Impact of alcohol use disorder comorbidity on defensive reactivity to errors in veterans with posttraumatic stress disorder

A meta-analysis of electrophysiological biomarkers of reward and error monitoring in substance misuse

Substance use disorders are characterized by marked changes in reward and error processing. The primary objective of this meta-analysis was to estimate effect sizes for the reward positivity (RewP) and error-related negativity (ERN), two event-related potential indicators of outcome monitoring, in substance users compared to controls. The secondary objective was to test for moderation by demographic, substance type, and EEG experiment parameters. Final PubMed searches were performed in August 2023. Inclusion criteria were substance use disorder/dependence or validated self-report of substance misuse, RewP/ERN means available, healthy control comparison group, non-acute drug study, peer-reviewed journal, English language, and human participants. Selection bias was tested through modified Egger's regression and exploratory 3-parameter selection model tests. The RewP results (19 studies, 1641 participants) did not support an overall effect (Hedges' g = 0.07, 95% CI [-0.44, 0.58], p = .777) and nor effect of any moderators. The ERN results (20 studies, 1022 participants) indicated no significant overall effect (g = 0.41, 95%CI [-0.05, 0.88]). Subgroup analyses indicated that cocaine users had a blunted ERN compared to controls (g = 1.12, 95%CI [0.77, 1.47]). There was limited evidence for publication/small study bias. Although the results indicate a potential dissociation between substance types, this meta-analysis revealed the need for additional research on the RewP/ERN in substance using populations and for better designed experiments that adequately address research questions.

Impact of handgun ownership and biological sex on startle reactivity to predictable and unpredictable threats

Extant literature suggests that many individuals obtain firearms because they perceive the world as unsafe and believe that firearm ownership increases physical protection. Converging evidence suggests that firearm owners are vulnerable to uncertainty and experience chronic anticipatory anxiety in daily life; however, biological sex is thought to potentially moderate this association. Studies have yet to examine this hypothesis using objective markers of anticipatory anxiety. The present study therefore examined the impact of handgun ownership and biological sex on psychophysiological reactivity to predictable (P-) and unpredictable (U-) threat (N = 133). Male and female adult participants were classified into two groups: a) individuals who do not currently own any handguns (n = 52), and b) individuals who currently own one or more handguns (n = 81). Startle eyeblink potentiation was recorded as an index of aversive reactivity during a well-validated threat-of-shock paradigm designed to probe anticipatory anxiety (during U-threat) and fear (during P-threat). Results revealed no main effect of group on startle reactivity to P- or U-threat. Females displayed greater startle reactivity to threat (P- and U-) compared with males. The main effect was qualified by a significant group x biological sex interaction. Male handgun owners exhibited greater startle to U-threat, but not P-threat, relative to non-handgun owners. There was no effect of group on startle reactivity in females. Findings revealed that biological sex and threat type influenced threat reactivity. Male handgun owners displayed increased sensitivity to stressors that are uncertain, which may reflect an objective mechanism related to firearm ownership.

Electrophysiological biomarkers in dual pathology

INTRODUCTION

The co-occurrence of substance use disorder with at least one other mental disorder is called dual pathology, which in turn is characterised by heterogeneous symptoms that are difficult to diagnose and have a poor response to treatment. For this reason, the identification and validation of biomarkers is necessary. Within this group, possible electroencephalographic biomarkers have been reported to be useful in diagnosis, treatment and follow-up, both in neuropsychiatric conditions and in substance use disorders. This article aims to review the existing literature on electroencephalographic biomarkers in dual pathology.

METHODS

A narrative review of the literature. A bibliographic search was performed on the PubMed, Science Direct, OVID, BIREME and Scielo databases, with the keywords: electrophysiological biomarker and substance use disorder, electrophysiological biomarker and mental disorders, biomarker and dual pathology, biomarker and substance use disorder, electroencephalography, and substance use disorder or comorbid mental disorder.

RESULTS

Given the greater amount of literature found in relation to electroencephalography as a biomarker of mental illness and substance use disorders, and the few articles found on dual pathology, the evidence is organised as a biomarker in psychiatry for the diagnosis and prediction of risk and as a biomarker for dual pathology.

CONCLUSIONS

Although the evidence is not conclusive, it suggests the existence of a subset of sites and mechanisms where the effects of psychoactive substances and the neurobiology of some mental disorders could overlap or interact.

Type of Trauma Exposure Impacts Neural Reactivity to Errors

Abstract. Studies suggest that individuals with a history of trauma exposure display abnormal reactivity to threat, though the pattern of findings across prior studies has been inconsistent. At least two factors likely contribute to previous discrepant findings: (1) the type of index trauma event and (2) the type of threat paradigm. Accordingly, the current study aimed to examine the impact of trauma type on a specific psychophysiological index of threat sensitivity – error negativity (Ne), also described as error-related negativity (ERN). Young adults were classified into three groups: lifetime history of interpersonal trauma (i.e., sexual assault, physical assault, or immediate family violence; n = 30), lifetime history of a non-interpersonal trauma (e.g., accidents, natural disasters; n = 30), or no lifetime history of trauma ( n = 64). All participants completed a well-validated flanker task designed to elicit the Ne/ERN during continuous electroencephalographic (EEG) data collection. Results indicated that individuals with non-interpersonal trauma exposure displayed reduced Ne/ERN amplitude compared with the other two groups (who did not differ from each other). Broadly, these findings highlight the importance of trauma type and theory suggesting different forms of trauma may result in different neurobiological profiles. These findings also add to a growing literature indicating that non-interpersonal traumas may be uniquely associated with blunted threat sensitivity and deficiencies in self-monitoring.

Associations between lifetime stress exposure and the error-related negativity (ERN) differ based on stressor characteristics and exposure timing in young adults

Life stress increases risk for multiple forms of psychopathology, in part by altering neural processes involved in performance monitoring. However, the ways in which these stress-cognition effects are influenced by the specific timing and types of life stressors experienced remains poorly understood. To address this gap, we examined how different social-psychological characteristics and developmental timing of stressors are related to the error-related negativity (ERN), a negative-going deflection in the event-related potential (ERP) waveform that is observed from 0 to 100 ms following error commission. A sample of 203 emerging adults performed an ERN-eliciting arrow flanker task and completed an interview-based measure of lifetime stress exposure. Adjusting for stress severity during other developmental periods, there was a small-to-medium effect of stress on performance monitoring, such that more severe total stress exposure, as well as more severe social-evaluative stress in particular, experienced during early adolescence significantly predicted an enhanced ERN. These results suggest that early adolescence may be a sensitive developmental period during which stress exposure may result in lasting adaptations to neural networks implicated in performance monitoring.

Impact of Trauma Type on Startle Reactivity to Predictable and Unpredictable Threats

ABSTRACT

Trauma exposure has been repeatedly linked to psychophysiological threat reactivity, although the directionality of this association has been inconsistent. Several factors likely contribute to inconsistent findings including type of trauma and threat paradigm. The present study therefore examined the impact of trauma type on psychophysiological reactivity to predictable (P-) and unpredictable (U-) threat in young adults (N = 112). Participants were classified into three groups: history of interpersonal or noninterpersonal trauma, or no history of trauma. Startle eyeblink potentiation was recorded during a well-validated threat-of-shock paradigm. Results indicated individuals with interpersonal trauma exposure displayed exaggerated startle reactivity to U-threat (only) compared with both other groups. In contrast, individuals with noninterpersonal trauma exhibited blunted startle reactivity to U-threat (only) compared with both other groups. Findings reveal that trauma and threat type influence threat reactivity and that those with a history of interpersonal trauma may uniquely display exaggerated sensitivity to stressors that are uncertain.

EEG correlates of attentional control in anxiety disorders: A systematic review of error-related negativity and correct-response negativity findings

BACKGROUND

Anxiety disorders are highly prevalent and cause substantial personal, social and economic burden. Altered attentional control has been shown to be present across anxiety disorders and is associated with specific changes in brain activity which can be recorded by electroencephalogram (EEG). These include changes in the EEG markers of error-related negativity (ERN) and correct-response negativity (CRN), both believed to reflect response monitoring and attentional control pathophysiology in anxiety. The aim of this review was to systematically assess the research on ERN and CRN in attentional control in individuals with clinical anxiety and healthy controls, across emotional and non-emotional attentional control.

METHODS

A comprehensive literature search was conducted for studies published prior to October 22^nd, 2020. Details of the protocol for this systematic review were registered on PROSPERO (CRD42019144885).

RESULTS

66 studies had their data extracted. All 66 studies measured ERN, with 85% finding significantly increased ERN amplitudes associated with clinical anxiety. Only 44 of the extracted studies analysed CRN and only ~20% of these found significant changes in CRN amplitude associated with individuals with clinical anxiety.

LIMITATIONS

There were several anxiety disorders that had either limited literature (i.e. specific phobia, separation anxiety disorder or agoraphobia) or nil literature (i.e. selective mutism) available. No extracted studies included samples of older adults (i.e. aged 60+ years), and only six extracted studies included measures of emotional attentional control.

CONCLUSIONS

Findings indicate the promising utility of ERN of attentional control as a robust, transdiagnostic trait marker of clinical anxiety.

Event-related potential (ERP) measures of error processing as biomarkers of externalizing disorders: A narrative review

Previous studies have shown that electrophysiological measures of error processing are affected in patients at risk or diagnosed with internalizing disorders, hence, suggesting that error processing could be a suitable biomarker for internalizing disorders. In this narrative review, we will evaluate studies that address the role of event-related potential (ERP) measures of error-processing in externalizing disorders and discuss to what extend these can be considered a biomarker for externalizing disorders. Currently, there is evidence for the notion that electrophysiological indices of error processing such as the error-related negativity (ERN) and error positivity (Pe) are reduced in individuals with substance use disorders, attention-deficit/hyperactivity disorder, and in forensic populations. However, it remains unclear whether this is also the case for other understudied disorders such as behavioral addiction. Furthermore, to fully understand how these deficits affect day to day behavior, we encourage research to focus on testing current theories and hypotheses of ERN and Pe. In addition, we argue that within an externalizing disorder, individual differences in error processing deficits may be related to prognosis and gender of the patient, methodological issues and presence of comorbidity. Next, we review studies that have related treatment trajectories with ERP measures of error processing, and we discuss the prospect of improving error processing as a treatment option. We conclude that ERP measures of error processing are candidate biomarkers for externalizing disorders, albeit we strongly urge researchers to continue looking into the predictive value of these measures in the etiology and treatment outcome through multi-method and longitudinal designs.

Were we erring? The impact of worry and arousal on error-related negativity in a non-clinical sample

The monitoring of one's own actions allows humans to adjust to a changing and complex world. Previous neuroscientific research found overactive action monitoring and increased sensitivity to errors to be associated with anxiety and it is assumed to contribute to the development and maintenance of anxiety symptoms. A largely shared decomposition of anxiety differentiates two dimensions: anxious apprehension (i.e., worry) and anxious arousal (i.e., physiological hyperarousal). Alterations in neural correlates of error monitoring have been more closely linked to anxious apprehension compared to anxious arousal. This study examined the relationship between anxiety dimensions and electrophysiological correlates of action monitoring (i.e., error-related negativity, ERN, and correct-response negativity, CRN). A total of 135 non-clinical participants performed a flanker task while their electroencephalogram was recorded. We recruited participants with converging and diverging anxiety dimension profiles (i.e., above or below median in anxious apprehension and anxious arousal or above median in one and below in the other dimension). This grouping strategy facilitates disentangling possible interactions and allows the investigation of the isolated effect of each anxiety dimension. Regression analyses did not reveal a significant main or interaction effect of anxiety dimensions on ERN or CRN, irrespective of gender. In addition, Bayesian statistical analyzes yielded evidence for the absence of an association between both anxiety dimensions and ERN and CRN. Altogether, our results suggest that the association of anxiety dimensions, particularly anxious apprehension, and action monitoring might be smaller in non-clinical samples as previous studies indicate.

The error-related negativity (ERN) moderates the association between interpersonal stress and anxiety symptoms six months later

Anxiety disorders are often preceded by interpersonal stress; however, most individuals who experience stress do not develop anxiety, making it difficult to predict who is most susceptible to stress. One proposed trans-diagnostic neural risk marker for anxiety is the error-related negativity (ERN), a negative deflection in the event-related potential waveform occurring within 100 ms of error commission. The present study sought to investigate whether interpersonal stress experienced over the course of a year interacts with ERN magnitude to prospectively predict anxiety symptoms. A sample of 57 emerging adults performed an arrow flanker task to elicit the ERN at the start of the academic school year (time one). Toward the end of the academic year (time two), participants reported on past-year interpersonal stress and anxiety symptoms. Stress interacted with ERN magnitude to predict anxiety symptoms, whereby, for individuals with an enhanced ERN at time one, greater interpersonal stress over the course of a year was significantly associated with increased anxiety symptoms at time two, even controlling for anxiety symptoms at time one. These findings suggest that enhanced performance monitoring may render individuals more susceptible to the adverse effects of interpersonal stress, thereby increasing risk for heightened anxiety.

Interpersonal trauma exposure and startle reactivity to uncertain threat in individuals with alcohol use disorder

BACKGROUND

Exposure to interpersonal trauma is highly prevalent within individuals with alcohol use disorder (AUD); however, the mechanisms underlying the pathway between trauma exposure and AUD are unclear. Preliminary evidence suggests that heightened reactivity to threats that are uncertain (U-threat) may characterize individuals with AUD and interpersonal trauma exposure and contribute to alcohol abuse within this subgroup of individuals; however, this hypothesis has yet to be tested.

METHOD

The aim of the study was to examine whether heightened reactivity to U-threat characterizes individuals with AUD and a history of interpersonal trauma. Specifically, the study compared defensive reactivity to U-threat (and predictable threat [P-threat]) in those with: 1) AUD and a history of interpersonal trauma (AUD + Trauma); 2) AUD and no history of interpersonal trauma (AUD-Trauma); and 3) matched controls. Participants (N = 77) completed a well-validated threat-of-shock task and startle eyeblink potentiation was collected as an index of aversive responding.

RESULTS

Results revealed a group by threat condition interaction (F[4, 142] = 3.17, p = 0.03; ηG2 = 0.08) such that individuals with AUD + Trauma exhibited greater startle reactivity to U-threat, but not P-threat, compared with individuals with AUD-Trauma and controls (who did not differ from each other). The findings were significant even when controlling for current anxiety and depression symptoms.

CONCLUSIONS

Within individuals with AUD, those with a history of interpersonal trauma exposure may be a neurobiologically unique subtype characterized by exaggerated U-threat reactivity and high levels of anticipatory anxiety. Reactivity to U-threat may be a promising alcohol use prevention and intervention target for trauma-exposed individuals.

Error-related neural activity and alcohol use disorder: Differences from risk to remission

Studies suggest that individuals with alcohol use disorder (AUD) display abnormal neural error-processing, measured via the error-related negativity (ERN). The nature of the error-related abnormalities in AUD is unclear, however, as prior research has yielded discrepant findings. In addition, no study to date has attempted to characterize the dispositional nature of the ERN in AUD and directly test to what extent ERN amplitude reflects a risk factor, disease marker, and/or scar of AUD psychopathology. The current study compared ERN amplitude across 244 adult volunteers in the following five groups: 1) current AUD (n = 39), 2) AUD in remission (n = 60), 3) at-risk for AUD (n = 43), 4) psychiatric controls with comparable rates of internalizing psychopathology as the AUD groups (n = 53), and 5) healthy controls with no lifetime history of psychopathology (n = 49). Risk for AUD was defined as a positive, first-degree family history. All participants completed a well-validated flanker task, designed to robustly elicit the ERN, during continuous electroencephalographic (EEG) data collection. Results indicated that individuals with current AUD displayed smaller ERNs compared with individuals at-risk for AUD, with AUD in remission, psychiatric controls, and healthy controls. There were no differences amongst any of the other groups. This suggests that a blunted ERN may be concomitant with current AUD psychopathology and relatedly, a novel neurobiological AUD treatment target and/or objective marker of AUD disease status.

Craving and substance use: Examining psychophysiological and behavioral moderators

Theories of substance use have emphasized the role of craving and inhibitory control in continued use, yet few studies have examined the interplay between momentary craving and inhibitory control in predicting illicit drug use in everyday life. The primary goal of this study was to examine whether individual differences in inhibitory control, indexed by laboratory-assessed electrophysiology and behavior, moderate the relation between momentary craving and alcohol and drug use assessed outside the lab using a smartphone. A secondary goal was to examine the extent of coherence in the results across different ERP components (e.g., no-go P3, ERN) purported to assess inhibitory control. Participants were current illicit drug users, who completed a flanker task that also contained go/no-go trials, and participated in two weeks of ambulatory assessments of their drug and alcohol craving and use. The results showed that craving a few hours before was related to subsequent drug and alcohol use; however, traditional measures of inhibitory control (e.g., go/no-go P3) did not moderate these effects as expected for illicit drug use. For alcohol use, individuals with less post-error slowing had a stronger relation between craving and alcohol use than those higher in post-error slowing. These results highlight that different cognitive processes are assessed by electrophysiological and behavioral measures of inhibitory control and may play different roles in drug and alcohol use and craving.

Error-related Brain Activity as a Treatment Moderator and Index of Symptom Change during Cognitive-Behavioral Therapy or Selective Serotonin Reuptake Inhibitors

Increased neural error monitoring, as measured by the error-related negativity (ERN), is a transdiagnostic neurobiological marker of anxiety. To date, little is known about whether the ERN can inform the choice between first-line anxiety disorder treatments and whether the ERN changes following treatment completion. The aim of the study was to therefore assess whether the ERN is a treatment moderator and index of symptom change during cognitive-behavioral therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs). Participants included adult volunteers (M age=25.8±8.5; 67% female) with principal anxiety disorders (n=60) or no lifetime history of Axis I psychopathology (ie, healthy controls; n=26). A flanker task was used to elicit the ERN at baseline and 12 weeks later, following either CBT or SSRIs in the patient sample. Results indicated that baseline ERN was a significant treatment moderator such that a more enhanced baseline ERN was associated with greater reduction in anxiety symptoms within individuals who received CBT but not SSRIs. Results also revealed that the ERN increased pre- to post-treatment among patients randomized to SSRIs, but remained stable among patients randomized to CBT and healthy controls. Together, these novel findings highlight that ERN may help guide treatment decisions regarding engagement in CBT or SSRIs, especially among individuals with an enhanced ERN. The findings also suggest that SSRIs have the capacity to alter individual differences in the ERN, providing evidence that the ERN is not entirely static in patients with anxiety disorders.

Individual differences in combat experiences and error-related brain activity in OEF/OIF/OND veterans

Increased error-related negativity (ERN) has been implicated in the pathophysiology of multiple forms of psychopathology. Although there is increasing evidence that the ERN can be shaped by environment and experience, no studies to date have examined this question in a clinical sample. In the current study, we examined the influence of combat exposure on the ERN using electroencephalogram (EEG) in a sample of military veterans with a high prevalence of psychopathology. Participants included sixty-seven U.S. military veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). The degree of combat exposure was assessed using the Deployment Risk and Resilience Inventory-2 (DRRI-2) and Combat Exposure Scale (CES). A well-validated flanker task was used to elicit the ERN during continuous EEG recording. Results revealed that veterans who reported experiencing greater combat exposure exhibited a more enhanced ERN, even when adjusting for broad anxiety and posttraumatic stress disorder (PTSD) symptoms. The association between combat exposure and ERN was not moderated by PTSD symptom severity. The current study demonstrates that greater combat exposure is associated with a more enhanced ERN among OEF/OIF/OND veterans. This enhanced ERN may be one mechanism that places veterans at greater risk for developing psychiatric disorders following exposure to combat. Future longitudinal studies are needed to directly test whether the ERN mediates the relation between level of combat exposure and the development of internalizing disorders.

Neural response to errors is associated with problematic alcohol use over time in combat-exposed returning veterans: An event-related potential study

BACKGROUND

Currently, we do not have biomarkers to help identify individuals at-risk for chronic, problematic alcohol use, especially among veteran populations, who have notoriously high rates of alcohol use. One biomarker that may predict individuals at risk for chronic, problematic alcohol use is error-related brain activity. We examined longitudinal associations between the error-related negativity (ERN), an event-related potential observed following the commission of errors, and problematic alcohol use among U.S. military veterans returning from recent conflicts in Iraq and Afghanistan.

METHODS

Forty-six military veterans, aged 18-55 years, completed a well-validated flanker task known to elicit the ERN at baseline. Problematic alcohol use and other clinically relevant variables were assessed at baseline, 3-, 6-, 9-, 12-, 15-, 18-, 21-months, and 2 years.

RESULTS

Results indicated that the ERN magnitude was associated with problematic alcohol use over time, even after controlling for relevant clinical variables. Specifically, veterans with a smaller ERN magnitude evidenced a decline in problematic alcohol use over time, while veterans with a larger ERN magnitude had no change in their problematic alcohol use across the follow-up. In addition, exploratory analyses found that treatment engagement during the study did not moderate these relationships.

CONCLUSIONS

Our findings provide preliminary evidence that ERN can be used as a predictor of problematic alcohol use over time. Therefore, neural response to errors could help to identify individuals at risk for continued problematic alcohol use for intervention efforts and suggests that error processing may be an important therapeutic target within Alcohol Use Disorder intervention efforts.

Error-related brain activity and internalizing disorder symptom dimensions in depression and anxiety

BACKGROUND

Research suggests that enhanced neural reactivity to errors, measured via the error-related negativity (ERN), is relatively unique to internalizing psychopathologies (IPs) and symptom clusters characterized by excessive worry and apprehension. However, no prior study has tested the association between the ERN and IP symptom dimensions in a heterogeneous, clinically representative patient population. The current study was designed to address this gap in the literature and clarify the role of the ERN in an adult IP treatment-seeking patient sample.

METHOD

Eighty-five participants completed a well-validated flanker task known to robustly elicit the ERN and a battery of questionnaires assessing a range of IP symptoms. All participants had at least one IP diagnosis and over 75% had co-occurring IPs. A principal components analysis (PCA) was performed on the questionnaire data indicating two distinct factors that characterized the IP sample: affective distress/misery and fear-based anxiety.

RESULTS

Analyses indicated that within this sample, an enhanced ERN, but not CRN, was associated with greater fear-based anxiety symptoms but had no relation with distress/misery symptoms.

CONCLUSIONS

Together, these findings indicate that an enhanced ERN may not be specific to worry/apprehension and may extend to the IP fear dimension. The results also converge with a broader literature suggesting that fear-based psychopathology is characterized by an exaggerated reactivity to threat and this objective, psychophysiological response tendency may distinguish fear disorders from distress.

Impact of posttraumatic stress symptom dimensions on psychophysiological reactivity to threat and reward

Posttraumatic stress symptoms (PTSS) are associated with significant distress and impairment. Research has therefore focused on identifying neurobehavioral deficits that contribute to the pathophysiology of PTSS. One issue that has contributed to difficulty in identifying these deficits is the highly heterogeneous nature of PTSS. PTSS is comprised of four, factor analytically distinct dimensions of symptoms - re-experiencing, avoidance, hyperarousal, and negative cognitions and mood. It is therefore unlikely that there is one single mechanism that accounts for all of PTSS and elucidating neurobehavioral deficits associated with specific PTSS symptom dimensions may better inform clinical prevention and intervention efforts. Within the broader internalizing disorder literature, two key constructs that contribute to psychopathology are aberrant neural reactivity to threat and reward. However, the literature linking PTSS to these deficits is mixed, suggesting that aberrant neural reactivity to threat or reward may be specific to certain PTSS dimensions. In a sample of 51 trauma-exposed adults with a range PTSS, the present study therefore examined how the four dimensions of PTSS uniquely relate to two well-validated event-related potential (ERP) neural indices of threat and reward reactivity - the error-related negativity (ERN) and reward-related positivity (RewP), respectively. Results indicated that hyperarousal symptoms were associated with enhanced ERN, and enhanced RewP. In contrast, negative cognitions and mood symptoms were uniquely associated with a more blunted RewP. These results indicate that certain PTSS symptom dimensions have unique relations with neural indicators of threat and reward reactivity and may therefore have distinct pathophysiologies.

Impact of anxiety symptoms and problematic alcohol use on error-related brain activity

Anxiety disorders are associated with enhanced defensive reactivity to errors, measured via the error-related negativity (ERN). There is some evidence to suggest that problematic alcohol use is also associated with an enhanced ERN; although prior studies have been almost exclusively in men and have yet to examine the potential interactive effects of anxiety and alcohol abuse symptoms. The aim of the current study was to address the gaps in this literature by examining the unique and interactive effects of anxiety symptoms and problematic alcohol use on the ERN in a sample of 79 heterogeneous internalizing disorder patients. All participants completed a flanker task designed to robustly elicit the ERN and questionnaires assessing current internalizing symptoms and problematic alcohol use. As expected, results revealed that greater anxiety symptoms, but not depressive symptoms, were associated with a more enhanced ERN. There was no main effect of problematic alcohol use but there was a significant anxiety by problematic alcohol use interaction. At high anxiety symptoms, greater problematic alcohol use was associated with a more enhanced ERN; at low anxiety symptoms, alcohol use was unrelated to the ERN. There was no depression by alcohol abuse interaction. The findings suggest that within anxious individuals, heightened reactivity to errors/threat may be related to risk for alcohol abuse. The findings also converge with a broader literature suggesting that heightened reactivity to threat may be a shared vulnerability factor for anxiety and alcohol abuse and a novel prevention and intervention target for anxiety-alcohol abuse comorbidity.