Monday, 26 September 2011

Defining Addiction - the Debate Goes On

Addiction has always been a controversial subject - even trying to define it has given rise to a lot of discussion and argument over the years. The discussion has been particularly lively again recently, as can be seen from the links at the end of this blog.

The American Society of Addiction Medicine, for instance, has just updated its definition of addiction, partly to make more room for behavioural addictions such as sex addiction.

The following is their current Short Definition:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

And here is a brief summary of the ASAM's other main points on the subject:

  1. Addiction reflects the same brain changes whether it arises in response to chemicals or behaviors.
  2. Addiction is a primary illness. It's not necessarily caused by mental health issues such as mood or personality disorders. This puts to rest the popular notion that addictive behaviors are always a form of "self-medication" to ease other disorders.
  3. Both behavioral and substance addictions cause the same major changes in the same neural circuitry: Hypofrontality, sensitization, and desensitization.
  4. Engagement in chronic "addictive behaviors" indicates the above brain changes have occurred. Addictive behaviors then become unconscious and habitual.
  5. The new definition eradicates the old "addiction vs. compulsion" distinction, which was often used to deny the existence of behavioral addictions, including Internet porn addiction.

Useful, by and large, I think, with a welcome emphasis on the neurological realities of the addicted “state of mind”.

My own current definition is as follows:

Addiction is a progressively tolerated & progressively damaging biopsychosocial adaptation to (and therefore preoccupation with) the intense emotional rewards (pleasure/pain-relief) provided by certain artificially-enhanced activities, and their associated rituals, which require minimal personal investment (e.g. heroin use, gambling, pornography use, etc). As addiction progresses, these Supernormal Stimuli hijack innate motivational systems, leading to a self-perpetuating cycle of compulsive behaviours, which the addicted person sporadically tries to control, with decreasing success, when crisis points are reached, but which they at other times resist acknowledging by the use of various cognitive-emotional defenses.

There are various other points regarding addiction that I have made over the years while teaching on the subject; each of them would find agreement from some practitioners/researchers in the field, and disagreement from others. Most of them tie in well with the ASAM perspective.

· Addictions can arise not just in relation to certain mood-enhancing drugs such as alcohol or heroin, but in relation to any intensely mood-enhancing activity such as gambling, pornography use, eating chocolate, etc. These can all be described as Supernormal Stimuli, a concept which deserves a separate blog post at a future date.

· Addictions occur along a continuum, i.e. they can be mild, moderate, severe. While it is certainly possible for an addiction to develop very rapidly, they more usually develop over a period of time.

· Addictions have biological, psychological and social aspects. The traditional medical approach to addiction focused almost entirely on the biological aspects; psychologists, psychotherapists and counsellors could be over-focused on the emotional-mental aspects; and community and social workers have been understandably most concerned with the socio-political aspects of addiction. Nowadays, more and more of those working in the addiction field are taking a bio-psycho-social approach to the problem.

· Addictions have obsessive and compulsive elements, but they are not the same as Obsessive Compulsive Disorders. OCD does not require an intensely mood-altering object, and can be seen as primarily a self-protective strategy rather than a self-rewarding one.

· Addictions are not always just symptoms of underlying issues, such as trauma or depression. Dependence on a mood-altering activity may begin in response to such issues, but it becomes self-perpetuating.

· Addicts enjoy their addiction less & less as it develops, and are not simply indulging themselves. Addiction is not the same as having a passion for something.

· Quantity of acting out is not always the best criterion of an addiction (“He drinks a lot”). Judgments of quantity are always relative and subjective.

· Drugs, pornography, gambling, prostitution etc. can be addictive; this does not necessarily make them “bad” or wrong in themselves. Of course, we can have valid moral judgments about some of these activities, but this is a separate issue from their potential addictiveness.

· Many different helping approaches to addiction work for different people. The 12-Step approach is probably still the most familiar to a lot of people, but various schools of psychotherapy also have important things to say about addiction; in particular, Cognitive-Behavioural Therapies have been found to be particularly helpful in the early stages of helping people to recover from an addiction.

· Complete, final recovery from addiction is not necessarily possible, in the sense that there may always be a remaining vulnerability (just as with depression etc). This is especially true if the addiction is chronic, and true in particular ways for food and sex addictions, given how central these activities are to our lives.

Finally, as promised, some links for further reading:

The debate goes on…