Cognitive Bias Modification for OCD

March 14, 2023 updated by: Martha J Falkenstein, Mclean Hospital

Cognitive Bias Modification as an Adjunctive Treatment for Treatment-Refractory OCD

This study will conduct the development and preliminary evaluation of Cognitive Bias Modification for Interpretation (CBM-I) and Approach Avoidance Training (AAT) as augmentations to treatment as usual for OCD and related disorders. CBM-I refers to computerized interventions designed to directly manipulate interpretation bias through repeated practice on a training task, thereby inducing cognitive changes in a relatively automatic or implicit manner. In AAT, automatic approach tendencies toward feared stimuli are re-trained. Specifically, this study will examine the feasibility, acceptability, and clinical outcomes associated with CBM-I and AAT.

Adults with obsessive compulsive disorder (OCD) and related disorders will be recruited from a treatment program for these disorders and participants will be randomly assigned to either receive: 1) eight sessions of CBM-I or eight sessions of psychoeducation as a control condition, or 2) AAT or eight sessions of an inactive (sham) version of the AAT training.

Study Overview

Study Type


Enrollment (Anticipated)



  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • United States
    • Massachusetts
      • Belmont, Massachusetts, United States, 02478
        • Recruiting
        • McLean Hospital
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers


Genders Eligible for Study



Inclusion Criteria:

  • Currently receiving treatment at the McLean Hospital OCD Institute
  • For CBM-I condition only: report a score of at least 131 on the Obsessive Beliefs Questionnaire-44 upon admission to the OCD Institute
  • For AAT condition only: endorse score of at least 7 on the DOCS subscale #1 (contamination subscale) upon admission to the OCD Institute
  • Able to complete a computer task for 20 minutes
  • Consent to main OCD Institute study protocol

Exclusion Criteria:

  • Currently undergoing electroconvulsive therapy (ECT)
  • Current symptoms of acute mania or psychosis
  • A reported diagnosis at admission of a psychotic disorder
  • History of traumatic brain injury

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Basic Science
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Triple

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Cognitive bias modification with treatment as usual
Participants in this group will receive usual treatment in the program and 8 sessions of a computerized cognitive training targeting interpretation bias
Eight sessions of scenario-based CBM-I training for OCD will be administered, based on the widely-used paradigm of ambiguous scenario training developed by Mathews and Mackintosh (2000), in which participants are presented with scenarios that are ambiguous in whether or not they are threatening. Participants will complete a computer task consisting of a series of written scenarios designed to improve interpretation and attributional biases; these scenarios conclude with word fragments, which participants must fill in to resolve the ambiguity.
Sham Comparator: Psychoeducation with treatment as usual
Participants in this group will receive usual treatment in the program and 8 sessions of psychoeducation
Eight sessions of psychoeducation will be administered, which will describe symptoms of anxiety, the nature of biased thinking in anxiety, and summarize common psychosocial as well as pharmacological treatments for anxiety. The sessions will provide relevant information but will not provide training in changing thinking styles.
Experimental: Approach avoidance training with treatment as usual
Participants in this group will receive usual treatment in the program and 8 sessions of a computerized cognitive training targeting automatic approach tendencies
Eight sessions of this computerized training program will be used to train approach tendencies, following previously validated procedures (Najmi, Kuckertz, & Amir, 2010). During the training program, participants will view a series of these images and be prompted to push or pull a joystick according to prompts on the screen, instead of the content of the picture. Avoidance will be stimulated through both pushing away (images on the screen will decrease in size upon the joystick being pushed), and approach will be stimulated through pulling towards pictures (images will increase in size to simulate approach).
Sham Comparator: Inactive sham approach avoidance training
Participants in this group will receive usual treatment in the program and 8 sessions of a sham approach avoidance training
Eight sessions of the approach avoidance training will be administered, however the percentage of push vs pull trials will be altered in this sham version of the training.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Average Score on Obsessive Beliefs Questionnaire
Time Frame: Weeks 0, 2, 4, and 8
Measure of interpretation biases, specifically: Inflated Responsibility/Overestimation of Threat, Perfectionism/Intolerance of Uncertainty, and Importance/Control of Thoughts. 44-item self-report measure, items scored 1-7 and summed; greater scores indicate greater severity.
Weeks 0, 2, 4, and 8

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Average Score on Yale-Brown Obsessive Compulsive Scale
Time Frame: Weeks 0, 4, and 8
Interviewer-rated measure of OCD symptoms. It is 19 items, with only items 1-10 scored (from 0-4). Total scores range from 0-40, with higher scores reflecting greater severity.
Weeks 0, 4, and 8
Change in Columbia-Suicide Severity Rating Scale
Time Frame: Weeks 0, 4, and 8
An interviewer-rated assessment of retrospective suicidality as well as recent suicidal ideation and behavior. Minimum total score 0, maximum total score 5, higher total scores indicate more suicidal ideation and/or behavior.
Weeks 0, 4, and 8
Change in Suicide Implicit Association Test
Time Frame: Weeks 0, 2, and 4
Computerized task which assesses implicit thoughts about self-injury, death, and suicide.
Weeks 0, 2, and 4
Change in Average Score on Depressive Symptom Index Suicidality Subscale. There are 4 items scored from 0-3 with greater numbers indicating greater severity.
Time Frame: Weeks 0, 1, 2, 3, and 4
Self-report measure of suicidality
Weeks 0, 1, 2, 3, and 4
Credibility/Expectancy Questionnaire
Time Frame: Week 0
Measure of treatment expectancy and rationale credibility in our study. The items are rated on 9-point scales, with a total score range of 3 to 27. Greater scores indicate greater expectations and perceptions of treatment credibility.
Week 0
Exit Interview
Time Frame: Week 4
This interview will be conducted by a member of the study staff to obtain participant feedback on satisfaction and how the intervention might be improved.
Week 4
Change in Behavioral Approach Test
Time Frame: Weeks 0, 2, and 4

Behavioral Approach Test (BAT) will be administered as a measure of OCD-related avoidance, based on previously validated procedures (Cougle et al., 2007; Amir, Kuckertz, & Najmi, 2013). Participants rate peak anxiety 0-100 for each step of approaching feared stimuli.

Three different types of BAT will be implemented in order to measure avoidance with multiple types of contaminants, each with six steps on a hierarchy to be completed sequentially, providing a rating of anxiety 0-100 for each step.

Weeks 0, 2, and 4
Change in Average Score on Behavioral Inhibition/Behavioral Activation Scales
Time Frame: Weeks 0, 2, 4, and 8
24-item measure of behavioral approach and behavioral avoidance, rated 1-4 and summed.
Weeks 0, 2, 4, and 8
Dimensional Obsessive-Compulsive Scale
Time Frame: Weeks 0, 2, 4, and 8
(DOCS; Abramowitz et al., 2010) participants with contamination fears will be identified by their DOCS contamination subscale score; the DOCS is part of the admission measures in the OCD Institute's main study protocol. Additionally, we will examine these scores as an outcome measure for contamination-related obsessions and compulsions. It includes 20 items and is rated 0-4.
Weeks 0, 2, 4, and 8

Collaborators and Investigators

This is where you will find people and organizations involved with this study.


Study record dates

These dates track the progress of study record and summary results submissions to Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

April 1, 2019

Primary Completion (Anticipated)

September 1, 2024

Study Completion (Anticipated)

December 1, 2024

Study Registration Dates

First Submitted

January 2, 2019

First Submitted That Met QC Criteria

January 7, 2019

First Posted (Actual)

January 10, 2019

Study Record Updates

Last Update Posted (Actual)

March 15, 2023

Last Update Submitted That Met QC Criteria

March 14, 2023

Last Verified

March 1, 2023

More Information

Terms related to this study

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product


Studies a U.S. FDA-regulated device product


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