I’ve generally felt critical of the “disease” label for addiction. But having read your many comments and looked up some recent literature, I can now give it its due. In my last post, I argued that models and metaphors are not intrinsically different. A metaphor is a kind of model. And I commented that the different metaphors/models of addiction work differently for different people. So the way a model functions should be a criterion for its acceptance.
But what about the “disease” model? Psychiatrists – because they are doctors – rely on categories to understand people’s problems, even problems of the mind. Every mental and emotional problem fits a label, a medical label, from borderline personality disorder to autism to depression to addiction. These conditions are described as tightly as possible, and listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases) for anyone to read.
The idea that addiction is a type of disease or disorder has a lot of support. I won’t try to summarize all the terms and concepts used to define it, but Steven Hyman does a good job (thanks to Elizabeth for the link). His argument, which reflects the view of the medical community (e.g., NIMH, NIDA, the American Medical Association), is that addiction is a brain disease. (Also see this piece in the Huffington Post.) Addiction is viewed a condition that changes the way the brain works, just like diabetes changes the way the pancreas works. Specifically, the dopamine system is altered so that only the substance of choice is capable of triggering dopamine release to the nucleus accumbens (ventral striatum), while other potential rewards do so less and less. The nucleus accumbens (NAC) is responsible for goal-directed behaviour and for the motivation to pursue goals, as I’ve described in detail in my book.
Different theories propose different variants. For some, dopamine means pleasure. If only drugs or alcohol can give you pleasure, then of course you will continue to take them. For others, dopamine means attraction. Berridge’s theory (which is the one I follow) shows that cues related to the object of addiction become “sensitized,” so they greatly increase dopamine and therefore attraction…which turns to craving when the goal is not immediately available. But pretty much all the major theories agree that dopamine metabolism is seriously altered by addiction, and that’s why it counts as a disease. The brain is part of the body, after all.
What’s wrong with this definition? Not much. It’s pretty accurate. It accounts for the neurobiology of addiction much better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It explains the incredible persistence of addiction, its proneness to relapse, and it explains why “choice” is not the answer (or even the question). That’s because choice is governed by motivation, which is governed by dopamine, and your dopamine system is “diseased.”
So, do I buy it? Not really. I do think it’s often very helpful. It truly does help alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and if I follow my own words, then a good metaphor and a good model aren’t much different. Their value depends on their usableness.
Then why don’t I buy it? Mainly because every experience that has some emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get when you’re on your way to visit Paris, or your favourite aunt, a disease. Each rewarding experience builds its own network of synapses in and around the NAC, and that network sends a signal to the midbrain: I’m anticipating x, so send up some dopamine, right now! That’s true of Paris, Aunt Mary, and heroin. In fact, during and after each of those experiences, that network of synapses gets strengthened: so the “specialization” of dopamine uptake is further increased. London just doesn’t do it for you anymore. It’s got to be Paris. Pot, sex, music…they don’t turn you on that much; but coke sure does. Physical changes in the brain are its only way to learn, to remember, and to develop. But we wouldn’t want to call learning a disease.
So how well does the disease model fit the phenomenon of addiction? How do we know which urges, attractions, and desires are to be labeled “disease”, and which are to be considered aspects of normal brain functioning? There would have to be a line in the sand somewhere. Not just the amount of dopamine released, not just the degree of specificity in what you find rewarding: these are continuous dimensions. They don’t lend themselves to two (qualitatively) different states: disease and non-disease.
Thus, addiction doesn’t fit a specific physiological category. But what about the functionality, the useability, of the disease model? That’s disputable. It works well for some, not at all for others. And I think that’s because addiction is an extreme form of normality, if I can say such a thing. The function of modelling addiction as a disease is limited because “disease” and “normality” are overlapping, not mutually exclusive, when it comes to the mind and the brain. Yet we sure recognize addiction as distinct from “normal” in our everyday lives. That’s the problem.
My solution will come several posts from now. Meanwhile, I hope readers will comment on other aspects of the disease model that fit, or that don’t fit, the phenomenon of addiction.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Marc,
Thank you for this post. I am in the ” program” and it IS working for me, when nothing else would. However, there are some parts of “how it works” that I disagree with and it is in my nature to question. For some, they’re whole life is AA\NA, I have my life and NA is a part of it, one piece of the pie. My daily goal is to fill my day with healthy choices like exercise, yoga, meditation, healthy diet (mostly, love those chicken wings!) and I’ve started to express my creativity through photography. (I was in an arts program in high school) Today I feel my feelings and I get as honest as I can. I stick with the “winners” in the program and choose to surround myself with positive people outside of the program. I believe in the connection with other people, fate, destiny and I don’t believe in coincidences. I find peace and serenity in my children’s faces that I look at through clear eyes. Disease? I say that I have ” disordered thinking” caused by 23 years of drug and alcohol abuse AND negative experiences.
“Disordered thinking” works for me. Maybe that also explains the chicken wings : )
When you say “feel my feelings” that’s precisely what I started to do when I stopped doing drugs. I remember thinking: so THIS is sadness! I’d forgotten what it feels like to be sad, I was so busy suppressing it. And shame came up A LOT, especially in the early days of recovery.
As for AA/NA, glad to hear your (somewhat) dissenting voice from the generally negative comments I’ve been reading. For examples, see the my comment following the last post and also the comments by Persephone and Jaliya from the previous post.
I really appreciate it that you reply to mostly all comments, it tells me that you you are a very engaged, caring person.
Shame was a big one for me as well, hard for me to identify at first after so many years of numbing and stuffing feelings in various ways – drugs, alcohol, sex, food, shopping, exercise etc. – whatever external thing I could put in my body to feel good about myself. I still do this with some of the less harmful options, but not to the same extent.
Thanks for the referral to the previous comments, I don’t always get the chance to read them all. It really is about changing the pathways in the brain and restoring depleted “feel good” chemicals (dopamine, serotonin, endorphins) isn’t it?
In this case how could you be an “addict forever?”
I would like to recommend “The Brain That Changes Itself” by Norman Doige
Amazing life stories of people that have overcome seemingly insurmountable obstacles and how they did it. There is only one section that speaks to addiction, but it’s worth the read.
Thanks to everyone and there experience and insight.
Hi again. I do try to reply to most comments. That way I can really get what people are saying, how they are feeling, what they are looking for. I don’t want to be the MC, and I don’t want the dialogue to be just between me and each reader. But as it turns out, there is a lot of sharing among readers, just as I’d hoped. So I’m really happy with how the blog is working.
Yes, shame is a huge central theme for most of us. And it is so depleting. It takes away not only the feeling of being worthwhile, it also takes away the whole purpose of quitting, which is taking care of yourself. Why take care of yourself if deep down you feel like a piece of shit? You are not worth taking care of.
There are many spinoffs from shame, but just about every one of them leads back to more using, rather than the other way. So, it is not surprising that most negative comments about AA/12-step have to do with the induction of shame — you are not trying, you are not resolved, you are not WITH the program, etc. At least that’s my impression. Now whether the group leaders are actually sending that message, or whether the group members are filling in the blanks from their own histories….I don’t really know.
The Doidge book is great, I agree, and so is The Woman who Changed her Brain, by Barbara Arrowsmith-Young.
addiction is a choice not a disease so your wrong I work with nasaaddictionlabs
Instead of just a medical/disease model why not try to figure out addiction with the help of theological/sin models too? Since AA is a spiritual program it makes more sense to me to create theological models rather than just medical models. Although it probably is better to use both medical and theological models. The problem then lies in which theological model explains the dynamics of addiction better than others. There are various theological models that interpret the source of theological truth (biblical revelation from God Himself) differently. This is going to be a long argument but I think one who has been through addiction programs (I have been through 6 inpatient programs and 2 outpatient programs) can follow the tract of where I want to go with this. I think the 12 steps are flawed in their theological thinking and not specific enough in explaining what the Gospel is and how everyone is prone to addiction of one sort or another. Good theology goes into this quite extensively. But it does take intellectual work to arrive at clear theological truth (just like medical truth).
Some addictions get more ingrained according to the substances and practices used, the intensity of these substances and practices and how long the subtances were used and practices performed. You need both the resisting help of the medical field along with a spirituality that can counter the addicting habits that get ingrained in the brain chemistry physiology, ie., there is a mental and spiritual aspect of addiction along with a physiological aspect. It seems to me that both have to be used to bring the addict back from self-destructive substances and practices. I think the inherent sin model of theology explains why we all are prone to addictions, if it is explained properly (which does not occur very frequently- just like there can be faulty medical models there can be faulty theological models too). Anyways, that is my two cents worth to this very complex problem of addiction. I am just trying to get out what I have learned in my14 years of seeking for a solution to the addictions I slowly and insiduously got myself involved in. This is an interesting blog and I will try to continue to learn from it and add anything I can to help other struggling addcits like myself. I need to talk about this with other addicts- we need each other to bring us back from our self-destructive habits.
I think that the AA/12-step philosophy is the only one (I know of) that uses theology quite explicitly. Others use “spirituality” — but I don’t think that’s what you’re talking about. And though some writings include the notion of disease, most of the classic AA texts rely on a Christian approach to the concepts of God, sin, and humanity. They see addiction as a product of sin, which according to many is inconsistent with the notion of disease. So…it’s a bit of a boggle.
Of course only some people, in fact a minority in most Western countries, believe in a Judeo-Christian God. So any treatment program based on such beliefs would have to be served up to a limited subpopulation.
If it works for you and others with those beliefs, that’s great. But I’d prefer to consider treatment approaches that can work more broadly.
I’m glad you dug into this topic, Marc. Interesting reasoning, I hadn’t delved into the aspects of disease theory you have (obviously), but had my own reasons for disliking it as a blanket (or even a conventional wisdom) explanation for addiction. My issues are generally with marking someone as diseased, and diseased in a way that supposedly makes them forever unable to control their own actions and motivations. It is a great danger (to the point where I don’t even believe I need to cite historical instances of it) to label certain people to be biologically inferior to others, which is precisely what this does when combined with the other stereotypes of addiction (I don’t find them or any stereotypes to hold much water, but: lying, manipulating, willing to steal, etc.). You can’t responsibly just do that to a segment of your society without facing extremely detrimental consequences, IMO. Certainly not while telling them that it’s a permanent condition and they’ll forever suffer from it, or have to work treating it.
If that were remotely true of everyone who had suffered an addiction, I’d also be more likely to believe it. But this is a field that also occasionally includes the phrase, “maturing out”. I am certainly not in the “choice” camp, which I see as just as much of a black-and-white-thinking sort of response to the other extreme of the disease model. There’s so much grey area here, I don’t think it benefits anyone (certainly not people struggling with this) for people to jump to the extremes, but that’s just my thinking on these issues.
I hate to be a sample of one, also, but in my case delay of gratification and extremely goal oriented thinking became the two main goalposts of my life almost directly after I recovered. That wasn’t a conscious choice, nor did anyone tell me to start thinking that way, but these things also reward the brain. It was as natural of a response on my part as was the instant gratification I got from the opiates. (Actually, what I was told in recovery circles IMHO was almost entirely a different form of instant gratification, furthering that behavior; i.e. that my every thought should be jumped on immediately and analyzed, not just by myself, but relayed instantly to a network of people and/or publicly shared. That’s a very self-indulgent way of thinking, to me, though I’d never consider it wrong, just not my bag.)
We’ve talked earlier on this blog about the problem of a label that condemns you to a permanent condition or predicament or deficiency. I totally agree: when the disease model does harm, that is usually the nature of the harm. I think it also gives people license to give up. So either you live with the stigma of having a mental disease or else you drown it with more of whatever you use. Not a pretty choice to have to make.
I guess I’d say that the disease model can reduce blame and guilt…it’s good for that, and that’s a lot of its function right there. But it does not necessarily reduce shame, and shame is about the worst emotion an addict can feel. See above comments. I wouldn’t feel ashamed if I caught pneumonia, but having a mental disease that I believe I’ve contributed to along the way….that can generate shame, sometimes a lot of shame. When it comes down to it, there really isn’t much difference between “disease” and “deficiency” at the feeling level.
Huge grey areas indeed. But I’ll get to the “choice” model soon. It’s not as black and white as you might imagine. In fact, the changes in your thinking that you describe as goalposts…might well be endorsed by the “choice” model as exactly the kind of choice people CAN make. You say you fell into it naturally…maybe so…but that goes with my understanding that “choice” doesn’t mean “free choice”. In fact, choice seems to ride on the crest of a wave of how one is feeling at the moment, or more broadly in one’s life. Well, more on that soon…
Well, I like the social model better. People react to social pressure by trying to escape the pain, and society tries to explain it in ways that do not reflect on its rectitude. In the words of Neville Dyson-Hudson, “People get screwed but the system never gets screwed.”
When we studied Moby Dick, there was a story, related by then current norms of a man who turning to alcohol, failed his wife and young child. At the time I wondered at what forced would cause such actions. Melville’s description was the mawkish of the era, and really was just moralizing.
In my greater age and experience I see that certain social situations for certain wirings can be horrid, and really not within their repertoire. You have internal and external conflict, approach and avoidance, you are going to split into little pieces and use substances as a salve.
I also remember a quote: “Every maiden deserves and honest young man to hound into an early grave.” People will kill themselves, quick or slow to meet social demands.
Sounds like the self-medication model applied to a social world that is truly full of thorns and brambles. You get cut up a lot, you have to apply salve to the wound. Well, I don’t have to call everything a model. I think your approach is more nuanced. It doesn’t fit any of the classic models perfectly. Including the pressures and traumas that life REALLY DOES bestow on people, especially, as you say, people with particular vulnerabilities, puts a special twist on the theme of self-medication. Rather than construe it as a hasty retreat from some sporadic hardship, you bring out the idea that sometimes, sometimes a lot of the time, life really really hurts. I see it that way too.
I wonder if it’s a fact that the human brain ‘self-medicates’ as a matter of course … just as the body will ‘self-medicate’ to heal a wound. The entire organism responds symphonically to illness / injury, does its best to restore homeostasis and vital health.
‘Self-medication’ as both instinctive / involuntary (if all systems are ‘go’) … and ‘self-medication’ as choice (whether undrerstood as such or not). All routes taken to wholeness, or perceived wholeness — even if the result does not appear to heal. Example: a person who self-injures — in a paradoxical way, the causing of pain is an attempt to mitigate / moderate pain, to release and expel pain. Might addiction act in this paradoxical manner as well?
I agree that opiates and alcohol work that way, to moderate pain. I’m not sure that uppers such as meth do that. But in general, the drive toward self-correction (which is broader than healing) has got to be the fundamental aim of the addictive path, whether by choice or by accident.
It’s true that we are tuned to seek homeostasis at both the physiological and psychological levels. That’s why we have an autonomic nervous system, to achieve balance in our bodies, and that’s why we have neuromodulators with complementary effects, to achieve balance in our minds. But I wonder if speed freaks find balance by adding intensity to their moods, while opiate freaks find balance by reducing it.
Either way, I’m really just quibbling. Self-medication as a goal makes sense, even when the outcome is one of greater harm than good.
Yes, I think too that the ‘driver drug’ is unique in each person, according to all kinds of factors … and it’s no coincidence, the drug that ‘sticks’… the one that is ‘IT!’ …
I’m loving this discussion, seriously! It’s been an excellent exercise for my brain.
In debating the “disease vs. not disease” characterization of addiction in my own mind, I ran into a possible argument in favor of the disease camp. Addiction causes real brain changes, this we agree on. These brain changes are associated with strong stimulus-response-outcome learned associations. Thus, addiction is a heightened form of learning. You justly argue that it is hard to say that learning is a disease in itself. However, I wonder if we say the same about something like schizophrenia and “salience misattribution.” I mean, salience attribution, or assigning value to objects, is certainly adaptive when applied to important stimuli in the environment. Part of the schizophrenia neuropathology is argued to result from assigning heightened value to stimuli that should not be attended to due to associated changes in dopamine release in the striatum (i.e., nucleus accumbens and associated limbic regions). Can it be argued that a similar misattribution in the perceived value of drug rewards, due to changes in neuronal functioning due to repeated drug use , parallel this phenomenon and can also be characterized as a disease? My main argument against the disease characterization in this instance is that a schizophrenic does not participate in the onset of his or her disease by his/her own volition. Those of us with addictive behaviors, in some sense, do. However, what about those with heart disease? The choice of poor dietary choices and lack of exercise certainly can contribute to the onset of that “disease” and a change in lifestyle can reverse some of the life-threatening effects.
I’d appreciate any thoughts! I’m most certainly still in flux, but perhaps that is the best way to be with something as complex as addiction.
I thought a lot both about schizophrenia and choice when composing my rejoinder to the disease model. So…I share your reflections on both.
Schizophrenia is indeed the closest thing to a brain disease or illness that I can think of. Yet there are differences with addiction. The onset and course of schizophrenia are very patterned, very regular, whereas the onset and course of addiction is not (in my view). Certain drugs have regular, predictable effects on delusions, the most serious symptom of schizophrenia. But I know of no drug that systematically reduces cravings, the most serious “symptom” of psychological addiction. Also, the physical brain changes that correspond with schizophrenia include certain irreversible changes, such as the increased volume of the ventricles, crowding out the tissue (so I understand). But even the most dopamine-crazed striatum can recover pretty fully. The sensitization of dopamine thus strikes me as more like learning than disease.
As far as choice, it gets pretty murky. Addicts may choose to take drugs, drink booze, or purge, gamble or whatever. But they do not choose addiction. Heart disease patients may choose to eat burgers and smoke cigarettes, but they don’t choose heart disease. So…in one way of speaking, the choices we make are not necessarily a part — I mean a defining aspect — of the state or condition we end up with. So I plan to give the “choice model” its due — I think there’s a lot going for it. But choice itself does not seem incompatible with disease. One is a sort of cognitive action and one is a lasting state.
Well, one problem with the strict disease theory adherents is that they do tend to discredit the effects of trauma and abuse on people and how that can play into the addictive process. I’m speaking here not of the study of addiction necessarily, but the treatment on the ground.
I agree. The role of trauma, which I personally think is huge, is best acknowledged by the “self-medication” model. (I’ve cited elsewhere a comorbidity rate of 60-80% between PTSD and alcoholism.)
Frankly, this confuses me. A lot of the psychiatrists I’ve met, who are quite committed to the disease model, also talk about the important role of trauma. I’m just not sure how they reconcile these two perspectives. They don’t seem to fit together easily.
I’m interested in what you have to say on the self-medication model. I’m not for any one model, personally, at this point. However, I cannot deny that trauma played a large role for me (and am more willing to come out of that closet after reading the first chapters of your book). When I did seek help, I was surrounded (especially at first) by disease model adherents who ended up almost being abusive in their attempts to frame my expressions of being traumatized as some sort of excuse or “denial”.
It confuses me as well. Further down the line I did run into people working in addiction treatment who acknowledged trauma/abuse as being almost tangential to their patients’ histories. They acted as if these experiences were part of the “addict personality” they were all busy studying, but definitely considered it to be outside the realm of what people needed help for. I know there are others, like the ones you mention, and like you, they leave me completely baffled. Which is probably why I’m still not for one model over another at this point!
That is just so sad…and angering. It’s crazy to try to force someone into the disease model…and sap their will in the process. And it’s even crazier to treat trauma as some tangential happenstance. Yes, it makes me mad.
I was also the victim of trauma/abuse. It is sometimes hard for others to understand, even superficially, the soul-crushing power of such experiences, and the way that drugs or other substances can cushion the intense, reeling sense of isolation and defeat that results. At least that’s what it was like for me.
So…self-medication….coming up.
Marc, my main concern is usually how this translates to the help people are getting out there. Disease model looks very different when being debated scientifically than it looks on the ground, translated by people working in the addiction field. Frequently, that understanding consists of people trained (a large percentage of them former/”recovering” addicts) to believe in the disease model, but without your understanding of how a brain disease would even work. This belief seems to encompass other supposed symptoms, such as the idea that anyone resistant to this model is simply in “denial” and should be broken down (bullied) for their own good. Also, treating trauma as some kind of excuse (I personally was punished for crying….in opiate detox…and wasn’t the 1st or the last). I’m sure this doesn’t happen across the board, but there really is no accountability for those working in this field.
The strongest reminder I have had of how I felt and was treated while seeking help was actually the section of your book on bullying and abuse at Tabor. I am not an angry person, but when it comes to how people are being treated (frequently while seeking HELP for and paying large sums of money for this treatment!) due to poor understandings of debatable/possibly not actual brain diseases, well, I’ll likely be pissed off for some time to come!
Interesting study published by Columbia University’s Center for Addiction and Substance Abuse on the state of addiction treatment in the US, in case you haven’t seen it:
http://www.casacolumbia.org/templates/NewsRoom.aspx?articleid=678&zoneid=51
(Slightly off topic, but not entirely)
After a month of lurking I think this is as good a time as any to jump in! For me the disease model makes a lot of sense in understanding my own personal story. At age 18 I was a very successful student and athlete who was packed for collage on a full scholarship…but while that was happening I also had my first drink of alcohol and first taste of drugs. From the start I loved being intoxicated and would always aim to be as intoxicated as possible. Quickly I lost interest in the things that made my life meaningful-namely athletics. Getting drunk and high seemed so much more relevant and exciting. Over the course of 7 years I became totally dependent on getting high. And if I could not find the drugs I wanted alcohol was the stand in. My use got heavier and heavier and my countless attempts to cut back never worked for long. At age 24 I overdose on cocaine and was terrified as I felt like my heart might stop. I really felt that if I did not quit it all for good something terrible would happen. That was 10 years ago and it has been more than 8 years that I have abstained from drugs and alcohol. For me the AA thing, which is modeled around the disease concept, was a lifesaver for me. I pause here and am laughing a bit to myself because as an atheist I have an endless list of complaints about the shortcomings of the 12 Step worldview. But since it has helped me and so many people I know I happily keep with it. The idea that addiction is LIKE a disease makes sense. Whether it is or is not a disease addiction is terribly powerful.
Welcome, LJ, into the hearth, and out of the ghostly realm of LURKING. Glad to hear your voice.
I understand, I think, how much LIKE a disease addiction seems to you. And your endorsement of AA is refreshing, in spite of, or even because of, your light-hearted ambivalence. It worked for you…that’s the main point.
I can certainly agree with “like” a disease, and as Nik says, that may be all that we sufferers care about. But IS it a disease?
What if you had fallen deeply, head-over-heals i love with someone who kept you entranced for those seven years. You couldn’t shake that love because this person repeatedly abandoned you, left you hanging, as much as she comforted and soothed you. From a brain’s eye point of view, you get the same intense, progressive “specialization” in the dopamine system, so that everything else loses its value in comparison with the love object. And pursuing her almost brings you to ruin. (there are so many examples of that in the classical and romantic literature!)
So would we call that love a disease? More likely, we’d call it “like” a disease and stop there. Just as you have. And the only thing we’d be sure of is the immense power of the experience.
But isn’t severe drug addiction much more harmful then your being “addicted” to a lover that is no good for you? Real physical dependence on heroin and alcohol for starters…..and then a psychological addiction that can even make dependence on marijuana SEEM like an ACTUAL bodily dependence. I am speaking for myself on that example. So I can see how the brain could look the same in the love versus drug example but wouldn’t the effects of doing a big dose of cocaine be MUCH more powerful as far as a rush of dopamine? For about two years I crushed and snorted A.D.D drugs which I really just loved because of the huge rush I got. Then I was given free rein with cocaine one night. I must have done a lot more then what I needed to get high. The only way I can describe the rush I got is to say that I felt (metaphorically) like “god”. And I thought to myself “nothing should make a person feel like this”! I think perhaps the deeper/older (in an evolutionary sense) part of my brain sensed that I was putting my life at risk and that fear perhaps saved me as it was a catalyst for “putting it all down for good..” So as powerful as love can be aren’t drugs more powerful to the person who is addicted/dependent on them? Looking forward to reading your book and then looking at these questions again!
I see your point, and I have argued elsewhere that drugs provide a uniquely powerful conduit to addiction because they speak directly to the brain. They don’t have to go through “some experience” as a middleman. I get into that in the book too.
But to play devil’s advocate, being intensely in love not only sends you into spasms of dopamine-induced craving, it can also get you into loads of trouble. Examples: extra-marital affairs, recurrent relationships with abusive partners, homosexuality, pedophilia, incest. Please understand, I am not saying these forms of love have ANYTHING in common WITH EACH OTHER, except that they have historically gotten the lover into a lot of trouble with his or her community. How about Romeo and Juliet? Or Nabokov’s Lolita? Intense love attraction can makes one’s life miserable for a lot of different reasons. It can destroy one’s life. And yet….it can’t easily be turned off.
Yes I think that the fact that drugs “speak directly to the brain” is why I see it as so powerful.
Marc, I have to play not ‘devil’s advocate’, but love’s advocate here. Affairs, abuse, pedophilia, and incest are NOT forms of love.
Hi Jaliya, Good that you’re being hard on me!
But in my defense: I said relationships with abusive partners. I’m not talking about the abuser as being in love, I’m talking about the abusee. Re pedophilia and incest, I’m trying to describe powerful attractions to another person. Maybe “love” is the wrong word, but maybe not. Of course these forms of attraction cause us to feel repulsion and disgust. But I recently read a blogpost by a pedophile. He says, yes, that’s what I am. He says he does not ever permit himself to act on his impulses. But the feelings don’t ever go away.
So I had to rethink a few things. (I’m a father of two 6-year olds at the moment.) How is this fundamentally different from other forms of “forbidden” love? I mean at the feeling level? Of course society needs to deal with the enactment of such feelings in clear and effective ways, probably in very harsh ways. But the feelings….? This man might love someone under 18 or 16 or 12 in a way not dissimilar to the way us “normal” people love an icon, a movie star, or even our neighbour’s spouse, to get biblical about it.
Since we don’t have ultimate moral spectacles, we have to be content to describe things at the feeling level as well as the level of norms. But of course we also need to take action to protect children whenever they’re in danger.
LJ, your post raises some good points with which I’d like to agree—and add my 3 cents.
Wikipedia, on the disease model and AA, reproduces founder Bill Wilson’s well-known quote. It seems he’s OK with ‘like a disease.’
//Though AA initially avoided the term “disease”, in 1973 conference-approved literature categorically stated that “we had the disease of alcoholism.”[51] Regardless of official positions, from AA’s inception most members have believed alcoholism to be a disease.[7] […]
Wilson explained in 1960 why AA had refrained from using the term “disease”:
“We AAs have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments or combinations of them. It is something like that with alcoholism. Therefore, we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Hence, we have always called it an illness or a malady – a far safer term for us to use.[53]” //
===
I think the problem is that “disease” [or ‘disorder,’ the psychiatrists’ preferred term]
is not an experience-near concept. First person experience is in terms of “I can’t stop”, “This is not the ‘me’ that I once knew,” “I’m harming –perhaps destroying–myself.” Of course, for some substances, there may be bodily distress, even pain.
In the grip of a symptom, including a mental one, one wants relief. So of course the origins of the symptom are relevant, even if not apparent. For example, if I have suicidal ideation, it may have an organic origin. Perhaps the ‘organic origin’ is easily dealt with, so it’s particularly crucial that I have a correct account: Suppose I’m a depressed but non-suicidal teen taking Prozac; then I start thinking a LOT, of suicide. Conclusion: I should stop the Prozac.
Leaving aside such ‘organic’ situations, the question, “Is what I have a disease or just ‘like a disease’? ”becomes mainly a theoretical issue for scientists to decide. Is an addiction a ‘disorder’ as per APA and DSM IV? Or is it merely a ‘condition which may be a focus of concern.’ Well, the substance abuse instances are said to be ‘disorders,’ but the behavioral ones are disorders only in some cases, e.g.gambling, Internet compulsive overuse does not, in the current DSM, qualify as disorder.
The field of organic or pharmaceutical interventions is fascinating; naltrexone curbs craving for alcohol, and bupropion (Zyban) curbs craving for nicotine. Cravings for food or sex may be susceptible to such approaches, but a downside may arise, e.g when dexedrine or phentermine are used to reduce appetite. On sexual compulsions, I’m not sure I want them treated with Prozac (let alone anti-androgens).
For any of us in the grip of compulsions or addictions, and leaving aside organic interventions, the issue—is it disease, ‘like a disease’, disorder, condition?– seems like something which our experience cannot, perhaps need not, decide. That’s what I think the Bill Wilson quotation, above, suggests. The scientists will debate about the right label, and their conclusions may be of benefit, but the ‘addict’ or afflicted person is, in my opinion, on the sideline of the theoretical debate; more pressing issues are at hand.
Nik, I did some rereading of AA literature and see your point on the wording. And I became curious!
“We became convinced that….we are in the grips of an progressive illness..” From “More on Alcoholism” from the book Alcoholics Anonymous.
I have thought about your statement that as people “afflicted” by addiction we have “more pressing issues at hand”. I think this is why for my first few years clean and sober I swallowed whole much of the stuff you find in 12 Step Literature. It made perfect sense that I did have an “progressive illness”…I have not yet read M’s book but have watched the video podcast (on Big Ideas..check it out if you have not already) where he suggested a metaphor that addiction is like ivy growing on a wall. First there is only a little ivy and then more and more….I suppose this is the accelerated learning? Anyway, to my point it helped me find sobriety (or whatever you like to call it) to see addiction as an illness…It was not that I was an utter failure-but I was dealing with something stronger then me. So for the addict (and not straight up academic) perhaps whatever “cause” of addiction you find helpful or illuminating should be the one you use.
Yup, the ivy is the accelerated learning. Or, more precisely, it is the proliferation of synaptic networks (webs of interacting neurons), such that they take over and cover everything….and that is the physical basis of accelerated learning. It’s a positive feedback cycle, a snowball effect, but more on that a couple of posts from now.
In any case, I definitely buy “progressive” — yes, that’s the essence of it, whether or not it’s truly a disease.
Thanks for such a clear statement, Nik, complete with important historical references. Frankly, I found it hard to figure out exactly when the “disease” term became formally endorsed by AA. But the main point you make is that the question can be posed as: is this a disease or is this “like” a disease? And when you put it like that, you’re right, it’s pretty academic to the person suffering, and indeed it can be left to the scholars, specialists, researchers, and so forth to figure out the fine points.
My conclusion wasn’t that different. The way I saw it, a model and an analogy are the same thing in many respects. (Recall Hofstadter, whom I linked to in my post.) And then it occurred to me that the most important criterion for the goodness of a model was its useability — how easily and how well can it be used? The point you seem to make is that the useability criterion is one thing for the sufferer and another thing for the researcher/scientist. True enough.
And yet your earlier point seems valid as well. it is important for everyone, scientist and addict alike, to understand the root cause of addiction, so that we can move most directly to the most effective treatment. That reasoning seems to undercut the useability criterion. Who cares how “convenient” the disease term might be, when what we need most is to understand exactly what addiction is and is not? This rings true to me as well.
WOW!
your book should be mandatory reading in high school.
not sure it matters whether addiction is a disease, a choice or another socially palatable moniker.
i first tried a schedule I when i was 12- got it from my parents’ friend. in college (miami in the late 80’s) we did massive amounts of X, LSD, cocaine and marijuana. i went to law school and carried on with my drug of choice, cocaine, it was as cheap as coffee in those days and worked better. i graduated and cleaned my act up. then in 2004 i was in 3 very bad motor vehicle accidents. the docs put me on percocet, roxycodone AND oxycontin, soma and xanax. not surprising,i becme addicted to opiates. shocking to me because i hate downers. i didn’t have any problem saying goodbye to cocaine but the opiates were something entirely different. i put myself into a 30 day in-house program at a psychiatric hospital, just being there was a huge experience. that was 3 years ago. i am lucky i love my job as a trial lawyer and that my practice area is super exciting (foreclosure defense and securities litigation). my mind pulled me through the addiction because failure is not an option. i cry for all the kids i know who are addicted to pills. they are losing time and don’t realize how precious it is-so many are dying it kills me. my youngest sister is 25 and over 30 of her high school classmates are dead from opiate overdoses. the state i live in has very few drug courts and even less treatment options for the financially challenged addicts so they ae creating more felons than the worst Jim Crow laws.
thank you for sharing your knowledge and experiences.
That is quite a mouthful! First, thanks for the compliment. Second, your story is really interesting, and it’s wonderful and optimistic to hear that your rationality, your determination, and your commitment to your career pulled you out in time.
You’re right that a lot of young people are doing themselves a great deal of harm. And the resources for treatment in the U.S., especially for those without money, are shocking. (Mind you, so is the whole health care system — what a fiasco!) But the numbers you cite — really? 30? — are especially upsetting.
Interestingly, opiates are not downers — they’re…opiates. In moderate doses they don’t put you to sleep. They don’t even make you drowsy, necessarily. Rats and mice play better on opiates than off. And many people socialize more easily with opioids in their systems. Opioids have one main function, to relieve stress, fear, pain, anxiety….allowing us to feel safe and comfortable. Super comfortable, when we get them from a pill or a needle.. That’s why they’re so attractive, and so insidious.
I still don’t understand your reluctance to call addiction a disease, and I really, really don’t understand your claim that schizophrenia is the only brain abnormaility that can be called a disease.
What about bipolar disorder?
And we’re finding out more about brain abnormalities associated with autism. Is autism not a disease?
Why the skittishness about calling brain abnormalities diseases?
Carolyn Kay
http://www.ManyYearsYoung.com
It’s a long story. And I have tried to tell parts of it in the current post and also previous posts…and also in my book. It’s not skittishness. It’s questioning whether the “disease” label (a) is accurate and/or (b) is useful. There have been many comments on this blog attesting to the negative impact this label sometimes has, so its usefulness is at least debatable. And as to whether addiction “really is” a disease….I don’t think anyone is sure.
I didn’t mean to say that schizophrenia is the only thing that can be called a brain disease. You’re right, bipolar disorder is also a physical condition of brain abnormality, that can and should be treated with medication…so, yes, it’s in the same ballpark. I would not call autism a disease. And already the picture starts getting murky. Is a developmental disorder the same as a disease? What about a spinal anomaly that gets worse with age? It can cripple you, but is it a disease? So then what about a brain anomaly that gets worse with age? Is that really a disease?
I don’t think these things are obvious or clear, so to me they are worth discussing in detail.
It may be tangential, but we certainly don’t treat addiction as a ‘legitimate’ disease the way we treat other diseases. There are no parades for it, no Susan G Koman for the Cure events.
As well, we shame (either overtly and covertly) addicts and alcoholics so they have to find a new community amongst their own kind (NA and AA groups); instead of being able to openly talk about their struggles amongst loving and supportive family and friends; as they would if they had cancer.
So true! In other words, we sometimes call addiction a disease out of one side of our mouths, while continuing to disparage addicts out of the other. That’s what I meant, above, about a disease we feel we have contributed to…and the shame that can induce. Hard to wear a ribbon and put out a donation box, when the disease is partly caused by one’s own actions.
I had some trouble with M’s critique of the disease model. He argued that it sets up a categorical, either-or (disease, lack of it) situation. I had some difficulty understanding this, because some ordinary ‘diseases’ like diabetes II seem to have subclinical levels, not to speak of mental diseases (DSM ‘disorders) such as depression.
A bit part of the problem is my lack of background in the neuro-anatomy and neuro-chemistry of addiction. This is where M is coming from. So in a small way, to remedy my ignorance, I started doing some reading. One was a source that Marc suggested.
Robinson & Berridge 2003 Addiction
http://www.lsa.umich.edu/psych/research&labs/berridge/publications/Robinson%20&%20Berridge%20An%20Rev%20Psy%20%282003%29.pdf
I got a clearer idea of a ‘learning model.’ Berridge partly subscribes to it, I believe, yet his model of based on incentive salientization is not exactly the same, more like a cousin. He and others have expressly used the term ‘aberrant learning.’
With that under my belt, I come to these understandings of what M is trying to say regarding ‘corrupted learning.’ If I read Marc correctly, he is referring to a normal process the psychologists talk about, namely learning. According to basic needs, one seeks ‘rewards’ and develops routine behavior patterns to obtain them, based on what experience ‘says,’ works. Also there are higher functions such as coordination of goal seeking, attending to the process of obtaining a given reward, etc. You may want to chat with a friend, but you’re also hungry; you postpone the chat, or incorporate it.
Now to the ‘disease’ issue. As I understand it, with mental ‘disease’ one is talking about non normal outer occurrences and non normal inner (brain) processes. Picture, say, a tertiary syphilis infection, or a battlefield trauma–seeing one’s best buddy shot to death. Unlike syphilis, PTSD has no disease-bearing entity to disrupt processes, but nonetheless these processes are non normal– e.g. reliving the experience at odd times ( the brain events correlated).
Consider something *not* a disease: ‘learned helplessness,’ exhibited both in rats and humans (a element of some depressions). As the name suggests it’s normal processes that brought about the state. For a period, no attempts at obtaining the important rewards worked. A kind of de-motivated (helpless) state results.
Addictions, on the learning model, have severely disrupted the ‘reward’ structure
of a person– not to say structures of memory, attention, etc.–. The addict has *learned* that the drug or behavior (e.g. bingeing) brings its reward, and that comes to have abnormal salience. “Obsessions,’ a common mark of addictions, disrupt the coordination of reward and goal seeking. Normal goals are not pursued. E.g. a normal person has food or sex moderately, *for a time*, then turns to other issues, such as going to work, caring for the kids.
I have some concerns that this stress on ‘normal processes’ that are corrupted, seems to ignore the form of some addictions. Injecting a drug, *is* an outside interference, maybe moreso than the trauma causing a PTSD. So to say, the ‘chemistry’ of learning is disrupted, becomes non-normal. For example, consider the underlying processes, if the pleasure of a heroin ‘rush’ becomes *the* thing sought, even to the exclusion of food. Perhaps gambling, food, and sex issues, (or even alcohol consumption) are better examples of ‘corrupted learning’, than IV drug abuse.
But (I’m guessing) perhaps M would say that the basic processes of learning are intact, in a way they are NOT with late stage syphilis or PTSD. Perhaps an argument in favor of this is that some of the severest addicts, e.g. extreme ‘coke’ abusers, have recovered, and arguably recovery is about a RE-learning process –over time, a resumption of normal goal seeking, such as care of self and family. The cokehead, so to say, had only the corrupted learning, e.g. that a certain powder brings pleasure. Yet somehow that changed. It is more accurate to say he RE learned, than that he was cured of a disease.
These are just some thoughts about the issues, and are purely inferential or speculative as to M’s precise thoughts on the matter. But perhaps other readers have struggled similarly to get clear on what’s at issue.
Indeed, I fully follow Berridge’s “incentive sensitization” ….leading to a state called “incentive salience”. His model is completely consistent with my learning model…. In fact, I learned my learning model partly from following his theory and data very carefully.
But as you say, the question of “disease” really depends on whether we see the underlying brain processes as “extreme” vs. “non-normal”. I think that’s a good way to parse the territory. I see them as extreme…and yet still fundamentally normal. In a previous comment, I wondered if I could get away with saying that.
Learned-helplessness is a great comparison to make. Here is a nasty end-point in a process that is entirely normal: learning that nothing you can do matters to avoid the aversive effect. (And the model extends to human depression and many other states, including, I’d say, bad marriages.) I do see addiction in a somewhat similar light. You have learned that something you CAN do helps put off the aversive outcome, at least for a while. Doing it stops the craving, if nothing else.
That’s normal learning in a sense.
I wouldn’t draw a line at drug injection. However unnatural it seems. There just isn’t much difference between the profile of, say, crack addiction, which involves smoking, and heroin addiction c/o the needle.
And yes, I would agree with your description of recovery as relearning. Absolutely. That’s a pretty fundamental point. Thanks for the extra ammunition!
Hello all
This dialogue is both informative and erudite– at a very high level. I shall continue to follow it as I wend my way thru Marc.s book.
Im also impressed at his amazing responsiveness
This debate is ongoing in many circles .and altho the government ( NIH ) and other agencies, and the med/psych professions have adopted the disease model , other recovery efforts such as Smart Recovery ( in which I am active) -a science based abstinence oriented recovery program- does not take sides one vs the other
The 12 step programs have done a disservice to the recovery efforts in their definition definition of the disease but I wont go there
I am a physician and as such am attracted to the disease model since it has recongnizable signs and symptoms, an identified cause, and a now known pathololgy in the body ( brain) . MOre important, in medical terms ,although it cant be cured ( very few diseases of any type are cured) it can be successfully managed just like diabetes and hypertension. And the patient must participate in that management- like measure blood sugar and take insulin. One cannot totally recover from diabetes but one can totally recover from an addiction. and the management tool is abstininence.
And there are psychological tools that help start and maintain that effort that include motivational enhancement and cognitive psychology to help do that.
Complete recovery is possible and many achieve it.. In fact over 50% of people do it entirely on their own- so called natural recovery. There is help for the others- alas some is not very good as has been recounted here– but some are excellent.
So whats the point– there are huge practical reasons to support the medical model having to do with money and research and financial support for people afflicted with this problem .
But further, by considering yourself with a self inflicted illness allows you to take ownership of it and deal with it. And I believe there is less stigma to the idea of being sick instead of being weak shameful and all of the rest of it if its merely a bad habit–maladaptive behaviour in professional lingo
Bottom line is however, what works best for the individual and gets her headed in the right direction and sticking with it is the most important thing. It is a matter of choice, and it you learn to make better ones for your self you become liberated and can learn or relearn to live a better life .
The true nature of the problem really isnt mainstream to its solution.What you do with it is.
Welcome, Bill, and thanks for your kind words.
I can see why you, as a physician, are not only attracted to the disease model but also judge it in terms of its utility, not its accuracy. Your last sentence says it all. To paraphrase: the exact scientific understanding of what addiction REALLY is, i.e., a precise and valid model, doesn’t matter as much as how USEFUL the model is, how well it spurs people to act in their own behalf and get better.
I think that’s true within the realm of treatment and recovery…or at least in the PRACTICE of treatment as it’s conducted in our current economic/political context. But I have two caveats.
The first is that the overwhelming message from readers on this blog is: some people resonate to the disease model and find it helpful, while others don’t, and find it unhelpful at best and harmful at worst.
Second, I still wonder…. I see the benefits of a good metaphor, and I have stated that “useableness” is a potent criterion for any metaphor OR model. And yet, knowing the precise nature of a phenomenon is what science is all about. (And I’m a scientist.) Finding that knowledge, pinning it down, may not help the current generation of “users” (think quantum mechanics in the 30’s), but it’s likely to help more than anything else could, in the future. Quantum mechanics gave us superconductors, TV, computers and cell phones. But it seemed like an exercise in abstraction at the time of its discovery.
The connection between science and treatment is tricky. My brother, also a doctor, says that doctors’ day-to-day decisions rely on “what works” in their experience far more than scientific facts and figures. The impact of science on treatment may simply take time to come to fruition. But once it comes, it pretty much always makes life better for all of us.
Hello!
Science is discovering the mechanism of addiction and the brain. Deciding what to call these discoveries can be dizzying. Dis-ease is a great place to start. If the systems are in a state of distorted message sending decision making can become daunting, and as many find- impossible. What are we responsible for in recovery? Finding the needed prescription for maintaining healthy decision making processes. This regime can be a mixed bag of supports and education. Like diabetes- not everyone treats their own dis-eases the same way or consistently. I Found Dr. McCauley’s video, Pleasure Unwoven, especially helpful in delineating where to apply effective prescriptions of recovery education, medication, talk support, and family inclusion. My guess is that one day people will have a quick saliva test that will let them know where their stress level is and in doing so the solutions for addressing this will be utilized. Or not. As it is today. It is tough to realize that our own brain can be changed so severely by the progressive use of chemicals or behaviors. But it can.
Yes it can. The problem for me is still that everything changes the brain. My training is mostly as a developmental psychologist, that turned into developmental neuroscience. Changes in the structure and function of many brain regions is the hallmark of brain development. Which is why I see addiction as a form of development that went off the rails. I guess you can argue that that is the same thing as a disease. But as I say in my post, it’s sort of arbitrary where one might draw the line.
Your focus on decision-making seems absolutely right. That is the centre of the problem. But note that the same issue can be addressed by a “choice” model. See my next post, in which I refer to Heyman’s “Addiction: A Disorder of Choice.” And he is no friend of the “disease” model.
Hi Marc,
Thank you for this article. I am a Registered Professional Counsellor and I have personally struggled with alcohol addiction in my life.
After the last three years of intense psycho-therapy and group work focused on healing my personal wounds from our childhood and dealing with our traumas, I have managed to come out of my addiction on to the other side.
I have many friends who still rely heavily on the AA program, and with no disrespect to the program – I can see how it works for them, it just does not work for me.
I have had a long hard look inside about how I feel personally about addiction. I do not feel that I have or had a disease. I see my past drinking as a behavioral problem, a learned response to dealing (or not dealing) with emotional pain and stress. Once I achieved the excavating of my wounds I no longer live with the same anxiety or sense of dread/guilt and shame. I was sober for over 6 years, and I needed that time to do my own emotional healing work. I have completed the steps, however I see them as a stepping stone for me rather than a Solution.
There are many things about the AA program that I find irrelevant to today’s emerging beliefs around neuroplasticity of the brain and how people are capable of healing from past trauma’s and we are not all necessarily powerless to our “Disease”.
I have managed to learn to drink responsibly, in that I have a glass of wine once and a while with others. This to me is the direct result of my healing and taking responsibility for my actions.
I needed the AA program for a period in my life, and I am now currently living a very different model. One that is empowering from the inside out and not dependent on any 1 belief system or program.
Have I cured a disease or merely managed to heal from my wounds, look at and re-feel my deep emotional pain and no longer need the dopamine-enhancing response of a drink. I drink for different reasons today and it feels healthy, liberating and solid in a very Self-Differentiated way.
Thank you again for posting such important words.
Sincerely,
Julie
Hi Julie,
I’ve been hearing some version of this story quite a bit now. I feel as you do about addiction. I don’t believe I ever had a disease that I eventually cured. By the end of today today I hope to publish another post, this one on the “self-medication” model, which seems to get much closer to your and my view of our addictions. There have been plenty of wounds. I keep hearing that from others, and I keep finding them in myself. Despite years of work, they’re still there, though I know them so much better now.
One question, though: Your comment suggests that the 12-step program was useful — even necessary? — for you as part of a process. Is that true? Do you respect it for that? Or do you still find it irrelevant, as you say, in today’s world? Would you have gone through it if you had it to do over again? Or would you choose a different route? I’m curious about that.
And I like your remark about neuroplasticity as a sort of icon for the attitude change we may be living through. That’s very provocative. I wonder if the writings of Doidge, and Arrowsmith-Young and others will have that kind of impact.
Thank you for joining us!