The Etiologic, Theory-based, Ontogenetic Hierarchical Framework of Alcohol Use Disorder: A translational systematic review of reviews

Abstract

Modern nosologies (e.g., ICD-11, 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 with the aim of identifying 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, as well as 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 towards 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 treatment matching.

Is alcohol use associated with psychological treatment attendance and clinical outcomes?

“…It has been proposed that alcohol use may be used as a way to supress mental health symptoms (i.e., disturbing thoughts or memories), downregulate intolerable emotions, or to upregulate desirable emotions (i.e., pleasure, feeling more confident in public). These explanations for this form of comorbidity are found in the literature on self‐medication (Khantzian, 1985), experiential avoidance (Forsyth, Parker, & Finlay, 2003), coping styles (Levin, Ilgen, & Moos, 2007), and the role of negative affect and impulsive downregulation (Boness et al., in press).…”

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 andWatts et al, 2021, for reviews). In turn, conventional taxonomies (e.g., have attempted to shift away from purely categorical descriptions of SUDs and towards dimensional diagnoses that grade along severity continua.…”

“…For instance, drunk driving is sufficient to qualify for the hazardous use criterion, but it appears to reflect general externalizing liability as opposed to liability specific to alcohol use disorder (Quinn & Harden, 2013). Additionally, some aspects of SUDs reflect dispositional or premorbid characteristics (i.e., impulsivity, reward sensitivity), whereas others reflect acquired neuroadaptations in response to excessive and chronic substance use (e.g., tolerance, withdrawal; Boness et al, 2021).…”

“…NIDA PhAB and HiTOP outline dimensions relevant to the experience of negative emotions (e.g., sadness, worry, anger), which is termed Negative Emotionality in NIDA PhAB and is encompassed by the Internalizing spectrum in HiTOP. These two dimensions across the systems are conceptually isomorphic (Boness et al, 2021).…”

“…Supporting this connection is the established finding that there is a marked degree of covariation among tendencies towards negative affect, antagonism, and impulsivity, each of which coalesce to form tendencies towards antagonistic forms of externalizing behavior (Krueger et al, 2021). Along these lines, Kwako and colleagues (2019) found that aggression loaded substantially on ANA's negative emotionality domain such that it was the strongest indicator of it (see Boness et al, 2021, for a critique).…”