An empirical test of a metacognitive model of craving

Gabriele Caselli1,2, Marcantonio M. Spada1,3

1 London South Bank University, London, UK2 Studi Cognitivi, Cognitive Psychotherapy School, Milano, Italy3North East London NHS Foundation Trust, London, UK

Craving• Powerful subjective experience that motivates individuals

to seek out and achieve a craved target in order to reach its desired effects (Marlatt, 1987)

• The experience of craving is qualitatively similar across a range of targets and only quantitavely different from everyday desires. (e.g. Castellani & Rugle, 1995; Field et al., 2008; May et al., 2004; Moreno et al., 2009)

• This construct has been central to analyses of addictive behaviour and relapse for decades and is a key focus in CBT treatment for addiction (Skinner & Aubin, 2010; O’Malley et al., 2002)

• It can be the result of the combination of automatic (conditioned) and voluntary processes (Kavanagh et al., 2005, Caselli & Spada 2010).

Elaborated-Intrusion Theory of Desire (Kavanagh et al., 2005)

1. Target- or negative affect-related cues exposure and associations

2. Break over the awareness treshold (e.g. intrusive thoughts, memories, sense of deprivation)

3. Cognitive rigid, perseverative elaboration of intrusions (desire thinking)

4. Escalation and persistence of subjective craving and deprivation

Desire Thinking• DT is a voluntary thinking process orienting to prefigure images, information and

memories about positive target-related experience and anticipating how to reach it (Caselli & Spada, 2010; 2011)• I anticipate the sensations I would feel practicing the desired activity• I imagine how I could realize my urges• How could I obtain it?• How could I hide my behaviour?

• In the short-term DT helps to manage negative internal states by shifting attention away from them and focusing on positive target related sensations

• However in medium-term DT • Increases levels of craving and perception of being out of control

• Increases accessibility of target-related information

• Hinders with down-regulation of desire and craving

Desire Thinking and Psychopathology

• Findings on significant structural differences between the construct of desire thinking and craving (Caselli & Spada, 2011)

• DT is associated to level of alcohol use, nicotine dependence, problematic gambling and internet addiction independently from craving, negative affect and gender (Caselli et al., 2011; 2012, 2013, 2014)

• The manipulation of desire thinking has a direct effect on craving accross a range of addictive behaviors (Caselli, Soliani & Spada, 2013).

• What make desire thinking becomes perseverative and poorly regulated?

S-REF Theory (Wells & Matthews, 1994)

• A set of metacognitive beliefs act as control components of information processing modes

• They are responsible for psychological disturbance by developing and maintaining a maladaptive mode of processing

• This maladaptive mode of processing (Cognitive-Attentional Syndrome or CAS) is constituted by perseverative thinking, threat monitoring, avoidance or safety behaviours)

The Application of S-REF to Desire Thinking and Craving

• Desire Thinking as a part of the CAS (addiction)• Individuals with addiction disorders would possess both

positive and negative meta-beliefs about desire thinking (Caselli & Spada, 2010; Spada Caselli & Wells, 2013):– Positive Meta-Beliefs: it helps not to be overhelmed by my

worries, it helps to have a greater control over my decisions)

– Negative Meta-Beliefs: (I cannot stop thinking about my desires, thinking about my desires bring me out of control)

Metacognitions and Addiction

• PMB predict desire thinking over and above craving and negative affect (Caselli & Spada, 2013)

• NMB predict addiction severity over and above craving, negative affect and desire thinking (Caselli & Spada, 2013).

• Need to Control Thoughts prospectively predict relapse in alcohol abusers over and above baseline alcohol use (Spada, Caselli & Wells, 2011)

Triphasic Metacognitive Formulation of

Problem Drinking

(Spada, Caselli & Wells, 2013)

Pre-Engagement Phase

Aim and ParticipantsThe aim was to test the statistical fit of the metacognitive model of craving

in clinical samples across a range of addictive behaviours: alcohol use disorder (AUD), Gambling Disorder (GD), Problematic Internet Use (PIU),

Tobacco users (TU)

Materials

• Desire Thinking Questionnaire (DTQ, Caselli & Spada, 2011)• The Metacognitions about Desire Thinking Questionnaire (MDTQ,

Caselli & Spada, 2013)

• Specific measures of craving and addictive behaviours

Disorder Craving Addictive Behaviours

Alcohol Use Penn Alcohol Craving Scale Quantity Frequency Scale

Gambling Disorder Gambling Craving Scale South Oaks Gambling Screen

Internet Use The Internet Use Craving Scale The Internet Addiction Test

Tobacco Use Brief Questionnaire of Smoking Urges

Fagerstrom Test of Nicotine Dependence

Path Analysis

• A group of multiple regression equations that estimate simultaneously the coefficient of the whole system.

• Fit indeces– Non-significant chi-square (X2)– Root Mean Square Error of Approximation (RMSEA) <.08– Standardised root Mean Square Residual (SRMR) < .09– Comparative Fit Index (CFI), Goodness of Fit Index (GFI),

Non-Normed Fit Index (NNFI) > .95

Discussion

• Preliminary cross-sectional support for the validity of the central structure of the model across four different addictive behaviors: alcohol, gambling, internet and tobacco.

• Absence of the link between PMDT and DT-VP in non-psychoactive substance related addiction (GD and PIU).– Impact of withdrawal symptoms?– Shortened pathway

Implications

• Desire thinking and associated meta-beliefs may be a core process that discriminate slight experience of desire/deprivation from excessive craving

• Key messages:1. Desires don’t matter, response to the does2. We cannot crave less by thinking more about our desires3. It’s not good to think too much about a target we do not

want to achieve.

Implications

• Improving on-line meta-awareness about (1) desire thinking, (2) personal goals and decisions

• Improving metacognitive control (e.g. postponing any further elaboration of target-related information)

• Modify Meta-Beliefs about uncontrollability, utility and need to control target-related intrusions

• Attentional Training, Detached Mindfulness, Meta-level verbal reattribution (Metacognitive Therapy, Wells, 2008).

Limitations and Future Directions

• Limitations– Cross-sectional design– Use of self-report– Samples limited in size

• Future Research– Explore neurobiological

basis and behavioral outcome of desire thinking

– Explore the link between desire thinking and intention to use

– Explore the prospective validity of the model

Thank you for your attention!

Contact details

Dr. Gabriele Caselli

Cognitive Psychotherapy School Studi Cognitivi, Modena, Italy

London South Bank University, London, UK

g.caselli@studicognitivi.net