New developments in understanding addiction

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New developments in understanding addiction

• Robert West
• University College London
• December 2006
• www.rjwest.co.uk

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Outline

• Understanding human motivation
• Addiction to cigarettes
• The process of smoking cessation

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Human motivation
Humans are more or less instinctive,
habit-driven, emotional decision-makers with a
propensity to plan ahead, powerfully influenced
by our social world, with a sense of identity
which can act as a source of self-control
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Responses

• At every moment our behaviour is generated by the
  balance between impulses and inhibitory forces
  active at that precise moment

Responses
Impulses versus inhibitory forces
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Impulses

• Impulses can be generated by
• Triggers interacting with innate dispositions
  (instincts) and learned dispositions (habits)
• Motives feelings of desire (anticipated
  pleasure or satisfaction) and/or need
  (anticipated relief from unpleasantness or
  tension)
• They decay quickly unless refreshed or sustained
  by triggers or motives

Responses
Impulses versus inhibitory forces
Triggers
Motives
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Motives

• Motives can be generated by
• Reminders interacting with the level internal
  tension at the time
• Evaluations beliefs about what is good/bad,
  right/wrong, useful/detrimental etc.

Responses
Impulses versus inhibitory forces
Triggers
Motives
Reminders
Evaluations
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Evaluations

• Evaluations are generated by
• Recall of observations
• Analysis, inference
• Accepting what others say
• Motives
• Plans

Responses
Impulses versus inhibitory forces
Triggers
Motives
Reminders
Evaluations
Plans
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Plans

• Plans are mental actions generated when
• Actions are considered to be required in the
  future
• Actions are considered to be more likely to meet
  desires or needs if undertaken at a future time
• Actions meeting desires or needs do have a
  sufficient priority to be enacted at the moment

Responses
Impulses versus inhibitory forces
Triggers
Motives
Reminders
Evaluations
Plans
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The human motivational system
Plans (intentions)
Evaluations (beliefs)
External environment (stimuli, information)
Internal environment (percepts, drives,
emotional states, arousal, ideas, frame of mind)
Motives (wants etc.)
Internal stimulation
Impulses (urges etc.)
Responses
External stimulation
Flow of influence through the system
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The importance of the moment
Evaluations, wants, emotional states, impulses
and plans are only present when triggered and
have no influence when not present

• Everything we think, feel or do is a reaction to
  what happened or our state just prior to that
  acting on our dispositions
• We only think about things when we are prompted
  to do so
• The way that we think or feel about things
  depends to some degree on what prompted this
• Not thinking about things is an important method
  of reducing tension

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How dispositions come about
Dispositions
Genetic endowment
Experience
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The development of dispositions
Waddingtons epigenetic landscape
Environmental forces
Critical periods points where the chreods fork
Deep chreods small forces will not lead to
escape the system will settle back once they are
removed but if the system is on a cusp a small
force will tip it into a new path
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Identity
Identity refers to a disposition to generate
particular thoughts and feelings about ourselves

• People differ in the propensity to think about
  ourselves, the nature of the thoughts and
  feelings that we have, and how consistent and
  coherent these are
• Identity is a very important source of motives
  it is the foundation of personal norms that shape
  and set boundaries on our behaviour

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Self-control
Self-control refers to wants and needs that arise
from evaluations associated with our identity

• Self-control is a cornerstone of behaviour
  change. The moment-to-moment wants and needs
  arising from that must be strong enough to
  overcome impulses, wants and needs coming from
  other sources
• The exercise of self-control is effortful it
  requires and uses up mental resources

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Addiction and dependence
Addictions are activities that are given an
unhealthy priority because of a disordered
motivational system
Dependence refers to the nature of that disorder.
It varies from individual to individual and
behaviour to behaviour
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Motivation to smoke
Smoking
Impulse to smoke
Cues/triggers
Desire to smoke
Need to smoke
Anticipated pleasure/ satisfaction
Nicotine hunger
Unpleasant mood and physical symptoms
Anticipated benefit
Reminders
Positive evaluations of smoking
Smoker identity
Beliefs about benefits of smoking
Plan to smoke
Nicotine dependence involves generation of
acquired drive, withdrawal symptoms, strong
desires from anticipated pleasure or satisfaction
and direct simulation of impulses through
associative learning
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Motivation not to smoke
Not smoking
Inhibition
Cues/triggers
Desire not to smoke
Need not to smoke
Anticipated praise
Anticipated disgust, guilt or shame Fears about
health
Anticipated self-respect
Positive evaluations of not smoking negative
evaluations of smoking
Reminders
Beliefs about benefits of not smoking
Non-smoker identity
Plan not to smoke
Nicotine dependence probably also involves
impairment of impulse control mechanisms
undermining response inhibition
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What smokers say about stopping

• At any one time, when asked, most smokers report
  that they
• want to stop, citing health concerns as the main
  reason
• intend to stop some time in the future
• regret having ever started smoking
• have tried to stop in the past
• have tried nicotine replacement to help them stop
• are trying to cut down
• but a minority
• are ready to try to stop right now
• are willing to see a stop smoking advisor or
  attend a stop smoking group

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Going beyond what smokers say

• Many smokers
• will respond positively to an offer of help with
  stopping who would not have done if they had been
  first asked whether they were interested in
  stopping
• will suddenly stop without making any prior plans
  to do so
• who say they plan to stop at a particular time or
  within a particular time window do not try to
  stop
• who try to stop, will later fail to report that
  they tried to stop if that quit attempt does not
  last very long
• misjudge what it is they find difficult about not
  smoking focusing on the activity when in fact
  they are responding to a basic pharmacologically-d
  riven need

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The process leading up to quit attempts
Motivational tension

• Smokers experience varying degrees of want or
  need (when it enters their consciousness) to do
  something about their smoking
• That motivational tension comes into and out of
  existence at varying levels of intensity

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The process leading up to quit attempts Triggers

• Triggers put the idea of stopping in the mind of
  the smoker in such a way that the desire or need
  to change overwhelms motivation not to change
• The change is either adopted immediately or a
  plan is made to stop in the future

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Generating more quit attempts by increasing
tension
Change in internal or external environment
Motivational tension
Competing motivations
Time
Low level of motivation
Increased motivational tension
Attempt
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Generating more quit attempts by reducing
competing motivations
Motivational tension
Reduced threshold
Competing motivations
Time
Attempt
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Generating more quit attempts by creating more
potential triggers
Motivational tension
More potential triggers
Competing motivations
Time
Increase in frequency of triggers
Attempt
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Attempts to stop smoking

• These are switches in identity from smoker to
  any of
• smoker attempting to stop
• smoker trying not to smoke
• would-be non-smoker
• definite non-smoker etc.

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Identity and behaviour in smoking cessation
Smoking
Attempting to stop
Identity
Not smoking
Behaviour
Cigarettes
Time
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Success of quit attempts

• The new identity must generate wants and needs
  that are powerful enough to counter impulses,
  wants and needs arising from the disposition to
  smoke whenever these arise
• As time passes, the impulses, wants and needs to
  smoke will usually decrease to some degree
  because of physiological normalisation and so
  the degree of self-control required will diminish
• However, habituation will often also decrease the
  wants and needs not to smoke

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Motivation to smoke during a quit attempt
Action threshold (restraint, competing motives)
Lapses
Impulse to smoke
Day 1
Day 2
Day 5
Day 10
Day 20
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Causes of relapse same day

• Same-day relapse is most often a result of the
  new identity being too unstable to withstand the
  relatively modest wants and needs to smoke
  arising from pharmacological dependence and/or
  social situations
• But it can arise from powerful pharmacological
  impulses, want or needs or instabilities in the
  system or events that precipitate heightened
  wants, needs or impulses

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Relapse Early weeks

• Relapse in the early weeks is most often a result
  of strong wants and needs arising from
  pharmacological dependence with social and other
  motives superimposed on this
• But it can result from instabilities in the
  system, moments of weakness, low levels of
  motivational resources required to exercise
  self-control, persistence of wants or needs to
  smoke that deplete motivational resources, or
  events that precipitate acute wants, needs or
  impulses.

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Relapse Late

• Late relapse is most often a result of a failure
  of the new identity to achieve sufficient
  stability at all times to overpower the momentary
  motives to smoke
• Over an extended period the chances of even a
  relatively modest motivation to smoke failing to
  provoke sufficient self-control is quite high
• For some smokers, the wants and needs to smoke do
  not diminish sufficiently, either because of
  continued positive evaluations of smoking,
  attachment to a smoker identity, continued
  pharmacologically based needs, or a failure for
  the learned habit to weaken