J. Behav. Ther. & Exp. Psychiat. 42 (2011) 298e308 Contents lists available at ScienceDirect Journal of Behavior Therapy and Experimental Psychiatry journal homepage: www.elsevier.com/locate/jbtep Modifying cognitive errors promotes cognitive well being: A new approach to bias modification Kathryn J. Lester a,*,1, Andrew Mathews b, Phil S. Davison c, Jennifer L. Burgess d,2, Jenny Yiend a,**,3 a Department of Psychiatry, University of Oxford, UK b Department of Psychology, University of California, Davis, USA c Oxfordshire Mental Healthcare NHS Trust, Warneford Hospital, Oxford, UK d Department of Experimental Psychology, University of Oxford, UK article info abstract Article history: Background: Cognitive Bias Modification (CBM) procedures have been used to train individuals to Received 14 July 2010 interpret ambiguous information in a negative or benign direction and have provided evidence that Received in revised form negative biases causally contribute to emotional vulnerability. 29 December 2010 Method: Here we present the development and validation of a new form of CBM designed to manipulate Accepted 3 January 2011 the cognitive errors known to characterize both depression and anxiety. Our manipulation was designed to modify the biased cognitions identified by Beck’s cognitive error categories (e.g. arbitrary inference, Keywords: overgeneralisation) and typically targeted during therapy. Cognitive bias modification Cognitive errors Results: In a later test of spontaneous inferences, unselected (Experiment 1) and vulnerable participants Anxiety (Experiment 2) who had generated positive alternatives rather than errors perceived novel hypothetical Depression events, their causes and outcomes in a non-distorted manner. These groups were also less vulnerable to Interpretation two different types of emotional stressor (video clips; and an imagined social situation). Furthermore participants’ interpretation of their own performance on a problem-solving task was improved by the manipulation, despite actual performance showing no significant change. Conclusions: These findings demonstrate that Cognitive Error Modification can promote positive infer- ences, reduce vulnerability to stress and improve self-perceptions of performance. Ó 2011 Elsevier Ltd. All rights reserved. 1. Introduction attributional style (e.g. Ahrens & Haaga, 1993; Cropley & MacLeod, 2003; Reardon & Williams, 2007), judge future negative events and Cognitive models propose that inferential biases in how people outcomes as more likely to occur than positive outcomes (e.g. interpret events, attribute the causes of events and predict future Butler & Mathews, 1983, 1987; MacLeod & Cropley, 1995; MacLeod, events are important for the aetiology and maintenance of Tata, Kentish, & Jacobsen, 1997) and systematically interpret psychological disorders (Beck, Rush, Shaw, & Emery, 1979). There is ambiguous cues as threatening (e.g. Eysenck, Mogg, May, Richards, compelling evidence that high trait anxious, dysphoric and clini- & Mathews, 1991; Lawson, MacLeod, & Hammond, 2002; Mogg, cally anxious and depressed individuals demonstrate a pessimistic Bradbury, & Bradley, 2006; Richards & French, 1992). Recently, experimental techniques known as cognitive bias modification for interpretation (CBM-I) have focused on this latter * Corresponding author. Social, Genetic and Developmental Psychiatry Centre, form of inferential bias, the interpretation of emotional ambiguity. PO80 Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK þ44 207 848 CBM-I has been developed to simulate interpretation biases in the 5414. laboratory and has produced evidence suggesting biased interpre- ** Corresponding author. PO63 Institute of Psychiatry, De Crespigny Park, London tations are causally implicated in anxiety (Mackintosh, Mathews, SE5 8AF, UK. E-mail addresses: [email protected] (K.J. Lester), [email protected] (J. Yiend, Ridgeway, & Cook, 2006; Murphy, Hirsch, Mathews, Smith, Yiend). & Clark, 2007; Wilson, MacLeod, Mathews, & Rutherford, 2006) 1 Kathryn Lester is now at the Social, Genetic and Developmental Psychiatry and depressive vulnerability (Holmes, Lang, & Shah, 2009). Several ’ Centre, Institute of Psychiatry, part of King s College London. studies have now demonstrated that CBM-I leads to congruent and 2 Jennifer Burgess is now at the Department of Psychiatry, University of Oxford. 3 Jenny Yiend is now at the Institute of Psychiatry, part of King’s College London spontaneous biases in interpretation of novel material (e.g. and King’s Health Partners. Mathews & Mackintosh, 2000). Furthermore, modifying biases in 0005-7916/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2011.01.001 K.J. Lester et al. / J. Behav. Ther. & Exp. Psychiat. 42 (2011) 298e308 299 a positive direction has also led to improvements in trait and social personalization, minimization and overgeneralisation (see Table 1). anxiety (Beard & Amir, 2008; Mathews, Ridgeway, Cook, & Yiend, We suggest that previous CBM versions have omitted important 2007; Salemink, van den Hout, & Kindt, 2009) and reduced antic- types of cognitive error categories, which are nevertheless ubiq- ipated anxiety when imagining performing a stressful speech uitous in clinical settings. If CBM techniques are to make their way (Murphy et al., 2007). These modification techniques have focused effectively into clinical settings, then translational researchers must solely on manipulating the interpretation of emotional ambiguity start to address this shortfall. It cannot be assumed that as yet and have largely ignored the potential of the technique to manip- untested forms of inferential reasoning will be amenable to bias ulate a wider range of inferential biases of the sort outlined above. modification in the same manner as previously found only for the In this paper, we validate a new form of modification designed to interpretation of ambiguity. First, we demonstrate its efficacy in manipulate a broader range of inferential biases including, but modifying inferences in a positive and negative direction and extending beyond, the interpretation of emotional ambiguity and response to stress in a healthy sample. Second, we report further which are characterized by cognitive errors. refinement to maximize translational relevance and we provide A limitation of previous CBM work is that no studies have evidence of efficacy in changing cognition, response to stress and developed a procedure whose content is designed specifically for performance evaluation in a vulnerable sample. use in anxiety and depression as it presents clinically. It is widely recognized that anxiety and depression co-occur (Carter, Wittchen, 2. Experiment 1 Pfister, & Kessler, 2001; Judd et al., 1998). Das-Munshi et al. (2008) have argued that subsyndromal mixed anxiety and depression Prior to conducting Experiment 1 an extensive phase of mate- (MADD) is the most prevalent psychological disorder, with a 1- rials development was undertaken to assemble new modification month point prevalence of 8.8% and an impact on health-related and test materials designed to capture 7 categories of cognitive quality of life similar to that of pure cases of anxiety and depression. error. Table 1 gives the range of errors targeted and provides A transdiagnostic approach would argue that such high rates of co- examples of both source and modification materials. Further details occurrence exist because different disorders (such as anxiety and of item formation and selection, including validity ratings, are depression) share maintaining cognitive processes, including provided in the Supplementary material. systematic biases and distortions in inference (Harvey, Watkins, Mansell, & Shafran, 2004). Therefore, targeting the negative dis- 2.1. Method torted inferential biases common across disorders offers an alter- native approach to treatment, which bypasses traditional 2.1.1. Participants diagnostic labels and has potentially broad application. Sixty undergraduate students, 23 males and 37 females (mean In the present study we apply this approach to CBM. As yet, little age ¼ 20.83, SD ¼ 3.55, range 18e42) took part and were awarded research has explicitly focused on developing CBM procedures in £10 for participation. All were fluent English speakers and had no such a way as to ensure that they are relevant across clinical current or previous history of psychological disorder. Half were conditions. The content used to date has been limited to experi- counterbalanced by participant number to generate cognitive mentally derived items concerning social threat, physical threat or errors during bias modification (error condition) and half to test anxiety situations, which have disorder specific relevance. By generating responses, which were not cognitive errors (non-error using clinically derived content of relevance to depression and condition). anxiety and formulating this content to allow a wide range of inferential biases, we adopt a functional approach, which highlights 2.1.2. Cognitive error modification procedure the transdiagnostic and real world clinical potential of CBM. Modification items were designed to allow a cognitive error to According to clinical theory and practice one manifestation of the occur (or not occur) in how described events were perceived, in inferential biases described above are cognitive errors (Harvey et al., inferring their cause or in forming an expectancy for a future 2004). Cognitive errors are systematic distortions of reality