The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders.

Impulsivity is considered a core feature of substance use disorders (SUDs), including personological (i.e., negative urgency, positive urgency, lack of premeditation) and neuropsychological (i.e., cognitive and motor disinhibition, impulsive choice) dimensions. Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone treatment is an effective intervention for alcohol use disorder (AUD) and other SUDs. However, there are no studies that have investigated changes in impulsivity levels during a DBT-ST program, especially testing the therapeutic effects of DBT skills. Twenty-nine patients with AUD and other SUDs were admitted to a 3-month DBT-ST program. Self-report (i.e., UPPS-P) and computerized neuropsychological (i.e., Attentional Network test; Go/No-Go task; Iowa Gambling Task) measures of impulsivity were administered at the beginning and end of the DBT-ST. Distress tolerance (DTS), mindfulness (MAAS, FFMQ) and emotion regulation (DERS) were also assessed pre- and post-intervention. The study included two age- and gender-matched control groups: (a) untreated patients with SUDs (N = 29); (b) healthy controls (HCs) (N = 29). Twenty-four (82.7%) patients concluded the DBT-ST program. Emotion-based forms of impulsivity significantly improved during the program. At the end of treatment, impulsivity levels were significantly lower than those of untreated patients with SUDs and they were not significantly different from HCs. Cognitive disinhibition significantly decreased during the treatment. The improvement in impulsivity was explained by pre- posttreatment changes in distress tolerance, mindfulness and emotion regulation. Motor disinhibition did not improve during the treatment. These findings supported the initial efficacy of the DBT-ST program for addressing different features of impulsivity among individuals with AUD and other SUDs. Future follow-up studies should demonstrate the role of impulsivity domains in long-term relapse prevention.

The Complexity of Impulsivity Dimensions among Abstinent Individuals with Substance Use Disorders.

Impulsivity is a complex construct that has been operationalized considering personality dimensions (e.g., negative urgency [NU], lack of perseverance [LPe], lack of premeditation [LPr], positive urgency [PU]), and neuropsychological processes (i.e., cognitive disinhibition, motor disinhibition, impulsive decision-making). Empirical research suggested that they could represent core features of substance use disorders (SUDs). However, there are no studies that have comprehensively assessed them among patients with SUDs. Furthermore, the quality of relationships among such domains remains unclear. The current case-control study included 59 abstinent patients with SUDs and 56 healthy controls (HCs). There were two independent assessment phases: i) the administration of UPPS-P impulsive behavior scale; ii) a computerized neuropsychological battery (i.e., Attentional Network Test, Go/No-Go task, Iowa Gambling task). Patients with SUDs reported higher levels of NU and PU than HCs. NU, LPe, and LPr were associated to the co-occurrence of multiple SUDs. Motor disinhibition was the core dimension of SUDs. Cognitive disinhibition and Impulsive decision-making were also associated to SUDs. Self-report and neuropsychological dimensions of impulsivity were not correlated within the clinical group. HCs showed significant associations among these domains of impulsivity. Impulsivity should be viewed as a complex system of personality traits and neuropsychological processes among individuals with SUDs.

Persistent Deficits in Self-Regulation as a Mediator between Childhood Attention-Deficit/Hyperactivity Disorder Symptoms and Substance Use Disorders.

BACKGROUND: The link between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) has been largely demonstrated. Some scholars have hypothesized that self-regulation mechanisms might play a key role in explaining this association. Objective(s): The current study tested the hypothesis that retrospective childhood ADHD symptoms might lead to more severe SUDs and this association should be mediated by current self-ratings of behavioral disinhibition, inattention, and emotional dysregulation among 204 treatment-seeking adults (male: 67.3%; female: 32.7%) with a primary diagnosis of alcohol use disorder and other SUDs. Methods: The mediational model was estimated through self-report measures of childhood ADHD symptoms (independent variable; WURS), current self-regulation mechanisms (mediators)-behavioral disinhibition (BIS-11 motor subscale), difficulties with attention regulation (MAAS) and emotion regulation (DERS)-and severity of SUDs (dependent variable; SPQ alcohol, illicit and prescribed drugs). Results: The analysis showed that alterations in the self-regulation system fully mediated the association between the severity of childhood ADHD symptoms and SUDs in adulthood. Behavioral disinhibition and difficulties in attention regulation were the most representative alterations in self-regulation processes that explained this association. Conclusions: These findings suggest it is useful to implement several therapeutic approaches (e.g. behavioral, mindfulness-based, and pharmacological) to increase the self-regulation abilities of children and adolescents with ADHD in order to reduce the probability of SUD onset in adulthood. However, future longitudinal neuroimaging and neuropsychological studies are needed to further support the role of self-regulation mechanisms in explaining the prospective association between childhood ADHD symptoms and SUDs in adulthood.

The investigation of mechanisms underlying addictive behaviors: a case-control study.

Background: The contradictory nature of behavioral addictions has sustained a nondefinitive debate regarding their construct validity. Objective(s): The current study aims at exploring mechanisms underlying two distinct classes of behaviors-behavioral addictions characterized by core alterations in reward processing systems (ARPS) and behaviors with a main function of maladaptive coping. Methods: This case-control study included 99 treatment-seeking individuals with a primary diagnosis of alcohol use disorder (male: N = 68; female: N = 31) and 74 healthy control (HC) subjects (male: N = 38; female: N = 36). The severity of maladaptive behaviors was measured through the Shorter PROMIS Questionnaire (SPQ). Latent mechanisms were assessed by the Disinhibition Domain of the Personality Inventory for DSM-5 (PID-5-DI) and the Acceptance and Action Questionnaire-II (AAQ-II). Results: The clinical group showed higher severity of behavioral addictions than HC. This difference was not replicated for the other class of maladaptive behaviors, except for compulsive buying. Ordinal regression analysis showed that the clinical group significantly predicted SPQ scores reflecting ARPS, SPQ shopping and starving subscales. This was not replicated for the overall SPQ score capturing maladaptive coping and binge eating behaviors. Controlling for PID-5-DI and AAQ-II scores, which were significantly associated to SPQ subscales, effects of the aforementioned clinical group were not significant. Conclusions: The study highlighted distinct and common mechanisms underlying different classes of maladaptive behaviors. Results supported future neuroscience research for clarifying the role of ARPS in compulsive sex and buying in order to consider them as addictive disorders.

DSM-5 Maladaptive Personality Domains among Treatment-Seeking Individuals with Alcohol Use Disorder: The Role of Disinhibition and Negative Affectivity.

Background: Dimensional models of personality and personality disorders (PDs) have been widely investigated among individuals with alcohol use disorders (AUD). Nevertheless, DSM-5 maladaptive personality domains showed mixed associations with AUD. Furthermore, no studies have explored the role of DSM-5 maladaptive personality domains on the comorbidity between AUD and different PDs. Objective(s): This study aims at investigating whether DSM-5 maladaptive personality dimensions could differentiate individuals with AUD from normative and healthy controls (HCs) subjects. The study also investigated relationships between these personality dimensions and AUD clinical features (i.e. onset, severity of concurrent substance use disorders), as well as their role in accounting for the comorbidity between AUD and PDs. Methods: This study administered the personality inventory for DSM-5 (PID-5) to 99 treatment-seeking individuals (male 68.8%; female 31.2%; age: 48.12 (14.32)) with AUD (41 AUD only; 58 AUD with PDs), comparing the participants' levels of PID-5 domains with normative data and the data from a HC sample (N = 40; male 50%; female 50%; age: 48.12 (14.32)). Results: Disinhibition and negative affectivity were relevant maladaptive personality dimensions of AUD, even when controlling for the impact of PD diagnoses. Disinhibition and negative affectivity were associated to the onset of AUD and the severity of concurrent substance use disorders. The co-occurrence of AUD and PDs is related to other two domains, namely antagonism and detachment. Conclusions: AUD is a complex psychopathological disorder in which both externalizing and internalizing aspects determine relevant clinical features.

Is craving a risk factor for substance use among treatment-seeking individuals with alcohol and other drugs use disorders? A meta-analytic review.

BACKGROUND: It is still unclear whether craving should be considered a key risk factor for substance-use behaviors (SUB) among treatment-seeking individuals with alcohol (AUD) and other drugs use disorders. Therefore, this study aims at clarifying this topic using a meta-analytic approach. METHODS: Cohen's d was computed as effect size (ES) measure. Heterogeneity of ESs was computed using the Q statistic and I2 index. The analyses also evaluated the impact assessment length on ESs. Furthermore, proximal effects of craving on SUB were compared to distal ones. The diagnoses of specific substance use disorders (SUDs), together with assessment instruments and research design were considered as additional moderators. RESULTS: Thirty-six independent studies were included for a total of 4868 treatment-seeking individuals with SUDs. Patients who used substances showed slightly higher levels of craving than abstinent ones. The heterogeneity of results was large and significant. The length of period of assessment was positively related to ESs. The analyses highlighted no differences between pooled ESs of proximal and distal impacts of craving on SUB. The diagnoses of SUDs were significant moderators. Considering AUD, assessment instruments and research design were additional moderators. CONCLUSIONS: Craving is a modest time-dependent proximal and distal risk factor for SUB among individuals with SUDs. Both the frequency of craving episodes and a heightened reactivity to craving cues are largely associated to SUB among individuals with AUD. Future studies should evaluate the mediating and moderating roles of self-regulatory mechanisms on the relationship between craving and SUB.

Mindful self-regulation of attention is a key protective factor for emotional dysregulation and addictive behaviors among individuals with alcohol use disorder.

Individuals with alcohol use disorder (AUD) and other substance use disorders (SUDs) frequently show co-occurrent behavioral addictions (BAs) (i.e., gambling and compulsive sex) and other inflexible behaviors (IBs) (i.e., compulsive buying and dysfunctional eating behaviors). The covariation of these conditions might be explained by a role of emotion dysregulation (ED) and executive dysfunctions. This study aims at investigating whether ED and self-regulation of attention (SRA) could be common processes that underpin BAs and other IBs among individuals with AUD. The study hypothesized that SRA should represent a key protective factor for the relationships between ED and BAs/IBs. The research included 319 treatment-seeking individuals with a primary diagnosis of AUD. Five independent multiple parallel mediational models were tested. Self-report instruments were administered in order to assess ED, BAs and other IBs, which represented independent and dependent variables respectively. SRA was self-report assessed and, it was considered the key mediator variable. The analyses highlighted significant total effects of ED on the severity of BAs and IBs. SRA fully mediated the relationships between ED and BAs/IBs, with exception of gambling. ED and SRA should be considered common dimensions that explain the covariation of BAs and IBs among individuals with AUD. SRA represents an adaptive form of emotion regulation that sustains the engagement in goal-oriented behaviors. Future neuroimaging and longitudinal studies are recommended in order to demonstrate the role of ED and SRA on development, maintenance and treatment of BAs and IBs among individuals with SUDs.

Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: the effect of emotion regulation and experiential avoidance.

BACKGROUNDS: Dialectical behavior therapy skills training (DBT-ST) is an effective treatment for alcohol use disorder (AUD). AUD frequently co-occurs with other addictive behaviors. OBJECTIVE: s: These secondary analyses of prior studies on the effectiveness of a 3-month DBT-ST program for AUD investigated pre- post-treatment changes in the severity of concurrent addictive behaviors. The study hypothesized that emotion regulation and experiential avoidance should be the key therapeutic mechanisms involved in the treatment of addictive behaviors. METHODS: The research included 186 individuals (110 males; 76 females) with a primary diagnosis of AUD. Mediational models were performed considering shorter PROMIS questionnaire subscales (i.e., gambling, sex, shopping, food binging, and starvation) as dependent variables. The difficulties in emotion regulation scale and acceptance and action questionnaire-II total scores were independent and mediator variables, respectively. RESULTS: Clinical variables significantly improved during the treatment, independent of baseline levels. Changes in emotion regulation showed significant total effects on improvements in addictive behaviors. Significant indirect effects of changes in experiential avoidance were detected considering compulsive buying and dysfunctional eating behaviors. CONCLUSION: The DBT-ST was a feasible treatment for several addictive behaviors frequently reported by individuals with AUD. The improvements in emotion regulation and experiential avoidance were relevant therapeutic mechanisms involved in the treatment of these conditions. Future controlled trials and follow-up studies are recommended to support the efficacy of DBT-ST as a stand-alone intervention for the treatment of different classes of addictive behaviors.

The therapeutic role of emotion regulation and coping strategies during a stand-alone DBT Skills training program for alcohol use disorder and concurrent substance use disorders.

Clinical trials on Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone intervention for alcohol use disorder (AUD) showed promising outcomes. Improvements in difficulties with emotion regulation (DER) played a mediating role on abstinence maintenance. However, the effect of DER, together with specific coping strategies, have not been considered yet in the treatment of clinical features associated to AUD and concurrent substance use disorders (CO-SUDs). The current study aims at investigating changes in the number of consecutive days of abstinence (CDA), severity of AUD and CO-SUDs (Shorter PROMIS Questionnaire; SPQ alcohol, prescription, illicit drugs subscale), DER (Difficulties in Emotion Regulation Scale; DERS) and coping strategies (DBT Way of Coping Checklist; DBT-WCCL) during a 3-month DBT-ST program for the treatment of AUD and CO-SUDs. Furthermore, four independent multiple parallel mediational models were estimated considering scores of CDA/SPQ, DERS and DBT-WCCL dimensions as dependent, independent and mediators variables respectively. One-hundred eight individuals with a primary diagnosis of AUD were consecutively admitted. The results showed significant and moderate to large improvements in CDA, severity of AUD, CO-SUDs and DER. The analyses detected significant improvements in the use of DBT Skills. The changes in DER predicted decreases in SPQ scores. The changes in DBT-WCCL scores were mediators of the previous relationships, considering SPQ alcohol and prescription drugs subscales. These findings support the implementation of DBT-ST as a stand-alone intervention for the treatment of AUD and CO-SUDs. DER together with coping strategies are relevant therapeutic mechanisms in the treatment of clinical features related to SUDs.

The Severity of Personality Pathology: A Risk Factor for Concurrent Substance Use Disorders in Alcohol Use Disorder.

Objective: Co-occurrence of substance use disorders (CO-substance use disorders) among individuals with alcohol use disorder (AUD) is largely recognized as a critical clinical issue. However, the specific clinical variables involved are still unclear. The recent findings are controversial in pointing out the unique contribution of both impulsivity and emotion dysregulation on CO-substance use disorders. Furthermore, the co-variation between AUD and other substance use disorders includes different aspects of maladaptive personality functioning (i.e., overall severity and specific features). Therefore, this study aims at clarifying the role of impulsivity, emotional dysregulation, and severity of personality pathology on CO-substance use disorders among treatment-seeking individuals with AUD. Methods: One hundred ninety-three treatment-seeking individuals with AUD (DSM-IV-TR) were consecutively recruited. Impulsivity (Barratt Impulsiveness Scale [BIS-11]), emotional dysregulation (Difficulties in Emotion Regulation Scale [DERS]), and personality pathology (Structured Clinical Interview for DSM-IV Axis II Personality Disorder [SCID-II]) were assessed after a 2-week detoxification period. The analyses were based on several stepwise forward logistic regressions. The total score of BIS-11 and DERS together with the number of SCID-II criteria were considered, in following the order, as independent variables controlling for the comorbidity with other lifetime Axis I disorders. CO-substance use disorders was the dependent variable (i.e., any CO-substance use disorders, benzodiazepine and cannabis/cocaine use disorders). Results: The number of SCID-II criteria was the only significant predictor of overall CO-substance use disorders, odds ratio (OR) = 1.16; 95% confidence interval (CI) [1.07, 1.26], p < .01, and cannabis/cocaine use disorders, OR = 1.19; 95% CI [1.08, 1.31], p < .01. On the contrary, DERS total score was the most robust predictor of benzodiazepine use disorder, OR = 1.02; 95% CI [1.01, 1.04], p < .01, albeit the severity of maladaptive personality functioning was also significantly associated with this disorder, OR = 1.09; 95% CI [1.00, 1.18], p < .05. Conclusions: The severity of maladaptive personality pathology represents one of the main aspects involved in CO-substance use disorders among individuals with AUD. This dimension predicts the CO-substance use disorders above and beyond specific personality dimensions and other psychiatric conditions. Therefore, personality functioning should be precisely assessed and personality pathology should be addressed in the framework of AUD treatments for promoting effective long-term outcomes.

Difficulties with emotion regulation, mindfulness, and substance use disorder severity: the mediating role of self-regulation of attention and acceptance attitudes.

BACKGROUND: Theoretical frameworks postulate that mindfulness represents a relevant therapeutic process in substance use disorders (SUDs), especially in treating difficulties with emotion regulation (DER). Nonetheless, it remains unclear how mindfulness dimensions, particularly self-regulation of attention and acceptance attitudes, are implicated in the well-validated relationship between DER and SUDs. It is also uncertain whether mindfulness is considered a common protective factor for SUDs. OBJECTIVES: To investigate the mediating role of mindfulness in the relationships between DER and SUDs among treatment-seeking patients with alcohol use disorder (AUD). METHODS: Two related domains of mindfulness were evaluated: (a) self-regulation of attention (Mindful Attention Awareness Scale, MAAS) and (b) acceptance attitudes (Five Facet Mindfulness Questionnaire, FFMQ, nonjudging, and nonreactivity subscales)). Two-hundred and forty-four (149 males and 95 females) participants with AUD were assessed. Mindfulness, DER, and SUD severity (alcohol, benzodiazepines, and other drugs) were assessed after a 2-week detoxification period. Three independent multiple parallel mediational models, controlling for the heterogeneity of sample characteristics, were proposed. RESULTS: MAAS and FFMQ nonjudging were significant mediators of the relationship between DER and AUD severity. Mindfulness dimensions and DER were not related to other drug use disorders. DER represented a relevant factor in explaining the severity of benzodiazepine use disorder, although mindfulness was not significantly related to it. CONCLUSION: Mindfulness appears to be a protective factor for DER effects on AUD. Future research should evaluate additional dysfunctional processes to clarify how unique dimensions are implicated in the development and maintenance of different SUDs.

The Clinical Efficacy of Mindfulness-Based Treatments for Alcohol and Drugs Use Disorders: A Meta-Analytic Review of Randomized and Nonrandomized Controlled Trials.

INTRODUCTION: The current study aims to evaluate if and to what extent mindfulness-based interventions (MBIs) could promote an incremental effectiveness compared to interventions usually provided in clinical practice to treat Alcohol and Drugs Use Disorders. In line with this aim, we accomplished a meta-analytic review of randomized and nonrandomized controlled trials, considering primary and secondary outcomes that comprehensively operationalize treatment efficacy. METHODS: We conducted the online research up to August 31st 2017. Adequate procedures for Cohen's d computation were applied. Heterogeneity indexes, moderators, bias of publication, and Orwin's fail-safe number were also estimated. RESULTS: Thirty-seven studies were included (n = 3,531 patients). We observed null effect sizes for attrition rate and overall mental health. Small effect sizes were detected in abstinence, levels of perceived stress, and avoidance coping strategies. Moderate effect sizes were revealed in anxiety and depressive symptoms. Large effect sizes were associated to levels of perceived craving, negative affectivity, and post-traumatic symptoms. CONCLUSION: MBIs seemed to show clinically significant advantages compared to other clinical approaches in relation to specific primary and secondary outcomes. Conversely, treatment retention was independent of the therapeutic approach.

Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment: Findings Based on an Open Trial.

BACKGROUND: Dialectical behavior therapy (DBT) has demonstrated efficacy in treating disorders such as alcohol dependence that are characterized by emotional dysregulation. Preliminary evidence has revealed the feasibility of DBT skills training (ST) as a stand-alone treatment for such disorders. Although emotional dysregulation plays a significant role in alcohol dependence, there are no previous reports of using DBT-ST to treat it. OBJECTIVES: The aim of this study was to evaluate the duration of abstinence and changes in emotional regulation in a 3-month DBT-ST program for alcohol-dependent patients and to look for relations between abstinence and emotional regulation. METHODS: We administered the Difficulties in Emotion Regulation Scale (DERS) and used urine toxicology screening to monitor alcohol/substance intake among the 244 subjects admitted to the program. RESULTS: Among the 157 patients who completed the treatment, 73.2% were abstinent at the end of the program, and their emotional regulation improved. Improvement was independent of the initial severity of both alcohol use and emotional dysregulation. For substance use outcomes, we found a partial mediation role of improved emotional regulation. CONCLUSIONS: This is the first open trial to show improved alcohol-related behavior and emotional regulation in alcohol-dependent patients treated with DBT-ST and to posit a partial but significant relation between improved emotional regulation and alcohol use outcomes. In the treatment of alcohol dependence, emotional regulation may be a relevant factor for therapists to consider.

Addictive behaviors in alcohol use disorder: dysregulation of reward processing systems and maladaptive coping strategies.

DSM-5 has included within the substance-related and addictive disorders diagnostic category behavioral addictions, such as gambling disorder. Some scholars also considered ICD-11 compulsive sex as a behavioral addiction. Furthermore, an addiction model of dysfunctional eating behaviors has been proposed. Consistently, the existence of common addiction mechanisms related to substance and non-substance related disorders has been hypothesized. Nevertheless, this approach was called into question, especially considering alternative processes which might be implicated in such conditions. This study aims to compare these opposite theoretical positions concerning substance- and nonsubstance related disorders, investigating the latent structure of addictive behaviors among alcohol use disorder (AUD) individuals. Addictive behaviors were self-reported assessed using the Shorter PROMIS Questionnaire (SPQ). We recruited 456 (59.2% male; 40.8% female) AUD treatment-seeking patients. Two latent structures were tested using a confirmatory factor analytic approach. We compared a one-factor (i.e., common addiction mechanisms) with a two-factor solution (i.e., dysregulation of reward processing systems and maladaptive coping strategies). The two-factor solution showed adequate goodness-of-fit indexes. Specifically, dysregulation of the reward processing systems dimension predicted the SPQ illicit and prescription drugs, gambling, and sex subscales. Conversely, the maladaptive coping strategies dimension predicted the SPQ compulsive buying, binge eating and food restriction subscales. The latent dimensions significantly correlated with each other. Compulsive sex might be preliminarily considered as a behavioral addiction. AUD individuals might show complex patterns of maladaptive behaviors functionally related to different latent processes. Differential treatment approaches are suggested to treat these conditions.