Multisession Cognitive Bias Modification Targeting Multiple Biases in Adolescents with Elevated Social Anxiety

Cognitive Therapy and Research https://doi.org/10.1007/s10608-018-9912-y ORIGINAL ARTICLE Multisession Cognitive Bias Modification Targeting Multiple Biases in Adolescents with Elevated Social Anxiety Stephen C. Lisk1 · Victoria Pile1 · Simone P. W. Haller2 · Veena Kumari3 · Jennifer Y. F. Lau1 © The Author(s) 2018 Abstract Research studies applying cognitive bias modification of attention (CBM-A) and interpretations (CBM-I) training to reduce adolescent anxiety by targeting associated cognitive biases have found mixed results. This study presents a new multi-session, combined bias CBM package, which uses a mix of training techniques and stimuli to enhance user-engagement. We present preliminary data on its viability, acceptability and effectiveness on reducing symptoms and biases using an A–B case series design. 19 adolescents with elevated social anxiety reported on their social anxiety, real-life social behaviours, general anxiety, depression, and cognitive biases at pre/post time-points during a 2-week baseline phase and a 2-week intervention phase. Retention rate was high. Adolescents also reported finding the CBM training helpful, particularly CBM-I. Greater reductions in social anxiety, negative social behaviour, and general anxiety and depression, characterised the intervention but not baseline phase. There was a significant correlation between interpretation bias change and social anxiety symptom change. Our enhanced multi-session CBM programme delivered in a school-setting appeared viable and acceptable. Trainingassociated improvements in social anxiety will require further verification in a study with an active control condition/group. Keywords Social anxiety · Adolescence · CBM training · Attention bias · Interpretation bias Introduction Social anxiety is prevalent in youth (Wittchen et al. 1999), can disrupt academic performance and interpersonal interactions (Owens et al. 2008), persist into adulthood, and impact other disabling mental health conditions and quality of life (Woodward and Fergusson 2001). Cognitive behavioural therapy (CBT), the current gold-standard treatment, can reduce social anxiety in youth (Scaini et al. 2016) but many fail to show clinically significant responses (Kendall et al. 2012), respond but subsequently relapse (Ginsburg et al. 2014), or find it difficult to access. Identifying more effective, accessible methods so that young people * Jennifer Y. F. Lau 1 Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK 2 Department of Experimental Psychology, University of Oxford, Oxford, UK 3 Centre for Cognitive Neuroscience, College of Health and Life Sciences, Brunel University London, London, UK can better manage their symptoms is a public health priority. Cognitive bias modification (CBM) training, which uses computerised tasks to target symptom-linked cognitive biases, has emerged as a potential adjunctive intervention (Butler et al. 2015; White et al. 2016) that may be amenable to delivery through computerised formats at home (Salemink et al. 2014) or in school (Fitzgerald et al. 2016). Yet, existing CBM packages remain weak at boosting more adaptive information-processing styles and at reducing symptoms (Cristea et al. 2015a, b; Heeren et al. 2015; Mogoaşe et al. 2014). This study presents a newly developed, multi-session computerised training program that targets multiple cognitive biases using a variety of training techniques and stimuli, for adolescents with elevated social fears. We assess the viability of administering this training tool at school, it’s acceptability to young people and compare changes in biases and symptoms across a baseline and an intervention phase. Drawing on cognitive models of social anxiety (Clark and Wells 1995; Rapee and Heimberg 1997), a large corpus of research has found a link between social anxiety and attention and appraisal biases in adults as well as adolescents (Bar-Haim et al. 2007; Haller et al. 2016; Klein et al. 2017; Miers et al. 2008; Rheingold et al. 2003). These manifest 13 Vol.:(0123456789) Cognitive Therapy and Research as: greater allocation of attention to threatening stimuli at involuntary and voluntary stages of processing (Roy et al. 2008; Stirling et al. 2006); a tendency to interpret ambiguous cues in threatening ways; and a tendency to disproportionately attribute negative events as caused by oneself (i.e., ‘internal’ reasons) and positive events as caused by others or circumstance (i.e., ‘external’ reasons). Computerised cognitive training methods, which encourage more adaptive styles of information-processing over repeated trials and practice, have been developed in adults to reduce general and social anxiety. Cognitive bias modification of attention (CBM-A) methods alter maladaptive attention-orienting patterns towards threat, and encourage selective attention towards neutral or positive stimuli. Most commonly, CBM-A methods use a modified dot-probe task in which probes only ever appear in place of non-threatening stimuli (MacLeod et al. 1986). In contrast, in ‘visual search’ CBM-A training the individual must locate a non-threatening stimulus from among threatening stimuli as quickly as possible (Waters et al. 2013). Cognitive bias modification for interpretations (CBM-I) targets biases in interpretation, mostly using the ‘ambiguous situations task’ (Mathews and Mackintosh 2000). Here, participants read a series of ambiguous sentences that end with a word fragment. Completion of the final word disambiguates the valence of the sentence in a positive direction. Participants receive a follow-up ‘yes/no’ comprehension question with ‘correct/incorrect’ feedback in order to reinforce the training. A few studies have developed programs to modify attributions in adults to reduce depressive mood (Peters et al. 2011) but not anxiety. However, studies of adults with various anxiety conditions (including trait anxiety) have only found weak (but significant effects) in symptom change (Hakamata et al. 2010; Hallion and Ruscio 2011; Heeren et al. 2015, but also see; Cristea et al. 2015a; Mogoaşe et al. 2014). Reduction in symptoms typically occur when there is also successful bias modification (MacLeod and Clarke 2015), and possibly through multiple training sessions (Hallion and Ruscio 2011). Extensions of CBM-A and CBM-I for use in adolescents (Bar-Haim et al. 2011; Lau et al. 2013), using the same tasks but with modifications to the stimuli content and modality (audio/text/pictures) have found small to medium effects of CBM-I and CBM-A training on cognitive biases, but no effect on general indices of mental health (nor on anxiety specifically) (Cristea et al. 2015b). Looking at these packages separately, Lowther and Newman (2014) identified that 8 out of 10 CBM-A studies reported positive changes in anxiety post-intervention (although only 4 of these 8 studies also found a change in attention bi (...truncated)