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.

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

Alcohol-dependent patients show attentional and approach biases for alcohol-related stimuli. Computerized cognitive bias modification (CBM) programs aim to retrain these biases and reduce relapse rates as add-ons to treatment. Retraining of alcohol-approach tendencies has already yielded significant reductions of relapse rates in previous studies, and retraining of biased attention toward alcohol is promising approach. The current large-scale randomized controlled trial compared the clinical effects of these training methods-separately and in combination-to those of sham training methods and a no-training control, as an add-on to regular treatment. Methods: Participants were 1,405 alcoholdependent patients of an inpatient rehabilitation clinic. In addition to regular treatment, patients were randomized to receive 6 sessions of approach-bias retraining, 6 sessions of attention-bias retraining, 3 sessions of each of these CBM training varieties, 6 sessions of variants of sham training, or no training. Effects of the training methods were evaluated by measuring treatment success at 1-year follow-up. Results: Primary outcome: The 3 active training conditions yielded higher success rates at 1-year follow-up than sham training or no training (8.4%, on average). Secondary results (available for half of the sample): Both varieties of CBM had only small effects on the targeted biases (significant only for the combined training). Moreover, neither significant mediation of the clinical effect by the change in trained bias nor significant moderation of the clinical effect was found. Conclusions: Both alcohol-avoidance training and alcohol-attention training increased success rates effectively, as did the combination of both methods. Future studies should test ways to increase training effectiveness further. What is the public health significance of this article?This large-scale study shows that relapse rates in abstinent alcohol-dependent patients can be reduced both by training to avoid alcohol pictures and by training to direct attention away from them. This offers new and cost-effective add-on treatments for alcohol addiction.

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.

Behavioral studies have shown an alcohol-approach bias in alcohol-dependent patients: the automatic tendency to faster approach than avoid alcohol compared with neutral cues, which has been associated with craving and relapse. Although this is a well-studied psychological phenomenon, little is known about the brain processes underlying automatic action tendencies in addiction. We examined 20 alcohol-dependent patients and 17 healthy controls with functional magnetic resonance imaging (fMRI), while performing an implicit approach-avoidance task. Participants pushed and pulled pictorial cues of alcohol and soft-drink beverages, according to a contentirrelevant feature of the cue (landscape/portrait). The critical fMRI contrast regarding the alcohol-approach bias was defined as (approach alcohol4avoid alcohol)4(approach soft drink4avoid soft drink). This was reversed for the avoid-alcohol contrast: (avoid alcohol4approach alcohol)4(avoid soft drink4approach soft drink). In comparison with healthy controls, alcohol-dependent patients had stronger behavioral approach tendencies for alcohol cues than for soft-drink cues. In the approach, alcohol fMRI contrast patients showed larger blood-oxygen-level-dependent responses in the nucleus accumbens and medial prefrontal cortex, regions involved in reward and motivational processing. In alcohol-dependent patients, alcohol-craving scores were positively correlated with activity in the amygdala for the approach-alcohol contrast. The dorsolateral prefrontal cortex was not activated in the avoid-alcohol contrast in patients vs controls. Our data suggest that brain regions that have a key role in reward and motivation are associated with the automatic alcoholapproach bias in alcohol-dependent patients.