Interpretation Bias Modification Research Articles

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.

Codesigned online cognitive bias modification of interpretations for anxiety and depression in children: study protocol of a randomised controlled trial

IntroductionPrevious research has shown that cognitive bias modification of interpretations (CBM-I) may be a promising intervention for anxiety in youth; however, results are mixed. Given the high comorbidity between anxiety...

Attention and Interpretation Bias Modification Transfers to Memory Bias: Testing the Combined Cognitive Bias Hypothesis

Abstract Purpose This study delves into the combined cognitive bias hypothesis in depression, exploring the interaction between negative attention, interpretation and memory biases. We aimed to assess whether modifying attention and interpretation bias would lead to congruent changes in memory bias, and to what extend and depth this causal effect can be. Method Ninety-nine undergraduates underwent either a positive (PT) or negative (NT) four-day attention and interpretation bias training. A set of well-established post-training assessments including free recall, recognition, autobiographic memory, and self-reference encoding tasks were used to evaluate memory bias. Affective states were measured pre- and post-training. Results Compared to PT, participants in NT correctly retrieved more negative trained stimuli, and falsely recognized more negative synonyms of trained terms. NT also exhibited an enhanced retrieval of negative autobiographical memory. No significant differences were found between NT and PT in self-referential encoding and retrieval bias, or affective states. Discussion The results suggested an extensive and strong transfer effect from attention and interpretation bias modification to different facets of memory bias, being found in retrieving trained emotional stimuli, in memory intrusion of negative synonyms, and in autobiographic memory recall. The findings underscored the causality between three biases, supporting the combined cognitive bias hypothesis. It might also suggest an effective new approach to modify memory bias via attention and interpretation bias training.

Transitioning to college: Testing cognitive bias modification for interpretations as an inoculation tool for social anxiety in college first-years

Background and objectivesReducing social anxiety development among incoming college students may improve college adjustment and mental health outcomes. This study tested whether cognitive bias modification for interpretations (CBM-I) reduces social anxiety and increases adjustment during the transition to college, and whether changes in outcomes would be mediated by changes in interpretation biases. MethodsParticipants (N = 73) were randomly assigned to a 3-session weekly CBM-I condition or symptom tracking (ST) control condition. Multilevel models were used to estimate within-person trajectories from baseline to one week post-intervention and to test whether trajectories differed by condition. ResultsThose in the CBM-I condition (vs. ST) reported higher increases in social adjustment across time. There were not significant differences between conditions for changes in social anxiety, academic adjustment, and personal adjustment. CBM-I was indirectly linked to improvements in outcome variables via more adaptive interpretation biases. LimitationsCBM-I was administered in a laboratory setting, requiring more resources than some computerized interventions. ConclusionsData tentatively support CBM-I for first-year students to increase social adjustment. Further, mediation findings provide support for targeting interpretation biases to improve social anxiety and adjustment outcomes. Yet, CBM-I did not outperform ST in improving social anxiety symptoms or other areas of college adjustment, and effect sizes were small, suggesting that more work is needed to amplify the potential of CBM-I as a therapeutic tool.

The effect of training to target cognitive biases towards social rejection in eating disorders.

This study examined the effect of cognitive bias modification for interpretation (CBM-I) training in Korean women with eating disorders (EDs). Sixty-three women with EDs participated in the study. Participants were randomly assigned to the intervention group where they received six sessions of CBM-I training (n=31) in addition to treatment-as-usual or were put on a waiting list (n=32). Participants' interpretation and attention biases, emotion regulation, affect, and ED psychopathology were assessed at baseline, end-of-intervention (4weeks), and follow-up (8weeks). Participants who completed the CBM-I training displayed greater reductions in negative interpretation bias (Δη2 =0.107) and emotion dysregulation (Δη2 =0.085) with medium to large effect sizes compared to the control group, which were maintained from baseline to follow-up. Disengagement from negative faces and a focus on positive faces was found in the intervention group with a moderate effect size at the end-of-intervention (Δη2 =0.090). Both intervention and control groups showed improvements in ED psychopathology. Baseline neuroticism was positively correlated with CBM-I effect. The results suggest that modifying interpretation bias towards ambiguous social stimuli might be an effective adjuvant treatment to reduce negative expectations of social situations and improve emotion regulation in women with bulimia nervosa and anorexia nervosa.

Interpretation bias modification for hostility to facilitate smoking cessation in a sample with elevated trait anger: A randomized trial

Problematic anger is linked with multiple adverse smoking outcomes, including cigarette dependence, heavy smoking, and cessation failure. A smoking cessation intervention that directly targets anger and its maintenance factors may increase rates of smoking cessation. We examined the efficacy of an interpretation bias modification for hostility (IBM-H) to facilitate smoking cessation in smokers with elevated trait anger. Participants were 100 daily smokers (mean age = 38, 62% female, 55% white) with elevated anger were randomly assigned to eight computerized sessions of either IBM-H or a health and relaxation video control condition (HRVC). Participants in both conditions attempted to quit at mid-treatment. Measures of hostility, anger, and smoking were administered at pre-, mid-, post-treatment, as well as at up to three-month follow-up. Compared to HRVC, IBM-H led to greater reductions in hostile interpretation bias, both at posttreatment and follow-up. IBM-H also led to statistically significant reductions in hostility only at posttreatment, and trait anger only at three-month follow-up. Both conditions experienced reductions in smoking, although they did not differ in quit success. We discuss these findings in the context of literature on anger and smoking cessation and provide directions for future research.

One research question, two meta-analyses, three conclusions: Commentary on “A systematic review with meta-analysis of Cognitive Bias Modification interventions for anger and aggression”

Recently two independent meta-analyses on the efficacy of Cognitive Bias Modification of Interpretation (CBM-I) to reduce aggressive behavior came to different conclusions: Ciesinski et al. (2023) concluded that “CBM demonstrates efficacy for the treatment of aggressive behavior” (Abstract), whereas our research team concluded that “findings show limited support for the efficacy of CBM-I to reduce aggressive behavior” (AlMoghrabi et al., 2023, Discussion). How can similar meta-analyses reach such different conclusions? In this commentary, we raise awareness concerning how 1) seemingly identical research questions can be based on meaningfully different definitions of the intervention and outcomes; 2) intervention efficacy conclusions can depend on outcome assessment type; and 3) the interpretation of underpowered moderator analyses should not depend on statistical significance. We end our commentary with a third, more nuanced conclusion that can reconcile the two disparate conclusions: that current CBM-I is an effective experimental manipulation to modify interpretation biases, but not an effective stand-alone treatment to reduce aggressive behavior.

Single session of interpretation bias modification helped to improve fear of COVID-19 and COVID-19-related post-traumatic stress symptoms

BackgroundPost-traumatic stress symptoms (PTSS) are frequently observed in those who have experienced trauma events like the COVID-19 outbreak. The cognitive model of PTSS highlights the relationship between PTSS and negative...

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

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

Cognitive bias modification of interpretations for anxiety and depression in children and adolescents: A meta‐analysis

AbstractBackgroundEvidence suggests that cognitive bias modification of interpretations (CBM‐I) is effective in modifying interpretation biases and has a small effect on reducing anxiety in children and adolescents. However, most evidence to date is based on studies which report anxiety or general distress using ad‐hoc Likert‐type or Visual Analogue Scales, which are useful but do not reliably index symptoms of clinical importance. This meta‐analysis aimed to establish the effects of CBM‐I for children and adolescents on both anxiety and depression using psychometrically validated symptom measures, as well as state negative affect and negative and positive interpretation bias.MethodsWe identified studies through a systematic search. To be eligible for inclusion, studies needed to target interpretation biases, not combine CBM‐I with another intervention, randomly allocate participants to CBM‐I or a control condition, assess a mental health outcome (i.e., anxiety or depression symptoms using validated measures or state measures of negative affect) and/or interpretation bias and have a mean age less than 18 years.ResultsWe identified 36 studies for inclusion in the meta‐analysis. CBM‐I had a small and non‐significant unadjusted effect on anxiety symptoms (g = 0.16), no effect on depression symptoms (g = −0.03), and small and non‐significant unadjusted effects on state negative affect both at post‐training (g = 0.16) and following a stressor task (g = 0.23). In line with previous findings, CBM‐I had moderate to large unadjusted effects on negative and positive interpretations (g = 0.78 and g = 0.52). No significant moderators were identified.ConclusionsCBM‐I is effective at modifying interpretation bias, however there were no effects on mental health outcomes. The substantial variability across studies and paucity of studies using validated symptom measures highlight the need to establish randomized controlled trial protocols that evaluate CBM‐I in clinical youth samples to determine its future as a clinical intervention.

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

Interpretation bias modification (IBM) and approach bias modification (ApBM) cognitive retraining interventions can be efficacious adjunctive treatments for improving social anxiety and alcohol use problems. However, previous trials have not examined the combination of these interventions in a young, comorbid sample. This study aims to describe the feasibility, acceptability, and preliminary efficacy of a web-based IBM+ApBM program for young adults with social anxiety and hazardous alcohol use ("Re-Train Your Brain") when delivered in conjunction with treatment as usual (TAU). The study involved a 3-arm randomized controlled pilot trial in which treatment-seeking young adults (aged 18-30 y) with co-occurring social anxiety and hazardous alcohol use were randomized to receive (1) the "integrated" Re-Train Your Brain program, where each session included both IBM and ApBM (50:50 ratio), plus TAU (35/100, 35%); (2) the "alternating" Re-Train Your Brain program, where each session focused on IBM or ApBM in an alternating pattern, plus TAU (32/100, 32%); or (3) TAU only (33/100, 33%). Primary outcomes included feasibility and acceptability, and secondary efficacy outcomes included changes in cognitive biases, social anxiety symptoms, and alcohol use. Assessments were conducted at baseline, after the intervention period (6 weeks after baseline), and 12 weeks after baseline. Both Re-Train Your Brain program formats were feasible and acceptable for young adults. When coupled with TAU, both integrated and alternating programs resulted in greater self-reported improvements than TAU only in anxiety interpretation biases (at the 6-week follow-up; Cohen d=0.80 and Cohen d=0.89) and comorbid interpretation biases (at the 12-week follow-up; Cohen d=1.53 and Cohen d=1.67). In addition, the alternating group reported larger improvements over the control group in generalized social anxiety symptoms (at the 12-week follow-up; Cohen d=0.83) and alcohol cravings (at the 6-week follow-up; Cohen d=0.81). There were null effects on all other variables and no differences between the intervention groups in efficacy outcomes. Should these findings be replicated in a larger randomized controlled trial, Re-Train Your Brain has the potential to be a scalable, low-cost, and non-labor-intensive adjunct intervention for targeting interpretation and comorbidity biases as well as generalized anxiety and alcohol-related outcomes in the real world. Australian New Zealand Clinical Trials Registry ACTRN12620001273976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364131. RR2-10.2196/28667.

The influence of outcome expectancy on interpretation bias training in social anxiety: an experimental pilot study.

Cognitive bias modification for interpretation (CBM-I) trainings have shown positive effects on interpretation bias in both active interpretation bias training conditions and structurally similar control conditions. Outcome expectations have been suggested to contribute to these placebo effects. The goal of this pilot experimental study was to test the feasibility of positive expectancy induction, to gain preliminary insight into whether this has implications for the efficacy of CBM-I training, and to assess the feasibility of recruitment and the overall study design. Socially anxious individuals aged 18years and older received a single session (approx. 45min) of either CBM-I or placebo training preceded by either a positive expectancy induction or no expectancy induction. We first tested whether the expectancy induction had modified participants' expectations of training. We then explored the effects of CBM-I training and expectancy induction on interpretation bias. Finally, we assessed the feasibility of recruitment and further study procedures. Due to pandemic-related difficulties, fewer participants were recruited than initially planned. Thirty-four (22 females and 12 males) participants were randomly assigned to one of four conditions (interpretation bias training + high expectancy = 10, interpretation bias training + no expectancy = 8, placebo training + high expectancy = 11, placebo training + no expectancy = 5). Participants in the positive expectancy condition had more positive expectations of the training (CBM-I or placebo) than participants in the no expectancy condition. We were unable to conduct the planned 2 × 2× 2 analysis of interpretation bias due to the small sample size. When looking at these groups individually, we found that participants in the active training condition and participants in the high expectancy condition showed increases in positive interpretation bias and decreases in negative interpretation bias from pre- to post-training, while participants in the placebo and no expectancy conditions showed no change. These findings suggest that the expectancy manipulation utilized in this study may be adopted by future studies which investigate outcome expectations as an unspecific mechanism of CBM-I. Preliminary analyses suggest that participants' expectations are likely to play a role in the effect of CBM-I training, although these effects require replication in a larger sample. Several observations about the study feasibility were made which could inform future trials. Retrospectively registered on the August 23, 2022, through the German Clinical Trials Register ( DRKS00029768 ).

Changes in Learning From Social Feedback After Web-Based Interpretation Bias Modification: Secondary Analysis of a Digital Mental Health Intervention Among Individuals With High Social Anxiety Symptoms.

Biases in social reinforcement learning, or the process of learning to predict and optimize behavior based on rewards and punishments in the social environment, may underlie and maintain some negative cognitive biases that are characteristic of social anxiety. However, little is known about how cognitive and behavioral interventions may change social reinforcement learning in individuals who are anxious. This study assessed whether a scalable, web-based cognitive bias modification for interpretations (CBM-I) intervention changed social reinforcement learning biases in participants with high social anxiety symptoms. This study focused on 2 types of social reinforcement learning relevant to social anxiety: learning about other people and learning about one's own social performance. Participants (N=106) completed 2 laboratory sessions, separated by 5 weeks of ecological momentary assessment tracking emotion regulation strategy use and affect. Approximately half (n=51, 48.1%) of the participants completed up to 6 brief daily sessions of CBM-I in week 3. Participants completed a task that assessed social reinforcement learning about other people in both laboratory sessions and a task that assessed social reinforcement learning about one's own social performance in the second session. Behavioral data from these tasks were computationally modeled using Q-learning and analyzed using mixed effects models. After the CBM-I intervention, participants updated their beliefs about others more slowly (P=.04; Cohen d=-0.29) but used what they learned to make more accurate decisions (P=.005; Cohen d=0.20), choosing rewarding faces more frequently. These effects were not observed among participants who did not complete the CBM-I intervention. Participants who completed the CBM-I intervention also showed less-biased updating about their social performance than participants who did not complete the CBM-I intervention, learning similarly from positive and negative feedback and from feedback on items related to poor versus good social performance. Regardless of the intervention condition, participants at session 2 versus session 1 updated their expectancies about others more from rewarding (P=.003; Cohen d=0.43) and less from punishing outcomes (P=.001; Cohen d=-0.47), and they became more accurate at learning to avoid punishing faces (P=.001; Cohen d=0.20). Taken together, our results provide initial evidence that there may be some beneficial effects of both the CBM-I intervention and self-tracking of emotion regulation on social reinforcement learning in individuals who are socially anxious, although replication will be important.

Developing an interpretation bias modification training task for alleviating loneliness in young people

ObjectiveLoneliness is common among young people and is associated with negative health outcomes. Because loneliness is associated with a bias for interpreting social situations as threatening, cognitive bias modification for interpretation (CBM-I) training is a potential early intervention tool. We developed and delivered a single session of mental imagery enhanced digital CBM-I training, assessing feasibility, acceptability, and magnitude of change in interpretational style and loneliness. MethodCBM-I training materials were developed using a co-creation approach with 18–25-year-olds with experience of loneliness. Another group of 18–25-year-olds with high loneliness received either online CBM-I (n = 29) or control (n = 27) training. ResultsCBM-I training uptake and retention rates were 88% and 92%, respectively. Participants found the training acceptable. The CBM-I group showed a reduction in social threat interpretations (d = 0.77), an increase in social benign interpretations (d = 0.84), and a decrease in loneliness (d = 0.56). The control group showed a small reduction in social threat interpretations (d = 0.21), no change in social benign interpretations (d = 0.04), and an increase in loneliness (d = 0.41). ConclusionsInterpretation biases relevant to youth loneliness may be modifiable, and CBM-I training could reduce feelings of loneliness. This informs psychological models of loneliness, and the development of CBM-I interventions targeting loneliness in young people.

Health anxiety and the negative interpretation of children’s bodily symptoms in mothers of cancer patients

PurposeFear of progression (FoP) is a substantial concern for family caregivers of cancer survivors and is related to a number of adverse outcomes, including increased mental distress and worse quality of life. Previous research has revealed that health anxiety (HA) contributes to fear of relapse, but cognitive factors underlying establishing and maintaining FoP in mothers of cancer patients have not been examined. In this study, we were looking to investigate this association.MethodsWe used the computerized interpretation bias (IB) assessment to investigate the biased interpretation of ambiguous bodily information and its association with FoP through HA among 69 mothers of cancer patients and 42 mothers of healthy kids.ResultsMothers of cancer patients interpreted more negatively ambiguous bodily symptoms than mothers of healthy kids. Moreover, they had higher levels of HA and FoP and lower quality of life than the healthy group. Also, among mothers of cancer patients, the relationship between negative IB and FoP is mediated by their HA.ConclusionsThe findings of this study imply that negative IB may contribute to increased HA, which in turn contributes to higher levels of FoP among the mothers of cancer patients, which may reduce the quality of life of their children.Implications for Cancer SurvivorsFrom these findings, we propose that changing HA through modification of IB might lower the FoP in mothers of kids with cancer and improve the mother and child’s quality of life.

Autonomic reactivity during acute social stress: exploratory investigation of an interaction by threat interpretation bias and emotion regulation difficulties

ABSTRACT Objective: This preliminary study examined the interactive influences of interpretation bias and emotion dysregulation in predicting autonomic stress response. Methods: Participants (N = 72 college students; ages 18–25, 70% female, 47% Hispanic/Latinx), completed a performance-based assessment of threat interpretation bias and self-report measures of emotion regulation difficulties. Electrodermal activity (EDA; skin conductance level) was collected while participants completed a standardized psychosocial stressor task. Results: Interpretation bias and emotion regulation difficulties interacted to predict EDA trajectories (β = 0.054, SE = .001, CI:.007, .002, p < .001) during acute stress: presence of either interpretation bias toward threat (β = 6.950, SE = 2.826, CI: 1.407, 12.488, p = .013) or emotion regulation difficulties (β = 9.387, SE = 3.685, CI: 2.141, 16.636, p = .011) was associated with greater reactivity and poorer recovery; presence of both was associated with the lowest resting state EDA and blunted reactivity (β = 1.340, SE = 3.085, CI: −4.721, 7.407, p = .66). Conclusions: Preliminary findings support interpretation bias and emotion regulation difficulties, and their distinct interactive patterns, as predictors of autonomic reactivity trajectories during stress. Interpretation bias modification and emotion regulation skills may be important intervention targets for common psychological conditions that are influenced by aberrant psychophysiological processes.

Computerized Cognitive Bias Modification for Interpretation (CBM-I) among Japanese university students with social anxiety

Computerized Cognitive Bias Modification for Interpretation (CBM-I) among Japanese university students with social anxiety

Appearance-related safety behaviors predict symptoms of body dysmorphic disorder following internet-based treatment

Recent experimental evidence has found that appearance related safety behaviors (i.e., practices meant to avoid a perceived feared outcome) likely play a crucial role in maintaining symptoms of body dysmorphic disorder (BDD). The present study sought to determine if these behaviors predicted BDD symptom severity following treatment. Participants (N = 50) with BDD were randomized to either eight sessions of interpretation bias modification or progressive muscle relaxation. Both treatments led to reductions in BDD symptom severity and appearance-related safety behaviors, though moderate levels of safety behaviors persisted at both posttreatment and follow-up. Importantly, post-treatment appearance related safety behaviors significantly predicted BDD symptom severity at three-month follow-up. Taken together, the present findings suggest appearance related safety behaviors maintain BDD symptoms following effective computerized treatments and provide further evidence for their importance in the treatment of BDD.

Development and refinement of the mobile anger reduction intervention for veterans with posttraumatic stress disorder.

Problematic anger is commonly reported among veterans with posttraumatic stress disorder (PTSD) and is associated with numerous psychosocial impairments. There is a clear need to develop innovative and effective anger interventions. One of the cognitive mechanisms associated with anger is the hostile interpretation bias, which is the tendency to interpret ambiguous interpersonal situations as hostile. The current study presents a successive cohort design methodology to develop and refine a mobile treatment application, entitled Mobile Anger Reduction Intervention (MARI), which uses interpretation bias modification techniques to modify hostile interpretation bias. Two cohorts (total N = 13) of veterans with PTSD and problematic anger used the MARI application for 4 weeks. After each cohort, qualitative and quantitative data were used to modify the MARI application. The intervention is described, as well as the qualitative and quantitative findings and subsequent changes made to the mobile application based on participant feedback. Treatment adherence was high (90% of participants completed all sessions). Participants reported that they found the treatment helpful and easy to use and experienced improvements in hostile interpretation bias and problematic anger. This study demonstrates the utility of a successive cohort treatment design for the development of mobile interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of interpretation bias modification on hostile attribution bias and reactive cyber-aggression in Chinese adolescents: a randomized controlled trial.

The online version contains supplementary material available at 10.1007/s12144-023-04433-3.