Diagnostic Difficulties

Towards an alternative theory of Alcoholism and Addiction

An alternative definition of Addiction?

Before we discuss the enormous contributions made by neurobiological ‘conditioning’ theories of addiction we will discuss alternatives to these theories of addiction. Interestingly, the theories we posit here, which are based on the role of emotional dysregulation in addiction and alcoholism build on these ‘conditioning’ models. By these we mean that there is an overlap in neural structures implicated in these neurobiological theories and affect-centred theories of addiction.

Our own experience of recovery, coupled with our research over several years, has  made us curious as why the ways addicts and alcoholics themselves talk about their condition or the explanations they forward all generally point to what they would call an “emotional disease” or “a parasite the feeds on their emotions”, an “emotional cancer” or a “fear based disease” yet these are rarely countenanced in any theory of addiction, whether neurobiological, psychological, psycho-analytical (although there have been very interesting ideas based on attachment within this methodology).

How could addicts and alcoholics be so wrong about themselves and what ails them? Especially when they see it also in hundreds of others with the same condition?

We doubt that they are wrong, in fact, we have in recent years taken the opposite approach and started to explore, in terms of research, if addiction and alcoholism, especially, have their roots in emotional dysregulation and emotional processing deficits. In even more recent times, we have been encouraged that these difficulties also shape decision making difficulties, distress based impulsivity (leading to compulsivity) lack of inhibition across various psychological domains, as well as more revealingly the cognitive and executive dysfunctions and ‘flight or flight’ reactions which seem common to this clinical group.

There appears to be a short termist decision making profile which we suggest is distress based, which implicates more emotive-motoric regions of the brain rather than goal-directed. This is also seen in children of alcoholics (14). Could this be an important vulnerabilty to alcoholics?

In order to get this debate going we will now consider whether there are possibilities for re-defining the DSM criterion in relation to the manifest difficulties observed in these clinical groups in relation to emotional dysregulation.

One important article to our emerging conception was written by Pani  et al (1).

Pani et al  argued that the “official” nosology (e.g. DSM IV) is largely limited to physical manifestations of addiction. However, they also argue that addicted individuals display additional psychiatric symptoms that affect their well-being and social functioning but which have been relegated to the domain of psychiatric “comorbidity.”   Although the relationship of these psychiatric symptoms with addiction is very close, substance abuse may modify pre-existing psychic structures and lead to addiction as a specific mental disorder, inclusive of symptoms pertaining to mood/anxiety, or impulse control dimensions, or, as we suggest, the various characteristics of emotional dysregulation.

All of which suggests the current DSM based nosology of addiction-related mental comorbidity does not consider the overlap of the biological substrates and neurophysiology of addictive processes and psychiatric symptoms associated with addiction, so fails to include specific mood, anxiety, and impulse control dimensions in the psychopathology of addictive processes.

Pani and colleagues suggest that addiction reaches beyond the mere result of drug-elicited effects on the brain and cannot be peremptorily equated only with the use of drugs despite the adverse consequences produced. Addiction is a relapsing chronic condition in which psychiatric manifestations play a crucial role. Thus it may be that the aetiology of addiction cannot be severed from its psychopathological connotations, particularly in view of the undeniable presence of symptoms, of their manifest contribution to the way addicted patients feel and behave, and to the role they play in maintaining the continued use of substances. Indeed the latter symptoms frequently precede the addictive process constituting a predisposing psychological background on which substance effects and addictive processes interact, leading to a full-fledged psychiatric disorder. Within the frame of the current DSM, numerous relevant psychiatric issues in substance abuse disorders may have been overlooked.

Even in the absence of psychiatric diagnosis, specific psychological vulnerabilities may constitute a background for the development of substance use disorders.

In fact, Cheetham, 2010  (2) conceptualises substance use disorders (SUDs) as disorders of affect, suggesting models of addiction have not generally provided a comprehensive account of the role of affect, that research has focused more upon the neurobiological substrates underlying addiction than on its affective components and emphasised how the dysregulation of brain reward and stress systems bias addicted individuals towards continued substance use.

That is not to say these are mutually exclusive; these neural circuitries overlap with those of emotional dysregulation and are not incompatible with an affect-centred theory of SUD (3)

The neural circuitry implicated in affective reactivity and regulation is closely related to the circuitry proposed to underlie addictive behaviours (4,5).

Some studies suggesting that substance use disorders ( SUDs) may play a causative role in the development of affective disorders (6,7).  Equally it may be the other way around; SUDs have also been linked to a range of deficits in the experience and expression of emotion in the absence of affective psychopathology (8-10)

Various forms of emotional distress may prompt substance use (11) .

Although affect is related to dysfunctional decision-making processes and risky behaviours (12,13) in those with SUDs, there has been little consideration of what these results mean for the affective processing capabilities of those at high risk of  developing SUDs.

Impairments in affective processing may mediate addictive behaviours, particularly via their contribution, for example,  to decision making deficits (2) .

In fact, we suggest these affective processing difficulties cause inherent decision making difficulties and constitute a premorbid vulnerability (14).

 

References

1. Pani, Pier Paolo, et al. “Delineating the psychic structure of substance abuse and addictions: Should anxiety, mood and impulse-control dysregulation be included?.” Journal of affective disorders 122.3 (2010): 185-197.

2. Cheetham, A., Allen, N. B., Yücel, M., & Lubman, D. I. (2010). The role of affective dysregulation. in drug addiction. Clinical Psychology Review30(6), 621-634.

3. Li, C. -S. R., & Sinha, R. (2008). Inhibitory control and emotional stress regulation: Neuroimaging evidence for frontal-limbic dysfunction in psycho-stimulant addiction. Neuroscience & Biobehavioral Reviews, 32(3), 581−597

4.  Koob, G. F. (2006). The neurobiology of addiction: A euroadaptational view relevant for diagnosis. Addiction, 101(Suppl 1), 23−30

5. Phan, K. L. (2002). Functional neuroanatomy of emotion: A meta-analysis of emotion activation studies in PET and fMRI. NeuroImage, 16, 331−348

6. Schuckit, M. A. (2006). Comorbidity between substance use disorders and psychiatric conditions. Addiction, 101(1), 76−88

7. Volkow, N. D. (2004). The reality of comorbidity: Depression and drug abuse. Biological Psychiatry, 56(10), 714−717.

8. Aguilar de Arcos, F., Verdejo-Garcia, A., Ceverino, A., Montanez-Pareja, M., Lapez-Juarez, E., Sanchez-Barrera, M., et al. (2008). Dysregulation of emotional response in current and abstinent heroin users: Negative heightening and positive blunting. Psychopharmacology, 198(2), 159−166.

9. Gerra, G., Baldaro, B., Zaimovic, A., Moi, G., Bussandri, M., Raggi, M. A., et al. (2003). Neuroendocrine responses to experimentally-induced emotions among abstinent opioid-dependent subjects. Drug and Alcohol Dependence, 71(1), 25−35

10. Sell, L. A., Morris, J. S., Bearn, J., Frackowiak, R. S. J., Friston, K. J., & Dolan, R. J. (2000). Neural responses associated with cue evoked emotional states and heroin in opiate addicts. Drug and Alcohol Dependence, 60(2), 207−216.

11. Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111(1), 33−51.

12. .Bechara, A., & Damasio, H. (2002). Decision-making and addiction (part I): Impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences.Neuropsychologia, 40(10), 1675−1689

13.  Cyders, M. A., & Smith, G. T. (2008). Emotion-based dispositions to rash action: Positive and negative urgency. Psychological Bulletin, 134(6), 807−828

14. Lovallo, William R., et al. “Working Memory and Decision‐Making Biases in Young Adults With a Family History of Alcoholism: Studies from the Oklahoma Family Health Patterns Project.” Alcoholism: Clinical and Experimental Research 30.5 (2006): 763-773.

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