Craving is a crucial category of the disease of addiction. It was added as a core symptom of substance use disorder to the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.
In 2016, former Surgeon General Vivek Murthy described a three-stage addiction cycle. According to that model, the cycle begins with the “preoccupation/anticipation stage” in which a person may begin to seek substances again after a period of abstinence. This is commonly called “craving,” he writes in Facing Addiction in America.
In his new book The Craving Mind, addiction psychiatrist Judson Brewer explores the central role craving plays in developing a variety of addictive behaviors. Like other experts, Dr. Brewer views addiction as a maladaptive use of the reward-based learning process. Very often, the addiction stories of his patients would reveal the addiction cycle described by Dr Murthy.
“I could line up their habit loop in my head. Trigger. Behavior. Reward. Repeat. In addition, they used substances as a way to ‘medicate’; by being drunk or high, they could prevent (or avoid) unpleasant memories or feelings from coming up.”
In a basic sense, addiction is a form of B.F. Skinner’s operant conditioning in which the strength of a behavior is modified by the behavior's consequences. “Addiction rides an evolutionary juggernaut: every abused drug hijacks the dopamine reward system,” writes Brewer.
This hijacking doesn’t necessarily require a substance. In the chapter titled “Addicted to Distraction,” Brewer offers the reader a checklist for possible smartphone addiction which is a modified version of the eleven categories for substance use disorder in DSM-5. If checking your emails, your messages, and your Facebook page incessantly hijacks your dopamine reward system, the negative consequences might not be comparable to heroin use but the brain circuits involved are the same.
Brewer points out that the dopamine release typically causes a neuronal reaction called “phasic firing” which helps humans “learn to pair a behavior with a reward.” And this is where the magic happens, says Brewer.
“Once behavior and reward are paired, the dopamine neurons change their phasic firing pattern to respond to stimuli that predict rewards. Enter the trigger into the scene of reward-based learning.”
It is also important to note that the reward is experienced shortly after the stimulus or behavior while the negative consequences take much longer to emerge and are consequently ignored.
Be Mindful and Change Your Mind
If addiction is a reward-based learning process, part of the solution is obviously to unlearn the behavior but that is easier said than done. Unlearning a conditioned behavioral pattern always seems a lot harder than learning it. This is especially true for addiction, hence the high rates of relapse.
For Brewer the core method to build resilience to craving is mindful awareness. This can be achieved by a number of methods. Formal systems are Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) which combines the ideas of cognitive therapy with meditative practices and attitudes based on the cultivation of mindfulness.
Cognitive Behavioral Therapy (CBT) is a psychosocial intervention focusing on the development of personal coping strategies and changing unhelpful cognitions (thought patterns). Brewer describes the CBT approach as “catch it, check it, change it.”
One of the mindfulness exercises described in The Craving Mind is called RAIN:
R - recognize the craving for what it is
A - Allow it to be there (without judging or denying it)
I - investigate bodily sensation, emotions, thoughts
N - note what is happening from moment to moment without identifying with it
Non-identification is very important because “when we notice (and note) the physical sensations arising in our bodies that make up a craving, we become less caught up in the habit loop, simply through that observation.”
Mindful resilience becomes especially important in the face of stress because—as Dr Brewer puts it—the prefrontal cortex (executive function) “goes offline from stress.” Without the buffer of mindfulness, the stress-triggered craving will go unchecked by the prefrontal cortex and can lead to a relapse even years into sobriety. On the other hand, if checked in time by coping skills learned through CBT or mindfulness training, the trigger can be resisted and a relapse into substance use avoided.