Craving to quit: Psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions.

Probably not a substantial claim: may not pass S4 (based).

Ancient Buddhist models closely resemble contemporary models of addiction, particularly in their shared emphasis on operant conditioning through positive and negative reinforcement.

“Interestingly, these early models show remarkable similarity to current models of the addictive process, especially in their overlap with operant conditioning (positive and negative reinforcement).”

May combine two claims.

Repeated smoking may make the addictive loop automatic or habitual, producing cue-induced behavior largely outside conscious awareness and control.

“Through repeated smoking, this addictive loop may become automated or habitual, leading to cue-induced behavior that is largely outside of consciousness, let alone conscious control”

May combine two claims.

Affective bias underlies emotional distortions of attention and memory, preventing accurate assessment of the present moment and appropriate action.

“Affective bias underlies emotional distortions of attention and memory (Elliot et al 2010), preventing individuals from accurately assessing what is happening in the present moment, and acting accordingly.”

• cites Elliot et al 2010Not checked yet

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May combine two claims.

Even after craving has arisen, mindful awareness can stop further aversive reactions to the unpleasant feelings of craving and reduce habitual attempts to escape that unpleasantness.

“even when craving has already arisen, mindful awareness can prevent further cycles of aversive reaction to the unpleasant feelings associated with this craving, and thus reduce habitual reactions that arise in an attempt to escape this unpleasantness.”

May combine two claims.

Current behavioral strategies may not target the core addictive loop; avoidance reduces input and substitutes bypass the loop, but the loop itself may remain dormant and later reactivate.

“Further, these strategies may not actually target the core addictive loop (e.g. avoidance of cues decreases input into the loop, Figure 1b grey arrows), while substitute behaviors (e.g. eating carrot sticks or candy) circumvent the loop (Figure 1b blue arrows).”

• Also stated in: § Why do we need new treatments for smoking? Limitations of current cessation treatments · hedged

  “Importantly, these strategies, at least in theory, may not diminish the loop itself (Figure 1b black arrows), instead leaving it dormant to reactivate at a later time”

May combine two claims.

Nicotine patch therapy helps nicotine withdrawal and background craving but not cue-induced craving.

“nicotine patch therapy has shown benefits for nicotine withdrawal and background craving (which in contrast to cue-induced craving fluctuates slowly over time (Ferguson & Shiffman, 2009)), but not for cue-induced craving”

• cites Ferguson & Shiffman, 2009Not checked yet

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May combine two claims.

Early Buddhist dialogues do not report the Buddha as claiming there is no self; both the view of no self and the view of a self are said to lead to suffering.

“nowhere in the early Buddhist dialogues is the Buddha reported as claiming that there is no self; on the contrary, both the view that there is no self and the view that there is a self are said to lead to suffering”

May combine two claims.

Applying mindfulness in Joe's case may not produce positive appraisal but will let him be aware of craving as it actually is and of what feeding it actually gives him.

“Thus, the application of mindfulness in Joe Smoker’s case (see Text Box 1) may not result in positive appraisal, but will allow him to clearly be aware of feelings of craving as they actually are, and what he actually gets from feeding them”

Classified as probably not a substantial claim.

The early Buddhist therapeutic model explains suffering, its cause, the possibility of cure, and the interventions needed for cure.

“The therapeutic model offered in early Buddhist texts aims at explicating suffering, its cause, the possibility of a cure, and the interventions required to achieve that cure.”

May combine two claims.

Mainstream behavioral smoking cessation treatments teach cue avoidance, positive affect, distraction from cravings, substitute activities, and social support.

“Mainstay behavioral treatments for smoking cessation have focused on teaching individuals to avoid cues, foster positive affective states (e.g. practice relaxation or physical exercise), divert attention from cravings, substitute other activities for smoking, and develop social support mechanisms”

• cites Fiore et al., 2000Not checked yet

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• cites Lando, McGovern, Barrios, & Etringer, 1990Not checked yet

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May combine two claims.

Mindfulness does not stop a person from being a person but stops them from taking things personally.

“In other words, mindfulness does not stop one from being a person, but rather from taking things personally.”

May combine two claims.

Satisfaction from feeding craving is short-lived because of nicotine's short half-life and biological effects, so dissatisfaction, stress, or suffering inevitably returns.

“As the state of satisfaction from feeding the craving is short-lived, given the nature of the short half-life of nicotine and its biological effects (Imperato et al., 1986), the passing away of this mind-state inevitably ensues, leading to dissatisfaction, stress or suffering once again.”

• cites Imperato et al., 1986Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

A desire or craving then arises as a psychological urge to act or perform a behavior.

“Subsequently, a desire or craving arises (definition: “an intense, urgent, or abnormal desire or longing” ) as a psychological urge to act or perform a behavior”

May combine two claims.

The self-propagating nature of the addictive loop matches both modern operant and classical conditioning models and pre-modern models of craving and attachment.

“Third, its self-propagating nature aligns not only with current models of operant and classical conditioning, but pre-modern psychological models of the causes of human suffering: craving and attachment.”

Classified as probably not a substantial claim. May combine two claims.

Craving aims at continuing pleasant feeling tones or ending unpleasant ones.

“The craving is for the continuation of pleasant, or the cessation of unpleasant feeling tones, respectively.”

May combine two claims.

A person learns that smoking reduces unpleasant feelings such as negative affect and craving, forms a behavior pattern around those affective reactions, and eventually becomes identified with it.

“an individual learns that smoking (action) decreases unpleasant feelings such as negative affect and craving, and s/he starts forming a behavior pattern related to these affective reactions, that with repetition, s/he eventually becomes identified with”

Classified as probably not a substantial claim.

The valence of affective tone is conditioned by associative memories formed from earlier experiences.

“The valence of this affective tone is conditioned by associative memories that were formed from previous experiences”

May combine two claims.

In the modern model, when Joe encounters stress or withdrawal, his brain interprets it as unpleasant, he wants it gone, craving to smoke arises, and smoking reinforces the habituated affective reaction.

“when Joe Smoker, who has learned to associate smoking with the reduction of stress and/or the temporary abatement of withdrawal states (#6), encounters a stressful situation or nicotine withdrawal symptoms such as irritability, restlessness and agitation (#1), his brain interprets these as unpleasant (#2).”

• Also stated in: § An early model of addiction · plain

  “He wants the unpleasant feeling to go away, and consequently gets a craving to smoke (#3). When he smokes, he reinforces the habituated reaction to affective experience”

Classified as probably not a substantial claim. May combine two claims.

In traditional presentations, practices such as loving-kindness are distinct from mindfulness, which involves not feeding desire or discontent toward external objects.

“In traditional presentations, however, these practices are clearly delineated from the practice of mindfulness (satipatthana), which involves not feeding desire or discontent in regard to external objects”

Classified as probably not a substantial claim.

Suffering is cured by relinquishing, releasing, and letting go of craving.

“It is through the “relinquishment, release, and letting go” of craving that suffering is cured”

Classified as probably not a substantial claim.

Relinquishing craving may be achieved through a simple psychological intervention.

“Remarkably, this relinquishment of craving may be achieved through a simple psychological intervention.”

May combine two claims.

Careful attention to present-moment experience can broaden awareness and allow new appraisals of life situations.

“By decoupling pleasant and unpleasant experience from habitual reactions of craving and aversion, careful attention to present moment experience can function to bring a broadening or spaciousness of awareness that allows new appraisals of life situations.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Ruminating about smoking and planning the day around cigarette access likely engages self-referential brain circuits and further fuels the process.

“He may even begin to ruminate about smoking and start planning his day around access to cigarettes, which, as we will see later, likely engages brain circuits involved in self-referential processing, thus further fueling this process.”

May combine two claims.

Evidence for the core links of the addictive loop and the modest long-term efficacy of current treatments together support the need for innovative treatments that directly dismantle the loop.

“The experimental evidence for the core links of the addictive loop and the modest long-term efficacy of current treatments provide compelling evidence for the need for innovative treatments that directly dismantle this loop instead of treating “around” it”

Classified as probably not a substantial claim.

Buddhist psychological models separate bodily, affective, cognitive, volitional, and conscious parts of emotional reactions to triggers.

“Buddhist psychological models distinguish bodily, affective, cognitive, volitional, and conscious components of emotional reactions to triggers.”

May combine two claims.

Cue exposure intended to reduce conditioned responses may not adequately disrupt the addictive loop and may instead create different situation-specific associations.

“Even cue exposure that aims to decrease the conditioned responses may not adequately disrupt the addictive loop, instead leading to different associations that are also situation-specific”

• cites Bouton, Westbrook, Corcoran, & Maren, 2006Not checked yet

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• cites Niaura et al., 1999Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Craving motivates action and fuels the birth of self-identity around the sense object, laying down an action-outcome link in memory.

“This craving motivates action (#4) and fuels the “birth” of a self-identity around the sense object (#5), creating a link between action and outcome that gets laid down in memory (#6).”

Classified as probably not a substantial claim.

By paying careful attention to experience, one can see that perceptions and affective reactions are separate from craving, aversion, and the thoughts they motivate.

“through paying careful attention to one’s own experience, the Buddhist accounts claim, one can see that perceptions and associated affective reactions (affective tone) are separate from – and indeed separable from – craving and aversion, as well as the elaborate thought processes these can motivate”

• cites Grabovac et al., 2011Not checked yet

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May combine two claims.

Craving and aversion are themselves unpleasant, so people often develop aversive reactions to their own craving and aversion.

“states associated with craving and aversion are themselves unpleasant, so that individuals often develop aversive reactions towards their own craving and aversion.”

May combine two claims.

Perception of an object is shaped by prior experience, and related memories create habits or dispositions that update future perception.

“The perception of an object is influenced by previous experiences, and the formation of related memories leads to habits or dispositions – consequently ‘updating’ how perception will function in the future”

Classified as probably not a substantial claim.

When environmental cues are registered through the senses, an affective tone automatically arises, usually felt as pleasant or unpleasant.

“when environmental cues are registered through the senses (and here thoughts are considered to be within the same category as the standard five senses, Figure 2, #1), an ‘affective tone’ automatically arises that is typically felt as pleasant or unpleasant”

May combine two claims.

Mindfulness does not prevent the cognitive construction of self-identity needed for functioning but instead targets affective bias.

“We postulate that mindfulness does not prevent the cognitive construction of self-identity necessary for functioning in the world, which traditional Buddhists call the relative level of self, but instead targets affective bias.”

Classified as probably not a substantial claim. May combine two claims.

Suffering is caused by many kinds of craving, especially craving for sense pleasure.

“Suffering is caused by many varieties of craving, or more literally translated, ‘thirst’; of particular relevance here is “craving for sense pleasure”.”

Classified as probably not a substantial claim.

In dependent origination, craving arises from automated affective reactions to perceptual stimuli.

“In this process, craving is said to result from a process based in automated affective reactions to perceptual stimuli.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Mindfulness training has been adapted for Western use in forms such as Mindfulness-based Stress Reduction, Mindfulness-based Cognitive Therapy, and Mindfulness-based Relapse Prevention.

“Derived from Buddhist practices, mindfulness training has been adapted for use in Western cultures, taking forms such as Mindfulness-based Stress Reduction, Mindfulness-based Cognitive Therapy (combined with Cognitive Therapy for depression relapse prevention), and Mindfulness-based Relapse Prevention (combined with Relapse Prevention for addiction treatment)”

• cites Bowen et al., 2009Not checked yet

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• cites Kabat-Zinn, 1982Not checked yet

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• cites Teasdale et al., 2000Not checked yet

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May combine two claims.

Mindfulness lets practitioners clearly see what drives their behavior and whether it moves them toward or away from their goals.

“From this perspective, mindfulness allows practitioners to clearly ascertain what is driving their behavior, and whether or not it is moving them toward or away from their goals.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Each time Joe smokes, he re-engages and reinforces the loop, producing further rounds of the process.

“Importantly, each time Joe smokes, he re-engages and reinforces this loop, resulting in a subsequent rounds of this process (#7)”

May combine two claims.

By changing one's relationship to craving through non-judgmental awareness, one removes fuel from it, so craving and related identity formations eventually burn out.

“Through changing one’s relationship to craving, via non-judgmental awareness, one begins to remove the fuel from its fire, such that over time, craving and its resultant identity formations eventually burn out or die off.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Theoretically, this simpler and more focused approach may improve mastery of conceptual and behavioral skills and make effects more durable in a brief treatment.

“Theoretically, this simpler, more focused approach may facilitate both conceptual and behavioral skills mastery and durability of effects in a relatively brief treatment.”

May combine two claims.

The mechanism of action is attenuation of the affective bias underlying the reaction of taking things personally, rather than a change in self-related thoughts.

“we postulate that the mechanism of action here is the attenuation of affective bias underlying the reaction of ‘taking things personally’, rather than a change in self-related thoughts.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These data are promising, but more confirmatory studies are needed because many studies were pilot, small, or used wait-list or other suboptimal controls.

“These data are promising, although more confirmatory studies are needed, as many of the studies were of pilot nature, small, and/or employed wait-list or other sub-optimal control conditions.”

May combine two claims.

Gifford et al. randomized 76 participants to nicotine replacement or ACT and found 24-hour abstinence of 33% and 35% after treatment and 15% and 35% at one-year follow-up.

“For example, Gifford et al. randomized 76 participants to nicotine replacement or ACT (seven individual + seven group sessions) and found 24-hour abstinence of 33% and 35% respectively after treatment and 15% and 35% at one year follow-up”

• cites Gifford et al., 2004Not checked yet

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May combine two claims.

Mindfulness training has only recently been evaluated for addictions and, more specifically, for smoking.

“Mindfulness training has only recently been evaluated in the treatment of addictions (Bowen et al., 2009; Brewer et al., 2009; Zgierska et al., 2008), and more specifically smoking (Cropley, Ussher, & Charitou, 2007; Davis, Fleming, Bonus, & Baker, 2007).”

• cites Bowen et al., 2009Not checked yet

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• cites Brewer et al., 2009Not checked yet

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• cites Zgierska et al., 2008Not checked yet

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May combine two claims.

Mindfulness training has been incorporated into addiction treatments such as Acceptance and Commitment Therapy and Relapse Prevention and has shown preliminary success.

“Mindfulness training has been incorporated into several approaches for addiction treatment, such as Acceptance and Commitment Therapy (ACT) (Hayes, Luoma, Bond, Masuda, & Lillis, 2006) and Relapse Prevention (Mindfulness-based Relapse Prevention (Bowen et al., 2009; Brewer et al., 2009)), and has shown preliminary success therein.”

• cites Hayes, Luoma, Bond, Masuda, & Lillis, 2006Not checked yet

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• cites Bowen et al., 2009Not checked yet

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• cites Brewer et al., 2009Not checked yet

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Classified as probably not a substantial claim.

Mindfulness has been operationalized as two components: maintaining attention on immediate experience and maintaining an accepting attitude toward that experience.

“It has been operationalized to include two distinct components: 1) maintaining attention on the immediate experience; and, 2) maintaining an attitude of acceptance toward this experience”

• cites Bishop et al., 2004Not checked yet

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May combine two claims.

Studies of mindfulness training for addictions remain preliminary; a recent review found only one of 22 trials was randomized.

“Studies on the efficacy of mindfulness training for addictions remain preliminary: a recent review of trials that included mindfulness training reported only one of 22 was randomized”

• cites Zgierska et al., 2009Not checked yet

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May combine two claims.

In treatment-seeking smokers, each standard deviation increase in craving scores on the target quit date was associated with a 43% higher risk of lapsing on that day and a 65% higher risk on the following day.

“in a study of treatment-seeking smokers, for each standard deviation increase in craving scores on the target quit date, the risk of lapsing rose by 43% on that day, and 65% on the following day (Ferguson, Shiffman, & Gwaltney, 2006).”

• cites Ferguson, Shiffman, & Gwaltney, 2006Not checked yet

  Not checked in the free run.

May combine two claims.

Mindfulness training is a promising though still emerging treatment for addictions.

“these studies suggest that mindfulness training is a promising though still emerging treatment for addictions.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

These two components may be two sides of the same coin because when attention dominates, self-referential processing drops away, and bare awareness is by definition free of judgment.

“These may even be viewed as ‘two sides of the same coin’ because when attention becomes predominant, self-referential processing (and thus judging or non-acceptance) drops away; ‘bare’ awareness or attention is by definition free from judgment”

Probably not a substantial claim: may not pass S3 (load-bearing).

Common features of mindfulness treatments include training attention to detect and modify one's relationship to automatic thought patterns.

“Common features of these treatments include the training of attention to detect and modify an individual’s relationship to automatic thought patterns, among others.”

Classified as probably not a substantial claim. May combine two claims.

The cross-sectional design of that study and possible self-selection bias mean its findings should be interpreted with caution.

“These findings should be interpreted with caution, as this study was cross-sectional, and could be influenced by self-selection bias.”

• cites Brewer, Worhunsky, et al., 2011Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The two primary nodes of the default mode network are the medial prefrontal cortex and the posterior cingulate cortex.

“There are two primary nodes of the DMN, the medial prefrontal cortex and the posterior cingulate cortex (PCC).”

May combine two claims.

High rates of comorbidity and possibly shared associative learning loops suggest overlap in neurobiological mechanisms of stress, affective-related, and substance use disorders, and that mindfulness training may target core features shared among these.

“The high rates of comorbidity and possibly shared associative learning loops suggest that there may also be overlap in the neurobiological mechanisms of stress, affective-related and substance use disorders, and that mindfulness training may target core features that are shared among these (Brewer et al., 2010).”

• cites Brewer et al., 2010Not checked yet

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May combine two claims.

These DMN nodes are temporally correlated with peripheral nodes and anti-correlated with brain regions involved in self-monitoring (dACC) and cognitive control (dlPFC).

“These have been shown to be temporally correlated with a number of peripheral nodes, and anti-correlated with brain regions involved in self-monitoring (the dorsal anterior cingulate cortex, dACC), and cognitive control (the dorsolateral prefrontal cortex, dlPFC)”

• cites Andrews-Hanna, Reidler, Sepulcre, Poulin, & Buckner, 2010Not checked yet

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• cites Fox et al., 2005Not checked yet

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May combine two claims.

Mindfulness-Based Relapse Prevention attenuated the link between depressive symptoms and craving at 2-month post-treatment follow-up, and this effect predicted diminished substance use at 4-month follow-up.

“Mindfulness-based Relapse Prevention attenuated the link between depressive symptoms and craving at a 2-month post-treatment follow-up, an effect that predicted diminished substance use at a 4-month follow-up time-point.”

• cites Witkiewitz & Bowen, 2010Not checked yet

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May combine two claims.

Taken together, these results suggest mindfulness training may help individuals develop tolerance to craving itself, thereby over time dismantling the addictive loop through dis-identification with the object or dismantling of self-identity.

“Taken together, these results suggest that mindfulness training may indeed help individuals develop a tolerance to craving itself, thus over time acting to dismantle the addictive loop through a dis-identification with the object or dismantling of self-identity.”

Classified as probably not a substantial claim.

These findings fit the hypothesis that if an individual smokes due to habitually responding to triggers, mindfulness training would help them disengage from self-identified patterns.

“These findings fit with the hypothesis that if an individual smokes due to habitually responding to triggers, be they ruminative thought patterns or negative affect and unpleasant bodily sensations from nicotine withdrawal, that MT would help them disengage from these self-identified patterns.”

May combine two claims.

The more individuals decouple craving from behavior through practicing mindfulness, the less they foster the addictive loop, leading to later dying away or cessation of craving itself.

“And the more individuals are able to decouple craving from behavior through practicing mindfulness, the less they foster the addictive loop, leading to the later dying away or cessation of craving itself.”

May combine two claims.

Modern treatments such as mindfulness training based on Buddhist models are beginning to show preliminary efficacy in the treatment of addictions, and may do so through changing one's relationship to core addictive elements such as craving.

“Modern treatments, such as MT that are based on these Buddhist models are beginning to show preliminary efficacy in the treatment of addictions, and may be doing so through changing one’s relationship to core addictive elements such as craving.”

May combine two claims.

A positive correlation between craving and cigarette use reappeared at two weeks follow-up (r = 0.47, p < 0.02) and grew stronger at three and four months after treatment initiation (r = 0.79, p < 0.001; r = 0.77, p < 0.001).

“A positive correlation reappeared again at follow-up two weeks later (r = 0.47, p < 0.02), and grew stronger both three and four months after treatment initiation (r = 0.79, p < 0.001; r = 0.77, p < 0.001)”

• cites Elwafi et al., under reviewNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Stress, anxiety, and depression are highly comorbid with substance use disorders; major depressive disorder has a lifetime co-occurrence prevalence of 30-43%.

“Stress, anxiety and depression have been shown to not only be highly comorbid with substance use disorders (e.g. major depressive disorder has a lifetime prevalence of co-occurrence ranging from 30–43% (Davis et al., 2005; Lopez & Mathers, 2006))”

• cites Davis et al., 2005Not checked yet

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• cites Lopez & Mathers, 2006Not checked yet

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May combine two claims.

The increased connectivity patterns in experienced meditators were present both at baseline and during meditation, suggesting that a new default mode had been established.

“However, the observed increased connectivity patterns seen in experienced meditators were present both at baseline and during meditation, suggesting that a ‘new’ default mode had been established.”

May combine two claims.

Increased home practice was correlated with decreased cigarette use for formal practice (r = −0.44, p < 0.02) and informal practice (r = −0.48, p < 0.01).

“Brewer et al. initially found that increased home practice was correlated with decreased cigarette use for both formal (r = −0.44, p < 0.02) and informal practice (r = −0.48, p < 0.01) (Brewer, Mallik, et al., 2011).”

• cites Brewer, Mallik, et al., 2011Not checked yet

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May combine two claims.

Because conflict monitoring (dACC) and cognitive control regions (dlPFC) are important in self-control, addictions, and treatment outcomes, these findings suggest mindfulness training may fundamentally alter brain activity and connectivity patterns in networks important for perpetuation of addictive behaviors.

“As conflict monitoring (the dACC) and cognitive control regions (the dlPFC) have been shown to be important in self-control, addictions and treatment outcomes (Brewer, Worhunsky, Carroll, Rounsaville, & Potenza, 2008; Hare, Camerer, & Rangel, 2009; Kober et al., 2010), these findings suggest that MT may fundamentally alter brain activity and connectivity patterns in networks that are important for”

• cites Brewer, Worhunsky, Carroll, Rounsaville, & Potenza, 2008Not checked yet

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• cites Hare, Camerer, & Rangel, 2009Not checked yet

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• cites Kober et al., 2010Not checked yet

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May combine two claims.

Mindfulness training may, at least in theory, confer advantages over other approaches for addictions, especially in cases of co-morbid disorders and when individuals are stuck in negative or positive reinforcement loops.

“MT may, at least in theory, confer advantages over other approaches for addictions, especially in cases of co-morbid disorders, and when individuals are particularly stuck in negative (or positive) reinforcement loops.”