Khazaal Y, Frésard E, Zullino D
Département Universitaire de Psychiatrie Adulte, Lausanne, Suisse.
Encephale. 2007 May-Jun;33(3 Pt 1):346-51. doi: 10.1016/s0013-7006(07)92049-7.
Exposure to drugs or related cues is associated with psycho-physiological reactivity. These responses are conditioned during periods of active consumption. Exposure with response prevention (EPR) is a treatment established for anxiety disorder and aims to reduce anxiety by an extinction of previously conditioned responses. The conditioning recognized in additive processes has led to research into EPR's therapeutic potential for treating addiction. This paper is a review of the main studies on reactivity to cues, and EPR, particularly with respect to addiction to alcohol, opiates, cocaine and tobacco.
This review is based on information from the Medline database, dealing with cue reactivity, attentional bias during exposure to cues and exposure treatment for addiction in general and, in particular, for each of the aforementioned substances.
Exposure to drug-related cues is clearly associated with psycho-physiological reactivity and with attentional bias. Those phenomena are associated with craving and more difficulty in maintaining abstinence. The subject's attention is thus held by a large number of drug-related environmental stimuli. These observations are linked with conditioning phenomena and suggest the possibility of treatment by EPR conditioning extinction procedures. EPR has been most widely studied for abuse and alcohol addiction. Case reports give favourable outcomes. Results from controlled studies are less clear. Studies on patients addicted to cocaine or heroine are still limited and not conclusive. Different controlled studies on EPR for nicotine addiction have not produced conclusions in favour of this treatment. Generally, the EPR procedures used vary among studies. Studies focussing particularly on the evolution of physiological responses in a laboratory setting after EPR have demonstrated reduced autonomic nervous system activity. These results do not consistently lead to a reduction in consumption behaviour and in craving when the patient is in his/her natural environment. The difficulties encountered in the development of EPR treatments, despite the appealing reasoning behind them, could be explained by the tendency of conditional stimuli to re-occur spontaneously. However, it is clear from the studies reviewed that by selecting EPR conditions more rigorously, more efficient procedures might be developed at least for some patients. It seems that the place and the conditions of exposure are factors essential to the success of these therapeutic procedures. Exposure in vivo is better than exposure in imagination. Prolonged exposure over an hour is more effective than exposure lasting 10 minutes. Exposures in close succession are also associated with a better extinction of conditioned responses. The moment that the stimulus occurs, how appropriate it is and its proximity with potential reinforcement are also essential elements for the conditioning procedures. Improving the conditions in which EPR is applied could then enhance the therapeutic potential of this approach.
接触毒品或相关线索与心理生理反应性相关。这些反应在积极消费期间形成条件反射。接触并阻止反应（EPR）是一种针对焦虑症建立的治疗方法，旨在通过消除先前形成的条件反应来减轻焦虑。在成瘾过程中认识到的这种条件反射促使人们研究EPR治疗成瘾的潜力。本文综述了关于线索反应性和EPR的主要研究，特别是关于酒精、阿片类药物、可卡因和烟草成瘾方面的研究。
本综述基于Medline数据库中的信息，涉及线索反应性、接触线索期间的注意力偏差以及成瘾的接触治疗，特别是针对上述每种物质的治疗。
接触与毒品相关的线索显然与心理生理反应性和注意力偏差有关。这些现象与渴望以及维持戒断的更大困难相关。因此，大量与毒品相关的环境刺激吸引了受试者的注意力。这些观察结果与条件反射现象相关，并提示通过EPR条件反射消退程序进行治疗的可能性。EPR在滥用和酒精成瘾方面研究最为广泛。病例报告给出了良好的结果。对照研究的结果不太明确。对可卡因或海洛因成瘾患者的研究仍然有限且尚无定论。关于EPR治疗尼古丁成瘾的不同对照研究尚未得出支持这种治疗方法的结论。一般来说，不同研究中使用的EPR程序各不相同。特别关注EPR后实验室环境中生理反应变化的研究表明自主神经系统活动有所降低。当患者处于自然环境中时，这些结果并不能一致地导致消费行为和渴望的减少。尽管EPR治疗背后的推理很有吸引力，但在其发展过程中遇到的困难可以通过条件刺激自发再次出现的趋势来解释。然而，从所综述的研究中可以清楚地看出，通过更严格地选择EPR条件，至少对一些患者可能会开发出更有效的程序。似乎接触的地点和条件是这些治疗程序成功的关键因素。体内接触比想象中的接触更好。持续一小时以上的接触比持续10分钟的接触更有效。连续接触也与条件反应的更好消退相关。刺激出现的时刻、其适当程度以及与潜在强化的接近程度也是条件反射程序的关键要素。改善EPR应用的条件可能会增强这种方法的治疗潜力。
