Stalking the disease model: One last tirade for 2013

Over the last year, I’ve explored the terrain between meaning and dogma, choice and compulsion, I’ve taken you with me to Dharamsala, found surprising convergences between Buddhist philosophy and dopamine metabolism, pondered the application of mindfulness to treatment. But the theme I seem to land on most is the search for an alternative to the disease model of addiction — a way to understand addiction that does not pit disease against choice, or self-medication against self-indulgence.  So for this final post of the year, I want to bring this discussion to some sort of close. Not a final answer: no way. But a plateau where it’s possible to set up  camp and rest a bit before delving further into the wilderness of this almost intractable problem we’ve all lived with one way or another.

Because I’m feeling stuffed, indulgent and lazy, as I hope you are too this Christmas day, I’ll just copy and paste a few paragraphs from the first chapter of the book I’m working on. It’s just a draft at this point, more revision to be done, but I think this captures the kernel of what I want my book to say:


“Among the opponents of the disease model, almost no one has fought fire with fire and tackled the neuroscience behind it. Most of those arguing against the disease model, like the general public, are spellbound, if not paralyzed, by the notion of “brain change.” … It’s almost as if students of addiction make a choice: either admit the brain is a really important organ, in which case addiction is a brain disease, or put the brain back in the closet, in which case you can go on talking about choice, environmental factors, social anthropology, and all the rest of it.

This strikes me as exceptionally odd. Surely the brain that underlies addiction is the same brain that we use to perceive and respond to our environments, make choices, and reflect on the benefits of being high — in context. So it seems extremely likely that the brain is fundamental to addiction, whether we construe addiction as a disease, a choice, or a self-medication strategy.

The fact is: brains change. They’re supposed to. These days it’s called neuroplasticity. Brain change is the fundamental mechanism by which infants grow into toddlers who grow into children who grow into adults. Brain change underlies the transformations in thinking and feeling that characterize early adolescence. (By some estimates, the prefrontal cortex loses 30,000 synapses per second during this period.) Brain change is necessary for perspective-taking and language acquisition in early childhood, and for falling in love, with a partner or with one’s children, later in life. And for learning to play a musical instrument or appreciate opera. Brains have to change for learning to take place. Without physical changes in brain matter, learning is impossible. Synapses appear and self-perpetuate or weaken and dissipate. These processes alter the communication patterns between brain regions and build unique configurations of synapses (synaptic networks) that represent knowledge, familiarity, and memory itself. The relation between learning and brain change has been studied for more than 100 years, it was reasonably well understood by the 1940s, and the search for specific cellular mechanisms of learning continues to point to new levels and mechanisms of change. Whether repairing the damage caused by a minor stroke or altering emotional processes in the wake of trauma, neuroplasticity is at the top of the brain’s resumé.

Proponents of the disease model argue that addiction changes the brain. And they’re right: it does. But the brain is designed to change. It’s primary functions — to think, feel, remember, and act — are served by structural transformations at every level, from gene expression to the size and shape of the cortex itself. The premise that brain change equals brain disease is so ill-founded, it’s hard to know exactly where to start chopping.

A new model of addiction and a plan for the book

This book makes the case that addiction results from accelerated learning — the acquisition of thought patterns that rapidly self-perpetuate because of the brain’s tendency to become sensitized to highly attractive rewards. I see this as a developmental process, accelerated by a neurochemical feedback loop that’s particular to strong attractions. Like other developmental outcomes, addiction isn’t easy to reverse, because it’s based on synaptic restructuring. Like other developmental outcomes, it arises from neural plasticity and uses it up at the same time. Addiction is definitely bad news for the addict and all those within range. But the severe consequences of addiction don’t make it a disease, any more than the consequences of violence make violence a disease, or the consequences of racism make racism a disease, or the folly of loving thy neighbour’s wife make infidelity a disease. What they make it is a very bad habit…

This book shows why the disease model is wrong — and how that wrongness is maintained by a biased view of the neural data. Then it shows how we can replace the disease model, not by shunning the biology of addiction but by examining it more closely. Rather than throw the brain out with the bathwater, as some anti-disease crusaders have attempted, I examine brain changes under a microscope that integrates depth and detail. And I show them to be developmental changes in an organ designed to restructure itself. I show how common neurodevelopmental processes yield uncommon results when we become attached to a narrow set of goals that squeeze out the competition….

I show how addiction arises through neural changes that constitute development, not disease — changes that nevertheless conspire to make it increasingly hard to quit. And I show how recovery is achieved when addicts continue to develop, by strengthening new connections among desire, self-regard, and self-control.”


So, stay tuned. The book, to be released in 2014, will spell out this meta-perspective through the telling of biographical accounts, slices of the incredible life stories some of you have shared with me — or who still might talk with me when I finally catch up enough to email, skype, and/or call you. And I’ll connect these stories to the science of brain change in a way that I hope will be accessible, persuasive, and un-put-downable as they say on back covers.

But as far as this blog goes, I think I’ll give this debate a rest — and move on to other things. We all need a break.

With that in mind, Happy Holidays, Happy New Year, get some rest, some peace, some refreshment, and some fun. Thanks for going the distance with me this year…and I promise to be staring at you from your inbox, once again, in 2014.

50 thoughts on “Stalking the disease model: One last tirade for 2013

  1. Kevin+Cody December 25, 2013 at 5:31 am #

    Fucking nailed it:
    And I show them to be developmental changes in an organ designed to restructure itself.

    • William+Abbott December 25, 2013 at 9:16 am #

      Have you been fibbing to us?? The book will be released in 2014?? Or have you just had a burst of creativity after your visit to HH. Whatever- the tease has worked and Ill pre order anytime.
      And Happy Holidays to you and even more wishes for a fulfilling new year.
      PS: more on the topic to come ( of course  )

      • Marc December 25, 2013 at 11:49 am #

        Well, honestly, I still have to write a lot of it. But I’m on a roll. Much of my present energy comes from being invited to a conference next month in Germany. It’s on “Neuroplasticity in substance addiction and recovery,” and here’s the link:

        This is the bandwagon I’d been hoping to start, and now I see it’s already started. So I’d better get on it!!!

        Great to have you with us this season, Bill. You’re like a court jester armed with a well-poised harpoon. Happy holidays to you and yours!

        • Liz December 25, 2013 at 2:18 pm #

          This looks so cool! I can’t wait to hear about it.

          Happy Holidays!

  2. Kevin+Cody December 25, 2013 at 5:34 am #

    maybe I would add fundamentally designed to restructure itself.

    Now maybe this will explain why few people are nice and most are not, just my understanding of reality.


    Happy Winter Solstice, Marc and all.

    • Marc December 25, 2013 at 11:53 am #

      There’s only so many times I can use the word “fundamentally”. It’s a habit I’m trying to break, or at least apply harm reduction.

      Happy Solstice to you too, bud. All the best for 2014!

      • NR+Sign+Inc. January 15, 2014 at 2:13 pm #

        If you stop using that word, are you fundamentally restructuring yourself anyways? 🙂

  3. David Clark December 25, 2013 at 6:32 am #

    Really looking forward to reading the new book. Sound great and I like your ideas, Marc.

    I am not a believer in the disease model and find no convincing evidence supporting this idea. However, if people with an addiction problem want to believe they have a disease and this helps them get better, then who am I to argue against their belief? However, I think this view can impair many people’s efforts to find recovery. It can help destroy hope and keep people locked into a negative mind set.

    The disease model is of great value to certain psychiatrists, those who believe the medical model is the only way to help people overcome addiction and mental health problems. It is of tremendous value to drug companies and alcohol companies, And the people at NIDA will always push this idea, because they have to justify their huge budget. Neuroscientists will push the idea to keep their funding.

    I always found it a great disappointment that with all the money that was invested in the
    NIDA addiction project with HBA and other associates, the main message was ‘addiction is a disease’. What a missed opportunity! And I was very disappointed by the video clip of Nora Volkow talking about the brain and addiction? Everyone I have shown it to thought it to be disempowering and some thought it to be condescending. I have to agree with them.

    When I was a neuroscientist – my research included neuroplasticity at single cell and behavioural levels, and I wrote a related review on addiction – I was struck by how narrow-minded many neuroscientists were. I have to confess that at times I was too wrapped up in my own world. Eventually, I realised that neuroscience was not helping people find recovery and I left to work in other ways.

    Now I see many people working in the addiction field as viewing the world as either black or white. Many of these people throw ‘out the brain’ when they argue against the disease model. That is wrong. Of course the brain changes. Life experiences produce permanent or long-term changes – they are called memories or habits.

    However, that does not mean that long-term changes in brain function are necessarily permanent or are a disease.

    Marc, thank you for much great reading and insights over the past year. I hope you have a great Christmas and all the best for 2014. I look forward to reading your new book.

    My best wishes, David

    • Marc December 25, 2013 at 2:56 pm #

      Thanks so much, David. It sounds like you and I are in synch on just about everything. For me, the big realization was that the brain data point away from the disease model, not toward it. And of course there are the vested interests that you mention which help keep the disease model in place.

      Psychiatrists have always viewed emotional problems in terms of categories — that is the medical approach. As a psychologist, I have long felt hemmed in by that world view. Psychologists, when they make sense (which they occasionally do) see emotional problems in terms of functionality, cause and effect, rather than categories. And for me, the most fundamental wisdom psychology has to offer is an understanding of human development.

      I once had a professor, Daniel Keating, who said: all psychology is (or should be) developmental psychology. I think he had a point.

      Thanks for your encouragement…and I hope you stick around through 2014.


      • David+Clark December 25, 2013 at 3:10 pm #

        I’m not going anywhere in 2014, although will be doing a lot more work with Aboriginal people. Interesting point from Daniel.

  4. William+Abbott December 25, 2013 at 9:41 am #

    Well here it the ” more” . I got on roll before the clan gathered for the festivities

    I’m going to take a total U turn posting from my usual position on the disease model. Who the hell cares what the fuck it is? WE all know what it is. It’s a terrible destructive life sapping problem that sometimes kills people often prematurely.
    And we know what the solution is to this problem. Stop doing it!!! With substances there is no mysterious “force” that somehow infuses this mind altering stuff into our body systems. WE know quite a lot about what it does to our various body parts including our brains – and fortunately that our body parts can repair themselves to some extent when no longer exposed to these mostly toxic foreign chemicals.
    So what’s the big deal…? Why all the passion?? Why do I get annoyed when I hear Nora Volkow talk with such surety? Why do I care? It’s a bit reminiscent of the argument of ID vs. Evolution.
    What IM driving at here – with a lot of tongue in cheek- is if we do know what the solution is, why all the energy here in this disease vs other quandary and not in finding better ways to implement and facilitate the solution(s) . {Note to Mark- hit me here, lol)}
    If we know that some of the ways of solving the problem are effective- and we are beginning to—wouldn’t it be more prudent to know more about WHY they are??
    All the best to all of us here for 2014

    • Marc December 25, 2013 at 3:01 pm #

      Why all the energy, the controversy, the hot air? Because that is what we do when we talk about things in an effort to understand them. Who the hell cares what we call it? I do. Because I think that careful definition is an important starting point in scientific investigation and knowledge building. And as far as evolution vs Intelligent Design, I think that’s another argument that deserves to be fought, and won, because its implications for how we think and how we live our lives are massive. It matters.

      Or maybe I just like repartee. It keeps me busy at the very least.

      • William Abbott December 26, 2013 at 3:42 pm #

        Jester?? No way..deadly serious.
        I do have a pitchfork as well as a feather.however
        You didn’t really bite at my lure .
        Of course I care to0. A lot.. To follow my line of thinking, one is left with the same sort of inconsequential subjective and incomplete information about what works and what does not work. We need to know more about the nature of the addiction, the anatomy, physiology and pathology as well as the psychology and sociology, and maybe even the spirituality in an order to know what to measure as possibly being effective or not.

        It’s not so important as to what exactly we call it, but more is just exactly what is it. I don’t know, but I sure would like to know.

        So keep busy. Keep writing. So we all can learn – together.

        Thanks again for all your efforts

        • Marc December 30, 2013 at 5:26 pm #

          Exactly. Which is why psychologists are superior to psychiatrists. There, I’ve said it. Psychologists care about cause-effect — at least they should. Psychiatrists care about categories.

          To forgive is divine.

          • William Abbott December 31, 2013 at 9:42 am #

            Psychologists are superior to psychiatrists. There Ive said it cause I agree

            Let me tell you why sometime – but psychiatry is commiting self destruction imo.

            Case in point : DSM 5

  5. Doug December 25, 2013 at 9:56 am #

    In some cases addiction is a side effect of treating a disease. Then the addiction becomes the disorder or disease that needs a different treatment, just like any other disorder. Let’s not get hung up on nomenclature when the disease in question is real and destroys so many lives.
    Can’t wait to read the new book though my mind may be a scary place, it is open to changing names of various phenomena.

    • Marc December 25, 2013 at 3:04 pm #

      Well I guess I am hung up on nomenclature. At least for now. But if your scary mind is open to changing names, we can still do business.

      Yet I don’t want to get hung up on nomenclature at the expense of everything else. So…I expect to be chasing different demons in the months to come.

      • Doug December 25, 2013 at 6:26 pm #

        My scary mind is a place that one can’t go, but it is Open to share demons. You are onto something big, like finding a cure for a disease that doesn’t exist. I hope we can continue to do business as this disease that isn’t continues to kill many people and make thousands of us walking wounded from this non disease. Just pick a name,,, the cure then can follow.

        • Marc January 6, 2014 at 5:41 am #

          Hi again, Doug. I’m not sure how much your tongue is in your cheek. But I believe the disease of car accidents kills quite a few more, not to mention the disease of over-eating and the disease of suicide :–)

  6. John Becker December 25, 2013 at 10:14 am #

    Merry Xmas All,

    Marc, I really like the way your book begins. I think it’s very exciting. And the writing is very exciting! Laying the disease model to rest and talking about how we change our brains when we do recovery–you’re bringing the study of addictions and recovery to the benefit of the whole world. Let’s open our presents!!


    • Marc December 25, 2013 at 3:06 pm #

      Yep, there are lots of new toys to play with. I’m excited about it too. And check out the conference link I included in my reply to Bill Abbott, near the top. Just the name of the conference is enough to warm the cockles. Happy trails, John.

    • Waylon December 31, 2013 at 12:24 pm #

      I totally agree, John! I am exited to see what’s to come! The study of recovery and addiction is something I have always been interested in. So glad I found this blog to follow!

      • Marc January 6, 2014 at 5:42 am #

        Welcome aboard, Waylon!

        • Waylon January 24, 2014 at 9:15 am #

          Thanks so much! Again, excited to see what’s ahead!

  7. Shaun Shelly December 26, 2013 at 2:43 am #

    Hey Marc, really interesting. While preparing a talk on the neurobiology of romantic love I felt like I was ready papers on addiction. More and more I am convinced that addiction is a redirection of very natural behaviours and neurological changes towards less helpful objects of affection. As you know, there are a few for whom I think a disease state MAY arise, but this is not primary, although it may appear so at times.

    You say: “I see this as a developmental process, accelerated by a neurochemical feedback loop that’s particular to strong attractions.” AJ Robison talks about a “feed-forward loop”, which I think is an interesting term. While studying cocaine addiction he found that elevating the levels of DeltaFOSB caused rats to behave as though on cocaine. The research team found that there is a reciprocal relationship between DeltaFOSB and CaMKIIα in the NAc.Both these proteins regulate AMPA receptor expression in the NAc, bringing glutamate into play. There is a snow-balling effect. The abstract is here:

    The memory/learning/reward systems all interact in a variety of ways and at various levels (from environmental to brain) to result in addictive behaviours.

    These systems can (relatively) easily be co-opted by various factors in those with vulnerability – Dirk has written about gambling machines being “skinner Boxes for human rats” –

    I see the brain changes not as “damage” but rather as a very efficient co-opting of natural brain mechanisms. This has profound implications for treatment methodologies, as we have previously discussed.

    As usual, interesting stuff and much to think about.

    • Marc December 30, 2013 at 5:31 pm #

      And as usual, I’ll have to read and think a bit before a decent reply. For now, yes, co-opting, except that term gets dangerously close to “hijacking”…oh what shall we do?

      And “feedback” is a lazy man’s way of describing both feedback and feedforward. More soon. Must party for awhile.

      I’m in a very large cabin in a very cold part of Canada. I went outside for 15 minutes today. That will do for a few days.

    • Susan February 5, 2014 at 5:53 pm #
      Helen Fisher on love and antidepressants many are interested in this issue because of marriage break down after the drugs are taken and the severe personality changes that go along with them.

      Would anyone care to comment.

  8. Janet December 26, 2013 at 9:56 pm #

    Bravo, Marc. You have really captured the debate. And with kindness. The heartache and suffering that have overwhelmed me as the mother of an addict, have forever been lightened by finding your voice, in your first book, and then here. Thank you, along with the others who speak so eloquently here.
    I have a question for the New Year. If addiction is NOT a disease, why does it follow such a predictable path? Why do addicts end up in almost indistinguishable behavior patterns and thinking patterns.
    When my brain changes, I don’t end up just like my friends, even if we both learn french at the same time.
    I struggle to understand… especially as addiction is so predictably unforgiving in it’s consequences and circumstances.
    May the New Year bring Peace. Janet

    • Marc December 30, 2013 at 5:52 pm #

      Janet, your story comes to my mind more than any other when I spend my efforts trying to eviscerate the disease model of addiction. What you’ve been through, what your son has been through, seem so much like a disease that it’s hard to take another definition seriously.

      I could argue with you. Why does adolescence take such a predictable form? That’s not a disease. Why do marriages very often assume the same trajectory? The seven-year itch, the 17-year redefinition, the….whatever comes next. I’m waiting. And old age, with its solitudes, its losses, and its reconciliations. So many developmental phenomena actually do take similar forms because our bodies and minds and our culture are made of particular components that fit together in only a small number of ways. I strongly believe this.

      And yet, I would never want to talk you out of your impression that addiction is a disease, because, in some cases, it is so much like a disease that further debate becomes inconsequential and maybe even offensive. Also see Shaun’s comments. I think he sees things in a similar way.

      In any case, happy new year, luck, health and wisdom to you and yours.

  9. Julia December 28, 2013 at 10:49 am #

    This discussion around naming reminds me of discussions I’ve heard about the power of labeling in political discourse… how one party or candidate can seize the upper hand or be doomed by what some policy or legislation is called in the minds of the public. For instance the terms “death tax” or “right to life.”

    Once the public picks up on the term it can dramatically determine how legislation goes and money flows. “Intelligent Design” is another such cleverly formulated term which has allowed the religious community to sound scientific and get their completely unscientific beliefs included where they have no business being, ever!

    Maybe that’s a big part of why what we call addiction is important? Certainly any individual therapist or researcher or addict can call it whatever they want. It’s still whatever it is. But whoever can control what the general public calls it can powerfully determine where research and treatment dollars go. That is worth fighting about/for.

    I personally find the disease model constraining, dis-empowering and demeaning. But that’s just me and I won’t use the term disease no matter what the general public or research community says.

    So, keep up the great work Marc! We need your informed and articulate voice promoting a non-disease (a catchier label would be good to come up with) model of addiction. Happy 2014 to All!

    • Marc December 30, 2013 at 6:05 pm #

      Julia, that was rather brilliant. And it pretty much eclipses what I’ve tried to say in the rest of Chapter 1. Let me know if you’d like to see a draft.

      Yes, how we name things determines how we deal with the issues, how we allocate resources, and how we treat those so categorized. In fact these labels serve as mediators between how we already felt about…abortion, or evolution, or health care…and how we’re encouraged to feel about it from this point onward, and how convincing we can be in drawing others into that view. It’s ammunition, and it gets allotted to the biggest players. That’s one of the things I get indignant about. Because the medical community giveth (labels, definitions) and the medical community taketh away (that would be dollars). So there’s a bit of a power problem built right in.

      Anyway, thanks for the clarity of your voice. It helps me think more about what I need to think about. Happy 2014!

      • Julia January 2, 2014 at 9:07 pm #

        I was just listening to an interview with an author whose work sounds like it is right in line with your thinking and possibly provides some additional backing for the non-disease model. Maybe you’re already familiar with it, but just in case… What particularly struck me was a statement he made is that “Addiction is not a disease. It’s a symptom.” His point being that addictive behavior can have a variety of causes. Some may, in fact, be physical diseases but there can be other causes and lumping all addiction together as a disease makes it that much harder to treat each individual. Conversely, a given condition may cause different symptoms in different individuals, in some it may be addiction but the same condition (or even disease) may cause other, or no, symptoms in another individual. Here’s the book and the interview I heard:

        The Mind Within the Brain: How We Made Decisions and How Those Decisions Go Wrong by A. David Redish

        Cheers, Julia

        • Shaun+Shelly January 3, 2014 at 1:53 am #

          Julia, I am always pointing out that addiction is a cummulation of multiple factors that result in a critical mass being reached. Mike Ashton for the very useful “Drug and Alcohol Findings” has said this:

          “If it is the case that there is no such thing as ‘addiction’ as a unitary medical or psychological condition, or even a set of such conditions (‘addictions’), then it also makes no sense to construct unitary, standardised responses. This is like developing standard medical responses to the behaviour we recognise as limping. Any number of conditions and combinations of circumstances can lead to this behaviour including being kicked by the doctor, hobbled by prison chains, a cancer, a poorly fitting shoe, or an uneven floor, it may or may not bother the limper in any number of different ways for shorter or longer periods, and what they want done about it, if anything, will similarly vary. We may need a doctor to fix it but we may as easily need a carpenter, a good shoe fitter or a lawyer. The unitary nature of the behaviour does not mean there is a similarly unitary cause or a standard set of responses.”

          Which I think is very useful.

          • Janet January 5, 2014 at 8:33 am #

            Agree. Thanks, Shaun.

        • Marc January 6, 2014 at 5:54 am #

          Hi Julia and Shaun. Great discussion. So there are multiple causes that can trigger (or generate) the effect called addiction. As Shaun says, we can find a line that gets crossed right around this point — a critical mass. Here are two further points that fit what you’re both saying:

          1. The “effect” — addiction — is not the end of the trajectory. It’s just a stage. Because that effect goes on causing other things, including ongoing or worsening addiction. This process of leap-frogging (spiraling) causes and effects is a fundamental engine of development. Even the development of something so mundane as “walking” (which occurs at around 12 months of age) can be seen as partial upright locomotion leading to greater efforts leading to improved balance, muscular growth, and coordination, which leads to more practice walking. So that babies turn from crawlers to walkers in only a few months, based on a self-perpetuating spiral or feedback process.

          2. Walking, addiction, and most other developmental outcomes can be described as a “narrowing”. The better you are at walking, the less likely you are to crawl, creep, or holler for mama to help you. This process of narrowing can also be seen at the brain level, where neuroplasticity is used up as particular pathways get strengthened and entrenched.

          So, addiction has a very particular shape which points to mechanisms that are universal engines of development. A more general term for this self-perpetuating, cohering, emergent process is “self-organization”. That’s a term from complexity theory (physics, math, biology) that covers a LOT of different kinds of growth in this here world of ours.

      • Julia February 11, 2014 at 10:07 am #

        Hi Marc, sorry I never responded to your offer to see a draft… yes, I would love to! I assume you have my direct email as the owner/host of this blog? Julia

    • Susan February 5, 2014 at 5:58 pm #

      Or the treatment of `chemical imbalance`in the brain…how important words are… be they truth or fiction.

    • Dave February 11, 2014 at 8:07 am #

      Excellent observation Julia.

  10. NN December 30, 2013 at 2:30 pm #

    Hi Marc,

    You said, “And I show them to be developmental changes in an organ designed to restructure itself. I show how common neurodevelopmental processes yield uncommon results when we become attached to a narrow set of goals that squeeze out the competition….”

    It looks like, here, you include changes due to learning, within development. Yes?
    That’s a somewhat broad usage, I think. In the case of an addiction, if it’s set in within a few months, can that be called, in the usual sense, a ‘developmental change’?

    I’m generally in full support of your approach and program. As I’ve said, this ‘disease’ issue was fought out among the psychiatrists who write the DSMs, and they decided on ‘[psychological] disorder’ over ‘ [mental] disease.

    As you say above, the problems of life functioning, of adaptation to everyday social living need their own categories. Further, one expects brain processes to vary in concordance with problem type– the ‘low’ of depression vs. mania.

    On the other hand, I don’t believe anyone has (or perhaps can) demonstrate the difference between the person’s brain ‘addicted’ to the thrill of skiing, versus the thrill of robbing banks. Or, ‘obsessed’ with finishing a novel (to the point of not sleeping) vs. obsessed with winning during a gambling spree.

    One problem of the ‘disease’ approach, for example of the ‘addiction medicine’ doctors and their (ASAM) society is that pharmacology seems to reign as the solution; talking and social approaches are acknowledged as ‘supportive’; the way that nurses’ role is conceived (by some doctors) as ‘hand holding.’

    The addiction physician will cure you, but you’ll feel better going to ‘support groups’ including some 12 step ones.

    Psychologists–I think you will agree– tend in the other direction: talking and social interventions, including behavioral, but SUPPORTED by pharmacologic methods where needed and efficacious.

    This is my attempt to say what’s at stake in the ‘disease’ issue.

    • Marc January 6, 2014 at 6:20 am #

      Hi NN. First things first. I generally try to avoid the terminological jungle around how “learning” and “development” are related: same thing? one embedded in the other? That really does seem to be a language issue for the most part. But as to rapid developmental changes? Sure, why not? How long does it take the child to learn to walk and henceforth to RELY on walking rather than crawling?

      So when we raise this “development” flag over the territories of “everyday social living” (your words)… well, either we dispense with categories altogether (after all, who can define “love” — only the crooners of the world still try, and they do so for the sake of song lyrics, not much else), OR we admit that we choose categories that will best serve our present social/moral viewpoints, arguments, potential gains, weapons, etc. Indeed, in your excellent example, the question arises as to what’s the basic cure and what’s the back-up quality-of-life support? Psychiatrists and psychologists INDEED view the primacy of medication vs. meditation in opposite ways (just wanted to use that phrase, but you know I mean all the social/cognitive/existential work that is done in the service of feeling better). Which is fine. Viva la difference. EXCEPT when we start trying to squeeze things like falling in love into the same category we use for addiction. Now, anyone who would advise medication over meditation (for the love-lorn) would look like an idiot. Which is why people don’t go to psychiatrists to get cured of “love” — UNLESS the object of that (romantic) love happens to be your mother, or, God forbid, a child, or perhaps a shoe. Which is where Freud comes in of course. Poor old Freud… But he does indeed serve a FUNCTION.

      See what I mean? The “disease” approach (which gets manifested pragmatically into the medication-first strategy) hits a brick wall — or perhaps I mean quicksand — when we acknowledge that intense cravings are a fairly universal problem, they extend on both sides of the propriety line (if it is a line), and so categorizing something as a disease is (must be) riddled with arbitrariness, moralistic thinking, cognitive biases that no one could hope to measure…not to mention conflicts of interest between your Hippocratic oath and your allegiance to your bank account.

      Sorry to ramble. Got very little sleep, due mostly to my son Ruben’s jet-lag. His body is convinced that we’re still in Toronto. But we’re not! Isabel is away, and I find it remarkable how one 7-year-old can fill up the bed, specializing in elbows, knees, and blanket envy.

  11. NN December 30, 2013 at 2:57 pm #

    A small addendum:

    Nora V, according to you, argued,

    But beyond the damage issue, when something doesn’t work the way it should, we call it a disease. That’s how the word is used — that’s how language works.

    (transferring discussion from the previous thread; hope that’s ok.)

    I think that’s a valid point. If the eye doesn’t see it’s diseased (or the associated nerve pathways, brain areas, etc.). (Though there are cases of ‘hysterical blindness.)

    IF an organism could not learn (e.g. past has no effect on it’s activities–deep defects of memory), you’d agree there’s disease. I think?

    Here, though, you say, the learning is “attached to a narrow set of goals.” And this is, in a way, rather normal: whether it’s writing the ‘great novel’ or getting a PhD or winning one’s beloved, there is this focus, often to the detriment of ‘social functioning’

    What you say, here, is crucial. Generally there is no ‘damage’, no pathology of brain state, structure or process; there is a possiblity to ‘unlearn’ and re-learn. The ‘disease’ folks are *very* avoidant on the issue of spontaneous recovery and skeptical about changes produced by non medical procedures.

    There has been a tradition in the literature, or at least the reporting of it, that ‘addiction’ is iron clad and physical: just look at the cocaine addicted mice that did themselves in.

    So I think you are dead on with the focus on learning processes and their matrix, developmental processes.

    • Marc January 6, 2014 at 7:42 am #

      Thanks, NN, for further fodder. I perceive, embedded in your general support, an arrow pointing to a potential serious weakness in my logic. If deep defects in memory, or the inability to learn anything, can be classed as a “disease”, then why not class highly-constrained learning, or learning attached to a narrow range of goals, as a “disease” also? In the first case, of total serious memory loss, we think of H.M., the most famous amnesic in the world, I think. (see

      Indeed his amnesia seemed to stem from brain damage — particularly in the temporal lobe/region of the hippocampus. Okay, damage = disease, or close enough. But if the difference between this kind of severe memory loss and the narrowing of memory characteristic of addiction is quantitative, rather than qualitative, we may have run into a snag. If the difference is quantitative, only, then, working backward from effect to cause, we can easily imagine “damage” in the case of the memory distortions that characterize addiction. And that’s just what Nora V. claimed! The damage may be more subtle (I infer), but where do you draw the line?

      Well, in the case of general sudden memory loss (amnesia), there is often clear evidence of lesions to the brain, as was the case with H.M., and even a foreign body, a bad guy, holding up a newspaper, wearing sunglasses, namely herpes simplex. ( How did he get in there? Must have got off at the wrong stop. Whereas the rewiring of synaptic clusters, changes in functional connectivity (communication between neurons), and changes in the level of substances like FosB and BDNF (different kinds of juice for brain cells) — which are attributed to drug use, at least with cocaine — are far more subtle. They are nothing like lesions, they are not caused by viruses, etc, etc.

      But if I were a disease-model advocate, I would argue that we simply don’t know enough to draw the line here vs. there. For now, brain changes responsible for constrained or distorted learning might not be so very different from brain changes responsible for memory LOSS.

      I know. I am rambling. And I’m playing the devil’s advocate. I attribute both to the delirious state caused by not sleeping (at least no more than an hour or two) plus culture shock, plus temperature dysregulation — it’s about 10+ degrees out there (centigrade), compared with minus-fifteen-to-twenty while we were in Toronto.

      But ANYWAY, I’m using your words, NN, as triggers and scaffolding to help me think about this “damage” issue. The disease vs. non-disease debate could easily hinge on (or reduce to) the presence (or absence) of damage, and I think that Nora V. would agree. The trouble is….damage is really hard to define in this incredibly complex, self-organizing, multi-layered, self-perpetuating, constantly changing (yet maintaining “structural closure” — see F. Varela) system of interconnected processors that make a mangrove swamp seem about as complicated as a ball-point pen in comparison. So shifting the battle lines from “disease” to “damage” doesn’t help very much, at least not yet.

      I think we gain more traction, for now, by comparing addiction with falling in love. It’s a fundamental human process, with a characteristic shape and trajectory, that frequently leads to suffering, but it’s not a disease. (Except that Caroline Knapp’s excellent book, Drinking: A Love Story, has it both ways.) Some day we will be able to look in detail at the neurobiology of love, infatuation, and then we shall see what we shall see.

      Okay, I just read “Knapp” — the book is sitting beside me — but the word that appeared in my mind was “nap”. I think it’s time I took one.

  12. Jenny Hong December 31, 2013 at 12:43 pm #

    From my reading and thinking, there are seems two phases: “dependence” and “addiction”. These two phases may be interchangeable. In the “dependence” phase, people may have some degree of “choice” ability. In the “addiction” phase, the ability to make a “choice” is about completely damaged… Also “absenting” is an ultimate goal, but may not be the only goal during the treatment. For some cases, a transitional “harm reduction” may be needed.

    • Marc January 6, 2014 at 7:59 am #

      This makes sense to me, Jenny, and it resonates with views of other readers, including Shaun Shelly and Dirk Hanson. But I can’t help notice that the word “damage” rears its ugly head again. Can we really say that the “ability to make a choice” is “damaged”? If you look at the work of Carl Hart, for example, (he’s the guy who does research with crack and meth addicts, letting them choose between monetary rewards and their drug of…ahem…choice) …..the addict is still making choices. They are just not the choices that other people often make, and that’s because they don’t have (or don’t see themselves as having) the same options.

      But I do agree that things seem to get more constrained, predictable, nasty, and hard to reverse, when people go from “dependence” to “addiction”. There does seem to be a line you cross, or at least a steep gradation, a slippery slope.

  13. Wendy Snyder January 6, 2014 at 11:01 pm #

    Dear Marc and MAB community,

    I so look forward to this book and to the discussions it will generate.
    I feel that this is amazingly important work and I have so much more to
    learn about it.

    The rewards for my learning have to do with making some sense of
    my family’s struggle with addiction but also the struggles of so many to
    adjust or maladjust to the sick society that we live in. I think this approach
    to what we call addiction will uncover things that will help to fundamentally change
    our world and with it, our brain structures and patterns. I truly believe that.

    Happy new year!

  14. Donnie Mac January 9, 2014 at 3:53 pm #

    For what it’s worth ,

    ” When AA co-founder Bill Wilson was asked in 1960 about AA’s position on
    the disease concept, he offered the following response:”We 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. Therefore, we always called it an illness,
    or a malady – a far safer term for us to use.”

  15. NN January 13, 2014 at 11:48 am #

    Hi Marc,

    You said,

    //This makes sense to me, Jenny, and it resonates with views of other readers, including Shaun Shelly and Dirk Hanson. But I can’t help notice that the word “damage” rears its ugly head again. Can we really say that the “ability to make a choice” is “damaged”? If you look at the work of Carl Hart, for example, (he’s the guy who does research with crack and meth addicts, letting them choose between monetary rewards and their drug of…ahem…choice) …..the addict is still making choices. They are just not the choices that other people often make, and that’s because they don’t have (or don’t see themselves as having) the same options. //

    In my opinion, we can say that the ability to make good choices is damaged, though I’m aware of the experiments showing that some choices are still made (contrary to the AA myth that once drinking, all power of choice vanishes).

    In the way, we can talk about damaged confidence.

    What we can’t do, in my view, is infer that there is ‘brain damage’ in any ordinary sense, i.e. that could be detected without outside clues and cues. In particular, ‘brain damage’ that the brain could not –or only with difficulty– repair. To use your type of example, in the famous “Blue Angel” film, a professor falls disastrously in love with a nightclub girl. Now you say, he’s *choosing* to lavish money on her (in accord with his love/infatuation) or that he’s lost some rationality in relation to his own goals (e.g. self preservation). Leave that aside. What I question is saying that his brain is damaged, can’t fix itself (etc. in the style of ASAM).

    In fact, leaving aside movie scripts, many of us have ‘fallen’ disastrously, then at some point picked ourselves up (or been picked up). A ‘brain disease’ with a usual and (often inevitable) downward course [MD’s version of an AA myth], simply does not fit the facts.

  16. Jenny Hong January 13, 2014 at 8:04 pm #

    Marc, this is off your subject here, but I want to get your opinion. I recently read about Asperger’s. My questions are: 1) Is there any link between Asperger’s and addiction? 2) What are the major difference between Asperger’s and Introvert personality?

  17. Jenny Hong January 14, 2014 at 10:16 am #

    From the surface of behaviors, there are many similarities between Asperger’s and Introvert. The main common issues are the “lack of” social and communication skills. So I wondered what are the major factors in *behavior* that make Asperger’s a “diagnosis” and Introvert a “personality trait”?

    How can we tell, from observation, that someone is Asperger’s, not Introvert?

    • Roman Morgenroth July 20, 2014 at 7:13 am #

      Hi Jenny,
      just reading your questions not answered yet I’ ll try to respond concerning the presumed behavioral difference of Asberger vs. Introvert.
      Indeed there haven’t necessarily to be one, ontologically speking! It’s two different clusters, the one is a medical-psychiatrist classification, the other is a more psychological construct.

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