Addiction

Question 1

What are addiction disorders/dependency syndromes?

Answer 1

• Addiction disorders/dependence syndromes are a cluster of physiological, behavioural, and cognitive phenomena
• Characterised by use of psychoactive drugs, alcohol, or tobacco
• Takes higher priority above other behaviours of previously greater value (WHO, 1964)
• Significantly increases risk of physical and mental health comorbidities and suicide

Question 2

Describe the aetiology of substance dependence from a psychological aspect

Answer 2

• Relates to classical conditioning and memory
• Described as a learnt behaviour originating from the memory of an event that is often highly emotional and troubling (such as stress or bereavement) (Prados, 2018)
• Maladaptive behaviours develop to avoid the fear and anxiety when retrieving these memories
• Creates a rewarding effect that perpetuates them

Question 3

Outline some of the diagnostic criteria (ICD-10, 1992) for dependence syndrome

Answer 3

• Strong desire/compulsion to take the substance
• Difficulties in controlling substance-taking behaviour
• Withdrawal symptoms
• Neglect of other alternative activities
• Persistent use despite evident harm
• Tolerance

Question 4

Using the example of smoking, describe how addiction learning occurs

Answer 4

• Using example of tobacco dependence originating from work stress
• Cigarette smoking is the unconditioned stimulus (US)
• Stress relief due to nicotine as the unconditioned response (UR)
• Over repeated exposure to smoking whilst on break, the smoking becomes associated with the break via classical conditioning
• Break is now a conditioned stimulus (CS)
• Overtime it becomes sufficient to generate a conditioned response (CR) of cravings or withdrawal, in the absence of smoking (US)

Question 5

Discuss how the conditioned response (CR) develops

Answer 5

• CR is produces as a consequence of psychological acquired tolerance
• With successive exposure to a substance, the body pre-emptively counteracts (CR) the unconditioned response
• In an attempt to maintain homeostasis when the substance is taken
• This has been demonstrated in animal models (Lubkov & Zilove, 1937; Siegel, 1975)
• If no substance-taking occurs, this CR is not corrected
• Resulting in the body generating drug-seeking behaviours

Question 6

What is a craving? Discuss how they explain a number of symptoms of addiction

Answer 6

• Craving is the memory of the positively rewarding effects of a substance (Wise, 1998), created in the first instance of substance taking
• One of the most frequent causes of relapse
• Emotional arousal plays an important role in memory retrieval
  
  • ​Emotional congruence is the tendency to recall memories that share the current experienced affect
  • High emotionally arousing memory are recalled more easily and vivdly (Lane et al, 2015)
  • ​Combined, this creates an emotional bias within memory
• The often-traumatic circumstances in which substance-taking begins, means that cravings are especially prone to recollection, with neutral or negative aspects of memory being forgotten
• Potency of cravings helps to explain why compulsion, loss of control, persistent use, and neglect in other areas occurs

Question 7

Outline the role conditioning plays in substance dependence

Answer 7

• Substance dependence results from the creation and reinforcement of drug-seeking behaviours due to a combination of classical conditioning (described above) and operant conditioning
• Succumbing to cravings (CR) is postively reinforced with stress relief (UR) and alleviation of withdrawal
• Negatively reinforced as this prevents withdrawal-like symptoms
• Abstinence is punished with withdrawal-like symptoms (CR) and loss of desired stress relief (UR)
• Cravings are one of the most frequent causes of relapse

Question 8

Discuss cue-exposure therapy

Answer 8

• Novel approach to treating dependence syndrome
• Based on theory of memory extinction
• Previous views stated that extinction caused deletion of original conditioning; more recent animal studies suggest it creates a new association of CR to no-reward, which overrides the original conditioning (Conklin & Tiffany, 2002)
  
  • ​Key difference: original association is maintained in the latter
  • New association results in a diminished impact and recollection of craving, subsequently reducing compulsions

Question 9

Discuss the evidence of effect for cue-exposure therapy

Answer 9

• Although theoretically promising, a review of 18 studies with meta-analysis of 9 failed to show a significant overall effect size for cue-exposure treatments (Conklin & Tiffany, 2002)
• Interestly, this finding was not considered surprising; practitioners of cue-exposure therapy note there has been little empirical evidence for its effectiveness

Question 10

Outline the barriers to practical use of cue-exposure therapy

Answer 10

• A key underlying difficulty is the retention and recollection of the original conditioning
• Renewal effect is one example of problematic recollection
• Reinstatement

Question 11

Describe the renewal effect

Answer 11

• The renewal effect is one example of problematic recollection
• The difference in context between the original conditioning and that of cue-exposure therapy provides two distinct pathways following re-exposure to a cue
  
  • ​Context A: smoking and stress relief in workplace
  • Context B: cue-exposure therapy in clinical setting
• This creates instances where the new learnt association that “cures their addicition” is only seen in Context B
• Upon return to context A, more likely to recall original cravings and relapse
• Additionally, introduction to a new context C also results in relapse (Conklin & Tiffany, 2002)
• Bouton (1994) summarises that conditioning is generalisable, but extinction appear to be largely-context dependent

Question 12

Suggest how cue-exposure therapy can be improved to overcome the renewal effect

Answer 12

• Provide cue-exposure therapy across multiple contexts to improve its generalisability
• This is supported by animal studies such as Gunther et al, 1998
• There have been suggests that the number of contexts for therapy must exceed the number of addiciton contexts (Chelonis et al, 1999)
  
  • ​However, this may be impossible in addictions such as tobacco dependence
• Further research is required to determine the minimum necessary number of contexts (Conklin & Tiffany, 2002)

Question 13

Describe the reinstatement effect

Answer 13

• Reinstatement effect is a similar problem as the renewal effect
• Responses to a previously extinguished CS reappear upon exposure to a US (Conklin & Tiffany, 2002)
• This is largely context dependent
• Demonstrated in animal models (de Wit & Stewart, 1981)
• Particularly troubling for widely available and socially acceptable substances (alcohol and tobacco) as it is impossible to completely avoid exposure (for example, second hand smoking or lapses)

Question 14

Discuss improvements to cue-exposure therapy to overcome reinstatement

Answer 14

• Research has shown that initial lapses do not immediately cause re-addiction (Monti et al, 1993)
• Attenuation may be achieved by exposure to context alone after a lapse without providing the reward once again
• This minimises the likelihood of continued use after the lapse
• Those able to cope and return to abstinence may become less prone to future reinstatement (Conklin & Tiffany, 2002)

Question 15

Discuss the potential for combination therapy in addiction treatment

Answer 15

• Perhaps the way to improve cue-exposure therapy is through utilisation as part of combined pyschotherapy
• It has been suggested the duration of exposure to a conditioned stimulus determines if extinction occurs
  
  • ​Prolonged or repeated exposure activates extinction learning
  • Brief exposure leads to reconsolidation of memory (Torregrossa & Taylor, 2012)
• Reconsolidation therapy aims to alter the original memory/conditioning behind addiction
  
  • Through interference with a memory’s labile nature in the early periods of memory creation (Lane et al, 2015)
  • Unlike, cue-exposure therapy, there is significant empirical evidence in animals and humans for the use of propranolol to trigger memory alteration by reconsolidation (Nadel et al, 2000; Xue et al, 2017)
  • Applauded for relevance to PTSD (Kimbrel et al, 2015) which shares a common pathway with addiciton stemming from a single traumatic event

Question 16

Discuss how cue-exposure therapy helps tackle the problems of reconsolidation therapy

Answer 16

• One of difficulties of reconsolidation therapy is targeting the deeper fundamental memories that are extremely stable
• Cue-exposure therapy is useful in these circumstances where memory cannot be rewritten
• Provide an alternative memory to be accessed

Question 17

Summaries addiction and the use of cue-exposure therapy in its treatment

Answer 17

• Addiction occurs as a result of classical and operant conditioning
• These create and maintain memories of positive drug effects, known as cravings, which become classically conditioned with environmental responses (cues)
• Cue-exposure therapy aims to treat addiction by uncoupling cue from triggering craving and drug-taking
• This is achieved through new learning where craving is associated with no-reward
• Evidence to support this still reamins to be seen, with key problems being the renewal and reinstatement effects
• Improvements may lie in attenuating such effects by:
  
  • Delivering therapy in wider more generalisable contexts
  • Supporting continued abstinence following commonly occuring lapses, to develop self-efficacy
• Broader terms, may require a combination approach of cue-exposure and reconsolidation therapy
  
  • ​Memory plays a central role in the aetiology of addiction
  • Utilising both may enable therapists to overcome the shortcomings of one or the other

Question 18

Discuss the spontaneous recovery effect

Answer 18

• Spontaneous recovery is when an extinguished response re-emerges upon exposure to CS after a period of time following cue-exposure treatment (Conklin & Tiffany, 2002)
• This is time-dependent as opposed to context-dependent

Question 19

Discuss improvements to cue-exposure therapy to overcome spontaneous recovery

Answer 19

• Attenuation requires consideration of temporal spacing of cue-exposures
  
  • ​Within-session spacing: frequency of exposure to cue, and time between cue exposures
  • Between-session spacing: amount of time from one exposure session to the next
• Animal study (Berman & Katzev, 1972) showed increased extinction learning with a series of shoft exposures to the CS verses a single mass exposure
• Current treatment sessions utilise multiple short cue-exposures in one session
  
  • ​Prevents any one cue from beoming fully extinguished as this requires multiple presentations of any one cue in a session
  • No animal research has shown that one unreinforced exposure is sufficient to extinguish a conditioned cue (Conklin & Tiffany, 2002)
• Allowing for longer between-session spacing, whilst slowing the rate of extinction, enables cue to be extinguished more completely
  
  • ​Reduces vulnerability to spontaneous recovery post-treatment