Craving, prayer, and the brain

Among the programs pursued to overcome addiction in the United States, perhaps the most widely adopted is the Twelve-Step Program that is at the heart of the Alcoholics Anonymous (AA) fellowship and others, including Narcotics Anonymous. In addition to heavy reliance on social support from members who are further along in their recovery, the program incorporates spiritual concepts, with the belief that “a power greater than ourselves” can influence recovery, and includes spiritual practices, such as prayer. This spiritual component may be an important aspect of its success, yet it has not been extensively examined. This may be, in part, because the heterogeneity of spiritual experiences may make a proper experimental design for empirical studies challenging. However, the acute effects of clearly defined, standardized spiritual practices may be more amenable to study and offer some insights. Prayer, in particular, has been shown to reduce alcohol consumption (1) and clinical interviews have revealed that AA participants often use prayer to stave off craving (2), a core feature of addiction that promotes its maintenance. However, the mechanisms by which such spiritual practices affect craving remain elusive as they often invoke a number of emotions, involve concepts that may be difficult to disentangle, and may have variable effects across individuals. Nevertheless, resolving questions about the neural processes invoked by prayer that lead to reduced craving can help determine circuits that have an important impact on controlling substance use behavior. In an attempt to address such questions, the report by Galanter et al. (2) in this issue of The American Journal of Drug and Alcohol Abuse provides an initial window into the neural systems underlying the influence of prayer on craving. In this study, the authors aimed to measure acute effects of prayer on brain activation using functional MRI during alcohol-cue exposure. Specifically, while undergoing scanning, long-time AA members recited a standard AA prayer before exposure to alcohol-related visual cues and subsequently reported their craving for alcohol. In order to control for focused engagement of attention, the authors had participants read news clips in a comparison condition. In a third experimental condition, to measure spontaneous cue-reactivity, they had participants passively view the cues (“reactivity”) without engaging in a task immediately before. This task paradigm has similarities to those found in the emotion regulation literature in which a “regulation” task condition, whether it involves explicit cognitive reappraisal (3,4) or implicit processes, such as affect labeling (5), is compared to a “reactivity” condition. Similar paradigms have been applied to the context of addiction, using drug cues (6). The task used by Galanter et al. is novel because of its use of prayer (unrelated to the specific cues or substance use) as an induction prior to exposure to drug cues as opposed to conceptually reframing or labeling cue-content during exposure. This is a relevant distinction in that the prayer induction puts the participant in a general mindset of requesting support (e.g., serenity, courage, wisdom; what may be primarily considered a “top-down” process) whereas reframing or labeling strategies involve addressing specific emotional/arousing content (an interaction of top-down/bottom-up processes). One might hypothesize that the craving reductions related to spiritual practices or experiences are due to the regulation of activity in neural circuits that are sensitive to appetitive stimuli, such as the mesolimbic dopamine pathway, and by circuitry important for cognitive control, primarily in lateral prefrontal cortex. Indeed, the authors hypothesized that prayer may shift bias of activity in the brain from an involuntary, bottom-up network that supports salience detection, reward valuation, and involuntary attention (e.g., the insula, ventromedial prefrontal cortex) to a voluntary control network that serves effortful top-down processes, such as conscious decisionmaking and goal maintenance (e.g., dorsolateral prefrontal cortex). An assumption underlying this