Alcohol craving in patients diagnosed with a severe mental illness and alcohol use disorder: bidirectional relationships between approach and avoidance inclinations and drinking.

Alcohol is the most widely used and abused substance in the United States with an estimated 18.7 million people diagnosed with an alcohol use disorder (AUD; SAMSHA, 2010). Severely mentally ill (SMI; i.e., schizophrenia spectrum, bipolar disorder) individuals are three times more likely to be diagnosed with an AUD as compared with individuals in the general population (Regier et al., 1990). Individuals diagnosed with both an AUD and a SMI experience greater negative consequences as compared to those with only an SMI including more severe psychiatric symptoms (e.g., Carey et al., 1991), more frequent psychiatric re-hospitalizations (e.g., Swofford et al., 1996), less stable living situations (e.g., Osher et al, 1994), and greater rates of violent behavior (e.g., Cuffel et al., 1994). Furthermore, among individuals diagnosed with SMI-AUDs, alcohol relapse rates are high with estimates exceeding 80% at 12-months post-treatment (e.g., Xie et al., 2010). Studies examining alcohol use and relapse among SMI-AUD individuals have primarily focused on the contextual or environmental factors related to use. For example, increased symptoms of mental illness, lack of supervised housing, social pressures to use within high drug use neighborhoods, interpersonal stressors, social isolation, and lack of meaningful activities are all associated with relapse following a period of abstinence (see Drake et al., 2005, for review). Although this work has drawn attention to the need to better understand relapse in this socially vulnerable population, few studies have examined the influence of psychological factors on relapse to alcohol use among SMI individuals. With the growing recognition that risk factors for alcohol use and relapse among SMI populations may be more similar than different to those found in non-SMI populations (e.g., Bradizza et al., 2009; Drake et al., 2005; Bradizza & Stasiewicz, 2003), greater understanding of the psychological factors influencing use is warranted. One area that has received significant attention among non-SMI substance abusers, but has yet to be examined in dually diagnosed populations, is craving. Craving has been described as the most studied and most misunderstood concept within addiction research (Lowman et al., 2000). It plays a prominent role in theoretical models regarding the development, maintenance, and reinstatement of AUDs (e.g., Marlatt & Witkiewitz, 2005; Tiffany & Conklin, 2000), and is assumed to be predictive of drinking and relapse. As such, craving is often targeted in both psychosocial and pharmacological treatments (e.g., Miranda et al., 2008; Stasiewicz et al., 2007) and is being considered for inclusion as a symptom of substance use disorders in the DSM-V (APA, 2012). Indeed, significant relationships have been found between craving and relapse during and following inpatient and outpatient treatment for AUDs (e.g., Flannery et al., 2003; Gordon et al., 2006); however, the literature has failed to yield consistent associations between craving and drinking (Drummond et al., 2000; Tiffany, 1990). Part of the difficulty in studying alcohol craving lies in the lack of consistent definitions (Rosenberg, 2009; Sayette et al., 2000; Tiffany et al., 2000). For example, craving has been operationalized within several theoretical frameworks, including conditioned-reinforcement (e.g., Koob, 2000), incentive sensitization (e.g., Robinson & Berridge, 2000), cognitive social learning theory (e.g., Niaura, 2000), and cognitive processing models (e.g., Tiffany, 1990). Further, many craving assessments are confounded by other factors known to contribute to drinking (e.g., expectancies, self-efficacy, mood; Kavanagh et al., 2012). More importantly, many of these approaches to assessing craving fail to capture the “ambivalence” or competing desires to drink and not drink often present in those diagnosed with AUDs (e.g., Smith-Hoerter et al., 2004; Sayette et al., 2000; Breiner et al., 1999; Tiffany, 1990), or account for craving as a function of recovery (Breiner et al., 1999; Stritzke et al., 2007). Thus, prediction of the craving-drinking relationship could be improved by applying a model of craving that assesses both the inclinations to approach and to avoid alcohol use. To address these concerns, Breiner, Stritzke, and Lang (1999) introduced an ambivalence conceptualization of craving (Ambivalence Model of Craving; AMC) that called for independent assessment of both approach and avoidance inclinations to use psychoactive substances. More precisely, the AMC views craving as a complex experience requiring consideration of both desires and behavioral intentions to use (approach inclinations) and not use (avoidance inclinations) alcohol or drugs (Breiner et al., 1999; McEvoy et al., 2004; Stritzke et al., 2004). Both are presumed to develop as a function of the positive and negative consequences of use (Breiner et al., 1999) and are proposed to be orthogonal to one another, resulting in four hypothetical quadrants (see Figure 1): approach (high approach, low avoidance), avoidance (low approach, high avoidance), ambivalence (high approach, high avoidance), and indifference (low approach, low avoidance). Consistent with neurobiological theories, although these dimensions may be activated reciprocally (e.g., high on one dimension, low on the other), approach and avoidance inclinations are independent and can be activated simultaneously to elicit different motivational states (Barkby et al., 2012; Cacioppo et al., 1999). Figure 1 Ambivalence Model of Craving. Measurement of both approach and avoidance inclinations as separate dimensions within the craving experience have several clinical and methodological advantages (see Stritzke et al., 2007). For example, the AMC provides a framework for the evaluation of craving (approach) and competing desires (avoidance) as a function of both substance use patterns and recovery status of those seeking and/or receiving treatment (see Figure 2). Further, it has been argued that measuring “craving” exclusively in terms of approach without consideration of a separate, yet concurrent, avoidance inclination may misrepresent a motivational disposition that is actually a combination of both, thereby significantly diminishing the utility of the information obtained (Breiner et al., 1999). Indeed, studies examining avoidance inclinations using both cue reactivity paradigms and self-report measures have provided considerable support for its incremental validity in predicting alcohol-related variables in both non-clinical and clinical samples (Schlauch et al., 2012; Schlauch, Breiner et al., 2013; Curtin et al., 2005; Klein et al., 2007; McEvoy et al., 2004; Stritzke et al., 2004; Stritzke et al., 2007). For example, avoidance inclinations are related to taking steps to make a change (Klein et al., 2007; Schlauch et al., 2012; Schlauch, Breiner et al., 2013), treatment retention (e.g., Schlauch et al., 2012), and recovery and relapse status (e.g., Stritzke et al., 2007). In addition, these dimensions appear to change during the course of recovery, with significant decreases in approach inclinations associated with decreases in drinking, while avoidance inclinations remain relatively high (Schlauch et al., 2012). Figure 2 Participant flow diagram To date, there has been limited investigation of alcohol craving in SMI-AUD populations. When assessed, alcohol craving is often reported as a secondary outcome in pharmacological treatment studies for alcohol use disorders, focuses exclusively on approach inclinations, and is rarely linked to drinking outcomes (e.g., Petrakis et al., 2004; Batki et al., 2007). Interestingly, of the factors found to be associated with drinking in SMI-AUD populations (e.g., high risk situations, interpersonal stressors), craving may function as a mediating variable in that relationship. Further, despite the dearth of literature linking craving to drinking outcomes in SMI-AUD populations, treatment recommendations continue to incorporate modules for coping with craving and avoiding high-risk situations (e.g., Bellack & DiClemente, 1999; Horsfall et al., 2009), suggesting that a better understanding of the craving-drinking relationship among SMI-AUD individuals has the potential to inform interventions for this vulnerable population.