A multi-session interpretation modification program: Changes in interpretation and social anxiety symptoms

Abstract

Previous research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. Recently, studies have experimentally modified interpretation and shown that this subsequently affected anxiety in non-anxious individuals. If similar procedures can modify interpretation biases in socially anxious individuals, they may lead to a reduction in social anxiety symptoms. In the current study, we examined the effect of a computerized Interpretation Modification Program (IMP) on interpretation bias and social anxiety symptoms. Twenty-seven socially anxious individuals were randomly assigned to the IMP or a control condition. Participants completed eight computer sessions over four weeks. The IMP modified interpretation by providing positive feedback when participants made benign interpretations and negative feedback in response to threat interpretations. The IMP successfully decreased threat interpretations, increased benign interpretations, and decreased social anxiety symptoms compared to the control condition. Moreover, changes in benign interpretation mediated IMP's effect on social anxiety. This initial trial suggests that interpretation modification may have clinical utility when applied as a multi-session intervention.

Introduction

Interpretation bias is the tendency to interpret ambiguous information in a threatening manner. An interpretation bias may be particularly influential in individuals with social anxiety because social cues are often ambiguous and thus easily distorted (Clark & Wells, 1995). For example, it is difficult to know if a conversation partner's yawn indicates boredom (threat interpretation) or exhaustion (benign interpretation). Cognitive models (Clark and Wells, 1995, Rapee and Heimberg, 1997), as well as empirical findings (see below) implicate interpretation biases in the maintenance of social anxiety.

A number of studies have supported the role of interpretation bias in social anxiety. Most studies have found that socially anxious individuals favor threat interpretations compared to non-anxious controls (e.g., Amir et al., 1998, Huppert et al., 2003, Roth et al., 2001, Stopa and Clark, 2000, Voncken et al., 2003). Additionally, some studies have found that socially anxious individuals also lack a benign interpretation bias exhibited by non-anxious individuals (Constans et al., 1999, Hirsch and Mathews, 1997, Hirsch and Mathews, 2000). Together, these studies suggest that socially anxious individuals make fewer benign interpretations and more threat interpretations than non-anxious individuals. It is possible that procedures that induce a benign interpretation bias or reduce threat interpretation bias may also reduce social anxiety symptoms.

Cognitive Bias Modification (CBM) procedures are well suited to modify interpretation bias. CBM refers to the experimental modification of cognitive biases, allowing researchers to examine the effect of modification on the constructs of interest (e.g., anxiety, depression, alcohol consumption, body dissatisfaction). For example, Grey and Mathews (2000) used homographs (i.e., words with multiple meanings, e.g., ‘mean’ can imply ‘average’ or ‘nasty’), to modify interpretation in non-anxious individuals. In one experiment, participants saw homographs followed by target words. Depending on a participant's randomly assigned condition, the target word either implied a threat (‘nasty’) or a 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. Thus, the procedure successfully induced interpretation biases that generalized to novel stimuli.

Extending these findings, research suggests that inducing different interpretation biases can causally affect anxiety (e.g., Mathews and Macintosh, 2000, Wilson et al., 2006). For example, in Wilson et al. (2006), participants completed either a threat or benign interpretation induction and then viewed stressful videos. Participants who received the threat induction displayed significant elevations of state anxiety in response to the stressor, whereas participants in the benign condition did not. These findings suggest that modifying interpretation can affect anxiety reactivity. The effect on state anxiety also suggests that similar procedures could be used to reduce anxiety in anxious individuals.

The above studies demonstrated that a single CBM session can modify interpretation bias and that such modification can affect state anxiety in non-anxious individuals. Mathews, Ridgeway, Cook, and Yiend (2007) extended these findings by increasing CBM from a single session to four sessions and by assessing trait anxiety one week later. High trait anxious individuals completed a CBM program that presented ambiguous scenarios, each resolved in an increasingly positive manner over the four sessions (completed over two weeks). The control group completed only a pre-assessment and post-assessment two weeks later. Results showed that the active group's interpretation was more positive and less negative than the control group at post-assessment. Moreover, one week following the post-assessment the active group had significantly lower trait anxiety scores than the control group, once pre-training scores were partialled out.

To our knowledge, only one study (i.e., Murphy, Hirsch, Mathews, Smith, & Clark, 2007) has examined interpretation modification in socially anxious individuals. In that study, participants who received a benign interpretation induction reported feeling less anxious about a future social situation compared to the control group. This effect on anticipatory anxiety was obtained from a single session of CBM. However, no study has examined the effect of multiple sessions of interpretation modification on symptoms of social anxiety. The changes in trait anxiety observed in Mathews, Ridgeway, Cook, and Yiend (2007) suggest that increasing the number of sessions could lead to changes in social anxiety symptoms.

In summary, evidence from correlational and experimental studies suggests that interpretation bias is involved in the maintenance of social anxiety and that interpretation is malleable via CBM procedures. With the exception of Murphy et al. (2007), researchers have only modified interpretation bias in non-anxious or generally anxious individuals. Additionally, most previous studies have examined brief effects of a single session of interpretation modification on state anxiety. We currently do not know if interpretation modification procedures will affect social anxiety symptoms in addition to state anxiety.

The current study addresses several of these limitations by examining the effect of interpretation modification on social anxiety symptoms. To this end, we evaluated a computerized Interpretation Modification Program (IMP) designed to change interpretation bias in socially anxious individuals in eight computer sessions delivered twice weekly. In previous interpretation modification programs, researchers have guided participants toward either a threat bias or a benign bias. However, because social anxiety involves both a lack of benign bias and the presence of a threat bias, we designed the IMP to guide participants toward making benign interpretations and rejecting threat interpretations. We examined the effect of IMP on interpretation bias compared to a control condition. Unlike previous studies that aimed to affect state anxiety, the current study aimed to change symptoms of social anxiety.

We tested four hypotheses: Participants completing the IMP would (a) endorse more benign interpretations than the control group at post-assessment, (b) endorse fewer threat interpretations than the control group at post-assessment, and (c) report fewer social anxiety symptoms than the control group at post-assessment. Moreover, we hypothesized that induced interpretation bias would mediate the effect of group assignment on social anxiety. We examined the above hypotheses in a randomized, double-blind study.