Future thinking to decrease real-world drinking in alcohol use disorder: Repairing reinforcer pathology in a randomized proof-of-concept trial

Episodic future thinking improves intertemporal choice and food choice in individuals with higher weight: A systematic review and meta-analysis

Episodic future thinking (EFT) strengthens self-regulation abilities by increasing the perceived value of long-term reinforcements and reducing impulsive choice in delay discounting tasks. As such, EFT interventions have the potential to improve dietary and eating-related decision-making in individuals with obesity or binge eating symptoms, conditions associated with elevated delay discounting. Here, we meta-analyzed evidence from 12 studies that assessed whether EFT interventions improve delay discounting and real-world food choice compared to control interventions. Included studies involved 951 adults with overweight or obesity (body mass index [BMI] ≥25). There were no studies involving participants with binge eating disorder. EFT intervention pooled effects were significant, improving delay discounting with a medium effect, g = 0.55, p < 0.0001, and subsequent food choice outcomes with a small effect, g = 0.31, p < 0.01. Notably, our review is the first to analyze mechanisms of effect in this population, demonstrating that improvements were greater when temporal horizons of EFT episodes were aligned with delay discounting tasks and more distant horizons predicted far-transfer to subsequent dietary and eating-related choices. Our findings thus show that EFT is an effective intervention for individuals with higher weight at risk of adverse health consequences.

Behavioral therapies targeting reward mechanisms in substance use disorders

Behavioral therapies are considered best practices in the treatment of substance use disorders (SUD) and used as first-line approaches for SUDs without FDA-approved pharmacotherapies. Decades of research on the neuroscience of drug reward and addiction have informed the development of current leading behavioral therapies that, while differing in focus and technique, have in common the overarching goal of shifting reward responding away from drug and toward natural non-drug rewards. This review begins by describing key neurobiological processes of reward in addiction, followed by a description of how various behavioral therapies address specific reward processes. Based on this review, a conceptual 'map' is crafted to pinpoint gaps and areas of overlap, serving as a guide for selecting and integrating behavioral therapies.

Acceptability and feasibility of a mobile behavioral economic health intervention to reduce alcohol use in adults in rural areas

Background

At-risk alcohol use is associated with increased adverse health consequences, yet is undertreated in healthcare settings. People residing in rural areas need improved access to services; however, few interventions are designed to meet the needs of rural populations. Mobile interventions can provide feasible, low-cost, and scalable means for reaching this population and improving health, and behavioral economic approaches are promising.

Methods

We conducted a pilot randomized controlled trial focused on acceptability and feasibility of a mobile behavioral economic intervention for 75 rural-residing adults with at-risk alcohol use. We recruited participants from a large healthcare system and randomized them to one of four virtually-delivered conditions reflecting behavioral economic approaches: episodic future thinking (EFT), volitional choice (VC), both EFT and VC, or enhanced usual care control (EUC). The intervention included a telephone-delivered induction session followed by two weeks of condition-consistent ecological momentary interventions (EMIs; 2x/day) and ecological momentary assessments (EMAs; 1x/day). Participants completed assessments at baseline, post-intervention, and two-month follow-up, and provided intervention feedback.

Results

All participants completed the telephone-delivered session and elected to receive EMI messages. Average completion rate of EMAs across conditions was 92.9%. Among participants in active intervention conditions, 89.3% reported the induction session was helpful and 80.0% reported it influenced their future drinking. We also report initial alcohol use outcomes.

Discussion

The behavioral economic intervention components and trial procedures evaluated here appear to be feasible and acceptable. Next steps include determination of their efficacy to reduce alcohol use and public health harms.

Brief online negative affect focused functional imagery training (FIT) improves four-week drinking outcomes in hazardous student drinkers: A pilot randomised controlled trial replication in South Africa

Background

Previous study has shown that functional imagery training (FIT) to utilise positive mental imagery in response to negative affect could improve alcohol-related outcomes. The current study aimed to replicate whether this negative affect focused FIT would improve alcohol-related outcomes in hazardous student drinkers in South Africa at four-week follow-up.

Methods

50 hazardous student drinkers who reported drinking to cope with negative affect were randomised into two groups. The active group (n = 25) was trained online over two weeks to respond to personalised negative drinking triggers by retrieving a personalised adaptive strategy they might use to mitigate negative affect, whereas the control group (n = 25) received standard risk information about binge drinking. Outcome measures including alcohol consumption, drinking motives, anxiety and depression, self-efficacy and use of protective behavioural strategies were obtained at baseline and four-week follow-up.

Results

FIT effects were revealed by three significant group-by-timepoint interactions in a per-protocol analysis: there was a significant decrease in depressive symptoms, drinking to cope and drinking for social reasons from baseline to follow-up in the active group, but not the control group. No effects were observed on alcohol consumption, self-efficacy, protective behaviour strategies and anxiety.

Conclusions

Preliminary evidence supports that online negative affect focused FIT can improve depression as well as coping and social drinking motives in South African hazardous student drinkers who drank to cope, at four-week follow-up, suggesting that the principles of this FIT approach might be adapted and incorporated into a clinical intervention to test for efficacy in mitigating substance use problems.

Writing about the future self to shift drinking identity: An experimental investigation

College student drinking is prevalent and costly to public and personal health, leading to calls to identify and target novel mechanisms of behavior change. We aimed to manipulate drinking identity (a cognitive risk factor for hazardous drinking) via three sessions of narrative writing about a future self. We tested whether writing could shift drinking identity and would be accompanied by changes in alcohol consumption and problems. Participants were college students meeting hazardous drinking criteria (N = 328; Mage = 20.15; 59% women, 40% men, 1% gender-diverse; 60% white; 23% Asian; 12% multiple races; 2% other racial groups; 8% identified as Hispanic/Latino/a/x). The study had a 2 [narrative writing topic: low-risk drinker vs. reduced smartphone use] × 2 [writing perspective: first person vs. non-first-person] × 2 [social network instruction: instructed to include vs. not] factorial design. Outcomes were drinking identity, drinking refusal self-efficacy, alcohol consumption, alcohol-related problems, and craving. Participants completed three writing sessions and online follow-up assessments at 2, 4, and 12 weeks. The study is a registered clinical trial; hypotheses and analyses were preregistered (https://osf.io/vy2ep/). Contrary to predictions, narrative writing about a future self as a low-risk drinker did not significantly impact outcomes. Null results extended to expected interactions with writing perspective and social network instructions. The narrative writing task did not shift drinking or alcohol-related outcomes. Future experimental work may benefit from greater flexibility in conceptualizing a future self, recruiting individuals interested in behavior change, and more sensitive measures of drinking identity.

Effects of episodic future thinking in health behaviors for weight loss: A systematic review and meta-analysis

BACKGROUND

Obesity and related diseases have become one of the leading causes of death worldwide, which has been linked to biopsychosocial effects such as type 2 diabetes, cardiovascular disease, various cancers, depression, and weight stigma. Episodic future thinking (EFT) has been found to support the development of changes in health behaviors. However, the effectiveness of EFT in enhancing weight loss behavior and health outcomes is not well supported.

OBJECTIVE

To establish implementation options for the EFT intervention, and critically synthesize the data that assesses the impact of EFT on weight loss behavior and health outcomes.

METHODS

Searches were performed across 5 Chinese and 9 English databases systematically from inception to March 2023. Randomized controlled trials, written in English or Chinese were included. Two independent reviewers evaluated all relevant studies, who also assessed the risk of bias, and extracted the data. Meta-analyses were conducted using Review Manager 5.4.1. The quantity of evidence's certainty was assessed using the Risk bias assessment tool RoB2 (revised version 2019). This study was registered in PROSPERO.

RESULTS

A total of 1740 participants were included, and 18 studies were eligible for inclusion. Meta-analysis reported a statistically significant effect size favoring EFT on delay discounting (AUC) (MD = 0.1, 95 % CI: [0.02, 0.17], P = 0.01; I2 = 73 %), delay discounting (K) (MD = -0.85, 95 % CI: [-1.44, -0.26], P = 0.005; I2 = 77 %), energy intake (MD = -107.59, 95 % CI: [-192.21, -22.97], P = 0.01; I2 = 57 %), grocery purchased (SMD: -0.91, 95 % CI:[-1.48, -0.34], P = 0.002; I2 = 63 %), and BMI (MD = -2.73, 95 % CI: [-5.13, -0.32], P = 0.03; I2 = 0 %, two studies).

CONCLUSIONS

EFT was found to have favorable effects on delay discounting, energy intake, grocery purchased, and BMI of individuals. The presence of high heterogeneity is evident in most of the outcomes. The modalities of EFT intervention are still in the exploratory phase, there is no consensus on the valence, context type, longest delay time, and practice strategy, and it needs to be further explored for different populations. It is anticipated that additional well-designed studies will continue developing high-quality evidence in this field.

Imagining the future can shape the present: A systematic review of the impact of episodic future thinking on substance use outcomes

OBJECTIVE

The combination of the high prevalence of problematic substance use and substance use disorders (SUD) with the low rates of spontaneous remission continues to generate interest in the development of novel and efficacious interventions. Theoretically, episodic future thinking (EFT) is capable of targeting various underlying psychological and neurobiological substrates of SUD by traversing various research domain criteria systems.

METHOD

The systematic review examines EFT as a potentially efficacious intervention for problematic substance use and SUD. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We examined 46 full-text studies (from 1,238 total records obtained from APA PsycInfo and Pubmed databases and reference list search), which yielded a final sample of 16 studies.

RESULTS

The studies showed heterogeneity in their risk of bias, EFT protocols, and control conditions. Overall, EFT showed benefits in reducing self-reported or task-based substance use-related outcomes.

CONCLUSIONS

Future research directions include establishing the feasibility of EFT, examining the generalizability in decreasing real-world substance use, identifying mediators and moderators of EFT outcomes, and determining the sustainability of EFT effects over time. EFT has high potential for dissemination. Limitations and potential for future research are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Value-based decision-making predicts alcohol use and related problems in young men

BACKGROUND

Alcohol consumption is a leading cause of morbidity and mortality worldwide, disproportionately affecting young men. Heavy episodic drinking is particularly prevalent among men, with this behavior peaking between the ages of 20 and 24.

AIMS

We sought to identify dimensions of decision-making in men that would predict the development of hazardous alcohol use through emerging adulthood.

METHODS

This prospective observational study profiled value-based decision-making in 198 healthy men at age 18 and assessed their alcohol involvement annually until age 24. Latent growth curve modeling estimated individual variability in trajectories of alcohol involvement and regressed this variability on five choice dimensions.

RESULTS

Low loss aversion predicted sustained heavy episodic drinking from age 18 to 24. Both high delay discounting and risk-seeking for gains independently predicted a considerably higher cumulative alcohol use during these 6 years, with high delay discounting indicating escalating consumption from age 21. Risk-seeking for gains additionally predicted meeting more criteria for Alcohol Use Disorder in these 6 years. Risk-seeking for losses was not significantly related to alcohol outcomes. Choice preferences were largely independent of each other but were correlated with choice consistency, with low consistency predicting heavy episodic drinking from age 18 to 24 beyond these associations.

CONCLUSIONS

The predictive effects collectively suggest that overvaluing immediate and probabilistic incentives, rather than underestimating harm, drives hazardous drinking in young men. The differential relations of choice preferences and consistency to alcohol involvement through emerging adulthood provide distinct cognitive-behavioral patterns that warrant consideration in the development of harm reduction interventions.

Episodic future thinking in type 2 diabetes: Further development and validation of the Health Information Thinking control for clinical trials

Episodic Future Thinking (EFT) reduces delay discounting and may have the potential as a clinical tool to increase the likelihood of health-promoting behaviors. However, evaluations of EFT in clinical settings require control conditions that match the effort and frequency of cue generation, as well as participants' expectations of improvement. The Health Information Thinking (HIT) control addresses these issues, but how this control affects delay discounting in individuals with diabetes and obesity when utilizing diabetes-management specific health-information vignettes is unknown. Moreover, little research has explored whether EFT reduces delay discounting in individuals with type 2 diabetes. To this end, we examined the impact of EFT, HIT, and a secondary no-cue control condition (NCC; assessments as usual) on delay discounting in 434 adults with self-reported type 2 diabetes and obesity recruited using Amazon Mechanical Turk. After completing an initial screening questionnaire, eligible participants reported demographics, then were randomized to EFT, HIT, or NCC conditions. Following the generation of seven EFT or HIT cues, participants assigned to EFT or HIT conditions completed a delay discounting task while imagining EFT or HIT cues; no-cue participants completed the task without cues. EFT participants demonstrated significantly lower delay discounting levels than HIT or NCC participants; no differences in delay discounting between HIT and NCC participants were observed. These results suggest that engaging in EFT, but not diabetes-specific HIT, results in lower delay discounting in adults with type 2 diabetes and obesity. This provides further evidence for the appropriateness of the HIT control for clinical trials examining the effect of EFT on delay discounting in adults with self-reported type 2 diabetes.

Rate-dependent effects of narrative interventions in a longitudinal study of individuals who use alcohol

BACKGROUND

Delay discounting (DD), the decrease in reward valuation as a function of delay to receipt, is a key process undergirding alcohol use. Narrative interventions, including episodic future thinking (EFT), have decreased delay discounting and demand for alcohol. Rate dependence, the relationship between a baseline rate and change in that rate after an intervention, has been evidenced as a marker of efficacious substance use treatment, but whether narrative interventions have rate-dependent effects needs to be better understood. We investigated the effects of narrative interventions on delay discounting and hypothetical demand for alcohol in this longitudinal, online study.

METHODS

Individuals (n = 696) reporting high- or low-risk alcohol use were recruited for a longitudinal 3-week survey via Amazon Mechanical Turk. Delay discounting and alcohol demand breakpoint were assessed at baseline. Individuals returned at weeks 2 and 3 and were randomized into the EFT or scarcity narrative interventions and again completed the delay discounting tasks and alcohol breakpoint task. Oldham's correlation was used to explore the rate-dependent effects of narrative interventions. Study attrition as a function of delay discounting was assessed.

RESULTS

Episodic future thinking significantly decreased, while scarcity significantly increased delay discounting relative to baseline. No effects of EFT or scarcity on the alcohol demand breakpoint were observed. Significant rate-dependent effects were observed for both narrative intervention types. Higher delay discounting rates were associated with a greater likelihood of attrition from the study.

CONCLUSION

The evidence of a rate-dependent effect of EFT on delay discounting rates offers a more nuanced, mechanistic understanding of this novel therapeutic intervention and can allow more precise treatment targeting by demonstrating who is likely to receive the most benefit from it.

Putting prospection into practice: Methodological considerations in the use of episodic future thinking to reduce delay discounting and maladaptive health behaviors

In recent years, episodic future thinking (EFT) has emerged as a promising behavioral intervention to reduce delay discounting or maladaptive health behaviors; however, considerable methodological heterogeneity in methods for eliciting engagement in EFT has been observed in prior research. In this narrative review, we briefly describe methods for generating EFT cues, the content of EFT cues, common control conditions for experiments utilizing EFT, and considerations for cue delivery and implementation. Where possible, we make suggestions for current best practices in each category while identifying gaps in knowledge and potential areas of future research. Finally, we conclude by using the NIH Stage model to better frame the current state of the literature on EFT and propose gaps to be addressed if EFT is to be both an efficacious and effective behavioral intervention.

Episodic Future Thinking about Smoking-Related Illness: A Preliminary Investigation of Effects on Delay Discounting, Cigarette Craving, and Cigarette Demand

Cigarette smokers show excessive delay discounting (devaluation of delayed rewards), which may contribute to tobacco use disorder. Episodic future thinking (EFT), or mental simulation of future events, has been shown to reduce both delay discounting and laboratory smoking behavior. Traditionally, EFT involves vividly imagining positive future events. In this preliminary investigation, we examined the effects of EFT specifically about smoking-related illness (SRI) on delay discounting, cigarette craving, and behavioral economic demand for cigarettes. In a 2 (episodic thinking) × 2 (smoking-related illness) factorial design, we randomly assigned smokers from Amazon Mechanical Turk to one of two EFT groups: EFT alone or EFT + SRI; or one of two episodic “recent” thinking (ERT) control groups: ERT alone or ERT + SRI. Both EFT groups generated and imagined positive future events, while both ERT groups imagined real events from the recent past. Both EFT + SRI and ERT + SRI groups imagined these events while also experiencing SRI symptoms. Participants then completed assessments of delay discounting, cigarette craving, and measures of cigarette demand. We observed significant main effects on delay discounting of both EFT (reduced discounting) and SRI (increased discounting), as well as significant main effects of both EFT and SRI on cigarette craving (in both cases, reduced craving). No significant main effect of EFT was observed on cigarette demand measures, although we observed a main effect of SRI on quantity of demand when cigarettes were free (Q0) (reduced demand). In all analyses, we observed no significant EFT × SRT interactions, indicating that these variables operate independently of one another. These methods may be adapted for use in clinical treatment to aid in smoking cessation interventions.

Reduced calibration between subjective and objective measures of episodic future thinking in alcohol use disorder

BACKGROUND

A reduced capacity to mentally simulate future scenarios could be of clinical importance in alcohol use disorder (AUD). However, little is known about the mechanisms underlying episodic future thinking (EFT) impairment in AUD.

METHODS

We tested patients with severe AUD using two measures of EFT: the individual's own subjective experience of their imaginings (phenomenology) and the objective number of details included in imagined events, as assessed by an independent observer (examination). The comparison between the two measures allowed us to investigate the extent to which the subjective and objective characteristics of EFT are calibrated in healthy and AUD participants matched for age, education, and gender. The possible impact of cognitive functioning and disturbed mood on EFT measures was also investigated.

RESULTS

In terms of objective details of EFT, patients with AUD (n = 40) generated fewer episodic components and more non-episodic components than control participants (n = 40), even when controlling for cognitive functioning. However, self-ratings of phenomenological characteristics indicated that participants with AUD perceived imagined future events at a similar level of detail as control participants. Additionally, there was a significant correlation between objective and subjective measures in healthy individuals but not in the AUD group. A higher depression score in the AUD group was not associated with the EFT measures.

CONCLUSIONS

These results suggest a distorted self-assessment of the richness of imagined future events in individuals with AUD. We discuss these apparent limitations in metacognitive abilities and verbal descriptions of imagined events among individuals with AUD and their clinical implications.

Virtual reality intervention effects on future self-continuity and delayed reward preference in substance use disorder recovery: pilot study results

Sustained remission from substance use disorder (SUD) is challenged by high relapse rates, which provides opportunities for novel clinical interventions. Immersive virtual reality (VR) permits delivering synthetic experiences that feel real and actualizes otherwise impossible scenarios for therapeutic benefit. We report on the feasibility of an immersive VR intervention designed to increase valuation of the future by enhancing future self-continuity and leveraging future self-discrepancy with personalized future selves as SUD recovery support. Twenty-one adults in early SUD recovery (< 1 year) interacted with versions of themselves age-progressed fifteen years from two different behavioral trajectories: an SUD Future Self and a Recovery Future Self. The future selves' interactive monologs include personalized details and voice for a lifelike interaction within a time travel vignette. Before and following the intervention, participants rated future self-continuity and performed delay discounting. Following the intervention, daily images of the Recovery Future Self were sent to participants' smartphones for thirty days. The VR intervention generated no adverse events, was well tolerated (presence, liking, and comfort), and significantly increased future self-continuity and delayed reward preference (doubling delay tolerance). The intervention also reduced craving, ps < 0.05. Thirty days later, n = 18 remained abstinent; importantly, increased future self-similarity persisted. Abstainers' future self-similarity increased following VR. All individual participants showing increased future self-similarity post-VR remained abstinent, and all participants who relapsed showed either reduced or zero effect on future self-similarity. Post-intervention semi-structured interviews revealed emotional engagement with the experience. VR simulation of imagined realities reifies novel clinical interventions that are practicable and personalized. The current study demonstrates an implementation readily applied in the clinic and shows promise for facilitating SUD recovery. Creative collaboration between researchers, clinicians, and VR developers has great potential to revolutionize mental health interventions and expand the range of tools for clinicians targeting SUD and other disorders.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-022-00022-1.

Behavioral economic cigarette demand among individuals who smoke with and without obesity

OBJECTIVE

Obesity and cigarette smoking are leading preventable causes of mortality, with greater mortality risk when these disorders occur together. Comorbid obesity and cigarette smoking may affect the valuation of cigarettes. The present study examines the demand for cigarettes between obese and nonobese smokers.

METHOD

Participants (N = 187) from four in-laboratory studies completed the hypothetical cigarette purchase task. According to self-reported height and weight, participants were assigned to either the obese group (body mass index [BMI] ≥ 30) or to the nonobese group (BMI < 30).

RESULTS

Significant differences in demand intensity were observed between individuals with and without obesity, F(1, 168) = 9.284, p = .003, with individuals who smoke and are obese showing higher demand intensity (product purchasing when free). These differences in demand intensity between groups remained after adjusting for the number of cigarettes consumed per day. No differences were observed in elasticity of demand, F(1, 168) = 1.033, p = .311.

CONCLUSIONS

The results reported here suggest that individuals who smoke and are obese may value brief, intense, and immediate reinforcers more than individuals who smoke and are not obese. Further research may suggest reinforcer pathology as a basis for this result. (PsycInfo Database Record (c) 2021 APA, all rights reserved).