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Background The U.S. National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal to improve diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the ‘primary' RDoC constructs most relevant to substance and behavioural addictions. Methods Forty‐four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions. Results Seven constructs were endorsed by ≥80% of experts as ‘primary' to the understanding of addictive behaviour: five from the Positive Valence System (Reward Valuation, Expectancy, Action Selection, Reward Learning, Habit); one from the Cognitive Control System (Response Selection/Inhibition); and one expert‐initiated construct (Compulsivity). These constructs were rated to be differentially related to stages of the addiction cycle, with some more closely linked to addiction onset, and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions. Conclusions The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.
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A transdiagnostic dimensional approach towards a
neuropsychological assessment for addiction: an
international Delphi consensus study
Murat Yücel
, Erin Oldenhof
, Serge H. Ahmed
, David Belin
, Joel Billieux
Henrietta Bowden-Jones
, Adrian Carter
, Samuel R. Chamberlain
, Luke Clark
Jason Connor
, Pinhas Dannon
, Theodora Duka
Maria Jose Fernandez-Serrano
, Ingmar Franken
Raul Gonzalez
, Anna E. Goudriaan
, Jon E. Grant
, Matthew J. Gullo
Robert Hester
, David C. Hodgins
, Bernard Le Foll
Anne Lingford-Hughes
, Valentina Lorenzetti
, Scott J. Moeller
, Marcus R. Munafò
Brian Odlaug
, Rebecca Segrave
, Zsuzsika Sjoerds
Nadia Solowij
, Wim van den Brink
, Valerie Voon
, Reinout Wiers
Leonardo F. Fontenelle
& Antonio Verdejo-Garcia
Background The US National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate
research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses.
The RDoC framework comprises 39 functional constructs designed to be revised and rened, with the overall goal
of improving diagnostic validity and treatments. This study aimed to reach a consensus among experts in the
addiction eld on the primaryRDoC constructs most relevant to substance and behavioural addictions.
Methods Forty-four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi
technique was used to determine a consensus as to the degree of importance of each construct in understanding
the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds
(97% completion rate), with each consecutive round offering feedback for experts to review their opinions.
Results Seven constructs were endorsed by 80% of experts as primaryto the understanding of addictive
behaviour: ve from the Positive Valence System (reward valuation, expectancy, action selection, reward learning,
habit); one from the Cognitive Control System (response selection/inhibition); and one expert-initiated construct
(compulsivity). These constructs were rated to be related differentially to stages of the addiction cycle, with some
linked more closely to addiction onset and others more to chronicity. Experts agreed that these neuropsychological
dimensions apply across a range of addictions. Conclusions The study offers a novel and neuropsychologically
informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction
research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.
Keywords Addiction, assessment, cognition, compulsions, decision-making, habit, RDoC, reward, transdiagnostic.
Correspondence to: Murat Yücel, Brain and Mental Health Research Hub, Monash Institute of Cognitive and Clinical Neurosciences (MICCN) and School of
Psychological Sciences, Monash University, Room 146I, 770 Blackburn Road, Clayton, VIC 3800, Melbourne, Australia. E-mail:
Submitted 22 July 2018; initial review completed 2 August 2018; nal version accepted 14 August 2018
*These authors contributed equally to this study.
The aetiopathogeny of addiction remains poorly understood,
as we lack assessment models to identify vulnerability
to addiction. Only 1020% of patients with substance
and behavioural addictions receive treatment [13],
which tend to have modest outcomes, reected in low
compliance and high relapse rates [4]. Thus, there is an
urgent need for alternative assessment and intervention
strategies to prevent or reduce the personal, social and
economic burden associated with addictions.
Important developments in neuroscience have begun to
reshape how addictions are understood [57]. For
instance, many individuals with addictions exhibit
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© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
neuropsychological decits across a range of functions
subserved by reward, stress and cognitive-control brain
circuitries [8]. These neuropsychological dysfunctions tran-
scend traditional diagnostic boundaries and form a shared
pathophysiological mechanism core to substance and
behavioural addictions [911]. Rapidly emerging evidence
afrms that such mechanisms and processes result from
dysfunction in frontal-subcortical brain circuits [12,13].
Key dysfunctions commonly shared across addictions
include aberrant reward-processing (e.g. inability to delay
gratication; reward prediction errorthe erroneous
prediction of potential gains and losses associated with
addictive behaviours) and increased stress sensitivity (e.g.
elevated baseline stress levels; stress-related cravings).
These constructs may underlie reduced sensitivity to the
negative consequences of addiction-related actions (e.g.
drug misuse or excessive betting) and have been associated
with the development and later relapse of addictive
behaviours [12,1421]. Other shared dysfunctions include
impaired self-control (e.g. reduced topdown, inhibitory
control); linked to dysfunction in frontal-subcortical brain
circuits ascribed to decision-making and goal-directed
behaviour [2231] which limit recovery [3236]. While
there may not be a single phenotype, or set of related
neural processes, that confers vulnerability to addictions,
impairment in these reward, stress and control-related
processes may shape various pathways in and out of the
addiction cycle.
Considering the above, supercially disparate (but
conceptually related) disorders, such as substance-use and
gambling disorders, may be underpinned by overlapping
neuropsychological processes and neural circuits. Such
disorders may respond to similar interventions that
target these common underlying mechanisms, such as
naltrexone (an opioid-receptor antagonist), which is
effective in treating alcohol use disorder and gambling
disorders putatively by targetingoverlapping dysfunctional
neurobiological systems [3739]. Synthesizing ndings on
effective treatments common to different substance and
behavioural addictions would clarify shared mechanisms
across addictive behaviours. It will also help to adjudicate
whether a transdiagnostic approach is most appropriate,
given alternative conceptualizations with the impulse
control disorders and a putative compulsivity spectrum
[40,41]. Importantly, the transdiagnostic approach high-
lights the clinical utility of targeting neuropsychological
systems linked to disturbances in reward processing, stress
reactivity and self-control.
Nevertheless, with the exception of some develop-
ments such as cognitive-bias modication [42], current
approaches to clinical assessment and management have
largely failed to integrate these developments into assess-
ment and intervention tools. Two principal barriers to
translation remain: (i) psychiatric assessment and diag-
nostic tools are based largely on characterization of
symptoms (versus mechanisms), predicated on clinical
reliability rather than biological validity, and based on
self-reports and observable behaviours rather than em-
pirically measured dimensions; and (ii) neuropsychologi-
cal assessments (as applied in the clinic) are based
typically on paradigms developed decades ago for use in
brain lesion cases and neurological disorders, which
may lack sensitivity to the speciccognitiveemotional
constructs key to the psychopathology of addiction.
To help address these shortcomings, the US National
Institute of Mental Health (NIMH) developed the Research
Domain Criteria (RDoC) initiative as a tool to encourage re-
searchers to ‘…develop, for research purposes, new ways of
classifying mental disordersbeyond traditional nosologies,
which were based on describing and counting overt signs
and symptoms and arbitrary clinical thresholds and
boundaries that encompass diverse and overlapping
biological mechanisms [43]. Biobehavioural dimensions
captured by RDoC are measurable and linked to neural
circuits and psychopathology; these are laid out as a series
of matrices. Each matrix represents a functional domain
that comprises several cognitive and affective processes,
divided systematically into smaller subunits, each reecting
aspecic measure of their corresponding construct.
Contrary to the diagnostic classication system [44], the
goal of this model is to use a data-driven approach to
determine constructs that aid in the understanding and
classication of mental disorders. These classiers are
intended to serve as intermediate phenotypes,or
neuroscientically derived measures for improved biological
modelling and targeted treatment interventions [45,46].
The RDoC framework offers a neuroscientically
grounded approach to bridge clinical practice with neuro-
science. It is operationalized via the RDoC matrix, which
is designed to promote ongoing testing and renement.
With regard to addiction, several constructs in the RDoC
matrix could be used to conceptualize transdiagnostic
processes implicated in such disorders. However, there is
currently a lack of consensus on the discrete processes of
the addiction cycle (i.e. initiation, regular use, impaired
control, cessation, relapse) [4750], probably reecting
the different processes and phenotypes that interact at dif-
ferent stages of addictions and/or a lack of evidence-based
conclusions. For instance, the Positive Valence System is re-
lated to the early stages of addictive disorders, where drug
use (for example) may lead to positive experiences (such
as increased social bonding). Instead, the Negative Valence
Reecting the evolving and dynamic nature of RDoC, changes were made recently made to the Positive Valence domain in late June 2018 (https://www.
2Murat Yücel et al.
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
System might potentially be more relevant for avoidance of
negative experiences (withdrawal symptoms) once drug-
seeking has become habitual and compulsive; the so-called
end-stateof substance-use disorders [51].
A common approach in mental health research to
developing and rening research criteria, guidelines,
reporting standards and protocols is the Delphi method
[52]. It is often used to capture practice-based evidence,
through an iterative process whereby a panel of topic ex-
perts is repeatedly surveyed until a consensus is reached
among them (which may be agreeing to agreeor agree-
ing to disagree). In this study, we applied the Delphi
method to synthesize expert opinion on which RDoC
constructs and associated paradigms are most relevant to
current understanding of addiction. The overarching aim
of this large, international consensus study is to strengthen
and integrate the knowledge gained from addiction neuro-
science with clinical practice. A rst step towards this goal
is to develop a core assessment and classication protocol
for substance and behavioural addictions through probing
shared, key neuropsychological constructs, with the
potential to improve health outcomes by allowing individ-
uals to have their treatments tailored according to their
underlying phenotype.
Expert panel
Recruited through purposive sampling, expert selection
was based on being known to the research group (M.Y.,
A.C., L.F., A.V.G.), having relevant clinical and/or
research experience or being internationally renowned
experts in substance and/or behavioural addictions. A
minimum of 5 years of professional experience and more
than 50 scientic articles authored in peer-reviewed
journals were additional requirements. Using the proce-
dure outlined by Okoli & Pawlowski [53], a work-sheet
was populated with potential experts who were subse-
quently categorized (i.e. eld of expertise, profession,
extent of clinical practice experience, number of publica-
tions, country and organizations), ranked and prioritized
on the basis of both eld of expertise and seniority in their
area of expertise, and then sent invitations based on the
target sample size. Although a sample of 20 has been
deemed sufcient in the literature [54], 44 experts
consented and 37 participated in the study. Expert views
were surveyed online over three rounds (97% completion
rate), with each successive round offering feedback for
experts to revaluate their opinions. These experts were
recruited from Australia (n= 8), Asia (n= 1), Europe
(n=18),NorthAmerica(n= 9) and South America
(n= 1). The study was approved by the local (Monash
University) Human Research and Ethics Committee
(CF15/34072 015 001 454).
Experts were required to participate in an online forum and
rate the relevance of all 39 constructs of the RDoC to the
concept of addiction (see Fig. 1). Although traditional
Figure 1 Overview of the Research Domain Criteria (RDoC) schema highlighting the ve major domains, comprising 23 main constructs (bold
text), wherein seven of these main constructs are further broken down into 23 subconstructs (italicized text), leading to a total of 39 primary and
subconstructs. Note that in June 2018 (after the immediate completion of this paper), the Positive Valence domain of the RDoC matrix underwent
a reorganization. The original constructs used in this study are mostly retained, but have been reorganized somewhat differently (see https://www.
domain-revisions.shtml) [Colour gure can be viewed at]
Transdiagnostic neuropsychological approaches to addiction 3
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
Delphi studies commence with an open-ended question-
naire, given the framework-driven nature of our primary
aim, the RDoC constructs formed the basis of the rst-
round survey. To provide an opportunity for open-ended
responding and to generate a more complete item pool,
experts were invited to suggest any additional constructs
important in understanding addiction not delineated in
the RDoC. After each round, constructs that did not
achieve consensus moved into the subsequent round for
re-rating. These constructs were presented along with
feedback outlining each experts own previous response
(blinded to other experts), the groupsprevious responses
(percentages reecting range and frequency) and a
synopsis of all comments offered, regardless of whether
the overall view was highly consistent or divergent.
Provision of these comments afforded insight and rationale
leading to a more accurate consensus, as opinion change is
unlikely to occur without strong causal reasoning [55]. To
preserve an acceptable response rate of at least 70% across
rounds [56], and to maintain rigour, identiable data
were disclosed to key researchers to follow-up with non-
responders (up to three times each round). In the third
and nal round, experts who remained outside the
consensus range were required to explain their rating in
order to clarify their judgements [57].
Consensus and conclusion
Ave-point Likert scale ranging from 1 (unimportant) to 5
(essential) was used, with a non-neutral midpoint of 3
(moderately important). Omitting a neutral mid-point forces
experts to deliberate and form an opinion, and where experts
did not have the knowledge, a dont know/unsureoption
was available as an addendum [58]. Consensus was dened
as 80% of experts endorsing a construct within two scale
points [5961]. Constructs were excluded from the study if
consensus fell between the lowest three scale points
(unimportantto moderately important)andincludedas
primary constructsif consensus was achieved between
the top two scale points (very importantto essential).
The criterion for concluding the Delphi was not solely
contingent upon reaching consensus, but also on the
stability of responses [62,63], allowing for any well-dened
disagreement to be maintained. The process was therefore
deemed complete either when all items had achieved
consensus or movement between rounds was less than
15%, indicating that opinions were not likely to change
further [64].
Quantitative analyses
SPSS (version 22) (IBM Corporation, Armonk, NY, USA,
2013) was used for all quantitative analyses. For the small
percentage of missing data (2.7%), pairwise deletion was
applied [65]. Frequencies were calculated to assess consen-
sus. Stability over rounds was assessed by the percentage of
change [64] between rounds.
Qualitative analyses
Expertscomments underwent several stages of thematic
analysis by the core committee (M.Y., A.C., L.F., A.V.G.
and E.O., collectively), in order to process the data sys-
tematically, rst by identifying categories and then by
identifying common themes [66]. Experts were asked
to rate constructs in relation to key stages of addiction
in general, namely vulnerability(both proximal and
distal predisposing factors leading to the development
of addictive disorders) and chronicity(the persisting
and relapsing state of addiction). Specically, comments
were rst coded as being either importance-related
and/or staging-related and then, within these categories,
comments were coded further based on their specicity;
that is, rating (unimportant to essential), and/or staging
(vulnerability, chronicity). The resulting matrix was then
grouped into themes. Within these themes, comments
were summated and reduced to eliminate repetition,
with more informative, rational or well-explained com-
ments chosen, while retaining as much of the experts
original wording as possible [67]. As repetition of state-
ments can increase same-thinking and result in in-
creased condence in ones own opinion, all types of
responses were included in order to challenge conven-
tional thinking [55].
As suggested by Jorm [52], the additional constructs
recommended by experts were evaluated by the research
team (M.Y., A.C., L.F. and A.V.G.) to conrm they were:
(i) not already covered by the survey (i.e. RDoC); (ii) within
the scope of the study; and (iii) articulated clearly; where
they were not, the research group reviewed and adjusted
the description accordingly. These additional constructs
were then added to subsequent rounds.
Retention and characteristics of experts
Of the original 44 consenters, 37 experts completed round
1 of the Delphi questionnaires. Retention was very high,
with 36 (97.3%) round 1 completers also completing both
second- and third-round surveys.
Experts who completed round 1 were aged 32
67 years [mean = 43.2, standard deviation (SD) = 8.95],
with 67.5% (n= 25) being male. They represented a
range of professions and academic disciplines (some mul-
tiple) including scientist/neuroscientists (54.1%; n=20),
psychiatrists (27.0%; n= 10), psychologists/clinical
psychologists/neuropsychologists (34.3%; n=13),other
medical doctors (5.4%; n= 2) and pharmacologists
4Murat Yücel et al.
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
(5.4%; n= 2). Their professional settings were primarily
universities (81.1%; n= 30), hospitals (21.6%; n=8)
and out-patient clinics (16.2%; n=6),andthemost
commonly held academic titles were Professor (43.2%;
n= 16), Associate Professor (21.6%; n=8)and
Research Fellow/Assistant Professor (24.3%; n=9),
with 89% (n= 33) of experts holding a PhD. Experts
represented many areas of addiction (e.g. alcohol,
cannabis opioids, gambling, internet), which supports
our transdiagnostic approach.
Expert consensus on functional domains
The consensus supported the inclusion of seven primary
constructs, namely: (1) reward valuation; (2) expectancy/
reward prediction error; (3) action selection/preference-
based decision-making; (4) reward learning; (5) habit; (6)
response selection/inhibition; and (7) compulsivity (see
Fig. 2 for ow-chart; Fig. 3 for an overview of theconsensus
level and range across the rounds for all constructs
considered; and Table 1 for denitions). Table 1 summa-
rizes the expertsinput on the neural circuits, physiological
underpinnings and behavioural correlates of the primary
constructs. Although this information was not analysed
quantitatively, it provides a conceptual matrix consistent
with the RDoC framework.
Relevance of primary constructs to stage of disorder
As shown in Fig. 4, reward valuationwas considered
the most relevant to vulnerability to addictions
(consensus rating of 94.6%). In contrast, while all seven
primary constructs were considered to be relevant
drivers of chronicity, habitand compulsivitywere
seen to be selectively relevant to chronicity and least
relevant to vulnerability(habit: 14.7% vulnerability,
97.1% chronicity; compulsivity: 28.5% vulnerability,
86.1% chronicity).
Utilizing Delphi methodology, experts identied a
circumscribed set of RDoC constructs, as well as other
novel dimensions central to understanding substance and
behavioural addictions. In total, seven constructs reached
consensus as being primary constructs in understanding
addiction, including RDoC reward valuation, expectancy/
reward prediction error, action selection/preference-based
decision-making, reward learning, habit and response
selection/inhibition. Compulsivity is not described in the
RDoC (at least as a monodimensional construct) but was
introduced by experts. Considerable evidence exists
supporting compulsivity as a core feature of addiction (al-
though see [68]), representing an ongoing and repeated
difculty in refraining from drug-seeking or -taking despite
negative consequences. It is worth noting that the Positive
Valence domain of the RDoC matrix recently underwent a
reorganization (published online 28 June 2018), where
both habit and aspects of compulsivity (reward valuation)
have been expanded upon, which should help in their
incorporation when studying addictions.
Figure 2 Aow-chart of the constructs over each round highlighting items that were endorsed by 80% of experts as being clearly relevant (i.e.
primary constructs; included items listed on the left together with percentage of experts endorsing the item), not relevant to addiction (excluded),
created (i.e. new constructs, indicated by the asterisk), or re-rated over the three survey rounds [Colour gure can be viewed at]
Transdiagnostic neuropsychological approaches to addiction 5
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
The high degree of consensus among experts across
seven core constructs supports the proposition that there ex-
ists a group of common neuropsychological functions (and
underlying neural processes) predisposing or maintaining
addictive behaviours in individuals. These substrates pri-
marily belong to the Positive Valence System in the RDoC
matrix, which is noteworthy, as most neuropsychological
assessment tools do not probe these functions thoroughly,
focusing more upon cognitive skills (i.e. attention, mem-
ory, cognitive control and working memory). Much of
the Positive Valence System research relies on neuroimag-
ing methods and animal studies [69], highlighting the
need for developing better, corresponding human behav-
ioural measures. However, the ndings align with empiri-
cally grounded neuropsychological models of addictive
behaviours, including: (i) the incentive sensitization the-
ory, emphasizing the link between aberrant reward learn-
ing and alterations in reward valuation [70]; (ii)
the Impaired Response Inhibition and Salience Attribution
(I-RISA) model, positing an imbalance between increased
Figure 3 An overview of the consensus level and range for all 39 Research Domain Criteria (RDoC) (sub)constructs and seven additional con-
structs suggested by the experts for inclusion. All constructs were investigated over three rounds (only the rst two rounds are shown, as the seven
essential domains were derived in these roundsall items in round three were excluded; percentages calculated relative to the total number re-
ported). Note that expert-suggested constructs were included in round 2 (bottom seven items in the list of constructs); the red highlight indicates
the constructs that were selected as Primaryacross the two rounds. V.Important = very important; M.Important = moderately important;
S.Important = somewhat important; I = initial; S = sustained; V = visual; A = auditory; O/S = olfactory/somatosensory; D = declarative; R = reception;
P = production; Expectancy = expectancy/reward prediction error; Action Selection = action selection/preference-baseddecision-making; Response
Selection = response selection/inhi bition [Colour gure can be viewed at]
6Murat Yücel et al.
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
Table 1 Denitions of the seven essentialconsensus domains, together with the relevant circuitry, self-report and neuropsychological testing paradigms.
Construct Denition Circuits Physiology/behaviour Self-reported examples Cognitive paradigms Expert commentary (selective)
Rewar d
Processes by which the
probability and benets
of a prospective outcome
are computed and calibrated
by reference to external
information, social context
(e.g. group input, counterfactual
comparisons) and/or prior
experience. This calibration is
inuenced by pre-existing biases,
learning, memory, stimulus
characteristics and deprivation
states. Reward valuation may
involve the assignment of
incentive salience to stimuli
Anterior medial
BAS reward sensitivity
Sensitivity to reward
subscale of the SRSPQ
Delay discounting
probability choice task
Willingness to pay task
‘…at the heart of addictive
behaviours: if you are not
sensitive to reward induced
by the addictive behaviour,
you wontdevelopthat
prediction error
A state triggered by exposure
to internal or external stimuli,
predict the possibility of reward.
Reward expectation can alter
and can inuence the use of
resources (e.g. cognitive resources)
Basal ganglia
Dorsal ACC
Lateral habenula
Rost ra l medial
Ven t r a l s tria t u m
Cortical slow waves
Heart rate change
Skin conductance
Goal tracking
Pavlovian approach
Reward-related speeding
Sign tracking
Affective Forecasting
ASAM scale
Eating expectancy
Generalized reward
and punishment
expectancy scale
Self-report of craving
TEPS anticipatory scale
Drifting double bandit
Rutledge passive lottery task
Monetary incentive
Delay task
Cuereactivity and related
constructs can play a role
in escalation and maintenance
of addictive behaviours. Reliable
assessment is an issue, therefore
not (yet) very suitable for
Action selection
preference based
Processes involving an
evaluation of costs/benets
and occurring in the context
of multiple potential choices
being available for decision-making
Amygdala Balloon analogue
risk task
Preference-based decision-making
is probably most important for
vulnerability (transition into
problematic use). Diagnosis and
chronicity are a bit more
Reward learning A process by which organisms
acquire information about stimuli,
actions and contexts that predict
Dorsal striatum
Correct related negativity
Error-related negativity
Ambulatory assessment
and monitoring
Drifting double bandit
Pavlovian conditioning
Positive reinforcement is the key
behavioural process behind
initial drug (or other behaviour)
Transdiagnostic neuropsychological approaches to addiction 7
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
Table 1 (Continued)
Construct Denition Circuits Physiology/behaviour Self-reported examples Cognitive paradigms Expert commentary (selective)
positive outcomes, and by which
behaviour is modied when
a novel reward occurs, or
outcomes are better than
expected. Reward learning
is a type of reinforcement
learning, and similar processes
related to negative reinforcement
Medial pre-
Ventral striatum
Midline theta
Approach behaviours
Consummatory behaviours
Ecological momentary
Gambling Task
Probabilistic reward task
Probabilistic stimulus
selection task
Val u e - m o d u l a t e d
attentional capture task
exploration. Hence particularly
relevant to initiation…’
Habit Sequential, repetitive, motor or
cognitive behaviours elicited
by external or internal triggers
that, once initiated, can go to
completion without constant
conscious oversight.
Habits can be adaptive by virtue
of freeing up cognitive resources.
Habit formation is a frequent
consequence of reward learning,
but its expression can become
resistant to changes in outcome
value. Related behaviours could
be pathological expression of a
process that under normal
circumstances subserves
adaptive goals
Dorsal striatum
Medial prefrontal
Ventral striatum
Compulsive behaviours
Repetitive behaviours
Stereotypical behaviours
Aberrant behaviours
Measures of repetitive
Self-report habit index
Devaluation task
Fruit task
Habit learning task
Habit task
‘“Unintentionalrelapse related
to shortened time-period of
consciousthought between
stimulus/drug availability
and use
A subconstruct of the cognitive
control system: that responsible
for operation of cognitive and
emotional systems, in the service
of goal-directed behaviour. This
function is required when prepotent
responses (those automatically elicited)
Ven t r a l
Short interval cortical
inhibition (TMS)
Impulsive behaviours
BRIEF (Gioa)
ADHD rating scale (Dupaul)
ATQ/CBQ effortful control
Conners impulsivity scale
Barratt questionnaire
Flanker, Simon, Stroop
motor response task
Inhibitory control is a
foundational decit in addiction,
from substance use initiation to
substance abuse treatment
‘….is a critical trait in risk of
addictions and also shapes
course of illness
8Murat Yücel et al.
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
Table 1 (Continued)
Construct Denition Circuits Physiology/behaviour Self-reported examples Cognitive paradigms Expert commentary (selective)
are not adequate to meet the demands
of the current context or need to be
suppressed. Response inhibition has
been presented in the literature as a
facet of response selection, an executive
process where one consciously
withholds a response in the service of
goal-directed behaviour
Off-task behaviours
Impulsivity from
Motor persistence paradigms
Stop-signal reaction time
Compulsivity This is the only additional construct
to the RDoC received endorsement as
a primary construct. In the present
study, compulsivity was delineated as
distinct from habit in that it can also be
repetitive, or automatic behaviour.
However, it is distinct from habit in that
it can also be associated with negative
outcome expectancy that contributes
or compelledto act despite negative
consequences, which further distinguishes it
from impulsivity (the experience of being
drivenand associated with positive
outcome expectancies)
Dorsal striatum
Difculties resisting
urges and the experience
of loss of voluntary control
Repetitive behaviours
performed in a habitual
or stereotyped manner;
inappropriate to the
Behaviour Checklist
Padua inventor y
OCPD screener
Probabilistic reversal
learning task
set Shifting task
Wisconsin card
sorting task
Contributes to the subjective
experience of lack of control
that is part of the diagnostic
criteria. The reported feeling of
being unable to resist the desire
to use undermines self-efcacy
and promotes relapse
OFC = orbito-frontal cortex; VTA = ventral tegmental area; VLPFC = ventrolateral prefrontal cortex; DLPFC = dorsolateral prefrontal cortex; BA = Brodmanns area; PPC = posterior parietal cortex; SMA = supplementary motor area;
SN = substantia nigra; ACC = anterior cingulate cortex; TMS = transcranial magnetic stimulation; BAS = behavioural approach system; SPSRQ = sensitivity to punishment and sensitivity to reward questionnaire; ASAM = American Society
of Addiction Medicine; TEPS = temporal experience of pleasure scale; BRIEF = behaviour rating inventory of executive function; SANS = scale for the assessment of negative symptoms; SAPS = scale for the assessment of positive symptoms;
PANSS = positive and negative symptoms scale; ADHD = attention-decit/hyperactivity disorder; ATQ = adult temperament questionnaire; CBQ = childrens behaviour questionnaire; UPPS = UPPS impulsive behaviour scale; CHI-
T=CambridgeChicago compulsivitytrait; YBOCS = YaleBrown obsessivecompulsive scale; OCDUS =ob sessive compulsive drug usescale; OCI = obsessivecompulsive inventory;OCPD = obsessivecompulsive personalitydisorder; RDoC = Re-
search Domain Criteria.
Transdiagnostic neuropsychological approaches to addiction 9
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
reward valuation/salience and decient action selection/
inhibitory control [13]; (iii) the maladaptive habit-learning
model, proposing a transition between goal-directed ac-
tion selection and stimulusresponse habits and compul-
sions [65]; and (iv) decision-making models, focusing
upon how reward prediction and affective valuation inu-
ence preference-based decisions [71,72]. There are robust
practical and theoretical reasons to incorporate the ve
neuropsychological constructs from the Positive Valence
System, plus the response inhibition and compulsivity
constructs, in future research and clinical programs.
Large-scale addiction studies such as the US National In-
stitutes of Health (NIH) ABCD study are already heading
in this direction (see
From a research perspective, our ndings stimulate the
development of new addiction models seeking to integrate
these constructs in a unifying framework that accounts for
disorder staging. By contrast, a widely used model for de-
scribing addictive behavioursthe dual systemsapproach,
referring to an imbalance between reward valuation and the
cognitive control systems [73]focuses upon only two of
the Delphi-identied constructs. However, some experts sup-
port a broader and more nuanced view [74,75] in which
many related, yet distinct, constructs (i.e. reward valuation,
reward learning, preference-based decisions, action selec-
tion, habits and corticostriatal neural systems) determine
the expression of addictive behaviours. It is promising that
the present consortium agrees with a high level of consensus
on the essential constructs underpinning addictions.
Future research should delineate how these seven
factors are independent or inter-related. From a clinical
perspective, a rst step towards knowledge implementation
is developing an assessment tool that measures these con-
structs validly and reliably. Along these lines, Kwako and
colleagues proposed an assessment battery to target three
primary domains (incentive salience, negative emotionality
and executive functions) [76]. The RDoC initiative is also
contributing tasks towards research programmes whose
goal is to collect data on dimensions relevant to mental
health from a sample of 1 million or more individuals
( Such large-scale data collection
efforts will help greatly in clarifying constructs broadly
relevant to addictive behaviours and the mechanisms and
processes relevant to various stages of addiction. Looking
ahead, we need to develop an assessment battery that is
time-efcient, ecologically valid, psychometrically sound,
sensitive to the seven primary domains identied herein,
incorporates performance- and questionnaire-based mea-
sures and is well tolerated.
Relevance to staging of disorder
Our ndings raise the important issue of how the
primary constructs (i) contribute to vulnerability to, or
maintenance of, addictive behaviour; and (ii) predate
addiction and emerge as a consequence of repeated drug
use in vulnerable individuals. In relation to the former,
aspects of the Positive Valence System, and the associ-
ated attribution of incentive salience to reward-related
stimuli, are considered important. For instance, at the
vulnerability stage, reward valuation and linked anticipa-
tion may be a prominent factor in determining an
individuals responsiveness to addiction-related cues. At
later stages of the addiction cycle, an allostatic-incentive
salience role of substance- or addiction-related cues is
likely to be present, and therefore reward valuation
remains relevant to both vulnerability to relapse and
chronicity. In relation to vulnerability to relapse (or
chronicity), all seven primary constructs were considered
relevant drivers (see Figs 4 and 5), but only habitand
compulsivitywere argued to be selectively relevant to
Pre-clinical data suggest that substance use may switch
from being impulsive to compulsive over time, reecting a
shift from dopaminergic dysregulation of ventral to dorsal
striatum function and related cortical, pallidal and
thalamic circuitry [50,77]. Despite recent evidence that
activation of the habit system during cue-elicited tasks in
humans is the best predictor of relapse [78], habit and
compulsivity are two constructs highlighted in this Delphi
study receiving the least human research to date. For
instance, there has been little research investigating
whether habits represent a gateway for the development
of compulsivity [16,29], and whether those with addic-
tions show altered habit formation [79], impaired ability
Figure 4 Expertsendorsements for stages of disorder for primary
10 Murat Yücel et al.
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
to disengage their habits in the face of negative conse-
nitive control retrained through intervention. Recent
meta-analyses conrmed habit-related neuropsychological
decits in individuals with alcohol use disorder [80] and
gambling disorder [81] compared to control participants.
Beyond cue-elicited tasks that relate partly to compulsivity
(but not designed originally to encompass it), laboratory-
based models have been developed to assay habit learning,
although these have yet to be applied widely to addictions
(see [82] for a detailed review). Such experimental
paradigms tend to be longer and more complex and may
require approaches from growing elds such as computa-
tional psychiatry to optimize them for use in research and
clinical settings. Validated clinical scales of compulsivity
are also needed.
Relevance to treatment and prevention and potential
barriers to progress
Evidently, the relevance of many neuropsychological
constructs are not constrained by traditional diagnostic
boundaries, forming (at least partially) shared dysfunctions
at the core of many substance and behavioural addictions.
Established approaches to the clinical assessment and
management of individuals with addictive disorders have
not beneted fully from these emerging insights, with
neuroscientists typically more aligned to the laboratory
than the clinic. The essential neuropsychological dimen-
sions currently identied provide a framework to guide cli-
nicians and researchers through a consensual,
collaborative agenda. Consistent with the RDoC frame-
work, this agenda involves examining the diagnostic and
prognostic value of dimensional measures of the constructs
identied here, and the design of targeted, transdiagnostic
treatment approaches to address these vulnerabilities and
dysfunctions. The identication of neuropsychological
targets may facilitate alternative interventions to
succeed where others have failed. For instance, in the case
of habits and compulsions (i.e. constructs related to
chronicity), activities that re-engage the cognitive
control/goal-directed systems (including mindfulness
meditation or goal management strategies) may be effective
in treating addictive behaviours [83]. Regarding reward
valuation, an individual who is vulnerable to placing a
high value on addiction-related hedonic experiences (e.g.
substance use) may be at risk of developing an addiction.
However, the same reward value system may also be
protective if one can apply (or be treated to apply) their
high reward value system to new forms of adaptive
learning towards less harmful and more functional
rewards or to distant rewards placing one towards a
non-use preference (see [84] for potential applications of
this approach to contingency management, motivational
interviewing/enhancement and targeted media cam-
paigns). Such redirectingapproaches assume that the re-
ward system is still fully operative and exible, and thus
malleable for domain-derivedinterventions [84]. Accord-
ingly, future research and clinical work can build upon
the available neuroscience knowledge and be evidence-
based. The consensus-derived knowledge from this paper
thus provides a framework for grouping more homoge-
neous subtypes of addictions (currently classied in dispa-
rate categories), more validly linking disorder categories to
molecular, cellular and neural dimensions, and guiding
clinical interventions and treatments to core dimensions
driving and maintaining addiction-related disorders. A
key additional advantage is the potential for prevention,
as aberrant functioning in these systems can be detected
well before rst use of a substance and/or engagement in
a maladaptive behaviour.
In relation to staging of illness, this neuropsychological
approach underscores the frequent nding that many
relevant phenomena vary continuously within and
between addictions and mental disorders more broadly
and in the population at large. These neuropsychological
dimensions (may/arguably) become pathological at the
extremes of an otherwise normal distribution [41]. An
online version of such an assessment battery could be
used to measure and monitor potential risk factors for
large cohort/population-based studies with an eye towards
early intervention.
Figure 5 Expert-endorsed primary constructs as a function of the
major Research Domain Criteria (RDoC) domains (green = positive va-
lence system; red = negative valance system; blue = cognitive system)
and the constructs within these domains that are most relevant to the
process of addiction (i.e. as a function of the relative size/width of the
circles). Also illustrated are the relative inuences of the seven primary
constructs on the vulnerability to or the chronicity of addiction
[Colour gure can be viewed at]
Transdiagnostic neuropsychological approaches to addiction 11
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
Experts were only included if they were uent English
speakers. A handful of experts disagreed fundamentally
with the use of the RDoC, arguing that they are too biolog-
ical and reductionist, making the translation to phenome-
nological and other applications difcult [85]. Indeed,
manyof the best currently available treatments are psycho-
social in nature. Our ndings need to be used to rene these
approaches to create new psychosocial options that are
more personalized and better targeted so as to improve cur-
rent standards of assessment and care. Such views may
have led experts to be less invested in the Delphi process, al-
though the very high retention rate suggests otherwise.
Other limitations relate to potential biases to our approach:
(i) the research team promoting the Delphi have expressed
publicly their views about addiction, which may have bi-
ased participants; (ii) although efforts were made to guar-
antee a broad representation of experts, the promoters
may have introduced biases in the selection of experts;
and (iii) nally, the pool of experts over-represented Euro-
pean locations (versus the Americas and other non-
western countries) and academic positions (versus clinical
practitioners), and thus results may be susceptible to biases
related to prevailing views on addiction within Europe and
The theoretical framework established in the current study
provides a platform to test predictions that: (1) the majority
of individuals with substance and behavioural addictions
have specic dysfunctions in the primary constructs identi-
ed by our International Expert Consortium; (2) these
dysfunctions cut across diagnostic boundaries (i.e. individ-
uals from different addictions will cluster into the same
neuropsychological phenotypes); and (3) these indices
can be linked differentially to vulnerability and chronicity
(i.e. stage of disorder). This framework may enable group-
ing of more homogeneous disorder subtypes, better linking
of behavioural questionnaire phenotypes to neural, cellular
and genetic dimensions,guiding clinical decisions to the
core issues that drive addictions and measuring the success
and failure of treatment (i.e. providinga clinical end-point).
It is envisioned that the ndings will guide and fast-track
the development of a new generation of neuropsychologi-
cal assessment tools, and improve the monitoring and
effectiveness of both established and future novel
Brain and Mental Health Research Hub, Monash Institute of Cognitive and Clinical
Neurosciences (MICCN) and School of Psychological Sciences, Monash
University, Melbourne, Australia,
Institut des Maladies Neurodégénératives,
Université de Bordeaux, Bordeaux, France,
Department of Psychology,
University of Cambridge, Cambridge, UK,
Addictive and Compulsive Behaviours
Laboratory (ACB-lab), Institute for Health and Behaviours, University of
Luxembourg, Esch-sur-Alzette, Luxembourg,
Department of Medicine, Imperial
College, London, UK,
Department of Psychiatry, University of Cambridge; and
Cambridge and Peterborough NHS Foundation Trust (CPFT), Cambridge, UK,
Centre for Gambling Research at UBC, Department of Psychology, University of
British Columbia, Vancouver, BC, Canada,
Discipline of Psychiatry, Faculty of
Medicine, and Centre for Youth Substance Abuse Research, The University of
Queensland, Brisbane, Australia,
Alcohol and Drug Service, Royal Brisbane and
Womens Hospital, Metro North HHS, Queensland Health and Discipline of
Psychiatry, The University of Queensland, Australia,
Antwerp U niversity (UA),
Collaborative Antwerp Psychiatric Research Institute (CAPRI), Antwerp,
Department of Psychiatry, the Sackler School of Medicine and Tel
Aviv University, Tel Aviv, Israel,
Sussex Addiction Research and Intervention
Centre, School of Psychology, University of Sussex, Brighton, UK,
Departamento de Psicología, Universidad de Jaén, Spain,
Department of
Psychology, University of Shefeld, Shefeld, UK,
Institute of Psychology,
Erasmus School of Social Sciences and Behavioral Sciences, Erasmus University,
Rotterdam, the Netherlands,
Department of Psychiatry and Neuroscience,
Icahn School of Medicine at Mount Sinai, NY, USA,
Center for Children and
Families, Department of Psychology, Florida International University, Miami, FL,
Arkin Mental Health and Amsterdam UMC, University of Amsterdam,
Department of Psychiatry, Amsterdam Institute for Addiction Research,
Amsterdam, Netherlands,
Department of Psychiatry and Behavioral
Neuroscience, University of Chicago, Chicago, IL, USA,
Centre for Youth
Substance Abuse Research, The University of Queensland, Brisbane, Australia,
School of Psychological Sciences, University of Melbourne, Melbourne,
Australi a,
Department of Psychology, University of Calgary, Calgary, Canada,
Translational Addiction Research Laboratory, Campbell Family Mental Health
Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto,
Department of Family and Community Medicine, Pharmacology and
Toxicology, Psychiatry, University of Toronto, Toronto, Canada,
Neuropsychopharmacology Unit, Centre for Psychiatry, Division of Brain
Sciences, Imperial College, London, UK,
School of Psychology, Faculty of
Health Sciences, Australian Catholic University, Melbourne, Australia,
Department of Psychiatry, Stony Brook University School of Medicine, Stony
Brook, NY, USA,
MRC Integrative Epidemiology Unit at the University of
Bristol and UK Centre for Tobacco and Alcohol Studies, School of Experimental
Psychology, University of Bristol, Bristol, UK,
Faculty of Health and Medical
Sciences, University of Copenhagen, Copenhagen, Denmark,
H. Lundbeck A/S,
Valby, Denmark,
Departments of Psychiatry and Neuroscience, Child Study
Center, Yale University School of Medicine and Connecticut Mental Health
Center and Connecticut Council on Problem Gambling, New Haven, CT,
Department of Neurology, Max-Planck Institute for Human Cognitive
and Brain Sciences, Leipzig, Germany,
Cognitive Psychology Unit, Institute of
Psychology, and Leiden Institute for Brain and Cognition, Leiden University,
Leiden, the Netherlands,
School of Psychology and Illawarra Health and
Medical Research Institute, University of Wollongong, Wollongong, NSW,
Australi a,
The Australian Centre for Cannabinoid Clinical and Research
Excellence (ACRE), New Lambton Heights NSW, Australia,
UMC, University of Amsterdam, Department of Psychiatry, Amsterdam Institute
for Addiction Research, Amsterdam, Netherlands,
Department of Psychiatry,
University of Cambridge, Cambridge, UK,
and Addiction, Development and
Psychopathology (ADAPT)-lab, Deptartment of Psychology, University of
Amsterdam, the Netherlands
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Transdiagnostic neuropsychological approaches to addiction 15
© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction. Addiction
... Estos criterios plantean la necesidad de adoptar un nuevo marco de referencia para clasificar los trastornos mentales, haciendo un llamamiento para desarrollar investigaciones en este ámbito que contribuyan a lograr una mayor precisión en el diagnóstico y a definir la eficacia y resultados de las intervenciones a nivel clínico, identificando los mecanismos comunes a diversos trastornos psiquiátricos (Yager y Feinstein, 2017). Esta aproximación transdiagnóstica ha sido adoptada también recientemente como contexto de estudio de los trastornos adictivos, tanto en el ámbito clínico (Narayanan y Naaz, 2018;Yücel et al., 2019) como a nivel experimental utilizando modelos animales (Lamontagne y Olmstead, 2019), constituyendo un nuevo marco de referencia que supone un cierto alejamiento, aunque no exclusión, de los enfoques basados en categorías diagnósticas estancas. Este nuevo planteamiento promueve una mejor comprensión de la relación entre los posibles factores de riesgo y el desarrollo de trastornos del comportamiento, incluidos los trastornos adictivos (Belloch, 2012; Malicki y Ostaszewski, 2014) y posibilita la superación de uno de los problemas actuales relativos a la organización de la atención en patología dual, la imposibilidad de aplicar tratamientos integrales. ...
... Se han planteado diversos factores transdiagnósticos para un amplio rango de trastornos psicopatológicos (Gloster et al., 2011;Leyro et al., 2010) y más recientemente los RDoC del NIMH en el ámbito de los trastor-nos adictivos (Yücel et al., 2019). En este contexto se ha propuesto también a la inflexibilidad psicológica como un posible factor transdiagnóstico en patología dual (Levin et al., 2014), entendiendo dicha inflexibilidad como la incapacidad de guiar la conducta en función de las contingencias, dejando que el papel regulador de la conducta que éstas deberían desempeñar sea llevado a cabo por eventos privados aversivos (pensamientos, sentimientos, emociones y/o sensaciones; Hayes et al., 2006). ...
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Psychological inflexibility is considered a risk factor in the development and maintenance of psychopathological disorders, including addictive disorders. This study aimed to evaluate the psychological inflexibility, psychopathological profile, and the relationship between them in 90 substance addicts (66 men, age range: 1859 years, M age = 33.83, SD age = 11.22; 24 women, age range: 2059 years, M age = 38.79, SD age = 12.84), who demanded assistance in an outpatient treatment center, being selected by order of application. Participants were assessed using DSM5 criteria for substance use disorders, the Symptom Checklist90Revised (SCL90R) to evaluate their psychopathological profile, and the Acceptance and Action Questionnaire II (AAQII) to assess psychological inflexibility. A structured interview was also applied to collect sociodemographic data and those related to their previous history of substance use. Sex differences were found in the sociodemographic profile and previous history of consumption. Participants showed high levels of psychological inflexibility (varying depending on the drug) and psychopathological comorbidity, with women showing higher levels of inflexibility and greater severity and diversity of psychopathological symptoms. Higher levels of inflexibility were found in those patients who presented greater severity of psychopathological symptoms, especially among women, and were associated with a pattern of daily consumption. Interventions for addictive disorders with comorbidity could adopt a more personalized approach including factors that may help explain individual vulnerability, among others, psychological inflexibility, sex, and the substance that motivates the demand for assistance. Resumen: La inflexibilidad psicológica es considerada un factor de riesgo en el desarrollo y mantenimiento de trastornos psico-patológicos, incluidos los trastornos adictivos. Este estudio pretende evaluar el rasgo de inflexibilidad psicológica, el perfil psico-patológico y la relación entre ambos, en 90 adictos a sustancias (66 hombres, rango de edad: 1859 años, M edad = 33.83, DT edad = 11.22; 24 mujeres, rango de edad: 2059 años, M edad = 38.79, DT edad = 12.84), que solicitaron asistencia en un centro de tratamien-to ambulatorio, siendo seleccionados siguiendo el orden de solicitud. Los participantes fueron evaluados mediante los criterios del DSM5 para los trastornos relacionados con el consumo de sustancias, el Symptom Checklist90Revised (SCL90R) para eva-luar su perfil psicopatológico y el Acceptance and Action QuestionnaireII (AAQII) para evaluar la inflexibilidad psicológica. Se aplicó igualmente una entrevista estructurada para recabar datos sociodemográficos y relativos a su historial previo de consumo de sustancias. Se encontraron diferencias entre hombres y mujeres en el perfil sociodemográfico e historial previo de consumo. Los participantes mostraron niveles elevados de inflexibilidad psicológica (diferentes según la sustancia) y comorbilidad psicopa-tológica, presentando las mujeres niveles más elevados de inflexibilidad y mayor gravedad y diversidad de síntomas psicopatoló-gicos. Se encontraron mayores niveles de inflexibilidad en aquellos pacientes que presentaron mayor gravedad de síntomas psico-patológicos, especialmente en mujeres, y estuvieron asociados a un patrón de consumo diario. Las intervenciones en trastornos adictivos con comorbilidad podrían ser más personalizadas, incluyendo aquellos factores que puedan contribuir a explicar la vulnerabilidad individual, entre otros, la inflexibilidad psicológica, el sexo y la sustancia que motiva la solicitud de asistencia.
... Compulsivity refers to the experience of feeling forced or compelled to act despite awareness of serious negative consequences, and to the behavior accompanying that experience (for reviews, see [1,2]). At a mechanistic level, compulsivity has been proposed to imply that: (a) the behavior has become goal-detached, and thus mostly automatic and inflexible (i.e., outcome expectancy valuation no longer plays a role in motivating it, as shown by insensitivity to contingency manipulation and outcome devaluation procedures [3,4]), or (b) the individual perseveres in behaviors driven by strong short-term motives (e.g., relief of craving/withdrawal symptoms or other intense affective states [5]) despite knowing such behaviors are pernicious in the long run. ...
... In spite of their differences, most models converge on conceptualizing compulsivity as the hallmark of addiction progression and maintenance [1,10]. This view is supported by translational research showing that compulsive drug use corresponds to an extreme stage of otherwise functional learning and neuroadaptation processes [11,12]. ...
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Background Compulsivity is the hallmark of addiction progression and, as a construct, has played an important role in unveiling the etiological pathways from learning mechanisms underlying addictive behavior to harms resulting from it. However, a sound use of the compulsivity construct in the field of behavioral addictions has been hindered to date by the lack of consensus regarding its definition and measurement. Here we capitalize on a previous systematic review and expert appraisal to develop a compulsivity scale for candidate behavioral addictions (the Granada Assessment for Cross-domain Compulsivity, GRACC). Methods The initial scale (GRACC90) consisted of 90 items comprising previously proposed operationalizations of compulsivity, and was validated in two panel samples of individuals regularly engaging in gambling and video gaming, using exploratory structural equation modeling (ESEM) and convergence analyses. Results The GRACC90 scale is unidimensional and structurally invariant across samples, and predicted severity of symptoms, lower quality of life, and negative affect, to similar degrees in the two samples. Additionally, poorer quality of life and negative affect were comparably predicted by compulsivity and by severity of symptoms. A shorter version of the scale (GRACC18) is proposed, based on selecting the 18 items with highest factor loadings. Conclusions Results support the proposal that core symptoms of behavioral addictions strongly overlap with compulsivity, and peripheral symptoms are not essential for their conceptualization. Further research should clarify the etiology of compulsive behavior, and whether pathways to compulsivity in behavioral addictions could be common or different across domains.
... Esta postura es actualmente compartida por una buena parte de los investigadores de las bases neuropsicológicas de las adicciones. En una revisión de consenso reciente, siguiendo la metodología estandarizada Delphi (Yücel et al., 2019), la compulsividad se definía como la experiencia de sentirse «forzado» a actuar de una determinada manera a pesar de las consecuencias negativas, y se manifiesta por la dificultad de resistir el impulso de realizar la actividad adictiva, la percepción de pérdida de control sobre la misma, y la conducta estereotipada o repetitiva, inadecuada para el contexto. ...
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La reciente inclusión del trastorno por juego de azar (TJA) en el Manual Diagnóstico y Estadístico de Trastornos Mentales (American Psychiatric Association, 2013) ha supuesto un hito conceptual importante en la definición de los trastornos adictivos, porque por primera vez éste reconoce que un trastorno adictivo no requiere el consumo de una sustancia química externa. En un primer momento, se tomó en consideración la posibilidad de que dicha nueva categoría de adicciones comportamentales incluyese también el uso excesivo de videojuegos en Internet, aunque finalmente esa propuesta se rechazó. Más recientemente, por el contrario, la Organización Mundial de la Salud sí ha incluido el trastorno por uso de (vídeo) juegos en su Clasificación Internacional de Enfermedades (World Health Organization, 2018). Al margen del DSM y la CIE, sin embargo, existen incontables propuestas de supuestas adicciones comportamentales. Algunas de ellas se refieren conductas que se realizan a través de dispositivos digitales, como el uso excesivo de redes sociales (He, Turel & Bechara, 2017; Andreassen, 2015; Griffiths, 2013) y de pornografía online (Duffy, Dawson & Das Nair, 2016; Love, Laier, Brand, Hatch & Hajela, 2015), el consumo de vídeos o series en forma de atracón (binge watching) (Flayelle, Maurage, Karila, Vögele & Billieux, 2019; Flayelle, Maurage & Billieux, 2017), u otras posibles conductas problemáticas vía móvil u ordenador sin especificar (Bisen & Deshpande, 2018; De-Sola Gutierrez, Rodríguez de Fonseca & Rubio, 2016; Kuss, Griffiths, Karila & Billieux, 2014). Otras se refieren a conductas que ocurren siempre o en su mayor parte fuera de Internet (Muller et al., 2019; Dumitru, Dumitru & Maher, 2018; Carter et al., 2016). Tales propuestas se basan en las similitudes que la realización excesiva de esas actividades parece tener con el juego de azar o con el consumo abusivo de sustancias. Sin embargo, como argumentaremos aquí, tales similitudes pueden ser superficiales, y la consideración de esos patrones comportamentales problemáticos como trastornos adictivos puede estar suponiendo un obstáculo para avanzar en su comprensión, su tratamiento y su prevención (Panova & Carbonell, 2018; Fletcher & Kenny, 2018; Carbonell & Panova, 2017; Griffiths, Pontes & Kuss, 2016; King & Delfabbro, 2014).
... Our finding of boredom-induced discounting -while not specific to PWUC -supports these reports of a link between boredom and relapse. A recent international Delphi consensus study identified dysregulated decision-making as a key process in addiction (100), proposing that decision-making difficulties and associated neurobehavioral processes should be considered in the treatment of addiction (101). Our findings support a role for boredom in these processes, suggesting that intervention strategies should also address boredom and its effects on choice. ...
... Alcohol-related attentional bias (AB) is the preferential allocation of attention towards alcohol-related stimuli. Prominent theoretical models assume that AB plays a causal role in the onset and persistence of severe alcohol use disorder (SAUD) [1][2][3]. The incentivesensitization theory [4] postulates that repeated alcohol exposures sensitize the reflexive/reward system, enhancing the incentive properties of alcohol-related cues through conditioning. ...
Background and aims Competing models disagree on three theoretical questions regarding alcohol‐related attentional bias (AB), a key process in severe alcohol use disorder (SAUD): (1) is AB more of a trait (fixed, associated with alcohol use severity) or state (fluid, associated with momentary craving states) characteristic of SAUD; (2) does AB purely reflect the over‐activation of the reflexive/reward system or is it also influenced by the activity of the reflective/control system and (3) does AB rely upon early or later processing stages? We addressed these issues by investigating the time‐course of AB and its modulation by subjective craving and cognitive load in SAUD. Design A free‐viewing eye‐tracking task, presenting pictures of alcoholic and non‐alcoholic beverages, combined with a concurrent cognitive task with three difficulty levels. Setting A laboratory setting in the detoxification units of three Belgian hospitals. Participants We included 30 patients with SAUD self‐reporting craving at testing time, 30 patients with SAUD reporting a total absence of craving and 30 controls matched on sex and age. All participants from SAUD groups met the DSM‐5 criteria for SAUD. Measurements We assessed AB through early and late eye‐tracking indices. We evaluated the modulation of AB by craving (comparison between patients with/without craving) and cognitive load (variation of AB with the difficulty level of the concurrent task). Findings Dwell time measure indicated that SAUD patients with craving allocated more attention towards alcohol‐related stimuli than patients without craving ( P < 0.001, d = 1.093), resulting in opposite approach/avoidance AB according to craving presence/absence. SAUD patients without craving showed a stronger avoidance AB than controls ( P = 0.003, d = 0.806). AB did not vary according to cognitive load ( P = 0.962, η ² p = 0.004). Conclusions The direction of alcohol‐related attentional bias (approach/avoidance) appears to be determined by patients' subjective craving at testing time and does not function as a stable trait of severe alcohol use disorder. Alcohol‐related attentional bias appears to rely on later/controlled attentional stages but is not modulated by the saturation of the reflective/control system.
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Purpose of Review Addiction may be characterized along three functional domains: Approach Behavior, Executive Function, and Negative Emotionality. Constructs underlying impulsivity thought to be relevant in addiction map on to these three functional domains. The purpose of the present review was to evaluate the extant research regarding sex/gender differences in the multi-dimensional domains of addiction using human neuroimaging and discuss their relevance to impulsivity. Recent Findings Few papers over the past two decades have used human neuroimaging to test sex/gender differences in addiction. There is therefore a significant gap in the literature regarding sex/gender differences in the neurobiological mechanisms driving the multi-dimensionality of addiction and their implications to impulsivity. Summary Of the 34 reviewed papers, the orbitofrontal cortex/ventromedial prefrontal cortex (OFC/vmPFC) was the most frequently reported brain region to evidence a sex/gender difference during fMRI tasks probing Approach Behavior and Negative Emotionality. This finding suggests potential sex/gender-specific patterns of subjective valuation in substance misuse, driven by OFC/vmPFC dysregulation.
This chapter will examine the pre-arrival, arrival and orientation, and transition phases of international school onboarding programs. The elements are the social media group, internet platform, airport protocol, arrival dossier, orientation schedule, events itinerary, and transition partnership. The phases were delineated based on a robust literature review and Klein and Heuser's inform-welcome-guide framework. The elements were created in alignment with the adult learning principles put forth by Knowles et al. and the concept of fulfilling a newcomer's psychological contract. The three phases and seven elements of the international school onboarding program are substantiated and moderately substantiated using the Delphi method. International school leaders, educators, and coordinators can use the findings to create a site-specific onboarding program.
Alcohol use disorder (AUD) is a common, complex condition with substantial heterogeneity that has confounded the understanding of its etiology, diagnosis, and outcomes. The Addictions Neuroclinical Assessment is a clinical framework that seeks to understand the etiology and heterogeneity of AUD and other substance use disorders based on three neurofunctional domains: incentive salience, negative emotionality, and executive functions. These domains are aligned with the three stages of the cycle of addiction—binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation—and are supported by our current understanding of the neuroscience of substance use disorders. The ANA includes a battery of measures to assess these neurofunctional domains, consisting of readily available neuropsychological and behavioral tasks, as well as clinical and self-report measures. Ancillary measures, such as genetic, epigenetic, and neuroimaging markers, as well as measures of the environmental and social determinants are recommended to provide additional information not otherwise captured by the three domains. This review summarizes the current empirical work on the ANA framework, and highlights important directions for future research. The ANA aims to serve as a critical tool for both researchers and clinicians to provide a common framework to aid in the understanding of the etiology and heterogeneity of substance use disorders.
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Current diagnostic systems for mental disorders were established before the tools of neuroscience were available, and although they have improved the reliability of psychiatric classification, progress toward the discovery of disease etiologies and novel approaches to treatment and prevention may benefit from alternative conceptualizations of mental disorders. The Research Domain Criteria (RDoC) initiative is the centerpiece of NIMH's effort to achieve its strategic goal of developing new methods to classify mental disorders for research purposes. The RDoC matrix provides a research framework that encourages investigators to reorient their research perspective by taking a dimensional approach to the study of the genetic, neural, and behavioral features of mental disorders, RDoCs integrative approach includes cognition along with social processes, arousal/regulatory systems, and negative and positive valence systems as the major domains, because these neurobehavioral systems have all evolved to serve the motivational and adaptive needs of the organism. With its focus on neural circuits informed by the growing evidence of the neurodevelopmental nature of many disorders and its capacity to capture the patterns of co-occurrence of behaviors and symptoms, the RDoC approach holds promise to advance our understanding of the nature of mental disorders.
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Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioural inhibition (motor inhibition, cognitive inflexibility) reversal learning and habit formation (shift from goal-directed to habitual responding) contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder (OCD), distributed network perturbation appears focussed around the pre-frontal cortex, caudate, putamen and associated neuro-circuitry. OCD-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of OCD symptoms reduced neural activation in brain regions implicated in goal-directed behavioural control (ventromedial prefrontal cortex (vmPFC), caudate) with concordant increased activation in regions implicated in habit learning (pre-supplementary motor area, putamen). The vmPFC plays a multifaceted role, integrating affective evaluative processes, flexible behavior and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which OCD patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of vmPFC safety signaling in OCD, which potentially undermines explicit contingency knowledge, and which may help to explain the link between cognitive inflexibility, fear and anxiety processing in compulsive disorders such as OCD.
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Compulsivity is a core feature of addictive disorders, including gambling disorder. However, it is unclear to what extent this compulsive behavior in gambling disorder is associated with abnormal compulsivity-related neurocognitive functioning. Here, we summarize and synthesize the evidence for compulsive behavior, as assessed by compulsivity-related neurocognitive tasks, in individuals with gambling disorder compared to healthy controls (HCs). A total of 29 studies, comprising 41 task-results, were included in the systematic review; 32 datasets (n=1,072 individuals with gambling disorder; n=1,312 HCs) were also included in the meta-analyses, conducted for each cognitive task separately. Our meta-analyses indicate significant deficits in individuals with gambling disorder in cognitive flexibility, attentional set-shifting, and attentional bias. Overall, these findings support the idea that compulsivity-related performance deficits characterize gambling disorder. This association may provide a possible link between impairments in executive functions related to compulsive action. We discuss the practical relevance of these results, their implications for our understanding of gambling disorder and how they relate to neurobiological factors and other 'disorders of compulsivity'.
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Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioural inhibition (motor inhibition, cognitive inflexibility) reversal learning and habit formation (shift from goal-directed to habitual responding) contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder (OCD), distributed network perturbation appears focussed around the pre-frontal cortex, caudate, putamen and associated neuro-circuitry. OCD-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of OCD symptoms reduced neural activation in brain regions implicated in goal-directed behavioural control (ventromedial prefrontal cortex (vmPFC), caudate) with concordant increased activation in regions implicated in habit learning (pre-supplementary motor area, putamen). The vmPFC plays a multifaceted role, integrating affective evaluative processes, flexible behavior and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which OCD patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of vmPFC safety signaling in OCD, which potentially undermines explicit contingency knowledge, and which may help to explain the link between cognitive inflexibility, fear and anxiety processing in compulsive disorders such as OCD.
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Prominent theories suggest that compulsive behaviors, characteristic of obsessive-compulsive disorder and addiction, are driven by shared deficits in goal-directed control, which confers vulnerability for developing rigid habits. However, recent studies have shown that deficient goal-directed control accompanies several disorders, including those without an obvious compulsive element. Reasoning that this lack of clinical specificity might reflect broader issues with psychiatric diagnostic categories, we investigated whether a dimensional approach would better delineate the clinical manifestations of goal-directed deficits. Using large-scale online assessment of psychiatric symptoms and neurocognitive performance in two independent general-population samples, we found that deficits in goal-directed control were most strongly associated with a symptom dimension comprising compulsive behavior and intrusive thought. This association was highly specific when compared to other non-compulsive aspects of psychopathology. These data showcase a powerful new methodology and highlight the potential of a dimensional, biologically-grounded approach to psychiatry research.
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The concept of compulsion, in which addictive behaviour is said to be carried out against the will, is central to the disease theory of addiction and ubiquitous in modern definitions. The aims of this article are: (i) to describe various meanings of compulsion in the literature; (ii) to compare the part thought to be played by compulsion in addiction with its suggested role in obsessive-compulsive disorder; (iii) to critically examine the place of compulsion in influential neurobiological accounts of addiction; (iv) to summarise the empirical evidence bearing on the usefulness of the compulsion concept, evidence that seems at first sight incompatible with the notion of compulsion. This is followed by a discussion of which possible meanings of compulsion can survive an empirical test and what role they might play in understanding addiction, paying particular attention to a distinction between strong and weak senses of compulsion. A conclusion is that addictive behaviour cannot be considered compulsive at the time it is carried out, though other possible meanings of compulsion as an explanation or description of addictive behaviour and experience are discussed. Among other conclusions, it is suggested that, although in some senses of the term it may seem arbitrary whether or not ‘compulsion’ should be retained, its use has important consequences for the public understanding of addiction, and is likely to deter people's attempts to overcome their addictions and their chances of success.
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Substance-dependent individuals often lack the ability to adjust decisions flexibly in response to the changes in reward contingencies. Prediction errors (PEs) are thought to mediate flexible decision-making by updating the reward values associated with available actions. In this study, we explored whether the neurobiological correlates of PEs are altered in alcohol dependence. Behavioral, and functional magnetic resonance imaging (fMRI) data were simultaneously acquired from 34 abstinent alcohol-dependent patients (ADP) and 26 healthy controls (HC) during a probabilistic reward-guided decision-making task with dynamically changing reinforcement contingencies. A hierarchical Bayesian inference method was used to fit and compare learning models with different assumptions about the amount of task-related information subjects may have inferred during the experiment. Here, we observed that the best-fitting model was a modified Rescorla-Wagner type model, the “double-update” model, which assumes that subjects infer the knowledge that reward contingencies are anti-correlated, and integrate both actual and hypothetical outcomes into their decisions. Moreover, comparison of the best-fitting model's parameters showed that ADP were less sensitive to punishments compared to HC. Hence, decisions of ADP after punishments were loosely coupled with the expected reward values assigned to them. A correlation analysis between the model-generated PEs and the fMRI data revealed a reduced association between these PEs and the BOLD activity in the dorsolateral prefrontal cortex (DLPFC) of ADP. A hemispheric asymmetry was observed in the DLPFC when positive and negative PE signals were analyzed separately. The right DLPFC activity in ADP showed a reduced correlation with positive PEs. On the other hand, ADP, particularly the patients with high dependence severity, recruited the left DLPFC to a lesser extent than HC for processing negative PE signals. These results suggest that the DLPFC, which has been linked to adaptive control of action selection, may play an important role in cognitive inflexibility observed in alcohol dependence when reinforcement contingencies change. Particularly, the left DLPFC may contribute to this impaired behavioral adaptation, possibly by impeding the extinction of the actions that no longer lead to a reward.
The impaired response inhibition and salience attribution (iRISA) model proposes that impaired response inhibition and salience attribution underlie drug seeking and taking. To update this model, we systematically reviewed 105 task-related neuroimaging studies (n > 15/group) published since 2010. Results demonstrate specific impairments within six large-scale brain networks (reward, habit, salience, executive, memory, and self-directed networks) during drug cue exposure, decision making, inhibitory control, and social-emotional processing. Addicted individuals demonstrated increased recruitment of these networks during drug-related processing but a blunted response during non-drug-related processing, with the same networks also being implicated during resting state. Associations with real-life drug use, relapse, therapeutic interventions, and the relevance to initiation of drug use during adolescence support the clinical relevance of the results. Whereas the salience and executive networks showed impairments throughout the addiction cycle, the reward network was dysregulated at later stages of abuse. Effects were similar in alcohol, cannabis, and stimulant addiction.
Objective: Recently, the National Institutes of Health (NIH) redefined clinical trials to include any study involving behavioral or biomedical interventions. In line with a general framework from experimental medicine, we argue that it is crucial to distinguish between experimental laboratory studies aimed at revealing psychological mechanisms underlying behavior and randomized controlled trials (RCTs) in clinical samples aimed at testing the efficacy of an intervention. Method: As an illustration, we reviewed the current state of the evidence on the efficacy of cognitive bias modification (CBM) interventions in alcohol use disorders. Results: A recent meta-analysis "cast serious doubts on the clinical utility of CBM interventions for addiction." That analysis combined experimental laboratory studies and RCTs. We demonstrated that, when studies are differentiated regarding study type (experimental laboratory study or RCT), mode of delivery (controlled experiment or Internet), and population (healthy volunteers or patients), the following effects are found: (a) short-lived effects of CBM on drinking behavior in experimental laboratory studies in students, but only when the bias is successfully manipulated; (b) small but robust effects of CBM on treatment outcome when administered as an adjunct to established treatments in clinical settings in RCTs with alcohol-dependent patients; and (c) nonspecific effects (reduced drinking irrespective of condition) in RCTs of CBM administered online to problem drinkers. Conclusions: We discuss how CBM might be improved when it is better integrated into regular treatment, especially cognitive behavioral therapy, and we conclude that disregarding the difference between experimental laboratory studies and RCTs can lead to invalid conclusions.