The etiologic, theory-based, ontogenetic hierarchical framework of alcohol use disorder: A translational systematic review of reviews.

Abstract

Modern nosologies (e.g., International Classification of Diseases, 11th edition [ICD-11], Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM–5]) for alcohol use disorder (AUD) and dependence prioritize reliability and clinical presentation over etiology, resulting in a diagnosis that is not always strongly grounded in basic theory and research. Within these nosologies, DSM–5 AUD is treated as a discrete, largely categorical, but graded, phenomenon, which results in additional challenges (e.g., significant phenotypic heterogeneity). Efforts to increase the compatibility between AUD diagnosis and modern conceptualizations of alcohol dependence, which describe it as dimensional and partially overlapping with other psychopathology (e.g., other substance use disorders), will inspire a stronger scientific framework and strengthen AUD’s validity. We conducted a systematic review of 144 reviews to integrate addiction constructs and theories into a comprehensive framework to identify fundamental mechanisms implicated in AUD. The product of this effort was the Etiologic, Theory-based, Ontogenetic Hierarchical Framework (ETOH Framework) of AUD mechanisms, which outlines superdomains of cognitive control, reward, and negative valence and emotionality, each of which subsume narrower, hierarchically organized components. We also outline opponent processes and self-awareness as key moderators of AUD mechanisms. In contrast with other frameworks, we recommend an increased conceptual role for negative valence and compulsion in AUD. The ETOH framework serves as a critical step toward conceptualizations of AUD as dimensional and heterogeneous. It has the potential to improve AUD assessment and aid in the development of evidence-based diagnostic measures that focus on key mechanisms in AUD, consequently facilitating precision medicine.

Contextual decision-making and alcohol use disorder criteria: Delayed reward, delayed loss, and probabilistic reward discounting.

“…Syndrome-level (AUD) analyses likely obscure the more specific symptom-level associations observed in the present study. As suggested elsewhere (Boness et al, 2021), these results support the idea that AUD symptoms are etiologically distinct and represent different profiles of risk between persons, with equally distinct endophenotypes undergirding symptom presentation. Indeed, the results may partially explain the small effect size relation between DRD and AUD (Amlung et al, 2017).…”

“…Personalized medicine acknowledges individual heterogeneity in the etiology and maintenance of psychopathology and targets varying mechanisms specific to the experience of the individual. The finding that each of the behavioral economic indices was most related to the AUD symptoms thought to index dysregulated reward processes is, although perhaps unsurprising (see Boness et al, 2021), useful for understanding treatment targets. DRD is a transdiagnostic phenomenon implicated in other forms of psychopathology such as major depressive disorder, schizophrenia, bipolar disorder, and borderline personality disorder, among others (Amlung et al, 2019).…”

Constructs derived from the addiction cycle predict alcohol use disorder treatment outcomes and recovery 3 years following treatment.

“…For example, prior work (Kwako et al, 2019) focused on general measures of executive function (e.g., impulsivity, urgency), while the present study used executive function indicators that specifically assessed control over drinking. There is good reason to expect that other executive functioning constructs (e.g., urgency, memory, and inhibition) are also relevant to AUD treatment outcomes and recovery (Boness et al, 2021). The executive functioning domain in the current study also had lower internal consistency and had the largest standard errors in models predicting recovery.…”

New approaches to deep phenotyping in addictions.

“…Traditionally, SUDs have been conceptualized as coherent, homogeneous syndromes that are categorical in nature and distinct from other forms of psychopathology (Hasin et al, 2013). Yet, substantial evidence has contradicted these assumptions (see Boness et al, 2021 and Watts et al, 2021, for reviews). In turn, conventional taxonomies (e.g., DSM-5 , ICD-11 ) have attempted to shift away from purely categorical descriptions of SUDs and toward dimensional diagnoses that grade along severity continua.…”