Search

The aim of the current study is to examine whether resonance frequency breathing (RFB) enhances the efficacy of Cognitive Bias Modification for interpretations (CBM-I). RFB is a widely used self-paced breathing paradigm that seeks to enhance cardiorespiratory control and in turn promote optimal physiological/emotion regulation (e.g., increased heart rate variability, decreased anxiety; Lehrer et al., 2020) and executive function (e.g., attentional control; Laborde et al., 2021). During RFB, individuals maintain a steady breathing rate at 6 breaths per minute (BPM) with the aid of a pacing stimulus (e.g., a computerised visual or auditory cue). CBM-I is an intervention designed to modify interpretation bias (IB; refers to the tendency to perceive ambiguous information in a threatening or negative manner). Specifically, CBM-I aims to modify IB by training individuals to generate consistently positive interpretations of emotional ambiguity (Mathews & Mackintosh, 2000). The success of CBM-I in effectively reducing maladaptive biases and emotional symptoms is well established (Hirsch et al., 2020, 2021), holding promise as a therapeutic target in psychiatric settings (Beard et al., 2019; Weisberg et al., 2022; Butler et al., 2015; Stevens et al., 2018) as well as for scalable online interventions (Yang et al., 2017; Nieto et al., 2021; Hirsch et al., 2021). An important next step in IB research is to examine the factors that influence, and enhance, CBM-I efficacy (Sakaki et al., 2020). One potential way of augmenting CBM-I efficacy is by incorporating RFB within IB training. Recent research shows that RFB is amenable to online delivery without the requirement of biofeedback (Laborde et al., 2021). An adapted version of CBM-I is investigated in the present online study, one which blends interpretation bias training with short doses of RFB. The aim of the current online study is to investigate whether RFB adapted CBM-I results in greater change to positive IB as compared to standard (positive) CBM-I training. Training efficacy is assessed by the magnitude of IB change pre- to post- training. The current online study is hosted within the Inquisit environment. Initially, participants will be presented with a study information page followed by a consent page. Subject to consent, participants will then complete the Penn-State Worry Questionnaire (PSWQ) and a demographical questionnaire. Participants will then complete a pre-assessment of IB, namely the Recognition task. Participants will be randomly assigned to one of two training conditions, namely RFB adapted CBM-I or standard CBM-I. In the RFB adapted CBM-I condition, after IB pre-assessment, participants rate self-perceived stress via a visual analogue scale (VAS), which is then followed by the RFB task (for a duration of five minutes). After RFB is complete, the stress VAS will be re-administered in order to assess the impact of RFB upon self-perceived stress, along with an additional VAS assessing self-perceived engagement with the RFB. Participants will then begin CBM-I training. Four two-minute periods of RFB are inserted within the CBM-I training (described in further detail below). After CBM-I training is complete, participants repeat the Recognition task (adopting different scenario materials to those used at pre-assessment) to provide a post-CBM-I measure of IB. The above procedure is identical in the standard CBM-I condition with the exception that no RFB (and therefore accompanying VAS), is administered at any stage during the experiment. In place of the four two-minute periods of RFB, participants are simply instructed to remain undistracted until training resumes. IB assessment: the recognition task. In the first half of this task, participants read 10 individually presented ambiguous scenarios, each presented with a descriptive title (e.g., ‘the evening stroll’). Participants complete a word-fragment of the final word for each scenario, followed by answering a yes/no comprehension question. In the second half of the task (recognition phase), the descriptive titles are presented only, followed by four disambiguating interpretative statements that relate to the original scenario. Participants must rate the degree of similarity between the interpretative statement and original scenario via a 4-point Likert scale. Two of the statements are classed as positive and negative ‘targets’, ratings of which provide independent indices of a positive or negative IB, respectively. The remaining two statements are positive and negative ‘foils’ and are not semantically related to the ambiguity context. Stress VAS: Participants are prompted with the question on the screen: ‘How stressed do you feel right now? (Click on the line)’. The line is anchored by the words ‘not at all stressed’ at the extreme left of the line and ‘extremely stressed’ at the extreme right of the line, with a response range of 0 – 100; responses are not revealed to participants. Engagement VAS: Participants are prompted with the question on the screen: ‘What percentage of the time did you successfully match your breathing with the pacer? (Click on the line)’. The line is anchored by the value ‘0 %’ at the extreme left of the line and ‘100%’ at the extreme right of the line. RFB: Participants are required to match their respiration rate to the speed of a visual cue located at the centre of the screen. The visual cue consists of a blue bar rising (prompting inhalation) and a green bar lowering (prompting exhalation). Specifically, participants are instructed to inhale through the nose and exhale through the mouth. RFB consists of an inhale-to-exhale ratio of 4.5-5.5 seconds. The animated pacer is presented on the initial instructional pages to aid familiarisation, after which participants self-initiate the main RFB task. RFB occurs for a period of five minutes prior to CBM-I in the RFB adapted CBM-I condition, and again for a duration of two minutes at four separate instances during CBM-I training. CBM-I: Participants will be allocated to one of two conditions namely, RFB adapted CBM-I or standard CBM-I. In both CBM-I conditions, participants hear a series of aurally presented ambiguous scenarios that are resolved in an emotionally positive manner the majority of the time. After participants have listened to the scenario, they are presented with a yes/no comprehension question on the screen that aims to further reinforce a positive interpretational response to ambiguity. They are then given feedback in the form of ‘correct’ or ‘incorrect’ (in tandem with a brief reinforcing auditory cue), with correct feedback being delivered when they endorse the positive statement. Thus, participants learn to systematically endorse positive interpretations of scenarios. Scenarios consist of 38 positively resolved scenarios, 6 negative scenarios and 6 catch trials presented in a randomized order (content of which is the same in both CBM-I conditions). Whilst the inclusion of negative trials serves to reduce the predictability and response bias of participants (inclusion of which has shown not to influence the efficacy of training), catch trials do not contain any particular reinforcement contingency (i.e., feedback), as such catch trials permit the assessment of participants’ spontaneously generated interpretations as an index of training efficacy. In RFB adapted CBM-I, participants are provided with two-minute doses of RFB after having completed every ten positively resolved scenarios. Thus, RFB is provided at four time points during training. In standard CBM-I, RFB doses are substituted by an instructional screen prompting participants to sit quietly and undistracted until a visually presented countdown cue reaches completion (equalling the two-minute durations of RFB), upon which training resumes.

Cognitive bias modification procedures have been designed to test the theoretical claim that selective information processing plays a causal role in the development and maintenance of emotional psychopathology (Koster et al., 2009). Hirsch and Mathews (2012) propose interpretation bias (IB) as a key maintaining factor of pathological worry, whereby individuals with high levels of worry tend to make relatively threatening interpretations which are thought to engender further worry. A number of different measures have been developed to assess IB, as well as adapted to train a more positive IB. Yet, few studies have looked at the reliability and validity of the measures used. This project therefore proposes to build on existing IB methodologies, specifically in relation to worry. We aim to develop material for an IB task to be used for assessment and training purposes. The objective of the study is to validate a measure of IB by looking at the resolutions that people have made to a list of ambiguous statements. It is hypothesised that the more positive resolutions generated, the lower the reported anxiety. References Hirsch, C. R., & Mathews, A. (2012). A cognitive model of pathological worry. Behaviour Research and Therapy, 50(10), 636-646. Koster, E. H., Fox, E., & MacLeod, C. (2009). Introduction to the special section on cognitive bias modification in emotional disorders. Journal of abnormal psychology, 118(1), 1.

The aim of the current study is to examine the relationship between executive function (EF) and responsiveness to Cognitive Bias Modification for Interpretations (CBM-I). EF refers to cognitive abilities such as working memory and attention (Chan et al., 2008), whilst interpretation bias (IB) refers to the tendency to interpret ambiguous information in a consistently negative manner, such as interpreting a stranger's smile as derisive rather than friendly (Grey & Mathews, 2000). Research suggests that interpretation bias plays a crucial role in the maintenance of pathological worry (Hirsch & Mathews, 2012; Hirsch et al., 2016). In addition, pathological worriers may lack a positive interpretational bias found in low worriers (Feng et al., 2019). CBM-I is an intervention aimed at correcting maladaptive biases and associated symptoms, training individuals to generate consistently positive interpretations of emotional ambiguity (Hirsch et al., 2016). Whilst studies show that single session training alone produces a marked degree of success, less is known about the factors underlying CBM-I efficacy. Furthermore, whilst CBM-I and EF remediation have been typically examined as separate targets/strategies for reducing worry or alleviating mood/emotional disorder symptoms (Gold et al., 2016), little research has assessed the direct relationship between CBM-I and EF in the adult population (Pergamin-Hight et al., 2016; Grol et al., 2018); a better understanding of which may permit future research to explore EF as a potential target for enhancing CBM-I efficacy. Thus, the present study aims to examine the extent to which EF moderates the efficacy of CBM-I. Participants will take part in an online implemented experiment powered by Inquisit version 5 (https://www.millisecond.com). Direct email will be used to recruit participants who volunteered to be on our pre-existing worry database, having completed the Penn State Worry Questionnaire (PSWQ) previously. We will initially recruit only high worriers (those scoring >= 62 on the PSWQ). A study information page, along with a consent form, will provide a brief description of the experiment, but crucially there will be no explicit mention of any training procedure (e.g. CBM-I) or interpretation bias to avoid alerting participants to the goals of the study. Subject to consent, participants will complete the PSWQ to confirm worry levels at the time of participation, and will then proceed to complete a series of tasks, detailed below. The first is a task assessing executive function, the N-back task. This will be followed by a pre-training interpretation bias measure, the Recognition task, after which the interpretation bias training task takes place. Finally, a post-training assessment of interpretation bias will be completed, again using the recognition task. Executive Function Measure, the N-back task: Participants must indicate with a key press as quickly and as accurately as possible when the currently presented stimulus is identical to the stimulus presented N trials previously, typically zero-back, one-back, two-back and three-back (during the zero-back block, participants must decide whether the currently presented stimulus is identical to that shown on the very first target trial). Participants are provided with an instructional reminder before the start of a given N-back block. 20 different consonants are used as stimuli (Ragland et al., 2002), and the task consists of 3 blocks of 15 trials for each N-back ‘level’ (12 blocks in all) presented in pseudo-random order. Of the 15 trials in each block, 5 present a target (the current stimulus matches the N-trials back) and 10 do not, appearing in a randomised order. IB assessment: the recognition task. In the first half of this task, participants read 10 individually presented ambiguous scenarios, each presented with a descriptive title (e.g. ‘the evening stroll’). Participants complete a word-fragment of the final word for each scenario, followed by answering a yes/no comprehension question. In the second half of the task (recognition phase), the descriptive titles are presented only, followed by four disambiguating interpretative statements that relate to the original scenario. Participants must rate the degree of similarity between the interpretative statement and original scenario via a 4-point Likert scale. Two of the statements are classed as positive and negative ‘targets’, ratings of which provide independent indices of a positive or negative IB, respectively. The remaining two statements are positive and negative ‘foils’, and are not semantically related to the ambiguity context. CBM-I: Participants will be allocated to one of two conditions namely, positive training or control training. In the positive training condition, participants will be (aurally) presented with a series of ambiguous scenarios that are resolved in a positive manner. After participants have listened to the scenario, they are presented with a yes/no comprehension question on screen that aims to further reinforce a positive interpretational response to ambiguity. They are then given feedback in the form of ‘correct’ or ‘incorrect’, with correct being delivered when they endorse the positive statement. Thus, participants learn to endorse positive interpretations of scenarios. In the control training condition, participants are presented with a series of ambiguous scenarios that remain neutral. In this condition, yes/no comprehension questions relate to factual aspects and therefore do not aim to reinforce any particular interpretative response. Participants receive 50 scenarios in each condition. The positive training condition presents 38 positively resolved scenarios, 6 negative scenarios and 6 catch trials. No feedback is provided on catch trials. After each of the tasks are complete participants will be asked if they consent to our looking up their Phenomenological Control (PC) Score in our participant database. Analysis will examine whether the extent of any change in IB from before to after CBM-I is related to participants EF score from the N-back task. In addition, for participants providing consent for us to look up their PC, we will examine whether the same change in IB from before to after CBM-I relates to their PC score (independently of EF).

Excessive and distressing worry is a key feature of Generalized Anxiety Disorder. Hirsch and Mathews (2012) in their cognitive model of worry highlight the role of impaired attentional control in the development and maintenance of pathological worry. There is evidence that worry impairs or depletes the resources of attentional control making it difficult to disengage from worry once started. In order to systematically examine the relationship between attentional control and worry we will examine trait attentional control in high and low worriers before and after a worry induction. We will then complete a stop-worry task as a behavioural measure of worry.

An important, yet under-explored area of interpretation bias research concerns the examination of potential physiological markers of this bias. Developing a better understanding of the physiological processes that underpin interpretation biases will extend current theoretical frameworks underlying interpretation bias, as well as optimising the efficacy of cognitive bias modification for interpretation (CBM-I) interventions aimed at improving symptoms of emotional disorders. To this end, systematic searches will be conducted across the Web of Science, PsycInfo and Pubmed databases to identify physiological markers of interpretation bias. In addition, grey literature database searches will be conducted to compliment peer-reviewed research and to counter publication bias. Eligible studies will be assessed using a quality assessment tool adapted from the Quality Checklist for Healthcare Intervention Studies. The respective theoretical and practical implications of the research will be discussed, followed by recommendations for future research.

Resonance frequency breathing (RFB) is a widely used self-paced breathing paradigm that seeks to enhance cardiorespiratory control (Lehrer & Gevirtz 2014) and in turn promote optimal physiological and emotional regulation (Lehrer et al., 2020). During RFB, individuals maintain a steady breathing rate at 6 breaths per minute (BPM) with the aid of a pacing stimulus (e.g., a computerised visual or auditory cue). Specifically, RFB works by increasing the pattern of synchronicity between heart rate and respiration. Previous studies indicate that biofeedback based RFB, for example, feedback on heart rate variability (HRV) which has been shown to increase with RFB, is associated with improved performance on tasks assessing executive function (EF), such as working memory and attention (for a systematic review, see Tinello et al., 2021). Whilst more recent research suggests a positive correlation between this type of intervention and EF performance, less is known about the extent to which online delivered RFB improves EF (Laborde et al., 2021, 2022; Bonomini et al., 2020; Chaitanya et al., 2022). Such research is necessary to establish the versatility and (far) transfer effects of RFB beyond the laboratory setting. If robust significant effects are observed, this would support the development of accessible and scalable online interventions aimed at emotionally vulnerable individuals (e.g., high worriers). Whilst impaired EF has long been associated with the maintenance of clinical anxiety and pathological worry (Eysenck et al., 2011; Fox et al., 2015), the efficacy of traditional cognitive training concerning negative emotional symptoms remains disputed (Keshavan et al., 2014). In a recent study, Hotton, Derakshan & Fox (2018) found that both active N-back training (reaching up to four N-back levels) and active N-back control training (remaining at the level of one-back only) provide equal improvement in working memory capacity and worry, although training-related improvements during active N-back training was positively associated with working memory enhancement and worry reduction. Such findings illustrate that there is a need for research to identify factors that augment existing EF remedial approaches (e.g., methods for optimising far-transference effects, individual differences etc), that in turn provide a stronger clinical impact for reducing anxiety and worry. If successful then, online RFB may provide a promising target for EF enhancement and as suggested by the previous literature provide an effective strategy for emotional regulation (Lehrer et al., 2020). The current study brings this objective into focus by examining the relationship between acute online implemented RFB and EF, assessed by the N-back task. The single N-back task is selected as the key outcome measure of EF, based on the previous literature utilizing this task in worry-based samples, in addition to recommendations for implementing single N-back as a simpler training paradigm, given that single- and dual- N-back versions provide equal training effects (Jaeggi et al., 2010). In accordance with neurovisceral integration theory (Thayer et al., 2009) and the resonance breathing model (Lehrer & Gevirtz, 2013), the current study predicts that EF performance is greater following RFB (6BPM) as compared to an active control breathing condition (12BPM) (the latter is considered within the range of normalised breathing; Tsai et al., 2015). The current online study is hosted within the Inquisit environment; initially participants will be presented with a study information page followed by a consent page. Subject to consent, participants will then complete the Penn-State Worry Questionnaire (PSWQ), a demographical questionnaire followed by self-assessment of baseline anxiety and relaxation levels, as measured by visual analogue scales (VAS). Participants will then receive a five-minute N-back practice block to aid with EF task familiarisation provided later on. During the N-back task, participants are required to respond (via keypress) when the stimulus on the current trial matches the stimulus N trials previously, typically one, two or three trials before. Once practice is complete, participants will be randomly assigned to a 5-minute self-paced breathing session, either the RFB or active control breathing condition (allocation is counter-balanced across participants). During self-paced breathing, participants are instructed to match their breathing rate to the speed of a visual cue on the screen (see below for further details). The visual cue consists of a blue bar rising (prompting inhalation) and a green bar lowering (prompting exhalation) (based on the EZ-Air software; Thought Technology Ltd., Montreal, Canada). Previous research suggests that 6BPM is an optimal breathing pace for evoking cardiac resonance (Laborde et al., 2021), whilst 12BPM is thought to be closer to our normative (although highly variable) breathing rate (Tsai et al., 2015). Once the self-paced breathing session is complete, participants rate their anxiety and relaxation levels, as well as their confidence in maintaining the required breathing pace throughout the block (included as a manipulation check). Finally, the main N-back task is immediately presented in order to minimize potential wash-out effects. The current study adopts a within-subject design; participants will therefore repeat the same procedure a second time starting from the breathing block. The breathing pacer will be for the alternate breathing condition from that seen in the first block; VAS ratings and the N-back will be unchanged. Overall, the study lasts approximately one hour. Executive Function Measure, the N-back task: Participants must indicate with a key press as quickly and as accurately as possible when the currently presented stimulus is identical to the stimulus presented N trials previously, typically zero-back, one-back, two-back and three-back (during the zero-back block, participants must decide whether the currently presented stimulus is identical to that shown on the very first target trial). Participants are provided with an instructional reminder before the start of a given N-back block. 20 different consonants are used as stimuli (Ragland et al., 2002), and the task consists of 3 blocks of 15 trials for each N-back ‘level’ (12 blocks in all) presented in pseudo-random order. Of the 15 trials in each block, 5 present a target (the current stimulus matches the N-trials back) and 10 present a nontarget (the current stimulus does not match the N-trials back), appearing in a randomised order. ‘Hits’ refer to those trials where participants have correctly identified the current stimulus as matching N trials previously, whereas ‘false alarms’ refer to those trials where participants have incorrectly identified the current stimulus as matching N trials previously. Self-paced breathing: As specified above, the self-paced breathing paradigm consists of two separate sessions, namely RFB (6BPM) and active control breathing (12BPM) conditions. During the session, participants are instructed to match their respiration rate to the speed of a visual cue located at the centre of the screen. The visual cue consists of a blue bar rising (prompting inhalation) and a green bar lowering (prompting exhalation). Participants are instructed to inhale through the nose and exhale through the mouth with pursed lips. RFB consists of an inhale-to-exhale ratio of 4.5-5.5 seconds whereas the 12 BPM condition consists of a ratio of 2.2-2.8 seconds, respectively. The self-paced breathing block lasts 5-minutes without any break (Laborde and colleagues (2022) implemented 5-minute RFB in conditions with and without HRV biofeedback). The animated pacer is presented on the instructional pages to aid familiarisation, and once participants have understood the instructions, they can begin the main session. Visual analogue scales (VAS): the VAS provides a measure of self-reported anxiety, relaxation and breathing efficacy. For the anxiety scale, participants are prompted with the question on the screen: ‘How anxious do you feel? (Click on the line)’ . The line is anchored by the words ‘not at all anxious’ at the extreme left of the line and ‘extremely anxious’ at the extreme right of the line, with a response range of 0 – 100; responses are not revealed to participants. This same scale is applied to the relaxation domain: ‘How relaxed do you feel? (Click on the line)’. The line is anchored by the words ‘not at all relaxed’ at the extreme left of the line and ‘extremely relaxed’ at the extreme right of the line. Finally, a third VAS serves as a manipulation check of self-paced breathing: ‘What percentage of the time did you successfully match your breathing with the pacer? (Click on the line)’. The line is anchored by the value ‘0 %’ at the extreme left of the line and ‘100%’ at the extreme right of the line. Previous research adopt VAS in RFB interventions (Laborde et al., 2021, 2022; Lin et al., 2014).