Translating CBM-I Into Real-World Settings: Augmenting a CBT-Based Psychiatric Hospital Program

Cognitive bias modification for interpretation (CBM-I) is an appealing augmentation to cognitive-behavioral therapy (CBT) because it targets cognitive bias efficiently via computerized training. Few studies have tested the combination of CBM-I and CBT, and none have translated lab-based CBM-I protocols to an acute psychiatric setting. The present study describes the development and implementation of CBM-I as an augmentation to a CBT-based partial hospital. We developed a transdiagnostic CBM-I based on the word–sentence association paradigm (WSAP), which reinforces individuals for endorsing benign interpretations and rejecting negative interpretations of ambiguous sentences. Over two iterations of development, we randomly assigned patients (N = 127; M age = 34.21; 58% female, 40% male, 2% nonbinary) to either CBM-I or a control group (Phase 1: neutral WSAP task; Phase 2: treatment as usual). CBM-I comprised daily sessions (10 minutes) completed during program hours, and number of sessions varied naturalistically according to patient length of stay. Primary outcomes included feasibility, acceptability, and target engagement (interpretation bias). CBM-I was feasible and acceptable to acute psychiatric patients, and successfully shifted interpretation for novel stimuli. Patient feedback suggested that participants viewed CBM-I as bolstering their primary CBT-based care. Exploratory analyses examining clinical benefit revealed a small between-group effect on anxiety severity (d = 0.378), but no group differences on depression outcomes (d = 0.008). Findings indicate that CBM-I is a feasible and acceptable augmentation to CBT-based partial hospital care. Future studies are warranted to determine who is most likely to benefit from this low-intensity approach.     

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.     

Brief report Low positive affect and less extreme emotional encoding

Current theories suggest low positive affect (PA) should be associated with negative encoding of ambiguous information. However, recent findings (Lawson & MacLeod, 1999) paradoxically suggest that low positive affect may lead to less negative encoding. One possibility is that low positive affect is associated with less emotionally extreme encoding rather than less negative encoding. Undergraduates (22 Low PA, 23 High PA) read potentially negative and potentially positive ambiguous sentences followed by a word related to an emotional or a non‐emotional interpretation of the sentence, or by an unrelated word. Low PA participants demonstrated greater priming for neural interpretations, while High PA participations showed the opposite pattern. There was no interaction with valence, suggesting low positive affect may be related to encoding ambiguity as less emotionally extreme.     

Resolving syntactic category ambiguity: An eye-movement analysis

In two experiments, participants' eye movements were monitored as they read sentences containing biased syntactic category ambiguous words with either distinct (e.g., duck) or related (e.g., burn) meanings or unambiguous control words. In Experiment 1, prior context was consistent with either the dominant or subordinate interpretation of the ambiguous word. The subordinate bias effect was absent for the ambiguous words in gaze duration measures. However, effects of ambiguity did emerge in other measures for the ambiguous words preceded by context supporting the subordinate interpretation. In Experiment 2, context preceding the target words was neutral. Ambiguity effects only arose when posttarget context was consistent with the subordinate interpretation of the ambiguous words, indicating that readers initially selected the dominant interpretation. Results support immediate theories of syntactic category ambiguity resolution, but also suggest that recovery from misanalysis of syntactic category ambiguity is more difficult than for lexical-semantic ambiguity in which alternate interpretations do not cross syntactic category.     

Sentential and discourse topic effects on lexical ambiguity processing: an eye movement examination

Models of lexical ambiguity resolution posit a role for context, but this construct has remained relatively undefined in the literature. The present study isolated two different forms of contextual constraint and examined how these sources of information might differentiate between a selective access and a reordered access model of ambiguity processing. Eye movements were monitored as participants read passages that contained either a balanced or a biased ambiguous word. The sentence containing the ambiguous word was held constant and instantiated either the subordinate meaning (Experiment 1) or the dominant meaning (Experiment 2) through the use of local context. These sentences were embedded in passages in which the topic was consistent, inconsistent, or neutral with respect to the meaning biased by the critical sentence. Experiment 1 provided evidence suggesting that the subordinate meaning of an ambiguous word was not selectively accessed even when sentence and discourse topic information biased that meaning. The data from Experiment 2 provided evidence that even the dominant meaning was not selectively accessed. These contextual sources of information were evaluated in terms of the roles they play in models of lexical ambiguity resolution.     

Effects of syntactic category assignment on lexical ambiguity resolution in reading: an eye movement analysis

Readers' eye movements were monitored as they read sentences containing lexically ambiguous words whose meanings share a single syntactic category (e.g., calf), lexically ambiguous words whose meanings belong to different syntactic categories (e.g., duck), or unambiguous control words. Information provided prior to the target always unambiguously specified the context-appropriate syntactic-category assignment for the target. Fixation times were longer on ambiguous words whose meanings share a single syntactic category than on controls, both when prior context was semantically consistent with the subordinate interpretation of a biased ambiguous word (Experiment 1) and when prior context was semantically neutral as to the intended interpretation of a balanced ambiguous word (Experiment 2). These ambiguity effects, which resulted from differences in difficulty with meaning resolution, were not found when the ambiguity crossed syntactic categories. These data indicate that, in the absence of syntactic ambiguity, syntactic-category information mediates the semantic-resolution process.     

Selection mechanisms in reading lexically ambiguous words

Readers' eye movements were monitored as they read sentences containing lexically ambiguous words. The ambiguous words were either biased (one strongly dominant interpretation) or nonbiased. Readers' gaze durations were longer on nonbiased than biased words when the disambiguating information followed the target word. In Experiment 1, reading times on the disambiguating word did not differ whether the disambiguation followed the target word immediately or occurred several words later. In Experiment 2, prior disambiguation eliminated the long gaze durations on nonbiased target words but resulted in long gaze durations on biased target words if the context demanded the subordinate meaning. The results indicate that successful integration of one meaning with prior context terminates the search for alternative meanings of that word. This results in selective (single meaning) access when integration of a dominant meaning is fast (due to a biasing context) and identification of a subordinate meaning is slow (a strongly biased ambiguity with a low-frequency meaning).     

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.     

Feasibility and Acceptability of Cognitive Bias Modification for Interpretation as an Adjunctive Treatment for OCD and Related Disorders: A Pilot Randomized Controlled Trial

Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs. We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation. Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation. This was the first study to evaluate CBM-I in naturalistic treatment for adults seeking IRT for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.     

Developing a measure of interpretation bias for depressed mood: An ambiguous scenarios test

The tendency to interpret ambiguous everyday situations in a relatively negative manner (negative interpretation bias) is central to cognitive models of depression. Limited tools are available to measure this bias, either experimentally or in the clinic. This study aimed to develop a pragmatic interpretation bias measure using an ambiguous scenarios test relevant to depressed mood (the AST-D).¹ In Study 1, after a pilot phase (N = 53), the AST-D was presented via a web-based survey (N = 208). Participants imagined and rated each AST-D ambiguous scenario. As predicted, higher dysphoric mood was associated with lower pleasantness ratings (more negative bias), independent of mental imagery measures. In Study 2, self-report ratings were compared with objective ratings of participants’ imagined outcomes of the ambiguous scenarios (N = 41). Data were collected in the experimental context of a functional Magnetic Resonance Imaging scanner. Consistent with subjective bias scores, independent judges rated more sentences as negatively valenced for the high versus low dysphoric group. Overall, results suggest the potential utility of the AST-D in assessing interpretation bias associated with depressed mood.     

A Randomized Test of Interpretation Bias Modification for Perfectionism Versus Guided Visualization Relaxation Among High Perfectionistic Undergraduate Students

Clinical perfectionism contributes to the onset and maintenance of multiple psychological concerns. We conducted a randomized, longitudinal test of the efficacy of a web-based intervention for perfectionism (specifically, cognitive bias modification, interpretation retraining; CBM-I), compared to an active treatment comparison condition (specifically, guided visualization relaxation training) for reducing perfectionism and related psychopathology. College students (N = 167) with elevated perfectionism were randomized to one of the two study conditions and were asked to complete their assigned intervention twice weekly for 4 weeks. Participants completed measures of perfectionism and psychological symptoms at baseline, 2 weeks (midway through the intervention period), 4 weeks (at the conclusion of the intervention period), and 8 weeks (1 month follow-up). CBM-I was rated as acceptable overall, though relaxation training was rated slightly more favorably. CBM-I outperformed relaxation training on improving perfectionism-relevant interpretation biases (i.e., increasing nonperfectionistic interpretations and decreasing perfectionistic interpretations), though with small effect sizes and inconsistency across study timepoints. Self-reported perfectionism showed small decreases across time in both intervention conditions. Support was found for a key hypothesized mechanism of CBM-I, such that randomization to CBM-I had a longitudinal, indirect effect on decreasing psychopathology symptom scores through improving perfectionism-relevant interpretation biases. However, in light of small effect sizes, the present study failed to provide compelling evidence that CBM-I for perfectionism contributes meaningfully to the treatment of perfectionism.     

Interpretation Bias Training in Depressed Adolescents: Near- and Far-Transfer Effects

Depressed adolescents are characterized by negative interpretation biases. Although investigators have used cognitive bias modification for interpretation (CBM-I) to experimentally manipulate interpretation biases in depressed adults, the near- and far-transfer effects are not well understood in adolescents diagnosed with Major Depressive Disorder (MDD). In this study, we extend previous research by investigating the near- and far-transfer effects of 6 sessions of Positive versus Neutral CBM-I on independent measures of interpretation bias (near-transfer effects) and on attention biases and clinical symptoms (far-transfer effects) in a sample of adolescents with MDD (n = 46). At post-training, adolescents who received Positive CBM-I interpreted ambiguous scenarios more positively than did participants who received Neutral CBM-I, providing evidence of training effectiveness. There was no evidence, however, of near- or far-transfer effects. These findings raise concerns about the malleability of interpretation biases in adolescent depression and suggest that further work is needed to establish the clinical utility of CBM-I for adolescents with MDD.     

There's more to emotion than meets the eye: A processing bias for neutral content in the domain of emotional prosody

Research on emotion processing in the visual modality suggests a processing advantage for emotionally salient stimuli, even at early sensory stages; however, results concerning the auditory correlates are inconsistent. We present two experiments that employed a gating paradigm to investigate emotional prosody. In Experiment 1, participants heard successively building segments of Jabberwocky “sentences” spoken with happy, angry, or neutral intonation. After each segment, participants indicated the emotion conveyed and rated their confidence in their decision. Participants in Experiment 2 also heard Jabberwocky “sentences” in successive increments, with half discriminating happy from neutral prosody, and half discriminating angry from neutral prosody. Participants in both experiments identified neutral prosody more rapidly and accurately than happy or angry prosody. Confidence ratings were greater for neutral sentences, and error patterns also indicated a bias for recognising neutral prosody. Taken together, results suggest that enhanced processing of emotional content may be constrained by stimulus modality.     

Effects of training on interpretation of emotional ambiguity

In four experiments we investigated whether interpretative biases found in anxious patients and high-trait anxious individuals can be induced by training in unselected volunteers. Repeated exposure to emotionally valenced (threatening) meanings of homographs during training was followed by relatively faster resolution of word fragments and faster lexical decisions for targets that matched the trained valence. Similar effects were found whether participants generated the meanings themselves, or verified a particular meaning of the homograph. Finally, comparison with a baseline condition confirmed that systematic exposure to threatening-but not non-threatening-resolutions of ambiguous words led to generally faster access times for congruent meanings, thus resembling the interpretative bias seen in anxiety states.     

Seeing through the eyes of anxious individuals: An investigation of anxiety-related interpretations of emotional expressions

The interpretation of emotional states is necessary for successful social communication. Often individuals interpret emotional expressions intuitively and without full cognitive awareness. The aim of the present study was to test whether anxiety would influence affect interpretation in the manner suggested by interpretation bias—the tendency to interpret ambiguous cues in a threatening way. Interpretation of social cues was assessed with the similarity rating task (simtask) in two studies (n₁ = 116, n₂ = 76). The similarity ratings were analysed with a multidimensional scaling (MDS) approach, and the effects of anxiety on the interpretation of emotional expressions were analysed with multilevel modelling. The results of both studies showed evidence for an anxiety-related interpretation bias. High-anxious individuals tended to interpret milder threats as more negative than low-anxious individuals did. The consequences for anxiety research are discussed.     

List of Reviewers

ABSTRACT

Anxious individuals report disproportionately negative expectations concerning the future, termed the negative expectancy bias. In contrast, ageing is associated with an inflated expectancy for positive future events. A recent study [Steinman, S. A., Smyth, F. L., Bucks, R. S., MacLeod, C., &; Teachman, B. A. (2013). Anxiety-linked expectancy bias across the adult lifespan. Cognition and Emotion, 27, 345–355. doi:10.1080/02699931.2012.711743] found using an interpretation bias task, a negative expectancy bias in young adults and positive expectancy bias in older adults with high trait anxiety. Extending this, the current study examined expectancy bias for positive, negative and ambiguously emotionally toned information in younger and older adults with clinical levels of depression and anxiety to community control groups, thus allowing examination of both disorder status and age on biases. Clinical participants reported a pervasive tendency to expect negative events relative to positive regardless of whether the current scenarios were positive, negative or ambiguous. Older adults showed greater expectancy for future positive scenarios when the initial scenario was negative or ambiguous. Age moderated the negative expectancy bias shown by clinical participants for ambiguous scenarios. Clinical disorders in older adults attenuated the positive expectancy bias that was otherwise strong in community participants. These findings provide further evidence for age differences in processing of emotionally toned information, with older adults showing a greater expectancy for positive future events.     

“I’m Not Really Afraid of Osama Bin Laden!” Fear of Terrorism in Dutch Children

We examined to what extent children in The Netherlands are affected by the threat of terrorism. For this purpose, a sample of school children living in Rotterdam or adjacent satellites (N = 216) completed a fear survey that included a number of terrorism-related items, and were confronted with ambiguous vignettes to measure threat-related interpretation bias. The results demonstrated that although a number of terrorism-related items (i.e., bombing attacks, explosions in a bus or subway) listed high in a ranking of most intense childhood fears, very few children made terrorist-related interpretations of ambiguous situations.     

藏-汉读者汉语歧义句加工的歧义效应及语境促进效应

采用眼动技术,通过两个实验,考察藏-汉读者阅读汉语歧义句时的歧义效应以及语境在句子歧义消解中的作用。结果发现:藏-汉读者在阅读汉语歧义句时存在歧义效应; 语境对歧义消解起促进作用,表现为,当语境置于歧义句之前或语境意义偏向歧义句主要意思时,藏-汉读者对歧义句的加工更容易。并且,歧义效应和语境促进效应贯穿于早期阶段到晚期阶段的整个句子加工过程。     

Underspecification of syntactic ambiguities: Evidence from self-paced reading

Syntactically ambiguous sentences are sometimes read faster than disambiguated strings. Models of parsing have explained this tendency by appealing either to a race in the construction of alternative structures or to reanalysis. However, it is also possible that readers of ambiguous sentences save time by strategically underspecifying interpretations of ambiguous attachments. In a self-paced reading study, participants viewed sentences with relative clauses that could attach to one of two sites. Type of question was also manipulated between participants in order to test whether goals can influence reading/parsing strategies. The experiment revealed an ambiguity advantage in reading times, but only when participants expected superficial comprehension questions. When participants expected queries about relative clause interpretation, disambiguating regions were inspected with more care, and the ambiguity advantage was attenuated. However, even when participants expected relative clause queries, question-answering times suggested underspecified representations of ambiguous relative clause attachments. The results support the construal and "good-enough" models of parsing.     

Interpretive habit is strengthened by cognitive bias modification

We investigated the nature of the memory mechanisms underlying cognitive bias modification by applying Jacoby's (1991) process-dissociation procedure to responses during the transfer task. In the two training conditions (negative and benign), students imagined themselves in 100 ambiguous scenarios, most with potentially negative resolutions; the ambiguity was resolved in a consistently negative or benign direction by completing the fragment of a final word. Control participants completed non-ambiguous, non-emotional scenarios. Next all participants responded on a final training block, where half of the scenarios were completed negatively and half benignly. Transfer was assessed by examining choices in the completion of test scenarios when participants were instructed to respond in the same way as they had to a final-block training scenario that was situationally similar. Benign training facilitated correct responding to benign analogues and impaired correct responding to negative analogues. Performance in the negative-training and control conditions was similar. Process-dissociation procedures revealed that this newly established habit and not controlled recollection provided the basis for transfer.