Emotional exposure in the treatment of substance use disorders: Conceptual model, evidence, and future directions
Introduction
This special series (Zvolensky & Leen-Feldner, 2005), with its focus on the issues surrounding the co-occurrence of anxiety and substance use disorders (SUDs), underscores the impact that advances in the study of one disorder may have on a second disorder. In this article, we continue this focus and consider advances in the conceptualization and treatment of anxiety disorders that may offer benefit for the treatment of SUDs. In doing so, we consider the ways in which strategies for altering avoidant and other maladaptive responses to affect, developed for the treatment of anxiety disorders, have applications for altering drug use responses. Strategies for affect management are relevant to SUD populations because of high rates of affective comorbidity, and the link between comorbidity and substance use severity (Farrell et al., 2003, Kushner et al., 2000, Merikangas et al., 1998, Skinstad & Swain, 2001). However, we believe that a more central link is the role of emotional states in cueing substance use and relapse (Lowman et al., 1996, O'Connell & Martin, 1987, Wikler, 1965), particularly for the subgroup of patients with SUDs whose drug use is linked to attempts to avoid or otherwise control negative affective experiences (Chaney et al., 1982, Stewart & Kushner, 2001, Zvolensky et al., 2003).
In this article, we discuss advances in the conceptualization and treatment of panic disorder, with a focus on the role that emotion may play as a specific cue and internal context for substance use behaviors. Next, we describe a cognitive-behavioral approach to treatment that is directed toward interrupting substance use patterns linked to emotional cues and context. Preliminary efficacy evidence is presented, and potential moderators and mediators of treatment are discussed.
Section snippets
Progress in the treatment of anxiety disorders—focus on panic disorder
The treatment of anxiety disorders is an area of distinct achievement for cognitive-behavioral therapy (CBT). Individual treatment studies and meta-analytic reviews provide consistent evidence for the efficacy of CBT over control conditions, with evidence for effects that rival or exceed that provided by pharmacotherapy, particularly when longer-term outcomes are considered (for review see Otto, Smits, & Reese, 2004). Among the anxiety disorders, research on the application of
External cue exposure and drug craving
The power of external cues in influencing drug craving and use patterns is clear. Consistent with classical conditioning models, external cues such as the sights or smells of alcohol, drug paraphernalia, or the locations (context) where substances are used, develop the capacity to elicit or enhance alcohol or drug cravings (see Drummond et al., 1995, Siegel, 1983). For example, McCusker and Brown (1990) found that urges for and tolerance to alcohol were greater when alcohol was used in a
Treatment implications
One implication of these findings is that to help patients best build resilience to cues and contexts for drug or alcohol use, treatment should consider both external and internal cues for use. Similar to internal cue exposure in panic disorder, exposure to emotional and somatic cues for drug use could be applied in an attempt to: (1) “inoculate” patients against cravings and drug use in response to these cues, and (2) ensure that non-drug responses are rehearsed in a variety of internal (e.g.,
Conclusions and future directions
In this article, we discussed how advances in the conceptualization and treatment of panic disorder underscore treatment processes that may be of value for patients with SUDs. Specifically, we hypothesized that individuals who have substance use patterns characterized by attempts to avoid internal emotional or somatic cues may be particularly helped by emotional-exposure interventions designed to enhance emotional acceptance and the selection of more adaptive responses to internal cues for
Acknowledgement
Support for work on this manuscript was provided, in part, by a National Institute on Drug Abuse grant to Dr. Otto (R01 DA017904). Portions of this theoretical model were previously presented in Otto, Safren et al. (2004).
References (99)
- et al.
Toward a unified treatment for emotional disorders
Behavior Therapy
(2004) - et al.
Behavioral treatment of panic disorder
Behavior Therapy
(1989) Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction
Biological Psychiatry
(2002)- et al.
Anxiety sensitivity: Relationship to negative affect smoking and smoking cessation in smokers with past major depressive disorder
Addictive Behaviors
(2001) - et al.
Distress tolerance and early smoking lapse
Clinical Psychology Review
(2005) - et al.
Relapse in opiate addicts: A behavioral analysis
Addictive Behaviors
(1982) - et al.
Can induced moods trigger drug-related responses in opiate abuse patients?
Journal of Substance Abuse Treatment
(1994) - et al.
The relations of trait anxiety, anxiety sensitivity, and sensation seeking to adolescents' motivations for alcohol, cigarette, and marijuana use
Addictive Behaviors
(2001) - et al.
Cue reactivity and effects of cue exposure in abstinent posttreatment drug users
Journal of Substance Abuse Treatment
(1999) - et al.
Prevention of panic disorder
Behavior Therapy
(2001)
A meta-analysis of treatment outcome for panic disorder
Clinical Psychology Review
Combined cognitive-behavioral and time-limited alprazolam treatment of panic disorder
Behavior Therapy
The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings
Clinical Psychology Review
Anxiety mediates the association between anxiety sensitivity and coping-related drinking motives in alcoholism treatment patients
Addictive Behaviors
Reactivity to alcohol cues and induced moods in alcoholics
Addictive Behaviors
Anxiety sensitivity and panic disorder
Biological Psychiatry
Comorbidity of substance use disorders with mood and anxiety disorders: Results of the International Consortium in Psychiatric Epidemiology
Addictive Behaviors
Anxiety sensitivity, self-reported motives for alcohol and nicotine use, and level of consumption
Journal of Anxiety Disorders
Integrating systematic cue exposure with standard treatment in recovering drug dependent patients
Addictive Behaviors
Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: A pilot study of combination treatment with cognitive-behavior therapy vs. sertraline alone
Behaviour Research and Therapy
Internal cue exposure and the treatment of substance use disorders: Lessons from the treatment of panic disorder
Journal of Anxiety Disorders
The anxiety sensitivity index: Construct validity and factor analytic structure
Journal of Anxiety Disorders
A novel cognitive-behavioral approach for treatment-resistant drug dependence
Journal of Substance Abuse Treatment
Rapid smoking, cue exposure, and support in the modification of smoking
Behaviour Research and Therapy
Anxiety sensitivity, anxiety frequency and the prediction of fearfulness
Behaviour Research and Therapy
Mood state and recent cocaine use are not associated with levels of cocaine cue reactivity
Drug and Alcohol Dependence
Subjective dimensions of heroin urges: Influence of heroin-related and affectively negative stimuli
Addictive Behaviors
Introduction to the special issue on anxiety sensitivity and addictive behaviors
Addictive Behaviors
Metacognitive therapy for anxiety disorders: Buddhist psychology applied
Cognitive & Behavioral Practice
Effects of cognitive-behavioral therapy for panic disorder on comorbid conditions: Replication and extension
Behavior Therapy
Anxiety and stress vulnerability and substance problems: Theory, empirical evidence, and directions for future research
Clinical Psychology Review
Administration of dexamethasone prior to training blocks ACTH-induced recovery of an extinguished avoidance response
Behavioral Neuroscience
Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial
Journal of the American Medical Association
Social context and sensation seeking: Gender differences in college student drinking motivations
International Journal of the Addictions
The Anxiety Sensitivity Index: Item analysis and suggestions for refinement
Journal of Personality Assessment
Context time and memory retrieval in the interference paradigms of Pavlovian learning
Psychological Bulletin
State dependent fear extinction with two benzodiazepine tranquilizers
Behavioral Neuroscience
Effects of contextual conditioning and unconditional stimulus presentation on performance in appetitive conditioning
Quarterly Journal of Experimental Psychology
The benefits of being present: Mindfulness and its role in psychological well-being
Journal of Personality and Social Psychology
You want to measure coping but your protocol's too long: Consider the brief COPE
International Journal of Behavioral Medicine
Assessing coping strategies: A theoretically based approach
Journal of Personality and Social Psychology
Measuring generalized expectancies for negative mood regulation: Initial scale development and implications
Journal of Personality Assessment
Effects of extinction context and retrieval cues on alcohol cue reactivity among nonalcoholic drinkers
Journal of Consulting and Clinical Psychology
Renewal of drug seeking by contextual cues after prolonged extinction in rats
Behavioral Neuroscience
The nature and function of interoceptive signals to feed: Toward integration of physiological and learning perspectives
Psychology Review
A controlled trial of cue exposure treatment in alcohol dependence
Journal of Consulting and Clinical Psychology
Substance misuse and psychiatric comorbidity: An overview of the OPCS National Psychiatric Morbidity Survey
International Review of Psychiatry
The effectiveness of inpatient and outpatient treatment for alcohol abuse: The need to focus on mediators and moderators of setting effects
Addiction
Cited by (47)
A single bout of either sprint interval training or moderate intensity continuous training reduces anxiety sensitivity: A randomized controlled trial
2018, Mental Health and Physical ActivityA multi-method analysis of distress tolerance in body dysmorphic disorder
2017, Body ImageCitation Excerpt :DT is conceptualized as the capacity to withstand or tolerate negative emotional or aversive psychological states (Gratz & Roemer, 2004; Leyro et al., 2010), and is a construct comparable to low frustration tolerance, as defined by Albert Ellis in the context of his theory underlying Rational-Emotive Behavior Therapy (Ellis, 1962; Rodman, Daughters, & Lejuez, 2009). An abundance of research has been conducted in an effort to explore the role of DT as a transdiagnostic process associated with a wide variety of psychopathology, including the development and maintenance of substance abuse (Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Chaney, Roszell, & Cummings, 1982; Otto, Powers, & Fischmann, 2005), personality disorders (Daughters, Sargeant, Bornovalova, Gratz, & Lejuez, 2008; Linehan, 1993), anxiety disorders (Keough, Riccardi, Timpano, Mitchell, & Schmidt, 2010; Macatee, Capron, Guthrie, Schmidt, & Cougle, 2015; Vujanovic, Marshall, Gibson, & Zvolensky, 2010), eating disorders (Corstorphine, Mountford, Tomlinson, Waller, & Meyer, 2007; Hambrook et al., 2011), and OC-related disorders such as OCD (Cougle, Timpano, Fitch, & Hawkins, 2011; Cougle, Timpano, & Goetz, 2012; Keough et al., 2010; Macatee, Capron, Schmidt, & Cougle, 2013; Robinson & Freeston, 2014) and hoarding disorder (Timpano, Buckner, Richey, Murphy, & Schmidt, 2009; Timpano, Shaw, Cougle, & Fitch, 2014). Individuals low in DT are posited to be more sensitive to distress and/or aversive states and, consequently, may be more likely to avoid distressing situations or to attempt to dissipate negative emotion more often (Leyro et al., 2010).
Global to Local: Adapting CBT for Cross-Cultural Expressions of Psychopathology
2017, The Science of Cognitive Behavioral TherapyA randomized clinical trial of a tailored behavioral smoking cessation preparation program
2016, Behaviour Research and TherapyTherapist perceptions and delivery of interoceptive exposure for panic disorder
2013, Journal of Anxiety DisordersCitation Excerpt :Analyses of individual items from this measure were based on the questionable assumption of their construct validity. Lastly, the present study focused exclusively on IE for PD did not examine perceptions and delivery of IE in the treatment of other disorders for which it is sometimes used such as hypochondriasis (Abramowitz & Braddock, 2011), post-traumatic stress disorder (Wald & Taylor, 2007), social phobia (Antony & Swinson, 2008), irritable bowel syndrome (Craske et al., 2011), and substance use disorders (Otto, Powers, & Fischmann, 2005). In summary, the present study demonstrated that therapists vary markedly in their style of delivering IE.