The common denominator of all addictions

I said I’d use the next few posts to share what I learned at a recent conference on behavioral addictions. I should emphasize that the conference, held in Budapest, was billed as the the First International Conference on Behavioral Addictions. The idea that gambling, hypersexualized behavior, eating disorders (including obesity), and internet addictions are in fact addictions is quite new, and even today there are many professionals, policy-makers, and researchers who bristle at the thought.

Think for a moment about the implications. If the medical world accepts, say, internet addiction and eating problems as addictions, requiring treatment, then insurance companies in the U.S. will go bust within weeks. Not that they don’t deserve it. If internet use is an addiction, then how do parents and teachers moderate kids’ internet use? Almost nobody would claim that internet use should be forbidden, yet, if it’s addictive, then shouldn’t it be tightly controlled? These are just a few of the problems society will face when behavioral addictions are acknowledged as addictions.

I say this as if the matter is resolved. Well, it is for me. I saw enough evidence in those two days at the conference to convince me, beyond a doubt, that behavioral addictions not only resemble substance addictions in “real life” but also arise from the same brain processes.

The most convincing parallels between substance and behavior addictions start by recognizing their common denominator: compulsion. When gambling is considered an addiction, it’s called compulsive gambling. Eating disorders including binging and bulemia are often wooldiscussed as compulsive. The same goes for sex addiction and a few other things. Then we cross the line into substances. Smokers smoke compulsively, alcoholics drink compulsively, and as for drug addiction,the National Institute on Drug Abuse defines it as characterized by “compulsive drug seeking and use.” In my last few posts, I’ve described a set of stages in the onset of addiction (and addictive acts), and the final stage is compulsion. So, if we are seeing evidence of a common denominator underlying both substance and behavioral addictions, both in people’s behavior and in their brain mechanisms, then the defense rests.

OCDInterestingly, the most fundamental behavioral addictions are the individual actions people perform repeatedly when they suffer from OCD (obsessive-compulsive disorder). When you wash your hands or check the stove 50 – 100 times a day, that’s a behavioral addiction! So a number of speakers at the conference directly compared the behavioral and neural portrait of OCD with both/either drug and/or behavioral addictions.

Naomi Fineberg, a well-recognized researcher in this area, sees OCD as the archetypical compulsive disorder: People with OCD can’t inhibit impulses, they show low cognitive flexibility, and narrow, limited goals. She uses a button-pressing task in which the “reward” is turning off a mild electric shock. After training on the task, the reward is withdrawn. From that time on, pressing the button accomplishes exactly nothing. Yet compulsives keep on pressing the button. Ordinary people do not. Compulsives report that they keep on pressing simply because they feel the “urge” to do so. Sound familiar? Sound like addiction? She concludes that OCD is not about repeating a behavior to get a reward — nothing good is anticipated. Rather, actions are performed to avoid “punishment” — the negative consequences of not doing something. And the negative consequence may simply be the build-up of anxiety. I’d say it’s very much the same with addiction.

brainbalanceDr. Fineberg also talked about her neuroscience research. OCD “patients” (I hate that term, but that’s what they call them) and stimulant (e.g., coke and meth) addicts show a host of similarities in the scanner. The ventral regions of the prefrontal cortex (such as the orbitofrontal cortex) are where emotional meaning grows and solidifies over time, and these regions show reduced connections with more dorsal areas involved in self-control. So the brain becomes less capable of exerting self-control.

Giacomo Grassi, from the University of Florence, talked about OCD and addiction as caused by “reward dysfunction” — a condition that starts out with anxiety but ends up as a behavior problem, becoming “addicted to compulsion” as he calls it. Dr. Grassi’s brain scan images showed that OCD patients have higher activation of the amygdala (the centre for emotional conditioning) and lower activation of the nucleus accumbens (or ventral striatum — the brain centre for motivated reward-seeking) — a pattern repeatedly shown in addicts as well. He also demonstrated a shift in activation from the nucleus accumbens to the dorsal striatum as compulsions set in, just as I discussed two posts ago as the final stage of addiction.

So we could say that OCD is the pure form — the grand-daddy syndrome — in which people fall into loops that are no longer rewarding, just difficult to turn off. Substance addictions and behavioral addictions are two derivatives or variants of that form. Two lines of descendants — its offspring. Substance addictions and behavioral addictions look the same, sound the same, smell the same — common sense suggests that they are, at least, very close cousins.

 

 

 

47 thoughts on “The common denominator of all addictions

  1. Richard Henry March 20, 2013 at 7:06 am #

    Thanks Marc

    I never thought of O.C.D as being an act that was performed to avoid the negative affects, of not doing it. I always thought the compulsion to say… Hoarding, was a satisfying reward of the accumulation of stuff, this giving comfort. Well hoarding may not be the best example, I get your meaning.
    It sure opens up a whole new set of problems. Like if someone is using Cocaine to enter into a state of hypersexualized behavior because they know they could never realize this enhanced feeling with out it. Its going to be hard to determined what the real addiction is, if an addiction at all? and only used on an occasion like Viagra. Can one become addicted to Viagra or is the act of hypersexualized behavior that he is addicted to. Can we even call it an addiction if alone or both partners receive no negative consequence from the use of it?
    Well Marc I think I open up a whole new can of worms, hahaha…
    Enjoy your post and like always , paying it forward..
    Regards Richard

    • Shaun Shelly March 20, 2013 at 7:32 am #

      Hi Richard, my feeling is that if someone was using cocaine as a form of viagra, occasionally, to achieve a particular end and there are no negative consequences, then it is certainly not addiction.

      • Donnie Mac March 20, 2013 at 2:36 pm #

        I do love/hate to be the “Devils Advocate” and believe I am far , far away from being pious . I understand what you are saying here completely !! But heres my question . So , one night you decide to “Score a Little” and go “Bang” whom ever. You get your package you on your way home , next thing your pulled over by the police and they “Find your Shit”. Face down on the front of a cop car with a gun to your head getting hand cuffed , pocket being searched . The tow trucks on the way to seize your car . Do you have a Problem with Drugs now ?
        Believe me the Judge will not understand your “hypersexualized behaviour” story.
        Just Asking ?
        Donnie

        • Shaun Shelly March 20, 2013 at 2:59 pm #

          “Do you have a Problem with Drugs now ?”
          No, you have a problem with the cops because of the public policy that makes possession for personal use illegal.

        • Marc March 24, 2013 at 3:09 am #

          For sure. You might also have a problem with thrill-seeking, one of the few personality traits that appears to be partly heritable.

      • Marc March 23, 2013 at 6:06 am #

        I agree, Shaun. But what about the man who couldn’t sleep, described in my comment below?

    • Marc March 23, 2013 at 5:50 am #

      In reply to Richard: Thanks, I enjoy your worms too. Co-addictions are very common, and not that hard to conceptualize. But you raise a different problem: if an “addiction” is actually a means to an end, and the end itself is constructive, then should we even call the “means” an addiction?

      Which reminds me of a recent comment I got: a man told me he smoked pot every night to get a good night’s sleep, because otherwise he suffered from insomnia, and he asked me if he was “addicted”.

      I’d like to think of this issue in terms of the end — that’s what justifies the means, as my politically-minded hippie friends used to say. So, if the end is, say, having healthy sex, then whatever you do to get there must be okay… Right? Unless the means BECOMES the end. I seem to remember that expression, as a counter-argument from my non-politically minded hippie friends (those of us who preferred sitting around and getting high).

      Wish it were all so simple…so formulaic. In fact life is much more complicated, and what you might term “healthy” at the beginning of the week could easily end up “sick” by Friday. I’m sure you catch my drift.

      • Shaun Shelly March 23, 2013 at 8:19 am #

        Like you say Marc, these are difficult questions with no easy answers. We had a patient a while ago who stayed in the house where his mother was murdered in front of him while he was a child. Every night he lay awake, wondering what he could have done to prevent this murder. Insomnia was his cruel companion until he discovered pot.

        It certainly provided a means to an end. and it was more available in his community than access to counselling, psycho-therapy or even primary medical care! However, it was perhaps incongruent with his job as a community youth development leader. Fortunately he had understanding employers, so when he tested positive they sent him to us, rather than dismiss him. He is still in therapy, and he still uses pot occasionally, but I certainly do not regard him as an addict. He may end up there, but not at the moment.

        Looking at your example, chronic use, for me, is not addictive use, or even abuse. I personally would not take that route because, well, I’m an addict and pot for me is a waste of time. Give me something to keep me up for 4 days and then I’ll sleep REALLY well on day 5 – after a huge dose of GHB. Makes sense to my addict brain! But if that is the route that particular person takes, and as long as they are doing it by choice and it is not causing some discord in their life, fine by me – as long as its fine by them.

  2. Shaun Shelly March 20, 2013 at 7:47 am #

    Marc, while I agree that late stage addiction mimics compulsivity, I would argue that calling addiction the same as OCD is to miss much of the nature of addiction. I feel that compulsive disorders start off being compulsive disorders – performing an act to reduce anxiety or stress with no “reward” – a form of negative reinforcement.

    Addictive disorders, in my opinion, start somewhere else (that is a whole topic in itself!), become (predominantly) impulse control disorders, and then become (predominantly) compulsive disorders. Impulsive disorders being more “positive” reinforcement.

    Perhaps, through repeated exposure to the addictive relationship, the addict brains morphs to become more like the OCD sufferers brain. Maybe this is where the mythical line between “abuser” and “addict” lies?

    • MB March 21, 2013 at 10:32 am #

      Shaun, I agree, but I would take it one step further – that equating addiction and OCD misses much of the nature of BOTH addiction and OCD. Growing evidence points to OCD as having a biological basis – damaged or deficient structures in the brain. While I wonder if addiction takes advantage of deficient or damaged structures, there doesn’t seem to be evidence for that in research. Addiction seemingly starts with an environmental or behavioral component, and then the processes of the brain take it from there.

      One of my sons had an horrific onset of OCD at the age of 19 while he was away at school. My other became an addict at 19 while he was in school. In retrospect, my OCD suffering son showed signs of obsession and compulsivity at a very early age. He became obsessed with letters and numbers at 14 months. He stuffed his pockets with little, plastic magnetic letters. He created nests of letters and letter blocks in his crib. He arranged, stacked, and created patterns with his letters. He noted letters in newspapers, magazines, signage. If you moved his letters, he became disconsolate and threw tantrums. He knew his letters and numbers by the time he was 16 months. Not surprisingly, he was reading at the age of 3.

      I was careful to make sure his world was broad – he did all the other normal toddler things too – played, laughed, ran outdoors, romped in the playground. And he grew to be a bright, broadly talented and loving boy. There were 2 red flags in early adolescence, but they passed quickly. His first major episode was terrible and plunged him into a great depression. He could not use the word “I” in speech or writing. He could not refer to himself. He was certain that his writings revealed his particular irrational, intrusive thought. He could not send or print his papers to professors.

      A therapist kept him afloat, but it was a combination of a supplement we read about and my son’s own research into CBT techniques that has helped him manage his OCD. We recommended he take high dosages of NAC (N-acetylcysteine), which impacts glutamate levels. After several weeks of NAC, he noticed the OCD had lost its edge and a particular technique he had identified was helping him to manage his OCD.

      My miniscule, anecdotal evidence leads me to suspect that my son’s OCD stems from a biological basis. I do wonder if my recovering son’s addiction has a similar etiology. Again, there seems to be no groundswell of support for that supposition. My grandmother died at 52 of an alcohol overdose. One of my sisters is both an OCD sufferer and an addict (former cocaine, now alcohol). One of my brothers is a very high functioning alcoholic. I can’t help but wonder…

      • Shaun Shelly March 22, 2013 at 2:49 am #

        Thanks for sharing your story. I would strongly agree with your opening statement: “that equating addiction and OCD misses much of the nature of BOTH addiction and OCD” I would also agree that OCD is more biological than environmental. This is borne out by the fact that psycho-social interventions, of which Exposure and Response Therapy is the only evidence based intervention, is very seldom beneficial without pharmacological intervention.

        There certainly is a growing body of evidence that brain structure can increase or decrease susceptibility to addiction. Dr Karen Ersche has just published work on brain structure of cocaine addicts. But certainly I would say environment plays a very significant and crucial role in addiction.

      • Marc March 24, 2013 at 5:16 am #

        HI MB. I remembered you story of your two sons while I was thinking about parallels between OCD and addiction. I’m not entirely clear what your question is, but I think I get it. You seem to recognize that there are substantial biological precursors, predispositions, whatever, that your two sons had in common. The onset age of their problems was identical. You also identify relatives who sound like they had similar vulnerabilities. I have not discussed genetic links, lately, but I’ll get back to it in a future post. For now, a specific variant in a gene for a dopamine receptor is implicated in cross-generational vulnerabilities to addiction.

        I think your confusion is that OCD can develop much earlier, showing behavioral anomalies that are sure to implicate brain anomalies, even in childhood. Whereas addiction seems to start whenever it starts, and the brain changes cascade out from that point into the future.

        But I think the resolution here is to recognize that addiction DOES have biological predispositions. They may be hard to identify from a distance, they may be very subtle, but a at least one recent large-scale study showed brain anomalies that precede drug “abuse” in adolescents. Then drug use extends the brain anomalies further. To further complicate the picture, early abuse or neglect can evidently set off subtle brain anomalies that predispose toward addiction years later.

        A simple example of an environmentally initiated biological precursor is depression. Depression, like addiction, is both a cause and an effect of brain change. I was quite depressed as a 15-17 year old. By the time I got to Berkeley, at age 17, I have no doubt that my brain was more vulnerable (than it might have been) to the immediate rewards offered by addictive drugs.

        But it sounds like your sons’ issues had a genetic basis. I think you and I agree on that.

    • Marc March 24, 2013 at 3:28 am #

      Shaun, I agree with you completely, and I’m glad you brought up this distinction. I never meant to imply that addiction is THE SAME as OCD, just that, exactly as you say, end-stage addiction overlaps substantially with OCD. That’s why there are all these similarities in the scanner. I agree that addiction starts off as reward pursuit / positive reinforcement — in fact that’s the second stage in my stage model.

      Wasn’t it you who just sent me that in-press paper by Everitt and Robbins? The title says most of it: From the ventral to the dorsal striatum: Devolving views of their roles in drug addiction. The abstract says the rest.

      From the abstract:

      “We revisit our hypothesis that drug addiction can be viewed as the endpoint of a series of transitions from initial voluntarily drug use to habitual, and ultimately compulsive drug use. We especially focus on the transitions in striatal control over drug seeking behaviour that underlie these transitions …. We also discuss the hypothesis in light of recent data that the emergence of a compulsive drug seeking habit both reflects a shift to dorsal striatal control over behaviour and impaired prefontal cortical inhibitory control mechanisms. We further discuss aspects of the vulnerability to compulsive drug use and in particular the impact of impulsivity.”

      The last sentence above refers to the “vulnerability” to becoming dominated by an OCD-like mechanism bestowed by what I would call giving into impulses time and time again.

      • Shaun Shelly March 25, 2013 at 3:17 am #

        Yup, it was me that sent that paper. So yes, that’s where its at.

  3. Elizabeth March 20, 2013 at 8:41 am #

    I think I’m in agreement with Shaun, the “addiction” for drug users seems to have a different origin than behavioral addicitons with OCD, although I think they tend to converge at the dorsal striatum. The thing that has confused me is that OCD individuals that are highly perfectionistic, tend to have blunted affective responses to rewards and are more punishment-focused. There is even some evidence for ELEVATED, as opposed to diminished, D2 receptor availability in the ventral striatum. I do think there is some sort of reward component to performing the “harm reducing” compulsion that we tend to ignore over when thinking about behavioral addictions and we refer to it as “negative reinforcement” instead of positive. Perhaps the relaxing act of performing a ritual is subjectively more reinforcing to these individuals. The neurological reward profile may look different, but we don’t know if that translates to a fundamental perceptual difference. Perhaps there is just enough of a transient DA signal to indicate incentive salience in these individuals and they start to perform the act over and over again, making it a compulsive habit?

    Sorry this is a bit disjointed. I have to run off to class, but I wanted to chime in as I have often grappled with this comparison myself.

    • Marc March 24, 2013 at 3:59 am #

      Well, sure it’s reinforcing. The question is whether it’s positive or negative reinforcement. But I agree that the distinction may become so confused as to become meaningless. In my book I talk about how the opioid system does not differentiate between relief and pleasure. What no longer feels bad certainly feels good.

      But please see my reply to Shaun, above. I agree that OCD and addiction don’t start off the same. Rather, in some important ways, they end up the same. And that includes hyporesponsiveness of the ventral striatum. In fact Naomi Fineberg found decreasing grey matter density in the OFC with increasing compulsivity, and the OFC is closely related to the ventral striatum. It may thus become increasingly difficult to feel positive about anything!

      Anyway, I was serious about the expression “addicted to compulsion.” This was Giacomo Grassi at the conference, and like you he sees OCD behavior as “rewarding”. Though he specifies negative reinforcement. What he says that’s most interesting is that both OCD people and addicts experience CRAVING before the reward onset. He also tells some powerful anecdotal stories. One OCD patient said “I WANT to do my compulsive ritual. Don’t take it away from me. I know I’ll feel better afterward.” I’ve always found it a bit confusing to distinguish negative and positive reinforcement. I think that, deep down, they’re no different.

      • Elizabeth March 24, 2013 at 9:04 am #

        “I’ve always found it a bit confusing to distinguish negative and positive reinforcement. I think that, deep down, they’re no different.”

        —> I couldn’t agree with you more. Often in our ED groups, one of the biggest fears among participants was LOSING the rituals and not knowing how to cope with the inevitable tension without it.

        • MB March 24, 2013 at 11:23 am #

          Elizabeth, that is interesting. My OCD son has no fondness for his OCD, nor his irrational, intrusive thoughts, and rituals. Ok, except for that one time he ran a half-marathon without training any longer than 7 miles. His OCD made him so paranoid as he passed other runners (they might somehow learn his intrusive thought / secret), that he ran the half marathon in 90 minutes! Returning to the point, he truly has no affection or attachment to his rituals.

          BUT, and perhaps this is where he differs from the participants who are afraid of losing their ritualistic behaviors, he recognized his OCD symptoms relatively early when he had his first major episode and understood they were NOT a normal behavioral response. His particular intrusive thought was clearly irrational to him, but outrageously tenacious. I wonder if other OCD sufferers slide into OCD, without specific awareness. Perhaps it sneaks up on them with a seemingly benign start?

          It could be my son’s self-monitoring and initial mindfulness gave him a perspective that others may not have the advantage of. My OCD sister, BTW, is very frightened of losing her ritual, which takes the form of very compulsive cleaning. But, then this culture equates cleanliness with godliness, so I’m sure she experiences plenty of positive reinforcement for her behavior.

          • Elizabeth March 24, 2013 at 12:34 pm #

            Interesting, I’ve had very love/hate relationships with my behaviors. On the one hand, I knew I was destroying various aspects of my life by engaging in my ED, but on the other hand, I didn’t know what else to do. I didn’t really have an alternative at first for living a better life. All I know was avoiding punishment and obsessing over finding rigid rules to avoid said punishment. I guess I learned it at an early age from my mother’s OCD. I thought that’s what life was, it wouldn’t get better. Perhaps other individuals have similar experiences: a hate for the disorder, but seemingly no pathway to change and find respite; sort of a “least worst toilet” scenario (you go into a public restroom, and all the toilets are bad, so you pick the least disgusting option).

  4. Chinagrrrl March 20, 2013 at 9:03 am #

    The “line in the sand” where a behavior slips into obsessive, then compulsive use. I was discussing with a group of professionals with personal experience with substance abuse how we all thought our “knowledge” would prevent any of us from slipping down the spiral into addiction. I know that I didn’t see my personal line in the sand until I was looking over my shoulder at it going “Oh crap!”

    And I’ve learned in the ten years since getting past that compulsive use of drugs that I can be compulsive in *many* things. My brain has apparently changed. Why? Don’t have the answer. How? Can’t really explain it. I just know it has and that keeps me on my toes enough. If someone wants to sit me down, study my brain and tell me why…I’m all ears. But living life is complicated and busy enough for a wee girl like me.

    I *do* know that I’m not the only one. I see, all the time, in the rooms of recovery and in “normal” people, that some of us just get a little *weirder* as we age. We develop little patterns that help us to feel safe. OCD? Obsessive? It seems that when we take those self-soothing behaviors and they start to interfere with our life (maladaptive) and we can’t stop them (compulsive), that we start to see where that tricky little “line in the sand” originates.

    Good post!

    • Richard Henry March 23, 2013 at 7:14 am #

      Chinagrrrl… I like the way you explain you view as a line in the sand. It reminds me of what my son said to me one time, Dad… Time to put yourself in check. Meaning… what I see in your interpretation as the line in the sand, where I can stop for a moment and say “O Crap!” it snuck up on me again… but in a different version of my additive behavior. I realize for me to accomplish something I must almost become abscessed toward it, in order to accomplish it. But I guess I must always be aware of that line in the sand as the line between obsession over addition. My obsession is a means to accomplishment, my end is completion. The rewards come to and end, and the cycle continues.

    • marc March 24, 2013 at 4:32 am #

      Hi you! Brain changes are real. But I’m glad that you brought up normal aging as a sort of baseline. It’s true that we get a little weirder. I recently turned 62, and my latest compulsion is to read trashy police stories (compulsively) whenever I’m on the bus or train. In fact it’s gotten to the point where I’ll take the slow train so I get more time to indulge. Granted this is a minor compulsion. Especially compared to the run-in I had with painkillers two years ago, after my back surgery. But there it is, and it’s likely to stick around.

      The brain does change, regardless, as we age. I imagine that’s why little habits become big craters in one’s character. But the changes aren’t necessarily bad. I’ve also gotten less sensitive to criticism, less defensive, and possibly less depressive as I age. Brain changes are habit forming, quite literally. The brain likes to find habits.

      But of course that’s where addiction comes in. When the brain gets hold of something that has big warning labels all over it — Caution! May be habit-forming! — then it’s like injecting growth hormones into the soil where the seeds are planted. Watch out!

      • Shaun Shelly March 25, 2013 at 3:21 am #

        Marc, read Ed McBain “Guns” !

        • Marc March 25, 2013 at 7:57 am #

          Trashy police story? I’m there. Lately I’ve discovered Jo Nesbo — actually so damn good it doesn’t count as trashy. This may be symptom substitution, but it’s got me out of my Michael Connelly phase.

  5. Peter March 20, 2013 at 9:23 am #

    Marc,

    I agree with the views in this post wholeheartedly, not just through knowledge, but experience as a behavioural addict. I see the distinction between substance and behavioural addiction as practically zero, apart from the fact that one has to eat, use internet etc for positive purposes.
    Very exciting ideas, and the conference sounded really interesting! Looking forward to hearing more on this subject.

    • Marc March 24, 2013 at 4:57 am #

      Thanks for chiming in. More to come…

  6. Robin Roger March 20, 2013 at 9:41 am #

    This might be a worthwhile point at which to mention Jeffrey Schwartz’s work on OCD and the treatment he developed based on mindfulness meditation. HIs book Brainlock is directed to OCD sufferers and is accessible to non-clinical readers. A more demanding book is called The Mind and the Brain, also by Schwartz. The author puts more emphasis on the caudate nucleus, but this is an older book so perhaps the research described in this post wasn’t available at that point. At any rate, it seems to me that what your observations suggest is that mindfulness is probably a good protective practice for everyone, before addiction starts and certainly a helpful way out of addiction.

    • Marc March 25, 2013 at 8:05 am #

      Hi Robin. Exactly so! I read the first Schwartz book and thought it excellent. To me, the take-home message was: even though there’s something fishy going on in your brain, you can still correct it through insight, courage, and persistence. And by the way, the caudate nucleus is precisely the same place as the dorsal striatum. So we’re all in agreement on that one.

      And the use of mindfulness/meditation…. Yes, I do think that its value is quite universal, at least with respect to problems that reside in one’s attachments, desires, wishes — the stuff that lives in the place where you’re supposed to find your “will”.

  7. Julia March 20, 2013 at 10:40 am #

    One other point that seems important to address in this analysis is what exactly you mean by “compulsion” or “compulsive.” From my lay reading/listening of research into motivation and behavior it seems like all of us have a lot less control over what we do and much, much less understanding of why we do it.

    There seems to be a major post facto explanatory mental process that is inherent to human cognition. We do what we do in response to all kinds of subconscious (in the sense of unavailable to conscious awareness, not the Freudian sense of that term, hence the lower case) forces including sensory, past experience, brain inclinations, etc. So at what point can one judge when an action is “compulsive” rather than seemingly freely chosen?

    Certainly there are degrees of self discipline that can be learned as well as inherent predisposition to having better impulse control (the now famous “marshmallow” studies with young children). Some people are able to adhere to a regimen of exercise, diet, work, etc. while others are less able. How much of that is learned and how much is inherent ability?

    In any case, I think that a more useful measure of there being a problem is when the behavior (which can include ingesting substances) has damaging effects physically, mentally or socially. This approach goes along with a more humanistic attitude that’s becoming integrated into medicine altogether. Rather than looking at a “patient” as a collection of test results, physiological measurements, etc. the physician listens to the patient, hears their story and what is important to them about their subjective experience. I am skeptical about labeling addictions according to their object rather than according to evidence of damage to the individual, their family and/or community. Could one theoretically be “addicted” to water? If you drink too much you could kill (or at least severely damage) yourself… right?

    • Marc March 25, 2013 at 8:16 am #

      Beautiful points, Julia. I strongly agree. What you are saying is that there is so much going on before we are conscious of, or consciously in control of, our choices, that you can’t draw a line based on labels like compulsivity. Indeed, much of what we do we do for reasons we’re not aware of, and we choose to do it before the choice is ever conscious. Or ever completely conscious. (by the way, I think that the Cognitive Science definition of consciousness you use is not completely incompatible with Freud’s unconscious. I think that both are true.) And actions may have a certain momentum, so that we fall into them, rather than “choose” them, even at the best of times. Compulsivity indeed.

      Psychologists and neuroscientists are putting a lot of energy into studying the processes that lead to the moment of choice. I’ve reviewed recent research showing that brain changes predict what one is going to choose seconds before one is aware of making the choice! Also, the study of delay discounting, ego fatigue, and other stuff that falls under the label of behavioral economics or decision science all seems to be directed at a more thorough examination of how we make choices.

      So, sure, let’s draw the line at the point where we begin to harm ourselves. When danger lurks, most people have the capacity to “go dorsal” and make conscious decisions to avoid it. Addicts (and others) do not. The degree to which this capacity is inborn as opposed to learned is a matter of great debate. But I think that a lot of it has to do with learning, and only a little to do with genetics.

      • Julia March 25, 2013 at 10:05 am #

        I agree that learning does have more to do with how people handle impulse control and decision making. But even if genetics have some role, by the time someone is an adult and has formed habits around their addiction, it’s probably a moot point as far as how to address their problem.

        One point you make seems to be kind of circular… that some people are able to recognize when their behavior or substance use has become damaging and are able to do something about it and others (the true addicts) are not. But that’s just restating the same dilemma!

        By definition, those who can recognize the destructiveness and do something about it are not truly addicts or at least are not the main subjects of your research since they can regulate on their own. So we’re still left with the original question about why some cannot “choose” to change their behavior, even if they seemingly recognize the damage being done when they are in certain states of mind.

        From my reading/listening, it seems like the most promising interventions have to do with changing the person’s environment, in small and big ways depending on the situation. That making access to the substance or behavior more difficult can give time to re-think the follow through. Also, just putting people into a completely different social setting, one which not only is absent the usual availability of the addictive object but also encourages and supports alternative behaviors, other ways of succeeding or meeting one’s needs. I guess that’s what residential treatment is supposed to do.

        But the problem arises when people are simply sent back to the original environment, whether it’s their neighborhood, their family, their same friends, etc. But that sort of intervention is a lot “messier” and harder to implement so is less explored. So we do what we can and certainly understanding the full spectrum of factors affecting each individual can only help! Thanks again for your work and this forum!

  8. nicolas ruf March 20, 2013 at 11:01 am #

    To my mind addiction is front-end loaded. The behavior detaches from the result and the result does not modify the behavior. The behavior is driven by cues to which the system becomes increasingly sensitive, through motivational dopamine and intermittent reinforcement, until it kindles. Isn’t negative reinforcement in this context really craving? If I say that I really need a drink, it’s the need not the drink or the result driving the behavior. Motivationally speaking both positive and negative reinforcement are irrelevant, and we can do away with both NAcc and amygdala input. Just point and click.

    • Marc March 25, 2013 at 8:24 am #

      I think I get you, but I’m not sure. You’re saying we can get rid of the NAcc and the amygdala once the dorsal striatum (caudate) is fully in charge? I’m not so sure. I agree that the behavior becomes an “automatic” response to cues. I agree that it’s no longer about reinforcement per se. But I don’t agree that negative reinforcement = craving. And I don’t agree that you can get rid of the NAcc and amygdala so easily.

      To my mind, maybe with the exception of purely compulsive behavior, like twiddling your hair or biting your nails or something, craving, which is still the province of the NAcc, is the LEAD-UP to addictive behaviors. It brings us into the sphere of the substance or activity. It brings it close, and through planning it makes it accessible. And only then does activation move to the caudate and become “automatic,” i.e., independent of reinforcement.

  9. JLK March 20, 2013 at 1:05 pm #

    Hi Marc

    Have start tell by telling a true funny story about OCD although I know you take these disorders quite seriously.

    Many years ago when I was broke and could not afford one-on-one counseling (they got it all wrong anyway) So I had to attend group therapy sessions. The guy who always sat next to me looked and acted quite normally but mentioned during the session that he had a pretty serious case of OCD.

    In those days washing your hands all the time was considered the prime indicator of the disorder. So being the diplomatic person I am I asked him how many times a day he washed his hands. He answered “three”. I said “Only three? I wash my hands more than that” He replied “but not 3 hours at a time”.

    Seriously though, with we Americans facing the full monty of Obamacare, next year behavioral addictions or compulsions will be a bitch to get treated. I have been studying up on the money quotes included in the 5000 pages and being an economic analyst I knew immediately that affordability is going to be issue #1. If it works the way they hope (which it won’t human nature being what it is) the current problems with massive govt overspending will explode in our faces. Especially in the individual states who are being stuck with most of the bills for Medicaid (as opposed to Medicare).

    The real victims will be the elderly as Medicare will be sliced and died to make room for all the Medicaid patients that are supposedly signing up for the new “insurance”.

    The result will make care for behavioral problems such as overeating virtually impossible for insurance to pay.So parents who come into a shrink’s office complaining that little Billy spend 5 hours a day playing violent shoot-em-up games are shit outta luck, no matter what the FDA or DSM decide.

    JLK

    • Marc March 27, 2013 at 7:16 am #

      Hi JLK. I think that story about the OCD guy is hilarious. I don’t know if there is a compendium of OCD jokes — I wouldn’t be surprised. But that one should make it to the top 10.

      As for behavioral addictions and insurance, I have several opinions. First of all, America’s health-care system is arcane. Nowhere else in the Western world does a whole industry live and breathe and get very wealthy in the space between people’s medical needs and the resources available for treating them. So I feel no pity and no regret if the whole system blows up. It could hardly be any worse than it is now.

      Still, you make a good point about whether people should be able to claim internet addiction of food addiction as grounds for receiving funding for care. Especially when those funds are needed for taking care of people who REALLY need them. Where does one draw the line? Should shopping addicts receive benefits for treatment? No, I think that, even in the case of substance addiction, people must take some responsibility for their own actions — and the medical community should be available to help them as far as possible.

      And yet there is something the society as a whole can do to minimize these problems: DON’T FEED ON THEM! There was an episode of “This American Life” about a woman who was a compulsive gambler. She had lost all of her money, her inheritance, and her home and family to the casinos in Las Vegas. Of course the casinos kept good track of how much money she was losing to them annually. And those bastards would phone her several times a year, warm-heartedly inviting her down for a few days of R&R, all expense paid, of course. For example, at Christmas, when she was likely to be most vulnerable. That’s like dangling drugs in front of a drug addict. She finally took the casino to court. Her lawyer argued that casinos had no right to manipulate people’s psychiatric problems for profit. After all, bartenders stop serving alcoholics once they’re stumbling around and puking.

      Well, she lost the case. America is the land of individual freedom, not care for anyone who needs it. And I think it’s this philosophy and this policy, at the society level, that makes addiction treatment overall such a shambles — never mind the rest of the health-care system.

  10. peter sheath March 20, 2013 at 3:50 pm #

    Hi Marc
    As always, fantastic blog. I believe this as another area we touched on when we met. As time goes on, and my life goes in ever different directions, I’m becoming more and more convinced that addiction = being human. They are so intrinsically linked with addiction probably being behind some of mans greatest triumphs and also his triumphany failures. It is probably somewhere in most human conditions either being directly responsible or working it’s magic vicariously, undercover, behind the scenes.
    I have just read a lovely book about addiction by a priest called Richard Rohr called breathing underwater. He says that addiction is anything that takes us away from God. Change that to life, love, wonder, awe, joy, etc. and you end up with a whole plethora of behaviours, conditions, illnesses, avoidance/coping techniques, etc. etc.
    I think it was a Roman poet who once said something like, “I am human and nothing that is human is alien to me”. I have always liked that as it does have many and vareied different reasons. Kind of works in this context, don’t you think?

    • Marc March 27, 2013 at 7:30 am #

      Hi Peter. Yes, it works very well. When people come down hard on “addicts”, with denigration, disgust, and rage, I often wonder how it’s possible that they see no thread connecting them with that person’s conditions. There but for the grace of….whomever, right?

      We all experience desire. It is certainly one of the most powerful emotions and one that is almost always behind our motivations — to get somewhere, do something, acquire something, change something… Thus your comments about humans’ greatest achievements make sense to me. But if one accepts that desire is universal, and it’s obvious that people continue to try time and time again, to acquire what they desire, no matter how hopeless it is, then indeed everyone should know what it’s like to be addicted.

      Some say that all people are addicted to something. I don’t know if that’s stretching the label too much, so that it stops being useful. But I do believe that all people know what it’s like to be addicted, to feel the intense desire for something that they cannot have or must not have, or SHOULD not have, to feel the relentlessness of that state, its endurance, its hold on oneself. That’s something that should not be alien to anybody!

  11. gywn March 20, 2013 at 4:55 pm #

    WOW! Great stuff! I like that Addiction = Being Human, Peter. I agree. I also believe that addiction ( I hate that word!) has become nothing more than a commodity. I am not a doctor. I am an Artist, a Thespian, but I’ve known many so-called Addicts. In 2006 I took Ancient Theatre History and Cultural Anthropology both in the same semester and learned a lot about human nature and where our constructed knowledge comes from. I read the stuff that Freud was reading for pleasure while he was whacked on cocaine and writing his theories of the mind that I believe scared the shit out of our “Puritanistic” medical society/industry. None of those men wanted their sexual fantasies exposed so we didn’t really start to study our brains until we could see inside them with MRIs and numb them with antidepressants. It gives me great joy to know that these discussions are finally going to get us somewhere…. Thank you, Marc!

  12. Nik March 21, 2013 at 1:32 am #

    Great topic, Marc!

    A behavioral pattern that one is ‘locked into’, which is dysfunctional, is virtually
    the definition of a psychological/behavioral disorder, in general. I say, ‘locked into’, referring to all the things mentioned under labels such as ‘loss of control’ ‘can’t help myself’ ‘couldn’t stop’ ‘resisting efforts to change’ and so on. Also, ‘compelled’, or ‘under compulsion.’

    The agoraphobic feels compelled to stay indoors. Surely this fits some wide
    definition of ‘compulsive behavior.’

    Sometimes a more ‘outward, goal-directed’ act is required, e.g. if one has a compulsive need to keep her hands clean, there is the act of washing. Another person feels ‘compelled’ to go out a set a fire. Probably this is what Shaun means by a problem of impulse. Do these sorts of ‘positive’ examples, define compulsive behavior?

    What of someone who compulsively seeks out bath houses or gaming tables. The label ‘addiction’ comes up when the pattern is self destructive (perhaps a step beyond ‘dysfunctional’), yet the person does not stop; says he ‘can’t’. Tries and can’t. Is ‘addiction,’ compulsion maintained to the point of self destruction?
    Rather more narrow definitions of ‘compulsive disorders’ need to be given.

    Shall, we say, per AA and others, there is a ‘disease of will,’ a spiritual malady demanding help such as is not found in humans? That it’s ‘progressive,’ i.e. inevitably downhill in course, untreated? Peele has made the excellent point that there is nothing exotic about the alleged ‘disease of will’ situations. All of one’s gestalt patterns, ways of life, have this property. It is *very difficult* to alter one’s caloric intake from 5000, to 1500 per day. If there’s a dangerous situation, and the person is ‘locked in’ to 5000, then the eater is said to have a ‘food addiction’. Yet, of course, some people, even without treatment have so to say, recovered will (regained control), and e.g. lost the weight, for long periods. “Disease of will” and terms like ‘progressive’ and ‘fatal’ are offered as universally applicable despite the vast evidence, for many, of a natural process of recovery or moderation. See the wonderful article, “Cocaine and the Concept of Addiction”
    http://www.peele.net/lib/cocaine.php Peele recounts Fitch and Roberts (1993) on how rats, in non forced environments do not give up food for cocaine and die, as in the scary, now legendary, reports of Bozarth and Wise (1985).

    12-Step programs obviously address compulsions; in practice, they, depending
    on leadership and local customs, exemplify and even encourage compulsions, but of a somewhat different kind. The scripting of meetings, is an example. I observed: One chairperson was at a loss to welcome someone, having misplaced the “Welcome” script. Mightn’t the assignment of listing of everyone one has ever harmed be called a compulsive exercise, not to say, attending 90 meetings in 90 days, a common recommendation? The issue of ‘total abstention’ might be a ‘compulsive’ demand, and one clearly unsuited to the so called ‘food addictions’ and ‘sex addictions.’

    The issue seems to be that a ‘positive compulsion’ is proposed to save one from the destruction of the addiction, the compulsion to use. Is this ‘recovery’? Is it a revision of a ‘compulsive’ person into a ‘spiritual’ version who is not self-harming. Yet Peele has made the point that a life of effortful ‘avoiding’ is not exactly recovery; true recovery would mean doing more healthy and productive things w/o even thinking of, or feeling inclined to, the previous destructive things.

    The co occurrence of OCD diagnoses with ‘addiction’ (and, I think, alcoholism) is quite apparent. Some sufferers in “S” groups I’ve attended report benefits from the newer OCD meds, with respect to their ‘addiction’. That said, I don’t see a reason to say that there is an OCD font and origin to all ‘addictions’. I think the varied and wide senses of ‘compulsion’ make such an endeavor unproductive.

  13. gywn March 21, 2013 at 6:36 am #

    Before we can call the common denominator “compulsion”, we must look back to the bare fact, and that is, what we were force fed, both nutritionally and visually, long before addiction or compulsive behaviors were even imagined.

    For three generations, or more than fifty years, TV has been America’s babysitter and as such we’ve been tricked into believing that what we saw was what we should do… and eat! Today, we are so far removed from the Natural Order of things that young people don’t have a clue that what they’re doing/eating will cause harm. They don’t even know where their food comes from and their bodies are poisoned from birth with MSG and artificial dyes, chemicals and sugar. They don’t stand a chance.

    The hand-washing thing is a good example. When flu season comes around, it’s all over the news…. Wash your hands… constantly… to avoid getting sick. So, if a person has experienced a bad flu or saw a loved one very sick or die from it, doesn’t it make sense that they might get compulsive with hand-washing to avoid flu? Yes, of course, it does.

    One of my best friends, a 6-year “recovering” alcoholic taught middle school music for 5 years and I volunteered there. Narcissism is programmed into our kids and so is bullying (compulsive, do you remember The Three Stooges?). It’s a sad fact that kids all think that playing “Guitar Hero” on the Wii is the same as playing a real musical instrument. Where did they get that idea? Yep! TV!

    And to reiterate, consider our National compulsion/addiction to fossil fuels. Where does that come from when there are many safer and easier alternatives? That’s right, we are force fed that “ideal” for somebody’s profit and TV advertising made it reality. Most people won’t even listen to the facts or the logic. There is no reasoning with them. They go on the defensive and will attack! Sound familiar?

    Born in 1956, my hometown was one of the first cities in America to experience cable TV. I clearly remember all the boys behaving like the “Stooges” because it was funny. I remember because I didn’t think it was funny. It was mean! It is also the “Home of Little League Baseball” and in my opinion, “home of American childhood competition”. You aren’t cool if you don’t play ball. So what happens to the non-athletic, creative kids?

    As I said, I am an just an Artist, however, 2011-12 graduate courses in The Sociology of Education, The Evolution of American Music and Understanding the Nature of Addiction, (where I wasn’t even permitted to bring up the MSG or nutrition or our collective addictions) validated what I already knew… and lived! I am very grateful that, except for smoking (an addiction I was born with), I’ve been able to “transfer” any other compulsion/addiction into learning how and why!

    If we ever want to get anywhere with this issue, this is where we need to start.

  14. George March 21, 2013 at 4:40 pm #

    Marc, you or others may have read this article somewhere along the line.
    If not, I recommend it:
    Gregory Bateson, “The Cybernetics of ‘Self’: A Theory of Alcoholism”
    (applicable to other types of addiction, I imagine)
    I’m re-reading it today, since I am viewing the documentary about him, “Ecology of Mind” this evening in Berkeley, California.
    I don’t know if the ideas in the article are dated or not, but I remember the article struck me as significant when I read it.

  15. George March 21, 2013 at 4:44 pm #

    Gregory Bateson’s article can be found in his book,
    Steps to an Ecology of Mind

    http://www.anecologyofmind.com/

    Other links:

    http://www.mashpedia.com/Gregory_Bateson

    http://www.onthisdeity.com/4th-july-1980-%e2%80%93-the-death-of-gregory-bateson/

  16. Ibid March 23, 2013 at 12:05 am #

    I’m thinking that this would shrink the next DSM to a fraction of its current size. Not a bad idea. It would also annihilate most of the drug treatments,i.e. methadone, etc. Remember this: Nobody has found any chemical imbalance to be associated with any disorder–at least before they begin medicating them. Any ideas of what treatments would become more reputable if this view of addiction were found to be valid?

  17. Nik March 24, 2013 at 11:58 am #

    Ibid, your point about chemical inbalances is well-taken. I was just reading about the antidepressant tianeptine which is a Seronton Reuptake Enhancer.

    The problem of biomarkers is that all these topics are in their infancy. Biomarkers–e.g. some chemical in the blood, spinal fluid, etc. — for compulsion or compulsive disorders are only beginning to be investigated. And there is a problem of overlap: one proposed biomarker of Alzheimers is also one for Major Depression.

    Compulsive Disorders and Depression overlap, and the state of marker for depression was recently summarized:

    http://web.comhem.se/u68426711/neuro/Mossner%202007%20Biological%20Markers%20in%20Depression.pdf

    The World Journal of Biological Psychiatry, 2007; 8(3): 141 174

    ///REVIEW
    Consensus paper of the WFSBP Task Force on Biological Markers:
    Biological Markers in Depression

    RAINALD MOSSNER [et al.]

    1
    Department of Psychiatry and Psychotherapy, University of Wurzburg, Wurzburg, Germany,

    Abstract

    Biological markers for depression are of great interest to aid in elucidating the causes of major depression. We assess currently available biological markers to query their validity for aiding in the diagnosis of major depression. We specifically focus on neurotrophic factors, serotonergic markers, biochemical markers, immunological markers, neuroimaging, neurophysiological findings, and neuropsychological markers.

    We delineate the most robust biological markers of major depression. These include decreased platelet imipramine binding, decreased 5-HT1A receptor expression, increase of soluble interleukin-2 receptor and interleukin-6 in serum, decreased brain-derived neurotrophic factor in serum, hypocholesterolemia, low blood folate levels, and impaired suppression of the dexamethasone suppression test.

    To date, however, none of these markers are sufficiently specific to contribute to the diagnosis of major depression.

    Thus, with regard to new diagnostic manuals such as DSM-V and ICD-11 which are currently assessing whether biological markers may be included in diagnostic criteria, no biological markers for major depression are currently available for inclusion in the diagnostic criteria.///
    ===

    The dexamethasone suppression test is of promise, and a recent paper looked into the problems of time sequencing of responses, and subtypes or issues of depression, e.g. suicidal ideation.

    http://www.annals-general-psychiatry.com/content/7/1/22

    “Revisiting the Dexamethasone Suppression Test in unipolar major depression: an exploratory study”

    Konstantinos N Fountoulakis1*, Xenia Gonda2,3, Zoltan Rihmer2, Costas Fokas4 and Apostolos Iacovides1

    =====
    The problem seems to be that the ordinary categories, such as depression or OCD are just too broad. The biochemical findings are generally complex. This makes testing of drugs as well as monitoring recovery a daunting task: No single marker (say, serotonin level or cortisol level) or group of them can be looked at, so that one can say: “The markers are moving in this direction, THEREFORE the patient is recovering.”

    This goes to the issue of alleged “diseases” such as alcoholism and heroin addiction. As Marc has pointed out, we have to assume brain states underlie the behavioral and mental processes. Yet for any of these “mental disorders” as in DSM IV, you cannot look at the brain and definitely say, for example, “addict”. You can look for heroin or its metabolites, for example, but once they’re gone, the question “What to look for?” is still challenging; mostly uncharted territory, in my non scientific impression and opinion.

    There is one interesting parallel, regarding the “physical” diseases. Alzheimers Disease is quite real and indentifiable after the fact of death. But to date, the problem of finding ANY reliable biochemical marker of, say early stages AD, has not been resolved definitively.

  18. Persephone March 27, 2013 at 10:04 am #

    I’m curious as to whether (and pardon me if it is a few posts back and I missed it) OCD symptoms pop up in people when they’re addicted that aren’t there before or after. Especially in the period before one spirals out of control, do other things become compulsive in addition to the drug use itself?

  19. Laura September 9, 2014 at 10:22 am #

    In all of the years that I have been surrounded with addiction, I never thought that there was a connection between OCD and addiction. You are absolutely correct, there is some correlation here. I am curious to know what research has been done for this topic. Thank you for your words and for sharing your knowledge with all of us.

    Kudos,
    Laura

    • Marc September 9, 2014 at 2:09 pm #

      Hi Laura. Yes, it makes a lot of sense. Especially after a year or so of addiction, the same brain regions are over-activated as in OCD. Just google OCD and addiction to pull up sources. I got a lot of my information from talks by experts given at the International Conference on Behavioral Addictions. You can google that as well.

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