Articles of Public Interest
A Problematic Cascade: Implicit Alcohol Attitudes and Heavy Drinking Reinforce Each Other in Emerging Adulthood
A new study has reinforced the importance of implicit attitudes toward alcohol in escalating risk for heavy drinking as a young person transitions from adolescence to adulthood. Alcohol use peaks in emerging adulthood, with many associated health risks and negative consequences, so understanding risk and protective pathways to heavy drinking in this age group is a critical public health issue. In contrast to conscious information processing, implicit information processing occurs spontaneously, without deliberation or awareness. Although implicit alcohol attitudes are considered important in prompting alcohol use and maintaining heavy drinking, previous studies have provided mixed support for the association between positive (i.e., favorable) implicit alcohol attitudes and greater drinking. This may be partly attributable to difficulties in measuring implicit attitudes. A further complication is that associations between implicit alcohol attitudes and heavy drinking may be reciprocal: not only may positive implicit alcohol attitudes precipitate drinking but also positive drinking experiences may in turn contribute to positive alcohol attitudes. Most studies to date have evaluated attitudes and drinking at only a single timepoint, and so have been unable to explore these relationships over time. The current study, reported in Alcoholism: Clinical and Experimental Research, aimed to clarify the association between implicit attitudes and heavy drinking by addressing these methodological limitations.
Over three consecutive years, 300+ emerging adults provided annual information on their drinking behavior, and completed a computer task (the Single Category Implicit Association Task; SC-IAT) aimed at measuring their implicit alcohol attitudes. The research team applied novel statistical models to the data from the IAT to better evaluate the implicit attitudes over time and to test for any bidirectional associations with heavy drinking.
The researchers found that within individuals, higher-than-usual levels of positive implicit alcohol attitudes did indeed predict higher-than-usual levels of heavy drinking for the young person, and increased heavy drinking predicted further increases in positive implicit alcohol attitudes. In other words, individuals who had a more positive implicit attitude at one assessment than was typical for them tended to engage in heavier drinking than expected (given their average levels of drinking) at their next assessment, and those who drank more heavily at one assessment than was typical for them had a more positive implicit attitude than expected (given their average levels of positive implicit attitudes) at the next assessment. These findings are consistent with the landscape of emerging adulthood, a time in which the socially rewarding aspects of alcohol intensify as parental monitoring weakens and the importance of peer relationships increases; thus, the context of emerging adult drinking provides more opportunities to experience the positive aspects of alcohol, thereby strengthening positive implicit alcohol attitudes. Of note, however, the study did not find that positive implicit attitudes were related to high levels of heavy drinking when comparing between individuals; it may be that reciprocal relationships between implicit attitudes and heavy drinking operate more strongly at the level of individual change.
Overall, the findings suggest that positive implicit alcohol attitudes and heavy drinking reinforce each other in a negative cascade within individuals over time. This highlights the importance of alcohol interventions that aim to target implicit alcohol attitudes in young people. The methodological advantages of the models and study design used in this research will also inform and facilitate future studies in this field.
Reciprocal associations between implicit attitudes and drinking in emerging adulthood. K. J. Paige, A. Weigard, C. R. Colder (pages xxx).
Prenatal Alcohol Exposure Exacerbates Vulnerability to Childhood Stressors and Mental Health Issues Through Middle Adulthood, Study Suggests
Exposure to alcohol in the womb exacerbates children's vulnerability to social and environmental stressors and to mental health issues in adulthood, according to a new study. Prenatal alcohol exposure (PAE) is known to cause neurocognitive and physical conditions, including facial and growth abnormalities. Previous research has also linked PAE to long-term mental health effects, although these outcomes are not well understood. This is partly because the impact of alcohol exposure before birth is difficult to separate from the effects of other early social and environmental stressors, including adverse childhood experiences, that often accompany PAE. For the new study in Alcoholism: Clinical & Experimental Research, investigators compared mental health conditions among adults who had been exposed to alcohol before birth with those who were not. They also explored the role of early childhood adversity and other social and environmental factors on mental health.
The study involved 283 adults, in Atlanta or Seattle, who had either been diagnosed with a fetal alcohol spectrum disorder (FASD) or exposed to alcohol prenatally (according to their mothers during pregnancy); all had been followed up over time. A contrasting group of adults had not experienced alcohol exposure before birth. The participants filled out surveys assessing their health, including certain mental health diagnoses and recent symptoms of anxiety and depression, in addition to adverse childhood experiences and demographic information. They were organized into three groups: adults without PAE; alcohol-exposed people with dysmorphic physical features who met criteria for fetal alcohol syndrome (FAS); and alcohol-exposed adults who were non-dysmorphic. The researchers used statistical analysis to examine associations between PAE, mental health, and other factors known to influence human development.
The alcohol-exposed adults reported fewer years of schooling, lower incomes and social status, and more adverse childhood experiences than the participants without PAE. They were likelier to report diagnoses of depression, bipolar disorder, anxiety disorder, and ADHD, although not psychotic disorders, compared to non-exposed participants. People with PAE also reported more recent symptoms of anxiety or depression. The findings indicate that the relationship between PAE and later mental health problems is indirect and influenced by childhood environmental factors, including adverse experiences and social and economic pressures. For example, alcohol exposure in the womb was associated with lower socioeconomic status, which in turn was linked to a depression diagnosis; PAE was associated with more adverse childhood experiences which in turn was linked to a higher risk of bipolar disorder. People without the physical features of FAS reported more current symptoms of depression than those with dysmorphic features. This is in line with previous data suggesting that the mental health burden falls more heavily on those with less obvious physical and cognitive effects of PAE.
The findings confirm that people with PAE are more likely than others to report symptoms of depression and varying mental health diagnoses well into adulthood. The study captures the effects of multiple hits during early development. Children exposed to alcohol in the womb may be especially vulnerable to additional environmental and social hardships, a combination that raises their long-term risk of mental health conditions. The study underscores the importance of preventing or reducing PAE and early childhood stressors. The researchers recommend that future studies assess the physiological impact of stress on emotional function as well as the possibility of increased vulnerability to stress in people with PAE.
Prenatal alcohol exposure and mental health at midlife: A preliminary report on two longitudinal cohorts. C. Coles, T. Grant, J. Kable, S. Stoner, A. Perez (pages xxx).
Dissociating from Traumatic Experiences May Raise the Risk for Alcohol-Related Problems
Emotionally detaching from a traumatic experience, a psychological defense known as dissociation may play a key role in nudging some people with posttraumatic stress disorder (PTSD) toward alcohol-related problems, a new study suggests. A large minority of people with PTSD also have a substance use disorder (SUD), implying that using alcohol or drugs is a form of self-medication among traumatized people. Dissociation, a common symptom of PTSD, is a psychological escape from threatening situations that substitutes for physical escape; it can reflect particularly harmful early-life trauma and more severe PTSD. Previous research has linked dissociation with alcohol and substance use. Understanding the relevant pathway, or mechanism, could potentially inform and expand treatment options and effectiveness—a critical advance, since co-occurring PTSD and SUD come with a magnified risk of suicidality, functional impairment, and death. For the study in Alcoholism: Clinical & Experimental Research, Canadian researchers examined dissociation as a potentially influential link between PTSD severity and alcohol-related problems.
Investigators worked with 334 adults at an Ontario in-patient program for PTSD treatment. The sample was evenly split between women and men, who had an average age of 44. The participants filled out questionnaires on their mental health, alcohol use, demographics, along with self-report checklists assessing PTSD (including four symptom clusters), dissociative symptoms, alcohol-related problems, emotional dysregulation, and childhood adversity. The researchers used statistical analysis to explore the influence of dissociative symptoms on the relationship between PTSD and alcohol-related problems, and in the context of specific PTSD symptom clusters.
The analysis revealed that more severe PTSD was associated with heightened dissociative symptoms, and dissociation in turn was linked to greater alcohol-related problems. In a contrasting model, greater dissociative symptoms were associated with more severe PTSD, but more severe PTSD was not associated with alcohol-related problems. The two findings together indicate that dissociative symptoms are a key influence, or mediator, in the relationship between PTSD severity and alcohol-related problems. Analyses involving specific PTSD symptom clusters provided supporting evidence. Alterations in arousal (i.e., hypervigilance, sleep disturbance, etc.), intrusive thoughts and memories, and negative shifts in cognition and mood were associated with dissociative symptoms, which in turn were linked to alcohol-related problems.
The study is believed to be the first that reveals the unique role of dissociative symptoms in raising the risk for alcohol-related problems among some people with PTSD. It suggests that people with PTSD who experience heightened symptoms of dissociation are at increased risk of self-medicating with alcohol and other substances and may experience more severe alcohol-related problems than people whose PTSD does not involve dissociation. Targeting patients' dissociative symptoms may be a helpful approach in treating PTSD and problematic drinking. The researchers recommend further examination of dissociation's role over time, including comparing its influence during and in the aftermath of trauma.
Dissociative symptomatology mediates the relation between posttraumatic stress disorder severity and alcohol-related problems. H. Patel, C. O'Connor, K. Andrews, M. Amlung, R. Lanius, M. McKinnon (pages xxx).
Impaired Mental Time Travel in People with Alcohol Use Disorder
People with alcohol use disorder (AUD) have a distorted perception of the richness of imagined future scenarios, according to a study in Alcoholism: Clinical and Experimental Research. The findings could have important implications for AUD treatment and rehabilitation. The ability to imagine specific future events is a type of mental time travel known as episodic future thinking (EFT). EFT contributes to a range of skills needed to safely navigate daily life, including planning, goal-directed behavior, and emotional regulation. Previous research has indicated that people with short-sighted maladaptive behaviors, such as drug misuse and excessive gambling, tend to imagine future events that lack vividness and specificity. Impaired EFT was also suspected to be of clinical importance in AUD, but little was known about the mechanisms underlying the impairment.
The new study involved 40 patients in rehabilitation for AUD, and 40 healthy individuals (controls) who matched the AUD patients in age, education, and gender. Participants underwent a range of neurological and psychiatric assessments and completed a future thinking task; this involved thinking of future events and imagining them in as much detail as possible, before orally describing the imagined events and rating different aspects of their own imagined experience. From this task, the researchers could assess two measures of EFT: first, individuals' own subjective experience of their imagined scenarios, and second, the objective number of reported details in these imagined events, as scored by an independent observer. By comparing the two measures, the research team could determine the extent to which the subjective and objective characteristics of EFT corresponded among both the AUD participants and the controls. The possible impact of cognitive functioning and disturbed mood on EFT measures was also investigated.
The subjective measure showed that those with AUD perceived their imagined future events with similar vividness and detail as the control participants. However, the objective measure showed that the AUD participants provided significantly fewer details about the event (such as happenings, people, time, place, sensory perceptions, thoughts, and emotions) than the non-AUD participants, even when controlling for differences in cognitive functioning. The quantity of reported details was found to correlate with participants' level of alexithymia (which refers to difficulties in understanding or describing one's emotions); however, a higher depression score (as often found in AUD) was not associated with either EFT measure.
These results reveal a lower calibration of subjective and objective characteristics of EFT in people with AUD than in healthy participants, and suggest a distorted self-assessment of the richness of imagined future events in AUD. The researchers propose two potential reasons for these differences: poorer metacognitive ability in AUD (i.e., limited awareness and understanding of one's own thought processes), leading to an overestimation of the self-perceived richness of the mental representations, or a compromised ability to verbalize the imagined future events (linked to alexithymic tendencies).
Impaired EFT may contribute to a lack of motivation to stop drinking or stay sober in people with AUD. The current findings therefore support the use of strategies, such as EFT training, to enhance future thinking. Interventions that target the potential mechanisms of EFT impairment, such as metacognitive therapy and strategies to promote verbal expression of the internal imaginary world, could also be helpful in reducing the personal and public health burden of AUD.
Reduced calibration between subjective and objective measures of episodic future thinking in alcohol use disorder. X. Noel, M. Saeremans, C. Kornreich, A. Chatard, N. Jaafari, A. D'argembeau (pages xxx).
