The role of affective dysregulation in drug addiction
Introduction
Evidence from epidemiological and clinical studies has consistently shown a strong association between affective and substance use disorders (SUDs). Individuals with affective psychopathology, such as mood and anxiety disorders, have been shown to demonstrate high rates of comorbid SUDs (Merikangas, Dierker, & Szamari, 1998). Similarly, affective psychopathology has been observed among those with primary SUDs, with some studies suggesting that SUDs may play a causative role in the development of affective disorders (Schuckit, 2006, Volkow, 2004). SUDs have also been linked to a range of deficits in the experience and expression of emotion in the absence of affective psychopathology (Aguilar de Arcos et al., 2008, Gerra et al., 2003, Sell et al., 2000). In short, the comorbidity of SUDs with affective dysfunction has been well established and has important theoretical and therapeutic implications (Volkow, 2004).
Despite these findings, models of addiction have not generally provided a comprehensive account of the role of affect in SUDs. Recent research has focussed more upon the neurobiological substrates underlying addiction than on its affective components, emphasising how the dysregulation of brain reward and stress systems bias addicted individuals towards continued substance use. Now widely accepted, this perspective has emphasised the importance of the circuitry that mediates the behavioural response to natural rewarding stimuli, the action of drugs of abuse within this system, and the resulting adaptations that occur within the brain in an attempt to maintain homeostasis (Altman et al., 1996, Koob & Le Moal, 1997). In doing so, it has helped explain the compulsive-like nature of addiction and the involuntary nature of cravings. However, although these findings are not incompatible with an affect-centred theory of SUD (Li & Sinha, 2008), most research within this field has not explicitly considered how affective processing may mediate addictive behaviours.
Theoretically, affect and SUD can be linked in a number of ways. Most relevant to this review is the crucial role that affective processes play in influencing motivated behaviours. The experience of affect facilitates action: it directs attention, prepares the individual for rapid physical responses, and guides behaviour to meet a particular need (Gross, 1998, Thompson, 1994). Affect is thus implicated in a range of concepts relevant to substance use, including positive and negative reinforcement, behavioural motivation, and the regulation of cognition and mood (Quirk, 2001). In a related vein, there is research suggesting that affect plays an important role in reasoning and decision-making (Bechara & Damasio, 2002, Damasio, 2001). As well as rational ‘cold’ cognition, human behaviour is driven by emotion-motivated reasoning: reasoning biased to select outcomes that minimise negative and maximise positive affective states (Westen, Blagov, Harenski, Kilts, & Hamann, 2006). Moreover, although the focus of this article is not on neurobiology, it is also relevant to note that the neural circuitry implicated in affective reactivity and regulation is closely related to the circuitry proposed to underlie addictive behaviours (Koob, 2003, Koob, 2006, Li & Sinha, 2008, Phan, 2002). Thus, many of the processes associated with substance abuse and addiction appear congruent with those underlying more naturally occurring affective experiences.
Given this apparent relationship, it is important that we understand the ways in which affect and substance use interrelate. As will be discussed in the following sections, this issue has been approached from a number of theoretical perspectives, including examination of how various forms of emotional distress can prompt substance use (e.g. Baker et al., 2004, Kassel et al., 2007, Robinson & Berridge, 2003), how substances can be powerful inducers of positive affective states (e.g. Volkow et al., 2005), how affect is related to dysfunctional decision-making processes and risky behaviours (e.g. Bechara & Damasio, 2002, Cyders & Smith, 2008), as well as how expectancy of affective change can motivate use (e.g. Cox & Klinger, 1988). While varied, these theories share common ground in that they posit a central role for affective processes in the motivation to use and abuse substances.
The primary goals of this paper are (i) to conceptualise SUDs as disorders of affect, and (ii) propose new ways of researching these constructs, beyond self-report. To this end, a selective review of the SUD literature was undertaken. Studies were identified through searches of relevant databases (e.g. Pubmed, PsycInfo, Web of Science) using combinations of the terms affect*, affect regulation, emotion, drug, substance, and alcohol*. The reference lists of selected articles were also scanned to identify additional relevant publications. Given the breadth of this review, and the large body of research within some areas, a systematic review of the literature was not undertaken. However, for areas in which little research has been conducted (e.g., the relevance of low positive affect to SUD risk), attempts were made to identify all articles with relevance to the topic. For more extensively researched areas (e.g., the relationship between SUD and negative affect), crucial articles representing well-validated findings were prioritised for inclusion, along with review articles, in order to provide a selection of articles that were representative of the larger body of findings.
The studies selected for review examine the relationship between SUDs and dysregulation within three dimensions of affective temperament and behaviour: negative affect (NA), positive affect (PA) and effortful control (EC). It is proposed that each of these affective dimensions strongly influence patterns of substance use, but do so at differing stages of illness (i.e., from early onset experimental use through to addiction and relapse: see Fig. 1). Research is reviewed with the following expected relationships in mind. High NA is predicted to be associated with substance use at all stages, particularly during the later periods of addiction and relapse. Low EC is also expected to relate to substance use at all stages. Finally, high PA is predicted to play a role in early onset and risky use, while low PA is expected to show a stronger relationship with the latter stages of addiction. The following sections will review the existing research in order to evaluate these relationships, and to identify areas in which further work is needed to understand the role of affective processes in SUDs.
Section snippets
What is affect?
Affect is a complex construct that has been examined from a number of different perspectives. Although an in-depth discussion of these is beyond the scope of this article, it is important to keep in mind how affect is to be conceptualised when reviewing the substance use literature. The theoretical orientation taken will not only impact upon the questions that are proposed regarding the affect/substance use relationship, but also the manner in which findings are interpreted.
Within this review,
Negative affect
A considerable body of both anecdotal and empirical evidence suggests that negative affect and SUDs are linked. Commonly, this relationship is conceptualised as a two-part model in which individuals who experience greater levels of negative affect are at a higher risk of using drugs or alcohol as a coping mechanism (e.g., to improve mood or provide distraction from unpleasant feelings; McCollam et al., 1980, Measelle et al., 2006). In turn, once the individual develops physical dependence,
Limitations of existing research
Although the literature reviewed above clearly shows that NA, PA, and EC all play a role in the development and maintenance of SUDs, there are several limitations that warrant consideration. First, most research conducted to date has focussed on high NA, utilising a wide array of methodologies and a broad range of populations (see Table 1). In contrast, PA and EC have generally been assessed using self-report measures or clinical interviews in a limited number of samples. Further research is
Future directions
Within the limitations noted, the research reviewed above generally supports the proposed relationships outlined in Fig. 1. High NA has been repeatedly associated with vulnerability to SUD, initiation of substance use, risky use, and the maintenance of addiction. While findings have not always been equivocal, this relationship appears to be strongest during addiction and NA has been found to be a powerful motivator for relapse. Again in line with predictions, low EC has been found to relate to
Conclusions
In conclusion, there is substantial evidence to suggest that dysregulation of affective processes underlies key aspects of substance use behaviour, encompassing vulnerability, early experimentation, as well as the development and maintenance of SUDs. While addiction has been most frequently described in terms of abnormalities of motivation and reward, we propose that it should also be conceptualised as a disorder of affect. Importantly, an affect-centred theory of SUD is not incompatible with
References (161)
- et al.
Experience of emotions in substance abusers exposed to images containing neutral, positive, and negative affective stimuli
Drug and Alcohol Dependence
(2005) - et al.
Decision-making and addiction (part I): Impaired activation of somatic states in substance dependent individuals when pondering decisions with negative future consequences
Neuropsychologia
(2002) - et al.
The mood-induced activation of implicit alcohol cognition in enhancement and coping motivated drinkers
Addictive Behaviors
(2008) - et al.
Can induced moods trigger drug-related responses in opiate abuse patients?
Journal of Substance Abuse Treatment
(1994) - et al.
Regional brain function, emotion and disorders of emotion
Current Opinion in Neurobiology
(1999) - et al.
Another look at impulsivity: A meta-analytic review comparing specific dispositions to rash action in their relationship to bulimic symptoms
Clinical Psychology Review
(2008) - et al.
Are nonpharmacological induced rewards related to anhedonia? A study among skydivers
Progress in Neuropsychoparmacology and Biological Psychiatry
(2006) - et al.
Cell phones for ecological momentary assessment with cocaine-addicted homeless patients in treatment
Journal of Substance Abuse Treatment
(2006) - et al.
Neuroendocrine responses to experimentally-induced emotions among abstinent opioid-dependent subjects
Drug and Alcohol Dependence
(2003) - et al.
Reduced amygdala activation in young adults at high risk of alcoholism: Studies from the Oklahoma family health patterns project
Biological Psychiatry
(2007)
Impact of positive and anxious mood on implicit alcohol-related cognitions in internally motivated undergraduate drinkers
Addictive Behaviors
A review of the modulation of the startle reflex by affective states and its application in psychiatry
Clinical Neurophysiology
Startle modulation in children at risk for anxiety disorders and/or alcoholism
Journal of the American Academy of Child & Adolescent Psychiatry
Right amygdala volume in adolescent and young adult offspring from families at high risk for developing alcoholism
Biological Psychiatry
Incidence and patterns of polydrug use and craving for ecstasy in regular ecstasy users: An ecological momentary assessment study
Drug and Alcohol Dependence
Feasibility and validity of computerized ambulatory monitoring in drug-dependent women
Drug and Alcohol Dependence
Neuroadaptive mechanisms of addiction: Studies on the extended amygdala
European Neuropsychopharmacology. Special Issue: Neuropsychopharmacology of Addiction
Drug addiction, dysregulation of reward, and allostasis
Neuropsychopharmacology
Inhibitory control and emotional stress regulation: Neuroimaging evidence for frontal-limbic dysfunction in psycho-stimulant addiction
Neuroscience & Biobehavioral Reviews
Salivary cortisol responses and the risk for substance abuse in prepubertal boys
Biological Psychiatry
The cognitive control of emotion
Trends in Cognitive Sciences
Affective picture processing: An integrative review of ERP findings
Biological Psychology
Dysregulation of emotional response in current and abstinent heroin users: Negative heightening and positive blunting
Psychopharmacology
The biological, social and clinical bases of drug addiction: Commentary and debate
Psychopharmacology
Addiction motivation reformulated: An affective processing model of negative reinforcement
Psychological Review
Risky business: Emotion, decision-making, and addiction
Journal of Gambling Studies
A factor analytic study of social context of drinking in a high school population
Psychology of Addictive Behaviors
Gray matter volume abnormalities and externalising symptoms in subjects at high risk for alcohol dependence
Addiction Biology
Emotion and motive effects on drug-related cognition
Circumstances surrounding the initial lapse to opiate use following detoxification
British Journal of Psychiatry
Heightened heart rate response to alcohol intoxication is associated with a reward-seeking personality profile
Alcoholism, Clinical and Experimental Research
A longitudinal study of children of alcoholics: Predicting young adult substance use disorders, anxiety, and depression
Journal of Abnormal Psychology
Relation of parental alcoholism to early adolescent substance use: A test of three mediating mechanisms
Journal of Abnormal Psychology
Affectivity and impulsivity: Temperament risk for adolescent alcohol involvement
Psychology of Addictive Behaviors
Attention bias and disinhibited behavior as predictors of alcohol use and enhancement reasons for drinking
Psychology of Addictive Behaviors
Disinhibited personality and sensitivity to alcohol reinforcement: Independent correlates of drinking behavior in sons of alcoholics
Alcoholism, Clinical and Experimental Research
Alcohol cue reactivity, negative-mood reactivity, and relapse in treated alcoholic men
Journal of Abnormal Psychology
Drinking to regulate positive and negative emotions: A motivational model of alcohol use
Journal of Personality and Social Psychology
Development and validation of a three-dimensional measure of drinking motives
Psychological Assessment
Transition into adolescent problem drinking: The role of psychosocial risk and protective factors
Journal of Studies on Alcohol
A motivational model of alcohol use
Journal of Abnormal Psychology. Special Issue: Models of Addiction
Emotion-based dispositions to rash action: Positive and negative urgency
Psychological Bulletin
Integration of impulsivity and positive mood to predict risky behavior: Development and validation of a measure of positive urgency
Psychological Assessment
Emotion and the human brain
Psychopathology associated with drinking and alcohol use disorders in the college and general adult populations
Drug and Alcohol Dependence
Up close and personal: Temporal variability in the drinking of individual college students during their first year
Journal of Consulting and Clinical Psychology
Neurobiology of the structure of personality: Dopamine, facilitation of incentive motivation, and extraversion
Behavioral and Brain Sciences
Arousal, affect, and attention as components of temperament
Journal of Personality and Social Psychology
Reciprocal suppression of regional cerebral blood flow during emotional versus higher cognitive processes: Implications for interactions between emotion and cognition
Cognition and Emotion. Special Issue: Neuropsychological Perspectives on Affective and Anxiety Disorders
The relations of regulation and emotionality to problem behavior in elementary school children
Development and Psychopathology
Cited by (228)
Differences in the associations between psychoactive substance use and alexithymia: A series of Meta-analyses
2023, Clinical Psychology ReviewMaternal alcohol dependence symptoms, maternal insensitivity to children's distress, and young children's blunted emotional reactivity
2024, Development and PsychopathologyA pilot study of virtual reality for inpatients with opioid use disorder
2024, American Journal on Addictions