Context-Specific Inhibition is Related to Craving in Alcohol Use Disorders: A Dangerous Imbalance

Development and standardization of Indian Alcohol Photo Stimuli (IAPS) for cue-reactivity paradigms in patients with alcohol use disorder

Background

The availability of appropriate alcohol-related stimuli is a crucial concern for the evaluation and treatment of patients with alcohol dependence syndrome. The study aimed to standardize alcohol-related images with cultural relevance to the Indian setting.

Methods

We produced an extensive database of 203 pictures, the Indian Alcohol Photo Stimuli (IAPS), portraying different categories and types of alcoholic beverages, after removing the confounding effects of low-level stimulus parameters (e.g. brightness and blurriness). Thirty patients with alcohol dependence syndrome, currently abstinent, rated each image on visual analog scale (VAS) ranging from 0 (no craving) to 10 (extreme), to determine how typical the stimuli served as craving-relevant stimuli.

Results

The mean VAS scores across beverages (ordered from highest to lowest) were whiskey >rum >beer >wine >vodka. Repeated-measures analysis of variance (ANOVA) showed a significant difference in mean VAS scores across beverages (F = 2.93, df = 2.9/86.3, P = 0.039, Greenhouse-Geisser corrected); the effect size for the difference was small (ηp2 = 0.092). A post hoc Bonferroni shows significantly higher VAS scores with whiskey compared with vodka (P = 0.029), whereas the scores were similar across other beverages. A two-way repeated-measures ANOVA for interaction between type of alcoholic beverages and activity was not significant (F = 2.67, df = 2.6/76.6, P = 0.061, Greenhouse-Geisser corrected).

Conclusions

We created a standardized alcohol-related image database for studying cue-reactivity paradigms in individuals with alcohol use disorder (AUD). Further research is needed to validate the impact of image features on cue reactivity.

Alcohol-specific inhibition training in patients with alcohol use disorder: a multi-centre, double-blind randomized clinical trial examining drinking outcome and working mechanisms

AIMS

For the first time, to our knowledge, in a clinical sample with alcohol use disorder (AUD), this study compared the effects of two versions of alcohol-specific inhibition training (Alc-IT) on drinking outcomes and on experimental parameters assessing two possible working mechanisms: stimulus devaluation and inhibitory enhancement.

DESIGN

Multi-centre, double-blind, three-arm clinical RCT with 3-, 6- and 12-month follow-up comparing standard Alc-IT, improved Alc-IT and an active control condition.

SETTING

Three specialized AUD treatment centres in Switzerland.

PARTICIPANTS

A total of 242 detoxified, recently abstinent patients with severe AUD (18-60 years; 29.8% female).

INTERVENTION AND COMPARATOR

Both interventions [standard Alc-IT (n = 84) and improved Alc-IT (n = 79)] and the comparator [unspecific inhibition training (n = 79)] consisted of six sessions of a modified inhibitory task (Go/NoGo task) with alcohol-related and neutral stimuli. Both versions of Alc-IT required response inhibition in alcohol-related trials but differed in Go/NoGo ratios (standard: 50/50; improved: 75/25), with improved Alc-IT posing higher inhibitory demands. The control condition, an unspecific inhibition training, featured alcohol-related pictures in Go as well as NoGo trials.

MEASUREMENTS

The primary outcome, percentage of days abstinent, was assessed at 3-month follow-up with a time-line follow-back interview.

FINDINGS

The group receiving improved Alc-IT showed a significantly higher percentage of days abstinent at 3-month follow-up compared with the control group [γ_control  = 74.30; γ_improved  = 85.78; β = 11.48, 95% confidence interval (CI) = 2.57, 20.40, P = 0.012, adjusted r²  = 0.062], while for standard Alc-IT no effect significantly different from zero was detected (γ_standard  = 70.95; β = -3.35, 95% CI = -12.20, 5.50, P = 0.457, adjusted r²  = -0.04).

CONCLUSIONS

Alcohol-specific inhibition training with high inhibitory demands increased days abstinent at 3-month follow-up in patients with severe alcohol use disorder. Such an improved, inhibitory-demanding, alcohol-specific inhibition training outperformed the standard version of alcohol-specific inhibition training, suggesting an inhibitory working mechanism.

Using Imagination to Integrate Contextual Effects in a Cue-Reactivity Paradigm in Patients with Alcohol Use Disorder: A Functional Magnetic Resonance Imaging Pilot Study

INTRODUCTION

In individuals with alcohol use disorder (AUD), the brain areas underlying cue-induced reactions (e.g., cingulum, striatum, thalamus) and altered activation of these regions have been identified by functional neuroimaging. Neuronal responses to a complex alcohol-related context are yet to investigate. To better understand contextual effects as well as the interplay of cue-induced neural reactions and context exposure, the present study implemented an imagination procedure during functional magnetic resonance imaging (fMRI).

METHODS

Thirteen patients with AUD and 13 healthy controls completed two rounds of a cue-reactivity paradigm inside an MRI scanner. Two individualized imagination tasks were conducted before each of the two cue reactivity tasks. A 2 (group) × 2 (imagination) × 2 (picture-type) analysis of variance (ANOVA) was performed.

RESULTS

The ANOVA revealed a main effect for imagination with higher activation in bilateral thalamus and right caudate nucleus and an interaction effect between imagination and group in right thalamus and left caudate nucleus, due to the patient group reacting stronger during alcohol-related imagination. These structures are involved in relaying sensory information and habit learning. No main or interaction effects of picture type were observed.

CONCLUSIONS

These results support the view that context effects alter the neural responses in thalamus and nucleus caudatus in patients with AUD, and that imagination tasks are suited to incorporate contextual influences in neurophysiological research designs. Future research needs to investigate whether the failure to observe a picture-type effect was due to limited statistical power and omission to individualize picture set, or whether an imagination procedure interferes with the evocation of picture-type effects.

Right Inferior Frontal Activation During Alcohol-Specific Inhibition Increases With Craving and Predicts Drinking Outcome in Alcohol Use Disorder

Alcohol use disorder (AUD) is characterized by enhanced cue-reactivity and the opposing control processes being insufficient. The ability to inhibit reactions to alcohol-related cues, alcohol-specific inhibition, is thus crucial to AUD; and trainings strengthening this ability might increase treatment outcome. The present study investigated whether neurophysiological correlates of alcohol-specific inhibition (I) vary with craving, (II) predict drinking outcome in AUD and (III) are modulated by alcohol-specific inhibition training. A total of 45 recently abstinent patients with AUD and 25 controls participated in this study. All participants underwent functional magnetic resonance imaging (fMRI) during a Go-NoGo task with alcohol-related as well as neutral conditions. Patients with AUD additionally participated in a double-blind RCT, where they were randomized to either an alcohol-specific inhibition training or an active control condition (non-specific inhibition training). After the training, patients participated in a second fMRI measurement where the Go-NoGo task was repeated. Percentage of days abstinent was assessed as drinking outcome 3 months after discharge from residential treatment. Whole brain analyses indicated that in the right inferior frontal gyrus (rIFG), activation related to alcohol-specific inhibition varied with craving and predicted drinking outcome at 3-months follow-up. This neurophysiological correlate of alcohol-specific inhibition was however not modulated by the training version. Our results suggest that enhanced rIFG activation during alcohol-specific (compared to neutral) inhibition (I) is needed to inhibit responses when craving is high and (II) fosters sustained abstinence in patients with AUD. As alcohol-specific rIFG activation was not affected by the training, future research might investigate whether potential training effects on neurophysiology are better detectable with other methodological approaches.

Electrophysiological indexes for impaired response inhibition and salience attribution in substance (stimulants and depressants) use disorders: A meta-analysis

The impairment of inhibitory control and reward system is the core feature underlying substance use disorder (SUD). Previous studies suggested that it can be regarded as impaired response inhibition and salience attribution syndrome (iRISA). The neural substrates of the two deficit functions were widely investigated in neuroimaging studies, and the impaired prefrontal cortex, limbic-orbitofrontal network, and fronto-insular-parietal network were observed. Previous Event-related potential (ERP) studies were also conducted to explore EEG indexes related to abnormal brain function. In the current meta-analysis, we aimed to explore the consistency of ERP indexes that can reflect the two aberrant processes: P300/slow potential (SP) for salience attribution and Error-related negativity (ERN)/Nogo-N200/Nogo-P300 for inhibitory control and conflict monitoring. Subgroup analyses for drug type and drug use conditions were also conducted. According to the 60 research studies, we found significantly enhanced drug-cue-induced P300 amplitude and attenuated Nogo-N200 amplitude in SUD individuals relative to Healthy control (HC), which supports the dual model. Moreover, the drug-cue-induced P300 displayed time-dependence recovery, suggesting a potential index for treatment evaluation. In conclusion, drug-cue-induced P300 and Nogo-N200 demonstrated high consistency, and the drug-cue-induced P300 can be used to track the changes of functional recovery for SUD. The integration of the two ERP components could be regarded as a potential biomarker for SUD, which may provide a new insight for clinical treatment and investigation.

Neurophysiological correlates of alcohol-specific inhibition in alcohol use disorder and its association with craving and relapse

OBJECTIVE

This study investigates neurophysiological correlates of general and alcohol-specific inhibitory control in patients with Alcohol Use Disorder (AUD), focusing on its association with individual craving levels and with relapse at three-month follow-up.

METHODS

59 abstinent AUD patients and 20 healthy controls performed a Go/NoGo task incorporating alcohol-related and neutral stimuli during 64-channel electroencephalography (EEG) recording, yielding four event-related potentials (ERP) per participant (NoGo-Alcohol, Go-Alcohol, NoGo-Neutral, Go-Neutral). Whole-scalp randomization-based statistics assessed effects of the factors group (patients/controls or relapsers/abstainers), craving level, response type (NoGo/Go) and picture type (alcohol/neutral) on topography and signal strength of the ERP components N2 and P3.

RESULTS

No differences on group level were observed between patients and controls. However, analyses incorporating individual craving indicated that the topographic difference between alcohol-related and neutral NoGo-N2 components increased with craving. Moreover, topographic differences in the alcohol-related and neutral NoGo-P3 component allowed for differentiation between relapsers and abstainers.

CONCLUSIONS

In alcohol-related contexts, the response inhibition conflict reflected in the NoGo-N2 seems enhanced in patients with high craving. The inhibition-sensitive NoGo-P3 varies in relapsers but not in abstainers between neutral and alcohol-related contexts.

SIGNIFICANCE

In AUD patients, neurophysiological correlates of inhibition vary with alcohol-related contexts and craving, and might be indicative of relapse risk.

Stop What You're Doing!-An fMRI Study on Comparisons of Neural Subprocesses of Response Inhibition in ADHD and Alcohol Use Disorder

Rationale: Both attention deficit-/hyperactivity disorder (ADHD) and alcohol use disorder (AUD) are accompanied by deficits in response inhibition. Furthermore, the prevalence of comorbidity of ADHD and AUD is high. However, there is a lack of research on whether the same neuronal subprocesses of inhibition (i.e., interference inhibition, action withholding and action cancellation) exhibit deficits in both psychiatric disorders. Methods: We examined these three neural subprocesses of response inhibition in patient groups and healthy controls: non-medicated individuals with ADHD (ADHD; N = 16), recently detoxified and abstinent individuals with alcohol use disorder (AUD; N = 15), and healthy controls (HC; N = 15). A hybrid response inhibition task covering interference inhibition, action withholding, and action cancellation was applied using a 3T functional magnetic resonance imaging (fMRI). Results: Individuals with ADHD showed an overall stronger hypoactivation in attention related brain areas compared to AUD or HC during action withholding. Further, this hypoactivation was more accentuated during action cancellation. Individuals with AUD recruited a broader network, including the striatum, compared to HC during action withholding. During action cancellation, however, they showed hypoactivation in motor regions. Additionally, specific neural activation profiles regarding group and subprocess became apparent. Conclusions: Even though deficits in response inhibition are related to both ADHD and AUD, neural activation and recruited networks during response inhibition differ regarding both neuronal subprocesses and examined groups. While a replication of this study is needed in a larger sample, the results suggest that tasks have to be carefully selected when examining neural activation patterns of response inhibition either in research on various psychiatric disorders or transdiagnostic questions.

Alcohol-related context modulates neural correlates of inhibitory control in alcohol dependent patients: Preliminary data from an fMRI study using an alcohol-related Go/NoGo-task

Alcohol use disorder (AUD) is characterized by both impaired inhibitory control and heightened cue reactivity, including enhanced craving and drinking urges in response to alcohol-related stimuli. The interaction between these two mechanisms is thought to be crucial in the maintenance of addiction and relapse. The present study used a newly developed alcohol-related Go/NoGo-task to investigate how exposure to alcohol-related cues affects neural processing of inhibitory control in subjects with AUD. Functional magnetic resonance imaging (fMRI) was recorded during performance of a Go/NoGo task, which incorporated alcohol-related and neutral stimuli as Go and NoGo trials in abstinent AUD patients and healthy controls (HC). AUD patients exhibited increased activation of a fronto-striatal-parietal network during successful response inhibition relative to HC. Within the AUD group, activation for alcohol-related (relative to neutral) inhibition was enhanced in regions including bilateral anterior cingulate cortex (ACC), right medial frontal and precentral gyri, and right putamen. Activation differences in the right ACC increased with subjective craving. These preliminary findings suggest that AUD patients need to recruit enhanced neuronal resources for successful inhibition. In parts of the inhibitory network, this hyperactivation is enhanced when inhibition takes place in an alcohol-related context. Activation in the ACC increased stronger in patients experiencing high craving, possibly because of an enhanced conflict. The task introduced here thus allows to investigate neural processing of alcohol-related inhibition in an AUD sample. The preliminary results suggest that exposure to alcohol-related cues intensifies the demand on an already challenged inhibitory system in recently abstinent patients with AUD.

The Neurophysiology of Implicit Alcohol Associations in Recently Abstinent Patients With Alcohol Use Disorder: An Event-Related Potential Study Considering Gender Effects

BACKGROUND

Neuroscientific models of alcohol use disorders (AUDs) postulate an imbalance between automatic, implicit, and controlled (conscious) processes. Implicit associations towards alcohol indicate the automatically attributed appeal of alcohol-related stimuli. First, behavioral studies indicate that negative alcohol associations are less pronounced in patients compared to controls, but potential neurophysiological differences remain unexplored. This study investigates neurophysiological correlates of implicit alcohol associations in recently abstinent patients with AUD for the first time, including possible gender effects.

METHODS

A total of 62 patients (40 males and 22 females) and 21 controls performed an alcohol valence Implicit Association Test, combining alcohol-related pictures with positive (incongruent condition) or negative (congruent condition) words, while brain activity was recorded using 64-channel electroencephalography. Event-related potentials (ERPs) for alcohol-negative and alcohol-positive trials were computed. Microstate analyses investigated the effects of group (patients, controls) and condition (incongruent, congruent); furthermore, possible gender effects in patients were analyzed. Significant effects were localized with standardized low-resolution brain electromagnetic topography analysis.

RESULTS

Although no behavioral group differences were found, ERPs of patients and controls were characterized by distinct microstates from 320 ms onwards. ERPs between conditions differed only in patients with higher signal strength during incongruent trials. Around 600 ms, controls displayed higher signal strength than patients. A gender effect mirrored this pattern with enhanced signal strength in females as opposed to male patients. Around 690 ms, a group-by-valence interaction indicated enhanced signal strength in congruent compared to incongruent trials, which was more pronounced in controls.

CONCLUSIONS

For patients with AUD, the pattern, timing, and source localization of effects suggest greater effort regarding semantic and self-relevant integration around 400 ms during incongruent trials and attenuated emotional processing during the late positive potential timeframe. Interestingly, this emotional attenuation seemed reduced in female patients, thus corroborating the importance of gender-sensitive research and potential treatment of AUD.

Deficient processing of alcohol cues in the addicted brain: Evidence from event-related potential microstates

OBJECTIVE

Patients with alcohol use disorder (AUD) show altered brain responses to alcohol cues as compared to healthy controls. Event-related potential (ERP) studies mostly focus on the P3, which is usually diminished in AUD patients. The few studies that have investigated earlier components have yielded inconsistent results. The present study aimed at identifying the onset of impaired alcohol cue processing in AUD patients, as well as the association between neurophysiological processing and subjective craving.

METHODS

A sample of 15 inpatients with AUD and 15 healthy controls completed a cue reactivity task with alcohol-related, neutral, and scrambled pictures. Multichannel-EEG was recorded from 70 scalp electrodes, and ERP microstates were analyzed.

RESULTS

Patients displayed impaired neurophysiological processing, as indexed by a weaker P3 and a weaker, insensitive P1. The blunted P1 was associated with higher subjective craving.

CONCLUSIONS

Impaired alcohol cue processing in AUD emerges early, at the stage of sensory processing. Such deficient initial processing seems crucial to understanding cue reactivity processes in the brain and in the subjective experience of craving.

SIGNIFICANCE

The results highlight the importance of investigating early ERP components preceding the P3, and contribute to the debate on the onset of information-processing dysfunction in the addicted brain.

Neuropsychophysiological Measures of Alcohol Dependence: Can We Use EEG in the Clinical Assessment?

Addiction management is complex, and it requires a bio-psycho-social perspective, that ought to consider the multiple etiological and developmental factors. Because of this, a large amount of resources has been allocated to assess the vulnerability to dependence, i.e., to identify the processes underlying the transition from substance use to dependence, as well as its course, in order to determine the key points in its prevention, treatment, and recovery. Consequently, knowledge \from neuroscience must be taken into account, which is why different initiatives have emerged with this objective, such as the "Research Domain Criteria" (RDoC), and the "Addiction Neuroclinical Assessment" (ANA). Particularly, neuropsychophysiological measures could be used as markers of cognitive and behavioral attributes or traits in alcohol dependence, and even trace clinical change. In this way, the aim of this narrative review is to provide an overview following ANA clinical framework, to the most robust findings in neuropsychophysiological changes in alcohol dependence, that underlie the main cognitive domains implicated in addiction: incentive salience, negative emotionality, and executive functioning. The most consistent results have been found in event-related potential (ERP) analysis, especially in the P3 component, that could show a wide clinical utility, mainly for the executive functions. The review also shows the usefulness of other components, implicated in affective and substance-related processing (P1, N1, or the late positive potential LPP), as well as event-related oscillations, such as theta power, with a possible use as vulnerability or clinical marker in alcohol dependence. Finally, new tools emerging from psychophysiology research, based on functional connectivity or brain graph analysis could help toward a better understanding of altered circuits in alcohol dependence, as well as communication efficiency and effort during mental operations. This review concludes with an examination of these tools as possible markers in the clinical field and discusses methodological differences, the need for more replicability studies and incipient lines of work. It also uses consistent findings in psychophysiology to draw possible treatment targets and cognitive profiles in alcohol dependence.

Posterior Cingulate Cortical Response to Active Avoidance Mediates the Relationship between Punishment Sensitivity and Problem Drinking

Many people drink to alleviate negative affect, reflecting an avoidance strategy which can lead to alcohol misuse. Individuals with heightened sensitivity to punishment (SP) are especially susceptible to problem drinking via this maladaptive coping mechanism. As imaging studies have largely focused on sensation-seeking traits and approach behavior, the neural substrates underlying behavioral avoidance as well as their relationship with punishment sensitivity and alcohol use remain unclear. Here, we examined in humans the cerebral correlates of response inhibition to avoid a penalty in relation to both problem drinking and SP, as evaluated by the Alcohol Use Disorders Identification Test and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire, respectively. Seventy nondependent female and male drinkers performed a reward go/no-go task with approximately two-thirds go and one-third no-go trials. Correct go and no-go responses were rewarded, and incorrect responses were punished. The results showed that SP and Alcohol Use Disorders Identification Test scores were both positively correlated with brain activations during response inhibition, and these activations overlapped in the posterior cingulate cortex (PCC). Thus, the PCC may represent a shared neural substrate for avoidance, punishment sensitivity, and problem drinking. Mediation analyses further suggested that PCC response to avoidance completely and bidirectionally mediated the relationship between SP and hazardous alcohol use. These findings substantiated the role of the PCC in behavioral avoidance and its link to problem drinking in punishment-sensitive nondependent drinkers.SIGNIFICANCE STATEMENT Many people drink to alleviate negative affect, reflecting an avoidance strategy that can lead to alcohol misuse. Individuals with heightened punishment sensitivity (SP) trait are particularly vulnerable to this maladaptive coping mechanism. The current study examined the neural substrates underlying behavioral avoidance and their relationship with SP and problem drinking. Using a reward go/no-go task, we showed both SP and drinking severity were positively correlated with the posterior cingulate cortex (PCC) activation during action inhibition. Thus, the PCC may represent a shared neural substrate for avoidance behavior, punishment sensitivity, and problem drinking. Further, PCC response to avoidance mediated the relationship between SP and alcohol use. These findings substantiated the neural processes linking avoidance tendency to alcohol misuse in punishment-sensitive drinkers.

Learning to resist the urge: a double-blind, randomized controlled trial investigating alcohol-specific inhibition training in abstinent patients with alcohol use disorder

Background

Alcohol use disorder (AUD) leads to a significant individual and societal burden. To achieve higher therapy success rates, therapeutic interventions still need to be improved. Most current neuroscientific conceptualizations of AUD focus on the imbalance between an enhanced automatic reaction to alcohol cues and impaired inhibition. Complementary to traditional relapse prevention strategies, novel computerized training interventions aim to directly alter these processes. This study tests a computerized alcohol-specific inhibition training in a large clinical sample and investigates its effects on behavioral, experimental and neurophysiological outcomes. It also analyzes whether variations in inhibition difficulty and/or endogenous cortisol levels during training impact these effects.

Methods

This is a double-blind, randomized controlled trial (RCT) with 246 inpatients with AUD participating. After baseline assessment, participants are randomly assigned to one of three computerized Go-NoGo-based inhibition training interventions (two alcohol-specific versions with different Go/NoGo ratios, or neutral control training) and one of two intervention times (morning/afternoon), resulting in six study arms. All patients perform six training sessions within 2 weeks. Endogenous cortisol is measured in 80 patients before and after the first training session. Inhibitory control and implicit associations towards alcohol are assessed pre and post training, at which point electroencephalography (EEG) is additionally measured in 60 patients. Patients’ alcohol consumption and relevant psychological constructs (e.g., craving, self-efficacy, treatment motivation) are measured at discharge and at 3-, 6- and 12-month follow-ups. Fifty healthy participants are assessed (20 with EEG) at one time point as a healthy control group.

Discussion

This study investigates the effects of a computerized, alcohol-specific inhibition training for the first time in patients with AUD. Results should give insight into the effectiveness of this potential add-on to standard AUD treatment, including proximal and distal measures and effects on behavioral, experimental and neurophysiological measures. Information about working mechanisms and potential optimizations of this training are gathered through variations regarding difficulty of inhibition training and training time. This study may thus contribute to a deepened understanding of AUD and the improvement of its evidence-based treatment.

Trial registration

ClinicalTrials.gov, ID: NCT02968537. Registered on 18 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3505-2) contains supplementary material, which is available to authorized users.

ERP study on the associations of peripheral oxytocin and prolactin with inhibitory processes involving emotional distraction

BACKGROUND

Child maltreatment is a major health and social welfare problem, with serious and longstanding consequences. Impulse control ability plays an important role in reducing the risk of child maltreatment. The aim of this study was to investigate the associations of oxytocin (OXT) and prolactin (PRL) with behavior inhibition using children's facial expressions (angry or neutral) as emotional distractions. This may clarify a part of the neuroendocrinological mechanism that modulates impulse control ability in the context of child caregiving.

METHODS

Participants were 16 females who had never been pregnant. Following venous blood sampling for OXT and PRL levels, participants performed an emotional Go/Nogo task during their follicular and luteal phases to test inhibitory control ability. Behavioral performance and event-related potentials (ERPs) during the task were measured.

RESULTS

The results showed that there were significant fixed effects of OXT on behavioral performance, as measured by sensitivity (d-prime). This suggests that high peripheral OXT levels may be associated with better performance on the emotional Go/Nogo task, regardless of emotional distractors. PRL was associated with inhibitory processes as reflected by the Nogo-N2 and Nogo-P3. Particularly, high PRL levels were associated with the Nogo-N2 latency extension with the emotional distractors.

CONCLUSIONS

Our findings suggest that OXT might be associated with improving behavioral performance regardless of emotional processes. It is suggested that processes related to PRL are related to premotor activities of behavioral inhibitions and emotions.

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD.

Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage.

Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed.

Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings.

Alcohol-Specific Computerized Interventions to Alter Cognitive Biases: A Systematic Review of Effects on Experimental Tasks, Drinking Behavior, and Neuronal Activation

Background: In patients with alcohol use disorder, novel interventions to increase abstinence have attracted growing attention. Interventions aimed at modifying cognitive biases linked to alcohol use [i.e. cognitive bias modification (CBM)] may serve as an add-on to standard therapy. This systematic review thoroughly aggregates existing data on the effects of three alcohol-specific computerized interventions, namely attentional bias modification (AtBM), approach bias modification (ApBM), and inhibition training (IT). In doing so, each CBM's effects on experimental tasks assessing the relevant biases, drinking behavior, and neurophysiology are summarized. Also, the influence of drinking behavior severity and motivation to change drinking behavior are discussed. Methods: A literature search was conducted in four databases for original research articles published between 2000 and May 2019. Studies were eligible if investigating the effects of alcohol-specific computerized interventions (AtBM, ApBM, IT) on drinking behavior, bias change, and/or neurophysiology. Forty eligible articles were classified as being either a non-clinical experimental lab study (ELS) or clinical randomized-controlled trial (RCT) and summarized. Results: While AtBM seems to influence attentional bias, its effects on drinking behavior are inconsistent. As for ApBM, the best effects on drinking behavior are obtained in clinical samples. Effects of ApBM on approach bias are mixed. Interestingly, those clinical RCTs which investigated ApBM effects on bias change as well as on drinking outcome, reported consistent effects in both measures (i.e. either effects on bias and drinking or no effects). Studies on IT are limited to non-clinical samples and show inconsistent effects on drinking behavior. Considering ITs effects on implicit semantic associations, most studies do not support the conceptualization of IT as a form of memory bias modification, while reports on IT's effects on inhibitory control are still incomplete. Conclusions about the overall influence of drinking behavior severity are hampered by the non-uniform use of sample descriptions. Conclusions: In clinical samples, ApBM has shown more consistent beneficial effects, while evidence on AtBM is more inconsistent, and data on IT still lacks important information. Conclusions about the influence of drinking behavior severity would be facilitated by a uniform use of clearly defined sample descriptions.