Chapter 1 Abstract

Despite growing interest over the past two decades in investigating boredom and

substance use, there has been no comprehensive review to elucidate the relationship between

boredom and substances. Boredom has been principally studied as either a state or trait. This

review aims to provide an exhaustive picture of the relationship between state and trait boredom

and substance use. Methods: A systematic search was conducted on MEDLINE, Embase,

CINHAL, PsycINFO, and PsycARTICLES, combining subject headings, keywords, and

wildcards related to boredom and substances, and a 2000-2020 year limiter. All English peer-

reviewed journal articles were included. From an initial 1,084 references retrieved, 46 were

included in this review. Results: State boredom was associated with greater alcohol, cigarette,

cannabis use, and use of illicit drugs in general, and fewer days to relapse after treatment. Trait

boredom was mostly positively associated with alcohol and illicit drug use, and alcohol use

disorder (AUD) in adults and binge drinking among young adults and adolescents, and

negatively predictive of treatment outcomes, with some differential patterns by participant sex.

Higher trait boredom was reported in AUD patients relative to patients with cannabis/opioid use

disorders. Conclusion: Studies overall implicated the involvement of boredom in developing and

worsening the use of various types of substances. We highlight boredom as a key risk factor

across age groups. Preventative programs and targeted care may help reduce negative outcomes

in identified at-risk populations. Given all reported findings are correlational, boredom

manipulation studies would be needed to establish causality.

 Chapter 2 Abstract

Impulsive decision-making increases the risk for cocaine use and relapse. Little is known

about the influence of transient states on decision-making in cocaine users. Experience-sampling

data suggest that cocaine use is often preceded by boredom. Transient boredom-related increases

in impulsive choice could mechanistically link boredom and cocaine use. This experimental

study investigated the effects of induced boredom on impulsive decision-making (i.e. temporal

discounting) in cocaine users relative to non-users of cocaine. Methods: Forty-one cocaine users

(M = 47.5, SD = 10.9 years old; 7 females) and 38 demographically-matched controls (M = 48.5,

SD = 8.7 years old, 5 females) completed a single experimental session comprising two

counterbalanced conditions (boredom and non-boredom), each followed by the Experiential

Discounting Task (EDT), a temporal discounting measure that is sensitive to state manipulations.

The boredom manipulation was a 15-minute Peg-Turning Task (PTT), while the non-boredom

condition involved viewing a self-selected television show clip (VT). Subjective mood states,

including boredom, were measured at baseline, during the manipulations, and post-EDT.

Results: As expected, the PTT increased boredom (p < .001) in the sample overall whereas the

VT decreased boredom, with higher boredom ratings during the PTT than the VT (p’s < .001).

Boredom increased impulsive decision-making overall relative to the video condition (p = .028),

with no preferential effects in cocaine users. Conclusion: Experimentally induced boredom

increased state impulsivity irrespective of cocaine use status. This study is the first to show that

boredom induction transiently increases choice impulsivity, demonstrating a viable laboratory

method for examining the influence of transient boredom on impulsivity and other drug-related

risk behaviors. Where one prior study offers data to suggest that group effects are more likely to

be seen in heavier cocaine users, our results indicate no bias in discounting in relatively lighter
cocaine users compared to controls matched carefully for demographics and drug use. Further

investigations are needed to support the findings of this study.

 A SYSTEMATIC REVIEW AND EMPIRICAL STUDY

OF THE ROLE OF BOREDOM IN SUBSTANCE USE PROBLEMS

by

Thomas Wen-Chi Chao

April 26th, 2021

Submitted to the New School for Social Research of The New School in partial fulfillment of the
requirement for the degree of Doctor of Philosophy.

Dissertation Committee:

Dr. McWelling Todman

Dr. Gillinder Bedi
Dr. Howard Steele
Dr. Jeffrey Goldfarb
 © 2021
Thomas Wen-Chi Chao
ALL RIGHTS RESERVE
 TABLE OF CONTENTS

LIST OF TABLES ......................................................................................................................... iv

LIST OF FIGURES ........................................................................................................................ v

LIST OF ABBREVIATIONS ........................................................................................................ vi

CHAPTER 1: A SYSTEMATIC REVIEW OF BOREDOM AND SUBSTANCE USE .............. 1

Introduction ................................................................................................................................. 1
Aims ............................................................................................................................................ 3
Methods ....................................................................................................................................... 4
Search strategy ......................................................................................................................... 4
Study selection......................................................................................................................... 5
Data extraction and organization ............................................................................................. 6
Results ......................................................................................................................................... 7
Description of studies .............................................................................................................. 7
State boredom and substance use ............................................................................................ 8
Trait boredom and substance use........................................................................................... 10
Discussion ................................................................................................................................. 22
State Boredom ....................................................................................................................... 22
Trait Boredom........................................................................................................................ 23
Sex Differences and Sociocultural Factors ............................................................................ 23
Measures of Boredom ............................................................................................................ 24
Limitations ............................................................................................................................. 25
Conclusions ............................................................................................................................... 25

i
CHAPTER 2: BOREDOM-INDUCED IMPULSIVE DECISION MAKING IN COCAINE

USERS .......................................................................................................................................... 27

Introduction ............................................................................................................................... 27
Methods ..................................................................................................................................... 32
Participants ............................................................................................................................ 32
Experimental Protocol ........................................................................................................... 33
Computerized Tasks .............................................................................................................. 35
Self-Reports ........................................................................................................................... 38
Data Analysis ............................................................................................................................ 41
Results ....................................................................................................................................... 44
Participants ............................................................................................................................ 44
Boredom in the Sample Overall ............................................................................................ 46
Subjective Moods in the Sample Overall .............................................................................. 48
Task Ratings in the Sample Overall ...................................................................................... 49
Subjective Affects and Task Ratings by Condition x Group................................................. 50
Peg Clicking Outcomes by Time x Group............................................................................. 51
Impulsive Decision-Making by Condition x Group .............................................................. 53
Experience of Boredom and Pattern of Cocaine Use ............................................................ 53
Discussion ................................................................................................................................. 55
Limitations ............................................................................................................................. 59
Conclusion ............................................................................................................................. 60
Appendix A: Systematic Review Full Search Strategy .............................................................. 62

Appendix B: Sample Screens of Computerized Tasks ............................................................... 63

Appendix C: List of Television Shows for Video Task .............................................................. 66

Appendix D: Boredom Proneness Scale ..................................................................................... 67

Appendix E: Boredom Susceptibility Scale................................................................................ 68

Appendix F: State Boredom Measure ......................................................................................... 69

Appendix G: 30-Day Timeline Followback ............................................................................... 71

Appendix H: Structured Interview for Current Drug Use .......................................................... 72

ii
Appendix I: Pattern of Use Questionnaire .................................................................................. 73

Appendix J: Calculating Area Under the Curve (AUC) ............................................................. 74

Appendix K: Consent Form ........................................................................................................ 75

Appendix L: Protocol Tracking Sheet ........................................................................................ 78

Appendix M: Standard Operating Procedures (SOP) ................................................................. 79

Appendix N: Timeline Followback Administration Script ......................................................... 82

References ..................................................................................................................................... 84

iii
 LIST OF TABLES

Page

Table 1.1 Known Measures that Assess Boredom ......................................................................... 5

Table 1.2 General Study Characteristics ....................................................................................... 7

Table 1.3 Summary of Studies Reporting Associations between State Boredom and Substance Use

....................................................................................................................................................... 16

Table 1.4 Summary of Studies Reporting Associations between Trait Boredom and Substance Use

....................................................................................................................................................... 18

Table 2.1 Demographic Characteristics ...................................................................................... 45

Table 2.2 Drugs and Alcohol Use ................................................................................................ 45

Table 2.3 State Boredom Measure between Cocaine Users and Controls .................................. 54

Table 2.4 Experiences of Boredom and Pattern of Cocaine Use (N = 39) ................................. 54

iv
 LIST OF FIGURES

Page

Figure 1.1 PRISMA Flowchart of Study Selection ...................................................................... 4

Figure 2.1 Experimental Timeline of Study Procedures ............................................................. 34

Figure 2.2 Peg-Turning Task Outcomes Derived from Mouse Click ......................................... 42

Figure 2.3 Subjective Affect as a Function of Time and Condition ........................................... 47

Figure 2.4 Task Ratings as a Function of Condition by Timepoint ............................................ 48

Figure 2.5 Affect and Task Ratings at Time 2 (Induction Tasks) as a Function of Condition and

Group ............................................................................................................................................ 50

Figure 2.6 Peg-Turning Task Outcomes as a Function of Time and Group ............................... 51

Figure 2.7 EDT Area Under Curve (AUC) as a Function of Condition and Group ................... 53

Figure B2.1 Sample Frame of the Peg-Turning Task ................................................................. 63

Figure B2.2 Sample Frame of the Video Task ........................................................................... 63

Figure B2.3 Sample Frame of the Experiential Discounting Task ............................................. 64

Figure B2.4 Sample Frame of Visual Analog Scale for Subjective Affect. ............................... 64

Figure B2.5 Sample Frame of Visual Analog Scale for Task Ratings ....................................... 65

Figure J2.1 Trapezoid Formula Visualized ................................................................................. 74

v
 LIST OF ABBREVIATIONS

ADHD Attention-deficit/hyperactivity disorder

ANOVA Analysis of Variance

ASSIST Alcohol, Smoking, and Substance Involvement Screening Test

AUDIT Alcohol Use Identification Test

BBC British Broadcasting Corporation

BDI Beck Depression Inventory

BPS Boredom Proneness Scale

BSMSS Barratt Simplified Measure Social Status

BSS Boredom Susceptibility Scale

CIDI Composite International Diagnostic Interview

CO Carbon monoxide

COC Cocaine user

CTRL Healthy control

DAST Drug Abuse Screening Test

DSM Diagnostic and Statistical Manual of Mental Disorders

EDT Experiential Discounting Task

EMA Ecological momentary assessment

Hx History

ICD International Classification of Diseases

ICI Interval-click interval

IP Indifference point

LBS Leisure Boredom Scale

vi
MA Master of Arts

MAST Michigan Alcohol Screening Test

Md Median

MDMA 3,4-Methylenedioxymethamphetamine

Meth Methamphetamine

MINI The Mini-International Neuropsychiatric Interview

Mod Mode

MSBS Multidimensional State Boredom Scale

NYSPI New York State Psychiatric Institute

N/R Nonrelevant or not reported

NS Not statistically significant

PhD Doctor of Philosophy

PsyD Doctor of Psychology

PTT Peg-Turning Task

PUQ Pattern of Use Questionnaire

Q Quartile

SBM State Boredom Measure

SCID Structured Clinical Interview for the DSM

STAI State-Trait Anxiety Inventory

SUD Substance use disorder

TLFB Timeline Followback

Tx Treatment

UTox Urine toxicology

vii
USA United States of America

VAS Visual analog scale

VT Video task

WAIS Weschler’s Adult Intelligence Scale

WRAT5 Wide Range Achievement Test, Fifth Edition

ZSS Zuckerman’s Sensation Seeking Scale

viii
 CHAPTER 1:

A SYSTEMATIC REVIEW OF BOREDOM AND SUBSTANCE USE

Introduction

Boredom is ubiquitous. The English word, as it is understood today, made its first

appearance in Charles Dicken’s 1852 novel “Bleak House.” In that context, it referred to the

experience of monotonous and repetitive factory labor (i.e., boring a hole by hand) in post-

industrial England. Though the word is recent, experiences akin to boredom can be traced back

to the early Latin “tædium,” Greek “akēdia”, and Anglo Saxon “īdel” (Brodsky, 1995).

Scientific efforts to define and operationalize boredom have spanned many decades, with

recent work continuing to resolve the incongruencies of early findings (e.g., Goetz et al., 2014;

Mills & Christoff, 2018; Raffaelli et al., 2018). Convergent evidence thus far indicates that

boredom is a multidimensional construct, with components associated with (1) excessive high or

low internal/external stimulation (e.g., when tasks are too hard or too easy; Westgate & Wilson,

2018), (2) greater distractibility (Critcher & Gilovich, 2010; Cunningham et al., 2000; Eastwood

et al., 2012; Steinberger et al., 2016), (3) slowed time perception, and (4) decreased self-agency

(Raffaelli et al., 2018). By consensus, boredom is defined as an aversive affective state that

functions as a signal to alter action or activity in response to a depreciating yield of reward

(Stringaris, 2016; Todman et al., 2008). It arises from difficulty sustaining task-oriented attention

under some condition of psychological constraint (Danckert & Merrifield, 2018; Eastwood et al.,

2012; Todman, 2003; Todman et al., 2008), where constraint can be described as having

repeatedly thwarted desires (or, ‘wanting’), such as having to do what you do not want to do, or

being barred from doing what you want to do (Eastwood et al., 2012; e.g., Troutwine & O'Neal,

1981).

1
 Studies have linked boredom to a range of psychiatric disorders (Elhai et al., 2018;

Mercer & Eastwood, 2010; Todman, 2007; Vodanovich & Watt, 2016), including substance use

disorders (Cao & An, 2019; Patterson & Pegg, 1999). Boredom can lead to experimentation with

drugs, heighten risks for problematic substance use (Csikszentmihalyi & Larson, 1978; Johnston

& O'Malley, 1986), and negatively impact treatment outcomes for substance use disorders

(SUD). For instance, studies have identified boredom as being amongst the most prevalent

aversive experiences that can accompany withdrawal symptoms and self-identified reasons for

relapse endorsed by psychiatric patients (Boggs et al., 2013; Levy, 2008), and the experience of

boredom in treatment settings has been shown to lead to higher rates of dropout (Chaudhry et al.,

2012).

In substance use research, boredom has often been studied either as a trait or a state. The

most widely used measures of trait boredom have been the Boredom Susceptibility Scale (BSS),

a subscale from Zuckerman’s Sensation Seeking Scale (Zuckerman et al., 1964), and Boredom

Proneness Scale (BPS; Farmer & Sundberg, 1986). Both assess vulnerabilities to experience

boredom but each is thought to address a nonoverlapping component of trait boredom (Mercer-

Lynn et al., 2013b). For instance, the BPS has been found to be more consistent with the

avoidance of experience, anxiety, mood disturbances, and attentional impulsiveness, and the BSS

is related to greater reward sensitivity, thrill-seeking, and motor impulsiveness (Mercer-Lynn et

al., 2013a). Another common measure, the Leisure Boredom Scale (LBS; Iso-Ahola &

Weissinger, 1990), captures boredom susceptibility specific to leisure activity (Weybright et al.,

2015). For state boredom, methods include ecological momentary assessment (EMA) techniques

and self-report instruments, including the Multidimensional State Boredom Measure (MSBS;

Fahlman et al., 2013) assessing boredom in the moment (i.e., “right now”), and the State

2
Boredom Measure (SBM; Todman, 2013) retrospectively examining state boredom experienced

in the past two weeks.

Investigations of boredom and substance use suggest that both vary individually as a

function of sex and age. Comprehensive meta-analyses show that men are more susceptible to

boredom than women (Cross et al., 2013; Vodanovich & Kass, 1990; Vodanovich et al., 2011),

and large experience sampling studies indicate that 63% of adults experience at least one

instance of boredom over a 10-day assessment period, with men having more frequent episodes

of state boredom than women (Chin et al., 2017). Both trait and state boredom decrease with age,

and this appear to be similar between males and females (Chin et al., 2017; Vodanovich & Kass,

1990; Zuckerman et al., 1978). In large studies, boredom was more commonly reported among

younger than older age groups (Britton & Shipley, 2010), with 17% of adolescents between ages

12-17 reporting being “often bored” and also showing a higher risk for substance use (Bearman,

2003). Higher boredom in adolescents has been linked to younger ages of first drug by increasing

the risk for delinquency (Ohannessian & Hesselbrock, 2008). Younger adults (ages 18-30) have

been found to use cannabis more for boredom than older adults (ages >30; Sottile et al., 2017).

Overall, these findings suggest that differences in demographics may impact the relationship

between boredom and substance.

Aims

It is not well understood the extent to which the state and trait boredom influence the use

of substances. For an exhaustive picture of their relationship with substance use and the

examination of potential differences across demographic groups, a systematic review of

published peer-reviewed articles was conducted to: (1) establish the significance of each type of

boredom in contributing to substance use, (2) identify the relevance of boredom in the context of

3
treatment for substance use, (3) elucidate patterns of differences based on demographics, and (4)

identify areas that warrant further investigation. Findings from this systematic review can

provide the background for further empirical research to address research gaps.

Methods

A systematic search was conducted in accordance with the Preferred Reporting Items for

Systematic Reviews and Meta-analyses (PRISMA) reporting guideline (Moher et al., 2009).

Institutional Review Board approval was not required for this systematic review because there

was no direct involvement of human subjects.

Search strategy

Five electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and

PsycARTICLES) were individually searched on January 4, 2021. Searches were restricted to

articles published from January 1, 2000 to December 31, 2020 to avoid prior work based on

earlier less nuanced definition of boredom (see Eastwood et al., 2012). Search terms comprised a

combination of subject headings, keywords, and wildcards related to boredom and substances

(see Appendix A for full list). A total of 1,078 citations were retrieved through database

searches, and an additional 6 citations were manually collected through review of reference lists

in included full-text articles (Figure 1.1).

Figure 1.1

PRISMA Flowchart of Study Selection

4
Study selection

All citations were compiled onto EndNote version x9.3.3 (Clarivate™, Philadelphia, PA)

for the removal of duplicate citations. The remaining citations (n = 602) were then exported,

with title, full abstract, author, and publication year in tab-delimited format, onto Excel® for

Office 365 (Microsoft, Redmond, WA) for initial screening. All titles and abstracts were

screened by the author (T.C.). The criteria at this stage were intentionally broad to allow the

inclusion of all relevant articles reporting on boredom (or that employed validated measures

known to assess state and trait boredom; Table 1.1) and substance use. Citations were excluded if

the abstract or title explicitly indicated that they were book chapters, theses or dissertations, non-

research articles (meeting abstracts, case reports, commentaries), or articles reporting on

unrelated topics, non-human studies, or qualitative or descriptive data only.

Table 1.1

Known Measures that Assess Boredom

5
 Acrony
Boredom Measure m Source
State Multidimensional State Boredom Scale MSBS Fahlman et al. (2013)
State State Boredom Measure SBM Todman (2013)
Trait Boredom Proneness Scale BPS Farmer and Sundberg (1986)
Trait Boredom Susceptibility Scalea BSS Zuckerman et al. (1964)
Trait Leisure Boredom Scale LBS Iso-Ahola and Weissinger (1990)
Trait Zuckerman’s Sensation Seeking Scale ZSS Zuckerman et al. (1964)
Note. Listed measures are validated self-reports with full-scale, independent domain, or item-level questions assessing boredom used to consider inclusion of citations at

the title and abstract screening stage.

a
Boredom Susceptibility Scale is a subscale of the Zuckerman’s Sensation Seeking Scale

Full-text-articles were obtained for the resulting 174 citations and reviewed by the author

(T.C.) for inclusion/exclusion. Articles were included if they: (1) were published in a peer-

reviewed journal and in English or another language with adequate English translation, (2)

reported quantitative data on trait or state boredom as a distinct variable, (4) and assessed the

relationship between boredom and substance use or substance-using status using inferential

statistics. They were excluded if boredom-related drug use or drug-using status outcomes were:

(1) solely descriptive (e.g., percentage of sample endorsed boredom) or (2) relevant only to

samples with low prevalence mental or physical health comorbidity (e.g., psychosis, bipolar

disorder; McKetin et al., 2006; Smith et al., 2009; Sonne & Brady, 1999), and would therefore

limit the generalizability of the data. In total, 85 articles were identified for further analysis.

Data extraction and organization

Information was extracted on study design, sample characteristics, measures, and

outcomes from the final 46 articles. Data from studies were identified as relevant to distinct

categories: primary substance of use, country of study, target age groups (adolescents, adults),

sample size and mean age, relevant sub-groups/samples, treatment status (non-treatment-

seeking/in treatment), age of substance initiation, duration of substance use and abstinence, and

boredom and substance use measures. Results were summarized according to the aims of this

6
review. The quality of the extracted information was examined by the author (T.C.) for

generalizability of data based on study methods, including reported sample characteristics.

Data on state and trait boredom were tabulated separately. Data were then organized

according to primary drug of focus and appeared in this order: alcohol, tobacco,

methamphetamine, heroin/opioid, and poly-drug. The poly-drug category comprised studies

involving multiple drug users and those without an identifiable drug focus (e.g., articles referring

to “drug use” or “drug users” more broadly).

Results

Description of studies

Table 1.2 depicts the study characteristics of the final 46 articles included in this review.

Results included a total of 13 studies focusing on state boredom and 33 for trait boredom. The

majority of studies were conducted in the US (41%), followed by Canada (9%) and Italy (9%).

Poly-drug (43%), alcohol (30%), and tobacco (15%) were the three most common drug

categories identified. Seventy percent of studies were conducted using adult (ages ≥18) samples

(younger adults, including college students, comprised 24% of total studies), and 30% focused

on secondary school students or adolescents.

Table 1.2

General Study Characteristics

Total Boredom Type
State Trait
N (%)
n (%) n (%)
N 46 (100.0) 13 (15.3) 33 (38.4)
Primary substance
Alcohol 14 (30.4) 3 (23.1) 11 (33.3)
Tobacco 7 (15.2) 4 (30.8) 3 (9.1)
Methamphetamine 1 (2.2) 0 1 (3.0)
Heroin or opioid 4 (8.7) 0 4 (12.1)
Poly-druga 20 (43.5) 6 (46.2) 14 (41.2)
Age groups
Secondary school students or adolescents 14 (30.4) 2 (15.4) 12 (36.4)
Adults (ages ≥ 18) 32 (69.6) 11 (84.6) 21 (63.6)
College students and young adults (ages ≤ 30) 11 (23.9) 5 (38.5) 6 (18.2)

7
 Country of study
North America 23 (50.0) 10 (76.9) 13 (39.4)
USA 19 9 10
Canada 4 1 3
Europe 11 (23.9) 1 (7.7) 10 (30.3)
Spain 1 0 1
France 3 0 3
Italy 3 0 3
Netherlands 3 1 2
Germany 1 0 1
Asia 7 (15.2) 1 (7.7) 6 (18.2)
India 3 0 3
Nepal 0 0 0
China 1 0 1
South Korea 2 1 1
Thailand 1 0 1
Oceania and Africa 5 (10.9) 1 (7.7) 4 (12.1)
Australia 1 0 1
South Africa 4 1 3
Note: data presented as number and percentage of total articles by category (primary substance, age group, and country of study) and

type of boredom.
a
includes substance users who use multiple substances and substance use assessed as a general category with undifferentiated drug type

State boredom and substance use

State boredom studies included those reporting results for alcohol (23%), tobacco (31%),

and poly-drug (46%), with a greater proportion of adult (85%) than adolescent (15%) samples

(Table 1.3).

Alcohol. Two studies prospectively tracked state boredom and alcohol use via EMAs

over periods ranging from one to two weeks, and one study retrospectively assessed state

boredom and alcohol use in the past two weeks. These studies all reported a positive relationship

between state boredom and alcohol use.

In one of the EMA studies, South Korean young adults (n = 119) showed higher intensity

of self-reported state boredom predicting greater alcohol craving after but not during elevated

periods of boredom (Kim & Kwon, 2020). Another EMA study of treatment-seeking US adults

with alcohol use disorder (n = 139) reported that an overall higher intensity of daily boredom

predicted a greater number of standard drinks consumed per day before starting treatment

(Kuerbis et al., 2018). In a sample of US college undergraduates (n = 84), self-reported

8
frequency of boredom was found to be positively correlated with the frequency of alcohol use,

controlling for trait boredom (Todman, 2013). This same study found frequency of alcohol use to

be negatively correlated with ratings for the unpleasantness of boredom and the degree of

difficulty avoiding boredom attributed to psychosocial problems.

Tobacco. Three US adult studies employed EMAs over periods ranging 1 to 2 weeks and

one study of adults conducted in the Netherlands retrospectively assessed boredom and tobacco

use in young adults. Overall, findings converged on a positive relationship between state

boredom and tobacco use.

Among tobacco-using college students in the US (n = 31), higher state boredom was

associated with a greater likelihood of tobacco use (cigarettes, cigars/cigarillos, e-cigarettes, or

“hookah”), and boredom was found to predict a greater likelihood of cigarette use in females

versus e-cigarette use in males (Berg et al., 2019). In adult daily smokers with attention-

deficit/hyperactivity disorder (ADHD; n = 17), episodes of increased state boredom predicted a

greater likelihood of cigarette use, while there were no changes to boredom after smoking

relative to before (Mitchell et al., 2014). In treatment-seeking adult daily cigarette smokers (n =

355), lower levels of state boredom in the 4 days prior to a predetermined “quit day” predicted a

greater likelihood of abstinence 7 days after the quit day, but not abstinence on the quit day itself

(Spears et al., 2019). In the Netherlands, a study of young adults of Turkish descent (n = 387)

reported that daily smokers had higher endorsement rates for “I often feel bored” compared to

never smokers (van Oort et al., 2006).

Poly-Drug. Considerable evidence supports positive relationships between state boredom

and drug use more broadly. One study of adult injecting drug users in the US (n = 845) reported

that those who experienced a higher rather than lower frequency of state boredom had greater

9
injected heroin and smoked cocaine use in the past 6 months (German & Latkin, 2012).

Conversely, the intensity of state boredom and substance use were not related in a small

Canadian sample of adults with a lifetime history of ≥1-month homelessness (n = 13), with no

correlation found between state boredom and severity of alcohol and substance use disorder

(Marshall et al., 2019). A US study of younger adults (ages 21-28; n = 583) reported that greater

frequency of boredom experienced in workplace settings predicted higher rates of binge drinking

(≥6 drinks/occasion) and drug use (cannabis, cocaine, other stimulants, barbiturates, or

hallucinogens), and greater likelihood of heavy drug use (≥4x/weekly cannabis or any illicit drug

use; Wiesner et al., 2005). There was no relationship reported between workplace boredom and

frequency of alcohol consumption or likelihood of heavy alcohol use. In a large South African

adolescent sample (n = 2,580), higher intensity of state boredom during leisure was associated

with a greater likelihood of substance use (e.g., alcohol, tobacco, cannabis, methamphetamine), a

relationship that was found to be moderated by trait boredom (Weybright et al., 2015).

Among those in treatment, one EMA study of US adult outpatients with co-occurring

heroin and cocaine dependence (n = 112) showed higher state boredom reported during ≥1-week

periods of regular cocaine use relative to ≥1-week periods of cocaine abstinence (Preston et al.,

2009). In a US sample of inpatients with SUD and another Axis I psychiatric disorder (n = 81),

adolescents who relapsed within the first 3 days following discharge were less likely to report

state boredom 2 weeks leading up to relapse compared to adolescents who maintained abstinence

for longer (Ramo et al., 2005).

Trait boredom and substance use

Trait boredom comprised studies reporting results related to all substance categories

except cannabis, and they comprised both adult (64%) and adolescent (36%) samples (Table

10
1.4). The top three most common drug categories identified were poly-drug (41%), alcohol

(33%), and heroin/opioid use (12%).

Alcohol. Evidence overall supported a positive relationship between trait boredom and

alcohol use. US adult studies reported higher trait boredom in alcohol drinkers with versus

without a history of alcohol dependence (n = 1,021; Flory et al., 2011), and higher trait boredom

in adult drinkers with current alcohol dependence compared to those with both past alcohol

dependence and ≥6 recent months of abstinence (n = 256; Fein et al., 2010). Moreover, it was

found that these abstainers had similar trait boredom levels relative to regular alcohol drinkers

without alcohol-related problems. Among those in treatment, inpatients in France (n = 101)

exhibiting severe alcohol withdrawal during detoxification had higher overall boredom

proneness compared to individuals with chronic medical illness (Constant et al., 2019). By

contrast, a study in the Netherlands (n = 2,248) reported no difference in trait boredom between

patients with lifetime alcohol dependence and heathy controls with no lifetime psychiatric

disorder (Boschloo et al., 2013).

Among younger adults (ages ranged 18-38; n’s ranged 34-293), studies of college

students reported that trait boredom was associated with higher frequency and intensity of

alcohol use (Lac & Donaldson, 2021) and binge drinking (Carlson et al., 2010; King & Byars,

2004), though one of these investigations assessing sex differences reported that a positive

correlation with binge drinking was observed only among females. Two studies focused on

college students in Canada (n’s were 179 and 300) reported a positive correlation between risk

for alcohol dependence and one measure of boredom proneness (the BSS) but not another (the

BPS; Mercer-Lynn et al., 2013a; Mercer-Lynn et al., 2013b).

11
 In adolescents, one study in Italy (n = 721) reported higher trait boredom in current binge

drinkers than non-binge drinkers (Biolcati et al., 2016). Similarly, a study in Thailand (n = 643)

found that trait boredom predicted a higher frequency of drinking and greater likelihood of

drinking to get drunk (Siviroj et al., 2012).

Tobacco. Findings highlighted sex differences in the relationship between trait boredom

and tobacco use. One study of adults in Spain (n = 210) showed that trait boredom predicted a

greater likelihood of smoking after smoking cessation treatment in males but not females, despite

similar rates of smoking between sexes (Martínez-Vispo et al., 2019). A study using a younger

sample of identical and fraternal twins (ages 12-25; n = 3,906) in the Netherlands reported that,

while both high and medium trait boredom in males predicted greater odds of regular cigarette

smoking two years later, only high boredom in females yielded a similar increased risk (Vink et

al., 2003). In a South Korean sample of 10th to 12th-grade adolescents (n = 915), trait boredom

did not differ among current cigarette smokers, past cigarette experimenters (lifetime use but

none in the past 30 days), and never-smokers (Hwang & Park, 2015).

Methamphetamine. Only one study reported findings on trait boredom and

methamphetamine use. A sample of treatment-seeking adult females with methamphetamine use

disorder in China (n = 37) exhibited no trait boredom differences from drug-naïve healthy

controls (Wei et al., 2020).

Heroin or opioids. Studies for heroin/opioids were exclusively comprised of adults

undergoing treatment, and results were somewhat mixed. In India, one study consisting of male

patients (n = 80) reported no trait boredom differences between early (ages ≤20) versus late (age

≥21) onset opioid dependence (De et al., 2002). A study in France also found no difference in

trait boredom, comparing patients with opioid dependence to college staff as healthy controls (n

12
= 102; Franques et al., 2003). By contrast, a study in Germany (n = 46) reported higher trait

boredom in methadone/buprenorphine-maintained outpatients compared to controls from their

prior study (Lemenager et al., 2011). A separate sample in France (n = 73) yielded data showing

lower trait boredom predicted greater likelihood of obtaining ≥75% negative opioid-negative

urine screens from outpatients who had undergone at least one month of buprenorphine-

maintenance treatment (Poirier et al., 2004).

Poly-drug. Studies focusing on poly-drug use or drug users more generally yielded

differential patterns of relationship between boredom and substance use depending on the

substances used, with further evidence to support sex differences. In a sample of US adults (n =

138), trait boredom was positively correlated with the frequency of substance use in the past 6

months (LePera, 2011). A larger US study of Caucasian college students (n = 439) showed that

aspects of boredom proneness (BPS subscales) were differentially associated with regular

tobacco use and risk for problematic alcohol and drug use between females and males

(Stoltenberg & Flitcroft, 2011). Overall, females showed a greater number of boredom proneness

subdomains associated with their substance use. Time perception was the only common factor

shared between males and females and was linked to more frequent use of tobacco (cigarette,

cigar, chewing tobacco). In a sample of young adults in Australia (n = 176), trait boredom was

positively correlated with alcohol and illicit drug use but not cigarette use in the past year

(Csabonyi & Phillips, 2020).

In the US, trait boredom was positively correlated with greater substance use in general

during episodes of boredom (n = 170; Harris, 2000), and in a sample involving both college and

secondary students (n = 717) this included cigarette, alcohol, and other drug use (Greene et al.,

2000). In a US sample of secondary school students followed longitudinally (n = 1,004), trait

13
boredom was positively correlated with daily average standard drink consumed, frequency of

binge drinking (≥6 drinks/occasion), and cannabis use. Trait boredom also predicted stronger

motives for drinking in young adulthood (Windle & Windle, 2018).

In Italy, adolescents with higher trait boredom were found to consume more drinks with

higher alcohol content and engage in more frequent binge drinking, but they used less hashish

than those with lower trait boredom (n = 478; Biolcati et al., 2018). In another Italian adolescent

sample (n = 10,790), higher trait boredom was found among current drug users than non-users,

and trait boredom predicted current drug use in 15-17-year old females but in not males (Scalese

et al., 2014). Studies of 8th, 10th, and 11th graders in South Africa reported no association

between leisure boredom and substance use status and history (n = 291; Hendricks et al., 2015),

including recent cigarette or alcohol use, and lifetime cannabis use (n = 621; Wegner et al.,

2006). By contrast, a longitudinal study of a larger adolescent sample (n = 1,118) found that

leisure boredom predicted a greater likelihood of alcohol, cigarette, and cannabis use in the 4

weeks prior to baseline testing at the start of 8th grade. From the 8th grade to 11th grade, increases

in leisure boredom over time predicted a greater likelihood of alcohol, cigarette, and cannabis

use (Sharp et al., 2011).

With active treatment seekers, a study of adults in the US (n = 247) found no trait

boredom differences among methadone-maintained patients with opioid dependence only and

those with mixed opioid and cocaine dependence versus a group of healthy controls consisting of

community volunteers (Nielsen et al., 2012). One study of adult males in India (n = 240)

reported higher trait boredom in substance users (alcohol, cannabis, heroin, and multiple drug

users) than drug-naïve controls (Dubey & Arora, 2008). In this same sample, higher trait

boredom was reported by alcohol users and heroin users versus cannabis users, with no boredom

14
difference between multiple drug users and the other substance-using groups. In another study of

Indian men in treatment for substance dependence (n = 230), higher trait boredom was found in

alcohol only, opioid only, and mixed alcohol and opioid-dependent patients compared to a prior

normative sample (Mattoo et al., 2001). Moreover, alcohol-dependent patients had higher trait

boredom than opioid-only or mixed alcohol and opioid users, with no boredom difference

between the latter two groups.

15
Table 1.3

Summary of Studies Reporting Associations between State Boredom and Substance Use
Sample Characteristic
Location
Drug Author and N
Mean
Substance use status Treatment
Use onset, duration, Measures Findings
Inclusion Age abstinence,
(Female) and groups Status
(SD) Mean (SD), or range

Alcohol Kim and South Korea 119 22.2 DSM-5 n/r n/r Boredom Measure • In overall sample, higher than usual boredom
Kwon (67%) (2.4) ­ Single EMA item assessing intensity of boredom over 2- predicted craving for alcohol after boredom
College students & community i. Social anxiety disorder (n = 66)
(2020) week period NS: no evidence for co-occurring increases in boredom
volunteers
ii. Healthy controls (n = 53) and alcohol craving
Ages: n/r Alcohol Use
 ≥2x alcohol use/month ­ Fixed interval EMA 4x/day alcohol consumed
Kuerbis et USA 139 43.2 DSM-5 Alcohol Use Disorder Tx-seeking Age of AUD onset: Boredom Measure • Overall higher daily boredom predicted greater
al. (2018) (57%) (12.5) (baseline) 30.9 (12.7) ­ Single EMA item assessing intensity of boredom over 7-day alcohol consumption
Adults i. Younger adults: (n = 91)
period
Ages: 18-75 ages ≤ 49 years
Alcohol Use
 >24 drinks weekly (>15 for ii. Older adults: (n = 48)
females) ­ Fixed interval EMA 1x/day alcohol consumed past 24 hours
ages ≥ 50 years
 Want to reduce but not stop
alcohol
Todman USA 84 28.7 n/r n/r n/r Boredom Measure • With SBM subscales, alcohol use positively correlated
(2013) (71%) (9.5) ­ SBM with boredom frequency but negatively correlated
Undergraduates
­ BSS with unpleasantness of boredom and difficulty
Ages: n/r
­ BPS avoiding boredom attributed to situation or social
problems, controlling for BSS and BPS
Alcohol Use
­ Frequency of alcohol use past 2 weeks
Tobacco Berg et al. USA 31 21.1 n/r n/r n/r Boredom Measure • Boredom predicted any tobacco product use
(2019) (45%) (2.0) ­ Single EMA item assessing intensity of boredom over 21- Boredom associated with greater cigarette use in
College students •

Ages: 18-25 day period females, but more e-cigarette use in males
Tobacco Use
 Tobacco use ≥15 days past 3
months ­ Fixed interval EMA 4x/day cigarettes, cigars/cigarillos, e-
cigarettes, hookah used
Mitchell et USA 17 32.3 n/r n/r Age onset use: Boredom Measure • Boredom associated with greater likelihood of
al. (2014) (47%) (9.7) 16.7 (2.9) ­ Single EMA item assessing intensity of boredom over 7-day cigarette smoking
Adults with ADHD
Years smoked: period NS: no difference in boredom before and after a cigarette
Ages: 18-50
8.6 (8.6) Tobacco Use
 ≥10 cigarettes daily
 CO ≥10 ppm ­ EMA self-initiated entries for cigarette use
Spears et al. USA 355 41.8 n/r Tx-seeking n/r Boredom Measure • Decreased mean boredom in 4 days before quit day
(2019) (55%) (11.2) ­ Single EMA item assessing intensity of boredom over 11- predicted greater likelihood of abstinence 7 days after
Adults
day period (4 pre-quit, 7 post-quit) quit day but not on quit day
Ages: ≥21
Tobacco Use
 ≥5 cigarettes daily past year
 Want to quit ­ EMA (yes/no) cigarette use on quit day and 7 days
following quit day
­ Self-reported abstinence (verified CO ≤6 ppm)
van Oort et Netherlands 387 18-23a i. Daily smokers (n = 204) n/r n/r Boredom Measure • “Often feel bored” more common in daily cigarette
al. (2006) (49%) (1.8)b ­ 1 of 4 items assessing psychosocial determinants of cigarette smokers than never smokers
Young adults ii. Never smokers (n = 183)
use
Ages: 18-28
Tobacco Use
 ≥1 parent born in Turkey ­ Lifetime and current frequency of cigarette use
Poly-drug German and USA 845 Md: 44 i. High boredom (n = 282) n/r n/r Boredom Measure • High boredom group reported more injected heroin
Latkin (36%) self-reported boredom “moderate” to ­ 1 item assessing frequency of boredom past week and smoked cocaine use in past 6 months than low
Adults
(2012) most times” past week boredom group.
Ages: ≥18 Substance Use
ii. Low boredom (n = 563) ­ Frequency of cocaine and heroin use NS: no difference between high versus low boredom for
 Injection drug use past 6 months injected cocaine, injected speedball, snorted heroin
or snorted cocaine use past 6 months

16
 Marshall et Canada 13 26-60 n/r Non-Tx- n/r Boredom Measure NS: no correlation between MSBS and AUDIT or DAST
al. (2019) (8%) (n/r) Seeking ­ MSBS
Adults
Ages: ≥18 Substance Use
 Hx ≥1month homelessness ­ AUDIT-10
­ DAST-10
Preston et USA 112 40.1 DSM-IV concurrent heroin and cocaine Tx-seeking n/r Boredom Measure • Higher boredom reported during a (≥1 week) period of
al. (2009) (37%) (8.1) dependence ­ Single EMA item assessing intensity of boredom over 28- cocaine use compared to a (≥1 week) period of
Outpatients
week period abstinence
Ages: 18-65
Substance Use
 Opioid dependence ­ Self-initiated entries for cocaine and heroin use
 Cocaine and opioid use
Ramo et al. USA 81 18.9 DSM-III-TR Tx-seeking Days abstinent post-Tx: Boredom Measure • Adolescents relapsing immediately after treatment
(2005) (56%) (1.2) 0-175 ­ 1 item assessing boredom in the 2 weeks before relapse on a were most likely to report boredom before relapse
Adolescent inpatients i. Immediate relapsers (n = 13)
Ages: n/r modified Contextual Assessment for Relapse interview relative to early and delayed relapse groups
relapse first 3 days post-Tx
 SUD plus Axis I ii. Early relapsers (n = 20) Substance Use
 Substance use within 6 months ­ TLFB
relapse between 4-30 days
post-Tx iii. Delayed relapsers (n = 48)
relapse after 30 days
Weybright South Africa 2,580 14.5 n/r n/r n/r Boredom Measure • State boredom was associated with substance use, a
et al. (2015) (51%) (0.9) ­ 3 items adapted from LBS assessing state and trait boredom, relationship moderated by trait boredom
8-11th graders
and 1 supplemented item for “absence of interest” Higher trait boredom associated with more substance
Ages: 12-19 •

Substance Use use

­ Frequency and recency of alcohol, tobacco, cannabis, meth,
and inhalant use
Wiesner et USA 583 23.7 i. Heavy alcohol users (n = n/r) n/r n/r Boredom Measure • High job boredom predicted more binge drinking,
al. (2005) (58%) (1.3) ≥45 drinks past 6 months and ≥6 drinks ­ 1 of 5 domains on a questionnaire assessing job stressors heavy drug use and higher levels of drug use
Young adults
≥3x past month, or ≥5 alcohol problems NS: no association between high job boredom and
Ages: 21-28 Substance Use
past 6 months amount and frequency of alcohol or heavy alcohol
 Worked past year ­ Amount and frequency of alcohol consumption, binge
ii. Heavy drug users (n = n/r) drinking episodes (≥6 drinks/occasion), cannabis, cocaine, use
≥4x cannabis use weekly or other stimulants, barbiturates, and hallucinogen use past 6 months
substance use past 6 months

Note. AUDIT = Alcohol Use Identification Test; BPS = Boredom Proneness Scale; BSS = Boredom Susceptibility Scale; CO = carbon monoxide; DAST = Drug Abuse Screening Test; EMA = ecological momentary assessment; Hx = history; LBS = Leisure Boredom Scale; Md = median; n/r =

nonrelevant or not reported; NS = not statistically significant; SUD = substance use disorder; TLFB = Timeline Followback; Tx = treatment; USA = United States of America.
a
Mean was an interval range reported on a Likert scale
b
Standard deviation based on tabled estimates for given sample size (see Higgins et al., 2019; Walter & Yao, 2007)

17
Table 1.4

Summary of Studies Reporting Associations between Trait Boredom and Substance Use
Sample Characteristic
Location
Drug Author and N
Mean
Substance use status Treatment
Use onset, duration, Measures Findings
Inclusion Age abstinence
(Female) and groups Status
(SD) Mean (SD), or range

Alcohol Biolcati et Italy 721a 16.0 i. Binge drinkersb (n = 303) n/r Age first use: Boredom Measure • Higher BPS in binge drinkers than non-binge drinkers
al. (2016) (61%) (1.6) past two weeks 12.8 (1.9) ­ BPS
Adolescents
Ages: 13-19 ii. Non-binge drinkers (n = 415) Alcohol Use
­ Amount and frequency of alcohol use
Boschloo et Netherlands 2,248 46.4 DSM-IV Tx-seeking n/r Boredom NS: no association between BSS and the likelihood of lifetime
al. (2013) (67%) (13.1) ­ BSS alcohol dependence relative to having no Hx of alcohol
Patients & community i. Lifetime alcohol dependence (n = 32)
volunteers Alcohol Use dependence (or other psychopathology)
ii. Healthy controls (n = 460)
Ages: 18-65 no Hx of psychopathology ­ CIDI

Carlson et Canada 293 20.7 i. Males (n = 94) n/r Age first drink: Boredom Measure • In overall sample, higher BSS predicted greater frequency of
al. (2010) (68%) (2.5) 15.8 (2.5) ­ BSS binge drinking
College students ii. Females (n = 199)
Ages: ≥19 Alcohol Use Secondary finding
­ Frequency of binge drinkingb past 12 months • In women, BSS positively correlated with binge frequency in
 Alcohol past year women but not in men
Constant et France 101 47.4 i. Excessive drinkers (n = 57) Tx-seeking n/r Boredom Measure • Excessive drinker >3x higher BPS internal and >2x external
al. (2019) (30%) (8.4) severe alcohol withdrawal in detox program ­ BPS (26-item French version) with only 2 stimulation relative to controls
Inpatients
factors: internal and external (lack of
Ages: >18 ii. Non-excessive drinkers (n = 44)
stimulation)
Medical patients as controls
Fein et al. USA 256 37.3 DSM-IV n/r Drinkers & abstainers Boredom Measure • Higher BSS in treatment-naïve active drinkers than long-term
(2010) (45%) (7.4) age onset drinking: ­ BSS abstainers
Adults i. Tx-naïve active drinkers (n = 86)
15.9 (3.1) NS: no BSS difference between nonalcoholic controls and
Ages: n/r current alcohol dependence Alcohol Use
Abstainers years ­ TLFB treatment naïve active drinkers or long-term abstainers
ii. Long-term abstainers (n = 52)
abstinent: ­ Computerized Diagnostic Interview Schedule
lifetime alcohol dependence, ≥6 months
6.4 (6.2)
abstinent from substances
(only)
iii. Controls (n = 118)
<30 drinks/month, never >60 drinks/month
Flory et al. USA 1,021 44.7 DSM-IV n/r n/r Boredom Measure • Higher BSS with than without lifetime alcohol dependence
(2011) (58%) (4.8) ­ BSS
Adults i. Hx alcohol dependence (n = 151)
Ages: 30-54 Alcohol Use
ii. No Hx alcohol dependence (n = 870)
­ DSM-IV
Mercer- Canada 300 21.5 n/r n/r n/r Boredom Measure • BSS but not BPS positively correlated with MAST
Lynn et al. (78%) (5.2) ­ BSS
Undergraduates
(2013b)
Ages: n/r Alcohol Use
­ MAST (short form, 25-item)
King and USA 34 28.6 i. Heavy drinkers (n = 20) n/r n/r Boredom Measure • Higher BSS in heavy than light drinkers
Byars (24%) (0.5) ≥10 drinks weekly, binge drinkb 1-4 ­ BSS
Adults
(2004) days/week
Ages: 24-38 Alcohol Use
ii. Light drinkers (n = 14) ­ Amount and frequency of drinking lifetime
 No Hx dependence
≤5 drinks weekly, no Hx of binge drinkingb and past 6 months
Lac and USA 201 18.6 n/r n/r n/r Boredom Measure • BSS positively correlated with amount and frequency of alcohol
Donaldson (59%) (0.7) ­ BSS use past 30 days
College students
(2021)
Age range <21 Alcohol Use
­ Amount and frequency alcohol use per
occasion past 30 days

18
 Mercer- Canada 179 19.9 n/r n/r n/r Boredom Measure • BSS but not BPS predicted higher MAST
Lynn et al. (51%) (3.0) ­ BPS
Undergraduates
(2013a) ­ BSS
Ages: n/r
Alcohol Use
­ MAST (short form, 10-item)
Siviroj et al. Thailand 643 15.1 n/r n/r n/r Boredom Measure • Higher BSS predicted greater frequency of drinking and
(2012) (52%) (n/r) ­ BSS likelihood of drinking until drunk
7th-12th graders
Ages: n/r Alcohol Use
­ Self-rated “drink to get drunk” and frequency
of alcohol use past year and 30 days
Tobacco Hwang and South Korea 915 n/r i. Current smokers (n = 159) n/r Age start smoking: Boredom Measure NS: no BSS difference across groups
Park (2015) (48%) cigarette use past 30 days 13.9 (2.1) ­ BSS
10th to 12th graders
Ages: n/r ii. Experimental smokers (n = 135) Tobacco Use
lifetime cigarette use and none past 30 days ­ (yes/no) cigarette use lifetime and past 30
iii. Non-smokers (n = 621) days
no lifetime cigarette use

Martínez- Spain 210 45.2 i. Males (n = 79) Tx-seeking n/r Boredom Measure • BSS predicted greater likelihood of smoking at 6-months and
Vispo et al. (63%) (12.0) ­ BSS 12-months follow-up in males but not females, despite similar
Adults ii. Females (n =131)
(2019) proportion of smokers between sexes
Ages: ≥18 Tobacco Use
 ≥8 cigarettes daily ­ Self-reported abstinence (verified CO ≤10
ppm)
Vink et al. Netherlands 3,906 17.6c i. High BSS (n = 1,172) n/r n/r Boredom Measure • Medium and high BSS in males and high BSS in females were
(2003) (56%) (3.1) 30% highest BSS ­ BSS associated higher odds of being a regular smoker two years later
Mono- and di-zygotic
twins ii. Medium BSS (n = 1,562) Tobacco Use
Ages: 12-25 iii. Low BSS (n = 1,172) ­ (yes/no) regular cigarette user
30% lowest BSS
Meth Wei et al. China 37 26.9 DSM-5 Tx-seeking Years of use: Boredom Measure NS: no BSS difference between users and controls
(2020) (100%) (5.0) 1.6 (1.2) ­ BSS
Women
i. Meth use disorder (n = 37) Months abstinent before
Ages: ≥18
ii. Healthy controls (n = 40) testing:
No Hx drug use 8.6 (4.8)
Opioid De et al. India 80 30.2 ICD-10 Tx-seeking Age onset dependence: Boredom Measure NS: no BSS difference between early and late onset opioid
(2002) (0%) (7.0) ­ BSS dependence
Adult male patients i. Early opioid dependence (n = 29) Mod: 21
Ages: 17-50 onset ≤20 years old Opioid Use
ii. Late opioid dependence (n = 51) ­ Age at Onset of Substance Dependence
Questionnaire
onset ≥21 years old
­ Severity of Opioid Dependence
Questionnaire
Franques et France 102 35.5 DSM-IV Tx-seeking n/r Boredom Measure NS: no difference in BSS between opioid dependence group
al. (2003), (35%) (6.2) ­ BSS versus controls
Patients & college staff i. Opioid-dependence (n = 34)
Ages: n/r Opioid Use
ii. Healthy controls (n = 34)
­ DSM-IV
Lemenager Germany 46 36.7 i. Inpatients (n = 46) Tx-seeking Age first use: Boredom Measure • Higher BSS in opioid-dependent patients than controls
et al. (2011) (39%) (8.9) ii. Controls (n = 11, from prior study) 21.2 (5.2) ­ BSS
Adult patients
Ages: n/r Years of use: Opioid Use
 Methadone/buprenorphin 15.5 (8.5) ­ Amount and frequency of heroin use –
e Tx lifetime and past 3 months
Poirier et al. France 73 30 DSM-III-R opioid dependence Tx-seeking Years opiate addiction: Boredom Measure • Lower BSS predicted greater likelihood of having >75% of
(2004) (18%) (n/r) 9.0 (5.4) ­ BSS urine toxicology results negative for opioid use during
Adult outpatients
Opioid Use buprenorphine treatment
Ages: n/r
 Opioid-positive UTox ­ UTox (2x/week)
 ≥1st-month Tx

19
Poly-drug Biolcati et Italy 478 16.3 i. Higher BPS (n = 226) n/r n/r Boredom Measure • Higher BPS group had more stronger alcohol drinks, more
al. (2018) (40%) (1.5) above median ­ BPS binge drinking lower BPS group
Secondary school students
Ages: 14-19 ii. Lower BPS (n = 203) Substance use • Lower BPS group reported more frequent hashish use than
below median ­ Amount and frequency of alcohol use, binge higher BPS group
drinkingb, cannabis/hashish, cocaine, and
ecstasy use past 3 months
Csabonyi Australia 176 25.6 n/r n/r n/r Boredom Measure • BSS positively correlated with alcohol and illicit drug use but
and Phillips (65%) (2.8) ­ BSS not cigarette use in the past year
College students &
(2020)
community volunteers Substance Use
­ Amount and frequency of cigarette and illicit
Ages: 18-30
drug use past year
Dubey and India 240 n/r ICD-10 Tx-seeking Age onset substance Boredom Measure • Higher BSS in substance abusers versus controls
Arora (100%) abuse: ­ BSS Lower BSS in alcohol than heroin or cannabis abusers, with no
Men i. Substance abusers (n = 120) •
(2008) 15-23 difference between multiple drug abusers versus other
Ages: ≥18 25% each alcohol, cannabis, heroin, and Substance Use
multiple-drug abusers ­ ICD-10 substance groups
 Alcohol, cannabis,
heroin, or multiple ii. Non-abusers (n = 120)
substance abuse never lifetime drug use
Greene et USA 717 17.8 n/r n/r n/r Boredom Measure • BSS positively correlated with cigarette, alcohol, and drug use
al. (2000), (57%) (1.7) ­ BSS
Secondary school and
college student Substance Use
Ages: 11-25 ­ Frequency of substance use (alcohol,
cigarette, cannabis, stimulants, depressants,
etc.)
Harris USA 170 28 n/r n/r n/r Boredom Measure • BPS correlated with drug use during boredom (i.e., “When I am
(2000) (78%) (7.1)d ­ BPS feeling bored, sometimes I like to use drugs or alcohol”)
Undergraduate and
­ 16 author-devised items assessing behaviors
graduate students
related to boredom
Ages: n/r
Substance Use
­ 1 item assessing substance use when bored
Hendricks South Africa 291 n/r n/r n/r n/r Boredom Measure • LBS and peer pressure together predicted substance use but not
et al. (2015) (60%) ­ LBS LBS alone
10th and 11th graders
Ages: 16-18 Substance Use and Other Measures
­ Drug Use Disorders Identification Test
­ Resistance to Peer Influence scale
LePera USA 138 31 n/r n/r n/r Boredom Measure • BPS correlated with higher frequency of substance use – past 6
(2011) (75%) (10.7) ­ BPS months
Adults
Substance Use
Ages: n/r
­ Select items adapted from ASSIST
Mattoo et India 230 32.9c ICD-10 Tx-seeking Abstinence before Boredom Measure • Higher BSS in all 3 drug groups compared to a prior normative
al. (2001) (0%) (8.6) testing: ­ BSS sample
Men i. Alcohol dependence (n = 103)
3-4 weeks Secondary Finding
Ages: 15-60 ii. Opioid dependence (n = 72) • Higher BSS in alcohol-only dependence than opioid-only
 Substance dependence dependence or mixed group, with no BSS difference between
iii. Mixed alcohol/opioid (n = 55)
opioid-only and mixed group
Normative sample (n = 104)
men aged 15-35; no DSM-III-R substance abuse
or dependence
Nielsen et USA 247 34.7 DSM-IV Tx-seeking n/r Boredom Measure NS: no BSS differences the three groups
al. (2012) (48%) (11.5) ­ BSS
Adult patients & i. Opioid-only dependence (n = 31)
community volunteers Substance Use
ii. Opioid + cocaine (n = 71)
Ages: n/r ­ SCID-IV
iii. Healthy controls (n = 145)
 Opioid dependence
 Methadone Tx
Scalese et Italy 10,790 17.1 i. Current drug users (n = 2,946) n/r n/r Boredom Measure • Higher BSS in current drug users than non-users
al. (2014) (55%) (1.5) ≥1x illicit drug use past month, or ­ BSS BSS predicted substance use status
Secondary school students •
≥5 drinks ≥3x past month plus ≥11 cigarettes
Ages: 15-19 Substance Use • In 15- to 17-year-old females, BSS increased likelihood of drug
daily ­ European School Survey Project on Alcohol use, but not in older females or males in general
and Other Drugs questionnaire

20
 Sharp et al. South Africa 1,118 14.0 n/r Non-Tx- n/r Boredom Measure • Baseline leisure boredom predicted past 4-week alcohol,
(2011) (51%) (n/r) seeking ­ 3 of 11 items on the Leisure Experience cigarette, and cannabis
8th graders
Battery for Adolescents Increases in leisure boredom overtime predicted alcohol,
Ages: n/r •
Substance Use cigarette, and cannabis use across assessment timepoints
 Followed to 11th grade
­ (yes/no) alcohol, cigarette, and cannabis use
lifetime and past 4 weeks
Stoltenberg USA 439 22.4 i. Males (n = 155) n/r n/r Boredom Measure • Higher BPS external stimulation, affect, time perception, and
et al. (2011) (65%) (6.1) ­ BPS (subscales: external stimulation, internal constraint in females with versus without regular tobacco use,
College students ii. Females (n = 283)
stimulation, affect, time perception, and same pattern for alcohol problems
Ages: 18-67
constraint) • Higher BPS time perception in females with versus without
Caucasian drug problems
Substance Use
­ 1-item (yes/no) regular tobacco use • In males, higher BPS time perception in those with versus
(cigarette, cigar, chewing tobacco) without regular tobacco use
­ MAST NS: no association between BPS and alcohol or drug problems, in
­ DAST
males
Wegner et South Africa 621 n/r n/r n/r n/r Boredom Measure NS: no association between LBS and recent cigarette or alcohol
al. (2006) (60%) ­ LBS use, or lifetime cannabis use
8th and 11th graders
Ages: n/r Substance Use
­ Lifetime, past year, or past month cigarette,
alcohol, or cannabis use in
Windle and USA 1,004 15.5 n/r n/r n/r Boredom Measure • BSS correlated with past-6-month alcohol use, binge drinking,
Windle (51%) (0.7) ­ BSS and cannabis use
Secondary school students
(2018) BSS during adolescence predicted stronger motives for alcohol
Ages: n/r Alcohol Use •

­ Amount and frequency of alcohol use, binge drinking at young adulthood

 Longitudinally followed
 Alcohol in adulthood drinking (≥6 drinks/occasion), and
cannabis/hashish use past 6 months
Note. ASSIST = Alcohol, Smoking, and Substance Involvement Screening Test; BPS = Boredom Proneness Scale; BSS = Boredom Susceptibility Scale; CIDI = Composite International Diagnostic Interview; DAST = Drug Abuse Screening Test; Hx = history; ICD = International Classification of

Diseases; LBS = Leisure Boredom Scale; MAST = Michigan Alcohol Screening Test; Meth = methamphetamine; n/r = nonrelevant or not reported; NS = not statistically significant; SCID = Structured Clinical Interview for DSM disorders; TLFB = Timeline Followback; Tx = treatment; UTox =

Urine Toxicology; USA = United States of America.

a
Authors did not discuss the three participants missing from total sample when the sample was split into two subgroups
b
Binge drinking defined as 5 or more drinks for males and ≥4 or more drinks for females in a single episode of drinking
c
Means or standard deviations computed from available data (see Higgins et al., 2019)
d
Standard deviation based on tabled estimates for given sample size (see Higgins et al., 2019; Walter & Yao, 2007)

21
Discussion

This study comprehensively reviewed the relationship between substance use and two

types of boredom (state and trait). Results across 46 primary research articles converged on a

positive association between boredom and substance use, with some differential patterns of

relationships by type of boredom, substances of use, participant age and sex, and potentially,

sociocultural factors.

State Boredom

Studies examining state boredom among adults and adolescents overall reported that the

intensity and frequency of state boredom were both associated with more alcohol consumption,

cigarette smoking, cannabis use, and use of illicit drugs more broadly (e.g., cocaine,

methamphetamine, heroin, etc.), and fewer days to relapse following discharge from treatment.

Moreover, some evidence seems to suggest the direct involvement of cocaine in maintaining

periods of elevated state boredom (Kim and Kwon, 2020).

One state boredom study stood out with discordant findings for alcohol and drug use,

finding that no correlation between state boredom and severity of alcohol and substance use

disorder (Marshall et al., 2019). Concerns are noted regarding its methodology. The study

comprised a small sample (n = 13), and the MSBS was administered as part of a lengthy face-to-

face interview battery. The latter is concerning since the MSBS has thus far only undergone

validation as self-report, and changing its intended mode of administration could potentially

compromise the validity of the collected data (Bowling, 2005; Schwarz et al., 1991). Moreover,

the MSBS was designed to assess boredom in the present moment ("right now"; Fahlman et al.,

2013). Data collected in this study is likely to reflect participant responses to their lengthy

22
interview, and boredom in such situational contexts might be less relevant to substance use (see

Chin et al., 2017).

Trait Boredom

Studies on trait boredom yielded mixed findings. Across non-treatment-seeking adult and

adolescent samples, studies were consistent in demonstrating a positive relationship between trait

boredom and general substance use (as a composite category). Among non-treatment-seeking

adults more broadly, trait boredom was associated with current use of alcohol and illicit drugs,

and current and past alcohol use disorder. Moreover, studies also suggested that trait boredom

contributes to worsened binge drinking during adolescence and young adulthood (ages 18-38). It

is noted that these periods of development present with the highest risk for binge drinking

(Centers for Disease Control and Prevention, 2019).

In the context of treatment, most consistently reported were results showing higher trait

boredom among patients with primary alcohol use disorder relative to healthy controls or users

of other substances (i.e., cannabis, opioid). Findings involving primary opioid or mixed

opioid/cocaine use disorders showed no relationship between trait boredom and age of onset or

use status; however, lower baseline trait boredom was found to predict better treatment outcome.

Only one study was identified for methamphetamine use, and it yielded no findings in their small

sample of females who recently completed substance use treatment.

Sex Differences and Sociocultural Factors

Results for trait boredom and tobacco use yielded differential patterns by sex, with no

effects reported in studies examining other groups or across overall samples. Trait boredom

increased the risk for current cigarette smoking and relapse following treatment in young adult

and adolescent males but not their female counterparts.

23
Measures of Boredom

Evidence from this review suggests that measures of trait boredom may vary in terms of

their sensitivity in different populations. For instance, high scores on the BSS were identified as

a relevant risk factor for cigarette use among adult males but not females (Martinez-Vispo et al.,

2019), while the reverse was observed for binge drinking and use of substances more broadly

among adult women and younger female adolescents (ages 15-17). By contrast, high scores on

the BPS predicted the use of substances in general across samples of adolescents and adults more

broadly (ages ≥18) but yielded no relationship with alcohol use risk among young adults (e.g.,

college-age students; Mercer-Lynn et al., 2013a; Mercer-Lynn et al., 2013b). Evidence from one

study suggests that the BPS assesses more relevant traits associated with alcohol use among

young adult women, given that a relatively large number of subscales were correlated with

higher risks for alcohol use (and regular tobacco use) in females (Stoltenberg et al., 2011).

Moreover, a BPS distorted time perception subfactor alone was revealed as significant in both

females and males, but it was associated with different substance risks as a function of sex (i.e.,

problem drug use in females and tobacco use in males). Differences in outcome are consistent

with prior work showing the BSS targets more externalizing problem behaviors (e.g., anger and

aggression), while the BPS is related more to internalizing issues (e.g., avoidance of experience,

anxiety, mood disturbancesMercer-Lynn et al., 2013a; Mercer-Lynn et al., 2013b). While males

have a higher risk for externalizing disorders, females show stronger links to internalizing

emotions and negative affectivity (Else-Quest et al., 2006; Rosenfield, 2000) that have distinct

pathways leading to substance use (Hussong et al., 2011), such as alcohol use (Dawson et al.,

2010), perhaps better captured by the BPS.

24
Limitations

Several limitations of the studies included in this review are noted. Sample sizes varied

widely with numbers ranging from 34 for a small single group study to 10,790 participants for a

nationally representative cohort study. For the smaller studies, there may have been limited

power to detect statistical significance in terms of the effects of boredom on substance use. Study

samples were also quite heterogenous. Studies varied in their criteria for recruitment and

distinguishing groups (e.g., “current user” as daily, past week, or past month substance use) or

defining patterns of use (e.g., binge drinking as ≥5 drinks versus ≥6 drinks). Moreover, socio-

economic status was not examined in this review, albeit it has been shown to be relevant to the

frequency of boredom (Chin et al., 2017). This was in part due to the large number of studies

included from different countries (50% from outside North America) that provided no

consistently available data on individual, community-level, or regional wealth status of their

samples. Though the findings of this review show, overall, relatively consistent patterns between

boredom and substance use, some incongruencies may be the result of these differences in

sample characteristics.

Finally, only one study has thus far examined boredom and primary methamphetamine

use. Because this sample was small and comprised exclusively of adult women undergoing

treatment, results from this study offer little generalizability to the broader methamphetamine-

using population. Thus, further research to elucidate the relationship between boredom and

methamphetamine is warranted.

Conclusions

Despite important limitations of the available evidence, studies overall implicated the

involvement of boredom in developing or worsening the use of various types of substances.

25
Boredom can be included amongst other risk factors that have previously been identified as

contributing to substance use across age groups. Targeted clinical interventions to manage state

boredom and boredom proneness for substance use in both at-risk and substance-using

populations may be beneficial for the prevention and amelioration of substance use disorders and

the associated negative consequences. Lastly, all studies included in this review provided

correlational results. Experimental investigation involving manipulations of boredom is needed

to establish direction and causality.

26
 CHAPTER 2:

BOREDOM-INDUCED IMPULSIVE DECISION MAKING IN COCAINE USERS

Introduction

Cocaine is among the most commonly used illicit drugs in the United States. Over 1.5

million current users are estimated to be dependent on cocaine (SAMHSA, 2014). In 2017, the

United Nations Office on Drugs and Crime estimated that an unprecedented amount of illicit

cocaine was being manufactured globally (1,976 tons seized, a 25% increase from the year prior;

United Nations Office on Drugs and Crime, 2019). The impact of increasing illegal cocaine-

related activities is apparent on public health. Over 18 million individuals worldwide are

estimated to use cocaine recreationally (United Nations Office on Drugs and Crime, 2019).

About 1 in 10 of these cocaine users (aged 12 years or older) reside in the US (NIDA, 2020;

SAMSHA, 2020), where incidence rates of cocaine use disorder (CUD) diagnoses have

increased in recent years (SAMSHA, 2019). Despite these figures, only 19% of individuals with

CUD seek treatment for their drug use (SAMSHA, 2019). It has previously been reported that 1

in 3 drug-related emergency room visits are directly tied to the use of cocaine (SAMHSA, 2013).

More recent evidence suggests that public health issues related to cocaine use have worsened in

recent years. In 2017, an estimated 40% of all fatal drug overdoses in the U.S. were found to

have involved cocaine, without any detected presence of opioids (Kariisa et al., 2019). Despite

decades of effort, there remain no pharmacological interventions approved by the Food and Drug

Administration, and psychological therapies thus far have generated only modest success

(McLellan et al., 2000). Understanding the mechanisms that sustain cocaine use problems is

crucial to strengthening the foundation from which efficacious CUD treatments are likely to be

discovered.

27
 Cocaine use is highly relapsing. An estimated one-third of regular cocaine users relapse

to weekly cocaine use within the first year after treatment (Simpson et al., 1999). Contributing to

poor outcomes are likely neuroadaptations that occur over prolonged exposures to the drug

(Geng et al., 2017). Neuropathological changes associated with cocaine use have been observed

in regions of the brain implicated in reward valuation and decision-making (Bolla et al., 2003;

Goldstein et al., 2007; Saddoris et al., 2017). While aberrant neurochemical functioning can also

be pre-existing (Trifilieff & Martinez, 2014), cocaine-related changes may negatively impact

cocaine users’ ability to make judgments about future consequences and promote impulsive

decisions and actions without foresight (Bechara, 2005). In controlled laboratory testing,

decision impulsivity is commonly operationalized as a persistent bias towards smaller immediate

rewards over larger delayed rewards (so-called ‘delay discounting’). People in general discount

delayed rewards, attributing subjective less value to those more distant into the future (Odum,

2011). In drug users, steeper patterns of delay discounting are reflective of processes that

influence the continuation of drug use (De Wit, 2009): drug users habitually discount the long-

term benefits of abstinence (e.g., health, relationships, career) in favor of immediately

reinforcing drug effects (e.g., Washio et al., 2011).

Impulsive decision-making has been well-studied as a contributor to the development and

maintenance of problematic drug-related behaviors (Reynolds, 2006; Stevens et al., 2014;

Teuscher & Mitchell, 2011). While individuals vary in their habitual level of impulsive decision-

making, transient affective states can also influence choice preferences (Gardner et al., 2014;

Hirsh et al., 2010; Koff & Lucas, 2011). Studies have identified stress and various mood

disturbances as vulnerability factors that perpetuate problematic drug use (Childress et al., 1994;

Epstein et al., 2009; Sinha, 2008). Yet, one ubiquitous emotion that has been less commonly

28
studied until recently is the experience of boredom (Corvinelli, 2010; Forest et al., 2006;

Smolkin, 2019). The past few years have seen a burgeoning body of work implicating boredom

in the development and maintenance of drug use disorders (Alhyas et al., 2015; Dillon et al.,

2007; Horyniak et al., 2015; Krotava & Todman, 2014; Lee et al., 2007; LePera, 2011; Palamar

et al., 2015; Peckham et al., 2015; Rubenis et al., 2018). However, few have experimentally

tested the mechanisms by which boredom influences the use of drugs such as cocaine. A prior

challenge was poor agreement amongst researchers on the definition of boredom (Eastwood et

al., 2012; Mercer-Lynn et al., 2013a).

Research to date provides some consensus on an empirically driven definition of the

psychological construct. Boredom has been described as an aversive emotional state arising from

an inability to focus attention in the way necessary to derive pleasure or satisfaction from the

present activity (Danckert & Merrifield, 2018; Eastwood et al., 2012). The experience of

boredom is phenomenologically akin to anhedonia, apathy, and depression, but is also

empirically distinct (Goldberg et al., 2011). A recent meta-analysis has shown that boredom is

consistent with (1) both under- and over-stimulation, (2) distractibility via thoughts unrelated to

the task at hand (Critcher & Gilovich, 2010; Cunningham et al., 2000; Eastwood et al., 2012;

Steinberger et al., 2016), (3) distorted (slowing) perception of time, and (4) decreased self-

agency (Raffaelli et al., 2018). With respect to the notion of agency, the experience of boredom

necessitates a condition of mental constraint, or the feeling of being psychologically trapped in.

Constraint can occur when one’s attempts to redirect attention are repeatedly thwarted (Todman,

2013), or when one is barred from doing what one wants to do or forced to do what one does not

want to do (Eastwood et al., 2012).

29
 The trait propensity to experience boredom, or trait boredom, has been associated with a

host of mental health problems (Abramson & Stinson, 1977; Malkovsky et al., 2012; Samuels &

Samuels, 1974; Sommers & Vodanovich, 2000), including problematic cocaine use (Ball et al.,

1994; Carroll et al., 1991; Malow et al., 1989; Wallace, 1989). Studies have shown that the use

of drugs to alleviate boredom increases their risk for future cocaine use (Palamar et al., 2015),

and adult drug users who report more frequent experiences of boredom also tend to use more

cocaine (German & Latkin, 2012). In an experience-sampling study of adult cocaine users,

boredom was frequently recorded as a trigger that preceded cocaine use, even in the absence of

increased cravings (Preston et al., 2009).

Several lines of evidence link boredom with impulsivity (Moynihan et al., 2017). Studies

involving healthy adults have shown that those with high trait boredom tend to report more

impulsive behaviors (Watt & Vodanovich, 1992) and commit more response inhibition errors

(i.e., antisaccadic eye movement; Pettiford et al., 2007). A behavioral genetic study revealed that

trait impulsivity and boredom share common genetic factors (Hur & Bouchard, 1997). In clinical

populations, elevated trait boredom is commonly found across psychiatric conditions that feature

core deficits in impulse-control (e.g., gambling, binge eating; Abramson & Stinson, 1977;

Blaszczynski et al., 1990; Blaszczynski & Nower, 2002; Faber et al., 1995; Grant & Potenza,

2004).

Recent brain imaging evidence suggests that state boredom decreases neural activation in

regions involved in reward valuation (Bertossi et al., 2016; Guo et al., 2017; Rushworth et al.,

2011) and decision-making (Bracken et al.), and blunted activation in these regions during

temporal discounting has been associated with greater impulsive decision-making (Meade et al.,

2011; Ripke et al., 2012). One study has shown that individuals with higher trait proneness for

30
boredom make more impulsive decisions on the Experiential Discounting Task (EDT), a state-

sensitive temporal discounting task (Reynolds & Schiffbauer, 2004; Smits et al., 2013). Patterns

of EDT discounting have been found to differentiate drug users from controls and to predict

severity of drug use as well as treatment outcomes (Fields et al., 2009; Krishnan-Sarin et al.,

2007; Meda et al., 2009; Melanko et al., 2009). Together, these findings suggest a potential

mechanism for the association between boredom and cocaine use: boredom may increase

impulsive decision-making, thereby producing a greater risk for use.

Despite the relevance of impulsive decision-making in the relationship between boredom

and substance use problems, no empirical research to date has examined whether the state of

boredom affects impulsive decision-making, and how this relates to cocaine use. Studies of

boredom thus far have focused primarily on self-reported trait boredom, and those involving

state boredom and impulsive behavior have yet to examine this relationship in drug users. Thus,

this study investigated the effects of boredom as a temporary state on impulsive decision-

making in cocaine users relative to demographically matched controls. In cocaine users, we also

examined the interrelationships among patterns of boredom, impulsive decision-making, and

cocaine use. Our primary hypothesis was that cocaine users would be more vulnerable to the

effects of boredom temporal discounting and thus preferentially show greater discounting in the

boredom than non-boredom condition relative to controls. We also hypothesized higher

boredom-induced temporal discounting in cocaine users would be correlated with greater

frequency or intensity of cocaine-related behaviors.

31
Methods

Participants

Participants were 18- to 60-year-old male and non-pregnant female cocaine users and

healthy controls who were fluent in English. Our sample came from a broader study addressing a

different set of hypotheses not presented here (unpublished; NIDA R01 DA035846). Individuals

who finished the broader protocol, including previous completers, were invited to participate in

this study.

Participants were excluded if they: (1) met DSM-5 (American Psychiatric Association,

2013) criteria for anxiety, bipolar or psychotic disorders or any other psychiatric disorders (e.g.,

depression) requiring medical or psychological intervention, except for transient drug-induced

psychosis, and specific phobias, (2) were currently taking medications that would interfere with

the study procedure, (3) had a history of an intellectual or neurodevelopmental disorder, such as

attention-deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), or (4) had

uncorrected visual or auditory deficits, or any inability to comply with the study requirements.

Cocaine Users (COC). COCs were individuals who reported smoking or snorting

cocaine in the past 3 months. They were excluded if they: (1) met current DSM-V (American

Psychiatric Association, 2013) criteria for severe substance use disorder within the past year

(SUD; i.e., ≥6 symptoms for severe), other than cocaine, nicotine, or caffeine. Cocaine users

with current cannabis use were included for a more representative sample, given high rates of

cannabis use in this population (Lindsay et al., 2009).

Healthy Controls (CTRL). CTRLs were included if they reported ≤10x lifetime cocaine

use, no past regular (≥weekly) use, and none within the past year. They were excluded if they

met current DSM-V (American Psychiatric Association, 2013) criteria for severe SUD within the

32
past year (≥6 symptoms for severe) for drugs, other than nicotine or caffeine. We included

CTRLs who reported cannabis, tobacco, and alcohol use to better match cocaine users.

Moreover, we prioritized participant sex, age, and socioeconomic status for matching over race

or ethnicity. Socioeconomic status alone has been shown to be clinically relevant in predicting

outcomes, including cocaine overdose (Origer et al., 2015).

Informed consent was obtained in accordance with procedures approved by the New

York State Psychiatric Institute (NYSPI) Institutional Review Board.

Experimental Protocol

Participants underwent 2 to 3 days of screening. A comprehensive psychiatric interview

and brief neurocognitive assessments were conducted by a clinician who had either a PhD, PsyD,

or MA in Clinical Psychology. The MINI 7.0 (Sheehan et al., 1998) was administered to screen

for DSM-5 disorders, in addition to SCID-5 supplementary screeners for neurodevelopmental

disorders (i.e., ADHD and ASD; First, 2014). Drug use was assessed via structured clinical

interviews and participant self-reports. Self-reported drug use was biochemically verified with

urine and breath alcohol tests across separate days of screening (e.g., urine drug screens had to

be positive for cocaine use if participants reported recent cocaine use). Volunteers were required

to pass a written consent quiz and score ≥5th percentile on WRAT5 Word Reading (Wilkinson &

Robertson, 2017) and the WAIS-IV Vocabulary and Block Design subtests (Wechsler, 2008), to

ensure competency to provide informed consent and ability to comply with the experiment

demands. All participants completed the broader study prior to taking part in this experiment.

Participants underwent a single outpatient experimental session, scheduled in the

afternoon to control for circadian variations. At arrival, urine toxicology, breath alcohol (Select

S80, BACTrack, San Francisco, CA), breath carbon monoxide (BreathCO Monitor, Vitalograph,

33
Lexington, SC), and, in females, urine pregnancy tests (Alere hCG Dipstick, Alere, Orlando, FL)

were conducted. Prior to the experiment, participants had been instructed not to use medications

or cannabis for at least 24 hours, and they could not test positive for alcohol or drugs other than

cannabis (because THC could be detectable in urine despite 24-hour abstinence), and, for female,

they could not be pregnant. Cigarette smoking participants were permitted to smoke a cigarette

before testing to reduce potential effects from nicotine withdrawal (Hughes et al., 1994).

The total experiment comprised a boredom and a video condition (counterbalanced) that

was separated by a mandatory 1-hour break (i.e., a washout period; Figure 2.1). Self-report

questionnaires for trait boredom and boredom experienced in the past two weeks, and drug use

were completed last. To minimize potential experimenter interference, experimental conditions

were programmed to run automatically on Inquisit Lab 5 (Millisecond, Seattle, Washington).

Figure 2.1

Experimental Timeline of Study Procedures

Upon entering the room, participants were asked to turn off/silent all electronic devices,

including watches and phones, and to move them to a designated storage space. Participants were

then instructed to remain seated for the remainder of the session, except during the break. At the

break, participants were permitted to move freely within the room, use a laboratory-provided

34
iPad (Apple Inc., Cupertino, CA), or use their personal items, but they could not eat food. A brief

training was conducted to familiarize participants with the computer tasks. The experiment did

not proceed until an understanding of the task procedures was demonstrated. Participants were

left alone once the experiment program was initiated but continuously monitored from a separate

observation room. Upon completing the session, participants were debriefed and compensated

$31 for the study and additional money from their task earnings ($10 to $15).

Computerized Tasks

Boredom Condition: The Peg Turn Task (PTT). The PTT is a 15-minute computerized

adaptation of the peg-turning task used in early studies of cognitive dissonance (Appendix B,

Figure B2.1; Festinger & Carlsmith, 1959). A variant 5-minute PTT has been shown to be the

most effective method for inducing boredom compared to four other validated techniques

(Markey et al., 2014). The PTT was introduced to participants as a task that measures sustained

attention (Markey et al., 2014). On the monitor, two rows of four green pegs (2 x 4) were

presented over a black background. Participants fully rotated pegs (360°) one after another by

clicking on each peg-icon four times (1 click = 1 quarter-clockwise turn) and did so repeatedly

for a continuous 15-minute period. Mouse clicks executed during the PTT were automatically

recorded and individually time-stamped as a measure of effort and engagement.

Non-Boredom Condition: Video Task (VT). For the video condition, participants

chose 1 of 17 television shows (see Appendix C) to watch for 15 minutes. Videos were intended

to be interesting or amusing without eliciting negative emotions such as boredom. This self-

selection method was chosen to decrease subjective constraint, which can arise as a function of

reduced autonomy and interest (Deci & Ryan, 1985; Harackiewicz et al., 1987). The BBC Series

Planet Earth was included as a video option given that its prior use as a comparison task to assess

35
the efficacy of the PTT in inducing boredom (e.g., Appendix B, Figure B2.2; Markey et al.,

2014; Merrifield & Danckert, 2014). Participants were explicitly asked to choose the one video

from the provided list that they desired to watch the most. Given studies have shown that cocaine

users have blunted reward sensitivity to non-drug-related stimuli (Goldstein et al., 2010; Parvaz

et al., 2012; Tobler et al., 2016), this self-selection method was intended to reduce the likelihood

that a video would be perceived as boring.

Experiential Discounting Task (EDT). The EDT (Reynolds & Schiffbauer, 2004) is a

temporal discounting task capable of assaying state-sensitive impulsive decision-making

associated with experimental manipulations, such as acute medication effects, alcohol

intoxication, and sleep deprivation (Reynolds et al., 2006; Reynolds & Schiffbauer, 2004; Shiels

et al., 2009). The EDT procedures employed in this study are the same as the most recent

methodology described in Smits et al. (2013). Unlike other delayed discounting tasks where

hypothetical delays are commonly used, the EDT subjects participants to real delays that are

associated with their choice responses. Participant instruction was to pick one of the two options

shown on the monitor (e.g., wait 14 seconds to get $0.30 versus not wait and get $0.09 right

now).

On the left was a non-adjusting delayed $0.30 that participants had to wait for and had a

35% chance of receiving if chosen, versus on the right was an adjusting immediate option

participant was guaranteed to win (100% chance) if chosen. The starting value of this adjusting

smaller option was $0.15, and its value increased or decreased on each trial depending on

participants’ last choice (see Appendix B, Figure B2.3). The initial change to the adjusting value

was by ±15%, and all subsequent changes after this first adjustment were incrementally lowered

by 2% (i.e., ±15%, ±13%, ±11%, ±9%, and so on).

36
 The EDT comprised four non-intermixed experimental blocks, each with a different

length of delay (0s, 7s, 14s, 28s) that was consigned to the non-adjusting option. An indifference

point (IP) was established if both options were chosen an equal number of times (3 each) across

6 consecutive trials after an initial 10 trials elapsed. An IP reflects the current value of the

adjusting reward option subjectively equal to a probabilistic $.30 at a given delay. For example,

if a respondent chooses “$0.03 right now” and “wait 7 seconds for $0.30,” each 3 times in the

last 6 trials, then $0.03 is considered subjectively equal to having to wait 7 seconds for 30 cents.

To discourage fixed response styles, if the same option is chosen four consecutive times,

then the program forces the participant to choose the other option. Each block contained a

minimum block duration that was equal to the length of delay of the non-adjusting option (e.g.,

7s, 14s, 28s) multiplied by 20 (e.g., 140s, 280s, or 560s). The timer controlling the block only

counted down during the delays of the non-adjusting option. Thus, choosing the non-adjusting

option 20 times caused the block to end without establishing an IP. If an IP was successfully

reached, the block ended on a blank screen with a visible timer counting down the remainder

duration left for the block. The area under the curve (AUC) of IPs was computed as the primary

outcome variable for the EDT (Myerson et al., 2001; Pruessner et al., 2003). Smaller AUCs

indicated greater discounting.

A standardized EDT practice block (see Reynolds & Schiffbauer, 2004) was administered

as part of the training given immediately before the experiment. All participants completed the

EDT experimental blocks twice, once after PTT (boredom) and once after VT (video). The

monetary earning from one of the two completed EDTs was randomly chosen and awarded in

cash payment (between $10 to $15) to ensure decisions made had real consequences.

37
 Subjective Affect and Task Ratings. Subjective affect and perceived task characteristics

were rated on computerized visual analog scales (VAS; Folstein & Luria, 1973), with 0 (“Not at

all”) to 100 (“Extremely”) as anchors. VAS items included six affective adjectives (‘bored’,

‘anxious’, ‘amused,’ ‘annoyed,’ and ‘interested’) presented below the stationary prompt: “I

FEEL…” (see Appendix B, Figure B2.4). An additional six descriptors (‘boring’, ‘anxiety-

provoking,’ ‘amusing,’ ‘enjoyable,’ ‘tedious,’ and ‘interesting’) reflecting qualities of a given

task (e.g. PTT or VT) appeared beneath the prompt: “The Task is…”(see Appendix B, Figure

B2.5). Similar procedures have previously been used to assess state boredom (Koval & Todman,

2015). Moreover, recent multi-modal testing has shown that, even amongst basic emotions,

boredom stands out as the most accurately identified subjective affect based on individualized

psychophysiological marks as references (Roza & Postolache, 2017). In this study, VAS

subjective ratings were measured at baseline, 10 minutes through VT/PTT, and immediately after

EDTs. Task characteristics were rated only during the latter two timepoints (10 minutes through

VT/PTT, and immediately after EDTs) since there was no assigned task at baseline or during the

1-hr break. These subjective affect and task ratings were employed as manipulation checks to

confirm boredom was induced as intended. They were administered during VT/PTT, and not

immediately before the EDT, to allow for a more seamless transition into the EDT and minimize

potential changes to induced boredom.

Self-Reports

Trait Boredom. Trait boredom measures were included as planned covariates in

assessing state boredom independent of trait boredom. The Boredom Proneness Scale (BPS;

Appendix D; Farmer & Sundberg, 1986) is a 28-item questionnaire of trait boredom rated on a 7-

point Likert scale from 1 = “Highly Disagree” to 7 = “Highly Agree.” Items describe situations

38
in which boredom is likely to be experienced and behavioral traits related to boredom. The BPS

comprises a three-factor structure: attention, interest, and restlessness (Gordon et al., 1997). Ten

items are reverse scored (e.g., “I am good at waiting patiently”). Items are summed to yield a

total scale score ranging from 28 to 196. The Boredom Susceptibility Scale (BSS; Appendix E;

Zuckerman, 1979) is a 10-item subscale of Form V of the Sensation Seeking Scale (see

Zuckerman, 1979) assessing trait boredom. Items present paired statements in forced-choice

format, describing past or current experiences related to boredom (e.g., “I get bored seeing the

same old faces” and “I like the familiarity of everyday friends”). Each item is scored 0 or 1 and

summed for a total scale score.

The use of two separate trait boredom measures is not redundant. The BPS and BSS

assess different aspects of trait boredom: correlations between the scales having been shown to

range from .17 to .24 (Mercer-Lynn et al., 2014; Mercer & Eastwood, 2010). Findings also

generally suggest the BPS is related more to internalizing issues (e.g., depression, anxiety), while

the BSS is tied more to externalizing ones (e.g., drug use, gambling; Harris et al., 2014; Mercer-

Lynn et al., 2013a; Mercer-Lynn et al., 2013b). Higher scores in both scales reflect greater trait

susceptibility to boredom.

Experience of State Boredom. The State Boredom Measure (SBM; Appendix F;

Todman, 2013) assesses chronic or sustained state boredom over the past two weeks. Comprising

8 item scored on a 7-point Likert scale, the SBM estimates the frequency, pervasiveness and

disruptiveness of boredom; the degree of sensitivity to boredom and tolerance for monotony; and

types of attributions made about the source of boredom. This questionnaire was included as an

outcome measure to examine the relationship between retrospectively reported drug use and

experiences of state boredom across each of the SBM dimensions. Unlike other measures, SBM

39
items are not summed for a total scale score but analyzed individually (see Todman, 2013). We

reverse-scored one item (“Longest period of time able to tolerate boredom before trying to do

something about it”), such that all higher values would reflect worse boredom.

Drug Use. The Timeline Followback (TLFB; Appendix G; Sobell & Sobell, 1992), self-

report format, was administered to assess drug use in the past 30 days. The TLFB is a valid and

reliable method for collecting retrospective drug use data (Ehrman & Robbins, 1994; Robinson

et al., 2014). Meta-analyses have shown high concordance rates with biological tests for

detecting illicit drug use (Hjorthoj et al., 2012). Participants were instructed to work backward,

starting from the day prior, and record the amount of alcohol or drug (cocaine, cannabis,

amphetamines, opioid, benzodiazepines, barbiturates, hallucinogens, inhalants), except caffeine

or nicotine, they used each day. In addition to the TLFB, a brief structured interview was used to

assess the frequency and quantity of drug (cannabis, cocaine, cigarette, and others) and alcohol

use (beer, wine, and liquor; Appendix H).

In COCs, an 11-item pattern of cocaine use questionnaire (PUQ; Appendix I; Levin et al.,

1998; Levin et al., 1996) was administered to assess current cocaine-related patterns of

behaviors. Five question items probed the frequency of cocaine use/binge use, the street value of

cocaine used weekly and per occasion, and the number of hours spent preparing for use and

using cocaine. An additional six VAS items measured the extent to which preparing and

using/binging cocaine interfered with other activities (“e.g., getting money, buying drugs, etc.”),

and, after cocaine use/binge, eagerness to use again, desire to cut down, and the intensity of guilt

and negative mood experienced. The VAS scale ranged “Not at all” to “Extremely,” except for

the item for mood, which was reversed scored from “Terrible” to “Great”.

40
Data Analysis

Two male COCs dropped out of the study at the midpoint (after completing one EDT):

one complained the experiment was “too boring” and the other left for a family emergency.

Additionally, EDT data from two male CTRLs and one male COC were lost due to computer

malfunction.

Isolated univariate outliers with z-scores ≥3.29 were truncated to one increment above or

below the closest non-outlier value within the group (Tabachnick & Fidell, 2013). Pre-truncated

data were retained if there were no differences in outcome compared to those obtained from

truncated data. For reported drug use, estimates of cannabis use were based on a rate of 1 “blunt”

= 2 cannabis cigarettes (or "joints"; Mariani et al., 2011), and consumed alcohol was converted

into numbers of standard drinks (1 drink contains approximately 0.5 fluid ounces of pure

alcohol; Osna et al., 2017).

PTT mouse click data were segmented into five 3-minute interval blocks. Total click

count was summed for each block. Further, inter-click intervals (ICIs) were calculated based on

latencies recorded between mouse clicks. We distinguished latency of movement between pegs

from the rate of clicking (without movement) by organizing ICI data into interquartile ranges.

Given four ICIs are generated with the five mouse clicks needed to fully rotate one peg and click

on the next peg (see figure 2.2), the added latency of moving from one peg to another (the 4th

ICI, in the series of clicks) equated to a longer ICI (or ICIs Between Pegs) that would be

captured between the third to fourth quartile. The remainder ICIs below the third quartile

reflected the rate of clicking on individual pegs (ICIs Within Pegs). To control for individual

variability, such as preferences for input device (i.e., some used mouse only, touchpad only, or

switched between devices), as well as the effects of age, and hand dominance on motor

41
responding (Hubel et al., 2013), PTT outcome data were normalized by dividing performance

scores across all 3-minute intervals by those obtained on the first block (baseline).

Figure 2.2

Peg-Turning Task Outcomes Derived from Mouse Click

EDT data were similarly normalized by dividing the IPs obtained across all blocks by the

IP obtained on the first block (i.e., normalized IP at 0s delay always equaled to 1.0), specifically

to reduce inter-individual variability in dealing with uncertainty (i.e., a probabilistic reward

choice; see Reynolds & Schiffbauer, 2004). However, normalization caused some isolated IP

outliers to become overrepresented in the data (one IP at 7s delay was 20x greater than at 0s

delay), due to inconsistencies in some respondents’ choice patterns. Recent studies have

cautioned about the susceptibility of AUC to biases, specifically by overrepresenting IPs at later

42
delays (Yoon et al., 2017). For this reason, we truncated outliers respectively within groups and

conditions before discounting AUCs were calculated using the trapezoidal formula (see

Appendix J, Figure J2.1; Myerson et al., 2001).

Demographics, psychiatric symptoms, and drug use data were compared between groups

using chi-square tests of independence and independent samples t-tests. 3x2x2 mixed ANOVAs

were conducted on all subjective affect variables, with time (baseline, 10-minute PTT/VT, and

post-EDT) and condition (boredom, video) as the within-subject factors and group (COC, CTRL)

as the between-subject factor. For task characteristics, we conducted separate analyses for each

timepoint using 2x2 mixed ANOVAs, where the condition was the within-subject factor (Time 1:

PTT versus VT; Time 2: EDT after PTT versus EDT after VT) and group was the between-

subject factor. EDT discounting AUCs were similarly assessed using a 2x2 mixed ANOVA,

between condition by group. 5x2 mixed ANOVA was performed on PTT outcomes, with time

(five 3-minute interval blocks) as the within-subject factor and group as the between-subject

factor. SBM items were individually compared between COCs and CTRLs with independent

samples t-tests. Lastly, correlational analyses examined the interrelationships between boredom,

temporal discounting, and cocaine use.

We retained non-normal data since ANOVAs and t-tests are relatively robust to

violations of normality when not due to outliers (Gravetter & Wallnau, 2004). Alpha was set

at .05 for all omnibus analyses. We interpreted Greenhouse Geiser corrected degrees of freedom

where Mauchly’s test indicated a violation of sphericity and Levene’s adjusted degrees of

freedom where equal variance could not be assumed. Interactions were followed up using simple

main effects and posthoc pairwise comparisons, and all results from these follow-up analyses

were reported in Bonferroni adjusted p-values. Effect sizes were presented as partial η2 or

43
Cohen’s d for statistically significant effects. All analyses were conducted using IBM SPSS

Statistics 22 (IBM, Armonk, NY) and Jamovi (Version 9, The Jamovi Project, www.jamovi.org).

Results

Participants

Table 2.1 shows demographics data of 41 (7 females) COC participants and 38 (5

females) CTRLs, including the two participants with partial data. Participants were well-matched

on age, education, and socioeconomic status. Relative to CTRLs, more COCs identified as non-

Hispanic (60% versus 90%), and COCs reported higher ADHD symptoms (p’s < 01), consistent

with prior data showing some overlap between CUD and ADHD (De Alwis et al., 2014; van

Emmerik-van Oortmerssen et al., 2012). Given no differences between COCs and CTRLs on

measures of trait boredom, BPS and BSS were excluded as covariates from all subsequent

analyses.

Table 2.2 presents drug use data. All COCs confirmed their last cocaine use was within

the past 3 months, and none were actively engaged in treatment. Of those who reported use

within the past month, 15 snorted, 13 smoked, and 8 both snorted and smoked cocaine. Four

COCs reported use of drugs other than cocaine, cannabis, alcohol, or cigarettes in the past

month: one used amphetamine ($30 in street value) once, two consumed a single tablet of

MDMA (~100mg dosage), and one used heroin twice ($50 in street value per occasion). Groups

were similar in their number of current regular (≥weekly) cannabis smokers, regular (≥weekly)

alcohol drinkers, and daily cigarette smokers, and cannabis use in current regular cannabis

smokers and alcohol consumed among current regular drinkers. CTRLs who were current daily

cigarette smokers reported more cigarettes smoked per day than those in the COC group, and

44
COCs reporting any alcohol use in the past 30 days consumed more drinks than those in the

CTRL group (p’s < .05; Table 2.2).

Table 2.1

Demographic Characteristics
Cocaine Users Controls
N 41 (7F) 38 (5F)
Race (Black/White/other) 32/8/1 26/9/3
Ethnicity (Hispanic/non-Hispanic) 4/37** 15/23
Age 47.5 ± 10.9 48.5 ± 8.7
Education (years) 13.6 ± 2.0 13.4 ± 1.2
BSMSS 31.2 ± 11.2 32.3 ± 10.1
Symptoms & Anxiety
Depression: BDI 6.5 ± 7.5 3.4 ± 6.5
State Anxiety: STAI 30.0 ± 7.6 31.1 ± 9.0
Trait Anxiety: STAI 33.1 ± 8.3 33.3 ± 6.6
ADHD: SCID 3.9 ± 4.2** 1.42 ± 1.9
Trait Boredom
Boredom Proneness Scale 86.6 ± 18.1 80.4 ± 19.4
Boredom Susceptibility Scale 2.6 ± 1.8 2.5 ± 2.1

Note. Data presented as means ± SD, except where otherwise specified. Despite a categorical diagnosis

of attention-deficit/hyperactivity disorder being a criterion for exclusion, there was variability of

symptoms in the non-clinical range. BDI = Beck Depression Inventory; BSMSS = Barratt Simplified

Measure of Social Status; SCID = Structured Clinical Interview for DSM Disorders; STAI = State-Trait

Anxiety Inventory.

** p < .01, cocaine users significantly different from controls

Table 2.2

Drugs and Alcohol Use

Cocaine Users Controls
N = 41 N = 38
Cocaine
Lifetime years weekly usea 22.8 ± 12.4 -
Current days/weeka 2.0 ± 1.7 -
Current ≥weekly user (n)a 25 -
Snort/smoke/bothb 9/9/7 -
Days/weekb 2.9 ± 1.4 -
Street value/weekb $191.00 ± $208.18 -
TLFB any use past 30 days (n)a 34 0
Days totalc 5.0 ± 3.7 N/A
Street value totalc $454.35 ± $711.70 N/A

45
 Cannabis
Lifetime weekly users (n) 18 11
Current weekly users (n) 16 10
Days/weekb 2.9 ± 2.0 3.2 ± 1.8
TLFB any use past 30 days (n)a 15 13
Days totalc 6.1 ± 6.1 9.4 ± 8.4
“Joints” totalc 23.6 ± 65.0 27.8 ± 36.6

Cigarettes
Current daily smokers (n) 28 20
Cigarettes/daye 6.1 ± 4.3* 9.3 ± 4.3
Alcohol
Lifetime weekly drinkers (n) 30 21
Current weekly drinkers (n) 27 17
Days/weekb 4.0 ± 2.9 3.0 ± 1.5
Drinks/occasionb 6.8 ± 4.6 5.5 ± 2.8
TLFB any use past 30 days (n)a 28 26
Days totalc 8.4 ± 6.9 5.3 ± 5.1
Drinks totalc 31.4 ± 34.5* 13.8 ± 12.2

Amphetamines
TLFB any use past 30 days (n)a 1 0
Days total 1 N/A
Street value total $30.00 N/A
MDMA
TLFB any use past 30 days (n)a 2 0
Days totalc 1 N/A
“Tablets” (100mg) totalc 1 N/A
Heroin
TLFB any use past 30 days (n)a 1 0
Days total 2 N/A
Street value/occasion $50.00 N/A

Note. Data presented as means ± SD, except where otherwise specified. Drug use was collected via structured clinical interviews

and self-report questionnaires. MDMA = 3,4-Methylenedioxymethamphetamine; TLFB = 30-day Timeline Followback; N/A =

Not Applicable

* p < .05, cocaine users significantly different from controls

a Cocaine: n = 40; control: n = 36, due to missing data
b Data from those who reported ≥weekly cocaine, cannabis, or alcohol use
c Data from those who reported past 30 days ≥1x cocaine, cannabis, alcohol, or MDMA use
e Data from those who reported daily cigarette use

Boredom in the Sample Overall

Subjective Boredom. There were main effects of time (F(2, 148) = 13.3, p < .001, partial

η2 = .15) and condition (F(1, 74) = 9.3, p = .003, partial η2 = .11) on subjective boredom (I feel

46
‘bored’), where PTT increased subjective boredom in the total sample, and boredom overall was

higher during the boredom condition than the video condition. Additionally, there was an

interaction of condition and time on ‘bored’ (F(1.8, 134.9) = 19.1, p <.001, partial η2 = .20).

Boredom increased during the PTT to levels greater than during VT (p < .001) and remained

elevated during EDT (p’s < .001), while VT decreased boredom (p = .034) with levels returning

back to baseline thereafter (Figure 2.3).

Figure 2.3

Subjective Affect as a Function of Time and Condition

Task Boredom. At Time 1, there was a main effect of condition on perceived task

boredom (F(1, 72) = 29.1, p < .001, partial η2 = .29), where the PTT was overall more ‘boring’

than the VT (Figure 2.4). At Time 2, there was also a main effect of condition (EDTs; F(1, 72) =

7.7, p = .007, partial η2 = .10), where the EDT after PTT was overall more ‘boring’ than the EDT

after VT (Figure 2.4).

47
Figure 2.4

Task Ratings as a Function of Condition by Timepoint

Subjective Moods in the Sample Overall

Negative Affect. Main effects of both time (all p values < .05) and main effects of

condition were observed on all negative affective variables. Participants were overall more

‘anxious’ (F(1, 74) = 9.1, p = .004, partial η2 = .11) and ‘annoyed’ (F(1, 74) = 13.4, p < .001,

partial η2 = .15) under the boredom than the video condition. There was interaction of time and

condition on ‘annoyed’ (F(1.7, 129.2) = 12.0, p < .001, partial η2 = .14). PTT increased

‘annoyed’ relative to baseline (p < .001), where levels exceeded that of VT (p < .001) but

decreased back to baseline thereafter. In the video condition, ‘annoyed’ was similar to baseline

during VT then increased during EDT (p < .001; Figure 2.3). The interactive effect of condition

and time on ‘anxious’ was not statistically significant (Figure 2.3).

48
 Positive Affect. Main effects of time and main effects of condition were observed on all

positive affective variables (all p values < .05). Participants felt overall less ‘amused’ (F(1, 74) =

11.1, p = .001, partial η2 = .13), ‘pleasant’ (F(1, 74) = 12.2, p < .001, partial η2 = .14), and

‘interested’ (F(1, 74) = 14.3, p < .001, partial η2 = .16) under the boredom than video condition.

There was an interaction of time and condition on ‘amused’ (F(1.9, 137.2) = 27.1 p < .001,

partial η2 = .27). VT increased ‘amused’ (p < .001) to levels greater than during PTT (p < .001)

then returned to baseline after EDT, while no comparison of timepoints relative to baseline in the

boredom condition was statistically significant with and without Bonferroni correction (Figure

2.3). There was an interaction of condition and time on ‘pleasant’ (F(1.8, 133.1) = 17.2, p < .001,

partial η2 = .19). The PTT decreased ‘pleasant’ (p < .001) to levels lower than that of VT (p

< .001) then increased back to baseline, whereas no timepoint comparison relative to baseline

was statistically significant in the video condition (Figure 2.3). There was an interaction of time

and condition on ‘interested’ (F(1.7, 123.6) = 20.3, p < .001, partial η2 = .22; Figure 2.3). PTT

decreased ‘interested’ with levels sustained after EDT (p’s < .001), whereas VT increased

‘interested’ (p = .014) with levels returning to baseline thereafter. Moreover, ‘interested’ was

lower during PTT and after EDT in the boredom condition than during VT (p < .001) and after

EDT in the video condition (p = .010), respectively (Figure 2.3).

Task Ratings in the Sample Overall

There were main effects of condition across all task ratings during the PTT/VT. PTT was

overall rated as more ‘anxiety-provoking’ (F(1, 72) = 39.8, p < .001, partial η2 = .36) and

‘tedious’ (F(1, 72) = 57.3, p < .001, partial η2 = .44), and less ‘amusing’ (F(1, 72) = 30.4, p

< .001, partial η2 = .30), ‘enjoyable’ (F(1, 72) = 61.5, p < .001, partial η2 = .46), and ‘interesting’

(F(1, 72) = 49.2, p < .001, partial η2 = .41) than VT (Figure 2.4).

49
 There were main effects of condition across all task ratings after the EDTs, except for

‘interesting.’ EDT after PTT was rated more ‘anxiety-provoking’ (F(1, 72) = 6.6, p = .012,

partial η2 = .08) and ‘tedious’ (F(1, 72) = 9.3, p = .003, partial η2 = .11), and less ‘amusing’ (F(1,

72) = 17.3, p < .001, partial η2 = .19), and ‘enjoyable’ (F(1, 72) = 12.8, p < .001, partial η2 = .15)

than EDT after the VT (Figure 2.4).

Subjective Affects and Task Ratings by Condition x Group

There was a main effect of group on ‘interested’ (F(1, 74) = 7.7, p = .007, partial η2

= .09), such that COCs were overall less “interested” than CTRLs (Figure 2.5). COCs were also

more ‘annoyed’ than CTRLs, but this main effect was only marginally significant (F(1, 74) =

4.0, p = .050, partial η2 = 0.05; Figure 2.5). No other main effects of group or interactive effects

of condition and group on affective variables, including subjective boredom (Figure 2.5), were

statistically significant.

With task ratings, there were main effects of group on perceived task characteristics at

time 2 (EDTs). COCs rated the EDTs overall as more ‘tedious’ (F(1, 72) = 4.5, p = .037, partial

η2 = .06; Figure 2.5), less ‘enjoyable’ (F(1, 72) = 4.8, p = .031, partial η2 = .06) and less

‘interesting’ (F(1, 72) = 4.2, p = .044, partial η2 = .06; Figure 2.5) than CTRLs. No other main

effects of group or interactive effects of condition and group, including boredom and all ratings

at time 1 (Figure 2.5), were statistically significant.

Figure 2.5

Affect and Task Ratings at Time 2 (Induction Tasks) as a Function of Condition and Group

50
Peg Clicking Outcomes by Time x Group

There was a main effect of time on total clicks (F(2.1, 155.9) = 7.1, p = .001, partial η2

= .09), such that total clicks increased sharply at the beginning and near the end of the PTT.

There was a main effect of time on ICIs Within Pegs (F(1.9, 146.0) = 3.6, p = .033, partial η2

= .05), such that the rate of clicking on individual pegs increased steadily over time (Figure 2.6).

No other main effects or interactive effects of time and group on PTT outcomes were statistically

significant.

Figure 2.6

Peg-Turning Task Outcomes as a Function of Time and Group

51
 AUCs for PTT outcomes were computed to examine the relationship between task

engagement and boredom. AUC for total clicks was negatively correlated with subjective

boredom during PTT (r = -.31, p = .007), subjective boredom during EDT in the boredom

condition (r = -.23, p = .040), and PTT task boredom (r = -.27, p = .020). AUC for ICIs Within

Pegs was positively correlated with subjective boredom during the PTT (r = .27, p = .019) and

PTT task boredom (r = .24, p = .042).

52
Impulsive Decision-Making by Condition x Group

There was a main effect of condition on EDT AUCs (F(1, 72) = 5.0, p = .028, partial η2

= .07), such that both COCs and CTRLs overall exhibited greater discounting in the boredom

condition relative to the video condition (Figure 2.7). There were no other main effects or

interactions between condition and group on EDT AUCs. In COCs, correlational analyses

revealed a small-moderate positive relationship between EDT AUCs during boredom and PUQ

eagerness to use/binge again after a typical binge (r = .37, p = .024). No other correlations

between cocaine use and EDT AUCs during the boredom or video condition were statistically

significant.

Figure 2.7

EDT Area Under Curve (AUC) as a Function of Condition and Group

Experience of Boredom and Pattern of Cocaine Use

On the SBM, COCs indicated a higher negative impact of boredom on quality of life than

did CTRLs (t(75) = 2.9, p = .005, d = .66; Table 2.3). In COCs, correlations revealed small to

moderate relationships between SBM items and pattern of cocaine use (Table 2.4). Of note,

degree of negative impact of boredom on quality of life in COCs was correlated with total years

of ≥weekly cocaine use (r = .34, p =.033) and hours typical use/binge lasts (r =.36, p = .024),

53
degree of interference with doing other activities (“spend time with family, children, go

shopping, etc.”) due to preparing use/binge (r = .60, p < .001) and time spent using/binging (r

= .54, p < .001), and, after typical use/binge, guilt about time and money spent on cocaine (r

=.36, p = .024) and negative mood (r = .41, p = .010).

Table 2.3

State Boredom Measure between Cocaine Users and Controls

Cocaine User Controls
N = 40a N = 37a d
Scale Items
SBM1: Frequency feeling bored 3.6 ± 1.6 2.9 ± 1.7 .40
SBM2: Frequency feeling bored >3 hours at a time 2.3 ± 1.5 2.2 ± 1.8 .05
SBM3: Longest period able to tolerate being bored 4.6 ± 1.9 4.7 ± 2.0 .05
SBM4: Unpleasantness of experiencing boredom 3.3 ± 1.5 2.8 ± 1.7 .29
SBM5: Negative impact of boredom on quality of life 3.1 ± 1.5** 2.2 ± 1.2 .66
SBM6: Frequency of boredom relative to 10yrs ago 3.6 ± 1.8 3.0 ± 1.8 .32
SBM7: Difficulty avoiding boredom: health problems 2.3 ± 1.6 1.9 ± 1.3 .29
SBM8: Difficulty avoiding boredom: social problems 3.1 ± 1.9 2.6 ± 1.8 .26

Note. Data presented are means ± SD, and Cohen’s d. Higher values (maximum score of 7) indicate greater frequency of (items

1, 2, and 6), duration (item 3), unpleasantness of (item 4), negative impact due to (item 5), or agreement with statements about

(item 7, 8) experiences of state boredom over their past 2 weeks. SBM = State Boredom Measure.

** p < .01
a Cocaine: n = 40, controls: n = 37, due to missing data

Table 2.4

Experiences of Boredom and Pattern of Cocaine Use (N = 39)

SBM1 SBM2 SBM3 SBM4 SBM5 SBM6 SBM7 SBM8
Yrs ≥weekly cocainea .29 .18 -.23 .10 .34* .36* .43** .25
Pattern of cocaine use
Frequency and duration
Use days/week .02 -.04 -.04 .02 .02 -.01 -.02 .17
Hours preparing use .14 -.11 -.33* .07 .08 .05 .06 .17
Hours use lasts .14 .14 -.25 .28 .36* .15 -.17 .22
$value/week -.22 .07 -.14 .07 .09 .06 -.04 -.03
$value/occasion -.14 .18 -.13 .18 .23 .21 -.14 .00
Interference with activities…

54
 …due to prepping use .45** .29 -.40* .20 .60** .14 .13 .31
…due to time using .38* .23 -.26 .25 .54** .07 .21 .30
After use or binge...
Want to use again .17 .07 -.32 .21 .25 .08 .09 .18
Guilt about time money .09 .13 -.11 .15 .36* .24 .36* .24
Want to cut down .12 .01 -.03 .10 .29 .06 .31 .22
Negative Mood .22 .43** -.40* .20 .41** .40* -.24 .13
Note. Correlations between items on the State Boredom Measure (SBM) and the Pattern of Use Questionnaire.

* p < .05

** p < .01
a
Data collected via structured interview

Discussion

This study examined the effects of experimentally induced boredom on decision-making

in cocaine users relative to controls. For our primary hypothesis, we found greater overall

impulsive decision-making following boredom than the video, with no preferential effects in

cocaine users. Among cocaine users, greater boredom-related EDT discounting was correlated

with decreased eagerness to use cocaine immediately following a typical binge but not with any

other cocaine-use variables. Overall, the PTT produced expected increases in subjective

boredom, and boredom remained elevated during the EDT, whereas the VT decreased boredom

with levels returning to baseline during the EDT. Similarly, PTT and EDT in the boredom

condition were rated as more boring than the VT and EDT in the video condition. Moreover,

PTT increased negative and decreased positive affects relative to the VT, except for subjective

anxiety. Anxiety was overall higher in the boredom condition, with no differences detected

across timepoints. Subjective interest alone remained decreased following PTT relative to after

VT, but neither EDTs during the boredom or video condition were perceived as more interesting.

With all other task variables, including ‘anxiety-provoking,’ higher negative and lower positive

task characteristics were attributed to the PTT and EDT in the boredom condition relative to the

55
VT and the EDT in the video condition. With PTT outcomes, total mouse clicks and intra-peg

clicking increased over time, suggesting levels of engagement on the boredom task were

comparable between cocaine users and controls. Global measurements (AUCs) of these PTT

outcomes revealed that greater boredom corresponded with slower and fewer responses during

boredom induction. The latter alone was also correlated with higher levels of boredom sustained

after PTT. SBM results revealed a greater negative impact of boredom on the overall quality of

life reported by cocaine users than controls, and in cocaine users, this SBM item was found to be

correlated with more years of regular (≥weekly) cocaine use, longer time spent using cocaine,

and greater interference with daily functioning as well as negative mood due to cocaine use.

Results are somewhat inconsistent with prior findings. While individuals with cocaine

dependence have been previously found to exhibit almost twice the rate of EDT discounting

compared to that of matched controls (Johnson, 2012), the present data shows that chronic

cocaine users did not discount more than controls. Instead, both groups exhibited a similar

increase in discounting following experimentally induced state boredom. This discrepancy of

results is likely due to differences in the severity of cocaine use (Heil et al., 2006). The prior

study comprised exclusively of cocaine users who met diagnostic criteria for cocaine dependence

and used cocaine weekly or more for the past 6 months, where the average cocaine days per

week nearly doubled the average frequency reported in our sample. By contrast, our focus was

on a broader range of cocaine users who used cocaine at least once in the past 3 months. Further,

controls in this study were carefully demographically matched to cocaine users, and with results

to suggest only minor differences in the use of drugs of than cocaine, it is possible higher

intensity cocaine use may be needed to identify group difference for boredom- and non-

boredom-related discounting. Irrespective of negative findings to support our primary

56
hypothesis, this study offers the first demonstration of the causal effects of boredom

manipulation on subsequent temporal discounting. While we did not show preferentially

apparent boredom-related patterns of decision-making in cocaine users, impulsive choice

remains a mechanism by which cocaine use (and other impulsive behaviors) could be

precipitated through experiences of boredom. This study establishes a viable methodology for

further investigations of boredom-related drug use and other problem behaviors.

Imaging research on resting-state functional connectivity highlights a potential

neurobiological mechanism for the influence of boredom on impulsive decision-making. Distinct

neural networks are associated with processes involved in temporal discounting (Kable &

Glimcher, 2009; Peters & Büchel, 2011), including those involved in the valuation of monetary

rewards and time delays (Ballard & Knutson, 2009; Li et al., 2013; Pine et al., 2009) and the

comparison of choice based on these valuations (i.e., dorsal anterior cingulate cortex-anterior

insular cortex; Hoffman et al., 2008; Monterosso et al., 2007). The functional connectivity of

regions within these networks predicts impulsive choice in both healthy adults (Hobkirk et al.,

2019; Li et al., 2013) and cocaine users (Camchong et al., 2011; Cisler et al., 2013), and

structural and functional alterations of network regions implicated in cocaine use disorder

(Goldstein et al., 2007; Meade et al., 2011; Volkow & Fowler, 2000) have been found to be

linked to greater temporal discounting (Contreras-Rodríguez et al., 2015; Meade et al., 2020).

Recent investigation of resting-state functional connectivity during laboratory boredom has

revealed a central deactivation in the anterior insula cortex (Danckert & Merrifield, 2018). The

anterior insula comprises subdivisions that function as key nodes in the “emotional salience

network” and “executive control network” that are integral to initiating and sustaining attention

on behaviorally relevant stimuli (Gao & Lin, 2012; Menon & Uddin, 2010; Seeley et al., 2007;

57
Spreng et al., 2013; Sridharan et al., 2008) and integrating external (e.g., reward value) and

internal inputs that guide choice behaviors (e.g., emotional states; Naqvi & Bechara, 2010;

Pessoa, 2009). During boredom, its deactivation may temporarily suspend access to more

cognitively demanding strategies, and as a result bias preferences for immediate reinforcers

(Botvinick, 2007; Danckert & Merrifield, 2018; Kuo et al., 2009; Rushworth et al., 2011). Thus,

boredom-related impulsive decision making may increase individual vulnerability to acting on

impulsive urges (Mascho, 2012), such as shopping (Sundström et al., 2019), eating (Abramson &

Stinson, 1977), gambling (Mercer & Eastwood, 2010), and drug use (LePera, 2011; Palamar et

al., 2015).

Given evidence are robust for the relationship between impulsive decision making and

worsened cocaine use and cocaine-related outcomes (De Wit, 2009; Heil et al., 2006; Washio et

al., 2011), transient boredom is likely to exacerbate these risks in chronic cocaine users. Data

from this study provides some support for greater negative cocaine outcomes associated with

boredom. Cocaine users reported a greater negative impact on their overall quality of life due to

boredom than controls, and the extent of this negative impact coincided with greater chronicity

of cocaine use, interference with psychosocial functioning, and negative mood.

Boredom-related discounting in cocaine users was found to be associated with decreased

eagerness to use/binge again after a typical binge. This result is consistent with prior studies

reporting reduced “cocaine wanting” following 2 to 3 consecutive days of cocaine self-

administration as part of a laboratory model for cocaine binging (Foltin & Fischman, 1997b;

Ward et al., 1997) and decreased delay discounting with acute administration of dopamine

agonists, including some drugs similar in pharmacodynamics as cocaine (e.g., methylphenidate;

see Perkins & Freeman, 2018). Moreover, given prior evidence for the varying intensity of

58
cocaine cravings as a function of time since last cocaine use (Foltin & Fischman, 1997a),

boredom-related discounting is likely to be associated with greater cocaine wanting prior to reuse

or after sufficient time has passed since last use. Since this was not assessed as part of the

presents study, future investigations could examine the relationship between boredom-related

discounting and drug-related “wanting” or craving.

Lastly, we found some incongruencies between subjective affect and task characteristics.

For instance, the sample overall reported experiencing less interest during the EDT in the

boredom condition, but participants did not rate the task as less interesting than the EDT

completed in the video condition. Such discrepancies may be explained from the frameworks of

causal attribution theory (Davis & Stephan, 1980). Performance on tasks with a lower

expectancy for success can often be attributed to personal dispositions (e.g., feeling less

interested), which can occur independent to beliefs held about the task itself (McMahan, 1973).

Moreover, tasks may seem more difficult, or less likely to lead to success, in the presence of

ongoing disruptions in attention (Arkin et al., 1982), similar to those during boredom (Eastwood

et al., 2012). Thus, participants may have reported feeling less interested during boredom in

anticipation of a smaller monetary reward but rated tasks as no less interesting than those

completed in the absence of boredom.

Limitations

As an initial investigation of boredom-related impulsive decision-making in cocaine

users, this study has limitations. First, groups differed in current use of substances other than

cocaine, specifically controls smoked more daily cigarettes and cocaine users reported greater

current alcohol use. However, correlations performed on these two drug use variables revealed

no relationship with the primary outcomes of this study, suggesting they are unlikely to have

59
influenced our results. Second, despite the exclusion of candidates who met criteria for ADHD,

cocaine users reported more symptoms than controls. We did not control for ADHD symptoms,

because phenomenological aspects of chronic cocaine dependency often overlap with key

symptoms of ADHD (Fatseas et al., 2012). Moreover, prior evidence suggests that ADHD is

likely to have little to no impact on boredom-related impulsive behaviors (Matthies et al., 2012).

Third, this study did not assess cocaine craving in cocaine users. As a result, we were unable to

examine if boredom directly influences cravings or if cravings are associated with boredom-

related impulsive decision making. Since experience-sampling data has shown that boredom can

trigger cocaine use even without changes in cocaine craving (Preston et al., 2009), we opted to

assess broader patterns of cocaine use. Fourth, the manipulation tasks (PTT, VT) varied along

several different affective dimensions in addition to boredom. Boredom is most commonly

contrasted against interest, considered to the opposite emotional state, and studies comparing

boredom to interest have employed tasks that are non-equivalent across a broader range of

factors (e.g., monitoring light flashes versus writing a story; London et al., 1972). Here, we

focused on deploying the most effective boredom methods deliverable in a computerized format,

allowing for built-in measures to assess participant engagement (i.e., mouse clicks) and confirm

the time course of boredom while minimizing potential interferences to the induced transient

affective states. Fifth, the sample was disproportionately male. As a result, findings cannot speak

to differences between male and female cocaine users and may not be fully generalizable to

female cocaine users. Future investigation examining potential sex differences is needed.

Conclusion

Limitations notwithstanding, this is the first study to demonstrate a viable method for

studying experimentally induced boredom and its effects on subsequent decision-making

60
behavior. Results demonstrate that transient state boredom increases impulsive decision-making

regardless of cocaine use status, and experiences of boredom in chronic cocaine users are

associated with a worsened pattern of cocaine use. These findings support further investigation

of transient states of boredom in other drug-using populations.

61
 Appendix A:
Systematic Review Full Search Strategy

Table A1.1

Full Systematic Review Search Strategy

Order Search Term Hit
Ovid MEDLINE®: inception to December 31, 2020
1 (bored* or boring).mp. 2,807
2 exp Substance-Related Disorders/ 282,326
3 exp Alcohol Drinking/ or alcohol.mp. or tobacco.mp. or cigarette.mp. or 475772
cannabis.mp. or hashish.mp. or marijuana.mp. or cocaine.mp. or heroin.mp. or
methamphetamine.mp.
4 2 or 3 625,497
5 1 and 4 266
6 Limit 5 to year = “2000-Current” 180
Ovid Embase®: inception to December 31, 2020
1 (bored* or boring).mp. 4,106
2 "Drug Use"/ or exp "Substance Use"/ or exp "Drug Abuse" or Substance Abuse/ 876,188
or exp Drug Dependence/
3 (alcohol or tobacco or cigarette* or cannabis or marijuana or methamphetamine 866,850
or cocaine or heroin).mp. or diamorphine/
4 2 or 3 1,319,561
5 1 and 4 522
6 Limit 5 to year = “2000-Current” 435
EBSCO CINHAL® Complete: inception to December 31, 2020
1 bored* or boring 1,288
2 (MH "Substance Use Disorders+") 167,827
3 alcohol or tobacco or cigarette* or cannabis or marijuana or methamphetamine 160,167
or heroin or cocaine
4 2 or 3 249,173
5 1 and 4 151
6 Limit 5 to Published Date: 20000101-20201231 131
EBSCO APA PsycArticles: inception to December 31, 2020
1 bored* or boring 372
2 SU "Drug Abuse" 1,473
3 alcohol or SU "Alcoholism" or tobacco or cigarette or cannabis or marijuana or 8,263
amphetamine or heroin or cocaine
4 2 or 3 8,823
5 1 and 4 21
6 Limit 5 to Published Date: 20000101-20211231 13
EBSCO APA PsycInfo: inception to December 31, 2020
1 bored* or boring 5,068
2 SU ("Drug Usage" or "Substance Use Disorder" or "Addiction" or "Drug 100,863
Abuse")
3 alcohol* or tobacco or cigarette or cannabis or marijuana or hashish or 241,214
methamphetamine or heroin or cocaine
4 2 or 3 279,907
5 1 and 4 473
6 Limit 5 to Published Date: 20000101-20211231 319

62
 Appendix B:
Sample Screens of Computerized Tasks

Figure B2.1

Sample Frame of the Peg-Turning Task

Figure B2.2

Sample Frame of the Video Task

63
Figure B2.3

Sample Frame of the Experiential Discounting Task

Figure B2.4

Sample Frame of Visual Analog Scale for Subjective Affect.

64
Figure B2.5

Sample Frame of Visual Analog Scale for Task Ratings

65
 Appendix C:
List of Television Shows for Video Task
(unpublished)

INSTRUCTION: Please select ONE video you would like to watch for 15 minutes.

TV SHOWS SEASON EPISODE 

Arrested Development 4 1 ⃝

Banshee 2 10 ⃝

Big Bang Theory 8 10 ⃝

Black-ish 1 19 ⃝

Boondocks 4 6 ⃝

Community 1 17 ⃝

Empire 1 7 ⃝

Gotham 1 13 ⃝

Grimm 1 11 ⃝

House 4 9 ⃝

Modern Family 1 21 ⃝

NCIS 12 13 ⃝

Power 1 5 ⃝

Sleepy Hollow 1 8 ⃝

The Wire 1 12 ⃝

Wild ‘N Out 5 7 ⃝

Planet Earth 2 3 ⃝

66
 Appendix D:
Boredom Proneness Scale
(Farmer & Sundberg, 1986)
Instructions: Please indicate the degree to which you agree or disagree with each question below by
circling the appropriate number on the scale provided. 1= highly disagree; 7= highly agree

______ 1. It is easy for me to concentrate on my activities.

______ 2. Frequently when I am working I find myself worrying about other things.

______ 3. Time always seems to be passing slowly.

______ 4. I often find myself at “loose ends,” not knowing what to do.

______ 5. I am often trapped in situations where I have to do meaningless things.

______ 6. Having to look at someone’s home movies or travel slides bores me tremendously.

______ 7. I have projects in mind all the time, things to do.

______ 8. I find it easy to entertain myself.

______ 9. Many things I have to do are repetitive and monotonous.

______ 10. It takes more stimulation to get me going than most people.

______ 11. I get a kick out of most things I do.

______ 12. I am seldom excited about my work.

______ 13. In any situation I can usually find something to do or see to keep me interested.

______ 14. Much of the time I just sit around doing nothing.

______ 15. I am good at waiting patiently.

______ 16. I often find myself with nothing to do, time on my hands.

______ 17. In situations where I have to wait, such as a line or queue, I get very restless.

______ 18. I often wake up with a new idea.

______ 19. It would be very hard for me to find a job that is exciting enough.

______ 20. I would like more challenging things to do in life.

______ 21. I feel that I am working below my abilities most of the time.

______ 22. Many people would say that I am a creative or imaginative person.

______ 23. I have so many interests, I don’t have time to do everything.

______ 24. Among my friends, I am the one who keeps doing something the longest.

______ 25. Unless I am doing something exciting, even dangerous, I feel half-dead and dull.

______ 26. It takes a lot of change and variety to keep me really happy.

______ 27. It seems that the same things are on television or the movies all the time; it’s getting old.

______ 28. When I was young, I was often in monotonous and tiresome situations.
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 Appendix E:
Boredom Susceptibility Scale
(Zuckerman, 1979)

Instructions: Each item below contains two choices: A and B. Please indicate which of the two
paired choices most describes your likes or the way you feel. Please choose only one which
better describes your likes or feelings, even if you find both choices describe your likes or
feelings. If you find items in which you do not like either choice, mark the choice you dislike
least. Please try to answer each item. It is important you respond to all items with only one
choice, A or B.

1. A. There are some movies I enjoy seeing a second or even a third time.
B. I can't stand watching a movie that I've seen before.

2. A. I get bored seeing the same old faces.

B. I like the familiarity of everyday friends.

3. A. I dislike people who do or say anything just to shock or upset others.

B. When you can predict almost everything a person will do and say he or she is
just a bore.

4. A. I usually don't enjoy a movie or play where I can predict what will happen in
advance.
B. I don't mind watching a movie or play where I can predict what will happen
in advance.

5. A. I enjoy looking at home movies or travel slides.

B. Looking at someone's home movies or travel slides bores me tremendously.

6. A. I prefer friends who are excitingly unpredictable.

B. I prefer friends who are reliable and predictable.

7. A. I enjoy spending time in the familiar surroundings of home.

B. I get very restless if I have to stay around home for any length of time.

8. A. The worst social sin is to be rude.

B. The worse social sin is to be a bore.

9. A. I like people who are sharp and witty even if they do sometimes insult others.
B. I dislike people who have their fun at the expense of hurting the feelings of
others.

10. A. I have no patience with dull or boring persons.

B. I find something interesting in almost every person I talk with.
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 Appendix F:
State Boredom Measure
(Todman, 2013)

Instructions: Circle the response that best describes your experience over the last TWO weeks

1. How often would say that you can remember feeling bored?

1 2 3 4 5 6 7
Never Sometimes Most or
or Rarely All of the time

2. How often would you say that you can remember feeling bored for longer than THREE
hours at a time?

1 2 3 4 5 6 7
Never Sometimes Very
Very Rarely Frequently

3. What is the longest period of time that you have been able to tolerate being bored before
trying to do something about it?

1 2 3 4 5 6 7
Only for very For very
brief periods long periods
of time of time

4. How unpleasant has the experience of boredom been for you?

1 2 3 4 5 6 7
Not Mildly Moderately Extremely
Unpleasant Unpleasant Unpleasant Unpleasant

5. How much of an impact has boredom had on the overall quality of your life?

1 2 3 4 5 6 7
None Very Small A Fairly A Very
Impact Large impact Large Impact

69
Instructions: Circle the response that best describes your experience over the last TWO weeks

1. Compared to how you felt 10 years ago, would you say that on average you have been:

1 2 3 4 5 6 7
Bored Much No Bored Much
Less Often Difference More
Often

2. Have there been physical or medical problems that you believe have made it more difficult
to avoid being bored?

1 2 3 4 5 6 7
Strongly Not Strongly
Disagree Sure Agree

3. Have there been situational or social problems (e.g., issues at work or home) that you
believe have made it more difficult to avoid being bored?

1 2 3 4 5 6 7
Strongly Not Strongly
Disagree Sure Agree

70
 Appendix G:
30-Day Timeline Followback
(Sobell & Sobell, 1992)

71
 Appendix H:
Structured Interview for Current Drug Use
(unpublished)

Alcohol
Beer
Amount/occasion
Times/wk In combination with cocaine Y/N
Wine
Times/wk Amount/occasion
In combination with cocaine Y/N
Liquor
Times/wk Amount/occasion
In combination with cocaine Y/N

Total alcohol units per week =

Marijuana Times/wk
Amount/occasion (bowls, blunts, joints, weight)
. Cocaine
Intranasal
Days/wk__________ Money spent/wk___________ Amount/occasion___________
Smoked
Days/wk__________ Money spent/wk____________ Amount/occasion___________
Injected
Days/wk__________
Money spent/wk____________ Amount/occasion_________
Last use:

When__________ Route__________ Amount used (Money spent)

Nicotine

Ppd__________

Other
Specify__________

72
 Appendix I:
Pattern of Use Questionnaire
(Levin, Foltin et al. 1996)

73
 Appendix J:
Calculating Area Under the Curve (AUC)

Figure J2.1

Trapezoid Formula Visualized

74
 Appendix K:
Consent Form

NEW YORK STATE PSYCHIATRIC INSTITUTE

COLUMBIA UNIVERSITY DEPARTMENT OF PSYCHIATRY

CLINICAL INVESTIGATION CONSENT FORM

Purpose of Study
You are being asked to participate in an additional 3-hour testing session that will be held on a day
separate to the main study in which you are already involved. The purpose of this session is to help
us better understand cognitive function (e.g. memory, attention, decision making) in people who use
drugs like cigarettes, cocaine, alcohol, and marijuana. Approximately 150 people will complete this
optional part of the study.

This study is being funded by a grant from the National Institutes of Health.

Alternatives to Participation
This is not a treatment study; data are being collected for research purposes only. The alternative is
to not participate in the study. If you are interested in treatment, we will give you a referral to a
treatment program.

Study Procedures
In order to participate, you must first complete the main study (IRB # 6912). At this optional session,
which you will be asked to do after you complete the main study, you will attend the laboratory for
approximately 3 hours. We will request a breath and urine sample to measure any recent alcohol or
drug use. You will complete a series of questionnaires and computerized tasks. You will need to
answer the questions as honestly as possible and try your best on each task. You cannot participate in
any other studies that you may also be eligible for until you have completed this study or
discontinued your participation.

If you are woman, you cannot be pregnant or breastfeeding. If you think you might be pregnant,
please tell the investigator; we will also conduct a urine pregnancy test. Since pregnant woman may
not participate in this research, you must practice an effective method of birth control until the end of
this study.

Risks
There are no significant risks associated with the completion of the computerized tasks and survey
questionnaires. You may be asked questions about personal and sensitive matters, which may cause
stress or be emotionally upsetting. You may find the computer tasks challenging or tiring.

Benefits
There are no direct benefits to you personally for participating in this session. The benefits of this
research related primarily to the general scientific value of gaining a better understanding of factors
related to drug use.

Compensation
You will be compensated in cash at the time of testing for your time and effort. You will be paid $31
($25

75
+ $6 for transportation) for competing this optional testing session. You may also earn up to $15 in
bonus compensation based on your task performance. In total your compensation will range from
$31-$46, depending on your earnings from the tasks.

Confidentiality
We have a Certificate of Confidentiality issued by the Department of Health and Human Services
(DHHS). With this Certificate, the researchers cannot be forced to release any research data in which
you are identified, even under a court order or subpoena, without your written consent. The
Certificate does not prevent the researchers from reporting suspected or known sexual or physical
abuse of a child, or threatened violence to self or others. Such information will be reported to the
appropriate authorities.

Research records will be available to research staff, and to Federal, State and Institutional regulatory
personnel (who may review records as part of routine audits). Signed consent forms will be kept in a
locked file, electronic data will be maintained on password-protected computers, and your name will
never be used in publications or presentations.

You should understand that a Certificate of Confidentiality does not prevent you or a member of
your family from voluntarily releasing information about yourself or your involvement in this
research. If an insurer, employer, or other person obtains your written consent to receive research
information, then the researchers may not use the Certificate to withhold that information.

Research Standards and Participants' Rights

Participation is Voluntary: Participation in this study is voluntary, and you may refuse to participate
or discontinue participation at any time without loss of benefits to which you are otherwise entitled.
You will be informed of any new findings or risks that arise that may affect your willingness to
continue in this study. A decision not to participate in this study or to withdraw at any time will not
affect your present or future medical care at the NYS Psychiatric Institute. The investigator may also
decide that your participation should be discontinued, if he/she thinks that this is better for you. You
will be notified of significant new findings that may relate to your willingness to continue to
participate.

Compensation for Research Related Injuries: Federal regulations require that we inform you about
our institution's policy with regard to compensation and payment for treatment of research-related
injuries. If you believe that you have sustained an injury as a result of participating in this research
study, you should contact the Principal Investigator, Dr. Richard Foltin at (XXX) XXX XXXX or
the New York State Psychiatric Institute Institutional Review Board at (XXX) XXX XXXX, so that
they can review the matter.
Please be aware that:

The New York State Psychiatric Institute will furnish that emergency medical care and assistance in
arranging follow up care to be determined to be necessary by its medical staff.
You will be responsible for the cost of such care, either personally or through your medical insurance
or other form of medical coverage.

No monetary compensation for wages lost as a result of injury will be paid to you by the New York
State Psychiatric Institute or by Presbyterian Hospital.

By signing this form, you are not waiving any of your legal rights to seek compensation through the
courts.

76
Questions: The investigators will answer, to the best of their ability, any questions you may have
now or in the future regarding study procedures or your response to them. You can call the Principal
Investigator, Dr. Richard Foltin, if you have any questions at (XXX) XXX XXX during office hours.
If you have any questions about your rights as a research participant, want to provide feedback, or
have a complaint, you may call the NYSPI Institutional Review Board (IRB). (An IRB is a
committee that protects the rights of participants in research studies). You may call the IRB Main
Office at XXX-XXX-XXXX during regular office hours.
You will be given a copy of this consent form to keep.

Statement of consent
I have discussed this study with to my satisfaction. I understand that my participation is
voluntary, and that I can withdraw from the study at any time without prejudice.
I have read the above, and I voluntarily agree to enter this research study.

Signature of Subject

Printed Name of Subject Date

Statement of the Investigator obtaining Consent

I have discussed the proposed research with this participant and, in my opinion, this participant
understands the benefits, risks and alternatives (including non participation) and is capable of freely
consenting to participate in this research.

Signature of Investigator obtaining consent Date

Printed Name of Investigator

77
 Appendix L:
Protocol Tracking Sheet

EDISC Subject #: ________________ Assigned Order: ___________ RA: ______________ Date: ________________

Preg Test: ________ UTOX: ________ BAL: ________ CO: ________ Cigarette: ________

1st Testing Block 2nd Testing Block

Ideal Actual 1hr
Time Time Training MChk Task MChk Task EDT MChk Break MChk Task MChk Task EDT MChk

13:30

13:35

13:45

13:50

14:10

15:10

15:20

15:25

15:45

Notes: LAST USED (#days ago)

_____________ Cocaine
_____________ Cannabis

EDT Block 1: ___________ Total Earned: $___________ _____________ Alcohol

EDT Block 2: ___________ Total Earned: $___________ ______________ Cigarettes

78
 Appendix M:
Standard Operating Procedures (SOP)

EDISC SOP - SETUP

1. Go over consent form with participant, but do not sign. Ask if they have any questions, and bring to
staff to consent /w signature.

2. If the participant wishes, he/she may smoke a cigarette before starting the experiment. Collect and
record: Utox, BAL and CO. If any positive Utox, other than THC, or positive BAL, then participant
will need to be rescheduled.

3. Retrieve participant’s assigned task order.

4. Setup MSNAK2 laptop in the NicLab. Prepare task program to play participant’s selected video,
which should have been collected during his/her outpatient screening. If not, collect from participant
while he/she waits in the waiting area.

5. From desktop, navigate to EDISC/Files/, locate ‘Vid5min’ and ‘Vid10min’ and do for each: double-
click to open and hit “Edit.” Scroll to the bottom of the script field and locate the file paths for
participant’s chosen video. Replace the text (like shown highlighted below) with the correct file
paths. Once change complete, hit “Run” to make sure the program is working properly. Enter
‘999’ for both subject ID and group. If video works end task by pressing ‘Alt+Q’ together. Save
and close program.

Vid5min EXAMPLE
<video Vid5> <video Vid5>
/ items = (“Video/Arres5.wmv”)  / items (“Videos/Bansh5.wmv”)
/ size = (1000, 1000) / size = (1000, 1000)
</video> </video>

Vid10min EXAMPLE
<video Vid10> <video Vid10>
/ items = (“Video/Arres10.wmv”)  / items (“Videos/Bansh10.wmv”)
/ size = (1000, 1000) / size = (1000, 1000)
</video> </video>

6. Go back to the ‘Edisc’ folder, double-click ‘EDTrain.iqx’ and leave open the new window.

7. Bring participant into the room and ask him/her to remove all personal belongings (e.g., electronic
devices and watches). They are to be locked up in a separate laboratory room. Participants will not
have access to these belongings until the end of the experiment.

EDISC - TRAINING PHASE:

1. Let participant know that the session will take a total of 2.5 hours to complete and includes a 1-hr
break half-way through. He/she will be asked to perform computerized tasks that look at people’s

79
 ability to hold attention as well as their preferences for making choices about money. He/she will
also watch 15 minutes of the TV-show he/she chose.

2. Tell participant that they will be doing one of the computer tasks twice. This task asks them to make
decisions about money and offers a real opportunity to earn money. The total amount of money on
one of the two attempts will be randomly chosen and awarded to them at the end of the study. Let
participant know that he/she will now get a chance to try out the task.

3. With the ‘TrainEDT.iqx’ program opened on the laptop, hit “Run”. Enter: ‘999’ for both subject
ID and group. With instructions page opened:

Read instructions (or simplified version /w screenshot):

“When you see this task, you will have the opportunity to make multiple choices between a delayed
and probabilistic 30 cents or an adjusting immediate and for sure amount of money to be deposited
into the bank. Probabilistic means, sometimes you will get the 30 cents and sometimes you wont;
it’s a chance. For every choice to the delayed 30 cents on the left, the adjusting immediate amount
on the right will go up in value for the next choice. For every choice to the adjusting immediate
amount on the right, the amount on that side will go down in value for the next choice. There are no
right or wrong ways to do this task, just do what you prefer. You will be completing several
sessions, all of which will differ in length of time—from short to long. At the end of each session,
you will signal for me and I will record how much money you have in the bank for that session and
will start your next session. You will receive the total amount of money deposited in the bank for
one of the times you will complete this task today.”

4. Tell participant that at various points during the session surveys will appear on the screen that asks
them to rate how they feel and how the task they just completed was. [Show participant the
screenshot of manipulation checks]. Note to the participant that he/she will have to pay close
attention to the prompt, which will appear as either “I feel (adjective)” or “The task is (adjective).” To
respond to each item, they must click along the white bar, from “Not at all” to extremely. Describe
meaning of:
Tedious –describes something that is slow and long, tiring work
Anxiety-provoking –describes something that makes you feel anxious

EDISC SOP – EXPERIMENT

• [BEGIN]: Ask participant if they understand how everything works and if they have any questions.

[IF NOT]: Go over the procedures from the training protocol again. Using EDT screenshot,
instruct:

“This green “START” button will appear near the top of the screen. After you click it, you will be
given a choice between two different amounts of money. This one here to the right is
immediately awarded but changes in amount depending on your previous choice. This 30 cents
one here on the left doesn’t change but it is probabilistic and delayed. When you see the “bank”
icon here light up with color, you can click it to collect your money.”

80
• [IF BOREDOM BLOCK]: ““The first thing that will appear on the screen is a survey to ask how you
are feeling. After that will be a 15-minute attention task. On the computer screen, you will see 8
green circles. Your job is to click on each glowing circle until it makes a full rotation and to keep on
clicking until the program automatically changes over to the next task. You might find this circle-task
challenging, but it is important that follow the instructions and actually do the task until it is done.”

[START PROGRAM: ‘BoBlock.iqx’] - Make sure participant actually doing the Peg-Turning task

• [IF NEUTRAL BLOCK]: “The first thing that will appear on the screen is a survey to ask how you
are feeling. After that will be the 15-minute video you chose. You are welcome to sit back and watch
the video. When 15 minutes are up, the program will automatically change over to the next task.”
[START PROGRAM: ‘ViBlock.iqx’]

SUBJECT ID: [First Initial] + [Last Initial] + S + ###

Controls: = 100’s: TCS101, SMS102, BGS103

Users: = 200’s: BGS201, EMS202, BRS203

GROUP ID: ‘1’ for boredom condition and ‘0’ for neutral

1. After each EDT, record the amount of earned money displayed at the end.
2. When first block is finished tell participant that he/she will now take a 1-hr break. He/she is free
to move around and to use the iPad, but will not be allowed to smoke during this time.
3. Once the hour has passed, open and run program for the remaining condition (see above).
4. Give participant the questionnaire package to complete: State Boredom Measure, Boredom
Proneness Scale, Boredom Susceptibility Scale and…

IF CONTROL, administer via interview Current Drug Use

IF USER, give Pattern of Use Questionnaire, then administer via interview Current Drug Use

5. Lastly, give participant the TimeLine Followback form (see next page for TLFB administration
instructions). Use random selector to choose one EDT. Inform participant the amount of money
earned.
6. Debrief, thank and pay the participant. Have him/her sign petty cash receipt.

81
 Appendix N:
Timeline Followback Administration Script

1. Use the calendar above. Draw an “X” on today’s date and write numbers in the boxes
backwards from 1 to 30 starting with yesterday’s date (i.e., yesterday will be day 30,
and 30 days ago will be day 1).
2. Introduce the assessment to the participant. Explain that the two of you will work
through the instrument together. Tell the participant that you understand it can be
difficult to remember exactly what you had to drink on each of the past 30-days.
Remind them to just do the best that they can.
3. Clarify the date range of data to be collected (e.g., “the time-period we are talking
about is [Date X] to [Date Y].”)
4. Orient the participant to the calendar. Ask the participant to identify any events they
would like to add to the calendar, such as birthdays, paydays, social gatherings,
arrests, hospitalizations, etc. that may help aid their memory. Optional: Point to one or
more of the pre-filled holidays on the calendar as an example.
5. Always start with the question: “Have you used any drugs or alcohol in the past 30
days. If participant has not used any drugs or alcohol in the past 30 days, then
assessment can be skipped. In these situations, the RA should be sure to confirm a
second time that no drugs or alcohol was used in the past 30 days, confirming the
date range and key dates again before moving on.
6. If the participant does report use in the past 30 days, then the RA should ask the
participant about their typical patterns. The purpose of this step is to identify
information related to quantity and frequency use that will help to improve the
accuracy of information collected and decrease redundancies, improving
administration of the instrument. This also helps to prime the participant for daily
recall. Below are some examples of questions that can help assess typical use
patterns:
a. “How many days a week do you usually use drugs or drink alcohol?” If the
participant tells you he typically uses or drinks Friday, Saturday and Sunday,
you already have 12 potential days to confirm with the participant on the
calendar.
b. “What do you usually use or drink?”
c. “How much do you usually use or drink?”

82
7. Record the exact quantity of each drug or alcohol on the day it was used (e.g., 2 coc
bags, 1 joint MJ, 2 Beers), or write “ ” (ZERO) if no drugs or alcohol was used on
a given day.

83
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