Motivation and emotion/Book/2011/Addiction

Overview
In our daily lives, we often hear the term "addiction". People use it in reference to a lot of things, from the most serious addictions such as cocaine or heroin, to the more mild habits, such as shopping, food, or even internet sites such as Facebook. To some extent, even the mild habits may be acquired and governed through similar processes, and those people may well be experiencing mild addictions to those substances or activities.

While mild addictions may not be life threatening, they can be annoying, difficult, or time consuming. So, where do we draw the motivation for these addictions, mild or otherwise, from? Why is it that we can spend so much time playing video games, and yet never find the drive to do any homework? Why are we motivated to continue smoking, even though we know it is doing damage to our bodies? And, more importantly, how can we control and remove the addiction, so as to use our time and resources in a more efficient and effective way?

This chapter defines addiction as a psychological or physical dependence on a substance or activity. The diagnostic and statistical manual of mental disorders (2000) describes behavioural and substance addictions separately, with the most relevant criteria for the purposes of this topic being that of substance abuse.

In this chapter, research concerning serious addictions will be reviewed so as to provide a guideline for how to control and manage the addictions that we experience in our everyday lives, from the mildest the to the most serious. The term "stimulus" will be used to encompass both addictive substance and addictive behaviour.

Origins of addiction
Throughout our lives, certain events occur that require discretion on our part before we engage in them. Once we have experienced a type of event, such as social networking, we make a judgement on it as it whether or not we liked the activity, and whether we should continue to do similar activities in the future. We tend to persist with behaviors that rewards us with positive outcomes, and avoid behaviors that lead us to less favourable consequences. To a large degree, this is the underlying principle from which addictions arise. These principles will be outlined with reference to a number of different theories.

Social learning theory
One of the most well known processes of addiction acquisition is the concept of social learning. The theory states that as behaviours are modelled they are learned by others, regardless of how ethical these actions are (Bandura, Ross & Ross, 1961). This was shown in a study by Bandura (1961) where children observed an adult violently attack a bobo doll. Subsequently, the study found that children who were exposed to the violent modelling were more likely to attack the doll themselves. It has also been asserted that the quality of the relationship with the model will contribute towards the likelihood of engaging in the behaviour (Borsari & Carey, 2006).

The effect is similar in the process of addiction (Wilson, 1987). If we observe an individual smoking a cigarette, or using Facebook, we are more likely to perceive that modelled behaviour as acceptable. As a result, we are more likely to engage in that behaviour, marking the beginning stages of the addiction process.

The social setting also has an impact on the likelihood of a behaviour occurring. The process, termed "social reinforcement", governs how acceptable an individual perceives an action to be, based on their current environment (Borsari & Carey, 2006). For example, you may be more likely to smoke in a designated smoking area than in someone's car, based on the feedback you have received for this action in the past. As a result, the social setting plays almost as critical a role in the development of an addiction as the peer group.

Conditioning principles
According to various theories of operant conditioning, behavioural responses to stimuli arise as a result of reinforcement and punishment, which can occur when the behavioural consequence is being added (positive) or removed (negative). In terms of processes of addiction, all of these operant principles play important roles.

Positive reinforcement is the first part of the undesirable path towards addiction. Positive reinforcement can be defined as an attractive stimulus given to an individual as a result of an action (Watkins, Koob & Markou, 2000). As such, when an individual initially begins to take an addictive substance, they will likely experience a euphoric sensation, immediately rewarding them for consumption (Watkins, Koob & Markou, 2000). It can be expected, then, that this reward leads to an increased likelihood of the behaviour being performed in the future. In a sense, this part of the addiction cycle is not problematic, the problem arises when the action loses any benefit, as the individual builds up a tolerance (Tiffany, 1990). When this happens, more of the substance needs to be taken in order to achieve the same sensation. At this point, addiction becomes a more serious concern (Tiffany, 1990).

It is common knowledge that when an individual builds up a dependence to a substance, and subsequently ceases to take it, withdrawal occurs (Wikler, 1980). What is less well known, is that similar symptoms have been exhibited in cases of behaviour cessation, where substances were not present (Cunningham-Williams, Gattis, Dore, Shi & Spitznagel, 2009). Research has shown that individuals who attempt to give up gambling can experience restlessness, irritability, anger, guilt and disappointment (Cunningham-Williams et al., 2009). Additionally, though less commonly, physiological symptoms, such as abdominal pain and diarrhea, may also arise (Custer, 1982; Rosenthal & Lesievr, 1992). Given that no substance is involved in this example, it can be argued that certain types of highly addictive activities may produce a dependence effect similar to that found in substance addiction. In any case, withdrawal symptoms are highly unpleasant. Not surprisingly, individuals often aim to avoid these aversive consequences, which can be achieved by avoiding the substance altogether. But if a dependence has already been formed, how does the individual avoid the unwanted consequences of cessation?

It is this exact tendency that, unfortunately, allows negative reinforcement to be so highly effective in fostering an addiction (Baker, Piper, McCarthy, Majeskie & Fiore, 2004). Individuals are rewarded for perpetuating the addiction through the absences of undesirable consequences (Baker et al., 2004). Consequently, the dependence to the substance or behaviour is strengthened, and a vicious cycle ensues.

So how does all of this research affect us? Initially, our first experience with an addictive stimulus may be the most positive, with the effect gradually declining overtime (Tiffany, 1990). For example, an Internet addiction, while it may be fun initially to browse the web, as usage reaches addiction levels the fun will wear off, becoming replaced with feelings of restlessness and unease when the behaviour has to stop (Young, 1999). As such, the focus now shifts from enjoying the behaviour to avoiding the cost of cessation, an effect similar to withdrawal avoidance (Young, 1999).

Opponent-process theory
In a similar process to the learning principles, the opponent-process theory of motivation can be applied to an understanding addiction formation (Ettenberg, 2004). The essential feature of the opponent-process theory is the idea that experiencing an extreme high or low (termed "the A process"), our bodies attempt to suppress this by adjusting the emotion in the opposite direction ("the B process"), to a small degree (Solomon & Corbit, 1973). As such, once the A process has worn off, the B process remains, leaving us in a more aroused or depressed state than we would expect to be (Solomon & Corbit, 1973).

In terms of addiction, this process displays how the stimulus creates unpredictably greater emotional states. When the individual has been without the stimulus for a period of time, they will achieve greater highs when using it (Solomon & Corbit, 1973). When the individual is using the stimulus, they will experience greater lows when it is not in use (Solomon & Corbit, 1973). While this not a massive effect, it does facilitate the development of the addiction to some extent (Ettenberg, 2004).

Environment
Psychologically, we are predisposed to pick up on cues that we have come to associate with other stimuli, especially in the case of addictions (Kuntze et al., 2001). Cues, such as sounds, smells or the sight of a particular setting are all able to elicit a particular addiction-related response. Indeed, these responses can range from a craving for the stimulus, to withdrawal symptoms and mood swings (Kuntze et al., 2001). In this way, the environment itself can foster the addiction process, as the learned responses to the particular environment may trigger these temptation effects, and lead to a compulsion to continue the adverse pattern of behaviours.

Neurological basis
A number of neurological structures are involved in the process of attaining and reinforcing an addiction. The manner in which some of these brain structures are affected by addiction will be briefly outlined here.

Basal ganglia
The basal ganglia, an area of the brain associated with procedural learning, increases production and transmission of dopamine in response to addiction (Kalivas & Volkow, 2005). Given the role of dopamine in valuing incentive and reward (Berridge & Robinson, 1998), this brain structure is one of the most important areas of the brain in facilitating addiction.

Amygdala
As the primary function of the amygdala is to govern emotional learning and memory (Everitt, Cardinal, Parkinson & Robbins, 2003), it plays a critical role in the formation of behavioural responses through its activation in response to motivationally relevant stimuli (Kalivas & Volkow, 2005).

Prefrontal cortex
Similar to the amygdala, the prefrontal cortex is activated in response to a motivationally relevant event, particularly in response to the likelihood of a reward (Berns, McClure, Pagnoni & Montague, 2001). However, this structure governs the intensity of the response, or indeed if a response will occur at all (Bush et al., 2002).

Nucleus accumbens
The nucleus accumbens is responsible for the attribution of learned associations between environment and events (Bassareo & Di Chiara, 1999), as well as governing a "liking" response to certain stimuli (Peciña & Berridge, 2005).

How to resolve addiction
Once the addiction has taken hold, the outlook may appear bleak. Not the case. Treatment options are always available, and with some self-control and regulation, breaking the addiction cycle is a distinct possibility. But which treatment will prove to be the most effective, and indeed will this treatment continue to be effective in the long term? With respect to practicality, the following treatment options are examined in-depth.

Prevention
As is the case with much of physical and psychological well-being, prevention is a very effective cure (McAlister, Perry, Killen, Slinkard & Maccoby, 1980). Of course, while it may be easy in theory to resist the temptation of an addiction, in reality it is a very difficult task. As such, in order to form a prevention strategy, the various factors which influence individuals towards the onset of an addiction must be examined.

One publicly familiar cause of addiction is social pressure, and more specifically, peer pressure. It is very difficult to say "no" to a group of friends as they compel you to try a substance, particularly when some of these friends are highly respected by you or others (McAlister, 1979). As a result, a number of government programs have been initiated, with the express aim of educating individual (in particular children) on how to resist this type of social pressure, often with surprisingly good results (McAlister, Perry, Killen, Slinkard & Maccoby, 1980). This suggests that one method of prevention is to simply to learn how to say no, and refuse the addictive behaviour before it takes hold.

Behaviour modification
It has been suggested that conditioning principles are, to some extent, a large contributor in the addiction development process (Watkins, Koob & Markou, 2000). Fortunately, these conditioning principles have also been shown to work in the opposite direction, facilitating treatment and extinction of adverse addictive behaviours (Chóliz, 2010). A number of studies (Petry, 2006; Silverman, 2004) have suggested a specific operant conditioning schedule designed to reward the cessation of addictive behaviours.

Essentially, this treatment proposes that the individual be rewarded, usually monetarily, when they present evidence of abstinence from the behaviour for a certain predetermined period of time. In this way, the individual is rewarded for not engaging in the drug behaviour, thereby facilitating the process of overcoming the addiction. In the past, this treatment has proved to be effective, across differing types of addictions (Higgins, Silverman, 1999). Indeed, this approach has even been shown to reduce usage of substances as addictive as cocaine, with one study finding over half of the participants remaining abstinent for almost the entire time-frame of the experiment (Silverman, 2004). Importantly, these studies found that the optimal level of behaviour modification occurred when the reward became greater overtime, and incentives such as "start-up bonuses" for initiating the abstinence behaviour had no additional benefit (Silverman, 2004; Silverman et al., 1998).

The research on behaviour modification has a number of implications for those of us wishing to give up an addiction. Firstly, it is not necessary to use willpower alone. It is both acceptable and ideal to reward ourselves for our own good behaviour. If a day without a cigarette is managed, reward yourself with a nice dinner. If you get through a whole week without using Facebook, buy yourself something you've wanted for a while. But in using this strategy, it is important to remember that the rewards must be consistent (Silverman, 2004), so don't forget to treat yourself if you achieve your goal.

Aversion therapy
Given the conditioning principles at play during the formation of an addiction, one factor is clear. In most cases, the immediate response to performing an addictive behaviour is positive reinforcement (Chóliz, 2010). That is, the individual immediately feels good about taking a substance or performing and adverse behaviour, even if that same individual feels guilt or regret moments later. The power of the immediacy of the reinforcement has been shown the play a large role in facilitating the addiction (Chóliz, 2010). As such, the fundamental goal of aversion therapy is to pair aversive and unpleasant stimuli with the desired stimuli, in order to replace this immediate reinforcement with punishment (Cannon, Baker, Gino & Nathan, 1986). An effective treatment, aversion therapy has been shown to reduce cravings for substances as addictive as cocaine (Bordnick, Elkins, Orr, Walters & Thyer, 2004), and is often used in the treatment of alcohol (Howard, 2001).

Generally, aversion therapy would need to be administered by a registered and trained health professional, due to the involvement of drugs and other potentially hazardous techniques (Cannon & Baker 1981). However, simplified versions are available for everyday use. For example, specific chemicals designed to be painted on fingernails can help to remove nail biting behaviours as a result of their repulsive taste. In any case, as long as the stimulus is undesirable, and presented simultaneously with the desired stimulus, a negative association can occur, leading to a reduction in craving responses to the addictive stimulus.

Environment
As human beings, we pick up and respond to various cues we have associated with particular stimuli, and this is especially true in the case of addictions (Kuntze et al., 2001). In this way, there are two possible resolution pathways for overcoming cue-elicited cravings: Desensitizing ourselves to these cues, or changing the environment.

Desensitisation has proven to be an effective method of eliminating the cue-elicited behaviours (Kuntze et al., 2001). As the individual is repeatedly exposed to the cues associated with the stimulus, over time the effect of these cues is lessened as the association tends towards extinction (Kuntze et al., 2001). While this does not resolve the addiction entirely, the removal of elicited responses will contribute significantly towards controlling cravings.

Secondly, if the environmental pressures are too much to handle, a change of social environment may be necessary. Given the role of cues in various settings (Kuntze et al., 2001), and social pressure (McAlister, 1979), removing the source of both of these will help significantly in overcoming an addiction. This may not be easy, as it would mean that contact with friends needs to be broken, but in the long-term it may prove to be a highly effective method.

Summary
The processes of acquisition and extinction of an addiction are relatively straightforward in theory, even if they are more difficult to implement or maintain in reality. The origins of addiction have been explored, shedding some light on how we acquire the motivation to pursue an addictive behaviour or substance, rather than focusing our attention on more positive and healthy activities. Social learning theory was examined, and the process of peer-influence and modelling showed how adverse behaviours can be acquired if modelled by the correct individual (Borsari & Carey, 2006).

Secondly, insight into the underlying learning principles suggested some processes by which addiction arises, notably the immediate positive reinforcement of the sensation (Chóliz, 2010), and the punishment of abstinence and withdrawal (Young, 1999). The opponent-process theory showed how these processes can be magnified, and the effect of the learning processes are increased as a result (Ettenberg, 2004). The effect of environmental cues was also shown to foster the addiction process (Kuntze et al., 2001). To complete the examination of addiction origins, a brief overview of brain structures was given, with sections of note being the basal ganglia, amygdala, prefrontal cortex and nucleus accumbens.

Once the process of acquisition was examined, the methods of breaking an addiction were also considered. Prevention was one method, which can be achieved by learning how to resist social pressure (McAlister, Perry, Killen, Slinkard & Maccoby, 1980). Secondly, some techniques of behaviour modification could be of use, such as rewarding oneself for more desired behaviour patterns (Silverman, 2004). Aversion therapy can also assist, as pairing the cues normally associated with addictive stimuli, with aversive stimuli can lead to a reduction in cravings overall (Cannon, Baker, Gino & Nathan, 1986). Finally, a change in environment, or desensitization to associated cues (Kuntze et al., 2001) might prove to be useful in controlling and breaking the addiction.

It is clear that while the process of addiction can be easily acquired, it is not impossible to break once it has been established, especially if appropriate measures are taken. In this way, as long as we utilize the treatment process that is right for us, anywhere from the most serious addiction to the smallest habit can be kept under control.