11-04-2026, 19:34 background module 5: Addiction and Compulsive Disorders
background module 5
Cognitive Bias Modification (CBM)
The current module on CBM builds on Modules 1 and 2, which introduced the roles of craving (via
Pavlovian conditioning), habits (via instrumental conditioning), and cognitive (or executive) control
processes in substance use. This module focuses on several key phenomena, including approach
bias toward drugs, memory bias, and attentional bias (briefly outlined below). Within the dual-
process framework of CBM, these biases are thought to arise from bottom-up associative
processes (Pavlovian and/or instrumental), with their influence shaped by top-down cognitive
control. In contrast, a more recent inferential account proposed by Wiers and colleagues (2020)
argues that the effectiveness of CBM primarily depends on inferential processes. Although this
remains an open debate, the assigned readings present the arguments advanced by Wiers et al.
(2020) in support of the inferential perspective.
The clinical relevance of the approach bias and attention bias is evident. Existing treatments
(mainly CBT) are not effective for all patients, with some estimates suggesting that 40-60% of
them relapse into the old pattern of substance abuse within ~6 months (source: NIDA), and 70%
within three years. Several recent studies suggest that additional cognitive bias retraining (i.e.,
cognitive bias modification; CBM) may reduce this high risk of relapse (Wiers et al., 2016).
Below, the three tasks that can be used to measure the approach bias, attentional bias, and
memory bias are briefly described.
Approach bias: The approach bias is the tendency to approach appetitive stimuli. This can be
investigated with the AAT: approach-avoidance task. For example, pictures of alcoholic and
non-alcoholic drinks are shown on the computer screen. Sometimes the images are tilted to the
right and sometimes to the left. Based on this 'irrelevant feature' (the direction in which the image
is tilted), participants are instructed to pull a joystick towards them (approach response: in this
case, the image becomes larger) or to push it away (avoidance response: in this case, the image
becomes smaller). For example: right tilt means approach, and left tilt avoid. The purpose of the
'zooming feature' (with pictures becoming larger or smaller depending on the response) functions
to generate a strong sense of approach and avoidance. The alcoholic and soft drinks are depicted
equally often with a tilt to the right and to the left. A faster reaction time when drawing the alcoholic
drinks towards you then when pushing it away would be interpreted here as an approach bias.
The soft drinks in this example serve as a control or baseline to determine whether the approach
bias to alcoholic drinks is stronger than to non-alcoholic drinks.
[Link] 1/4
11-04-2026, 19:34 background module 5: Addiction and Compulsive Disorders
Illustration of the (irrelevant-feature) AAT with smoking-related cues, from: Machulska et al. (PLOS-one, 2015)
Attention bias: The attention bias is a form of selective attention that addicts have for drug-
associated stimuli. This can be examined with several tasks. The addiction Stroop task (based
on the classical Stroop task) requires participants to name the font colour of written words, with
interference occurring when the words are drug-related, resulting in a slower reaction time
(Ramey & Regier, 2020). Another attention task is the dot-probe test. In this test, subjects are
presented with two stimuli, e.g. a drug-related one and a neutral one. Then one of the two stimuli
is replaced with a specific stimulus to which the subject must respond (e.g.: "do you see 1 or 2
dots?"). A shorter response time to a stimulus that replaces a substance-related cue (as opposed
to a neutral cue) is interpreted here as a attentional bias for substance-related peripheral stimuli.
Illustration of the dop-probe task, from: Zhao et al. (Front. Hum. Neurosci., 2018)
Memory bias: Automatically activated memory associations can be measured with the Implicit
Association Task (IAT). This is a categorization task in which the subject has to categorize words
or pictures into 2 x 2 categories with a left and right button. For example: pictures of drinks should
be categorized by nonalcoholic (left) versus alcoholic (right), and active versus passive (arousal
dimension). If subjects respond more quickly when alcohol and 'active’ share a button (and thus
non-alcoholic drinks and passive share the other button), than when the categories are divided
[Link] 2/4
11-04-2026, 19:34 background module 5: Addiction and Compulsive Disorders
over the buttons the opposite way, this would indicate that they associate alcohol with high
arousal. Or alternatively, the categories could be evaluative (positive versus negative).
Illustration of the IAT
The three tasks that are briefly explained here can also be used to re-train cognitive biases, as will
be discussed during the lecture by Prof. Reinout Wiers (also see the study material for an
explanation: Schoenmakers et al. (2010) and Wiers et al (2011)).
Weighing the evidence: the importance of distinguishing between proof-of-principle studies and
clinical trials
When reviewing the evidence for the effectiveness of CBM it is crucial to distinguish between
experimental proof-of-principle studies and clinical studies. Proof-of-principle studies are typically
conducted in the lab to reveal psychological mechanisms underlying human behavior in the lab
(usually in healthy volunteers). In contrast, randomized controlled trials (RCTs) are conducted in a
clinical setting with patients, to test the efficacy of an intervention in a clinical sample. In RCT's,
the effect of a treatment (intervention) is compared with that of a control treatment (either another
treatment or placebo), and patients are randomly assigned to the experimental and control
groups. RCT's are generally considered the gold standard for testing the effectiveness of a
treatment.
Wiers, Boffo and Field (2018) reviewed the evidence for the effectiveness of CBM interventions for
alcohol use disorders. They distinguished between (1) proof-of-principle studies, (2a) online
studies in which self-identified problem drinkers receive CBM as a stand-alone intervention, and
(2b) RCT’s in which CBM is added to treatment as usual of alcohol-dependent patients.
They concluded that proof-of-principle studies are important, because these provide the basis for
clinical trials, but that CBM tends to have only small, short-lived effects on drinking in student
volunteers, that are not clinically relevant. However, clinical trials show that CBM does hold
promise as an add-on intervention to treatment of alcohol-dependent patients. There are many
differences between proof-of-principle studies and clinical trials that could explain the slight
divergence in findings, but the most important are outlined in the table below (derived from Wiers,
Boffo and Field, 2018).
[Link] 3/4
11-04-2026, 19:34 background module 5: Addiction and Compulsive Disorders
ABC training
As part of the study material for this module, you will learn about the recent suggestions of Wiers
and colleagues for improving traditional CBM. In ABC training, patients are trained with personally
relevant antecedent cues (A) to make goal-relevant behavioral choices (B) in light of their
consequences (C).
[Link] 4/4