Does Attachment Anxiety Moderate the Influence of Social Rejection on Alcohol Use Among Young Adults?

Excessive alcohol use is a common but tragically destructive behavioral pattern, accounting for roughly 178,000 deaths per year in the United States in 2020 and 2021 (Centers for Disease Control and Prevention, 2024). This staggering estimate represents a 29% increase in the number of deaths due to drinking that was observed just a few years ago (between 2016 and 2017; Esser et al., 2024). Moreover, nearly a third of these alcohol-related deaths were due to "in-the-moment" binge drinking (Centers for Disease Control and Prevention, 2024). Clearly, more work is needed to identify the contextual and person-level risk factors that heighten one's vulnerability to drinking excessively and to develop effective interventions to ameliorate that risk. The present proposal focuses on one particular type of social risk factor-social rejection-that may be especially powerful in terms of increasing maladaptive drinking behavior, due to its capacity for enhancing pain experiences and diminishing self-regulatory restraint. Furthermore, in the present proposal, we identify a specific trait-attachment anxiety-that should serve as a significant, person-level risk factor, due to its association with threat appraisal, pain sensitivity, fear of rejection, and substance use. Thus, individual differences in attachment anxiety should amplify one's vulnerability to over-drinking after experiencing rejection. To date, we know that social rejection can cause people to drink greater amounts of alcohol compared to those who are socially accepted (Rabinovitz, 2014), particularly when that rejection comes from a close relationship partner (Laws et al., 2017). However, what remains unclear is why the link between social rejection and "in the moment" drinking exists and who among drinkers is most at risk. Our study was designed to fill this gap in the literature.

In the present study, we will recruit 152 carefully screened participants (aged 21 - 25) to participate in a double-blind between-subjects experiment to address the causal nature of the associations between social rejection and alcohol use. We will employ a two (social rejection vs. social acceptance) X two (male vs. female) double-blind between-subjects experimental design to examine the causal link between social rejection and drinking behavior and, further, whether increased pain experience and reduced self-control each mediate the effect of rejection on drinking. We do not expect significant gender differences in the pattern of mediation; however, we will include gender as a covariate factor, given inconsistent gender effects in the literature (see Bacon et al., 2015) and to maintain a balanced design. Finally, attachment anxiety will be examined as a potential, trait-level moderating factor.

Experimental Session:

1. Informed Consent Process:

   The Experimental session will take place in a softly-lit, sound-controlled laboratory with three separate, private data collection rooms equipped with desks, chairs, and computers. Each room will be "treated" with vodka mist so that it smells like alcohol. Participants, aged 21 to 25 (established through checking driver's licenses), will enter the lab in groups of 3 (gender-matched). The session will begin with a research assistant (RA1; gender-matched) making introductions and starting the informed consent process. Participants will be told they will participate in a series of experiments in the UNCW Psychology Department and that "some of this research will require the tasting of alcoholic beverages," so participants must be willing and able to drink alcohol in a laboratory setting. During the informed consent process, participants will confirm that they know that they may stop the experimental procedure at any time, but, because they will consume alcohol, they must remain in the lab until their BAC level is zero. RA1 will then breath-test participants to confirm that their BAC is zero. Participants will then be asked if they complied with the substance use, food, and beverage intake requirements. Failure to comply, or a BAC above zero, will require rescheduling the appointment. Participants will then self-administer a pregnancy test (females only) and a urine drug test to confirm that they are not pregnant or currently using psychoactive drugs that might interfere with or mask alcohol effects. Participants will be told that the results of the tests will be confidential and only used to determine eligibility, after which the tests will be discarded. If an indicator is "positive", potential participants will be told that "the screening result indicates you may be ineligible today; we can discuss next steps privately".

2. Screening:

   For participants that meet the qualifications, they will be asked to sign a consent form and provide their full name, date of birth, sex at birth, and city/municipality of birth for the generation of an anonymous, Global Unique Identifier compliant with NIAAA's requirements. This information will be collected and stored separately from all other participant data and will be destroyed at the end of the study.

   Participants will then be asked to complete a Screening Package containing the following instruments:

   Paper Questionnaires:

   1. Alcohol Use \& Drug Problems:

      • Alcohol Use Disorders Identification Test (AUDIT: Saunders et al., 1993)
      • Timeline Follow Back (TLFB: Sobell \& Sobell, 2000) / Daily Drinking Questionnaire (DDQ: Collins et al., 1985)
      • Drug Abuse Screening Test (DAST: Skinner, 19820
      • 90-day checklist of psychoactive substance use (Noel et al., 2015)

   2. Physical health:

      - CDC Adult Health History (CDC, 2011)

   3. Psychological health:

      - Brief Symptom Inventory (BSI: Derogatis \& Melisaratos, 1983)

      Electronic Questionnaires:

   4. Demographics (gender, marital status, race, ethnicity, education, height, \& weight)

   5. Trait moderators:

      • Attachment = Experiences in Close Relationships -Short Form (ECR-S: Wei et al., 2007)
      • Alcohol Expectancy Questionnaire - Revised (AEQ - Rohsenow, 1983)
      • Borderline Personality Symptoms = Personality Assessment Inventory - Borderline Scale (PAI-BOR: Morey, 1991)
      • Chronic Ostracism = Ostracism Experiences Scale (Carter-Sowell, 2010)
      • Childhood Trauma Questionnaire (CTQ: Bernstein \& Fink, 1998)
3. Procedure:

After completing the initial consent and screening process for the experimental session, participants will be told that they are going to participate in a series of "decision-making" tasks (including the "get-to-know-you" paradigm, the Cued Go-No Go task, and taste-testing).

First, participants will take part in the "get-to-know-you paradigm" (a well-validated manipulation of rejection that reliably elicits strong feelings of social exclusion; Leary et al., 1995). Participants will be told that they will have the opportunity to get to know each other and then make a decision to work on the remaining study tasks individually or in a group. First, they will complete an essay about "what it means to be me?" and rate themselves on two bogus questionnaires with personality descriptors (e.g., "out-going", "shy"). However, they will be asked not to provide any identifying information within their essays. Participants will be informed that their essays and questionnaire responses will be distributed to each of the other two participants and that they will also read the materials from the other participants. After receiving and reading the distributed materials, participants will be asked to choose one individual with whom they would like to form a group for the next portion of the experiment. This will be done via the use of another questionnaire on which they will note the individual they would prefer to partner with for the next task based solely on their reading of the materials from the other participants.

Participants will then be randomly assigned to one of two conditions: social rejection or social acceptance.

For those assigned to the social acceptance condition, they will receive the following feedback:

"Unfortunately, as I was organizing the group materials, I noticed that we have run too many group conditions for the day. So even though everyone chose to work with you for the next portion, we won't be forming a group, and everyone will instead be working on their own."

Those assigned to the social rejection condition will receive the following feedback:

"Unfortunately, no one chose to work with you on the next task, so you will be engaging in the next task alone."

Following the rejection manipulation, participants will complete a manipulation check, a measure of state pain, and a measure of state affect (i.e., the Need Threat Scale, items from McGill Pain Questionnaire, \& PANAS) and then perform a version of the Cued Go-No Go task (Fillmore, 2003; our measure of self-regulation).

Next, alcohol consumption will be assessed through a taste-task procedure with a second, gender-matched "experimenter" (RA2; Noel et al., 2009). RA2, who is blind to the participant's experimental condition, will give the participant four chilled beverages in opaque plastic cups. Two will be labeled "alcoholic" and two will be labeled "no alcohol". We will give participants 150 ml total of the alcoholic beverage (divided equally into 75 ml per glass) and the same amount for the non-alcoholic beverage. The alcoholic beverage will be orange juice mixed with enough vodka to allow the participant to taste the alcohol. Based upon their height and weight, no participant will be given more alcohol than needed to reach a .03% BAC level of intoxication (i.e., our safety ceiling). We will use the Widmark Equation to determine amount of alcohol to distribute across participants [i.e., (Dose in grams/(Body weight in grams x Distribution ratio "r"))x100, where r(male)=.68 and r(female)=.55 and assuming an average constant rate of -0.016 BAC per hour.] The non-alcoholic beverage will be a lemonade mixture with no taste of vodka. Participants will have 20 minutes to rate each beverage according to a list of gustatory adjectives. RA 2 will then say that if the participant finishes his/her ratings during the 20 minutes, he or she is welcome to "finish any or all of the beverages you would like." RA 2 will then leave the room. After 20 minutes, RA 2 will return and collect the taste rating sheets and any remaining beverage. The Research Coordinator will measure the remainder of each participant's beverages (in ml) and subtract that from the original amount to calculate how much alcohol each participant consumed. All participants will then be fully debriefed and compensated for their participation.

After the debriefing, participants will be restricted from leaving until their BAC has reached zero, as measured by a breathalyzer. A snack will be provided and card games, videos, and so on will be available for entertainment.