Understanding Attentional Biases in Severe Alcohol Use Disorder: A Combined Behavioral and Eye-Tracking Perspective

Abstract

Rationale Severe alcohol use disorder (SAUD) is a psychiatric condition linked to cerebral and cognitive consequences. SAUD is notably characterized by an overactivation of the reflexive/reward system when confronted with alcohol-related cues. Such overreactivity generates a preferential allocation of attentional resources toward these cues, labeled as attentional biases (AB). Theoretical assumptions have been made regarding the characteristics of AB and their underlying processes. While often considered as granted, these assumptions remain to be experimentally validated. Aims We first identify the theoretical assumptions made by previous studies exploring the nature and role of AB. We then discuss the current evidence available to establish their validity. We finally propose research avenues to experimentally test them. Methods Capitalizing on a narrative review of studies exploring AB in SAUD, the current limits of the behavioral measures used for their evaluation are highlighted as well as the benefits derived from the use of eye-tracking measures to obtain a deeper understanding of their underlying processes. We describe the issues related to the theoretical proposals on AB and propose research avenues to test them. Four experimental axes are proposed, respectively, related to the determination of (a) the genuine nature of the mechanisms underlying AB; (b) their stability over the disease course; (c) their specificity to alcohol-related stimuli and (d) their reflexive or controlled nature. Conclusions This in-depth exploration of the available knowledge related to AB in SAUD, and of its key limitations, highlights the theoretical and clinical interest of our innovative experimental perspectives capitalizing on eye-tracking measures.

Exploring Attentional Bias toward Alcohol Content: Insights from Eye-Movement Activity

“…Considering the dual-process model, the theoretical framework emphasizes the over-activation of the reflexive system (facilitating appetitive processes) and an under-activation of the reflective system (controlled and voluntary processes) within this model, which ultimately impacts the decision-making process in favor of motivationally salient stimuli (e.g., drinking-related behaviors). The dual process model suggests a high sensitivity to alcohol-related cues and contexts as a result of the imbalance between the two systems [5,9]. Regarding the incentive-sensitization theory, alcohol-related cues become highly motivational, and over time, due to neuroadaptation, the individual's focus is displayed on the appetitive cues (alcohol) [10][11][12].…”

“…Examples of the attention maps with high vs. low salience are shown in Figure 2. (5) Regarding the final 12 alcohol-related stimuli, 33% of the images focused on beer, 33% on wine, and 33% on liquor-related stimuli. (6) The final version of the VAT consisted of pairs of alcohol-neutral images, and each alcohol image from the 12 alcohol-related images was paired with each of the other 12 neutral images, resulting in 144 pairs of alcoholneutral images.…”

“…Attentional bias (AB) is an implicit selective attention toward processing disorder-significant information while neglecting other environmental cues [1][2][3]. Considerable empirical evidence highlights the clinical implication of AB in the onset and maintenance of substance use disorder [4][5][6][7][8][9].…”

“…In alcohol use disorder (AUD), the dual process model emphasizes the interplay between the "reflective system" (controlled, deliberate responses governed by emotion regulation and expected outcomes) and the "reflexive system" (implicit appraisal of appetitive/alcohol-related stimuli) [15,16]. Decision-making reflects an imbalance between the two systems and an enhanced reflexive system ("impulsive system") may facilitate implicit re-sponses that favor the approach of alcohol-related stimuli [5,9]. Previous studies have highlighted that AB toward alcohol content and alcohol craving (i.e., obsessive alcohol-related thoughts and compulsive urge to drink alcohol) are among the underlying mechanisms of the development and maintenance of AUD [2,17,18].…”

A Randomized Controlled Trial of Attentional Control Training for Treating Alcohol Use Disorder

“…Furthermore, the intervention should also provide valuable insights into implicit cognitive processes and relationships among alcohol ABs, action-tendency bias (i.e., approach-avoidance bias), and inhibition bias. These implicit processes have all been studied extensively in patients with AUD (16,25,87), but there is still a need for more integrative evidence on the associations between the various types of alcoholrelated cognitive biases and their role in the maintenance of addictive behaviors (88).…”