Implicit cognition and the maintenance of addictive behaviour: A short review

Alexander W M Wright 2012

A vast amount of cognitive research in addiction has been focussed on a single question: what causes substance abusers to repeat the damaging choice of substance use, despite

processes. There are many names by which these two processes have been described. The first explicit, thoughtful processing makes use of conscious, logical, rational thought, represented symbolically through language. This processing appears distinctly human (or, at least, is associated with ideas of intelligence) and uses considerable attentional

resources, making it subjectively effortful. Labels applied to this processing mode include explicit (Reber, 1993), analytic (Evans, 1989; Hammond, 1996), reflective (Strack and Deutsch, 2004) and rulebased (Sloman, 1996; Smith and Decoster, 2000). Implicit processing, on the other hand, has been labelled within dual-process models as automatic (Schneider and Schiffrin, 1977), associative (Sloman, 1996; Smith and Decoster, 2000), intuitive (Hammond, 1996), and impulsive (Strack and Deutsch, 2004). Implicit processes are constantly gathering information and building associations within this information over the course of ones life. These processes are generally thought to be fast acting, automatic and to occur without conscious awareness. Smith and Decoster (2000) argue that this form of processing is reproductive, as information that has been repeatedly associated with an object is automatically brought into mind (or pre-consciousness) whenever cues are present in the environment. They also argue that in reproducing information, this mode of processing acts as a pattern completion mechanism and uses only general, overall similarity between cues and stored representations to guide retrieval. As a result, often superficially similar or logically irrelevant information may be activated. This form of automatic processing, therefore, can be thought of as a kind of crude, simplistic, animal-like mode of processing, and is reflected in the behaviourist theories that dominated the early twenty-first century. Although a relatively recent import from social and cognitive research, theories of implicit processing in addiction have led to a broad range of research that is multifaceted and complicated by a number of factors. It is studied using a number of experimental

overwhelming evidence of deterioration in their living standards, personal relations and health? This question is divisive; some Heyman (2009), for example argue for a choice model of addiction, citing the influence of factors such as legality and fear of punishment in decisions to abuse substances.

However, while individuals clearly do possess the ability to reason and contemplate choices and outcomes, there is also a clear dissociation between intentions and behaviour that is often seen in substance abuse. Indeed, this dissociation is implicit in DSM-IV criteria for substance dependence, which cites amongst its criteria: use of a substance in larger amounts or over a longer period than was intended. And: unsuccessful efforts to cut down or control substance use. This suggests a degree of compulsion in the behaviour of substance abusers. There appears to be more to understand about an individuals addictive behaviour than conscious decision-making. Within psychology, distinctions have long been drawn between explicit, conscious processes and implicit, automatic processes. Such ideas can be traced back at least as far as the 19th century and are essential to Freudian ideas of the unconscious mind. Similar categorisations are also seen in the work of pioneering psychologist William James; the distinction between rational and associative thought seen in his theories of reasoning (1913) closely mirrors modern dual-process theories of cognition, which seek to explain human behaviour in terms of an interaction between two separate and contrasting mental

A.W.M. Wright paradigms and deals with several distinct processes and constructs (e.g. motivation, impulsivity), each of which may be applicable only to specific

2012; unpublished manuscript strong moderators (Rooke, Hine & Thorsteinsson, 2008), It should also be noted that the IAT has produced some contradictory findings. For example, whilst it has been found that heavy, light and problem drinkers associate negative valence more strongly with alcoholic drinks than control categories (Wiers, van Woerden, Smulders, & De Jong, 2002; De Houwer, Crombez, Koster & De Beul, 2004), in studies in which positive and negative valence have been assessed using separate IATs, both have been associated with alcohol use in a student population (Houben & Wiers,

circumstances or time-frames in the progression towards dependence. This paper provides a limited overview of these (rather issues, than focussing on the of

maintenance

the

development)

addictive behaviours, and gives a critical overview of three widely-studied concepts in this domain: affective associations (implicit memory), attentional bias and approach-avoidance

Implicit memory is a widely studied concept in psychology that has been applied extensively in addiction modelling. Studies in this domain have generally assessed affective associations (or attitudes) for a given substance. In general, there are several advantages to assessing implicit affective judgements over explicit ones, such as the avoidance of well known artefacts related to introspection and subjective recall (demand characteristics, cognitive dissonance). Investigating implicit associations could also address the disconnect between subjective intention and action that is typical of addictive behaviour. These affective associations have often been assessed using reaction time paradigms; most notably with the Implicit

2006). Subsequently, the validity of the IAT has been criticised on a number of counts (see Stacy & Wiers, 2010). Consider that many of these results were originally discussed in relation to incentive-

sensitization theory (Robinson & Berridge, 1993) which posits wanting (sensitized arousal) and liking (attitudes) as separable processes. The above findings of implicit valence associations with alcohol were intended to reflect only the liking aspect of addiction; however the IATs ability to capture the separate processes of wanting and liking has recently been critically undermined by results demonstrating an apparent increased liking for smoking in cigarettedeprived conditions (as opposed to cigarette-satiated conditions) and no differences in levels of wanting, in contradiction to explicit measures (Tibboel et al.,

Association Test (IAT; for a review of measures used in implicit processes in addiction, see Stacy & Wiers, 2010). Overall, IAT scores have predicted unique variance in drinking behaviour over that explained by explicit measures; however, the variance explained by implicit measures is generally small enough that it may not be considered of clinical significance (Reich, Below & Goldman, 2010). This is with the exception of some particularly significant moderators: working memory capacity (Thush et al., 2008) is one, being inversely related to the variance in drinking accounted for by implicit measures. Some studies also suggest that situational and individual difference variables may be

2011). Methodological criticisms such as these make it difficult to interpret many of the findings regarding affective associations.

Another

form

of

associative

process

in

addiction is attentional bias: the consistent finding that substance-related stimuli grab the attention of those that use them, increasing physiological arousal in turn (see Field & Cox, 2008). This process is thought to induce craving through eliciting the expectancy of substance availability, thus motivating substanceseeking. However, some debate surrounds the extent

A.W.M. Wright to which attentional bias is an implicit, automatic process and the mechanisms by which it influences substance-seeking behaviour. Some models (e.g. Tiffany, 1990) suggest the automatic detection of substance-related cues and habit-like substanceseeking mechanisms, separable from subjective

2012; unpublished manuscript significant yet weak relationship between the two constructs. The estimate of shared variance was 2-4%, though varying greatly between substances. This was, however, found to be moderated by experimental method, with direct measures of attention such as eyetracking and event-related potentials increasing shared variance to 13% (see also Littel, Euser, Munaf & Franken, 2012). Furthermore, in terms of a positive relationship between attentional bias and risk of relapse, there exist conflicting findings (e.g. Cox, Hogan, Kristian & Race, 2002; cf. Carpenter, Schreiber, Church & McDowell, 2006), and in addition heightened

experiences such as craving. Models such as these seem to have limited explanatory capabilities, being particularly relevant to habitual rather than compulsive substance use (see, e.g., Baxter & Hinson, 2001). Other incentive-motivational stimuli models acquire suggest motivational

substance-related

properties which are to some extent available to consciousness, with craving and attentional bias both outcomes of underlying processes (e.g. incentivesensitization theory, Robinson & Berridge, 1993) and have broader appeal. Many modern theories, however, suggest a reciprocal relationship between subjective craving and cue reactivity. For example, Franken (2003; broadly an extension of incentive-sensitization theory) suggests attentional bias is subjectively experienced, with cues becoming salient as a result of conditioned

attentional bias for substance-related stimuli seen in heavy alcohol users (Field, Mogg, Zetteler & Bradley, 2004) is not seen in abstaining alcohol-dependent patients, who in fact show bias away from such stimuli (Vollstdt-Klein, Loeber, von der Goltz, Mann & Kiefer, 2009; Noel et al., 2006). In spite of this, manipulation of attentional bias has been shown to alter motivations to drink alcohol (Field & Eastwood, 2005) with some clinical interventions developing as a result (e.g. Fadardi & Cox, 2009; Ostafin, Bauer & Myxter, 2012).

dopaminergic responses (classical conditioning). This induces craving, which in turn heightens the attention grabbing properties of cues, with each process acting to excite the other and thus motivating substanceseeking (see also Kavanagh, Andrade & May, 2005). Furthermore, these processes have been shown to be mediated by traits such as impulsivity, degree of inhibitory control (see Field & Cox, 2008) as well as stress (Field & Quigley, 2009; Garland, Boettiger, & Howard, 2011) and (in smokers) priming doses of alcohol (Field, Mogg & Bradley, 2005). Indeed, many studies have produced findings consistent with these reciprocality theories, primarily through the use of variations of Stroop tests and of the visual probe task (see reviews in Field & Cox, 2008; Stacy & Wiers, 2010). However, although each of these models predicts a positive correlation between attentional bias and craving, a meta-analysis conducted by Field, Manaf and Franken (2009) found a statistically The complex relationship between attentional bias and motivational processes has led to extensive investigation concerning the extent to which these processes are able to elicit approach-avoidance outcomes. The application of implicit measures to this issue allows these processes to be studied without confounding approach tendencies with actual

substance administration. A relatively new paradigm to have emerged in this domain is the use of the Stimulus-Response Compatibility tasks (SRC; see review in Stacy & Wiers, 2010) which requires participants to move a manikin towards or away from substance-related and matched control stimuli as an analogue of approach/avoidance tendencies. Some studies using SRC tasks suggest a tendency for alcohol-related stimuli to activate

approach/avoidance tendencies, and in particular that

A.W.M. Wright heavier drinkers show faster approach responses than light drinkers (Field, Kiernan, Eastwood & Child, 2008). This has been associated with both alcohol intake and measures of subjective craving and reflects findings using an IAT (Ostafin & Palfai, 2006). Causal links between approach/avoidance tendencies and alcohol consumption have also been evidenced. A study by Wiers, Rinck, Kordts, Houben and Strack (2010) found participants drank more alcohol following conditions in which they had been trained to approach alcohol with an Approach-Avoidance Task (AAT; see below) and to avoid alcohol following aversive training. These results transferred to an IAT and were not reported in measures of subjective craving. The clinical

2012; unpublished manuscript related stimuli were avoided in the task, and opposing explicit measures. These findings are at odds with earlier findings of approach tendencies in heavy drinkers (Field et al., 2008), though it is suggested this phenomenon is limited to abstaining drinkers. An inference of this is that maintaining an aversive strategy may be harmful in abstaining from alcohol. However, there is some debate as to whether certain confounds exist in the SRC. That is, participants are explicitly instructed to approach or avoid target stimuli (i.e. substance-related or control), with reaction times measured and compared depending upon the

category/action assignments. An AAT, in contrast, does not request that participants make

significance of this was demonstrated by Wiers, Eberl, Rinck, Becker and Lindenmeyer (2011) in a sample of alcoholic inpatients using similar approach/avoidance training mechanisms. Results showed changes from approach to avoidance behaviour following avoidance training, again generalising to an IAT and followed by improved treatment outcomes one year later. However, unexpected some studies have shown for

approach/avoidance actions according to the content of stimuli. Instead, participants are requested to pull or push a joystick to zoom in or out of pictures in response to some content-irrelevant feature such as format or orientation. Recent evidence using an AAT (Eberl et al., in press) contradicts findings in Spruyt et al. (in press), highlighting these potential confounds (but see also Field, Caren, Fernie & De Houwer, 2011; Wiers et al., 2011).

approach/avoidance

tendencies

substance-related stimuli. This has been shown in abstaining alcoholics who showed no difference to controls in approach tendencies (Barkby, Dickson, Roper & Field, 2012) and in heavy drinking As a limited discussion of findings in this domain, it is important to emphasise that the research reported here equates to only a rudimentary

adolescents (van Hemel-Ruiter, de Jong & Wiers, 2011) who instead showed relative avoidance

understanding of the role of implicit cognition in addiction. Discussion here has been focussed

tendencies. Spruyt et al. (in press) speculate that these relative avoidance tendencies are demonstrative of the discord between immediate desires to consume alcohol and long-term desires to abstain, consistent with findings which suggest that alcohol dependent patients develop attentional biases away from alcoholrelated stimuli (e.g. Noel et al., 2006). Following these findings, they showed in a sample of abstaining alcoholics a relative avoidance bias in alcohol dependent patients following approach/avoidance

primarily on the maintenance of addictive behaviours and has centred overwhelmingly on alcohol abuse and treatment; studies by Field and Cox (2008), Field et al. (2009) and Rooke et al. (2008) present a more indepth analysis of variations between substances. Nonetheless, the research presented here

demonstrates a great deal of empirical support for the involvement addiction. There remain, however, a number of key issues within the literature which warrant further investigation. Criticisms apply particularly to research of implicit cognitive processes in

measurement with an SRC task. However, of particular clinical relevance was that relapse rates in the sample increased in relation to the speed at which alcohol-

A.W.M. Wright regarding IATs in assessing affective associations, and as a result there is little clarity concerning implicit associative processes in addiction. Regarding

2012; unpublished manuscript

attentional bias, some synthesis has occurred in recent years between models explicating its role in craving (e.g. Field & Cox, 2008). A weak correlation between these constructs, and conflicting findings regarding correlations between attentional bias, relapse and other behavioural tendencies are indicative of the great number of modulating factors in addiction. In spite of this, interventions in implicit processes have led to promising clinical developments. In particular, the use of SRCs and associated paradigms look to be capable of unravelling some of the complex issues surrounding approach biases, including paradoxical findings

concerning causal links between avoidance tendencies and abstinence in alcoholics, though some potential methodological flaws in this paradigm have been highlighted in recent literature. The overall picture, however, is that implicit processes are an inextricable component of the maintenance of addictive behaviours in particular, with important implications for the development disorders. of treatments for substance-use

A.W.M. Wright References

2012; unpublished manuscript

Barkby, H., Dickson, J.M., Roper, L., Field, M. (2012). To approach or avoid alcohol? Automatic and self-reported motivational tendencies in alcohol dependence. Alcoholism: Clinical and Experimental Research, 36, 361-368. Baxter, B.W., & Hinson, R.E. (2001) Is smoking automatic? Demands of smoking behaviour on attentional resources. Journal of Abnormal Psychology, 110, 59-66. Carpenter, K.M., Schreiber, E., Church, S., & McDowell, D. (2006). Drug Stroop performance: relationships with primary substance of abuse and treatment outcome in a drug-dependent outpatient sample. Addictive Behaviour, 31, 174-181. Cox, W.M., Hogan, L.M., Kristian, M.R., & Race, J.H. (2002). Alcohol attentional bias as a predictor of alcohol abusers treatment outcome. Drug and Alcohol Dependence, 68, 237-243. De Houwer, J., Crombez, G., Koster, E.H.W., & De Beul, N. (2004). Implicit alcohol-related cognitions in a clinical sample of heavy drinkers. Journal of Behaviour Therapy and Experimental Psychiatry, 35, 275-286. Eberl, C., Reinout, W.W., Pawelczack, S., Rinck, M., Becker, E.S., & Lindenmeyer, J. (in press). Approach bias modication in alcohol dependence: Do clinical effects replicate and for whom does it work best? Developmental Cognitive Neuroscience, http://dx.doi.org/10.1016/j.dcn.2012.11.002 Evans, J.St.B.T. (1989). Bias in human reasoning: Causes and consequences. Brighton: Erlbaum. Fadardi, J.S., & Cox, W.M. (2009). Reversing the sequence: Reducing alcohol consumption by overcoming alcohol attentional bias. Drug and Alcohol Dependence, 101, 137-145. Field, M., Caren, R., Fernie, G., De Houwer, J. (2011). Alcohol approach tendencies in heavy drinkers: comparison of effects in a Relevant Stimulus-Response Compatibility Task and an approach avoidance Simon task. Psychology of Addictive Behaviors, 25 (4), 697-701. Field, M., & Cox, W.M. (2008). Attentional bias in addictive behaviors: A review of its development, causes, and consequences. Drug and Alcohol Dependence, 97, 1-20. Field, M., & Eastwood, B. (2005). Experimental manipulation of attentional bias increases the motivation to drink alcohol. Psychopharmacology, 183, 350-357. Field, M., Kiernan, A., Eastwood, B., & Child, R. (2008). Rapid approach responses to alcohol cues in heavy drinkers. Journal of Behaviour Therapy and Experimental Psychiatry, 39 , 209-218. Field, M., Manaf, M.R., & Franken, I.H.A. (2009). A meta-analytic investigation of the relationship between attentional bias and subjective craving in substance abuse. Psychological Bulletin, 135 (4), 589-607. Field, M., Mogg, K., & Bradley, B.P. (2005). Alcohol increases cognitive biases for smoking cues in smokers. Psychopharmacology, 180, 63-72. Field, M., Mogg, K., Zetteler, J., & Bradley, B.P. (2004). Attentional biases for alcohol cues in heavy and light social drinkers: The roles of initial orienting and maintained attention. Psychopharmacology, 176, 88-93.

A.W.M. Wright

2012; unpublished manuscript

Field, M., & Quigley, M. (2009). Mild stress increases attentional bias in social drinkers who drink to cope: A replication and extension. Experimental and Clinical Psychopharmacology, 17 (5), 312-319. Franken, I.H.A. (2003). Drug craving and addiction: Integrating psychological and neuropsychopharmacological approaches Progress in Neuro-Psychopharmacology & Biological Psychiatry, 27, 563-579. Garland, E.L., Boettiger, C.A., & Howard, M.O. (2011). Targeting cognitive-affective risk mechanisms in stressprecipitated alcohol dependence: An integrated, biopsychosocial model of automaticity, allostasis, and addiction. Medical Hypotheses, 76, 745-754. Heyman, G.M. (2009). Addiction: A disorder of choice. Cambridge, MA: Harvard University Press. Houben, K., & Wiers, R.W. (2006). Assessing implicit alcohol associations with the Implicit Associations Test: Fact or artifact? Addictive Behaviors, 31, 1346-1362. James, W. (1913). The Principles of Psychology, Volume II. New York, NY: Henry Holt and Co. Kavanagh, D.J., Andrade, J., & May, J. (2005). Imaginary relish and exquisite torture: The elaborated intrusion theory of desire. Psychological Review, 112, 446-467. Littel, M., Euser A.S., Munaf, M.R., Franken, I.H.A. (2012). Electrophysiological indices of biased cognitive processing of substance-related cues: A meta-analysis. Neuroscience and Biobehavioral Reviews,36,18031816. Noel, X., Colmant, M., Van Der Linden, M., Bechara, A., Bullens, Q., Hanak, C., & Verbanck, P. (2006). Time course of attention for alcohol cues in abstinent alcoholic patients: the role of initial orienting. Alcoholism: Clinical and Experimental Research, 30, 1871-1877. Ostafin, B.D., Bauer, C., & Myzter, P. (2012). Mindfulness decouples the relation between automatic motivation and heavy drinking. Journal of Social and Clinical Psychology, 31 (7), 729-745. Ostan, B.D., & Palfai, T.P. (2006). Compelled to consume: The Implicit Association Test and automatic alcohol motivation. Psychology of Addictive Behaviors, 20, 322-327. Reber, A.S. (1993). Implicit learning and tacit knowledge. Oxford: Oxford University Press. Reich, R.R., Below, M.C., & Goldman, M.S. (2010). Explicit and implicit measures of expectancy and related alcohol cognitions: A meta-analytic comparison. Psychology of Addictive Behaviors,24 (1), 13-25. Robinson, T.E., & Berridge, K.C. (1993). The neural basis of drug craving: An incentive-sensitization theory of addiction. Brain Research Review, 18, 247-291. Rooke, S.E., Hine, D.W., & Thorsteinnsson, E.B. (2008). Implicit cognition and substance use: A meta-analysis. Addictive Behaviors, 33, 13141328. Schneider W, Shiffrin RM. 1977. Controlled and automatic human information processing I: Detection, search and attention. Psychol. Rev. 84, 1-66 Sloman, S.A. (1996). The empirical case for two systems of reasoning. Psychol. Bull., 119, 3-22.

A.W.M. Wright

2012; unpublished manuscript

Smith, E.R., & Decoster, J. (2000). Dual-process models in social and cognitive psychology: Conceptual integrations and links to underlying memory systems. Pers. Soc. Psychol. Rev., 4, 2, 108-31. Spruyt, A., De Houwer, J., Tibboel, H., Verschure, B., Crombez, G., Verbanck, P., Noel, X. (in press). On the predictive validity of automatically activated approach/avoidance tendencies in abstaining alcohol-dependent patients. Drug and Alcohol Dependence, http://dx.doi.org/10.1016/j.drugalcdep.2012.06.019 Strack, F., & Deutsch, R. (2004). Reflective and Impulsive determinants of behaviour. Pers. Soc. Psychol. Rev., 8, 3, 220-247 Stacy, A.W., & Wiers, R.W. (2010). Implicit cognition and addiction: A tool for explaining paradoxical behaviour. Annual Review of Clinical Psychology, 6, 551-575. Thush, C., Wiers, R.W., Ames, S.L., Grenard, J.L., Sussman, S., & Stacy, A.W. (2008). Interactions between implicit and explicit cognition and working memory capacity in the prediction of alcohol use in at-risk adolescents. Drug and Alcohol Dependence, 94, 116-124. Tibboel, H., De Houwer, J., Spruyt, A., Field, M., Kemps, E., & Crombez, G. (2011). Testing the validity of implicit measures of wanting and liking. Journal of Behavior Therapy and Experimental Psychiatry, 42, 284-292. Tiffany, S.T. (1990). A cognitive model of drug urges and drug-use behaviour: Role of automatic and nonautomatic processes. Psychol. Rev.,97, 147-168 Van Hemel-Ruiter, M.E., de Jong, P.J., & Wiers, R.W. (2011). Appetitive and regulatory processes in young adolescent drinkers. Addictive Behaviors, 36,18-26. Vollstdt-Klein, S., Loeber, S., von der Goltz, C., Mann, K., & Kiefer, F. (2009). Avoidance of alcohol-related stimuli increases during the early stage of abstinence in alcohol-dependent patients. Alcohol and Alcoholism, 44 (5), 458-463. Wiers, R.W., Eberl, C., Rinck, M., Becker, E.S., & Lindenmeyer, J. (2011). Retraining automatic action tendencies changes alcohol patients approach bias for alcohol and improves treatment outcome. Psychological Science, 22, 490-497. Wiers, R.W., Rinck, M., Kordts, R., Houben, K., & Strack, F. (2010). Retraining automatic action tendencies to approach alcohol in hazardous alcohol drinkers. Addiction, 105, 279-287. Wiers, R.W., Van Woerden, N., Smulders, F.T.Y., & De Jong, P.J. (2002). Implicit and explicit alcohol-related cognitions in heavy and light drinkers. Journal of Abnormal Psychology, 111, 648-658.