Addiction and Compulsive Disorders Block 1 Overview summary by Bente Niemeijer
De nition
• The National Institute on Drug Abuse: a chronic, relapsing disorder, characterised by compulsive drug
seeking, continued use despite harmful consequences, and long-lasting changes in the brain.
• Craving is considered an essential driving force in substance abuse by many researchers and clinicians,
and it has been incorporated into the DSM-5 as one of the criteria.
• Tolerance: reduction of a (desired or undesired) effect of a substance when administered chronically.
• Withdrawal symptoms: after prolonged abuse, these symptoms may occur with (temporary) abstinence.
• Compulsivity: behavior that is continued despite explicit knowledge of profound negative consequences
• The DSM-5 guidelines for the diagnosis of a substance use or alcohol use disorder require that the
individual has significant impairment or distress from their pattern of drug use (A), and at least 2 of the 11
symptoms in a given year (B).
• The 11 criteria can be broadly categorized into issues arising from substance use related to:
• Loss of control
• Strain to one's interpersonal life
• Hazardous use
• Pharmacologic effects
• The criteria (2-3: mild; 4-5: moderate; ≥6: severe)
1. Taking the substance in larger amounts or for 8. Using substances again and again, even when
longer than you're meant to it puts you in danger
2. Wanting to cut down or stop using the 9. Continuing to use, even when you know you
substance but not managing to have a physical or psychological problem that
3. Spending a lot of time getting, using, or could have been caused or made worse by the
recovering from use of the substance substance
4. Cravings and urges to use the substance 10. Needing more of the substance to get the
5. Not managing to do what you should at work, effect you want (tolerance)
home, or school because of substance use 11. Development of withdrawal symptoms, which
6. Continuing to use, even when it causes can be relieved by taking more of the
problems in relationships substance
7. Giving up important social, occupational, or Criteria 10 and 11 are not met if taking prescribed
recreational activities because of substance use drugs under supervision
Prevalence
• Most people recover without treatment: spontaneous remission
• 19% has ever had SUD
• 6% has had SUD during the last 12 months
• An estimation of 50% of patients with SUD have a comorbid disorder
• Especially mood disorders, anxiety disorders, ADHD, personality disorders
• SUD is more prevalent in men, and anxiety disorders are more prevalent in women.
• Only 6% of individuals with alcohol use disorders and 16% with drug use disorders enter treatment
Consequences substance use
• Decreased quality of life and physical health (also transmission of infectious diseases)
• Brain changes (molecular, cellular, structural, and functional)
• Some are persistent (namely sensitization) even after a period of abstinence
• Some improve when abstinent
• Increased risk for mortality
• Decreased social relationships and professional functioning
• Societal costs (e.g. health care, crime, productivity loss)
Substances of abuse
1. Sedatives: make you calm
2. Stimulants: make you energised
fi
, Addiction and Compulsive Disorders Block 1 Overview summary by Bente Niemeijer
3. Psychedelics: alter consciousness and perception
• They affect the brain in different ways
• Commonality: (in)direct effect on release of dopamine
History of models of addiction
• Morel model: addiction was a sign of moral weakness. People with an addiction were locked up in prison
or re-education institutions, often under challenging circumstances.
• Pharmacological model: The blame for the addiction was taken away from the addicts and attributed to
the addictive substance. People needed to be prevented from becoming involved with these substances.
• Symptomatic model: psychoanalytically inspired model, in which addiction is not viewed as a condition in
itself, but rather as a symptom of an underlying character-neurosis or personality disorder. The most
treatment should be a long-term, insight-oriented psycho-therapeutic treatment of character-neurosis
• Disease model: fundamental (premorbid) biological and psychological differences exist between addicts
and non-addicts, as a result of which the former are unable to use alcohol and other drugs in moderation.
The main features of the addiction disease are the uncontrolled use and the physical dependence
(tolerance and withdrawal symptoms). The main implication of this model is that moderate use by non-
addicts is quite possible, while for (latent) addicts complete abstinence is the only option.
• Learning theory model of addiction: addiction is viewed as a form of maladaptive learned behavior that
could be un-learned with the help of behavioral therapeutic interventions. Main interventions are aversion
therapy and cue exposure, but there is no good evidence that they work.
• Bio-psycho-social development model: it became increasingly clear that there is not one absolute
difference (i.e. there is only relative difference) between addicts and non-addicts. Both the onset and
termination of the addiction are seen as the result of a continuous interaction between innate vulnerability
(biological), personal development (psychological) and circumstances (social).
• Based on this vision, the ‘dependence syndrome’ has been postulated and multi-modal interventions
have become popular; interventions in which attention is paid to biological (psychopharmacology),
psychological (psychotherapy) as well as social (e.g. housing) aspects.
• Brain disease model: an innate vulnerability forms the basis for repeated use of psychoactive substances,
while the repeated use of them in turn leads to important, difficult to reverse, changes in the brain.
Pharmacological and behavioral therapeutic interventions are seen as the most promising interventions.
Brain disease model (Volkow & Leshner)
• Addiction is a chronic, relapsing brain disease, that is characterised by compulsive drug seeking and use,
despite harmful consequences (advantage of this view: less stigma)
→ Viewing addiction as a chronic, relapsing disorder would mean that a good treatment outcome is a
significant decrease in drug use and long periods of abstinence, with only occasional relapses
• Genetic bases is very important to the vulnerability of addiction
1. Impaired cognitive control/executive functioning (making it harder to resist craving and change habits)
2. Emergence of craving (through incentive-sensitization) and habits
→ uncontrolled use and relapse
Learning
• Pavlovian conditioning: a change in behavior due to experience with a relationship between a (neutral)
conditioned stimulus (CS) and a (motivationally relevant) unconditioned stimulus (US)
→ stimuli that predict a reward evoke conditioned responses and craving
• Incentive-sensitization theory (Berridge & Robinson): drug-associated stimuli gradually acquire
incentive salience (by dopamine release); they attract the attention of the person with the addiction,
become attractive in themselves and lead to ‘wanting’ → eliciting targeted behavior to acquire the
drug (explanation relapse) → meanwhile the hedonic experience during consumption (liking1) decreases
1This has a different brain mechanism that is not sensitized. This explains why it is not true that the incentive-sensitization view would
predict that with repeated use, addicts would take less drug.
De nition
• The National Institute on Drug Abuse: a chronic, relapsing disorder, characterised by compulsive drug
seeking, continued use despite harmful consequences, and long-lasting changes in the brain.
• Craving is considered an essential driving force in substance abuse by many researchers and clinicians,
and it has been incorporated into the DSM-5 as one of the criteria.
• Tolerance: reduction of a (desired or undesired) effect of a substance when administered chronically.
• Withdrawal symptoms: after prolonged abuse, these symptoms may occur with (temporary) abstinence.
• Compulsivity: behavior that is continued despite explicit knowledge of profound negative consequences
• The DSM-5 guidelines for the diagnosis of a substance use or alcohol use disorder require that the
individual has significant impairment or distress from their pattern of drug use (A), and at least 2 of the 11
symptoms in a given year (B).
• The 11 criteria can be broadly categorized into issues arising from substance use related to:
• Loss of control
• Strain to one's interpersonal life
• Hazardous use
• Pharmacologic effects
• The criteria (2-3: mild; 4-5: moderate; ≥6: severe)
1. Taking the substance in larger amounts or for 8. Using substances again and again, even when
longer than you're meant to it puts you in danger
2. Wanting to cut down or stop using the 9. Continuing to use, even when you know you
substance but not managing to have a physical or psychological problem that
3. Spending a lot of time getting, using, or could have been caused or made worse by the
recovering from use of the substance substance
4. Cravings and urges to use the substance 10. Needing more of the substance to get the
5. Not managing to do what you should at work, effect you want (tolerance)
home, or school because of substance use 11. Development of withdrawal symptoms, which
6. Continuing to use, even when it causes can be relieved by taking more of the
problems in relationships substance
7. Giving up important social, occupational, or Criteria 10 and 11 are not met if taking prescribed
recreational activities because of substance use drugs under supervision
Prevalence
• Most people recover without treatment: spontaneous remission
• 19% has ever had SUD
• 6% has had SUD during the last 12 months
• An estimation of 50% of patients with SUD have a comorbid disorder
• Especially mood disorders, anxiety disorders, ADHD, personality disorders
• SUD is more prevalent in men, and anxiety disorders are more prevalent in women.
• Only 6% of individuals with alcohol use disorders and 16% with drug use disorders enter treatment
Consequences substance use
• Decreased quality of life and physical health (also transmission of infectious diseases)
• Brain changes (molecular, cellular, structural, and functional)
• Some are persistent (namely sensitization) even after a period of abstinence
• Some improve when abstinent
• Increased risk for mortality
• Decreased social relationships and professional functioning
• Societal costs (e.g. health care, crime, productivity loss)
Substances of abuse
1. Sedatives: make you calm
2. Stimulants: make you energised
fi
, Addiction and Compulsive Disorders Block 1 Overview summary by Bente Niemeijer
3. Psychedelics: alter consciousness and perception
• They affect the brain in different ways
• Commonality: (in)direct effect on release of dopamine
History of models of addiction
• Morel model: addiction was a sign of moral weakness. People with an addiction were locked up in prison
or re-education institutions, often under challenging circumstances.
• Pharmacological model: The blame for the addiction was taken away from the addicts and attributed to
the addictive substance. People needed to be prevented from becoming involved with these substances.
• Symptomatic model: psychoanalytically inspired model, in which addiction is not viewed as a condition in
itself, but rather as a symptom of an underlying character-neurosis or personality disorder. The most
treatment should be a long-term, insight-oriented psycho-therapeutic treatment of character-neurosis
• Disease model: fundamental (premorbid) biological and psychological differences exist between addicts
and non-addicts, as a result of which the former are unable to use alcohol and other drugs in moderation.
The main features of the addiction disease are the uncontrolled use and the physical dependence
(tolerance and withdrawal symptoms). The main implication of this model is that moderate use by non-
addicts is quite possible, while for (latent) addicts complete abstinence is the only option.
• Learning theory model of addiction: addiction is viewed as a form of maladaptive learned behavior that
could be un-learned with the help of behavioral therapeutic interventions. Main interventions are aversion
therapy and cue exposure, but there is no good evidence that they work.
• Bio-psycho-social development model: it became increasingly clear that there is not one absolute
difference (i.e. there is only relative difference) between addicts and non-addicts. Both the onset and
termination of the addiction are seen as the result of a continuous interaction between innate vulnerability
(biological), personal development (psychological) and circumstances (social).
• Based on this vision, the ‘dependence syndrome’ has been postulated and multi-modal interventions
have become popular; interventions in which attention is paid to biological (psychopharmacology),
psychological (psychotherapy) as well as social (e.g. housing) aspects.
• Brain disease model: an innate vulnerability forms the basis for repeated use of psychoactive substances,
while the repeated use of them in turn leads to important, difficult to reverse, changes in the brain.
Pharmacological and behavioral therapeutic interventions are seen as the most promising interventions.
Brain disease model (Volkow & Leshner)
• Addiction is a chronic, relapsing brain disease, that is characterised by compulsive drug seeking and use,
despite harmful consequences (advantage of this view: less stigma)
→ Viewing addiction as a chronic, relapsing disorder would mean that a good treatment outcome is a
significant decrease in drug use and long periods of abstinence, with only occasional relapses
• Genetic bases is very important to the vulnerability of addiction
1. Impaired cognitive control/executive functioning (making it harder to resist craving and change habits)
2. Emergence of craving (through incentive-sensitization) and habits
→ uncontrolled use and relapse
Learning
• Pavlovian conditioning: a change in behavior due to experience with a relationship between a (neutral)
conditioned stimulus (CS) and a (motivationally relevant) unconditioned stimulus (US)
→ stimuli that predict a reward evoke conditioned responses and craving
• Incentive-sensitization theory (Berridge & Robinson): drug-associated stimuli gradually acquire
incentive salience (by dopamine release); they attract the attention of the person with the addiction,
become attractive in themselves and lead to ‘wanting’ → eliciting targeted behavior to acquire the
drug (explanation relapse) → meanwhile the hedonic experience during consumption (liking1) decreases
1This has a different brain mechanism that is not sensitized. This explains why it is not true that the incentive-sensitization view would
predict that with repeated use, addicts would take less drug.
