Wednesday, 9 April 2014

What is Addiction?

A recent paper has been published in Frontiers of Psychiatry which attempts to rebuke the supposedly dominant view of addiction as a brain disease. I think it’s a decent paper - it gives a good account of the problems with the “disease” view, and also covers evidence for both sides of the debate – brain disease versus choice – in a balanced, well-structured fashion. However, I think the authors’ conclusion and suggestions for future perceptions of addiction are a little vague and, ultimately, unhelpful, so I thought I’d try and clarify things a little further. I say this not because I think that they’re wrong, but because they offer no structured way of viewing addiction which others can draw from.


Background:
 
Addiction appears to be a nebulous concept in society, being used in everyday discourse to denote something generally absorbing, or even just somewhat appealing. Even some “experts” seem to have been drawn into the haze of confusion regarding the reality of addiction, with this psychiatrist comparing the “Trojan horse” of excessive texting to drink and drug abuse (warning, stupidity may be contagious)*. Such confusion is one of the reasons I’m writing this post – another is that, even when confident of what something is not, it is still pertinent to clarify what it is. Hopefully, this is what this post will achieve. So without further ado, if addiction isn’t the propensity to eat more than one (or eight) Ferrero Roche in one sitting, or the continuation of watching the always looming next episode of your favourite show on Netflix (until you suddenly realise it’s time for work), what exactly is it? The point of this piece is to lay out a robust way in which addiction can be viewed in everyday terms.

Theoretically, contemporary models generally pose addiction as a power struggle between a strong motivation to use the drug, and a limited capacity to constrain such motivation. Practically, the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-V) has melded the previously distinct categories of substance abuse and substance dependence into a unitary substance use disorder (SUD) with which to diagnose addiction-related problems. Each substance-specific problem is granted its own SUD type (e.g. alcohol use disorder, stimulant use disorder etc.), with each measured on a continuum from mild to severe. In addition, the “behavioural addiction” of pathological gambling has now been recognised as a disorder possessing similar clinical manifestations and even neural correlates to that of drug addiction.

Essentially, addiction is a concept used to denote a set of states, behaviours and consequences which centre around particular substances or actions, and which are conducive to a problematic life. That’s it. Addiction can principally be viewed as a set of behaviours that encumber much more negative consequences than they do positive, but which the individual continues to perform anyway (though as alluded to above, addiction also possesses biological and cognitive components). That’s fine, but how about the all-important label? Is it a biological disorder, or a disease, or a choice? And also, what about sex, internet and “selfie” addictions – are these things real? We’ll start with the latter.



Might as well face it, we’re addicted to… everything:
 
As we know, drugs are not the only things people have suggested can be addictive. We’ve already seen how people somehow allowed on TV have termed the very act of texting addictive; well, such claims stretch far and wide. Sex, exercise, the internet and videogames are just some of the behavioural normalities accused of enticing some of us to the point of dependence. Could these things ever be considered truly addictive? Well, why not? Many objections to such a proposal seem to rest upon arguments from incredulity, that there’s no way a videogame could ever be that enjoyable or satisfying – but a lack of imagination as to how gratifying someone else may find something is not in itself an argument. 

Take a recent example. The Mirror recently reported that a teenager had become addicted to taking selfies – something which conjures up images of older readers shaking their heads and muttering “this country…” But if their report is accurate, this case was extreme and the person in question undoubtedly needed help. This individual dropped out of school, didn’t leave his house in six months and lost two stone due to his obsession of taking the perfect picture. When he realised his goal was unattainable, he attempted suicide. This spiralling out of control due to fixation on one particular thing is reminiscent of addiction, and so it’s plausible to see why the connection has been made.

However, despite such similarities some caveats need to be made. First, it might be the case that “technology addictions” actually exist and that such addicts can be categorised alongside drug addicts (or perhaps more reasonably alongside the only recognised behavioural addiction, gambling), but we need to be sure that these are in fact the same disorders. It is plausible, for example, that this case in particular was just an unusual manifestation of obsessive compulsive disorder (OCD) and body dysmorphia – two underlying conditions which gave rise to behaviour eerily similar to addiction. If this is the case with the other suggested “addictions” mentioned above – that sufferers are in fact just showing an unusual presentation of symptoms of already established disorders – then there is no reason for the creation of “new” addictions. To clear up such confusion we only need ask a single, but broad, question: are the profiles of such addictions similar to “classic” addiction? We can take “profiles” to mean clinical manifestations, environmental and biological causes, underlying dysfunctions of the cognitive system and so on. If these things are the same (or very similar) in these new age addictions, then there’s no reason not to classify them as such. If they’re not then they must either be classified as unusual manifestations of already-established disorders or something completely new – either way, the important thing is to find the right diagnosis for the right treatment.

The second caveat is that, even if we do eventually classify sex and videogames as being potentially addictive, this does not mean that we have to recognise them as having the same level of addictiveness as drugs. It also, crucially, does not mean that we have to grant that such addictions confer the same potential for harm (particularly in health terms). Even between drug classes, we recognise that some are potentially more addictive and harmful than others – the same could be done between different classes of addictions. For example, gambling may confer similar negative social consequences to addictive drugs (loss of money, falling out with friends), but it does not possess the same potential to deteriorate one’s health. Some addictions, it would seem, are simply worse than others.



The Choice versus Disease debate:
 
Scenario: You’re at a dinner party and after the initial merriment which a few glasses of wine delivers conversation turns thoughtful and, once the obligatory topics of politics and religion have been navigated, talk turns to problems in society, including addiction. Some suggest that addiction is an excuse, a way out for the weak-willed and the morally bankrupt – after all, most of us enjoy a few drinks on occasion, but we suck it up and turn in for work the next day. We take responsibility. Others rebuke such claims with anecdotes of perfectly respectable family members or friends who have succumbed to addiction – something which they describe as a disease. You – who now can’t remember why you ever agreed to attend a party with such dull people – are at a loss. On the one hand drug-taking is a choice, isn’t it? On the other, why would people choose such a life – and aren’t there addicts who want to recover, but can’t?

These are reasonable questions, and even researchers in the field are having similar discussions. Nora Volkow – head of the National Institute on Drug Abuse (NIDA) – is in the “addiction as brain disease” camp, while Gene Heyman – a psychologist at Harvard University – sees addiction as a problem of choice. So which is it? Well, a “disease” is defined as a “disorder in structure or function… that produces specific symptoms or that affects a specific location”. Now, presentations of the evidence show that addiction can certainly fit the criteria of disease; chronic use of drugs for example can significantly alter the “reward pathways” of the brain over time. However, as Heyman points out in his book “Addiction: a disorder of choice”, many addicts can and do quit when the stakes are raised high enough – something not possible for “real” diseases such as cancer and diabetes.

The problem with debates of this kind is that the opposing sides can force each other into ever more extreme positions, leading to a false dichotomy – the positions of which nobody wants to side with. It is true that drugs can change the brain; it is also true that it is inevitably choice which initiates and maintains recovery. If both are true, we have no need to distinguish between disorder and choice – instead of choice versus disorder, how about disordered choice? This is not a new concept, Mark Lewis – a “former”** drug addict and current psychologist and neuroscientist – espoused just such a view a number of years ago in response to Heyman’s book. Though not a simple disorder, our conception of it can be simple. We don’t need to quibble about choice versus, well, anything, because choice is a part of addiction. As long as we include all the components in our explanation, we’re doing okay.

But what about the treatment and care addicts get? If it’s a choice should we really be spending taxpayers’ money “helping” them? Well, it’s important to note that “choice” does not equal “free”. Our choices are swayed All. The. Time. And though you may think yourself immune, this is plausibly just the result of another cognitive bias (which ironically indicates just how influenced we are by things of which we’re not aware). Though, clearly, some influences are more compelling than others. This brings us back to spectral thinking – it is not a case of choice versus no choice, but how compelling one choice is compared with another. In the case of addiction, the “choice” to keep using is far more gripping than the “choice” to turn your life around and abstain. Consider the scenario below:

Imagine a favourite reward of yours, a reward which – though enjoyable – impacts negatively on some aspect of your life. On occasion you feel the urge to obtain that reward, but you keep these cravings at bay with minimal effort and only indulge every now and then. You fill in the majority of your time doing other things you love – maintaining other hobbies, obtaining other rewards. Now imagine that – relative to everything else – the reward has become five times, ten times more valuable. The urge to indulge has become far greater than it ever was before – your thoughts continue to cascade onto the same track again and again, with the reward always meeting you at the end of the line. Alongside the increase in craving, in wanting, there’s a decline in liking. You no longer enjoy the reward the way you used to – but you no longer enjoy anything the way you used to. Work, hobbies, social occasions – none make you feel the way they should. But the reward takes the edge off. Sure, it’s not as good as it used to be, but it’s as good as it gets. So you have a choice, you can muster all the effort and willpower you can, for as long as you can and reject the only thing that now offers any relief from the constant psychological and physical craving – or you can accept that not having that reward in your life is no longer an option. You want it. You need it. Life without it is unbearable.

Based on descriptions from addicts themselves, this would seem to be not too far from what it’s like to be dependent on highly addictive drugs like heroin. Notice that the more one uses the substance the worse one’s life becomes, but that the major source of relief is also the substance itself. It’s an ever-escalating drama, with the substance playing both villain and hero. Addiction is neither a complete disease, nor a complete choice; rather, it contains aspects of both.



Addiction’s Grasp:

Much of Heyman’s and others’ arguments centre on the fact that, when offered a great enough incentive, many addicts do turn their life around and give up drugs. For example, the paper I mentioned at the very start of this post cites numerous examples where addicts have gotten clean after threatened with unemployment, jail time or them being declared unfit to raise their children. However, a crucial thing to notice is that they need such significant incentives in the first place – slowly killing themselves and gradually worsening their quality of life isn’t reason enough. If that isn’t disordered choice I don’t know what is. It’s also worth noting that not all addicts can be dissuaded of their drug habit – NIDA estimates that around 50% of those receiving treatment still relapse. Further, it seems some addicts never fully recover and remain addicted for life regardless of their loss of earnings, partners, friends and even loss of their own children. These would be regarded as the most severe cases on our spectrum; those for which incentives – no matter how great – will not work.
 
Such instances do not disrupt our view of addiction as a disorder in need of treatment. Disordered thinking, which leads to disordered decision-making and therefore distorted choice, needs to be rectified if people are to live happy, productive lives free from drug abuse. This is better not only for individuals themselves, but also for society at large. Furthermore, treatments of various “levels” of the addiction landscape can be considered, something Satel and Lilienfeld discuss in the paper which initiated this post. They argue that one reason for discounting addiction as a brain disease is that it is not the most useful way to view addiction, given that other factors (social, economic, geographical etc.) play a more significant role. Leaving aside any discussion of the fact that such factors exert their influence by affecting the brain (something which the authors do address briefly but which I won’t bother with here), this seems like a sensible argument. This also means that there must be many “levels” at which to treat addiction: social, economic, cognitive and others.
 
Such a “levelled” approach to treatment is likely to prove most effective overall, compared with any approach which attempts to “cure” addiction via some pharmaceutical wizardry alone. It may also be the case that different treatment levels or types correspond optimally to certain parts of the spectrum. For example, small incentives (e.g. monetary rewards) and cognitive training may be helpful for persons located on a part of the spectrum labelled hazardous; however, such approaches may be futile for those deemed to be at the more extreme end, who more so resemble what we picture when we hear words like “addict”. For these individuals large incentives (e.g. loss of job, family) or pharmacotherapy may be needed while, further still, the group who seem immune to any kind of treatment may need to be subjected to multiple approaches simultaneously. Again this is not new, it’s just that this seems to me to be the most reasonable way to structure our discussions of addiction – to view it as a problematic extreme of normal human behaviour, rather than an abnormal category reserved only for those suffering from either biological or moral disease. 
 
 


* If, like me, you too have a masochistic penchant for viewing media sources presenting baffling levels of scientific ignorance, The O’Reilly Factor is your holy grail. Enjoy.
 
** I’ve placed “former” in quotation marks here as it’s arguable that no one ever fully recovers from addiction.

 










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Liverpool, United Kingdom
I'm a PhD student in experimental psychology at the University of Liverpool. My research is focused on automatic versus deliberative processes in general drug use and addiction. Here I blog about my research as well as casting a critical eye over new - and sometimes old - news in the world of psychology.