Is the concept of compulsion useful in the explanation or description of addictive behaviour and experience?

Explaining the causes and motivations for multiple substance use from the perspectives of users and therapists: A qualitative study

Background

The high prevalence of multiple substance use (MSU) is concerning, given the weak awareness about this issue and the potential impact this unawareness has on the severity of substance use disorder (SUD) and treatment outcomes. The aim of this study is to identify and elucidate the causes and motivations for MSU from the viewpoints of users and therapists in this field.

Methods

In this qualitative study, the conventional content analysis approach and purposive sampling were utilized. Deep semi-structured exploratory interviews were conducted with 17 substance users and 8 addiction therapists (including 4 psychiatrists, 3 general practitioners, and 1 psychologist). Field notes were also taken to identify and explain the motivations and reasons for MSU from the perspectives of users and therapists. The data were analyzed comparatively and simultaneously using the method suggested by Graneheim and Lundman (2004).

Results

Based on the findings of this study, the motivations for MSU are reflected in four main categories: 'Pharmacological factors' with subcategories such as achieving desired states and mitigating the undesirable effects of substances through leveraging the balancing, synergistic, and antagonistic effects of substances, substituting the effects of other substances, self-medication of the undesirable effects of other substances, enhancing the overall consumption experience such as heightened peak experience and enhanced pleasure, moderating the come-down, and seeking euphoria experiences in different substances; 'Biological factors' with subcategories including different neurobehavioral systems, individual differences determining substance dependence and the somatic-neural vulnerability of consumers; 'Psychosocial factors' with the subcategories of undesirable norms like the need for acceptance and social interactions, the context of substance use, consumers' experiences and expectations of substance use, and the maladaptive personality traits of consumers; and 'Addiction's inevitability' with the subcategories of coercion and the need to maintain equilibrium, and the difficulties of substance detoxification.

Conclusion

The motivations behind Multiple Substance Use (MSU) behaviors are multifaceted, including pharmacological, biological, psychosocial, and addiction-related factors. Recognizing and comprehending the interplay between these factors and motivations can inform better prevention strategies, assessment of treatment needs, and enhancement of treatment outcomes for individuals dealing with MSU.

The role of CART peptide in learning and memory: A potential therapeutic target in memory-related disorders

Cocaine and amphetamine-regulated transcript (CART) mRNA and peptide are vastly expressed in both cortical and subcortical brain areas and are involved in critical cognitive functions. CART peptide (CARTp), described in reward-related brain structures, regulates drug-induced learning and memory, and its role appears specific to psychostimulants. However, many other drugs of abuse, such as alcohol, opiates, nicotine, and caffeine, have been shown to alter the expression levels of CART mRNA and peptides in brain structures directly or indirectly associated with learning and memory processes. However, the number of studies demonstrating the contribution of CARTp in learning and memory is still minimal. Notably, the exact cellular and molecular mechanisms underlying CARTp effects are still unknown. The discoveries that CARTp effects are mediated through a putative G-protein coupled receptor and activation of cellular signaling cascades via NMDA receptor-coupled ERK have enhanced our knowledge about the action of this neuropeptide and allowed us to comprehend better CARTp exact cellular/molecular mechanisms that could mediate drug-induced changes in learning and memory functions. Unfortunately, these efforts have been impeded by the lack of suitable and specific CARTp receptor antagonists. In this review, following a short introduction about CARTp, we report on current knowledge about CART's roles in learning and memory processes and its recently described role in memory-related neurological disorders. We will also discuss the importance of further investigating how CARTp interacts with its receptor(s) and other neurotransmitter systems to influence learning and memory functions. This topic is sure to intrigue and motivate further exploration in the field of neuroscience.

Obsessive compulsive disorder: overview of the condition and its nursing management

Obsessive compulsive disorder (OCD) is a complex condition characterised by intrusive and distressing thoughts (obsessions) and repetitive behaviours or mental acts (compulsions). The symptoms of OCD cause significant distress and anxiety and can have a debilitating effect on a person's daily functioning. This article gives an overview of OCD, including its prevalence, aetiology, symptoms and treatment strategies, with the aim of enhancing nurses' understanding of the condition and its adverse effects on a person's life. The author also discusses some of the ways in which nurses in any setting can support a person with OCD.

Differential effects of acute and prolonged morphine withdrawal on motivational and goal-directed control over reward-seeking behaviour

Opioid addiction is a relapsing disorder marked by uncontrolled drug use and reduced interest in normally rewarding activities. The current study investigated the impact of spontaneous withdrawal from chronic morphine exposure on emotional, motivational and cognitive processes involved in regulating the pursuit and consumption of food rewards in male rats. In Experiment 1, rats experiencing acute morphine withdrawal lost weight and displayed somatic signs of drug dependence. However, hedonically driven sucrose consumption was significantly elevated, suggesting intact and potentially heightened reward processing. In Experiment 2, rats undergoing acute morphine withdrawal displayed reduced motivation when performing an effortful response for palatable food reward. Subsequent reward devaluation testing revealed that acute withdrawal disrupted their ability to exert flexible goal-directed control over reward seeking. Specifically, morphine-withdrawn rats were impaired in using current reward value to select actions both when relying on prior action-outcome learning and when given direct feedback about the consequences of their actions. In Experiment 3, rats tested after prolonged morphine withdrawal displayed heightened rather than diminished motivation for food rewards and retained their ability to engage in flexible goal-directed action selection. However, brief re-exposure to morphine was sufficient to impair motivation and disrupt goal-directed action selection, though in this case, rats were only impaired in using reward value to select actions in the presence of morphine-paired context cues and in the absence of response-contingent feedback. We suggest that these opioid-withdrawal induced deficits in motivation and goal-directed control may contribute to addiction by interfering with the pursuit of adaptive alternatives to drug use.

Motivation Science Can Improve Diversity, Equity, and Inclusion (DEI) Trainings

Recent reviews of efforts to reduce prejudice and increase diversity, equity, and inclusion (DEI) in the workplace have converged on the conclusion that prejudice is resistant to change and that merely raising awareness of the problem is not enough. There is growing recognition that DEI efforts may fall short because they do not effectively motivate attitudinal and behavioral change, especially the type of change that translates to reducing disparities. Lasting change requires sustained effort and commitment, yet insights from motivation science about how to inspire this are missing from the scientific and practitioner literatures on DEI trainings. Herein, we leverage evidence from two complementary approaches to motivating change and reducing defensiveness: self-determination theory, a metatheory of human motivation, and motivational interviewing, a clinical approach for behavior change, to tackle the question of how to improve DEI efforts. We distill these insights for researchers, teachers, practitioners, and leaders wanting to apply motivational principles to their own DEI work. We highlight challenges of using this approach and recommend training takes place alongside larger structural and organizational changes. We conclude that motivation is a necessary (but insufficient) ingredient for effective DEI efforts that can energize personal commitment to DEI.

Operationalization and measurement of compulsivity across video gaming and gambling behavioral domains

BACKGROUND

Compulsivity is the hallmark of addiction progression and, as a construct, has played an important role in unveiling the etiological pathways from learning mechanisms underlying addictive behavior to harms resulting from it. However, a sound use of the compulsivity construct in the field of behavioral addictions has been hindered to date by the lack of consensus regarding its definition and measurement. Here we capitalize on a previous systematic review and expert appraisal to develop a compulsivity scale for candidate behavioral addictions (the Granada Assessment for Cross-domain Compulsivity, GRACC).

METHODS

The initial scale (GRACC90) consisted of 90 items comprising previously proposed operationalizations of compulsivity, and was validated in two panel samples of individuals regularly engaging in gambling and video gaming, using exploratory structural equation modeling (ESEM) and convergence analyses.

RESULTS

The GRACC90 scale is unidimensional and structurally invariant across samples, and predicted severity of symptoms, lower quality of life, and negative affect, to similar degrees in the two samples. Additionally, poorer quality of life and negative affect were comparably predicted by compulsivity and by severity of symptoms. A shorter version of the scale (GRACC18) is proposed, based on selecting the 18 items with highest factor loadings.

CONCLUSIONS

Results support the proposal that core symptoms of behavioral addictions strongly overlap with compulsivity, and peripheral symptoms are not essential for their conceptualization. Further research should clarify the etiology of compulsive behavior, and whether pathways to compulsivity in behavioral addictions could be common or different across domains.

Internet gaming disorder and psychological well-being among university students in Egypt

BACKGROUND

Internet gaming disorder (IGD) is a serious rising problem affecting people of all ages. Many researchers reported that students' addictive gaming behavior resulted in the loss of function and the development of psychological problems. In this study, we aimed mainly to measure the prevalence of internet gaming disorder among Mansoura University students and find its relationship with psychological well-being.

METHODS

A cross-sectional observational study was carried out during the academic year (2021-2022) at the University of Mansoura. Students from four different faculties were included. Participants ages ranged from 18 to 25 years old. An online Google Form questionnaire gathering the tools (questionnaire of demographic and clinical data, Internet Gaming Disorder Short Form scale, Ryff's scale of psychological well-being) was distributed among them.

RESULTS

In this study, 870 students were included. The age range was 18-25 years. They were divided into three groups: 315 normal gamers (36%), 500 risky gamers (58%), and 55 disordered gamers (6%), with no significant gender difference in each group (p-value = 0.138). A negative correlation was found between IGD and psychological well-being (r = -0.303).

CONCLUSIONS

The prevalence of IGD was 6% among Mansoura University students. Participants in the theoretical faculties who started playing internet gaming at a younger age and spent more than 2 h per week playing and more than 3 h per week thinking about playing internet games were more likely to develop IGD. Whenever IGD scores increased, psychological well-being scores were found to decrease (r = -0.303).

Differential effects of acute and prolonged morphine withdrawal on motivational and goal-directed control over reward-seeking behavior

Opioid addiction is a relapsing disorder marked by uncontrolled drug use and reduced interest in normally rewarding activities. The current study investigated the impact of spontaneous withdrawal from chronic morphine exposure on emotional, motivational, and cognitive processes involved in regulating the pursuit and consumption of natural food rewards in male rats. In Experiment 1, rats experiencing acute morphine withdrawal lost weight and displayed somatic signs of drug dependence. However, hedonically-driven sucrose consumption was significantly elevated, suggesting intact and potentially heightened emotional reward processing. In Experiment 2, rats undergoing acute morphine withdrawal displayed reduced motivation when performing an effortful response for palatable food reward. Subsequent reward devaluation testing revealed that acute withdrawal also disrupted their ability to exert flexible goal-directed control over their reward-seeking behavior. Specifically, morphine-withdrawn rats displayed insensitivity to reward devaluation both when relying on prior action-outcome learning and when given direct feedback about the consequences of their actions. In Experiment 3, rats tested after prolonged morphine withdrawal displayed heightened rather than diminished motivation for food rewards and retained their ability to engage in flexible goal-directed action selection. However, brief re-exposure to morphine was sufficient to impair motivation and disrupt goal-directed action selection, though in this case insensitivity to reward devaluation was only observed in the presence of morphine-paired context cues and in the absence of response-contingent feedback. We suggest that these opioid-withdrawal induced deficits in motivation and goal-directed control may contribute to addiction by interfering with the pursuit of adaptive alternatives to drug use.

Pathways to the persistence of drug use despite its adverse consequences

The persistence of drug taking despite its adverse consequences plays a central role in the presentation, diagnosis, and impacts of addiction. Eventual recognition and appraisal of these adverse consequences is central to decisions to reduce or cease use. However, the most appropriate ways of conceptualizing persistence in the face of adverse consequences remain unclear. Here we review evidence that there are at least three pathways to persistent use despite the negative consequences of that use. A cognitive pathway for recognition of adverse consequences, a motivational pathway for valuation of these consequences, and a behavioral pathway for responding to these adverse consequences. These pathways are dynamic, not linear, with multiple possible trajectories between them, and each is sufficient to produce persistence. We describe these pathways, their characteristics, brain cellular and circuit substrates, and we highlight their relevance to different pathways to self- and treatment-guided behavior change.

Cocaine falls into oblivion during volitional initiation of choice trials

When facing a choice, most animals quit drugs in favour of a variety of nondrug alternatives. We recently found, rather unexpectedly, that choice of the nondrug alternative is in fact inflexible and habitual. One possible contributing factor to habitual choice is the intermittency and uncontrollability of choice trials in previous studies. Here, we asked whether and to what extent volitional control over the occurrence of choice trials could change animals' preference by preventing habitual choice. To do so, rats were trained to nosepoke in a hole to trigger the presentation of two operant levers: one associated with cocaine, the other with saccharin. Rats were then free to choose among the two levers to obtain the corresponding reward, after which both levers retracted until rats self-initiated the next choice trial. Overall, we found that volitional control over choice trials did not change preference. Most rats preferred saccharin over cocaine and selected this option almost exclusively. Intriguingly, after repeated choice and consumption of saccharin, rats transiently lost interest in this option (i.e., due to sensory-specific satiety), but they did not switch to cocaine, preferring instead to pause during long periods of time before reinitiating a choice trial for saccharin. This finding suggests that during volitional initiation of a choice trial, rats fail to consider cocaine as an option. We discuss a possible associative mechanism to explain this perplexing behaviour.

From concepts to treatment: a dialog between a preclinical researcher and a clinician in addiction medicine

The debate surrounding the brain disease model and the associated questioning of the relevance of animal models is polarizing the field of addiction, and tends to widen the gap between preclinical research and addiction medicine. Here, we aimed at bridging this gap by establishing a dialog between a preclinical researcher and a clinician in addiction medicine. Our objective was to evaluate animal models and the neuroscientific conceptualization of addiction in light of alcohol or drug dependence and treatment in patients struggling with an addiction. We sought to determine how preclinical research influenced addiction medicine over past decades, and reciprocally, what can preclinical researchers learn from addiction medicine that could lead to more effective approaches. In this dialog, we talk about the co-evolution of addiction concepts and treatments from neuroscientific and medical perspectives. This dialog illustrates the reciprocal influences and mutual enrichment between the two disciplines and reveals that, although preclinical research might not produce new pharmacotherapies, it does shape the theoretical conceptualization of addiction and could thereby contribute to the implementation of therapeutic approaches.

Is addiction a brain disease? A plea for agnosticism and heterogeneity

RATIONALE

Although increasingly subject to criticism, the brain disease model of addiction (BDMA) remains dominant within addiction science. Yet few advocates or critics of the BDMA have provided an account of what a brain disease is. The aim of this review is to conceptually clarify what it would mean for the BDMA to be true, rather than to argue decisively for or against it.

OBJECTIVES

Conceptual clarification of the BDMA requires consideration of possible models of disease and their relationship to the BDMA. A barrier to such consideration is belief that the BDMA is necessary to combatting addiction stigma. To address this barrier, I begin with discussion of what we know about the effects of the brain disease label on addiction stigma, and why labelling effects should have no bearing on the validity of the BDMA. I then distinguish strong, minimal, network, and mismatch models of disease, and I argue that the BDMA aligns with a strong disease model. This means that underlying brain pathology is hypothesized to be the cause of the personal-level observable signs and experienced symptoms characteristic of addiction. Evaluation of the BDMA therefore requires analysis of the concepts of brain dysfunction and causation, and their application to addiction science.

RESULTS

Brain dysfunction cannot be analyzed merely as brain changes or brain differences; nor can it be inferred merely from the presence of personal-level signs and symptoms. It is necessary to have an account of normal brain function by which to measure it. The theoretical and empirical challenges to developing such an account are not insurmountable, but they are substantial. Although there exist competing analyses of causation, there is a relatively standard method used to establish it within experimental science: intervention. Using this method, the causal significance of brain states, such as, e.g., extensive gray matter loss and/or neuroadapations in the mesocorticolimbic dopamine system, is not yet fully demonstrated. Further studies are necessary to determine their effect compared with other possible variables, such as, e.g., alternative reinforcers.

CONCLUSIONS

Conceptual clarification and preliminary empirical assessment of the BDMA recommends agnosticism about its validity and an openness to heterogeneity; in some cases addiction may be a brain disease, in others not. Either way, addiction stigma can be combatted by fighting moralism about drugs and moralistic drug policies directly, as opposed to resting hopes on the brain disease label.

Increased responsiveness to punishment of cocaine self-administration after experience with high punishment

One behavioral feature of drug addiction is continued drug use despite awareness that this causes negative consequences. Attempts to model this feature in animals typically involve punishing drug self-administration with electrical footshock to identify individuals whose drug use is differently suppressed by punishment. Here we sought to further study individual responsiveness of drug use to punishment in rats self-administering intravenous cocaine. Rats were first trained during several weeks to self-administer cocaine under a fixed-ratio 3 schedule of reinforcement. Then, their self-administration behavior was punished with increasing intensity of footshock (i.e., from 0.1 mA to 0.9 mA, every 30 min). With increasing intensity of punishment, rats first continued to self-administer cocaine before eventually stopping near completely. When retested, however, drug use became more responsive to punishment and was suppressed by a low and initially ineffective footshock intensity (i.e., 0.1 mA). This increase in responsiveness to punishment was seen in all individuals tested, albeit with varying degrees, and was acquired after one single experience with an intensity of punishment that near completely suppressed drug self-administration. Mere passive, non-contingent exposure to the same intensity, however, had no such effect. Once acquired, increased responsiveness to punishment persisted during at least one month when rats were tested every week, but not every day. Finally, increased responsiveness to punishment was not observed after exposure to a non-painful form of punishment (i.e., histamine). Overall, this study reveals that initial responsiveness of drug use to punishment can change rapidly and persistently with experience. We discuss several possible mechanisms that may account for this change in punishment responsiveness and also draw some of the implications and future perspectives for research on animal models of compulsion-like behavior.

Value-based cognition and drug dependency

Value-based decision-making is thought to play an important role in drug dependency. Achieving elevated levels of euphoria or ameliorating dysphoria/pain may motivate goal-directed drug consumption in both drug-naïve and long-time users. In other words, drugs become viewed as the preferred means of attaining a desired internal state. The bias towards choosing drugs may affect one's cognition. Observed biases in learning, attention and memory systems within the brain gradually focus one's cognitive functions towards drugs and related cues to the exclusion of other stimuli. In this narrative review, the effects of drug use on learning, attention and memory are discussed with a particular focus on changes across brain-wide functional networks and the subsequent impact on behaviour. These cognitive changes are then incorporated into the cycle of addiction, an established model outlining the transition from casual drug use to chronic dependency. If drug use results in the elevated salience of drugs and their cues, the studies highlighted in this review strongly suggest that this salience biases cognitive systems towards the motivated pursuit of addictive drugs. This bias is observed throughout the cycle of addiction, possibly contributing to the persistent hold that addictive drugs have over the dependent. Taken together, the excessive valuation of drugs as the preferred means of achieving a desired internal state affects more than just decision-making, but also learning, attentional and mnemonic systems. This eventually narrows the focus of one's thoughts towards the pursuit and consumption of addictive drugs.

Quantifying value-based determinants of drug and non-drug decision dynamics

RATIONALE

A growing body of research suggests that substance use disorder (SUD) may be characterized as disorders of decision making. However, drug choice studies assessing drug-associated decision making often lack more complex and dynamic conditions that better approximate contexts outside the laboratory and may lead to incomplete conclusions regarding the nature of drug-associated value.

OBJECTIVES

The current study assessed isomorphic (choice between identical food options) and allomorphic (choice between remifentanil [REMI] and food) choice across dynamically changing reward probabilities, magnitudes, and differentially reward-predictive stimuli in male rats to better understand determinants of drug value. Choice data were analyzed at aggregate and choice-by-choice levels using quantitative matching and reinforcement learning (RL) models, respectively.

RESULTS

Reductions in reward probability or magnitude independently reduced preferences for food and REMI commodities. Inclusion of reward-predictive cues significantly increased preference for food and REMI rewards. Model comparisons revealed that reward-predictive stimuli significantly altered the economic substitutability of food and REMI rewards at both levels of analysis. Furthermore, model comparisons supported the reformulation of reward value updating in RL models from independent terms to a shared, relative term, more akin to matching models.

CONCLUSIONS

The results indicate that value-based quantitative choice models can accurately capture choice determinants within complex decision-making contexts and corroborate drug choice as a multidimensional valuation process. Collectively, the present study indicates commonalities in decision-making for drug and non-drug rewards, validates the use of economic-based SUD therapies (e.g., contingency management), and implicates the neurobehavioral processes underlying drug-associated decision-making as a potential avenue for future SUD treatment.

Are methamphetamine users compulsive? Faulty reinforcement learning, not inflexibility, underlies decision making in people with methamphetamine use disorder

Methamphetamine use disorder involves continued use of the drug despite negative consequences. Such 'compulsivity' can be measured by reversal learning tasks, which involve participants learning action-outcome task contingencies (acquisition-contingency) and then updating their behaviour when the contingencies change (reversal). Using these paradigms, animal models suggest that people with methamphetamine use disorder (PwMUD) may struggle to avoid repeating actions that were previously rewarded but are now punished (inflexibility). However, difficulties in learning task contingencies (reinforcement learning) may offer an alternative explanation, with meaningful treatment implications. We aimed to disentangle inflexibility and reinforcement learning deficits in 35 PwMUD and 32 controls with similar sociodemographic characteristics, using novel trial-by-trial analyses on a probabilistic reversal learning task. Inflexibility was defined as (a) weaker reversal phase performance, compared with the acquisition-contingency phases, and (b) persistence with the same choice despite repeated punishments. Conversely, reinforcement learning deficits were defined as (a) poor performance across both acquisition-contingency and reversal phases and (b) inconsistent postfeedback behaviour (i.e., switching after reward). Compared with controls, PwMUD exhibited weaker learning (odds ratio [OR] = 0.69, 95% confidence interval [CI] [0.63-0.77], p < .001), though no greater accuracy reduction during reversal. Furthermore, PwMUD were more likely to switch responses after one reward/punishment (OR = 0.83, 95% CI [0.77-0.89], p < .001; OR = 0.82, 95% CI [0.72-0.93], p = .002) but just as likely to switch after repeated punishments (OR = 1.03, 95% CI [0.73-1.45], p = .853). These results indicate that PwMUD's reversal learning deficits are driven by weaker reinforcement learning, not inflexibility.

Sign Tracking in an Enriched Environment: A Potential Ecologically Relevant Animal Model of Adaptive Behavior Change

When an object conditioned stimulus (CS) is paired with a food unconditioned stimulus (US), anticipatory goal-directed action directed at the US location (goal tracking) is accompanied by behavior directed at the object CS (sign tracking). Sign-tracking behavior appears to be compulsive and habit-like and predicts increased vulnerability to the addictive potential of drugs in animal models. A large body of the literature also suggests that environmental enrichment protects against the development of addiction-prone phenotypes. Thus, we investigated whether compulsive-like sign tracking develops in environmentally enriched rats trained directly in their enriched home environment. We demonstrate that adolescent enriched-housed male Sprague-Dawley rats readily sign track a 5% ethanol bottle CS in their home environment and at a rate higher than adolescent standard-housed rats. We also show that enriched adolescent rats sign track less than enriched adult-trained rats and that acute isolation stress affects sign- and goal-tracking performance of adolescents and adults differently. Sign tracking increased more in the adult than the adolescent rats. Whereas the younger rats showed a decrease in goal tacking after the final stressor manipulation, the adults showed increased goal tracking. Our results are consistent with recent studies, which suggest that although sign tracking performance is compulsive-like, it is not as inflexible and habit-like as previously assumed. Testing in an enriched home environment with object CSs having greater affordance than "neutral" lever CSs may provide greater ecological relevance for investigating the development and expression of adaptive and compulsive-like behaviors in translational research.

Habit, choice, and addiction

Addiction was suggested to emerge from the progressive dominance of habits over goal-directed behaviors. However, it is generally assumed that habits do not persist in choice settings. Therefore, it is unclear how drug habits may persist in real-world scenarios where this factor predominates. Here, we discuss the poor translational validity of the habit construct, which impedes our ability to determine its role in addiction. New evidence of habitual behavior in a drug choice setting are then described and discussed. Interestingly, habitual preference did not promote drug choice but instead favored abstinence. Here, we propose several clues to reconcile these unexpected results with the habit theory of addiction, and we highlight the need in experimental research to face the complexity of drug addicts' decision-making environments by investigating drug habits in the context of choice and in the presence of cues. On a theoretical level, we need to consider more complex frameworks, taking into account continuous interactions between goal-directed and habitual systems, and alternative decision-making models more representative of real-world conditions.

Curing the broken brain model of addiction: Neurorehabilitation from a systems perspective

The dominant biomedical perspective on addictions has been that they are chronic brain diseases. While we acknowledge that the brains of people with addictions differ from those without, we argue that the "broken brain" model of addiction has important limitations. We propose that a systems-level perspective more effectively captures the integrated architecture of the embodied and situated human mind and brain in relation to the development of addictions. This more dynamic conceptualization places addiction in the broader context of the addicted brain that drives behavior, where the addicted brain is the substrate of the addicted mind, that in turn is situated in a physical and socio-cultural environment. From this perspective, neurorehabilitation should shift from a "broken-brain" to a systems theoretical framework, which includes high-level concepts related to the physical and social environment, motivation, self-image, and the meaning of alternative activities, which in turn will dynamically influence subsequent brain adaptations. We call this integrated approach system-oriented neurorehabilitation. We illustrate our proposal by showing the link between addiction and the architecture of the embodied brain, including a systems-level perspective on classical conditioning, which has been successfully translated into neurorehabilitation. Central to this example is the notion that the human brain makes predictions on future states as well as expected (or counterfactual) errors, in the context of its goals. We advocate system-oriented neurorehabilitation of addiction where the patients' goals are central in targeted, personalized assessment and intervention.

Association between adult ADHD, self-report, and behavioral measures of impulsivity and treatment outcome in cocaine use disorder

A large and growing body of literature supports the association between cocaine addiction and impulsivity. The aim of the study was to test whether pretreatment screening for adult ADHD, and self-report and behavioral measures of impulsivity have prognostic utility in clinical practice with cocaine users. We enrolled a cohort of N = 86 treatment-seeking cocaine users, assisted by a public addiction service, in a 24 week study. At baseline, we performed screening for adult ADHD, assessed the presence of co-occurring mental disorders, and applied measures of drug use severity, trait-like impulsivity (Barratt Impulsiveness Scale; BIS-11), decision-making (Iowa Gambling Task; IGT), risk-taking (Balloon Analogue Risk Task; BART), and ability to inhibit cognitive interference (Stroop Color Word Test; SCWT). Patients positive to the screening for ADHD showed a higher level of self-reported impulsivity and a longer history of drug use, but did not differ from those without ADHD in adherence to psychosocial treatments and number of negative urines for cocaine during the 24 weeks. Among all of the self-report and behavioral measures used, only IGT BIS-11 was associated with cocaine abstention. The small effect size and the problematic direction of the associations found do not give strong support to the routine use of self-regulation measures to guide clinical decisions in public addiction treatment settings.

Relative expected value of drugs versus competing rewards underpins vulnerability to and recovery from addiction

Behavioural economic theories of addiction contend that greater expected value of drug relative to alternative non-drug rewards is the core mechanism underpinning vulnerability to and recovery from addiction. To evaluate this claim, we exhaustively review studies with human drug users that have measured concurrent choice between drugs vs. alternative rewards, and explored individual differences. These studies show that drug choice can be modulated by drug cues, drug devaluation, imposition of costs/punishment and negative mood induction. Regarding individual differences, dependence severity was reliably associated with overall drug preference, and self-reported drug use to cope with negative affect was reliably associated with greater sensitivity to mood induced increases in drug choice. By contrast, there were no reliable individual differences in sensitivity to the effect of drug cues, drug devaluation or punishment on drug choice. These findings provide insight into the mechanisms that underpin vulnerability to dependence: vulnerability is conferred by greater relative value ascribed to drugs, and relative drug value is further augmented by negative affective states in those who report drug use coping motives. However, dependence does not appear to be characterised by abnormal cue-reactivity, habit learning or compulsion. We then briefly review emerging literature which demonstrates that therapeutic interventions and recovery from addiction might be attributed to changes in the expected relative value of drug versus alternative rewards. Finally, we outline a speculative computational account of the distortions in decision-making that precede action selection in addiction, and we explain how this account provides a blueprint for future research on the determinants of drug choice, and mechanisms of treatment and recovery from addiction. We conclude that a unified economic decision-making account of addiction has great promise in reconciling diverse addiction theories, and neuropsychological evaluation of the underlying decision mechanisms is a fruitful area for future research and treatment.

The concept of akrasia as the foundation for a dual systems theory of addiction

The aim of this article is to argue that the ancient concept of akrasia can serve as the conceptual foundation and theoretical justification for a dual systems theory of addiction. Akrasia refers to acting against one's better judgement and thus to behaviour that agents know is bad for them and have previously resolved to abjure, addiction being seen as an extreme form of akrasia. In this way akrasia can provide the basis for accounts of addictive behaviour that stress its inconsistency over time and the great difficulty addicts experience in changing it. A definition of addiction consistent with this view is offered and defended, and some of its general advantages for understanding and responding to addiction described. A consequence of defining addiction in this way is that it should be seen as a disorder of choice or, alternatively, of self-regulation, and reasons are given why the latter term should be preferred. It is then proposed that the concept of akrasia and the perspective on addiction that follows from it lead logically to the need for a dual systems theory of addiction. Although no such theory is presented here, terminological issues are clarified, criticisms of dual systems theories are noted, and a rudimentary description of what an integrated dual systems theory of addiction might look like is provided.

Addiction is driven by excessive goal-directed drug choice under negative affect: translational critique of habit and compulsion theory

Drug addiction may be a goal-directed choice driven by excessive drug value in negative affective states, a habit driven by strong stimulus-response associations, or a compulsion driven by insensitivity to costs imposed on drug seeking. Laboratory animal and human evidence for these three theories is evaluated. Excessive goal theory is supported by dependence severity being associated with greater drug choice/economic demand. Drug choice is demonstrably goal-directed (driven by the expected value of the drug) and can be augmented by stress/negative mood induction and withdrawal-effects amplified in those with psychiatric symptoms and drug use coping motives. Furthermore, psychiatric symptoms confer risk of dependence, and coping motives mediate this risk. Habit theory of addiction has weaker support. Habitual behaviour seen in drug-exposed animals often does not occur in complex decision scenarios, or where responding is rewarded, so habit is unlikely to explain most human addictive behaviour where these conditions apply. Furthermore, most human studies have not found greater propensity to habitual behaviour in drug users or as a function of dependence severity, and the minority that have can be explained by task disengagement producing impaired explicit contingency knowledge. Compulsion theory of addiction also has weak support. The persistence of punished drug seeking in animals is better explained by greater drug value (evinced by the association with economic demand) than by insensitivity to costs. Furthermore, human studies have provided weak evidence that propensity to discount cost imposed on drug seeking is associated with dependence severity. These data suggest that human addiction is primarily driven by excessive goal-directed drug choice under negative affect, and less by habit or compulsion. Addiction is pathological because negative states powerfully increase expected drug value acutely outweighing abstinence goals.

Are animal models of addiction useful?

BACKGROUND

Pre-clinical research involving non-human animals has made important contributions to our understanding of risk factors for addiction, neuroadaptations that follow chronic drug exposure and to the development of some efficacious pharmacotherapies for addiction. Despite these contributions, we argue that animal models of addiction have impeded progress in our understanding of addiction and its treatment in humans.

ARGUMENT

First, the majority of pharmacological treatments that were initially developed using animal models have failed to prove effective for the treatment of addiction in humans, resulting in a huge waste of resources. Secondly, we demonstrate that prevailing animal models that portray addiction as a disorder of compulsion and habit cannot be reconciled with observations that psychoactive drug use in humans is a goal-directed operant behaviour that remains under the control of its consequences, even in people who are addicted. Thirdly, addiction may be a uniquely human phenomenon that is dependent on language, which necessarily limits the validity of animal models. Finally, we argue that addicted brains must be understood as one component of broader networks of symptoms and environmental and social factors that are impossible to model in laboratory animals.

CONCLUSIONS

A case can be made that animal models of addiction have not served us well in understanding and treating addiction in humans. It is important to reconsider some widely held beliefs about the nature of addictive behaviour in humans that have arisen from the zeal to translate observations of laboratory animals.

Exploring the contribution of exercise dependence to eating disorder symptoms

OBJECTIVE

Exercise dependence is a set of cognitive and behavioral symptoms that constitute a reliance on exercise and is related to eating disorder (ED) symptoms. There are seven components of exercise dependence: tolerance, withdrawal, continuance, lack of control, reduction in other activities, time, and intention effects. Exercising in response to negative affect (NA) is a key feature of dysfunctional exercise in the EDs. However, it is unknown which specific components of exercise dependence relate to ED symptoms, above and beyond NA.

METHOD

The current study (N = 168 individuals with EDs) investigated which components of exercise dependence relate to ED symptoms both cross-sectionally and prospectively.

RESULTS

In cross-sectional data, we found that withdrawal, tolerance, and time were associated with ED symptoms, above and beyond NA. Prospectively over 1 month, when adjusting for baseline ED symptoms and NA, we found that lack of control, withdrawal, and time positively predicted ED symptoms.

DISCUSSION

These findings inform future research on how exercise dependence relates to ED symptoms, showing that withdrawal and time are uniquely associated with ED symptoms both cross-sectionally and over time.

The Fyn kinase inhibitor, AZD0530, suppresses mouse alcohol self-administration and seeking

Fyn is a member of the Src family of protein tyrosine kinases (PTKs) that plays an important role not only in normal synaptic functions but also in brain pathologies including alcohol use disorder. We previously reported that repeated cycles of binge drinking and withdrawal activate Fyn in the dorsomedial striatum (DMS) of rodents, and that Fyn signaling in the DMS contributes to rat alcohol intake and relapse. Here, we used AZD0530, a CNS penetrable inhibitor of Src PTKs developed for the treatment of Alzheimer disease and cancer and tested its efficacy to suppress alcohol-dependent molecular and behavioral effects. We show that systemic administration of AZD0530 prevents alcohol-induced Fyn activation and GluN2B phosphorylation in the DMS of mice. We further report that a single dose of AZD0530 reduces alcohol operant self-administration and promotes extinction of alcohol self-administration without altering basal and dopamine D1 receptor-dependent locomotion. Together, our findings suggest that AZD0530, through its inhibitory actions on Fyn kinase, dampens alcohol seeking and drinking.

A transdiagnostic dimensional approach towards a neuropsychological assessment for addiction: an international Delphi consensus study

BACKGROUND

The US National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal of improving diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the 'primary' RDoC constructs most relevant to substance and behavioural addictions.

METHODS

Forty-four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions.

RESULTS

Seven constructs were endorsed by ≥ 80% of experts as 'primary' to the understanding of addictive behaviour: five from the Positive Valence System (reward valuation, expectancy, action selection, reward learning, habit); one from the Cognitive Control System (response selection/inhibition); and one expert-initiated construct (compulsivity). These constructs were rated to be related differentially to stages of the addiction cycle, with some linked more closely to addiction onset and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions.

CONCLUSIONS

The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.

Neurocognitive correlates of medication-induced addictive behaviours in Parkinson's disease: A systematic review

Dopaminergic medication can induce severe addictive behaviours (e.g., pathological gambling) in susceptible Parkinson's disease (PD) patients. It is still unknown which particular neurocognitive processes become exacerbated or dysfunctional in PD patients with addictive behaviours. We sought to systematically review the relevant literature to identity potential neurocognitive correlates of medication-induced addictive behaviours in PD. We framed our review around neurocognitive processes central to four dominant accounts of substance addiction: 'aberrant learning', 'incentive sensitization', 'impulsivity to compulsivity' and 'impaired response inhibition and salience attribution'. Searches of the PubMed and Scopus databases were completed on June 23, 2017. To be included, studies were required to involve: (a) medicated PD patients, without a history of deep brain stimulation, with and without addictive behaviours; (b) a reward-related or decision-making task; and (c) statistical comparison of addictive and non-addictive groups' 'on' medication performance on the task(s). Studies were summarised qualitatively with statistically significant (p<.05) group differences and effect sizes (Cohen's d) highlighted. 35 studies were included. Findings showed that the extant literature is highly heterogeneous. The domains of reward and punishment learning, reflection impulsivity and disadvantageous decision-making exemplify this. More homogeneity exists in domains in which (a) neurocognitive dysfunction is not apparent (motor control, cognitive/attentional flexibility and cognitive control) or (b) typical neurocognitive processes appear exacerbated by medication (reward motivation and choice impulsivity). Future large-scale neurocognitive studies are still required to develop our scientific understanding of addictive behaviours in PD and aid their clinical treatment and prediction.

Are Cocaine-Seeking "Habits" Necessary for the Development of Addiction-Like Behavior in Rats?

Drug self-administration models of addiction typically require animals to make the same response (e.g., a lever-press or nose-poke) over and over to procure and take drugs. By their design, such procedures often produce behavior controlled by stimulus-response (S-R) habits. This has supported the notion of addiction as a "drug habit," and has led to considerable advances in our understanding of the neurobiological basis of such behavior. However, to procure such drugs as cocaine, addicts often require considerable ingenuity and flexibility in seeking behavior, which, by definition, precludes the development of habits. To better model drug-seeking behavior in addicts, we first developed a novel cocaine self-administration procedure [puzzle self-administration procedure (PSAP)] that required rats to solve a new puzzle every day to gain access to cocaine, which they then self-administered on an intermittent access (IntA) schedule. Such daily problem-solving precluded the development of S-R seeking habits. We then asked whether prolonged PSAP/IntA experience would nevertheless produce "symptoms of addiction." It did, including escalation of intake, sensitized motivation for drug, continued drug use in the face of adverse consequences, and very robust cue-induced reinstatement of drug seeking, especially in a subset of "addiction-prone" rats. Furthermore, drug-seeking behavior continued to require dopamine neurotransmission in the core of the nucleus accumbens (but not the dorsolateral striatum). We conclude that the development of S-R seeking habits is not necessary for the development of cocaine addiction-like behavior in rats.SIGNIFICANCE STATEMENT Substance-use disorders are often characterized as "habitual" behaviors aimed at obtaining and administering drugs. Although the actions involved in consuming drugs may involve a rigid repertoire of habitual behaviors, evidence suggests that addicts must be very creative and flexible when trying to procure drugs, and thus drug seeking cannot be governed by habit alone. We modeled flexible drug-seeking behavior in rats by requiring animals to solve daily puzzles to gain access to cocaine. We find that habitual drug-seeking isn't necessary for the development of addiction-like behavior, and that our procedure doesn't result in transfer of dopaminergic control from the ventral to dorsal striatum. This approach may prove useful in studying changes in neuropsychological function that promote the transition to addiction.

Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither

This article uses Marc Lewis' work as a springboard to discuss the socio-political context of the brain disease model of addiction (BDMA). The claim that promotion of the BDMA is the only way the general public can be persuaded to withhold blame and punishment from addicts is critically examined. After a discussion of public understandings of the disease concept of addiction, it is pointed out that it is possible to develop a scientific account of addiction which is neither a disease nor a moral model but which the public could understand. Evidence is reviewed to suggest that public acceptance of the disease concept is largely lip-service and that the claim the BDMA removes stigma among the public and professionals is unsupported by evidence. Further, there is good evidence that biogenetic explanations of mental/behavioural disorders in general have been counterproductive in the attempt to ally stigma. A model of addiction as a disorder of choice may attract special problems in public-facing communications and risks being misunderstood. However, ways of presenting this model to the public are suggested that may avoid such risks. Lastly, the claim that the BDMA is the only way of ensuring access to treatment and of maintaining research funding for addiction is disputed and a way in which these benefits can be retained under a disorder-of-choice model proposed. The article concludes by enthusiastically endorsing Lewis' call for a third stage in the governing image of addiction.