Cogn Ther Res (2012) 36:493501 DOI 10.

1007/s10608-011-9379-6

ORIGINAL ARTICLE

Too Much of a Good Thing: Testing the Efcacy of a Cognitive Bias Modication Task for Cognitively Vulnerable Individuals
Gerald J. Haeffel David C. Rozek Jennifer L. Hames Jessica Technow

Published online: 13 July 2011 Springer Science+Business Media, LLC 2011

Abstract A growing body of research indicates that cognitive bias modication (CBM) may be an effective intervention for individuals with anxiety. However, few studies have tested whether CBM works for other disorders characterized by negative cognitive biases such as depression. This experiment tested the efcacy of CBM for altering depressogenic self-worth biases. Consistent with hypotheses, results showed that CBM was more effective than a control condition in teaching participants a more adaptive cognitive style (i.e., increased attention for adaptive self-worth stimuli). Those who successfully learned a more adaptive style reported fewer depressive symptoms and exhibited greater persistence (i.e., less helplessness) on a difcult laboratory task. However, the task proved difcult for cognitively vulnerable participants; they were not able to maintain their new learning over the entire course of the CBM training. Rather, their negative cognitive bias began to re-emerge after only 20 learning trials. These results indicate that CBM attention

training might be most effective in reducing cognitive vulnerability when initially used in small doses. Keywords Depression Cognitive vulnerability Cognitive bias modication Attention

Introduction According to the cognitive theories of depression (Abramson et al. 1989; Beck 1967), some individuals have a cognitive vulnerability that interacts with stress to produce depression. Specically, people are vulnerable to depression because they tend to view stressful life events as having negative implications for their future and for their self-worth. Recent research has provided strong support for the cognitive vulnerability hypothesis (Abramson et al. 2002). Prospective studies have consistently found that cognitive vulnerability interacts with stressful life events to predict the development of depressive symptoms and depressive disorders (Abramson et al. 1999; Alloy et al. 2006; Gibb et al. 2006; Haeffel et al. 2007; Hankin et al. 2004; Metalsky and Joiner 1992). Taken together, prior studies indicate that individuals with a cognitive vulnerability are at heightened risk for depression. Thus, it is important to create interventions that can reduce this vulnerability, and in turn, increase resilience to depression. One strategy for reducing cognitive vulnerability is with an intervention such as cognitivebehavioral therapy (CBT), which focuses on helping individuals make more adaptive cognitions. Research has shown that CBT is as effective as medication, has no side effects, and may even have a relapse prevention effect (Hollon et al. 2002). However, CBT is also time intensive (e.g., [12 sessions) and requires trained professionals.

This research was supported in part by an Undergraduate Research Opportunity Grant to Jennifer Hames. G. J. Haeffel (&) D. C. Rozek J. L. Hames J. Technow Department of Psychology, University of Notre Dame, Haggar Hall, Notre Dame, IN 46556, USA e-mail: ghaeffel@nd.edu Present Address: J. L. Hames Department of Psychology, Florida State University, Tallahassee, FL, USA J. Technow Department of Psychology, University of Denver, Denver, CO, USA

123

494

Cogn Ther Res (2012) 36:493501

These characteristics make dissemination to the general public difcult. Ideally, an intervention should be highly accessible and cost effective. To this end, researchers have begun to test an alternative intervention strategy called cognitive bias modication (CBM; Koster et al. 2009). CBM typically uses a computer task to target a specic pattern of cognitive processing that is thought to confer risk for psychopathology (e.g., an attentional bias toward negative stimuli). CBM helps to correct the bias by having people repeatedly practice a competing stimulus contingency (e.g., an attentional bias toward neutral or positive stimuli). The CBM approach has been used almost exclusively in the area of anxiety (Amir et al. 2009; Schmidt et al. 2009). Research has shown that individuals with high levels of anxiety are more likely to attend to threatening stimuli (e.g., threatening words) than individuals with low levels of anxiety. Importantly, these biases appear to precede and predict anxiety reactivity (Salemink et al. 2007; Wilson et al. 2006). Thus, the CBM approach has been used to train participants to attend to neutral rather than threatening stimuli. This typically has been accomplished by modifying an attentional dot-probe task (MacLeod et al. 1986). In a traditional dot-probe task, a threatening and neutral word pair is presented to participants with one word above and the other below a central xation point. A dot-probe then appears in the position of one of the words immediately after its presentation. Participants are required to indicate the position of the dot by using the numeric keypad. The speed at which participants can detect the dot-probe is an indication of attention allocation. MacLeod et al. (2002) modied the dot-probe paradigm to create a CBM task that could change the attentional biases found in anxious individuals; we will refer to CBM that focuses specically on altering attentional biases as CBM-A (attention). Rather than having the dot-probes appear randomly behind both neutral and threatening words, this task had the dot-probes appear more often in the vicinity of the neutral words, thus creating a word-dot contingency. After repeated trials, participants learned the word-dot contingency and began to attend to neutral rather than threatening words (because they had learned that this was where the dot-probe was most likely to occur). Using MacLeods CBM-A task (and variations of it), researchers have shown that they can reduce attentional biases, and in turn, reduce anxiety for up to 48 h after completing the training (Amir et al. 2009; Li et al. 2008; Schmidt et al. 2009; See et al. 2009). Moreover, a recent study by Schmidt et al. (2009) provided evidence that CBM-A can even lead to the remission of clinically signicant anxiety. They found that patients diagnosed with Social Anxiety Disorder who were randomly assigned to a CBM-A condition were signicantly more likely to remit from anxiety

than patients assigned to a control condition. This study provides the rst evidence that engaging in a CBM-A task can have both long-term and clinically signicant effects. More research is still needed, however, to conrm the longterm efcacy of CBM-A, and also to determine whether it can reduce risk for the initial onset of clinically signicant anxiety. The results of studies testing CBM-A for anxiety are promising and indicate that it may be an effective strategy for changing negative cognitive patterns (see Hakamata et al. 2010 for an extensive review). However, few studies have tested whether the efcacy of CBM-A translates to the area of depression (Holmes et al. 2009; Joormann et al. 2009). To date, there are only 2 studies that have applied the dot-probe paradigm from the anxiety literature to the area of depression. In the rst study, Wells and Beevers (2010) trained a sample of dysphoric college students to attend to neutral rather than negative stimuli. After four sessions, they found that students who received the dotprobe training reported fewer depressive symptoms than students who were in a control group. This was the rst study to support the use of an attention-training task for reducing depression. However, the results of the second study to test CBM-A for depression were not as promising. In this study, Baert et al. (2010) found that the dot-probe training was not effective in altering participants negative cognitive patterns. Moreover, the training actually led to increased symptom severity for some participants (those with moderate to severe depressive symptoms). They concluded that CBM-A should be counter indicated for individuals with signicant levels of depressive symptoms. The mixed ndings from these two studies indicate that the translation of CBM-A from anxiety to depression might not be a straightforward one. One explanation for why CBM-A might be less effective for depression than anxiety is that those at risk for depression tend to have limited cognitive resources (e.g., decreased working memory capacity). We suspect that low levels of cognitive resources may affect a cognitively vulnerable individuals ability to learn and consolidate the new cognitive associations taught by CBM-A tasks. CBM-A is cognitively demanding. It requires cognitively vulnerable individuals to suppress their prepotent tendency to attend to negative stimuli so that they can attend to more neutral stimuli. This process of suppressing a well-established pattern of thinking in order to form a new pattern of thinking can be very difcult. There is a large body of research documenting the trouble that individuals have forming new cognitive associations when there exists a competing and well-established associations in the same domain (e.g., McNeil and Alibali 2005). The winner of the competition between old and new thinking depends, in part, on the availability of cognitive resources.

123

Cogn Ther Res (2012) 36:493501

495

Cognitive resources are necessary for suppressing established knowledge in order to learn new and competing material. Thus, the effectiveness of CBM-A relies heavily on the ability of the cognitively vulnerable individual to use cognitive resources to inhibit their well-established attentional pattern and form a more adaptive pattern.1 We suspect that CBM-A may be difcult for individuals with a cognitive vulnerability because they tend to have reduced cognitive resources. A growing body of research demonstrates that cognitive vulnerability is associated with decits in cognitive capacity, cognitive exibility, taskswitching, concentration, attention, and memory (e.g., Lyubomirsky et al. 1999; Nolen-Hoeksema et al. 2008; Ray et al. 2005; Watkins and Brown 2002). This work strongly suggests that vulnerable individuals might not have the cognitive resources needed to maintain the contingencies learned during CBM-A. Cognitive resources have been compared to a muscle (Muraven and Baumeister 2000); their strength and power are nite, and can be depleted with repeated use. Thus, we predicted that CBM-A might eventually wear-out the already weakened cognitive muscle of vulnerable individuals. Once the resources are depleted by CBM-A then the training effects should begin to diminish and the negative attentional biases re-emerge. In summary, there is a paucity of research on CBM-A for depression, and further research is sorely needed. Thus, the goal of the current experiment was to add to the body of literature on CBM-A for depression as well as to help to reconcile inconsistencies in this area. We tested three hypotheses. First, we hypothesized that participants would exhibit lower levels of cognitive vulnerability after CBM-A training. Consistent with prior research, we reasoned that participants would be able to learn the contingencies they practiced during CBM-A. However, we also hypothesized that the efcacy of CBM-A would deteriorate over time, particularly for participants with a cognitive vulnerability. The CBM-A task requires individuals to repeatedly control or inhibit their prepotent tendency to attend to negative inferences (i.e., inhibit their well-established cognitive vulnerability). We hypothesized that this resource-intensive process would fatigue participants with a cognitive vulnerability over time, and in turn, allow for their more established negative pattern of thinking to re-emerge. Finally, we hypothesized that CBM-A (when successful) would lead to changes in participants mood and actual behavior. Specically, we predicted that CBM-A training

would lead to decreases in depressive symptoms and greater persistence on a difcult laboratory task.

Method Participants Participants were 61 undergraduates from a mid-sized private university in the Midwestern United States; they were recruited via a volunteer sign-up procedure. Sixtynine percent of the sample reported their ethnicity as Caucasian, 13% Asian, 10% Hispanic, 3% African American, and 5% endorsed an other category. One participant was excluded from data analyses because of extreme responding (i.e., greater than 3 standard deviations) on multiple measures; thus, the nal sample consisted of 60 participants (39 women, 21 men; M age = 20.09). Participants were compensated with extra credit points for a psychology course. Measures Cognitive Bias Modication Task The CBM-A task was modeled after the attentional dotprobe task created by MacLeod et al. (2002). In this task, a word pair (one adaptive and one maladaptive) is presented to participants with one word above and the other below a central xation point. A dot-probe then appears in the position of one of the words and participants are required to detect the location of a dot-probe as quickly as possible by pressing either up or down on an input box. We made one modication to this basic CBM-A task. Specically, we included a priming stimulus before the presentation of the word pair. We added a prime because the cognitive theories of depression propose a vulnerability-stress model. This means that cognitive vulnerability is most likely to emerge in the presence of stress. In other words, cognitive biases lie dormant until activated (or primed) by the requisite negative context. Thus, it is imperative that individuals be primed to ensure that their negative cognitive biases are activated and, in turn, amenable to modication. At the start of each trial, participants were presented with a black central xation cross (on a white background) for 1,000 ms. Then, participants were primed (750 ms) with one of 20 negative scenarios (e.g., rejected by friend; see appendix for all scenarios used). Next, the word-pair, which consists of one adaptive and one maladaptive self-worth inference (see appendix for adjectives used), was presented for 1,000 ms. The adaptive and maladaptive word lists were matched for average length and frequency of use (Carroll et al. 1971). After the word

It is important to note that even associative and implicit learning tasks (similar to the dot-probe training task) require cognitive resources and working memory (Carter et al. 2003; Jonides et al. 1998; Reber and Kotovsky 1997; Ridderinkhof et al. 2004).

123

496

Cogn Ther Res (2012) 36:493501

pair disappeared, a dot appeared in the location of one of the words and remained there until the participant indicated its location by pressing a top or bottom button on an input box. In order to create the contingency between negative scenarios and adaptive words, the dot-probe was presented behind the adaptive word approximately 95% of the time. The control condition did not create a contingency; rather, in this condition, the dot-probe was equally likely to appear behind the adaptive and maladaptive words (i.e., the dobprobe was presented behind the adaptive word 50% of the time. Participants completed 2 blocks of 40 trials (80 trials total) in both the training and control conditions. Participants response latencies from only the correct trials were analyzed. Consistent with prior research, selfcorrected trials as well as reaction times of less than 100 ms and more than 1,000 ms were removed (Joormann and Gotlib 2007); omitted trials accounted for a small percentage of all trials (\6%). Average reaction times for matched (dot-probe appeared in the same location that the maladaptive word appeared) and mismatched trials (dotprobe appeared in the location opposite of where the maladaptive word appeared) were calculated for each set of twenty trials (020, 2140, 4160, and 6180). The average matched score was then subtracted from the average mismatched score at each interval to create a measure of cognitive bias with greater reaction time difference scores indicating a greater bias for attending to maladaptive stimuli. Cognitive Vulnerability to Depression

to solve a series of anagrams. They were told to hit the space bar once they solved the anagram or, if they could not solve the anagram, then they should hit the space bar to receive the next anagram. The time spent trying to solve the three anagrams was used as a behavioral measure of persistence (i.e., resistance to helplessness). Depressive Symptoms The Mood and Anxiety Symptom Questionnaire (MASQ; Watson et al. 1995) was used to assess levels of depressive symptoms at baseline and upon completion of the CBM-A task. The MASQ is a self-report questionnaire that assesses symptoms specic to depression and anxiety based on the tripartite theory of anxiety and depression (Clark and Watson 1991). In this study, we used the anhedonic subscale, which contains 22 items that assess symptoms hypothesized to be specic to depression such as low positive affect (example items: Thought about death or suicide, Felt really up or lively, Felt cheerful). In this study, participants were instructed to rate the items with regard to how the felt right now [it is important to note that a number of studies have shown that the MASQ is still a reliable and valid measure of depressive symptoms even when the instructions are changed to assess either shorter or longer durations than originally intended (e.g., Hankin 2005; Haeffel and Mathew 2010; Sarin et al. 2005)]. The MASQ has demonstrated good reliability and validity in previous research (Watson et al. 1995). Procedure

The Cognitive Style Questionnaire (CSQ; Haeffel et al. 2008; Alloy et al. 2000) was used to assess participants baseline levels of cognitive vulnerability to depression. The CSQ is widely used self-report questionnaire that assesses the cognitive vulnerability factor featured in the hopelessness theory of depression. The CSQ assesses participants causal attributions for the 12 hypothetical negative events on dimensions of stability and globality; in addition, participants rate the probable consequences of each event and the self-worth implications of each event. Mean-item scores can range from 1 to 7, with higher scores reecting more negative cognitive styles. The CSQ has good internal consistency, reliability, and validity (Haeffel et al. 2008). Difcult Laboratory Task Participants were asked to solve a set of 10 difcult and unsolvable anagrams (Tresselt and Mayzner 1966). Participants rst completed two example anagrams (that were solvable) and were told that, being good at solving anagrams requires good vocabulary and good memory. Participants were then instructed that they had unlimited time

At baseline, participants completed a brief demographics questionnaire and measures of cognitive vulnerability (CSQ) and depressive symptoms (MASQ). They were then randomly assigned to either a CBM-A or control intervention. After the intervention, participants completed the measure of depressive symptoms (MASQ) and a difcult laboratory task (anagram failure task; Haeffel et al. 2007; MacLeod et al. 2002; Mogg et al. 1990). Participants were then debriefed about the unsolvable nature of many of the anagrams and the purpose of the experiment.

Results Three hypotheses were tested. First, we hypothesized that most participants would be able to learn the contingencies they practiced during CBM-A. However, we also hypothesized that the efcacy of CBM-A would deteriorate over time for participants with a cognitive vulnerability. Finally, we hypothesized that CBM-A (when successful) would lead to changes in mood and behavior. Specically, we predicted

123

Cogn Ther Res (2012) 36:493501

497
20 10 0

Reaction Time (ms)

that CBM-A training would lead to decreases in depressive symptoms and greater persistence on a difcult laboratory task. Participants in the CBM-A and control conditions did not differ signicantly on any of the baseline variables (age, gender, cognitive vulnerability, and depressive symptoms). Effect of CBM-A Training on Cognitive Biases To test the efcacy of CBM-A training over time, we conducted a 2 (condition: CBM-A or control) 9 2 (cognitive vulnerability: high or low as determined by a median split on the CSQ) 9 4 (trial set: 020, 2140, 4160, 6180) mixed-factor ANCOVA. The dependent variable was cognitive bias (i.e., the tendency to attend to adaptive relative to maladaptive stimuli during the CBM-A task). Taking a conservative analytic approach, MASQ score at baseline was used as covariate in analyses to control for any individual differences in initial level of depressive symptoms. As predicted, there was a signicant betweensubjects effect for condition, F(1, 52) = 13.79, P \ .001, g2 p = .21. Corroborating prior research, participants in the CBM-A condition were able to learn the cognitive associations taught by the task; overall, they were much more likely to attend to adaptive stimuli relative to maladaptive stimuli (M reaction time = -27.41 ms, SE = 5.68 ms) than participants in the control condition (M reaction time = .54 ms, SE = 4.83 ms; note that smaller values indicate a greater bias for adaptive stimuli). However, as predicted, the main effect of condition was qualied by the interaction of condition, cognitive vulnerability, and trial set, F(3, 156) = 4.52, P = .005, g2 p = .08. As shown in Fig. 1, the efcacy of CBM-A for cognitively vulnerable individuals weakened considerably over time whereas the efcacy of CBM-A for non-vulnerable individuals remained steady across trials. Interaction contrasts conrmed the linear pattern of results, F(1, 52) = 9.05, P = .004, g2 p = .15 (neither the quadratic nor any of the higher-order trends were signicant). The gure also showed an unexpected result for the training condition. In contrast to non-vulnerable individuals in the training condition, vulnerable individuals in this condition did not show clear evidence of learning the contingencies taught by CBM-A. At rst blush, it appears that vulnerable individuals in the training condition actually started with a positivity bias whereas non-vulnerable learned the positivity bias over the rst 20 trials (which then remained steady over the duration of the task). However, another explanation for this discrepancy is that the trials were averaged in groups (every 20 trials) that were too large to detect rapid learning. To test this explanation, we divided the data from trials 040 into groups of 10 rather than groups of 20.

-10 -20 -30 -40 -50 -60 -70 0-20 21-40 41-60 61-80

Trial
Training-Vulnerable Training-NonVulnerable Control-Vulnerable Control-NonVulnerable

Fig. 1 Cognitive bias as a function of condition (CBM-A training or control), cognitive vulnerability (vulnerable vs. non-vulnerable), and time (trial number). Note that smaller reaction time values indicate a greater bias for adaptive relative to maladaptive stimuli

By parsing the trials more closely together (every 10 trials), we found clear evidence of learning in the cognitively vulnerable group of participants. Corroborating the initial results, there was a signicant interaction of condition, cognitive vulnerability, and trial set, F(3,135) = 2.60, P = .056, g2 p = .05. As Fig. 2 shows, individuals with a cognitive vulnerability quickly acquired the new associations taught by CBM-A, however, this learning began to deteriorate after about 20 training trials. Interaction contrasts conrmed the pattern of the interaction, F(1, 45) = 4.67, P = .04, g2 p = .09. Effect of CBM-A Training on Mood and Behavior We tested the hypothesis that CBM-A training would lead to changes in depressive symptoms and helplessness behavior. Specically, we tested whether CBM-A outcome (i.e., the cognitive bias score for trials 6080) predicted levels of depressive symptoms upon completion of training and the amount of time spent on a difcult laboratory task. We conducted an ANCOVA with CBM-A training end-state (successful or non-successful as operationalized by a median split of the cognitive bias score for trials 6080) as the independent variable and MASQ score post-intervention and time spent on the laboratory stressor as the dependent variables, respectively. MASQ and CSQ scores at baseline were used as covariate in all analyses to control for any individual differences in initial level of depressive symptoms or cognitive vulnerability. As predicted, there was a signicant

123

498
20

Cogn Ther Res (2012) 36:493501

56 55 54

MASQ Score

53 52 51 50 49 48 47 46 45 Successful CBM Non-Successful CBM

Reaction Time (ms)

-20

-40

-60

-80

25
-100 0-10 11-20 21-30 31-40

Trial
Training-Vulnerable Training-NonVulnerable Control-Vulnerable Control-NonVulnerable

Time (Minutes)

20 15 10 5 0 Successful CBM Non-Successful CBM

Fig. 2 Cognitive bias as a function of condition (CBM-A training or control), cognitive vulnerability (vulnerable vs. non-vulnerable), and time (trial number). Note that smaller reaction time values indicate a greater bias for adaptive relative to maladaptive stimuli

effect of CBM-A end-state on both depressive symptoms (at the level of a trend; F[1, 23] = 3.61, P = .07, g2 p = .14) and time spent on the laboratory task (F[1, 22] = 4.79, P = .04, g2 p = .18) with effect sizes in the medium to large range. As shown in Fig. 3, participants who exhibited the contingencies taught by the CBM-A task reported signicantly lower levels of depressive symptoms and spent signicantly more time on the difcult laboratory task than participants who did not successfully learn the CBM-A contingencies (even after controlling for initial levels of depressive symptoms and cognitive vulnerability).

Fig. 3 Top panel: Level of depressive symptoms upon completion of CBM-A training as function of CBM-A outcome (successful vs. nonsuccessful). Bottom panel: Time spent on a difcult laboratory task as a function of CBM-A outcome (successful vs. non-successful)

Discussion This study contributes to the small, but important body of research testing the efcacy of CBM-A tasks for depression. Consistent with hypotheses, results showed that CBM-A was more effective than a control condition in altering attentional biases. Moreover, those who exhibited a more adaptive attentional style after CBM-A training reported fewer depressive symptoms and had greater persistence (i.e., less helplessness) on a difcult laboratory task. These results map onto the ndings from the anxiety literature, corroborate the recent ndings of Wells and Beevers (2010), and provide evidence that CBM-A has potential for helping reduce cognitive vulnerability to depression.

The results of the experiment also highlight potential problems with CBM-A for depression. Our ndings are the rst to show that cognitively vulnerable individuals might struggle to maintain newly learned associations over the duration of a CBM-A training session. After approximately 20 trials, the negative cognitive patterns of vulnerable participants began to re-emerge. These ndings corroborate those of Baert et al. (2010) who recently found that CBMA was ineffective in altering cognitive biases (and actually led to increased depression in some participants). The results also add to a large body of research in cognitive psychology, which shows that people have great difculty forming new cognitive associations when there exists a competing and well-established associations in the same domain (McNeil and Alibali 2005; Diamond and Kirkham 2005; Zevin and Seidenberg 2002). Our results indicate that CBM-A training should be provided, at least initially, in low-doses. It is important to remember, however, that we tested participants after a single 20-min training session. With repeated training (e.g., everyday for 1 month), it may be that the contingencies learned during CBM-A could be strengthened, and over time, require less cognitive resources (i.e., become more automatic).

123

Cogn Ther Res (2012) 36:493501

499

The current ndings also provide a clue for how to reconcile the different results found by the previous two CBM-A studies for depression. Wells and Beevers (2010) found that CBM-A was effective in reducing depressive symptoms whereas Baert et al. (2010) found that CBM-A might actually lead to increases in depressive symptoms. Baert and colleagues attributed the opposite ndings to differences in participants levels of depression. Participants in the Wells and Beevers study had lower levels of depression than those in the Baert and colleagues study. However, our results suggest that the discrepant results could be also be due to participants having different levels of cognitive vulnerability. Cognitive vulnerability is consistently and robustly correlated with depression levels. Thus, it is possible (or even likely) that participants in the Wells and Beevers study had lower levels of cognitive vulnerability than those in the Baert study. This means that some of the participants in the Wells and Beevers study probably did not have the pre-existing and highly engrained negative associations that make learning a CBM-A contingency difcult. Participants higher levels of cognitive vulnerability in the Baert et al. study might also explain why they found that CBM-A was detrimental for some participants. There is some evidence that suppressing a highly engrained pattern of thinking can actually lead to an increase in the thoughts that are being suppressed. For example, Erskine et al. (in press) recently found that when smokers suppressed thoughts about smoking there was an initial decrease in smoking. However, as cognitive resources diminished over time, there was a rebound effect and individuals exhibited an increase in smoking. Thus, it is possible that once the cognitive resources of the highly vulnerable individuals in Baert et al.s study were depleted by CBM-A they actually experienced an increase in the negative cognitions that they were previously suppressing. This increase in negative cognitions could have led to increased depression levels. The current study had both strengths and limitations. For example, a signicant strength of this study is that it is one of the few to test whether or not the efcacy of CBM-A translates from anxiety to depression. In addition, we used an experimental design with multiple outcome measures (i.e., self-report and behavior). The study also provided some of the rst support for the novel hypothesis that learning would deteriorate for cognitively vulnerable individuals over time. These results highlight the importance of examining the trial-by-trial learning in CBM-A tasks. If we had only tested the main effect of condition, we would have overlooked important information about the efcacy of CBM-A for individuals with cognitive vulnerability. By using a ne-grained analysis, we were able to identify a subgroup of individuals (i.e., those with a cognitive vulnerability) for which long sessions of CBM-A

might be counterproductive (at least initially). In addition, analyses aimed at understanding trial-by-trial learning can help to determine the number of trials and sessions necessary for optimal CBM-A efcacy. A nal strength of this study was the use of a highly specic measure of depressive symptoms (the MASQ). Previous studies have been limited by symptom measures (e.g., the Beck Depression Inventory) that lack specicity and are saturated with high levels of negative affect (Clark and Watson 1991). Using the MASQ enabled us to examine the specicity of our results to the depressive symptoms. That said, it is important to note that measures such as the MASQ (and the Beck Depression Inventory) were not designed to measure short-term changes in depressive symptoms. Rather, these measures are typically used to measure symptom change over the course of weeks, months, and event years. We chose the MASQ because it was used in one of the two prior CBM-A studies of depression (Baert et al. 2010), it is specic to depression, and it contains items (mood adjectives) that are more amenable to short-term change than the items on the Beck Depression Inventory (e.g., change in weight). Both our study and Baert et al. (2010) support the use of the MASQ as a short-term measure of change; however, future work in this area is still needed to validate these more long-term measures for use in short-term experimental designs. Limitations of the current study should also be noted. First, it would be premature to make conclusions about the effect of CBM-A on clinically signicant forms of depression because the current study used a relatively health sample and we only assessed depressive symptoms (rather than disorder). Second, the study examined college freshmen. Although freshmen are ideal for testing prevention interventions because they are at the peak age for developing depression (Hankin et al. 1998) and are likely to experience high levels of stress, the results may not generalize to community samples. Finally, it is important to note the preliminary nature of these ndings and the need for replication in a larger sample. Indeed, this is the rst study to examine the moderating effects of cognitive vulnerability on trial-by-trial learning in CBM-A for depression. Moreover, our CBM-A task did not map directly onto the CBM-A task used by the prior two studies in this area. Unlike prior work, we used a priming stimulus in our task to ensure the activation of cognitive biases during our task. Our use of a prime provided a greater level of theoretical validity as well as a more rigorous test of the CBM-A hypothesis; however, it also does not allow us to directly equate our results to the two prior studies in this area. Our CBM-A task was likely more difcult for cognitively vulnerable individuals than prior CBM-A tasks because their cognitive biases were continually activated by the prime during our task. However, this is likely what happens

123

500

Cogn Ther Res (2012) 36:493501 In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression. New York: Guilford. Abramson, L. Y., Alloy, L. B., Hogan, M. E., Whitehouse, W. G., Donovan, P., Rose, D., et al. (1999). Cognitive vulnerability to depression: Theory and evidence. Journal of Cognitive Psychotherapy: An International Quarterly, 13, 520. Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Review, 96, 358372. Alloy, L. B., Abramson, L. Y., Hogan, M. E., Whitehouse, W. G., Rose, D. T., Robinson, M. S., et al. (2000). The Temple-Wisconsin cognitive vulnerability to depression project: Lifetime history of axis I psychopathology in individuals at high and low cognitive risk for depression. Journal of Abnormal Psychology, 109, 403418. Alloy, L. B., Abramson, L. Y., Whitehouse, W. G., Hogan, M. E., Panzarella, C., & Rose, D. T. (2006). Prospective incidence of rst onsets and recurrences of depression in individuals at high and low cognitive risk for depression. Journal of Abnormal Psychology, 115, 145156. Amir, N., Beard, C., Burns, M., & Bomyea, J. (2009). Attention modication program in individuals with generalized anxiety disorder. Journal of Abnormal Psychology, 118, 2833. Baert, S., De Raedt, R., Schacht, R., & Koster, E. H. W. (2010). Attentional bias training in depression: Therapeutic effects depend on depression severity. Journal of Behavior Therapy and Experimental Psychiatry, 41, 265274. Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row. Carroll, J. B., Davies, P., & Richman, B. (1971). Word frequency book. New York: American Publishing Co., Inc. Carter, R. M., Hofstotter, C., Tsuchiya, N., & Koch, C. (2003). Working memory and fear conditioning. Proceedings of the National Academy of Science, 100, 13991404. Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316336. Diamond, A., & Kirkham, N. (2005). Not quite as grown-up as we like to thinkparallels between cognition in childhood and adulthood. Psychological Science, 16, 291297. Erskine, J.A., Georgiou, G.J., & Kvavilashvili, L. (in press). I suppress, therefore I smoke: Effects of thought suppression on smoking behavior. Psychological Science. Gibb, B. E., Beevers, C. G., Andover, M. S., & Holleran, K. (2006). The hopelessness theory of depression: A prospective multiwave test of the vulnerability-stress hypothesis. Cognitive Therapy and Research, 30, 763772. Haeffel, G. J., Gibb, B. E., Abramson, L. Y., Alloy, L. B., Metalsky, G. I., Joiner, T., et al. (2008). Measuring cognitive vulnerability to depression: Development and validation of the cognitive style questionnaire. Clinical Psychology Review, 28, 824836. Haeffel, G. J., Abramson, L. Y., Brazy, P., Shah, J., Teachman, B., & Nosek, B. (2007). Explicit and implicit cognition: A preliminary test of a dual-process theory of cognitive vulnerability. Behaviour Research and Therapy, 45, 11551167. Haeffel, G. J., & Mathew, A. R. (2010). Inside thoughts and outside inuences: Cognitive vulnerability moderates the effect of decreases in perceived social support on depressive symptoms. Journal of Social and Clinical Psychology, 29, 283302. Hakamata, Y., Lissek, S., Bar-Haim, Y., Britton, J. C., Fox, N. A., Leibenluft, E., et al. (2010). Attention bias modication treatment: A meta-analysis toward the establishment of novel treatment for anxiety. Biological Psychiatry, 68, 982990. Hankin, B. L. (2005). Childhood maltreatment and psychopathology: Prospective tests of attachment, cognitive vulnerability, and stress as mediating processes. Cognitive Therapy and Research, 29, 645671.

in the real world when encountering a stressful life event. Thus, we contend that by not using a prime, there is danger in overestimating the positive effects CBM-A as it is unclear if the training will hold up when participants need it mostduring times of stress. In conclusion, our results suggest that CBM-A has the potential to be an easily disseminated and effective intervention for reducing cognitive vulnerability to depression. However, there are some important caveats to consider. CBM-A is a learning process, which requires the effortful suppression of a pre-potent response. This suppression is cognitively taxing and can affect learning over time. In our experiment, cognitively vulnerable participants quickly learned the contingencies taught by CBM-A; unfortunately, this new learning faded rapidly over repeated trials. It will be important for future studies to test whether the efcacy of CBM-A can be better sustained with repeated training.

Appendix Negative Scenarios Negative scenarios: failed a class presentation, rejected by friend, got low grade on a paper, couldnt nish your homework, partner breaks up with you, you are unhappy, job performance criticized, betrayed by family member, GPA is low, parents disapproved of your behavior, got in serious trouble, felt unattractive, not in a romantic relationship, red from job, failed to achieve goal, people not interested in you, have no close friends, failed a test, criticized by professor, rejected by romantic partner Maladaptive Adjectives Maladaptive adjectives: dumb, failure, incompetent, inadequate, incapable, inept, inferior, loser, nobody, pathetic, pitiful, stupid, unable, unt, unimportant, unlovable, unwanted, useless, weak, worthless Adaptive Adjectives Adaptive adjectives: able, capable, competent, condent, desirable, determined, hopeful, important, inspire, lovable, motivated, procient, skillful, smart, talented, useful, valuable, winner, worthy

References
Abramson, L. Y., Alloy, L. B., Hankin, B. L., Haeffel, G. J., MacCoon, D. G., & Gibb, B. E. (2002). Cognitive vulnerability-stress models of depression in a self-regulatory and psychobiological context.

123

Cogn Ther Res (2012) 36:493501 Hankin, B. L., Abramson, L. Y., Miller, N., & Haeffel, G. J. (2004). Cognitive vulnerability-stress theories of depression: Examining affective specicity in the prediction of depression versus anxiety in three prospective studies. Cognitive Therapy and Research, 28, 309345. Hankin, B. L., Abramson, L. Y., Moftt, T. E., Silva, P., McGee, R., & Angell, K. E. (1998). Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study. Journal of Abnormal Psychology, 107, 128140. Hollon, S. D., Thase, M. E., & Markowitz, J. C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest, 3, 3977. Holmes, E. A., Lang, T. J., & Shah, D. M. (2009). Developing interpretation bias modication as a cognitive vaccine for depressed mood: Imagining positive events makes you feel better than thinking about them verbally. Journal of Abnormal Psychology, 118, 7688. Joormann, J., & Gotlib, I. H. (2007). Selective attention to emotional faces following recovery from depression. Journal of Abnormal Psychology, 116, 8085. Joormann, J., Hertel, P. T., LeMoult, J., & Gotlib, I. H. (2009). Training forgetting of negative material in depression. Journal of Abnormal Psychology, 118, 3443. Jonides, J., Smith, E. E., Marshuetz, C., Koeppe, R. A., & ReuterLorenze, P. A. (1998). Inhibition in verbal working memory revealed by brain activation. Proceedings of the National Academy of Sciences, 95, 84108413. Koster, E. H. W., Fox, E., & MacLeod, C. (2009). Introduction to the special section on cognitive bias modication in emotional disorders. Journal of Abnormal Psychology, 118, 14. Li, S., Tan, J., Qian, M., & Liu, X. (2008). Continual training of attentional bias in social anxiety. Behaviour Research and Therapy, 46, 905912. Lyubomirsky, S., Tucker, K. L., Caldwell, N. D., & Berg, K. (1999). Why ruminators are poor problem solvers: clues from the phenomenology of dysphoric rumination. Journal of Personality and Social Psychology, 77, 10411060. MacLeod, C., Mathews, A., & Tata, P. (1986). Attentional bias in emotional disorders. Journal of Abnormal Psychology, 95, 1520. MacLeod, C., Rutherford, E., Campbell, L., Ebsworthy, G., & Holker, L. (2002). Selective attention and emotional vulnerability: Assessing the causal basis of their association through the experimental manipulation of attentional bias. Journal of Abnormal Psychology, 111, 107123. McNeil, N. M., & Alibali, M. W. (2005). Why wont you change your mind? Knowledge of operational patterns hinders learning and performance on equations. Child Development, 76, 883899. Metalsky, G. I., & Joiner, T. E. (1992). Vulnerability to depressive symptomatology: A prospective test of the diathesis-stress and causal mediation components of the hopelessness theory of depression. Journal of Personality and Social Psychology, 63, 667675.

501 Mogg, K., Mathews, A., Bird, C., & MacGregor-Morris, R. (1990). Effects of stress and anxiety on the processing of threat stimuli. Journal of Personality and Social Psychology, 59, 12301237. Muraven, M., & Baumeister, R. F. (2000). Self-regulation and depletion of limited resources: Does self-control resemble a muscle? Psychological Bulletin, 126, 247259. Nolen-Hoeksema, S. N., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3, 400423. Ray, R. D., Ochsner, K. N., Cooper, J. C., Robertson, E. R., Gabrieli, J. D. E., & Gross, J. J. (2005). Individual differences in trait rumination and the neural systems supporting cognitive reappraisal. Cognitive, Affective & Behavioral Neuroscience, 5, 156168. Reber, P. J., & Kotovsky, K. (1997). Implicit learning in problem solving: The role of working memory capacity. Journal of Experimental Psychology: General, 126, 178203. Ridderinkhof, K. R., Ullsperger, M., Crone, E. A., & Nieuwenhuis, S. (2004). The role of the medial frontal cortex in cognitive control. Science, 306, 443447. Salemink, E., van den Hout, M., & Kindt, M. (2007). Trained interpretive bias and anxiety. Behaviour Research and Therapy, 45, 329340. Sarin, S., Abela, J. R. Z., & Auerbach, R. P. (2005). The response styles theory of depression: A test of specicity and causal mediation. Cognition and Emotion, 19, 751761. Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118, 514. See, J., MacLeod, C., & Bridle, R. (2009). The reduction of anxiety vulnerability through the modication of attentional bias: A real world study using a home-based cognitive bias modication procedure. Journal of Abnormal Psychology, 118, 6575. Tresselt, M. E., & Mayzner, M. (1966). Normative times for a sample of 134 solution words and 378 associated anagrams. Psychonomic Monograph Supplements, 1, 293298. Watkins, E., & Brown, R. G. (2002). Rumination and executive function in depression: an experimental study. Journal of Neurology, Neurosurgery and Psychiatry, 72, 400402. Watson, D., Clark, L. A., Weber, K., Assenheimer, J. S., Strauss, M. E., & McCormick, R. A. (1995). Testing a tripartite model: II. Exploring the symptom structure of anxiety and depression in student, adult, and patient samples. Journal of Abnormal Psychology, 104, 1525. Wells, T. T., & Beevers, C. G. (2010). Biased attention and dysphoria: Manipulating selective attention reduces subsequent depressive symptoms. Cognition & Emotion, 24, 719728. Wilson, E. J., MacLeod, C., Mathews, A., & Rutherford, E. M. (2006). The causal role of interpretive bias in anxiety reactivity. Journal of Abnormal Psychology, 115, 103111. Zevin, J. D., & Seidenberg, M. S. (2002). Age of acquisition effects in word reading and other tasks. Journal of Memory and Language, 47, 129.

123