implicit cognitive processes in the addiction clinic
DESCRIPTION
Presentation to BPS Division of Clinical Psychology Annual Conference London December 2008TRANSCRIPT
Definitely, maybe:
Implicit cognitive processes in
the clinic.
Frank Ryan
Clinical Psychologist Honorary Research Fellow
CNWL NHS Foundation Trust Birkbeck College
London
Overview
• Implicit cognitive processes are plausible
mechanisms to account for involuntary aspects
of addiction
• These are potential targets for direct or indirect
modification but component processes (e.g. goal
maintenance) operate in existing treatments
• Addressing these processes has the potential to
enhance outcomes
Time for CHANGE
• Change
• Habits
• And
• Negative
• Generation of
• Emotion(Ryan, 2006)
Definitely! Maybe?
Should be doing ( good
evidence both laboratory
& clinic)
• Focus on addictive habits
• Contingency management
• Encouraging attendance at
self-help “recovery” groups
• Behavioural Couples Therapy
Could be doing (plausible in
laboratory & indicative
trials)
• Cognitive bias reversal
(attentional bias reversal;
targeting automatic approach
tendencies; implicit challenges
or behavioural experiments)
• Mindfulness practice
• Trans Cranial Brain
Stimulation
An Appraisal Model of Cue Reactivity (Ryan, 2002)
(arrows indicate influence of cognitive biases which can be facilitative or
inhibitory)
Schematically Encoded Information
about self and addiction in LTM
Cognitions e.g.
Expectancies
Action Tendencies
and Behaviour
Physiological
Reactivity
Experience
of
Craving
Cognitive
Appraisal:
Stimulus
encoded as
drug cue
Adapted from Eysenck,1997
Cycle of pre-occupation
Attentional bias
Contents of
Working memory
Attentional bias
Attribution of
incentive salience
A year is a long time in cognitive neuroscience…
• fMRI : appetitive cues detected at 33ms Childress et al
2008
• Subliminal priming: 17 ms masked prime can lead to
processing bias of smoking cues (Leventhal et al 2008)
• Stimuli stored in WM automatically attract attention (Soto
et al 2008)
Basic Assumptions
• Impairment of executive control due to cognitive
processing biases, poor goal maintenance, error
detection and compromised decision making.
• These cognitive processes can be vulnerability factors
for relapse.
• These are also potential targets for direct or indirect
modification and can index therapeutic gain.
(Ryan, (2006)
The “Gateway” and the “Desktop”
Working memory <STM+Attentional control>
• Maintains representations of external stimuli
• Stores action plans
• Goal representations
• Task relevant information
NB:Even when goal maintenance fails in WM, goal
is still retrievable from LTM !
Kane, MJ & Engle RW (2003) Working memory capacity and the control of attention: The contribution of goal
neglect, response competition, and task set to Stroop interference. J Exptl Psych:(Gen) 132. 47-70
Three Executive Functions
• Shifting (e. g . Switching from addition to subtraction-or from
addiction to sobriety ?)
• Updating (Monitoring progress, keeping track or goal
maintenance- or “I am not going to use today” ?)
• Inhibition (suppressing pre-potent responses e.g. Stroop task or
anti-saccade task or “I will not dwell on my thoughts about drinking”)
Miyake et al (2000) The unity and diversity of executive functions and their contributions to complex
“frontal lobe” tasks: A latent variable analysis.
Cognitive Psychology 41. 49-100.
Motivational Enhancement
• Ambivalence is seen as conflict between controlled and
automatic processes rather than a “balance sheet”
• Focus on decision making and goal specification is
consistent with recruiting working memory processes
and exerting a “top-down” regulation.
Therapeutic strategies with potential for increasing
cognitive control
• Goal specificity
• Stimulus Control: know those
triggers
• Implementation intentions
• Be aware of and attempt to correct
cognitive biases
• Identify alternative rewards/goals
• Self-monitoring
• Distance /de- centre / mindfulness
meditation
• Challenge expectancies and
implicit cognitions via behavioural
experiments
• Support self-efficacy
Implementing intentions to change
• If situation X occurs at time Y I will perform behaviour Z e.g.
“If I have money when I get paid on Friday I will do my shopping before visiting the cocaine dealer”
“If I am offered alcohol to drink at the party I will say no thanks, but I would love a mineral water”.
Prestwich et al ( in Wiers & Stacy, 2006)
Summary
• In the context of addiction, attentional bias prioritises cue
detection and infiltration of working memory in a
reciprocal way.
• This compromises executive control.
• If therapeutic intervention can increase cognitive control
(e.g. by capturing WM resources) it is likely to reduce
preoccupation with salient cues and attendant cue
reactivity.
“The Road to recovery…is paved with good
rehearsals.”
• Enhanced outcome in addiction requires changes in both
controlled and automatic processing
• Automatic processes, previously overlooked, can be
reversed through practice and pre-empted by a range of
techniques relying on goal maintenance and cognitive
control.
• “Tried & tested” interventions need to delineate and
accentuate the role of implicit cognitive processes.
• Emerging cognitive bias reversal technologies need to
be evaluated and developed for further use.
• To maximise efficiency these need to be easily available.
Selected References
Childress, A R et al (2008) Prelude to passion: Limbic activation by “unseen” drug and sexual cues. ( click to view)
Leventhal, A.M.et al (2008). Subliminal processing of smoking related and affective cues in tobacco addiction. Experimental and Clinical Psychopharmacology. 4. 301-312
Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical Psychopharmacology. 10. 67-76.
Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP
Soto, D. et al. (2008) Automatic Guidance of Attention by Working Memory. Trends in Cognitive Sciences 342-348
Wiers, W.W., & Stacy, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.