Understanding, preventing and treating addiction through the lens of PRIME Theory

1. Understanding, preventing and treating addiction through thelens of PRIME Theory Robert West University College London January 2009

2. Outline • Defining addiction and motivation • Developing a theory of motivation • Applying the theory to addiction

3. Outline • Defining addiction and motivation • Developing a theory of motivation • Applying the theory to addiction

4. Addiction • Individuals repeatedly experience powerful motivation to engage in particular maladaptive behaviours that often undermine and overwhelm motivation to exercise restraint • Two elements: • strength of motivation • capacity for restraint • Degree of addiction can be measured by indices of the dominance of the motivation • subjective reports or strength, persistence and/or frequency of urges • observations of priority given to the behaviour

5. Motivation • Not just ‘reasons’ • Brain processes that energise and direct behaviour • Relevant concepts: • impulse • drive • want • need • goal • choice • intention

6. Where does motivation fit in? Response control system Response control system Response control system Response control system Skill Skilled Skilled Skill Skilled Skill Skilled Skill Response generation system Response generation system Response generation system Response generation system Motivation Motivation Motivation Motivation Motivation Motivation Motivation Motivation Cognitive system Cognitive system Cognition Memory and inference Memory and inference Mental representation system Information acquisition system Sensory system Information acquisition Sensation Information acquisition Information acquisition Each system can operate in isolation but is usually strongly under the influence of other systems

7. Outline • Defining addiction and motivation • Developing a theory of motivation • Applying the theory to addiction

8. A starting point for understanding behaviour • We: • act on impulse • we do it without thinking about the consequences • want or need something • we seek a source of pleasure or satisfaction, or of relief • think it is right or will serve a purpose • we do what we consider best • are following a plan • we act on a prior intention • And this motivation is stronger than any competing motivation present at the time

9. Example • Faced with what appears to be a thief running towards us on the street: • the impulse is to avoid physical contact (‘flinch’) • there may be anticipation of satisfaction from catching a criminal • there may be anticipation of harm from being attacked • there may be a belief that one should be a good citizen • there may be a prior generalised intention to fight crime where possible • Conflict between these different types of motivation will determine what action is taken ‘in the moment’

10. A possible structure for the motivational system • A motivational system with 5 levels, with higher levels feeding into lower levels • Responses • starting, stopping or modifying actions • Impulses vs inhibition • Activation of CNS pathways underpinning actions, and competing pathways inhibiting them (urges) • Motives • Mental representations of future world states with feelings of anticipated pleasure or satisfaction (wants) or relief (needs) • Evaluations • Beliefs involving sense of what is useful/harmful (functional), right/wrong (moral), pleasing/displeasing (aesthetic) • Plans • Mental representations of future actions associated with feeling of varying degrees of commitment (intentions and rules)

11. The structure of the motivational system Five interacting subsystems providing varying levels of flexibility and requiring varying levels of mental resources and time p Plans r Responses i Impulses m Motives e Evaluations Higher level subsystems have to act through lower level ones where they compete with direct influences on these

12. ‘Oughts’ • We use the term ‘ought’ or ‘should’ to refer to actions that we do not want to do or feel a need to do but which we evaluate positively • According to PRIME Theory, ‘oughts’ will not lead to behaviour unless they can interact with identity (see later) to generate wants or needs

13. Implications • All goal directed behaviour is channelled through motives (wants and needs) operating ‘in the moment’ • Motives are not the same as intentions or cognitions • Evaluations and intentions will not influence behaviour unless they generate motives at the relevant time • Therefore measuring motives offers the best prediction of goal directed behaviour and the best starting point for understanding it • Shift in focus from beliefs and intentions at the time of measurement to predicting wants and needs in the future

14. Dispositions and how they change • Dispositions refer to characteristics of the system that govern its operation • Dispositions vary in stability and context sensitivity • Dispositions change through: • maturation • learning • habituation and sensitisation • associative learning • explicit memory • analysis • re-formulation • The process of change is ‘chaotic’ (involving semi-stable states with pseudo-random switching during periods of instability) and ‘dialectic’ (involving mutually interacting elements)

15. Implications • Behaviour change need not proceed in a linear fashion through stages; change from one major disposition to another can: • occur in a single complete transformation • happen without being intended • involve periods of instability of varying duration • occur in response to apparently insignificant triggers

16. The role of identity • Identity refers to our disposition to form mental representations of ourselves and the feelings attached to these • It is a potentially important source of motives • It is the ultimate source of self-regulation • It is a major source of stability of behaviour • Major elements are: • Labels (e.g. non-smoker) • Attributes (e.g. health-conscious) • Rules (e.g. I do not smoke)

17. Deliberate cessation of behaviour patterns • Self-consciously stopping doing something typically means: • forming a rule (plan) not to do it, or • forming a rule (plan) that one will ‘try’ not to do it • Applying that rule in relevant situations which generates a want or need not to do it which adds to those that led to the rule

18. Self-control • Self-control refers to the self-conscious application of a plan/rule in the face of competing wants, need or impulses • This process is effortful and require and use mental energy to the extent that it involves conflict with other wants and needs • ‘Deep’ identity change involving changes to labels, attributes and development of rules with clear boundaries opposes formation of conflicting wants and needs and reduces conflict

19. Implications • A strong, coherent, deeply entrenched identity that places clear boundaries around a category of behaviour and which anticipates potential challenges will provide strong stability to that behaviour and yield a powerful predictive measure • Fostering such an identity around a new behaviour pattern is a potentially important target for behaviour change interventions

20. Key points • Our behaviour is motivated at multiple levels from impulses, motives and evaluations to plans • Higher level motivations must work through lower level ones where they may come into conflict with other motivations at that level • Plans in the form of ‘rules’ have a vital role to play in organising our behaviour and protecting our longer term interests in the face of immediate demands • Implementing them in the face of conflicting wants, needs and urges can be effortful and use up mental resources • But ‘deep’ identity change and rules with clear boundaries reduce conflict and effort required

21. Outline • Defining addiction and motivation • Developing a theory of motivation • Applying the theory to addiction

22. Understanding why people smoke ... • They light up and puff on impulse • much smoking is ‘habitual’, done without thinking • They want or need to • they expect to enjoy it; they experience a ‘hunger’ for a cigarette after a period of not smoking • They think it serves a purpose • they expect it to help with stress, weight control and concentration • They form plans to smoke • they plan to go for a cigarette during coffee breaks • These motivations are stronger than any competing motivations including a plan not to smoke

23. How does this arise? • Nicotine ‘hits’ from each puff of a cigarette binds to nicotinic acetylcholine receptors in the brain causing: • dopamine release in the nucleus accumbens which: • generates an automatic impulse to smoke in the presence of smoking cues • provides pleasure and satisfaction associated with smoking • makes other experiences associated with smoking more pleasurable • changes the functioning of the brain region concerned so that when CNS nicotine levels are depleted there is need to smoke to restore those levels (nicotine hunger) • other chronic changes to brain chemistry resulting in • adverse mood and physical symptoms such as anger, depression and difficulty concentrating generate an additional need to smoke

24. Nicotine reward • When nicotine is absorbed it attaches to nicotinic acetylcholine receptors in the Ventral Tegmental Area (VTA) of the mid brain • This stimulates firing of neurons that project forward to the Nucleus Accumbens (NAcc) • This causes dopamine release in the NAcc • This results in: • an impulse (urge) to smoke in situations that have been associated with smoking • a mildly pleasant sensation • amplification of pleasures arising from other rewards present at the time • a belief that smoking is enjoyable and adds pleasure to life

25. Mesolimbic dopamine pathway Nucleus accumbens Ventral tegmental area

26. Drug actions on the mesolimbic pathway

27. Nicotine hunger • After repeated ingestion of nicotine, the motivational pathways are altered to create a ‘drive’, somewhat similar to hunger, except that it is for cigarettes • The drive increases in the minutes to hours since the last cigarette and is influenced by triggers, reminders, stress and distractions • The drive is experienced as a ‘need’ to smoke • It usually reduces over weeks of not smoking but can re-emerge unexpectedly • Relief from this need can be pleasurable and memory of the pleasure makes smokers feeling that they ‘want’ to smoke: the expect to enjoy it

28. Nicotine withdrawal symptoms • After repeated nicotine exposure, abstinence results in unpleasant withdrawal symptoms including depression • Adverse mood therefore comes to generate a need to smoke and a belief that smoking can help with stress and concentration

29. The process of smoking cessation • The process of smoking cessation involves a number of events: • the ‘quit attempt’ • initiation of arulethat smoking is not permitted • arises at a moment when the desire to stop now is greater than the desire to carry on • lapse • smoking a cigarette butkeeping or suspending the no-smoking rule • arises when the desire to smoke is greater than the desire not to • relapse • abandoning the no smoking rule • arises when the desire to abandon the no-smoking rule is greater than the desire to keep it

30. ‘Wants’ and ‘oughts’ to stop smoking • 3173 adult cigarette smokers in the Smoking Toolkit Study • Allowed to endorse either or both of • I want to stop smoking • I ought to stop smoking • Reports of ‘want’ to stop are lower than seen when asked on its own • In multiple logistic regression, only ‘want’ is associated with quit attempts

31. Why smoking cessation is difficult • The impulse to smoke • Many smokers experience powerful cue-driven impulses in situations in which they would normally smoke • The want to smoke • Many smokers enjoy and get satisfaction from smoking • The need to smoke • ‘Nicotine hunger’, adverse effects of abstinence • Positive beliefs about smoking • Stress relief, aid to concentration, weight control • The routine of smoking • Strong over-learned plans to smoke at certain times

32. Wanting and needing to smoke • Wanting to smoke appears to deter attempts to stop while needing to smoke leads to relapse once an attempt is made Data from 1479 smokers in Smoking Toolkit Study, followed up 6 months after ratings or enjoyment and urges were made to find out whether: had attempted to stop and if so had relapsed

33. Tackling the problem at all levels: reducing motivation to smoke • Reduce the impulse • medication during smoking to break the smoking-reward link • reduce exposure to smoking cues • Reduce the want and need • medication during smoking and abstinence to make smoking less satisfying and reduce nicotine hunger and adverse symptoms • control exposure to events that provoke wanting and needing • Change beliefs • convince smokers that smoking does not confer benefits • Change plans • change routines that involve smoking

34. Tackling the problem at all levels: increasing motivation not to smoke • Generate competing impulses • set up competing habitual responses to smoking cues • Increase the want and need not smoke • use extrinsic rewards and punishments (e.g. social approval, disapproval, vouchers) • maintain salience of negative feelings about smoking (e.g, disgust, anxiety) • foster intrinsic rewards for not smoking (e.g. achievement) • Change beliefs • foster negative beliefs about smoking and positive non-smoker identity • Establish firm, coherent plans • Establish clear ‘not a puff’ rule as part of new identity • Establish clear if-then rules to minimise wants, needs and urges

35. Implications: a reminder • All goal directed behaviour is channelled through motives (wants and needs) operating ‘in the moment’ • Motives are not the same as intentions or cognitions • Evaluations and intentions will not influence behaviour unless they generate motives at the relevant time • Therefore measuring motives offers the best prediction of goal directed behaviour and the best starting point for understanding it • Shift in focus from beliefs and intentions at the time of measurement to predicting wants and needs in the future

36. A simplification of PRIME Theory • Most of our actions involve following what wemost want or need at that moment • Wanting and needing involve forming an image of a possible future and feelings associated with this • Want: feeling of anticipated pleasure or satisfaction • Need: feeling of anticipated relief • We follow wants and needs when we can imagine how to attain them or can do it without conscious thought to generate impulses • ‘Oughts’ (wants and needs based purely on plans) carry little motivational impact

37. What activities are addictive? • They may increase reliance on the addictive behaviour as a source of reward or means of meeting particular needs • They may create unpleasant reactions when the activity is stopped • They may create a ‘habit’ • They may create an ‘acquired drive’ They are activities that generate powerful impulses, wants or needs and/or reduce competing wants or needs West (2006) Theory of Addiction: Oxford: Blackwells

38. Who is susceptible to development of addiction? They have greater pre-existing wants and needs, greater sensitivity to the motivating effects of the behaviour, reduced competing wants or needs or reduced capacity for self-control • They are more impulsive • They are less committed to conventional morality • They have a greater propensity to depression or anxiety • They are lower in self-esteem • They may be more sensitive to the rewarding effects of the activity/drug • They may be less sensitive to the aversive effects of the activity • They may be more sensitive to lasting effects of the drug on the brain West (2006) Theory of Addiction: Oxford: Blackwells

39. What conditions promote addiction? • A culture in which the activity is commonplace and regarded as normal • Peer groups in which the activity forms a part of social identity • An environment with greater opportunities to engage in the activity • An environment with reduced opportunities for other sources of reward • Adverse social, economic or environmental circumstances • Possibly an environment in which there is lower propensity for the activity to lead to immediate adverse consequences Social and physical conditions that provide opportunities for the behaviour, establish wants or needs or reduce competing wants or needs West (2006) Theory of Addiction: Oxford: Blackwells

40. What conditions promote suppression and recovery? • Full or partial agonist therapy can lead to suppression and sometimes recovery • Life-changing events that introduce powerful new competing motivations • Epiphanies can lead to recovery Suppression is achieved by pharmacological, environmental or psychological methods that reduce wants, needs or impulses to engage in the behaviour or increase competing wants or needs. Recovery is achieved by methods that effect permanent changes to the motivational system or environment that promote suppression. West (2006) Theory of Addiction: Oxford: Blackwells

41. Predicting smoking cessation • Medium term prediction of attempts to stop smoking • Thinking back over the past few weeks how much of the time have you felt you wanted to stop smoking? • How strong has that desire been? • Prediction of early relapse • How much of the time have you felt urges to smoke? • How strong have those urges been? • Prediction of late relapse in short-term successes • Do you now think of yourself as a non-smoker for whom smoking is not something you would even contemplate doing?

42. Predicting successful interventions • Generating quit attempts in unselected smokers • focus on triggering action rather than changing beliefs • promote use of effective aids to cessation to all smokers without asking whether they are interested in stopping first • time interventions to coincide with each other or other times of heightened motivation to change • Aiding quit attempts • focus on developing and fostering a new identity • abrupt not gradual change • clear boundaries (not a puff) • re-evaluate place of smoking in relation to other core identities

43. Review • Motivation involves multiple levels from impulses to plans; higher levels must work through lower levels • Wants and needs ‘in the moment’ are the key to goal-directed behaviour • Plans/rules provide structure and stability but must create wants and needs at the relevant time • Self-control is fundamental to deliberate behaviour change and stems from self-conscious plans interacting with identity to generate wants and needs • Self-control is effortful but less so when it involves ‘deep’ identity change and rules with clear boundaries