Koster EH, Fox E, MacLeod C. Introduction to the special section on cognitive bias modification in emotional disorders. J Abnorm Psychol 118: 1-4

Abstract

Cognitive models of anxiety disorders and unipolar depression have postulated that selective information processing plays an important role in the development and maintenance of emotional psychopathology. Cognitive bias modification (CBM) procedures have recently been developed to test this theoretical claim. The purpose of this special section is to introduce the central ideas underlying CBM and to bring together the research that exemplifies the theoretical and clinical potential of the CBM approach.

Full text

Introduction to the Special Section on Cognitive Bias Modification
in Emotional Disorders
Ernst H. W. Koster
Ghent University
Elaine Fox
Essex University
Colin MacLeod
University of Western Australia, Perth, Australia
Cognitive models of anxiety disorders and unipolar depression have postulated that selective information
processing plays an important role in the development and maintenance of emotional psychopathology.
Cognitive bias modification (CBM) procedures have recently been developed to test this theoretical
claim. The purpose of this special section is to introduce the central ideas underlying CBM and to bring
together the research that exemplifies the theoretical and clinical potential of the CBM approach.
Keywords: anxiety, depression, cognitive bias, training
Across the past 30 years, cognitive models of anxiety disorders
and unipolar depression have emphasized the crucial role that
selective information processing plays in the development and
maintenance of emotional psychopathology (Beck & Clark, 1997;
Eysenck, 1992; 1997; Mogg & Bradley, 1998; Wells & Matthews,
1994; Williams, Watts, MacLeod, & Mathews, 1988, 1997). The
extensive research programs generated by these models have dem-
onstrated that anxious and depressed individuals are characterized
by particular types of attentional, interpretive, and/or memory bias
when processing affective material relevant to their emotional state
(cf., Mathews & MacLeod, 2005). The progression in this research
domain has led to the idea that information-processing approaches
are likely to offer greater potential in terms of developing theo-
retical understanding and clinical treatments than is provided by
the standard nosological approach to psychopathology (e.g.,
Harvey, Watkins, Mansell, & Shafran, 2004).
Research designed to differentiate the cognitive biases associ-
ated with alternative types of emotional dysfunction has revealed
that anxiety disorders are principally characterized by the negative
interpretation of ambiguous information and by an attentional bias
that favors threatening stimuli (Williams et al., 1997; Mathews &
MacLeod, 2005). Recent research indicates that this attentional
bias may be a very rapid response, in that higher levels of trait
anxiety are associated with a very early neural signal to threat
(Fox, Derakshan, & Shoker, 2008). There has been considerable
recent interest in determining the precise cognitive nature (Fox,
Russo, Bowles, & Dutton, 2001), time-course (Koster, Crombez,
Verschuere, Van Damme, & Wiersema, 2006), and neural basis
(Bishop, 2007) of this anxiety-linked attentional bias.
Individuals with anxiety disorders sometimes show improved
implicit memory for threatening information, but there is little
evidence that such disorders are characterized by biases in explicit
memory. In contrast, people with major depression do reliably
show enhanced explicit memory for negative information (Teas-
dale & Barnard, 1993). Recent work also suggests that depressed
individuals tend to retrieve overgeneral autobiographical memo-
ries, even when prompted to retrieve detailed, specific memories
(Williams et al., 2007). In general, depression is not associated
with the rapid attentional bias that characterizes anxiety, although
people with depression do demonstrate maintained attention to
negative material and reduced inhibitory control at later stages of
information processing (Joormann, 2004).
These patterns of selective information processing not only are
shown by people who suffer from clinical anxiety disorders or
major depression but also are observed in nonclinical individuals
who display emotional dispositions known to reflect vulnerability
to such forms of psychopathology (e.g., Williams et al., 1997).
This is consistent with cognitive models that consider the opera-
tion of such processing biases to influence the development and
maintenance of emotional disorders (e.g., Eysenck, 1992). By
attributing causal status to cognitive bias in the etiology of emo-
tional psychopathology, such models implicate selective process-
ing in the explanation of clinical anxiety and depression and also
identify such biases as major targets for therapeutic intervention in
the remediation of such conditions. Nevertheless, despite the im-
portance of this account, most existing studies use cross-sectional
designs that cannot serve to determine whether cognitive bias
plays a causal role in the development of emotional dysfunction.
The main problem is that although such studies verify the
existence of an association between emotional vulnerability and
cognitive bias, the critical question of whether such cognitive bias
causally contributes to this emotional variability is left unresolved.
It is likely, for example, that the experience of an emotional
disorder or the frequent past experience of negative emotional
states could lead to the development of biases in particular cogni-
Ernst H. W. Koster, Department of Psychology, Ghent University, Gent,
Belgium; Elaine Fox, Department of Psychology, Essex University, Essex,
England; Colin MacLeod, Department of Psychology, University of West-
ern Australia, Perth, Australia.
Correspondence concerning this article should be addressed to Ernst
H. W. Koster, Department of Psychology, Ghent University, Henri Dun-
antlaan 2, B-9000 Gent, Belgium. E-mail: ernst.koster@ugent.be
Journal of Abnormal Psychology © 2009 American Psychological Association
2009, Vol. 118, No. 1, 1–4 0021-843X/09/$12.00 DOI: 10.1037/a0014379
1

tive operations. Such cognitive biases would represent the conse-
quence, not a cause, of heightened emotional vulnerability. In an
effort to more directly address the causal hypothesis, several
investigators have sought to determine whether differential cogni-
tive bias precedes and predicts variability in negative emotional
reactions to later stressful life events. In general, the results of such
studies have shown this to be the case. The magnitude of atten-
tional and interpretational biases, favoring the processing of neg-
ative information, has been shown to predict heightened emotional
reactivity to a subsequent stressful experience (Amir, Beard, &
Bower, 2005; MacLeod & Hagan, 1992). Attentional bias associ-
ated with initially mild dysphoria have also been found to predict
the levels of dysphoria experienced 7 weeks later, in interaction
with intervening life stress (Beevers & Carver, 2003). Likewise,
early measures of intrusive negative memories predict subsequent
emotional distress in cancer patients (Brewin, Watson, McCarthy,
Hyman, & Dayson, 1998), and early measures of selective memory
have been shown to predict depression 6 months later (Brewin,
Reynolds, & Tata, 1999). Thus, cognitive bias can clearly predict
later levels of emotional distress. These results are consistent with
the hypothesis that cognitive bias can play a causal role in the
development of emotional vulnerability.
Although such longitudinal studies are of great interest, the
findings remain open to alternative explanations that do not at-
tribute causal status to cognitive bias in the determination of
emotional reactivity. Most obviously, it is possible that the early
measures of cognitive bias and the later measures of emotional
reactivity are both independent consequences of some third per-
sonality variable that remains stable across the timescale of the
study. This would explain the observed predictive relationship
without implying a causal association between these two measures.
The only adequate test of the causal hypothesis is therefore to
directly manipulate the target cognitive bias in order to test the
prediction that such manipulation will also serve to modify emo-
tional vulnerability.
The recent development of novel experimental techniques that
have proven to be effective in directly manipulating cognitive bias
is therefore of great interest (Grey & Mathews, 2000; MacLeod,
Rutherford, Campbell, Ebsworthy, & Holker, 2002; Mathews &
MacLeod, 2002). The central idea behind such cognitive bias
modification (CBM) procedures has been to expose participants to
an experimentally established contingency during performance of
a simple task designed to encourage the acquisition or attenuation
of the target selective processing bias. To illustrate, one CBM
procedure, developed to induce biases in selective interpretation,
involves presenting people with a series of ambiguous scenarios
that they are constrained to repeatedly and consistently resolve in
either a negative or positive manner to effectively resolve an
incomplete word fragment that follows each passage (Grey &
Mathews, 2000). This procedure has proven successful in inducing
the desired interpretation bias, which then generalizes to new
ambiguous scenarios (Mathews & Mackintosh, 2000) and persists
across several days (Yiend, Mackintosh, & Mathews, 2005). Of
most direct relevance to the causal hypothesis under consideration,
inducing an increase in negative interpretation bias serves to
elevate state anxiety responses to a subsequent stressor, whereas
inducing a decrease in negative interpretive bias serves to attenuate
state anxiety reactions to such a later stressor (Wilson, MacLeod,
Mathews, & Rutherford, 2006).
CBM procedures also have proven effective in modifying se-
lective attentional responses to negative information, making it
possible to determine whether such attentional bias makes a causal
contribution to anxiety reactivity. For example, MacLeod et al.
(2002) manipulated attentional bias by having a task-relevant
visual probe always appear either spatially proximal to threatening
information (attend threat condition) or spatially distal from threat-
ening information (avoid threat condition). To perform each task
variant optimally, it would be best for participants to selectively
deploy attention either consistently toward or consistently away
from the more threatening stimuli, under these respective condi-
tions. MacLeod and colleagues delivered a single session of this
attentional CBM procedure, comprising around 600 trials, and
found this sufficient to induce the intended bias in attentional
response to emotional information, which generalized to new
stimulus materials. Again, of greatest relevance to the causal
hypothesis, this CBM procedure was found to modify emotional
reactivity to a subsequently encountered laboratory stressor, with
attenuated dysphoric responses to this stressor being reported by
individuals who were induced to acquire an attentional bias to
avoid threatening information. Such findings indicate that selective
processing biases can indeed make a causal contribution to emo-
tional vulnerability.
These encouraging early findings suggest that CBM procedures
may provide powerful new tools for investigating the role of
information-processing factors in psychopathology. The capacity
to directly manipulate precisely determined dimensions of process-
ing selectivity and to observe the resulting consequences for dif-
ferent dimensions of emotional disposition offers the promise of
enabling researchers to now systematically map out the functional
contributions made by alternative types of cognitive bias to normal
and abnormal variations in emotional experience. These findings
also provide grounds for optimism that use of CBM approaches to
manipulate the information-processing biases that lie at the heart
of clinical anxiety and depression might have therapeutic benefits
in the treatment of these disorders. Additionally, it becomes ex-
citing to speculate that such CBM techniques might contribute to
the prevention of emotional psychopathology, particularly given
the recent evidence that certain genotypes predisposing people to
emotional disorders (Caspi et al., 2002) influence information-
processing bias (Beevers, Gibb, McGeary, & Miller, 2007). Given
the ease with which computerized forms of CBM techniques can
be implemented and the relatively low costs associated with their
delivery, it is unsurprising that a growing number of investigators
have established research programs designed to extend in various
important ways the fairly small number of seminal CBM studies
published to date.
The Special Section
This special section is intended to expose readers to the central
ideas underlying CBM, and to provide them with examples of
CBM research that exemplifies the theoretical and clinical poten-
tial of the approach. We have selected articles that each represent
stand-alone reports of state-of-the-art studies and that collectively
illustrate the diversity of the CBM techniques that are beginning to
emerge from laboratories around the globe. Given that this is a
young and still developing research field, we have been unable to
rely on a predetermined set of collegially agreed criteria to define
2KOSTER, FOX, AND MACLEOD

the boundaries of the CBM approach. However, when classifying
studies as examples of CBM work, we were guided by the pres-
ence of two key features that have been strongly characteristic of
existing CBM studies. First, the direct target of change in each
case is a cognitive bias known to characterize a clinical disorder,
a clinically relevant symptom, or a personality trait associated with
vulnerability to clinical dysfunction. Commonly, it has been the
case that the targeted bias represents a pattern of processing
selectivity that appears to operate automatically, in the sense of
proceeding swiftly without intention, and so is not readily amena-
ble to volitional control. Second, the method of manipulating the
target cognitive bias has not principally relied on instruction but
instead has involved extensive practice on a cognitive task de-
signed to encourage and facilitate the desired cognitive change.
Thus, for example, this task may incorporate a certain contingency
that renders performance easier or more successful to the extent
that the desired pattern of processing selectivity is acquired.
From a procedural perspective, the CBM approach bears some
superficial similarities to some of the training modules applied
within cognitive rehabilitation programs. However, these training
modules usually are designed to enhance a more general class of
cognitive functioning that has been impaired through some neu-
ropsychological anomaly. In contrast, CBM is typically designed
to alter a specific pattern of processing selectivity, which is known
to represent a risk factor for one or more clinical disorders, to date,
mostly conditions associated with emotional dysfunction. None-
theless, there may be synergies to be found between these con-
ventional cognitive rehabilitation techniques and the more recently
evolving CBM approaches. For some conditions, such as severe
depression or anxiety, it could even be useful to combine both
methods (see Siegle, Ghinassi, & Thase, 2007).
The articles presented in this special section go significantly
beyond the limitations associated with previously published CBM
research, which are important to acknowledge. First, these earlier
CBM studies have been narrow in the scope of biases they have
been designed to manipulate, investigating only the impact of
modifying either selective attention or selective interpretation,
principally on measures of anxiety. Whether CBM approaches can
serve to modify a wider variety of cognitive biases associated with
other dimensions of psychological dysfunction, such as depres-
sion, remains unanswered by this earlier work. A second limitation
is that these published studies have been carried out only on
nonclinical participants. They leave uncertain, therefore, whether
CBM procedures will prove effective in attenuating the established
cognitive biases evidenced by individuals with anxiety disorders
and major depression and, consequently, ameliorate the symptom-
atology associated with such psychopathology. A third limitation
of the previously reported studies is that they have examined the
effects of delivering CBM within single experimental sessions,
considering only the short-term emotional impact of such proce-
dures, for instance, in terms of reactivity to a contrived laboratory
stressor. Such an approach cannot reveal whether the repeated or
extended administration of CBM can produce enduring changes in
selective information processing that serve to modify naturalistic
emotional experience within real world settings.
The articles contained in the present special section targeted a
wider range of biases for modification through the application of
CBM approaches and examined the impact of such modification
on a greater breadth of emotional dimensions. Thus, for example,
Watkins and Moberly (2009) described a newly developed CBM
training procedure designed to modify concreteness of thinking and
reported that this serves to reduce dysphoria. Schartau, Dalgleish,
and Dunn (2009) introduced another new CBM approach, this time
aimed at modifying reappraisal, and examined its impact on both
self-report and psychophysiological measures of emotional reac-
tivity. Holmes, Lang, & Shah (2009) created new variants of
interpretive training procedures, which implicate either visual or
verbal processing, and demonstrated that the emotional conse-
quences of modifying interpretive bias critically depends on the
modality of training. Hirsch, Hayes, and Mathews (2009) exam-
ined the capacity of an interpretive CBM procedure to influence a
specific symptom of anxiety: worry.
The studies reported in the special section are not restricted to
nonclinical symptoms and samples. Joormann, Hertel, LeMoult,
and Gotlib (2009) used clinically depressed participants when they
investigated the effectiveness of a novel CBM approach designed
to assist in selective forgetting of negative material. Moreover,
several of the studies reported in this special section looked at the
effects of extending CBM delivery across longer periods of time.
For instance, See, MacLeod, and Bridle (2009) reported evidence
that a 16-day attentional training program served to reduce anxiety
vulnerability and attenuate anxiety reactions to a real world stres-
sor. Some of these extended CBM studies have appraised their
therapeutic impact on clinical samples. Thus, Amir, Beard, Burns,
Bomyea (2009) reported the success of an extended CBM pro-
gram, designed to reduce attentional bias to threat, in attenuating
the symptoms of GAD, whereas Schmidt, Richey, Buckner, and
Timpano (2009) presented similarly encouraging results from a
study that examined the clinical benefits of a similar, extended
CBM approach for participants with generalized social anxiety
disorder.
The work contained within this special section represents the
next wave of CBM research, and we believe the findings reported
by these investigators amply justify the initial optimism generated
by the small number of seminal CBM studies published to date. At
the end of the section, we offer a more detailed commentary
concerning the theoretical, methodological, and clinical issues
raised by these important new findings. For the moment, we invite
the reader to enjoy these excellent articles. We hope the section
will be of interest to all readers of the Journal of Abnormal
Psychology and that it encourages colleagues to further pursue the
exciting potential offered by the CBM approach to illuminate and
to remediate the patterns of cognitive biases that underlie psycho-
pathology.
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Received August 20, 2008
Revision received September 2, 2008
Accepted September 2, 2008 !
4KOSTER, FOX, AND MACLEOD