Interpretation training in individuals with generalized social anxiety disorder: a randomized controlled trial

Social Anxiety Disorder (SAD) is a common and disabling condition (e.g., Stein & Stein, 2008) with a lifetime prevalence of 12% (Kessler et al., 2005). Research supports the efficacy of a number of psychosocial (e.g., Hofmann & Smits, 2008) and pharmacological treatments for SAD (e.g., Stein & Stein, 2008). Despite their established efficacy, however, extant treatments leave room for improvement. For example, using conventional treatment strategies (i.e., cognitive behavioral or pharmacological regimens), only about 50% of patients diagnosed with SAD are classified as treatment responders (e.g., Heimberg et al., 1998; Davidson et al., 2004; see Stein & Stein, 2008 for a review). Moreover, many individuals diagnosed with SAD fail to access existing empirically supported treatments (Coles, Turk, Jindra, & Heimberg, 2004; Huppert, Franklin, Foa, & Davidson, 2003; Olfson et al., 2000). Considered together, these findings underscore the potential value of exploring novel treatment approaches that may augment existing interventions and/or increase accessibility to effective treatments for SAD. Cognitive Bias Modification (CBM) research represents one emerging area of translational clinical science that shows promise in the development of novel interventions for emotional disorders (see Beard, 2011; Koster, Fox, & MacLeod, 2009 for recent reviews). CBM involves the application of experimental procedures used in cognitive science to measure basic cognitive processes (e.g., attention, interpretation) to manipulate factors involved in the etiology and maintenance of emotional disorders (Mathews & MacLeod, 2005). Previous research supports the efficacy of CBM procedures in modifying selective information processing biases for emotionally salient stimuli (e.g., Grey & Mathews, 2000; MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002) and conferring differential emotional vulnerability under conditions of heightened stress (e.g., Amir, Beard, Weber, Bomyea, & Taylor, 2008). Although promising, the majority of previous studies have examined the effects of CBM procedures in non-clinical samples, on state measures of anxiety or depression (rather than symptoms), using brief (e.g., single-session) manipulations. Moreover, few studies have tested the clinical utility of CBM procedures in the remediation of clinical disorders and those that have done so, have been restricted to attentional manipulations (CBM-A; Amir, Beard, Burns, & Bomyea, 2009; Amir, Beard, Taylor et al., 2009; Schmidt, Richey, Buckner, & Timpano, 2009) or have combined attentional and interpretation manipulations (Beard, Weisberg, & Amir, in press; Brosan, Hoppitt, Shelfer, Sillence, & Mackintosh, 2011). Thus, our goal in the present study was to extend previous CBM research by testing the efficacy of a multi-session computerized procedure designed to modify interpretation bias alone in individuals meeting diagnostic criteria for generalized social anxiety disorder (GSAD). Interpretation bias towards threat refers to the tendency to construe ambiguous information in an overly threatening manner. Cognitive models of emotional disorders propose that interpretation bias may be particularly influential in individuals with SAD because social cues are often ambiguous and therefore open to a range of interpretations (Clark & Wells, 1995; Rapee & Heimberg, 1997). For example, during a social interaction a conversation partner’s laughter after a comment one makes may indicate ridicule (threat interpretation) or amusement (benign interpretation). In support of cognitive models, previous studies find that socially anxious individuals display greater endorsement of threat interpretations compared to non-anxious controls (e.g., Amir, Foa, & Coles, 1998; Stopa & Clark, 2000; Huppert, Foa, Furr, Filip, & Mathews, 2003). Moreover, negative interpretation bias has been found to mediate the relationship between social anxiety and state anxiety in response to social-evaluative threat (Beard & Amir, 2010). Research also suggests that socially anxious individuals lack the benign interpretation bias exhibited by non-anxious individuals (Constans, Penn, Ihen, & Hope, 1999; Hirsch & Mathews, 2000; Moser, Hajcak, Huppert, Foa, & Simons, 2008). Numerous studies support the efficacy of CBM procedures in modifying interpretation bias (CBM-I; see Beard, 2011 for a review). Although methodologies vary across studies, the basic premise underlying CBM-I procedures involves manipulating the frequency with which an ambiguous stimulus and a target stimulus that conveys one meaning of the ambiguous information are paired together. This manipulation is intended to encourage participants to think of the ambiguous information in either a negative or positive way. For example, in their seminal study, Grey and Mathews (2000) used homographs (i.e., words with multiple meanings, e.g., ‘mean’ can imply ‘average’ or ‘nasty’), to modify interpretations in non-anxious individuals. In one experiment, participants saw homographs followed by target words implying a threatening (‘nasty’) or benign (‘average’) meaning of the homograph (‘mean’). Participants decided whether or not the two words were related. When tested later with new homographs, participants in the threat condition were faster to respond to threat interpretations in a lexical decision task. Similarly, participants in the benign condition were faster to respond to benign interpretations. Subsequent extensions of this research in non-anxious (e.g., Mathews & Mackintosh, 2000; Wilson, MacLeod, Mathews, & Rutherford, 2006) and high anxious samples (e.g., Hayes, Hirsch, Krebs & Mathews, 2010) have demonstrated that experimentally manipulating interpretation of ambiguous information can causally influence anxiety and related outcomes (e.g., negative thought intrusions) in response to laboratory-induced stress (see, however, Salemink, E., van den Hout, M., & Kindt, 2007). More relevant to the current study, in a sample of individuals with elevated levels of social anxiety, participants who received a single-session benign interpretation induction procedure reported experiencing less anticipatory anxiety about a future social situation relative to the control group (Murphy, Hirsch, Mathews, Smith, & Clark, 2007). To our knowledge, four published studies have examined the effects of multi-session computerized interpretation training programs in reducing anxiety symptoms. First, in a sample of individuals with high levels of trait anxiety, Mathews, Ridgeway, Cook, and Yiend (2007) demonstrated that a four-session interpretation training procedure (administered over one week) that encouraged participants to resolve ambiguous scenarios in a positive manner resulted in significantly lower trait anxiety scores at post-assessment relative to a control group who did not receive the training procedure. Similarly, Salemink, van den Hout, and Kindt (2009) found that high trait anxious students who completed a positive interpretation training program online for eight consecutive days were less state and trait anxious, and scored lower on a measure of general psychopathology compared to the control group. However, no effects were observed on measures of social anxiety and stress vulnerability. Most relevant to the current study, Beard and Amir (2008) examined the effects of an eight-session interpretation training program in an analogue sample of 27 individuals with elevated levels of self-reported social anxiety. Using a modified word-sentence association paradigm (WSAP; Beard & Amir, 2009), participants in the two experimental conditions were differentially reinforced for rejecting threatening interpretations and endorsing benign interpretations of ambiguous social information. Results revealed that participants who were trained to repeatedly interpret ambiguous social information in a less threatening and more benign manner displayed a significant reduction in threat interpretations and increase in benign interpretations. Moreover, the actively trained group displayed a significantly larger reduction in social anxiety symptoms compared to the control condition. Change in benign interpretations mediated the relationship between interpretation training and change in social anxiety. The groups did not differ, however, on change in trait anxiety or depression. More recently, two studies have found that a combined regimen that included the interpretation procedure used by Beard and Amir (2008) and an attentional training procedure (Amir, Beard, Taylor et al., 2009; MacLeod et al., 2002) resulted in significant reductions in anxiety symptoms in individuals diagnosed with GSAD (Beard et al., in press) or either GSAD or GAD (Brosan et al., 2011). In summary, previous research supports the efficacy of CBM procedures in modifying interpretations of ambiguous information and reducing anxiety symptoms in analogue and clinical samples. However, previous CBM-I studies were conducted in small, analogue samples (Beard & Amir, 2008) or in combination with CBM-A procedures (Beard et al., in press; Brosan et al., 2011). Thus, the efficacy of interpretation training procedures alone in individuals presenting with greater severity of symptoms and functional interference remains to be established. Accordingly, the primary aim of the current study was to test the efficacy of a multi-session Interpretation Modification Program (IMP) in a sample of patients meeting diagnostic criteria for GSAD. We predicted that IMP would reduce threat interpretations, increase benign interpretations, as well as decrease social anxiety symptoms and associated functional impairment from pre- to post-assessment relative to the Interpretation Control Condition (ICC). We also explored the effects of IMP on symptoms of trait anxiety and depression.