L4: Addiction

Question 1

1. learn what akrasia is and how it relates to addiction.
2. learn the biomedical explanation of addiction (chronic brain disease) and on what grounds it has been criticized.
3. learn about alternatives: rational choice and biased choice
4. learn how these different perspectives relate to interventions.

Answer 1

oke

Question 2

akrasia=

Answer 2

‘gebrek aan zelfbeheersing’, dan voert iemand een handeling uit hoewel men weet dat iets anders beter zou zijn.

Question 3

knowingly act against own will. You consider all arguments; A is the better option and you do B.
Is this possible?
Wat vinden Plato, Aristoteles en Protagoras

Answer 3

Plato - nee
Aristoteles & Protagoras - ja

Question 4

modern explanations of akrasia

Answer 4

• Philosophy: Harry Frankfurt distinghuished 1st and 2nd order desires > a primary sensory-evoked wanting vs. a 2nd order wish to not want that
• psychology & neuroscience : dual process models (impulsive processes (GO) vs reflective processes (STOP))
• intuitively attractive, but validity recently
  questioned

Question 5

impulsive vs reflective influences on health behaviour: a theoretical framwork and empirical review (Hofmann, Friese, Wiers)

Answer 5

• impulsive precursors: automatic affective reactions and automatic approach-avoidance reactions
• boundary conditions: habitualness, cognitive load, ego depletion, alcohol, wmc, mood
• reflective precursors: reasoned attitudes, restraint standards

-> leiden samen tot health-related behaviour

Question 6

hoe kijkt het dual process model naar addiction

Answer 6

• addiction is a conflict between system 1 and system 2, where system 1 pulls you to the behaviour and system 2 does not inhibit these behaviours
• system 1: with repeated use there is sensitization (stronger arousal reactions with the addiction cue) -> automatic appetitive action tendencies, sensitive to current needs (cravings, thirst)

Question 7

kijken naar model van hoe alcohol & drug use beinvloedt wordt in schrift

Answer 7

oke

Question 8

metafoor voor verslaving en angst

Answer 8

impulse is het paard, reflection is de rijder.
addiction: horse who easily runs wild
anxiety: fearful horse
(both have a weak rider)

Question 9

criticism on dual process models

Answer 9

• characteristics of the systems are not well correlated
• many processes have some mixture of characteristics
• no two isolatable systems

Question 10

wat was de conclusie van dit artikel: Dynamics of unfolding interactions “automatic” and “controlled” processes (Cunningham & Zelazo, 2007; Gladwin et al, 2011)

Answer 10

yes, there are different subsystems, but well
integrated whole in healthy individuals: predictive brain

Question 11

addiction is a chronic brain disease: argumenten

Answer 11

• permanent neuro-adaptations that make recovery difficult/impossible
• drugs all have an effect on the mesolimbic reward system, therefore making addiction a brain disease
• chronic, abstinence is rare
• less stigma, take the blame away

Question 12

classical models of health psychology: problemen

Answer 12

1) assessment: typically questionnaires
- prediction is pretty good for intentions
- prediction is very bad for behaviour: intention to behaviour gap

2) We assume people engage in rational decisions regarding substance use (weigh pros and cons, but… to what extent are addictive behaviors (and health behaviors in general) rational?

3) Automatic and habitual processes not
incorporated
4)They predict better in highly educated
individuals than in more poorly educated
individuals (who are most in need of
health psychology interventions!)

Question 13

intention behaviour gap=

Answer 13

beliefs, attitudes, etc. predict intention well, but not (much) behavior

Question 14

BDMA: With development of addiction, several changes in the brain (“neuroadaptations”):

Answer 14

1. enhanced sensitivity to reward
2. negative feelings remediated by addictive behavior
3. preoccupation

-> progressively less control, conditioned cue -> act (from impulsive decision making to compulsive stimulus-bound behavior)

Question 15

twee research areas waar discussies over the BDMA zijn

Answer 15

1. within neuroscience (e.g., relative importance of different neuroadaptations for different substances; role dopamine, etc.)
2. growing criticisms from social sciences

Question 16

2 categories of BDMA criticisms

Answer 16

1. is it correct
2. is it correct that the societal implications are positive? (patient ipv immoral character)

Question 17

criticism on BDMA: is it true?

Answer 17

1. when you learn something, there are brain changes, so brain changes do not indicate addiction or disease (Lewis)
2. epidemiology: most people stop or reduce (most without help) (Heyman)
3. motivation crucial, in contrast to real chronic brain diseases (e.g., Alzheimer), MI. There are life changing events that lead to quitting. (Miller)
4. core based on animal models, but validity questioned: most rats prefer social contact over heroin (Alexander)
5. even in severely addicted people: had to choose between vouchers and preferred drug, most chose vouchers. therefore there still is an element of choice. BDMA would predict there is no choice involved (Hart)
6. despite billions of investments no new treatments. we need to include the higher motivation (Hall; Hyman)

Question 18

criticism on BDMA: positive effect?

Answer 18

• Claim was less blame & stigma, blame correct, but in many cases more stigma by BDMA. (Haslam)
• Related to essentialism: reinforces the idea that addicted people (or more general: mentally ill) are qualitatively different from others (“different species”)
• Thinking it is a chronic brain disease leads to discouragement, less motivation, in client and therapist (Miller)

Question 19

wat denkt meneer Wiers er zelf over

Answer 19

niet chronic brain disease, niet moral problem/the addicts choice/akrasia, maar biased choice

Question 20

biased choice uitleg

Answer 20

• Choice between A (e.g., cigarette) or B (healthy alternative).
• Neuroadaptations influence threshold values (smoking > lowered for future smoking).
• Genetic and social factors also influence threshold values
• Focus on long-term goals (e.g., episodic future thinking) reduces threshold healthy alternative

Question 21

wat is er met goal-directed inferences in addiction

Answer 21

goal-directed automatically activated inferences play an important role in addictive and health behaviors: no return to “rational” immoral addiction

Question 22

treatment implications van de 3 modellen

Answer 22

1) chronic brain disease: medication & brain stimulation
2) moral problem/the addicts choice/akrasia: health education & scare/warn people
3) biased choice: targeted cognitive training

Question 23

ways of helping people make better choices via the biased choice model

Answer 23

• Motivational Interviewing
• Cognitive Behavioral Therapy
• Cognitive Bias Modification (after the break)
• Mindfulness
• Episodic future thinking

Question 24

hoe is motivational interviewing beter dan informatie geven over de risico’s

Answer 24

counter-arguing occurs if you provide info only (well, that’s a long time from now, i know someone, etc).
bij MI ga je hier tegen in met hun eigen argumenten

Question 25

confrontational style vs empathic style

Answer 25

• confrontational: righting reflex, ambivalence, eliciting sustain talk
• empathic: listening, ambivalence, eliciting change talk

Question 26

motivational interviewing

Answer 26

• Empathic style
• Counselor does not convince, but elicits change talk. Why do you want to change?
• How will change make your life better
• Positive experiences with change?

Question 27

cognitive biases in addiction

Answer 27

1. Attention: relatively strong attention (engagement/disengagement) for substancerelated stimuli (= where do you look?)
2. Action-tendencies: approach-bias (what movement would you tend to?)
3. Memory: relatively easy retrieval substance-related associations (antecendents/effects) (what is your first association?)

-> Unique prediction of behavior after controling for explict cognitions

Question 28

attentional bias=

Answer 28

• eye movements
• motivationally relevant stimuli attract and capture attention
• related to subjective craving, with elaboration in working memory

Question 29

attentional bias in de alcohol latency trial

Answer 29

1) Assessment

• Probe replaces problem category (alcohol,
  cannabis, anxiety) and control category equally often

2) Training

• Experimental group: Participants underwent attentional re-training, which involved repeatedly directing their attention away from alcohol-related stimuli and towards non-alcoholic alternatives (soft drinks).
• Control group: continued assessment/nothing/different task

Binge-drinking students, recruited for experiment on alcohol and reaction times, including taste-test.
Half trained away from alcohol-pictures,
half no training + check for generalized
effects

Findings:
1. Reduction in Attentional Bias: The study found that attentional re-training successfully decreased attentional bias towards alcohol in heavy drinkers.
2. Lack of Generalization: Importantly, the reduction in attentional bias did not generalize beyond the specific stimuli used in the training (no significant effect on untrained pictures). This means the effects were limited to the exact images or cues used during the re-training process. Also no effect on actual drinking behaviour.
3. Implications for Alcohol Dependence: The results suggest that attentional re-training could potentially be a useful tool in treating alcohol dependence, as attentional bias is known to increase with prolonged alcohol use

Question 30

conclusies van single session attention re-training alcohol

Answer 30

• It is possible to train heavy drinking students toward alcohol
• It is possible to train heavy drinking students away from alcohol, but:
• no generalization to new stimuli
• no effects on behavior
• Multiple training-sessions?

Question 31

clinical trial van attention bias modification

Answer 31

• 21 alcohol dependent patients
• Attentional Bias Modification (ABM): Manipulating the location of the probe to appear consistently behind either neutral or salient stimuli. When the probe always replaces neutral stimuli, it trains participants to shift attention away from substance-related cues. This training typically occurs over multiple sessions to reduce attentional bias towards salient stimuli
• Half of them received ABM, half of them received a control training: irrelevant IAT-like categorization task, with same stimuli and feedback
• Both groups were tested using the visual probe task: A fixation cross appears in the center of the screen. Two images are presented side by side - one substance-related (e.g., alcohol) and one neutral. The images disappear, and a dot (probe) appears in the location of one of the former images. Participants must indicate the location of the dot as quickly as possible. Reaction times are measured by the computer. Faster reaction times to probes replacing substance-related images indicate an attentional bias towards those stimuli.
• Results:
• After 5 sessions, generalized effects to untrained pictures
• Promising clinical effects (later relapse)

Question 32

exp. for assessing automatically activated action-tendencies to approach alcohol

Answer 32

This study investigated whether automatic approach action tendencies for alcohol-related stimuli were associated with variation in the mu-opioid receptor gene (OPRM1), previously related to rewarding effects of alcohol and craving. An adapted approach avoidance task was used, in which participants pulled or pushed a joystick in reaction to the format of a picture shown on the computer screen (e.g. pull landscape pictures and push portrait pictures). Picture size on the screen changed upon joystick movement, so that upon a pull movement picture size increased (creating a sense of approach) and upon a push movement picture size decreased (avoidance). Participants reacted to four categories of pictures: alcohol-related, other appetitive, general positive and general negative. This task is regarded as an ‘irrelevant feature’ task: participants are instructed to react to the format of the picture [landscape or portrait, with a push or pull movement, irrespective of the contents.

Resultaten: heavy drinkers were faster to approach alcohol, especially those with risk allele OPRM1

Question 33

proof of principle study over approach/avoid alcohol trials

Answer 33

Participants were randomly assigned to one of two conditions:
1. Avoid-alcohol condition
2. Approach-alcohol condition

Training Task: The study used a modified version of the Approach Avoidance Test (AAT):
Participants used a joystick to push or pull images based on their format (landscape or portrait). Images depicted either alcoholic or non-alcoholic drinks. In the avoid-alcohol condition, participants mostly pushed alcohol images and pulled non-alcohol images. In the approach-alcohol condition, these actions were reversed.

Generalized effects on untrained pictures; different task using words (Implicit association test), and behavior (taste-test).

Question 34

clinical study on retraining alcohol approach behaviour

Answer 34

4 conditions:
- relevant training (push alcohol away)
- irrelevant training (portrait-landscape)
- assessment control (50-50)
- no training

Significant generalizations to untrained pictures and to IAT (verbal memory association task)

Adding CBM to CBT results in 13% less relapse a year later

Question 35

RCT die attentional retraining and approach bias retraining combineerde

Answer 35

• Replicated beneficial training effects: hoogste effect voor alleen attention
• We expected best outcomes of combined
  training (attention & behaviour). But behaviour training and both training had similar results, higher than attention training
• Probably too short for most (3 + 3);
  meanwhile we learned that median number of sessions needed in AAT-training is 6 (with lots of variation, Eberl et al., 2014, ACER)

Question 36

voor wie werkt cognitive bias modification het beste

Answer 36

CBM effects best for patients with comorbidity
(internalizing problems)

Question 37

conclusies over cognitive bias modification

Answer 37

• CBM is effective as add-on in the treatment
  of AUD when people are motivated to change (but have problems succeeding in change due to cuereactivity, strong bias, strong impulsivity
• Now in clinical guidelines as add-on to therapy of AUD in several countries
• Not effective in binge-drinkers not motivated to change.
• Not as stand alone online intervention
• Less good results in smoking

Question 38

4 ways to improve cognitive training

Answer 38

• Make it more playful? -> no, not necessarily better
• Training based on more reliable assessment (dual probe)
• Add neurostimulation (tDCS, rTMS)
• Personalize alternatives, add antecedent contexts and consequences: ABC-training

Question 39

wat was de oude verklaring voor de werking van CBM

Answer 39

General idea: addictive behaviors strong impulsive, associative component, weak control, CBM uniquely changes automatic associative component.

Question 40

alternative account for mechanism of action:

Answer 40

automatic inferential propositional mechanisms, rather than association
- effects only occur with conscious awareness
- Some CBM Effects can be generated by instruction only
- Therefore important to include consequence in the training

Question 41

ABC training

Answer 41

Personalized: participants choose personally-relevant:
- As (Antecedent contexts), e.g., coming home stressed
- Bs (Behavioral Alternatives relevant in that context), e.g., go for a walk rather than smoke/drink (especially important for other addictions than alcohol, where there is universal alternative)
- Cs (Consequences), e.g., better health, save money, etc

Question 42

hoe is ABC training anders dan CBM, en what does it add?

Answer 42

ABC training directly related to CBT (important because original CBM was often found to be rather meaningless to patients and unrelated to their therapeutic goals), what does it add?
systematic and controllable personalized training rather than homework people have difficulties with

Question 43

3 phases per ABC

Answer 43

1. Forced choice to learn consequences (continued in shamtraining)
2. Open choice with consequences
3. Speeded open choice with consequences, to foster automatization

Question 44

proof of principle study of ABC training

Answer 44

193 hazardous drinkers recruited through Prolific randomized over ABC-training vs. sham-control (& 282 in replication study)
– Replicated stronger increase in self-reported and automatic negative alcohol expectancies after ABCtraining (primary outcome)

Exploratory:
* Stronger increase self-efficacy after ABC (bothstudies)
* Heavier drinkers reduced drinking more after ABC-training (exp 2 only)

Question 45

abstinence challenge

Answer 45

ABC vs. CBM vs. sham-CBM as add-on to NoThanks! (~dry January abstinence challenge, in prep).
– 263 (2021) and 320 (2022) volunteers NoThanks! Randomized over ABC, CBM, sham-CBM
– Stronger increase successful abstinence in ABCtraining group vs. CBM / sham-CBM
– No differential effect in drinking during two weeks after challenge

Question 46

• ABC-training is theory-based new variety of
  cognitive training aimed at targeting actions
  based on automatic inferences (expectancies)
  rather than associations
• Promising initial results in volunteers
• Next step: RCTs in clinical samples

Answer 46

oke

Question 47

bigger picture of this lecture

Answer 47

• Chronic brain disease? No isolated brains, but developing brains in (social) context; postal code better prediction of smoking than brain scan…
• BDMA good label for small subset of all people who meet criteria of addiction
• Early use will (more strongly) influence later
  decision making: prevention important
• Successful treatment… back in old social context. When strongly promoting use, difficult.
• Maybe target individual & social context?