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If meta-analysis is to provide valuable answers, then it is critical to ensure clarity about the questions being asked. Here, we distinguish two important questions concerning cognitive bias modification research that are not differentiated in the meta-analysis recently published by Cristea et al (2015) in this journal: (1) do the varying procedures that investigators have employed with the intention of modifying cognitive bias, on average, significantly impact emotional vulnerability?; and (2) does the process of successfully modifying cognitive bias, on average, significantly impact emotional vulnerability? We reanalyse the data from Cristea et al to address this latter question. Our new analyses demonstrate that successfully modifying cognitive bias does significantly alter emotional vulnerability. We revisit Cristea et al's conclusions in light of these findings.

People with social anxiety disorder tend to interpret ambiguous social information in a negative rather than positive manner. Such interpretation biases may cause and maintain anxiety symptoms. However, there is considerable variability in the observed effects across studies, with some not finding a relationship between interpretation biases and social anxiety. Poor psychometric properties of interpretation bias measures may explain such inconsistent findings. We evaluated the internal consistency, test–retest reliability, convergent validity, and concurrent validity of four interpretation bias measures, ranging from more implicit and automatic to more explicit and reflective: the probe scenario task, the recognition task, the scrambled sentences task, and the interpretation and judgmental bias questionnaire. Young adults ( N  = 94) completed interpretation bias measures in two sessions separated by one week. Psychometric properties were poor for the probe scenario and not acceptable for the recognition task. The reliability of the scrambled sentences task and the interpretation and judgmental bias questionnaire was good, and they correlated highly with social anxiety and each other, supporting their concurrent and convergent validity. However, there are methodological challenges that should be considered when measuring interpretation biases, even if psychometric indices suggest high measurement validity. We also discuss likely reasons for poor psychometric properties of some tasks and suggest potential solutions to improve the assessment of implicit and automatic biases in social anxiety in future research.

Interpreting ambiguous situations in a rigidly negative manner contributes to emotional disorders. Although negative interpretation biases have been well studied in relation to anxiety and depression, the relationship between interpretation flexibility (vs. rigidity) and emotional health remains understudied. The present study is a secondary analysis to test the hypothesis that higher interpretation flexibility is associated with better emotional health, as indicated by lower anxiety and depression levels, and higher quality of life. Here, interpretation flexibility focuses specifically on the ability to recognize multiple possible interpretations within and across ambiguous situations. Using baseline data from N = 939 high trait-anxious community participants who enrolled in an online anxiety intervention, multiple ways of computing interpretation flexibility were applied to help the field learn how different operationalizations can lead to varied conclusions about the connection between interpretation flexibility and emotional health. Using two measures of interpretation style, four approaches (some pre-registered, some exploratory) to computing interpretation flexibility were tested using an internal replication analytic approach. Results varied across type of approach, but in general, contrary to hypotheses, results indicated that higher interpretation flexibility was either unrelated to, or associated with higher, anxiety, and depression, and lower quality of life.

Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and reinforce anxiety. The repetitive and monotonous features of CBM-I can negatively impact training adherence and learning processes. This proof-of-concept study aimed to examine whether performing a CBM-I training using mobile virtual reality technology (virtual reality Cognitive Bias Modification of Interpretations [VR-CBM-I]) improves training experience and effectiveness. A total of 42 students high in trait anxiety completed 1 session of either VR-CBM-I or standard CBM-I training for performance anxiety. Participants' feelings of immersion and presence, emotional reactivity to a stressor, and changes in interpretation bias and state anxiety, were assessed. The VR-CBM-I resulted in greater feelings of presence (P<.001, d=1.47) and immersion (P<.001, η =0.74) in the training scenarios and outperformed the standard training in effects on state anxiety (P<.001, η =0.3) and emotional reactivity to a stressor (P=.03, η =0.12). Both training varieties successfully increased the endorsement of positive interpretations (P<.001, d [d ]=0.79) and decreased negative ones. (P<.001, d =0.72). In addition, changes in the emotional outcomes were correlated with greater feelings of immersion and presence. This study provided first evidence that (1) the putative working principles underlying CBM-I trainings can be translated into a virtual environment and (2) virtual reality holds promise as a tool to boost the effects of CMB-I training for highly anxious individuals while increasing users' experience with the training application.

Negatively biased interpretations play an important role in anxiety and depression, which are highly prevalent in adolescence, and changing such biases might thus reduce or prevent emotional disorders. We investigated the short- and long-term effects of an online interpretation bias modification training in unselected adolescents to explore its potential in preventing anxiety and depression. Participants (N = 173) were randomly allocated to eight online sessions of interpretation or placebo training. Interpretation bias was assessed pre- and post-training. Primary outcomes of anxiety and depression, and secondary measures of emotional resilience were assessed pre- and post-training and at three, six, and twelve months follow-up. Compared to placebo, interpretation training marginally increased positive interpretations. Irrespective of training condition, symptoms of anxiety and depression showed a decline post-training and at follow-up, and indices of resilience showed an increase. Change in interpretation bias, baseline interpretation bias, stressful life events, or number of training sessions completed did not moderate the effects on anxiety or depression. Results suggest that interpretation training as implemented in this study has no added value in reducing symptoms or enhancing resilience in unselected adolescents.

IntroductionPrevious research has shown that cognitive bias modification of interpretations (CBM-I) may be a promising intervention for anxiety in youth; however, results are mixed. Given the high comorbidity between anxiety and depression in youth, it is surprising that no child studies have targeted biases associated with both. This study aims to evaluate the effectiveness and acceptability of an online CBM-I intervention (Mindmaster) for children with symptom scores of anxiety or depression above a borderline or clinical threshold. The intervention has been codesigned with children, parents and mental health professionals to promote user engagement.Methods and analysisThe study is a randomised controlled trial, with two parallel arms. Participants are 143 children aged 8–10 years with scores of anxiety and/or depressive symptoms above a borderline or clinical threshold. They will be allocated to either the intervention group or the waitlist control group. The intervention consists of 2 weeks of online CBM-I training, with four sessions (10–15 min) per week. Outcome assessments will be conducted at baseline, 4 weeks after baseline (post-training/post-waitlist) and 8 weeks after baseline (follow-up) for the intervention group only. The primary outcome is interpretation bias. Secondary outcomes are anxiety and depressive symptoms and life interference. Analyses will be conducted within an intention-to-treat framework using mixed models for repeated measures.Ethics and disseminationThe study was approved by the University of New South Wales Human Research Ethics Committee (HC220758). Findings will be reported to (1) participating families; (2) presented at scientific conferences and (3) disseminated to peer-review publications. Data will be available from the corresponding author on request.Trial registration numberACTRN12622001493730.

Aims Cognitive models propose that negative cognitive biases in attention (AB) and interpretation (IB) contribute to the onset of depression. This is the first prospective study to test this hypothesis in a sample of youth with no mental disorder. Methods Participants were 61 youth aged 9–14 years with no mental disorder. At baseline (T1) we measured AB (passive-viewing task), IB (scrambled sentences task) and self-report depressive symptoms. Thirty months later (T2) we measured onset of mental disorder, depressive symptoms and life events (parent- and child-report). The sample included children of parents with (n = 31) and without (n = 30) parental depression. Results Symptoms of depression at T2 were predicted by IB (ß = .35, p = .01) but not AB (ß = .05, p = .72) at T1. This effect was strongest for children who experienced multiple negative life events (F2,48 = 6.0, p = .018, ΔR2 = .08). IB did not predict depressive symptoms at T2 over-and-above the effect of depressive symptoms at T1 (ß = .21, p = .13). Discussion These findings suggest that IB (but not AB) plays an important role in the aetiology of depression. Modifying IB may have a preventive effect on youth depression, particularly for youth who experience negative life events. This prospective study provides important foundations for future experimental studies.

Cognitive Bias Modification – Interpretation (CBM-I) aims to alter maladaptive interpretations in social anxiety, yet effects are often small and outcome measures are diverse. Although CBM-I has shown promise, its underlying mechanisms remain unclear and integration with psychophysiological and neural measures has been limited. In this randomized controlled trial, eighty-eight participants with high levels of social anxiety completed two lab sessions, an online training in between, and online follow-up. Participants filled out questionnaires, completed interpretation bias tasks, and underwent neuro-psychophysiological assessments. Active CBM-I trained positive resolutions of ambiguous social scenarios, while the sham version used neutral scenarios. The primary outcome, i.e., scores on the Liebowitz Social Anxiety Scale (LSAS), decreased across time in both groups, without group differences. However, the Brief Fear of Negative Evaluation decreased only in the active group. Interpretation bias shifted more strongly toward positive outcomes in the active group. Autonomic measures confirmed sensitivity to stress induction but did not differentiate between conditions. Electrophysiological results paralleled subjective ratings, as participants exhibited ambivalent responses to socially relevant stimuli but clearly differentiated responses toward neutral stimuli. Baseline correlations indicated strong convergence across self-report and interpretation tasks. Mediation analyses showed that reductions in negative interpretations mediated the effect of the training group on LSAS scores at follow-up. These findings identify interpretation bias as a modifiable mechanism underlying social anxiety and underscore its role as a transdiagnostic marker. Targeting interpretation bias through easily accessible and applicable online interventions may strengthen preventive and therapeutic approaches for social anxiety and related disorders.

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. 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). There was no additional benefit for the attentional bias training over the placebo training on sleep-related indices/outcome measures. 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.

While taxonomy segregates anxiety symptoms into diagnoses, patients typically present with multiple diagnoses; this poses major challenges, particularly for youth, where mixed presentation is particularly common. Anxiety comorbidity could reflect multivariate, cross-domain interactions insufficiently emphasized in current taxonomy. We utilize network analytic approaches that model these interactions by characterizing pediatric anxiety as involving distinct, inter-connected, symptom domains. Quantifying this network structure could inform views of pediatric anxiety that shape clinical practice and research. Participants were 4964 youths (ages 5-17 years) from seven international sites. Participants completed standard symptom inventory assessing severity along distinct domains that follow pediatric anxiety diagnostic categories. We first applied network analytic tools to quantify the anxiety domain network structure. We then examined whether variation in the network structure related to age (3-year longitudinal assessments) and sex, key moderators of pediatric anxiety expression. The anxiety network featured a highly inter-connected structure; all domains correlated positively but to varying degrees. Anxiety patients and healthy youth differed in severity but demonstrated a comparable network structure. We noted specific sex differences in the network structure; longitudinal data indicated additional structural changes during childhood. Generalized-anxiety and panic symptoms consistently emerged as central domains. Pediatric anxiety manifests along multiple, inter-connected symptom domains. By quantifying cross-domain associations and related moderation effects, the current study might shape views on the diagnosis, treatment, and study of pediatric anxiety.