CP08CH08-MacLeod ARI 1 March 2012 8:11 Cognitive Bias Modification Approaches to Anxiety Colin MacLeod1 and Andrew Mathews2 1School of Psychology, The University of Western Australia, Crawley WA 6009 Australia; email: [email protected] 2Department of Psychology, University of California, Davis, California 95616, and MRC Cognition and Brain Sciences Unit, Kings College, London CB2 2EF United Kingdom; email: [email protected] Annu. Rev. Clin. Psychol. 2012. 8:189–217 Keywords First published online as a Review in Advance on CBM, CBM-A, CBM-I, attentional bias, interpretive bias October 25, 2011 The Annual Review of Clinical Psychology is online Abstract at clinpsy.annualreviews.org Clinical anxiety disorders and elevated levels of anxiety vulnerability by University of Iowa on 12/04/13. For personal use only. This article’s doi: are characterized by cognitive biases, and this processing selectivity has 10.1146/annurev-clinpsy-032511-143052 been implicated in theoretical accounts of these conditions. We re- Copyright c 2012 by Annual Reviews. view research that has sought to evaluate the causal contributions such All rights reserved biases make to anxiety dysfunction and to therapeutically alleviate anx- Annu. Rev. Clin. Psychol. 2012.8:189-217. Downloaded from www.annualreviews.org 1548-5943/12/0427-0189$20.00 iety using cognitive-bias modification (CBM) procedures. After con- sidering the purpose and nature of CBM methodologies, we show that variants designed to modify selective attention (CBM-A) or interpre- tation (CBM-I) have proven capable of reducing anxiety vulnerability and ameliorating dysfunctional anxiety. In addition to supporting the causal role of cognitive bias in anxiety vulnerability and dysfunction and illuminating the mechanisms that underpin such bias, the findings sug- gest that CBM procedures may have therapeutic promise within clinical settings. We discuss key issues within this burgeoning field of research and suggest future directions CBM research should take to maximize its theoretical and applied value. 189 CP08CH08-MacLeod ARI 1 March 2012 8:11 Contents Extended Applications INTRODUCTION.............. 190 of Interpretive Bias BACKGROUND TO Modification . 201 COGNITIVE BIAS COGNITIVE BIAS MODIFICATION MODIFICATION RESEARCH.................. 191 TARGETING OTHER Cognitive Bias and Anxiety. 191 TYPES OF PROCESSING The Purpose of Cognitive Bias SELECTIVITY.............. 202 Modification Research . 193 Modification of Memory. 202 The Nature of Cognitive Bias ModificationofImagery....... 202 Modification Modification of Appraisal . 203 Methodologies . 193 COGNITIVE BIAS COGNITIVE BIAS MODIFICATION AND MODIFICATION COGNITIVE TARGETING MECHANISMS.............. 204 ATTENTIONAL Can CBM Findings Be SELECTIVITY.............. 194 Attributed to Demand Development of Attentional Effects?.................... 204 Bias Modification Do CBM Effects Reflect Techniques . 194 Change in the Intended Single-Session Applications Cognitive Process? . 205 of Attentional Bias Is CBM Change Restricted to Modification . 195 the Targeted Cognitive Extended Applications Bias?....................... 205 of Attentional Bias FUTURE DIRECTIONS FOR Modification . 197 COGNITIVE BIAS COGNITIVE BIAS MODIFICATION MODIFICATION RESEARCH.................. 206 TARGETING Extending the Reach INTERPRETIVE of CBM Research . 207 Enhancing the Efficacy of by University of Iowa on 12/04/13. For personal use only. SELECTIVITY.............. 198 Development of Interpretive Cognitive Bias Modification Bias Modification Procedures................. 207 Techniques . 198 Refining the Therapeutic Application of CBM in Annu. Rev. Clin. Psychol. 2012.8:189-217. Downloaded from www.annualreviews.org Single-Session Applications of Interpretive Bias Clinical Contexts . 208 Modification . 199 CLOSING COMMENTS . 209 INTRODUCTION change. Deeper understanding of any complex system results in a heightened ability to iden- Scientific progress is characterized by a close tify the changes to key variables needed to pro- association between advancement of under- duce desired outcomes. Of equal importance, standing and increased ability to bring about it is by changing such variables and observing 190 MacLeod · Mathews CP08CH08-MacLeod ARI 1 March 2012 8:11 the consequences that understanding is deep- developing new field of clinical research, ened. Hence, the ability to directly manipulate focusing particularly on its contribution to the Anxiety vulnerability: component elements of a complex system is of understanding and attenuation of dysfunctional a continuously crucial importance if we are to gain insight into anxiety. Although the great majority of CBM distributed individual difference variable its nature and effectively exploit the resulting work published to date has focused on atten- reflecting tendency to applied benefits. tional bias and interpretive bias, the principles readily experience Cognitive models of anxiety vulnerability underlying the CBM approach can readily be anxiety and dysfunction have proven highly influential extended to other types of cognitive biases also. Cognitive bias: across recent decades (cf. Brown & Barlow systematic selectivity 1994, Clark & Beck 2010). These models in information share the premise that biased patterns of basic BACKGROUND TO COGNITIVE processing that operates to favor one information processing, operating early within BIAS MODIFICATION RESEARCH type of information the cognitive system and at a low level that over another Cognitive Bias and Anxiety may be inaccessible to awareness, play a central Cognitive bias causal role in vulnerability to experience Cognitive accounts of anxiety dysfunction modification (CBM): unduly intense anxiety symptoms, though the attribute both heightened anxiety vulnerability direct manipulation of specific nature of the proposed cognitive biases and clinical anxiety to maladaptive patterns a target cognitive bias, varies from theory to theory (cf. Mathews & of selective information processing. They by extended exposure to task contingencies MacLeod 2005). Despite the indirect support have been motivated by the observation that that favor such accounts have received from confirmation patients with anxiety disorders commonly predetermined that such processing biases are indeed charac- report experiencing distinctly threatening patterns of processing teristic of heightened anxiety vulnerability and thoughts of a type that plausibly could elicit, selectivity anxiety pathology (cf. Ouimet et al. 2009), the sustain, or intensify their anxiety symptoms Attentional bias: ability of researchers to adequately test the cru- (e.g., Ghahramanlou-Holloway et al. 2007). a commonly studied cial idea that cognitive biases causally influence However, theoretical models developed to form of cognitive bias involving preferential clinically relevant symptoms has been handi- explain these idiosyncrasies in thought content attention to one capped by the lack of established procedures causally attributed them to systematic biases particular type of to directly manipulate these cognitive biases. in low-level cognitive mechanisms not readily information This also has limited the ability of clinicians to available to introspective assessment. In par- Interpretive bias: deliver the potential therapeutic benefits such ticular, biases in attention and interpretation a commonly studied theoretical accounts predict should be gained that operate to selectively favor the processing form of cognitive bias from the direct modification of these biases for of emotionally negative information have involving the tendency by University of Iowa on 12/04/13. For personal use only. to preferentially individuals experiencing problematic anxiety. commonly been implicated in these models of resolve ambiguity in Hence, there has been considerable interest anxiety, and sometimes biases in memory func- one particular way in recently developed techniques that have tion also have been thought to play a role (cf. Anxiety dysfunction: proven capable of directly modifying low-level Ouimet et al. 2009). Cognitive-experimental problematic anxiety Annu. Rev. Clin. Psychol. 2012.8:189-217. Downloaded from www.annualreviews.org cognitive biases implicated in such models methodologies that directly assess selective symptoms that are of anxiety pathology (cf. Bar-Haim 2010, information processing have confirmed the unwarranted by the Hakamata et al. 2010, Hallion & Ruskio 2011, presence of such biases both in people suffering situation and interfere with adaptive Hertel & Mathews 2011, Mathews 2011). The from anxiety disorders and in nonclinical functioning exponential growth of research employing individuals with an elevated dispositional Anxiety disorder: a these cognitive bias modification (CBM) vulnerability to experience anxiety symptoms. particular syndrome of procedures has been remarkable. Although Clinically anxious patients reliably display dysfunctional anxiety the seminal studies were conducted around a an attentional bias toward negative informa- symptoms matching decade ago, over 70% of the contemporary tion, which is also sometimes shown by healthy diagnostic criteria for CBM literature is composed of publications individuals who reported elevated levels of one of several clinically recognized categories that have appeared only within the past three trait anxiety (cf. Bar-Haim et al. 2007). This of anxiety pathology years. We provide an overview of this rapidly attentional bias has been assessed in a variety of www.annualreviews.org • Cognitive Bias Modification