A developmental model of addictions: integrating neurobiological and psychodynamic theories through the lens of attachment

Supporting positive parenting among pregnant people in recovery from opioid use disorder: Introducing family check‐up–prenatal

Opioid use disorder (OUD) among pregnant people has increased dramatically during the opioid epidemic, affecting a significant number of families with young children. Parents with OUD commonly face significant challenges as they are often balancing the stress of caring for young children with maintaining recovery and co-occurring psychosocial challenges (e.g., mental health, low social support). Toward designing interventions to address parenting needs among parents with OUD, we conducted a mixed-methods study to understand the acceptability of receiving parenting support prenatally among pregnant people with OUD residing in the United States. Semi-structured interviews were conducted among 18 pregnant and early postpartum people recruited from a substance use treatment program specializing in the care of pregnant and parenting populations. Among all participants, a prenatal parenting program that comprehensively addresses recovery, parenting, and wellbeing was found to be widely acceptable. Regarding content most desirable within a parenting intervention, participants indicated an interest in breastfeeding, caring for newborns with in-utero opioid exposure, parent-infant bonding, infant soothing techniques, their own wellbeing/mental health, and parenting skills. We introduce a prenatal adaptation of the well-established Family Check-up parenting intervention as a novel, prenatal intervention to prevent negative outcomes for caregivers in recovery and their children.

The role of attachment and personality traits in choosing opiate addiction replacement therapy

Contemporary medical approaches for opioid addiction often include medication-assisted therapy, utilizing methadone and buprenorphine. However, factors influencing patient preferences for starting buprenorphine or methadone therapy are poorly understood. This study aims to explore whether variances in personality traits and attachment styles are related to treatment preferences among individuals undergoing buprenorphine and methadone maintenance therapies. 300 participants completed the Big Five Questionnaire for personality traits and sub-dimensions and the Experiences in Close Relationship Scale for assessing attachment styles. The results indicated that patients with higher levels of Dynamism, Conscientiousness, and Perseverance personality traits were more likely to choose buprenorphine over methadone for achieving and maintaining abstinence. Although attachment styles showed a greater ability to differentiate between groups compared to personality traits, the differences were not significant. However, Conscientiousness stood out for its high discriminant validity, suggesting that scores in this personality dimension could significantly distinguish between groups, with individuals in the buprenorphine group showing higher levels of Conscientiousness compared to the methadone group. The study suggests a partial association between individuals' preference for abstinence therapy and their personality traits. These findings could be considered useful indicators when choosing maintenance therapy to help opiate-addicted patients achieve and maintain abstinence.

The associations between attachment, self-esteem, fear of missing out, daily time expenditure, and problematic social media use: A path analysis model

The present study investigated the factors that may be associated with a dysfunctional use of social media use, by exploring the association between adult attachment patterns and problematic social media use and analyzing the sequential mediation of self-esteem, fear of missing out (FoMO), and time spent on social media. A sample of 470 social media users (M_age = 33.76 years; SD = 14.267; 70 % women) completed the Bergen Social Media Addiction Scale, Fear of Missing Out Scale, Rosenberg Self-Esteem Scale, and Relationship Questionnaire. Results showed a path analysis model providing an excellent fit to the data (χ² = 2.939, p = 0.230; GFI = 0.998, TLI = 0.987, CFI = 0.998, RMSEA = 0.032, SRMR = 0.016). A significant and positive total effect in the associations between preoccupied and fearful attachment patterns and problematic social media use emerged. Both preoccupied and fearful attachment patterns were also related to self-esteem, FoMO, and time spent on social media, which were sequentially associated and were, in turn, significantly related to problematic social media use. Finally, when self-esteem, FoMO, and time spent on social media were added into the model, they totally mediated the relationships between preoccupied and fearful attachment patterns and problematic social media use, suggesting a full multiple mediation model (R² = 0.33). Such data may provide useful information for clinical practice to develop tailored interventions and prevention programs to address the compensatory and problematic use of social media.

Telehealth delivery of modified attachment and biobehavioral catch-up: feasibility, acceptability, and lessons learned

The COVID-19 pandemic necessitated dramatic shifts in the delivery and evaluation of attachment-based home-visiting services. The pandemic disrupted a pilot randomized clinical trial of modified Attachment and Biobehavioral Catch-Up (mABC), an attachment-based intervention adapted for pregnant and peripartum mothers with opioid use disorders. We transitioned from in-person to telehealth delivery of mABC and modified Developmental Education for Families, an active comparison intervention targeting healthy development. Of 40 mothers then enrolled in study interventions, 30 participated in telehealth, completing an average of 4.7 remote sessions each (SD = 3.0; range = 1-11). Following the transition to telehealth, 52.5% of randomized cases and 65.6% of mothers maintaining custody completed study interventions, comparable to pre-pandemic rates. Overall, telehealth delivery was feasible and acceptable, and mABC parents coaches' ability to observe and comment on attachment-relevant parenting behaviors was preserved. Two mABC case studies are presented and lessons learned for future telehealth implementation of attachment-based interventions are discussed.    .

The Relationship between Early Maladaptive Schemas and Problematic Facebook Use: The Indirect Effects of Perceived Stress

Facebook is one of the most popular social media platforms. As well as facilitating contact and the exchange of information, the use of Facebook can lead to problematic Facebook use (PFU) among a small number of users. Previous studies have shown the relationship between PFU and early maladaptive schemas (EMSs). Additionally, previous studies have reported associations between PFU and perceived stress and between EMSs and perceived stress. Consequently, the main aim of the present study was to investigate the relationship between PFU and EMSs and the role of perceived stress as a mediator of this relationship. The study comprised 993 Facebook users (505 female, M = 27.38 years, SD = 4.79, aged from 18 to 35 years). PFU was assessed using the eight-item Facebook Intrusion Scale, perceived stress was assessed using the Perceived Stress Questionnaire, and EMSs were assessed using the Young Schema Questionnaire (YSQ-S3). The results suggested that insufficient self-control/self-discipline, approval seeking, dependence/incompetence, enmeshment, and entitlement/grandiosity schemas were positively associated with PFU. There was also a negative relationship between PFU and EMSs, such as social isolation/alienation and defectiveness/shame schemas. The findings showed that PFU was positively associated with external stress. Additionally, external stress had an indirect effect in the relationship between mistrust/abuse and PFU, failure to achieve and PFU, and self-punitiveness and PFU. These results contribute to a better understanding of PFU development mechanisms associated with early maladaptive schemas and perceived stress. Additionally, knowing the EMSs associated with PFU and perceived stress might improve the therapeutic interventions and prevention of this problematic behavior.

Potential Biological Markers and Treatment Implications for Binge Eating Disorder and Behavioral Addictions

The reward system is highly relevant to behavioral addictions such as gambling disorder (GD), internet gaming disorder (IGD), and food addiction/binge eating disorder (FA/BED). Among other brain regions, the ventral striatum (VS) has been implicated in reward processing. The main objective of the present state-of-the-art review was to explore in depth the specific role of the VS in GD, IGD and FA/BED, understanding it as a possible biomarker of these conditions. Studies analyzing brain changes following interventions for these disorders, and especially those that had explored possible treatment-related changes in VS, are discussed. More evidence is needed on how existing treatments (both pharmacological and psychobehavioral) for behavioral addictions affect the activation of the VS and related circuitry.

Practical Considerations for Treating Comorbid Posttraumatic Stress Disorder in the Addictions Clinic: Approaches to Clinical Care, Leadership, and Alleviating Shame

A practical, common-sense framework for recognizing and addressing comorbid posttraumatic stress disorder (PTSD) in the substance use disorder (SUD) clinic is outlined. The article focuses on strategies that can help establish trauma-informed care or augment an existing approach. Interventions are organized around the task of ameliorating shame (or shame sensitivity), which represents a transdiagnostic mediator of psychopathology and, potentially, capacity for change. Countershaming strategies can guide a trauma-responsive leadership approach. Considering the striking rate of underdiagnosis of PTSD among patients with SUD, implementing routine systematic PTSD screening likely represents the single most consequential trauma-informed intervention that SUD clinics can adopt.

The Relationship Between Early Maladaptive Schemas, Depression, Anxiety and Problematic Video Gaming Among Female and Male Gamers

The present study investigated the relationship between problematic video gaming (PVG) and early maladaptive schemas (EMSs) among male and female gamers. Additionally, the present study investigated depression and anxiety as mediators in the relationship between EMSs and PVG. The study comprised 673 videogame players (391 female gamers) aged from 18 to 38 years. PVG was assessed using the nine-item Internet Gaming Disorder Scale-Short-Form (IGDS9-SF). Depression and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). EMS dimensions were assessed using the Young Schema Questionnaire (YSQ-S3). Results suggested that EMSs such as practical incompetence/dependence were positively related to PVG. The findings showed gender differences in these relationships. The vulnerability to harm or illness, enmeshment and subjugation schemas were positively related to PVG among male gamers. However, depression and anxiety did not mediate the relationship between EMSs and PVG. These findings may contribute to a better understanding of mechanisms related to PVG development, which are associated with maladaptive schemas.

Supplementary Information

The online version contains supplementary materials available at 10.1007/s11469-022-00858-2.

Addictions: current perspectives

This paper seeks to integrate the perspectives of analytical psychology and neurobiology in order to understand the phenomenon of addiction in contemporary society, taking into account the COVID-19 pandemic. Jung emphasizes the role of the psyche's self-regulation and the development of consciousness in the individuation process. The search for experiences of transcendence is archetypal and can be achieved by the use of some substances or behaviours and can contribute to individuation. However, in contemporary society, many individuals seek to restore internal balance through behaviours that merely soothe discomfort. The difficulty in discerning use, abuse, and dependence, particularly in the case of behavioural addictions, is discussed and neurobiological factors are presented. Empathic relationships play a key role in this process as they can promote the integration of the right and left hemispheres, integrating non-verbal experiences and language, contributing to self-regulation. Jung emphasizes the importance of real encounters in the transformation process. Currently, meetings have become a source of anguish. The author concludes that more than ever it is necessary to invest in the quality of the interactions to prevent and treat addictions.

Meditation and Five Precepts Mediate the Relationship between Attachment and Resilience

Secure attachment is fundamental to the development of resilience among adolescents. The present study investigated whether meditation and precept practices influence the relationship between attachment and resilience. This study recruited 453 10th−12th-grade boarding school students who completed the Experience of Close Relationship Questionnaire (revised), Resilience Inventory, Inner Strength-Based Inventory, and Precept Practice to assess attachment, resilience, meditation practice, and precepts adherence. The participants’ mean age was 16.35 ± 0.96 years; 87.9% were females, and 89.2% were Buddhists. A parallel mediation model within the structural equation framework was used for an analysis of the indirect effect of attachment on resilience through meditation and precept practices. The indirect effects of attachment anxiety and avoidance on resilience were β = −0.086, 95% CI = −0.125, −0.054, p < 0.001, and β = −0.050, 95% CI = −0.088, −0.021, p = 0.006, respectively. The indirect effect size resulting from meditation was significantly higher than that resulting from observance of the precepts. The parallel mediation model explained the 33% variance of the resilience scores, compared with 23% from the direct effect of attachment anxiety and avoidance only. This work provides evidence that meditation and precepts significantly affect the relationship between attachment and resilience.

[Comorbidity of posttraumatic stress disorder and addiction from a biopsychosocial perspective]

Posttraumatic stress disorder and substance use disorder often co-occur within the health care system. Their comorbidity is associated with more serious acute clinical symptomatology, more frequent hospital admissions in state of emergency and significantly lower chances of improvement by psychological and pharmacological treatment. Their comorbidity contributes to dramatically unfavourable courses of illness as regards all biopsychosocial levels. The survey presented will discuss empirical findings from various perspectives: general epidemiology, substance use disorder as risk factor of trauma and PTSD, trauma and PTSD as risk factor of SUD, neurobiological effects of SUD converging towards neurobiology of PTSD, shared common factors of genetics/epigenetics, personality traits, and early developmental stress and trauma. The main focus of analysis will be put on processes that are intrinsically linked to the development and course of both disorders.

Transtorno de Jogo: contribuição da abordagem psicodinâmica no tratamento

Resumo Jogos de azar podem ser uma atividade de lazer, mas sua prática em excesso pode levar a consequências adversas, como o Transtorno de Jogo. Apesar dos sérios prejuízos provocados por esse quadro, tanto o Transtorno de Jogo em si quanto estratégias de tratamento são pouco conhecidos no Brasil. Este trabalho aborda o Transtorno de Jogo e seu tratamento, tendo como objetivo explicitar a contribuição da abordagem psicodinâmica. São apresentadas as principais hipóteses psicodinâmicas existentes na literatura e tecidas considerações sobre a psicoterapia psicodinâmica realizada em um serviço que atende jogadores em São Paulo, o Programa Ambulatorial do Jogo Patológico (PRO-AMJO) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (IPq HC-FMUSP). Por fim, alguns exemplos de perfis de jogadores patológicos são apresentados.

Common Features in Compulsive Sexual Behavior, Substance Use Disorders, Personality, Temperament, and Attachment-A Narrative Review

Do addictions share common traits of an “addictive personality” or do different addictions have distinct personality profiles? This narrative review examines the differences in the associations between substance use disorder (SUD) and compulsive sexual behavior disorder (CSBD), on the one hand, and personality traits, attachment dispositions, and temperament, on the other hand. We found that both people with a SUD and people with CSBD tended to be more spontaneous, careless, and less reliable, to place self-interest above getting along with others, to show emotional instability and experience negative emotions such as anger, anxiety, and/or depression, to be less able to control their attention and/or behavior, and to be engulfed with a constant sensation of “wanting”. Only people with CSBD, but not SUD, noted concerns with their social ties, fear of losing close others, and/or trusting others around them. Results also suggested that people with a SUD and people with CSBD share high commonalities in personality traits and temperament, yet there are noted differences in their social tendencies, especially with close others. People with CSBD reported more concerns with possible relationship losses compared to people with SUD issues, who may be more worried about losing their source of escapism.

Parenting and addictions: Current insights from human neuroscience

Purpose

A growing body of human research has documented associations between the maternal brain and maternal substance use and addictions. This neuroscience-informed approach affords the opportunity to unpack potential neurobiological mechanisms that may underscore challenges in maternal caregiving behavior among mothers with addictions and provide new directions for parenting interventions.

Findings

Consistent with theoretical models of parenting and addictions, five studies evidence both hypo- and hyper-reactivity to infant affective cues across neuroimaging methods and tasks that incorporate both infant face and cry stimuli. Three structural and resting-state brain studies as a function of maternal substance use are also reported.

Conclusions

While human neuroimaging research converges in showing that maternal substance use is associated with differential reactivity to infant affective cues, further multi-level/multi-modal, longitudinal, and dimensional research is critically needed to advance this area of investigation.

Adapting an Evidence-Based Home Visiting Intervention for Mothers With Opioid Dependence: Modified Attachment and Biobehavioral Catch-up

Infants born to mothers who are dependent on opioids often have difficulty regulating behavior and physiology at birth. Without sensitive maternal care, these infants are at risk for ongoing problems with self-regulation. Mothers who are dependent on opioids may experience challenges related to their substance use (e.g., unsupportive and/or risky environment, impulse control and reward system problems) that increase the likelihood of insensitive parenting in the absence of effective intervention. In this paper, we describe a home-visiting intervention we have adapted to enhance sensitive, responsive caregiving tailored to the specific needs of mothers with opioid dependence. The original intervention, Attachment and Biobehavioral Catch-up (ABC), was designed for mothers of infants aged 6-24 months who were exposed to early adversity. ABC has been shown to enhance sensitive parenting as well as children's behavioral and biological functioning, with positive outcomes extending into at least middle childhood. Mothers who are opioid dependent need earlier support than provided by ABC because opioid-exposed infants are often vulnerable at birth. The adapted intervention (modified ABC or mABC) includes one prenatal session and one early postnatal session, followed by 10 sessions every 2-3 weeks. In the initial two sessions in particular, mothers are helped to anticipate the challenges of caring for a baby who may be difficult to soothe while nonetheless providing sensitive care. mABC is intended to help mothers see the importance of responding sensitively so as to help infants overcome the developmental risks associated with opioid exposure. Additionally, mABC is structured to support mothers with the challenges of early parenting, especially if the mother herself was not parented sensitively. Throughout, the focus is on helping the mother nurture the distressed infant, attend to the infant's signals, and avoid behaving in overstimulating or intrusive ways. Case examples are presented that highlight both the challenges of working with this population as well as the gains made by mothers.

Impaired Learning From Errors and Punishments and Maladaptive Avoidance-General Mechanisms Underlying Self-Regulation Disorders?

Self-regulation (SR) is an important human function that relates to quality of life in multiple domains including mental health. Previous studies have found important correlates of low SR including impulsivity and poor emotional regulation; however, underpinnings of low SR are incompletely understood. Individuals low in SR frequently engage in maladaptive behaviors (substance abuse, procrastination, etc.) despite negative consequences. This phenomenon suggests that impaired learning from errors and punishments may be important mechanisms underlying low SR. Consistently, previous studies observed impaired error processing in a wide spectrum of individuals with low SR and impaired learning from errors and punishments in SR-related disorders. We also note a possible role for poor emotional regulation and refer to concepts suggesting that engaging in maladaptive behaviors may serve as short term emotion regulation strategies aimed at avoiding or alleviating negative affect. We speculate on transdiagnostic factors underlying poor SR. We propose that impaired error processing (possibly related to striatal functioning) may prevent subjects with low SR from learning from errors and punishments and thus learning better SR skills or tendencies. Additionally, impaired coping in emotionally challenging situations, possibly related to prefrontal-cortical functioning, may lead to maladaptive avoidance. Moreover, maladaptive behaviors may be reinforced by the temporary decreases in negative affect and rewarding values of behaviors. Given existing knowledge gaps, we call for more extensive research and describe possible directions and challenges for future studies.

Attachment Styles, Personality Organization, and Substance Use as Predictors of Emotion Regulation Strategies "Suppression" and "Reappraisal" in Young Adults

BACKGROUND

As evidenced by current literature, there is a crucial link between emotion regulation, attachment, personality patterns, and substance abuse. However, knowledge regarding the exact interactions of these specific parameters in terms of substance abuse development is still sparse. Therefore, this study is aimed to shed light on how two specific emotion regulation strategies ("Reappraisal" and "Suppression") might be influenced by the relationship between attachment, structural deficits in personality organization, and addictive behaviors.

METHOD

A total sample of 299 non-clinical young adults (Age: M = 22; SD = 3.81; 74.2% females) filled in the Emotion Regulation Questionnaire (ERQ) together with the Adult Attachment Scale (AAS), the Personality Organization Inventory (IPO-16), and the Alcohol, Smoking and Substance Involvement Screening (ASSIST) by means of an online survey.

RESULTS

As suggested by hierarchical regression analysis, attachment specifically predicted differences in Emotion Regulation (ER), whereby the AAS subscales "Close" ness (β = -0.38, p < 0.01) and "Depend" ence (β = -0.18, p < 0.01) were negatively associated with increased use of maladaptive strategies of expressional suppression of emotion, and "Depend" (β = 0.26, p < 0.01) was positively associated with increased use of adaptive strategies of cognitive reappraisal.

DISCUSSION

In line with our assumptions, we observed a more secure attachment system to be predictive for an increased use of adequate emotion regulation strategies. The findings support the suggestion that a focus on underlying attachment-related processes in a psychotherapeutic setting might be a promising way to promote adaptive self-regulation of emotions.

Adverse childhood experiences, dissociation, and anxious attachment style as risk factors of gaming disorder

INTRODUCTION

The aim of this study was to explore the relationship between adverse childhood experiences (ACEs), attachment styles, dissociation, and symptoms of gaming disorder (GD). Methods: The total sample of the survey was 1288 gamers who completed a set of questionnaires via the Internet; they included questions on ACEs, attachment styles (anxious and avoidance styles in intimate relationships), symptoms of dissociation, and GD. Structural equation modeling (SEM) was performed to examine the detailed relationships between variables.

RESULTS

In the hypothesized model, ACEs, dissociation, and the scales of avoidance and anxiety were considered predictors of gaming disorder. Only the avoidance subscale proved to be statistically insignificant; the model without this variable fit the data and had good psychometric properties.

CONCLUSIONS

To conclude, this study showed a link between adverse childhood experiences, dissociation, and anxiety experienced in relationships as significant risk factors for symptoms of gaming disorder.

Differential responses to infant faces in relation to maternal substance use: An exploratory study

BACKGROUND

Maternal substance use and addiction has been associated with negative consequences for parenting and may increase addiction vulnerability in the developing child. Neuroimaging research suggests that substance use may decrease the reward of caring for infants and heighten stress reactivity to affective infant cues.

METHODS

Thirty-two substance-using mothers and twenty-two non-substance-using mothers were presented with emotional face and cry stimuli generated from their own and a demographically matched unknown infant during fMRI scanning. Between-group differences in neural activity during task performance were assessed using whole-brain, mixed-effects models corrected for multiple comparisons (voxel-level p < 0.001, pFWE<0.05).

RESULTS

Relative to non-substance-using mothers, substance-using mothers exhibited greater activation when viewing their own infant's face as compared to an unknown infant's face across multiple brain regions, including superior medial frontal, inferior parietal, and middle temporal regions. Substance-using mothers also had a decreased response to sad infant faces in the ventral striatum relative to the non-substance-using mothers. Neural responses to own vs. unknown infant cries did not significantly differ between substance-using and non-substance-using mothers.

CONCLUSIONS

Findings suggest overlapping cortical and subcortical brain regions implicated in responding to infant faces, with activation differences related to infant familiarity, emotional expression, and maternal substance use. While prior work has focused on attenuated neural responses to infant cues, greater attention is needed toward understanding the increased reactivity to affective infant cues observed in substance-using mothers.

Spiritual experiences are related to engagement of a ventral frontotemporal functional brain network: Implications for prevention and treatment of behavioral and substance addictions

BACKGROUND AND AIMS

Spirituality is an important component of 12-step programs for behavioral and substance addictions and has been linked to recovery processes. Understanding the neural correlates of spiritual experiences may help to promote efforts to enhance recovery processes in behavioral addictions. We recently used general linear model (GLM) analyses of functional magnetic resonance imaging data to examine neural correlates of spiritual experiences, with findings implicating cortical and subcortical brain regions. Although informative, the GLM-based approach does not provide insight into brain circuits that may underlie spiritual experiences.

METHODS

Spatial independent component analysis (sICA) was used to identify functional brain networks specifically linked to spiritual (vs. stressful or neutral-relaxing) conditions using a previously validated guided imagery task in 27 young adults.

RESULTS

Using sICA, engagement of a ventral frontotemporal network was identified that was engaged at the onset and conclusion of the spiritual condition in a manner distinct from engagement during the stress or neutral-relaxing conditions. Degree of engagement correlated with subjective reports of spirituality in the scanner (r = .71, p < .001) and an out-of-the-magnet measure of spirituality (r = .48, p < .018).

DISCUSSION AND CONCLUSION

The current findings suggest a distributed functional neural network associated with spiritual experiences and provide a foundation for investigating brain mechanisms underlying the role of spirituality in recovery from behavioral addictions.

Parenting stress: A novel mechanism of addiction vulnerability

Addiction remains a significant public health concern. Despite numerous public health initiatives, many parents continue to use substances during the prenatal and postpartum period. While stress has been implicated in the maintenance of substance use disorders more generally, we propose that parenting stress specifically increases vulnerability to substance use in adults caring for young children. To explore this notion, we first consider the neurobiology of the adult transition to parenthood and the value of adopting a parenting-specific approach to understanding addictive processes. Next, we consider the neurobiology of addiction and parenting before directly addressing parenting stress in the context of addiction. Finally, we describe current interventions with parents that incorporate the management of negative affect to enhance caregiving quality and decrease substance use. Taken together, this article proposes that the unique demands of caring for a developing child may be more stressful above and beyond other forms of stress. As a consequence, intervention approaches that target stress in the parenting role hold promise for decreasing parental substance abuse.

The Interaction of Person-Affect-Cognition-Execution (I-PACE) model for addictive behaviors: Update, generalization to addictive behaviors beyond internet-use disorders, and specification of the process character of addictive behaviors

We propose an updated version of the Interaction of Person-Affect-Cognition-Execution (I-PACE) model, which we argue to be valid for several types of addictive behaviors, such as gambling, gaming, buying-shopping, and compulsive sexual behavior disorders. Based on recent empirical findings and theoretical considerations, we argue that addictive behaviors develop as a consequence of the interactions between predisposing variables, affective and cognitive responses to specific stimuli, and executive functions, such as inhibitory control and decision-making. In the process of addictive behaviors, the associations between cue-reactivity/craving and diminished inhibitory control contribute to the development of habitual behaviors. An imbalance between structures of fronto-striatal circuits, particularly between ventral striatum, amygdala, and dorsolateral prefrontal areas, may be particularly relevant to early stages and the dorsal striatum to later stages of addictive processes. The I-PACE model may provide a theoretical foundation for future studies on addictive behaviors and clinical practice. Future studies should investigate common and unique mechanisms involved in addictive, obsessive-compulsive-related, impulse-control, and substance-use disorders.

Attachment and Substance Use Disorders-Theoretical Models, Empirical Evidence, and Implications for Treatment

Introduction: The article reviews attachment-oriented research in individuals with substance use disorders (SUDs). Based on attachment theory, substance abuse can be understood as "self-medication," as an attempt to compensate for lacking attachment strategies. Attachment theory suggests a developmental pathway from insecure attachment to SUD and, on the other hand, a negative impact of substance abuse on attachment security. Earlier reviews have indicated a general link but have been inconclusive with regard to other aspects. In the light of a growing body of research, this review is looking for evidence for the general link, for its direction, for differences due to different patterns of attachment, different substances and severities, comorbid psychiatric disorders, and age groups. Methods: Using medical and psychological databases, 34 cross-sectional studies, three longitudinal studies, and a systematic meta-analysis were identified. Methodological problems such as poor assessment of SUD and the use of different measures of attachment limit comparability. Results: All cross-sectional studies in the review confirm a link between insecure attachment and SUD. Results of longitudinal studies show insecure attachment to be a risk factor for SUD, while continued substance abuse impairs the ability to form close relationships. With regard to specific patterns of attachment, results mainly point toward very insecure patterns. They indicate different patterns of attachment in different groups of substance abusers, suggesting different developmental pathways. Fearful-avoidant attachment was frequent in heroin addicts, while alcohol abusers displayed more heterogeneous patterns. Comorbid mental disorders and severity of SUD seem to be important factors, but data are still inconclusive. The link between insecure attachment and SUD seems to be stronger in adolescence compared to adulthood. Discussion: The last decades have seen a substantial growth in studies on attachment and SUDs. Despite methodological problems, the general link between insecure attachment and SUD today is well established. Attachment theory might contribute to the understanding and treatment of SUDs in a significant way. But to do so, a lot of open questions have to be answered. We will need more carefully designed longitudinal studies, more studies connecting psychological data with brain processes, and more clinical trials.

Pathways Relating the Neurobiology of Attachment to Drug Addiction

Substance use disorders constitute a significant public health problem in North America and worldwide. Specifically, substance addictions in women during pregnancy or in the postpartum period have adverse effects not only on the mother, but also on mother-infant attachment and the child's subsequent development. Additionally, there is growing evidence suggesting that parental addiction may be transmitted intergenerationally, where the child of parents with addiction problems is more likely to experience addiction as an adult. The current review takes a developmental perspective and draws from animal and human studies to examine how compromised early experience, including insecure attachment, early abuse/neglect, and unresolved trauma, may influence the development of neurobiological pathways associated with addictions, ultimately increasing one's susceptibility to addictions later in life. We approach this from three different levels: molecular, neuroendocrine and behavioral; and examine the oxytocin affiliation system, dopamine reward system, and glucocorticoid stress response system in this regard. Increased understanding of these underlying mechanisms may help identify key targets for early prevention efforts and inform needed intervention strategies related to both insecure attachment and addiction.

Attachment-Based Family Therapy for Adolescent Substance Use: A Move to the Level of Systems

This paper provides an account of the theoretical basis of a family-based intervention called Behaviour Exchange and Systems Therapy (BEST). The model described here has also been applied to adolescents with substance abuse and other mental health problems such as depression and anxiety disorders in both children and adolescents. Evaluative studies of the model have been published including randomised clinical trials as well as qualitative analyses. The current paper discusses a theory of the family system as a discourse and represents an integration of aspects of attachment, psychoanalytic, and systems theories. Key concepts elaborated are the attachment-family system, the family as a single discourse, the use of segregation as a defense in relation to trauma and loss and its manifestation in a family narrative, and the role of the family secure base in affect regulation. The paper also briefly describes specific treatment techniques that are derived from the theoretical model. Our approach has wide application as a discourse focused treatment for children and adolescents using a family systems approach. Future work requires the comparison of this model to similar attachment-based models of intervention for children and families, further development and validation of measures able to be used for whole families in a clinical setting, and further empirical demonstration of treatment efficacy in a variety of clinical settings.