Addiction: Disease, Learning/Conditioning or Attachment Injury?

One of the most debated topics in mental health surrounds the concepts of addition and the many theories used to define it. What lens do you use when you look at addiction, as an illness, a disease or a disorder of learning? Many struggle to use pathologies and use such labels as illness or disorder. The more we study the brain, the more neuroscience gives us insight into the addiction system in the brain yet still opens up concepts of not only neurobiological aspects but also psychological theories to explain this phenomenon. Can the vulnerability of addiction include genetic factors, more contextual factors such as attachment injuries, environment and ones life experiences? I would like to brake it down and open the concept up for reflection and ones own interpretation using the concept of disease or choice:

• Addiction is a disease of choice, the ability to make a reasoned, healthy choice.

The argument: “is it a choice or is it a disease?” is really the question about causality: what causes addiction?

The Choice argument says: because behavior is a choice, addiction cannot be a disease.
The Choice argument says: Addictions are not diseases but rather bad choices. Calling addiction a disease undermines personal responsibility.

The counter argument (disease argument) is that choice is deteriorated/hampered/limited/compromised because of the brain’s association of the drug to the survival of the person.

There are implications of choosing either argument:

• The Choice argument implies that substance use is always under control of the user, that the user doesn’t care enough about the consequences to health, family, work, etc.. to stop. Further implications include bad morals, lacking intelligence, bad upbringing or even as the result of family, ethnicity or cultural values (obviously poor or bad values). From this argument also stems the mode of treatment for addiction: “just say no”, incarceration, removal of basic rights (testing for social service applicants). Additionally, the choice argument promotes the idea of ‘harm reduction’: which is, the addict will come to their own, reasoned decision to stop using. Therefore society needs to provide the means for an addict or alcoholic to use up until they are ready.
• The Disease argument states that addiction is a stress induced dysregulation of the
brain, specifically the mid-brain where the pleasure/reward system is located, which
negatively impacts the ability for a person to choose sobriety despite the consequences. Implications of this include: the addict is a patient, not a criminal. Addiction is treated by education, by supported abstinence, by social support and possibly through treatment of co-morbid disorders like depression and anxiety. Certain medications can help reduce cravings and/or drug effect, which also support abstinence. Very important is treatment for the psychological and behavioural symptoms which accompany the formation of the addiction and maintain the addiction, even when a person has wanted to stop.

-The disease model: ORGAN > DEFECT > SYMPTOMS
-The defected organ in this model is the brain.

THE PLEASURE CONSTRUCT:
5 levels of brain processing come together at the same time to construct a conscious
experience of pleasure. These levels are:

Genetic: speaks to innate vulnerability or resilience towards reactions or behaviors. Ex: studies show that ‘low responders’ to alcohol drink more to get the same effect as ‘high responders” and there is evidence that is genetically hard wired.

Reward: the pleasure of an experience is itself motivation to seek the experience again. Neurotransmitters are released during pleasurable experiences. It tells the brain when an experience is good and that it should be sought out an repeated. Dopamine tells the brain: “this is great, even better than expected”. The brain assign a high value to this experience and gives it top priority, even over other rewards needed for survival. Each time the experience (or drug) is used, the brain gives hit higher and higher value and higher priority even though it really isn’t. Because of the high value, the person takes greater risks to get it. This explains why negative consequences do not stop the use.

Memory/learning: information about the stimuli which accompanies the pleasurable experience and how one might reacquire it again. Includes emotional cues. Glutamate tells the brain “this is fantastic-you must remember this”. This is how the brain lays down the memories of the drug, cues and settings. Over time, the brain rewires to prefer the drug pathways even at the expense of non-drug using pathways. These changes persist and leave the person vulnerable to relapse even after years of abstinence.

Stress: the pleasurable experience served to reduce a stressor: hunger, fear, the drive to procreate, safety from harm. Chronically high levels of the stress hormone CRF causes the brain to make fewer dopamine D2 receptors, what the brain needs to process the experience of pleasure. Not experiencing pleasure is called ‘anhedonia”.

Choice: Drug abuse negatively impacts the brain’s executive functions, the ability to make decisions and exercise control over behavior. Conscious choice (free will) is mediated by the pre-fontal cortex (PFC). As addiction takes hold, the PFC weakens and more automatic or only semi-conscious decisions making processes take over.
Unfortunately for the addict (but fortunately for the addiction) there already is a mechanism in the brain which can step in and take over from the PFGC-the mid-brain.

THE PRE-FRONTAL CORTEX
Usually the pre-frontal cortex is in charge of our higher functions: reasoning, assigning meaning judgment, etc. We are able to plan, organize, respond and delay gratification from this part of the brain, the newest part of the brain(evolutionarily).The PFC typically exerts a ‘top down’ influence over the mid-brain.

THE MID-BRAIN

The mid-brain is all about survival, the next 15 seconds. The mid-brain is unconscious, meaning we are not aware of its functioning unless it is expressed in behaviours and/or emotions. We are no more conscious of how are mid-brain is working than we are of the normal functioning of our other organs. The mid-brain works in conjunction with other parts of the brain and body to coordinate responses to threats but also responses to ‘rewards”: things/activities which it designates as necessary for survival. BTW-our perception of trauma is also located here and is
often why people with trauma are also obsessed, or compulsive or ‘feel out of control’ as an addict or alcoholic. Through the release of dopamine from the mid-brain to the PFC (“Pay attention to this – this is good”) to then the release of glutamate from the PFC (“Okay then, remember this and go get some more”) the brain makes a ‘pleasure construct”: that is, when all the factors are combined-the substance (or process)-the setting-sensory inputs (taste, smell, touch), the addiction is formed as a complete package.

THE DYSFUNCTION
In the addicted brain, the dysfunction is considered to be ‘bottom up’ meaning from the most basic to the most sophisticated factors:

5. Choice

4. Stress

3. Memory

2. Reward

1. Genes

Genes: addicts are ‘low responders’ meaning, genetically, they need more of the drug to get the effect, almost like an inherent tolerance. “High responders” (lightweights, “normies”) aren’t affected the same way.

Reward: The dopamine release in the brain says “wow! This is better than expected-pay attention to this”. Dopamine is a learning signal to the brain “pay attention”. Drugs, alcohol and processes like sex, gambling, binge eating trigger greater dopamine release than ‘natural activities’. BTW-the ‘dopamine hypothesis’ states that because all drugs of abuse, including nicotine, sugar, caffeine, release dopamine, ‘cross-addiction’ will occur. This is why an alcoholic cannot use cocaine ‘recreationally”.

Memory: Glutamate, the chemical responsible for remembering in the pleasure/reward system says “Remember this and let’s get some more, now-or the next time? Aka this is obsession. Glutamate goes from the PFC down to the mid-brain. This is how the connection to survival is made.

Stress: There are 3 causes of relapse; drug use (because of the dopamine surges), second is drug ‘cues’ (people, places, things because they effect glutamate) and STRESS (because of the release of the neuro-hormone corticotrophin-releasing factor (CRF). In the addicted brain, CRF works against the high dopamine release in an attempt to return the brain back to homeostasis (balance). In the non-addicted brain, this works easily. However in the addicted brain, the CRF and dopamine inability to establish balance leads to the brain resetting its ‘hedonic set-point’. Hedonic, like the word ‘hedonism’ is about ‘joy’ or feeling good. The hedonic set-point is out of whack, reset to a higher level because of dopamine’s overwhelm of the brain and insufficient
response from CRF to get things back to normal. Homeostasis is not achieved, instead that is called ‘alastasis”. Implications:

• The pleasure center is not as sensitive, therefore harder to feel good feelings, even in what used to cause pleasure. It feels ‘flat’.

• Alastasis leads to ‘anhedonia (no joy) or ‘pleasure deaf”. Only very high levels of dopamine releases meet the new, higher set point therefore the seeking out of the drug/process.

• When the person experiences stress, but only gets relief from high levels of dopamine (brought by the drugs) the stress is perceived as a threat to survival, unbearable, must be relieved at all costs. The buildup of stress is mostly unconscious, until it breaks through to awareness or the person becomes trained to be aware of stress coming on. That is a purpose of treatment and recovery.

HYPOFRONTALITY (AKA THE BRAIN HAS BEEN HIJACKED)

Brain scans in addicted persons, with this dysregulation (also called the meso-lymbic system dysregulation) show abnormalities in the areas of the brain responsible for emotional attachment and decision making. This explains how the addicted brain places an overwhelming emotional and psychological importance on the drug and the uncontrollable urge (cravings) to seek them out despite the fact that there have been or could be negative consequences to using. Hypo (“low”) frontality is an indication that the PFC is not working correctly, meaning ‘top down’ control over the mid-brain is not working. Denial is a product of the person’s inability to see, understand, accept, and resolve unconscious processes and the choices that they make because of those unconscious processes stemming from a crippled ability to choose.

Also, because the PFC is responsible for emotional attachment, a deregulated PFC assigns too high of a valuation to the drug. Normal emotional attachments, like to others, is simply not as important to the person. The brain has been “hijacked”.

Cravings: an intense, emotional obsessional experience. The presence of cravings is the counter to the choice argument: even when the person can exert enough choice to not use THIS TIME, their ability to continue abstaining is conditional on the recalibration of the effected brain, return of the hedonic set-point to ‘normal’ and the ability to choose abstinence even under stress. We call that recovery.

In conclusion, I would like to point to three areas of reference when looking at the many theories of addiction and how they can interrelate:

“Pleasure Unwoven” Dr. Kevin McCauley (Supports Addiction as Disease)

“Unbroken Brain” Maia Szalavitz (Supports Addiction as Learning/Conditioning))

“Mother Hunger” Kelly McDaniel CSAT (Supports Addiction as Attachment Injury)

Mike Quarress CSAT-S