Habitual Drug Intake Is Hard to Change: On the Discussion About Habits and Compulsions in Drug Addiction

IF 2.6 3区 医学 Q3 BIOCHEMISTRY & MOLECULAR BIOLOGY
Andreas Heinz, Stefan Gutwinski, Eva Friedel, Nadja Samia Bahr, Rainer Spanagel, Gaetano Di Chiara
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Instead, we claim that ‘individuals with drug addiction are neither automatons carrying out habitual behaviour without cognitive control nor merely individuals making bad choices’. Altogether, we conclude that habit formation can contribute to drug intake, as long as habitual behaviour is regarded as dimensionally but not categorically different from goal-directed decision-making and modifiable by human cognition. This statement is supported by studies from the ReCoDe consortium [<span>2</span>] and by a recent meta-analysis of the habit construct in animal models of alcohol use disorder [<span>3</span>], which did not indicate a strict habit-goal dichotomy. Instead, this meta-analysis suggests (i) a nuanced transition between goal directed and habitual decision making and (ii) distinguishes habitual responding from compulsivity [<span>3</span>].</p><p>Karen Ersche [<span>4</span>] criticizes our paper and suggests that OCD and addiction have more in common than we describe. She states that positive and negative reinforcement are associated with both drug intake and OCD, with which we agree. However, we disagree with Ersche's definition of compulsion as ‘ongoing actions that have become inappropriate to the immediate context’, because this definition is too broad and would, for example, include behaviours observed in bipolar and psychotic disorders unrelated to both OCD and addiction.</p><p>At one point, Ersche seems to confuse our criticism of the concept of compulsion in addiction with Lee Hogarth's criticism of the habit construct when she directly refers to one of his publications [<span>5</span>] which, however, was not cited in our opinion paper. In fact, we are not simply ‘rejecting’ the habit theory of addiction. Instead, we argue that the dual-system approach posits a categorical distinction between a habit and a goal-directed brain system, whereas nuanced transitions between these behavioural control systems occur in animals [<span>3</span>] and humans [<span>6</span>]. Thus, we argue that there is no overall loss of goal-directed behaviour, nor a general over-reliance on habits in individuals with drug addiction, but drug use itself can become a ‘habit’, that is, a bias toward drug-seeking in certain (e.g., stressful) circumstances [<span>7</span>].</p><p>Lee Hogarth [<span>8</span>] challenges our claim that habit formation contributes to drug addiction. He understands habits within the narrow confines of the habit/compulsion theory of addiction, where habits are defined as ‘representations of stimulus–response links that do not refer to goals’ [<span>9</span>]. Hogarth claims that this habit theory constructs ‘drug users as intellectually impaired’ and thus ‘recapitulate[s] the social injustice of the racial intelligence era by prematurely attributing lower task performance to drug user group membership’. His argument rests on three points: (i) that it is racist to attribute lower cognitive test performance in racialized groups to ‘race’ while ignoring social disadvantage, (ii) that habit formation is a form of intellectual impairment and (iii) that, by analogy, attributing increased habit formation as intellectual impairment to individuals with drug use disorders while ignoring social disadvantage amounts to scientific racism. With respect to (i), Hogarth cites the findings of Weiss [<span>10</span>] and claims that social disparity fully explains the difference in IQ test results between racialized groups. However, this is not true. Weiss [<span>10</span>] suggests that gaps remaining in cognitive performance after correcting for social disparities are due to ‘historical discrimination’, which includes racism. Therefore, argument (i) of Hogarth needs to be revised: It is indeed racist to attribute lower cognitive test performance in racialized groups to ‘race’ while ignoring social disadvantage AND the impact of racism itself on cognitive test performance. In fact, racism and other forms of historically embedded discrimination can induce severe stress and have profound negative effects on mental health [<span>11, 12</span>] and cognitive performance [<span>13</span>]. Such effects are then reified by the ‘race’ term, which falsely postulates categorical rather than gradual differences among populations [<span>14</span>]. Regarding argument (ii), we agree with Hogarth that some theories of addictive behaviour stigmatize patients and wrongly attribute cognitive effects of social exclusion and discrimination to genetic causes [<span>15</span>]. However, we do not view habitual behaviour as an intellectual impairment.</p><p>Habits are useful for all human beings: We could not drive a car and have a complex discussion at the same time without habit formation. In accordance with a recent meta-analysis [<span>3</span>], we observed gradual differences between habitual and goal-directed decision making and did not find a general deficit in goal-directed decision-making in persons with alcohol use disorders (AUD) [<span>16</span>]. Emphasizing that individuals with drug addiction are not ‘automatons carrying out habitual behaviour without cognitive control’ [<span>1</span>] does not rule out that specific behaviour patterns (including e.g., individually disadvantageous stress coping mechanisms) can become habitual, as evinced by the alcohol approach bias [<span>17</span>]. Individuals with AUD can change this approach bias with intensive training, indicating that individuals with habitual drug use patterns may need specific support to ‘break the habit’ Hogarth's claim that attributing habitual behaviour to individuals with substance use disorders amounts to labeling them as intellectually impaired may be motivated by theories that explain habit formation as the result of dysfunction of a higher cognitive control centre or goal-directed system. 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引用次数: 0

Abstract

In our recent opinion paper in Addiction Biology ‘Does compulsion explain addiction’? [1], we criticize that compulsive behaviour as defined primarily from the perspective of animal experimentation falls short of the clinical phenomenon. In particular, we argue that animal models of compulsion with immediate punishment do not adequately reflect long-term negative outcomes in human addiction. We also discuss that compulsive behaviour in OCD and addiction differ phenomenologically. Finally, we opine that human drug use can become a habit, but this does not imply a general loss of goal-directed decision-making. Instead, we claim that ‘individuals with drug addiction are neither automatons carrying out habitual behaviour without cognitive control nor merely individuals making bad choices’. Altogether, we conclude that habit formation can contribute to drug intake, as long as habitual behaviour is regarded as dimensionally but not categorically different from goal-directed decision-making and modifiable by human cognition. This statement is supported by studies from the ReCoDe consortium [2] and by a recent meta-analysis of the habit construct in animal models of alcohol use disorder [3], which did not indicate a strict habit-goal dichotomy. Instead, this meta-analysis suggests (i) a nuanced transition between goal directed and habitual decision making and (ii) distinguishes habitual responding from compulsivity [3].

Karen Ersche [4] criticizes our paper and suggests that OCD and addiction have more in common than we describe. She states that positive and negative reinforcement are associated with both drug intake and OCD, with which we agree. However, we disagree with Ersche's definition of compulsion as ‘ongoing actions that have become inappropriate to the immediate context’, because this definition is too broad and would, for example, include behaviours observed in bipolar and psychotic disorders unrelated to both OCD and addiction.

At one point, Ersche seems to confuse our criticism of the concept of compulsion in addiction with Lee Hogarth's criticism of the habit construct when she directly refers to one of his publications [5] which, however, was not cited in our opinion paper. In fact, we are not simply ‘rejecting’ the habit theory of addiction. Instead, we argue that the dual-system approach posits a categorical distinction between a habit and a goal-directed brain system, whereas nuanced transitions between these behavioural control systems occur in animals [3] and humans [6]. Thus, we argue that there is no overall loss of goal-directed behaviour, nor a general over-reliance on habits in individuals with drug addiction, but drug use itself can become a ‘habit’, that is, a bias toward drug-seeking in certain (e.g., stressful) circumstances [7].

Lee Hogarth [8] challenges our claim that habit formation contributes to drug addiction. He understands habits within the narrow confines of the habit/compulsion theory of addiction, where habits are defined as ‘representations of stimulus–response links that do not refer to goals’ [9]. Hogarth claims that this habit theory constructs ‘drug users as intellectually impaired’ and thus ‘recapitulate[s] the social injustice of the racial intelligence era by prematurely attributing lower task performance to drug user group membership’. His argument rests on three points: (i) that it is racist to attribute lower cognitive test performance in racialized groups to ‘race’ while ignoring social disadvantage, (ii) that habit formation is a form of intellectual impairment and (iii) that, by analogy, attributing increased habit formation as intellectual impairment to individuals with drug use disorders while ignoring social disadvantage amounts to scientific racism. With respect to (i), Hogarth cites the findings of Weiss [10] and claims that social disparity fully explains the difference in IQ test results between racialized groups. However, this is not true. Weiss [10] suggests that gaps remaining in cognitive performance after correcting for social disparities are due to ‘historical discrimination’, which includes racism. Therefore, argument (i) of Hogarth needs to be revised: It is indeed racist to attribute lower cognitive test performance in racialized groups to ‘race’ while ignoring social disadvantage AND the impact of racism itself on cognitive test performance. In fact, racism and other forms of historically embedded discrimination can induce severe stress and have profound negative effects on mental health [11, 12] and cognitive performance [13]. Such effects are then reified by the ‘race’ term, which falsely postulates categorical rather than gradual differences among populations [14]. Regarding argument (ii), we agree with Hogarth that some theories of addictive behaviour stigmatize patients and wrongly attribute cognitive effects of social exclusion and discrimination to genetic causes [15]. However, we do not view habitual behaviour as an intellectual impairment.

Habits are useful for all human beings: We could not drive a car and have a complex discussion at the same time without habit formation. In accordance with a recent meta-analysis [3], we observed gradual differences between habitual and goal-directed decision making and did not find a general deficit in goal-directed decision-making in persons with alcohol use disorders (AUD) [16]. Emphasizing that individuals with drug addiction are not ‘automatons carrying out habitual behaviour without cognitive control’ [1] does not rule out that specific behaviour patterns (including e.g., individually disadvantageous stress coping mechanisms) can become habitual, as evinced by the alcohol approach bias [17]. Individuals with AUD can change this approach bias with intensive training, indicating that individuals with habitual drug use patterns may need specific support to ‘break the habit’ Hogarth's claim that attributing habitual behaviour to individuals with substance use disorders amounts to labeling them as intellectually impaired may be motivated by theories that explain habit formation as the result of dysfunction of a higher cognitive control centre or goal-directed system. However, in our opinion article [1], we explicitly rejected reifying behaviour patterns such as goal-directed behaviour into ‘systems’, and we understand habit formation as an important ability. Therefore, argument (ii) of Hogarth is not in line with our point of view. With respect to argument (iii), we agree with Hogarth that social disadvantage, exclusion and discrimination play an important role in the predisposition to addiction [18, 19]. Moreover, we do not claim that habit formation is a pathological process that can only occur when goal-directed behaviour is impaired due to neurotoxic effects of alcohol. This being said, alcohol intake can cause neurotoxicity, which in turn can contribute to cognitive impairments that require support and therapy [20-24]. Ignoring the effects of drugs and drug-related mental disorders on motivation and cognition risks blaming the victims for their problems [15]. This unintended consequence is illustrated by Thomas Szasz [25], who reasoned that considering his postulated absence of valid concepts of mental illness, individuals do not have mental disorders but are instead just lazy and should therefore lose social support. In summary, we advise against trivializing the important topic of racism by inadequately equating studies measuring the neurotoxic and neurobiological effects of drugs of abuse on cognition with racist theories of group inferiority. Instead, the effects of racism on cognition and health should be taken seriously in their own right [26-28].

We agree with Ersche [4] and Hogarth [8] that in order to avoid stigmatization and discrimination, we need to reflect on our disease categories and their implications.

Our disease concepts must avoid stigmatizing individuals who use drugs, without denying the negative medical consequences of drug use and without excluding individuals with drug addiction from receiving the necessary support within the medical care system. We concur with Ersche's assertion that while a critical reflection of theories of addictive behaviour is good scientific practice, it necessitates the development of a more comprehensive theory to take its place. What the field of addiction critically requires is a unifying theory that integrates consistent findings across all levels of analysis—from genetic and molecular to neuronal, circuit, behavioural, and social aspects of addiction. This is an ambitious endeavour that can only be achieved through an open-minded approach by numerous experts.

The authors declare no conflicts of interest.

Abstract Image

习惯性吸毒难以改变:论吸毒成瘾的习惯与强迫
在我们最近发表在《成瘾生物学》上的观点文章中,“强迫能解释成瘾吗?”[1],我们批评主要从动物实验的角度定义的强迫行为与临床现象不符。特别是,我们认为立即惩罚的强迫动物模型不能充分反映人类成瘾的长期负面结果。我们还讨论了强迫症和成瘾的强迫行为在现象上的不同。最后,我们认为人类使用药物可以成为一种习惯,但这并不意味着普遍失去目标导向的决策。相反,我们声称“吸毒成瘾的人既不是没有认知控制的习惯性行为的机器人,也不仅仅是做出错误选择的个人”。总之,我们得出的结论是,只要习惯行为被认为是在维度上而不是在类别上与目标导向的决策不同,并且可以被人类认知所改变,习惯的形成可能有助于吸毒。这一说法得到了ReCoDe联盟的研究和最近对酒精使用障碍动物模型中习惯结构的荟萃分析的支持,该分析没有显示严格的习惯-目标二分法。相反,这一荟萃分析表明:(1)目标导向和习惯性决策之间存在微妙的转变;(2)区分习惯性反应和强迫性反应。Karen Ersche b[4]批评了我们的论文,并认为强迫症和成瘾有比我们描述的更多的共同点。她指出,正强化和负强化都与药物摄入和强迫症有关,我们同意这一点。然而,我们不同意Ersche将强迫定义为“不适合当前环境的持续行为”,因为这个定义太宽泛了,例如,包括在双相情感障碍和精神障碍中观察到的与强迫症和成瘾无关的行为。在某一点上,Ersche似乎混淆了我们对成瘾中强迫概念的批评和Lee Hogarth对习惯结构的批评当她直接提到他的一篇出版物b[5]时,而b[5]并没有在我们的观点论文中被引用。事实上,我们并不是简单地“拒绝”成瘾的习惯理论。相反,我们认为,双系统方法假设习惯和目标导向的大脑系统之间存在绝对的区别,而这些行为控制系统之间的细微转变发生在动物[3]和人类[6]中。因此,我们认为,吸毒成瘾者并没有完全丧失目标导向的行为,也没有普遍过度依赖习惯,但吸毒本身可以成为一种“习惯”,也就是说,在某些(如压力)环境下倾向于寻求药物[10]。Lee Hogarth b[8]对我们关于习惯形成导致吸毒成瘾的说法提出了挑战。他在成瘾的习惯/强迫理论的狭窄范围内理解习惯,其中习惯被定义为“与目标无关的刺激-反应联系的表征”[9]。霍加斯声称,这种习惯理论将“吸毒者视为智力受损者”,因此“通过过早地将较低的任务表现归因于吸毒者群体成员身份,概括了种族智力时代的社会不公正”。他的论点基于三点:(i)在种族化的群体中,将较低的认知测试表现归因于“种族”而忽视社会劣势,这是种族主义;(ii)习惯形成是一种智力损伤;(iii)通过类比,将吸毒障碍患者的习惯形成归因于智力损伤,而忽视社会劣势,这相当于科学种族主义。关于(1),Hogarth引用了Weiss b[10]的研究结果,并声称社会差异完全解释了种族化群体之间智商测试结果的差异。然而,事实并非如此。Weiss[10]认为,在纠正社会差异后,认知表现上的差距是由于“历史歧视”,其中包括种族主义。因此,Hogarth的论点(i)需要修正:将种族化群体中较低的认知测试成绩归因于“种族”,而忽视社会劣势和种族主义本身对认知测试成绩的影响,确实是种族主义。事实上,种族主义和其他形式的历史上根深蒂固的歧视会导致严重的压力,并对心理健康和认知表现产生深远的负面影响[11,12]。这种影响随后被“种族”一词具体化,它错误地假设了种群之间的绝对差异,而不是逐渐差异。关于论点(ii),我们同意Hogarth的观点,即成瘾行为的一些理论将患者污名化,并错误地将社会排斥和歧视的认知影响归因于遗传原因。
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来源期刊
Addiction Biology
Addiction Biology 生物-生化与分子生物学
CiteScore
8.10
自引率
2.90%
发文量
118
审稿时长
6-12 weeks
期刊介绍: Addiction Biology is focused on neuroscience contributions and it aims to advance our understanding of the action of drugs of abuse and addictive processes. Papers are accepted in both animal experimentation or clinical research. The content is geared towards behavioral, molecular, genetic, biochemical, neuro-biological and pharmacology aspects of these fields. Addiction Biology includes peer-reviewed original research reports and reviews. Addiction Biology is published on behalf of the Society for the Study of Addiction to Alcohol and other Drugs (SSA). Members of the Society for the Study of Addiction receive the Journal as part of their annual membership subscription.
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