Category: Connect

Hi from Hungary. I’m at a conference on behavioral addictions. Two days of talks by experts — psychologists, neuroscientists, psychiatrists, clinical researchers, etc. — who want to understand behavioral addictions. These include compulsive gambling, eating disorders, hypersexuality or sex addiction, and internet or gaming addiction.  And I am really high on the flood of information, insight, commitment and good intentions, knowledge, creativity, blah blah blah, not to mention that I happen to be in Budapest, which looks like a magical kingdom from some angles and a Communist-bloc relic from others.

I knew so little about Hungary, I actually forgot the name of my destination when checking in for my flight in Amsterdam. I was standing at one of those automatic check-in terminals, had entered my passport information, and then when the prompt asked me for the first three letters of my destination, I blanked out. I asked the guy next to me, which was kind of embarrassing as he was deep in a conversation with someone else: What’s the capital of Hungary? He thought about it for awhile and then said “Bucarest”. I typed in BUC, and then realized that’s where my wife, Isabel, was born — and she’s Romanian, not Hungarian. It finally came:

Budapest

Coming in from the airport by cab, we crossed into another dimension. Mile after mile of hulking, dilapidated rectangular buildings, looking like they were last used 70 years ago to make bomb parts for the war. There was this stale ghost of leftover Communism everywhere. Everything looked shut down, grey slabs of concrete under a grey sky. This was Budapest?

My first surprise came when the driver demanded 5,450 for the ride. What? This could be trouble. But it turned out that 5,450 whatevers translated to 20 euros. Whew.  My next surprise was how beautiful the inner city turned out to be. At some invisible line the Communist-era shabbiness rolled back to reveal a land of Oz: Enormous but gorgeous monuments to a thousand years of changing architecture — churches, castles, museums, fountains — with elaborate arches and elegant turrets, tapering to slender needles pointed at the sky. All connected by wide avenues, full of shoppers, and bridges that appeared to be held up by steel lace. History oozing out of every stone in every facade.

The third surprise was that the talks were so riveting I was hardly tempted by the marvels just outside the door. In two days I learned so much, met so many amazing people, discovered new research strategies, new devices, new recovery tools. For example, today I chatted for an hour with a man named Robert Pretlow, who spent two years — full-time — developing a cell-phone app, and a couple of decades studying child and adult eating disorders. This app (displayed on the right — so far only available for research) lets you chat with other recovering individuals, warns you about addictive triggers, reminds you about your own effective coping strategies, records your progress day by day. It’s like having a treatment centre in your pocket. Dr. Pretlow is using it to study eating disorders, but it seems that it could be applied to many other addictive problems as well. Bob agrees, but there is a lot of work to be done.

I learned about the hidden dangers in sex and gambling. This was not one of those conferences where you have to douse yourself with coffee to keep awake. I learned about the diversity of eating disorders — from binging, which looks a lot like substance addiction, according to Marc N. Potenza at Yale  — to anorexia — which looks more like over-control. A lot of talks focused on OCD, obsessive-compulsive disorder, and quite a few speakers connected the compulsive nature of OCD with that of addiction. People talked about stages in the development of addiction (not far from the stages I listed the last couple of posts), and compared them with stages in the development of OCD. One guy showed how the addictive progression of stages coverged with the OCD progression — starting out in different places but ending up almost completely overlapping.

And these people weren’t just talking about behavior. There were neuroscience data in half the talks. The striatum was the overwhelming star of the show — the ventral striatum and its role in craving, and the dorsal striatum responsible for compulsion. It appears that OCD sufferers talk about their compulsions a lot like addicts talk about their addictions. I don’t want to stop it. I know it’s bad for me, but it makes me feel better. And their brains light up in almost all the same places! In fact, their brains show changes in synaptic density (some areas getting more connected, other areas getting less connected) that look exactly like what you see in addicts, over the same time frame, as they get worse — or better.

In just two days I learned so much, met with so many experts, exchanged email addresses, got books and papers handed to me…enough to keep me busy for quite a while.

And to keep you busy! In the next few posts I’m going to try to synthesize what I’m learning about behavioral addictions — gambling, sex, food, and internet — how they develop, how they stabilize, and most of all how the same or at least overlapping brain changes underlie them all.  And here’s the clincher: I’m going to show you, as I continue to digest it myself, how similar ALL addictions are. When it comes to substance addictions versus behavioural addictions, there’s just not much difference in what the brain is doing.

So, it might seem counterintuitive, but heroin addicts, codependent partners, gaming addicts, and sex addicts are very, very much alike. In other words, you don’t have to be a heroin addict or an alcoholic to wreck your life. You can wreck it just as well by spending 18 hours a day on the internet, while the bills pile up, the unemployment cheques fizzle out (and you didn’t notice), and your wife starts packing, not only her stuff but the kids’ stuff too. You might reply: yeah, sure, but substance addiction can kill you! Behavioral addiction? That’s pretty wimpy in comparison. If you believe that, as I did until yesterday, I’ve got news for you. According to the stats, obesity (a result of food addiction) causes 4 – 5 times more “preventable deaths” in the U.S. than the number caused by alcohol.

The conference just ended. I’m going to go out and check on Budapest now — gaze at statues and absorb some culture. But stay tuned for a deeper look at the core processes underlying  behavioral and substance addictions — in other words all addictions. Coming up next.

 

Hi again. Last post I argued that the growth of addictive behaviour takes place at several scales. A “real-time” scale of minutes or hours, approximately, and a much slower scale that we can properly call “development” — something that takes place over months or years. And perhaps other scales as well.

I realize now, as then, that the picture I painted was not only dense and abstract but also incomplete. I fleshed out the real-time scale, but not the others.

Since most of us have been or still are “addicts,” the real-time scale is probably the most familiar and the most upsetting and frightening to contemplate. Here’s how I summarized it last post:

Attraction leading to craving, leading to pursuit, leading to…a brief period of pleasure or relief, followed by more attraction and craving. In other words, wanting leading to getting, leading finally to loss or emptiness, which leads once more to wanting.

I didn’t cover it last post, but I think there is an even faster scale of addictive cycling, which we particularly see with certain drugs (e.g., cocaine), with binge eating, and probably with gambling. For these addictions, the “reward” is not long-lasting, so the whole cycle of craving, doing, and loss can repeat itself every 10-20 minutes. This may also describe addictive drinking, when the satisfaction of the last drink rapidly fades and the urge for the next one rapidly grows.

We’ve also talked about the rapid brain changes that take place when we are in the clutches of this spiralling pattern — for example the shift from default mode activation to the rapidly rising activation of the ventral striatum (v.s. or nucleus accumbens), fueled by dopamine from the VTA (the ventral tegmental area in the midbrain), and accompanied by lots of action in the prefrontal cortex (PFC, especially orbitofrontal/ventral regions) and the amygdala (that almond-shaped repository of emotional associations).

But what about the developmental scale? That’s where the big picture of addiction gets drawn, first in broad brush strokes and then with the details more and more fleshed out. What changes over months and years, as we become addicts? Does this process really show the same sequence of states we can trace in real time? Do brain changes really follow the same pattern? The answer, I think, is yes, and this is a very important issue.

Many prominent addiction neuroscientists theorize about developmental changes in the brain. And many of them point to those changes as evidence for the argument that addiction is a disease. As you know, I don’t call addiction a disease, but it is like a disease in some ways, and the slow, insidious sequence of brain changes bring us face to face with this perplexing definitional challenge.

So here’s a rough sketch of the developmental changes in brain and mind that take place as we become addicts:

1. At the start, like most other people, we spend a lot of our time in the default mode network, daydreaming, rehearsing things we’d like to say and do, imagining our lives, past and future. In other words, our brains start out “normal,” except that addicts spend more and more time in the default mode, as focused attention gives way to fantasy. Over weeks or months, we find ourselves indulging in fantasies of getting or doing that one special thing. We find ourselves floating away more often on unbidden thoughts — “what if…?” — while we’re  supposed to be reading, writing, calculating, buying, selling, or whatever it is.

2. As time goes by, and we keep going back to that special “pastime,” we find that the drugs, drink, food, or gambling isn’t just fun anymore. It’s more than fun. It makes us feel better than we could have felt doing anything else — so it seems. Now the fantasies — the thoughts, memories, images, and stimuli related to our thing of choice — become more and more compelling. They take on unprecedented power to switch our thinking from a daydreaming mode to a highly focused mode, where sharp attention and motivational thrust join forces, and we start to crave and to make plans.

The brain change associated with this stage is called incentive sensitization. Our brains become more and more sensitized to specific cues and reminders that rapidly trigger the incentive to go, do, get, score, acquire…. I’ve written about this in detail elsewhere. In a nutshell, a whole lot of cells in the nucleus accumbens  (NAcc, or ventral striatum) are getting more and more strongly linked to the the cells in perceptual (posterior) cortex that represent coke, or sex, or booze, and many of those linkages run right through the amygdala, which records the hot flush of emotional potency that goes with them. Now those specific synapses in the NAcc, and between the NAcc and the prefrontal/orbital cortex, and between the NAcc and the amygdala, start to multiply. Those synapses, those hundreds of millions of connections, are all shouting “cocaine!” or “sex!” or “vodka!” more and more loudly as they grow fatter and stronger — by sucking up the dopamine that was designated for alternative synapses, representing other goals, other wishes, now fading in comparison.

3. The period of increased craving/planning and procuring, of increased desire and demand, may continue to grow for weeks, months and even years, before impulse turns to compulsion. It’s not that I really want to, it’s that I really have to. Now the anticipation of the “drug reward,” or “drink reward,” or whatever, is actually replaced. Now what’s driving our thinking and behaviour is the enormous anxiety of a need that has to be fulfilled. Attraction, anticipation, planning, and behaviour have already been set in motion, and now any doubts or drawbacks feel like temporary obstacles — “temporary” because they have to be overcome. It becomes paramount to complete the behavioural sequence. To leave it hanging feels like being trapped in suspended animation: nowhere else to go, nothing else to do.

The brain changes that takes place when impulsive turns to compulsive have been worked out in animal research, and powerful new models are appearing in the literature. The striatum — whose job it is to initiate behaviour — has a dorsal region and a ventral region, which you can imagine as a northern region and a southern region. The dorsal region is in charge of automatic behaviour sequences triggered by a stimulus. This is not where new learning takes place. Rather it’s where old learning gets packed into habit, and habit gets triggered by cues or stimuli, from inside our heads or from the outside world. As synapses in the dorsal striatum start to become sensitized to addictive cues, they join in a network with the nucleus accumbens/ventral striatum and the amygdala. They suck up additional dopamine — now from another little dopamine factory called the substantia nigra — a factory designed to power behaviour directly, without having to wait for the rest of the brain to come on board.

So you see? There is a direct parallel — a self-similarity — between the developmental changes that take place in the structure of these systems and the real-time progression that takes place as these systems get activated, one after another.

Kinda scary. These brain changes are real, at both scales, and the underlying structural “wiring” may never be completely reversible. But we do have the power to overcome these biological processes, along with the feelings and actions they generate. Next post, I’ll show how self-control, and the brain changes that power it, also evolve with time, changing our lives for the better.

 

Whenever I take a couple of weeks between postings I start to feel home-sick for my blog. I miss you guys. I miss having something to say to you — something that’s at least a bit thought-provoking and interesting — and I miss your comments. Whether lengthy and rich with content or brief musings, reactions on the fly, your comments engage me, teach me something, or remind me of things I’ve thought about, insufficiently, or simply touch me with some shared emotion, maybe a recognition of past or present feelings and struggles of my own. And of course, after all this time, I’m getting to know many of you, becoming familiar with your personal style of questioning or arguing, extending or contextualizing, trying on ideas, accepting, rejecting, fitting, refitting – one way or another joining me in a deep exploration of addiction and trying to understand its massive reverberations in our lives.

But I’ve started teaching this term, and the last two weeks have been something of a blizzard: reading, preparing slides, lecturing to 200-plus undergraduates at a time, and then coming home to my own kids, still only six but starting to ask big questions. From a teaming mass of unnervingly young, stylishly dressed, device-laden, Dutch-speaking, half-interested (on average) post-teens to my own little haven of unnervingly witty six-year-olds with ever-changing constellations of teeth (new and old).

But now here’s a free couple of hours, and I’m ready to serve the first course of something I’ve been cooking up for awhile.

In my recent posts I outlined four stages leading from unguided daydreaming to the ironclad compulsion to get or do the thing you’re addicted to. Here are the steps in summary:

		Mind	Brain
Daydreaming	||	Thoughts flowing freely without direction	Default mode network: including posterior cingulate and medial PFC
Impulse	||	Switch to attractive image of addictive goal and urge to pursue it	Amygdala (AMG), ventral striatum, VTA (motivation-targeted dopamine/DA)
Goal-seeking	||	Rapidly-growing anticipation, concrete action plan forming, driven by craving	Orbitofrontal cortex, ACC, ventral striatum, VTA, AMG, hippocampus
Compulsion	||	Shift from anticipation of reward / relief to urgent need to act at once	OFC and v.s. deactivation; dorsal striatum, AMG, DA from substantia nigra/motor loop

 

Note that the brain column is pretty skeletal. Most (but not all) of these brain bits have been fleshed out in earlier posts and/or the book. Also note that I’ve skipped any step labeled “cognitive control attempts” — because I think these evolve in stages as the addictive urge evolves, with or without success.

So here’s the question: what is the time scale? How fast do we move through these steps, from the first fluttering of addictive images, interrupting our innocent fantasies, to a lurching momentum — gotta have it, gotta do it?

And the answer is: there is more than one scale. I count at least three different time scales for moving through steps 1 to 4.

A lot of natural phenomena have a property called self-similarity. That means that the same pattern gets repeated at different scales — whether in time or in space. Examples include the geometrical motif in the fronds of a fern, the curvature of beaches within bays within inlets that give shape to a shoreline, and the clustering of nests within communities within societies. Those natural forms show similar patterns at different scales — in space — from small to large. But we see the same kind of thing in time: for example, the back-and-forth cycles of advance-retreat in a conversation or argument can also be seen in the large-scale progression of a relationship: when one or both partners oscillate between confidence and surrender over weeks or months. And ocean waves break in dramatic clusters, leaving periods of relative calm, while the small wavelets within them follow the same rhythmic pattern of interspersed bunches. Maybe you’ve heard of fractals — patterns within patterns within patterns: where you see the same geometrical images at very different scales, all expressions of some common theme, some common structural principle.

Well this is all a bit dense, isn’t it? And what does it have to do with addiction…and the brain…and the way our lives unfold over time?

It’s going to take another post or two to flesh this out, but here’s where I’m going with it.

In addiction, we see this pattern: attraction leading to craving, leading to pursuit, leading to…a brief period of pleasure or relief, followed by more attraction and craving. In other words, wanting leading to getting, leading finally to loss or emptiness, which leads once more to wanting. For example: craving booze, drugs, or food, leading to binging, leading to saturation or tolerance, and then loss or maybe even withdrawal symptoms, then running out of the substance or the money to get it, leading to more emptiness, more craving. And this kind of cycling is fairly well recognized in the addiction field. A prominent review of addiction neuroscience has this to say:

Three major components of the addiction cycle have been identified — binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation (craving) — and incorporate the constructs of impulsivity and compulsivity…

But the first amazing thing is that this pattern, this cycle, can be seen at different time scales.

The slow scale tracks our hero as he or she develops a fondness for some substance or activity, leading to repeated experimentation, leading to a period of more intense experimentation, greater amounts, more potent concoctions (beer to vodka?  painkillers to heroin?) as the fondness turns into strong desire turns into addiction. Self-control is easy to come by in the first month or two; but a couple of years later, once you’ve gone all the way, self-control is a plastic bag you’re chasing in strong wind.

The fast scale tracks our hero as he or she wakes up one Saturday morning, lies in bed daydreaming, suddenly gets hit with vivid images of doing it, tries to chase them away, fails, starts to crave, starts to plan, lifts up the phone and starts dialing…so that by early afternoon he or she is pacing frantically, waiting for Mr. Dealer to pick up the phone.

It’s the same sequence! The same sequence of psychological states, and — here’s the second amazing thing — the same sequence of brain stages. With one difference. The slow scale traces the development of addiction, the development of that unholy love affair, and the gradual brain changes that support it. The fast scale traces (the microdevelopment of) an addictive episode, or, we could say, the activation of the addiction on one particular Saturday morning.

And what about the brain changes? At the fast scale, the wiring pattern of your brain isn’t changing; that’s already set. Rather, the wired-up brain regions become activated — in roughly the same order they got wired up — and that happens fast! Because you are the proud owner of a set of biological connections, giving rise to a familiar cascade of feelings and actions, that took years to develop. At the slow scale, what fired together time and time again ended up wiring together. Remember Hebb’s Law? And now, what got wired together over months and years quickly starts to fire together — over seconds and minutes. Enjoy the ride: that downhill cascade that takes just an hour or two, and that’s self-similar to the developmental cascade that took years to complete.

As for a third scale, stay tuned.

My next post, coming much quicker than this one, I hope, will flesh all this out in detail. I think I finally get it, and I’m serving it up all month.

 

This morning I woke up before the rest of my family. We’re in a hotel in Switzerland, on a ski holiday. Switzerland isn’t that far from our home in Holland, but I know that I’m a lucky guy. My life has improved substantially since sitting in a cell in Thunder Bay, Ontario, waiting to get bailed out (after raiding a pharmacy with a motion detector). So I snuck out of the room, trying not to wake anybody else. But of course one kid started coughing and the other went to pee, by which time Isabel was frowning at me in her first moments of wakefulness. Was I being too noisy?

Anyway, I’m feeling a bit disoriented. Vacations are nice, but I find it hard to just….um….relax. So I get to the lobby and boot up my computer and the first thing I read is a comment on one of the memoirs, by “jaqueline” (about 15 comments down this page).  Now suddenly I’m not bored anymore, or preoccupied with petty things like wondering when the grandparents will come down for breakfast and whether I’m supposed to get back to the room to help the kids dress. Suddenly I’m with this person in the freezing cold – cold attacking her body from the outside and her soul from the inside – trying to figure out what she can sell to get a bit of heroin. Her mother offers to get her a hotel room but refuses to give her any money. And she thinks: what good is a hotel room without drugs?

I remember that feeling so clearly. Viscerally. Even though it’s been a long time for me. The need for drugs that attaches itself to you so thoroughly that every movement of your body, even turning over in bed, feels like you’re pulling against a second skin. There’s this dark sticky second skin that’s stretched around you, irritated, pulling away patches of your own skin with every move you make. I’m here. I want drugs. What are you going to do about it?

That old expression, “monkey on your back,” isn’t far off. But it feels bigger than a monkey and so much darker. And there’s really nothing else to do. That’s the point: there’s only one thing to do and no other action has any point to it.

So you lurch out into the cold of early morning or late night, seeking, searching, there’s got to be a way. There’s got to be a sequence of steps. If I can only figure out where the path starts, I know, I just know, that there will be drugs at the far end.

That’s called compulsion. The drive to act, to do something, without thought or reason.

I promised last post to continue the model of addictive behaviour I was working on.  I’ve been reading more neuroscience papers, and there is a final state in the sequence of states I outlined. A final stage that I think is applicable to most people and most addictions: When addiction tightens its grasp, impulse turns to compulsion, and that’s when you just can’t stop – or so it seems.

There’s a distinct neurobiological change when this happens. I have focused a lot of attention on the ventral striatum or nucleus accumbens. That’s where attraction and focus suddenly converge to create the impulse to go after the thing you crave. But the striatum has another whole subsystem within it, higher up in the brain, which we can call the dorsal striatum. When impulsive drug-seeking behaviour turns to compulsive drug-seeking behaviour, it’s the dorsal striatum that gets activated. This is a definite change in how the brain processes cues – and when I say cues I mean the thoughts, memories, withdrawal symptoms, or reminders out there in the world that call your attention to the thing you’re addicted to. Now, the action sequence, the set of steps, the behavioural response, whatever you want to call it, is suddenly resonating, vibrating with life. You are plunged into action, forced into action by the wiring of your dorsal striatum. Much like Pavlov’s dog, who starts to salivate when he hears the bell. There’s nothing to think about, no more reflection on whether it’s worth it or not. You just have to act. Which means: you just have to get some.

I’ll say more about compulsive addictive behaviour next post. For many experts in addiction neuroscience, compulsive drug-seeking is the definition of addiction, and it’s worth our attention. For now, I feel a bit compelled to get this post up. (I’ll probably revise it more later). Jaqueline’s story, so resonant with Janet’s memoir and so searing a reminder of my own crazy drug days, got my fingers going until this post was done.

Now I’ll go see what’s up with the family.

 

 

In my last post I explored the role of the default mode network in addiction. One conclusion was that addicts’ brains activate the default mode network more than the brains of nonaddicts.

This brought us to a paradox. Actually two paradoxes. (My wife hates it when I pun, but a pair o’ ducks already sounds like two… Ok, ignore that and we’ll proceed.) The default mode network (a set of 6-8 brain regions that often become synchronized) corresponds with daydreaming, nondirected thinking, going with the flow, imagining oneself in the past and/or future, etc.

Paradox 1: Isn’t it good to be in the default mode? Isn’t that the foundation of creativity or at least relaxed self-reflection? (well expressed by Persephone in a comment on the last post)

Paradox 2: Addiction is characterized by craving, which means highly focused attention on a single goal. I want to get some…..now! This focused state corresponds with an entirely different network of brain structures (including the dACC) — those involved in intense, planful activity, or homing in on a problem that needs to be resolved.

So how do we reconcile the “positives” of the default mode network, and the “negatives” of the task-focused network, in order to arrive at a coherent model of addictive behaviour?

And while we consider this, let’s reflect on Shaun’s lovely metaphor, also from comments on the last post:

I have always described addictive behaviour as walking through a field of tall grass. We tread a path and we become “programmed” to walk this path. We return to this path every time we feel “lost”.

Getting lost in tall grass might correspond with the unguided thinking of the default mode. But once we’re truly lost in our fantasies, we return to a single well-worn path.

My former student, Professor Rebecca Todd, suggested something similar, but in more concrete terms. Falling into an addictive act should be seen as a micro-developmental process. That means it isn’t a single event; it develops, but it develops in micro time — in seconds or minutes. Duh. Why didn’t I think of that? Almost every emotional phenomenon is best seen as a micro-developmental process — a cascade (love that word) that takes a few seconds, minutes, or even hours to unfold. Thank you, Rebecca! (I like to think I taught her to be brilliant, but maybe she just came that way.)

So here’s the beginning of a micro-developmental model that puts these ideas together:

Step 1: fantasizing. You are in the default mode. Your thoughts are running wild and free.

Step 2: Impulse. This is exactly the state from which impulsive behaviour can easily spring. Because it’s…thoughtless. Free-floating fantasies lead to images of drugs, booze, sex, food, or whatever it is that attracts you. And off you go!

Scientists have very good evidence of the link between impulsivity and drug-taking. The following is from an article by Dalley, Everitt, and Robbins, 2011:

Impulsivity is the tendency to act prematurely without foresight…. One form of impulsivity depends on the temporal discounting of reward [which means going after immediate rewards, even at the expense of long-term consequences], another on….response disinhibition [what it sounds like: just do it!]. Impulsivity is commonly associated with addiction to drugs from different pharmacological classes…

Step 3: Focused attention driven by desire. The third step is that tightly focused preoccupation with the soon-to-be (I hope, I wish) reward. Now brain activation patterns have switched over completely, from the nondirected to the directed, from the default mode to the highly-focused, task-oriented mode (which, in the case of addiction, must include hyperactivation of the nucleus accumbens / ventral striatum, spiking on dopamine). Now all your energies are directed at solving the problem: getting it and doing it — plus subsidiary problems like paying for it, lying about, and hiding it.

I believe there is a fourth step, compulsion, which is not the same thing as impulse (though they are related). More about that next post.  I also believe there are different strategies for trying to stop the cascade, depending on which step you’re in. I’d love to hear your ideas about that.

 

Finally, here’s Bhagavan Das, that wise / spiritual / contemplative / meditative dude with a huge beard, talking to us from a recent documentary:

You’ve got to realize one thing: you need to tame your wild and crazy mind. Your mind has a very very bad habit, which we call self-cherishing.

That may be where all the trouble starts: the free-ranging fantasies of the default mode converge on the wish to improve the way you feel.