Marilisa Boffo

Combining cognitive bias modification training with motivational support in alcohol dependent outpatients : study protocol for a randomised controlled trial

BackgroundAddiction research has hypothesised that automatic and reflective cognitive processes play an important role in the onset and maintenance of alcohol (ab)use, wherein automatic reactions to drug-related cues steer the drug user towards consuming before reflective processes can get over and steer towards a different behavioural response. These automatic processes include the tendency to attend and approach alcohol cues. These biases may be trained away from alcohol via computerised cognitive bias modification (CBM). The present protocol describes the design of a double-blind randomised controlled trial (RCT) testing the effectiveness of attentional bias and approach bias re-training with a 2×2 factorial design, alongside a brief motivational support (MS) program.Methods/DesignParticipants (n = 120) are adult alcohol dependent outpatients, recruited from a public health service for addiction in Italy, who have been abstinent for at least two months, and with a main diagnosis of alcohol dependence disorder. Participants are randomly assigned to one of four experimental conditions and complete 11 sessions of training after a baseline assessment. The MS takes place before each training session. Post-intervention and three-month follow-up assessments examine the change in clinical outcome variables and attentional and approach biases (measured with the Visual Probe Task and the Approach-Avoidance Task, respectively). Alcohol approach-avoidance implicit memory associations (measured with the Brief Implicit Association Test) are also evaluated at pre- and post-intervention to explore generalisation effects. Primary outcome measure is relapse rate at follow-up. Secondary outcome measures include change in cognitive biases, in alcohol-related implicit memory associations, and in the clinical variables assessed. An exploratory analysis is also planned to detect interaction effects between the CBM modules and possible moderators (interference control capacity, gender, age, number of previous detoxifications) and mediators (change in cognitive bias) of the primary outcome measure.DiscussionThis RCT is the first to test the effectiveness of a combined CBM intervention alongside motivational support in alcohol-dependent outpatients. The results of this study can be extremely valuable for future research in the optimisation of CBM treatment for alcohol addiction.Trial registrationCurrent Controlled Trials ISRCTN01005959 (registration date: 24 October 2013).

Anxiety, bulimia, drug and alcohol addiction, depression, and schizophrenia: what do you think about their aetiology, dangerousness, social distance, and treatment? A latent class analysis approach

PurposeMental illness stigma is a serious societal problem and a critical impediment to treatment seeking for mentally ill people. To improve the understanding of mental illness stigma, this study focuses on the simultaneous analysis of people’s aetiological beliefs, attitudes (i.e. perceived dangerousness and social distance), and recommended treatments related to several mental disorders by devising an over-arching latent structure that could explain the relations among these variables.MethodsThree hundred and sixty university students randomly received an unlabelled vignette depicting one of six mental disorders to be evaluated on the four variables on a Likert-type scale. A one-factor Latent Class Analysis (LCA) model was hypothesized, which comprised the four manifest variables as indicators and the mental disorder as external variable.ResultsThe main findings were the following: (a) a one-factor LCA model was retrieved; (b) alcohol and drug addictions are the most strongly stigmatized; (c) a realistic opinion about the causes and treatment of schizophrenia, anxiety, bulimia, and depression was associated to lower prejudicial attitudes and social rejection.ConclusionBeyond the general appraisal of mental illness an individual might have, the results generally point to the acknowledgement of the specific features of different diagnostic categories. The implications of the present results are discussed in the framework of a better understanding of mental illness stigma.

Exploring elements of fun to motivate youth to do cognitive bias modification

OBJECTIVE Heavy drinking among young adults poses severe health risks, including development of later addiction problems. Cognitive retraining of automatic appetitive processes related to alcohol (so-called cognitive bias modification [CBM]) may help to prevent escalation of use. Although effective as a treatment in clinical patients, the use of CBM in youth proves more difficult, as motivation in this group is typically low, and the paradigms used are often viewed as boring and tedious. This article presents two separate studies that focused on three approaches that may enhance user experience and motivation to train: a serious game, a serious game in a social networking context, and a mobile application. MATERIALS AND METHODS In the Game Study, 77 participants performed a regular CBM training, aimed at response matching, a gamified version, or a placebo version of that training. The gamified version was presented as a stand-alone game or in the context of a social network. In the Mobile Study, 64 participants completed a different CBM training, aimed at approach bias, either on a computer or on their mobile device. RESULTS Although no training effects were found in the Game Study, adding (social) game elements did increase aspects of the user experience and motivation to train. The mobile training appeared to increase motivation to train in terms how often participants trained, but this effect disappeared after controlling for baseline motivation to train. CONCLUSIONS Adding (social) game elements can increase motivation to train, and mobile training did not underperform compared with the regular training in this sample, which warrants more research into motivational elements for CBM training in younger audiences.

Assessing mental disorder causal beliefs: a latent dimension identification.

A Many-Facet Rasch analysis was carried out with the intent of identifying a latent trait dimension characterized by mental disorders causal beliefs variables. The present research consists of two studies. In Study 1, the responses of 443 Italian university students to a 40-item scale were analyzed by means of Rasch models. In Study 2, the responses of two new groups of subjects, of 300 and 135 people respectively, were examined to further validate the mental disorders causal beliefs dimension obtained in Study 1. Specific bias/interactions between the MDCB dimension and other variables, such as gender and university faculties, were detected. Correlation analyses between the MDCB dimension and attribution theory and social desirability variables were also carried out. The results showed that a 30-item Mental Disorder Causal Beliefs (MDCB) latent dimension exists, characterized by contents representative of biological-genetic and psycho-social causes. Males and females did not differ on their causal beliefs, whereas Psychology students presented more psycho-social etiology beliefs. The MDCB dimension was correlated neither to a general locus of control scale nor to the social desirability measure, whereas it was significantly correlated to the psychotherapeutic attribution measure. The results evidenced a well devised measure which can be potentially useful in the research and clinical practice for the assessment of people’s etiology beliefs about mental illness, focusing on the development of personalized interventions to reduce or modify eventual negative attitudes and misconceptions.

An Implicit Measure of Associations with Mental Illness versus Physical Illness: Response Latency Decomposition and Stimuli Differential Functioning in Relation to IAT Order of Associative Conditions and Accuracy

The present study aimed at the definition of a latent measurement dimension underlying an implicit measure of automatic associations between the concept of mental illness and the psychosocial and biogenetic causal explanatory attributes. To this end, an Implicit Association Test (IAT) assessing the association between the Mental Illness and Physical Illness target categories to the Psychological and Biologic attribute categories, representative of the causal explanation domains, was developed. The IAT presented 22 stimuli (words and pictures) to be categorized into the four categories. After 360 university students completed the IAT, a Many-Facet Rasch Measurement (MFRM) modelling approach was applied. The model specified a person latency parameter and a stimulus latency parameter. Two additional parameters were introduced to denote the order of presentation of the task associative conditions and the general response accuracy. Beyond the overall definition of the latent measurement dimension, the MFRM was also applied to disentangle the effect of the task block order and the general response accuracy on the stimuli response latency. Further, the MFRM allowed detecting any differential functioning of each stimulus in relation to both block ordering and accuracy. The results evidenced: a) the existence of a latency measurement dimension underlying the Mental Illness versus Physical Illness - Implicit Association Test; b) significant effects of block order and accuracy on the overall latency; c) a differential functioning of specific stimuli. The results of the present study can contribute to a better understanding of the functioning of an implicit measure of semantic associations with mental illness and give a first blueprint for the examination of relevant issues in the development of an IAT.

The relevance of security: A latent domain of attachment relationships

In the present study an adult attachment dimension, latent to the constructs of security, anxiety, and avoidance, was hypothesized, wherein security was expected to occupy the most relevant position. Furthermore, the reciprocal functioning of attachment constructs and their interactions with self-esteem were explored. Four hundreds and thirty-four Italian university students responded to two adult attachment questionnaires (Attachment Style Questionnaire and Adult Attachment Questionnaire) and to the Rosenberg Self-esteem scale. A Many-Facet Rasch Measurement modeling approach was adopted. The main results can be summarized as follows: (a) security, anxiety, and avoidance are nested under one latent attachment dimension; (b) security occupies the most prominent position on the dimension; (c) security is positively associated with a moderate level of attachment anxiety and negatively related to avoidance; and (d) a positive interaction between self-esteem and security, and a negative relation between self-esteem and anxiety, were detected. Theoretical, clinical, and empirical implications of the results are further discussed.

Attentional bias modification training for insomnia: A double-blind placebo controlled randomized trial

Background Attentional bias toward sleep-related information is believed to play a key role in insomnia. If attentional bias is indeed of importance, changing this bias should then in turn have effects on insomnia complaints. In this double-blind placebo controlled randomized trial we investigated the efficacy of attentional bias modification training in the treatment of insomnia. Method We administered baseline, post-test, and one-week follow-up measurements of insomnia severity, sleep-related worry, depression, and anxiety. Participants meeting DSM-5 criteria for insomnia were randomized into an attentional bias training group (n = 67) or a placebo training group (n = 70). Both groups received eight training sessions over the course of two weeks. All participants kept a sleep diary for four consecutive weeks (one week before until one week after the training sessions). Results There was no additional benefit for the attentional bias training over the placebo training on sleep-related indices/outcome measures. Conclusions The absence of the effect may be explained by the fact that there was neither attentional bias at baseline nor any reduction in the bias after the training. Either way, this study gives no support for attentional bias modification training as a stand-alone intervention for ameliorating insomnia complaints.

Etiological Beliefs, Treatments, Stigmatizing Attitudes toward Schizophrenia. What Do Italians and Israelis Think?

Background: Although scientific research on the etiology of mental disorders has improved the knowledge of biogenetic and psychosocial aspects related to the onset of mental illness, stigmatizing attitudes and behaviors are still very prevalent and pose a significant social problem. Aim: The aim of this study was to deepen the knowledge of how attitudes toward people with mental illness are affected by specific personal beliefs and characteristics, such as culture and religion of the perceiver. More precisely, the main purpose is the definition of a structure of variables, namely perceived dangerousness, social closeness, and avoidance of the ill person, together with the beliefs about the best treatment to be undertaken and the sick person’ gender, capable of describing the complexity of the stigma construct in particular as far as schizophrenia is concerned. Method: The study involved 305 university students, 183 from the University of Padua, Italy, and 122 from the University of Haifa, Israel. For the analyses, a latent class analysis (LCA) approach was chosen to identify a latent categorical structure accounting for the covariance between the observed variables. Such a latent structure was expected to be moderated by cultural background (Italy versus Israel) and religious beliefs, whereas causal beliefs, recommended treatment, dangerousness, social closeness, and public avoidance were the manifest variables, namely the observed indicators of the latent variable. Results: Two sets of results were obtained. First, the relevance of the manifest variables as indicators of the hypothesized latent variable was highlighted. Second, a two-latent-class categorical dimension represented by prejudicial attitudes, causal beliefs, and treatments concerning schizophrenia was found. Specifically, the differential effects of the two cultures and the religious beliefs on the latent structure and their relations highlighted the relevance of the observed variables as indicators of the expected latent variable. Conclusion: The present study contributes to the improvement of the understanding of how attitudes toward people with mental illness are affected by specific personal beliefs and characteristics of the perceiver. The definition of a structure of variables capable of describing the complexity of the stigma construct in particular as far as schizophrenia is concerned was achieved from a cross-cultural perspective.

Distorted Beliefs about Luck and Skill and Their Relation to Gambling Problems and Gambling Behavior in Dutch Gamblers

Gamblers’ cognitive distortions are thought to be an important mechanism involved in the development and maintenance of problem gambling. The Gambling Cognitions Inventory (GCI) evaluates two categories of distortions: beliefs that one is lucky (i.e., “Luck/Chance”) and beliefs that one has special gambling-related skills (i.e., “Skill/Attitude”). Prior psychometric evaluations of the GCI demonstrated the utility of both subscales as measures of distortions and their concurrent relations to gambling problems among Canadian gamblers. However, these associations have not yet been studied in gamblers from other cultures nor have relationships between the GCI and indices of gambling behavior been investigated. In addition, the predictive validity of the GCI scales have not been evaluated in studies to date. The present study investigated the validity of the GCI as a measure of cognitive distortions in a sample of 49 Dutch gamblers by examining its concurrent and prospective relationships to both gambling problems (as measured through a standardized nine-item questionnaire assessing gambling-related problems) and behaviors (as measured through two variables: days spent gambling and time spent gambling in minutes) at baseline and over 1-month and 6-month intervals. The GCI subscales were internally consistent at all timepoints, and moderately to strongly inter-correlated at all timepoints. Each subscale correlated with an independent dimension of gambling both concurrently and prospectively: Luck/Chance was related to greater gambling problems and Skill/Attitude was related to greater gambling behavior. Thus, the two GCI subscales, while inter-correlated, appear to be related to different gambling outcomes, at least among Dutch gamblers. Moreover, the first evidence of the predictive validity of the GCI scales was demonstrated over a 1-month and 6-month interval. It is recommended that both types of cognitive distortions be considered in research and clinical practice to fully understand and address individual risk for excessive and problematic gambling.

Gamified attentional bias modification in heavy drinking youth

Objective Young adults often experiment with heavy use of alcohol, which poses severe health risks and increases the chance of developing addiction problems. In clinical patients, cognitive re-training of automatic appetitive processes, such as selective attention towards alcohol (known as “Cognitive Bias Modification of Attention”, or CBM-A), has been shown to be a promising add-on to treatment, helping to prevent relapse. To prevent escalation of regular use into problematic use in youth, motivations appear to play a pivotal role. As CBM-A is often viewed as long and boring, we present this training in the form of a serious game, as a novel approach aimed at enhancing motivation to train. Methods: 96 Heavy drinking undergraduate students carried out either a regular CBM-A training, a gamified version (called “Shots”), or a placebo training version over four training sessions. Measures of motivation to change their behavior, motivation to train, attentional bias for alcohol and drinking behavior were included before and after training. Results: Alcohol attentional bias was reduced after training only in the regular training condition. Self-reported drinking behavior went down slightly in all conditions, but motivation to train also decreased in all conditions, suggesting that the motivational features of the Shots game were not enough to fully counteract the tiresome nature of the training. Moreover, some of the motivational aspects decreased slightly more in the Game condition, which may indicate potential detrimental effects of disappointing gamification. Conclusions: We therefore stress that caution is advised when using gamification, as well as underscore the importance of careful scientific evaluation.Purpose: A role of the immune system in the pathology of alcohol hangover has been proposed, and previous research have shown changes in serum cytokine concentrations during alcohol hangover relative to a control alcohol-free day. The current analyses compare determinations of saliva cytokine concentrations during alcohol hangover and a control day, conducted at different times after stopping alcohol consumption. Methods: Two naturalistic studies were conducted in social drinkers aged 18-35 years old. The first study (N = 36) collected saliva samples approximately 9 h after stopping alcohol consumption. The second study (N = 119) collected saliva samples approximately 13 h after stopping alcohol consumption. In both studies, saliva cytokine concentrations of IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, GM-CSF, IFN-γ and TNF-α were determined on the hangover and control day. Results: Nine hours after stopping alcohol consumption (Study 1), relative to the control day, significant increases in IL-2, IL-4, IL-5, IL-6, IL-10, IFN-γ and TNF-α concentrations were observed. In contrast, 13 h after stopping alcohol consumption (Study 2), relative to the control day, significant decreases in IL-2, IL-4, IL-5, IL-6, IL-10, GM-CSF, IFN-γ and TNF-α concentrations were observed. In both studies, changes in saliva cytokine concentrations were not significantly correlated with the amount of alcohol consumed. Whereas 13 h after stopping alcohol consumption (study 2) changes in saliva concentrations of some cytokines (i.e. levels of IL-1b, IL-2, IL-4, IL-5, and GM-CSF) were significantly negatively correlated with hangover severity. Discussion: The data suggest that the being in the alcohol hangover state is associated with changes in immune reactivity. As the direction of the changes in saliva cytokine concentrations seems time-dependent, to better understand this association, additional research is necessary, assessing immune biomarkers throughout the day.