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Published in final edited form as: Curr Opin Behav Sci. 2016 Nov 25;13:91–98. doi: 10.1016/j.cobeha.2016.11.005

Cognitive Mechanisms and Therapeutic Targets of Addiction

Marc L Copersino 1
PMCID: PMC5461927  NIHMSID: NIHMS830972  PMID: 28603756

Abstract

Fundamental to cognitive models of addiction is the gradual strengthening of automatic, urge-related responding that develops in tandem with the diminution of self-control-related processes aimed at inhibiting impulses. Recent conceptualizations of addiction also include a third set of cognitive processes related to self-awareness and superordinate regulation of self-control and other higher brain function. This review describes new human research evidence and theoretical developments related to the multicausal strengthening of urge-related responding and failure of self-control in addiction, and the etiology of disrupted self-awareness and rational decision-making associated with continued substance use. Recent progress in the development of therapeutic strategies targeting these mechanisms of addiction is reviewed, including cognitive bias modification, mindfulness training, and neurocognitive rehabilitation.

INTRODUCTION

Addiction is a brain disease characterized by the compulsion to use psychoactive substances despite negative consequences. Although different methods and models have been used to explain addiction, its etiology is generally attributed to neurobehavioral adaptations resulting from a combination of predisposing factors and chronic substance use that gradually strengthen the urge to use substances, weaken willpower and resolve to resist these urges, and diminish critical awareness of the growing strength and range of stimuli that trigger these urges.

Recent conceptualizations of addiction [1–3]• include three disparate but interactive sets of mental processes instrumental to the initiation, progression, and maintenance of addiction1: (1) implicit cognitive processes, which encompass learning and memory; (2) metacognitive processes, including self-awareness, reflective thinking, and superordinate self-regulation; and (3) executive function, which includes other higher order mental processes necessary for the planning, execution, and monitoring of goal-directed behavior. Central to the compulsive nature of addiction is the gradual strengthening of stimulus-driven implicit processes, which overwhelm a progressively weaker executive control system and interfere with awareness and rational thinking about the costs and benefits associated with continued substance use. The purpose of this paper is to provide a concise yet integrative review of the literature since 2014 that has contributed to a greater understanding of these cognitive processes both as mechanisms of addiction and as therapeutic targets.

Implicit Cognitive Processes

Implicit, or automatic, cognition includes classically and operantly conditioned responses, which are controlled respectively by repeated pairings with their antecedents and consequences. Implicit responding is generally measured indirectly as central task disruption or facilitation, or the degree to which drug-or-alcohol-related cue responding impedes or facilitates performance of (i.e., increases or decreases latency to complete) a goal-directed task. The three most common implicit cognition paradigms examined in addiction literature include spontaneous memory association (i.e., memory bias), attentional capture (i.e., attentional bias), and action tendency (i.e., approach-avoidance biases). These are sometimes referred to collectively as measures of cognitive bias. It is, however, important to differentiate cognitive bias paradigms, that vary the type of central task, from the underlying cue-reactivity, or implicit processing, which influences central task performance.

Recent studies provide evidence in support of [4], in partial support of [5] and contrary to [6] the validity and clinical relevance of specific cognitive bias measures. Recent papers have also reviewed the clinical relevance of attentional bias in substance use disorders (SUD) in general [7, 8] and in cocaine use disorder specifically [9].

There is no universal consensus regarding how implicit processes are strengthened over the course of addiction, but the progression appears to be multidetermined. One way implicit processes are regarded to strengthen over time is through incentive sensitization [10], in which chronic substance use is posited to hypersensitize mesocorticolimbic reward pathways resulting in enhanced incentive motivation (i.e., “wanting”). Recent studies provide evidence in support of incentive sensitization theory. For example, repeated exposure to amphetamine in a human laboratory study resulted in increased fMRI BOLD activation in the caudate nucleus during reward anticipation that was correlated with enhanced subjective amphetamine-like responding [11]••. Other clinical studies similarly identify reward pathway hypersensitivity associated with quantity of recent cannabis use [12] and duration and severity of alcohol dependence [13]. Furthermore, across twenty-four neuroimaging studies of cognitive interventions for addiction, the reduction of reward pathway sensitivity was identified as one of two brain changes common to successful treatment outcomes [14].

Another mechanism by which implicitly learned habits become increasingly resistant to extinction is through Pavlovian-to-instrumental transfer (PIT). Closely related to incentive sensitization, PIT represents a shift over the course of addiction in which increasingly stronger incentive motivation in response to predictive cues maintains operantly conditioned habits in the apparent absence of a reinforcement mechanism. A recent study showed PIT associated BOLD activation in the nucleus accumbens that was predictive of subsequent relapse in alcohol dependent individuals [15]. Central to PIT is the maintenance of habit via predictive, or anticipatory, responding. Investigators in another study examined anticipatory cue responding using a modified alcohol approach-avoidance task, and found cue-reactivity to be associated with strength of anticipatory processing as measured by EEG beta-band event-related desynchronization [16].

Although no reinforcement mechanism may be apparent in PIT, hedonic shifting over the course of addiction [17] suggests that drug-and-alcohol-related predictive cues trigger avoidance responding, which is a negatively reinforced behavior. This would provide an additional mechanism for the further strengthening of learned habits. Potential support for this mechanism is provided by a recent study in which reward anticipation was associated with anhedonia in cocaine users, suggesting implicit responding may be driven by “wanting” to alleviate a negative affective state [18].

Another mechanism that contributes to the resistance to extinction of implicitly learned associations is the impaired ability for new learning. Whether a cognitive predisposition or consequence of the neurotoxic effects of prolonged substance use (or both), learning and memory deficits likely play a role in the maintenance of implicitly learned associations. For example, in comparison to healthy control subjects, people with SUDs in one study were more likely to develop habitual responding to stimulus response contingencies that interfered with the learning of new response contingencies [19]. In contrast, Sebold and colleagues [20] found that chronic alcohol use was associated with impaired goal-directed responding, but not increased habitual responding. Lengthier discussion about addiction related learning and memory impairment is beyond the scope of this review, but impairment is likely influenced by the chronicity of substance use, duration of time since last use, and quantity and type of substances used.

Cognitive Bias Modification

Implicit measures of cognitive bias associated with drug-and-alcohol-related stimuli have also been examined as platforms for cue exposure and counter-conditioning methods. Collectively, these approaches are referred to as cognitive bias modification. Primarily, attentional bias and approach-avoidance bias measures have been adapted for this purpose and examined for their effectiveness in reducing cue responding and other clinically relevant outcomes. Recent studies provide evidence in support of [21], in partial support of [22]•, and contrary to [23, 24]• the clinical utility of cognitive bias modification.

One important challenge associated with cognitive bias modification appears to be the increasing complexity of implicit responding over the course of addiction. In other words, addicted individuals develop sophisticated and individualized associative networks that selectively activate information processing (e.g., heuristics, attributions, appraisals, schemata, etc.) and complicate retraining as a therapeutic strategy. For example, Woud and colleagues [25] found that alcohol-dependent patients in their study demonstrated biased interpretation processes, in which alcohol-related contexts were attributed to emotionally relevant but ambiguous scenarios. Findings from these investigators also showed that coping motives were associated with the attribution of negatively valenced scenarios to alcohol-related contexts [26]; which provides additional evidence that predictive cues may trigger negatively reinforced avoidance responding. However, when Woud and colleagues [27] examined the malleability of alcohol interpretation bias using a cognitive bias modification paradigm, they found that biased interpretations could be increased but not decreased via the experimental parameters used in their study.

See the annotated bibliography for descriptions of other studies examining dispositional drinking motives associated with implicit associations [28]•• and heuristic appraisal of alcohol effects [29]••; and for other potential therapeutic strategies for targeting implicit responding, including memory reconsolidation [30]•• and cognitive reappraisal in the context of memory retrieval-destabilization [31]••.

Explicit Cognitive Processes: Metacognition

In contrast to the automatic and stimulus-driven processes associated with the implicit system, the explicit system includes higher order brain functions that are non-automatic and effortful. The compulsion to use substances, or lack of control over substance use, may be regarded as an imbalance between the implicit and explicit systems, in which explicit processes aimed at self-regulation are unable to control urge-related responding. The processes subsumed under the explicit system are neither universally designated nor operationalized, but have been conceptualized as having two subsystems [1, 3, 32] that are referred to here as “metacognition” and “executive function.”

Metacognition involves the critical awareness, knowledge and control of our own cognitive processes, reasoning and decision-making. Recent studies support an association between metacognitive processing deficits and addiction [33, 34]••. Although one recent study reported a relationship between maladaptive metacognitive style and addiction potential in college students [35]•, there is little evidence at present to comment on the comparative influence of predisposing cognitive factors versus acquired deficits on metacognitive functioning.

As opposed to a cognitive deficit or weakness, implicit processes may directly interfere with metacognitive awareness of reasoning and decision-making about drugs and alcohol. The rational mind relies on heuristics and other mental short cuts (e.g., attributions, appraisals, schemata) representing implicitly activated information processing to avoid the need to relearn previously acquired knowledge. However, these automatic processes foster an irrational persistence of belief – e.g., positive expectancies regarding continued substance use – that contributes to the maintenance of addiction. A recent paper provides a detailed review and commentary regarding automatically triggered thoughts in addiction, and how they may, furthermore, interact with explicit cognitive processes to intensify cue-reactive responding based on Elaborated Intrusion Theory [36].

Mindfulness

Several constructs examined in recent addiction literature are conceptually similar to metacognitive processes, including self-reflection and rational decision-making [1], insight and self-awareness [37, 38], and appraisal of affective and motivational significance [37, 39]. In particular, a large amount of recent literature has been devoted to the construct of mindfulness [40], which may be defined as focused awareness on the present moment.

A recent meta-analysis of thirty-nine studies [41] identified a relationship between indices of substance use severity and mindfulness domains based on the Five Facet Mindfulness Questionnaire [42]. In that study, mindfulness domains including acting with awareness, non-judgment, and non-reactivity (but not observing or describing) were negatively associated with problem substance use.

Interventions aimed at increasing mindfulness have also been examined as a therapeutic strategy for the treatment of addiction. A recent meta-analytic review of twenty-four studies provides evidence for the effectiveness of mindfulness-based interventions in reducing substance use [43]. Furthermore, in a recent clinical trial, the integrated delivery of mindfulness-based and relapse-prevention interventions showed added benefit over standard relapse prevention in reducing long-term substance use [44]. These investigators speculate that mindfulness practices may support long-term outcomes by strengthening the ability to monitor and cope with dysphoria associated with negative hedonic processing in addiction. In the context of implicit processes, mindfulness may also increase awareness of automatic thinking that can interfere with thoughtful consideration about continued substance use. Recent papers also discuss other mechanisms through which enhanced mindfulness is theorized to improve SUD treatment outcomes [45, 46].

Explicit Cognitive Processes: Executive Function

Executive function represents the second major sub-division of the explicit system, and broadly includes mental operations necessary for the planning, execution, and monitoring of goal-directed behavior. Whereas metacognition includes subjective processes, the executive system is regarded to include mental operations that are value free, purposeful, and algorithmic [32]. The processes subsumed under executive function are not universally operationalized, but are typically measured using performance based neuropsychological tests or cognitive neuroimaging paradigms. Inventory questionnaires of executive function measure subjective self-appraisal of ability [47]• that, like performance measures, appear to be state dependent [48], but may also be influenced by the reliability of the historian.

Functional organization of the executive system is complex and composed of modular and superordinate processes. Execution of more complex goal-directed activities (e.g., self-control, decision-making, problem solving, and concept formation) requires multiple subordinate executive functions that include purposeful manipulation of core cognitive processes (e.g., working memory and selective attention). For example, executive processes associated with inhibitory control, error detection (or self-monitoring), and error correction (or self-adjustment) appear to comprise a dissociable yet interactive set of elements responsible for self-control [49]. These dissociable elements, furthermore, depend on other parallel and subordinate executive functions (e.g., initiation, scanning, selective attention, working memory, maintenance of set, pattern recognition, response selection, flexibility, switching, etc.). Similar cognitive processes are posited to exist for the control, or regulation, of cognitive, behavioral, and emotional responding.

Although profiles of executive dysfunction vary by substance [50], combinations of substances [51], and duration of abstinence [52], failure of the executive system to override drug-or-alcohol-related impulses is regarded as central to the development of addiction [53]. In other words, fundamental to cognitive conceptualizations of addiction is the dynamic opposition between self-control and urge-related responding. The etiology of executive control failure is commonly examined in three contexts: (1) predisposing cognitive vulnerabilities and personality characteristics (e.g., attention deficit hyperactivity disorder, and other trait-related impulse control deficiencies), (2) neurodevelopmental immaturity of brain areas associated with executive control in adolescents and young adults, and (3) the neurotoxic and neuroadatptive changes associated with chronic substance use. Failure of executive control attributable to multiple etiologies appears to be most strongly associated with addiction [54].

Impulsivity

Among the constructs most commonly associated with executive control failure is impulsivity. Due, in part, to its flexible measurement and multicausal etiology, there is no consensus regarding its dimensionality or the respective clinical relevance of core components or subtypes. Recent papers have contributed to increased knowledge about impulsivity dimensionality through data classification methods [55] and computational modeling [56]; and to the clinical relevance of core components through mediation analysis [57, 58]. In addition to studies examining predominantly data-driven analyses of impulsivity, expert judgment has also played an important role in providing evidence for the content-related validity of critical impulsivity subtypes and dimensions [59, 60].

A significant amount of recent research has also examined the relationship between impulsivity and its many associated constructs, including novelty seeking [57], risk taking [61], delay discounting [51], delay of gratification [62], impulsive choice or decision-making [58] and response inhibition [50, 63]. A recent paper by Bickel and colleagues [64] uniquely integrates many constructs associated with impulsivity through their elaboration of competing neurobehavioral systems theory [65]. Among the benefits of their model is that it meets previously suggested criteria for assessing the utility of impulsivity-related models of addiction [66]. Specifically, Bickel and colleagues [64] propose a theory-driven two-factor model (i.e., based on the dynamic opposition of self-control and urge-related responding in addiction) that is supported by neural evidence and provides a balance of explanatory power, parsimony and integration of evidence.

Relevance of Executive Function in the Treatment of Addiction

The strengthening of the inhibitory control neural network was recently identified as a possible common therapeutic mechanism across addiction treatment modalities, even when control processes are not specifically targeted [14, 67]. Thus, while the remediation of control processes is a valuable therapeutic approach, indirect relationships between self-control and treatment outcome are important to consider in efforts to improve treatment effectiveness. For example, a recent study showed that promoting greater metacognitive level construal of one’s smoking induced greater inhibitory control that mediated a reduction in cigarette consumption [68]. Another recent paper describes self-control strategies relevant to addiction, in which metacognitive processes related to situational awareness and prediction of self-control exertion are enlisted to minimize exposure to drug-and-alcohol-related cues [69].

Important indirect relationships between self-control and treatment outcome may also involve the enlistment of parallel and subordinate processes. One promising therapeutic approach involves working memory training –i.e., neurocognitive rehabilitation aimed at increasing storage capacity for, and ability to, hold, process, and manipulate information in the present. Working memory training has been shown to decrease delay discounting among stimulant addicts [70], and is posited to build self-control capacity [71] and improve efficacy of existing treatments when delivered adjunctive to standard care [72].

The use of neurocognitive rehabilitation strategies in addiction, however, is an area in its relative infancy. Executive and other core cognitive dysfunction in addiction includes deficits that may hinder the learning and effective application of skills and strategies taught in standard addiction treatment. Further research is needed to determine if delivering adjunctive neurocognitive rehabilitation of a broader set of executive and cognitive domains can enhance standard addiction treatment effectiveness.

Conclusions

Cognitive mechanisms of addiction may be broadly conceptualized as three sets of mental processes. The implicit system includes automatic and stimulus-driven processes. Metacognition and executive function are two major subdivisions of the explicit system that respectively represent subjective processes and value-free, purposeful mental operations. Fundamental to cognitive models of addiction is the gradual strengthening of implicitly developed urge-related responding that progressively overwhelms effortful cognitive processes aimed at self-control. Automatic processes can also disrupt substance use-related metacognitive self-awareness. Promising new therapeutic strategies target different cognitive mechanisms of addiction. Evidence suggests that the reduction of reward pathway sensitivity and strengthening of inhibitory control may be common to successful outcomes across treatment modalities. However, indirect relationships between control processes and treatment outcome are important to consider in order to improve treatment effectiveness. Neurocognitive rehabilitation delivered adjunctive to standard addiction treatment has shown some success, but more research is needed to adequately assess its effectiveness.

Figure 1. Visual representation of the cognitive mechanisms of addiction.

Figure 1

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(A) Implicit, or automatic, cognition includes classically and operantly conditioned responses that strengthen over time, resulting in increased cue salience and conditioned response complexity; (B) Metacognition is a subdivision of explicit, or controlled, cognitive processes, and includes subjective, self-reflective and rational thinking, and appraisal and superordinate regulation of executive function. Complex conditioned responses (i.e., automatic information processing) happen outside of metacognitive self-awareness and can bypass reflective thinking. (C) Executive function represents the second sub-division of the explicit system, and includes mental operations that are value free, purposeful, and algorithmic. Fundamental to cognitive conceptualizations of addiction is the dynamic opposition between self-control and implicitly strengthened urge-related responding.

Highlights.

  • Cognitive mechanisms of addiction include automatic and controlled processes.

  • Strengthening of automatic and weakening of controlled processes are multicausal.

  • Automatic processes can disrupt substance use-related self-awareness.

  • Promising new therapeutic strategies target various mechanisms of addiction.

  • More research is needed to examine effectiveness of neurocognitive rehabilitation.

Acknowledgments

This work was supported by the National Institutes of Health [grant number K23DA027045], and The Peter and Elizabeth C. Tower Foundation [grant number AGR-1505-02589]

Footnotes

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Conflict of interest

The author has no conflicts of interest to report.

1

These authors present cognitive models of addiction whose elements are not necessarily named the same, but include similar characteristics. The labels, implicit, metacognitive, and executive were selected for this review because they appear with greater frequency as PubMed keywords in the context of addiction than do alternative search terms of similar meaning.

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