1. Addiction in daily life: mobile assessment and treatment
Chair: Ingmar Franken, Netherlands
Room   Introduction to mobile assessments and treatment, Ingmar Franken, Netherlands Cognitive measures in EMA research. Andy Jones, United Kingdom The use of EMA in a clinical trial. Ilse Verveer, Netherlands Smartphone apps for the treatment of addictive disorders. Yasser Khazaal, Switzerland Discussant: Matt Field, United Kingdom

2. Measuring addiction in real life: EMA
Self-report and Cognition
Ingmar Franken, Ph.D.
Erasmus University Rotterdam,
the Netherlands
Thanks to:
Joel Swendsen, Ph.D.
National Center for Scientific Research, Bordeaux, France

3. Limitations current “lab” studies
There is a tendency to investigate in increasing detail the specific cognitive mechanisms, specific brain areas and the specific conditions under which cognitive (attention, cognitive control, inhibition etc) and physiological events take place.
This “micro” approach yielded a lot of knowledge on basic mechanisms of addiction, including neurobiology and cognitive mechanisms.
However, what do strictly controlled conditions tell us about real life situations and real life problems?
For example, there is no correlation between Self-report –Behavioural – EEG measures: trait vs. state?
No correlation between Lab-Real life cue reactivity (Shiffman et al., 2015).
Patients/participants can perform quite well for 10 minutes in artificial lab situations?
Can’t capture complexity of systems because of limited measurements

4. Correlations between “lab” measures of risk behavior

5. Laboratory Setting vs. Field Setting
Controlled environment
Replicate testing conditions
But…
Not “real-world” context
Limited no. of assessments
- Experience and behavior assessed in the “real world” (hence “ecological”)
- Experience assessed “right now”, or in the very recent past (hence “momentary”)
- Multiple repeated assessments for each participant (“assessment”)
Ecological Momentary Assessment Setting:
“real world” → Ecological
“right now” → Momentary (prospective)
multiple repeated measures → Assessment 5

6. Self-report
EMA studies using self-report provide very useful information and are used increasingly world-wide (e.g. the Bordeaux group; Joel Swendsen; Saul Shiffman; US)
However, up to date only a handful of studies have been published addressing cognitive functions in real life conditions (Moore, Swenden et al., 2017).
Even less studies address the assessment of physiological measures in real life.
Technical advances in mobile assessment make don’t hamper the implementation of more ecological valid assessments anymore.

7. Why not test in real life on mobile devices?
Stop signal task
Drug Stroop task

8. Mobile EEG
Eye-movements / attention

9. Typical EMA assessment
Can be user/event initiated:
e.g. assessment when there is a temptation to use
Or when you use a substance
Random assessment: e.g. 3-4 time a day at random moments.

10. February 22, 2017 4:36 pm Where were you? What were you doing?
What were your thoughts, feelings, degree of
stress at that moment… ?
J.Swendsen, 2017

11. Two EMA examples -Self report in social drinkers:
Impaired Control: Associations with Craving and Alcohol Use in an Ecological Momentary Assessment Study (Remmerswaal & Franken, in preparation)
-Behavioral measures in drug use patients:
Marhe, R., Waters, A. J., van de Wetering, B. J. M., & Franken, I. H. A. (2013). Implicit and explicit drug-related cognitions during detoxification treatment are associated with drug relapse: An ecological momentary assessment study. Journal of Consulting and Clinical Psychology, 81(1), 1-12.

12. Impaired control
It has been suggested that impulsivity and poor inhibitory control act as both a consequence and as contributor for drug use (Verdejo-Garcia et al., 2008; de Wit, 2009 Cross-sectional and longitudinal studies have supported impaired control as a crucial factor in understanding problem drinking. However, Impaired control is thought to be a dynamic construct that fluctuates over time influenced by factors such as exposure to alcohol related cues eliciting craving (Jones & Field, 2015).

13. Several theoretical models state that addictive disorders are characterized by both an increase in the salience of drug-related cues and by a loss or impairment to control drug-seeking behavior (Goldstein & Volkow, 2002; Wiers et al., 2007).
Craving
Control

14. Method
N = 172
Assessment: control (VAS), craving (VAS), alcohol use (amount of beverages)
Procedure:
three random prompts a day for seven days (random assessment; RA).
Participants were instructed to initiate an EMA assessment when they started drinking (alcohol assessment; AA).

15. Preliminary results
-Higher levels of craving were associated with lower levels of control. -Craving and impaired control were both predictive for alcohol use. That is, individuals reported higher levels of craving and lower levels of perceived control on random assessments within two hours of an alcohol assessment. -It seems that craving, impaired control and amount of alcohol use are closely associated during a drinking session.

16. Cognitive processes Attentional bias
YES!
NO!
Attentional bias
The automatic tendency of drug abuse patients to focus their attention predominantly on drugs or drug-related stimuli
Implicit associations
Automatic thoughts on drugs (can be positive or negative)

17. Goals TEMPTATIONS & RELAPSE REAL TIME Craving Explicit Attitude Affect
Attentional
Bias
Implicit
Associations
1e doel: zijn deze variabelen geassocieerd met terugval
2e doel: fluctuaties over tijd
TEMPTATIONS
&
RELAPSE 17

18. PDA versions of the tasks
Drug Stroop Task
Implicit Association Test
Estimated internal reliability = .70
Estimated internal reliability = .75 18

19. Method
68 heroin/cocaine dependent patients starting detoxification treatment (addiction treatment center Bouman GGZ, Rotterdam)
2-3 days after intake patients were trained how to use the PDA
4 Random Assessments a day
Temptation Assessments = an acute rise in urge to use heroin or cocaine or when they felt they were on the brink of acquiring and using heroin or cocaine
Assessment: Self-report of craving, explicit attitude to drugs (and affect); Stroop task or IAT 19

20. Outcome measures N=64 contributed data to the study
Outcome measure: Relapse during PDA study
Relapsers: n=10 vs Non-Relapsers: n=54

21. Procedure
Day
BoumanGGZ 21

22. Procedure

23. Assessments N=64 contributed data to the study (1098 RAs, 339 TAs)
Relapsers (n=10): 147 assessments prior to relapse
Non-Relapsers (n=54): 1290 assessments

24. Results – relapse:
explicit cognitions

25. Results – relapse: Implicit cognitions Days before Relapse
Marhe, R., Waters, A. J., van de Wetering, B. J. M., & Franken, I. H. A. (2013). Journal of Consulting and Clinical Psychology, 81(1), 1-12.