From cognitive targets to symptom reduction: overview of attention and interpretation bias modification research

Abstract

Cognitive bias modification (CBM) is a class of mechanised psychological interventions designed to target specific aberrant cognitive processes considered key in the aetiology and/or maintenance of specific psychiatric disorders. In this review, we outline a multistage translational process that allows tracking progress in CBM research. This process involves four steps: (1) the identification of reliable cognitive targets and establishing their association with specific disorders; (2) clinical translations designed to rectify the identified cognitive targets; (3) verification of effective target engagement and (4) testing of clinical utility in randomised controlled trials. Through the prism of this multistage process, we review progress in clinical CBM research in two cognitive domains: attention and interpretation; in six psychiatric conditions: anxiety disorders, major depressive disorder, post-traumatic stress disorder, addictive disorders, eating disorders and obsessive-compulsive disorder. The review highlights achievement as well as shortcomings of the CBM approach en route to becoming a recognised evidence-supported therapy for these disorders.

Keywords: anxiety disorders; depression & mood disorders; eating disorders; substance misuse.

Figure 1

In each trial of the probe detection task, the most commonly used RT-based form of ABM, a fixation cross is followed by two stimuli of various valences, which are then replaced with a visual probe (eg, an arrow pointing left or right) at the location of one of the stimuli. Patients are asked to discriminate the probe’s type as quickly and accurately as possible. For example, when aiming to rectify an attentional bias towards threat, target arrows will be placed at the location of the neutral face location with higher frequency than in the threat face location. With repeated trials (and training sessions), patients gradually learn the predictive value of neutral faces in relation to target location and thus shift their attention to these locations as this facilitates task performance. Repeated training is thought to rectify the bias and consequently reduce symptoms. Treatment protocols range from 1 to 24 sessions, presenting 100–400 trials per session. The most commonly applied protocols involve eight biweekly sessions with 160 trials per session. Face stimuli were taken from the Karolinska Directed Emotional Faces stimulus set. ABM, attention bias modification; RT, reaction time.

Figure 2

In each trial of gaze-contingent therapy, a second-generation ABM protocol using eye-tracking technology, participants view a matrix of mixed valance stimuli and are reinforced with music when looking at the targeted stimuli. For example, if the aim is to increase attention to neutral over disgusted faces with the intention to rectify a bias observed in patients with SAD, music will play as long as the patient is fixating on one of the neutral faces and will stop when fixating on one of the disgusted faces. With repeated trials of this protocol, attention is gradually shifted away from threat and symptoms reside. Face stimuli were taken from the Karolinska Directed Emotional Faces stimulus set. ABM, attention bias modification; SAD, social anxiety disorder.

Figure 3

In each trial of the word–sentence association paradigm, one of the most common CBM-I tasks, patients are presented with a fixation cross followed by a word representing either a benign or a negative interpretation to an ambiguous situation presented in the following screen. Patients are then asked if the word and situation presented were related. Positive feedback is provided for responses that accept benign interpretation or reject negative interpretations. With repeated trials, it is expected that patients will make more benign or positive interpretation, rectifying an interpretative bias and reducing symptoms. CBM-I, cognitive bias modification of interpretation.