Probability, cost, and interpretation biases' relationships with depressive and anxious symptom severity: differential mediation by worry and repetitive negative thinking.

People high in depressive or anxious symptom severity show repetitive negative thinking, including worry and rumination. They also show various cognitive phenomena, including probability, cost, and interpretation biases. Since there is conceptual overlap between these cognitive biases and repetitive negative thinking - all involve thinking about potential threats and misfortunes - we wondered whether repetitive negative thinking could account for (mediate) these cognitive biases' associations with depressive and anxious symptom severity. In three studies, conducted in two languages and cultures, cost bias and (in two studies) interpretation bias only predicted symptom severity via worry and repetitive negative thinking; this suggests these biases are actually associated with repetitive negative thinking, rather than with symptoms. In contrast, probability bias showed direct relationships with depressive (all studies) and anxious (two studies) symptom severity, suggesting its relationships with symptoms are partly independent of repetitive negative thinking. These results show the value of studying relationships among the various cognitive features of psychopathology. Furthermore, new interventions which target cognitive biases in depression or anxiety must show that they can improve upon cognitive behavioural therapy, which is already widely available, targets both repetitive negative thinking and probability bias, and is highly effective.

"It's Difficult, There's No Formula": Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals.

INTRODUCTION: Stroke survivors have complex health needs requiring long-term, integrated care. This study aimed to elicit generalists' and specialists' experience of stroke-related interprofessional communication, including perceived barriers and enablers. DESIGN AND SETTING: Qualitative study involving generalist (primary care) and specialist services (acute and community) in England. Six focus groups (n = 48) were conducted. METHOD: Healthcare professionals were purposively selected and invited to participate. Audio-recordings were transcribed verbatim and analysed using Framework Analysis. RESULTS: Four themes were identified: 1) Generalists and specialists have overlapping roles but are working in silos; 2) Referral decision-making process as influential to generalist-specialist communication; 3) Variable quality of communication; and 4) Improved dialogue between generalist and specialist services. CONCLUSIONS: Generalists and specialists recognise the need for better communication with each other. Current care is characterised by silo-based working that ignores the contribution of other sectors. Failure to bridge this communication gap will result in people with stroke continuing to experience unmet stroke needs and fragmented care.

Believing Is Seeing: A Proof-of-Concept Semiexperimental Study on Using Mobile Virtual Reality to Boost the Effects of Interpretation Bias Modification for Anxiety.

BACKGROUND: Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and reinforce anxiety. The repetitive and monotonous features of CBM-I can negatively impact training adherence and learning processes. OBJECTIVE: This proof-of-concept study aimed to examine whether performing a CBM-I training using mobile virtual reality technology (virtual reality Cognitive Bias Modification of Interpretations [VR-CBM-I]) improves training experience and effectiveness. METHODS: A total of 42 students high in trait anxiety completed 1 session of either VR-CBM-I or standard CBM-I training for performance anxiety. Participants' feelings of immersion and presence, emotional reactivity to a stressor, and changes in interpretation bias and state anxiety, were assessed. RESULTS: The VR-CBM-I resulted in greater feelings of presence (P<.001, d=1.47) and immersion (P<.001, ηp2=0.74) in the training scenarios and outperformed the standard training in effects on state anxiety (P<.001, ηp2=0.3) and emotional reactivity to a stressor (P=.03, ηp2=0.12). Both training varieties successfully increased the endorsement of positive interpretations (P<.001, drepeated measures [drm]=0.79) and decreased negative ones. (P<.001, drm=0.72). In addition, changes in the emotional outcomes were correlated with greater feelings of immersion and presence. CONCLUSIONS: This study provided first evidence that (1) the putative working principles underlying CBM-I trainings can be translated into a virtual environment and (2) virtual reality holds promise as a tool to boost the effects of CMB-I training for highly anxious individuals while increasing users' experience with the training application.

Cognitive Interpretation Bias: The Effect of a Single Session Moderate Exercise Protocol on Anxiety and Depression.

Research conducted within the cognitive bias modification (CBM) paradigm has revealed that cognitive biases such as negative cognitive interpretation biases contribute to mental health disorders such as anxiety (Beard, 2011). It has been shown that exercise reduces anxiety (Ensari et al., 2015). Exercise has also been found to reduce negative cognitive attention biases (Tian and Smith, 2011), however, no research to date has investigated the effect of exercise on cognitive interpretation bias. The key aims of the current project is to investigate whether moderate exercise reduces self-reported symptoms of depression and stress. Additionally, to establish which intensity of exercise is required to achieve anxiety reduction and reduce an individual's negative cognitive interpretation biases. Study 1 recruited a healthy sample of adult participants who were randomly assigned to one of two conditions: a walking exercise protocol or a control condition (n = 2 × 12). Participants completed anxiety and cognitive interpretation bias measures before and after the walking exercise or control condition. Those in the walking exercise condition presented less symptoms of trait anxiety on a measure of state and trait anxiety inventory (STAI), compared to controls relative to baseline measures following the intervention. Study 2 recruited frequent exercisers who were assigned to an exercise or control group (n = 2 × 24). Participants completed anxiety, depression, psychological stress, and cognitive interpretation bias measures before and after the exercise or control condition. Following the intervention, negative interpretation biases decreased in the exercise group and stayed stable in the control group. The exercise group also had significantly decreased anxiety, depression, and stress measures after the exercise condition, while controls did not. The research concludes that CBM holds promise for the management of mood disorders and exercise is an effective accompaniment to psychotherapy.

Cognitive bias modification for social anxiety in adults who stutter: a feasibility study of a randomised controlled trial.

OBJECTIVE: To determine the feasibility and acceptability of a computerised treatment for social anxiety disorder for adults who stutter including identification of recruitment, retention and completion rates, large cost drivers and selection of most appropriate outcome measure(s) to inform the design of a future definitive trial. DESIGN: Two-group parallel design (treatment vs placebo), double-blinded feasibility study. PARTICIPANTS: 31 adults who stutter. INTERVENTION: Attention training via an online probe detection task in which the stimuli were images of faces displaying neutral and disgusted expressions. MAIN OUTCOME MEASURES: Psychological measures: Structured Clinical Interview Global Assessment of Functioning score; Liebowitz Social Anxiety Scale; Social Phobia and Anxiety Inventory; State-Trait Anxiety Inventory; Unhelpful Thoughts and Beliefs about Stuttering. Speech fluency: percent syllables stuttered. Economic evaluation: resource use questionnaire; EuroQol three-dimension questionnaire.Acceptability: Likert Scale questionnaire of experience of trial, acceptability of the intervention and randomisation procedure. RESULTS: Feasibility of recruitment strategy was demonstrated. Participant feedback indicated that the intervention and definitive trial, including randomisation, would be acceptable to adults who stutter. Of the 31 participants who were randomised, 25 provided data at all three data collection points. CONCLUSIONS: The feasibility study informed components of the intervention. Modifications to the design are needed before a definitive trial can be undertaken. TRIAL REGISTRATION NUMBER: I SRCTN55065978; Post-results.

Working memory regulates trait anxiety-related threat processing biases.

High trait anxious individuals tend to show biased processing of threat. Correlational evidence suggests that executive control could be used to regulate such threat-processing. On this basis, we hypothesized that trait anxiety-related cognitive biases regarding threat should be exaggerated when executive control is experimentally impaired by loading working memory. In Study 1, 68 undergraduates read ambiguous vignettes under high and low working memory load; later, their interpretations of these vignettes were assessed via a recognition test. Trait anxiety predicted biased interpretation of social threat vignettes under high working memory load, but not under low working memory load. In Study 2, 53 undergraduates completed a dot probe task with fear-conditioned Japanese characters serving as threat stimuli. Trait anxiety predicted attentional bias to the threat stimuli but, again, this only occurred under high working memory load. Interestingly however, actual eye movements toward the threat stimuli were only associated with state anxiety, and this was not moderated by working memory load, suggesting that executive control regulates biased threat-processing downstream of initial input processes such as orienting. These results suggest that cognitive loads can exacerbate trait anxiety-related cognitive biases, and therefore represent a useful tool for assessing cognitive biases in future research. More importantly, since biased threat-processing has been implicated in the etiology and maintenance of anxiety, poor executive control may be a risk factor for anxiety disorders. (PsycINFO Database Record

Effects of standard and explicit cognitive bias modification and computer-administered cognitive-behaviour therapy on cognitive biases and social anxiety.

BACKGROUND AND OBJECTIVES: This study examines the effects of a single session of Cognitive Bias Modification to induce positive Interpretative bias (CBM-I) using standard or explicit instructions and an analogue of computer-administered CBT (c-CBT) program on modifying cognitive biases and social anxiety. METHODS: A sample of 76 volunteers with social anxiety attended a research site. At both pre- and post-test, participants completed two computer-administered tests of interpretative and attentional biases and a self-report measure of social anxiety. Participants in the training conditions completed a single session of either standard or explicit CBM-I positive training and a c-CBT program. Participants in the Control (no training) condition completed a CBM-I neutral task matched the active CBM-I intervention in format and duration but did not encourage positive disambiguation of socially ambiguous or threatening scenarios. RESULTS: Participants in both CBM-I programs (either standard or explicit instructions) and the c-CBT condition exhibited more positive interpretations of ambiguous social scenarios at post-test and one-week follow-up as compared to the Control condition. Moreover, the results showed that CBM-I and c-CBT, to some extent, changed negative attention biases in a positive direction. Furthermore, the results showed that both CBM-I training conditions and c-CBT reduced social anxiety symptoms at one-week follow-up. LIMITATIONS: This study used a single session of CBM-I training, however multi-sessions intervention might result in more endurable positive CBM-I changes. CONCLUSIONS: A computerised single session of CBM-I and an analogue of c-CBT program reduced negative interpretative biases and social anxiety.

Modifying social anxiety related to a real-life stressor using online Cognitive Bias Modification for interpretation.

Modifying threat related biases in attention and interpretation has been shown to successfully reduce global symptoms of anxiety in high anxious and clinically anxious samples (termed Cognitive Bias Modification, CBM). However, the possibility that CBM can be used as a way to prevent anxiety associated with an upcoming real-life stressful event in vulnerable populations has yet to be systematically examined. The present study aimed to assess whether a two-week course of online CBM for interpretations (CBM-I) could reduce social evaluative fear when starting university. Sixty-nine students anxious about starting university completed five sessions of online CBM in the two weeks prior to starting university, or completed a placebo control intervention. Results indicated that CBM-I reduced social evaluative fear from baseline to day one of starting university to a greater extent than the placebo control intervention. Also, there was a greater reduction in state anxiety and a trend indicating a greater reduction in social evaluative fear in the CBM-I group at 4 weeks follow-up. Results suggest that CBM-I could be used as a preventative tool to help reduce anxiety specific to challenging life events.

Indicators of implicit and explicit social anxiety influence threat-related interpretive bias as a function of working memory capacity.

Interpretive biases play a crucial role in anxiety disorders. The aim of the current study was to examine factors that determine the relative strength of threat-related interpretive biases that are characteristic of individuals high in social anxiety. Different (dual process) models argue that both implicit and explicit processes determine information processing biases and behavior, and that their impact is moderated by the availability of executive resources such as working memory capacity (WMC). Based on these models, we expected indicators of implicit social anxiety to predict threat-related interpretive bias in individuals low, but not high in WMC. Indicators of explicit social anxiety should predict threat-related interpretive bias in individuals high, but not low in WMC. As expected, WMC moderated the impact of implicit social anxiety on threat-related interpretive bias, although the simple slope for individuals low in WMC was not statistically significant. The hypotheses regarding explicit social anxiety (with fear of negative evaluation used as an indicator) were fully supported. The clinical implications of these findings are discussed.

Reducing analogue trauma symptoms by computerized reappraisal training - considering a cognitive prophylaxis?

BACKGROUND AND OBJECTIVES: Distressing intrusions are a hallmark of posttraumatic stress disorder (PTSD). Dysfunctional appraisal of these symptoms may exacerbate the disorder, and conversely may lead to further intrusive memories. This raises the intriguing possibility that learning to 'reappraise' potential symptoms more functionally may protect against such symptoms. Woud, Holmes, Postma, Dalgleish, and Mackintosh (2012) found that 'reappraisal training' when delivered after an analogue stressful event reduced later intrusive memories and other posttraumatic symptoms. The present study aimed to investigate whether reappraisal training administered before a stressful event is also beneficial. METHODS: Participants first received positive or negative reappraisal training (CBM-App training) using a series of scripted vignettes. Subsequently, participants were exposed to a film with traumatic content. Effects of the CBM-App training procedure were assessed via three distinct outcome measures, namely: (a) post-training appraisals of novel ambiguous vignettes, (b) change scores on the Post Traumatic Cognitions Inventory (PTCI), and (c) intrusive symptom diary. RESULTS: CBM-App training successfully induced training-congruent appraisal styles. Moreover, those trained positively reported less distress arising from their intrusive memories of the trauma film during the subsequent week than those trained negatively. However, the induced appraisal bias only partly affected PTCI scores. LIMITATIONS: Participants used their own negative event as a reference for the PTCI assessments. The events may have differed regarding their emotional impact. There was no control group. CONCLUSIONS: CBM-App training has also some beneficial effects when applied before a stressful event and may serve as a cognitive prophylaxis against trauma-related symptomatology.

A comparison of cognitive bias modification for interpretation and computerized cognitive behavior therapy: effects on anxiety, depression, attentional control, and interpretive bias.

OBJECTIVE: Computerized cognitive behavioral therapy (cCBT) and cognitive bias modification for interpretation (CBM-I) both have demonstrated efficacy in alleviating social anxiety, but how they compare with each other has not been investigated. The present study tested the prediction that both interventions would reduce anxiety relative to a no-intervention comparison condition, but CBM-I would be particularly effective at modifying threat-related cognitive bias under high mental load. METHOD: Sixty-three primarily Caucasian adults (mean age = 22.7, SD = 5.87; 68.3% female) with high social anxiety, randomly allocated to 3 groups: CBM-I (n = 21), cCBT (n = 21), and a no-intervention control group (n = 21) provided complete data for analysis. Pre- and postintervention (4 sessions lasting 2 weeks, control participants only attended the pre-post sessions) self-report measures of anxiety, depression, attentional control, and threat-related interpretive bias were completed. In addition, interpretive bias under high versus low cognitive load was measured using the Scrambled Sentences Test. RESULTS: Both CBM-I and cCBT groups reported significantly reduced levels of social anxiety, trait anxiety, and depression and improved attentional control, relative to the control group, with no clear superiority of either active intervention. Although both active conditions reduced negative bias on the Scrambled Sentences Test completed under mental load, CBM-I was significantly more effective at doing so. CONCLUSIONS: The results suggest that although not differing in therapeutic efficacy, CBM-I and cCBT might differ in the resilience of their effects when under mental load.

Ameliorating intrusive memories of distressing experiences using computerized reappraisal training.

The types of appraisals that follow traumatic experiences have been linked to the emergence of posttraumatic stress disorder (PTSD). Could changing reappraisals following a stressful event reduce the emergence of PTSD symptoms? The present proof-of-principle study examined whether a nonexplicit, systematic computerized training in reappraisal style following a stressful event (a highly distressing film) could reduce intrusive memories of the film, and symptoms associated with posttraumatic distress over the subsequent week. Participants were trained to adopt a generally positive or negative poststressor appraisal style using a series of scripted vignettes after having been exposed to highly distressing film clips. The training targeted self-efficacy beliefs and reappraisals of secondary emotions (emotions in response to the emotional reactions elicited by the film). Successful appraisal induction was verified using novel vignettes and via change scores on the post traumatic cognitions inventory. Compared with those trained negatively, those trained positively reported in a diary fewer intrusive memories of the film during the subsequent week, and lower scores on the Impact of Event Scale (a widely used measure of posttraumatic stress symptoms). Results support the use of computerized, nonexplicit, reappraisal training after a stressful event has occurred and provide a platform for future translational studies with clinical populations that have experienced significant real-world stress or trauma.

Cognitive bias modification in the treatment of social anxiety in early psychosis: a single case series.

BACKGROUND: Social anxiety is a common problem among people who are recovering from psychosis. At present there is no evidence based psychological treatment targeting social anxiety in this population. Cognitive Bias Modification for Interpretation (CBM-I) has been shown to be effective in reducing social anxiety in people who do not have a history of psychosis. AIMS: To assess the feasibility and acceptability of the CBM-I methodology for use in a clinical setting with people who are experiencing social anxiety following an episode of psychosis. METHOD: Eight participants with social anxiety were recruited from an early intervention service. A single session of computerized CBM-I was conducted, with mood and cognitive interpretation bias being assessed before and after the session. RESULTS: All participants reported an improvement in mood immediately following the CBM-I session (n=8). For those participants who had a negative interpretation bias, none became more negative following the CBM-I session, with three out of six participants showing a beneficial change. CONCLUSION: These results suggest that CBM-I is acceptable for use with people who are experiencing social anxiety following a psychotic episode. Further research looking at how CBM-I could be made more interactive and producing more applicable scenarios for use in a clinical setting is recommended.

Cognitive bias modification for attention and interpretation reduces trait and state anxiety in anxious patients referred to an out-patient service: results from a pilot study.

It is well established that anxious individuals show biases in information processing, such that they attend preferentially to threatening stimuli and interpret emotional ambiguity in a threatening way. It has also been established that these biases in attention and interpretation can causally influence anxiety. Recent advances in experimental work have involved the development of a paradigm known as Cognitive Bias Modification (CBM), a constellation of procedures which directly modify bias using computerised tasks. Excitingly, these procedures have been shown to reduce bias in attention to threat (CBM-A), and to promote a positive interpretive bias (CBM-I) in anxious populations; furthermore, these modifications are associated with reductions in anxiety. We believe that these techniques have the potential to create a real clinical impact for people with anxiety. Initial studies involved volunteer participants who reached criteria for clinical diagnoses to be made, but emerging evidence suggests that patients referred for therapy also benefit. For the purposes of experimentation researchers have normally looked at one procedure at a time. In order to try to maximise the potential clinical impact we wished to investigate whether the combination of the procedures would be more effective than either alone. We also wished to investigate whether the procedures could be carried out in routine clinical settings with patients referred to an out-patient psychological treatment service. We therefore carried out a pilot study using a combined approach of CBM-A and CBM-I with a sample of 13 anxious patients referred to an out-patient psychology service for cognitive therapy. The results showed successful reductions in threat related attentional and interpretive bias, as well as reductions in trait and state anxiety. Participant reports describe the procedures as acceptable, with the attentional task experienced as boring, but the interpretive one experienced as helpful. While recognising the methodological problems of the pilot study we believe that these results give indications that the techniques could provide an effective intervention for anxiety, and that further study is well justified.

Interpretation training influences memory for prior interpretations.

Anxiety is associated with memory biases when the initial interpretation of the event is taken into account. This experiment examined whether modification of interpretive bias retroactively affects memory for prior events and their initial interpretation. Before training, participants imagined themselves in emotionally ambiguous scenarios to which they provided endings that often revealed their interpretations. Then they were trained to resolve the ambiguity in other situations in a consistently positive (n = 37) or negative way (n = 38) before they tried to recall the initial scenarios and endings. Results indicated that memory for the endings was imbued with the emotional tone of the training, whereas memory for the scenarios was unaffected.

Cognitive bias modification: the critical role of active training in modifying emotional responses.

Training participants to select threat or nonthreat interpretations of emotionally ambiguous stimuli or passively exposing them to valenced scenarios can modify later interpretation of ambiguity. However, only when encouraged to actively select meanings do congruent changes in emotional response occur during training itself (Mathews & Mackintosh, 2000). The present study assessed the more critical question of whether active training is also necessary for modifying subsequent emotional responses to images of new ambiguous scenarios presented after training. As predicted, active training did lead participants to rate their images of emotionally ambiguous scenarios as being more unpleasant after training as compared to a matched passive condition. This finding supports the view that active generation of meaning during interpretive training is critical for the modification of later emotional responses.

An investigation of the implicit control of the processing of negative pictures.

The implicit control of emotion processing was investigated by varying encoding instructions for both negative and neutral pictures while measuring psychophysiological responses. Participants made comparative judgments about consecutive pictures for blocks of neutral or negative content. The highly specified judgment task was designed to minimize variance in the implementation of implicit control of processing. Affective modulation of startle amplitude was significantly reduced during judgments involving nonnegative content (how "planned" an image was compared to its predecessor), compared to those that involved negative content (how "frightening" an image was compared to its predecessor), indicating successful implicit control of processing. The more attenuated affect modulation was, the less anxious individuals became during the task, suggesting that the implicit control of emotion processing is significantly associated with emotional experience. These data provide convergent evidence for a companion neuroimaging study because of the similar neural substrates thought to underlie affective modulation of startle. This supports the view that higher-level top-down pathways modulate activation of the amygdala.

Attentional bias training and cue reactivity in cigarette smokers.

AIMS: Attentional bias for drug-related cues has been associated with drug maintenance and relapse. We investigated whether attentional bias for smoking-related stimuli could be altered using a modified visual probe task in cigarette smokers. We also sought to determine whether changes in attentional bias were associated with changes in subsequent craving and cue reactivity. PARTICIPANTS: Male and female (n=54) current smokers (>or=5 cigarettes per day), aged between 18 and 40 years, were recruited from staff and students of the University of Bristol, and from the general population. DESIGN: Participants attended a single test session and completed an attentional training procedure in which they were either trained to attend to smoking-related pictorial stimuli (attend group) or to neutral pictorial stimuli (avoid group). Group allocation was randomized. MEASUREMENTS: Following attentional training, participants underwent a smoking cue exposure procedure in which they were exposed to smoking-related stimuli. Subjective measures of mood and craving were taken at baseline and before and after cue exposure. Participants then smoked a cigarette and smoking topography was measured. FINDINGS: Attentional training increased attentional bias among participants in the attend group, and decreased attentional bias among those in the avoid group. There were also differences between the attend and avoid groups in post-training changes in craving during exposure to in vivo smoking cues, reflecting greater increases in craving in the attend group, although these effects were observed in males only. CONCLUSIONS: These data are the first to show alterations in attentional bias for smoking-related stimuli following a modified visual probe training procedure. Furthermore, post-training group differences in subjective craving suggest potential clinical utility of training procedures, although these effects may operate only in males. Future research should investigate whether multiple training sessions enhance post-training reductions in craving and cue reactivity, and the longer-term persistence of training effects.

The causal effect of mental imagery on emotion assessed using picture-word cues.

The hypothesis that mental imagery is more likely to elicit emotion than verbal processing of the same material was investigated in two studies. Participants saw a series of pictures, each accompanied by a word, designed to yield a negative or benign meaning when combined. Participants were either free to combine the picture and word as they wished (Experiment 1) or instructed to integrate them using either a descriptive sentence or a mental image (Experiment 2). Emotional response was consistently greater following imagery than after producing a sentence. Experiment 2 also demonstrated the causal effect of imagery on emotion and evaluative learning. Additional participants in Experiment 2 described aloud their images/sentences. Independent ratings of descriptions indicated that, as well as being more emotional, images differed from sentences elicited by identical cues by greater similarity to memories, and greater involvement of sensations and specific events. Results support the hypothesis that imagery evokes stronger affective responses than does verbal processing, perhaps because of sensitivity of emotional brain regions to imagery, the similarity of imagery to perception, and to autobiographical episodes.

Levels of specificity of autobiographical memories and of biographical memories of the deceased in bereaved individuals with and without complicated grief.

Traumatized individuals experiencing posttraumatic stress have difficulty retrieving specific autobiographical memories to cue words on the Autobiographical Memory Test (AMT; J. M. G. Williams & K. Broadbent, 1986). This may represent a generalized, functional avoidance of the personal past. However, such individuals also often report specific intrusive memories of their trauma in the day-to-day. This raises the possibility that memories tied to the source of the person's distress are immune to this putative avoidance process. This was investigated in bereaved individuals with complicated grief (CG) who reported intrusive, specific memories from the life of their deceased loved one, and matched bereaved controls without CG. Participants performed the AMT and two Biographical Memory Tests (BMTs), cueing memories from the life of the deceased (BMT-Deceased) and from a living significant other (BMT-Living). To negative word cues, the CG group showed reduced specificity for the AMT and BMT-Living, relative to controls, but this effect was reversed on the BMT-Deceased. These data support the proposal that memories tied to the source of an individual's distress are immune to the processes that underlie the standard reduced specificity effect.