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Does altered state of awareness mediate the relationship between the unusual experiences trait and alcohol cue-reactivity?

Cue-reactivity refers to responses to environmental stimuli or "cues" (e.g., an individual's favorite alcoholic beverage), which include changes in physiology (e.g., heart rate, salivation), affect, and craving. Previous research has begun to examine the role of personality and cognitive variables in influencing alcohol cue-reactivity in an attempt to uncover possible individual factors which may help explain craving responses (e.g., Franken, 2002; Glautier, Bankart, & Williams, 2000; Kambouropoulos & Staiger, 2001, 2004; McCusker & Brown, 1991). These studies consistently point to deficient attentional processes and heightened levels of impulsive type personality traits as markers of increased cue-reactivity. Specifically, it appears that high levels of impulsivity, disinhibition, and elevated sensitivity to reward may facilitate self-reports of craving when in the presence of alcohol cues (Glautier et al., 2000; Kambouropoulos & Staiger, 2001, 2004). Thus, focusing on individual personality characteristics appears to be a useful method for investigating the processes underlying cue-reactivity. However, a potentially relevant personality trait that has been neglected by cue-reactivity researchers is "mental boundaries."

Hartmann's (1991) mental boundary construct refers to the notion that the contents of the human mind (e.g., memories, feelings, thoughts) constitute "... parts, regions, functions, or processes that are separate from one another and yet connected with one another" (p. 4). The 145-item Boundary Questionnaire (BQ) was developed by Hartmann (1989) to quantify the "thinness" or permeability of boundaries. Rawlings (2001-2002) factor-analyzed the BQ scores of 300 undergraduates and concluded that the boundary construct consists of six factors (i.e., unusual experiences, childlikeness, trust, perceived competence, need for order, and sensitivity). Individuals with "thin" boundaries tend to be described as "open," "sensitive" and "fluid" (Rawlings, 2001-2002). It is perhaps also noteworthy that thinness of boundaries is positively correlated with the transliminality construct (Sherwood & Milner, 20042005), which refers to "a hypothesized tendency for psychological material to cross thresholds into or out of consciousness" (Lange, Thalbourne, Houran, & Storm, 2000, p. 591). Consequently, thin boundary individuals tend to be high transliminals, who demonstrate the ability to transition with relative ease between ordinary waking states and altered states of awareness (unusual states of consciousness). Indeed, in a review of previous research concerning the boundary construct, Hartmann, Harrison and Zborowski (2001) cite studies suggesting that thinner boundaries are associated with various altered states of awareness (e.g., lucid dreaming, nightmares, hypnotic induction). Given that altered states of awareness typically consist of unusual experiences relative to the ordinary waking state (e.g., distortions in space-time perception, body image), it seems reasonable to suggest that the unusual experiences factor of the boundary construct may be a general trait tendency to experience altered states of awareness.

The hypothesized link between the unusual experiences factor and altered states of awareness is particularly salient in light of the notion of alcohol cue-reactivity. Indeed, it is perhaps noteworthy that certain individuals demonstrate a capacity to exhibit a transliminality with regards to mental states that allows them to "flashback" when exposed to a salient cue (Fischer, 1980). That is, according to Fischer (1980, p. 311) this "fluidity within mental states... allows them to flashback, that is, re-experience an altered state rather than simply remember it. For these people, movies, novels, and the like may be especially gripping, and the moods they evoke particularly real." Thus, some individuals are more likely to experience an altered state of awareness when exposed to an appropriate stimulus (Pekala, 1991). Therefore, certain individuals who are presented an alcohol-related cue may re-experience, rather than merely remember, the altered state of awareness (e.g., intoxication, elevation in positive mood) associated with previous alcohol consumption and this may, in turn, facilitate increases in positive urge to drink (i.e., the desire to consume alcohol for its pleasant effects).

We propose that the unusual experiences factor may affect one's altered state of awareness during alcohol cue exposure. Furthermore, if, as previously suggested, re-experiencing altered states of awareness associated with previous alcohol use serves to increase alcohol cue-reactivity in regular drinkers, then perhaps the unusual experiences factor affects positive urge to drink. This line of inquiry is important because it has the potential to contribute to our understanding of patterns of alcohol abuse by identifying phenomenological "triggers" of alcohol craving.

The present study aimed to investigate the relationship between the unusual experiences factor of boundaries and positive urge to drink, and whether altered state of awareness mediated (i.e., contributed to) this relationship. It was hypothesized that positive urge to drink would significantly increase from a neutral cue (i.e., a glass of water) to alcohol cue exposure, while controlling for baseline levels. It was further hypothesized that positive urge to drink would be positively correlated with unusual experiences and altered state of awareness, and these correlations would be statistically significant for alcohol cue exposure, but not for neutral cue exposure and baseline. Finally, it was hypothesized that altered state of awareness would mediate the relationship between unusual experiences and positive urge to drink during alcohol cue presentation.

METHOD

Participants

The 58 participants (14 [24.1%] male, 44 [75.9%] female) in the present study consisted of post-graduate and under-graduate students from Deakin University, and non-students who responded to recruitment posters. Ages ranged from 20 to 72 years (M = 30.29, SD = 13.16). Participants scored from 1 to 28 on the Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, De la Fuente, & Grant, 1993), a measure of alcohol use and alcohol-related problems. The mean score on the AUDIT was 9.06 (SD = 6.83) indicating a generally high level of consumption.

Design

The present study consisted of a repeated measures design whereby participants were assessed at baseline for positive urge to drink and altered state of awareness. Subsequently, participants were exposed to counterbalanced sequences of a neutral cue (a glass of water) and an alcohol cue (participants' favorite alcoholic beverage).

Counterbalancing is inconsistent with standard cue-reactivity protocols (e.g., Monti et al., 1987), which stipulate that the neutral cue should be presented first followed by the alcohol cue. Specifically, Monti et al. reported a general decrease in reactivity to cues that are presented second (possibly due to experimental effects such as time in the laboratory; McCusker & Brown, 1991). Thus, when significant increases in reactivity to alcohol cues presented second are found they are likely to be robust and reliable effects. However, the results of more recent research (e.g., Kambouropoulos & Rock, in press) have provided support for the utility of counterbalancing water cue and alcohol cue presentation and, thus, challenge standard cue-reactivity protocols. Consequently, for the purpose of the present study we chose to counterbalance water and alcohol cue exposure.

Measures

Unusual experiences factor of mental boundaries. The Rawlings (2001-2002) Boundary Questionnaire Short Form (BQ-Sh) was used in the present study to quantify the unusual experiences factor of mental boundaries. The BQ-Sh is an empirically derived shortened version of the 145-item Hartmann (1991) Boundary Questionnaire (BQ). The BQSh consists of 46 items with a five-point Likert scale, and produces six subscales: unusual experiences, need for order, trust, perceived competence, childlikeness, and sensitivity. The BQ-Sh has adequate psychometric properties as evidenced by Rawlings' empirical examination of the scale. For example, the BQ-Sh strongly correlates with the BQ (r = .88) and the alpha coefficients for the BQ-Sh subscales range from .69 to .80 (Rawlings, 2001-2002).

Urge to drink. Urge to drink was measured using a 10cm visual analogue scale (VAS). The scale provided an index of urge to drink for positive reinforcement (Dawe & Gray, 1995). Specifically, positive urge to drink was assessed by asking participants to rate "How much do you want to drink alcohol at this moment for its pleasant effect?" The VAS was anchored with the phrases "not at all" and "extremely." This type of measurement has been found to be an effective and reliable method for assessing urge to drink in cue-reactivity assessments (e.g., Coffey, Saladin, Libet, Drobes, & Dansky, 1999).

Altered state of awareness. The Phenomenology of Consciousness Inventory (PCI; Pekala, 1991) was used in the present study to quantify altered state of awareness. The PCI purportedly quantifies the structures of consciousness and consists of 53 items scored on a 7-point Likert scale (Pekala & Wenger, 1983). The PCI has been shown to reliably discriminate between qualitatively different states of consciousness (thus supporting the scale's criterion validity), and has demonstrated good internal consistency, yielding coefficient alphas between .70 and .90 (Pekala, Steinberg, & Kumar, 1986).

Procedure

Participants were recruited primarily from Deakin University by advertisements placed throughout the metropolitan campus. Prior to the experimental sessions, participants were asked to verify by self-report that they had not consumed alcohol in the previous 24 hours. Participants then completed the demographics/AUDIT questionnaire.

Participants were seated in a comfortable reclining chair and were first asked to complete baseline assessments of positive urge to drink and altered state of awareness. Next, participants were presented with counterbalanced sequences of: (a) a glass of water (neutral stimulus), which they were required to sip and then focus on for a period of 3 minutes; and (b) their favorite alcoholic beverage, equivalent to one standard drink, which was administered in the manner that it was usually consumed (e.g., scotch on ice). Participants were asked to pick up, smell, sip and then focus on this alcohol stimulus for a period of 3 minutes. Following each counterbalanced presentation, participants completed the urge and altered state of awareness ratings. Finally, participants were debriefed as to the nature of the study and thanked for their involvement.

One might argue that our methodology raises what may be referred to as a "temporal sequencing" issue. That is, if one wishes to investigate whether altered state of awareness mediates the relationship between the unusual experiences trait and alcohol cue-reactivity (i.e., positive urge to drink), then the altered state of awareness must exist temporally prior to the cue-elicited urge to drink response. This is rendered problematic by the methodological decision to assess urge to drink temporally prior to altered state of awareness. This "problem" is circumvented, however, upon recognizing that the urge to drink is concerned with one's level of craving for alcohol "now" (i.e., directly after the stimulus presentation), while the altered state of awareness assessment is retrospective: it pertains to how the participant felt during exposure to the stimulus. That is, the cue-responses quantify positive urge to drink subsequent to altered state of awareness, thus satisfying the temporal sequence required for the proposed mediational analysis. In other words, we are arguing that the actual assessment of the phenomena in time does not reflect the temporal sequence in which they were experienced.

RESULTS

Changes in positive urge to drink in response to the neutral and alcohol cue were examined using a repeated measures analysis of covariance (ANCOVA). Baseline urge to drink (M = 5.84, SD = 3.06) was entered as a covariate into the analysis. The analysis consisted of one within-subjects variable, cue, with two levels (neutral and alcohol). Changes across cue condition on positive urge to drink were examined.

The ANCOVA indicated a significant main effect of cue F(1, 56) = 9.29, p < .01, partial [[eta].sup.2] = .14. Specifically, positive urge to drink increased significantly from neutral cue (M = 4.40, SD = 3.23) to alcohol cue presentation (M = 5.53, SD = 3.32).

Pearson correlations were computed to examine the degree of relationship between the unusual experiences trait, altered state of awareness, and positive urge to drink across the three conditions (baseline, neutral, alcohol).

For the baseline condition, positive urge to drink was not significantly associated with either unusual experiences (r = .09, p > .05) or altered state of awareness (r = .09, p > .05). However, unusual experiences was significantly and positively associated with altered state of awareness (r = .47, p < .001).

For the neutral cue condition, no significant association was observed between positive urge to drink and unusual experiences (r = .06, p > .05) or altered state of awareness (r = .24, p > .05). However, unusual experiences was significantly and positively associated with altered state of awareness (r = .32, p < .05).

For the alcohol cue condition, positive urge to drink was significantly and positively associated with altered state of awareness (r = .32, p < .05), but not with unusual experiences (r = .07, p > .05). Consistent with the baseline and neutral cue conditions, unusual experiences was significantly and positively associated with altered state of awareness (r = .48, p < .001).

The preceding correlational analysis does not support the use of mediational testing because the unusual experiences trait was not significantly related to positive urge to drink. However, the correlational analysis does support the use of indirect effects testing (e.g., McKinnon, Lockwood, & Williams, 2004), which does not require an association to exist between the independent variable (unusual experiences) and the dependent variable (positive urge to drink). Specifically, the analyses indicate that altered state of awareness was significantly associated with both positive urge to drink and unusual experiences at alcohol cue presentation. However, unusual experiences (IV) was not associated with positive urge to drink (DV). It is noteworthy that the aforementioned significant positive association between altered state of awareness and positive urge to drink was only present for the alcohol cue condition. Thus, an indirect effects test was conducted to examine whether unusual experiences was associated with positive urge to drink in response to alcohol via altered state of awareness.

The first step in the indirect effects test was to examine the association between unusual experiences and altered state of awareness. A linear regression analysis was performed with altered state of awareness as the dependent variable and unusual experiences as the predictor. Unusual experiences was a significant positive predictor of altered state of awareness following alcohol cue-exposure ([beta] = 0.48, p < .001). The second step of the analysis examined the relationship between altered state of awareness and positive urge to drink, while controlling for levels of unusual experiences. Specifically, a hierarchical regression was conducted with positive urge to drink as the dependent variable (see Table 1). Unusual experiences was included at step 1, followed by altered state of awareness at step 2. The association between altered state of awareness and positive urge to drink at step 2 was significant and positive ([beta] = 0.39, p < .05; see Table 1). Overall, the model explained 12% of the variance (8.6% adjusted) in positive urge to drink in response to alcohol, F(2, 52) = 3.55, p < .05.

The final component of this analysis was to test the significance of the indirect pathway (unusual experiences--altered state of awareness--positive urge to drink). Following the Sobel (1987) method, the significance of the indirect effect was tested by dividing the indirect effect estimate by its standard error (see also McKinnon et al., 2004). This analysis indicated that the effect was statistically significant (z = 2.21, p < .05), suggesting that there exists a significant indirect pathway from unusual experiences to positive urge to drink through altered state of awareness.

DISCUSSION

The present study was the first to examine the relationship between the unusual experiences factor of the boundary construct and positive urge to drink during exposure to an alcohol cue and whether altered state of awareness mediated this relationship. The results contain numerous primary points of interest. First, the findings supported the prediction of significant increases in positive urge to drink from neutral to alcohol cue exposure. This significant result is in accordance with an appetitive motivational conceptualization of cue-reactivity and supports a number of studies emphasizing the appetitive nature of alcohol cues (e.g., Franken, 2002; Kambouropoulos & Staiger, 2001; Mucha, Geier, Stuhlinger, & Mundle, 2000).

Second, in line with our predictions, positive urge to drink in response to the alcohol cue was significantly and positively associated with altered state of awareness. Furthermore, for the baseline and neutral cue conditions, positive urge to drink was not significantly associated with altered state of awareness. This result is consistent with our proposal that, for some individuals, alcohol cues may trigger "flashbacks" (e.g., Fischer, 1980) to mood (e.g., positive urge to drink) and altered states linked to previous drinking situations. Given that the baseline and neutral cue conditions did not involve the presentation of an alcohol stimulus which might serve as a catalyst for the aforementioned "flashbacks," it was expected that, for these conditions, the relationship between positive urge to drink and altered state of awareness would be non-significant. It is also noteworthy that for the baseline, neutral cue and alcohol cue conditions, unusual experiences was significantly and positively associated with altered state of awareness. This result suggests that the unusual experiences factor may be a general trait tendency to experience altered states of awareness that is not contingent upon exposure to a particular stimulus condition (e.g., an alcohol cue).

Finally, in contrast to our expectations, the relationship between unusual experiences and positive urge to drink was not mediated by altered state of awareness. However, a significant--yet weak--indirect pathway was found from unusual experiences to positive urge to drink via altered state of awareness. That is to say, an effect was found between unusual experiences and altered state of awareness which in turn influenced positive urge to drink, or, put simply, an indirect effect was found through altered state of awareness. This finding extends previous research (e.g., Kambouropoulos & Staiger, 2004) that examined the relationship between personality and positive urge to drink in the context of exposure to alcohol cues but neglected to assess indirect effects. In the present study, thinner mental boundaries for the unusual experiences factor seemed to promote increased altered state of awareness intensity ratings, which appeared to facilitate increased positive urge to drink during exposure to alcohol cues, possibly due to the "re-experiencing" of affective states related to previous alcohol consumption. This interpretation is consistent with: (1) the fact that the unusual experiences construct may be conceptualized as a general trait tendency to experience altered states of awareness; (2) previous studies that have found a relationship between thin boundaries and altered states of awareness (e.g., Hartmann et al., 2001; Krippner, Wickramasekera, Wickramasekera, & Winstead, 1998); and (3) our contention that experiencing an altered state of awareness during exposure to an alcohol cue should increase positive urge to drink.

A number of limitations warrant consideration. For example, the study was concerned with a relatively small number of participants drawn from a community sample. The degree to which this significant indirect pathway may be replicated with a clinical population (e.g., dependent drinkers) is uncertain. Furthermore, the mean AUDIT score in this sample was 9.06, which is suggestive of hazardous drinking levels (Saunders et al., 1993), and the mean age of 30.29 suggests that participants in the present study were, on average, older than college students who are typically sampled from introductory psychology participant pools. Thus, it is unclear to what extent these findings are applicable to, for example, "lighter" drinking groups (e.g., a sample consisting exclusively of social drinkers). Consequently, there is a need to examine the unusual experiences, altered state of awareness and positive urge to drink constructs in clinical populations and social drinking populations. Indeed, it would be edifying to investigate whether the indirect effect of altered state of awareness is replicated using, for example, a clinical population or whether other constructs (e.g., volitional control, rationality) are more significant indirect effect variables. It will also be prudent to replicate and extend the current findings by examining other personality constructs (e.g., transliminality, absorption) that may contribute to a significant indirect pathway to positive urge to drink via altered state of awareness. Such research will be crucial in identifying which personality types are most prone to alcohol craving when a salient cue is presented.

Overall, the findings reported here suggest that a significant positive relationship exists between altered state of awareness and positive urge to drink during exposure to alcohol cues. Furthermore, a significant--yet weak--indirect pathway exists from the unusual experiences factor of the boundaries construct to alcohol cue-reactivity (i.e., positive urge to drink) through altered state of awareness. Thus, it appears that the unusual experiences construct is interpretable as a general trait tendency to experience altered states of awareness, whereas altered state of awareness is an important state variable which may, in turn, promote positive urge to drink during alcohol cue exposure. The findings of the present study, therefore, contribute to an understanding of phenomenological "triggers" (e.g., altered state of awareness) of differential levels of alcohol craving. Indeed, this type of research may ultimately prove important in terms of understanding patterns of alcohol consumption and, consequently, the psychology of alcohol addiction.

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Adam J. Rock & Nicolas Kambouropoulos

Deakin University

Author info: Correspondence should be sent to: Adam J. Rock, PhD, School of Psychology, Deakin University, Burwood, VIC, 3125, Australia. email: rock@deakin.edu.au
TABLE 1 Hierarchical Regression analysis with Unusual
Experiences & Altered State of Awareness as Predictors
of Urge to Drink in Response to the Alcohol Cue

                       [DELTA]
                      [R.sup.2]     B     Std error   [beta]    t

Step 1                 0.004

Unusual experiences               0.21      0.46       0.06    0.44

Step 2                 0.12 *

Unusual experiences              -0.45      0.50      -0.14    0.90

Altered state of
awareness                         8.32      3.17       0.39    2.62

Note: * p < .05
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Author:Rock, Adam J.; Kambouropoulos, Nicolas
Publication:North American Journal of Psychology
Article Type:Report
Geographic Code:100NA
Date:Dec 1, 2009
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