The tendency to misinterpret ambiguous situations, termed interpretation bias, is proposed to maintain a range of emotional disorders (e.g., Mathews and MacLeod 2005
). Consistently, interpretation biases are considered to be transdiagnostic phenomena (Craske et al. 2009
; Harvey et al. 2004
; Mansell et al. 2008
), emerging from aberrant information processing (see Gladwin and Figner 2014
; Ouimet et al. 2009
; Strack and Deutsch 2004
) that is guided by underlying dysfunctional beliefs and current concerns. Such current concerns are linked to pursuing a goal (e.g., achieving attractiveness) and prompt the preferential processing of goal-relevant stimuli (e.g., others' reactions to one's appearance; Klinger and Cox 2011
). Over time, current concerns may thereby shape associative memory networks through learning processes (Anderson 1983
; Collins and Loftus 1975
; Foa et al. 2006
) and produce disorder-specific cognitive profiles—including interpretation biases—that elicit emotional states (e.g., Beck and Clark 1988
; Beck and Haigh 2014
To date, these disorder-specific cognitive profiles have mainly been investigated by contrasting self-reported cognitive content. A classic meta-analysis in this field yielded mixed results, demonstrating that anxiogenic and depressogenic cognitions were related to symptoms of both disorders, with only the latter showing a specific association with depression (Beck and Perkins 2001
). However, more recent research supported the assumption of cognitive profiles, indicating that some emotional disorders are linked to distinct underlying core beliefs (Cooper et al. 2006
; Dozois et al. 2008
; Schulz et al. 2008
Considering interpretation biases, prior studies have mainly focused on their assessment in single
disorders, e.g., depression (e.g., Hindash and Amir 2012
; Wisco and Nolen-Hoeksema 2010
), social anxiety disorder (SAD; e.g., BeVonard and Amir 2009
; Hirsch and Clark 2004
; Huppert et al. 2003
; Voncken et al. 2003
), generalized anxiety disorder (GAD; e.g., Hazlett-Stevens and Borkovec 2004
), and eating disorders (e.g., Rosser et al. 2010
). Conversely, few studies have systematically compared interpretation bias patterns (e.g., Buhlmann et al. 2002
; McManus et al. 2000
; Voncken et al. 2007
). Exemplarily, Buhlmann et al. (2002
) showed that individuals with body dysmorphic disorder (BDD) favored more threatening and less non-threatenineg interpretations for appearance-related (e.g., “While talking to some colleagues, you notice that some people take special notice of you.”) and social scenarios (e.g., “You are having a conversation with some friends. You say something and the conversation stops.”) than individuals with obsessive–compulsive disorder and mentally healthy controls. However, both clinical groups exhibited a negative interpretation bias for generally ambiguous scenarios (e.g., “A letter marked “URGENT” arrives.”), potentially reflecting an overarching vulnerability factor for psychopathology (Buhlmann et al. 2002
). Similarly, Voncken et al. (2007
) demonstrated that individuals with SAD (vs. individuals with depression and mentally healthy controls) displayed a distinct negative interpretation bias for social scenarios. Further, individuals with depression, compared to non-clinical controls, exhibited a more global negative bias encompassing various situation categories.
In sum, the studies cited above indicate that maladaptive, concern-specific interpretation biases characterize a range of emotional disorders. Nevertheless, prior research has mainly relied on restrictive self-report formats, such as forced-choice, which allow unlimited time for evaluation and may be prone to confounds (e.g., response selection bias and demand effects; Mathews and MacLeod 2005
). Further, such measures preclude a clear differentiation between tendencies to endorse negative and reject positive interpretations (i.e., pronounced negative bias and a lack of positive bias). However, these tendencies have been shown to represent two distinct, equally pertinent factors in bias phenomenology, being tied to different behavioral implications that warrant further investigation (Huppert et al. 2003
; Steinman et al. 2020
). Specifically, while negative interpretation bias has been linked to behavioral avoidance, a lack of positive bias has been suggested to dampen positive affect during behavioral approach (Amir et al. 2012
; Kuckertz and Amir 2017
Additionally, most cognitive theories posit that interpretation bias is characterized by a more implicit, reaction time-based (RT) component (Hirsch and Clark 2004
), requiring assessment via opaque, time-limited task designs (e.g., Schoth and Liossi 2017
). Within such implicit designs, RT is conceived to index the speed by which situational interpretations are accessible and activated within semantic memory (see de Houwer et al. 2009
). Hence, when resolving ambiguity, RT theoretically quantifies the associative strength between a situation and its valent interpretation. However, it has not been studied yet whether observed RT differences indeed emerge from relatively faster information uptake, or confounds, such as low response thresholds or general response slowing (Voss et al. 2015
). Overall, examining the aforementioned bias indices and dissecting their underlying cognitive components within associative memory organization appears critical to further characterize interpretation biases phenomenologically.
The Word Sentence Association Paradigm (WSAP; Beard and Amir 2009
) was designed to yield different explicit and implicit interpretation bias indices. In this task, participants are asked to judge as fast as possible if an ambiguous sentence and a positive or negative interpretation are related. Importantly, both decision rates (i.e., the explicit component) and congruent RT (i.e., the more implicit component) may be recorded. Using the WSAP, Beard and Amir (2009
) demonstrated that participants high (vs. low) in social anxiety exhibited a pronounced negative and a lack of positive interpretation bias. Further, individuals high (vs. low) in social anxiety also showed this bias implicitly, as they were slower in endorsing positive and rejecting negative, and faster in endorsing negative and rejecting positive interpretations. Since this study, interpretation biases have been investigated using the WSAP in various emotional disorders (see Gonsalves et al. 2019
, for a review). However, to our knowledge, the WSAP has never been used to compare interpretation biases across disorders and current concerns. Such comparative assessments are paramount to determining common and disorder-specific bias features that may be addressed within interventions, such as Cognitive Bias Modification for Interpretation (CBM-I; see Cristea et al. 2015
; Hallion and Ruscio 2011
; Jones and Sharpe 2017
; Menne-Lothmann et al. 2014
, for meta-analyses).
The present study investigated interpretation biases for different current concerns across three disorders: BDD, SAD, and GAD. The key characteristics of these disorders involve preoccupation about subjectively perceived bodily flaws in BDD, fear and avoidance of social situations in SAD, as well as anxiety and worry about various domains in GAD (American Psychiatric Association 2013
). BDD, SAD and GAD can be represented on a continuum of phenomenological proximity. In this respect, BDD and SAD can be considered phenomenologically proximal
. Both disorders are characterized by social anxiety and avoidance, similar onset and trajectories, and high mutual comorbidity (Fang and Hofmann 2010
; Pinto and Phillips 2005
). BDD and SAD might further relate on a cognitive level as they potentially share maladaptive social and appearance-related interpretation patterns, given their overlap in anxiety and appearance-related concerns during social situations (Fang and Hofmann 2010
). Indeed, cognitive-behavioral models of BDD and SAD propose that interpretation biases maintain symptoms (e.g., Hofmann 2007
; Wilhelm et al. 2013
). Relatedly, SAD-specific cognitive-behavioral interventions have been found to improve BDD symptoms (Fang et al. 2013
), suggesting common underlying factors (e.g., fear of negative evaluation or self-focused attention; Fang and Hofmann 2010
). Thus, investigating interpretation bias profiles in BDD and SAD would further elucidate their role in symptom maintenance, which remains unstudied at present.
GAD can be viewed as phenomenologically distal
to BDD and SAD. Despite some commonalities, such as trait anxiety, excessive worry, avoidance, and safety behaviors to reduce anxiety (American Psychiatric Association 2013
; Craske et al. 2009
; Turk et al. 2005
), GAD appears distinct on a cognitive level as it is associated with various current concerns (i.e., different worry domains, primarily concerning a potentially aimless future, relationships, work incompetence, and physical threat; Dugas et al. 1998
). The differences between GAD, BDD and SAD are further reflected in their low mutual comorbidity rates and diverging age of onset (e.g., Gunstad and Phillips 2003
). Moreover, cognitive-behavioral models of GAD identify intolerance of ambiguity as a catalyst for habitual negative interpretations and worry (see Hirsch et al. 2016
, for an overview). However, it remains unclear how individuals with GAD respond to concerns present in other disorders.
Addressing these questions, we explored interpretation bias patterns in individuals fulfilling self-report DSM-5 criteria for BDD, SAD, GAD, and non-clinical controls (NC). Using an adapted version of the WSAP (Hindash and Amir 2012
), we assessed decision rates and RT for positive and negative interpretations in three categories central to these disorders: appearance-related, social, and generally threatening situations. We used a multilevel approach (MLM) and Wiener diffusion models (Ratcliff and McKoon 2008
; Voss et al. 2013
) to determine cognitive parameters within RT. In reference to classic cognitive models, we explored the contributive value of decisional processes in implicit interpretation bias, which may be interpreted as indices of associative memory underlying interpretations (McKoon and Ratcliff 2012
; White et al. 2010
Consistent with prior evidence, we hypothesized that (1) clinical groups would overall exhibit maladaptive interpretation biases across situation categories, endorsing more negative and fewer positive interpretations than NC (transdiagnostic hypothesis). Within clinical groups, we predicted that (2) individuals with BDD would exhibit an appearance-related interpretation bias (vs. SAD and GAD) and a social interpretation bias (vs. GAD). Further, we expected that (3) SAD (vs. GAD) would show an appearance-related and social interpretation bias, and last, (4) individuals with GAD would show a general interpretation bias compared to NC only (current concern hypotheses). We further assumed that these disorder-specific patterns would be reflected in concurrent RT, i.e., faster endorsement and slower rejection of negative interpretations, and the reverse pattern for positive interpretations, as compared to NC.
This study investigated the phenomenology of interpretation bias across different clinical disorders (i.e., BDD, SAD, GAD, vs. NC) and current concerns. Using the SWAP paradigm, we examined explicit and more implicit, RT-based bias components for positive and negative interpretations. Further, we proposed a multilevel, diffusion model-based approach in analyzing SWAP-based RT bias indices to examine the relative contribution of underlying cognitive processes.
Explicit interpretation bias (i.e., based on decision rates) was present in BDD, SAD, and GAD, as consistent with the transdiagnostic hypothesis. However, bias patterns were shaped by content-specific differences between these groups, in line with the current concern hypothesis. As expected, both individuals with BDD and SAD, compared to GAD and NC, showed diminished positive appearance-related interpretation bias. However, BDD participants displayed a pronounced negative appearance-related interpretation bias, relative to all other groups. Similarly, both the BDD and SAD groups, vs. GAD and NC, exhibited reduced positive and enhanced negative social interpretation bias patterns. Only the BDD group endorsed fewer positive general interpretations than the GAD and NC group, while all clinical groups demonstrated a more pronounced negative general interpretation bias than NC. These results are largely in line with the findings of Buhlmann et al. (2002
), showing that BDD is associated with reduced positive and enhanced negative interpretation bias for appearance-related, social, and general situations. Importantly, the similarities of interpretation profiles further support the postulate that BDD and SAD are cognitively proximal (Fang and Hofmann 2010
; Fang and Wilhelm 2015
). Future research might aim to identify contributive factors driving these commonalities, such as fear of negative evaluation (Fang and Hofmann 2010
). Examining dimensional relationships between these factors, bias patterns, behavioral implications (e.g., approach and avoidance), and symptom severity represent critical next steps to empirically explore the etiological role of interpretation biases within emotional disorders.
Relatedly, all clinical groups endorsed more negative general interpretations, suggesting a common vulnerability factor reflected in this pattern (Buhlmann et al. 2002
). Nonetheless, it should be noted that general situations encompass relatively heterogeneous current concerns (e.g., romantic relationships, finances, health concerns), which might, in sum, be of broader relevance across
mental disorders as compared to more circumscribed concerns. In this respect, future studies might disentangle response patterns to specific current concerns contained in general situation sets.
In line with the current concern hypothesis, our results indicate a pronounced negative but no lack of positive interpretation bias for general situations in GAD compared to NC. One WSAP-based study had previously demonstrated this pattern in an unselected sample, showing that explicit threat bias, and not reduced positive bias, was predictive of GAD symptoms (Ogniewicz et al. 2014
). The present study extends these findings by demonstrating the identical relationship in a sample meeting self-report DSM-5 GAD criteria.
Concerning the implicit, RT-related bias component, MLM analyses revealed a relatively inhomogeneous outcome. For appearance-related and social situations, the BDD and SAD (vs. GAD) group exhibited differences in RT, with slower endorsement of positive and slower rejection of negative interpretations being the most consistent findings. RT differences for these groups (vs. GAD and NC) were non-substantial for general situations. Moreover, findings for the GAD group reflected a differentially faster endorsement of negative and faster rejection of positive general interpretations compared to NC. We were further able to identify differential RT to both positive and negative general interpretations in GAD, while there was only a negative explicit interpretation bias. Overall, patterns of decision rates and RT partially diverged, which, within methodological limitations, might be due to several reasons, such as quick interpretation changes or conflicting evaluation of individuated behaviors (see Rydell et al. 2008
). In sum, these discrepancies highlight the benefit of RT-based indices as a supplement in understanding the architecture of interpretation bias. Nevertheless, more implicit RT results only partially supported the current concern hypothesis, as clinical groups showed alterations that were specific for some, but not all current concerns. Hence, further research is needed to reinvestigate the relationship of implicit and explicit interpretation bias, i.e., within clinically diagnosed, larger samples, and lab-based settings.
The examination of cognitive components via Wiener diffusion models revealed that between-group and between-content RT differences originated mainly from alterations in drift rate; that is, faster information uptake. As all other parameters did not vary substantially across groups and concerns, RT differences cannot be attributed to non-decisional factors, e.g., differential response caution (i.e., boundary separation) or response bias (i.e., initial bias). Drift rate relates to recognition and classification speed of stimuli, and thus, inter alia, associative strength in memory (McKoon and Ratcliff 2012
; White et al. 2010
). Hence, the current findings illustrate that faster reaction to an interpretation is a product of closely associated sentence-word-combinations being processed more easily than other distal combinations. In sum, as content-specific drift rate differences and endorsement rates were meaningfully associated with clinical group status, these results suggest that associative memory networks might indeed be organized as per disorder-relevant current concerns. Future studies should validate this novel application and interpretation of Wiener diffusion model indices for this task within larger replication studies.
This study has some limitations. Aiming to reach a heterogeneous range of participants, it was entirely web-based, thus conducted in a less controlled environment, with clinical diagnoses based on self-report DSM-5 criteria. Previous research indicates no validity differences between in-lab and web-based settings for most experimental tasks (e.g., Hilbig 2016
; Ramsey et al. 2016
; Semmelmann and Weigelt 2017
), which is in line with the good psychometric properties found for all measures used in this study. Nonetheless, regarding self-report diagnoses, it remains unclear how well participants were able to accurately respond to diagnostic criteria, which might have affected validity. Overall, replication studies using clinician-administered interviews appear warranted.
Relatedly, the present study design did not allow for an assessment of comorbidities, which are prevalent in the disorders tested (Kessler et al. 2005
). Depression, in particular, has been shown to be associated with a medium-sized effect on interpretation bias patterns (Everaert et al. 2014
). Hence, future research should investigate the influence of comorbidities determined through standardized clinical interviews. In this respect, diagnostic procedures might especially aid in differentiating GAD from depression. The considerable overlap between these disorders (e.g., concerning repetitive negative thinking) has been empirically discussed (e.g., Mennin et al. 2008
), highlighting problems in effectively distinguishing them through self-report. Notably, depression scores for the GAD group in this study were significantly higher than for all other clinical groups and might have influenced interpretation bias patterns.
Further, it is noteworthy that SWAP interpretation options might be somewhat heterogeneous, potentially affecting the association between interpretation bias and symptoms. For instance, while some interpretations reflect attributions (e.g., “funny” vs. “stupid”), others more indirectly refer to behavioral responses (e.g., “help” vs. “avoid”; see Supplementary Table A1 in the Appendix). This heterogeneity is an inherent characteristic of most interpretation bias stimulus sets and potentially yields a more comprehensive picture of bias features. Nonetheless, future studies might focus on specific aspects of interpretation bias (e.g., attribution) to test their association with symptom severity. Last, although our study was powered to detect large between-group differences in mentally healthy vs. clinical populations, statistical power might not have been sufficient to observe small to medium-sized effects (e.g., between clinical groups). The investigation of these effect sizes prospectively requires replication in a larger sample.
In sum, this study is the first to provide a comparative account of interpretation bias across BDD, SAD, and GAD, showing its transdiagnostic presence and specific modulation by current concerns, most coherently for explicit bias patterns. Our findings also demonstrate a shared propensity of BDD and SAD to misinterpret ambiguous appearance-related and social situations. Further, GAD appears to be characterized by both an explicit and implicit negative, as well as a lack of positive general interpretation bias. Additionally, mechanistic insights from RT-based results indicate a differential structural organization of associative memory within different disorders and current concerns, which is consistent with pertinent models of information processing (e.g., Beck and Haigh 2014
). They further underscore the importance of identifying and targeting disorder-relevant interpretation bias profiles in cognitive-behavioral therapy, for example, via functional analyses, idiosyncratically tailored cognitive interventions, and CBM-I. In this respect, clinicians should attend to potential cognitive overlap, e.g., for appearance-related and social scenarios in BDD and SAD. Prospective CBM-I programs should equally incorporate such overlap and flexibly address different current concerns within training rationales to enhance intervention efficacy.
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