ReviewAttentional bias in addictive behaviors: A review of its development, causes, and consequences
Introduction
Regular substance use and dependence are commonly associated with reactivity to substance-related stimuli. For example, when alcohol abusers are exposed to the sight or smell of an alcoholic beverage, or smokers are asked to hold a lit cigarette, they react with increased physiological arousal and subjective craving (see Carter and Tiffany, 1999). These processes have long been thought to be important in the maintenance of addictive behaviors and in relapse among users who have quit and are attempting to remain abstinent. More recently, theorists have begun to argue that biases in substance users’ cognitive processing of addiction-related stimuli are a critical aspect of substance cue reactivity that has been relatively overlooked but which is important to consider when trying to understand the effects of substance cue exposure on substance-seeking, craving, and relapse.
Early work on the general principles of motivational influences on psychological processes demonstrated that having goals affects attention, recall, and the content of thoughts and dreams (Hoelscher et al., 1981, Klinger, 1978, Klinger, 1996). That is, becoming committed to a goal pursuit makes the individual responsive to cues associated with those goals in the sense of potentiating emotional and cognitive responses to them, thus giving those cues increased priority in cognitive processing and leading to “attentional biases” for them. During the past 15 years, a considerable body of evidence has accumulated to suggest that substance use and abuse are characterized by biases in the attentional processing of substance-related stimuli. That is, substance-related stimuli acquire the ability to grab the user's attention.
In this manuscript, we review this evidence and propose a theoretical integration of previous disparate theories in order to explain how attentional bias develops, and how it is related to important aspects of addictive behaviors, such as subjective craving and impaired inhibitory control. Our goal is not to propose a completely new model of attentional bias and related phenomena. Instead, we aim to integrate existing models and to restate some of their theoretical predictions in terms of biases in selective attention for drug-related cues. This is important because many previous models discuss a general process (e.g., an increase in the “salience” of drug-related cues, Goldstein and Volkow, 2002), but they do not explicitly state how this process might be manifest in terms of selective attention. We argue that being motivated to use a substance of abuse potentiates attentional processing of substance-related cues, and this focus on substance-related cues produces further increases in subjective craving. However, what constitutes a substance-related cue must first be established by experience, so that attentional biases develop largely as a consequence of classical conditioning.
Section snippets
Theoretical background
For many years, substance users’ responses to substance-related cues were seen as Pavlovian responses that occurred as a consequence of repeated pairings of the effects of a psychoactive substance in the brain with contingently presented environmental cues (e.g., the pairing of the rewarding effects of alcohol with the sight and smell of vodka). Conditioned responses were generally argued to be either appetitive, substance-like (i.e., conditioned responses that mimic the unconditioned effects
Defining attentional bias for substance-related stimuli
In order to demonstrate attentional bias for substance-related cues, it is important to compare the attentional processing of substance-related and matched control stimuli in substance users and an appropriate control group. The choice of control stimuli is very important, but the key parameters vary depending on the measure of attentional bias that is used. For example, in the addiction Stroop task (described below), substance-related and matched control words should be matched in terms of
Attentional bias and subjective craving: a causal relationship?
As the models of attentional bias and craving described earlier would predict, many studies have found that substance-related attentional bias is associated with subjective craving for the substance. For example, positive correlations between subjective craving and Stroop interference (or other, less ambiguous measures of attentional bias) have been found among tobacco smokers (Mogg and Bradley, 2002, Mogg et al., 2003, Mogg et al., 2005, Zack et al., 2001), alcohol abusers (Field et al., 2004a
Trying to remain abstinent
Substance users who are trying to remain abstinent might try to control their intrusive substance-related cognitions. For example, they might try to suppress their subjective craving or try to divert their attention away from substance-related stimuli. However, in the research described in the previous sections, various kinds of substance users have participated who probably have differed widely in their use of such strategies. At the one extreme, much of the previous attentional bias research
How attentional bias develops: conditioning and substance-related expectancies
Classical conditioning can explain how attentional bias for substance-related stimuli develops. As is commonly understood (e.g., Robinson and Berridge, 1993), substances of abuse can function as unconditioned stimuli (USs) that elicit unconditioned responses (URs). Through conditioning, a substance can become associated with environmental stimuli that are contiguous with and contingent on the effects of that substance. That is, after repeated pairings of the US with a conditioned stimulus (CS),
Perceived substance availability, craving, and cue reactivity
The perceived availability of a substance appears to influence the strength of self-reported substance craving. Across several studies, Wertz and Sayette (2001b) reported that treatment-seeking inpatients’ subjective craving during substance cue exposure was relatively low (37% of the scale maximum) compared to continuing drug users (69% of the scale maximum). Of course, inpatients and continuing substance users would be expected to differ on a number of dimensions, including dependence
Theoretical synthesis
In the preceding sections, we reviewed evidence which suggests that substance-related attentional bias, subjective craving, and expectations of the opportunity to use a substance are interrelated reactions to substance-related stimuli that seem to develop through classical conditioning. In this section, we present an integration of previous models of substance-related attentional bias, a schematic of which is shown in Fig. 1.
As a consequence of repeated pairings of (a) the subjective effects of
Summary and conclusions
We reviewed evidence which suggests that substance-related attentional bias is an important characteristic of alcohol and other substance users. We suggested that the attentional bias develops partly as a consequence of classical conditioning, which causes substance-related stimuli to elicit in substance users the expectation that they will have an opportunity to use their substance of abuse. This expectation, in turn, causes them to experience subjective craving, and it increases the
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgements
We thank Eric Klinger for his helpful comments on the manuscript.
Role of funding sources: Funding for much of the authors’ own research which is described in this review was provided by research grants from the British Academy (Grants LRG-37196 (awarded to Matt Field) and SG-45289 (awarded to W. Miles Cox and Steven P. Tipper)), Economic and Social Research Council (Grants RES-000-22-1860 (awarded to Matt Field and Theodora Duka) and RES-000-23-1269 (awarded to W. Miles Cox, Javad S. Fadardi,
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