Elsevier

Biological Psychiatry

Volume 54, Issue 12, 15 December 2003, Pages 1427-1436
Biological Psychiatry

Original article
Reduced heart rate variability in chronic alcohol abuse: relationship with negative mood, chronic thought suppression, and compulsive drinking

https://doi.org/10.1016/S0006-3223(02)01926-1Get rights and content

Abstract

Background

Previous research suggests that heart rate variability (HRV) may be an important factor in various maladaptive psychological conditions.

Methods

This study was conducted to investigate vagal tone assessed as tonic vagally mediated heart rate variability in alcoholic (n = 49) and control subjects (n = 45).

Results

Alcoholic subjects had faster heart rate and lower preimaginary exposure levels of HRV compared with the control group. An increase in HRV was observed in the alcoholic group when subjects were exposed to an imaginary alcohol script. Tonic HRV was found to be related inversely to negative mood and chronic thought suppression and positively to positive mood. Furthermore, the compulsive subscale of the Obsessive Compulsive Drinking Scale (OCDS) was inversely related to HRV during the imaginary alcohol exposure.

Conclusions

It is concluded that the findings are in agreement with the neurovisceral integration model of affective regulation, which claims that dysfunctional psychologic states are rooted in an impaired inhibitory mechanism that is associated with low HRV.

Introduction

The recovering alcoholic must face the difficulty of having his or her ambition to remain abstinent challenged in various situations in which memories about the pleasurable effects of alcohol are activated and the striving for abstinence no longer seems meaningful Anton 1999, Marlatt and Gordon 1985. The odds for successful coping with such temptations are related to numerous factors, such as one’s subjective affective state and the ability to shift one’s focus from the automatic impulse to drink toward a cognitive reconstruction of the situation Palfai et al 1997b, Tiffany 1990. Despite the importance of attentional flexibility in effectively modulating such “high-risk” situations, research on the topic is scarce.

Cognitive neuroscience is a rapidly growing discipline that has as yet only been given a limited degree of the attention it deserves by mainstream addiction researchers. For example, the vast amount of research of self-reported craving has had limited success in explaining relapse to heavy drinking Litt et al 2000, Tiffany and Carter 1998, although autonomic activity has sometimes proved useful in predicting drug use (Niaura et al 1989). Recently, however, an integrated physiologic model for understanding cognitive, emotional, and behavioral regulation has been proposed Porges 1998, Thayer and Lane 2000. Thayer and Lane (2000) suggested that the interplay between positive (excitatory) and negative (inhibitory) feedback circuits in the nervous system (NS) allows for flexible and adaptive behavior across a wide range of situations. The uniqueness of this model lies with its emphasis on the importance of inhibitory processes in effective modulation of affective experience. In short, these researchers propose that the defects in neurovisceral regulation of affective experience seen in various psychiatric conditions (e.g., anxiety disorders) may be better explained by faulty inhibitory function in the NS than by unitary arousal models.

Tonic heart rate variability (HRV) may be a physiologic indicator of such inhibitory processes Friedman and Thayer 1998a, Porges 1995. Heart rate variability refers to the complex beat-to-beat variation in heart rate produced by the interplay of sympathetic and parasympathetic (vagal) neural activity at the sinus node of the heart. Importantly, heart rate (HR) is under tonic inhibitory control via the vagus nerve (Levy 1990). These neural connections to the heart are linked to brain structures involved in goal-directed behavior and adaptability (Thayer and Lane 2000). Compelling evidence now exists to show that high levels of HRV are related to cognitive flexibility (Johnsen et al 2003), modulation of affect and emotion (see Bazhenova 1995, cited in Porges 1995), and increased impulse control Allen et al 2000, Porges et al 1996.

The hypothesis that reduced HRV is related to defective affective and emotional regulation has been supported in recent research in which reduced HRV was present in clinical disorders such as generalized anxiety disorder (Thayer et al 1996), panic disorder (Friedman and Thayer 1998b), posttraumatic stress disorder (Cohen et al 1997), and depression (Thayer et al 1998). The role of such reduced HRV in alcohol abuse or addiction, however, has not been studied thoroughly. This state of knowledge is disappointing given the obvious conceptual relevance of inhibitory functions and impulse control in a disorder that has long been characterized by “loss of control” of voluntary behavior related to the relapse phenomenon Jellinek 1960, Keller 1972, Lyvers 2000.

Indeed, several scientific arguments suggest that impaired inhibitory function may play a role in chronic alcohol abuse. First, alcoholics have repeatedly been shown to have problems shifting attention and directing their attention away from task-irrelevant information Johnsen et al 1994, Setter et al 1994, Stormark et al 2000. Second, frontal areas of the brain are most affected by the acute and chronic effects of alcohol, and these structures are of crucial importance in inhibitory functioning and self-control (Lyvers 2000). Third, acute effects of alcohol ingestion result in reductions in HRV, implying that chronic alcohol ingestion may result in a long-lasting impairment of the vagal modulation of HR Reed et al 1999, Weise et al 1986. Fourth, severely dependent alcoholics show a sustained phasic HR acceleration when processing alcohol information, indicating defective vagal modulation of cardiac function (Stormark et al 1998). Tonic HRV has similarly been found to be a useful measure of physiologic activity in challenging situations (Thayer and Lane 2000). Appropriate modulation of HRV (increases, decreases, or no change) depends on the type of challenge and the characteristics of individuals as they interact with specific contextual manipulation Friedman and Thayer 1998a, Hughes and Stoney 2000, Porges et al 1996, Thayer et al 1996. For example, during attention-demanding tasks, healthy individuals show appropriate reductions in HRV (Porges 1995). In general, high tonic levels of HRV allow for the flexible deployment of organism resources to meet environmental challenges. With respect to attention, it is suggested that high levels of HRV reflect flexible attentional focus, whereas low HRV is related to “locked in attention” (Porges et al 1996). Moreover, increased tonic vagal activity is related to adaptive development and lack of behavioral and emotional problems Hughes and Stoney 2000, Porges et al 1996.

If reduced vagal activity is associated with maladaptive psychiatric conditions, one could speculate that increased activity could be an indication of therapeutic effectiveness and recovery to healthier functioning. Several studies indeed suggest that increases in vagal activity as a result of treatment are a sensitive indicator of recovery from depression (Balogh et al 1993) and anxiety (Middelton and Ashby 1995). Furthermore, it has been demonstrated that increases in vagal activity during challenging tasks discriminates between individuals who have experienced traumatic events and managed to recover from them and those who still suffer from chronic symptoms of posttraumatic stress (Sahr et al 2001). Such increases in vagal activity during challenging tasks are particularly interesting because studies on alcohol abusers have found increases in HRV after exposure to alcohol-related cues Jansma et al 2000, Rajan et al 1998. One could speculate that such enhanced vagal activity could be a sign of compensatory coping aimed at taming automatic drinking-related processes (Larimer et al 1999). Such an interpretation is in agreement with cognitive theories predicting that alcoholics and other drug users do not simply respond passively to exposure to drug-related cues, but, on the contrary, in such situations conscious processes are invoked, inhibiting execution of drug-related cognition Tiffany 1990, Tiffany 1995. If this explanation is correct, alcoholics who have more effective coping resources should show stronger increases in vagal activity during such challenging exposure than alcoholics who express greater difficulty in resisting drinking-related impulses. Unfortunately, however, such individual differences in impulse control were not reported in these studies, and thus such explanations remain highly speculative.

Nevertheless, studies suggest that individual differences are important in adaptive vagal functioning in processing of alcohol-related information (Stormark et al 1998), and treated individuals may sometimes manage to inhibit processing of drug-related information Johnsen et al 1997, Stormark et al 1997. Thus, more research is needed to examine increases in HRV activity as a sign of activation of nonautomatic higher cognitive processes in alcoholics coping with “high-risk” situations.

Although general differences in HRV between alcoholics and nonalcoholics are interesting indicators of defective inhibitory functioning, it is necessary to assess the psychologic factors that are theoretically related to the neurovisceral integration model (Thayer and Lane 2000). An obvious candidate for such assessment is the measurement of affective tone to investigate whether dysphoric states are related to reduced vagal influences on heart rate and positive affective states are related to high vagal tone (Porges 1995). Furthermore, specific measures assessing the degree of impulse control related to drinking are needed to test whether such a reduced level of inhibition when processing alcohol-related information is related to low HRV Anton 1999, Anton et al 1996. Moreover, a measure of rigid thought-control strategies and lack of cognitive control should be an important indicator of defective inhibitory function and “positive feedback loops” reflected as low HRV (Wegner and Zanakos 1994). Linking these measures to the physiologic index of HRV makes a stronger case for attributing reduced vagal tone (HRV) to a defective regulatory mechanism resulting in unpleasant affective states and maladaptive coping with psychologic stressors.

We therefore expected that alcoholics would have lower HRV than the control group and that HRV in alcoholics would increase after exposure to an alcohol-related imaginary script reflecting compensatory coping. Thus, we also expected that HRV in alcoholics would be negatively related to obsessive thoughts of alcohol and compulsive drinking. We expected that HRV would also be inversely related to negative affective states and rigid cognitive coping measures such as chronic thought suppression.

Section snippets

Participants

Forty-nine alcoholics (12 women) in treatment for alcohol abuse and 45 control subjects (14 women) participated in the experiment. The alcoholics were slightly older (M = 45.4) than the control subjects (M = 42), but this difference was not statistically significant. The alcoholic subjects were recruited from three inpatient treatment clinics at the Bergen Clinics Foundation and the Askøy Treatment Center as part of the Blue Cross substance abuse program. They had to be sober on the day of the

Heart rate variability

There was a negative relationship between HRV and HR, supporting the theoretical assumption that HRV mainly reflects level of inhibitory effects of HR (r = −.47, p < .0001). As expected, the alcoholic participants had a generally lower HRV compared with the control group: F(1,89) = 2.67, p = .05 (one-tailed). Planned comparison analyses suggested that the alcoholic participants had significantly lower HRV compared with the control participants during the preimaginary exposure: F(1,89) = 3.08, p

Discussion

The main results of our study may be summed as follows. First, as expected, alcoholic participants had lower HRV compared with the nonalcoholic control group. Second, the imaginary alcohol exposure increased HRV in the alcoholic participants. Third, across the groups, an inverse association was found between HRV and negative mood and a positive association between positive mood and HRV. Fourth, HRV was negatively correlated with compulsive drinking during the imaginary alcohol exposure in the

Acknowledgements

This study was supported by research grant to the first author from the University of Bergen. We thank Dag Hammerborg for technical assistance with this experiment.

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