You are giving a presentation to a group of people. You look at the audience. Do you notice the ones who are yawning or do you look for those who are smiling? Do the yawns mean that your presentation is boring or are they just tired? People with social anxiety are more likely to notice yawns (“unhelpful attention patterns”); they are also more likely to assume that those yawns means their presentation is boring (“unhelpful interpretation patterns”).

Social anxiety is defined as “a persistent fear of negative evaluation from others in social or performance situations, with associated avoidance of these anxiety-provoking social contexts”. It is one of the most common mental health problems and because social interactions are such an integral part of human life, social anxiety can interfere with daily life.

A large number of cases of social anxiety start in youth. As untreated social anxiety contributes to the development of other serious mental health problems such as depression, suicide and substance abuse, intervening as they emerge is crucial. Delivering interventions during youth can also capitalise on any naturally-occurring inclination to learn and be receptive to new skills in this age range.

Modifying these unhelpful attention and interpretation patterns and encouraging more resilient patterns through computerised training programmes could be a viable intervention strategy. Especially as they could be implemented through technology (e.g. digital apps), so they could be more easily accessible. Indeed, early data from adults show some promise. However, as young people may vary in how they respond to these training tasks to adults, it is important to measure their effectiveness in young people through independent studies.

In their 2020 review, Biagianti and colleagues synthesised findings across these so-called “Cognitive Bias Modification (CBM)” training studies that aimed to modify unhelpful attention patterns, unhelpful interpretation patterns, and those that targeted both within young people with social anxiety. The authors were interested in quantifying where possible, the degree of change in attention or interpretation patterns and in social anxiety symptoms.

Methods

The authors searched the scientific literature for articles that used “Cognitive bias modification” training to modify unhelpful attention and/or interpretation patterns, within young people with social anxiety. They were specifically interested in studies where the samples had a mean age between 12 to 18 years.

They only included studies published in English peer-reviewed journals that used human participants. As long as they reported numeric data on cognitive patterns and/or social anxiety symptoms, studies using a variety of study designs were included. Therefore, both Randomised Controlled Trials (RCTs) (where there was a comparison condition) as well as “single-arm” case series (i.e. where all participants received CBM) were included.

The authors followed published guidelines for the reporting of studies for systematic reviews and meta-analyses.

Results

The systematic search identified 142 articles that included the relevant keywords. After assessing these articles against a list of eligibility criteria, only 9 articles were included in this review.

Unhelpful interpretation patterns

Three articles modified unhelpful interpretation patterns, by presenting participants with hypothetical written scenarios that were ambiguous in their outcomes. By completing a word at the end of the scenario, participants were forced to adopt a positive or benign explanation or outcome of the scenario. This was further reinforced by the correct completion of a comprehension question.

1. The first of these studies only delivered a single session of training and reported only small changes in the selection of negative interpretations in the intervention group; there were also no improvements in negative mood that were unique to the intervention group.
2. The second of these studies compared 8 sessions of interpretation training that were delivered to 6 young people, to 6 parents about negative parenting practices or to 6 pairs of both parents and children. All three groups showed similarly large changes on interpretation measures, in the expected direction, but these were found when parents were asked about their children’s interpretations (child self-report measures did not show these same changes). There were also similarly large reductions in social anxiety across all three groups.
3. Finally, one study delivered 5 sessions of computerised training to socially-anxious young people with mild intellectual disability. This study reported both changes in interpretation patterns (in the expected direction) and improvements in social anxiety, which persisted to a 10-week follow-up.

Unhelpful attention patterns

Three studies modified unhelpful attention patterns. These studies used a training task that simultaneously presented two faces (one with a negative and one with a neutral expression), which were then replaced by a probe that the participant had to respond. The probe mostly appeared in the location of the more neutral face to encourage attention patterns away from negative to neutral information. None of the three studies showed any clear effect of the attention training sessions on attention patterns or on social anxiety symptoms, independently and/or compared to the control training.

Unhelpful attention AND interpretation patterns

Finally, three studies targeted both unhelpful attention and interpretation patterns in the same intervention program.

1. The first of these involved a large sample of young people and compared 20 sessions of CBM training to a school-based group cognitive behavioural therapy (CBT) package and to young people who received nothing. There was some suggestion that CBM training did change unhelpful interpretation patterns, but there was no clear advantage in symptom reduction relative to the two comparison conditions either at 6 or 12 months.
2. In a two-year follow-up of these same participants, a second study reported large reductions in social anxiety in the CBM training and group-based CBT conditions. There were also changes in unhelpful interpretation patterns unique to the CBM training condition, but these were only found when using a measure of interpretation pattern that was similar in its presentation to the training task. When a slightly different measure of interpretations was used, these training effects unique to the CBM training condition were less apparent.
3. The third study to jointly target these cognitive patterns recruited 19 young people all receiving computerised training. This study reported significant changes in both interpretation measures and social anxiety symptoms; moreover, these changes correlated, such that those who showed the greatest change on the interpretation measure also showed the greatest change on the other social anxiety measure.

Conclusions

The authors noted that CBM training, particularly those focusing on challenging unhelpful interpretation patterns had a “possible efficacy signal”; what this suggests is that with further investigation, training tasks targeting unhelpful interpretations could potentially reduce symptoms of social anxiety. They note that the current training interface may not make the most out of what motivates and makes young people learn best. Recommendations include applying training within real-world social situations to give young people an opportunity to embed their learning within daily life.

The authors also noted that more research was needed to investigate whether jointly targeting unhelpful attention and interpretation patterns would be more beneficial than programs targeting only one of these cognitive factors. In a similar way, while CBM uses simple training techniques to change more basic patterns or cognitive ‘habits’, perhaps these could be delivered with techniques that use more effortful, “goal-directed” strategies to regulate emotions. Examples of these strategies include consciously bringing to mind alternative interpretations of the same situations and weighing these up. Another example is consciously learning to shift your attention focus away from distracting thoughts to other more neutral thoughts or natural sensations. These strategies are thought to enhance our “cognitive control”; to better manage our emotions (including fear), but also our impulses and behaviour.

In conclusion, the authors list possible advantages of computerised CBM methods, including their potential to be delivered remotely and to reach more young people. However, they caution against delivering these interventions in their current form.

Strengths and limitations

A strength was the focus on studies measuring social anxiety, but as anxiety disorders are highly overlapping in youth, this also means missing out on studies that used CBM training in anxious (or depressed) young people who also had social concerns.

Although the studies used strict inclusion and exclusion criteria to identify relevant studies for this review, they did not rate studies for their methodological quality. Some of the studies involved small sample sizes with differences between participants in their treatment history, which could affect whether an overall training effect was found.

Implications for practice

There is potential in using computerised training to augment existing psychological interventions for social anxiety in young people. However, more research is needed to discover optimal training methods and materials.

Promoting helpful attention and interpretation patterns to improve well-being in young people – my #ActiveIngredientsMH project

Building on findings from this report (Biagianti et al, 2020), we have recently been commissioned by the Wellcome Trust to explore whether promoting helpful attention and interpretation patterns is an “active ingredient” of early interventions for youth anxiety and depression. We extended this report in several ways. We decided to include studies of a) all anxiety subtypes and depression to inform whether these cognitive factors contribute similarly to symptom reduction across symptom clusters, and b) where the mean age of participants fell between 14 and 24 years, as unhelpful attention and interpretation patterns are more reliably linked with anxiety and depression across this period, and could be better intervention targets of emotional symptoms. As well as conducting a systematic search of the scientific literature, we also spoke to young people with experiences of anxiety and depression to solicit their views on any strategies they found especially useful in challenging negative thought patterns.

Our search revealed a number of studies using CBM techniques to modify attention and interpretation, as did the earlier review (Biagianti et al, 2020). The data so far suggest that training can change the way that young people attend to positive over negative information, and their consideration of positive endings over negative ones. However, their effects on anxiety and depression symptoms are not always strong or immediate. To increase their therapeutic benefits, more research needs to be done to develop training exercises that are more engaging and relevant to young people. This should be achieved through co-design with young people.

However, our search also showed that beyond CBM training, there are other techniques that can be used to encourage more helpful ways of attending to and interpreting information – some of these borrowed from therapeutic techniques used in other larger treatment protocols. These techniques are designed to increase young people’s capacity to control their own attention (choosing when and where to focus attention) and to consider and evaluate other perspectives to a stressful situation. Our research shows that these techniques are effective at reducing anxiety and depression, but more work needs to be done to establish why they work. Pinpointing the reasons for why they work can help to develop brief interventions that may be easier and cheaper to administer.

The young people who we consulted all agreed that adopting alternative perspectives, such as those used in challenging unhelpful interpretation patterns was useful in daily life. However, a few also noted obstacles in current interventions, underscoring a need to help young people discover better methods for learning and implementing helpful cognitive patterns. Some suggested that deliberately recalling positive past experiences or remembering positive features about themselves could be helpful in countering negative thinking.

In summary, young people suggested that it would be empowering to have a toolbox of evidence-based strategies that they could learn and apply in daily life. Such a toolbox, could be amenable to delivery in schools or through technology, thereby improving access to help.

Statement of interests

This work was funded by a Wellcome Trust Mental Health Priority Area ‘Active Ingredients’ commission awarded to Jennifer Lau at King’s College London.

Links

Primary paper

Biagianti B, Conelea C, Brambilla P, Bernstein G. (2020) A systematic review of treatments targeting cognitive biases in socially anxious adolescents: Special Section on “Translational and Neuroscience Studies in Affective Disorders” Section Editor, Maria Nobile MD, PhD. J Affect Disord. 2020;264:543-551. doi:10.1016/j.jad.2019.12.002