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Tuesday, June 10, 2014
Instant Gratification As A Way Out of Addiction?
Seeking instant gratification instead of waiting for a more valuable prize can get people into addiction, but this "delay discounting" mentality can be used to break free of addiction as well.
By Dana Smith
What if I told you you could have $10 today or $20 next week, which would you choose? What about $100 today or $110 in six months? Rationally, we should always opt for the larger amount, no matter what the wait. But our brains process these two rewards differently, under-valuing the later option and preferring an immediate satisfaction far more than a delayed prize.
This inability to defer gratification is a type of impulsivity called “delay discounting,” and it is considered to be a hallmark of addiction. While the tendency to live in the moment is prized in self-help articles, numerous studies have linked this type of “myopia for the future” to an increased risk for drug dependence—users preferring the immediate rush of a high over the delayed benefit of a long and healthy life.
However, new research has emerged showing that while this type of “irrational” decision-making can contribute to someone developing an addiction, it may also help get them out of it.
Discounting and Drug Abuse
Dr. Warren Bickel has been researching drug addiction for the last 20 years, and he thinks that this trait is “part and parcel” with the addictive experience. “Data suggests discounting is predictive of who becomes addicted versus not,” he says. “If you compare addicts versus non-addicts on [this trait], addicts discount substantially more. [Moreover,] it seems proportional with their drug use—the more they use, the more they discount.”
Additionally, discounting has been linked to treatment outcomes, with higher rates of impulsivity associated with a greater risk for relapse after rehab. This predictive ability is true regardless of the drug being used, be it heroin or nicotine—the longer you can wait for any type of reward, the longer you are likely to go without using.
In the lab, delay discounting is assessed by giving people a series of “smaller sooner” versus “larger later” choices, like the ones above. The point at which you switch from preferring the future to the present reward determines your discounting rate and is thought to reflect your capacity for self-control.
This ability to delay gratification is linked to activation in a specific part of your brain—the dorsal (top) lateral (outside) prefrontal cortex, located near your hairline and above your eyebrows. This region is associated with planning and decision-making, and typically the more activation you have in this area, the better you are at self-control. However, the prefrontal cortex is known to be abnormal in dependent drug users, and numerous studies have shown that addicted individuals have less brain volume in this region than non-drug users. This decrease in size seems to be directly related to drug use itself, with severity and length of use linked to a greater decrease in volume and activity. Losing brain cells is never a good idea, but in the prefrontal cortex it can be especially detrimental, impacting the ability for self-control and making someone even more impulsive than they already were. But all is not lost, andstudies have shown that our brains can bounce back once off drugs, the cells regenerating like leaves growing back on the trees after a long winter.
A New Type of Treatment
Which brings us back to Dr. Bickel’s work. Reanalyzing five previous studies, the researchers looked at how different treatment options affected this trait of discounting, and how this may in turn relate to abstinence efforts. Remarkably, this time it was the users who had the highest rates of discounting that improved the most with treatment. That is, those who were initially the most impulsive in their decision-making became less impulsive over time. Notably, this was not the case in the control arms of the experiments, suggesting there was an important effect of the treatment program itself on discounting. Even more remarkable, this improvement in discounting was linked to abstinence success, with the individuals who had the largest decreases in discounting also having the lowest number of positive drug screens.
This result is particularly surprising as it is in direct contrast with previous studies showing that high impulsivity, particularly in regards to future discounting, is typically linked to worse treatment outcomes. One possible explanation is that this discrepancy is due to the type of treatment used across the different studies. For example, in one of the original trials, multiple types of treatments were used, effectively “throwing the kitchen sink” at the patients. As a result, abstinence levels were an impressive 80-90%, roughly double the success rates for the current standard treatment options.
Dr. Bickel thinks that it is this difference in the effectiveness of the treatments that resulted in the conflicting discounting trends. “It looks like the predictive ability of discounting for a therapeutic outcome occurs with moderately effective treatment. But when you have highly effective treatment, which is where we found these changes in discounting, that’s the difference…The efficacy of the treatment determines whether discounting is a predictor or if discounting changes.”
Improving Memory and Self-Control
Perhaps the most exciting finding of the new research is the link between working memory and improvements in discounting. One of the trials that was re-analyzed involved training participants on a working memory task, trying to improve their abilities in this domain. However, the researchers discovered an unexpected link between improvements in working memory and an increase in self-control. While at first this result was surprising, discounting and working memory being separate cognitive processes, the two functions overlap in the brain, both linked to activation in the dorsal lateral prefrontal cortex. Thus, it appears that improving working memory can strengthen activation in this area, which can subsequently enhance other behaviors (like self-control) that tap into it.
Working memory is also thought to be related to abstinence success, for in order to achieve your goals, you have to be able to keep them in mind first. Indeed, more and more, future planning is being thought of as a type of working memory, remembering how you acted in the past and keeping in mind how you’d like to change your behaviors in the future.
Dr. Bickel explains, “Remembering an event in the past and thinking about the future are really tied processes. And working memory, being able to hold ideas and concepts or facts in our heads for a certain period of time, may be necessary for us to think about and value things that occur in the future.”
Together, these findings suggest there may be a way to improve decision-making in drug users, which could then result in an increase in treatment efficacy. As the current options for rehab are often less than perfect, improving any chance for success, particularly in those who are most likely to fail, seems like a worthwhile endeavor.
Regression to the Mean
However, before we get too excited about the possibility, it’s important to keep in mind a small statistical effect that may be having a large impact on the current findings.
One alternative explanation for the results is that those who have lost the most have the most to gain. This is true both mathematically in the idea of “regression to the mean,” where outliers on both ends of a spectrum have a tendency to pull in towards the center, as well as more colloquially in the idea that the lower one starts off, the more potential there is for growth. Also, rather than looking at the trait of discounting itself, these findings can be viewed more abstractly, in that individuals who are able to significantly improve in any arena might be the ones who are most readily helped by treatment.
Additionally, while the current analysis had a dataset of over 200 participants to work with, another 300 individuals dropped out during the initial studies. Considering that drug users who are highest in impulsivity also have the highest likelihood for relapse, this loss could have skewed the data, not taking into account the most extreme cases. Unfortunately, this is a problem that almost all studies on addiction treatment encounter, in that they are largely made up of a self-selecting group of individuals who want to get clean and are willing and able to stick with it. However, it is often those who drop out who might need the most help and who would be able to shed light on what doesn’t work and why in terms of treatment.
At the end of the day, though, any opportunities to advance treatment success rates should be taken, and the current findings do provide a promising new avenue for improving self-control, and subsequently abstinence efforts. Dr. Bickel says, “I think often in addiction we deal with either the symptoms of addiction or the demographics of the participants, but it could be that decision making processes are really key in understanding how addiction operates and perhaps how to treat it.”
Dana Smith has written for The Guardian, The Atlantic and Scientific American: Mind, among other publications.