Cue reactivity

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Cue reactivity is a type of learned response which is observed in individuals with an addiction and involves significant physiological and psychological reactions to presentations of drug-related stimuli (i.e., drug cues). [1] [2] The central tenet of cue reactivity is that cues previously predicting receipt of drug reward under certain conditions can evoke stimulus associated responses such as urges to use drugs. [3] In other words, learned cues can signal drug reward, in that cues previously associated with drug use can elicit cue-reactivity such as arousal, anticipation, and changes in behavioral motivation. [4] [3] Responses to a drug cue can be physiological (e.g., sweating, salivation, brain activity), behavioral (e.g., drug seeking), or symbolic expressive (e.g., craving). [3] The clinical utility of cue reactivity is based on the conceptualization that drug cues elicit craving which is a critical factor in the maintenance and relapse to drug use. [5] [6] Additionally, cue reactivity allows for the development of testable hypotheses grounded in established theories of human behavior. [4] Therefore, researchers have leveraged the cue reactivity paradigm to study addiction, antecedents of relapse, and craving, translate pre-clinical findings to clinical samples, and contribute to the development of new treatment methods. [4] Testing cue reactivity in human samples involves exposing individuals with a substance use disorder to drug-related cues (e.g., cigarettes, alcohol, drug paraphernalia) and drug neutral cues (e.g., pencils, glasses of water), and then measuring their reactions by assessing changes in self-reported drug craving and physiological responses (e.g., blood pressure, salivation, brain activity). [4] [7]

Contents

Cue types

Drummond (2000) identified a preliminary classification of cue types including four main categories: (1) Exteroceptive; (2) Interceptive; (3) Temporal; and (4) Cue relationship. [4] Cues that are exteroceptive are characterized as external drug-related stimuli, such as sight, smell, and taste. [4] Visual cues include sight of a preferred drug, or advertisement, or environment where drug use occurs (e.g., bar, house, neighborhood). [4] Olfactory cues include smell of preferred drug or smells associated with drug use. Gustation cues include having a sip of alcohol or initial inhale of smoke. Cues that are exteroceptive are the most commonly studied in the laboratory. [4] [6] Interoceptive cues are characterized as internal cues, such as stress response, negative or positive mood, and withdrawal related states. [4] [6] Temporal cues relate to the proximity or distance to substance use and time of day. [6] For instance, cues occurring more proximally to the ingestion of a substance may be more salient and produce greater reactivity compared to distal cues. [4] Additionally, the time of day at which cues are encountered may impact the salience of the cue, such that the time of day when a substance is habitually consumed may become a temporal cue (Drummond, 2000). For example, the end of a workday or a weekend day may become in and of itself a cue eliciting craving. [6] Lastly, the theory behind cue relationships is that it is likely there is a complex relationship between cues. [4] Drug cues rarely occur in isolation in the real-world, thus an inter-relationship between cues in eliciting cue reactivity is possible (Drummond, 2000). Such inter-relationship can be described as a “cue cluster,” “cue chain,” and “cue cascade.” [4] A “cue cluster” describes co-occurring cues, such that each co-occurring cue is necessary for reactivity but not a sufficient condition for substance use. A “cue chain” describes the sequential relationship between cues leading up to use. For example, the sight of a preferred substance like an alcoholic drink may be more salient for an individual in a certain context like at a bar. [6] Similarly, a “cue cascade” describes the process of each cue increasing the likelihood of encountering and the salience of the next cue. [4]

Theoretical background

Cue reactivity is most often conceptualized through models of classical conditioning, such that it is theorized that cues that are nearly exclusively encountered at the time of drug administration will develop the ability to predict the administration and effect of the substance. [8] In other words, after systematic association of exteroceptive or interoceptive cues (i.e., conditioned stimuli) with drug administration (i.e., unconditioned stimuli), the cues will reliably signal administration and drug effects. When cues predict administration, they acquire the ability to elicit physiological and psychological responses (i.e., cue reactivity/ conditioned response) which increase the likelihood of substance use. [8] Although there is a substantial amount of research on cue reactivity, the exact theoretical explanation of cue reactivity remains unclear. [4]

Prominent models of cue reactivity

There are three prominent models of cue reactivity: (1) Conditioned withdrawal model; (2) Conditioned appetitive motivational model; and (3) Conditioned compensatory response model. [4] In common across all three models is that they are all described in terms of classical conditioning and that cues repeatedly associated with substance administration will eventually elicit a conditioned reaction. [4] [9] The three models differ in the nature of the reaction that is elicited. [9]

The conditioned withdrawal model, developed by Wikler (1948), characterizes the conditioned response as an unconditioned substance withdrawal state. [8] [10] For instance, during a drinking episode and individual with an alcohol use disorder is exposed to cues (e.g., sight and smell of preferred beverage containing alcohol) at a point when their blood alcohol level is falling (i.e., unconditioned stimuli), such as the morning after a heavy drinking episode. [4] During this time the individual is likely in a state of unconditioned alcohol withdrawal (i.e., unconditioned response). The exteroceptive cue becomes associated with alcohol withdrawal. Therefore, during a period of abstinence and the individual is exposed to the exteroceptive cues (i.e., conditioned stimuli) a conditioned withdrawal-like reaction is elicited (i.e., conditioned response). The conditioned appetitive motivational model states that drug cues become associated with the pleasurable unconditioned effects of substances and leads to drug-like conditioned responses. [11] In other words, the conditioned response resembles the unconditioned effect of the substance. [8] The conditioned compensatory response model, formed by Siegel (1975), postulates that the conditioned response is opposite to the unconditioned drug effect, such that the conditioned response is part of a homeostatic response resulting in the development of drug tolerance. [8] [12] Each conditioning model is empirically supported. [13]

Cognitive theories of cue reactivity

Although most theories of substance dependence acknowledge the role of conditioning and view this research as invaluable, not all theories assume that conditioning is sufficient in explaining this phenomenon as cue reactivity appears to be complex and highly individual. [2] Therefore, cognitive theories have been proposed. The cognitive urge and automaticity model is a prominent cognitive theory of addiction and purposes that behaviors associated with substance administration become automatic and cues can trigger such automatized behaviors. [2] This model is consistent with addiction models that emphasize habit-like processes. Additionally, cognitive labeling theory argues that the contextual and cue state an individual is in contributes to the interpretation of an arousal, such that a cue may trigger an arousal and the individual may perceive the cue as predicting substance administration which then triggers craving and substance intake. [2] Other cognitive behavioral theories hypothesize that cues can elicit craving by highlighting the positive effects of the substance resulting in substance use. [2] Lastly, attentional bias has been used to conceptualize cue reactivity in that substance-related cues can “grab” the attention of the individual engaging in substance use behaviors. [2]

Factors affecting cue reactivity

Cue, individual, contextual, and substance factors affect the salience of cue reactivity. Regarding cue characteristics, in vivo cues, cues that are directly experienced, have greater salience than imaginal cues (i.e., vividly imagined cue). [4] Moreover, interoceptive cues (e.g., initial priming effects of substance) have been found to have greater salience than imaginal and visual cues. [4] Overall, cues with greater association with substance consumption are likely to be more salient than cues with limited association. [4] Research has found individual variability in cue reactivity. For instance, craving is highly variable among individuals and reactions to laboratory cues vary with some participants not showing much cue reactivity. [6] Specific sources of individual variability include gender, genetic factors, personality (e.g., introversion, neuroticism, and impulsivity), and treatment status of the individual. [4] [6] Degree of alcohol dependence is an additional individual factor affecting cue reactivity, in that individuals who are more alcohol dependent are more cue-reactive. [4] Additionally, context-specific expectancies such as perceived availability of a substance and efficacy expectations have been found to be important. [4] [14] Pertaining to substance factors, latency since last use is an important factor to consider. [6] [1] A critical component of this factor is the impact of withdrawal, such that withdrawal may increase the salience of cues. [6] Similarly, an additional potential effect is the deprivation of one substance on another in that the deprivation of one substance will increase urge or reactivity of another substance. [6]

Cue reactivity in different substances

Research has shown that cue reactivity is experienced among individuals dependent on a variety of substances including alcohol, nicotine, opiates, and cocaine. [6] [15] However, research focused on these substances have been primarily done in isolation of each other and there are nuances regarding cue reactivity within each substance. The cues that elicit the greatest reactivity among those with an alcohol use disorder are the ingestion of a small amount of alcohol or expectancy of alcohol availability. [9] The responses most commonly elicited from alcohol cue exposure among those with an alcohol use disorder includes increased salvation, increased sweating, and greater self-reported alcohol craving. [9] The smoking cue-reactivity responses commonly reported are psychophysiological arousal including skin conductance, vasoconstriction, heart rate, and craving as the strongest response. [9] [16] Regarding opiates, auditory, visual, or role play of drug sales appear to be the most influential cues. [9] Mood states may also significantly elicit cue-reactivity. Psychophysiological responses commonly elicited by opiate cues include decreases peripheral temperature and skin resistance. [9] Cocaine cue reactivity is much less researched. [9] Of the limited research, audiovisual stimuli of drug sales and consumption commonly elicit significant reactivity. Psychophysiological responses associated with cocaine use cues are decreased peripheral temperature, skin resistance, decreased heart rate, and greater self-reported craving. [9]

Cue reactivity and substance use relapse

Cue reactivity is predictive of relapse and reinstatement of dependence, which is empirically and theoretically supported. [4] [17] Even after extended periods of abstinence (i.e., years) cues are reported as preceding relapse. [3] Moreover, the degree of cue-reactivity may predict individual differences in relapse risk. [2] A study by Abrams and colleagues (1988) found that individuals who resumed smoking after smoking cessation had significantly higher interceptive cue reactivity (e.g., anxiety) and cigarette craving than those who continued cessation or controls. [18] The authors concluded that it is suggested that reactivity to smoking cues plays a role in smoking relapse. [18] A more recent study by Grusser and colleagues (2004), looked at the association between alcohol cues and relapse among a sample of detoxified, abstinent, patients with alcohol use disorder. [19] Findings showed that greater visual alcohol cue-elicited activation of the dorsomedial prefrontal cortex (dmPFC) predicted resuming alcohol consumption following discharge. [19] Moreover, findings from a review of two functional brain imaging studies investigating the association of stress and drug-related cues and relapse, suggested that specific regions of the corticostriatal limbic circuitry involving stress- and drug cue- induced craving are associated with drug relapse. [20] Given the theoretical conceptualization of the influence of cue reactivity on relapse, it could be understood that greater cue-induced craving in the laboratory should predict risk for relapse in the real-world when similar cues are encountered in the natural environment. [21] Therefore, psychotherapy and pharmacotherapy that blunts cue reactivity in the laboratory should be a marker of treatment efficacy in the real-world. [21] This gives merit to research utilizing the cue reactivity paradigm as a relevant theory and treatment approach in addictions research. [22]

Cue reactivity paradigm in research

Cue reactivity is typically studied in a laboratory paradigm. [6] This laboratory paradigm involves participants being systematically exposed to substance cues that elicit substance related responses. Cue exposure laboratory paradigms have a relatively standard protocol. [6] [23] First, participants complete a battery of baseline measures including psychological and physiological assessments (pre-exposure measurements). Second, participants are exposed to either a neutral or substance related cue. Third, psychological and physiological measurements are repeated (post-exposure measurements). A variety of cue presentations are utilized in this procedure, such as in vivo (e.g., sitting in front of a preferred substance like a bottle of beer), imaginal (e.g., vividly imagining situations related to drug use), audio (e.g., listening to a recording of someone describing substance use), pictorial (e.g., viewing pictures of substance use), and virtual reality. [6] [24] These cue presentations can also be in combination. For instance, the participant is interacting (smelling, seeing) with a preferred alcohol drink while listening to a recording recounting past substance use. It is recommended that researchers use both drug-related and neutral control cues (e.g., pencil, glass of water) rather than drug-related cues to pre-exposure baseline measures. [6] Another recommended approach is for the neutral cue to have no psychoactive effect yet be similar to the active substance, like holding a pencil for a smoking cue paradigm. A variety of reactions to the cues are assessed, including self-reported craving and mood states, physiological changes (e.g., heart rate, skin conductance, salvation, blood pressure, skin temperature), and lever pressing (i.e., pre-clinical studies). [6] More recently, the cue reactivity paradigm has been used in neuroimaging methods to study regional changes in brain activity following exposure to cues. [25] [26] [27] The cue reactivity paradigm is a frequently used method within the addictions field because it allows for testing hypotheses regarding the additions process in a controlled laboratory setting and is grounded in theory. [6]

Laboratory vs. real world cues

Although the cue reactivity paradigm was established in the laboratory which promotes standardization of cues to reduce noise within the paradigm, there is a lack of generalizability to real-world cue reactivity. This is an important limitation because cue reactivity is most salient to substance use when exposed to relevant cues at vulnerable times. [6] [28] Researchers have made efforts to make the cue reactivity paradigm more ecologically valid by having participants take digital pictures of their environments. [24] Another more commonly used methodology is ecological momentary assessment (EMA) which involves real-time data collection in the natural environment. [6] EMA methods allow for collection of real-time craving, mood, substance use, contextual information, which is not possible in a laboratory setting. These ecologically valid methods build on the classic cue reactivity paradigm and increase generalizability to the natural environment of those who use substances. [6]

Clinical implications

The cue reactivity paradigm is a useful method to understand pharmacotherapy and psychotherapy efficacy. [4] This paradigm is used to evaluate treatment efficacy, given the hypothesis that reducing cue-elicited urge to use, or withdrawal can protect against continued substance use among those with substance use disorders. [6] Moreover, treatments are often designed to mitigate craving and the cue reactivity paradigm allows for testing potential efficacy. Cue reactivity as an outcome measure that has been widely used in pharmacotherapy studies and is labeled as a gold-standard measure. [6] [29] [30] [31] [32] [33] [34] [35] [36] [37] For instance, Miranda and colleagues (2014) tested the effects of naltrexone, an opiate receptor antagonist, on adolescent alcohol cue reactivity. The study found that naltrexone blunted alcohol cue elicited craving in the laboratory and natural environment. [38] Regarding psychotherapy, assessing cue reactivity has provided insight into potential relapse triggers and cue exposure has been used as a treatment approach. Given that substance related cues can promote substance use, common treatment strategies in cognitive behavioral therapy are to assist patients in identifying cues and developing strategies to avoid avoidable cues. [39] In cue exposure treatment, patients are exposed to personally relevant substance cues through in vivo and imaginal exposures. [6] Repeated unreinforced exposure to stimuli that was previously associated with substance use is thought to extinguish or rid the conditioned response to the personally relevant cues. Although cue exposure treatment has shown some benefit and has been validated in clinical trials, there is controversy around this approach. [4] [40]

Related Research Articles

Classical conditioning is a behavioral procedure in which a biologically potent stimulus is paired with a neutral stimulus. The term classical conditioning refers to the process of an automatic, conditioned response that is paired with a specific stimulus.

<span class="mw-page-title-main">Reinforcement</span> Consequence affecting an organisms future behavior

In behavioral psychology, reinforcement refers to consequences that increase the likelihood of an organism's future behavior, typically in the presence of a particular antecedent stimulus. For example, a rat can be trained to push a lever to receive food whenever a light is turned on. In this example, the light is the antecedent stimulus, the lever pushing is the operant behavior, and the food is the reinforcer. Likewise, a student that receives attention and praise when answering a teacher's question will be more likely to answer future questions in class. The teacher's question is the antecedent, the student's response is the behavior, and the praise and attention are the reinforcements.

<span class="mw-page-title-main">Drug rehabilitation</span> Processes of treatment for drug dependency

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin, and amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and medical consequences that can be caused.

Motivational salience is a cognitive process and a form of attention that motivates or propels an individual's behavior towards or away from a particular object, perceived event or outcome. Motivational salience regulates the intensity of behaviors that facilitate the attainment of a particular goal, the amount of time and energy that an individual is willing to expend to attain a particular goal, and the amount of risk that an individual is willing to accept while working to attain a particular goal.

In internal medicine, relapse or recidivism is a recurrence of a past condition. For example, multiple sclerosis and malaria often exhibit peaks of activity and sometimes very long periods of dormancy, followed by relapse or recrudescence.

Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has developed within the individual from psychoactive substance consumption that results in the experience of withdrawal and that necessitates the re-consumption of the drug. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

Attentional bias refers to how a person's perception is affected by selective factors in their attention. Attentional biases may explain an individual's failure to consider alternative possibilities when occupied with an existing train of thought. For example, cigarette smokers have been shown to possess an attentional bias for smoking-related cues around them, due to their brain's altered reward sensitivity. Attentional bias has also been associated with clinically relevant symptoms such as anxiety and depression.

An addictive behavior is a behavior, or a stimulus related to a behavior, that is both rewarding and reinforcing, and is associated with the development of an addiction. There are two main forms of addiction: substance use disorders and behavioral addiction. The parallels and distinctions between behavioral addictions and other compulsive behavior disorders like bulimia nervosa and obsessive-compulsive disorder (OCD) are still being researched by behavioral scientists.

<span class="mw-page-title-main">Reward system</span> Group of neural structures responsible for motivation and desire

The reward system is a group of neural structures responsible for incentive salience, associative learning, and positively-valenced emotions, particularly ones involving pleasure as a core component. Reward is the attractive and motivational property of a stimulus that induces appetitive behavior, also known as approach behavior, and consummatory behavior. A rewarding stimulus has been described as "any stimulus, object, event, activity, or situation that has the potential to make us approach and consume it is by definition a reward". In operant conditioning, rewarding stimuli function as positive reinforcers; however, the converse statement also holds true: positive reinforcers are rewarding.The reward system motivates animals to approach stimuli or engage in behaviour that increases fitness. Survival for most animal species depends upon maximizing contact with beneficial stimuli and minimizing contact with harmful stimuli. Reward cognition serves to increase the likelihood of survival and reproduction by causing associative learning, eliciting approach and consummatory behavior, and triggering positively-valenced emotions. Thus, reward is a mechanism that evolved to help increase the adaptive fitness of animals. In drug addiction, certain substances over-activate the reward circuit, leading to compulsive substance-seeking behavior resulting from synaptic plasticity in the circuit.

Virtual Reality Cue Reactivity (VRCR) is a computer-enhanced methodology used to assess behavioral and physiological reactivity to drug and alcohol sensory cues. Studies indicate that cue reactivity—a response to the presentation of various visual, auditory, olfactory, and tactile cues—increases physiological excitement in addicts. VRCR utilizes virtual reality (VR) technology to stimulate cue reactivity in the most efficient and realistic environments possible; the intention being that coping skills can be taught in a contextual scenario that reflect a real world situation. While still in the early stages of development, studies have shown that VRCR is an effective means of generating a craving-inspiring environment that is tempting to a patient suffering from addiction.

<span class="mw-page-title-main">Conditioned place preference</span> Pavlovian conditioning

Conditioned place preference (CPP) is a form of Pavlovian conditioning used to measure the motivational effects of objects or experiences. This motivation comes from the pleasurable aspect of the experience, so that the brain can be reminded of the context that surrounded the "encounter". By measuring the amount of time an animal spends in an area that has been associated with a stimulus, researchers can infer the animal's liking for the stimulus. This paradigm can also be used to measure conditioned place aversion with an identical procedure involving aversive stimuli instead. Both procedures usually involve mice or rats as subjects. This procedure can be used to measure extinction and reinstatement of the conditioned stimulus. Certain drugs are used in this paradigm to measure their reinforcing properties. Two different methods are used to choose the compartments to be conditioned, and these are biased vs. unbiased. The biased method allows the animal to explore the apparatus, and the compartment they least prefer is the one that the drug is administered in and the one they most prefer is the one where the vehicle is injected. This method allows the animal to choose the compartment they get the drug and vehicle. In comparison, the unbiased method does not allow the animal to choose what compartment they get the drug and vehicle in. Instead, the researcher chooses the compartments.

Self-administration is, in its medical sense, the process of a subject administering a pharmacological substance to themself. A clinical example of this is the subcutaneous "self-injection" of insulin by a diabetic patient.

<span class="mw-page-title-main">Addiction</span> Disorder resulting in compulsive behaviours

Addiction is a neuropsychological disorder characterized by a persistent and intense urge to use a drug or engage in a behavior that produces natural reward, despite substantial harm and other negative consequences. Repetitive drug use often alters brain function in ways that perpetuate craving, and weakens self-control. This phenomenon – drugs reshaping brain function – has led to an understanding of addiction as a brain disorder with a complex variety of psychosocial as well as neurobiological factors that are implicated in addiction's development.

Addiction vulnerability is an individual's risk of developing an addiction during their lifetime. There are a range of genetic and environmental risk factors for developing an addiction that vary across the population. Genetic and environmental risk factors each account for roughly half of an individual's risk for developing an addiction; the contribution from epigenetic risk factors to the total risk is unknown. Even in individuals with a relatively low genetic risk, exposure to sufficiently high doses of an addictive drug for a long period of time can result in an addiction. In other words, anyone can become an individual with a substance use disorder under particular circumstances. Research is working toward establishing a comprehensive picture of the neurobiology of addiction vulnerability, including all factors at work in propensity for addiction.

Euphoric recall is a cognitive bias that describes the tendency of people to remember past experiences in a positive light, while overlooking negative experiences associated with some event(s). Euphoric recall has primarily been cited as a factor in substance dependence. Individuals may become obsessed with recreating the remembered pleasures of the past, where positive expectancy of outcomes results in the belief that substance use can provide immediate relief.

Personality theories of addiction are psychological models that associate personality traits or modes of thinking with an individual's proclivity for developing an addiction. Models of addiction risk that have been proposed in psychology literature include an affect dysregulation model of positive and negative psychological affects, the reinforcement sensitivity theory model of impulsiveness and behavioral inhibition, and an impulsivity model of reward sensitization and impulsiveness.

Evolutionary models of drug use seek to explain human drug usage from the perspective of evolutionary fitness. Plants for instance, may provide fitness benefits by relieving pain. Proponents of this model of drug use suggest that the consumption of pharmacological substances for medicinal purposes evolved in the backdrop of human-plant coevolution as a means of self-medication. Humans thus learned to ignore the cues of plant toxicity because ingesting the bioactive compounds of plants in small amounts was therapeutic.

Pavlovian-instrumental transfer (PIT) is a psychological phenomenon that occurs when a conditioned stimulus that has been associated with rewarding or aversive stimuli via classical conditioning alters motivational salience and operant behavior. Two distinct forms of Pavlovian-instrumental transfer have been identified in humans and other animals – specific PIT and general PIT – with unique neural substrates mediating each type. In relation to rewarding stimuli, specific PIT occurs when a CS is associated with a specific rewarding stimulus through classical conditioning and subsequent exposure to the CS enhances an operant response that is directed toward the same reward with which it was paired. General PIT occurs when a CS is paired with one reward and it enhances an operant response that is directed toward a different rewarding stimulus.

Treatment and management of addiction encompass the range of approaches aimed at helping individuals overcome addiction, most commonly in the form of substance use disorders and behavioral addictions. Effective treatment often includes a combination of medical, psychological, and social interventions tailored to the specific needs of the individual. Common practices to this end include detoxification, counseling, behavioral therapy, medication-assisted treatment, and support groups. The goal of addiction treatment is to reduce dependence, improve quality of life, and ultimately support long-term recovery. Comprehensive management addresses both the physical and psychological aspects of addiction, recognizing it as a chronic but treatable condition.

<span class="mw-page-title-main">Mindfulness-Oriented Recovery Enhancement</span> Mind-Body therapy program

Mindfulness-Oriented Recovery Enhancement (MORE) is an evidence-based mind-body therapy program developed by Eric Garland. It is a therapeutic approach grounded in affective neuroscience that combines mindfulness training with reappraisal and savoring skills. Garland developed this approach by combining the key features of mindfulness training, "Third Wave" cognitive-behavioral therapy, and principles from positive psychology.

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