Implementing Approach-Bias Modification as Add-On to Varieties of Clinical Treatment for Alcohol Use Disorders: Results of a Multicenter RCT

INTRODUCTION

Abstinence rates after inpatient treatment for alcohol use disorder (AUD) are modest (1-year rate around 50%). One promising approach is to re-train the automatically activated action tendency to approach alcohol-related stimuli (alcohol-approach bias) in AUD patients, as add-on to regular treatment. As efficacy has been demonstrated in well-controlled randomized controlled trials, the important next step is to add alcohol-approach-bias modification (alcohol-ApBM) to varieties of existing treatments for AUD. Therefore, this prospective, multicenter implementation-RCT examined whether adding alcohol-ApBM to regular treatments (various abstinence-oriented treatments including both individual and group-based interventions) would significantly increase abstinence rates compared to receiving regular treatment only, in a variety of naturalistic settings with different therapeutic approaches.

METHODS

A total of 1,586 AUD inpatients from 9 German rehabilitation clinics were randomly assigned to receive either ApBM in addition to regular treatment or not. Training satisfaction of patients and therapists was measured after training. Success rates were determined at 3, 6, and 12 months post-treatment.

RESULTS

Return rates of the post-treatment assessments varied greatly between clinics, often being low (18-76%). Nevertheless, ApBM significantly increased success rates after 3 months. After 6 and 12 months, the differences were not significant. ApBM was evaluated mostly positively by patients and therapists.

DISCUSSION/CONCLUSION

ApBM was an effective add-on to regular treatment of AUD at 3 months follow-up, across a variety of AUD treatment settings. However, low return rates for the clinical outcomes reduced the effect size of ApBM considerably. The application of ApBM proved feasible in varying clinical settings, offering the opportunity to modify automatic processes and to promote abstinence.

Approach-Bias Retraining and Other Training Interventions as Add-On in the Treatment of AUD Patients

In the past two decades, a variety of cognitive training interventions have been developed to help people overcome their addictive behaviors. Conceptually, it is important to distinguish between programs in which reactions to addiction-relevant cues are trained (varieties of cognitive bias modification, CBM) and programs in which general abilities are trained such as working memory or mindfulness. CBM was first developed to study the hypothesized causal role in mental disorders: by directly manipulating the bias, it was investigated to what extent this influenced disorder-relevant behavior. In these proof-of-principle studies, the bias was temporarily modified in volunteers, either temporarily increased or decreased, with corresponding effects on behavior (e.g., beer consumption), in case the bias was successfully manipulated. In subsequent clinical randomized controlled trials (RCTs), training (away from the substance vs. sham training) was added to clinical treatment. These studies have demonstrated that CBM, as added to treatment, reduces relapse with a small effect of about 10% (similar effect size as for medication, with the strongest evidence for approach-bias modification). This has not been found for general ability training (e.g., working memory training), although effects on other psychological functions have been found (e.g., impulsivity). Mindfulness also has been found to help people overcome addictions, and different from CBM, also as stand-alone intervention. Research on (neuro-)cognitive mechanisms underlying approach-bias modification has pointed to a new perspective in which automatic inferences rather than associations are influenced by training, which has led to the development of a new variety of training: ABC training.

Cognitive training and remediation interventions for substance use disorders: a Delphi consensus study

AIMS

Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions.

DESIGN, SETTING AND PARTICIPANTS

We used a Delphi approach with two sequential phases: survey development and iterative surveying of experts. This was an on-line study. During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n = 54) identified via recommendations from the Steering Committee and a systematic review.

MEASUREMENTS

Survey with 67 items covering four key areas of intervention development: targets, intervention approaches, active ingredients and modes of delivery.

FINDINGS

Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias modification, goal-setting, strategy learning and meta-awareness as active ingredients; and (iv) both addiction treatment work-force and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities.

CONCLUSIONS

Expert recommendations on cognitive training and remediation for substance use disorders highlight the relevance of targeting implicit biases, reward, emotion regulation and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.

Does selective inhibition training reduce relapse rates when added to standard treatment of alcohol use disorder? A randomized controlled trial

BACKGROUND

Alcohol-dependent individuals tend to selectively approach alcohol cues in the environment, demonstrating an alcohol approach bias. Because approach bias modification (ApBM) training can reduce the approach bias and decrease relapse rates in alcohol-dependent patients when added to abstinence-focused treatment, it has become a part of regular treatment. Moreover, in selective inhibition (SI) training, responses to one category of stimuli (i.e., alcohol stimuli) are selectively inhibited in an adapted Go/No-Go task. SI-Training has been found to effectively devalue the inhibited category and to reduce consumption of alcohol among social drinkers. This study investigated whether SI-Training can further improve the effects of treatment as usual that includes ApBM, and if so, whether the effect is mediated by a devaluation of the inhibited alcohol stimuli.

METHODS

Abstinent alcohol-dependent inpatients (N=434) were randomly assigned to receive 6 sessions of either active (n = 214, 32% female) or sham (n = 220, 38% female) SI-Training, in addition to standard treatment that includes active ApBM. Ratings were used to assess changes in the evaluation of alcohol stimuli after the training. Relapse rates were assessed 3 and 12 months after treatment discharge.

RESULTS

Alcohol stimuli were rated negatively before and after the training, and the training did not influence these ratings. Evaluation of nonalcoholic drinks became more positive after active SI-Training. Both ApBM and SI-Training showed the expected training effects on reaction times. Contrary to expectations, SI-Training conditions did not yield different abstinence rates 3 or 12 months after treatment.

CONCLUSIONS

We found no evidence supporting the hypothesis that SI-Training amplifies the relapse-preventing effect of ApBM. Moreover, alcohol stimuli were rated negatively before and after treatment and were not influenced by SI-Training.

German Guidelines on Screening, Diagnosis, and Treatment of Alcohol Use Disorders: Update 2021

INTRODUCTION

Alcohol consumption in Germany is associated with considerable health and economic consequences. In addition to prevention, the early detection and differential treatment of those affected play an important role. The guideline "Screening, Diagnosis, and Treatment of Alcohol Use Disorders" forms the basis of this care for people suffering from alcohol use disorders. Regular updates integrate the current state of research evidence and clinical expertise.

METHODS

Under the auspices of the German Society for Psychiatry, Psychotherapy, Psychosomatics, and Neurology and the German Society for Addiction Research and Addiction Therapy e.V. (DG-Sucht), the 2019-2020 S3 guideline on alcohol was revised by eight working groups. Thirty-five professional societies participated in a structured consensus process to deliberate the recommendations. Potential conflicts of interest were examined in advance, documented, and taken into account during the voting on the recommendations.

RESULTS

The guideline provides recommendations on screening and brief interventions for different groups of people, as well as on treatment of individuals in the acute and post-acute phases of withdrawal. Special emphasis was placed on the treatment of comorbid somatic and psychological disorders. In addition, recommendations for specific groups of people (e.g., children and adolescents, pregnant women) have been made and adapted to the German care landscape.

Does comorbid anxiety or depression moderate effects of approach bias modification in the treatment of alcohol use disorders?

Objective: Approach bias modification (ApBM) is a promising new add-on training intervention for patients with alcohol use disorder (AUD). Given that comorbid anxiety and major depressive disorders are very common in AUD, and that such comorbidity affects psychological treatments negatively, the primary aim of the present study was investigating whether ApBM training is moderated by anxiety/major depressive disorder comorbidity. The secondary aim was to examine whether ApBM's relapse-preventive effect can be replicated. Method: We conducted a large-scale randomized controlled trial (RCT) in a clinical sample of AUD inpatients (n = 729) with a follow-up assessment after 1 year. All patients received 12 weeks of inpatient treatment as usual (TAU). On top of that, patients were randomized to a 12-session ApBM (TAU + ApBM), and a no-training control condition (TAU-only). Treatment success was defined as either no relapse or a single lapse shorter than 3 days in duration, ended by the patient and followed by at least 4 weeks of abstinence. Failure was defined as relapse, passed away, no contact, or refusal to provide information. Results: We found that TAU + ApBM had significantly higher success rates than TAU-only at 1-year follow-up. Importantly, anxiety/depressive comorbidity moderated ApBM's effects: Adding ApBM to TAU increased success rates more for patients with a comorbid anxiety and/or depressive disorder than for patients without such comorbidity. Conclusions: Our data suggest that adding ApBM to TAU works better in patients with a comorbid anxiety and/or depressive disorder; a promising finding gave the high rates of comorbidity in clinical practice. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

S3-Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“

Zusammenfassung. Zielsetzung: Alkoholkonsum ist in Deutschland mit erheblichen gesundheitlichen und wirtschaftlichen Folgen assoziiert. Neben der Prävention spielen die Früherkennung und differentielle Behandlung von Betroffenen eine bedeutende Rolle. Die Leitlinie „Screening, Diagnose und Behandlung alkoholbezogener Störungen“ bildet die Grundlage für die Versorgung betroffener Personen. Die regelmäßigen Updates implementieren evidenzbasiert den aktuellen Forschungsstand von Literatur und klinischer Expertise. Methodik: Unter Federführung der Deutschen Gesellschaft für Psychiatrie, Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) und der Deutschen Gesellschaft für Suchtforschung und Suchttherapie e. V. (DG-Sucht) wurde die S3-Leitlinie Alkohol von 2019–2020 in acht Arbeitsgruppen überarbeitet. Am strukturierten Konsensprozess zur Beratung der Empfehlungen beteiligten sich 35 Fachgesellschaften. Potentielle Interessenskonflikte wurden im Vorfeld erfragt, dokumentiert und in der Abstimmung der Empfehlungen berücksichtigt.: Die Leitlinie gibt Empfehlungen zu Screening und Kurzintervention für verschiedene Personengruppen, sowie zur Behandlung von Betroffenen in der akuten und postakuten Phase des Entzugs. Besondere Bedeutung kommt der Behandlung von komorbiden somatischen und psychischen Störungen zu. Außerdem wurden Empfehlungen für bestimmte Personengruppen (z. B. Kinder und Jugendliche, Schwangere) ausgesprochen und auf die deutsche Versorgungslandschaft adapiert.

Positivity-approach training for depressive symptoms: A randomized controlled trial

OBJECTIVE

Depression is highly comorbid and depressive symptoms are very common. Symptom severity adversely affects treatment outcome and later health status. Established interventions for depression leave ample room for improvement. Short interventions that target specific vulnerabilities emerge as plausible augmentation strategies. In this study, we tested the efficacy of a computerized general positivity-approach training and its effect on depressive symptoms.

METHODS

Patients (N = 240) with various diagnoses of mental disorders who received treatment-as-usual in an inpatient setting were randomly assigned to also receive either 4 sessions of a positivity-approach training or 4 sessions of sham training. Depression severity was assessed at baseline and post-treatment. Training data were analyzed for a subset of 111 patients.

RESULTS

Depressive symptoms were reduced more after positivity-approach training than after sham training. Initial depression symptom severity moderated the intervention effects, such that approach tendencies and depression symptoms were only affected positively among patients with higher levels of initial depression symptom severity.

CONCLUSIONS

The findings provide preliminary support for positivity-approach training as an add-on treatment option for depressive symptoms.

A Clinical Trial with Combined Transcranial Direct Current Stimulation and Attentional Bias Modification in Alcohol-Dependent Patients

BACKGROUND

Modifying attentional processes with attentional bias modification (ABM) might be a relevant add-on to treatment in addiction. This study investigated whether influencing cortical plasticity with transcranial direct current stimulation (tDCS) could increase training effects. tDCS could also help alcohol-dependent patients to overcome craving and reduce relapse, independent of training. These approaches were combined to investigate effects in the treatment of alcoholism.

METHODS

Ninety-eight patients (analytical sample = 83) were randomly assigned to 4 groups in a 2-by-2 factorial design. Patients received 4 sessions of ABM (control or real training) combined with 2 mA tDCS (active: 20 minutes or sham: 30 seconds) over the left dorsolateral prefrontal cortex. Alcohol bias and craving were assessed, and treatment outcome was measured as relapse after 1 year.

RESULTS

Attentional bias scores indicated that during the training only the group with active tDCS and real ABM displayed an overall avoidance bias (p < 0.05). From pre- to postassessment, there were no main or interaction effects of tDCS and ABM on the bias scores, craving, or relapse (p > 0.2). However, effects on relapse after active tDCS were in the expected direction.

CONCLUSIONS

There was no evidence of a beneficial effect of tDCS or ABM or the combination. Whether the absence of effect was due to issues with the outcome measurements (e.g., lack of craving, high dropout, and unreliable measurements) or aspects of the intervention should be further investigated.

Self-esteem consistency predicts the course of therapy in depressed patients

Previous studies on self-esteem and depression demonstrated the usefulness of both implicit and explicit self-esteem as well as their congruence (also known as self-esteem consistency) to predict future depressive symptoms. High self-esteem consistency describes when implicit and explicit self-esteem match (e.g., both high or both low). In the current study, we investigated if implicit and explicit self-esteem and self-esteem consistency predict the course of treatment efficacy of a cognitive behavioral depression therapy. Explicit self-esteem was assessed by the Rosenberg Self-Esteem Scale, implicit self-esteem by a priming task. Participants were 31 patients with a major depressive or recurrent depressive disorder receiving cognitive behavioral therapy treatment in an inpatient setting. Self-esteem measures were administered before treatment. The development of depression symptoms during treatment and at the 4-month follow-up was measured on the Beck Depression Inventory. Implicit and explicit self-esteem did not predict the course of the therapy. Patients with congruent self-esteem, however, improved faster and showed lower severity of symptoms throughout treatment. In contrast, neither explicit nor implicit self-esteem nor self-esteem consistency predicted the stability of effects after treatment. Practical implications such as targeting discrepancies in self-esteem during treatment are discussed.

Predictors of Utilization of an Addiction-Specific Behavioural Couple Therapy in Alcohol Dependence

PURPOSE

The aim of this study was to examine predictors that lead to the utilization of Behavioural Couple Therapy (BCT) for patients with alcohol dependence (AD) in a -European health care system and to identify groups that have a low probability of utilizing BCT.

METHODS

Using routinely collected data from a German rehabilitation clinic, a sample of 1,843 inpatients with AD living in a couple relationship was examined. Each patient could freely choose to participate in an addiction-specific BCT as a voluntary additional intervention during an inpatient treatment program.

RESULTS

The logistic regression analysis indicated that female gender, older age and a higher number of comorbid disorders were associated with a decreased probability of utilizing BCT. The decision tree found that for men, the lowest utilization rate was in the age range of 51-54 and from the age of 58 years; women with higher pressure by their partner in combination with more than 1 comorbid mental disorder and women with lower pressure by their partner (regardless of comorbid disorders) showed the lowest utilization rate.

CONCLUSIONS

Certain subgroups of patients with AD are less likely to participate in BCT during inpatient treatment.

A clinical trial with combined transcranial direct current stimulation and alcohol approach bias retraining

Two studies showed an improvement in clinical outcomes after alcohol approach bias retraining, a form of Cognitive Bias Modification (CBM). We investigated whether transcranial direct current stimulation (tDCS) could enhance effects of CBM. TDCS is a neuromodulation technique that can increase neuroplasticity and has previously been found to reduce craving. One hundred alcohol-dependent inpatients (91 used for analysis) were randomized into three experimental groups in a double-blind parallel design. The experimental group received four sessions of CBM while receiving 2 mA of anodal tDCS over the dorsolateral prefrontal cortex (DLPFC). There were two control groups: One received sham stimulation during training and one received active stimulation at a different moment. Treatment outcomes were abstinence duration (primary) and relapse after 3 and 12 months, craving and approach bias (secondary). Craving and approach bias scores decreased over time; there were no significant interactions with experimental condition. There was no effect on abstinence duration after three months (χ2(2) = 3.53, p = 0.77). However, a logistic regression on relapse rates after one year (standard outcome in the clinic, but not-preregistered) showed a trend when relevant predictors were included; relapse was lower in the condition receiving active stimulation during CBM only when comparing to sham stimulation (B = 1.52, S.E. = .836, p = .07, without predictors: p = .19). No strong evidence for a specific enhancement effect of tDCS on CBM was found. However, in a post-hoc analysis, tDCS combined with CBM showed a promising trend on treatment outcome. Important limitations are discussed, and replication is necessary to find more reliable effects.

Applying the ‘Cognitive Bias Modification’ concept to smoking cessation – A Systematic Review

Abstract. Background: In recent years, new neurocognitive explanatory approaches such as dual-process theories offer significant progress in understanding long-term relapse in substance use disorders. Based on such explanatory concepts stemming from basic research, novel methods of intervention have been deduced which focus on directly changing cognitive biases. The efficacy of these Cognitive Bias Modification (CBM) concepts has been evaluated in a growing number of studies in the context of different substance use and addictive disorders. By now, there are also first findings for using CBM in the context of smoking. Objectives: To evaluate the empirical evidence, whether CBM qualifies i) for reducing attentional or approach bias towards smoking-related cues, ii) for effectively reducing the high relapse rates in smoking cessation, iii) for the reduction of smoking behaviour and iv) craving. Methods: The systematic evidence search has been carried out in clinical databases (Cochrane Library, PsycArticles, PSYNDEX, PsycINFO, Medline) as well as via manual reverse search. Finally, 12 studies have been identified which met the inclusion criteria (RCT, CBM interventions for smokers; outcomes: change in attentional or approach bias, craving, number of cigarettes smoked, abstinence). Results: Despite the heterogeneity of the studies in terms of sample selection, realisation of interventions and methodological aspects, the findings collectively indicate that different forms and ‘dosages’ of CBM interventions can influence attentional or approach bias in smokers. Also, positive effects on craving and motivation to quit could be detected. Effects on smoking behaviour are inconsistent and often statistically non-significant. First online applications showed encouraging results. Discussion: The results concerning the efficacy of CBM in smoking cessation are still rudimentary and inconsistent. However, a large portion of the studies was not conducted under naturalistic conditions, but rather in laboratories with non-treatment seekers or participants partially motivated to quit. Despite these limitations, the findings can be evaluated as encouraging. The results suggest that CBM will be implemented in routine care as an adjunct intervention within a behavioural therapy-oriented cessation programme. However, specific studies which assess the efficacy of CBM as a component for relapse prevention in smoking cessation intervention in routine care are still lacking.

Effects of depressive symptoms and peripheral DAT methylation on neural reactivity to alcohol cues in alcoholism

In alcohol-dependent (AD) patients, alcohol cues induce strong activations in brain areas associated with alcohol craving and relapse, such as the nucleus accumbens (NAc) and amygdala. However, little is known about the influence of depressive symptoms, which are common in AD patients, on the brain's reactivity to alcohol cues. The methylation state of the dopamine transporter gene (DAT) has been associated with alcohol dependence, craving and depression, but its influence on neural alcohol cue reactivity has not been tested. Here, we compared brain reactivity to alcohol cues in 38 AD patients and 17 healthy controls (HCs) using functional magnetic resonance imaging and assessed the influence of depressive symptoms and peripheral DAT methylation in these responses. We show that alcoholics with low Beck's Depression Inventory scores (n=29) had higher cue-induced reactivity in NAc and amygdala than those with mild/moderate depression scores (n=9), though subjective perception of craving was higher in those with mild/moderate depression scores. We corroborated a higher DAT methylation in AD patients than HCs, and showed higher DAT methylation in AD patients with mild/moderate than low depression scores. Within the AD cohort, higher methylation predicted craving and, at trend level (P=0.095), relapse 1 year after abstinence. Finally, we show that amygdala cue reactivity correlated with craving and DAT methylation only in AD patients with low depression scores. These findings suggest that depressive symptoms and DAT methylation are associated with alcohol craving and associated brain processes in alcohol dependence, which may have important consequences for treatment. Moreover, peripheral DAT methylation may be a clinically relevant biomarker in AD patients.

Effects of cognitive bias modification training on neural signatures of alcohol approach tendencies in male alcohol-dependent patients

Alcohol-dependent patients have been shown to faster approach than avoid alcohol stimuli on the Approach Avoidance Task (AAT). This so-called alcohol approach bias has been associated with increased brain activation in the medial prefrontal cortex and nucleus accumbens. Cognitive bias modification (CBM) has been used to retrain the approach bias with the clinically relevant effect of decreasing relapse rates one year later. The effects of CBM on neural signatures of approach/avoidance tendencies remain hitherto unknown. In a double-blind placebo-controlled design, 26 alcohol-dependent in-patients were assigned to a CBM or a placebo training group. Both groups performed the AAT for three weeks: in CBM training, patients pushed away 90 percent of alcohol cues; this rate was 50 percent in placebo training. Before and after training, patients performed the AAT offline, and in a 3 T magnetic resonance imaging scanner. The relevant neuroimaging contrast for the alcohol approach bias was the difference between approaching versus avoiding alcohol cues relative to soft drink cues: [(alcohol pull > alcohol push)  > (soft drink pull > soft drink push)]. Before training, both groups showed significant alcohol approach bias-related activation in the medial prefrontal cortex. After training, patients in the CBM group showed stronger reductions in medial prefrontal cortex activation compared with the placebo group. Moreover, these reductions correlated with reductions in approach bias scores in the CBM group only. This suggests that CBM affects neural mechanisms involved in the automatic alcohol approach bias, which may be important for the clinical effectiveness of CBM.

Decreased gray matter volume in inferior frontal gyrus is related to stop-signal task performance in alcohol-dependent patients

Impairment in inhibitory control has been proposed to contribute to habitual alcohol use, abuse and eventually dependence. Moreover, alcohol-dependent (AD) patients have shown a loss of gray matter volume (GMV) in the brain, specifically in prefrontal regions associated with executive functions, including response inhibition. To date, no study has evaluated whether this prefrontal GMV reduction is related to response inhibition in alcohol dependence. To address this issue, we acquired high-resolution T1-weighted magnetic resonance mages from recently detoxified AD patients (n = 22) and healthy controls (HC; n = 21). Differences in local GMV between groups were assessed by means of voxel-based morphometry (VBM). Moreover, within the AD group, mean local GMV reductions were extracted and correlated with behavioral performance on the stop-signal task. We found a significantly decrease in GMV in the left inferior frontal gyrus (IFG) in AD patients compared with HC subjects. Further, mean local GMV in this area correlated positively with reaction times on go trials during the stop-signal task in AD patients. Our findings suggest that GMV losses in the IFG in AD patients are related to faster go responses on the stop-signal task.

Effects of cognitive bias modification training on neural alcohol cue reactivity in alcohol dependence

OBJECTIVE

In alcohol-dependent patients, alcohol cues evoke increased activation in mesolimbic brain areas, such as the nucleus accumbens and the amygdala. Moreover, patients show an alcohol approach bias, a tendency to more quickly approach than avoid alcohol cues. Cognitive bias modification training, which aims to retrain approach biases, has been shown to reduce alcohol craving and relapse rates. The authors investigated effects of this training on cue reactivity in alcohol-dependent patients.

METHOD

In a double-blind randomized design, 32 abstinent alcohol-dependent patients received either bias modification training or sham training. Both trainings consisted of six sessions of the joystick approach-avoidance task; the bias modification training entailed pushing away 90% of alcohol cues and 10% of soft drink cues, whereas this ratio was 50/50 in the sham training. Alcohol cue reactivity was measured with functional MRI before and after training.

RESULTS

Before training, alcohol cue-evoked activation was observed in the amygdala bilaterally, as well as in the right nucleus accumbens, although here it fell short of significance. Activation in the amygdala correlated with craving and arousal ratings of alcohol stimuli; correlations in the nucleus accumbens again fell short of significance. After training, the bias modification group showed greater reductions in cue-evoked activation in the amygdala bilaterally and in behavioral arousal ratings of alcohol pictures, compared with the sham training group. Decreases in right amygdala activity correlated with decreases in craving in the bias modification but not the sham training group.

CONCLUSIONS

These findings provide evidence that cognitive bias modification affects alcohol cue-induced mesolimbic brain activity. Reductions in neural reactivity may be a key underlying mechanism of the therapeutic effectiveness of this training.

Alcohol-related interpretation bias in alcohol-dependent patients

BACKGROUND

Models of addictive behaviors postulate that implicit alcohol-related memory associations and biased interpretation processes contribute to the development and maintenance of alcohol misuse and abuse. The present study examined whether alcohol-dependent patients (AP) show an alcohol-related interpretation bias. Second, the relationship between the interpretation bias and levels of harmful drinking was investigated.

METHODS

The sample included 125 clinically diagnosed AP and 69 clinically diagnosed control patients (CP) who had either a mood or an anxiety disorder. Participants completed a booklet containing 12 open-ended ambiguous scenarios. Seven scenarios were alcohol-relevant, and 5 were emotionally relevant, that is, panic- or depression-relevant. Participants were asked to read each scenario and to generate a continuation. In addition, the Alcohol Use Disorder Identification Test (AUDIT) and Beck Depression Inventory were administered.

RESULTS

Logistic multivariate multilevel analyses revealed that AP' probability of generating an alcohol-related continuation on all 3 scenario types was higher than that of CP. Moreover, alcohol-related interpretation biases were positively associated with levels of harmful drinking (i.e., AUDIT scores).

CONCLUSIONS

These findings are the first to show that AP show an alcohol-related interpretation bias, which generalizes to other ambiguous emotionally relevant contexts, and therefore advance our understanding of the role of implicit biased alcohol-related memory associations and interpretation processes.

Approach bias modification in alcohol dependence: do clinical effects replicate and for whom does it work best?

BACKGROUND

Alcoholism is a progressive neurocognitive developmental disorder. Recent evidence shows that computerized training interventions (Cognitive Bias Modification, CBM) can reverse some of these maladaptively changed neurocognitive processes. A first clinical study of a CBM, called alcohol-avoidance training, found that trained alcoholic patients showed less relapse at one-year follow-up than control patients. The present study tested the replication of this result, and questions about mediation and moderation.

METHODS

509 alcohol-dependent patients received treatment as usual (primarily Cognitive Behavior Therapy) inpatient treatment. Before and after treatment, the implicit approach bias was measured with the Alcohol Approach-Avoidance Task. Half of the patients were randomly assigned to CBM, the other half received treatment as usual only. Background variables, psychopathology and executive control were tested as possible moderating variables of CBM. One year after treatment, follow-up data about relapse were collected.

RESULTS

The group receiving CBM developed alcohol-avoidance behavior and reported significantly lower relapse rates at one-year follow-up. Change in alcohol-approach bias mediated this effect. Moderation analyses demonstrated that older patients and patients with a strong approach-bias at pretest profited most from CBM.

CONCLUSIONS

CBM is a promising treatment add-on in alcohol addiction and may counter some of the maladaptive neurocognitive effects of long-term alcoholism.

[Rehabilitee-management-categories (RMK)--results of the development phase and of the first clinical implementation in alcohol rehabilitation centres]

BACKGROUND

Due to the introduction of lump sum reimbursement systems for acute-care settings (DRGs), patient classification systems have been developed in Germany during the last 15 years to adapt a case-based lump sum system to the field of medical rehabilitation. The concept of Rehabilitee-Management-Categories (RMK), developed by the Charité - Universitätsmedizin Berlin, classifies rehabilitees primarily by their relevant impairments of activity and participation, as these factors mainly determine treatment needs and resources required in rehabilitation. It can, inter alia, be used to optimize the demand-related allocation of treatment services in the rehabilitation centres as well as lead to more transparency in the allocation process. RMK results are reported on the example of inpatient rehabilitation of alcohol dependence.

METHODS

Utilizing internationally established assessments, an RMK-assessment was developed that allows the assessment of rehab treatment needs of patients undergoing alcohol dependence rehabilitation. The RMK-assessment was completed by n=731 rehabilitees. Latent class analysis was applied to find groups of cases. To facilitate the RMK-patient classification a software-based algorithm was developed and implemented in 12 rehabilitation centres (implementation study). To validate the results of the first study phase, the data collected during implementation (n=1,533) was again analyzed using latent class analysis. Combined standardized and qualitative user surveys were conducted at the end of the implementation study.

RESULTS

On the basis of 15 needs-related patient characteristics, 4 comparable case groups (AL-1 to AL-4) each were identified in 2 independent samples, groups that differed significantly in their degree of dependence-related, psychological and social impairment. The user survey confirmed the basic clinical plausibility of the 4 different case groups as well as the feasibility of the instruments applied in a rehabilitation setting.

CONCLUSIONS

The RMK-concept offers a new approach for a demand-related patient classification in medical rehabilitation. The RMK-instruments allow a standardized initial assessment of impairment and treatment needs in alcohol rehabilitation and can hence be used for objective comparisons between rehabilitation centres. The results of the RMK-assessment provide relevant information about demand-related treatment requirements, which is a matter of great interest in the context of limited resources. Appropriate treatment requirements for the 4 RMK-case groups will be defined and verified in the next step of the RMK-concept. A financial evaluation of the RMK is possible in principal, will however require more extensive development, not least in order to model and evaluate the health-economic implications involved.

When paranoia fails to enhance self-esteem: explicit and implicit self-esteem and its discrepancy in patients with persecutory delusions compared to depressed and healthy controls

The hypothesis that persecutory delusions function to enhance self-esteem implies that patients will show normal explicit, but low implicit self-esteem. As evidence for this has been inconsistent, our study assessed delusional state, explicit and implicit self-esteem and depression in a large sample (n=139) of schizophrenia patients with acute persecutory delusions (n=28), patients with remitted persecutory delusions (n=31), healthy controls (n=59), and depressed controls (n=21). Patients with delusions and patients with depression both showed decreased levels of explicit, but normal levels of implicit self-esteem when compared to healthy controls. The direct comparison of levels of explicit and implicit self-esteem within each group revealed that healthy controls had higher explicit than implicit self-esteem, while the converse pattern was found for depressed controls. No discrepancy between explicit and implicit self-esteem was found for acute deluded or remitted patients with schizophrenia. Although these findings do not support the hypothesis that delusions serve to enhance self-esteem, they underline the relevance of low self-esteem in patients with persecutory delusions and point to the necessity of enhancing self-esteem in therapy.

Retraining Automatic Action Tendencies Changes Alcoholic Patients’ Approach Bias for Alcohol and Improves Treatment Outcome

This study tested the effects of a new cognitive-bias modification (CBM) intervention that targeted an approach bias for alcohol in 214 alcoholic inpatients. Patients were assigned to one of two experimental conditions, in which they were explicitly or implicitly trained to make avoidance movements (pushing a joystick) in response to alcohol pictures, or to one of two control conditions, in which they received no training or sham training. Four brief sessions of experimental CBM preceded regular inpatient treatment. In the experimental conditions only, patients’ approach bias changed into an avoidance bias for alcohol. This effect generalized to untrained pictures in the task used in the CBM and to an Implicit Association Test, in which alcohol and soft-drink words were categorized with approach and avoidance words. Patients in the experimental conditions showed better treatment outcomes a year later. These findings indicate that a short intervention can change alcoholics’ automatic approach bias for alcohol and may improve treatment outcome.

Ressourcenrealisierung und Therapieerfolg von alkoholabhängigen Patienten. Bericht über eine katamnestische Studie

Fragestellungen: Erstens interessierte, welche Ressourcen Alkoholabhängige zu Therapiebeginn realisieren. Zweitens wurde untersucht, inwieweit ein Ressourcenzuwachs bei Therapieende feststellbar ist. Drittens wurde überprüft, ob sich die Ressourcenrealisierung als Prädiktor für längerfristigen Therapieerfolg (Abstinenz) ein Jahr nach Therapieende eignet. </p><p> Methodik: 548 stationär behandelte alkoholabhängige Patienten wurden hinsichtlich ihrer Ressourcenrealisierung mittels des RES-Fragebogens (Trösken, 2002) zu Therapiebeginn und Therapieende untersucht. Der Therapieerfolg (Abstinenz) wurde im Rahmen einer Ein-Jahres-Katamnese erfasst. </p><p> Ergebnisse: Die alkoholabhängigen Patienten realisieren zu Therapiebeginn weniger Ressourcen als psychisch Gesunde (Normstichprobe des RES-Fragebogens). Es kann ein statistisch und klinisch bedeutsamer Ressourcenzuwachs festgestellt werden. Bereits die Ressourcenrealisierung zu Therapiebeginn, aber auch zu Therapieende, ist prognostisch bedeutsam für die spätere Abstinenz. </p><p> Schlussfolgerungen: Für die Behandlung von Alkoholabhängigen wird die Durchführung einer sorgfältigen Ressourcendiagnostik zur Vorbereitung ressourcenorientierter Interventionen als entscheidenden Beitrag zur Sicherung langfristiger Abstinenz vorgeschlagen.