Simon E. Blackwell

Cognitive Bias Modification Using Mental Imagery for Depression: Developing a Novel Computerized Intervention to Change Negative Thinking Styles

Why do some people see their glass as half–empty rather than half–full or even imagine that the glass will be filled in the future? Experimental methods can illuminate how individual differences in information processing style can profoundly impact mood or even result in disorders such as depression. A computerized cognitive bias modification intervention targeting interpretation bias in depression via positive mental imagery (CBM–I) was evaluated by investigating its impact on mental health and cognitive bias compared with a control condition. Twenty–six depressed individuals completed either positive imagery–focussed CBM–I or a control condition daily at home over one week. Outcome measures were collected pre–treatment and post–treatment and at two–week follow–up. Individuals in the positive condition demonstrated significant improvements from pre–treatment to post–treatment in depressive symptoms, cognitive bias and intrusive symptoms compared with the control condition. Improvements in depressive symptoms at two–week follow–up were at trend level. The results of this first controlled comparison of positive imagery–focussed CBM–I for depression further support the clinical potential of CBM–I and the development of a novel computerized treatment that could help patients imagine a more positive future. Broader implications concern the modification of individual differences in personality variables via their interaction with key information processing targets. Copyright

Combining imagination and reason in the treatment of depression: a randomized controlled trial of internet-based cognitive-bias modification and internet-CBT for depression.

Objective: Computerized cognitive-bias modification (CBM) protocols are rapidly evolving in experimental medicine yet might best be combined with Internet-based cognitive behavioral therapy (iCBT). No research to date has evaluated the combined approach in depression. The current randomized controlled trial aimed to evaluate both the independent effects of a CBM protocol targeting imagery and interpretation bias (CBM-I) and the combined effects of CBM-I followed by iCBT. Method: Patients diagnosed with a major depressive episode were randomized to an 11-week intervention (1 week/CBM-I + 10 weeks/iCBT; n = 38) that was delivered via the Internet with no face-to-face patient contact or to a wait-list control (WLC; n = 31). Results: Intent-to-treat marginal models using restricted maximum likelihood estimation demonstrated significant reductions in primary measures of depressive symptoms and distress corresponding to medium-large effect sizes (Cohen’s d = 0.62–2.40) following CBM-I and the combined (CBM-I + iCBT) intervention. Analyses demonstrated that the change in interpretation bias at least partially mediated the reduction in depression symptoms following CBM-I. Treatment superiority over the WLC was also evident on all outcome measures at both time points (Hedges gs = .59–.98). Significant reductions were also observed following the combined intervention on secondary measures associated with depression: disability, anxiety, and repetitive negative thinking (Cohen’s d = 1.51–2.23). Twenty-seven percent of patients evidenced clinically significant change following CBM-I, and this proportion increased to 65% following the combined intervention. Conclusions: The current study provides encouraging results of the integration of Internet-based technologies into an efficacious and acceptable form of treatment delivery.

Optimism and mental imagery: a possible cognitive marker to promote well-being?

Optimism is associated with a range of benefits not only for general well-being, but also for mental and physical health. The development of psychological interventions to boost optimism derived from cognitive science would have the potential to provide significant public health benefits, yet cognitive markers of optimism are little understood. The current study aimed to take a first step in this direction by identifying a cognitive marker for optimism that could provide a modifiable target for innovative interventions. In particular we predicted that the ability to generate vivid positive mental imagery of the future would be associated with dispositional optimism. A community sample of 237 participants completed a survey comprising measures of mental imagery and optimism, and socio-demographic information. Vividness of positive future imagery was significantly associated with optimism, even when adjusting for socio-demographic factors and everyday imagery use. The ability to generate vivid mental imagery of positive future events may provide a modifiable cognitive marker of optimism. Boosting positive future imagery could provide a cognitive target for treatment innovations to promote optimism, with implications for mental health and even physical well-being.

Positive Imagery-Based Cognitive Bias Modification as a Web-Based Treatment Tool for Depressed Adults: A Randomized Controlled Trial

Depression is a global health problem requiring treatment innovation. Targeting neglected cognitive aspects may provide a useful route. We tested a cognitive-training paradigm using positive mental imagery (imagery cognitive bias modification, imagery CBM), developed via experimental psychopathology studies, in a randomized controlled trial. Training was delivered via the Internet to 150 individuals with current major depression. Unexpectedly, there was no significant advantage for imagery CBM compared with a closely matched control for depression symptoms as a whole in the full sample. In exploratory analyses, compared with the control, imagery CBM significantly improved anhedonia over the intervention and improved depression symptoms as a whole for those participants with fewer than five episodes of depression and those who engaged to a threshold level of imagery. Results suggest avenues for improving imagery CBM to inform low-intensity treatment tools for depression. Anhedonia may be a useful treatment target for future work.

Mental Imagery in Depression: Phenomenology, Potential Mechanisms, and Treatment Implications

Mental imagery is an experience like perception in the absence of a percept. It is a ubiquitous feature of human cognition, yet it has been relatively neglected in the etiology, maintenance, and treatment of depression. Imagery abnormalities in depression include an excess of intrusive negative mental imagery; impoverished positive imagery; bias for observer perspective imagery; and overgeneral memory, in which specific imagery is lacking. We consider the contribution of imagery dysfunctions to depressive psychopathology and implications for cognitive behavioral interventions. Treatment advances capitalizing on the representational format of imagery (as opposed to its content) are reviewed, including imagery rescripting, positive imagery generation, and memory specificity training. Consideration of mental imagery can contribute to clinical assessment and imagery-focused psychological therapeutic techniques and promote investigation of underlying mechanisms for treatment innovation. Research into mental imagery in depression is at an early stage. Work that bridges clinical psychology and neuroscience in the investigation of imagery-related mechanisms is recommended.

Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): A randomized controlled trial

Background Accruing evidence suggests that positive imagery-based cognitive bias modification (CBM) could have potential as a standalone targeted intervention for depressive symptoms or as an adjunct to existing treatments. We sought to establish the benefit of this form of CBM when delivered prior to Internet cognitive behavioral therapy (iCBT) for depression Methods A randomized controlled trial (RCT) of a 1-week Internet-delivered positive CBM vs. an active control condition for participants (N=75, 69% female, mean age=42) meeting diagnostic criteria for major depression; followed by a 10-week iCBT program for both groups. Results Modified intent-to-treat marginal and mixed effect models demonstrated no significant difference between conditions following the CBM intervention or the iCBT program. In both conditions there were significant reductions (Cohen׳s d .57–1.58, 95% CI=.12–2.07) in primary measures of depression and interpretation bias (PHQ9, BDI-II, AST-D). Large effect size reductions (Cohen׳s d .81–1.32, 95% CI=.31–1.79) were observed for secondary measures of distress, disability, anxiety and repetitive negative thinking (K10, WHODAS, STAI, RTQ). Per protocol analyses conducted in the sample of participants who completed all seven sessions of CBM indicated between-group superiority of the positive over control group on depression symptoms (PHQ9, BDI-II) and psychological distress (K10) following CBM (Hedges g .55–.88, 95% CI=−.03–1.46) and following iCBT (PHQ9, K10). The majority (>70%) no longer met diagnostic criteria for depression at 3-month follow-up. Limitations The control condition contained many active components and therefore may have represented a smaller ‘dose’ of the positive condition. Conclusions Results provide preliminary support for the successful integration of imagery-based CBM into an existing Internet-based treatment for depression.

Autobiographical episodic memory-based training for the treatment of mood, anxiety and stress-related disorders: A systematic review and meta-analysis

We review evidence for training programmes that manipulate autobiographical processing in order to treat mood, anxiety, and stress-related disorders, using the GRADE criteria to judge evidence quality. We also position the current status of this research within the UK Medical Research Councils (2000, 2008) framework for the development of novel interventions. A literature search according to PRISMA guidelines identified 15 studies that compared an autobiographical episodic memory-based training (AET) programme to a control condition, in samples with a clinician-derived diagnosis. Identified AET programmes included Memory Specificity Training (Raes, Williams, & Hermans, 2009), concreteness training (Watkins, Baeyens, & Read, 2009), Competitive Memory Training (Korrelboom, van der Weele, Gjaltema, & Hoogstraten, 2009), imagery-based training of future autobiographical episodes (Blackwell & Holmes, 2010), and life review/reminiscence therapy (Arean et al., 1993). Cohens d was calculated for between-group differences in symptom change from pre- to post-intervention and to follow-up. We also completed meta-analyses for programmes evaluated across multiple studies, and for the overall effect of AET as a treatment approach. Results demonstrated promising evidence for AET in the treatment of depression (d=0.32), however effect sizes varied substantially (from -0.18 to 1.91) across the different training protocols. Currently, research on AET for the treatment of anxiety and stress-related disorders is not yet at a stage to draw firm conclusions regarding efficacy as there were only a very small number of studies which met inclusion criteria. AET offers a potential avenue through which low-intensity treatment for affective disturbance might be offered.

The filling of granules into hard gelatine capsules

Four different granule size fractions of Sorbitol instant(R) were filled into hard gelatine capsules on a tamp filling (Bosch) and a dosator nozzle machine (Zanasi) to allow comparison of the filling principles. An acceptable filling performance was always achieved and was independent of the machine type employed. Tamp filling was found to be slightly better for the coarser granule size fractions, because it does not seem to rely on a firm plug formation. A direct relationship between the angle of internal flow (Varthalis and Pilpel, 1976) and the coefficient of fill weight variation was found for both systems. Using the dosator nozzle machine, the plug formed was always denser than the maximum bulk density, whereas on the tamp filling machine for smallest granule size the maximum plug density could not be achieved with the settings employed. The results suggest that in situations where a low plug density is an essential prerequisite for drug dissolution and bioavailability the tamp filling machine appears the more suitable filling principle. However, if a greater extent of compression is required in order to fill large dose drugs or to use a smaller capsule size, the dosator nozzle principle might work more successfully for granules.

Simply imagining sunshine, lollipops and rainbows will not budge the bias: The role of ambiguity in interpretive bias modification

Imagery-based interpretive bias modification (CBM-I) involves repeatedly imagining scenarios that are initially ambiguous before being resolved as either positive or negative in the last word/s. While the presence of such ambiguity is assumed to be important to achieve change in selective interpretation, it is also possible that the act of repeatedly imagining positive or negative events could produce such change in the absence of ambiguity. The present study sought to examine whether the ambiguity in imagery-based CBM-I is necessary to elicit change in interpretive bias, or, if the emotional content of the imagined scenarios is sufficient to produce such change. An imagery-based CBM-I task was delivered to participants in one of four conditions, where the valence of imagined scenarios were either positive or negative, and the ambiguity of the scenario was either present (until the last word/s) or the ambiguity was absent (emotional valence was evident from the start). Results indicate that only those who received scenarios in which the ambiguity was present acquired an interpretive bias consistent with the emotional valence of the scenarios, suggesting that the act of imagining positive or negative events will only influence patterns of interpretation when the emotional ambiguity is a consistent feature.

Optimizing the ingredients for imagery-based interpretation bias modification for depressed mood: Is self-generation more effective than imagination alone?

Negative interpretation is thought to be crucial in the development and maintenance of depression. Recently developed cognitive bias modification paradigms, intending to change these biases towards a more optimistic interpretation tendency (CBM-I), seem to offer new promising implications for cognitive therapy innovation. This study aimed to increase our knowledge of the underlying mechanisms of action of imagery-based CBM-I in the context of depressed mood. We therefore compared the efficacy of CBM-I requiring participants to imagine standardized positive resolutions to a novel, more active training version that required participants to generate the positive interpretations themselves. Fifty-four participants were randomly allocated to (1) standardized CBM-I, (2) self-generation CBM-I or (3) a control group. Outcome measures included self-report mood measures and a depression-related interpretation bias measure. Both positive training variants significantly increased the tendency to interpret fresh ambiguous material in an optimistic manner. However, only the standardized imagery CBM-I paradigm positively influenced mood.