Toward a phenomenology of urge to drink: a future prospect for the cue-reactivity paradigm.

Numerous studies have shown that alcohol-related environmental stimuli (e.g., the sight of alcohol) can produce emotional responses such as craving in regular drinkers, termed cue-reactivity. The cue-reactivity paradigm grew out of the behaviorist tradition with a focus on reinforcement mechanisms. However, subsequent studies have focused on personality traits as predictors of craving and most recently cognitive states associated with craving. We advocate more rigorous process-oriented research to determine why exposure to an alcohol-related stimulus facilitates one's urge to drink. It is argued here that previous research has attempted to delineate the etiology of subjective craving or 'urge to drink' whilst simultaneously neglecting to adequately operationally define the phenomenology of urge to drink states. We try to resolve this issue by advocating the use of a novel retrospective phenomenological assessment instrument that, to date has not been applied within the cue-reactivity paradigm. Finally, we proposed an experiment that uses that novel instrument to phenomenologically map and diagram 'urge to drink' states of consciousness.

Repeated alcohol use is associated with a range of social, economic, psychological and health related problems (Chisolm, Monteiro, Rem & Ommerman, 2004). Specifically, alcohol use ranks in the top five risk factors for disease and has been identified as a primary cause of mortality and disability (Chisolm et al., 2004; WHO, 2002). Given this, many studies have attempted to uncover potential risk factors and antecedents of excessive alcohol consumption (Ray, McGeary, Marshall & Hutchison, 2006). For example, within the study of alcohol abuse and relapse there is a particular focus on heightened craving or 'urge to drink' as a crucial indicator of alcohol-related problems (e.g., Carter & Tifanny, 1999; Ooterman et al., 2006; Tiffany, 1990). Craving is considered to be a subjective state characterized by the urge to re-experience the effect of a previously experienced substance (Ooterman et al., 2006; UNDCP/WHO, 1992). Numerous studies have investigated levels of self-reported craving in social and dependent drinkers upon exposure to alcohol-related stimuli (e.g., the sight of alcohol). Various models have been proposed to explain craving, in particular conditioning-based theories and cognitive accounts, and there is a plethora of differing definitions (Anton, 1999).

However, it is clear that previous research (e.g., Field, Mogg & Bradley, 2005; Tiffany, 1990) has sought to investigate the etiology of 'urge to drink' states while simultaneously neglecting to adequately empirically verify the constituents of these states (e.g., phenomenological elements). It is arguable that such studies have employed a potentially misdirected procedure by attempting to investigate the etiology of a variable, X, before determining what X is. Consequently, what is needed is a measure that may be used to quantify and, thus, operationally define 'urge to drink' states.

It is noteworthy that, in the past few decades, a variety of measures (e.g., Martin, Sloan, Sapira & Jasinski, 1971; Pekala, 1991; Strassman, Qualls, Uhlenhath & Kellner, 1994) have been constructed to retrospectively assess phenomenology. That is, one's perception or experience of occurrences, events, happenings, and so forth (Reber, 1985). One's phenomenology is clearly subjective and "that which is subjective is internal, personal, not available for public scrutiny" (Reber, 1985, p. 765). Phenomenological instruments or measures have been used extensively to quantify the subjective effects of, for example, hallucinogens (e.g., Gonzalez, Riba, Bouso, Gomez-Jarabo & Barbanoj, 2006; Strassman et al., 1994), hypnosis (Pekala & Kumar, 1986, 1989), and visualizing while listening to drumming (Rock, Casey & Baynes, 2006). However, to date, such measures have failed to permeate the cue-reactivity paradigm.

The aims of the present essay are to: (1) review the cue-reactivity literature pertaining to alcohol craving; and (2) provide a cartography of a phenomenological methodology and proposed experiment that may be used to quantitatively assess and diagram 'urge to drink' states of consciousness. (1) This will be accomplished by, first providing a review of the cue-reactivity literature with a special emphasis on subjective craving. Subsequently, a novel retrospective phenomenological assessment instrument will be described. Finally, we demonstrate how the aforementioned instrument may be applied in the context of the cue-reactivity paradigm by formulating a proposed experiment designed to investigate the phenomenology of 'urge to drink'.

The Cue-Reactivity Paradigm: An Overview

Many studies have shown that repeated substance use in the presence of particular environmental stimuli can produce conditioned responses in individuals when they are confronted with such 'cues' (Carter & Tiffany, 1999; Curtin et al., 2005). These responses, termed cue reactivity, include changes in physiology (e.g., heart rate, salivation), affect, and craving for the drug. For example, research has demonstrated that dependent and social drinkers display substantial alterations in self-reported mood and desire for alcohol when presented with the sight, smell and taste of alcohol, alcohol advertisements, and alcohol-related words (e.g., Carter & Tiffany, 1999; Franken, 2002; Kambouropoulos & Staiger, 2004; Monti et al., 1987). Of these responses, increased urge to drink is considered the most crucial given that it is a fundamental feature in the development and maintenance of hazardous drinking and alcoholism (Ooteman et al., 2006; Robinson & Berridge, 1993). Thus, a heightened urge to drink response to alcohol-related environmental stimuli is thought to be an important indicator of alcohol problems. Consequently, evidence derived from cue-reactivity studies has been used in the development of cue-exposure treatment programs designed to reduce urge responses in individuals when they encounter environmental cues (Drummond & Glautier, 1994; Monti et al., 2001; Staiger et al., 1999).