Addiction Module 3

3.1
Reports of feelings of compulsion
A key issue in understanding addiction is the feeling of compulsion reported
by many addicts when they are about to relapse. They describe this as a strong
urge they actively try to resist, distinct from a simple desire. This highlights a
failure of impulse control in addiction.
The concepts of compulsion, craving, and self-control are central to the
Disease Model of addiction. This model, initially formulated by Jellinek,
proposes that addiction involves pathological changes in the brain that lead
individuals to act against their expressed will.
Powerful motives versus impaired control: A crucial distinction is whether
compulsion arises because the desire for the drug is overwhelmingly strong
or because the ability to resist that desire (self-control) is impaired. While
definitions of addiction often imply impaired control, much theory assumes an
overwhelming desire. The Disease Model, particularly in Edwards and Gross's
formulation, emphasizes a failure to exercise control, though it notes the
difficulty in distinguishing between genuinely losing control and deciding not to
exercise it.

The Disease Model of addiction

The Disease Model states that addiction involves pathological brain changes
resulting in overpowering urges. It defines addiction as a medical disorder with
an abnormality of brain structure or function leading to impairment. It can be
diagnosed and treated.
Loss of control: Under this view, addicted individuals genuinely want to stop
but cannot. This loss of control is evident over both short and long periods. For
example, an alcoholic intending to have one or two drinks finds it impossible to
stop, consuming more and more. Over longer periods, an addict may plan to
abstain but soon engages in the addictive behavior despite their intentions. The
addict "chooses to do one thing but does something else."
The importance of craving: At the core of the Disease Model is craving,
defined as an "urgent and overpowering desire." This is seen as a motivational
state that entirely overwhelms the individual, dominating thoughts, feelings,
and actions, leading to a single-minded pursuit of the drug. To the addict and
observers, this often feels like there is no real choice, but rather compulsion.
Self-cure: An observation challenging the Disease Model is that some
"addicts" stop on their own without apparent difficulty. The model presumes
either a sudden normalization of brain abnormality or that the individual was
never truly addicted. It's also suggested that a distinction might be needed
between heavy, regular users and truly addicted individuals who might not
spontaneously recover in this manner.
Issues and evaluation:
● The Disease Model is criticized for implying that addicts are powerless
onlookers who can only be stopped by physical restraint.
● By focusing solely on compulsion, it doesn't encompass aspects of
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choice and identity in addiction.

● It doesn't fully explain why some people become addicted while others
don't, though it suggests it relates to factors making the behavior
more rewarding or abstinence more distressing.

Personality and addiction typologies

While past efforts to find a single "addictive personality" (e.g., traits like
dependency, immaturity) were largely unsuccessful, leading many to dismiss
their importance, recent research is rekindling interest.
Tridimensional Personality Theory
Cloninger’s Tridimensional Personality Theory proposes that three
fundamental personality dimensions affect addiction susceptibility and can
categorize addicts into subtypes. It's similar to other dimensional theories of
personality (like Eysenck's or McCrae and Costa's Five-factor Theory).
The three dimensions are:
● Novelty seeking: Propensity to pursue new experiences.
● Harm avoidance: Tendency to avoid risky or harmful situations.
● Reward dependence: Degree to which one seeks and relies on
rewards.
These dimensions interact to influence responses to novelty, punishment, and
reward, impacting alcohol and drug dependence. The theory also proposes two
main subtypes of alcoholics:
● Type I alcoholics: Later onset, less genetic influence, more likely
female, fewer problematic behaviors.
● Type II alcoholics: Earlier onset, greater genetic influence, often male,
more associated with antisocial behavior.
Evidence: Research has found novelty seeking distinguishes alcoholics from
non-alcoholics and smokers from non-smokers, and predicts early-onset
alcohol abuse and serious delinquency. However, findings for harm avoidance
and reward dependence are less consistent. Some studies have struggled to
classify many individuals into clear Type I or Type II profiles.
Issues and evaluation:
● Cloninger’s theory is important for grounding addiction in a broader
personality theory and recognizing the variety within dependence.
● While it captures some key distinctions, broader contentions haven't
always been strongly supported by evidence.
● Other typologies exist, such as Babor’s Type A and Type B
alcoholics, which were based on characteristics observed in
treatment rather than a personality theory. Type A alcoholics generally
have later onset, less severe dependence, and fewer problems, while
Type B alcoholics have earlier onset, greater severity, more problems,
and a poorer treatment outlook.

Self-efficacy
Self-efficacy refers to an individual's confidence in their ability to organize and
carry out actions to achieve specific goals, such as exercising restraint or
maintaining abstinence from drugs. Simply put, if a person doesn't believe they
can do something, they are less likely to try or will give up easily.
Self-efficacy Theory
Overcoming addiction is directly related to a person's belief in their ability to
control their behavior and achieve abstinence. Core hypotheses include:
● Self-efficacy influences the goals people pursue.
● It affects the effort put into achieving those goals.
● It influences how long people persevere despite barriers.
● It impacts the likelihood of achieving the goal.
Self-efficacy is influenced by past successes or failures but can also predict
future behavior beyond past experience.
Generalised versus specific self-efficacy: It can relate to very specific tasks
(like stopping heroin use) or be more general, extending to perceived control
over thoughts, feelings, and environment. Reduced self-efficacy is thought to
contribute to the "loss of control" in addiction. Marlatt classified different
types, including resistance self-efficacy (ability to avoid first use) and harm
reduction self-efficacy (ability to reduce risks once addicted).
Craving and self-efficacy: These two concepts are often seen as inversely
related: high craving can severely disrupt an addict's coping skills. Self-
efficacy has been found to predict success in cessation attempts, even when
accounting for current substance use patterns.
Changes in self-efficacy: Successfully giving up a drug tends to increase an
individual's self-efficacy. Conversely, continuing use or relapsing often leads to
decreased self-efficacy. This concept also shows parallels with Identity Shift
Theory.
Issues and evaluation:
● Self-efficacy theory aligns well with observations and rational choice
models of behavior.
● It's considered important due to its potential influence on addictive
behavior.
● However, evidence hasn't conclusively established how important self-
efficacy itself is in maintaining addiction. For example, it's questioned
whether confidence alone can overcome severe addiction, or if
increasing self-efficacy through intervention has a substantial impact
on actual restraint. The concept is part of many broader theories.

The transition from lapse to relapse

The concept of self-efficacy (one's belief in their ability to succeed) is crucial
to understanding the transition from a single slip in behavior (a lapse) to a full
return to old patterns (a relapse). This process is explained by the Abstinence
Violation Effect (AVE).
The Abstinence Violation Effect
The AVE proposes that if an individual attributes the cause of a lapse to
internal, stable, and global factors (e.g., "I lapsed because I'm inherently
weak," "I'll always be this way," "This affects every part of my life"), along with
feelings of guilt and loss of control, they are much more likely to return to
regular substance use. It views relapse as a learning experience where
inadequate coping resources play a key role, and cognitive factors are crucial.
Marlatt argued the AVE is a highly destructive cognitive process.
Genesis of the AVE: The AVE occurs when a person sees their drug use as a
major deviation from absolute abstinence, causing cognitive dissonance
(mental discomfort from conflicting beliefs). To resolve this, they might
conclude that some intrinsic personal flaw makes abstinence impossible
("personal attribution"), which then undermines future attempts at sobriety.
Effects of the AVE: The theory suggests that a constructive way to view a
lapse is to identify circumstantial factors that made resistance difficult. This
allows for developing future coping plans. The AVE frames relapse as a learning
experience, where an individual's reaction and interpretation of a lapse
determine their future commitment to abstinence.
Empirical evidence: Studies show that negative emotional states often
precede lapses in various addictions, supporting the idea that addiction is
sometimes used for stress control. Lack of coping skills has been identified as
a strong predictor of relapse. While studies on attributions (internal/external,
stable/unstable, global/specific) in lapsers vs. relapsers have yielded complex
and sometimes mixed results, they highlight the intricate nature of cognitive
processing during early recovery. Some findings suggest that while self-
efficacy and initial reactions to lapses might not always predict full relapse,
attempts at restorative coping (how a person tries to recover after a lapse)
can reduce the likelihood of a second lapse. High nicotine dependence, for
example, increases the chance of subsequent lapses.
Implications and interventions: The Relapse Prevention Model was
developed from the AVE concept. This model emphasizes individualized
treatment, where therapists thoroughly assess an individual's risk factors, cues,
and coping skills. It focuses on helping individuals find alternative strategies
for avoiding or coping with risky situations (using both cognitive and behavioral
techniques). Crucially, it aims to enhance the addict's self-efficacy in using
these new strategies through practice. Finally, it prepares individuals for how to
deal with a lapse, including developing a structured plan for what to do if one
occurs.
Motivational Interviewing, a counseling technique, emerged from the relapse
prevention approach. It focuses on engaging individuals in a dialogue to foster
their long-term commitment to behavior change by identifying risky situations
and evaluating coping strategies in a supportive environment. Research
supports its value in improving abstinence rates and time spent drug-free.
Issues and evaluation: While not all aspects are fully supported by evidence,
the AVE theory captures important features of relapse and aligns with real-
world observations. Its main tenets are considered essential for any general
theory of addiction. However, it's important to note that the concept of
"relapse" itself is complex and an oversimplification of the transition from
abstinence to renewed use.
Impulse control
The concepts of self-efficacy and the AVE draw attention to beliefs and feelings
that undermine change. Problems with impulse control are also associated
with the extent of addictive substance use. The failure of self-control is
explored more generally in several theories.
Inhibition Dysregulation Theory
This theory proposes that addiction involves a progressive dysregulation
(malfunction) of the brain's ability to inhibit rewarded behaviors. It suggests
that the inhibitory system, involving specific brain regions (like the orbitofrontal
cortex and anterior cingulate cortex), underlies the compulsive behaviors seen
in addiction. It argues that while individuals aren't automatons, their decision-
making is compromised by a dysfunctional inhibitory or reward system.
Commonalities between addiction and disorders of control: Substance
abuse is common in disorders characterized by impaired inhibitory processes,
such as schizophrenia, depression, ADHD, and Obsessive Compulsive Disorder
(OCD). Some aspects of addiction are very similar to OCD, as both involve an
inability to inhibit intrusive thoughts (obsessions/cravings) and ritualistic
behaviors (compulsions/drug-taking).
Brain regions involved in inhibition: Studies have found significant under-
activity in the orbitofrontal cortex (OFC) and anterior cingulate cortex
(ACC) in cocaine addicts and alcoholics, both during active use and long-term
abstinence. These areas are highly active during cue exposure and withdrawal,
suggesting they form the core of the inhibitory system responsible for self-
regulation. The theory proposes that compulsive behavior requires not just
strong desires but also dysfunctional inhibitory processes in the OFC and ACC.
Failure of inhibition and relapse: This theory is supported by findings that
craving is less often a primary relapse factor than impulsive action (reduced
inhibitory control). Underactivity of the inhibitory system might also lead to a
failure to consider future consequences. The theory suggests the inhibitory
system is overwhelmed by strong motives, leading to impulsive behavior
(experienced as loss of control) and recurrent compulsive drug taking, with
little regard for negative outcomes.
Interventions to enhance inhibitory control: Many self-help and clinical
interventions, like Alcoholics Anonymous and motivational interviewing, aim to
improve inhibitory control. Pharmacotherapy (like substitution treatments) is
also seen as consistent with this model.
Issues and evaluation: This theory shifts focus from tolerance/withdrawal to a
compulsive drug-seeking explanation driven by drug effects and the struggle
for abstinence. It attempts to integrate findings on neuroadaptation, dopamine
systems, cue reactivity, and inhibitory system malfunction. While it incorporates
elements of conscious choice and habit, evidence points to a failure of
inhibitory mechanisms in many addiction cases, and we are beginning to
understand its neurological basis.

Self-regulation as a broadly based concept

Self-regulation is a broad concept describing how we consciously use our will
to achieve goals, including conscious restraint and inhibiting responses. It
involves higher-level mental processes overriding lower-level, impulsive ones.
Self-regulation Theory
This theory states that actions arise from a hierarchy of competing processes.
Self-regulation occurs when higher-order processes (involving complex
meanings, abstract goals) override lower-order processes. Self-regulation
failure happens when lower-order impulses win. This theory highlights
commonalities between addiction and other behavioral problems like poor self-
management, obsessions, and overeating. It suggests stable individual
differences in self-control may predate addiction and considers the effects of
drugs, tiredness, emotions, and environment on self-regulation.
Issues and evaluation: This theory has significant potential to explain links
between personality and addiction, mental illness and addiction, different forms
of addiction, and recovery. It emphasizes that abnormalities in self-control are
crucial to understanding addiction, alongside the feeling of irresistible urge or
compulsion.

Urges and craving

The terms "urge" and "craving" are often used interchangeably, but "urge"
generally refers to a feeling of being impelled to do something, which isn't
always the same as wanting to do it. Tiffany developed a theory about how
urges develop and their role in maintaining drug use.
A Cognitive Model of Drug Urges
This model proposes that compulsive drug use involves more than just
subjective feelings of craving. It involves the enactment of highly automated
action sequences driven by cue-response associations. Craving, in this model,
has two related dimensions:
. A conscious attempt to block automated action sequences.
. The anticipation of pleasure from the behavior.
The theory suggests that craving largely represents the addict's effort to
interrupt ingrained, automated drug-use behaviors. Thus, an addict's intention
to use drugs should influence their reported craving. While active users might
show a strong link between desire and intention, this link can become
"uncoupled" in those trying to quit.
Two dimensions of urge: Craving is divided into an urgent need linked with
withdrawal symptoms and an expectation of pleasure. Studies on smokers have
claimed to support this, but the evidence is debated. Factor analysis (a
statistical method) applied to questionnaires like the Questionnaire of Smoking
Urges (QSU) has been used to support the two dimensions, though its
reliability depends heavily on question wording and methodology.
Automaticity and addiction: The theory also aims to explain how
environmental cues relate to craving reports and why relapse can occur without
craving. Research shows that truly absent-minded lapses are rare.
Issues and evaluation: This theory aims to integrate cognitive processing with
non-conscious motivational systems. It acknowledges that urges don't solely
come from anticipated pleasure. Its key insight is that urges can arise from the
effort to interrupt an automated action sequence, essentially the "flip side" of
self-restraint.
Addiction as a failure of self-control over desires and urges: Overall, adding
concepts of self-control and compulsion to a theory of addiction suggests that
while conscious choice is still involved, many processes are non-conscious or
automatic. Anomalies exist, such as addictive behaviors occurring without full
conscious awareness, and a mismatch between the intensity of urges and the
perceived rewards.

Psychological Theories (Continued)

Personality Theories
A counselor using personality theory would typically begin by assessing
relevant personality traits. If using the Big Five theory, for example,
instruments like the NEO Personality Inventory-Revised or the Big Five
Inventory (BFI, or its updated BFI-2) could be used. After assessment, the
counselor would then develop interventions to reduce problematic traits and
enhance adaptive ones.
Strengths of this approach: Research exploring links between personality
theories and addiction is ongoing, with correlations being found, particularly
with the Big Five theory.
Limitations of this approach: Currently, there isn't enough empirical evidence
to strongly support using personality theory as a primary treatment approach
for addiction in practice. Counselors are generally advised to use empirically
validated treatments.

3.2
Family or “Systems Theory” Models
Historically, addiction counselors focused only on the addicted individual.
However, they soon realized the significant role family members play in
motivating clients for treatment. Systems theory, which underlies all family
counseling approaches, views the family as a single interconnected system. A
change in one part of the system affects all other parts. Therefore, if a family is
dysfunctional, its members, especially children, can become vulnerable to
addictions or mental disorders.
There are three predominant family models in addiction counseling:
. Behavioral Family Model: Suggests that one or more family members
might reinforce the addictive behavior. For example, some family
members might prefer the client to be actively addicted because they
exhibit more desirable qualities during active use than during
withdrawal.
. Family Systems Model: Views the client as the "scapegoat" or
"identified patient" who most overtly expresses the family's
underlying dysfunction, often through addiction. Other family
members might express their problems differently (e.g., via other
mental disorders).
. Family Disease Model: Believes the entire family has a disorder or
 .
disease. For counseling to be effective, the whole family needs to
participate simultaneously. Family members are often seen as
codependent (exhibiting specific personality traits common in
chemically dependent families) and engaging in enabling behaviors
that perpetuate the addiction.
Research suggests that addiction occurs within complex family systems that go
through cycles of stability and change. Interventions should consider addiction
as involving adaptive cycles: the addictive cycle, a transitory cycle, and a
recovery maintenance cycle.
Role of the Counselor: The counselor's role depends on the specific school of
family counseling:
● Bowen Systems Theory (BST): Counselors coach clients to be more
cognitive and rational in their interactions, using Socratic questioning
to encourage independent thinking.
● Structural Family Counseling (SFC): Counselors act as observers
and experts, making interventions to change the family's underlying
structure and establish clear boundaries between members.
● Strategic Counseling (SC): Counselors focus on the process of
dysfunctional interactions, actively, directly, and pragmatically
encouraging clients to try new behaviors.
● Emotion-Focused Family Therapy (EFT): Counselors aim to build
stronger, healthier emotional bonds within the family, helping members
identify and express their primary emotions to each other.

3.3

Personality Disorders, Psychosis, and Schizophrenia

This section overviews personality disorders, psychosis, and schizophrenia,
noting their common comorbidity with Substance Use Disorders (SUDs).
Counselors are cautioned that working with psychosis typically requires
psychiatric consultation.
Personality disorders
The current classification of personality disorders in DSM-5 (Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition) is widely criticized for being
complicated and difficult to apply. These disorders are frequently comorbid
with SUDs.
DSM-5 lists various personality disorders (e.g., paranoid, antisocial, borderline,
narcissistic). For the first time, DSM-5 also offers an Alternative Model for
Personality Disorders (AMPD). Instead of diagnosing each disorder
separately, the AMPD characterizes personality disorders by:
. Impairment in personality functioning (at least moderate).
. Presence of pathological personality traits.
. Inflexibility and pervasiveness of these impairments across
situations.
. Stability (long-lasting impairments).
 . Impairments not explained by other mental disorders.
. Not caused by SUDs or medical conditions (active SUDs can mimic
personality disorder traits).
. Not resulting from normal development or environment.
The AMPD details specific personality disorders (e.g., Antisocial, Borderline,
Narcissistic). Research offers some support for the AMPD, though validity
issues exist for several disorders. A new questionnaire, the DLOPFQ, measures
personality disorders in this alternative model. It's crucial to remember that
SUDs can temporarily mimic other mental disorders, so professionals must
assess this by having the client stop using the substance to determine the role
of the SUD.
What Is It Really Like to Experience Antisocial Personality
Disorder?
Individuals with Antisocial Personality Disorder (APD) differ from those with
Narcissistic Personality Disorder (NPD). APD involves manipulation and
personal gain, risky behavior (even if it leads to incarceration or injury),
impulsivity, and a lack of concern for the future or respect for authority. Unlike
NPD, it's not about feeling superior or needing excessive approval.
Psychosis
Individuals experiencing psychosis are, to varying degrees, out of touch with
reality. The most common symptoms are:
● Hallucinations: Sensations that aren't real (e.g., hearing voices,
seeing things that aren't there). These can affect any sense.
● Delusions: Strong beliefs that are not true (e.g., believing someone is
following you, having extraordinary abilities).
Other psychotic symptoms include racing thoughts, difficulty concentrating,
and inability to complete tasks. Childhood trauma is identified as a risk factor
for developing psychosis, with emotional abuse and neglect linked to later
hallucinations and delusions.
Common delusions involve paranoia (being persecuted, conspiracy),
grandiosity (special abilities, divine connection), or unusual body awareness.
Interestingly, hallucinations are not always pathological; some people
experience common non-pathological hallucinations like hearing their name
called, comforting voices, or seeing deceased loved ones. Cultural context can
shape the type of voices heard (e.g., violent commands in the US vs. relational
voices in India/Ghana).
Psychoactive drugs can cause visual hallucinations, and some substances
(hallucinogens, stimulants) or withdrawal from depressants can lead to
temporary psychotic states. Hallucinations can involve many sensory
modalities. While auditory verbal hallucinations (AVH) are common in
schizophrenia, multimodal hallucinations are also prevalent. AVHs can also
occur in other mental disorders like major depression, bipolar disorder, and
PTSD.
Schizophrenia
Schizophrenia is an illness characterized by psychosis and other symptoms
that lead to cognitive, social, and functional impairment. Its symptoms are
typically categorized into three domains:
. Positive symptoms: Delusions, hallucinations, disorganized thoughts,
or bizarre behavior.
. Negative symptoms: Anhedonia (inability to feel pleasure), reduced
ability to think/speak, lack of motivation, and social/emotional
withdrawal. Anhedonia is considered a central negative symptom.
. Cognitive impairment: Problems with memory, attention, and
executive functioning.
Many patients with schizophrenia continue to experience significant positive
and negative symptoms even with medication, making independent living, daily
activities, socializing, and work difficult.
What Is It Really Like to Experience Schizophrenia?
Experiencing schizophrenia, particularly hearing voices, is difficult to describe.
Voices can range from sounding like someone nearby to being like thoughts.
They might give harmful commands, be critical, or even be neutral or
complimentary. Voices can be constant and debilitating, leading to isolation.

Role of the Insula in Addiction

The insular cortex (IC), or insula, plays a crucial and complex role in addiction,
primarily through its involvement in processing interoceptive signals – the
sensations from within our bodies (like hunger, pain, or the feeling of a drug's
effect). These signals profoundly influence drug cravings and the experience of
withdrawal.
Research highlights the insula's dual nature in addiction:
● Lesion Studies (Damage to the Insula): Studies on patients who
experienced brain damage to the insula, often due to stroke, have
shown a remarkable phenomenon: sudden and effortless cessation of
addiction, particularly smoking. This suggests that the insula might be
essential for maintaining the drive to use substances.
● Neuroimaging Studies (Insula in Addicts): Paradoxically,
neuroimaging research on individuals with Substance Use Disorders
(SUDs) often reveals a reduced gray matter volume in the insula.
Furthermore, its activity is altered during tasks involving craving and
decision-making.
How the Insula Contributes to Addiction:
● Salience Network Connection: The insula is a key hub in the
salience network, a brain system responsible for detecting and
prioritizing important internal and external stimuli. Its strong
connection and interaction with the anterior cingulate cortex (ACC)
in this network enhance attention to drug-related cues. This
heightened attention reinforces addictive behaviors, making drug cues
more compelling.
● Emotional Regulation and Decision-Making Deficits: The insula is
also involved in emotional regulation and decision-making. Deficits in
these areas, linked to insula dysfunction, contribute to impulsivity
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and poor self-control. This, in turn, makes drug-seeking behaviors

more compulsive and difficult to resist.
Divisions of the Insula and Their Functions:
The insula is generally divided into three regions, each with proposed distinct
roles:
. Granular Insula: Primarily associated with awareness of bodily
states.
. Dysgranular Insula: Involved in processing emotional responses.
. Agranular Insula: Linked to motivation and goal-directed behavior.
The Insula Paradox:
The seemingly contradictory findings – where insula damage can reduce
addiction while neuroimaging shows lower insular activity in addicts – suggest
that the insula's precise role might depend on the severity of addiction and
the specific substance type. It's possible that in a healthy state, the insula
contributes to a "normal" motivation for reward, but in addiction, its
dysregulation or altered function (either too much or too little activity in
specific subregions) contributes to the compulsive drive.
Treatment Implications and Future Research:
The insula's critical role makes it a potential target for neuromodulation
therapies, such as transcranial magnetic stimulation (TMS). These
therapies aim to regulate the insula's function and potentially reduce
compulsive substance use.
Future research must clarify whether insular dysfunction is a cause or a
consequence of addiction. Understanding this will be vital for developing
effective interventions that can restore the insula's normal function, ultimately
aiding in addiction recovery.