Understanding Addiction

Category: Connect

  • Self-medication or self-destruction?

    Self-medication or self-destruction?

    Last post I reviewed a study showing powerful correlations between traumatic experiences in childhood and adolescence and addictive behaviours in adulthood. Although several readers found significant holes in the research, the study maintains a fair bit of respectability, and besides, if we look at our own lives, I think we often see clear connections between personal hardships and addiction. This sort of “anecdotal” evidence, subjective and biased though it may be, is often the strongest reason, deep down, for accepting (or rejecting) the self-medication model.

    The self-medication model portrays addictive behaviours as attempts to diminish the feelings of anxiety, loss, shame, and loneliness left in trauma’s wake. For me, the connection is too obvious for words. I was lonely, depressed, and constantly on the lookout for personal attacks while at boarding school as a teenager. Within a year of leaving, I had shot enough heroin to end up unconscious in a bathtub, appearing to my friends to be dead. I don’t for a moment doubt the connection between these episodes of my life. And I say that, not as a scientist, but as a regular person, trying to make sense of my life.

    I recently spoke with a reader who has serious problems with alcohol, but only when things go wrong in her personal life. Eleven months of the year she has no craving, no attraction to alcohol. She doesn’t even have to be on guard because there’s no urge to get drunk. However, when her (now, thankfully, ex) husband became verbally and physically abusive, when her custody of her child was being challenged, when she had to go and live with her parents because the matrimonial home was a torture chamber….those were the times she drank to excess. Emphasis on excess. How can you be an “addict” only when things get tough, and then become a non-addict when life goes back to normal? The disease model simply can’t explain that sort of pattern, whereas the self-medication model predicts it. Threat and anxiety lead her to take alcohol, which makes it easier for her to bear.

    But there are problems with the self-medication model that need to be addressed.

    First, although trauma may lead to addiction, it isn’t necessary — addiction does not have to be preceded by trauma. Some people fall into addiction without any evident history of trauma. Instead, other factors, such as peer pressure or simple exposure, might be sufficient. Check out the video recommended by Steve Matthews as a prime example.

    Second, we know that self-medication doesn’t work very well. The things we take or do to diminish bad feelings actually increase them in the long run, or even in the not-so-long run. Maybe we’re not very good doctors. We prescribe for ourselves treatments that do more harm than good. Or they work for a little while — a month, a week, an evening — and then we get hit by the after-effects. Our dopamine-powered beam of attention cares only about the immediate, not the long run. Pretty short-sighted for a doctor.

    These iatrogenic (more harm than good) effects don’t actually conflict with the theme of self-medication. If you’ve ever tried prescription antidepressants (SSRIs) or painkillers for legitimate reasons, you know that many medications produce iatrogenic effects. These drugs often lead to dependency and an uncomfortable period of withdrawal. But the fact that self-medication often makes matters worse leads us to another question: Is the trauma we are “medicating” produced by the medication itself? That’s about as vicious a circle as I can imagine, and it challenges the very idea that trauma causes addiction — rather than the other way around, as pointed out recently by Conor (in a comment following my last post).

    So let’s imagine a causal story that goes completely opposite to that proposed by the self-medication model.

    As I noted above, some people start down the road to addiction without having lived through serious trauma. But even given a certain amount of trauma in childhood/adolescence, one’s PTSD or depression might be under control. When I first tried heroin, I wasn’t terrifically happy but I wasn’t in great psychic pain, relatively speaking. Then I stumbled on a substance that made me feel terrifically happy. Enter the choice model: I want to do that again, because it’s more valuable to me than any alternative. After a while, the substance or activity is a presence in one’s life. And that presence takes on increasing value: it’s sorely missed when it’s gone. Now the source of my anxiety wasn’t so much my historical injuries (e.g., my mother’s depression, my stint at boarding school).  Rather it was my present fear of going without dope, and wanting it badly, and not being able to stop thinking about it. Now we’ve got at least two of the most common outcomes of trauma – loss and anxiety – both caused by present drug-taking rather than historical events.

    Then along comes outcome number 3: shame. The loss of self-control – whether due to dirty underwear at age 4 or slavering desperation to get high at age 24 – is contemptible. That’s how others see it, so that’s how we see it. The result is shame, and guess what? Shame is one of the most common residues of trauma.

    From an article in The Fix, on 25 Sept 2011, comes the following:

    Of all the ACEs (adverse childhood experiences) that muck up one’s life, “’the one with the slight edge, by 15% over the others, was chronic recurrent humiliation, what we termed as emotional abuse,’ says Dr. Vincent Felitti, one of the directors of the study.” Shame is one of the few emotions that is directly, viscerally painful. Now, combine the loss you feel after running out or stopping, with the anxiety you get from craving what you can’t seem to get, with the shame that comes from your lack of self-control, and you’ve got a feast of negative emotions. The need for self-medication is now at its peak — indicating that the addiction itself is the trauma.

    The vicious circle — connecting addiction to psychic pain leading to further addiction – may well be the causal engine we’ve been searching for. But self-medication is only one part of this cycle: it doesn’t work all that well as an explanation that connects traumatic life events to a special, intrinsic need for self-soothing. What it really shows, as suggested by Nik, is that, for some period of time, we believe that there’s one thing in the world that can make us feel better.

    Of the three models of addiction, self-medication works best for me. As long as we acknowledge that trauma is an ongoing progression with its roots in our childhood but its branches still growing, still advancing, sometimes wildly, out of control, with each addictive act.

  • Addiction as self-medication

    A while back I promised to survey the three most common models of addiction – disease, choice, and self-medication – and say something about the advantages and weaknesses of each. I got hung up on the choice model for a few posts: there’s so much there to think about. But now let’s look at self-medication as the essence of addiction.

    The self-medication model seems to be the kindest of the three. It has the advantage of the disease model, in absolving the addict of excessive blame, but it has the additional advantage of avoiding the stigma of “disease” and all that goes with it. In fact, it gives control (agency) back to the addict, who is, after all, acting as his or her own physician. Whereas the disease model places agency in the hands of others and casts the addict as a passive victim. Furthermore, the self-medication model just might be the most accurate of the three.

    The idea is simple: trauma is the root cause. Trauma includes abuse, neglect, medical emergencies, and other familiar categories, but it also includes emotional abuse, and above all loss. Loss of a parent during childhood or adolescence can take many forms, including divorce, being sent away from home (in my case) or the shutting down of one or both parents due to depression or other psychiatric problems. Trauma is often followed by post-traumatic stress disorder (PTSD), which includes partial memory loss, intrusive thoughts, anxiety and panic attacks, avoidance of particular places, people, or contexts, emotional numbing or a sense of deadness, and overwhelming feelings of guilt or shame. But if that’s not bad enough, PTSD is about 80% comorbid with other psychiatric conditions – depression and anxiety disorders being chief among them.

    A famous study using a huge sample (17,000) looked at Adverse Childhood Experiences (ACEs) in relation to subsequent physical and mental problems. The results of the study are nicely summarized in the Sept. 25/2011 issue of The Fix. Take-home message: the relationship between trauma and addiction is unquestionable. An ACE score was calculated for each participant, based on the number of types of adverse experience they endured during childhood or adolescence. The higher the ACE score, the more likely people were to end up an alcoholic, drug-user, food-addict, or smoker (among other things). Here are two graphic examples:

    These figures, which are likely to be low estimates, show a 500% increase in the incidence of adult alcoholism, and a 4,600% increase in the incidence of IV drug use, predicted by early adverse experiences. Wow!!

    So how does self-medication work? There must be something about PTSD, depression, and anxiety that gets soothed by drugs, booze, binge-eating, and other addictive hobbies. Again, it’s not complicated. PTSD, depression, and anxiety disorders all hinge on an overactive amygdala – one that is not controlled or “re-oriented” by more sophisticated (and realistic) appraisals coming from the prefrontal cortex and ACC. That traumatized amygdala keeps signalling the likelihood of harm, threat, rejection, or disapproval, even when there is nothing in the environment of immediate concern. In fact, this gyrating amygdala lassos the prefrontal cortex, foisting its interpretation on the orbitofrontal cortex (and ventral ACC) rather than the other way around. The whole brain is dominated by limbic imperialism — making it a less-than-optimal neighbourhood in which to reside.

    At the very least, drugs, booze, gambling and so forth take you out of yourself. They focus your attention elsewhere. They may rev up your excitement and anticipation of reward (in the case of speed, coke, or gambling) or they may quell anxiety directly by lowering amygdala activation (in the case of downers, opiates, booze, and maybe food). The mechanisms by which this happens are various and complex. But we all know what it feels like. If we find something that relieves the gnawing sense of wrongness, we take it, we do it, and then we do it again.

    So, according to the self-medication model, addictive behaviours “medicate” depression, anxiety, and related feelings. But is that the whole story? I don’t think so, and I’ll get into why in my next post.

     

    PS: I have just installed new anti-spam software. If you write a reply that does not appear immediately on the blog site, please let me know!

  • This is your brain on choice

    Let’s return to John’s driving metaphor and fit it with what we know of the brain. As per my last post, let’s look at choice as a blip, a flash of intention, that rides on the momentum of underlying habits. Skillful drivers have built up a repertoire of good habits, like alertness, sensitivity, self-monitoring, and flexibility. So, even though they can’t promise to never have an accident, they can minimize the risk.

    “Driving responsibly” like “drinking responsibly” sounds like Big Brother claptrap. In fact driving well is very Zen. Today I took the car out on the winding roads at the foot of the French Pyrenees. I thought about John’s metaphor and became more aware of what I actually do when I’m driving. I took the curves gracefully, skillfully, even though the skill wasn’t something I could put my finger on. It wasn’t something I possessed. Rather, it felt like a moment-to-moment balance between assertion and surrender, focus and flexibility. It had to be that way, because I was moving fast through complex terrain, and I was thinking with my head but also with my body, my instincts, and that vast unconscious part that puts it all together, moment by moment.

    This view of choice fits well with brain mechanics. Sensory input pours in from the retina to the occipital area at the very back of the brain. That’s the primary visual cortex. Then it gets passed forward toward the centre of the brain, and it becomes more holistic, more comprehensive, along the way. Stage by stage (but very quickly) it joins with other sensory information (e.g., the feeling of the wheel in my hands) as well as memories and feelings. By the time it arrives at the orbitofrontal cortex, it is a gestalt with a familiar meaning.

    At the same time, motor output cascades from the centre of the cortex outward toward the periphery, going through stages in the opposite order. It starts in the dACC, or a region just north of the dACC called the supplementary motor area. That’s where plans seem to emerge. From there the output stream gets increasingly articulated, as it passes through the premotor cortex, where plans are translated into global action patterns, and finally to the motor cortex, where the actual muscle movements are orchestrated.

    These streams, input and output, flow at the same time – the output stream doesn’t wait for the input stream to finish before it starts up.(If it did, we’d respond to our environment at the pace of a slug.) So a special trick is needed to coordinate these streams. The brain connects the input stream to the output stream at each level, from detail to gist, with multiple connecting links, like rungs on a  narrowing ladder. At the bottom rung, concrete sensory details connect with concrete action commands, so the visual details of a sudden curve in the road are coordinated with the movements of my hands on the wheel. The rungs continue to connect the two pathways, as they get closer to the centre of the cortex, where a meaningful visual scene connects with a meaningful motor plan: I’m driving this narrow winding road, which feels good, but a car could come around the corner at any moment so I’ll downshift to second gear and slow down. Which I do.

    Intention – where “I” make a voluntary choice – is a difficult thing to locate in the brain. But our best guess is that it happens near the centre of the cortex, where orbitofrontal meaning connects with emerging plans in and around the dACC.

    So choice takes up a rather small part of the whole sensory-motor process. Think of it as the top rung of the ladder, with all the other rungs stretched out below it, doing their business of integrating perception and action. Was it a choice to change gears just then? Certainly. But that choice was the cream at the top of a dark, frothing mixture of perception and action at multiple levels. And what about those links below the level of choice? They are automatic, unconscious, and they are shaped and refined through repetition, through learning. Those links are where habits get built, by way of synaptic shaping, and those habits determine a very large part of our behaviour.

    Driving is a great metaphor for how we negotiate the attractions and hazards of life, which is also complex and difficult, and which also comes at us around each corner with great speed. Driving relies on something like flow, but flow depends on smoothly running habits. Being a good driver requires good habits, to give choice a chance (paraphrasing John Lennon). Being a good ex-junkie or ex-drunk also requires good habits, if you’re going to stay on track. First we try to build up those habits, then we simply do our best to make good choices, whenever the road takes an unexpected turn.

  • Addendum on choice

    A comment by John Becker, near the bottom of the page two posts ago, gave us this automotive metaphor — for steering through a thicket of addictive possibilities and staying on the road:

    “…you drive defensively, paying attention. Not too tight; not too loose. You’re not so afraid of having an accident that you’re all frozen up…not so tight you can’t take in the wider picture, but not careless either, you keep your eyes on the road. You’re not alone in the car; [you’re] responsible for your family, you want to be skillful.”

     

    That was a therapist’s response to an (ex?) addict who wished it were possible to say “never again” and be absolutely certain.

    I love it. You can’t be certain you won’t have an accident, but you can drive well — flexibly, with awareness — to minimize the chances. John used this metaphor to reflect on the nature of choice. To call addiction a “disorder of choice” merely scratches the surface, he says, and I agree, because we don’t really know what choice is. We don’t know how it works, and therefore we can’t avoid the uncertainty surrounding addictive choices, present or future.

    Right now I’m in this “villa” (not such a villa) in the south of France, and it’s hot, day and night. So I’ve been spending a number of hours in this semi-meditative state, rather than sleeping, which I would prefer by 2 AM. In this state I sometimes focus on my breathing, in and out, in and out, and I discover for the umpteenth time that breathing is fascinating. When you focus on your breath, you seem to be right there, present, at the moment when each breath begins. You say: ok, I’m going to inhale now, and you do. But when you relax a bit more, or when your mind wanders, you find that the breath comes anyway. Of course it does.

    What’s most interesting is the place where the choice and the automatic reflex converge. There you find that the choice to begin another breath coincides with an impulse that’s already gathering. Like froth on a wave – the wave being an underlying biological rhythm that senses the world and responds to it. The breath happens on its own even when you’re doing it intentionally. So what proportion of the “decision” to inhale is actually coming from you? Or, to put it differently, how much of that inhale was actually your decision?

    I think choice is like that most of the time, maybe always. Certainly the “choice” to reach for that bottle or that phone (to call your dealer)  is only part choice. It’s also part impulse — the gathering and then discharging of an underlying urge or plan — mixed together with conscious volition. So your moment of intention rides like a little boat carried by a wave.

    The trick then would be to work on shaping the wave – to become “skillful” in order to help protect you and your family from disaster.

    Making good choices requires good habits — skillful habits. Driving habits, like addictive habits, are not built in like breathing habits. But that’s what permits us to work on them and improve them. Through effort and practice. Good habits allow the spark of choice to flair in the right direction, the way you want it to, the way that keeps you safe.

     

    This little breathing exercise is a great way to study choice, from the inside — a start toward understanding it. But we can go further. In a couple of days I’ll post Part 2 –a look at what your brain is doing when you make a choice.

  • Just a few notes…

    Hi all. Here are a few updates to fill the idle hours of summertime.

    First, the homepage of this site has been revised, thanks to Victor (my web guy). It now includes links to a number of blogs, magazines, and other online entities that deal with addiction (mostly drugs and booze…but other stuff too) and recovery. I hope this will make it easier for all of us to get informed, find help, and/or explore the ongoing waves of late-breaking news.

    Here’s a quick guide:

    The ScienceDaily Addiction News page reports on research concerning substance use and addiction.

    The Berridge Lab site describes the research findings of a particular team — one I greatly respect.

    Heroin and Cornflakes and The Fix present research, social issues, news, interviews, and stories related to substance use and addiction.

    Addiction and Recovery News, Addiction Blog, and Dryblog give you news, stories, opinions, and links re drugs, booze, and recovery.

    Drug Addiction Support, Harm Reduction for Alcohol (HAMS), and Recovery Nation specialize in what’s old, new, available and useful in treatment and recovery (along with their individual biases, of course). These are the places to go for immediate help.

    Gabor Mate’s site is about…Gabor Mate. Mostly his books and talks, about addiction and other psychological messes.

    PLEASE let me know if there are other links you think should be added to the list.

    Second, I’ll have a live interview with the HAMS blog today at 6 PM EST. I should have announced this days ago. Oops. Anyway, these guys are pretty serious. They have a number of interesting and relevant interviews posted here. Including one with Stanton Peele, whom I always enjoy. An old geezer (older than me!) who knows a lot and likes to be controversial.

    Third, through multiple communications — which I’ve been pleasantly drowning in — I’ve started to piece together a perspective on treatment politics at the international level. It seems that in North America and especially the U.S., the treatment network is dominated by the disease model and an overarching focus on full recovery (most often 12-step based). In contrast, in the U.K. and Europe, the treatment network highlights harm reduction — living with addiction.

    Each of course has its benefits and drawbacks. A primary drawback of the harm reduction ethos is that people become stagnant in their addictions, living life on methadone or just continuing to use, and dropping out of dynamic contributions to their society, in terms of employment and lots else. The drawbacks of the disease model…well, I’ve already expounded on those enough in this blog, but it looks like that’s where my next book is taking me.

    Which brings me to #4: Countless emails have revealed a thicket of upsetting, sometimes toxic, interactions between people who really want to improve their lives and a treatment industry that is narrow in scope, demanding in its policies, and one-sided in its interpretations of addiction. That’s where I now think my next book is going, along with my trademark (?!) emphasis on neuroscience and biography. I didn’t think I’d be heading in that direction, but more and more I see that the social-political side of addiction is important to understand as part of a well-rounded picture. (And it connects with my recurrent dreams of trying to deceive suspicious doctors in white coats. Yup, still get em.)

    Enjoy your local brand of climate change, wherever you are. We’re heading to the south of France, which is just around the corner, for two weeks. But I’ll have another post up soon anyway.