Towards implementation of cognitive bias modification in mental health care: State of the science, best practices, and ways forward.

Cognitive bias modification (CBM) has evolved from an experimental method testing cognitive mechanisms of psychopathology to a promising tool for accessible digital mental health care. While we are still discovering the conditions under which clinically relevant effects occur, the dire need for accessible, effective, and low-cost mental health tools underscores the need for implementation where such tools are available. Providing our expert opinion as Association for Cognitive Bias Modification members, we first discuss the readiness of different CBM approaches for clinical implementation, then discuss key considerations with regard to implementation. Evidence is robust for approach bias modification as an adjunctive intervention for alcohol use disorders and interpretation bias modification as a stand-alone intervention for anxiety disorders. Theoretical predictions regarding the mechanisms by which bias and symptom change occur await further testing. We propose that CBM interventions with demonstrated efficacy should be provided to the targeted populations. To facilitate this, we set a research agenda based on implementation frameworks, which includes feasibility and acceptability testing, co-creation with end-users, and collaboration with industry partners.

Fear-related associations in children of parents with an anxiety disorder.

BACKGROUND AND OBJECTIVES: Children of parents with an anxiety disorder are at elevated risk for developing an anxiety disorder themselves. According to cognitive theories, a possible risk factor is the development of schema-related associations. This study is the first to investigate whether children of anxious parents display fear-related associations and whether these associations relate to parental anxiety. METHODS: 44 children of parents with panic disorder, 27 children of parents with social anxiety disorder, and 84 children of parents without an anxiety disorder filled out the SCARED-71, and the children performed an Affective Priming Task. RESULTS: We found partial evidence for disorder-specificity: When the primes were related to their parent's disorder and the targets were negative, the children of parents with panic disorder and children of parents with social anxiety disorder showed the lowest error rates related to their parents' disorder, but they did not have faster responses. We did not find any evidence for the expected specificity in the relationship between the parents' or the children's self-reported anxiety and the children's fear-related associations, as measured with the APT. LIMITATIONS: Reliability of the Affective Priming Task was moderate, and power was low for finding small interaction effects. CONCLUSIONS: Whereas clearly more research is needed, our results suggest that negative associations may qualify as a possible vulnerability factor for children of parents with an anxiety disorder.

Implementing Approach-Bias Modification as Add-On to Varieties of Clinical Treatment for Alcohol Use Disorders: Results of a Multicenter RCT.

INTRODUCTION: Abstinence rates after inpatient treatment for alcohol use disorder (AUD) are modest (1-year rate around 50%). One promising approach is to re-train the automatically activated action tendency to approach alcohol-related stimuli (alcohol-approach bias) in AUD patients, as add-on to regular treatment. As efficacy has been demonstrated in well-controlled randomized controlled trials, the important next step is to add alcohol-approach-bias modification (alcohol-ApBM) to varieties of existing treatments for AUD. Therefore, this prospective, multicenter implementation-RCT examined whether adding alcohol-ApBM to regular treatments (various abstinence-oriented treatments including both individual and group-based interventions) would significantly increase abstinence rates compared to receiving regular treatment only, in a variety of naturalistic settings with different therapeutic approaches. METHODS: A total of 1,586 AUD inpatients from 9 German rehabilitation clinics were randomly assigned to receive either ApBM in addition to regular treatment or not. Training satisfaction of patients and therapists was measured after training. Success rates were determined at 3, 6, and 12 months post-treatment. RESULTS: Return rates of the post-treatment assessments varied greatly between clinics, often being low (18-76%). Nevertheless, ApBM significantly increased success rates after 3 months. After 6 and 12 months, the differences were not significant. ApBM was evaluated mostly positively by patients and therapists. DISCUSSION/CONCLUSION: ApBM was an effective add-on to regular treatment of AUD at 3 months follow-up, across a variety of AUD treatment settings. However, low return rates for the clinical outcomes reduced the effect size of ApBM considerably. The application of ApBM proved feasible in varying clinical settings, offering the opportunity to modify automatic processes and to promote abstinence.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives.

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Interpretation biases in childhood spider fear: Content-specificity, priming, and avoidance.

BACKGROUND AND OBJECTIVES: The relation between fear and interpretation bias has been widely studied in children. However, much less is known about its content-specificity and how interpretation biases predict variance in avoidance. The current study examined different interpretation bias tasks, the role of priming and the ability of the interpretation bias tasks to predict spider fear-related avoidance behaviour. METHODS: 169 children with varying levels of spider fear performed a behavioural avoidance task, two versions of the Ambiguous Scenarios Task (AST; with and without priming), and a size and distance estimation task. RESULTS: Both versions of the AST and the size-estimation were significantly related to self-reported spider fear and avoidance. These relations were content-specific: children with higher levels of spider fear had a more negative interpretation bias related to spider-related materials than to other materials, and a more negative bias than children with lower levels of spider fear. Furthermore, self-reported spider fear, the AST with priming, and the size-estimation predicted unique variance in avoidance behaviour. LIMITATIONS: Children varied in their level of spider fear, but clinical diagnoses of spider phobia were not assessed. The participants of this study were not randomly selected, they were children of parents with panic disorder or social anxiety disorder or no anxiety disorder and could therefore partly be seen as children at risk. CONCLUSIONS: The results support cognitive models of childhood anxiety and indicate that both controlled and automatic processes play an important role in fear-related behaviour.

Hostile and threatening interpretation biases in adolescent inpatients are specific to callous-unemotional traits and social anxiety.

Psychopathological syndromes, such as disruptive behavior and anxiety disorders in adolescence, are characterized by distorted cognitions and problematic behavior. Biased interpretations of ambiguous social situations can elicit both aggressive and avoidance behavior. Yet, it is not well understood whether different interpretation biases are specific to different syndromes, or whether they can co-occur. We assessed both hostile and threatening interpretation biases in identical social situations, and proposed that they are uniquely related to callous-unemotional (CU) traits and social anxiety, respectively. We also explored the role of gender and age herein. The sample consisted of 390 inpatients between 10 and 18 years of age with a variety of psychiatric disorders. Hostile and threatening interpretations were assessed with the Ambiguous Social Scenario Task (ASST) consisting of 10 written vignettes. Both CU-traits and social anxiety were assessed with self-report questionnaires. Results showed that, overall, CU-traits were related to more hostile interpretations, whereas social anxiety was related to more threatening interpretations. In addition, in boys, hostile and threatening interpretations correlated significantly positive with each other. Age was not related to interpretation biases. Together, these results generally support the content-specificity of interpretation biases in concepts relevant to disruptive behavior disorders and anxiety disorders, and indicate that different interpretation biases can co-occur specifically in boys.

Although I know it: Social anxiety is associated with a deficit in positive updating even when the cost of avoidance is Obvious.

Social anxiety (SA) is associated with difficulties in positively updating negative social information when new information and feedback about chosen options (actual decisions) are received. However, it is unclear whether this difficulty persists when hidden information regarding unchosen options is explicitly presented. The aim of the current study was to address this gap. Participants (Mturk; n = 191) completed a two-phases novel task. In the task, participants chose to approach or avoid people, represented by images of faces. During the initial (learning) phase, participants learned, in a probabilistic context, which people are associated with negative outcomes and should be avoided, and which are associated with positive outcomes and should be approached. During the subsequent updating phase, people previously associated with negative outcomes became associated with positive outcomes and vice versa. Importantly, participants received feedback not only on their approach (actual) decisions, but also on their avoidance (counter-factual) decisions (e.g., approaching this person would have been beneficial). The results revealed that even when the consequences of avoidance were explicitly presented, SA was associated with difficulty in positive updating of social information. The findings support the view that biased updating of social information is a change-resistant mechanism that may underlie the maintenance of SA.

Watch out! A path from anxiety to anorexia nervosa through biased attention?

OBJECTIVE: Evidence points towards heightened anxiety and attention biases (AB) towards disorder-specific (threatening) stimuli in patients with anorexia nervosa (AN). To date, it is unclear how anxiety and AB interact in eating disorders (ED). The present study tests the causal role of anxiety by inducing anxiety before a dot-probe task with either ED-specific stimuli or unspecific negative (threat-related) information. We expected that anxiety would elicit AB for ED-specific, but not for unspecific threat-related stimuli. METHODS: Adolescents with AN (AN, n = 32) or depression (DEP, n = 27) and healthy controls (HC, n = 29) underwent an anxiety induction or a low anxiety control task before a pictorial dot-probe task with either under-/overweight body-related pictures or non-disorder-related threatening pictures (angry faces). BMI, level of ED symptoms, anxiety, stress, and depression were assessed at baseline. RESULTS: The anxiety induction did not affect the observed attention pattern. AN showed an AB towards underweight body pictures compared to HC, whereas no disorder-unspecific threat-related AB emerged. Regression analyses revealed that only anxiety predicted the AB towards underweight body pictures. DISCUSSION: Further experimental research may integrate eye tracking as an additional tool, or collect information on body dissatisfaction to obtain a better understanding of how anxiety biases attention.

Follow-up outcomes of Mindfulness-Based Cognitive Therapy (MBCT) for patients with chronic, treatment-resistant depression.

BACKGROUND: Mindfulness-based cognitive therapy (MBCT) is an evidence-based treatment for depression. The current study focused on the long-term outcomes of MBCT for chronically, treatment-resistant depressed patients during a 6-months follow-up period. Additionally, predictors of treatment outcomes were explored. METHOD: The outcomes of MBCT on depressive symptoms, remission rates, quality of life, rumination, mindfulness skills and self-compassion were investigated in a cohort of chronically, treatment-resistant depressed outpatients (N = 106), who had taken part in an RCT comparing MBCT with treatment-as-usual (TAU). Measures were assessed pre-MBCT, post-MBCT, at 3-months follow-up, and at 6-months follow-up. RESULTS: Results of linear mixed effect models and Bayesian repeated measures ANOVA's reveal that depressive symptoms, quality of life, rumination, mindfulness skills and self-compassion consolidated during follow-up. Remission rates even further increased over the course of follow-up. When controlling for symptoms at baseline, higher baseline levels of rumination predicted lower depressive symptoms and quality of life at 6-month follow-up. No other predictors (i.e. duration of current depressive episode, level of treatment-resistance, childhood trauma, mindfulness skills, self-compassion) were found. LIMITATIONS: All participants received MBCT, therefore time or other non-specific effects might have influenced the results and replication studies including a control conditions are needed. CONCLUSIONS: Results indicate that the clinical benefits of MBCT for chronically, treatment-resistant depressed patients persist up to 6 months after completing MBCT. Duration of the current episode, level of treatment-resistance, childhood trauma and baseline levels of mindfulness skills and self-compassion did not predict treatment outcome. When controlling for baseline depressive symptoms participants with high levels of rumination seem to benefit more; however more research is needed. TRIAL REGISTRY: Dutch Trial Registry, number NTR4843.

Specific interpretation biases as a function of social anxiety and callous-unemotional traits in a community and a clinical adolescent sample.

BACKGROUND: Threatening and hostile interpretation biases are seen as causal and maintaining mechanisms of childhood anxiety and aggression, respectively. However, it is unclear whether these interpretation biases are specific to distinct problems or whether they are general psychopathological phenomena. The specificity versus pervasiveness of interpretation biases could also differ depending on mental health status. Therefore, in the current study, we investigated whether social anxiety and callous-unemotional (CU) traits were uniquely related to threatening and hostile interpretation biases, respectively, in both a community and a clinical sample of adolescents. METHODS: A total of 161 adolescents between 10 to 15 years of age participated. The community sample consisted of 88 participants and the clinical sample consisted of 73 inpatients with a variety of psychological disorders. Social anxiety and CU-traits were assessed with self-report questionnaires. The Ambiguous Social Scenario Task was used to measure both threatening and hostile interpretations in response to written vignettes. RESULTS: Results showed that social anxiety was uniquely related to more threatening interpretations, while CU-traits were uniquely related to more hostile interpretations. These relationships were replicated for the community sample. For the clinical sample, only the link between social anxiety and threatening interpretations was significant. Explorative analyses showed that adolescents with externalizing disorders scored higher on hostile interpretations than adolescents with internalizing disorders. CONCLUSIONS: Overall, these results support the content-specificity of threatening interpretation biases in social anxiety and of hostile interpretation biases in CU-traits. Better understanding the roles of interpretation biases in different psychopathologies might open avenues for tailored prevention and intervention paradigms.

Does selective inhibition training reduce relapse rates when added to standard treatment of alcohol use disorder? A randomized controlled trial.

BACKGROUND: Alcohol-dependent individuals tend to selectively approach alcohol cues in the environment, demonstrating an alcohol approach bias. Because approach bias modification (ApBM) training can reduce the approach bias and decrease relapse rates in alcohol-dependent patients when added to abstinence-focused treatment, it has become a part of regular treatment. Moreover, in selective inhibition (SI) training, responses to one category of stimuli (i.e., alcohol stimuli) are selectively inhibited in an adapted Go/No-Go task. SI-Training has been found to effectively devalue the inhibited category and to reduce consumption of alcohol among social drinkers. This study investigated whether SI-Training can further improve the effects of treatment as usual that includes ApBM, and if so, whether the effect is mediated by a devaluation of the inhibited alcohol stimuli. METHODS: Abstinent alcohol-dependent inpatients (N=434) were randomly assigned to receive 6 sessions of either active (n = 214, 32% female) or sham (n = 220, 38% female) SI-Training, in addition to standard treatment that includes active ApBM. Ratings were used to assess changes in the evaluation of alcohol stimuli after the training. Relapse rates were assessed 3 and 12 months after treatment discharge. RESULTS: Alcohol stimuli were rated negatively before and after the training, and the training did not influence these ratings. Evaluation of nonalcoholic drinks became more positive after active SI-Training. Both ApBM and SI-Training showed the expected training effects on reaction times. Contrary to expectations, SI-Training conditions did not yield different abstinence rates 3 or 12 months after treatment. CONCLUSIONS: We found no evidence supporting the hypothesis that SI-Training amplifies the relapse-preventing effect of ApBM. Moreover, alcohol stimuli were rated negatively before and after treatment and were not influenced by SI-Training.

The longitudinal link between popularity, likeability, fear of negative evaluation and social avoidance across adolescence.

This study investigated the longitudinal bidirectional associations between likeability, popularity, fear of negative evaluation, and social avoidance, to aid in preventing the negative consequences and persistent trajectories of low social status and heightened social anxiety. In total, 1741 adolescents in grades 7-9 participated at 3 yearly waves. A self-report questionnaire measured fear of negative evaluation. Peer nominations assessed likeability, popularity, and social avoidance. Lower popularity predicted more avoidance, and vice versa. More avoidance was related to lower likeability over time. Being less popular and/or more liked by peers, increased fear of negative evaluation. Support for a transactional model between social anxiety and social status was found, but distinguishing different social status and social anxiety components is necessary.

An experimental test of integrating imagery with approach bias modification for alcohol: A cautionary tale.

OBJECTIVES: In terms of dual process models, behaviour can be conceived of as the outcome of an interplay between reflective, top-down and impulsive, bottom-up processes. Behaviour change interventions may benefit from targeting both types of processes in a coherent way. One approach to this, in the context of reducing hazardous drinking, is to combine imagery involving real-life situations involving alcohol with the simple actions involved in Approach Bias Modification (ApBM), a form of Cognitive Bias Modification. DESIGN: We developed and tested a version of this Imagery-enhanced Approach Bias Modification (IApBM) in an experimental design, with two independent factors: imagery versus control and ApBM versus control training components (N = 139). METHODS: An effect of integrating the training factors was hypothesized on the alcohol-approach bias of an alcohol Approach-Avoidance Task. Further exploratory analyses were performed for the bias on alcohol-related Single Attribute Implicit Association Tests and on alcohol-related questionnaires. Finally, the psychometric properties of an imagery interference effect during training were explored. RESULTS: Results showed no benefit of the training and in fact suggested a negative interaction in which combining the training components appeared to block reductions in craving effected by each in isolation. The reliability of the imagery-related interference effect was high and the effect was correlated with alcohol-related scales. CONCLUSIONS: In conclusion, it appears that interference between training components decreases their individual effects when combining imagery and ApBM in the current way. The imagery-related interference effects that could be measured during training conditions may be useful as an implicit measure of automatic processes underlying hazardous drinking.

I C U but I don't care: Callous-unemotional traits and approach-avoidance behaviour in conduct disorder.

BACKGROUND AND OBJECTIVES: Conduct disorder (CD) is associated with deficits in social-emotional behaviour, such as increased levels of aggression. Callous-unemotional (CU-) traits foster those deficits and contribute to severe rates of instrumental aggression in CD. Previous studies of that increase in aggression have mainly focused on intentional aspects of behaviour. Unintentional behaviour, such as automatic approach and avoidance, has not been taken into account despite being highly relevant for behaviour. Therefore, the relevance of CU-traits for automatic actions and the feasibility of an approach-avoidance-task to measure those actions in CD-patients were investigated in a study series. METHODS: Study 1 22 CD-patients executed an approach-avoidance task, where participants pushed or pulled pictures of emotional faces using a joystick. CU-traits were assessed via parent-report. Study 2 28 CD-patients and 19 typically developing children (TD) executed the AAT. Again, CU-traits were assessed via parent-report. RESULTS: The AAT was a feasible instrument to measure automatic action tendencies and revealed that, while TD-children showed an avoidance bias towards angry faces, CD-patients showed a lack of automatic avoidance of anger. Across the whole sample (TD and CD combined), CU-traits predicted less threat avoidance. LIMITATIONS: The small sample size may have limited the power to detect smaller approach-avoidance tendencies towards other emotions. CONCLUSIONS: The findings suggest that CD is associated with a lack of automatic avoidance of social threat and that CU-traits predict that lack of avoidance. Divergent automatic threat responding might underlie the extreme levels of instrumentally aggressive behaviour observed in CD-patients with distinctive CU-traits.

Facing Uncertainty: Interpretation of Ambiguous Emotional Faces in Childhood Social Anxiety Disorder.

OBJECTIVE: The current study examined whether children with a social anxiety disorder (SAD) demonstrate divergent facial emotion processing and a disorder-specific negative interpretation bias in the processing of facial emotional expressions. This study aimed to overcome previous study limitations by including both a nonsocially anxious control group and a healthy control group to examine whether childhood SAD is characterized by a general emotion labeling deficit, and/or by a negative interpretation bias, indicated by systematic misclassifications, or a lower threshold for recognizing threatening emotions. METHOD: Participants were 132 children aged 7-12 years (Mage = 9.15; 45.5% female). Children with SAD (n = 42) were compared to children with other, nonsocial, anxiety disorders (n = 40) and healthy control children (n = 50) on a novel facial emotion recognition task. Children judged ambiguous happy/neutral, angry/neutral and fear/neutral faces that were morphed at different intensities (10%, 30%, 50%, 70%). RESULTS: Children with SAD did not differ from other groups in their accuracy of identifying emotions. They did not show systematic misclassifications or a heightened sensitivity to negative, threatening faces either. Rather, children with nonsocial anxiety disorders showed a generally heightened sensitivity to emotional faces. CONCLUSIONS: The current study does not provide evidence for a general deficit in labeling of emotional faces in childhood SAD. Childhood SAD was not characterized by an interpretation bias in processing emotional faces. Children with nonsocial anxiety disorders may benefit from assistance in accurately interpreting the degree of emotionality in interpersonal situations.

No evidence for disruption of reconsolidation of conditioned threat memories with a cognitively demanding intervention.

Simultaneous execution of memory retrieval and cognitively demanding interventions alter the subjective experience of aversive memories. This principle can be used in treatment to target traumatic memories. An often-used interpretation is that cognitive demand interferes with memory reconsolidation. Laboratory models applying this technique often do not meet some important procedural steps thought necessary to trigger reconsolidation. It remains therefore unclear whether cognitively demanding interventions can alter the reconsolidation process of aversive memories. Here, 78 (41 included) healthy participants completed an established 3-day threat conditioning paradigm. Two conditioned stimuli were paired with a shock (CS+ s) and one was not (CS-). The next day, one CS+ (CS+ R), but not the other (CS+), was presented as a reminder. After 10 min, participants performed a 2-back working memory task. On day three, we assessed retention. We found successful acquisition of conditioned threat and retention (CS+ s > CS-). However, SCRs to the CS+ R and the CS+ during retention did not significantly differ. Although threat conditioning was successful, the well-established cognitively demanding intervention did not alter the reconsolidation process of conditioned threat memories. These findings challenge current views on how cognitively demand may enhance psychotherapy-outcome.

A New Social Picture Task to Assess Interpretation Bias related to social fears in adolescents.

This pre-registered study focused on developing a new social picture task to assess interpretation bias related to social fears in adolescents. Using such a pictorial task may increase ecological validity and readily trigger emotional processes compared to more traditional verbal tasks that are often used. In the picture task, ambiguous social pictures were presented, followed by a positive and negative interpretation. In this study, we examined how the new task relates to an already existing interpretation bias task and how the new pictorial task relates to social fears in adolescents. The sample consisted of 329 adolescents aged 12 to 18 years. Interpretation bias was assessed with the newly developed pictorial task and with more traditional verbal vignettes. Social fears were measured with self-report questionnaires. The results suggest that the pictorial task was able to assess interpretation bias comparable to the verbal vignettes, suggesting appropriate convergent validity. Interpretation bias assessed with the picture task was linked to higher levels of fear of negative evaluation, the core symptom of social anxiety, but not to social anxiety symptoms in general. The verbal task was linked to both social fears and thus still seems the preferred method to investigate interpretation bias related to social fears in adolescents. However, we do believe that with further improvement of the pictorial task, it could be a useful addition to the research field.

Does comorbid anxiety or depression moderate effects of approach bias modification in the treatment of alcohol use disorders?

Objective: Approach bias modification (ApBM) is a promising new add-on training intervention for patients with alcohol use disorder (AUD). Given that comorbid anxiety and major depressive disorders are very common in AUD, and that such comorbidity affects psychological treatments negatively, the primary aim of the present study was investigating whether ApBM training is moderated by anxiety/major depressive disorder comorbidity. The secondary aim was to examine whether ApBM's relapse-preventive effect can be replicated. Method: We conducted a large-scale randomized controlled trial (RCT) in a clinical sample of AUD inpatients (n = 729) with a follow-up assessment after 1 year. All patients received 12 weeks of inpatient treatment as usual (TAU). On top of that, patients were randomized to a 12-session ApBM (TAU + ApBM), and a no-training control condition (TAU-only). Treatment success was defined as either no relapse or a single lapse shorter than 3 days in duration, ended by the patient and followed by at least 4 weeks of abstinence. Failure was defined as relapse, passed away, no contact, or refusal to provide information. Results: We found that TAU + ApBM had significantly higher success rates than TAU-only at 1-year follow-up. Importantly, anxiety/depressive comorbidity moderated ApBM's effects: Adding ApBM to TAU increased success rates more for patients with a comorbid anxiety and/or depressive disorder than for patients without such comorbidity. Conclusions: Our data suggest that adding ApBM to TAU works better in patients with a comorbid anxiety and/or depressive disorder; a promising finding gave the high rates of comorbidity in clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).