Review
Attentional bias in addictive behaviors: A review of its development, causes, and consequences

https://doi.org/10.1016/j.drugalcdep.2008.03.030Get rights and content

Abstract

A wealth of research from the past two decades shows that addictive behaviors are characterized by attentional biases for substance-related stimuli. We review the relevant evidence and present an integration of existing theoretical models to explain the development, causes, and consequences of addiction-related attentional biases. We suggest that through classical conditioning, substance-related stimuli elicit the expectancy of substance availability, and this expectancy causes both attentional bias for substance-related stimuli and subjective craving. Furthermore, attentional bias and craving have a mutual excitatory relationship such that increases in one lead to increases in the other, a process that is likely to result in substance self-administration. Cognitive avoidance strategies, impulsivity, and impaired inhibitory control appear to influence the strength of attentional biases and subjective craving. However, some measures of attentional bias, particularly the addiction Stroop, might reflect multiple underlying processes, so results need to be interpreted cautiously. We make several predictions that require testing in future research, and we discuss implications for the treatment of addictive behaviors.

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,

References (161)

  • M. Field et al.

    Selective processing of cannabis cues in regular cannabis users

    Drug Alcohol Depend.

    (2006)
  • M. Field et al.

    Cognitive bias and drug craving in recreational cannabis users

    Drug Alcohol Depend.

    (2004)
  • I.H.A. Franken

    Drug craving and addiction: integrating psychological and neuropsychopharmacological approaches

    Prog. Neuro-Psychopharmacol. Biol. Psychiatry

    (2003)
  • I.H.A. Franken et al.

    Influence of individual differences in craving and obsessive cocaine thoughts on attentional processes in cocaine abuse patients

    Addict. Behav.

    (2000)
  • V.V. Grant et al.

    Impact of positive and anxious mood on implicit alcohol-related cognitions in internally motivated undergraduate drinkers

    Addict. Behav.

    (2007)
  • R. Guerrieri et al.

    The influence of trait and induced state impulsivity on food intake in normal-weight healthy women

    Appetite

    (2007)
  • R. Hester et al.

    A consistent attentional bias for drug-related material in active cocaine users across word and picture versions of the emotional Stroop task

    Drug Alcohol Depend.

    (2006)
  • A.A. Klein

    Suppression-induced hyperaccessibility of thoughts in abstinent alcoholics: a preliminary investigation

    Behav. Res. Ther.

    (2007)
  • E.H.W. Koster et al.

    Time-course of attention for threatening pictures in high and low trait anxiety

    Behav. Res. Ther.

    (2005)
  • J. Lusher et al.

    Alcohol dependence and the alcohol Stroop paradigm: evidence and issues

    Drug Alcohol Depend.

    (2004)
  • D. Algom et al.

    A rational look at the emotional Stroop phenomenon: a generic slowdown, not a Stroop effect

    J. Exp. Psychol. Gen.

    (2004)
  • A. Allport

    Visual attention

  • T.B. Baker et al.

    Motivational influences on cigarette smoking

    Annu. Rev. Psychol.

    (2004)
  • D. Bauer et al.

    Alcohol-related words are distracting to both alcohol abusers and non-abusers in the Stroop colour-naming task

    Addiction

    (1998)
  • B.W. Baxter et al.

    Is smoking automatic? Demands of smoking behavior on attentional resources

    J. Abnorm. Psychol.

    (2001)
  • W.K. Bickel et al.

    Toward a behavioral economic understanding of drug dependence: delay discounting processes

    Addiction

    (2001)
  • D. Bindra

    A motivational view of learning, performance, and behavior modification

    Psychol. Rev.

    (1974)
  • B. Bradley et al.

    Attentional and evaluative biases for smoking cues in nicotine dependence: component processes of biases in visual orienting

    Behav. Pharmacol.

    (2004)
  • B.P. Bradley et al.

    Attentional bias in drug dependence: vigilance for cigarette-related cues in smokers

    Psychol. Addict. Behav.

    (2003)
  • G. Bruce et al.

    A pictorial Stroop paradigm reveals an alcohol attentional bias in heavier compared to lighter social drinkers

    J. Psychopharmacol.

    (2004)
  • S.M. Burton et al.

    The effect of alcohol consumption on craving to smoke

    Addiction

    (1997)
  • B.L. Carter et al.

    Meta-analysis of cue-reactivity in addiction research

    Addiction

    (1999)
  • B.L. Carter et al.

    The cue-availability paradigm: the effects of cigarette availability on cue reactivity in smokers

    Exp. Clin. Psychopharmacol.

    (2001)
  • N.L. Cooney et al.

    Alcohol cue reactivity, negative-mood reactivity, and relapse in treated alcoholic men

    J. Abnorm. Psychol.

    (1997)
  • W.M. Cox et al.

    The effects of alcohol cue exposure on non-dependent drinkers’ attentional bias for alcohol-related stimuli

    Alcohol Alcohol.

    (2003)
  • W.M. Cox et al.

    The addiction-Stroop test: theoretical considerations and procedural recommendations

    Psychological. Bull.

    (2006)
  • W.M. Cox et al.

    A motivational model of alcohol use

    J. Abnorm. Psychol.

    (1988)
  • W.M. Cox et al.

    Incentive motivation, affective change, and alcohol use: a model

  • W.M. Cox et al.

    A motivational model of alcohol use: determinants of use and change

  • W.M. Cox et al.

    Motivational basis of cognitive determinants of addiction

  • W.M. Cox et al.

    Cognitive-motivational predictors of excessive drinkers’ success in changing

    Psychopharmacology (Berl.)

    (2007)
  • W.M. Cox et al.

    Alcohol abusers’ and nonabusers’ distraction by alcohol and concern-related stimuli

    Am. J. Drug Alcohol. Abuse

    (2000)
  • D. Davidson et al.

    Using the cue-availability paradigm to assess cue reactivity

    Alcohol Clin. Exp. Res.

    (2003)
  • P.J. de Jong et al.

    Relevance of research on experimental psychopathology to substance misuse

  • H. de Wit et al.

    Increased ethanol choice in social drinkers following ethanol preload

    Behav. Pharmacol.

    (1993)
  • H. de Wit et al.

    Dual determinants of drug use in humans: reward and impulsivity

  • M. Dols et al.

    The urge to smoke depends on the expectation of smoking

    Addiction

    (2002)
  • T. Duka et al.

    The priming effect of alcohol pre-load on attentional bias to alcohol-related stimuli

    Psychopharmacology (Berl.)

    (2004)
  • T. Duka et al.

    Kindling of withdrawal: a study of craving and anxiety after multiple detoxifications in alcoholic inpatients

    Alcohol Clin. Exp. Res.

    (2002)
  • J. Duncan et al.

    Direct measurement of attentional dwell time in human vision

    Nature

    (1994)
  • Cited by (0)

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