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Authors’ reply

Published online by Cambridge University Press:  20 March 2018

Ben Grafton*
Affiliation:
Centre for the Advancement of Research on Emotion, School of Psychological Science, University of Western Australia, Crawley, Australia
Colin MacLeod
Affiliation:
Centre for the Advancement of Research on Emotion, School of Psychology, University of Western Australia, Crawley, Australia School of Psychology, Babes-Bolyai University, Romania
Daniel Rudaizky
Affiliation:
Centre for the Advancement of Research on Emotion, School of Psychology, University of Western Australia, Crawley, Australia
Elske Salemink
Affiliation:
Developmental Psychology, University of Amsterdam, Amsterdam, the Netherlands
Elaine Fox
Affiliation:
Oxford Centre for Emotion and Affective Neuroscience, and Department of Experimental Psychology, University of Oxford, Oxford, UK
Lies Notebaert
Affiliation:
Centre for the Advancement of Research on Emotion, School of Psychology, University of Western Australia, Crawley, Australia
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Abstract

Type
Correspondence
Copyright
Copyright © The Royal College of Psychiatrists 2018 

Kruijt & Carlbring misrepresent the position conveyed in our commentary,Reference Grafton, MacLeod, Rudaizky, Holmes, Salemink and Fox1 wrongly attributing to us the suggestion ‘that we should only call CBM CBM if it is successful’. Our actual points are: (a) it cannot be claimed that cognitive bias has been modified when assessment data reveal that no modification of cognitive bias has taken place; and (b) the emotional impact of modifying cognitive bias cannot be determined from studies that fail to modify cognitive bias. Also, incorrectly, they describe our commentary as an ‘exposé on the correct question to meta-analyse’. We highlight the need to distinguish two quite different questions, without claiming that either is ‘correct’, and emphasise the resulting problems when meta-analyses fail to do so.

Our position adheres to the tenets of experimental medicine.Reference Sheeran, Klein and Rothman2 The first step in experimental medicine is to identify a target mechanism that plausibly contributes to the dysfunction of interest. For example, high blood pressure represents a mechanism that may contribute to the dysfunction of elevated stroke risk, and attentional bias to threat represents a mechanism that may contribute to the dysfunction of anxious disposition. Step two involves developing a candidate intervention intended to manipulate this mechanism. This could involve a drug intended to reduce blood pressure, or a computer procedure intended to reduce attentional bias to threat. Step three involves delivering the intervention to determine: (a) whether the intervention impacts the mechanism, as intended; and if so (b) whether this impact on mechanism therapeutically attenuates dysfunction. Should the drug fail to reduce blood pressure, with no observed reduction in stroke risk, it cannot be concluded that reducing blood pressure has no impact on stroke risk. Likewise, should the computer procedure fail to modify attentional bias to threat, with no observed reduction in anxious disposition, it cannot be concluded that modifying attentional bias to threat has no impact on anxious disposition. If the drug sometimes reduces blood pressure, and whenever this occurs stroke risk also decreases, this suggests that blood pressure reduction attenuates stroke risk. Likewise, if the computer procedure sometimes reduces attentional bias to threat, and whenever this occurs anxious disposition also decreases, this suggests that attentional bias modification alters anxious disposition.

We re-analysed Cristea et al’sReference Cristea, Kok and Cuijpers3 effect sizes to demonstrate that, when procedures intended to modify cognitive bias elicit the process of cognitive bias modification, there is consistent impact on emotional disposition. Kruijt & Carlbring contend that Cristea et al’s method of computing effect sizes compromises sensitivity to emotional disposition, which would represent a further limitation of this meta-analysis. However, compelling evidence that when procedures intended to evoke the process of cognitive bias modification do so successfully then so too do they alter emotional disposition, is not restricted to our re-analysis, and has been reported elsewhere.Reference Price, Wallace, Kuckertz, Amir, Graur and Cummings4

We advocate adherence to the experimental medicine framework, by clearly distinguishing two questions: one asks whether successfully modifying cognitive bias yields therapeutic benefit, and the other asks whether procedures intended to modify cognitive bias successfully induce this process of cognitive change.

Declaration of interest

B.G. is supported by Australian Research Council Grant DP170104533. C.M. is supported by Australian Research Council Grants DP170104533 and FL170100167. E.F. is supported by a European Research Council Advanced Investigator award (CogBIAS project REF: 324176).

References

1Grafton, B, MacLeod, C, Rudaizky, D, Holmes, EA, Salemink, E, Fox, E, et al. Confusing procedures with process when appraising the impact of cognitive bias modification on emotional vulnerability. Br J Psychiatry 2017; 211: 266–71.Google Scholar
2Sheeran, P, Klein, WMP, Rothman, AJ. Health behaviour change: moving from observation to intervention. Annu Rev Psychol 2017; 68: 573600.Google Scholar
3Cristea, IA, Kok, RN, Cuijpers, P. Efficacy of cognitive bias modification interventions in anxiety and depression: meta-analysis. Br J Psychiatry 2015; 206: 716.Google Scholar
4Price, RB, Wallace, M, Kuckertz, JM, Amir, N, Graur, S, Cummings, L, et al. Pooled patient-level meta-analysis of children and adults completing a computer-based anxiety intervention targeting attentional bias. Clin Psychol Rev 2016; 50: 3749.Google Scholar
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