Short communicationHeart rate variability predicts alcohol craving in alcohol dependent outpatients: Further evidence for HRV as a psychophysiological marker of self-regulation
Introduction
Alcohol use is a major risk factor for disease with 9% of global disease burden attributed to alcohol in developing countries (Rehm et al., 2009). A significant issue with alcohol use disorders is the high levels of relapse; almost 60% of patients relapse a year after commencing treatment (Ilgen et al., 2008). In addition, less than half of alcohol dependent outpatients are able to abstain from drinking during treatment (Charney et al., 2010) suggesting that outpatient treatment provides unique challenges for treatment given easy access to alcohol. An important predictor of response to treatment and dependence severity is alcohol craving and the ability to resist drinking-related impulses (Bottlender and Soyka, 2004). Reflecting its multi-factorial nature, craving for alcohol has been conceptualized as having both obsessive and compulsive features (Anton, 2000). In relation to drinking, obsessive features relate to the effort required to resist thoughts of alcohol whereas the compulsive features of craving refer to the effort needed to resist the impulse to drink.
Alcohol dependence can be conceptualized as disorder of cognitive, emotional and behavioral dysregulation. Thayer and Lane (2000) neurovisceral integration model highlights the role of the central autonomic network (CAN) in cognitive, emotional and behavioral dysregulation. Neural structures in the CAN include the prefrontal cortex, the nucleus of the solitary tract, the nucleus ambiguous, the ventrolateral medulla and the central nucleus of the amygdala. Importantly, the main output of the CAN is mediated through the preganglionic parasympathetic neurons that innervate the heart via the vagus nerve. The influence of the parasympathetic nervous system, which generates the complex rhythms of a healthy heart, can be indexed non-invasively by heart rate variability (HRV) and the high frequency (HF) component (0.15–0.4 Hz) in particular.
HRV is a measure of beat-to-beat temporal changes in heart rate (HR). The application of the Fast Fourier transformation allows for indices of cyclic changes in R–R intervals to be extracted (Berntson et al., 1997). The HF peak of the frequency domain is a relatively pure index of parasympathetic activity and may reflect an index of vagal tone (Akselrod et al., 1981). The low frequency (LF) peak (0.04–0.15 Hz) of the frequency domain and the associated LF/HF ratio has also been used as a representation of sympathetic nervous system. However, converging evidence suggests that LF provides an index of baroreflex function, rather than sympathetic tone (Goldstein et al., 2011). Related to this issue, the validity of the LF/HF ratio as an index of ‘sympathovagal balance’ has also been called into question (Goldstein et al., 2011, Heathers, 2012).
Reduced HF HRV increases risk of all-cause mortality and may reflect an overall marker of disease (Thayer et al., 2010). In the context of alcohol dependence, we recently reported that HRV is reduced in this disorder in comparison to healthy controls (Quintana et al., 2013), a finding that has important implications for the morbidity and mortality of alcohol dependent patients. We have also shown that resting-state HRV is increased following administration of oxytocin (Kemp et al., 2012a), indicating that HRV may provide a marker of an individual's capacity for social engagement and social approach motivation. These findings suggest an explanation for the frequent comorbidity between alcohol dependence and the mood and anxiety disorders (Jané-Llopis and Matytsina, 2006). Cue-elicited HRV predicts relapse following treatment (Garland et al., 2011) indicating that HRV may also reflect self-regulatory effort required to cope with cravings. The prefrontal cortex plays a particularly important role in self-regulation as well as autonomic cardiac control (Segerstrom and Nes, 2007, Thayer et al., 2009). Indeed, research has demonstrated that decreased autonomic cardiac control is associated with impulse control problems (Allen et al., 2000).
Prior research in alcohol dependent participants has explored the relationship between compulsive and obsessive behavior, indexed by different subscales of the obsessive compulsive drinking scale (OCDS; Anton and Moak, 1995). Results suggest that compulsive behavior is inversely related to HRV during imaginary alcohol exposure via audiotape, although there was no such relationship with obsessive behavior or overall OCDS score (Ingjaldsson et al., 2003). However, the participants in this study were inpatients who did not have access to alcohol. While no relationship was found between baseline levels of HRV and compulsion in this population, this may be a consequence of dropping 2 items relating to alcohol consumption from the 8-item compulsion subscale given their in-treatment status. Extending this research, Garland et al. (2011) explored phasic HRV in reaction to alcohol cues in alcohol dependent patients. Unlike tonic (i.e., resting state) HF-HRV, phasic HF-HRV captured during reactivity tasks, such as alcohol cue-exposure, conceivably captures different phenomena than during resting state as phasic HRV may index the regulation of appetitive responses to a specific stimulus (Segerstrom and Nes, 2007).
To date, it remains unclear whether resting state HRV, an index of dysregulation, predicts craving in outpatients. As alcohol is more accessible and relapse, more likely in outpatients we hypothesize that resting-state HRV will be associated with craving in alcohol dependent individuals who are at high risk of relapse. This is important because it may provide useful information relating to underlying physiology that may benefit from specific targeted treatments to help ameliorate physiological vulnerability. Therefore, the aim of our study was to assess the predictive power of resting-state HRV for levels of craving (i.e., drinking related impulses) for alcohol in outpatients whom were continuing to consume alcohol. Considering past research, we hypothesized that HRV would predict overall ODCS scores.
Section snippets
Participants
Twenty-six outpatient volunteers with alcohol dependence (23 males, 3 females) aged 24–66 (mean ± SD, 39.42 ± 11.6) were recruited via community advertisement to the Brain and Mind Research Institute, University of Sydney. Participants were reimbursed for their time and gave written informed consent in accordance with National Health and Medical Research Council guidelines. The University of Sydney, Human Research Ethics Committee provided ethical approval for the research. Exclusion criteria
Results
An independent samples t-test revealed no significant difference in HF HRV on the basis of whether or not participants were medicated (N = 10, M = −3.39, SD = .38) or unmedicated (N = 16, M = −3.63, SD = .38; t(24) = 1.73, p = .1). Initial Pearson correlations revealed a significant relationship between the total OCDS score and HRV (r = −.334; p = .047), while the relationships approached significance for the compulsion (r = −.302; p = .067) and obsession subscales (r = −.288; p = .077). For the overall OCDS score, the
Discussion
This study demonstrates that resting-state HF HRV predicts overall alcohol craving in alcohol dependent participants. Critically, this result was obtained after controlling for a number of factors that may influence alcohol craving such as age and anxiety. Furthermore, HRV predicted craving even after controlling for levels of alcohol consumption. There was no significant interaction between the OCDS subscales, suggesting that HRV may not be a more robust predictor of responses to the
Role of funding source
This research was supported by the National Health and Medical Research Council (571101, 510135) and the Australian Research Council (LP110200562, 0771426). Scholarship support for author Quintana came from Australian Rotary Health/The Hooton Family. The National Health and Medical Research Council, Australian Research Council or Australian Rotary Health/The Hooton Familyhad no further role in study design; in the collection, analysis and interpretation of data; in the writing or the report; or
Contributors
Authors Quintana, Guastella, Kemp, McGregor and Hickie designed the study and wrote the protocol. Authors Quintana and Kemp undertook the statistical analysis. Author Quintana wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
Nothing declared.
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2020, AppetiteCitation Excerpt :Lower HF HRV during the resting state is generally linked to poorer emotion regulation, self-regulation, and cognitive control (Holzman & Bridgett, 2017; Beauchaine, 2015; Volokhov & Demaree, 2010), including dysregulated alcohol and substance use behaviors. In terms of alcohol use, lower HF HRV was associated with increased alcohol and substance craving (Quintana et al., 2013; Eddie et al., 2014), whereas relatively greater resting HF HRV was associated with a greater decrease in substance craving (Eddie et al., 2014). In terms of eating behavior, lower resting HF HRV is associated with dysregulated eating behaviors and obesity in adults (Godfrey et al. 2019; Meule et al., 2012,).