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EmotionRegulation in SubstanceUse Disorders
HedyKober
Have you everhad coffeeor rea?A glassof drug crAvings,as weli as fr:rther drug use. winp?S-olrrd even) single:igare.re?Virru- As such, lossof regulotorycontrol is ^ key ally.rll .rclulr'reporr consumirg psychoac- featureof SUDS.The addition of dtus ctau- rive.d-trgsrat scme,poinr in r\err lires,srg, izg (strongdesire for drugs)as a dialnostic gesnngrh.1r c.rsu<1r drug use l< qu tecorot oo crite(ion for SUDSin DSM-S emergedfronr @ lslbsfancenl-use and Melt.tl Heahh scr- a weAlth of accumlrlatedresearch over the vicesAdministrarion ISAMHSAI, 2011). On llsr decadedirectly Linking cravr:rg to drug o rheorhc- end of dredrug r)especr(un. sub- Eseatcl rclapse(renrrn to drug use follo',v- sr.rrceu,e di:orders SUDsjor addicrionr) ing abstinence;e.g., Shiflman er a1.,2013; rre cornplexilLnesses. encornpassing a hosr se€later sectjonsfor additional discussion), ot severenegrrrrc physic;1, e.ononrc, arrd This sugg€stslhat crAvingis also a key fea- so.ial cursequerces. r1d Jorr-iburjrg !o mre in SUDs,and thar regulationof craving worldwjdedisrbj' r). wi,l, r lI.ri,,( prc'u is a specjficform of emorionregularion dmt l€nce of 35.3% in the generalpopularion, can directly reducedrug use. rndividu.l1.rvirh SUDs.Jnsrjn re I .e rrivcl) This chaprerfocuses on the crucial and cmJIlp-opo"r^n oIc'.url drug'r.^-s. ler complexrole of emotionregularion in SUDs they also representthe most prevalentand (seeFigure 26.1 for a schematicsummary). co.r y o' pstchiarri. d .order, rNauoral In the first sectlon,I discussrhe roLe ofaclrte Insritute of M€nral I{ea1th [NIMH], 2007; drug intoxicationas ameansof emodonreg, SAMFTSAT2011). ulation, arguingspecifically that peL:rpleuie Dctincdr. r ornhler,"rrcparerrordrlg drugsin part to regulateiheir currenr emo- u,e.lerd:'1g ro .l c.rly ,ig-if:canrimfJ'r tionals,r.r te. This ma1 inJLrde in.rcasing pos Irent or d qrress Americr- l,).l,idrri. lrrv€rrrecr, rmetrorarrng a preexrstrng ncga- {.,o.irrior.20l1. p.4al).suns rre borL tive state,or decreasingcraving. In the next pcr,on.rlly.rnd .ocir'r dera.tarirginrhrL section,I explore the role of emotion dys- rt r. ofrencl"o',jc ard.. n seveel1 ir parr regulationin SUDS,both as a possiblecaLrse .Fe F\e h {. li'" r r,.,i^ninsrn tfth -di- for 1ndJ possibleconsequencc of drug use. tioa o' LheDra3,rosrrr a,d \talisti.dl \,4na- ln thissecrion, I mJle sevcralspecific rrgu- ml of \4cnralDi"o'd"r" D(M-s , \UD. r-e menrs.Fi.st.I arguerh,rr emotion dysreguh, characrerizedby the presenceol symptoms tionin childhoodand adolescence may be rn including tolerance,withdrawal, continued early risk tactor and/or disral causalfacror 'o urp de,oireri.he. 'top.conrin:ed rr.r rn rnelrrer oe!etopmenror 5uus,second.I despiteknown negrtive coDsequences,rnd argue '^,,,' that an inability to regularenegative irport. rly -Fgrl)r^,y,.nro o'p- enotion prope.ly in specificmoments may 428
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Emoto. Begularionin SLrbltanceUse Disorders 429
FIGUBE 26.1. A sinplified nodcl oI erotioD rcsulatjon ni SUDs.rd,!1,,1: Beloie SUDs.prcfront!t coftcx (?Fc) and drrgs can bolh serveto rcsulaieernorioD. 1r s rhoushrlhar prc imptcrncnrsregula- tlon overnesirne emorionand ciaving (irdicrted br downward btunre.taros,s). In rurn. un.csuld,ed ncs.liveenotion and ffrving arcassociated witl rnckr.eddrus u\r rrp$ rrd .,(o*51.HcLc I froposc rhardtugs can be ken $ a forn ofemorjonrcgulation as rveU (indicarcd br dolnwrrd blr,*at aro-,;, in.fc!sios feelingsof high, ard deorensinsnegati'c cnotjon and c!xv!rs. rr lhis corrext, dcficjcnrdno tion resulalionor Pl-Cconrrol mar s(ve asrisL< facrors for SUDs.t a,slB, Afrer dcvctoDnenrof SUDs. 'hroni.J rs:" .lrh..n.rr.c.....i,i,,.- . . f'..,.rr..,,.i,FJo | r.,r: ,\ o Br.t.r ...!. - eho!io,1,.s \eell as drur crtrvins(drshed dowdwrLd blo,!d rro$,t. l,r iLrL!, unreg;tlrcd !€;!rvc cmo!'on and cr.rviogfurrher leadro incrciscd dmg !rschilivard ar:rorvt.Drug uscirself conrjnucs ro rcgulzueborh ncsarivee olion lnd dii,g cr.rving{rhough p$haps lcsselfc$ivcl}). ftris rcsulrsin a vici"u-styclc rf rcduccdl,l C-br$d cmori,D ,cgulrrion, lrcgariveaftect, craving. an '@) bc a proxinral causalfacrof for instanccsof crl profrlcsol ircliridualdrrqs !Lilfcr,tln!l drlrgusc in individunlswho ar.ealready suf- Lhc'c(liffcrenccs h-rre LroLh rlirorcri.ai :rnJ fcringfrom SUDs.Th1rd, i Dositdlar SUDs neurobiologicrlmplrr.rtions (e.g., B.rcli:ni, rrc nrrrl.edb) dcficiI,r n LeguIntror of .rspe Belin,Epstein, C;rlL. & Shrhrnl,20r1), crfl( ,1ppcfifivest.rrc. n]rnety, dLLrq cLrving, mrny drugs arc Lrhimarclydescribc,:l as whichis rt drecore,)f rhe\e Jisorders. I rhLn euphoricrincressing positive emotion (laffe reviewevidcnce that suggestsdiffcrcnces in &Jaffc, 1989).InhuDrrn labcLraLory cxperi, the strLrctLLreand function ol the prefronral nenis,self adninisrfarion of dLugs,includ cortcx(PFC) mny be rhe neural mechanisDs lng alcohol, nethamphctamine,coc;rine, uDderl,virrgcnlotion dlrsrcgulrrjonin SUDS. .rnd nrrrijurnr. siqDific.rnrlyrncrersc feet 'gooil This s€ctionfLrrthcr highljghrs rhar ahhough ingsot "high' .rnd drugetfcets' te.e.. somel'FC ilrnurmJliriesprccede d, ug rrse, Hrrr. V:rd. Ihncy, folrrlr, & rischman. rheLong-rcrm efiecr of thronn JrL,s!se or 2001;see Figurc 26.1A). Consisrently, jt is PFC Dreyflriher inrr.ir enodon regulatlon hasbeen proposed dlathcsc posirivccffects in SUDS.In this way, drug usc may Ieadto of drugs lead to posirivereinforcenenr and further emotion dysrcgulation.The chap increasethc likelihoodof fLrruredruc use tcr conclucleswith a scction on treatmenis lKobcr, Tllfza, & LIafr, 2009). Furrh€r- ior SUDS,mary oI which focus on emorion more, drug users often clevelopposltlve regLrhtiorskilts gcrred sprtif,crl\ tow:rd expecrrr.icsregrrLJing drug use(e.g., ..f I regulrrionor !rr\ing r, me:nso{ rcdurirg drink.T will feelqood") rhrr,rre:ssoci,rted with incr.aseddrng use and ;ncreasedrisk ot dc\elopinssUD5 (e.s., Jol]es, Curbin. & Frurnme,200l1. DrugUse as EmotionRegulation In addirion to increasingpositive en1o- tion, vafious drugs are knorvn ro alleviate Drugs can regulateenorion by pharmaco- negativeemotionrl states,including anni logically ahering one's current state. for ety (e.g.,alcohol, and anxiolytic treciication exemple,although the exacrpharrnacoiogi, such as VaLiun and Xanax), eadnessand 4] o 430 PSYCHOPATHOLOGY depression(e.g., stimularts slrch as cocaine quentlyreduces drug use (Nunes & Levin, and amphetamincs),and pain (c.s.,hcloiD, 2004). SccondJard sinrilarly,those rvirh norphine, and orher syrthetic prescrip- chronic pain are far more likely to develop tion opiatessuch as Vicodin). Consistently, SUDsrelative to the general,painJree pop it has been proposedthat rhesenegrtiviry- ulation, especiallyro pairl-reducingdrrgs reducing eflects of drllgs lead ro negarive suchas opiates (Morasco et aI.,20t1). reinforcement,thus increasing the likeli- Thircl, even normal-rangetrait levelsof hood of future drLrguse (Koob & Lc Moal, negativeaffeci are relatedto drug use.lor 2008). This idea was inithlly popularized example,trait depressionand ncuroticism by the "self-medication hypothesis" pro' cofrelate negativelyrvith rime to relapse posedby Khanuian(19B5), which has rwo in cigarerte smokers (Gilbert, Craurhers, main components:(1) Unpleasantaffectn'e Mooney. McClernon.& Jens€n,1999), starespredispose individuals lo drug Lrse, whilerrajr le\ els of arrgcrand anxirry corre- and (2) the choiceof drLrgis not randomj Iatewilh cfavingto drink in alcoholics(Lirt, rarh€f, it is the n:ture of the drug\ effects Coonet.& MoFe,.2000).Fourrh, negar vc ln amcliorntingthepreexistingDegdrivestateJltecfivcst,rtes.rre known trrggers ior cra!- that rendersa particular drug mofe ot less ing in the contcxrof bothcasral .rnd prob, feinforcing. In other words, those with a lematicqubsr.rnce use (e.9.. Shiffman. Par\. particular predispositionto ncgativeaffecr Gnys.I(assel. & Flickcox-.1996). This ph;- statcsare more likely to develop.r,rSUD for rromcnonraDges from lhe comflroDeDithet a drug that reversesthose particular affec, "l had such a hard dav, I needa bee; or a tive sr:Ltes.To illustrate, I(hanlzian sug- sriff drink" to insrdnccsoI relap$ ro dtug geste.lthat indiviclualswith strongraee an-d use alter expenencrnga slrong l1le stressor aggressionuse opiate dxugs to regulatedlese (e.g.,dearh in lamily).lndeed, it has been emotions.ln contrast,individuals with pre" well documentedthar borhndturally occur- existingdepressioD aDd melancholy develop ring aod cxperjmenullyinduced negatrve @ cocaineuse disorders due to cocainc'sabil- .lttcct.ndsnc55 iDqease .L ugcrd!ing, ctrug ity ro relieve these syrnptonrs.The self- xse)and rehpse (e.g., Sinha & Lr,2007). @ nr€dicarion hyporhesisis consistent with Finally, drLrgrlse also serv€sto reglrlate patients'reporrs rhat "they got hooked nor the experienceof craving, whjch is one of bccalrsethey had taken the drLLg,but bccause the most common motivatorsfol clruEuse lhey were not nonnal beforein such a way (Childrcsset al., 1993; Shiffnran,ei al., tharthedrugs were. . . notrhe problcm but a 2013).Thar is, individualswirh SUDSL,se solution"(T e M.ia1,2009),p. 542).k is fu(- drugs to temporarily alleviatethcir cxpcti- lher consistenrwith d1eobservarion rhat rhe en(e of cr.rving.rhus gencrating I vrcioLrs expectancythar drugs will :rllcvrateneg.rrive cycleoi Lrcrersrngeraving and use.Taken affecr(e.g., "Drlnking $ ill crlm medown") togetherJthe evidencereviewed in rhis sec- is associatedwhh increaseddrug use and tron suggeststhar drlrg raking can be a jncreased form risk for SUDs(Jones et al., 2001). of emotionregulation. Specilically. rhe acute AlthuuShrhe selfmedic.rtion hypotbesis eifectsof drLrgsmry regulJrepre€xisring hasbeen chrllcnsed, sever: I l,nes ot' evidence emori,,nsin hothcrsurtand problen drug suppoft_lhehypothesis thar drug useserves users,including increasing positive emotio\ to regulare negativeemorion. Firsr, SUDS oecreaslngneganve emobon! and decreas- irequentlyco'occur with a nunrberof other ing cravingfor drugs themselves(see Fieure psychiatricdisorders, cspcciriiy nood and 26.1A). anxiety disorders. Moreover, preexisting psychiatricdiagnoses increase the likelihood of an indivjdual to sLrbsequendydevelop an Emotion(dys)Regulation ls a Causal sUD (e.9..Kessler er rl., 200J).Thi\ qusqesrs Factorin SUDs that individualswho rlreadyexperJerrre d,f- licuh enotions are more likely to seekand Althoughmanl pcopleLi,ullly LLsedruss usedrugs, and to dcvclopproblematic habits .,,,1al.uhul, onty .r sm:rl per(enraee develoD of drug usethatpresumably ameliorare their SUDs.highlrghring rhe nied ro rdintit'lrisi aflective sympbms. A telated point is rhar and causalfactors for the iniriation, develop (eatrnent lor such comorbid disorder.sfre, rnent. and maintenanceof thesesevere dis- o o EnrolionRegulation in SubslanceLJse Disorders 431 orders. Of coLlrse,because SUDs are com- rs presrhooJ)m,ry predare rhe deielopmenr plcx disordels, they are likely causedard ',1SUDs rrLLl ruuld rherefore hr conceprual maintained by an intricate combinaiion of izedas a risk f:ctor predictingillness onset. factors,including generic,cognitive, behav- In the yearssince thisworkwas published, ioral, indiliduafdiiference, and environ additionaldata has accumulated ro frrrther mental variables,that likely interact across suggestrhat poor self-control,in childhood nultiple levelsofanalysis. At is time, enlo, is indeeda risk factor for drug use and the tion regulationabilities are already emerging developmentof SUDs. For example,Mof- as one importsnt conrributorin the eciology lirt and coli.rgLrc5(l0rl) tollowed1J000 and maintenanceof SUDs, ahhough in the childrenfrom binh tn:ge 32.In childhood, next decadeit is likely that larger longitu- participants\vefe :rssessedon various self- dinal studieswill allow us to identify addi control measuresrelated ro emorionregula- rion, inclLrdingemotional labiliry, {ruitra- tion tolerance,and persisrence.The authors Emotion(dys)Regulation as an Early report that individual differencesin self, Risk Factor co trol weresignificlnrly pfedictiveof eduh health outcomes,includitg substanceuse As reviewed below, SUDs are frequendy and dependence,as much as 30 years l:rr€r. associatedwith €morionregulation delicirs. Importantly,the con!ributionof ielf-cottrol The speciiicqucsLiol |erc is: Do rhesedefi, facrorswas distinct from rhecontriburion of cils plecedethe devclopmen!of rhe disofder intelligeoce,social clnss,and odrer fanrilv- so tl'n! rheymay b€ considereda fisk faclor? life variablcs.Srrikingly, the highesrand The answerappears ro bc ycs.Beginning lowesrone-fifth nf rhc q,mfle ni meesured with thecl.lssic "nr:lrshrnallow test cxperi- seli-conrrolwere associJted wirh a preva- nents in rhe 1960s by Mischel and col- lenceof 3 and 10%, respeclively,of polysub- leagues,it hasbeen proposcd rhar rheabiliry stancedependence in aduhhood, o to dday gratification,and rcgularccrlotions In addi(io'r,in chjldhood,rhe relared like desirc,is cLr.rcialto children'sdevelop- consrrucr of truit ifipuLsiuity-the ten^ @ meurallrajectories (for review,see Mischel, dcncy to ac! wirhour thoughr or regard for Ayduk,Berman, Casey, Gotlib, er a1.,2011 consequenc€s-hasbeen repeatedly asso- and Luerssen& Ayduk, this volume). In cjated with tbe developnent of SLtDs in thesestudies, preschool children wcre typi- larer adolescenceand adulrhood (seeIva- cally presentedwith a tasty rreat and told nov, N€wcorn, Morton, & Tricamo, 2011j thnt they could haveit now, or alternrtively, VerdejoCarcia, Lalvrencc, & ClaLk,2008. wai! ro receivetwo treatsat a later time-if tor reviews). Furthermore, iongitudinal they could delaygratification. In his seminal srLrdressugg€sr that chjlJrcn who suffcr work, Mischelleportedthat childrenvary in from childlooJdrsorders sLrch as arrenrion- dreif abiliryro de1.1)gfanicJrron. LdngiLrg deficit/hyperactivitydisorder and conduct rrom nor DelngtrDte to w.ritit a to w.Lt- disorder, which are associaredwith poor ing as long as the experincnterallowed (ald emotional/behavioralregularion and impul- Lrsinsr vJriety of @ e) 432 PSYCHOPATHOLOGY risk for developmentof SUDs (deternined (Steinbers,2005), both ofwhich exposeaclo, by parenralSUD diagnosis).Inaddirion, rhis lescentsto drugs. Thus, increasedexposure construct was lound to predict slrbsranc€ to drugs, coupledwith increasedemorional Lrseat age15, as well as SUDsin earlyadult, reactivity and decleasedregulatori' capaci- hood(e.s., Tarter er a]..2003). ties(rooted;n onsojng brain developnrnr), The mechanismsby rvhich early emotion make adolesccncea particularly vulncrable regulationproblems lead to later SUDs are perjod 1orsubsrance use. x target oI current investigation.One pre- Indeed, drug use is most often initiated vailing hypothesisis that eDotio! regulalion tu adolescence.For example,82.4% of first abilities (and cognitivecontrol more gener- usesof alcohol occur in indiliduals under ally) dependon the function oI PFC resions the age of 21 (the legal drinking age),and (s€eOchs)rer & Gross, this volume; John- 58.8% of smokershave their first cigarene stone & \{Iahef, this volume) rhar rfe nor undcrthe ase of 18(S,\MHSA,2011). These ret fully developedin children and adoles- early usestaristics are especiallyrmporrant, cents(see Riediger & Klipkef, rhis volume). becauseearlier age ofonset is associated with Indeed, edolescencerepresents e petiod of higher ratcs of SUDs and both r'educedemotion reeulariot abilities For example, those who initiated alcohol (Silverset a1.,2012)as well as subsranrial useprior to age14 are more ihan four times neural devclopmen!(cjedd €t al., 1999). more likely to receivean SUD diagnosisin Spccifically, regions of Iareral PFC have adulthood(16.2 vs. 3.8%;similar rates are becnfouDd !o be reiativelyhypoAcrive dur- reporrcd for illicit drug$. Similarly, earlier ing emotion'relaredlasks in adolescenrsas ageol smokingonset predicts a highernum' conrparedfo 'd,rlts(c.s., Pfeifer, Liebe nan, beLof cisarettessmoked in adulthood (Tai & DApfetlo,2007), with regularjon-relatedoli & Wynder, 1991).Taken logerher,these Acrivationin this area incrcasingwirh age dAra support rhe norion that emotion (dys) (McRaeet al.,2012). regulationis an earlylisk facrorlor SUDs. (u. . Givtn rhrsdevelopmenralrL.riecrory, cmo- Next I discrisshow enrotionreguiarion nlay rrondysreguliiror) rn adoercence may con- opclateas an ongoingca],rsal facror that may {+) !ribu!eto SUD risk via rwo p^rallelroutes. contributeto and exacerbateexisting SUDs. First, immature emotion regulationcapaci- ties in adolescenc€ may r€sulrin hisher lev- E otion (dys) g elsofstress and negativeemotion, wiich has m Re uI atio n beenshown to lead to rhe injtiation of drug in CuftentSUDs usc;nanimal modcls (c.g.,I-Ianey, MaccaLi Scvcralmodels of SUDsdirecdy impli.atc Le Moal, Simon,& VincenzoPiazza, 1995) deficientregulation as a key and piimary and in human adults (seeSirha & Li, 2002 mutivefof ongoingdrug userrd rehpse, for review). Second, self-regulation fail- irclLrdirrgrhc relapseprcuention model ures in adolescencemay underlieincreased (Marlntt & Vitkielvitz, 2OOS),the at'fectiue implrlsivity and risk-taking behaviorsthar ftucessillg ltlodel lBnker,Piper, McCarrhy, nay.rlsolead to initialiorof drug use(e.g., MaJeskie,& Iiore,2004),and rhe aforemen- Ivrnover rl., l0tl). Ukmirrly, thede'clop tioncd selfriedicdtia D l,ypoLbcsisl,Kbanr- nlentaltrajecrory of self-regulatoryfuncrion zian, 1985),among others.Indeed, whether suggeststhat at leastsome adolescents nray or nor emotion regLrlationdeficirs are a pre- be less able to recruit the neural circuitry existing risk facror for SUDs (as proposed neededto regulatetheir emotionsoprimally in tbe previoussection), drose wiro currently and to ultimatelyavo;d substance use. sufier from SUDs frequently display such The idea that adolescentsas a group may deflcits,which may contributero the clinical in fact be les :hle to recruir the nece*ary courseof the disorder.Several lincs of cvi- neurocrrcl lry ro regulate emofions and dcnce,support.rhrsasrociaron 1f igLrr e2o.18 avoid substanceuse-along wirh the obser, rorscljernattc rllxstrarion), vation that individual differences in the first, self-reported emotion regulation abiliry to do so are predictjveof flrrure sub- skills are ]owei in individuals wn-h SllDs stanceuse-is especiallyimporrant, because than in healthy controls (e.g.,Fox, Hong, adolescenceis a period of heightenedrisk & Sinha,2008).In addition,grearer diffi- takinc{SAMHSA, 2011) and peerinflfence culties in fegulating enotion is associared crcss rbkEmdnRdgldi2E.ndb €2 6 o EmolionRegulat on n SLrbstanceUse Dlsorderc 433 with more drug use (e.g.j Berking er al., exhibit felativedeficits in nonaffectivcforms 2011)possibly as a meansof emorionregu- of self regulation and execurivefuncdon, lation (Bonn'Miller, Vujanovic, & Zvolen- lncluding working memory and response skn 2008). Second,less effective styles of inhibliion, which may also relare to PFC emotion regulation (e.g.. suppressionvs. tuncion (Goldstein& Volkow, 2011). reappraisal)are felated to increaseddfug use {Fucito,Juliano, & Toll, 2010). Third, (dys)Pegulation indnidual differencesin negariveaffect have Emotion in Cuftent bccn rcpcrrcdlyrssociared uith drug usc SUDs:Regulation of Crcving and relapseir cliricrl (e.r.,Grnbl. er al.. In rhe previoussecrion, I reviewedevidence 2010),as well as laborarorystudies (e.g., suggesringdrat those with SUDs have dif- Sinha& Li,2007).Fourrh, as reviewed ear- ficulties regulating emotions.Notably, the lier, SUDsare highly comorbidwirh affecrire evidcnceoverwhelmingly centers on regula- disordcrs,such as depfession,which fearure tion ol negativeemotions. Howcver, in the impaired regulation of negariveaffect as a contexr of SUDs, ir is crirical !o consider key diagnosticfeattr.a (Americ.n Psy.hiarric not only reguiationof Degarive€motion but Associsrion,2013). Furthermore, those wirh also an additionaland very specificform oI co-occufringsymptoms of SUDs and affec, emotion rcgulation,namely, the regulation tive disordersshow significantlyhigher rates or cravlng, of relapsero drug use afref tteaiment (e.g., Craring, deflr,eC,bere as "itrense desir€ Bfadizza,Stasiewicz, & Paas,2006) offer- for drugs," has long beenconsidercd a key ing additional sl]pporr for rhe link berween contriblrtof !o dtug use (e.g.,O'Brien, Chil- emotion(dys)reglrlation deticits ard SIlDs. dress,Ehfnr.rf. & Robhins,199S). ALhough Additional evidence lini 6 +) 434 PSYCHOPATHOLOGY and betrer outcomesfor those with SUDs. !houghrto instantiatethe experienceolcrav, This ir Lurnsuggcsrs rlar regularionofcrav- ing. Pfeliminarily,ir fufther appearsrhat rhe ing is a specificform of regulation thar is use oI cognrtrvesftategres to regulatecrav- or-r:iu1-rl\,'rpo-rrrrirr the nr-r"nance ing may dependon incfeasedactivity ir PFC or o "ugr r ."'"""'''-"."""','"."..",',.. 6 @ EmotlonFegulaUon jn SubsianceUse Disorders 435 roimaging studies directly testing emorion Daumannet a1.,2011)and in right ven- regularionabilities in SUDSare scafc€.Nev- rrolnteral PFC (vlPFC) specifically,where eftheless,in the following sections)I review thicknesswas invefselycorrelated with drug findings thar indnidLralswith SUDsexhlbit craving(Tabibnia et a1.,2011).In alcohol, srudural abnormalities in various IFC dependentsubjects conpared to controls, regions, as rvell as functional diflerences rower gray meiter volume was reported in studies of nonaffective{orms of cogni- acrossthe PFC (Fein,Di Sclafani,& Mey- tive conrrol (foI a brief review of neuroim- erhoff, 2002) and more specificallyin the agins mcthodologiesused ir such stud;cs, laterLrlarrrl superior PFC and OFC (Durazzo seeKober & Deleone,2011).Impor.tandy, et al.,2011) and medialand lateralPFC although some of rhesePFC xbnormaliries (Randoet a1.,2011).In thesclarter srudies, may precederhe developmentof SUDS, I iower medial PIC rolume was associated review evidence suggestingrhar chronic with moredrinking posftreatmentof shorrer drug use is associatedwirh both strucrural lime to relapse.In addirion, in somesrudies ano runcuonsrchanges In tlc, )Uchdrug- lbut llot all) PIC volumewas inverselyasso, inchrcedchanges, in turn, suggestrhat SUDs cicredwirh cognitjveconrrol m.asurcs.For nlayalso lead to decrementsin PFCrhat may example,PFC gray mafter volume correlated underliefurther emotiondysregularion (fig- inverselywith executivefunction measures ure26.1B). i cocainc-dependentindividuals {Iein et In reviewingfiis evidence,it is importart al.,2002). to note tl1:Ltthe PFC is a very laree struc- Consistentwkh these qfay matler find- tural divisionin rhe brain, and rhat?ifferent ings in PFC,diffusion tersor imaging (DTI) subregionswithin the PFCperform vcry dif- meanrresof PFC white m^rrer inregrirydis- ferent computationsand subservedifferent linguish between inclivjdualswith alcohol functions-even within rhe qeneral"cosni- use disordersand contfols (e.g.,Pfeffer- tive control" framewoLk(Miller & Coiien, baum.Rosenbloon, Rohlfrng, & SLrllivar. (D 2001).i-i,rwcvcr, at this srage)rhere are nor 2009)ard f!rdter differbetween lndrvidu- ye! sufficientdata to mak€ finer distinctions als who relapsedand lhose who slrstained o abourrhe func!ionalrole ofPFC subdivisions absrincncefollowing rreafment (Sorg et al., in sUDs, or to begin to speculateabout lhe 20ll). In c^cxine-deperdentp: rri,.rprnrs, roieeach subregion lnjghr have in rhe neu- lower mezlsurementsof white matter integ- roparhologyof rhesedisordefr. I hopcthrr rity are consistendyfor.rnd in various PFC data collectedin the next decadewill allow regLons(e.9., llomero, Asensio,Palau, San- us to.answerslrch quesrions with far grcater chez,& RomeL,:,2010).Sjnilar findings specllrcrtythan we can loclay, w€re reported jn methampheranine (Ali- cata,Changr Cloak, Abc, & Ernst,2009) (Bora Sttuclural Diftercnces ih the PFC andin opiateus€rs et al.,2012rLiu et a|.,2008). Diflerences in brain structure have been Takentogether, rh is body of srrucrLrm I neu- reporred betrveen those wirh SUDs and rolmagingwork suggestsrhar thereare con- healthy controls, usirg several different sisrentanatomicai differences bctween rhose melhodologies,especially in various subre- ivirh SUDsand healthyconrols. A caution- gionsoIPFC. For example,using voxel-based ary note hereis that it is not yet clear whar morphomerryJcigarette smokers exhibited rhesedifferences meau. \fhile ir is temptins reducedPFC gray matrer densitycompared to interpret these differencesas indicatirg to hcalthy controls,and PFC thicknesswas impairment in lndividuals wirh SUDs. thii negativelycorrelated to feporred smoking link has nor yet been consistendydemon {mersuredin packs-per-year;Brody et al.. strrted.For insr.rnf.,rkhough reporredty 2004). In cocaine-dependentindividuals, luwerrhan rh.lt ifl controls,corricnl rhi!k, relatively reduced gray maner densiry in nessand cognitivefllnction are often within orbitofrontal cortex (OFC)and anreriorcin normal rangein SUDS(and seeHart, Mar- suletc correx (ACC) was reported(Franklin vin, Silver,E{ Smirh,2011, lor exrendeddjs et al., 2002). Similarly,lo$'er rhicknessand cussion).NevertheLess, these differences are volume were reported for other srimr ant consislenrlyreported across PFC and across users in various prefrontal regions (e.g, typesoi SUDS.Furthermore, although indi t6) o\ 436 PSYCHOPATHOLOGY viduajstudiesdiifer with respectto the 1o*l- askedto respondto:rl1l€tters except X with ization of thesedifferences (possjbly due to a butron press,and to withhold rcspord- samplecharacteristics, drug pharmacology, ing to X. Using this rask, a seriesof stud- drLlguse patterns,and methodologicaland ies reportedrelatively worse performancein statistlcaldifferences)J and only somestud- cocaine- and heroin-dependentindividuals ies find associationwirh clinical ourcomes. compared to hcalthy controls, along with the PFC is repeatedlyinplicated, especially reduced.ctiyir) in sever:l PfC regiorrs, lateral portions. Reported differencesare in(ludingrhe dor .0I g Emotionnegutaton jn SubstanceUse Disorders 437 craving and smoking during subsequenr orltsideofthe scopeof this chapterto discuss the uniqucncchanism of action or pharna Taken together,these studies suggest rhat cologicnl effccts of individual drugs, one dlosewith SUDsexhibir poorcr perfofmance now classicfinding js that all drugsrbat are in cognirivecontrol tasks, as well as lower ablrsedby humers shareonecommon effecr. acrivity in PFC regiolls rypically associated That is, all drugs of abuse-either directly with emorionregulation and executivefunc, or indifectly*increasecorcentrations of the tion more generally,includifg dIPFCand neurotransmitterdopamine in the "meso dACC. Somesrudics reporred dir.t rsso- corticolimb;c" pathway,wh;ch includesthe ciation between lower PFC function and ventraltcgmental area, the ventralstriatum, lesscognirive controlor emodonreguLarion, and rle PFC le.g..Dichiara & lmpcLato, while otherslinL greaterPFC ncrivity to bet- 1988;Volkow rr rl., 2011).1ln r!rn. thi, rcr rreatnrenrourco'nes (e.g., Berkrnan ea dfug-indLLcedincrease in dopamineis asso, al., 201:l; Kober et al.) uncl€rrevie\r), These ciated with long-term changesor adapra- findings are therelore consistenrwirh fte tion\ ro neuronsin rhispatbwav. rncludine hypothesisthat PFC abnornaliriesin s!fltc- in PFClLbschc, & Mrlinka.2ht l). Thcs.: t!rreor function underlieemorion dysfegula, changesare rhought to facilirate associa- tion in SUDS. tions betweendrugs and drug-relaredcues (e.g.,alcobol and lhe barwhere one drinkst Etlects of Dtug Use on PFC cigarcttesand rl)elighlcr on€ usesfor smok- ing), Iead to future cue-induceddrug crav- Darareviewed rhus far suggeslsrhar those ing, ^nd reducecognitive conrrol (Volkow et with SUDsexhibir deficirs in emotionrequ- a1,,20i1). lation,and both srru*ural and functioial Furdrernrore,ir is rhoughrthxr sorneof differelcesin PFCcomparcd to heaithycon- rhecfiects of acureas r\ell as chLonicdrug trols, Notablyrmosr of the xcvicweddara use Mc 11eulotaxic*damaging ro nelfal @ were gen er.a ted in thecontext of ccse-control tissue(\fleiss & Koob,2001).Such clains studies-me^suredat a sjnglepoint in time, emergcprimarily from an animal litetature o in individualswith actiyeSUDS. Ther€fore. experimentallydocunrenting variolts forms it is uotclear whethcr some of lhesefeporteci of n€uronald:rmaee followine heavv drlrg abnormAlitiesprecede the develoDmentof ,dmrnrstrstr.n(e.g., Gouzoriits,Uayfrani< SUDs(and may s€rveas a risk iactorJas 3< DaRrrnnn,2009).Aldrough it is ror discussedpreviously), wherher they arerhe clearthrr slrchfindings rranslare to human resultof chronicc{rug use (and reflect rhe clrugusers (Hart et a1.,2011), some snrdies effectsof drug cxposure)of an interaclion in hunrns h,rw lrnkedlengrh of drug Lrse of bodr.Evidence lor PFCabnornalities as wLrhmersurcs of strlrcturalor flLncrional a preexistingrisk factor includesa recenr integrily, which is consisrentwitlr animal studyoI n ividualswirh SUDS(coc;rine of findings.for examplerin opiate usersjPFC amphetaminedependence) and their unaf- white mlrr€r inrcgritycorLelared negatively fectedsiblings compared to healthyadults. w,th lengr|oi opi.reusc (Bora et r1.,2012r Bothindividuals with SUDsand their rrn:f- Ltu er a1.,2001).Similarly, some hunan fectedsiblings shared a neurologicalpheno studieshave shown tliat various fLurctional type of reducedsrructural connectivity in and structlrral abnormalitiesnormalize fol- the right vlPIC, which wasfurrher felatcd lowing drug rbsrinence.implicrring drLlg ro pcrformanee rhesr"p-tignal Lcsporrc "n usc irseltin rhe oflginallyobserved drtfer- inh;birionrnsk lErschc er al., lOt2). These encesin PFC (e.g.,Gouzoulis-Mayfrank & iindingssuggest that potenrialabnormalir;es Daumann, 2009). Taken together,the evi- in lrreralPfC mxy underlieregularory defi, dencesuggests tbat evenif somePIC ahnor citsrh,rr in facrpredrre the onser of SUDs. malities precederhe developmentof SUDS, On the orhet hand, there is ample evi- drlrg Lrseirsell is associaredwith long tern dence, mosrly from animal stL:dies,that changesto many brain circlrirs, includins chronictegult drug use ahem borh func- PIC. Iur ermore, Lhesechanges may cre- tion and structure of PFC and other brail areor exacerbatedeficits in emotionfegula- circuits (for an exceilentrecent revie$,' see tion in SUDs.In essence,this suggestsihat Liischer& Melenka,2011).Although ir is chronicdrllg usemay leadto a viciouscycle, I ","""**.,,""",,",,*,"" .", o @ 438 PSYCHOPATHOLOGY in which impaired emotionregularion leads rhat difficulties regLrlatingborh negative Lodrug use,and drug use may furrher lead lst e5s.rnxiery, or depressrontand appetr, to impairedemorion regularion. tive(drug cra\ inq) srates rre assoriaredwrth drug use and with relapseto drug use fol- lowing abstinence.Therefore. it is no sur- Treatmentfor SUDs: priserhat at rhis fecoveryphase, many of the TheRole of EmotionRegulalion leadingtreatments include tralning of emo, rionLegularron skills in gererrl,.rndriguJa Trcatmcntsfor SUDS are raried and conl tiu,,ui !.r! ingin pafficulrr (e.g..Por€nzr, er plex, as is appropriate given rhe h€tero al. 2011;see Figure 26.1B). hrdeed, learning geneousand complex narure of the disor- to tolerateor r€gularecravings and not ro ders tha! they rrear. Ar rhis time, d€spire ac! on them is lhe cornefsroneof rnan_vof rep€ated scientific efforts, there ar€ felv the availabletrearments, as discussedbelow' FDA-approvedpharmacological treatnents Finalln dre lasr phaseof treatrnent,relapse for SUDs. Therefore, nonpharmacological prevention,focuses on implementinglong, (e.s., psychological)rrea nents ale mosr term stratesieslor nahtainins absrinence, conmon. While rhe goal of rtealmenrmay which includesfeplacing old behaviors*.itL be conceptualjzedas reductionsin drug use a new and hcalrhy,drug-free lifestyle. Over- and in drug-relatedharm, and itcreasesir all, there are many types oI treatmentsfor psychosocialfunctioning, trearmenr s!rc- SUDS,and eachtype has many unique fea- cessis most often measuredt^ abstinence, tlr,:es.The followiig sectionsfocus on two ^' .^--1"r" .....ri^"_.. ^f. . ,1,,,_...9Ise. As such, typesofrreatmenr that arerelared to the role dre availabletr.catmcnts are onll moderately of emotionrerularion In SUD9:cosDiflvc effecrive;indeed, acrossall rrcatmentsfor behauor:rlarrd mindfirlness-based-rrear- SUDS,thc lnosrcommon outcoDreis relapse (Durfaer a1.,2008). This slragests that while someirrdivitluals a.i)'- succcssfullyrcmain absti- Cog n itive- nenr, the majority of patientseirher do not Be h avi o rc | The tapi es o achieveabstinence or relurn to drug use Cognitive-behavioralrherApies (CBTs) are rvithin a year, evenwith the best of treat- consideredthe most efl'ecriverreitment fof nents. These gri findings undefscor€the marry psychiarric disorders (e.g., depres- needto berter understaDdrhe mechanisms sion3nd anxiety).A versiondeveloped sDe- of action behind rhe trealments rhat do cificrlly for SUDslC,rrroll, 1998) 6rs been work, in orcicrto improvcthcrn further. erupiricrllyvali.lared in muhiplerandomizcd trom r ciinicrl perspecr've.rr(alne-r controlledtrials and is consideredby l]ranv ior SUDscar be divid€dinro LhreeDhl,c.: to be the "gold standard" (e.g.,Durra er al., detoxification,recovery, and relapsefLeven- 2008;Forenza et a1..2011).CBT for SUDS tion (e.9.,Porenza er aI.,2011).The goalof has two crirical components: functional the detoxificarionstage is to achieveabsti- analysis and skills trainine. Irr.rior,i/ nenceand undergo withdrawai synproms drdll,sis is used to iclcnd{y and assessthe safely,until they rbrte. The onset, charac individual;zcdcircunstances rhar are likely ter, and lengrh of this sragedepend on the to lead to drug use, and provides insighrs pharmacologicalproperties o{ the individual into sonl€ of the reasons the individLial drugJas well as tuearmentrype (sometrear- may be using drugs.These "high-risk situa- mentsbegin with (ecoveryelements, then se! tions" are thosein which new skills mav be a "qlrit clare" ro begin detoxification).The applied ro avoid drLrguse during and ifteL narn stageol rfeatDent is recovery,u'hich trealment. ThcreforeJin a complementary can last from 1 week to nany weeks.The f:shion,,kill,rrrinifs (in(ludi;scmorion goalof the recoverystage is ro developmori- reguation) is indiridLLalizedro help rhose varionto avoid drug useand relapse,as well with SUDs "unlearn old habirs associated as learn rhc skills to do so successfully.In with [drug] . . . abuseand learn or relearn rhar sense,whar does recoverye taili The heahhierskills and habirs" (Carroll, 1998, data rer.iewedin this chapter suggesrthar p. 2). Mor€ speciiically,these sltills initiatlv di{ficulties regulating emotions are a core include regulatilg thoughts about drugs, leatureof SUDs.Specificalln I haverrgued learnrngsfuaregics to regulatecravings for 16 o Emo|onRegu ation in SubstanceUse Disorders 439 drugs, and rnanagiDgsituations relaredro with (2) an attitude of acceprancero$'ard drug-uscoppoftunities G.g.,refusing offefs Ihepresen. moment (Bishop et .r1.,200,1). As such,mindfulness is often practicedthroush Subsequenttreatment sessions(modrles) mindfulnessmedrtation, which consistsof focus on problem soiving, tolerating and locusingatiention on one'simmediare expe- regulating negative affect, and improv- rience(e.9., sensations, brearhing, rhoughts, ing social skills more generally.Ultimitell enotion), xnd regarding ir noljudgmen- individualswho undergoCBT (comparedro tally. This is thoughr to cukivate dre abil- other treatments)are more l;kely ro dccrcase ny to observe-uLhcrLhan be caughr.up drug use and/or achieveabsrinence drrinC m-ones own expelencej xn.l to turther and even alter rrearment has ended (i.e., faciliratenrore skillfLrl or mindful respord- "the sleepereffeca'; Potenzaet al., 2011). lng (as opposed ro nutomatrc reacnoni Althollgb the rreatmentincludes manv mod- Zgierskaet aI.,2009). Impoftanrly, medlra, ulesand stages,one importanrnechanisnr tion and MBTS bavc been associatedwith of actionis thoughr ro ber ia en-hrncingcog, bcnefLcirleffecrq on strurc.anxiet), px;n1 nrrrveconrrol ov.r nFg.rh\e .rtlc.trh.rr m.y crrdi-r!he.llth, imrrune ftrnctions, psycho le.rdto ilrugcrrving. and ovcrdrug craving iogicil $ell being, cogniri\e {unctroning, anddrug rrking behavior ie.g., I(iluk, Nich, and se\eralprychirrric disorders (rncluding BxbLrscio,& C.rrroli,20i0; Porenz:rer al., mood and anxiety disordcrs;see Hcilze) ei 2011).Thjs hyporhesisis supporredby the al., 2011,for revievr).Iherefofe, ir is nol finding thnr the nunber and qualiry of strar- difficult to extrapolarehow MBTS could be egiesfor regulationof cradng increasefrom beneiicirlfor fosterinsbeter cmolionreeu, pre-to posr-CBTrrextment, and predicred l.rhonin sLlD< relapse(e.g., Carroll, et al., 1999),and foF Indeed,several mindfrjlness-based tr€ar, mally mediate the lelationslrip between menrshave recently been adapted for SUDs. re4rm€n! and durarionof abs!inence(KiluL( Unlike the well-estahlishedCBTs, these (> cr a1,,2010).h tufr, thisllcLcase irr recula- uearmentshave just shownprcliminary effi- tion skills is hyporhesizedto be medinte-dby cncyand are now dre focus of risorou; ran- @ improved PFC function from pre- to post- dornizedcontrolled rrials, MBT; for SUDS treatment(Porerza et al., 201l; seeFigure typicallyincludc training in mindfulncss 26.18 for a schematicillustration). Consis- neditation, and a foclrson attention to ilnd tenrwiththis hypo rhesis, I(o ber, Kross, etal. acceplanceof pfesent-momentexpefience (2010)have shown that useof CBTlike cos- (inclrdinaneeative emorion and drus cruv- nirivestrltegies dufing cue induced craving ins).Th.;rod;1if'r' u.r urr;:rcr rcgrri irrer- is sssociaredrvirh decre:rses rn self-reported nal experjences(e.g.r drug cravlng)as rran- craving,aswelL as increasedacrivity in sien!,and ro obsefveand acceprthem as-is, dIPFCand vIPFC (l(ober, Mende-Siedlecki, ivithout reacting (e.g.,rvithout engaeingin etal.J 2010). In addirion,Deviro er al. (2011) drug Llse).!or ex.wple, borh mjndfulness- feccndyreport€d that thosewho underwenr based relapseprevention (MBRP; Bowen. CBT exhibitedincreased e{ficiency in vlPlC Chawla,& MaLlart,2010) and mindfulness and dIPFCdrting the Stoop task fton pre- treining for smol 1a o 440 PSYCHOPATHOLOGY itv. As such, mindful attentlon and accep, rhes€disoiders. In this chaprer,I reviewed tan.e mry bc rcgulatory,by prerentirgtre data suggesrirgthar emotion reglrlalion is amplliic.rriorrof cra\ingrrrher rfan drmp one such crucial facror. Indeed,difficLilties in emotionregulntion in childhoodand ado- Clinicalln MBRP, typically administered lescenceserve as predictivefactors for luture as a lollow up to inpetient treatmentl is drug useand the developmentotSUDs. Sub feportedly efficaciousin reducingdrug use \equentl),rlrore sith SUDSreporr srerr€r and relapseacross several dilferent ooou- difhrulr).regrlaring negrrive cmorr<,ris thrn let;ons.;irh SUDs, including al.ohoj ;nd do hcalthy controls, which coDrriburesLo polysubslancc usefs (e.g., Witk;ewitz & ongoingdrug use.FLrrthennore, I revioved Bowen,2010).In addition,Brewer et al. evidencesuggesting that cravingfor drugsis (2011)have recently shown in a pilor ran- one of the key predictorsof drug use, and donrizedcontrolled rrial rharMTS admin- rh.t the rhiliry ro regrlarecr;ving effec- isteredas a stand-alonetreatment was effec- tivelyis directlyreTared to reduceddrus use tive in achievingsmoking cessation. Firally, in SllDs. similareleinents of mirdl'Dlrnenrior rnrl Consistert s'irh these observations,psy- accept:rnceare parts of dialectical behav- chosocialtreatmcnrs for SUDs often focus ior therapy and acceptanceand commit- on emotion reguhrion and on rhe regula- n]ent therapy, borh of which have shown rion ol cra\ing.rc eansfor redr.rcingdfug preliminary €ffic:rc) lor SUDs (HcrnAndez- usc.Indeed, inrprovement in thosesl Casual drLrgusc is qrite prevalent,and a percenLrgeui drug usersde!elop SUDs, Acknowledgments whi(h ,rreseverc pslchixtri! condrrions r{irh staggeringsocial. economit. and penonal I wouldlike !o thankDanicllc Bolling, Caneron (u5Ls. This underscoresrhe neellfo idenrity Dcleo.€,andMiggie Mae Mellforthei. invatu, risk factors that render specific individu ablehclp preparing rhis chapter. Thanks also go ah more vulnerablero the developmentof to Alen Anticevic,Rebccca tsoswcll, Kfthlecn SUDs. Furrhern1ore.once established, SUDs Carroll. Rrlph Dile6ne, Janes cro*, 3nd one are chronic, relapsing,and very difficult to anonynousrevlelver, for lery helpfulcommers. ||eatpsychiarricconditionsirhisund€rscores Ard flnalll rha*s to ail rhosewho invesligarc rheneeJ io betrercharrcrerize rhe proximal emotion regulation in subsrancellse disorders. rausclfactors rL:t leal Loconrin;ed drug Your worL rnspi.ed rls chapter and lvill con- use, and to better understandthe mecha trnuc to insp;e researchin this arca for vearsro nismsthat underlieeflective trearments for €t I EmorionFeg! aion in SubsranceUse Disordefs 441 Notes (2011). Deficirs in €motion-resulationshills predictalcohol Lrse durins and after cogritive 1. Psycho.ctivedrugs arc those that prinarlly behavioral the.apr ior al.ohol dependence. acr on the brain and changerhjnkins, mood, lo"lhll of CakeLl*ts and Ctitical psychol. and beharior.These include lcsal dtugs (e.s., ogy, 7913),347-318 . alcohol, .;cor;re, caffeine, ind opioid pain Bed{man,E. T., Fall<,[. 1., Lt Liebe'']!D, \.{. nedicrtiont, as welLas illicir drugs (e.s.,her D. (2011).In rhe trcnchesof .cal,world self- oin, coca;ne,amphctanines, and lnarijuana). conirol: Neual coffelaresof bieaking rhelink 2. Settrontlal is atre\1,Jefincd as rhe lroce$ of berwccncraving and snokitry. Isy.hatasi.al inhibrdon ol an orhcrwiseimninent rhought, scie3ce, 2214),498-sA6. emotior, or acrion-ind as s!ch, ir inchides Bishop,S. R., Lau, M., Shapno,S., Carlson,l_., emotion regulation. Rclarcd io rhis is rhe ALrduson,N. D., Carmody,J., ei al. (2004). construcr of cognitivc conftol, whi.h more \'tindfulnc$: A proposcdope.ational dcfni broadly inclldcs goai nailtenancc, selective tion. Clini.aL Psr.halosy: S.ienceand Pn.- aitentioniconflic! morirofiig and resohrion, tice, 11\3),230-241. .esponscinhibu;on, and enotion reguladon. Bolld, K., Elisr, M., Kiohl, K., Mouraridis, M., Ser Gross(rhis voLune) for ctiscussion. Eldreth, D., conto.csgi, c.r er at. 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