Brief Lecture Notes for Unit 11

In the minds of many social analysts, America has become an "addictive society". Not only is substance abuse the biggest single financial drain on the health care system in America today, but when one factors in other behaviors that have quasi-addictive properties (workaholism, overeating, compulsive gambling, sexual addictions, excessive viewing of Mannix reruns), it sometimes seems as if every American suffers from at least one "disorder of control".

At the same time, because the word "addiction" is bandied about so loosely in our post-Oprah culture, it may be helpful to begin by working toward a definition of addiction that is sufficiently narrow to be helpful (that is, one that actually manages to exclude some human behaviors from being classified as addictions). We'll take advantage of the distinction between defining and characteristic features (remember that?) to help us with that challenge.

Primary or "defining" features of addiction include:

Volitional impairment: a person experiences a loss of control or the inability to stop the unwanted behavior; engaging in the behavior becomes compulsory
Lifestyle impairment: more than one major life domain (work, relationships, leisure) are significantly impacted negatively by the unwanted behavior or its aftermath, as a person's life becomes increasingly centered solely around that behavior to the exclusion of other, balancing activities
Psychological or physiological dependence, which may or may not involve physical neuroadaptation, are involved, including tolerance or withdrawal
Continued engagement in the unwanted behavior in the face of adverse (ego dystonic) consequences or effects

In simpler terms, "I can't give this up even though it is destroying me." All features must be present (in reality, #3 may be optional?).

Secondary (characteristic) features include:

Denial or other reality distortions including delusions about self-control, e.g., "I don't drink all that much", "I could stop any time I wanted to", "others do this as much as I do"
Preoccupation or fixation with the unwanted behavior, e.g., "it's all I ever think about", "it's the center of my world now"
Motivational ambivalence or a "love/hate relationship" with the unwanted behavior, e.g., "I hate it that I smoke, but I can't imagine life without it"
Cognitive impairments such as blackouts, memory distortions, temporal distortions (don't require the presence of an abused substance, e.g., "when I'm into a work project, time stands still for me")
Cultural devaluation (in some cases, reserved for excess only), e.g., "people look down on me because I'm fat"
Statistical rarity or lack of universality (few other people act this way)
Shame (e.g., "I don't want others to know how often I go to the casino")

As always in this definitional approach, not all of the characteristic features need to be present, but the more that are, the closer the behavior is a "prototypical exemplar" of addiction.

Based on this set of terms,

Could a person be said to be "addicted" to breathing oxygen? (After all, it's impossible to stop!) Answer: no, because there is a "loss" of control (technically, there never was any control), there are no negative effects of the behavior; it does not lead to any sort of lifestyle imbalance ("sorry, honey, I'd like to spend some time with you, but I'm too busy breathing") and does not involve ego dystonia. None of the characteristic features are present ("all I can think about these days is breathing").

Could a person become addicted to reading in the bathroom? Not likely: no true loss of control (merely a habit or a voluntary choice, even if it's hard to "tear oneself away" from a book), certainly no tolerance ("I just don't get a kick out of the Reader's Digest the way I used to"), minimal evidence of lifestyle impairment (though one might possibly neglect one's job or family in order to read) or of ego dystonia. Few characteristic features.

How about addiction to coffee? Debatable. Physiological dependence on caffeine is commonplace, but we don't worry about a "caffeine epidemic" sweeping the nation, because there are few if any lifestyle impairments (other than disturbed sleep) and few characteristic features. But this one is closer because there is a true loss of control (due in part to physiological neuroadaptation). And in reality you are semi-permanently altering your brain chemistry if you drink too much coffee...

Addiction to work? "Workaholism" is in the official lexicon of clinical psychology (though hardly in the DSM-IV); serious journal articles have been written about "work addiction". Does this behavior really qualify? Because of the possibility of a seriously imbalanced life, and the difficulty a "workaholic" might have in cutting back even in the face of ego dystonic consequences, it might qualify. But again there are few characteristic features (society tends to reward, not punish, those who make their job their life).

The moral of the story? All definitional categories are (in Zadeh's sense) "fuzzy", including this one. Some writers reserve the term "addiction" for situations involving the abuse of an ingested substance only, calling other similar behavior patterns "quasi-addictions".

Is there an "addictive personality"? While your textbook expresses skepticism about this idea, I think there is somewhat more evidence for it than is suggested there (though certainly no proof):

The fact of addictive clustering suggests that some people have more of a general proneness to addictive (and/or quasi-addictive) behaviors than others. Certainly it is much easier to trade one addiction for another than it is to give up an addiction and leave nothing in its place, as most of us know all too well from painful experience. For instance, people who stop smoking usually gain weight.
Studies of people with diagnosed addictive disorders do suggest (in my view) some common themes that contrast them from the normal population. (Bear in mind that this is a sample of severely addicted individuals who were in treatment for their addiction, however, leaving open some tough cause-effect questions.) Specifically, in Big Five terms, the addicted group appeared much more N+, more C-, and more O+. (Can you see why this makes sense? Hopefully, the N+ and the C- are obvious. What about the O+?) Addicts (or those at risk for developing addiction) probably have weaker coping or rational problem solving strategies at their disposal: are more likely overwhelmed (N+) and have a somewhat weaker grasp on reality (O+), or as I might put it, on what O- types call reality.
Regardless of the above, there is a high degree of comorbidity between addiction and a wide variety of other clinical disorders (again, cause-effect links are hard to pin down), with the strongest overall relationships being with (a) depression, (b) antisocial PD. (Can you hypothesize why?)

Biochemical models of addiction

It seems clear that addiction is so prevalent because of the way that the reward systems of the brain work. All (or nearly all) addictive substances impact the same part of the brain, one which is directly linked to the normal emotional-motivational reward structures of behavior (e.g., those that make activities like eating and sex rewarding). Many addictive substances (e.g., the opiates) chemically mimic the activity of natural neurotransmitters (such as the endorphins, released into the brain during times of stress or trauma to exert a natural narcotic or calming effect).

Five major brain centers (all of which also have specific connections to certain types of nonaddictive disorders, by the way, as briefly noted below) may have implications for the understanding of addiction:

The deep limbic system can be thought of as the emotional bonding and mood control center of the brain. When it is not functioning properly, an affective disorder is likely to result. The strong correlational link between depression and addiction suggests that many people in our culture may attempt to deal with low-grade depression through “self-medication” with alcohol or other substances.
The basal ganglia control the brain’s “idling speed” – overactivity in this area is likely to generate an anxiety disorder. In addition, this part of the brain is associated with the reward system. (Substances like cocaine produce a “high” largely by causing a “spike” in dopamine availability in this brain area.) Anxiety and conflict-avoidance are behaviors that some people may choose to deal with by means of resorting to disinhibiting substances such as alcohol.
The prefrontal cortex is the “supervisory” part of the brain, associated with mental focus, planning and strategizing, decision making, and impulse control. Underactivity in this area may lead to attention deficit problems including short attention span, disorganization, and weak follow through. Self-medication through stimulants – ranging from caffeine to cocaine – may be utilized in an attempt to “wake up” a sluggish brain.
The cingulate gyrus can be thought of as the brain’s “gear shifter”. It allows you to shift attention from thought to thought or behavior to behavior. An overactive cingulate may cause pathologically perseverant behavior such as might be associated with obsessive-compulsive patterns, or with repetitive worry (as opposed to diffuse anxiety) and behavioral rigidity. A person can get stuck in various negative behavior patterns, including addictive behavior, as a consequence of problems in this area.
The temporal lobes of the brain are associated with a diffuse range of cognitive skills including memory, language, and control of emotive reactions. Underactivity here can cause deficits in any of the above. Some clinicians associated overactivity in this region with symptoms analogous to those of the cognitive disorders. As with the prefrontal cortex, some people might attempt to “wake up” their brain through the use of artificial stimulants. Or a person might attempt to sedate an overactive temporal lobe to “shut off” unwanted cognitive symptoms.

Because the use of addictive substances causes changes in brain chemistry which become self-sustaining (as physiological tolerance develops), a downward spiral can occur, as one finds it necessary to use increasing amounts of the “drug of choice” to maintain even a semblance of brain normality.

Click here for a questionnaire related to brain activity. (I'm still working on this hyperlink, so be patient.)

Another important biochemical model of addiction is opponent process theory. This model is based on the notion that, because the nervous system attempts to maintain a state of physiological balance or homeostasis, any deviation from that state of balance in one direction (call that the A process) will be counteracted automatically by an opposing process (the B process) designed to restore the balance. You can see this, for instance, in your own mood states: apart from clinical conditions, bad moods tend eventually to lift "on their own", and good moods don't last -- the bubble bursts eventually.

The opponent process explanation of addiction (which, by the way, explains both "positive" and "negative" addictions, as we'll see below) rests on three assumptions:

The B process lags behind the A process: it begins later and ends later.
The A process becomes weaker with repeated exposure to the triggering factor.
The B process becomes stronger with repeated exposure to the triggering factor.

Thus, the "high" experienced when taking a drug is followed by a "low", and with repeated use, it takes more and more of the drug to produce the "high" (tolerance) while the "low" state becomes more prevalent, chronic, and troublesome (withdrawal). Thus, early stages of use are motivated by a desire to obtain the reward state ("high"), but later stages are motivated by a desperate though futile attempt to avoid or counteract the aversive state ("low). See text, p. 586, Figure 14-3.

Note that the reverse process occurs with positive addictions (e.g., to exercise). At first, exercise is unpleasant (negative A process) but is followed by a sense of relief, calm, or a very mild positive emotional state (positive B process). Over time, the A process weakens while the B process intensifies -- e.g., the "runner's high". (I've never experienced this personally, but often experience the "remote user's high" when I press the buttons on the TV remote for a sufficiently long period of time.)

Finally, the high heritability of addictive disorders is strong evidence of a biological component. For instance, children of alcoholic parents have about 4 times the risk of becoming alcoholic themselves as compared to children of nonalcoholic parents. These odds are not much altered in situations where children were separated from their parents at birth; they seem primarily to reflect genetic influence. Neurologically, the effect seems mediated by an increased capacity to develop physiological dependence (tolerance and withdrawal) sooner.

Cognitive models of addiction

Marlatt and others have spent the past 20 years studying cognitive influences on recovery from addiction and the ability to remain abstinent from the addictive behavior over the long term. They emphasize that since addiction involves a loss of voluntary control over behavior, and since self-control is so prized in our society as a basis of self-esteem, individuals' thought processes related to control and efficacy are primary. The more self-confident (efficacious) an individual is regarding his or her behavior, the better the chance s/he has to stay nonaddicted.

Most recovering alcoholics, for instance, will state that they suffered for years from low self-esteem (often masked on the surface by a superficial braggadocio or a public persona of inflated self-esteem). As often in such cases, there is a paradoxical sense of narcissism or entitlement -- so that elements of excessive and of insufficient self-esteem appear mixed in a particularly toxic combination. (Note how this is consistent with the statistic above indicating high comorbidity between addiction and both depression and antisocial personality disorder.)

Marlatt's studies focus on relapse behaviors -- times when a person who is in recovery and who has made progress toward an abstinent lifestyle "slips" or "falls off the wagon". (Anyone who has tried to go on a diet, stop smoking, give up coffee, or the like knows how frequent relapses can be and how hard they are to avoid.) His focus was on the question of what kinds of thought patterns predicted or precipitated a relapse (note the mediated model of behavior, characteristic of all cognitive approaches as noted in an earlier unit of the course). Three particular thought patterns were highly predictive of relapse as noted below; his treatment program was designed to help individuals identify, anticipate, and counteract these thought patterns before they led to a behavioral relapse, or to limit the intensity and duration of relapses by these means:

In the abstinence violation effect (also known more simply as the all-or-nothing syndrome), an individual sets a standard of behavioral perfection: "I will stick strictly to a 1200-calorie/day diet and will eat absolutely no sweets." Because the standard is so rigid and because of the mental perfectionism involved, the person does not distinguish between minor and serious deviations from the standard: "I ate one cookie, so I might as well binge and eat a thousand cookies." This becomes a double bind in two ways: the person does not allow her/himself even a small "safety valve" of a controlled sort, and when a slip does occur, the resulting self-loathing produces a negative state that is most easily dampened by engaging in the addictive behavior. Note that this line of theorizing leads to a controversial issue that divides addiction counselors today: is abstinence the only acceptable standard for recovering addicts, or is controlled use a feasible and desirable goal?
In the apparently irrelevant decisions syndrome, the person engages in behaviors that are not themselves violations of the abstinence rule, but that set him or her up for "easy" slips later: the recovering alcoholic who buys a bottle of Scotch, not for himself, but to keep around the house "in case company comes by"; the dieter who chooses to eat in a restaurant that serves tempting high-calorie desserts, even if she sticks to the diet while doing so. This usually involves some denial or self-deception about the real motives involved (so that the person can claim at a conscious level to be "sticking to the program" while at an unconscious level preparing the way for a relapse).
The entitlement syndrome, in which a person convinces her/himself, "Life is so hard right now that I deserve just one [fill in the blank with addictive behavior of choice]." Since part of addiction is presumably a lack of more positive, rational coping strategies (ones that actually solve problems, or that do not create new ones in a socially trapping sort of way), sooner or later a person will feel, "It's so unfair that everyone else can indulge, but I can't." Of course there is a half-truth in that statement, but it is a dangerous half-truth in that it is very likely to lead to self-sabotaging relapse behavior.

On a practical note

(yes, even O+ types can be practical on occasion)

While most of the material above has been abstract, theoretical, and cerebral, as you might expect, I'm quite aware that -- by some estimates -- upwards of 25% of college students (a conservative estimate) are struggling personally with some form of addictive behavior. I want to offer some practical, real-world help if you happen to be one of those, and am trying to arrange with a friend of mine -- a professional counselor who works regularly with addiction issues -- to speak to the class. While we're waiting for that, here are a few unstructured thoughts of my own -- from someone who no doubt has an addictive personality, even if I've managed to avoid the most debilitating addictions behaviorally:

Don't think you're alone. You're not... but every recovering addict will tell a story that begins, "I thought I was the only one." Isolation and shame are your enemies; community and faith, your allies. Find others who have been where you are and who share a commitment to recovery (e.g., groups like AA, NA, EA, OA). Know that there's no shame in struggle: the shame is in not admitting the struggle.
Don't conclude that there's no hope. There is... many people have made the journey from addiction to sobriety, from despair to meaning. You can too... one step at a time. But not by yourself.
Don't minimize the problem. It's not true that "it's no big deal" or that "everyone does it". Denial is the primary cognitive symptom of addiction. If you've been telling yourself "I can stop any time" (but never somehow seem to do so), or if your life revolves around a behavior that has negative consequences and that doesn't play any part in the lives of others you know, stop and think. You're crossing an important line.
Don't get locked into the all-or-nothing syndrome, as discussed above. Small steps that persist over time are the most productive way to change. Don't worry about changing the rest of your life: worry about taking positive steps today. When you fail, get up and start over.

More -- from a practitioner's standpoint -- if I can get the guest speaker's schedule to work out.