Access to environmental reward mediates the relation between posttraumatic stress symptoms and alcohol problems and craving

Transdiagnosis of alcohol use and psychopathologies: A systematic review

Multiple diagnoses are the rule in Mental Health and alcohol use disorder (AUD) is a psychopathology with many comorbidities, requiring interventions that consider common factors, which means using a transdiagnostic perspective. This study aimed to identify in the scientific literature the main common transdiagnostic factors that link AUD to other psychopathologies in people over 18 years of age. A systematic review of the literature was carried out in the portals of the databases Pubmed, PsychINFO and CAPES. 37 articles were selected for analysis, which resulted in 25 transdiagnostic factors linked to AUD and to several other related disorders and health conditions. The results emphasize the variety of disorders and health conditions related to AUD, which highlights the importance of transdiagnostic factors for these conditions as targets for both scientific research and therapeutic interventions for this population.

Intersections between environmental reward availability, loss aversion, and delay discounting as potential risk factors for cigarette smoking and other substance use

Behavioral theory suggests that density of environmental rewarding activities and biases in decision making influence risk for substance use disorder (SUD). To better understand intersections of these potential risk factors, this study examined whether environmental reward predicted smoking status or other drug use and whether such associations were independent of two decision-making biases known to predict SUD risk, namely loss aversion and delay discounting. Individuals that reported current daily cigarette smoking (n = 186; >10 cigarettes/day) and never-smoking (n = 241; <100 cigarettes lifetime) were recruited with standard crowdsourcing methods. Participants answered questions on alcohol and other drug use. Environmental reward was assessed using the Reward Probability Index (RPI), and loss aversion (LA) and delay discounting (DD) using a gamble-acceptance task and monetary choice questionnaire, respectively. Associations of RPI, LA, and DD with cigarette smoking, alcohol use, other drug use, and combinations of co-use were examined with logistic regression controlling for sociodemographic variables (educational attainment, gender, age). Low RPI (odds ratio[OR] = 0.97, p = .006), low LA (OR = 1.22, p < .001), and high DD (OR = 1.12, p = .03), were each independently associated with increased risk for cigarette smoking, as well as other substance use, and use combinations. We saw no evidence that RPI was significantly influencing associations between LA and DD with smoking status or other substance use. Finally, RPI, but not LA or DD, was significantly associated with depressed mood and sleep disturbance. These results provide new evidence on associations of RPI with smoking status and other substance use while further documenting independent associations between LA and DD and those outcomes.

The associations between posttraumatic stress disorder and delay discounting, future orientation, and reward availability: A behavioral economic model

The theoretical framework of behavioral economics, a metatheory that integrates operant learning and economic theory, has only recently been applied to posttraumatic stress disorder (PTSD). A behavioral economic theory of PTSD reflects an expansion of prior behavioral conceptualization of PTSD, which described PTSD in terms of respondent and operant conditioning. In the behavioral economic framework of PTSD, negatively reinforced avoidance behavior is overvalued, in part due to deficits in environmental reward, and may be conceptualized as a form of reinforcer pathology (i.e., excessive preference for and valuation of an immediate reinforcer). We investigated cross-sectional relationships between PTSD severity and several constructs rooted in this behavioral economic framework, including future orientation, reward availability, and delay discounting in a sample of 110 military personnel/veterans (87.2% male) who had served combat deployments following September 11, 2001. Total PTSD severity was inversely related to environmental reward availability, β = -.49, ΔR² = 0.24, p < .001; hedonic reward availability, β = -.32, ΔR² = 0.10, p = .001; and future orientation, β = -.20, ΔR² = 0.04, p = .032, but not delay discounting, r = -.05, p = .633. An examination of individual symptom clusters did not suggest that avoidance symptoms were uniquely associated with these behavioral economic constructs. The findings offer support for a behavioral economic model of PTSD in which there is a lack of positive reinforcement as well as a myopic focus on the present.

Wanting, Liking, and Missing Out: Exploring the Role of Reward Functioning in the Overlap Between PTSD and Depression

ABSTRACT

Diminished reward functioning (anhedonia) is an aspect of multiple psychiatric diagnoses and is a critical component of depression, yet it has rarely been examined in the context of posttraumatic stress disorder (PTSD). Deficits in reward function may be a transdiagnostic factor contributing to the high rate of comorbidity between PTSD and depression. The present study examined the commonality and distinction between PTSD and depression and their relationship to reward functioning using a bifactor model in a sample of 106 trauma-exposed undergraduates. Results indicated a strong commonality factor between PTSD and depression. Of three indices of reward functioning (i.e., hedonic pleasure, reward motivation, and environmental reward availability), environmental reward availability alone was related to unique latent factors for PTSD and depression, and their commonality. Findings suggest that environmental context may be the key to understanding the role of reward in PTSD, depression, and psychopathology broadly.

Open trial of a personalized feedback intervention and substance-free activity supplement for veterans with PTSD and hazardous drinking

This study reports findings from an open trial of a two-session intervention for veterans with symptoms of PTSD and hazardous drinking. Rooted in behavioral economic theory, this intervention aimed to decrease alcohol use and increase alcohol-free activities through personalized and normative feedback. This trial assessed the feasibility and acceptability of the intervention in a sample of 15 veterans. Participants completed assessments at baseline and post-intervention (1-month and 3-months). Thirteen participants (86.6%) were retained between the baseline assessment and second intervention session. Acceptability data indicated that veterans overwhelmingly viewed the intervention positively with little dropout between the two sessions. Further, participants in our study reduced alcohol consumption from 37.30 (SD = 17.30) drinks per week at baseline to 22.50 (SD = 27.75) drinks per week at the 1-month assessment and then to 14.60 (SD = 18.64) at the 3-months assessment, representing medium to large effects. PTSD severity also decreased from 57.20 (SD = 16.72) at baseline to 48.90 (SD = 18.99) at the 1-month assessment, representing a small effect. Though effect sizes from pilot trials should be interpreted with caution, findings suggest that this intervention was well-received, feasible to deliver, and may have resulted in improvements in intervention targets.

Trajectories of reward availability moderate the impact of brief alcohol interventions on alcohol severity in heavy-drinking young adults

BACKGROUND

Behavioral economic theory predicts that low access to environmental reward is a risk factor for alcohol use disorder (AUD). The Substance-Free Activity Session (SFAS) is a behavioral economic supplement to standard brief alcohol interventions that attempts to increase environmental reward and may therefore have beneficial effects, particularly for individuals with low levels of environmental reward.

METHODS

Participants were 393 college students who reported at least 2 heavy-drinking episodes in the past month. Participants were randomly assigned to 1 of 3 conditions following a baseline assessment: a standard alcohol-focused brief motivational intervention plus relaxation training session (BMI + RT), BMI plus Substance-Free Activity Session (BMI + SFAS), or an assessment-only control condition (AO). In a secondary analysis of the data from this study, we used person-centered statistical techniques to describe trajectories of alcohol severity and environmental reward over a 16-month follow-up and examined whether environmental reward levels moderated the effectiveness of the interventions.

RESULTS

Piecewise growth mixture modeling identified 2 trajectories of reward availability: low increasing (LR; n = 120) and high stable (HR; n = 273). Depressive symptoms, cannabis use, sensation seeking, and low life satisfaction were associated with a greater probability of classification in the LR trajectory. Alcohol severity was greater in the LR trajectory than the HR trajectory. For students in the LR trajectory, at 1, 6, and 12 months, BMI + SFAS led to greater increases in reward availability and reduced levels of alcohol severity compared with the BMI + RT and AO conditions and at 16 months compared with AO.

CONCLUSIONS

Young adults with low levels of environmental reward are at heightened risk for greater alcohol severity and may show greater benefit from brief alcohol interventions that focus on increasing substance-free reward than individuals who are not deficient in reward availability.

The role of reward and reinforcement in understanding alcohol use among adults living with HIV in South Africa

OBJECTIVE

Most research investigating reinforcement in alcohol use is from high-income countries. The current study sought to understand the association of different reinforcement types (alcohol-specific reward, environmental reward, behavioral activation) with multiple measures of alcohol use and cravings among individuals living with HIV in South Africa.

METHOD

Baseline data were obtained from a substance use clinical trial in Cape Town (N = 65). Unhealthy alcohol use was measured using the biomarker phosphatidylethanol (PEth), Alcohol Use Identification Test (AUDIT-C), average number of drinks from the timeline follow back (TLFB), and self-reported cravings. Reinforcement was measured using the proportion of income spent on alcohol (alcohol-specific reward), both subscales of the Reward Probability Index (environmental reward), and the Behavioral Activation Depression Scale (activation). Poisson and linear regression analyses were conducted.

RESULTS

Each percentage point increase in income spent on alcohol was significantly associated with PEth, RR = 1.004 [95% CI (1.001, 1.007)], which translates to a 13.6% increase in the relative risk of unhealthy alcohol use for the average person in the study. More alcohol-specific reward was significantly associated with higher scores on the AUDIT-C, higher average number of drinks on the TLFB, and more cravings. Higher activation was associated with lower scores on the AUDIT-C. Neither subscale of environmental reward was associated with model outcomes.

CONCLUSION

Greater alcohol-specific reward and less behavioral activation were associated with more frequent and unhealthy alcohol use in this setting, but not environmental reward. Findings highlight how different reinforcement types potentially influence alcohol use in a low-resource global setting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Alcohol Craving and Psychiatric Disorders Among Current Drinkers

BACKGROUND AND OBJECTIVES

Previous research has shown that alcohol craving is associated with psychiatric comorbidities. However, no population studies have examined the odds of psychiatric disorders in cravers and noncravers. The purpose of this study was to investigate current prevalence rates and odds ratios of psychiatric disorders among alcohol drinkers with and without alcohol craving in a population-based sample. We also compared four craving groups (cravers with and without alcohol use disorder [AUD], noncravers with and without AUD) for psychiatric comorbidities.

METHODS

The study data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). A subset of the NESARC sample (N = 22 000) who reported alcohol use during the past 12 months was included. Prevalence rates of psychiatric disorders were compared among current drinkers with alcohol craving (N = 900) and without alcohol craving (N = 21 500).

RESULTS

Cravers had higher prevalence rates of current psychiatric disorders than noncravers. Even after adjustment for other psychiatric disorders including AUD, cravers had significantly higher odds of any substance use disorder (adjusted odds ratio [AOR], 9.01), any mood disorder (AOR, 1.78), any anxiety disorder (AOR, 1.86), and any personality disorder (AOR, 1.92) than noncravers. Interestingly, cravers without AUD had even higher rates of any anxiety disorder and any personality disorder than noncravers with AUD.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Alcohol craving is associated with a higher prevalence of various psychiatric disorders. These findings suggest that alcohol craving may be related to transdiagnostic features that are present across various psychiatric disorders. (Am J Addict 2021;30:34-42).

Behavioral economics and coping-related drinking motives in trauma exposed drinkers: Implications for the self-medication hypothesis

Behavioral economic theory can help researchers understand complex behavior by considering the availability and economic value associated with an individual's choices. This study explored how behavioral economic constructs relate to alcohol consumption and alcohol problems in a sample of trauma-exposed young adults. We further explored whether these behavioral economic constructs explained unique variance in alcohol outcomes beyond coping-related drinking motives. Participants were 91 trauma-exposed young adults who reported recent alcohol consumption (M_age = 26.53, female = 36.26%, non-White = 41.75%). Participants were recruited through Amazon Mechanical Turk. Questionnaires measured alcohol consumption, problems, and motives for use, as well as alcohol demand, delay discounting, future orientation, and access to environmental reward. Future orientation (ΔR2 = .05, p = .03) and delay discounting (ΔR2 = .04, p = .05) explained unique variance in alcohol problems after controlling for coping-related drinking motives. Further, alcohol demand indices (ΔR2s = .04-.10, ps = .00-.05) explained unique variance in alcohol consumption after controlling for coping-related drinking. Both coping motives and behavioral economic variables contribute to alcohol consumption and alcohol-related consequences among trauma-exposed young adults. Findings suggest that, beyond coping motives, behavioral economics may play a meaningful role in understanding alcohol misuse. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Experimental manipulations of behavioral economic demand for addictive commodities: a meta-analysis

BACKGROUND AND AIMS

Reinforcing value, an index of motivation for a drug, is commonly measured using behavioral economic purchase tasks. State-oriented purchase tasks are sensitive to phasic manipulations, but with heterogeneous methods and findings. The aim of this meta-analysis was to characterize the literature examining manipulations of reinforcing value, as measured by purchase tasks and multiple-choice procedures, to inform etiological models and treatment approaches METHODS: A random-effects meta-analysis of published findings in peer-reviewed articles. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol, studies were gathered through searches in PsycINFO and PubMed/MEDLINE (published 22 May 2018). Searches returned 34 unique studies (aggregate sample n = 2402; average sample size = 68.94) yielding 126 effect sizes. Measurements included change (i.e. Cohen's d) in six behavioral economic indices (intensity, breakpoint, O_max , P_max , elasticity, cross-over point) in relation to six experimental manipulations (cue exposure, stress/negative affect, reinforcer magnitude, pharmacotherapy, behavioral interventions, opportunity cost).

RESULTS

Cue exposure (d range = 0.25-0.44, all Ps < 0.05) and reinforcer magnitude [d = 0.60; 95% confidence interval (CI) = 0.18, 1.01; P < 0.005] manipulations resulted in significant increases in behavioral economic demand across studies. Stress/negative affect manipulations also resulted in a small, significant increase in O_max (d = 0.18; 95% CI = 0.01, 0.34; P = 0.03); all other effect sizes for negative affect/stress were non-significant, albeit similar in size (d range = 0.14-0.18). In contrast, pharmacotherapy (d range = -0.37 to -0.49; Ps < 0.04), behavioral intervention (d = -0.36 to -1.13) and external contingency (d = -1.42; CI = -2.30, -0.54; P = 0.002) manipulations resulted in a significant decrease in intensity. Moderators (substance type) explained some of the heterogeneity in findings across meta-analyses.

CONCLUSIONS

In behavioral economic studies, purchase tasks and multiple-choice procedures appear to provide indices that are sensitive to manipulations found to influence motivation to consume addictive substances in field experiments.

Altered brain activities associated with cue reactivity during forced break in subjects with Internet gaming disorder

BACKGROUND

Studies have proven that forced break can elicit strong psychological cravings for addictive behaviors. This phenomenon could create an excellent situation to study the neural underpinnings of addiction. The current study explores brain features during a cue-reactivity task in Internet gaming disorder (IGD) when participants were forced to stop their gaming behaviors.

METHODS

Forty-nine IGD subjects and forty-nine matched recreational Internet game users (RGU) were asked to complete a cue-reactivity task when their ongoing gaming behaviors were forced to break. We compared their brain responses to gaming cues and tried to find specific features associated with IGD.

RESULTS

Compared with RGU, the IGD subjects showed decreased activation in the anterior cingulate cortex (ACC), parahippocampal gyrus, and dorsolateral prefrontal cortex (DLPFC). Significant negative correlations were observed between self-reported gaming cravings and the baseline activation level (bate value) of the ACC, DLPFC, and parahippocampal gyrus.

CONCLUSIONS

IGD subjects were unable to suppress their gaming cravings after unexpectedly forced break. This result could also explain why RGU subjects are able to play online games without developing dependence.

Blunted Reward Sensitivity and Trait Disinhibition Interact to Predict Substance Use Problems

Reward deficit models of addiction posit weaknesses in reward sensitivity to be promotive of substance dependence, while the externalizing spectrum model views substance problems as arising in large part from a general disinhibitory liability. The current study sought to integrate these perspectives by testing for separate and interactive associations of disinhibition and reward dysfunction with interview-assessed substance use disorders (SUDs). Community and college adults (N = 199) completed a scale measure of trait disinhibition and performed a gambling-feedback task yielding a neural index of reward sensitivity, the 'Reward Positivity' (RewP). Disinhibition and blunted RewP independently predicted SUDs, and also operated synergistically, such that participants - in particular, men - with high levels of disinhibition together with blunted RewP exhibited especially severe substance problems. Though limited by its cross-sectional design, this work provides new information about the interplay of disinhibition, reward processing, and gender in SUDs and suggests important directions for future research.

Measurement of substance-free reinforcement in addiction: A systematic review

A robust body of theoretical and experimental work highlights the influence of alternative, substance-free rewards on decisions to use alcohol and other drugs. However, translational applications have been limited in part by the lack of consensus on how to measure substance-free reinforcement in applied and clinical settings. The current study summarizes extant research utilizing self-report reinforcement or reward methodologies, and critically reviews the psychometric properties of the available measures. These studies (N = 50) fell into three categories: measures of recent substance-related and substance-free activity participation and enjoyment (n = 32), measures of time or monetary resource allocation (n = 15), and rating scale measures of reward availability and experience (n = 8). The available research suggests that, consistent with experimental laboratory research and with behavioral economic predictions, there is an inverse relation between substance-free reinforcement and substance use. These studies also support the clinical utility of these measures in predicting substance use severity and course. Reinforcement measures could be improved by enhancing content validity, multimethod convergent validity, and generalizability.

Applying behavioral economic theory to problematic Internet use: An initial investigation

The widespread availability of the Internet has had profound social, educational, and economic benefits. Yet, for some, Internet use can become compulsive and problematic. The current study seeks to apply a behavioral economic framework to Internet use, testing the hypothesis that, similar to other addictive behaviors, problematic Internet use is a reinforcer pathology, reflecting an overvaluation of an immediately acquirable reward relative to prosocial and delayed rewards. Data were collected through Amazon's Mechanical Turk data collection platform. A total of 256 adults (Mage = 27.87, SD = 4.79; 58.2% White, 23% Asian; 65.2% had an associate degree or greater) completed the survey. Measures of delay discounting, consideration of future consequences, Internet demand, and alternative reinforcement all contributed unique variance in predicting both problematic Internet use and Internet craving. In aggregate models controlling for all significant predictors, alternative reinforcement and future valuation variables contributed unique variance. Individuals with elevated demand and discounting were at greatest risk for problematic Internet use. Consistent with behavioral economic research among substance abusing samples, individuals engaging in heavy Internet use report elevated motivation for the target behavior coupled with diminished motivation for other potentially rewarding activities, especially those associated with delayed reward. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Depressive symptoms as predictors of alcohol problem domains and reinforcement among heavy drinking college students

Heavy drinking among college students in the United States is common and results in a wide range of problems. Symptoms of depression are also common among college students and may exacerbate problems associated with heavy drinking, but to date most studies have been cross sectional and relied on an aggregate measure of alcohol problems. Further, depressive symptoms may also predict other elements of risk among heavy drinkers, including greater experience of substance-related reinforcement, and diminished experience of substance-free reinforcement. The current study examines depressive symptoms as a prospective predictor of changes in alcohol problem domains and reward variables in a sample of heavy drinking college students. Heavy drinking college students (N = 138) completed a survey assessing depressive symptoms, alcohol problems, and reinforcement at baseline and after a 12-month follow-up period. Multiple regressions examined the utility of depressive symptoms (DASS-21) in predicting alcohol problems, substance-related reinforcement, and substance-free reinforcement at the 12-month follow-up after controlling for baseline drinking level and the baseline level of the relevant outcome variable. Baseline depressive symptoms predicted 12-month alcohol problems related to impaired control (i.e., drinking more than planned), self-perception, and self-care. Depressive symptoms also predicted lower 12-month substance-free, but not substance-related, reinforcement. Finally, change in depressive symptoms was associated with total alcohol problems, impaired control, self-perception, self-care, academic/occupational, and physiological dependence problems at 12-month follow-up. Heavy drinkers with depressive symptoms may benefit from interventions targeting alcohol problems that also increase access to and engagement in rewarding alternative activities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).