Today I thought I’d talk about something I find fascinating, and that’s attentional bias. Attentional bias has been proposed to be significant in understanding addiction, especially in regards to treatments designed to overcome addiction and it’s accompanying behaviours. Thus, I will make the case for the evidence of attentional bias in addiction and addictive behaviours.
Let’s start with a quick definition of attentional bias. In relation to addiction and mental health, attentional bias is the tendency to focus more on certain things, which might also mean simultaneously ignoring others.
Attentional bias in addiction is not a unique consequence of addiction, it can be found in the average healthy person who doesn’t or hasn’t suffered from substance dependence, through simple exposure to associative learning between any stimuli and a rewarding outcome.
The difference between those suffering from addiction and non-addicted people is how it goes from our brain’s normal desire to facilitate previously rewarded behaviour to something more pathological that has stopped being of benefit to the system (Anderson, 2016). As Christiansen, Schoenmakers, and Field (2015) put it, an anxious person will pick up on threatening shapes in the shadows and the corners of their eyes, the struggling dieter will notice the deserts in the café, and the depressed person will favour the negatives comments over of the positive ones. Attentional bias is a problem for many people struggling with a range of issues, addiction is no different.
Field and Cox (2008) stated that attentional bias in addiction works through classical conditioning (learning through association), with the attentional biases being paired through repeated use and reward of what will become their addiction. For example, pairing drinking with the sight of a pub, leading to an unconditioned stimuli triggering an unconditioned response. Simply put, you learn to associate seeing a pub with drinking through repeated enjoyable drinking episodes at a pub, which will then trigger a drinking response whenever you see a pub.
However, some people see this explanation of attentional bias as being too simplistic regarding its effect in addiction. This is where the incentive-sensitization theory comes into play. Robinson and Berridge (2001) pointed out that there was a problem with the previous theories’ attempts at explaining addiction and attentional bias because they often thought that people suffering from addiction engage in their addiction for pleasure or to avoid the undesirable consequences of withdrawal.
Incentive-sensitization theory, however, states that through associative learning, like that of classical conditioning of stimuli and pleasure reward, form what is known as “liking”. However, there is a secondary component, where the “liking” stimuli become overly sensitized, to the point that those suffering from addiction will seek to engage in the behaviour, even when the “liking” of the behaviour has long gone, this is known as “wanting”.
Basically, liking is the stage where you still enjoy using the substance and wanting is what replaces that liking stage, where you’re driven to use the substance even though you no longer like and enjoy using it.
Thus, those suffering from addiction experience pathological “wanting” (or craving) which will continue even as those suffering from addiction dislike engaging in the behaviour. This take on attention bias, craving, and addiction explains the problem with relapsing, even after significant time without using, because their cravings can be triggered by attention-grabbing things they’ve associated with using the substance they’re addicted to or were addicted to.
A study by Field, Munafò, and Franken (2009) found that the relationship between attentional bias and craving could be modified by other factors, such as the state of craving someone was in. This is something Waters et al. (2003) also believed, finding that attentional bias impacts smokers in a number of ways, with individuals with a larger collection of paired attentional biases being more likely to notice more addiction related-stimuli in their surroundings. Basically, a heavy smoker will more likely be triggered to smoke than a new or casual smoker, as they’re more likely to have paired more objects and activities with smoking.
Waters et al. (2003) also offered some other insight, whereby there could be other mental processes going into action as well, such as conditioned withdrawal or intrusive thoughts. For example, the attentional bias stimuli might trigger a depressive thought pattern of how you are a bad person, rather than triggering craving to smoke, which will affect cessation attempts and day-to-day activities.
Lapsing and replacing during treatment is common because of things like attentional bias. According to Niaura et al. (1988), people suffering from addiction who have stronger reactions to addiction related-stimuli prior to the end of their treatment will engage in more of theiraddiction behaviours than those who have a lesser reaction to their addiction related-stimuli.
In short, if you haven’t learnt to change or mitigate your reactions to the addiction-related attentional biases that draw your attention, then reaching your recovery goals will be difficult.
Niaura et al. (1988) also suggested that along with altering reactions to addiction related-stimuli, a comprehensive treatment model should also feature coping skills for cravings, as well as other modifying factors to attentional biases and cravings, like stress (Tiffany, 1990). Therefore, any treatment programme should have components that try to identify clients triggers (addiction related-stimuli), create plans to overcome those identified triggers, have backup plans for how to manage cravings should they be triggered, and teach other skills to help people avoid being in a more susceptible state where being triggered is more likely.
This is supported by Waters et al. (2003) study, which I mentioned earlier. However, what I didn’t mention then was that this study involved putting 158 smokers randomly into a group with a nicotine patch or a placebo patch, where they had to do a Stroop task. For those that don’t know, a Stroop task it involves the mismatch between the name of a colour and the actual colour of that word, for example, Blue, Red, and Pink, with you having to say the colour of the word and not the word itself.
The results of Waters et al. (2003) Stroop task showed that the nicotine patch group having a source of nicotine replacement to reduce their cravings, displayed less attentional bias to addiction related-stimuli than the control/placebo group. This study managed to show the importance of attentional bias in engaging in addiction behaviours and relapsing, and how important it could be for the treatment of addiction.
Schoenmakers et al. (2010) conducted a study into attentional bias modification training using 43 patients with a clinical diagnosis of alcohol dependence, who were randomly assigned to two groups (bias modification training intervention or the control) to take part in five sessions. The bias modification training group was trained to disengage attention from alcohol related-stimuli, while the control group was given an irrelevant reaction time test. The results showed that bias modification training increased the ability to disengage from alcohol related-stimuli. Although this was conducted on a small sample, it does allow for a glimpse at how treatment can be changed to help people overcome addiction, providing a clinical application for attentional bias and retraining of attentional biases.
This is supported by Kerst and Waters (2014) who conducted a study on attentional retraining on 60 smokers who weren’t looking to quit, split into two groups (attentional retraining and control). Both groups were asked to complete four assessments a day, for a week, using a PDA. The results showed two important things: the first was that attentional retraining can reduce attentional bias, and the second being that it can be done using a mobile device, such as a phone. This study offers the potential of creating a smartphone app that would allow people seeking help with their addiction, to be able to work on it whenever and wherever they wanted, which would be a useful tool for those seeking treatment or have completed treatment.
All this highlight the importance of individual differences in attentional bias as well, which could explain why some people suffering from addiction have a much harder time giving up than others. That is because everyone will have their own attentional biases and modifiers that need to be tackled with strategies that use the individual’s strengths to mitigate their weaknesses.
Interestingly, the increases in attentional biases for addiction related-stimuli among those suffering from addiction also seems spread to other reward related-stimuli, according to a study by Anderson, Faulkner, Rilee, Yantis, and Marvel (2013). They conducted a small study on 17 opium dependent and 17 control participants and found that the opium dependent participants also displayed attentional bias towards previous nondrug reward-related stimuli.
If true, then it stands to reason that people suffering from addiction create minds geared towards favouring other reward-related stimuli, which might go some way to explaining how some suffering from addiction can pick up a new addiction as they try to, or have, overcome another addiction.
Weaknesses of Attentional Bias
However, according to Field et al. (2016) who conducted a review of the attentional bias literature on obesity and addiction, found that the relationship between attentional bias and how it affects behaviour is overestimated. Thus, even though we might have an attentional bias towards addiction related-stimuli, how that then goes on to affect our behaviour is somewhat of a grey area, as it allows for the possibility to start mechanisms that would trigger a craving, but does not grantee it.
Unfortunately, attentional bias studies that look into addiction tend to be conducted differently than other studies into attentional bias. Studies into areas like anxiety and attentional bias also look into interpretation bias, but for some reason, addiction based studies don’t appear to look for other variables of influence.
In anxiety, the role interpretation bias plays is how people with anxiety resolve ambiguity relating to their disorder, so for social anxiety disorders, it would be how they interpret social situations, which obviously would be different to how someone without an anxiety disorder would interpret the same social situation (Mobini, Reynolds, and Mackintosh, 2013). So it begs the question, would interpretation bias affect attentional bias in addiction? Would that grey area be where the interpretation bias becomes important in addiction research?
To sum up, the evidence shows that attentional bias exists in addiction, but how significant a role it plays might be the real question that needs answering. Attentional bias has been shown to have links to cravings and how it can affect lapsing/relapsing. Without attentional bias, can craving treatment be as effective as it could be? So what do you think? Is attentional bias a useful thing to add to the treatment of addiction or not?
As always, leave your feedback in the comments section below. Also, feel free to share your experiences of attentional bias and addiction in the comments section below as well. If you want to stay up-to-date with my blog, then sign up for my newsletter below. Alternatively, get push notifications for new articles by clicking the red bell icon in the bottom right corner.
Lastly, if you’d like to support my blog then you can make a donation of any size below as well. Until next time,
Unwanted Life readers.
Anderson, B. A. (2016). What is abnormal about addiction-related attentional biases?. Drug and Alcohol Dependence, 167, 8-14. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037014.
Anderson, B. A., Faulkner, M. L., Rilee, J. J., Yantis, S., & Marvel, C. L. (2013). Attentional bias for nondrug reward is magnified in addiction. Experimental and Clinical Psychopharmacology, 21(6), 499-506. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934504.
Christiansen, P., Schoenmakers, T. M., & Field, M. (2015). Less than meets the eye: Reappraising the clinical relevance of attentional bias in addiction. Addictive Behaviors, 4443-50. Retrieved from https://www.nivel.nl/nl/publicatie/less-meets-eye-reappraising-clinical-relevance-attentional-bias-addiction.
Field, M., & Cox, W. M. (2008). Attentional bias in addictive behaviors: A review of its development, causes, and consequences. Drug and Alcohol Dependence, 97(1-2), 1-20. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0376871608001257.
Field, M., Munafò, M. R., & Franken, I. H. A. (2009). A Meta-Analytic Investigation of the Relationship Between Attentional Bias and Subjective Craving in Substance Abuse. Psychological Bulletin, 135(4), 589–607. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999821.
Field, M., Werthmann, J., Franken, I., Hofmann, W., Hogarth, L., & Roefs, A. (2016). The role of attentional bias in obesity and addiction. Health Psychology, 35(8), 767-780. Retrieved from https://www.researchgate.net/publication/306024686_The_Role_of_Attentional_Bias_in_Obesity_and_Addiction.
Kerst, W. F., & Waters, A. J. (2014). Attentional retraining administered in the field reduces smokers’ attentional bias and craving. Health Psychology, 33(10), 1232-1240. Retrieved from https://doi.org/10.1037/a0035708.
Mobini, S., Reynolds, S., & Mackintosh, B. (2013). Clinical implications of Cognitive Bias Modification for interpretative biases in social anxiety: An integrative literature review. Cognitive Therapy and Research, 37(1), 173-182. Retrieved from https://link.springer.com/article/10.1007%2Fs10608-012-9445-8.
Niaura, R. S., Rohsenow, D. J., Binkoff, J. A., Monti, P. M., Pedraza, M., & Abrams, D. B. (1988). Relevance of cue reactivity to understanding alcohol and smoking relapse. Journal of Abnormal Psychology, 97(2), 133-152. Retrieved from https://doi.org/10.1037/0021-843X.97.2.133.
Robinson, T. E., & Berridge, K. C. (2001). Incentive-sensitization and addiction. Addiction, 96(1), 103-114. Retrieved from https://deepblue.lib.umich.edu/bitstream/handle/2027.42/74047/j.1360-0443.2001.9611038.x.pdf.
Tiffany, S. T. (1990). A cognitive model of drug urges and drug-use behavior: Role of automatic and nonautomatic processes. Psychological Review, 97(2), 147-168. Retrieved from https://doi.org/10.1037/0033-295X.97.2.147.
Waters, A. J., Shiffman, S., Sayette, M. A., Paty, J. A., Gwaltney, C. J., Balabanis, M. H. (2003). Attentional bias predicts outcome in smoking cessation. Health Psychology, 22 (4), 378-387. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244587.