[email protected]. uk The hidden agenda: Cognitive processes as vulnerability factors in addiction Frank Ryan Clinical Psychologist Honorary Research Fellow CNWL NHS Mental Health Trust Birkbeck College London
The Hidden Agenda: Cognitive processes in addiction
Dec 18, 2014
Presentation to Division of Clinical Psychology Conference December 2007
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The hidden agenda: Cognitive processes as vulnerability factors in
addiction
Frank RyanClinical Psychologist Honorary Research FellowCNWL NHS Mental Health Trust Birkbeck College
London
Overview & Scope
• Processing biases (latent but increase during craving)
• Impairments in executive/frontal processes (subtle and not generally apparent on psychometric tests)
• Implications for therapy• Context is translational or applied research
Basic Assumptions
• Executive control is the basis for the regulation of human action.
• Recovery from addiction is impeded by cognitive processing biases, impaired goal maintenance & error detection and compromised decision making.
• In combination, these cognitive processes can be latent vulnerability factors for relapse.
• These are potential targets for direct or indirect modification and can index therapeutic gain.
( Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP
Reward radar is always on!
• Emphasis on remediation of cognitive deficits and reversal of cognitive biases.
• Focus on goal maintenance and WM mechanisms
• Prioritises impulse control strategies
Two Functions of Attentional Control
• Resisting the lure of distractions
• Arresting the impulse to initiate pre-potent responses
Neuropsychological sequalae of drug misuse
Heavy long term us of alcohol, cannabis, inhalant, opiate & psychostimulant use ha been linked to deficits in:
• Attention/executive function• Learning and memory• Visuospatial abilities• Postural stability(Everitt et al (2001) The neuropsychological basis of addictive behaviour. Brain Res. Rev. 36.129-138
nm’,
Impaired inhibition and learning in substance misusers
To go, or not to
go: failure to suppress
pre-potent responses.
Experimental analogue
for restraining drug
use?
Review see Garavan, H. Stout, J.C. (2005)
Neurocognitive insights into substance misuse.
Trends in Cognitive Sciences 9.195-201
What is good for me or
bad for me? –
impaired learning from
implicit or indirect
feedback on
Iowa Gambling Task.
Cognitive biases are linked to craving
Cognitive biases are associated with increased craving.
Increased craving leads to increased cognitive bias.
Increased cognitive bias leads to increased craving
Bias tends towards maintenance rather than engagement: this has implications for treatment.
(Field, Mogg & Bradley, 2006 Attention to drug-related cues in addiction: Component processes in Wiers, W.W., & Stacey, A.W Handbook of implicit cognition and addiction.(Eds) Sage. London.
An Appraisal Model of Cue Reactivity (Ryan, 2002)(arrows indicate influence of cognitive biases which can be facilitative or
inhibitory)
Schematically Encoded Informationabout self and addiction in LTM
Cognitions e.g.Expectancies
Action Tendenciesand Behaviour
PhysiologicalReactivity
Experience of
Craving
Cognitive Appraisal:Stimulus
encoded as drug cue
Adapted from Eysenck,1997
Work in progress…..
Working Memory
Top downProcesses
(goals and coping strategies)
Bottom upProcesses
“Reward Radar”
The Gateway and the Desktop
Working memory <STM+Attentional control>• Maintains representations of external stimuli• Stores action plans• Goal representations• Task relevant information
Even when goal maintenance fails in WM, goal is still retrievable from LTM
Kane, MJ & Engle RW (2003) Working memory capacity and the control of attention: The contribution of goal neglect, response competition, and task set to Stroop interference. J of Exp Psych:(Gen) 132. 47-70
Bridging the gap between laboratory and clinic
• There are now about 45 studies using diverse methods implicating attentional biases in addiction (Franken, 2003)
• This is consistent with the “attribution of incentive salience” to cues that signal drug availability
• This suggests that detection of drug cues is the result of relatively automatic and hence involuntary processes that occur outside of awareness.
• Biased attentional processes are thus seen as influential in fostering the persistence or resumption of drug taking.
• This early preferential processing decisively influences subsequent mental operations such as memory.
Different concepts…Not so different therapies?
Cognitive Behaviour ModelEmphasises:• Multiple Causation• Addiction is compensatory: Dysphoria
precedes drug use• Negative reinforcement/safety seeking• “Liking” (positive expectancies)• Unspecified role for attentional
processes• Focus on secondary, deliberate
appraisal• Declarative/explicit memory system• Relapse due to wide range of factorsTherapeutic Implications:Cognitive re-structuringLifestyle change/coping skills training
“Neuro-Behaviour” Model Emphasises:
• Addiction is primary: dysphoria a consequence of drug use
• Drugs are primary reinforcers• “Pathological Wanting”• Hypervigilance• Primary appraisal • Implicit memory systems• Cognitive deficits from drug effects
contribute to the persistence of addiction
Therapeutic Implications:Focus on cuesReverse automaticity /cognitive deficitsPharmacotherapyMindfulness Meditation
Why Drugs are Addictive
• Drugs of abuse such as alcohol, amphetamine cocaine act as primary reinforcers.
• This operates directly or indirectly through dopaminergic systems in the mesolimbic region .
• Some people find this hard to resist.
Wanting and Liking
• Drugs stimulate dopamine neurotransmission in reward pathways
• Stimuli associated with this process are invested with incentive properties: An attributional learning process
• In some individuals repeated drug use produces incremental neuroadaptations which “hypersensitise” the relevant neural system
• This “pathological wanting” is subserved by mechanisms distinct from those that govern liking.
Robinson & Berridge,1993
Attentional bias associated with dependence severity: Two UK studies
Alcohol / Stroop paradigm
Ryan (2002)
Severity of Alcohol Dependence
Questionnaire, years heavy
drinking & quantity per occasion
predicted attentional bias in
sample of clinic alcoholics &
social drinker controls (N=65)R=.44 (p<01)
Heroin/ Flicker change blindness paradigm
Beare et al (2007)
Severity of heroin dependence
(monthly frequency of heroin use
in previous year) correlated with
attentional bias . N=28
r= 0.44 (P<0.02)
Outcomes Overview
Effect sizes for addictive disorders are diverse:
Alcohol (r=.27) 36-63%Cocaine (r=-.03) ??Tobacco (r=.09) 45-55%
Relapse Prevention Skills Training does not consistently confer superior outcomes across addictive spectrum compared to control interventions but substantially larger effect sizes have been found for:
Psychosocial gains (r=.48 i.e. 25%-75%) compared to substance use reduction (r=.14).
Irwin et al(1999)
Summary
Attentional bias prioritises cue detection and infiltration of working memory. The
contents of working memory in turn influence attentional bias.
Result is preoccupation with salient cues.
Implicit cognitive processes can subvert therapeutic allegiance
Scenario 1: Client blames themselves: “I’m lacking will power and I’m useless anyway…”
Scenario 2: Therapist blames client ( sometimes with their full agreement/collusion): “ You are not motivated or committed, come back when you’re ready: You say one thing and do another!)
Scenario 3: Therapist blames themselves: “I’m no good at this, my clients never seem to improve”
Scenario 4: Client blames therapist : “ You don’t understand me or my problems and the treatment is useless”.
General implications
• Prevention: Deferring age of first use is desirable (Tarter et al 2004)
• Treatment: Needs to be more intensive, more focused on impulse control and possibly including “brain re-training”
• Addiction is enduring due to the mandatory role of cognitive biases and the subversive action of subtle but pervasive cognitive failure
Easier said than done!
• Translating cognitive psychology findings into clinical applications is difficult.
• With compulsive (high-frequency) behaviours the way to combat “bottom-up” processing is to first acknowledge with the client that control is compromised; then devise intervention to address this.
IntroducingNeuro Cognitive Behaviour Therapy
• Emphasis both on remediation of cognitive deficits and reversal of cognitive biases.
• Focus on goal maintenance and working memory mechanisms
• Prioritises impulse control strategies
Therapeutic Strategies
• Stimulus Control: know those triggers• Implementation intentions• Be aware of and attempt to correct cognitive biases• Identify alternative rewards/goals (Cox et al) • Self-monitoring• Distance /de- centre / mindfulness meditation• Challenge expectancies and implicit cognitions via
behavioural experiments • Support self-efficacy• Goal specificity
Implementing intentions to change
• If situation X occurs at time Y I will perform behaviour Z e.g.
“If I have money when I get paid on Friday I will do my shopping before visiting the cocaine dealer”
If I am offered alcohol to drink at the party I will say “no thanks, but I would love a mineral water”.
Prestwich et al (2006)
“Road to recovery…
…is paved with good rehearsals.”
• Successful execution of any task requires both controlled and automatic processing- Treatment for addiction requires that automatic processes are recruited through practice, implementation intentions, cue exposure and stimulus control.
• Robust practice has been shown to increase automatic inhibition of competing goals (Palfai, p 416, Wiers & Stacey).
Concluding comments
• Addiction is maintained by enduring changes in priorities and deficits in information processing.
• Therapies that infiltrate and modify this, mainly via working memory processes, are more likely to be effective.
• There is a potential role for cognitive rehabilitation using the prototypical neurocognitive behaviour therapy described.
• Conversely, changes in attentional and mnemonic functioning, especially implicit processes, will index and predict therapeutic gain.
Poetry, cognition and motivation
“Two principles of human nature reign;
Self-love, to urge, and reason to restrain;
Nor this a good, nor this a bad we call,
Each works its end, to move or govern all.”
Alexander Pope
An Essay on Man 1732
Selected References
Irvin, J.E, Bowers, C.A, Dunn, M.E. & Wang, M.C.(1999) Efficacy of Relapse Prevention: A Meta-Analytic Review. J. of Consulting and Clinical Psychology. 67.563-570
Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical Psychopharmacology. 10. 67-76.
Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction
Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP
Wiers, W.W., & Stacey, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.
Selected Bibliography: Cognitive neuroscience and addiction
Franken, I.H.A. (2003) Drug craving and addiction: Integrating psychological and
neuropharmacological approaches. Progress in Neuro-Psychopharmacology and Biological Psychiatry.27, 563-57
Garcia, A V, Torrecillas, F L, de Arcos, F A & Garcia, M P (2005) Effects of executive impairments on maladaptive explanatory styles in substance abusers: Clinical implications. Archives of Clinical Neuropsychology 20. 67-80
Rogers. R D, Everritt, B J, Baldichino, A. et al (1999) Dissociable deficits in the decision making cognition of chronic amphetamine abusers,opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: Evidence for monoaminergic mechanisms
Neuropsychopharmacology 20. 4 322-339.
Robinson T E & Berridge, K C (1993) The neural basis of drug craving: An incentive sensitization theory of addiction. Brain Research Reviews 18 247-291
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