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Toward a Triadic Approach to Craving in Addictive Disorders

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Toward a Triadic Approach to Craving in Addictive Disorders ADDICTION Editor: Hilary Smith Connery, MD, PhD Toward a Triadic Approach to Craving in Addictive Disorders: The Metacognitive Hub Model 09/19/2019 on AF1pYRGU7tvUvvutufdIuARIS+GLUElns+4E6vR83hda5oHGzanZ472X8TosGH+Gj41mqMzgysxMbiE/unXQuSBG9QM1dWbsypg3iq0Fcx++MdT880cmeJWogen3UlC6VPRk7DdL3Rg= by http://journals.lww.com/hrpjournal from Downloaded Valentin Flaudias, PhD, Alexandre Heeren, PhD, Georges Brousse, PhD, Downloaded and Pierre Maurage, PhD from http://journals.lww.com/hrpjournal Keywords: addiction, affective neuroscience, alcohol, craving, dependence, tobacco raving is a key factor in substance-related and behav- conceptual framework to explore the interactions between crav- by ioral addictions, as illustrated by its recent inclusion ing and other key processes involved in addictive disorders. AF1pYRGU7tvUvvutufdIuARIS+GLUElns+4E6vR83hda5oHGzanZ472X8TosGH+Gj41mqMzgysxMbiE/unXQuSBG9QM1dWbsypg3iq0Fcx++MdT880cmeJWogen3UlC6VPRk7DdL3Rg= as a diagnosis criterion in the most recent, fifth edition C 1 of the Diagnostic and Statistical ManualofMentalDisorders. RECENT CONCEPTUALIZATIONS OF CRAVING It globally refers to the subjective motivational state facilitating In a comprehensive review, Skinner and Aubin11 identified 18 the emergence of addiction-related obsessive thoughts and craving models: four “conditioning” models (considering crav- compulsive approach behaviors, despite repeated efforts to ing as an automatic reaction to a stimulus), seven “psychobiolog- 2–5 stop the addictive behavior. Reduced craving may produce ical” models (considering craving as mostly related to biological a cascade of downstream benefits, ultimately preventing re- factors), three “motivational” models (considering craving as a 6,7 8 lapse, but its underlying mechanisms remain uncertain. consequence of larger decision-making impairments), and four We present a conceptual, experimental, and clinical ap- “cognitive” models (considering craving as related to biased 9 proach to craving that aligns it with the triadic model — are- information-processing systems). While identifying the major di- cently developed, prominent model of addictive disorders. mensions of craving and highlighting the variety of its related Our central assumption is that craving should not be considered symptoms,8 these earlier models have all focused on specific fac- as a unitary process but rather as the emerging consequence of tors without offering an integrative theoretical approach to crav- the interplay between three subcomponents, namely (1) cogni- ing. Moreover, these models have mostly considered craving as a 10 tive craving (or “obsessive craving”) relatedtocognitiveabil- phenomenon in seclusion, whereas research has shown that crav- 10 ities (e.g., executive functions), (2) automatic craving, linked to ing actually interacts with a large range of processes assumedly in- cue reactivity and implicit processes (e.g., attentional biases), volved in addictive disorders (e.g., implicit cognitions, attentional 10 and (3) physiological craving (or “relief craving”), corre- bias, approach/avoidance tendencies).12 Skinner and Aubin11 rec- sponding to bodily perceptions and related to withdrawal ommended the development of an integrated model to overcome symptoms. We relate these three components to the systems the limitations of these approaches to craving. To do so, they sug- proposed by the triadic model and suggest that metacognitive gested that the model incorporate the multifaceted nature of the abilities may constitute a mechanism bridging the three subcom- processes involved in craving (e.g., conditioning, psychobiologi- ponents. This approach offers an innovative and integrative cal, motivational, cognitive) and address craving’s interactions with other key factors of addictive disorders. Dovetailing with this proposal, a recent review by Sayette13 identified four major concerns to be urgently clarified regarding craving: From NPsy-Sydo, Université Clermont Auvergne (Drs. Flaudias and Brousse) on –Craving’s underlying psychological processes. Some models 09/19/2019 (France); Pôle Psychiatrie B, Centre hospitalier universitaire Clermont-Ferrand (Drs. Flaudias and Brousse) (France); Laboratory for Experimental Psychopathol- focus on impulsion and thoughts (i.e., automatic craving), ogy, Psychological Sciences Research Institute, Université catholique de Louvain, whereas others focus on behavioral features (compulsion Louvain-la-Neuve (Drs. Heeren and Maurage) (Belgium); Clinical Neuroscience Division, Institute of Neuroscience, Université catholique de Louvain, Brussels and actions; i.e., behavioral craving). (Drs. Heeren and Maurage) (Belgium). –Craving’s temporal stability. Several models consider crav- Supported, in part, by grants from Cancéropole Lyon Auvergne Rhône-Alpes ing as a dynamic state (relying on the presence of specific and Fondation pour la Recherche en Alcoologie (Dr. Flaudias), and by the stimulations and thus presenting large intra-individual variability), Belgian Fund for Scientific Research (FRS-FNRS) (Drs. Heeren and Maurage). whereas others describe it as a stable individual characteristic. Correspondence: Professor Pierre Maurage, Université catholique de – Louvain, Institut de Psychologie, LEP, Place du Cardinal Mercier, 10, B-1348 Awareness of craving. Strong inconsistencies persist across Louvain-la-Neuve, Belgium. Email: [email protected] models regarding craving’s explicit or implicit nature. © 2019 President and Fellows of Harvard College –Craving’s links with desire. Some models propose a con- DOI: 10.1097/HRP.0000000000000225 tinuum with craving merely considered an intensified 326 www.harvardreviewofpsychiatry.org Vo lu me 2 7 • Number 5 • September/October 2019 Copyright © 2019 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited. Triadic Approach to Craving desire, whereas others propose a qualitative discontinuity empirical support for this model. First, the insula has been between healthy desire and pathological craving. identified as an integrative interoceptive site connecting auto- We argue that these critical questions can be addressed by nomic, affective, and cognitive processing.19,20 For instance, reconsidering craving in the light of a recent and promising the anterior insula has bidirectional connections to the amyg- neurocognitive conceptualization of addictive disorders— dala, ventral striatum, and orbitofrontal cortex, and the ho- that is, the triadic model. meostatic imbalance emerging in several psychological states (e.g., stress, sleep deprivation) is related to interoceptive signals THE TRIADIC MODEL OF ADDICTIONS received by the insula, which, in turn, influences other In their triadic neurocognitive approach to addiction, Noël neural systems.17,18,21,22 and colleagues9 enriched the classical dual-process models Second, a growing body of research indicates that the by adding a third component focusing on interoception and insula is involved in detecting salient or novel stimuli in the insular pathways. The most prominent models of addictive environment, and in initiating the resulting switch between disorders have long been dual-process models,14 positing that routine brain functioning (based on the default mode net- decision making related to substance use is determined by the work) and activation of the frontal executive network, balance between two functionally and neuroanatomically dis- needed to efficiently process and respond to these incoming – tinct but interacting systems: (1) the automatic/impulsive sys- stimulations.19,23 25 The insular system is thus connected tem, an appetitive system underpinned by limbic structures with frontal areas and plays a role in the interactions between andinvolvedintheimpulsiveprocessing of stimuli, triggering automatic and controlled processes, with such interactions automatic responses based on associative learning, and (2) the being strongly involved in addictive disorders. controlled/reflective system, an inhibitory system underpinned Third, evidence supporting the role of the insula in reward by frontal regions, involved in the cognitive processing of stim- seeking has come from human brain lesion studies, notably uli, and relying on memory and executive functions to initiate showing that long-term smokers enduring a brain stroke were controlled-deliberate response. According to these models, ad- more likely to abruptly and easily quit smoking, without re- dictive disorders emerge when these two systems are out of bal- lapse or persistent craving, when the stroke encompassed ance, such that the impulsive system becomes sensitized (e.g., by insular regions.26 repeated exposure associating substance intake and reward) Despite the presence of experimental support, the triadic while the reflective system is compromised (e.g., following the model of addiction needs further elaboration on several frontal dysfunctions related to the neurotoxic effects of a sub- levels. Among the dimensions that are still insufficiently con- stance), leading to dysregulated consumption. Although experi- ceptualized by the triadic model, craving is prominent. Noël mentally robust and widely accepted, dual-process models have and colleagues9 considered craving to be exclusively initiated neglected another key system involved in addictive disorders— by the interoceptive system, which seems reductive insofar as namely, interoception.15 craving is considered a multidimensional phenomenon. Cap- A triadic model of addiction has thus emerged,
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