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The clinical relevance of attentional bias in substance use disorders

  • Matt Field (a1), Reshmi Marhe (a2) (a3) and Ingmar H. A. Franken (a2)


Individuals with substance use disorders typically show an “attentional bias” for substance-related cues: Those cues are able to grab and hold the attention, in preference to other cues in the environment. We discuss the theoretical context for this work before reviewing the measurement of attentional bias, and its relationship to motivational state and relapse to substance use after a period of abstinence. Finally, we discuss the implications of this research for the treatment of substance use disorders. We conclude that attentional bias is associated with subjective craving, and that moment-by-moment fluctuations in attentional bias may precede relapse to substance use. The evidence regarding the predictive relationship between attentional bias assessed in treatment contexts and subsequent relapse is inconsistent. Furthermore, there is currently insufficient evidence to endorse attentional bias modification as a treatment for substance use disorders. Clinical implications and suggestions for future research are highlighted.


Corresponding author

*Address for correspondence: Prof. Matt Field, School of Psychology, University of Liverpool, Liverpool, L69 7ZA, UK. (Email


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1.Cisler, JM, Koster, EHW. Mechanisms of attentional biases towards threat in anxiety disorders: an integrative review. Clin Psychol Rev. 2010; 30(2): 203216.
2.Field, M, Cox, WM. Attentional bias in addictive behaviors: a review of its development, causes, and consequences. Drug Alcohol Depend. 2008; 97(1–2): 120.
3.Franken, IHA. Drug craving and addiction: integrating psychological and neuropsychopharmacological approaches. Prog Neuropsychopharmacol Biol Psychiatry. 2003; 27(4): 563579.
4.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.Washington, DC: American Psychiatric Association; 2013.
5.Robinson, TE, Berridge, KC. The neural basis of drug craving: an incentive-sensitization theory of addiction. Brain Res Brain Res Rev. 1993; 18(3): 247291.
6.Goldstein, RZ, Volkow, ND. Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci. 2011; 12(11): 652669.
7.Stacy, AW, Wiers, RW. Implicit cognition and addiction: a tool for explaining paradoxical behavior. Annu Rev Clin Psychol. 2010; 6: 551575.
8.Cox, WM, Fadardi, JS, Pothos, EM. The addiction-stroop test: theoretical considerations and procedural recommendations. Psychol Bull. 2006; 132(3): 443476.
9.Noël, X, Colmant, M, Van Der Linden, M, etal. Time course of attention for alcohol cues in abstinent alcoholic patients: the role of initial orienting. Alcoholism Clin Exp Res. 2006; 30(11): 18711877.
10.Ataya, AF, Adams, S, Mullings, E, etal. Internal reliability of measures of substance-related cognitive bias. Drug Alcohol Depend. 2012; 121(1–2): 148151.
11.Field, M, Christiansen, P. Commentary on ‘Internal reliability of measures of substance-related cognitive bias.’ Drug Alcohol Depend. 2012; 124(3): 189190.
12.Mogg, K, Bradley, BP, Field, M, De Houwer, J. Eye movements to smoking-related pictures in smokers: relationship between attentional biases and implicit and explicit measures of stimulus valence. Addiction. 2003; 98(6): 825836.
13.Littel, M, Euser, AS, Munafò, MR, Franken, IHA. Electrophysiological indices of biased cognitive processing of substance-related cues: a meta-analysis. Neurosci Biobehav Rev. 2012; 36(8): 18031816.
14.Luijten, M, Veltman, DJ, den Brink, WV, etal. Neurobiological substrate of smoking-related attentional bias. Neuroimage. 2011; 54(3): 23742381.
15.Luijten, M, Veltman, DJ, Hester, R, etal. Brain activation associated with attentional bias in smokers is modulated by a dopamine antagonist. Neuropsychopharmacology. 2012; 37(13): 27722779.
16.Janes, AC, Pizzagalli, DA, Richardt, S, etal. Brain reactivity to smoking cues prior to smoking cessation predicts ability to maintain tobacco abstinence. Biol Psychiatry. 2010; 67(8): 722729.
17.Nestor, L, McCabe, E, Jones, J, Clancy, L, Garavan, H. Differences in “bottom-up” and “top-down” neural activity in current and former cigarette smokers: evidence for neural substrates which may promote nicotine abstinence through increased cognitive control. Neuroimage. 2011; 56(4): 22582275.
18.Vollstädt-Klein, S, Loeber, S, Richter, A, etal. Validating incentive salience with functional magnetic resonance imaging: association between mesolimbic cue reactivity and attentional bias in alcohol-dependent patients. Addict Biol. 2012; 17(4): 807816.
19.Hester, R, Garavan, H. Neural mechanisms underlying drug-related cue distraction in active cocaine users. Pharmacol Biochem Behav. 2009; 93(3): 270277.
20.Janes, AC, Pizzagalli, DA, Richardt, S, etal. Neural substrates of attentional bias for smoking-related cues: an fMRI study. Neuropsychopharmacology. 2010; 35(12): 23392345.
21.Cox, WM, Pothos, EM, Hosier, SG. Cognitive-motivational predictors of excessive drinkers’ success in changing. Psychopharmacology. 2007; 192(4): 499510.
22.Carpenter, KM, Schreiber, E, Church, S, McDowell, D. Drug Stroop performance: relationships with primary substance of use and treatment outcome in a drug-dependent outpatient sample. Addict Behav. 2006; 31(1): 174181.
23.Cox, WM, Hogan, LM, Kristian, MR, Race, JH. Alcohol attentional bias as a predictor of alcohol abusers’ treatment outcome. Drug Alcohol Depend. 2002; 68(3): 237243.
24.Marissen, MAE, Franken, IHA, Waters, AJ, etal. Attentional bias predicts heroin relapse following treatment. Addiction. 2006; 101(9): 13061312.
25.Waters, AJ, Shiffman, S, Sayette, MA, etal. Attentional bias predicts outcome in smoking cessation. Health Psychol. 2003; 22(4): 378387.
26.Powell, J, Dawkins, L, West, R, Powell, J, Pickering, A. Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors. Psychopharmacology. 2010; 212(4): 537549.
27.Waters, AJ, Shiffman, S, Bradley, BP, Mogg, K. Attentional shifts to smoking cues in smokers. Addiction. 2003; 98(10): 14091417.
28.Field, M, Mogg, K, Mann, B, Bennett, GA, Bradley, BP. Attentional biases in abstinent alcoholics and their association with craving. Psychol Addict Behav. 2013; 27(1): 7180.
29.Marhe, R, Luitjen, M, van de Wetering, BJM, Smits, M, Franken, IHA. Individual differences in anterior cingulate activation associated with attentional bias predict cocaine use after treatment. Neuropsychopharmacology. 2013; 38(6): 10851093.
30.Waters, AJ, Marhe, R, Franken, IHA. Attentional bias to drug cues is elevated before and during temptations to use heroin and cocaine. Psychopharmacology. 2012; 219(3): 909921.
31.Marhe, R, Waters, AJ, van de Wetering, BJM, Franken, IHA. Implicit and explicit drug-related cognitions during detoxification treatment are associated with drug relapse: an ecological momentary assessment study. J Consult Clin Psychol. 2013; 81(1): 112.
32.Field, M, Munafò, MR, Franken, IHA. A meta-analytic investigation of the relationship between attentional bias and subjective craving in substance abuse. Psychol Bull. 2009; 135(4): 589607.
33.Preston, KL, Vahabzadeh, M, Schmittner, J, etal. Cocaine craving and use during daily life. Psychopharmacology. 2009; 207(2): 291301.
34.Field, M, Powell, H. Stress increases attentional bias for alcohol cues in social drinkers who drink to cope. Alcohol Alcohol. 2007; 42(6): 560566.
35.Schoenmakers, T, Wiers, RW, Field, M. Effects of a low dose of alcohol on cognitive biases and craving in heavy drinkers. Psychopharmacology. 2008; 197(1): 169178.
36.Fernie, G, Christiansen, P, Cole, JC, Rose, AK, Field, M. Effects of 0.4g/kg alcohol on attentional bias and alcohol-seeking behaviour in heavy and moderate social drinkers. J Psychopharmacol. 2012; 26(7): 10171025.
37.Field, M, Mogg, K, Bradley, BP. Eye movements to smoking-related cues: effects of nicotine deprivation. Psychopharmacology. 2004; 173(1): 116123.
38.Field, M, Rush, M, Cole, J, Goudie, A. The smoking Stroop and delay discounting in smokers: effects of environmental smoking cues. J Psychopharmacol. 2007; 21(6): 603610.
39.Cox, WM, Yeates, GN, Regan, CM. Effects of alcohol cues on cognitive processing in heavy and light drinkers. Drug Alcohol Depend. 1999; 55(1–2): 8589.
40.Field, M, Hogarth, L, Bleasdale, D, etal. Alcohol expectancy moderates attentional bias for alcohol cues in light drinkers. Addiction. 2011; 106(6): 10971103.
41.Jones, A, Hogarth, L, Christiansen, P, etal. Reward expectancy promotes generalized increases in attentional bias for rewarding stimuli. Q J Exp Psychol (Hove). 2012; 65(12): 23332342.
42.Field, M, Eastwood, B. Experimental manipulation of attentional bias increases the motivation to drink alcohol. Psychopharmacology. 2005; 183(3): 350357.
43.Field, M, Duka, T, Eastwood, B, etal. Experimental manipulation of attentional biases in heavy drinkers: do the effects generalise? Psychopharmacology. 2007; 192(4): 593608.
44.Field, M, Duka, T, Tyler, E, Schoenmakers, T. Attentional bias modification in tobacco smokers. Nicotine Tob Res. 2009; 11(7): 812822.
45.Attwood, AS, O'Sullivan, H, Leonards, U, Mackintosh, B, Munafò, MR. Attentional bias training and cue reactivity in cigarette smokers. Addiction. 2008; 103(11): 18751882.
46.McHugh, RK, Murray, HW, Hearon, BA, Calkins, AW, Otto, MW. Attentional bias and craving in smokers: the impact of a single attentional training session. Nicotine Tob Res. 2010; 12(12): 12611264.
47.Fadardi, JS, Cox, WM. Reversing the sequence: reducing alcohol consumption by overcoming alcohol attentional bias. Drug Alcohol Depend. 2009; 101(3): 137145.
48.Schoenmakers, TM, de Bruin, M, Lux, IFM, etal. Clinical effectiveness of attentional bias modification training in abstinent alcoholic patients. Drug Alcohol Depend. 2010; 109(1–3): 3036.
49.MacLeod, C, Mathews, A. Cognitive bias modification approaches to anxiety. Annu Rev Clin Psychol. 2012; 8: 189217.



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