Verslavingsgedrag van DSM-IV naar DSM-5Van den Brink, W. (2014).Tijdschrift voor psychiatrie, 56(3), 206-210IntroductieVan immoreel gedrag naar afhankelijkheidssyndroom In de DSM-I en DSM-II werden alcoholisme en drugsverslaving opgenomen als subcategorie van sociopathische persoonlijkheidsstoornis. Hiermee werd verslaving gezien als immoreel gedrag op basis van een ernstige persoonlijkheidsstoornis. Verslaving werd in de DSM-III voor het eerst een aparte categorie. Hier werd een onderscheid gemaakt tussen misbruik en afhankelijkheid van psycho-actieve midellen. In de DSM-III-R werd aansluiting gezicht bij het alcoholafhankelijkheidssyndroom, waarbij er onderscheid werd gemaakt in mate van afhankelijkheid.In de DSM-IV bleef het onderscheid tussen misbruik en afhankelijkheid ongeveer gelijk. Er werd ook onderscheid gemaakt tussen vroege en langdurige remissie.Pathologisch gokken Vanaf de DSM-III was er sprake van een diagnostische categorie ‘pathologisch gokken’. Hier ging het voornamelijk om de onmogelijkheid om de impuls om te gokken te weerstaan en om financiële en juridische gevolgen. De belangrijkste veranderingen van de DSM-5 ten opzichte van de DSM-IV zijn: de samenvoeging van de DSM-IV stoornissen in en door het gebruik van middelen en de DSM-IV diagnose pathologisch gokken werd één DSM-5 categorie ‘verslaving en stoornissen door het gebruik van middelen’, en de samenvoeging van DSM-IV diagnosen ‘misbruik’ en ‘afhankelijkheid’ tot één DSM-5 diagnose ‘stoornissen in het gebruik van middelen’. Deze heeft de niveaus beperkt, matig en ernstig.Samenvoeging stoornissen in het gebruik van middelen en pathologisch gokken Deze samenvoeging kwam doordat deze stoornissen...

Drug addiction as incentive sensitizationBerridge, K. C., & Robinson, T. E. (2011).Addiction and responsibility, 21-54. The MIT Press. Addiction refers specifically to a pathological and arguably compulsive pattern of drug-seeking and drug-taking behaviour, which occupies an inordinate amount of an individual’s time and thoughts, and persists despite adverse consequences. Addicts find it difficult to quit taking drugs, even when they express a strong desire to do so. If they manage to abstain, addicts remain highly vulnerable to relapse for long periods of time.Drugs themselves can change the brains of susceptible individuals in complex ways. These drug-induced changes contribute to the transition to addiction. Some of these changes, especially those related to mesolimbic sensitization, are very persistent and far outlast other changes associated with tolerance and withdrawal.Drug-induced changes in the brain alter a number of different psychological processes in parallel, contributing to multiple symptoms of addiction. The incentive-sensitization theory of addiction holds that the most important of these psychological changes is a persistent ‘sensitization’ or hypersensitivity to the incentive motivation effects of drugs and drug-associated stimuli. Incentive...

Handboek verslavingHoofdstuk 13Controleverlies Verlies van controle is een belangrijk kenmerk van verslavingsgedrag. Controleverlies betekent het onvermogen om weerstand te bieden aan de zucht tot gebruik, en het verder gebruiken ondanks de negatieve gevolgen. Verslavingsgedrag kan begrepen worden als het eindresultaat van twee grote pathogenetische dimensies. Dit zijn de neurobiologische mechanismen die verantwoordelijk zijn voor een overmatige waarde die gehecht wordt aan het gebruik van middelen en aan gebruiks-gerelateerde stimul, en de neurobiologische processen die een rol spelen bij het, deels bewust, onder controle houden van een impuls tot actie.Verslaving wordt beschreven als een chronische stoornis waarbij er, naast een overmatige waarde die gehecht wordt aan het gebruik, tegelijkertijd sprake is van een stoornis in de top-downreguleringsmechanismen. Op gedragsniveau kan impulsiviteit omschreven worden als een waaier van veelal onaangepast gedrag. Dit kan zijn: een onvermogen om een onaangepaste (re)actie te onderdrukken, een onvermogen om uit te stellen of rekening te houden met langetermijngevolgen van gedrag, een verandering in de tijdsbeleving, of het volharden in gedrag ondanks negatieve gevolgen. Impulsieve mensen hebben moeite om hun respons te inhiberen, hebben een voorkeur voor directe beloningen en hebben moeilijkheden om...

Handboek cognitieve gedragstherapie bij middelengebruik en gokkenHoofdstuk 2Interventies in de cognitieve gedragstherapie van problematisch middelengebruik en gokken Cognitieve gedragstherapie (CGT) helpt mensen met problematisch middelengebruik door het identificeren van de functies die middelengebruik of het gokken heeft en de wijze van gebruik. Op grond hiervan richt CGT zich op het aanleren van vaardigheden waarmee die functies kunnen worden veranderd en het gebruik kan worden verminderd of gestopt. Inleiding Het laten uitvoeren van registraties vormt doorgaans het vertrekpunt van de cognitieve gedragstherapeutische behandeling van verslaving. Het gaat hier om het registreren van twee specifieke momenten. Dit zijn het gebruik van middelen of het gokgedrag en de aandrang (trek) om te gaan gebruiken.Gedurende de behandeling houdt de cliënt bij wanneer, onder welke omstandigheden, en in welke mate het gebruik of de trek zich voordoen. Hiermee komen risicosituaties in beeld waarop de interventies zijn af te stemmen. Dit bied ook de mogelijkheid om te evalueren of de behandeling het juiste effect oplevert.Theoretische beschouwing Observeren en registreren is nodig om inzicht te krijgen in de externe en interne variabelen die het problematische middelengebruik uitlokken en in stand houden. Dit zijn stimuli.Volgens het klassieke of Pavloviaanse leerparadigma...

Retraining automatic action tendencies changes alcoholic patients’ approach bias for alcohol and improves treatment outcomeWiers, Eberl, Rinck, Becker & Lindenmeyer (2011)Psychological science 490-497 A short intervention change alcoholics’ automatic approach bias for alcohol and may improve treatment outcome. Behaviour is partly governed through relatively automatic processes that may exert their influence outside conscious control. Addictive behaviours are an imbalance between strong impulsive or associative reactions to drug-related cues and relatively weak reflective or controlled processes. This makes the individual susceptible to sensitized cues triggering action tendencies leading to the addictive behaviour.This can be reflected in different cognitive biases: an attentional bias for alcohol-related stimuli, a memory bias for the automatic activation of alcohol-related associations, and a bias toward automatically activated action tendencies to approach alcoholIf people are not willing or able to counter these biases, the addictive behaviour is likely to continue.In the alcohol approach/avoidance task (alcohol-AAT), participants are instructed to respond with an approach movement (pulling a joystick) to pictures of one type and to respond with an avoidance movement (pushing a joystick) to pictures of another type. Pulling the joystick increases the size of the picture, and pushing it decreases the size. This zooming effect generates a sensation of approach or avoidance respectively.Heavy drinkers show an approach bias toward alcohol pictures.Training...

Community reinforcement and family traning: an effective option to engage treatment-resistant substance-abusing individuals in treatmentRoozen, de Waart, & van der Kroft (2010)Addiction, 1729-1783 Many individuals with substance use disorders are opposed to seeking formal treatment, often leading to disruptive relationships with concerned significant others (CSO)s. Community reinforcement and Family Training (CRAFT) provides an option to the more traditional treatment and intervention approaches. CRAFT has been found to be superior in engaging treatment-resistant substance-abusing individuals compared with traditional programmes. The vast majority of individuals with substance use disorder refuse to be engaged into treatment.Substance-suing individuals often have a dire impact on the lives of family members and friends, inflicting marital distress, social problems, financial troubles, aggression and violence. This co-occurs frequently with a myriad psychological problems. Many family members desperately need help to stop the disruption of their family life, to improve the ongoing substance-using individual.Concerned significant others are not powerless and pursuing couples’ disconnection may be counterproductive. Community Reinforcement and Family Training (CRAFT) is a rigorous treatment package designed to specifically engage resistant substance users into treatment by working with their concerned significant others. Environmental contingencies play an important role in promoting treatment entry of the substance-abusing individual and reducing physical and...

A specific role for posterior dorsolateral striatum in human habit learningTricomi, Balleine, & O’Doherty (2009)European journal of neuroscience Extensive training on a free-operant task reduces the sensitivity of participants’ behaviour to a reduction in outcome value. There is an increase in task-related cue sensitivity in a right posterior putamen/globus pallidus region as training progressed.Cue-driven activation in a specific region of dorsolateral posterior putamen may contribute to the habitual control of behaviour in humans. The development of habits allows responses to be efficiently executed, freeing up valuable cognitive resources.Different neural systems contribute to habitual and goal-directed behaviour and learning. Goal directed action are in the prefrontal cortex and the dorsomedial striatum. Habit-based behaviour are in the dorsolateral striatum There is a habit learning system in humans.There is a region in the posterior putamen extending into the globus pallidus that becomes increasingly sensitive to stimuli that were associated with a particular behavioural response, consistent with a potential role in S-R learning. The posterior putamen/globus pallidus region may play a central role in the development and/or control of habitual behaviour in humans.The transition from goal-directed to habitual control of behaviour is highly dynamic and the early phase of the habit learning process occurs even while behaviour is still...

Obesity and the brain: how convincing is the addiction model?Ziauddeen, Farooqi & Fletcher (2012)Nature reviews neuroscience Central to weight gain is the development of an energy imbalance, a situation that arises as a result of complex interactions between an individual’s biology and environmental factors. Central is the idea that someone can become a ‘food addict’.Two broad ideas of food addiction are: 1) Certain foods are akin to addictive substances insofar as they engage brain systems and produce behavioural adaptions comparable to those engendered by drugs of abuse. What the putatively addictive foods are has yet to be fully defined. 2) A behavioural phenotype that is seen in a subgroup of people with obesity and resembles drug addiction. Food-addiction phenotype is most apparent in individuals with binge-eating disorder. At a population level, one of the main drivers of the rise in prevalence of obesity seems to be increased availability of food, with a consequent imbalance between energy intake and expenditure. Any loss of control of eating, which is important to the idea of obesity as addiction, is very subtle in most of the obese population. We cannot ignore social circumstances.Five key pieces of evidence cited in support of the addiction model are: 1) A clinical overlap between obesity (or more specifically binge eating disorder) and drug...

Eating disordersTreasure, Claudino & ZuckerThe Lancet Diagnostic symptoms and associated behaviours substantially overlap across the range of eating disorders. The subjective interpretation and justification behind diagnostic behaviours is often not clear or is limited by developmental constraints.In the DSM-IV, three broad categories of eating disorders are delineated. These are: Anorexia nervosa, Bulimia nervosa, Eating disorder not otherwise specified. Binge eating disorder is a subcategory of this.Support is growing for recognition of binge eating disorder as a specific entity.Interest is growing in a transdiagnostic approach to eating disorders. Comorbidity is common for people with eating disorders. Eating disorders and related behaviours are common in young people. Eating disorders have been reported worldwide. Women are more affected than men. Genetic factors The most potent risk factor is female gender. How much this association can be attributed to biological factors is uncertain.Eating disorders are complex genetic diseases. Biological factors Although many of the biological findings in eating disorders can best be understood as results of starvation and disturbed eating behaviours, some are causally linked as risk for...

E-health interventions for eating disorders: Emerging findings, issues, and opportunitiesAardboom, Dingemans, & van Furth (2016)Curr psychiatry rep Internet-based cognitive behavioural therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. E-health interventions reach an underserved population and improve access to care. E-health for eating disorders: emerging findings Treatment and self-help interventions Internet is a potentially useful mean to deliver interventions targeting individuals with an eating disorder who are ambivalent towards change. Aftercare and maintenance treatment Flexibility may be one of the key reasons for individuals to prefer E-health interventions over face-to-face interventions. Predictors of outcome and dropout Higher motivation to change, higher harm-avoidance, higher drive for thinness, lower binge eating, and lower body dissatisfaction at baseline predicts better outcomes.Higher baseline levels of depression and eating disorder psychopathology were shown to predict dropout. Smartphone applications in the treatment of eating disorders: emerging findings The apps available for eating disorders are of limited functionality. The development and implementation of...

Breaking habits with implementation intentions: A test of underlying processesAdriaanse, Gollwitzer, de Ridder, de Wtit & Kroese (2011)Personality and social psychology bulletin Implementation intentions specifying the replacement of a habitual response with an alternative response in a critical situation can overrule habits. Implementation intention eliminate the cognitive advantage of the habitual means in the race with the alternative response. The cognitive advantage of the habitual means is not immediately replaced by an automatic activation of the alternative means.Formulating counter-habitual implementation intentions increases individuals’ flexibility to choose with behaviour to perform in the critical situation. Actual behaviour will depart form their habits only to the extent that individuals have strong alternative goal intentions. Habits develop as people repeatedly perform a specific behaviour in a stable situation to pursue their goals. This co-occurrence between the situation and the behaviour eventually creates a direct mental association between the situation and the behaviour, which is strengthened each time they subsequently covary. This association is strengthened to the extent that when the situation is encountered, the behaviour follows automatically.The most important moderator of the intention-behaviour relation is the extent to of habitual control over...

Handboek angst- en dwangstoornissenHoofdstuk 10Cognitieve gedragstherapie De basis voor de te gebruiken interventies wordt bij cognitieve gedragstherapie gevormd door verschillende soorten analyses die de therapeut maakt van de individuele problematiek van de patiënt.Nadat de classificatie is gesteld en daarna de diagnose, worden de klachten van de patiënt en de samenhang daartussen in kaart gebracht. De analyses om deze in kaart te brengen zijn gebaseerd op de leerprincipes. De meeste gebruikte analyses zijn: 1) Funciteanalyses (FA’s), de beschrijving van de operante conditionering bij de patiënt. Er wordt onderscheid gemaakt tussen de context/situatie (discriminatieve stimulus Sd), de respons daarop ® en de consequenties (C+ of C-). 2) Betekenisanayses (BA’s) De beschrijving van de klassieke conditionering bij de problematiek van de patiënt. Er wordt hier onderscheid gemaakt tussen de gebeurtenis of het gedrag (CS) en de verbonden cognitieve representatie van een andere betekenisvolle gebeurtenis (UCS/UCR-representatie) en de emotionele reactie daarop (CR).Deze kunnen worden gezien als individuele diagnostiek. Er wordt hier op microniveau gekeken naar de factoren die klachten in stand houden of versterken.Hoe de verscheidene problemen en klachten onderling samenhangen wordt in kaart gebracht door een holistische theorie. Hier wordt er op ‘macroniveau’ naar de problemen gekeken.De eerste gesprekken met de patiënt zullen onder andere gaan over het ontstaan, het beloop en de huidige...

Goal-directed learning and obsessive-compulsive disorderGillan & Robbins (2014)Philosophical transactions of the royal society Compulsions in OCD may derive from manifestations of excessive habit formation. The irrational threat beliefs (obsessions) characteristic of OCD may be a consequence, rather than an instigator, of compulsive behaviour in these patients. Compulsivity is ‘a hypothetical trait in which actions are persistently repeated despite adverse consequences’.There are two main schools of thought regarding the underlying mechanism that leads to compulsive behaviour. These are: 1) Cognitive, compulsivity is mediated by dysfunction in the assignment of value to available alternatives. The compulsive individual may view the cost of cessation of behaviour to be higher than the benefits of thereof. In this sense, the choice to continue the behaviour is purposeful and goal directed. Compulsions are performed to reduce the likelihood that an unwanted, or feared, consequence will take place. 2) OCD doesn’t necessarily arise form faulty value attribution or cognitive bias. It may result from goal-directed dysfunction that interacts with anxiety and irrational belief. Patients with OCD largely understand the relative value of the available outcomes and the cost of actions, and aim to promote expected values of outcomes and desist from compulsive behaviour, but cannot exert...