Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients

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Abstract

A new training to decrease attentional bias (attentional bias modification training, ABM) was tested in a randomized controlled experimental study with alcohol-dependent patients as an addition to cognitive behavioral therapy. In alcohol dependence, attentional bias has been associated with severity of alcoholism, craving, treatment outcome, and relapse. Forty-three patients with DSM-IV diagnosis of alcohol dependence were randomly assigned to an ABM intervention or control training. The procedure consisted of five sessions in which patients were trained to disengage attention from alcohol-related stimuli (ABM condition) or in which they were trained on an irrelevant reaction-time test (control condition). We measured the effects of ABM on the visual-probe task, with stimuli that were presented in the ABM and with new stimuli. Craving was measured with the Desires for Alcohol Questionnaire. Follow-up data were gathered for overall treatment success, and relapse up to 3 months after the intervention. ABM was effective in increasing the ability to disengage from alcohol-related cues. This effect generalized to untrained, new stimuli. There were no significant effects on subjective craving. For other outcome measures there were indications of clinically relevant effects. Results indicate that ABM among alcohol-dependent patients was effective and that it may affect treatment progression. Large-scale trials are warranted to further investigate this new field.

Introduction

Cognitive behavioral treatment programs primarily target voluntary information processing, ignoring the potential significance of any disadvantageous involuntary processes (McNally, 1995, Öhman, 1996). However, there is accumulating evidence that involuntary or uncontrolled cognitive mechanisms play an important role in psychopathology (Mobini and Grant, 2007, Wiers et al., 2007). New interventions directly targeting these processes may therefore be a valuable addition to existing cognitive behavioral treatment programs.

In alcohol and drug addiction, an extensively researched involuntary cognitive process is attentional bias (AB). AB is a selective attention for drug cues, which is hypothesized to have causal effects on substance abuse, addiction development and maintenance (Field, 2005, Franken, 2003, Robinson and Berridge, 1993, Weinstein and Cox, 2006). According to the incentive sensitization theory, AB results from repeated pairing of alcohol cues with direct effects of alcohol, leading to a sensitized reaction to alcohol cues which causes them to become highly salient (Robinson and Berridge, 1993, Robinson and Berridge, 2001). AB has been studied in relation to alcohol dependence (e.g. Field and Cox, 2008, Jones et al., 2006, Stetter et al., 1995) and in relation to dependence on other illicit drugs, including heroin (Lubman et al., 2000) and cocaine (Vadhan et al., 2007).

AB has been theorized to share a reciprocal causal relationship with craving (Franken, 2003, Robinson and Berridge, 1993). This relationship however, is not evident under all circumstances (Lubman et al., 2000, Noel et al., 2006, Waters et al., 2003). A recent meta-analysis showed a significant, albeit weak relationship between self-reported craving and AB (r = .19; Field et al., 2009b). This moderate correlation may be explained by a direct effect of AB on behavior without craving as a mediating factor: either as a result of habit (Tiffany, 1990) or as a result of incentive salience (Robinson and Berridge, 2001). In addition to craving and drinking behavior, studies have shown associations between AB and the severity of addiction (Bearre et al., 2007, Fadardi and Cox, 2006, Jones et al., 2006, Noel et al., 2006), poor treatment outcome (Carpenter et al., 2006), and relapse following treatment (e.g. Cox et al., 2002, Marissen et al., 2006). Further, excessive drinkers with low compared to high AB have been found to be three times more successful in cutting down (Cox et al., 2007). Altogether, these data suggest that patients may benefit from interventions that help decrease their AB toward their drug of preference, and thus positively influence their recovery.

MacLeod et al. (2002) developed a computerized task to directly modify AB for negative stimuli in anxiety. This attentional bias modification training (ABM), was based on the visual-probe task which measures AB. ABM in anxiety has been found to modify relatively early attention processes, such as the speeded detection of disorder-related stimuli (words or pictures), as well as relatively late attentional processes, such as the difficulty to disengage from these stimuli. Typically, the effectiveness of this ABM procedure has been assessed by measuring effects on AB for new stimuli that have not been used in the training (generalization), and on other disorder-relevant cognitions and behaviors.

Previous studies applying this ABM were in anxiety (Amir et al., 2009, MacLeod et al., 2002, MacLeod et al., 2007, Mathews and MacLeod, 2002, Schmidt et al., 2009, See et al., 2009), smoking (Attwood et al., 2008, Field et al., 2009a), and non-clinical samples in alcohol abuse (Field et al., 2007, Field and Eastwood, 2005, Schoenmakers et al., 2007). The effectiveness of alcohol-ABM in decreasing AB and related symptoms in controlled studies with non-clinical samples has been limited. The effects did not generalize toward new stimuli, which is essential for the training to be useful outside the laboratory. Moreover, these studies did not show any decrease in craving or drinking behavior (Field et al., 2007, Field and Eastwood, 2005, Schoenmakers et al., 2007). Such generalization appears to be an essential prerequisite for a clinically useful application of ABM, a step recently taken in anxiety research (Schmidt et al., 2009). More positively, a recent study employing a different ABM technique (based on the alcohol-Stroop task) found that after repeated training sessions, ABM and alcohol use reduced compared with baseline (there was no control group; Fadardi and Cox, 2009). Here, we present results of a randomized controlled experimental study of repeated ABM in alcoholic patients.

To the best of our knowledge, the present study is the first randomized controlled experimental study on the effectiveness of a visual probe based ABM in a clinical sample of (alcohol) dependent patients. Based on the literature, we identified three factors that appear to increase the effectiveness of ABM interventions. The first is motivating participants to improve training performance and control over their attention (Fadardi and Cox, 2009, Wiers et al., 2006). The second is the presentation of a large number of different stimuli in the training, since generalization toward new stimuli has only been found after trainings with more stimuli than used in previous alcohol-ABM studies (Amir et al., 2009, MacLeod et al., 2002, MacLeod et al., 2007, See et al., 2009, Smith et al., 2006). The final aspect is performing multiple training sessions, which have been shown to have more profound effects than single session trainings: single ABMs affected only state vulnerability for stress (MacLeod et al., 2002) whereas repeated ABM sessions affected trait anxiety (Amir et al., 2009, Mathews and MacLeod, 2002, Schmidt et al., 2009, See et al., 2009). In addition, effects on fast attentional processes were only found after multiple sessions, both in anxiety (Mathews and MacLeod, 2002), and in addiction (Fadardi and Cox, 2009).

The goal of the present randomized controlled experimental study was to test alcohol-ABM in a clinical sample of alcohol-dependent patients. The objective of the training was to improve patients’ ability to control their attention for alcohol cues. We modified our earlier ABM paradigm (Schoenmakers et al., 2007) based on the three aspects reviewed above: motivating participants, presenting many stimuli, and presenting multiple sessions. We expected the ABM to decrease the speeded detection of old and new alcohol stimuli and to decrease the difficulty to disengage from those stimuli. Additionally, we explored effects of ABM on craving, relapse and overall treatment success, as judged by patients’ therapists.

Section snippets

Overview

The intervention consisted of five sessions in which half of the participants (the ABM group) performed the ABM and the other half of the participants (the control group) performed a control training task. Pre-test measurements of AB and craving took place in the first session prior to the ABM or control training, post-test measures took place in a sixth session, 3–4 days after the last ABM or control training. Three months after the last training session, follow-up data were gathered on

Attentional bias

There were no pre-test differences between groups on both components of AB: the speeded detection of alcohol stimuli, t(41) = .70, p = .49, and difficulty to disengage from alcohol stimuli, t(41) = .13, p = .90. ANCOVA on post-test scores showed that groups’ speeded detection of alcohol-related cues did not differ for old pictures, F(1, 40) = .69, p = .41, d = .32, or for new pictures, F(1, 23) = 1.88, p = .18, d = .57. Groups did differ on the difficulty to disengage attention from old pictures, F(1, 40) = 7.54, p < 

Discussion

The primary objective of this randomized controlled experimental study was to test the effectiveness of ABM as an additional intervention in the clinical treatment of alcohol dependence. The main finding was that the ABM intervention led to a generalized decrease in one component of AB for alcohol, the difficulty to disengage attention from alcohol-related stimuli, with a large effect size (d > 1). No effects were found on the other component of AB, speeded detection, nor on subjective craving.

Role of funding source

The study was funded by the N.W.O. (Netherlands Organization for Scientific Research) Vidi-Grant 452.02.005, awarded to Reinout W. Wiers.

Contributors

Authors TS and RW designed the study and wrote the protocol. Authors IL, AG and DK ran the training sessions and data collection. Authors TS and MB undertook the statistical analysis, and author TS wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflict of interest.

Acknowledgements

We thank the people from Mondriaan Zorggroep (Heerlen and Maastricht), and from Iriszorg (Arnhem), for their contributions to this study. We thank Matt Field for helpful comments on the paper. The work was carried out at the department of Clinical Psychological Science, Maastricht University.

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