The sliding doors: how counterfactual thinking modulates alcohol use disorder decision-making process.

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Imagine yourself stands in front of a very important crossroad of your life and you have only few seconds to choose your direction. Considering you know each outcomes probability, which is the main driver of your decision? Probably avoiding or minimizing subsequent negative feelings and, at the same time, reaching the most desirable outcome.

Most of all own experience is built on this kind of decisions and the emotions that arise from them are a fundamental ingredient of behavioural learning processes, able to shape our future directions. Decision-making involves several cognitive processes underlying the selection of the optimal choice among the existing alternatives. Moreover, the evaluation of prospective outcomes entails the anticipation of their rewarding or punishing affective consequences. Emotions are indeed considered to potentiate the appetitive or aversive drives generated by such anticipatory processes, thus modulating choice behaviour and adaptive behavioural learning.

In the case of alcohol use disorder (AUD) this mechanism is particularly struggling. AUD is a chronic relapsing condition characterized by the continuous consumption of alcohol despite its devastating consequences in terms of cognitive functioning, social life and health status.

So why alcoholic patients couldn’t use their experienced emotions, such as regret or disappointment, in order to brake their maladaptive vicious circle linking immediate reward generated by consumption of alcohol, subsequent negative emotions and craving? It is a problem of “learning-from-experience” impairment, a reward-related dysregulation or both?

With our study we tried to shed light on possible alterations in adjusting choices to complex emotions resulting from counterfactual thinking in AUD patients compared with a group of healthy controls. In particular we investigated two different models of choice focused on the implementation of complex emotions, such as regret and disappointment. Our results highlighted that alcoholic patients neglected the affective consequences of their choices when evaluating prospective outcomes. This impairment might contribute to AUD patients’ behavioural alterations in everyday life. The ability to anticipate negative emotions is indeed considered a powerful motivator to change behavioural strategies in order to reach better outcomes associated with healthy behaviours. Since the associated emotions of disappointment and regret are considered to enhance adaptive behavioural learning from past experiences, driving motivated behaviour away from risk, the observed impairment is thus likely to promote patients’ inability to learn from the negative consequences of chronic alcohol consumption, and thus the maintenance of AUD.

Although preliminary and in need of further supporting evidence, our results highlight the defective implementation, and thus avoidance, of disappointment and regret as a component of AUD patients’ alterations in learning from negative experiences.

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