Psychological and Physiological Elements of Cravings in Substance Use Disorders
This is written in an academic style, If you want a less boring version, I rewrote it here:
Introduction
Cravings are widely understood to be a critical component of substance use disorder (SUD) and recovery; they are also a significant predictor of relapse (Cless et al., 2023). As understanding of the effects of cravings becomes more available through reliable research in the field, it is more evident that cravings have deep roots in both our psyche and our physiology. The seriousness of cravings is evident in their inclusion in the DSM-5 TR as a diagnostic criterion for SUD (American Psychiatric Association, 2020). An examination of the various psychological and physiological factors is essential to uncovering how cravings develop in individuals with substance use disorders. Stressing the need for a more comprehensive understanding of cravings will make the audience feel the importance of their work in the field of SUD.
There is a consensus that cravings are defined as intense and often overpowering desires to use substances stemming from the pathological effects on neurobiology. Research often highlights the dopaminergic system as a primary focus (Cless et al., 2023; Pergolizzi et al., 2019). Some researchers and clinicians challenge the standard narrative, proposing a more thorough definition to include a psychological element. Lavallee (2020) contends that such a narrow focus on physiological elements, though critical, often ignores many individuals who experience these cravings and may be seeking psychological experiences. Given these differing perspectives, it is evident that cravings in SUD involve both psychological and physiological components. The extent to which each contributes remains debated, underscoring the necessity of developing personalized, multidisciplinary treatment strategies in addiction counseling. This approach empowers counselors and researchers to address the unique needs of each individual, fostering a sense of capability and empowerment in the field.
Psychological Aspects of Cravings
Building upon the understanding that psychological and physiological factors influence cravings in SUD, it is worthwhile to evaluate them individually. Psychological cravings originate from a desire to experience specific psychological states, such as numbness, escape, relief from distress, or a sense of safety and acceptance. When considering the manifestation of psychologically based cravings, it is essential to explore the emotional triggers and stress responses that fuel these cravings.
In her article, Lavallee (2020) analyzes Khantzian’s 1985 hypothesis of addiction as a means of self-medication in response to overwhelming psychological disturbances. When an individual is experiencing a high degree of stress or emotional dysregulation, it is natural to seek out a type of relief, whether that be numbness or dissociation. Lavallee (2020) continues by citing the work done by Maté regarding trauma. When individuals are unable to self-regulate, they may seek out external means to do so; in many cases, this use of drugs to manage trauma and fill the emptiness is akin to using Ibuprophen when an individual has a broken leg: while it may alleviate the pain momentarily, it will not resolve the problem. Similarly, while substances may conceal psychological distress, they do not resolve the underlying trauma, often leading to continued self-medication and worsening emotional and physical health.
Furthermore, Lavallee (2020) explains that cravings are not limited to emotional and stress responses; they are also learned behaviors. Individuals may develop intense associations through classical or operant conditioning—as well as many other learning models—and this may be from experimental or social use. These associations may lead to biopsychosocial and environmental triggers that are not simply a means to cue a craving for the substance itself. Instead, these triggers often prompt hoped-for emotional responses and psychological rewards associated with the substance (Lavallee, 2020). Such thoughts can lead to overwhelming intrusive thoughts and ruminations that can trigger a cycle of compulsive use due to the high level of psychological reward from these experiences.
Physiological Aspects of Cravings
The importance of cravings’ psychological elements should not be underestimated, notwithstanding the need to be aware of the physiological factors involved. A critical component of understanding the effect of physiological craving is the awareness of neuroplasticity—the brain’s ability to adapt and modify its patterns and functions. As an individual engages in problematic substance use, this leads to chemical and even structural changes in the brain. One of the most commonly affected neurotransmitters is dopamine. Tanabe et al. (2019) explain that addictive substances cause dopamine stimulation in the mesolimbic reward system. This system is comprised of “dopaminergic neurons with cell bodies in the ventral tegmental area of the midbrain and terminal projections in the ventral striatum (nucleus accumbens), prefrontal cortex, and limbic regions” (Tanabe et al., 2019). With prolonged use, various stimuli—such as people, places, and emotions—can become triggers for cravings as the mesolimbic system is activated during substance use in connection with these various stimuli.
Through brain imaging studies, there is evidence that prolonged exposure to addictive substances not only causes widespread maladaptive neurological stimulation but also results in loss of gray matter in many cases. Tanabe et al. (2019) highlight how drug-related cues activate areas, including the nucleus accumbins, prefrontal cortex, anterior cingulate cortex, and amygdala. These regions are responsible for reward processing, decision-making, and emotional regulation, with greater cue-reactivity often correlating with stronger cravings. Additionally, withdrawal symptoms can amplify cravings through stress-induced activation of the brain’s reward system, underscoring the physiological interplay between stress and substance use. Correspondingly, chronic drug exposure manages to damage the brain’s response to non-substance rewards, making substances more desirable while diminishing stimuli that were previously rewarding (Tanabe et al., 2019). This is potentially due to the striatal dysfunction related to altered dopamine function.
Limitations
The various articles selected included reasonably large sample sizes; however, due to time constraints and the inability to access to a diverse range of studies, it is reasonable to conclude that the information provided may not be generalizable to all groups and individuals from differing racial and cultural backgrounds. This lack of sufficient representation from individuals who are minorities emphasizes a significant gap in the vast, but still limited, pool of research. A greater awareness and focus on including minorities would greatly enhance further research and allow for a better representation of all people. Emphasizing the need for inclusive research in the field of SUD will make the audience feel the urgency and importance of addressing this gap.
Implications for Counseling Practice
Individuals with SUD have complex and often unique cravings that manifest on a spectrum of psychological and/or physiological. In order to foster holistic wellness, it is essential to avoid absolute thinking regarding whether cravings stem from psychological or physiological roots. Instead, it is crucial to recognize that they are part of the same tree. Some individuals may exhibit more symptoms of emotional origin than biological, but this does not indicate the latter's absence; instead, it allows for a more focused treatment plan. With this understanding, a counselor can attempt to manage the physical cravings while addressing and working through the underlying psychological cravings as needed.
Holding a dualistic view of cravings allows a counselor to address psychological cravings via evidence-based methods such as cognitive behavioral therapy (CBT) while including the use of medication-assisted treatment (MAT) through medications like naltrexone, methadone, and buprenorphine and or fostering lifestyle changes such as regular exercise and maintaining a healthy diet in congruence with the implementation of mindfulness-based interventions and techniques. Returning to the broken leg analogy, if a client had a broken leg, the intention would be to heal the leg while managing the pain. Counseling does not need to be any different; it works in unison with the client, and when appropriate, psychiatrists or other medical doctors can help clients receive the appropriate holistic wellness interventions to maximize their recovery process.
Conclusion
The intention is not to imply that every client will benefit from a dualistic approach; instead, it is essential to hold this perspective when developing a treatment plan. Each individual has a distinct personal background and genetic composition; these aspects contribute to the complexity of their cravings, underscoring the importance of a person-centered approach. By acknowledging potential psychological and physiological factors that may be pivotal in craving manifestation, a counselor can skillfully weigh the variables to distinguish the most effective approach to help the client. Further research will be of great importance to allow for more accurate information when working with individuals from marginalized backgrounds, as it is culturally unethical to assume that research without proper representation applies to individuals from all backgrounds. Prioritizing inclusive research will strengthen the foundation of evidence-based, equitable care for all clients.
References
American Psychiatric Association. (2020). Substance-related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders
Cless, M. M., Courchesne-Krak, N. S., Bhatt, K. V., Mittal, M. L., & Marienfeld, C. B. (2023). Craving among patients seeking treatment for substance use disorder. Discover Mental Health, 3(1), 23. https://doi.org/10.1007/s44192-023-00049-y
Lavallee, Z. (2020). Addictive craving: There's more to wanting more. Philosophy, Psychiatry, & Psychology, 27(3), 227–238. https://doi.org/10.1353/ppp.2020.0028
Pergolizzi, J. V., Raffa, R. B., Rosenblatt, M. H., & LeQuang, J. A. (2019). Craving and opioid use disorder: A scoping review. Drug and Alcohol Dependence, 205, 107639. https://doi.org/10.1016/j.drugalcdep.2019.107639
Tanabe, J., Regner, M., Sakai, J., Martinez, D., & Gowin, J. (2019). Neuroimaging reward, craving, learning, and cognitive control in substance use disorders: review and implications for treatment. The British journal of radiology, 92(1101), 20180942.
