Transdiagnostic Approach to Addiction

According to the newly revised DSM V, nearly all psychopathology has some form of emotional dysregulation. For the first time addiction is now considered as a behavioural problem and not just linked to pharmaceutical substance and addictions to sex and gaming etc have been moved from the “impulse control” category to the substance related and addictive disorders section. It has been well documented that behavioural addiction such as gambling, gaming, sex etc… share neurological and etiological clinical features with substance use addictions, but these have traditionally been treated differently.

The National Institute of Mental Health’s Research Domain (RDoC) is promoting a transdiagnostic approach to classifying mental disorders, based more on neurobiology and behaviour than on a list of symptoms.

As regard to addictive disorders we can see many similarities between substance- based addictions and behavioural- based addiction. At a neurological level they both share a dysregulation in the dopamine reward pathways and although a dysregulation may be different for substance addiction and behavioural addiction, they both clearly act upon the dopaminergic reward pathways. These result in similar expressions such as deficits in executive functioning related to decision making, impulsiveness and difficulties in delaying reward.

Emotion is described as having an interpersonal function that pathology interferes with and there is good evidence of this interference at a substance- based addiction level where impaired facial emotion expression recognition has been documented in alcoholics and opiate users (Konreich et al 2003), with opiate users being more sensitive to facial expression of disgust (Martin et al 2006), but more research is needed into emotional facial expression recognition in behavioural- based addiction.

A transdiagnostic approach to pathology has been developed for anxiety, depression and eating disorders and is now being applied to the field of addiction treatment. This accounts for the very high levels of comorbidity often experienced by people suffering from addiction disorders.

It also points to the fact that there may exist common processes across different disorders

Treatment for one disorder may affect another

The RDoC has outlined some domains or constructs that may be core themes related to pathology that can be extrapolated to addiction disorders, these are:

Negative valence systems (fear, anxiety)
Positive valence (reward, effort, reward prediction)
Cognitive systems (attention, perception, cog control and working memory)
Social processes (attachment, facial expressions, empathy)
Arousal (sleep regulation and arousal)

A transdiagnostic approach can be useful for refining categorical diagnosis of pathology, identifying common emotional related causes or maintenance processes and give direction to treatment with an emphasis on emotional change.

The advantage of a transdiagnostic approach is that is can cut across specific diagnosis and works well in cases of comorbidity. A trial treating client with anxiety also showed a reduction in depressive symptoms even though depression was not specifically targeted by the treatment (Barlow 2010).

By using a transdiagnostic approach to addiction disorders, it may be possible to influence a variety of addictive expressions by targeting underlying mechanisms. Also allowing the treatment of emerging addictive and substance-based behaviours without having to elaborate new behaviour or substance-specific interventions due to the fact that the underlying mechanisms are similar. There exist common component vulnerability factors which lead to different addictive expressions in different individuals. These may include broad overarching components such as: attachment and interpersonal difficulties, impulsivity, expectancy and deficits in executive functioning.

Empirical evidence does show that a “negative urgency” compulsion is related to nicotine addiction, alcohol abuse and gambling, common comorbidity in addictive disorders. By targeting the underlying theme of impulse control, it is not necessary to design treatment interventions that target specific substances (Boothby 2017).

Using a transdiagnostic treatment protocol, Barlow and Ellard (2011) outlined core emotion-related mechanisms that are common across pathology and indicated core skills necessary to intervene in treatment. These include:

Emotion awareness
Cognitive flexibility
Identification of avoidance strategies
Awareness and tolerance of emotional sensations

The following components are considered by Hyoun and Hodgkins (2018) as fundamental constructs in a transdiagnostic approach to addictive disorder treatment. These are outlined in their component model of addiction treatment.

Although slightly different from the core emotion-related mechanisms outlined by Barlow and Ellard, we can see the way these cut across specific substance- based and behavioural- based addiction intervention.

Motivation for change

Motivation for change can be targeted by therapies such as motivational interviewing where ambivalence about change is worked on by assuming that motivation to change addictive habits is dynamic and fluctuating, as in the transtheoretical model of change by Prochaska and DiClemente. Due to the poor treatment outcomes related to lack of motivation, this is considered key in the treatment of addictive disorders. Metanalysis has shown that targeting motivational components first can lead to better treatment outcomes in nicotine, alcohol, marijuana and gambling (DiClemente et al 2017).

Negative Urgency

An integration of urgency and negative affect and explains why people engage in destructive addictive behaviours when unable to emotionally regulate negative affect.

Highly related to controls of impulsivity, negative urgency has been shown as a key component in addictive disorders related to alcohol, shopping, sex, binge eating and gambling. Inability to tolerate negative affect.

Distress tolerance in simple behavioural tasks such as holding one’s breath or handgrip persistence is a good indicator of negative treatment outcomes or relapse.

Negative affect distress tolerance can be targeted by exposure therapy using both cognitive and behavioural interventions and where mindfulness has been shown to be helpful in awareness and in reducing reactivity. Third wave behavioural therapies, such as DBT and ACT, have also been shown to be effective in distress tolerance interventions.

Evidence provides promising support for interventions directed at distress tolerance, with positive outcomes being shown in substance abuse (Bornovalova 2011), nicotine (Brown et al 2013) and opioid addiction (Stein et al 2015).

Deficit in self-control

Self- control can be considered as the ability to see beyond the present moment and focus attention on goals and is especially useful in relapse prevention and abstaining from addictive substances or behaviours.

Based on the theory of resource depletion, interventions are focussed on situations that may cause emotional and cognitive overload where less resources become available for self-control. Again, this component is a facet of the distress tolerance construct mentioned above.

Expectancy

Identified two types of dysfunctional thinking processes. Permissive beliefs about justification of substance use and anticipatory beliefs related to the outcome of using substance or behaviour to regulate emotion.

Expectancy challenge intervention such as cognitive therapy interventions are shown to be successful in reducing expectancy regarding the outcome of engaging in substance consumption or addictive behaviours.

Due to the fact that one of the major reasons people engage in addictive behaviours is as a coping mechanism (the others being enhancement and social motives), it is of fundamental importance to implement a program of emotional regulation in parallel with challenging expectancy. If you take away someone`s only coping mechanism, it’s a good idea to have something more adaptive in place already.

Deficits in Social support

Consistently shown to be linked to different expressions of addictive disorders, and spans both substance- based addictions such as alcohol and marijuana as well as more behavioural-based addictions such as gaming, gambling and sex. Also, a lack of social support is linked to poor treatment outcomes. Interpersonal conflict can cause intense negative affect, reinforcing addictive behaviour as a coping mechanism.

Family-based or couple therapies are shown to be a good compliment to addictive treatment and the sense of community that one derives from groups such as Alcoholics Anonymous give people a sense of belonging often lacking when engaged in addictive behaviours. Community reinforcement and family training (CRAFT) that engages client`s significant others in the process is showing signs of having success.

Compulsivity and repeated maladaptive behaviour

Where impulsivity is shown to play a prominent role in the onset of addictive behaviours, compulsivity is shown to have a key role in maintaining addictive behaviours through negative reinforcement. That is to say if I use gambling to regulate emotional distress it will become a reinforced compulsion.

Liking can be related to the impulsive nature of addiction (hedonism) whereas the wanting aspect of addiction can be related to the compulsive nature of addiction. One can engage in addictive behaviours without liking them.

Possible interventions for compulsivity include stimulus control (people, places and things), attentional bias retraining (unconscious attention to addictive cues), positive reinforcement and contingency management (positive reinforcement from not engaging in addictive behaviour).

Component Model of Addiction

Draws on constructed components that are deemed to be core emotion-related mechanisms of addiction, without referring to substance or behavioural-specific interventions.

Observations

Although a component model of addictions points to overarching core mechanisms, we must be careful so as not to apply a “one size fits all” approach to addiction. There are very real differences between substances and behavioural addictions, the most obvious being physical addiction and withdrawal symptoms from some substances, namely heroin, cocaine and barbiturates.

Related harms are significantly different between substance-based and behavioural- based addictive behaviours, the same as there exist difference within substance-based and behavioural- based addictive behaviours. interpersonal conflict has been associated with causing more interpersonal problems in alcohol users than in other substance users. Whereas the withdrawal and tolerance are associated with substance-based addiction, the jury is still out regarding behavioural- based addiction.

Negative consequences also vary between addictions, with financial consequences being more prominent in gamblers and overdose being more prominent in opiate users than in sex addicts.

Psychosocial intervention with people receiving opiate agonist treatment such as methadone is shown to have no effect on outcome or treatment adherence. Also, addiction cue exposure techniques can have disastrous effects on opiate users.

These last points seem to indicate that a component model for intervention in addictions should be used alongside a traditional categorical diagnosis of addiction where specific distinctions are made between possible interventions with specific substances or behaviours.

References

Barlow DH, Ebrary I. (2010) Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. Oxford: Oxford University Press.

Boothby CA, Kim HS, Romanow NK, Hodgins DC, Mcgrath DS. (2017) Assessing the role of impulsivity in smoking & non-smoking disordered gamblers. Addict Behav. 70:35–41. doi: 10.1016/j.addbeh.2017.02.002

Hyoun S. Kim* and David C. Hodgins (2018) Component Model of Addiction Treatment: A Pragmatic Transdiagnostic Treatment Model of Behavioral and Substance Addictions. HYPOTHESIS AND THEORY published: 31 August 2018 doi: 10.3389/fpsyt.2018.00406

Kornreich, Charles ; Foisy, Marie-Line ; Philippot, Pierre ; Dan, Bernard ; Tecco, Juan ; Noël, Xavier ; Hess, Ursula ; Pelc, Isidore ; Verbanck, Paul. (2003) Impaired emotional facial expression recognition in alcoholics, opiate dependence subjects, methadone maintained subjects and mixed alcohol-opiate antecedents subjects compared with normal controls. Psychiatry Research, 2003, Vol.119(3), pp.251-260

Kring & Mote. (2016). Emotion Disturbances as Transdiagnostic Processes in Psychopathology. Feldman-Barett, Lewis, Haviland-Jones (Eds). Handbook of emotion. Guilford Publications

Linton, S.J. (2013). A Transdiagnostic Approach to Pain and Emotion. Journal of Applied Biobehavioral Research, 18; 82-103

Louise Martin, Joanna Clair, Paul Davis, Dominic O’Ryan, Rosa Hoshi & Valerie Curran (2006) Enhanced recognition of facial expressions of disgust in opiate users receiving maintenance treatment. Clinical Psychopharmacology Unit, UCL, London, UK and Substance Misuse Services, Camden and Islington Mental Health and Social Care Trust, London, UK

Transdiagnostic Approach to Addiction