Attentional bias in alcohol drinkers: A systematic review of its link with consumption variables

Patterns of implicit and explicit identity as a vegan or vegetarian in predicting healthy orthorexia and orthorexia nervosa

Orthorexia nervosa (OrNe) is an eating disorder characterised by a pathological interest and preoccupation with healthy foods and a healthy diet. Evidence suggests that tendencies towards OrNe may be prevalent across diet groups, and this is particularly the case in vegans and vegetarians. Our previous work has identified that alongside individual differences in obsessive compulsiveness and perfectionism, cognitive biases (attentional preference for healthy-related cues) are associated with OrNe, whereas explicit identity (as a vegan/vegetarian) is only associated with a healthy orthorexia form. No work has assessed whether one's known identity (explicit identity) or that form of identity which is based on fast acting cognitive associations (implicit identity) further differentiate healthy orthorexia from OrNe tendencies in addition to compulsiveness and perfectionism. One hundred and forty-four self-identified vegans (n = 45), vegetarians (n = 50) and meat-eaters (omnivores) (n = 49) (66 females, 74 males, 4 non-binary; M age = 35.09) completed measures of current hunger status, obsessive compulsivity, perfectionism, the Teruel Orthorexia Scale, perceived identity centrality as a vegan/vegetarian (explicit identity) and a "self as vegan/vegetarian" implicit association test (implicit identity). Results showed increased orthorexia tendencies in both vegans and vegetarians compared to meat eaters (omnivores) but only in terms of healthy orthorexia. In addition, no differences were shown for OrNe suggesting the diet type is not influential in pathological orthorexia. Explicit identity and current hunger status were both shown to be associated with healthy orthorexia and not OrNe. Implicit identity as a vegan/vegetarian was unrelated to both dimensions, while compulsiveness and perfectionism predicted OrNe. Despite individuals implicitly associating the self with being a vegan/vegetarian, this identity does not serve as a maker of orthorexia nervosa.

The only constant is change: Stable vs. variable aspects of food approach bias relate differently to food craving and intake

The tendency to approach food faster than to avoid it (i.e., approach bias) is thought to facilitate food intake, particularly foods that conflict with one's dietary goals. However, this relationship has been difficult to demonstrate, which ties into an ongoing debate about whether such cognitive-behavioral biases represent stable traits or fluctuating states. We thus investigated the temporal fluctuations of food approach bias (1), its within-participant association with food craving (2) and intake (3), and the role of top-down control in this bias-intake association (4). The 76 participants completed an impulsivity questionnaire and performed a smartphone-based approach-avoidance task on nine days. Every day, they also reported their daily craving, intake, and dietary intentions for 12 personalized foods they wanted to eat less or more often over the study period. Approach bias varied considerably within individuals (1), and correlated in unexpected ways with food craving (2) and intake (3); this association of approach bias with intake was moderated by inter-individual differences (rather than day-to-day fluctuations) in dietary intentions and impulsivity (4). Results emphasize the need to re-conceptualize approach bias as comprising both state and trait components, and indicate that the more trait-like aspects of top-down control gate the relationship of approach bias with intake. The large day-to-day variation in approach bias may explain why single-session bias measures often do not predict distal outcomes like body weight. Furthermore, our results suggest that interventions targeting approach bias may be most effective for certain timepoints (high-risk situations) and individuals (those with weak dietary intentions).

Neuropsychological Abnormalities Associated with Alcohol Dependence During Long-Term Rehabilitation Treatment of German Inpatients

BACKGROUND

Alcohol dependence is associated with several neuropsychological abnormalities, such as increased impulsivity or attentional bias towards drug-related stimuli. However, it is debated whether these abnormalities are on the decline after long-term abstinence from alcohol. Inpatient rehabilitation treatment enables the longitudinal investigation of such variables during a long, largely secured, period of abstinence.

METHODS

This study involved alcohol-dependent patients consecutively admitted for a duration of 14-26 weeks to an inpatient rehabilitation treatment center located in a hospital specializing in substance use disorders. Craving and impulsivity were assessed with the means of two questionnaires (e.g., OCDS-G and BIS-11); conversely, attentional bias and problems with inhibition were measured with the help of two computer-based experiments (e.g., dot-probe task and stop-signal-reaction task). Investigations were conducted at entry, after 6 weeks, and during the last two weeks of the inpatient treatment.

RESULTS

A total of 130 patients with alcohol dependence (mean age 43.3 years; 78.5% male) completed the first, N = 102 the second, and N = 83 the final assessment. Over the whole period of inpatient treatment, there was a significant decrease in patients' scores for both craving (t(83) = 7.8, p < 0.001) and impulsivity (t(82) = -3.75, p < 0.001, t(82) = 4.4, p < 0.001). However, there were no significant changes regarding attentional bias (t(82) = 0.16, p = 0.494) and inhibitory control (t(76) = 0.04, p = 0.482) scores.

CONCLUSIONS

Neuropsychological abnormalities associated with alcohol dependence might persist even after a long abstinence period. The decrease in both craving and impulsivity levels may be explained by the protected, alcohol-free, hospital environment; however, patients' risk of post-discharge relapse may remain high, as the basic neurobiological mechanisms of alcohol dependence may persist for long periods, and possibly for more than 3-6 months.

Changes of attentional bias in patients with alcohol use disorder during abstinence: A longitudinal study

BACKGROUND

Alcohol Use Disorder (AUD) is linked to an attentional bias towards alcohol-related cues (e.g. images, smells), which acquire incentive properties and promote continued consumption.

METHOD

We investigated how the general and alcohol attentional bias evolved longitudinally in AUD patients along two periods of abstinence: t = 0 (baseline, 1-3 months of abstinence) and t = 1 (follow-up; 6 months of abstinence), as well as their relationship with alcohol-related variables. General and alcohol-specific attentional bias were evaluated by the Classic and the Alcohol Stroop tests (neutral and alcohol conditions) in abstinent AUD patients and controls.

RESULTS

At t = 0, the AUD group exhibited both general and alcohol-specific attentional biases, with greater effect in the general bias. At t = 1, alcohol-specific attentional bias decreased specifically in the AUD group and reached control levels (with interference index levels increasing from 1-3 months to 6 months). However, general attentional bias showed a trend toward improvement but it did not significantly change through abstinence process (linear mixed models, controlling for age, BMI, sex and education).

CONCLUSIONS

In AUD patients, general and alcohol attentional biases exhibit different trajectories during abstinence, with the attentional bias toward alcohol improving significantly throughout this process whereas general attentional bias is maintained.

Five Challenges in Implementing Cognitive Remediation for Patients with Substance Use Disorders in Clinical Settings

Many patients with substance use disorders (SUDs) present cognitive deficits, which are associated with clinical outcomes. Neuropsychological remediation might help rehabilitate cognitive functions in these populations, hence improving treatment effectiveness. Nardo and colleagues (Neuropsychology Review, 32, 161-191, 2022) reviewed 32 studies applying cognitive remediation for patients with SUDs. They underlined the heterogeneity and lack of quality of studies in this research field but concluded that cognitive remediation remains a promising tool for addictive disorders. We capitalize on the insights of this review to identify the key barriers that currently hinder the practical implementation of cognitive remediation in clinical settings. We outline five issues to be addressed, namely, (1) the integration of cognitive remediation in clinical practices; (2) the selection criteria and individual factors to consider; (3) the timing to be followed; (4) the priority across trained cognitive functions; and (5) the generalization of the improvements obtained. We finally propose that cognitive remediation should not be limited to classical cognitive functions but should also be extended toward substance-related biases and social cognition, two categories of processes that are also involved in the emergence and persistence of SUDs.

Exploring the multiverse of analysis options for the alcohol Stroop

The alcohol Stroop is a widely used task in addiction science to measure the theoretical concept of attentional bias (a selective attention to alcohol-related cues in the environment), which is thought to be associated with clinical outcomes (craving and consumption). However, recent research suggests findings from this task can be equivocal. This may be because the task has many different potential analysis pipelines, which increase researcher degrees of freedom when analysing data and reporting results. These analysis pipelines largely come from how outlying reaction times on the task are identified and handled (e.g. individual reaction times > 3 standard deviations from the mean are removed from the distribution; removal of all participant data if > 25% errors are made). We used specification curve analysis across two alcohol Stroop datasets using alcohol-related stimuli (one published and one novel) to examine the robustness of the alcohol Stroop effect to different analytical decisions. We used a prior review of this research area to identify 27 unique analysis pipelines. Across both data sets, the pattern of results was similar. The alcohol Stroop effect was present and largely robust to different analysis pipelines. Increased variability in the Stroop effect was observed when implementing outlier cut-offs for individual reaction times, rather than the removal of participants. Stricter outlier thresholds tended to reduce the size of the Stroop interference effect. These specification curve analyses are the first to examine the robustness of the alcohol Stroop to different analysis strategies, and we encourage researchers to adopt such analytical methods to increase confidence in their inferences across cognitive and addiction science.

Exploring Attentional Bias toward Alcohol Content: Insights from Eye-Movement Activity

INTRODUCTION

Attentional bias (AB) is an implicit selective attention toward processing disorder-significant information while neglecting other environmental cues. Considerable empirical evidence highlights the clinical implication of AB in the onset and maintenance of substance use disorder. An innovative method to explore direct measures of AB relies on the eye-movement activity using technologies like eye-tracking (ET). Despite the growing interest regarding the clinical relevance of AB in the spectrum of alcohol consumption, more research is needed to fully determine the AB patterns and its transfer from experimental to clinical applications. The current study consisted of three consecutive experiments. The first experiment aimed to design an ad-hoc visual attention task (VAT) consisting of alcohol-related and neutral images using a nonclinical sample (n = 15). The objective of the second and third experiments was to analyze whether the effect of type of image (alcohol-related vs. neutral images) on AB toward alcohol content using the VAT developed in the first experiment was different for type of drinker (light vs. heavy drinker in the second experiment [n = 30], and occasional social drinkers versus alcohol use disorder (AUD) patients in the third experiment [n = 48]).

METHODS

Areas of interest (AOIs) within each type of image (neutral and alcohol-related) were designed and raw ET-based data were subsequently extracted through specific software analyses. For experiment 1, attention maps were created and processed for each image. For experiments 2 and 3, data on ET variables were gathered and subsequently analyzed through a two-way ANOVA with the aim of examining the effects of the type of image and drinker on eye-movement activity.

RESULTS

There was a statistically significant interaction effect between type of image and type of drinker (light vs. heavy drinker in experiment 2, F(1, 56) = 13.578, p < 0.001, partial η2 = 0.195, and occasional social drinker versus AUD patients in the experiment 3, F(1, 92) = 35.806, p < 0.001, partial η2 = 0.280) for "first fixation" with large effect sizes, but not for "number of fixations" and "dwell time." The simple main effect of type of image on mean "first fixation" score for AUD patients was not statistically significant.

CONCLUSION

The data derived from the experiments indicated the importance of AB in sub-clinical populations: heavy drinkers displayed an implicit preference for alcohol-related images compared to light drinkers. Nevertheless, AB fluctuations in patients with AUD compared to the control group were found. AUD patients displayed an early interest in alcohol images, followed by an avoidance attentional processing of alcohol-related images. The results are discussed in light of recent literature in the field.

Physical Exercise to Redynamize Interoception in Substance use Disorders

Physical exercise is considered a promising medication-free and cost-effective adjunct treatment for substance use disorders (SUD). Nevertheless, evidence regarding the effectiveness of these interventions is currently limited, thereby signaling the need to better understand the mechanisms underlying their impact on SUD, in order to reframe and optimize them. Here we advance that physical exercise could be re-conceptualized as an "interoception booster", namely as a way to help people with SUD to better decode and interpret bodily-related signals associated with transient states of homeostatic imbalances that usually trigger consumption. We first discuss how mismatches between current and desired bodily states influence the formation of reward-seeking states in SUD, in light of the insular cortex brain networks. Next, we detail effort perception during physical exercise and discuss how it can be used as a relevant framework for re-dynamizing interoception in SUD. We conclude by providing perspectives and methodological considerations for applying the proposed approach to mixed-design neurocognitive research on SUD.

Craving modulates attentional bias towards alcohol in severe alcohol use disorder: An eye-tracking study

BACKGROUND AND AIMS

Competing models disagree on three theoretical questions regarding alcohol-related attentional bias (AB), a key process in severe alcohol use disorder (SAUD): (1) is AB more of a trait (fixed, associated with alcohol use severity) or state (fluid, associated with momentary craving states) characteristic of SAUD; (2) does AB purely reflect the over-activation of the reflexive/reward system or is it also influenced by the activity of the reflective/control system and (3) does AB rely upon early or later processing stages? We addressed these issues by investigating the time-course of AB and its modulation by subjective craving and cognitive load in SAUD.

DESIGN

A free-viewing eye-tracking task, presenting pictures of alcoholic and non-alcoholic beverages, combined with a concurrent cognitive task with three difficulty levels.

SETTING

A laboratory setting in the detoxification units of three Belgian hospitals.

PARTICIPANTS

We included 30 patients with SAUD self-reporting craving at testing time, 30 patients with SAUD reporting a total absence of craving and 30 controls matched on sex and age. All participants from SAUD groups met the DSM-5 criteria for SAUD.

MEASUREMENTS

We assessed AB through early and late eye-tracking indices. We evaluated the modulation of AB by craving (comparison between patients with/without craving) and cognitive load (variation of AB with the difficulty level of the concurrent task).

FINDINGS

Dwell time measure indicated that SAUD patients with craving allocated more attention towards alcohol-related stimuli than patients without craving (P < 0.001, d = 1.093), resulting in opposite approach/avoidance AB according to craving presence/absence. SAUD patients without craving showed a stronger avoidance AB than controls (P = 0.003, d = 0.806). AB did not vary according to cognitive load (P = 0.962, η2 p  = 0.004).

CONCLUSIONS

The direction of alcohol-related attentional bias (approach/avoidance) appears to be determined by patients' subjective craving at testing time and does not function as a stable trait of severe alcohol use disorder. Alcohol-related attentional bias appears to rely on later/controlled attentional stages but is not modulated by the saturation of the reflective/control system.

Tell me how you feel, I will tell you what you look at: Impact of mood and craving on alcohol attentional bias in binge drinking

BACKGROUND

Alcohol-related attentional bias (AB) is thought to play a key role in the emergence and maintenance of excessive alcohol use. Recent models suggest that AB, classically considered as a permanent feature in alcohol use disorders, is rather modulated by temporary motivational states.

AIMS

We explored the influence of current mood and craving on AB in binge drinking, through a mood induction procedure combined with eye-tracking measures of AB.

METHODS

In Experiment 1, we measured AB (visual probe task with eye-tracking measures) among binge drinkers (n = 48) and light drinkers (n = 32) following positive, negative and neutral mood inductions. Participants reported subjective craving and mood before/after induction. In Experiment 2, we measured AB among the same binge drinkers compared with 29 moderate drinkers following alcohol-related negative, non-alcohol-related negative and neutral mood inductions.

RESULTS

In Experiment 1, induced negative mood and group positively predicted subjective craving, which was positively associated with AB. We found no effect of induced positive mood nor a direct mood-AB association. In Experiment 2, the relationships AB presented with both induced negative mood and group were again mediated by craving. Inducing alcohol-related negative mood did not modify the mood-craving association.

CONCLUSIONS

Alcohol-related AB is not a stable binge drinking characteristic but rather varies according to transient motivational (i.e., craving) and emotional (i.e., negative mood) states. This study provides important insights to better understand AB in subclinical populations and emphasizes the importance of considering motivational and affective states as intercorrelated, to offer multiple ways to reduce excessive alcohol use.

In people who drink more, facets of theory of mind may be impaired by alcohol stimuli

BACKGROUND

Theory of mind (ToM) - the ability to understand others' beliefs, mental states, and knowledge - is an important part of successful social interaction. There is a growing (albeit mixed) evidence base suggesting that individuals with substance use disorder or who are intoxicated (relative to sober controls) perform worse on a number of ToM tasks. The aim of this study was to explore the hitherto little explored notion that ToM-related capabilities such as the ability to see the world from another person's perspective (termed Visual Perspective Taking; VPT), may be impacted by alcohol-related stimuli.

METHOD

In this pre-registered study, 108 participants (M age = 25.75, SD age = 5.67) completed a revised version of the director task where they followed the instructions of an avatar to move both alcohol beverages and soft drinks that were mutually visible (target objects) while avoiding those only visible to the participant (distractor items).

RESULTS

Contrary to predictions, accuracy was lower when the target drink was alcohol and the distractor was a soft drink, although higher AUDIT scores were associated with significantly lower accuracy when alcohol drinks were the distractor items.

CONCLUSIONS

There may be some contexts when being able to see alcohol beverages makes it harder to take another person's perspective. It also appears that poorer VPT and perhaps ToM capacity may be evident in individuals who consume more alcohol. Future research is warranted to examine how alcohol beverages, alcohol consumption behaviours, and intoxication interact to impact VPT capacity.

Does alcohol automatically capture drinkers' attention? Exploration through an eye-tracking saccadic choice task

RATIONALE

Dominant theoretical models postulate the presence of an automatic attentional bias (AB) towards alcohol-related stimuli in alcohol use disorder, such AB constituting a core feature of this disorder. An early alcohol AB has been documented in subclinical populations such as binge drinking (i.e., a drinking pattern prevalent in youth and characterized by repeated alternation between alcohol intoxications and withdrawals, generating cerebral consequences). However, the automatic nature of AB remains to be established.

OBJECTIVES

We investigated the automatic nature of AB in binge drinkers through the saccadic choice task. This eye-tracking paradigm consistently highlights the extremely fast and involuntary saccadic responses elicited by faces in humans, relative to other object categories. Through an alcohol-related adaptation of the saccadic choice task, we tested whether the early and automatic capture of attentional resources elicited by faces can also be found for alcohol-related stimuli in binge drinkers, as predicted by theoretical models.

METHODS

Forty-three binge drinkers and 44 control participants performed two versions of the saccadic choice task. In the original version, two images (a face, a vehicle) were displayed on the left and right side of the screen respectively. Participants had to perform a saccade as fast as possible towards the target stimulus (either face or vehicle). In the alcohol-related version, the task was identical, but the images were an alcoholic beverage and a non-alcoholic stimulus.

RESULTS

We replicated the automatic attraction towards faces in both groups, as faces generated higher saccadic accuracy, speed, and amplitude than vehicles, as well as higher corrective saccade proportion. Concerning the alcohol-related adaptation of the task, groups did not differ for the accuracy, speed, and amplitude of the first saccade towards alcohol. However, binge drinkers differed from controls regarding the proportion of corrective saccade towards non-alcoholic stimuli after an error saccade towards alcohol, suggesting the presence of an alcohol disengagement bias specific to binge drinkers.

CONCLUSIONS

Alcohol-related AB in binge drinkers is not characterized by an early and automatic hijacking of attention towards alcohol. This AB rather relies on later and more controlled processing stages, namely a difficulty to disengage attentional resources from alcohol-related stimuli.