A cognitive-affective theory of craving and relapse

Treating Addiction as an Emotional Regulation and Processing Disorder

Treating Addiction as an Emotional Regulation and Processing Disorder  

Translating accurate diagnosis into effective treatment

Around this time last year and just weeks before The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (1), DSM-5, was due to appear, the National Institute of Mental Health (NIMH), the world’s largest funding agency for research into mental health, indicated the need for an alternative to the manual, citing “the weakness” of the manual and “it’s lack of validity.”

Others observed that “the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure” and asked whether “Patients with mental disorders deserve better”.

Obviously a year on this question is still very pertinent.

NIMH went on to suggest areas that possibly needed inserting into a fuller diagnosis of mental health conditions and which would include considering mental disorders as biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behaviour; that “mental disorders” are not viewed and studied entirely as “biological disorders .

According to Pani et al (2) the “official” nosology (the classification of diseases) of the DSM is largely limited to physical manifestations of addiction that can be objectively observed and are suited to the maintaining of an “atheoretical” perspective. The DSM treats the additional psychiatric symptoms that affect the well-being and social functioning of addicted individuals by relegating them to the domain of psychiatric “comorbidity”.

Although the relationship of these psychiatric symptoms of, for example. depression or anxiety disorders with addiction is very close, as demonstrated by the high frequency of association observed, it does not rule out the possibility, certainly not in theoretical grounds, that addiction may modify pre-existing psychic structures via chronic drug or alcohol use. There may be similar neural mechanisms which manifest in different behaviours and worsened or made more chronic via substance abuse.

Addiction may be a specific mental disorder, inclusive also of symptoms pertaining to mood/anxiety, or impulse control dimensions and which effect cognitive, executive and emotional dysfunction.

We would add that addiction also has inherent decision making difficulties (3) often based on the observed, underlying emotional processing and regulation deficits.  We believe that all these symptoms satisfactorily all come under the umbrella term of emotional dysregulation. We believe emotional dysregulation initiates, maintains and perpetuates the addiction cycle to it’s emotionally distressing endpoint, compulsive addictive behaviours. It is via emotional dysregulation that the impaired neurobiology of addiction is manifest.

It is also illuminating to see that emotional dysregulation is cited as being present in some 75% of disorders listed in DSM-5 (4). This emotional dysregulation is at the heart of addiction, as it is for these other disorders, although we believe it manifests differently in different psychiatric disorders and as such needs to be treated differently.

We believe addiction needs to be treated as addiction, mediated by emotional distress to the endpoint of addiction and manifest via maladaptive emotional strategies, strategies which are similar but not the same as other posited “co-morbidities” and certainly different in terms of the behaviour this dysregulation prompts, such as relapse to chronic drug or alcohol abuse. In short, these disorders may have similarities but are not the same.

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.

Our own experience of recovery, coupled with our research over several years, has made us curious as to why the way addicts and alcoholics themselves talk about their condition as an “emotional disease” or “a parasite the feeds on their emotions”, an “emotional cancer” or a “fear based disease” is rarely countenanced in any theory of addiction.

We doubt that they are wrong in their descriptions of their disease, in fact, we have in recent years taken the opposite approach and started to explore, in terms of research, if addiction and alcoholism have their roots in emotional dysregulation and emotional processing deficits. We have been encouraged that these difficulties shape decision making difficulties, distress based impulsivity, lack of inhibition across various psychological domains, e.g. executive dysfunction. This emotional dysregulation also heightens reward sensitivity. Thus, the combination of emotional dysregulation and high reward sensitivity may be a potent risk factor for the development and maintenance of various addictive disorders (5).

We suggest that emotional dysregulation can account for the majority of symptoms seen in addicts and alcoholics.

For us, any definition or diagnosis needs to aim for this type of universality and ecological validity. It needs to explain a disorder across various strata from neurobiological mechanisms to manifest behaviour. It needs to be able to explain the symptoms of a disorder that can be observed in the sufferers of this disorder. It needs to have the validity sought above.

It needs to move beyond “atheoretical” and it needs to be driven by experimental research that has sound conceptual rationale, not on “consensus about clusters of clinical symptoms” but on objective laboratory measurement. Let’s experimentally test our theoretical accounts.

In fact, there is an quickly accumulating body of research evidence that  demonstrates altered morphology, functionality and connectivity of  brain regions and in the neural networks implicated in emotional regulation that would certainly suggest inherent impairments in processing and regulating emotion which would have repercussions for manifest behaviours of impulsivity, decision making deficits, as well as difficulties in regulation of stress and behaviour.

It is interesting nonetheless, that the “atheoretical” DSM previously used a working group to consider what constituted “craving” (6) and forwarded an essentially neurobiological account based on reinforcement models which is not particularly “atheoretical”. These “conditioning” accounts of “craving” have also been challenged with some researchers suggesting emotional dysregulation provides a most comprehensive “cognitive” account of craving also (7).

We firmly believe that viewing addiction as the consequence of emotional dysregulation opens up the possibility of more co-operative therapeutic exchange in relation to addiction as all major treatments from 12 step recovery to ACT or DBT, all of which can easily be framed or reframed to view addiction and alcoholism as disorders of emotional regulation. There can be a move towards a universality of treatment too. Even the cognitive distortions of CBT, can be viewed as the consequence of emotional dysregulation, e.g. catastrophizing.

Prevention can also consider this inherent emotional dysregulation. There are a host of emotional regulation difficulties which can serve as vulnerabilities or risk factors for later addiction, especially in children of alcoholics. We have measurements to aid us in highlighting these biomarkers, such as the use of heart rate variability, a putative index of emotional dysregulation.

We can intervene to aid in reinforcing emotional regulation strategies in those exhibiting vulnerability. We can tackle this disease at source.

To help those at risk and those currently suffering from addiction we first have to accurately define the disorder and accurately diagnose difficulties; only then can be hope to be more effective in treating this most profound of mental disorders.  


  1. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5–25.

2. 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.

3. Murphy, A., Taylor, E., & Elliott, R. (2012). The detrimental effects of emotional process dysregulation on decision-making in substance dependence. Frontiers in integrative neuroscience, 6.

4. Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework.

5. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review30(2), 217-237.

6. Agrawal, A., Heath, A. C., & Lynskey, M. T. (2011). DSM‐IV to DSM‐5: the impact of proposed revisions on diagnosis of alcohol use disorders. Addiction,106(11), 1935-1943.

7. Ingjaldsson, J. T., Laberg, J. C., & Thayer, J. F. (2003). Reduced heart rate variability in chronic alcohol abuse: relationship with negative mood, chronic thought suppression, and compulsive drinking. Biological Psychiatry, 54(12), 1427-1436.

Related blogs:- http://alcoholicsguide.wordpress.com/2014/05/21/is-there-an-emotional-processing-problem-in-alcoholics/http://alcoholicsguide.wordpress.com/2014/05/20/so-how-is-your-decision-making/

2 replies »

  1. Very important article. Even something as simple as bringing DBT into the mainstream or adapting it for early childhood intervention could make a huge difference particularly for children at risk for addiction. Emotional abuse, domestic violence, child abuse, all of these are connected to emotional dysregulation. Here’s hoping for change in this area.

  2. thank you Joanna – I agree especially with intervention and even prevention via primary/junior schools when children at risk are very young – with those vulnerable to addiction it is noted that emotions are avoided and not then regulated or processed even – this leads to constant feelings of distress and often subsequent behavioural problems even at an early age and way before drinking or drug use – I firmly believe this deficit in emotional processing is the area that can be addressed and “treated” in early life so that addiction is dealt with at source. It is worth trying at least, at worst many children would grow up to be happier and emotionally better equipped for later life.

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