Samenvatting
Summary GGZ3025 - Verslaving - Taak 2
- Instelling
- Maastricht University (UM)
Complete en uitgebreide samenvatting van alle bronnen van de tweede taak van GGZ3025 - Verslaving. Grootste deel is in het Engels geschreven.
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Voorbeeld van de inhoud
GGZ3025 VerslavingTASK 2 – VERSLAVING IS AANGELEERD
CUE REACTIVITY
Bron: Rose, Field, Franken & Munafò (2013), p413-423
Conditioning and learning theories
A risk factor believed to be important in substance-related behaviors is cue reactivity. When
an individual comes into contact with a stimulus associated with the substance, psychological
and physiological reactions occur, which may tigger substance-related behaviors. Substance
cues can increase craving and self-administration in both dependent and non-dependent
populations, and the degree of cue reactivity may predict individual differences in the risk of
relapse. However, evidence is inconsistent.
It was originally suggested that, as dependence on a substance developed, withdrawal
symptoms (unconditioned responses) would be experienced and cues (conditional stimuli)
associated with substance administration would come to elicit withdrawal-like responses
(conditioned responses, figure next page). Substance use is (in this account) defined as an
operant behavior that alleviates withdrawal symptoms (avoidance or escape learning), and
each successful reduction of negative effect reinforces subtance use. These withdrawal-
based theories were originally formuled due to reports from opiate addicts who claimed to
experience withdrawal-like symptoms when coming into contact with opiate-related cues (e.g.
previous substance-related contexts). Models have shown that, if withdrawal is accompanied
by a conditioned stimulus (e.g. tone, odor), the CS alone can precipitate withdrawal.
However, substance-associated cues have also been found to alleviate withdrawal symptoms.
It has also been proposed that, through attempts to maintain homeostasis, opponent
processes (physiological and affective responses that work in direct opposition to the effect of
the substance itself) develop in anticipation of, and to counteract, the effects of the
substance (figure next page). These opponent processes may underlie the development of
tolerance and support the administration of greater doses to experience the desired effects.
The absence of a conditioned opponent process has been put forward as a reason for why
fatal overdoses occur in experienced substance usesrs when they have adminstered in an
environment free from the usual substance cues. Both the theories of conditioned withdrawal
and conditioned opponent processes argue that physiological changes are key in activating
substance urges, and that these urges motivate substance intake to reduce these physiological
changes.
Competing theories postulate that cues take on positive incentive properties and trigger
substance-like effects (figure next page). General incentive motivation frameworks propose
that cues can develop conditioned incentive properties in their own right and elicit
motivational states. These may support specific types of behavior and can interact with
internat states. For example, the sight of beer may elicit a desire to drink alcohol, which
triggers approach and consummatory behaviors; however, this effect may be greater in a
person who is also thirsty. In terms of withdrawal, instead of negative reinforcement per se,
the withdrawal state makes the incentive value of the substance so great that substance use
prevails. When applying these general ideas to addiction, substance-associated cues elicit
substance-like, as opposed to substance-opposite, effects.
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Figure; typical types of cues, possible cue reactions according to major conditioning theories
of addiction, and potential outcomes from cue exposure.
The evidence concerning single process theories (i.e. those that focus on positive or negative
reinforcement, and substance-like or substance-opposite effects) with regard to cue reactivity
shows inconsistentie.
Another key area addressed by learning theories is whether substance behavior is habit-like or
goal-directed. Habit-like behavior is thought to be based upon stimulus-response
associations, in which behavior (e.g. substance intake) is triggered by a cue with little or no
mediation by the intention to engage in substance use, or anticipated outcomes of substance
use. Goal-directed behavior involves stimulus-outcome-response associations, which then
triggers behavior. Devaluation paradigms are often used to compare these two learning
processes. When food or substance outcomes have been devalued (e.g. through being paired
with an aversive consequence), some research has found that animals will stop responding for
the former, but not for the latter. This indicates that, whereas food-seeking behavior is goal-
directed (i.e. governed by expectancy of outcome), substance-seeking behavior is
insensitive to the devaluation effect, indicating a habit-like stimulus-response association.
Findings indicate that although substance-related behavior involves both goal-directed and
habit-like learning, it may also be particularly susceptible to the influence of cues. This lends
itself to the compulsive nature of addiction and fits with findings that cues can trigger
relapses in indivisuals, even though they are aware of the adverse consequences of returning
to substance use. In addition, the finding that cues can trigger substance-related behavior may
help explain the claims that craving elicited by cues is not consistently related to relapse risk.
The effects of cues on substance behaviors may bypass craving mechanisms, which may be
more associated with the perceived value of the substance, and trigger administration
behaviors in a more automatic fashion.
Due to discrepancies in results, theoretical accounts of substance use moved towards
dual process theories with an increased focus on more complex learning processes and,
initially, there were two primary versions; motivation and expectation. The motivation
framework suggests that cues (e.g. exteroceptive stimulus or interoceptive state) can
motivate a response and that the response outcome (e.g. a new state) can provide feedback to
strenghten this assocation. The expectation framework argues that the cue first activates an
expectation of the response outcome, which then triggers the response. The actual response
outcome can than feedback on to the expectation (figure next page).
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As the latter model incorporates outcome expectancies, the expectation framework better fits
with the finding that if the outcome is devalued or revalued, the response for that outcome is
decreased or increased respectively. However, the model does not directly explain the
possibility that cues may trigger a general outcome expectancy.
Figure; outline of the motivation and expectation dual process theories. The motivation
theory suggests that outcome of a response can feedback and strengthen the stimulus-
response association. The expectation theory suggests that the cue stimulates an expectancy
of the outcome, which then triggers a response (stimulus-outcome response). The outcome
therefore feedbacks on this association and can affect the nature of responses in the future.
Although most recent theories of substance dependence acknowledge a role of conditioning,
not all theories assume that conditioning is sufficient to explain substance use and relapse. In
its simplest form, conditioning theories argue that over time, cues can elicit physiological
responses and/or motivational states (e.g. urges, craving) which promote substance use.
However, there is lack of consistent evidence that self-reported urges or physiological
reactivity account for a significant amount of the variance seen within actual substance use.
severity is not always correlated with degree of cue reactivity, as would be expected, and not
all dependent individuals experience cue reactivity. In addition, substance use involves a
number of aspects, such as deciding to buy a bottle of wine, preexisting plans, substance-
related memories, and perceived self-control.
Cognitive theories
At the more basic level, it has been suggested that urges simply reflect a state of
physiological arousal and that the details of this state have been cognitively interpreted as
‘urges’ by the individual. Any substance cue may trigger arousal and the individual may
perceive the cue as associated with substance administration. These two processes may result
in the individual interpreting the arousal as craving, which triggers subtance intake. These
propositions come from a general cognitive labelling theory, which argues that the cognitive
and contextual/cue state that the individual is in is key to the interpretation of arousal. In
addition, arousal can have effects on other processes, including focusing attention, and
emotional influences on decision making, which could result in attentional bias for substance
cues and disrupted rational decision making regarding substance use.
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Some cognitive-behavioral theories argue that cues can trigger craving by highlighting the
positive effects of the substance and, if powerful enough, this craving will translate into
substance use. Outcome expectancies concerning positive and negative reinforcing effects of
substances are related to greater substance administration, more positive cue rating, and
responding to cues with greater craving. An additional element to several cognitive theories is
abstinence self-efficacy, which is the extent to which a person believes themselves capable of
maintaining abstinence. Addicts with low abstinence self-efficacy are more likely to report
higher levels of craving in the presence of cues. It is possible that the association between low
abstinence self-efficacy and cue-induced craving reflects an impaired cognitive control, such
that cues are able to have a greater effect.
The dual affect theory argued that substance urges represent either positive affect
(associated with appetitive motivational systems) or negative affect (related to withdrawal
systems) and that these frameworks of cognitive urges were mutually inhibitory. The dual
affect theory proposed that substance administration, availability and cues could activate a
positive appetitive state and result in excessive and compulsive substance intake. In addition,
withdrawal, withdrawal-related cues, and aversive cues and states (e.g. stress) could trigger a
‘negative affect urge framework’ and drive substance use. The theory argued that as the
conditions of the eliciting stimuli better matched the prototype, the stronger the network
activation. There are a number of problems with the dual affect theory; evidence does not
support mutually inhibitory affective systems.
A prominent cognitive theory of addiction, the cognitive urge and automaticity model,
proposes that, over time, behaviors associated with substance use become automatic
(figure). According to this theory, substance-related behaviors are stored in memory as
‘automatized action schemata’, and these action plans contain information on behavioral
sequences/procedures and cues which could trigger automatized behaviors. In addition, the
action plans incorporate physiological responses that support the behavior, and alternative
behavioral sequences which could be triggered to ensure the behavioral goal is achieved even
in the presence of obstacles. Repetition results in behavior becoming automatic.
Figure; cues can elicit automatic action schema which trigger substance-seeking and
administration behaviors quickly and effortlessly. If these actions are blocked, effortful
processes are activated to deal with the impediment and the individual may experience
craving.
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