A scale-free systems theory of motivation and addiction

Proposing an integrative, dynamic and transdiagnostic model for addictions: dysregulation phenomena of the three main modes of the predostatic mind

Several theories have been proposed to explain the complex diagnostic aspects related to addiction disorders and their development. Recent frameworks tend to focus on dimensional perspectives of symptoms rather than categorical systems, since substance use disorders are frequently comorbid with other psychiatric and especially personality disorders. However, useful transdiagnostic models that could integrate clinical evaluation derived from neuroscientific theories are lacking. In the present manuscript, the authors propose a model based on a new paradigm, in an attempt to better explain this complex, multifaceted phenomenon. The new paradigm presupposes that emotions and behavior are a response to risk prediction. Individuals make choices and engage in actions to manage potential risks/rewards in order to seek or maintain homeostasis in their internal and external environments - a mechanism that the authors call predostatic (predictive mechanism with homeostatic purpose). The model considers three main modes of the predostatic mind: (1) Alarm Mode, activated by high and/or imminent risk prediction; (2) Seek Mode, activated by long-term risk or reward prediction; and (3) Balance Mode, a self-regulating state of mind related to low risk prediction, a soothing system and a calm state. Addiction is seen as a chronic dysregulation of organism systems leading to internalizing or externalizing phenomena mainly related to the Seek and Alarm Modes, which are persistently activated by reward and risk prediction, respectively, thus hindering Balance. Addiction neuroscience research has shown that chronic drug use or engagement in addictive behaviors can lead to neuroadaptations in the brain reward circuitry, disrupting normal balance and the regulation of reward processes. This dysregulation can contribute to persistent drug-seeking/addictive behaviors despite negative consequences. This newly proposed dynamic and integrative model, named dysregulation based on externalizing and internalizing phenomena of the three main modes of the predostatic mind (DREXI3), proposes six dysregulation dimensions with basic emotional and behavioral symptoms, such as neurophysiological alterations, impulsivity, compulsion, cognitive impairment/psychosis, mood, and anxiety/anger. In this paper, the authors explain the rationale behind DREXI3 and present some hypothetical clinical examples to better illustrate the use of the model in clinical practice. The development of this innovative model could possibly guide tailored treatment interventions in the addiction field.

Deep Network Pharmacology: Targeting Glutamate Systems as Integrative Treatments for Jump-Starting Neural Networks and Recovery Trajectories

Significant advances in pharmacological treatments for mental illness and addiction will require abandoning old monoaminergic theories of psychiatric disorders and traditionally narrow approaches to how we conduct treatment research. Reframing our efforts with a view on integrative treatments that target core neural network function and plasticity may provide new approaches for lifting patients out of chronic psychiatric symptom sets and addiction. For example, we discuss new treatments that target brain glutamate systems at key transition points within longitudinal courses of care that integrate several treatment modalities. A reconsideration of what our novel and already available medications are intended to achieve and how and when we deliver them for patients with complex illness trajectories could be the key to unlocking new advances in general and addiction psychiatry.

Treating Opioid Use Disorder in Peripartum Mothers: A Look at the Psychodynamics, Neurobiology, and Potential Role of Oxytocin

The peripartum period (pregnancy and postpartum) is a unique time filled with psychodynamic and biological changes that are critical in affecting the lives of mother and baby. Attachment, the biologically based emotional connection between a caregiver and infant, is critical to the development of the child. The early interactions in an infant's life shape their reward neuro-circuitry and the development of their internal working models and styles of attachment. Opioid use disorders in the mother affect the psychodynamics and neurobiology of attachment. There is significant overlap between the neurobiology of attachment and that of opioid use disorders. In this article, we hope to describe how opioid use disorders affect mother-infant attachment and how psychodynamic psychotherapy that is informed by attachment theory may be a potential treatment for mothers with opioid use disorders. Further, oxytocin plays a role in the attachment process and may function abnormally in mothers with opioid use disorders. As oxytocin affects attachment, administration of oxytocin during postpartum mother-infant interactions in the setting of psychotherapy may facilitate bonding and promote recovery from opioid use disorders in the peripartum population.

Integrated Effects of Neonatal Ventral Hippocampal Lesions and Impoverished Social-Environmental Rearing on Endophenotypes of Mental Illness and Addiction Vulnerability

A wide range of mental illnesses show high rates of addiction comorbidities regardless of their genetic, neurodevelopmental, and/or adverse-environmental etiologies. Understanding how the spectrum of mental illnesses produce addiction vulnerability will be key to discovering more effective preventions and integrated treatments for adults with addiction and dual diagnosis comorbidities. A population of 131 rats containing a spectrum of etiological mental illness models and degrees of severity was experimentally generated by crossing neonatal ventral hippocampal lesions (NVHL; n = 68) or controls (SHAM-operated; n = 63) with adolescent rearing in environmentally/socially enriched (ENR; n = 66) or impoverished (IMP; n = 65) conditions. This population was divided into 2 experiments: first, examining NVHL and IMP effects on novelty and mild stress-induced locomotion across 3 adolescent ages; second, looking at initial cocaine reactivity and long-term cocaine behavioral sensitization in adulthood. NVHL and IMP-environmental conditions independently produced remarkably similar and robustly significant abnormalities of hyperreactivity to novelty, mild stress, and long-term cocaine sensitization. The combined NVHL-IMP groups showed the most severe phenotypes across the board, so that the mental illness and addiction vulnerability phenotypes increased together in severity in a consistent stepwise progression from the healthiest rats to those with the greatest loading of etiological models. These findings add weight to our understanding of mental illness and addiction vulnerability as brain disorders that are biologically and developmentally unified in ways that transcend etiological causes, and yet co-intensify with increased loading of etiological conditions. Combining neurodevelopmental and adverse-environmental models of mental illness may provide an approach to identifying and therapeutically targeting cortical-striatal-limbic network mechanisms that generate addiction and dual diagnosis diseases.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.

Alteration to hippocampal volume and shape confined to cannabis dependence: a multi-site study

Cannabis use is highly prevalent and often considered to be relatively harmless. Nonetheless, a subset of regular cannabis users may develop dependence, experiencing poorer quality of life and greater mental health problems relative to non-dependent users. The neuroanatomy characterizing cannabis use versus dependence is poorly understood. We aimed to delineate the contributing role of cannabis use and dependence on morphology of the hippocampus, one of the most consistently altered brain regions in cannabis users, in a large multi-site dataset aggregated across four research sites. We compared hippocampal volume and vertex-level hippocampal shape differences (1) between 121 non-using controls and 140 cannabis users; (2) between 106 controls, 50 non-dependent users and 70 dependent users; and (3) between a subset of 41 controls, 41 non-dependent users and 41 dependent users, matched on sample characteristics and cannabis use pattern (onset age and dosage). Cannabis users did not differ from controls in hippocampal volume or shape. However, cannabis-dependent users had significantly smaller right and left hippocampi relative to controls and non-dependent users, irrespective of cannabis dosage. Shape analysis indicated localized deflations in the superior-medial body of the hippocampus. Our findings support neuroscientific theories postulating dependence-specific neuroadaptations in cannabis users. Future efforts should uncover the neurobiological risk and liabilities separating dependent and non-dependent use of cannabis.

On Mourning and Recovery: Integrating Stages of Grief and Change Toward a Neuroscience-Based Model of Attachment Adaptation in Addiction Treatment

Interpersonal attachment and drug addiction share many attributes across their behavioral and neurobiological domains. Understanding the overlapping brain circuitry of attachment formation and addiction illuminates a deeper understanding of the pathogenesis of trauma-related mental illnesses and comorbid substance use disorders, and the extent to which ending an addiction is complicated by being a sort of mourning process. Attention to the process of addiction recovery-as a form of grieving-in which Kubler-Ross's stages of grief and Prochaska's stages of change are ultimately describing complementary viewpoints on a general process of neural network and attachment remodeling, could lead to more effective and integrative psychotherapy and medication strategies.

Substance use associated with short sleep duration in patients with schizophrenia or schizoaffective disorder

STUDY OBJECTIVES

To examine the association between substance use and short sleep duration in individuals with schizophrenia or schizoaffective disorder, depressive type (SADD).

DESIGN

Cross-sectional, retrospective study.

SETTING

Urban, suburban, and rural centers across the United States.

PARTICIPANTS

2,462 consented, adult individuals with schizophrenia or schizoaffective disorder, depressive type (SADD). Participants included inpatients in acute or chronic care settings as well as outpatients and residents in community dwellings.

MEASUREMENTS

Substance use was assessed with 10 questions adopted from well-validated measures (e.g., CAGE questionnaire) for alcohol, marijuana, and illicit drugs. Short sleep duration was defined as <6 hr of self-reported sleep per night.

RESULTS

Close to 100% of our sample used nicotine while 83% used substances other than nicotine. More importantly, there was a significant association between substance use and short sleep duration. Interestingly, this association was strongest among African-Americans with schizophrenia or SADD.

CONCLUSIONS

Because psychiatric medications often target chemical receptors involved with both sleep and substance use, understanding the association between short sleep duration and substance use in individuals with schizophrenia and SADD is important. Given that the majority of premature deaths in individuals with psychotic illness are due to medical conditions associated with modifiable risk factors, prospective studies designed to examine the effect of short sleep duration on behaviors like substance use should be undertaken. Finally, analyzing genetic and environmental data in a future study might help illuminate the strong association found between short sleep duration and substance use in African-Americans with schizophrenia and SADD. © 2015 Wiley Periodicals, Inc.

Toward early estimation and treatment of addiction vulnerability: radial arm maze and N-acetyl cysteine before cocaine sensitization or nicotine self-administration in neonatal ventral hippocampal lesion rats

RATIONAL

Prefrontal cortical (PFC)-hippocampal-striatal circuits, interconnected via glutamatergic signaling, are dysfunctional in mental illnesses that involve addiction vulnerability.

OBJECTIVES

In healthy and neurodevelopmentally altered rats, we examined how Radial Arm Maze (RAM) performance estimates addiction vulnerability, and how starting a glutamatergic modulating agent, N-acetyl cysteine (NAC) in adolescence alters adult mental illness and/or addiction phenotypes.

METHODS

Rats with neonatal ventral hippocampal lesions (NVHL) vs. SHAM-operated controls were randomized to NAC vs. saline in adolescence followed by cognitive testing (RAM) in early adulthood and then cocaine behavioral sensitization (experiment 1; n = 80) or nicotine self-administration (experiment 2; n = 12).

RESULTS

In experiment 1, NVHL rats showed over-consumption of food (Froot-Loops (FL)) baiting the RAM with poor working memory (low-arm entries to repeat (ETR)), producing an elevated FL to ETR ratio ("FLETR"; p < 0.001). FLETR was the best linear estimator (compared to FL or ETR) of magnitude of long-term cocaine sensitization (R ² = 0.14, p < 0.001). NAC treatment did not alter FL, ETR, FLETR, or cocaine sensitization. In experiment 2, FLETR also significantly and uniquely correlated with subsequent drug seeking during nicotine-induced reinstatement after extinction of nicotine self-administration (R ² = 0.47, p < 0.01). NAC did not alter RAM performance, but significantly reversed NVHL-induced increases in nicotine seeking during extinction and reinstatement.

CONCLUSIONS

These findings demonstrate the utility of animal models of mental illness with addiction vulnerability for developing novel diagnostic measures of PFC-hippocampal-striatal circuit dysfunction that may reflect addiction risk. Such tests may direct pharmacological treatments prior to adulthood and addictive drug exposure, to prevent or treat adult addictions.

Metacognition in persons with substance abuse: Findings and implications for occupational therapists

Background

Addiction is a massive public health problem in which a person’s occupational life is compromised and metacognition is impaired. Occupational therapists may play a critical role in addiction rehabilitation, but more information about patterns of metacognitive deficit co-occurring with addictive behaviour is needed to develop interventions that specifically target these impairments.

Purpose

This study examined whether persons with addiction(s) demonstrated specific patterns of metacognitive deficit on four subscales of metacognition measuring self-reflectivity, understanding others’ thoughts, decentration, and mastery.

Method

Using a mixed-methods design, qualitative data were obtained via the Indiana Psychiatric Illness Interview, which was then rated using a quantitative scale, the Metacognition Assessment Scale–Abbreviated.

Findings

Persons with addiction(s) demonstrated significant impairments in metacognitive mastery but not other areas of metacognition.

Implications

Occupational therapy interventions for addiction should focus on improving metacognitive mastery. Future efficacy studies of interventions to improve mastery and overall outcomes are warranted.

Gambling disorder and other behavioral addictions: recognition and treatment

Addiction professionals and the public are recognizing that certain nonsubstance behaviors--such as gambling, Internet use, video-game playing, sex, eating, and shopping--bear resemblance to alcohol and drug dependence. Growing evidence suggests that these behaviors warrant consideration as nonsubstance or "behavioral" addictions and has led to the newly introduced diagnostic category "Substance-Related and Addictive Disorders" in DSM-5. At present, only gambling disorder has been placed in this category, with insufficient data for other proposed behavioral addictions to justify their inclusion. This review summarizes recent advances in our understanding of behavioral addictions, describes treatment considerations, and addresses future directions. Current evidence points to overlaps between behavioral and substance-related addictions in phenomenology, epidemiology, comorbidity, neurobiological mechanisms, genetic contributions, responses to treatments, and prevention efforts. Differences also exist. Recognizing behavioral addictions and developing appropriate diagnostic criteria are important in order to increase awareness of these disorders and to further prevention and treatment strategies.

Transcranial magnetic stimulation: potential treatment for co-occurring alcohol, traumatic brain injury and posttraumatic stress disorders

Alcohol use disorder (AUD), mild traumatic brain injury (mTBI), and posttraumatic stress disorder (PTSD) commonly co-occur (AUD + mTBI + PTSD). These conditions have overlapping symptoms which are, in part, reflective of overlapping neuropathology. These conditions become problematic because their co-occurrence can exacerbate symptoms. Therefore, treatments must be developed that are inclusive to all three conditions. Repetitive transcranial magnetic stimulation (rTMS) is non-invasive and may be an ideal treatment for co-occurring AUD + mTBI + PTSD. There is accumulating evidence on rTMS as a treatment for people with AUD, mTBI, and PTSD each alone. However, there are no published studies to date on rTMS as a treatment for co-occurring AUD + mTBI + PTSD. This review article advances the knowledge base for rTMS as a treatment for AUD + mTBI + PTSD. This review provides background information about these co-occurring conditions as well as rTMS. The existing literature on rTMS as a treatment for people with AUD, TBI, and PTSD each alone is reviewed. Finally, neurobiological findings in support of a theoretical model are discussed to inform TMS as a treatment for co-occurring AUD + mTBI + PTSD. The peer-reviewed literature was identified by targeted literature searches using PubMed and supplemented by cross-referencing the bibliographies of relevant review articles. The existing evidence on rTMS as a treatment for these conditions in isolation, coupled with the overlapping neuropathology and symptomology of these conditions, suggests that rTMS may be well suited for the treatment of these conditions together.

Future pharmacological treatments for substance use disorders

Substance use disorders represent a serious public health and social issue worldwide. Recent advances in our understanding of the neurobiological basis of the addictive processes have led to the development of a growing number of pharmacological agents to treat addictions. Despite this progress, there are no approved pharmacological treatments for cocaine, methamphetamine and cannabis addiction. Moving treatment development to the next stage will require novel ways of approaching substance use disorders. One such novel approach is to target individual vulnerabilities, such as cognitive function, sex differences and psychiatric comorbidities. This review provides a summary of promising pharmacotherapies for alcohol, opiate, stimulant and nicotine addictions. Many medications that target positive and negative reinforcement of drugs, as well as individual vulnerabilities to addiction, are in different phases of development. Clinical trials testing the efficacy of these medications for substance use disorder are warranted.

Neurobiology of adolescent substance use and addictive behaviors: treatment implications

Psychoactive substance and nonsubstance/behavioral addictions are major public health concerns associated with significant societal cost. Adolescence is a period of dynamic biologic, psychological, and behavioral changes. Adolescence is also associated with an increased risk for substance use and addictive disorders. During adolescence, developmental changes in neural circuitry of reward processing, motivation, cognitive control, and stress may contribute to vulnerability for increased levels of engagement in substance use and nonsubstance addictive behaviors. Current biologic models of adolescent vulnerability for addictions incorporate existing data on allostatic changes in function and structure of the midbrain dopaminergic system, stress-associated neuroplasticity, and maturational imbalances between cognitive control and reward reactivity. When characterizing adolescent vulnerability, identifying subgroups of adolescents at high risk for addictive behaviors is a major goal of the addiction field. Genetics, epigenetics, and intermediate phenotypes/endophenotypes may assist in characterizing children and adolescents at risk. Improved understanding of the neurobiology of adolescence and addiction vulnerability has the potential to refine screening, enhance prevention and intervention strategies, and inform public policy.

Activity in dlPFC and its effective connectivity to vmPFC are associated with temporal discounting

There is widespread interest in identifying computational and neurobiological mechanisms that influence the ability to choose long-term benefits over more proximal and readily available rewards in domains such as dietary and economic choice. We present the results of a human fMRI study that examines how neural activity relates to observed individual differences in the discounting of future rewards during an intertemporal monetary choice task. We found that a region of left dorsolateral prefrontal cortex (dlPFC) BA-46 was more active in trials where subjects chose delayed rewards, after controlling for the subjective value of those rewards. We also found that the connectivity from dlPFC BA-46 to a region of ventromedial prefrontal cortex (vmPFC) widely associated with the computation of stimulus values, increased at the time of choice, and especially during trials in which subjects chose delayed rewards. Finally, we found that estimates of effective connectivity between these two regions played a critical role in predicting out-of-sample, between-subject differences in discount rates. Together with previous findings in dietary choice, these results suggest that a common set of computational and neurobiological mechanisms facilitate choices in favor of long-term reward in both settings.

Making choice between competing rewards in uncertain vs. safe social environment: role of neuronal nicotinic receptors of acetylcholine

In social environments, choosing between multiple rewards is modulated by the uncertainty of the situation. Here, we compared how mice interact with a conspecific and how they use acoustic communication during this interaction in a three chambers task (no social threat was possible) and a Social Interaction Task, SIT (uncertain situation as two mice interact freely). We further manipulated the motivational state of the mice to see how they rank natural rewards such as social contact, food, and novelty seeking. We previously showed that beta2-subunit containing nicotinic receptors-β2(*)nAChRs- are required for establishing reward ranking between social interaction, novelty exploration, and food consumption in social situations with high uncertainty. Knockout mice for β2(*)nAChRs-β2(-/-)mice- exhibit profound impairment in making social flexible choices, as compared to control -WT- mice. Our current data shows that being confronted with a conspecific in a socially safe environment as compared to a more uncertain environment, drastically reduced communication between the two mice, and changed their way to deal with a social conspecific. Furthermore, we demonstrated for the first time, that β2(-/-) mice had the same motivational ranking than WT mice when placed in a socially safe environment. Therefore, β2(*)nAChRs are not necessary for integrating social information or social rewards per se, but are important for making choices, only in a socially uncertain environment. This seems particularly important in the context of Social Neuroscience, as numerous animal models are used to provide novel insights and to test promising novel treatments of human pathologies affecting social and communication processes, among which Autistic spectrum disorders and schizophrenia.

Adult hippocampal neurogenesis in the pathogenesis of addiction and dual diagnosis disorders

BACKGROUND

As knowledge deepens about how new neurons are born, differentiate, and wire into the adult mammalian brain, growing evidence depicts hippocampal neurogenesis as a special form of neuroplasticity that may be impaired across psychiatric disorders. This review provides an integrated-evidence based framework describing a neurogenic basis for addictions and addiction vulnerability in mental illness.

METHODS

Basic studies conducted over the last decade examining the effects of addictive drugs on adult neurogenesis and the impact of neurogenic activity on addictive behavior were compiled and integrated with relevant neurocomputational and human studies.

RESULTS

While suppression of hippocampal neurogenic proliferation appears to be a universal property of addictive drugs, the pathophysiology of addictions involves neuroadaptative processes within frontal-cortical-striatal motivation circuits that the neurogenic hippocampus regulates via direct projections. States of suppressed neurogenic activity may simultaneously underlie psychiatric and cognitive symptoms, but also confer or signify hippocampal dysfunction that heightens addiction vulnerability in mental illness as a basis for dual diagnosis disorders.

CONCLUSIONS

Research on pharmacological, behavioral and experiential strategies that enhance adaptive regulation of hippocampal neurogenesis holds potential in advancing preventative and integrative treatment strategies for addictions and dual diagnosis disorders.

Biological contributions to addictions in adolescents and adults: prevention, treatment, and policy implications

PURPOSE

Despite significant advances in our understanding of the biological bases of addictions, these disorders continue to represent a huge public health burden that is associated with substantial personal suffering. Efforts to target addictions require consideration of how the improved biological understanding of addictions may lead to improved prevention, treatment, and policy initiatives.

METHOD

In this article, we provide a narrative review of current biological models for addictions with a goal of placing existing data and theories within a translational and developmental framework targeting the advancement of prevention, treatment, and policy strategies.

RESULTS

Data regarding individual differences, intermediary phenotypes, and main and interactive influences of genetic and environmental contributions in the setting of developmental trajectories that may be influenced by addictive drugs or behavior indicate complex underpinnings of addictions.

CONCLUSIONS

Consideration and further elucidation of the biological etiologies of addictions hold significant potential for making important gains and reducing the public health impact of addictions.

Roles of nucleus accumbens CREB and dynorphin in dysregulation of motivation

Psychostimulants such as amphetamine and cocaine are believed to produce dependence by causing rapid, supraphysiological elevations in synaptic dopamine (DA) within the nucleus accumbens (NAc) (Volkow et al. 2009, Neuropharmacology 56: 3-8). These changes in forebrain DA transmission are similar to those evoked by natural reinforcers (Louilot et al. 1991, Brain Res 553: 313-317; Roitman et al. 2004, J Neurosci 24: 1265-1271), but are of greater magnitude and longer duration. Repeated drug exposure causes compensatory neuroadaptations in neurons of the NAc, some of which may modulate excess DA in a homeostatic fashion. One such adaptation is the activation of the transcription factor CREB (cAMP response element-binding protein) within neurons of the NAc. Although elevated levels of transcriptionally active CREB appear to attenuate DA transmission by increasing expression of the endogenous κ opioid receptor (KOR) ligand dynorphin, increased dynorphin transmission may ultimately have undesirable effects that contribute to drug withdrawal states as well as comorbid psychiatric illnesses such as depression. This state may prompt a return to drug use to mitigate the adverse effects of withdrawal. This article summarizes our current understanding of how CREB and dynorphin contribute to the dysregulation of motivation and describes novel therapeutic strategies that derive from preclinical research in this area.

The Addiction Psychiatrist as Dual Diagnosis Physician: A Profession in Great Need and Greatly Needed

Addiction is the number one cause of premature illness and death in the U.S., especially among people with mental illness. Yet American medicine lacks sufficient workforce capacity, expertise, training, infrastructure, and research to support treatment for people with co-occurring addictions and mental illness. This essay argues that the addiction psychiatrist is essential in dual diagnosis care.

Problematic Internet Use, Mental Health and Impulse Control in an Online Survey of Adults

BACKGROUND AND AIMS

Internet use has become a popular entertainment source and has become highly integrated into daily life. However, some people display problematic or addictive usage of the Internet. The present study attempts to fill current knowledge gaps regarding at-risk/problematic Internet use (ARPIU) and its relation to various health and functioning measures.

METHODS

Online survey data from 755 adults in the United States were analyzed using chi-square and ANOVAs.

RESULTS

The ARPIU group did not differ from the non-ARPIU group with respect to substance use. Individuals with ARPIU were, however, more likely to report at-risk/problematic engagement in video-game playing and gambling. Compared to the non-ARPIU group, the ARPIU group reported poorer self-control and higher levels of impulsivity and depression.

CONCLUSIONS

ARPIU appears associated with other risk behaviors, particularly those that might be performed on the Internet. Future studies should examine the extent to which the Internet may promote engagement in these risk behaviors and the extent to which preventative interventions targeting better self-control or negative mood states might help a range of non-substance-related addictive behaviors.

Are Internet use and video-game-playing addictive behaviors? Biological, clinical and public health implications for youths and adults

Internet use and video-game playing are experiencing rapid growth among both youth and adult populations. Research suggests that a minority of users experience symptoms traditionally associated with substance-related addictions. Mental health professionals, policy makers and the general public continue to debate the issue of Internet addiction (IA) and problematic video-game playing (PVG). This review identifies existing studies into the clinical and biological characteristics of these disorders that may help guide decisions as to whether or not IA and PVG should be grouped together with substance use disorders (SUDs).

Psychiatric disease and drug abuse

PURPOSE OF REVIEW

The term 'dual diagnosis' most commonly refers to the combination of severe mental illness and substance-use disorder (SUD). It is estimated that 7-10 million people in the USA alone have at a minimum one psychiatric disorder in addition to a SUD. As many of the psychiatric illnesses implicated have their origins in childhood, the pediatric population is not immune to this 'dual diagnosis', particularly with the increasing availability of street drugs and increasing accessibility to prescription drugs. The purpose of this review is to identify the magnitude of the problem and strengthen awareness among pediatric healthcare professionals who may provide prevention and/or early intervention.

RECENT FINDINGS

Causes for the dual diagnosis are unknown, but there are four hypotheses: common factors (risk factors common to both disorders), secondary mental disorder (substance use precipitates mental disorder), secondary substance use ('self-medication hypothesis') and bidirectional (presence of either mental illness or SUD can contribute to the development of the other).

SUMMARY

Those with the presence of this dual diagnosis are more likely to be nonadherent to treatment and may well have poorer outcomes. Integrated care for the maladies rather than split or isolated care is recommended. Psychosocial therapy holds promise for treating patients with dual diagnosis.

Beta2-containing neuronal nicotinic receptors as major actors in the flexible choice between conflicting motivations

Beside a critical role in nicotine addiction, the role of nicotinic receptors in cognitive or emotional processes remains difficult to elucidate, mostly because of a lack of specificity of compounds and because they up or down regulate easily. Using knockout mice may be one key to elucidate the role of nicotinic receptors stimulated by their endogenous ligand acetylcholine. We and others have previously explored the behaviour of mice knockout for the beta2-subunit containing nicotinic receptor - β2*nAChRs - β2(-/-) mice. These mice exhibit a particular kind of hyperactive locomotion, with profound deficits in cognitive and social interaction tasks, only when they have to show flexible choices. We wonder here whether the latter is due to a lack of motor control - i.e. motor impulsivity, a lack of estimation of reward value - i.e. cognitive impulsivity, and/or a lack of appropriate ranking or choice between different motivations. We designed behavioural tasks allowing the study of these distinct processes in mice. Our current results highlight the important role of β2*nAChRs in flexible behaviours in conflicting situations, such as social contact, spatial exploration and food consumption. They also show that the cognitive deficits exhibited by β2(-/-) mice cannot be explained by impaired inhibitory behaviours. Although social cognition is considerably enriched in humans as compared to rodents, we provide here novel data for the neurobiology of flexible social behaviours that could ultimately be useful for humans. Indeed, the ability to show flexible behaviours and to display adapted social interactions is profoundly impaired in a myriad of psychiatric disorders.

Neuroscience of behavioral and pharmacological treatments for addictions

Although substantial advances have been made in behavioral and pharmacological treatments for addictions, moving treatment development to the next stage may require novel ways of approaching addictions, particularly ways based on new findings regarding the neurobiological underpinnings of addictions that also assimilate and incorporate relevant information from earlier approaches. In this review, we first briefly review theoretical and biological models of addiction and then describe existing behavioral and pharmacologic therapies for the addictions within this framework. We then propose new directions for treatment development and targets that are informed by recent evidence regarding the heterogeneity of addictions and the neurobiological contributions to these disorders.

Maternal neural responses to infant cries and faces: relationships with substance use

Substance abuse in pregnant and recently post-partum women is a major public health concern because of effects on the infant and on the ability of the adult to care for the infant. In addition to the negative health effects of teratogenic substances on fetal development, substance use can contribute to difficulties associated with the social and behavioral aspects of parenting. Neural circuits associated with parenting behavior overlap with circuits involved in addiction (e.g., frontal, striatal, and limbic systems) and thus may be co-opted for the craving/reward cycle associated with substance use and abuse and be less available for parenting. The current study investigates the degree to which neural circuits associated with parenting are disrupted in mothers who are substance-using. Specifically, we used functional magnetic resonance imaging to examine the neural response to emotional infant cues (faces and cries) in substance-using compared to non-using mothers. In response to both faces (of varying emotional valence) and cries (of varying distress levels), substance-using mothers evidenced reduced neural activation in regions that have been previously implicated in reward and motivation as well as regions involved in cognitive control. Specifically, in response to faces, substance users showed reduced activation in prefrontal regions, including the dorsolateral and ventromedial prefrontal cortices, as well as visual processing (occipital lobes) and limbic regions (parahippocampus and amygdala). Similarly, in response to infant cries, substance-using mothers showed reduced activation relative to non-using mothers in prefrontal regions, auditory sensory processing regions, insula and limbic regions (parahippocampus and amygdala). These findings suggest that infant stimuli may be less salient for substance-using mothers, and such reduced saliency may impair developing infant-caregiver attachment and the ability of mothers to respond appropriately to their infants.

Non-substance-addictive behaviors in youth: pathological gambling and problematic Internet use

Adolescence is characterized by participation in multiple novel and potentially risky behaviors. Amongst these behaviors are gambling and use of the Internet, and excessive engagement in these activities (as seen in pathological gambling and problematic Internet use) may be accompanied by serious impairments in school, mental health, and social functioning. This article reviews the potential impact of pathological gambling and problematic Internet use in youth, the relevance of subsyndromal levels of participation, and how prevention and treatment strategies may be considered and tested within a developmental framework.

Cortical-striatal integration of cocaine history and prefrontal dysfunction in animal modeling of dual diagnosis

BACKGROUND

High rates of substance disorders in schizophrenia and other mental illnesses may reflect biological vulnerabilities to the addiction process. Interactions between addictive drug effects and mental illness involving circuits that generate motivated behavior may underpin this vulnerability.

METHODS

We examined separate and combined effects of neonatal ventral hippocampal lesions (NVHLs)-a neurodevelopmental model of schizophrenia (vs. SHAM-operated control animals)--and a behaviorally sensitizing cocaine history (15 mg/kg/day x 5 days vs. saline injections) on acute cocaine-induced neural activation signaled by c-Fos expression. Stereological assessment of activation densities spanned six ventral to dorsal cortical-striatal compartments.

RESULTS

Cortically, NVHLs showed hypoactivation and decreased volume of the ventral medial prefrontal cortex. In contrast, cocaine history was only expressed subcortically and as a hyperactivating effect in the dorsal striatum where significant NVHL-induced hyperactivation also emerged. Across all subjects and brain regions, only dorsal striatal activation was correlated with differences in sensitized locomotion. However, this activation was tightly correlated to a simple multiplicative function of ventral medial prefrontal hypoactivation and cocaine history-related increases in striatal activation.

CONCLUSIONS

These findings suggest drug history and developmental temporal limbic abnormalities associated with prefrontal dysfunction produce compounding effects within cortical-striatal circuits as mechanistic basis for dual diagnosis.

The relationship between impulse-control disorders and obsessive-compulsive disorder: a current understanding and future research directions

Impulse-control disorders (ICDs) constitute a heterogeneous group of conditions linked diagnostically by difficulties in resisting "the impulse, drive, or temptation to perform an act that is harmful to the person or to others." Specific ICDs share clinical, phenomenological and biological features with obsessive-compulsive disorder (OCD) that have suggested that these disorders might be categorized together. However, other data suggest significant differences between OCD and ICDs. In this article, clinical, phenomenological and biological features of the formal ICDs are reviewed and compared and contrasted with those of OCD. Available data indicate substantial differences between ICDs and OCD that suggest independent categorizations. Existing research gaps are identified and avenues for future research suggested.

Toward the Study of Trans-Disease Processes: A Novel Approach With Special Reference to the Study of Co-morbidity

The objective of this article was to propose a novel approach, referred to as the study of trans-disease processes (TDPs), to the neuroscientific study of disease processes in general and to co-morbid diseases in particular. The features of this approach are outlined; one potential TDP-delay discounting, which may help account for the co-morbidity of cigarette smoking and schizophrenia-is explored; and the concept of TDPs is contrasted with the concept of endophenotypes. TDPs have the potential for a variety of positive impacts on science.

Psychiatric comorbidities and schizophrenia

Psychiatric comorbidities are common among patients with schizophrenia. Substance abuse comorbidity predominates. Anxiety and depressive symptoms are also very common throughout the course of illness, with an estimated prevalence of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for obsessive-compulsive disorder. It is estimated that comorbid depression occurs in 50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime diagnosis of comorbid substance abuse. This article chronicles these associations, examining whether these comorbidities are "more than chance" and might represent (distinct) phenotypes of schizophrenia. Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder. Additional studies in newly diagnosed antipsychotic-naive patients and their first-degree relatives and searches for genetic and environmental risk factors are needed to replicate preliminary findings and further investigate these associations.

Behavioral and neurological foundations for the moral and legal implications of intoxication, addictive behaviors and disinhibition

Disinhibition and addictive behaviors are related and carry moral implications. Both typically involve diminished consideration of negative consequences, which may result in harm to oneself or others. Disinhibition may occur on state and trait levels, and addictive substances may elicit disinhibitory states, particularly when intoxication is reached. Data suggest that trait disinhibition and addictions may be conceptualized as involving misdirected motivation with underlying biological bases including genetic factors, alterations in neurotransmitter systems and differences in regional brain function. The influences of intoxication on the brain share similarities with cognitive impairments in individuals with chronic substance abuse and those with trait disinhibition related to frontal lobe injuries. These findings raise questions about volitional impairment and morality. Although impaired volition related to disinhibition and addictive behaviors has been studied from multiple perspectives, additional research is needed to further characterize mechanisms of impairment. Such findings may have important implications in multiple legal and psychiatric domains.

Review. The neurobiology of pathological gambling and drug addiction: an overview and new findings

Gambling is a prevalent recreational behaviour. Approximately 5% of adults have been estimated to experience problems with gambling. The most severe form of gambling, pathological gambling (PG), is recognized as a mental health condition. Two alternate non-mutually exclusive conceptualizations of PG have considered it as an obsessive-compulsive spectrum disorder and a 'behavioural' addiction. The most appropriate conceptualization of PG has important theoretical and practical implications. Data suggest a closer relationship between PG and substance use disorders than exists between PG and obsessive-compulsive disorder. This paper will review data on the neurobiology of PG, consider its conceptualization as a behavioural addiction, discuss impulsivity as an underlying construct, and present new brain imaging findings investigating the neural correlates of craving states in PG as compared to those in cocaine dependence. Implications for prevention and treatment strategies will be discussed.

Impulsivity, dual diagnosis, and the structure of motivated behavior in addiction

Defining brain mechanisms that control and adapt motivated behavior will not only advance addiction treatment. It will help society see that addiction is a disease that erodes free will, rather than representing a free will that asks for or deserves consequences of drug-use choices. This science has important implications for understanding addiction's comorbidity in mental illness and reducing associated public health and criminal justice burdens.

Addiction as vulnerabilities in the decision process

In our target article, we proposed that addiction could be envisioned as misperformance of a decision-making machinery described by two systems (deliberative and habit systems). Several commentators have argued that Pavlovian learning also produces actions. We agree and note that Pavlovian action-selection will provide several additional vulnerabilities. Several commentators have suggested that addiction arises from sociological parameters. We note in our response how sociological effects can change decision-making variables to provide additional vulnerabilities. Commentators generally have agreed that our theory provides a framework within which to site addiction and treatment, but additional work will be needed to determine whether our taxonomy will help identify and treat subpopulations within the addicted community.

Addiction science as a hedgehog and as a fox

Redish et al. provide a significant advance in our understanding of addiction by showing that the various addictive processes are in fact all decision-making processes and each may undergird addiction. We propose means for identifying more central addiction processes. This recognition of the complexity of addiction followed by identification of more central processes would help guide the development of prevention and treatment.