengagement from food cues, though its capacity to enhance dieting success has not yet been established.

Dispositional negativity, cognition, and anxiety disorders: An integrative translational neuroscience framework

When extreme, anxiety can become debilitating. Anxiety disorders, which often first emerge early in development, are common and challenging to treat, yet the underlying mechanisms have only recently begun to come into focus. Here, we review new insights into the nature and biological bases of dispositional negativity, a fundamental dimension of childhood temperament and adult personality and a prominent risk factor for the development of pediatric and adult anxiety disorders. Converging lines of epidemiological, neurobiological, and mechanistic evidence suggest that dispositional negativity increases the likelihood of psychopathology via specific neurocognitive mechanisms, including attentional biases to threat and deficits in executive control. Collectively, these observations provide an integrative translational framework for understanding the development and maintenance of anxiety disorders in adults and youth and set the stage for developing improved intervention strategies.

The effects of attentional bias modification on emotion regulation

BACKGROUND AND OBJECTIVES

In two experiments, we investigated the effects of Attentional Bias Modification (ABM) on emotion regulation, i.e. the manner in which people influence emotional experiences. We hypothesized that decreases in attentional bias to threat would impair upregulation and improve downregulation of negative emotions, while increases in attentional bias to threat would improve upregulation and impair downregulation of negative emotions.

METHODS

Using the emotion-in-motion paradigm (Experiment 1, N = 60) and the visual search task (Experiment 2, N = 58), we trained participants to attend to either threatening or positive stimuli and we assessed emotion intensity while observing, upregulating, and downregulating emotions in response to grids of mixed emotional pictures.

RESULTS

In Experiment 1, the attend positive group reported more positive emotions while merely watching grids of training pictures and the attend threat group showed impaired upregulation of negative affect. In Experiment 2, the attend threat group reported intensified negative emotions for all three instructions, while the attend positive group remained largely stable over time.

LIMITATIONS

We cannot unequivocally attribute these changes in emotion regulation to changes in attentional bias, as neither of the experiments yielded significant changes in attentional bias to threat.

CONCLUSIONS

By showing that attentional bias modification procedures affect the manner in which people deal with emotions, we add empirical weight to the conceptual overlap between attentional bias modification and emotion regulation.