The search for new ways to change implicit alcohol-related cognitions in heavy drinkers

This article summarizes a symposium on new ways to change implicit alcohol-related cognitions, presented at the 2005 Annual Meeting of the Research Society on Alcoholism in Santa Barbara, California, organized by Wiers and Cox. During the past few years, research has demonstrated that implicit cognitions predict unique variance in prospective alcohol use and preliminary results indicate that they also predict treatment outcomes. The central question in this symposium was how implicit cognitions can be changed and how the changes will influence behavior. Field presented data showing that an attentional bias for alcohol can be altered by attentional training: heavy drinkers who were trained not to attend to alcohol stimuli reported less craving and drank less beer than those trained to attend to alcohol stimuli. Schoenmakers used a similar, clinically relevant attentional retraining (AR) procedure, heavy drinkers were trained not to attend to alcohol pictures or received no training. After the training, the AR group attended less to the alcohol pictures than the control group. Fadardi described the Alcohol Attentional Control Training Program (AACTP), which makes alcohol drinkers aware of the automatic, cognitive determinants of their drinking and aims to help them to gain control over these processes. Data were presented to support the effectiveness of the AACTP. Palfai presented data showing that alcohol drinkers can be taught to use implementation intentions to gain control over their drinking, which may be used to automatically activate self-control skills in the presence of alcohol cues. In his discussion, Stacy pointed out the importance of recent cognitive theories that integrate attention and memory processes-theories that can help us better understand the mechanisms involved in AR. Together, the studies presented demonstrate that there are promising new ways in which implicit alcohol-related cognitions and their effects on drinking can be changed. After further refinement, these procedures might be used in clinical interventions that have not previously addressed implicit cognitive processes.     

Challenging implicit and explicit alcohol-related cognitions in young heavy drinkers

AIMS: To test whether an expectancy challenge (EC) changes implicit and explicit alcohol-related cognitions and binge drinking in young heavy drinkers. This is important for theoretical and practical reasons: the EC presents a critical test for the hypothesized mediational role of alcohol cognitions and the EC has been presented as a promising intervention to counter alcohol problems in heavy drinking youth. SETTING, PARTICIPANTS AND INTERVENTION: Ninety-two heavy drinking college and university students (half women) were assigned randomly to the EC or control condition (a sham alcohol experiment in the same bar-laboratory). MEASUREMENTS: Explicit alcohol cognitions and alcohol use were assessed with paper-and-pencil measures. Alcohol use was assessed prior to the experiment and during a 1-month follow-up. Implicit alcohol-related cognitions were assessed with two versions of the Implicit Association Test (IAT), adapted to assess implicit valence and arousal associations with alcohol. FINDINGS AND CONCLUSIONS: The EC resulted in decreased explicit positive arousal expectancies in men and women alike. There was some evidence for a differential reduction in implicit arousal associations, but findings depended on the version of the IAT and on the scoring-algorithm used. In men (but not in women) there was a short-lived differential reduction in prospective alcohol use (significant in week 3 of the follow-up), and this reduction was partially mediated by the decrease in explicit positive arousal expectancies. These findings suggest that an EC successfully changes explicit alcohol cognitions and that this may have short-lived beneficial effects in heavy drinking young men.     

Changing expectancies: cognitive mechanisms and context effects

This article presents the proceedings of a symposium at the 2002 RSA Meeting in San Francisco, organized by Reinout W. Wiers and Mark D. Wood. The symposium combined two topics of recent interest in studies of alcohol expectancies: cognitive mechanisms in expectancy challenge studies, and context-related changes of expectancies. With increasing recognition of the substantial role played by alcohol expectancies in drinking, investigators have begun to develop and evaluate expectancy challenge procedures as a potentially promising new prevention strategy. The two major issues addressed in the symposium were whether expectancy challenges result in changes in expectancies that mediate intervention (outcome relations), and the influence of simulated bar environments ("bar labs," in which challenges are usually done) on expectancies. The presentations were (1) An introduction, by Jack Darkes; (2) Investigating the utility of alcohol expectancy challenge with heavy drinking college students, by Mark D. Wood; (3) Effects of an expectancy challenge on implicit and explicit expectancies and drinking, by Reinout W. Wiers; (4) Effects of graphic feedback and simulated bar assessments on alcohol expectancies and consumption, by William R. Corbin; (5) Implicit alcohol associations and context, by Barry T Jones; and (6) A discussion by Kenneth J. Sher, who pointed out that it is important not only to study changes of expectancies in the paradigm of an expectancy challenge but also to consider the role of changing expectancies in natural development and in treatments not explicitly aimed at changing expectancies.     

Response Inhibition Moderates the Relationship Between Implicit Associations and Drinking Behavior

Background:  Contemporary dual-process models of alcohol abuse propose that alcohol abuse develops because of dysfunctions in the impulsive system, which generates automatic impulses to drink alcohol, and disruptions in the reflective system, which becomes unable to inhibit the influence of these automatic impulses. Based on these insights, this study investigated whether individual differences in the ability of the reflective system to exert response inhibition moderate the relationship between automatic cognitive processes and drinking behavior. Specifically, it was examined whether the interaction between implicit alcohol-related associations and response inhibition predicted drinking behavior.
Methods:  Seventy-one university students completed the study online via the Internet. Implicit alcohol associations with positive affect and with arousal were assessed with variants of the Implicit Association Test. Response inhibition was measured using the original Stroop task. Participants also reported their weekly alcohol use and alcohol-related problems.
Results:  As predicted, implicit associations were unrelated to drinking behavior when response inhibition was high. In contrast, when response inhibition was low, stronger implicit associations between alcohol and positive affect predicted increased alcohol use and alcohol-related problems.
Conclusions:  These findings indicate that the relationship between automatic cognitive processes, originating in the impulsive system, and drinking behavior depends on individual differences in response inhibition exerted by the reflective system. As prolonged alcohol abuse is known to impair response inhibition, alcohol abusers may benefit from interventions that increase response inhibition, thereby restoring inhibitory control over automatic impulses.     

Implicit and explicit alcohol cognitions and observed alcohol consumption: three studies in (semi)naturalistic drinking settings

Aims Dual‐process models imply that alcohol use is related to implicit as well as explicit cognitive processes. Few studies have tested whether both types of processes are related to ad libitum drinking. In a series of three studies, we tested whether both implicit and explicit alcohol‐related cognitions predicted the amount of alcohol consumed in an ad libitum (semi)naturalistic drinking situation. Design Two experimental studies used trained confederates (same‐sex peers) who consumed either alcoholic or non‐alcoholic beverages, while observing participants' drinking behaviour in a 30‐minute session. The third study involved observations of participants' alcohol use during a 45‐minute session in which participants spent time with five to seven friends. Setting A (semi)naturalistic drinking setting, a laboratory bar. Participants Participants were undergraduates recruited at Radboud University (study 1: n = 115; study 2: n = 121; study 3: n = 200). Measurements We used coding of drinking behaviour from observations, questionnaire data on positive alcohol expectancies and alcohol use patterns and implicit association tests to assess alcohol associations. Findings Implicit associations were not related to observed alcohol use, whereas explicit positive expectancies were related positively to observed alcohol use in study 1 and study 2. Conclusions Among undergraduate students in (semi)naturalistic drinking settings with peers, implicit alcohol‐related cognitions do not predict the amount of alcohol consumed.     

Alcohol Expectancies and Drinking Refusal Self‐Efficacy Mediate the Association of Impulsivity With Alcohol Misuse

Background: Recent work suggests that 2 biologically based traits convey risk for alcohol misuse: reward sensitivity/drive and (rash) impulsiveness. However, the cognitive mechanisms through which these traits convey risk are unclear. This study tested a model predicting that the risk conveyed by reward sensitivity is mediated by a learning bias for the reinforcing outcomes of alcohol consumption (i.e., positive alcohol expectancy). The model also proposed that the risk conveyed by rash impulsiveness (RI) is mediated by drinkers’ perceived ability to resist alcohol (i.e., drinking refusal self‐efficacy). Methods: Study 1 tested the model in a sample of young adults (n = 342). Study 2 tested the model in a sample of treatment‐seeking substance abusers (n = 121). All participants completed a battery of personality, cognitive, and alcohol use questionnaires and models were tested using structural equation modeling. Results: In both studies, the hypothesized model was found to provide a good fit to the data, and a better fit than alternative models. In both young adults and treatment‐seeking individuals, positive alcohol expectancy fully mediated the association between reward sensitivity and hazardous alcohol use. For treatment seekers, drinking refusal self‐efficacy fully mediated the association between RI and hazardous drinking. However, there was partial mediation in the young adult sample. Furthermore, neither trait was directly associated with the other cognitive mediator. Conclusions: The hypothesized model was confirmed on a large sample of young adults and replicated on a sample of treatment‐seeking substance abusers. Taken together, these findings shed further light on the mechanisms through which an impulsive temperament may convey risk for alcohol misuse.     

Influence of Alcohol Use Experience and Motivational Drive on College Students' Alcohol-Related Cognition

Background: Cognitive processes are thought to be pivotal to risk for heavy drinking. However, few studies have examined the alcohol cue‐activated positive and negative semantic memory networks that may be pivotal to drinking behavior. Moreover, much is to be understood about the influences of cognitive processes, particularly in high‐risk drinking samples such as college students. The current study examines the sequential process of alcohol cues activating valenced semantic memory networks, and the influences of prior drinking experience and individual differences in motivational drive on this automatic (implicit) cognitive process. Methods: Participants (N = 138, 52% women) were college freshmen prescreened to represent the full range of drinking experience (i.e., current abstainers, light and heavy drinkers). Participants completed self‐reports of past month alcohol use, and individual differences in behavioral inhibition system (BIS) and behavioral approach/activation system (BAS). Alcohol cue‐elicited positive and negative semantic memory networks were assessed using a priming task. Results: Results from the priming task revealed that for light drinkers alcohol cues were equally as likely to activate positive and negative semantic memory networks, suggesting relatively neutral cue‐elicited alcohol attitudes. Conversely, for heavy drinkers, alcohol cues more readily activated positive relative to negative semantic memory networks, suggesting relatively positive cue‐elicited alcohol attitudes. Furthermore, positive alcohol cue‐elicited semantic memory networks (positive attitudes) were evident for individuals characterized by a strong BAS and weak BIS (as hypothesized) and those characterized by a weak BAS and weak BIS. Conclusions: The findings suggest that alcohol‐cue elicited positive semantic memory networks may be pivotal to risk for heavy drinking. Specifically, it is via the influence on this cognitive process that prior drinking experience and individual differences in motivational drive, respectively, may maintain and predispose individuals to risk for heavy alcohol use.     

Mood and implicit alcohol expectancy processes: predicting alcohol consumption in the laboratory

Background: Implicit positive alcohol expectancy (PAE) processes are thought to respond phasically to external and internal stimuli—including mood states—and so they may exert powerful proximal influences over drinking behavior. Although social learning theory contends that mood states activate mood‐congruent implicit PAEs, which in turn lead to alcohol use, there is a dearth of experimental research examining this mediation model relative to observable drinking. Moreover, an expectancy theory perspective might suggest that, rather than influencing PAEs directly, mood may moderate the association between PAEs and drinking. To test these models, this study examined the role of mood in the association between implicitly measured PAE processes (i.e., latency to endorse PAEs) and immediate alcohol consumption in the laboratory. Gender differences in these processes also were examined. Method: College students (N = 146) were exposed to either a positive, negative, or neutral mood induction procedure, completed a computerized PAE reaction time (RT) task, and subsequently consumed alcohol ad libitum. Results: The mood manipulation had no direct effects on drinking in the laboratory, making the mediation hypothesis irrelevant. Instead, gender and mood condition moderated the association between RT to endorse PAEs and drinking in the laboratory. For males, RT to tension reduction PAEs was a stronger predictor of volume of beer consumed and peak blood alcohol concentration in the context of general arousal (i.e., positive and negative mood) relative to neutral mood. RT to PAEs did not predict drinking in the laboratory for females. Conclusions: The results show that PAE processes are important determinants of immediate drinking behavior in men, suggesting that biased attention to mood‐relevant PAEs—as indicated by longer RTs—predicts greater alcohol consumption in the appropriate mood context. The findings also highlight the need to consider gender differences in PAE processes. This study underscores the need for interventions that target automatic cognitive processes related to alcohol use.     

Association of alcohol dehydrogenase genes with alcohol-related phenotypes in a Native American community sample

Background: Previous linkage studies, including a study of the Native American population described in the present report, have provided evidence for linkage of alcohol dependence and related traits to chromosome 4q near a cluster of alcohol dehydrogenase (ADH) genes, which encode enzymes of alcohol metabolism. Methods: The present study tested for associations between alcohol dependence and related traits and 22 single‐nucleotide polymorphisms (SNPs) spanning the 7 ADH genes. Participants included 586 adult men and women recruited from 8 contiguous Native American reservations. A structured interview was used to assess DSM‐III‐R alcohol dependence criteria as well as a set of severe alcohol misuse symptoms and alcohol withdrawal symptoms. Results: No evidence for association with the alcohol dependence diagnosis was observed, but an SNP in exon 9 of ADH1B (rs2066702; ADH1B*3) and an SNP at the 5′ end of ADH4 (rs3762894) showed significant evidence of association with the presence of withdrawal symptoms (p = 0.0018 and 0.0012, respectively). Further, a haplotype analysis of these 2 SNPs suggested that the haplotypes containing either of the minor alleles were protective against alcohol withdrawal relative to the ancestral haplotype (p = 0.000006). Conclusions: These results suggest that variants in the ADH1B and ADH4 genes may be protective against the development of some symptoms associated with alcohol dependence.     

Subdiagnostic alcohol use by depressed men and women seeking outpatient psychiatric services: consumption patterns and motivation to reduce drinking

Background: This study examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment, including factors associated with recent heavy episodic drinking and motivation to reduce alcohol consumption. Methods: The sample consisted of 1,183 patients aged 18 and over who completed a self‐administered, computerized intake questionnaire and who scored ≥10 on the Beck Depression Inventory‐II (BDI‐II). Additional measures included current and past alcohol questions based on the Addiction Severity Index, heavy episodic drinking (≥5 drinks on 1 or more occasions in the past year), alcohol‐related problems on the Short Michigan Alcoholism Screening Test (SMAST), and motivation to reduce drinking using the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Results: Among those who consumed any alcohol in the past year (73.9% of the sample), heavy episodic drinking in the past year was reported by 47.5% of men and 32.5% of women. In logistic regression, prior‐year heavy episodic drinking was associated with younger age (p = 0.011), male gender (p = 0.001), and cigarette smoking (p = 0.002). Among patients reporting heavy episodic drinking, motivation to reduce alcohol consumption was associated with older age (p = 0.008), greater usual quantity of alcohol consumed (p < 0.001), and higher SMAST score (p < 0.001). Conclusions: In contrast to prior clinical studies, we examined subdiagnostic alcohol use and related problems among psychiatric outpatients with depression. Patients reporting greater drinking quantities and alcohol‐related problems also express more motivation to reduce drinking, providing intervention opportunities for mental health providers that should not be overlooked.     

Students' Drinker Prototypes and Alcohol Use in a Naturalistic Setting

Background:  Perceptions about the type of people who drink, also referred to as drinker prototypes, may strengthen young people's motivation to engage in alcohol use. Previous research has shown that drinker prototypes are related to alcohol consumption in both adolescents and young adults. However, the evidence for the strength of these relationships remains inconclusive. One of the caveats in former studies is that all insights about prototype relations are based on self-reported data from youngsters themselves, mostly gathered in a class situation, which may contain bias due to memory distortions and self-presentation concerns.
Methods:  The present study examined the impact of drinker prototypes on young adults' drinking patterns by using a less obtrusive measure to assess alcohol consumption, i.e. ad lib drinking among friend groups in the naturalistic setting of a bar lab. Drinker prototypes, self-reported alcohol use in the past, and observed alcohol intake in the bar lab were assessed among 200 college students. Relations between participants' drinker prototypes and their self-reported and observed drinking behavior were examined by computing correlations and conducting multilevel analyses.
Results:  Drinker prototypes were related to both self-reported and observed alcohol use. However, the drinking patterns of friend group members had a strong impact on participants' individual drinking rates in the bar lab. After these group effects had been controlled for, only heavy drinker prototypes showed relations with observed alcohol intake in the bar lab.
Conclusions:  These findings further establish the value of drinker prototypes in predicting young adults' drinking behavior and suggest that people's motivation to drink alcohol in real-life drinking situations is related to their perceptions about heavy drinkers.     

Acute Alcohol Effects on Inhibitory Control and Implicit Cognition: Implications for Loss of Control Over Drinking

Alcohol impairs inhibitory control, and it alters implicit alcohol cognitions including attentional bias and implicit associations. These effects are seen after doses of alcohol which do not lead to global impairments in cognitive performance. We review studies which demonstrate that the effects of alcohol on inhibitory control are associated with the ability of alcohol to prime alcohol‐seeking behavior. We also hypothesize that alcohol‐induced changes in implicit alcohol cognitions may partially mediate alcohol‐induced priming of the motivation to drink. Based on contemporary theoretical models and conceptualizations of executive function, impulsivity, and the motivational salience of alcohol‐related cues, we speculate on other aspects of cognition that may underlie alcohol’s effects on alcohol seeking. Inconsistencies in existing research and priorities for future research are highlighted, including dose effects and the potential interactions between chronic heavy drinking and the acute effects of alcohol on these cognitive processes.     

Maximum quantity consumed and alcohol-related problems: assessing the most alcohol drunk with two measures

PURPOSES: The maximum amount of alcohol consumed on any day is an important indicator of problem drinking. This study examined the ability of 2 maximum measures, taken individually and in combination, to predict alcohol-related consequences and dependence symptoms. METHOD: We analyzed data from 4,296 current drinkers who participated in the 2000 National Alcohol Survey (N10) and provided complete data on several alcohol measures. Items included the most they drank in any day in the past 12 months assessed by 2 questions: a standard question with a 6-level categorical response format and an open-ended (continuous) question referencing the occasion that you had the most to drink that followed items on drinking contexts. RESULTS: In a within-subjects analysis, more than two-thirds of the respondents provided consistent responses on both questions (69.9%), 12.4% respondents reported higher maximum quantities on the open-ended question partitioned into equivalent categories, and 17.7% reported a higher maximum on the initial categorical question. In multiple logistic regression analyses predicting alcohol-related consequences, the continuous open-ended maximum or the mean of the 2 maximum items were the strongest predictors, whereas for predicting alcohol dependence symptoms, the maximum of the open-ended and closed-ended maximum items was a better predictor than each measure alone. CONCLUSION: Although categorical response formats generally capture high-quantity drinking better than open-ended formats, use of a second, alternatively formatted "most drunk" question may modestly improve ability to predict survey indicators of alcohol use disorders.     

Visuoperceptual learning in alcoholic Korsakoff syndrome

Relative to the characteristically profound deficits of explicit memory, components of implicit memory remain largely intact in patients with alcohol-induced Korsakoff syndrome (KS). Perceptual priming occurs in KS and transfer of learning has been consistently observed on mirror reading, a perceptual reversal task. Although priming also occurs with fragmented pictures, a perceptual closure task, it is unclear whether transfer of learning can occur. This study examined visuoperceptual learning in 4 men with alcoholic KS, 9 recently detoxified alcoholic men (ALC), 21 healthy age-matched normal control men (NC), and 6 young normal control men (YNC). Subjects were tested with the Gollin Incomplete Pictures Test at initial and 1-hour and 1-day retest sessions. Both alcoholic groups (KS, ALC) were impaired in visuoperceptual ability. All subject groups showed visuoperceptual learning. The KS group showed additional learning after continued exposure to the stimuli, despite their nonmnemonic visuospatial deficits and profound explicit memory impairment for the test stimuli. Transfer of learning to similar but new stimuli was not evident in either the KS or young healthy control subjects; learning occurred only for the specific items presented. The persistence of learning beyond the life of the percept, which was independent of declarative features (such as item recall), suggests that perceptual learning and memory reflects an intact cognitive memory process in KS. This process is likely mediated by posterior cortical networks relatively unaffected in KS and that are independent of the hippocampal-diencephalic declarative memory system.     

Paradoxical Effects of Alcohol Information on Alcohol Outcome Expectancies

Background: Cognitive associations with alcohol predict both current and future use in youth and young adults. Much cognitive and social cognitive research suggests that exposure to information may have unconscious influences on thinking and behavior. The present study assessed the impact of information statements on the accessibility of alcohol outcome expectancies. Methods: The 2 studies reported here investigated the effects of exposure to alcohol statements typical of informational approaches to prevention on the accessibility of alcohol outcome expectancies. High school and university students were presented with information statements about the effects of alcohol and other commercial products. The alcohol statements were taken from expectancy questionnaires. Some of these statements were presented as facts and others as myths. The retention of detailed information about these statements was manipulated by (i) divided attention versus focused attention or (ii) immediate versus delayed testing. Accessibility of personal alcohol outcome expectancies was subsequently measured using an open‐ended question about the expected effects of alcohol. Results: Participants reported more alcohol outcomes seen during the information task as personal expectations about the effects of alcohol use than similar unseen items. Paradoxically, myth statements were also more likely to be reported as expectancies than unseen items in all conditions. Additionally, myth statements were generated less often than fact statements only under the condition of immediate testing with strong content processing instructions. Conclusions: These observations are consistent with findings from cognitive research where familiarity in the absence of explicit memory can have an unconscious influence on performance. In particular, the exposure to these items in an informational format increases accessibility of the seen items even when the participants were told that they were myths. The findings have implications for the development of effective prevention materials.     

Free-choice ethanol consumption under the influence of GABAergic drugs in rats

BACKGROUND: Neurobiological mechanisms leading from controlled alcohol consumption to addiction are poorly understood. Among multiple neurotransmitters gamma-amino-butyric acid (GABA) is suggested to play a role. The present investigation studied effects of drugs interacting with the GABAergic system on the motivation of ethanol consumption. METHODS: Fifty male PVG/OlaHsd rats were analyzed for free-choice ethanol drinking behavior without and with pre-exposure to drugs acting on the GABAergic system. For pretreatment, animals received the benzodiazepine agonists or antagonists diazepam, flumazenil, or Ro15-4513, or the GABA uptake inhibitor tiagabine via the drinking water for 4 weeks (day -21 until day 7). On day 0, two bottles containing 5% and 12% ethanol were added. On day 7, GABAergic drug exposure was discontinued and drug solutions were replaced by water. Between days 8 and 35, three alcohol deprivation periods of 1 to 3 days were randomly implemented. RESULTS: The animals ingested substantial amounts of ethanol that was differentially affected by the GABAergic drugs. Diazepam increased and flumazenil decreased ethanol consumption significantly by about 30%. Without GABAergic drug pretreatment, a significant alcohol deprivation effect indicated by enhanced ethanol consumption after re-exposure to alcohol was observed after the third deprivation phase. The deprivation effect was prevented by pretreatment with diazepam or flumazenil, unaffected by Ro15-4513, and advanced by tiagabine. CONCLUSIONS: Modulation of GABAergic neurotransmission affects subsequent ethanol consumption and deprivation effects. Because enhancing of the GABAergic tone by the GABA uptake inhibitor tiagabine or by the benzodiazepine diazepam had different behavioral consequences, it seemed likely that the two drugs induce differential adaptive changes leading to distinct alterations in the motivation to consume alcohol.