summary of four psychology articles

BRIEF REPORT

A Pilot Open Trial of Cognitive Bias Modification for Panic Disorder

Courtney Beard1,2 • Cara Fuchs2,3 • Anu Asnaani4 • Molly Schulson2 •

Casey A. Schofield5 • Elise M. Clerkin6 • Risa B. Weisberg2,7,8

� Springer Science+Business Media New York 2016

Abstract Although cognitive biases are involved in the

maintenance of panic disorder (PD), cognitive bias modi-

fication (CBM) has not been tested in PD. The current

study developed and piloted a combined CBM-attention/

CBM-interpretation PD treatment to determine initial

acceptability and efficacy. Ten individuals diagnosed with

PD (nine with Agoraphobia) were asked to complete 8,

20-min sessions of a CBM-A (Dot Probe task with fearful

faces) and CBM-I (Word-Sentence Association Paradigm)

intervention. Cognitive bias, panic symptom severity, and

anxiety during interoceptive exercises were assessed at pre-

and post-assessments. At post-treatment, participants

showed increased benign interpretations, reduced threat

interpretations of ambiguous panic situations, and reported

significantly less severe panic symptoms with six individ-

uals meeting criteria for remission. Anticipatory anxiety for

interoceptive exercises decreased following treatment, but

duration of exercises and anxiety following the exercises

did not. Results suggest that further testing of the treatment

and putative mechanisms of action is warranted.

Keywords Panic disorder � Cognitive bias modification � Attention � Interpretation

Introduction

Cognitive bias modification (CBM) refers to a variety of

tasks designed to affect cognitive biases underlying psy-

chopathology. When used as a treatment, CBM tasks

attempt to induce a healthier cognitive style in order to

improve emotional reactivity and clinical symptoms. Var-

ious CBM tasks targeting attention (CBM-A) and inter-

pretation (CBM-I) biases have been tested in most anxiety

disorders and related disorders (for reviews, see Beard

et al. 2012; Linetzky et al. 2015; Menne-Lothman et al.

2014; Mogoaşe et al. 2014; and Special Section of Cog-

nitive Therapy and Research, Woud and Becker 2014).

However, no studies have tested CBM as a treatment for

panic disorder (PD). Given that PD is also characterized by

attention and interpretation biases (Harvey et al. 1993;

Maidenberg et al. 1996; McNally et al. 1990; Teachman

et al. 2007), CBM may also be indicated for PD.

There is experimental evidence suggesting CBM may be

able to modify cognitive bias in individuals with related

symptoms to PD. These studies have focused on modifying

interpretation bias in individuals with elevated anxiety

sensitivity, a cognitive vulnerability closely linked to PD

(Olatunji and Wolitzky-Taylor 2009; Pilecki et al. 2011).

For example, Steinman and Teachman (2010) presented

ambiguous scenarios describing physical sensations to

individuals with elevated anxiety sensitivity. Participants

& Courtney Beard [email protected]

1 McLean Hospital/Harvard Medical School, 115 Mill St,

Mailstop 113, Belmont, MA 02478, USA

2 Department of Psychiatry, Alpert Medical School of Brown

University, Providence, RI, USA

3 Department of Psychiatry, Brigham and Women’s Hospital,

Boston, MA, USA

4 Department of Psychiatry, University of Pennsylvania,

Philadelphia, PA, USA

5 Department of Psychology, Skidmore College,

Saratoga Springs, NY, USA

6 Department of Psychology, Miami University, Oxford, OH,

USA

7 VA Boston Healthcare System, Boston, MA, USA

8 Boston University School of Medicine, Boston, MA, USA

123

Cogn Ther Res

DOI 10.1007/s10608-016-9790-0

assigned to the positive condition completed word frag-

ments that always resolved the scenario in a benign manner

and subsequently reported lower anxiety sensitivity com-

pared to control groups. This positive training group also

showed a trend of reporting less fear in response to inte-

roceptive exposures. Similar results were obtained using a

different protocol, the Word Sentence Association Para-

digm (WSAP; Beard and Amir 2009), that trained partic-

ipants to endorse benign interpretations and reject

threatening interpretations of ambiguous sentences

(MacDonald et al. 2013). Participants completing the

active version of the WSAP reported lower anxiety sensi-

tivity compared to participants completing a control task.

However, these results were inconclusive because the

overall Time 9 Condition test for anxiety sensitivity was

not significant. Further, Clerkin et al. (2015) found that two

sessions of the WSAP effectively increased benign inter-

pretation endorsement and decreased threat interpretation

endorsement in individuals with elevated anxiety sensitiv-

ity. However, no group differences emerged for anxiety

sensitivity or anxiety in response to interoceptive exercises.

These authors suggest that a lack of group differences may

be due to aspects of the control condition that encourage a

more benign interpretation style, therefore leading both

groups to show reduced anxiety. Finally, a recent ran-

domized control trial evaluated a single session of the

WSAP that incorporated a context-shifting task among a

sample with elevated anxiety sensitivity (Capron and

Schmidt 2016). Critically, this study found that changes in

interpretation bias significantly mediated the relationship

between treatment condition and reductions in anxiety

sensitivity.

These initial studies in students with elevated anxiety

sensitivity are encouraging as they all demonstrated that

CBM affected interpretation bias. Effects on self-reported

anxiety sensitivity and anxiety in response to interoceptive

exercises are also promising, but were small and not

observed across all studies. It is unclear whether or not a

higher dosage (more than one or two sessions) would

produce more robust effects on anxiety sensitivity and

reactivity. Meta-analyses suggest that there is a dose–re-

sponse relationship for CBM (e.g., Beard et al. 2012); thus,

one would expect more sessions to produce greater clinical

effects. It is also unclear whether CBM can alter attention

bias in PD because there are no studies targeting attention

bias in PD or anxiety sensitivity. Finally, it is unclear

whether findings from individuals with elevated anxiety

sensitivity will generalize to a clinical sample of individ-

uals with PD. Further studies examining the utility of CBM

as a multi-session treatment for PD are warranted.

The current study’s primary aims were to test the initial

feasibility, acceptability, and efficacy of a CBM treatment

for PD in an open trial. Similar to prior work (Beard et al.

2011; Brosan et al. 2011), we tested a combined protocol

targeting attention and interpretation biases. Both attention

and interpretation biases have been implicated in the

maintenance of PD and simultaneously targeting two

cognitive vulnerabilities may produce greater clinical

impact than only one given their combined influence (e.g.,

Everaert et al. 2013; Hirsch et al. 2006). We were inter-

ested in the percentage of participants who would complete

an eight-session protocol. We also examined changes in

cognitive bias, panic symptom severity, and anticipatory

anxiety and reactivity to interoceptive exercises. We

compared the obtained effect sizes to those of existing

treatments for PD.

Method

Participants

The local Institutional Review Board approved all study

procedures. Participants were recruited from the commu-

nity via flyers and the internet (n = 6) and from an

ongoing, longitudinal study of the naturalistic course of

anxiety disorders conducted at the same institution (n = 4).

Potential participants were initially screened for eligibility

over the telephone using the Panic Disorder Severity Scale

(PDSS; Shear et al. 2001). Participants scoring 8 or above

(Shear et al. 2001) were invited to participate in the pre-

treatment assessment. Inclusion criteria included a primary

DSM-IV diagnosis of PD established by a PhD-level

clinical psychologist using the Structured Clinical Inter-

view for the DSM-IV (First et al. 2002). Exclusionary

criteria included current (a) suicidal intent, (b) substance

dependence, (c) psychosis or manic episode, (d) cognitive

behavioral therapy (CBT), and (e) change in pharmaco-

logical treatments during the eight weeks prior to study

entry. Participants provided informed written consent and

were compensated $40 for the pre- and post-assessment.

Participants were not compensated for attending the CBM

sessions. Participants were 50 % female and diverse in

ethno-racial background (See Table 1).

CBM Intervention

Participants completed eight, 20-min CBM sessions. Con-

sistent with the most common CBM protocol participants

were asked to complete two sessions per week, separated

by at least 1 day (e.g., Amir et al. 2009a, b; Schmidt et al.

2009). Participants completed all sessions in a research

office space, and a research assistant set up the computer

and provided instructions for the tasks. During the first

session, participants received written materials providing

brief psychoeducation about anxiety and cognitive biases

Cogn Ther Res

123

(referred to as mental habits), as well as a treatment

rationale adapted from Beard et al. (2011).

During each session, participants first completed 128

trials of the CBM-Attention dot probe task. 1 Consistent

with prior protocols (Amir et al. 2009b; Schmidt et al.

2009), trials comprised combinations of probe type (E or

F), fear face position (top or bottom), and person (four

male and four female faces). Each trial began with a fix-

ation cross (‘‘?’’) presented in the center of the monitor for

500 ms. Immediately following termination of the fixation

cue, the computer presented two faces of the same indi-

vidual for 500 ms, one face on top and one on bottom. One

face displayed a neutral expression and one fear. Imme-

diately following termination of the faces, a probe (either

the letter E or F) appeared in the previous location of one

of the two faces. Participants were instructed to decide

whether the letter was an E or an F and press the corre-

sponding button (left or right) on the computer mouse. The

probe remained on the screen until participants responded,

after which the next trial began. Participants were told to

perform the task as quickly and as accurately as possible.

In order to train attention away from threat, the probes

always replaced the neutral faces.

Second, participants completed 122 trials of the CBM-I

task, the panic-relevant version of the Word-Sentence

Association Paradigm (WSAP; Beard and Amir 2009). A

trial began with a fixation cross that appeared on the

computer screen for 500 ms. Second, a word representing

either the threat (‘‘cardiac’’) or benign (‘‘exercise’’) inter-

pretation of an ambiguous sentence (‘‘Your heart is rac-

ing’’) that followed appeared in the center of the computer

screen for 500 ms. Third, the ambiguous sentence

appeared. Participants were asked to use the computer key

board to indicate their response. They were instructed to

press ‘#1’ on the number pad if the word and sentence were

related or to press ‘#3’ on the number pad if the word and

sentence were not related. Stimuli for the WSAP task were

developed to target interpretations of physical sensations

related to anxiety and to situations where individuals with

PD may feel trapped. We adopted this stimulus set from

Clerkin et al. (2015) who report piloting information.

This version of the WSAP provided feedback about

responses designed to extinguish threat interpretations and

encourage benign interpretations of ambiguous situations.

Participants received positive feedback (‘‘You are cor-

rect!’’) when they endorsed the benign interpretation or

rejected the threat interpretation of the ambiguous sen-

tence. Participants received negative feedback (‘‘Incor-

rect’’) when they endorsed the threat interpretation or

rejected the benign interpretation. Speed and accuracy

were emphasized.

Measures

Symptom Severity

The primary symptom outcome measure was the PDSS-SR

(Houck et al. 2002). We also included a behavioral

assessment of panic severity. Specifically, at both pre- and

post-treatment assessments, participants were asked to

complete four interoceptive exercises (jumping jacks,

hyperventilation, chair spinning, straw breathing), each for

60 s. They were instructed that they could stop at any time.

They reported their anxiety level (0–10) immediately

before and after each exercise, and the duration of each

exercise was recorded.

Attention Bias

Participants completed 256 trials of a dot probe assessment

task at pre- and post-treatment. The assessment task is

identical to the CBM task, with the exception that probes

replaced threat and neutral faces with equal frequency.

Interpretation Bias

Participants completed 122 trials of the WSAP. In the

assessment version, feedback about participants’ responses

is not provided. Percent of threat and benign interpretations

endorsed were calculated.

Table 1 Demographic characteristics

N (%)

Age M = 51 (SD = 8.5)

Female 5 (50 %)

Marital status

Single 4 (40 %)

Married/partner 2 (20 %)

Divorced/widowed 4 (40 %)

Highest educational degree

High school/GED 4 (40 %)

Some college 3 (30 %)

Bachelors? 3 (30 %)

Ethnoracial background

Non-Latino White 4 (40 %)

Latino 3 (30 %)

Black/African American 2 (20 %)

Multi-racial 1 (10 %)

1 The following NIMSTIM model numbers were used (fearful and

neutral expressions for each): 3, 6, 7, 9, 11, 14, 18, 19, 28, 30, 34, 37,

38, 41, 42, 43.

Cogn Ther Res

123

Results

The attrition rate was low (10 %, one participant dropped

out after session 2). Nine participants completed eight

sessions within 6 weeks and the post-treatment assessment.

We conducted paired-samples t tests and calculated

Cohen’s d effect size estimates to examine pre-post chan-

ges on outcomes.

Panic Symptom Severity

At pre-treatment, participants’ PDSS-SR scores fell in the

moderate range (M = 12.4, SD = 4.16), and at post-

treatment were in the borderline normal range (M = 4.4,

SD = 4.95), t(8) = 5.15; p = .001, d = 1.86). Speaking to

the clinical significance of these changes, six of the nine

completers (67 %) had post-treatment scores B5, a cut

point for remission (Furukawa, et al. 2009). Figure 1 pre-

sents the scores at each weekly assessment point.

Interoceptive Exercises

One participant used a wheel-chair and was unable to

attempt jumping jacks or chair spinning. The following

number of participants attempted each interoceptive exer-

cise at both time points (pre- and post-treatment): jumping

jacks (n = 6); hyperventilation (n = 8); chair spinning

(n = 7); and straw breathing (n = 8). We averaged anxiety

ratings for the exercises prior to each exercise (anticipatory

anxiety) and immediately following each exercise (anxiety

reactivity) (See Fig. 2 for ratings for each exercise).

Average anticipatory anxiety decreased from pre- to post-

treatment (t(7) = 2.5, p = .04, d = 1.2),with significant

changes specifically for hyperventilation (t(7) = 2.5,

p = .04, d = 1.04) and chair-spinning (t(6) = 2.7,

p = .035, d = 1.00). Average anxiety reactivity also

decreased from pre- to post-treatment, but this medium

effect size was not significant in this small sample

(t(7) = 1.4, p = .21, d = .71).Chair-spinning was the only

individual exercise to significantly improve on anxiety

reactivity (t(6) = 3.8, p = .009, d = 1.31). Finally, we

also averaged the amount of time participants spent doing

the exercises (duration). Duration did not change from pre-

to post-treatment (t(7) = -.65, p = .54, d = .25).

Attention Bias

Seven participants had complete attention bias data from

pre- and post-treatment assessments (one dropped out, two

participants’ data did not save correctly at one of the time

points). Accuracy was good (92 %) at pre- and post-treat-

ment. Inaccurate trials were excluded from analyses. Fol-

lowing recent recommendations for enhancing reliability of

dot probe bias scores, we eliminated response latencies

using the Winsor approach (Price et al. 2014). This elim-

inated 17 % of accurate trials. Standard attention bias

scores were calculated (mean reaction time for incongruent

trials in which probe replaced neutral face—mean reaction

time for congruent trials in which probe replaced threat

face), such that positive scores reflect more attention bias

toward threat. Attention bias scores reduced following

treatment [Pre-treatment M = 19.1 (SD = 49); Post-treat-

ment M = 4.2 (SD = 23)], but this small to moderate

effect size was not significant, (t(6) = .60, p = .57,

d = .42).

Interpretation Bias

Eight participants had complete pre- and post-treatment

WSAP data (one dropped out, one participant’s data did not

save correctly at one of the time points). Participants

showed a significant increase in benign interpretation

endorsement on the WSAP (Pre = 60 %, Post = 77 %,

t(7) = 3.20, p = .015, d = 1.22) and decrease in threat

interpretation endorsement (Pre = 64 %, Post = 22 %,

Fig. 1 Weekly PDSS-SR scores Fig. 2 Anxiety ratings for each interoceptive exercise (*p \ .05)

Cogn Ther Res

123

t(7) = -5.20, p = .001, d = 2.61), both with large effect

sizes.

Discussion

This is the first study to test a CBM intervention for PD.

Given the pilot nature of this initial study, we focused on

feasibility and effect sizes, as opposed to significance

values. The low attrition rate (1 out of 10 participants)

suggests that the intervention was acceptable to a clinical

population diagnosed with PD. As expected, attention bias

scores decreased following treatment with a small to

moderate, but not significant effect size. Effects for inter-

pretation bias were more robust; participants showed large

increases in benign interpretations and large reductions in

threat interpretations on the assessment version of the

WSAP. This successful interpretation modification con-

verges with prior studies targeting interpretation bias in

individuals with elevated anxiety sensitivity (Clerkin et al.

2015; MacDonald et al. 2013; Steinman and Teachman

2010).

Self-reported panic symptom severity decreased signif-

icantly from pre- to post-treatment. Regarding the clinical

significance of this change, the average post-treatment

panic symptom severity fell to the borderline/normal range,

with 66 % completers meeting a recommended cut-off for

remission. This response rate and the large effect size

(d = 1.86) for panic symptom severity are comparable to

those obtained following Cognitive behavioral therapy and

pharmacotherapy (Bandelow et al. 2015; Vos et al. 2012)

for PD. Consistent with meta-analyses of CBM, examina-

tion of weekly scores revealed a consistent slope of panic

symptom improvement across the eight sessions, suggest-

ing that fewer sessions may result in smaller effects on

panic symptoms.

Anticipatory anxiety, measured by anxiety ratings prior

to conducting interoceptive exposures, also reduced fol-

lowing treatment. However, anxiety following the exer-

cises, reflecting anxiety reactivity, as well as duration of

exercises, did not significantly change.

Together, these results suggest that CBM was accept-

able and potentially efficacious for improving cognitive

bias and clinical symptoms of PD. These positive initial

findings extend prior work in non-clinical samples of

individuals with elevated anxiety sensitivity (MacDonald

et al. 2013; Steinman and Teachman 2010) and converge

with prior studies employing similar combined CBM-A/

ABM-I protocols for other anxiety disorders (e.g., social

and general anxiety disorder; Beard et al. 2011; Brosan

et al. 2011). The fact that the obtained effect sizes paral-

leled existing treatments without requiring clinician contact

(with the exception of assessments) and a total of 160 min

of intervention is encouraging. However, randomized

controlled trials are necessary before we can draw con-

clusions about efficacy.

Strengths of the study include the clinical sample,

inclusion of a behavioral assessment, and ethno-racially

representative sample. However, as with all open trials, the

promising findings must be interpreted with caution due to

the pilot nature of the study. Specifically, improvement in

panic symptoms may simply be due to regression to the

mean, habituation to the panic-relevant stimuli, or more

general effects of participating in a research study (e.g.,

attention from research assistant). Reductions in anticipa-

tory anxiety at post-treatment may have been due to

practice effects of having completed the exercises in the

pre-treatment assessment. In this initial study, we did not

include a clinician-rated measure of severity or improve-

ment. Additionally, pre-post improvement in cognitive bias

only reflects the most basic of manipulation checks, as we

did not include novel stimuli or an independent task that

differed from the training task. Moreover, recent data

suggests that the dot probe task may not be a reliable

assessment of attention bias (Schmukle 2005; Staugaard

2009; Waechter et al. 2014). Thus, future studies should

include other types of attention assessments (e.g., eye

tracking, EEG). Finally, no data was collected about eye

glass/contact use.

The results of this pilot trial suggest that larger, ran-

domized controlled trials of CBM for PD are warranted to

confirm mechanisms of action and clinical efficacy. Future

study designs that include follow-up assessments and multi-

modal assessment of cognitive bias and symptoms will

greatly enhance our understanding CBM’s efficacy for PD.

It is not yet clear whether CBM can effectively alter atten-

tion bias in this population. Furthermore, larger scale studies

will enable more extensive examination into whether

changes in interpretation or attention bias (due to CBM)

directly contribute to reductions in PD symptom severity.

Clinical impact may potentially be maximized in future

studies with a higher dose, treatment matching to only those

who demonstrate cognitive biases at baseline, and more

personalized CBM tasks. Developing an appropriate control

group will be crucial given recent evidence that typical

CBM control tasks may actually be active interventions in

their own right (see Heeren et al. 2015). Results also suggest

that it may be appropriate for transdiagnostic CBM

approaches to include individuals with PD, in addition to

social anxiety and generalized anxiety, given the favorable

response to training seen in the present study.

Acknowledgments We thank Claire Walker for her assistance in data collection and entry.

Cogn Ther Res

123

Funding This study was supported by funds from the Department of Psychiatry and Human Behavior of Alpert Medical School of Brown

University.

Compliance with Ethical Standards

Conflict of Interest Courtney Beard, Cara Fuchs, Anu Asnaani, Molly Schulson, Casey A. Schofield, Elise M. Clerkin and Risa B.

Weisberg declare that they have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of

the institutional and/or national research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical

standards.

Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human exper-

imentation (national and institutional). Informed consent was

obtained from all individual subjects participating in the study.

Animal Rights No animal studies were carried out by the authors for this article.

References

Amir, N., Beard, C., Burns, M., & Bomyea, J. (2009a). Attention

modification program in individuals with generalized anxiety

disorder. Journal of Abnormal Psychology, 118, 128. doi:10.

1037/a0012589.

Amir, N., Beard, C., Taylor, C. T., Klumpp, H., Elias, J., Burns, M., &

Chen, X. (2009b). Attention training in individuals with

generalized social phobia: A randomized controlled trial.

Journal of Consulting and Clinical Psychology, 77, 961–973.

doi:10.1037/a0016685.

Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., &

Wedekind, D. (2015). Efficacy of treatments for anxiety

disorders: A meta-analysis. International Clinical Psychophar-

macology, 30, 183–192. doi:10.1097/YIC.0000000000000078.

Beard, C., & Amir, N. (2009). Interpretation in social anxiety: When

meaning precedes ambiguity. Cognitive Therapy and Research,

33, 406–415. doi:10.1007/s10608-009-9235-0.

Beard, C., Sawyer, A. T., & Hofmann, S. G. (2012). Efficacy of

attention bias modification using threat and appetitive stimuli: A

meta-analytic review. Behavior Therapy, 43, 724–740. doi:10.

1016/j.beth.2012.01.002.

Beard, C., Weisberg, R. B., & Amir, N. (2011). Combined cognitive

bias modification treatment for social anxiety disorder: A pilot

trial. Depression and Anxiety, 28, 981–988. doi:10.1002/da.

20873.

Brosan, L., Hoppitt, L., Shelfer, S., Sillence, A., & Mackintosh, B.

(2011). Cognitive bias modification for attention and interpre-

tation reduces trait and state anxiety in anxious patients referred

to an out-patient service: Results from a pilot trial. Journal of

Behavior Therapy and Experimental Psychiatry, 42, 258–264.

doi:10.1016/j.jbtep.2010.12.006.

Capron, D. W., & Schmidt, N. B. (2016). Development and

randomized trial evaluation of a novel computer-delivered

anxiety sensitivity intervention. Behaviour Research and Ther-

apy,. doi:10.1016/j.brat.2016.04.001.

Clerkin, E. M., Beard, C., Fisher, C. R., & Schofield, C. A. (2015). An

attempt to target anxiety sensitivity via cognitive bias modifi-

cation. PLoS ONE,. doi:10.1371/journal.pone.0114578.

Everaert, J., Tierens, M., Uzieblo, K., & Koster, E. H. W. (2013). The

indirect effect of attention bias on memory via interpretation

bias: Evidence for the combined cognitive bias hypothesis in

subclinical depression. Cognition and Emotion, 27, 1450–1459.

doi:10.1080/02699931.2013.787972.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002).

Structured clinical interview for DSM-IV-TR axis I disorders,

research version, patient edition. (SCID-I/P) New York:

Biometrics Research, New York State Psychiatric Institute.

Furukawa, T. A., Shear, K. M., Barlow, D. H., Gorman, J. M., Woods,

S. W., Money, R., et al. (2009). Evidence-based guidelines for

interpretation of the panic disorder severity scale. Depression

and Anxiety, 26, 922–929. doi:10.1002/da.20532.

Harvey, J. M., Richards, J. C., Dziadosz, T., & Swindell, A. (1993).

Misinterpretation of ambiguous stimuli in panic disorder.

Cognitive Therapy and Research, 17, 235–248. doi:10.1007/

BF01172948.

Heeren, A., Mogoaşe, C., McNally, R. J., Schmitz, A., & Philippot, P.

(2015). Does attention bias modification improve attentional

control? A double-blind randomized experiment with individuals

with social anxiety disorder. Journal of Anxiety Disorders, 29,

35–42. doi:10.1016/j.janxdis.2014.10.007.

Hirsch, C. R., Clark, D. M., & Mathews, A. (2006). Imagery and

interpretations in social phobia: Support for the combined

cognitive biases hypothesis. Behavior Therapy, 37, 223–236.

doi:10.1016/j.beth.2006.02.001.

Houck, P. R., Spiegel, D. A., Shear, M. K., & Rucci, P. (2002).

Reliability of the self-report version of the panic disorder

severity scale. Depression and Anxiety, 15, 183–185. doi:10.

1002/da.10049.

Linetzky, M., Pergamin-Hight, L., Pine, D. S., & Bar-Haim, Y.

(2015). Quantitative evaluation of the clinical efficacy of

attention bias modification treatment for anxiety disorders.

Depression and Anxiety, 32, 383–391. doi:10.1002/da.22344.

MacDonald, E. M., Koerner, N., & Antony, M. M. (2013).

Modification of interpretive bias: Impact on anxiety sensitivity,

information processing and response to induced bodily sensa-

tions. Cognitive Therapy and Research, 37, 860–871. doi:10.

1007/s10608-012-9519-7.

Maidenberg, E., Chen, E., Craske, M., Bohn, P., & Bystritsky, A.

(1996). Specificity of attentional bias in panic disorder and social

phobia. Journal of Anxiety Disorders, 10, 529–541. doi:10.1016/

S0887-6185(96)00028-X.

McNally, R. J., Riemann, B. C., & Kim, E. (1990). Selective

processing of threat cues in panic disorder. Behaviour Research

and Therapy, 28, 407–412. doi:10.1016/0005-7967(90)90160-K.

Menne-Lothman, C., Viechtbauer, W., Hohn, P., Kasanova, Z.,

Haller, S. P., Drukker, M., & Lau, J. Y. F. (2014). How to boost

positive interpretations? A meta-analysis of the effectiveness of

cognitive bias modification for interpretation. PLoS ONE, 9(6),

e100925. doi:10.1371/journal.pone.0100925.

Mogoaşe, C., David, D., & Koster, E. H. W. (2014). Clinical efficacy

of attentional bias modification procedures: An updated meta-

analysis. Journal of Clinical Psychology, 70, 1133–1157. doi:10.

1002/jclp.22081.

Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity

and the anxiety disorders: A meta-analytic review and synthesis.

Psychological Bulletin, 135, 974. doi:10.1037/a0017428.

Pilecki, B., Arentoft, A., & McKay, D. (2011). An evidence-based

causal model of panic disorder. Journal of Anxiety Disorders, 25,

381–388. doi:10.1016/j.janxdis.2010.10.013.

Price, R. B., Kuckertz, J. M., Siegle, G. J., Ladouceur, C. D., Silk, J.

S., Ryan, N. D., et al. (2014). Empirical recommendations for

improving the stability of the dot-probe task in clinical research.

Psychological Assessment, 27, 365–376. doi:10.1037/

pas0000036.

Cogn Ther Res

123

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, 5. doi:10.1037/a0013643.

Schmukle, S. C. (2005). Unreliability of the dot probe task. European

Journal of Personality, 19, 595–605. doi:10.1002/per.554.

Shear, M. K., Rucci, P., Williams, J., Frank, E., Grochocinski, V.,

Vander Bilt, J., et al. (2001). Reliability and validity of the Panic

Disorder Severity Scale: Replication and extension. Journal of

Psychiatric Research, 35, 293–296. doi:10.1016/S0022-

3956(01)00028-0.

Staugaard, S. R. (2009). Reliability of two versions of the dot-probe

task using photographic faces. Psychology Science Quarterly,

51, 339–350.

Steinman, S. A., & Teachman, B. A. (2010). Modifying interpreta-

tions among individuals high in anxiety sensitivity. Journal of

Anxiety Disorders, 24, 71–78. doi:10.1016/j.janxdis.2009.08.

008.

Teachman, B. A., Smith-Janik, S. B., & Saporito, J. (2007).

Information processing biases and panic disorder: Relationships

among cognitive and symptom measures. Behaviour Research

and Therapy, 45, 1791–1811. doi:10.1016/j.brat.2007.01.009.

Vos, S. P. F., Huibers, M. J. H., Diels, L., & Arntz, A. (2012). A

randomized clinical trial of cognitive behavioral therapy and

interpersonal psychotherapy for panic disorder with agoraphobia.

Psychological Medicine, 42, 2661–2672. doi:10.1017/

S0033291712000876.

Waechter, S., Nelson, A. L., Wright, C., Hyatt, A., & Oakman, J.

(2014). Measuring attentional bias to threat: Reliability of dot

probe and eye movement indices. Cognitive Therapy and

Research, 38, 313–333. doi:10.1007/s10608-013-9588-2.

Woud, M. L., & Becker, E. S. (2014). Editorial for the special issue on

cognitive bias modification techniques: An introduction to a time

traveller’s tale. Cognitive Therapy and Research, 38, 83–88.

Cogn Ther Res

123