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Alcohol cue reactivity and private self-consciousness among male alcoholics
Addictive Behaviors, Vol. 24, No. 4, pp. 543–549, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0306-4603/99/$–see front matter
Pergamon
PII S0306-4603(98)00093-8
BRIEF REPORT ALCOHOL CUE REACTIVITY AND PRIVATE SELF-CONSCIOUSNESS AMONG MALE ALCOHOLICS CLARA M. BRADIZZA,* SUZY B. GULLIVER,* PAUL R. STASIEWICZ,* ROBYN TORRISI,* DAMARIS J. ROHSENOW,*† and PETER M. MONTI*† *Brown University; and †Veterans Affairs Medical Center
Abstract — Recent alcohol cue exposure studies have noted that not all alcoholics demonstrate increased reactivity when presented with alcohol-related cues. This study examined the relationship of private self-consciousness (PSC) to subjective, self-report measures of reactivity and measures of negative mood states that involve a focus on internal processes. These subjective measures of reactivity were contrasted with salivary reactivity, an objective measure of reactivity which does not require individual self-report or awareness. A cue reactivity assessment was administered to 47 men meeting DSM-III-R criteria for a diagnosis of alcohol dependence. Our hypothesis, that PSC would predict urge reactivity status and greater levels of negative mood states, was supported. Urge reactors were more likely to be high in PSC, while the proportions of salivary reactors and nonreactors were not significantly different between the high and low PSC groups. Although regression analyses indicated that PSC did not significantly predict urge to drink alcohol, it did predict angry/frustrated mood and sad/depressed mood at the first alcohol trial. These results suggest that individuals high in PSC may benefit more from cue exposure-based treatment, as they are more likely to be urge reactors and to evidence negative mood reactivity. Low PSC individuals may be at higher risk for relapse given they are less able to recognize internal reactions signaling the presence of a highrisk alcohol use situation, and therefore less likely to mobilize coping responses. © 1999 Elsevier Science Ltd
Alcohol cue exposure studies have found significantly greater reactivity for alcoholics than nonalcoholics on measures of urge to drink alcohol and measures of physiological reactivity (Monti et al., 1987). Alcohol cue reactivity is typically measured both objectively (e.g., physiological measures of heart rate, GSR, or salivation) and subjectively (e.g., self-reported urge and mood). Increased reactivity in the presence of alcohol cues has been associated with decreased latency to relapse following cue exposure treatment (Drummond & Glautier, 1994) and more frequent posttreatment drinking (Rohsenow et al., 1994). During alcohol cue reactivity assessment, not all alcoholics demonstrate significant increases in all response channels when presented with the sight and smell of alcohol (Niaura et al., 1988). As a result, an investigation examining variables associated with Clara M. Bradizza and Paul R. Stasiewicz are now at the Research Institute on Addictions, Buffalo, New York. An extended version of this article is available by contacting the corresponding author. This research was supported by a National Institute on Alcohol Abuse and Alcoholism Training Grant (AA07459), a National Institute on Alcohol Abuse and Alcoholism grant (AA07850), and a National Institute on Drug Abuse grant (DA00311). The contribution of Cheryl Eaton to data analyses is appreciated. Requests for reprints should be sent to Clara M. Bradizza, Research Institute on Addictions, 1021 Main Street, Buffalo, NY 14203-1016; E-mail: [email protected] 543
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alcohol cue reactivity may serve to increase our understanding of why some individuals are more reactive in the presence of alcohol cues. Several factors may influence an individual’s self-report of reactivity, including the ability to attend to internal events (Monti et al., 1993a). Self-focused attention refers to the awareness of internally generated information, as opposed to information that originates from the external environment (Ingram, 1990). The construct of private self-consciousness (PSC) is defined as the tendency for an individual to direct attention inward towards thoughts, feelings, and behaviors (Fenigstein, Scheier, & Buss, 1975). Individuals high in trait PSC tend to focus attention on internal events to a greater extent than individuals low in trait private self-consciousness. A number of studies have examined differences between individuals high and low in private self-consciousness. A study by Scheier and Carver (1977) found that individuals high in PSC were more responsive to both negatively and positively induced transient affective states, suggesting that high PSC individuals are more attentive to internally generated information. Research has also examined the relationship between PSC and diverse clinical disorders. A consistent relationship has been found between increased self-focused attention and higher levels of depression and anxiety (Ingram, 1990). A model that specifically addresses dysfunctional alcohol abuse has been proposed by Hull and Levy (1979). In this model, self-awareness corresponds to the encoding of information in terms of self-relevance, such that self-awareness increases sensitivity to self-relevant information. Alcohol reduces self-relevant cognitions that may be a source of tension for the individual, thus increasing the likelihood of further alcohol consumption. A common finding across studies examining anxiety, depressive, and alcohol-use disorders is that individuals high in PSC focus more attention on internally generated cognitive, emotional, and sensory processes. These findings may be extended to explain why some alcoholics report greater subjective reactivity and greater levels of negative mood during alcohol cue exposure. During a cue exposure assessment, individuals must focus on internal processes in order to self-report their level of urge to drink alcohol and their mood states. It was hypothesized that a greater proportion of individuals high in PSC would be classified as urge reactors, compared with individuals low in private self-consciousness. Similarly, a higher level of PSC should predict greater levels of urge for alcohol and negative mood states during alcohol cue exposure. In contrast, it was predicted that salivation, a relatively unconscious process that does not require self-report or awareness, would be unrelated to degree of private self-consciousness. M E T H O D
Participants Participants were 47 men recruited from three sites participating in a larger study. Fourteen men hospitalized for alcohol detoxification were recruited from a Veterans Affairs Medical Center, 19 men were recruited from a private rehabilitation program and 14 men were recruited from a residential alcohol treatment facility. Participants’ mean age (6 SD) was 35.8 6 10.3 years (range, 19 to 63); 21% were married or cohabiting; 75.5% had obtained at least a high school diploma; 85% were White, 13% were Black, and 2% were Native American. Participants’ mean score on the Alcohol Dependence Scale (ADS; Skinner & Allen, 1982) was 18.9 6 8.3. All participants met DSM-III-R criteria for alcohol dependence and must have had at least 13 heavy drinking days in the 6 months prior to admission. In addition, participants must have had
Private self-consciousness and reactivity
545
their last very heavy drinking day (more than 9 drinks) within 30 days prior to admission. Patients were excluded if they evidenced acute psychosis, major organic impairment, major medical illness (e.g., severe liver disease), or the use of anti-anxiety medication or any medications that inhibit salivation. Procedure Following admission, potential participants were informed about the nature of the study1 and written consent was obtained from those individuals who agreed to participate. The questionnaire assessment and the cue reactivity assessment were conducted within 3 days of admission. The assessment procedures for the larger study are reported in detail elsewhere (Rubonis et al., 1994). The cue reactivity assessment (CRA) was based on procedures developed by Monti et al. (1987) and modified for this study. The participant sat at a table separated from the experimenter by a barrier with a one-way mirror. Beverages were hidden from view under two inverted opaque pitchers, and vials containing cotton rolls were placed in front of the pitchers. Under one pitcher was a glass of cold water and commercially labeled bottle of spring water. Under the other pitcher was a glass of the patient’s most frequently consumed alcoholic beverage prepared the way he/she normally drank it (e.g., Jim Beam and Pepsi) and the commercial container for the alcoholic beverage (e.g., pint bottle of Jim Beam). The experimenter explained the self-report instruments, the exposure procedures and informed participants that either the experimenter or an audio tape would tell them when to carry out each procedure. All participants received a water trial, followed by an alcohol trial, a mood induction trial, and a final alcohol trial. This study examined data from the water and first alcohol trials only; the remaining mood and alcohol trials are not relevant to this study. Sniffing of the beverages was signaled by audiotaped tones occurring 13 times during a 3-minute trial on a variable ratio schedule in order to minimize temporal conditioning. Each participant was asked to relax for 3 minutes, then to insert cotton rolls in his mouth. Next, the participant uncovered the water, and held and sniffed the glass of water when signaled for 3 minutes. The participant then covered the water, put the cotton rolls back in the vial, sealed the vial and completed the urge and mood questionnaires described below. Following the CRA session, the participant completed several questionnaires prior to being completely debriefed. Cue reactivity measures Salivation. Amount of salivation was assessed by weighing the vials and cotton rolls before and after the CRA session. Saliva was collected during the water and alcohol beverage trials. Urge scales. Participants were asked, “How strong is your urge to drink alcohol (water) right now?” on 11- point Likert scales (0 to 10) following each alcohol and water trial.
1Patients were assigned to one of four treatment groups in a 2 3 2 factorial design. Patients received four to eight individual sessions of Cue Exposure treatment or Relaxation Training and four to eight group sessions of Alcohol Education or Communication Skills training. The details of these treatments are not relevant to the current study. The assessment procedures for the larger study are described elsewhere (Rubonis et al., 1994).
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Internal state and personality measures Mood questionnaire. Each of the four target moods was assessed with one of the following four questions: (1) “How happy do you feel right now?” (2) “How sad or depressed do you feel right now?” (3) “How angry or frustrated do you feel right now?” (4) “How nervous or jittery do you feel right now?” Each item was rated on 0-to-10 Likert scales after each beverage exposure. Only the measures of negative mood (i.e., sad/depressed, angry/frustrated, nervous/jittery) were analyzed in this study, given the research examining the relationship of private self-consciousness and negative mood states (see Ingram, 1990). Self-consciousness Scale. Private self-consciousness was assessed by the Self-Consciousness Scale (SCS; Fenigstein et al., 1975) which consists of three factors: Private self-consciousness, public self-consciousness, and social anxiety. The SCS consists of 23 items rated on a scale from 0 (extremely uncharacteristic of self) to 4 (extremely characteristic of self). The entire SCS was administered, but only the PSC scale was used in this study. Recently, studies have confirmed that the SCS is both reliable and valid. R E S U L T S
When sites were compared on marital status and educational achievement, no statistically significant differences were found. Participants from the VA Medical Center were significantly older (mean age 5 43.6) than participants from the private rehabilitation program (mean age 5 30.5) F(2, 44) 5 8.7, p , .001. However, no significant age differences were found between high and low PSC groups. In addition, analyses of the main dependent measures (e.g., urge for alcohol, salivation, negative mood states) indicated no statistically significant correlation between age and any of these dependent measures. There were no differences among participants from either the three sites or the high and low PSC groups on any of the drinking dependent variables. Participants from the three sites were combined in all subsequent analyses. Chi-square analyses were used to examine the relationship between PSC and reactor status. For the chi-square analyses, study participants were divided into high and low PSC groups by way of a median split of the PSC scale scores. The use of a median split to determine high and low groups has been used in several prior studies (e.g., Scheier & Carver, 1977). Data for 3 participants were incomplete, resulting in 44 participants with complete data. The range of possible scores is 0 to 40, and the median for this sample was 21. This resulted in 23 participants in the high PSC group and 21 participants in the low PSC group. The results of t tests indicated no statistically significant differences between the high and low groups on age, race, marital status, and education. Separate multiple regression analyses were used to determine whether degree of PSC predicted several continuous dependent variables including urge to drink alcohol, salivation, and negative mood states. For each analysis, we entered the water trial values first, in order to control for baseline levels of the dependent variable, followed by the PSC scale score. Urge and salivary reactor data To explore the relationship of PSC and alcohol cue reactivity, all participants were classified as either reactors or nonreactors for urge, and reactors and nonreactors for
Private self-consciousness and reactivity
547
salivation. An individual was considered to be an urge or salivary reactor if he demonstrated any increase in the relevant variable (i.e., urges or salivation) from the water trial to the first alcohol trial. Nonreactors were individuals who did not demonstrate any increase in the target variable. Urge reactors. The association between high and low private self-consciousness and urge reactivity status (Table 1) was examined by conducting a chi-square test. As predicted, urge reactors were more likely to be high in PSC and urge nonreactors were more likely to be low, x2 5 4.92, n 5 44, p , .03. Salivary reactors. A chi-square analysis of the association between PSC and salivary reactivity status (Table 1) indicated that the proportions of reactors and nonreactors were not significantly different between the high and low PSC groups, x2 5 .02, n 5 44, ns. Alcohol reactivity measures Contrary to our predictions, a multiple regression analysis revealed that PSC did not significantly predict urge to drink alcohol at the first alcohol trial (DR2 5 .02, Finc(1, 41) 5 1.16, ns). Consistent with our predictions, a regression analysis of the salivation data revealed that PSC did not significantly predict salivation during the first alcohol trial (DR2 5 .0004, Finc(1,41) 5 .04, ns). Negative mood states Regression analyses of the negative mood data revealed similarities in the relationship of PSC to each of the three negative mood states. Private self-consciousness significantly predicted both angry/frustrated mood (DR2 5 .09, Finc(1, 40) 5 5.22, p 5 .03), and sad/depressed mood (DR2 5 .10, Finc(1, 40) 5 5.70, p 5 .02), at the first alcohol trial. However, no significant relationship was found between self- consciousness and nervous/jittery mood at the first alcohol trial (DR2 5 .05, Finc(1, 40) 5 2.61, ns). D I S C U S S I O N
Consistent with our main predictions, a greater proportion of urge reactors were high in PSC and a greater proportion of urge nonreactors were low in PSC, whereas salivary reactors and nonreactors were equally likely to be high or low in private selfconsciousness. Also consistent with our predictions, higher levels of PSC predicted greater levels of negative mood, particularly angry/frustrated and sad/depressed mood.
Table 1.
Number of urge and salivary reactors and nonreactors in low and high private self-consciousness groups
Variable Urge Low PSC High PSC Salivation Low PSC High PSC
Reactors
Nonreactors
12 20
9 3
15 16
6 7
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In contrast, PSC did not significantly predict amount of salivation, an objective measure of reactivity that is generally independent of self-report measures. Contrary to our predictions, degree of PSC did not significantly predict degree of urge to drink alcohol. It seems that although PSC is related to reactivity status, there does not appear to be a linear relationship between level of PSC and level of self-reported urge to drink alcohol. The main predictions were supported by a significant relationship between PSC and urge reactivity status, and no significant relationships between PSC and salivary reactivity status. These results support the view that individuals focus on internal processes in order to assess and self-report an urge or negative mood state. During alcohol cue exposure, an individual’s ability to focus internally will affect whether he or she demonstrates reactivity to alcohol cues on subjective self-report measures. However, an individual’s level of PSC does not appear to affect his or her salivary response, an objective measure of reactivity that does not require an individual to focus on internal processes. These results are consistent with prior alcohol cue exposure studies demonstrating that urge to drink alcohol and salivary reactivity are not highly correlated (Monti et al., 1993b) and that awareness of internal states mediates the relationship between salivary response and urge to drink (Monti et al., 1993a). An individual’s level of PSC may have important implications for who benefits from cue exposure treatment. A recent reformulation of Tiffany’s (1990) cognitive model (Rohsenow et al., 1994) proposes that alcoholics with less awareness of their reactions while in a high-risk situation may be more susceptible to the influence of automatic drug-seeking processes. In the present study, individuals low in PSC were more likely to be urge nonreactors and to report lower levels of negative mood states following exposure to alcohol cues. Given their generally lower levels of reactivity and awareness of negative mood states, low PSC individuals may be less able to recognize internal reactions signaling the presence of a high-risk alcohol use situation and therefore less likely to mobilize coping responses. In contrast, individuals high in PSC were more likely to be urge reactors and to report increased levels of negative mood states. Given their generally greater levels of reactivity on self-report measures, high PSC individuals may benefit more from exposure-based treatment techniques designed to reduce reactivity to alcohol cues. R E F E R E N C E S Drummond, D. C., & Glautier, S. (1994). A controlled trial of cue exposure treatment in alcohol dependence. Journal of Consulting and Clinical Psychology, 62, 809–817. Fenigstein, A., Scheier, M. G., & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of Consulting and Clinical Psychology, 43, 522–527. Hull, J. G., & Levy, A. S. (1979). The organizational functions of the self: An alternative to the Duval and Wicklund model of self-awareness. Journal of Personality and Social Psychology, 37, 756–768. Ingram, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin, 107, 156–176. Monti, P. M., Binkoff, J. A., Abrams, D. B., Zwick, W. R., Nirenberg, T. D., & Liepman, M. R. (1987). Reactivity of alcoholics and nonalcoholics to drinking cues. Journal of Abnormal Psychology, 96, 122– 126. Monti, P. M., Rohsenow, D. J., Rubonis, A. V., Niaura, R., Sirota, A. D., Colby, S. M., & Abrams, D. B. (1993a). Alcohol cue reactivity: Effects of detoxification and extended exposure. Journal of Studies on Alcohol, 54, 235–249. Monti, P. M., Rohsenow, D. J., Rubonis, A. V., Niaura, R., Sirota, A. D., Colby, S. M., Goddard, P., & Abrams, D. B. (1993b). Cue exposure with coping skills treatment for male alcoholics: A preliminary investigation. Journal of Consulting and Clinical Psychology, 61, 1011– 1019. Niaura, R. S., Rohsenow, D. J., Binkoff, J. A., Monti, P. M., Abrams, D. B., & Pedraza, M. (1988). The rele-
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vance of cue reactivity to understanding alcohol and smoking relapse. Journal of Abnormal Psychology, 97, 133–152. Rohsenow, D. J., Monti, P. M., Rubonis, A. V., Sirota, A. D., Niaura, R. S., Colby, S. M., Wunschel, S. M., & Abrams, D. B. (1994). Cue reactivity as a predictor of drinking among male alcoholics. Journal of Consulting and Clinical Psychology, 62, 620–626. Rubonis, A. V., Colby, S. M., Monti, P. M., Rohsenow, D. J., Gulliver, S. B., & Sirota, A. D. (1994). Alcohol cue reactivity and mood induction in male and female alcoholics. Journal of Studies on Alcohol, 55, 487–494. Scheier, M. F., & Carver, C. S. (1977). Self-focused attention and the experience of emotion: Attraction, repulsion, elation and depression. Journal of Personality and Social Psychology, 35, 625–636. Skinner, H. A., & Allen, B. A. (1982). Alcohol dependence syndrome: Measurement and validation. Journal of Abnormal Psychology, 91, 199–209. Tiffany, S. T. (1990). A cognitive model of drug urges and drug use behavior: Role of automatic and nonautomatic processes. Psychological Review, 98, 147–168.
Pergamon
PII S0306-4603(98)00093-8
BRIEF REPORT ALCOHOL CUE REACTIVITY AND PRIVATE SELF-CONSCIOUSNESS AMONG MALE ALCOHOLICS CLARA M. BRADIZZA,* SUZY B. GULLIVER,* PAUL R. STASIEWICZ,* ROBYN TORRISI,* DAMARIS J. ROHSENOW,*† and PETER M. MONTI*† *Brown University; and †Veterans Affairs Medical Center
Abstract — Recent alcohol cue exposure studies have noted that not all alcoholics demonstrate increased reactivity when presented with alcohol-related cues. This study examined the relationship of private self-consciousness (PSC) to subjective, self-report measures of reactivity and measures of negative mood states that involve a focus on internal processes. These subjective measures of reactivity were contrasted with salivary reactivity, an objective measure of reactivity which does not require individual self-report or awareness. A cue reactivity assessment was administered to 47 men meeting DSM-III-R criteria for a diagnosis of alcohol dependence. Our hypothesis, that PSC would predict urge reactivity status and greater levels of negative mood states, was supported. Urge reactors were more likely to be high in PSC, while the proportions of salivary reactors and nonreactors were not significantly different between the high and low PSC groups. Although regression analyses indicated that PSC did not significantly predict urge to drink alcohol, it did predict angry/frustrated mood and sad/depressed mood at the first alcohol trial. These results suggest that individuals high in PSC may benefit more from cue exposure-based treatment, as they are more likely to be urge reactors and to evidence negative mood reactivity. Low PSC individuals may be at higher risk for relapse given they are less able to recognize internal reactions signaling the presence of a highrisk alcohol use situation, and therefore less likely to mobilize coping responses. © 1999 Elsevier Science Ltd
Alcohol cue exposure studies have found significantly greater reactivity for alcoholics than nonalcoholics on measures of urge to drink alcohol and measures of physiological reactivity (Monti et al., 1987). Alcohol cue reactivity is typically measured both objectively (e.g., physiological measures of heart rate, GSR, or salivation) and subjectively (e.g., self-reported urge and mood). Increased reactivity in the presence of alcohol cues has been associated with decreased latency to relapse following cue exposure treatment (Drummond & Glautier, 1994) and more frequent posttreatment drinking (Rohsenow et al., 1994). During alcohol cue reactivity assessment, not all alcoholics demonstrate significant increases in all response channels when presented with the sight and smell of alcohol (Niaura et al., 1988). As a result, an investigation examining variables associated with Clara M. Bradizza and Paul R. Stasiewicz are now at the Research Institute on Addictions, Buffalo, New York. An extended version of this article is available by contacting the corresponding author. This research was supported by a National Institute on Alcohol Abuse and Alcoholism Training Grant (AA07459), a National Institute on Alcohol Abuse and Alcoholism grant (AA07850), and a National Institute on Drug Abuse grant (DA00311). The contribution of Cheryl Eaton to data analyses is appreciated. Requests for reprints should be sent to Clara M. Bradizza, Research Institute on Addictions, 1021 Main Street, Buffalo, NY 14203-1016; E-mail: [email protected] 543
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C. M. BRADIZZA et al.
alcohol cue reactivity may serve to increase our understanding of why some individuals are more reactive in the presence of alcohol cues. Several factors may influence an individual’s self-report of reactivity, including the ability to attend to internal events (Monti et al., 1993a). Self-focused attention refers to the awareness of internally generated information, as opposed to information that originates from the external environment (Ingram, 1990). The construct of private self-consciousness (PSC) is defined as the tendency for an individual to direct attention inward towards thoughts, feelings, and behaviors (Fenigstein, Scheier, & Buss, 1975). Individuals high in trait PSC tend to focus attention on internal events to a greater extent than individuals low in trait private self-consciousness. A number of studies have examined differences between individuals high and low in private self-consciousness. A study by Scheier and Carver (1977) found that individuals high in PSC were more responsive to both negatively and positively induced transient affective states, suggesting that high PSC individuals are more attentive to internally generated information. Research has also examined the relationship between PSC and diverse clinical disorders. A consistent relationship has been found between increased self-focused attention and higher levels of depression and anxiety (Ingram, 1990). A model that specifically addresses dysfunctional alcohol abuse has been proposed by Hull and Levy (1979). In this model, self-awareness corresponds to the encoding of information in terms of self-relevance, such that self-awareness increases sensitivity to self-relevant information. Alcohol reduces self-relevant cognitions that may be a source of tension for the individual, thus increasing the likelihood of further alcohol consumption. A common finding across studies examining anxiety, depressive, and alcohol-use disorders is that individuals high in PSC focus more attention on internally generated cognitive, emotional, and sensory processes. These findings may be extended to explain why some alcoholics report greater subjective reactivity and greater levels of negative mood during alcohol cue exposure. During a cue exposure assessment, individuals must focus on internal processes in order to self-report their level of urge to drink alcohol and their mood states. It was hypothesized that a greater proportion of individuals high in PSC would be classified as urge reactors, compared with individuals low in private self-consciousness. Similarly, a higher level of PSC should predict greater levels of urge for alcohol and negative mood states during alcohol cue exposure. In contrast, it was predicted that salivation, a relatively unconscious process that does not require self-report or awareness, would be unrelated to degree of private self-consciousness. M E T H O D
Participants Participants were 47 men recruited from three sites participating in a larger study. Fourteen men hospitalized for alcohol detoxification were recruited from a Veterans Affairs Medical Center, 19 men were recruited from a private rehabilitation program and 14 men were recruited from a residential alcohol treatment facility. Participants’ mean age (6 SD) was 35.8 6 10.3 years (range, 19 to 63); 21% were married or cohabiting; 75.5% had obtained at least a high school diploma; 85% were White, 13% were Black, and 2% were Native American. Participants’ mean score on the Alcohol Dependence Scale (ADS; Skinner & Allen, 1982) was 18.9 6 8.3. All participants met DSM-III-R criteria for alcohol dependence and must have had at least 13 heavy drinking days in the 6 months prior to admission. In addition, participants must have had
Private self-consciousness and reactivity
545
their last very heavy drinking day (more than 9 drinks) within 30 days prior to admission. Patients were excluded if they evidenced acute psychosis, major organic impairment, major medical illness (e.g., severe liver disease), or the use of anti-anxiety medication or any medications that inhibit salivation. Procedure Following admission, potential participants were informed about the nature of the study1 and written consent was obtained from those individuals who agreed to participate. The questionnaire assessment and the cue reactivity assessment were conducted within 3 days of admission. The assessment procedures for the larger study are reported in detail elsewhere (Rubonis et al., 1994). The cue reactivity assessment (CRA) was based on procedures developed by Monti et al. (1987) and modified for this study. The participant sat at a table separated from the experimenter by a barrier with a one-way mirror. Beverages were hidden from view under two inverted opaque pitchers, and vials containing cotton rolls were placed in front of the pitchers. Under one pitcher was a glass of cold water and commercially labeled bottle of spring water. Under the other pitcher was a glass of the patient’s most frequently consumed alcoholic beverage prepared the way he/she normally drank it (e.g., Jim Beam and Pepsi) and the commercial container for the alcoholic beverage (e.g., pint bottle of Jim Beam). The experimenter explained the self-report instruments, the exposure procedures and informed participants that either the experimenter or an audio tape would tell them when to carry out each procedure. All participants received a water trial, followed by an alcohol trial, a mood induction trial, and a final alcohol trial. This study examined data from the water and first alcohol trials only; the remaining mood and alcohol trials are not relevant to this study. Sniffing of the beverages was signaled by audiotaped tones occurring 13 times during a 3-minute trial on a variable ratio schedule in order to minimize temporal conditioning. Each participant was asked to relax for 3 minutes, then to insert cotton rolls in his mouth. Next, the participant uncovered the water, and held and sniffed the glass of water when signaled for 3 minutes. The participant then covered the water, put the cotton rolls back in the vial, sealed the vial and completed the urge and mood questionnaires described below. Following the CRA session, the participant completed several questionnaires prior to being completely debriefed. Cue reactivity measures Salivation. Amount of salivation was assessed by weighing the vials and cotton rolls before and after the CRA session. Saliva was collected during the water and alcohol beverage trials. Urge scales. Participants were asked, “How strong is your urge to drink alcohol (water) right now?” on 11- point Likert scales (0 to 10) following each alcohol and water trial.
1Patients were assigned to one of four treatment groups in a 2 3 2 factorial design. Patients received four to eight individual sessions of Cue Exposure treatment or Relaxation Training and four to eight group sessions of Alcohol Education or Communication Skills training. The details of these treatments are not relevant to the current study. The assessment procedures for the larger study are described elsewhere (Rubonis et al., 1994).
546
C. M. BRADIZZA et al.
Internal state and personality measures Mood questionnaire. Each of the four target moods was assessed with one of the following four questions: (1) “How happy do you feel right now?” (2) “How sad or depressed do you feel right now?” (3) “How angry or frustrated do you feel right now?” (4) “How nervous or jittery do you feel right now?” Each item was rated on 0-to-10 Likert scales after each beverage exposure. Only the measures of negative mood (i.e., sad/depressed, angry/frustrated, nervous/jittery) were analyzed in this study, given the research examining the relationship of private self-consciousness and negative mood states (see Ingram, 1990). Self-consciousness Scale. Private self-consciousness was assessed by the Self-Consciousness Scale (SCS; Fenigstein et al., 1975) which consists of three factors: Private self-consciousness, public self-consciousness, and social anxiety. The SCS consists of 23 items rated on a scale from 0 (extremely uncharacteristic of self) to 4 (extremely characteristic of self). The entire SCS was administered, but only the PSC scale was used in this study. Recently, studies have confirmed that the SCS is both reliable and valid. R E S U L T S
When sites were compared on marital status and educational achievement, no statistically significant differences were found. Participants from the VA Medical Center were significantly older (mean age 5 43.6) than participants from the private rehabilitation program (mean age 5 30.5) F(2, 44) 5 8.7, p , .001. However, no significant age differences were found between high and low PSC groups. In addition, analyses of the main dependent measures (e.g., urge for alcohol, salivation, negative mood states) indicated no statistically significant correlation between age and any of these dependent measures. There were no differences among participants from either the three sites or the high and low PSC groups on any of the drinking dependent variables. Participants from the three sites were combined in all subsequent analyses. Chi-square analyses were used to examine the relationship between PSC and reactor status. For the chi-square analyses, study participants were divided into high and low PSC groups by way of a median split of the PSC scale scores. The use of a median split to determine high and low groups has been used in several prior studies (e.g., Scheier & Carver, 1977). Data for 3 participants were incomplete, resulting in 44 participants with complete data. The range of possible scores is 0 to 40, and the median for this sample was 21. This resulted in 23 participants in the high PSC group and 21 participants in the low PSC group. The results of t tests indicated no statistically significant differences between the high and low groups on age, race, marital status, and education. Separate multiple regression analyses were used to determine whether degree of PSC predicted several continuous dependent variables including urge to drink alcohol, salivation, and negative mood states. For each analysis, we entered the water trial values first, in order to control for baseline levels of the dependent variable, followed by the PSC scale score. Urge and salivary reactor data To explore the relationship of PSC and alcohol cue reactivity, all participants were classified as either reactors or nonreactors for urge, and reactors and nonreactors for
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547
salivation. An individual was considered to be an urge or salivary reactor if he demonstrated any increase in the relevant variable (i.e., urges or salivation) from the water trial to the first alcohol trial. Nonreactors were individuals who did not demonstrate any increase in the target variable. Urge reactors. The association between high and low private self-consciousness and urge reactivity status (Table 1) was examined by conducting a chi-square test. As predicted, urge reactors were more likely to be high in PSC and urge nonreactors were more likely to be low, x2 5 4.92, n 5 44, p , .03. Salivary reactors. A chi-square analysis of the association between PSC and salivary reactivity status (Table 1) indicated that the proportions of reactors and nonreactors were not significantly different between the high and low PSC groups, x2 5 .02, n 5 44, ns. Alcohol reactivity measures Contrary to our predictions, a multiple regression analysis revealed that PSC did not significantly predict urge to drink alcohol at the first alcohol trial (DR2 5 .02, Finc(1, 41) 5 1.16, ns). Consistent with our predictions, a regression analysis of the salivation data revealed that PSC did not significantly predict salivation during the first alcohol trial (DR2 5 .0004, Finc(1,41) 5 .04, ns). Negative mood states Regression analyses of the negative mood data revealed similarities in the relationship of PSC to each of the three negative mood states. Private self-consciousness significantly predicted both angry/frustrated mood (DR2 5 .09, Finc(1, 40) 5 5.22, p 5 .03), and sad/depressed mood (DR2 5 .10, Finc(1, 40) 5 5.70, p 5 .02), at the first alcohol trial. However, no significant relationship was found between self- consciousness and nervous/jittery mood at the first alcohol trial (DR2 5 .05, Finc(1, 40) 5 2.61, ns). D I S C U S S I O N
Consistent with our main predictions, a greater proportion of urge reactors were high in PSC and a greater proportion of urge nonreactors were low in PSC, whereas salivary reactors and nonreactors were equally likely to be high or low in private selfconsciousness. Also consistent with our predictions, higher levels of PSC predicted greater levels of negative mood, particularly angry/frustrated and sad/depressed mood.
Table 1.
Number of urge and salivary reactors and nonreactors in low and high private self-consciousness groups
Variable Urge Low PSC High PSC Salivation Low PSC High PSC
Reactors
Nonreactors
12 20
9 3
15 16
6 7
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In contrast, PSC did not significantly predict amount of salivation, an objective measure of reactivity that is generally independent of self-report measures. Contrary to our predictions, degree of PSC did not significantly predict degree of urge to drink alcohol. It seems that although PSC is related to reactivity status, there does not appear to be a linear relationship between level of PSC and level of self-reported urge to drink alcohol. The main predictions were supported by a significant relationship between PSC and urge reactivity status, and no significant relationships between PSC and salivary reactivity status. These results support the view that individuals focus on internal processes in order to assess and self-report an urge or negative mood state. During alcohol cue exposure, an individual’s ability to focus internally will affect whether he or she demonstrates reactivity to alcohol cues on subjective self-report measures. However, an individual’s level of PSC does not appear to affect his or her salivary response, an objective measure of reactivity that does not require an individual to focus on internal processes. These results are consistent with prior alcohol cue exposure studies demonstrating that urge to drink alcohol and salivary reactivity are not highly correlated (Monti et al., 1993b) and that awareness of internal states mediates the relationship between salivary response and urge to drink (Monti et al., 1993a). An individual’s level of PSC may have important implications for who benefits from cue exposure treatment. A recent reformulation of Tiffany’s (1990) cognitive model (Rohsenow et al., 1994) proposes that alcoholics with less awareness of their reactions while in a high-risk situation may be more susceptible to the influence of automatic drug-seeking processes. In the present study, individuals low in PSC were more likely to be urge nonreactors and to report lower levels of negative mood states following exposure to alcohol cues. Given their generally lower levels of reactivity and awareness of negative mood states, low PSC individuals may be less able to recognize internal reactions signaling the presence of a high-risk alcohol use situation and therefore less likely to mobilize coping responses. In contrast, individuals high in PSC were more likely to be urge reactors and to report increased levels of negative mood states. Given their generally greater levels of reactivity on self-report measures, high PSC individuals may benefit more from exposure-based treatment techniques designed to reduce reactivity to alcohol cues. R E F E R E N C E S Drummond, D. C., & Glautier, S. (1994). A controlled trial of cue exposure treatment in alcohol dependence. Journal of Consulting and Clinical Psychology, 62, 809–817. Fenigstein, A., Scheier, M. G., & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of Consulting and Clinical Psychology, 43, 522–527. Hull, J. G., & Levy, A. S. (1979). The organizational functions of the self: An alternative to the Duval and Wicklund model of self-awareness. Journal of Personality and Social Psychology, 37, 756–768. Ingram, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin, 107, 156–176. Monti, P. M., Binkoff, J. A., Abrams, D. B., Zwick, W. R., Nirenberg, T. D., & Liepman, M. R. (1987). Reactivity of alcoholics and nonalcoholics to drinking cues. Journal of Abnormal Psychology, 96, 122– 126. Monti, P. M., Rohsenow, D. J., Rubonis, A. V., Niaura, R., Sirota, A. D., Colby, S. M., & Abrams, D. B. (1993a). Alcohol cue reactivity: Effects of detoxification and extended exposure. Journal of Studies on Alcohol, 54, 235–249. Monti, P. M., Rohsenow, D. J., Rubonis, A. V., Niaura, R., Sirota, A. D., Colby, S. M., Goddard, P., & Abrams, D. B. (1993b). Cue exposure with coping skills treatment for male alcoholics: A preliminary investigation. Journal of Consulting and Clinical Psychology, 61, 1011– 1019. Niaura, R. S., Rohsenow, D. J., Binkoff, J. A., Monti, P. M., Abrams, D. B., & Pedraza, M. (1988). The rele-
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