Lara Moody

Therapeutic Opportunities for Self-Control Repair in Addiction and Related Disorders: Change and the Limits of Change in Trans-Disease Processes.

Contemporary neuroeconomic approaches hypothesize that self-control failure results from drugs annexing normal learning mechanisms that produce pathological reward processing and distort decision making as a result from the dysregulation of two valuation systems. An emphasis on processes shared across different diseases and disorders is at odds with the contemporary approach that assumes unique disease etiologies and treatments. Studying trans-disease processes can identify mechanisms that operate in multiple disease states and ascertain if factors that influence processes in one disease state may be applicable to all disease states. In this article we review the dual model of self-control failure, the Competing Neurobehavioral Decision System approach, the relationship of delay discounting to the relative control of these two systems, and evidence that the executive system can be strengthened. Future research that could result in more potent interventions for executive system improvement and potential constraints on the repair of self-control failure are discussed.

A Competing Neurobehavioral Decision Systems model of SES-related health and behavioral disparities

We propose that executive dysfunction is an important component relating to the socio-economic status gradient of select health behaviors. We review and find evidence supporting an SES gradient associated with (1) negative health behaviors (e.g., obesity, excessive use of alcohol, tobacco and other substances), and (2) executive dysfunction. Moreover, the evidence supports that stress and insufficient cognitive resources contribute to executive dysfunction and that executive dysfunction is evident among individuals who smoke cigarettes, are obese, abuse alcohol, and use illicit drugs. Collectively these data support the dual system model of cognitive control, referred to here as the Competing Neurobehavioral Decision Systems hypothesis. The implications of these relationships for intervention and social justice considerations are discussed.

Comorbid depression, antisocial personality, and substance dependence: Relationship with delay discounting

BACKGROUND Within the field of addiction, as many as four-fifths of individuals in treatment for substance use disorder have co-existing lifetime psychopathology and as high as two-thirds have current psychopathology. Among substance-dependent individuals, excessive delay discounting is pervasive. Despite evidence of excessive discounting across substance use disorders, few studies have investigated the impact of co-occurring psychopathologies and SUD on delay discounting. METHODS We compared delay discounting in currently abstaining substance users with (a) SUD (n=166), (b) SUD and managed major depressive disorder (MDD; n=44), (c) SUD and antisocial personality disorder (APD; n=35), (d) SUD and managed MDD and APD (n=22) and (e) no SUD or co-occurring psychopathology (n=60). RESULTS All groups with SUD discounted future delayed rewards significantly more than healthy controls (p<0.001 in each case, d=0.686, 0.835, 1.098 and 1.650, respective to groups a-d above). Individuals with both APD and SUD and individuals with MDD, APD, and SUD discounted future rewards significantly more than substance users without comorbid psychopathology (p=0.029, d=0.412 and p<0.001, d=0.964, respectively). CONCLUSIONS Overall, individuals with multiple psychopathologies in addition to substance use have exacerbated deficits in discounting of the future, above and beyond that observed in substance use alone. Increased discounting in combined substance and psychopathology profiles suggest a greater chance of treatment failure and therefore may necessitate individualized treatment using adjunctive interventions to achieve better treatment outcomes.

Some current dimensions of the behavioral economics of health-related behavior change.

Health-related behaviors such as tobacco, alcohol and other substance use, poor diet and physical inactivity, and risky sexual practices are important targets for research and intervention. Health-related behaviors are especially pertinent targets in the United States, which lags behind most other developed nations on common markers of population health. In this essay we examine the application of behavioral economics, a scientific discipline that represents the intersection of economics and psychology, to the study and promotion of health-related behavior change. More specifically, we review what we consider to be some core dimensions of this discipline when applied to the study health-related behavior change. Behavioral economics (1) provides novel conceptual systems to inform scientific understanding of health behaviors, (2) translates scientific understanding into practical and effective behavior-change interventions, (3) leverages varied aspects of behavior change beyond increases or decreases in frequency, (4) recognizes and exploits trans-disease processes and interventions, and (5) leverages technology in efforts to maximize efficacy, cost effectiveness, and reach. These dimensions are overviewed and their implications for the future of the field discussed.

Impulsivity and polysubstance use: A systematic comparison of delay discounting in mono-, dual-, and trisubstance use.

Understanding the association between polysubstance use and impulsivity is pertinent to treatment planning and efficacy. Delay discounting, a measure of impulsivity, supplies the rate at which a reinforcer loses value as the temporal delay to its receipt increases. Excessive delay discounting has been widely observed among drug-using individuals, though the impact of using more than 1 substance has been only minimally studied. Here, after controlling for demographic variables, we systematically compared delay discounting in community controls, heavy smokers, and alcohol- and cocaine-dependent individuals to assess the impact of non-, mono-, dual-, and trisubstance use. All substance-using groups discounted significantly more than did community controls (p < .05). Additionally, groups that smoked cigarettes in addition to another substance dependency discounted significantly more than did the group that smoked cigarettes only (p < .05). Last, trisubstance users who were alcohol-dependent, cocaine-dependent, and heavy cigarette smokers discounted significantly more than did heavy smokers (p < .01). However, trisubstance users did not discount significantly more than did any dual-substance group. Trisubstance use was associated with greater impulsivity than was monosubstance smoking but exhibited no greater impulsivity than did dual-substance use, suggesting a ceiling effect on discounting when more than 2 substances are in use. The present study suggests that smokers who engage in additional substance use may experience worse treatment outcomes, given that excessive discounting is predictive of poor therapeutic outcomes in several studies.

Neural signatures of third-party punishment: Evidence from penetrating traumatic brain injury

The ability to survive within a cooperative society depends on impartial third-party punishment (TPP) of social norm violations. Two cognitive mechanisms have been postulated as necessary for the successful completion of TPP: evaluation of legal responsibility and selection of a suitable punishment given the magnitude of the crime. Converging neuroimaging research suggests two supporting domain-general networks; a mentalizing network for evaluation of legal responsibility and a central-executive network for determination of punishment. A whole-brain voxel-based lesion-symptom mapping approach was used in conjunction with a rank-order TPP task to identify brain regions necessary for TPP in a large sample of patients with penetrating traumatic brain injury. Patients who demonstrated atypical TPP had specific lesions in core regions of the mentalizing (dorsomedial prefrontal cortex [PFC], ventromedial PFC) and central-executive (bilateral dorsolateral PFC, right intraparietal sulcus) networks. Altruism and executive functioning (concept formation skills) were significant predictors of TPP: altruism was uniquely associated with TPP in patients with lesions in right dorsolateral PFC and executive functioning was uniquely associated with TPP in individuals with lesions in left PFC. Our findings contribute to the extant literature to support underlying neural networks associated with TPP, with specific brain-behavior causal relationships confirming recent functional neuroimaging research.

Toward Narrative Theory: Interventions for Reinforcer Pathology in Health Behavior

Reinforcer pathology describes the interaction between excessive devaluation of delayed rewards and excessive valuation of commodities such as drugs or food. In isolation, both components of reinforcer pathology increase risk for substance-use disorders and other maladaptive health behaviors (e.g., poor diet); in combination, these components synergistically increase risk. In this chapter, we review evidence that reinforcer pathology may arise from imbalance between two competing neurobehavioral decision systems (CNDS)—the impulsive system, comprising the limbic and paralimbic brain regions, and the executive system, comprising the prefrontal and parietal cortices. To correct imbalance between these systems and restore normative decision making, we introduce narrative theory, a novel intervention framework that seeks to harness humans’ unique sensitivity to language and storytelling in order to both understand and potentially treat the maladaptive decision making observed in addiction and other maladaptive health behaviors. We provide both an overview of methods used in investigations of narrative theory and a summary of effects of these methods on both discounting of delayed rewards and valuation of commodities that may damage health, such as drugs and energy-dense food.

Novel Therapeutics for Addiction: Behavioral Economic and Neuroeconomic Approaches

Opinion statementBehavioral economic and neuroeconomic understandings of addiction offer both established and empirically supported treatments as well as a foundation from which promising new treatment options are emerging. Addiction must be understood and treated as a state of pathological overvaluation of the reinforcement of drug use fueled by an imbalance of the competing neurobehavioral decision systems that govern decision making (CNDS theory). The CNDS theory presents two systems, the executive and impulsive, which are dysregulated in reinforcer pathology by greater relative control of the impulsive, hedonic system, and lesser relative control of the executive, regulatory system. This leads to a reinforcer pathology where drug use is maladaptively overvalued in comparison to other reinforcers, leading to a chronic and often relapsing state of addiction. Some treatments which directly alter economic variables associated with drug use have already been empirically supported, including contingency management (which increases the short-term price of drug use) and drug agonist therapies (which decrease the short-term value of drug use compared to other reinforcers). New, promising treatments which bring the fundamental CNDS dysregulation of addiction into balance include episodic future thinking, which increases the temporal window over which the opportunity costs of drug use are integrated by engaging executive control, and TMS therapies which directly increase activity, and therefore relative control, in the executive system. The maturing fields of behavioral economics and neuroeconomics provide conceptual understanding of the competing neurobehavioral decision systems theory (CNDS) and reinforcer pathology (i.e., high valuation of and excessive preference for drug reinforcers), allowing us to coherently categorize treatments into a theoretically comprehensive framework of addiction. In this chapter, we identify and clarify how existing and novel interventions can ameliorate reinforcer pathology in light of the CNDS and be leveraged to treat addiction.

Cross-Commodity Delay Discounting of Alcohol and Money in Alcohol Users

Despite real-world implications, the pattern of delay discounting in alcohol users when the commodities now and later differ has not been well-characterized. In this study, 60 participants on Amazon’s Mechanical Turk completed the Alcohol Use Disorder Identification Test (AUDIT) to assess severity of use and completed four delay discounting tasks between hypothetical, equivalent amounts of alcohol and money available at five delays. The tasks included two cross-commodity (alcohol now-money later and money now-alcohol later) and two same-commodity (money now-money later and alcohol now-alcohol later) conditions. Delay discounting was significantly associated with clinical cutoffs of the AUDIT for both of the cross-commodity conditions but not for either of the same-commodity delay discounting tasks. The cross-commodity discounting conditions were related to severity of use wherein heavy users discounted future alcohol less and future money more. The change in direction of the discounting effect was dependent on the commodity that was distally available suggesting a distinctive pattern of discounting across commodities when comparing light and heavy alcohol users.

Substance use in rural Central Appalachia: Current status and treatment considerations.

The burden of substance use and especially the unmatched rates of overdoses in rural Central Appalachia highlight the need for innovative approaches to curb the initiation to drug misuse and to address current substance use disorders. Effective substance use interventions involve a thorough understanding of the region. In Central Appalachia, many of the barriers to treatment are shared with other rural and impoverished areas, including a lack of access to health care and lack of health care providers with specialized training. Parts of Appalachia also present their own considerations, including the challenges of fostering trust and encouraging treatment-seeking in communities with dense, long-term, place-based social and family networks. Current policies and interventions for substance use have been largely inadequate in the region, as evidenced by continued increases in substance use and substance-related deaths, especially related to nonmedical prescription drug use and increasing heroin use. The authors discuss ways in which rural life, poverty, identity, and values in Appalachia have influenced substance use and treatment and propose strategies and interventions to improve outcomes.