Cognitive Concepts of Craving

Alcohol Research & Health, Fall, 1999 by Stephen T. Tiffany

Traditional models of craving have been based primarily on the concept of classical conditioning. In recent years, however, researchers increasingly have introduced cognitive concepts, such as memory, expectancies, interpretation, and automatic behavior, into their conceptualizations of craving. These efforts have culminated in the development of four cognitive models of craving: cognitive labeling, outcome expectancy, dual-affect, and cognitive processing. The cognitive processing model posits that although many alcohol use behaviors have become automatized processes in the course of an alcoholic's drinking career, craving is a nonautomatic process that requires mental effort and is limited by a person's cognitive capacity. This model also implies that alcohol use and alcohol-seeking behavior can occur in the absence of craving. In addition to introducing various new concepts and models into craving research, the cognitive sciences also offer well-established methodologies for testing these models and analyz ing craving processes. KEY WORDS: AOD (alcohol and other drug) craving; scientific model; cognition; research method and evaluation; conditioning; expectancy; emotion; memory; AOD use behavior; literature review

Imagine that you are an alcoholic trying to quit drinking. You have not had a drink in a month, but during the past several days, you have thought about alcohol constantly. These thoughts occupy your mind, making it nearly impossible to concentrate on anything else. Everything around you seems to invoke memories of how pleasant and satisfying drinking can be. You have wrestled with the idea of having a drink, but you have decided to wait at least a little longer. Today, however, after leaving work, you find yourself somewhat mindlessly driving by your favorite bar. You cannot help but notice the front door of the bar propped open, seeming to beckon you inside. You pull over to the curb, park your car, and find yourself standing at the door. As you look through the doorway, it is all so familiar: The bar stools, the television flickering in the corner, and even the smell of stale cigarette smoke are comfortable and inviting. Your heart races and your hands sweat; you realize that this is craving at its worst. You are drawn inexorably into the bar. There is no way you can fight it any longer; you must have a drink.

Although fictional, this situation is not farfetched. In fact, many alcoholics will describe in vivid derail similar stories about craving and relapse (Ludwig 1988). The conventional explanation for this scenario, based on classical conditioning models, is relatively straightforward: Over along history of drinking, stimuli and events routinely paired with alcohol consumption (e.g., the sight of a bar) become conditioned stimuli-- that is, they induce the same responses that are produced by alcohol itself. These conditioned stimuli activate conditioned motivational states [1] that produce craving experiences, physiological reactions, and alcohol-seeking behaviors. Thus, all the events described in the opening paragraph could be viewed as the consequences of classical conditioning mechanisms (for a review of the classical conditioning model, see sidebar, p. 216, and Tiffany 1995a).

Numerous components of the scenario described previously, however, go beyond simple conditioning processes. For example, the fictional scene includes descriptions of alcohol-specific memories, positive expectancies about alcohol use, difficulties in concentration, decisions about drinking, attention focused on alcohol cues, interpretations of physiological reactions, and automatic behavior (i.e., automaticity), all of which are cognitive concepts.

Craving researchers increasingly apply these concepts in their attempts to understand the processes underlying craving.

What does the term "cognitive approach" mean when applied to craving or to other areas of research? Cognitive approaches investigate the processes that control mental functions, such as communication, learning, classification, knowledge representation, problemsolving, planning, remembering, and decisionmaking. To this end, cognitive science incorporates the contributions of several disciplines, including psychology, philosophy, linguistics, neuro biology, computer science, and engineering. Modern cognitive science generally describes the operation of mental functions in terms of information-processing systems--hypothesized mechanisms that control the acquisition and manipulation of information and translate that information into action.

During the past 25 years, even conventional conditioning models of craving often have invoked cognitive processes. For example, an influential craving theory presented by Ludwig and Wikler (1974) (see sidebar, below) hypothesized that exposure to withdrawal-related cues led to a conditioned withdrawal syndrome, which the alcoholic, through cognitive processes, would experience as craving for alcohol. In another major conditioning model, Wise (1988) described craving as the memory of the positively reinforcing effects of alcohol and other drugs (AODs). Finally, Berridge and Robinson (1995) argued that conditioned drug motivational states were largely unconscious and resulted in conscious experiences of craving only through mechanisms of a process called cognitive interpretation. Although these influential theories all cited cognitive processes as central to the development of craving, they did not elaborate on how those cognitive processes might operate.