The final stage: compulsion

This morning I woke up before the rest of my family. We’re in a hotel in Switzerland, on a ski holiday. Switzerland isn’t that far from our home in Holland, but I know that I’m a lucky guy. My life has improved substantially since sitting in a cell in Thunder Bay, Ontario, waiting to get bailed out (after raiding a pharmacy with a motion detector). So I snuck out of the room, trying not to wake anybody else. But of course one kid started coughing and the other went to pee, by which time Isabel was frowning at me in her first moments of wakefulness. Was I being too noisy?

Anyway, I’m feeling a bit disoriented. Vacations are nice, but I find it hard to just….um….relax. So I get to the lobby and boot up my computer and the first thing I read is a comment on one of the memoirs, by “jaqueline” (about 15 comments down this page).  Now suddenly I’m not bored anymore, or preoccupied with petty things like wondering when the grandparents will come down for breakfast and whether I’m supposed to get back to the room to help the kids dress. Suddenly I’m with this person in the freezing cold – cold attacking her body from the outside and her soul from the inside – trying to figure out what she can sell to get a bit of heroin. Her mother offers to get her a hotel room but refuses to give her any money. And she thinks: what good is a hotel room without drugs?

I remember that feeling so clearly. Viscerally. Even though it’s been a long time for me. The need for drugs that attaches itself to you so thoroughly that every movement of your body, even turning over in bed, feels like you’re pulling against a second skin. There’s this dark sticky second skin that’s stretched around you, irritated, pulling away patches of your own skin with every move you make. I’m here. I want drugs. What are you going to do about it?

That old expression, “monkey on your back,” isn’t far off. But it feels bigger than a monkey and so much darker. And there’s really nothing else to do. That’s the point: there’s only one thing to do and no other action has any point to it.

So you lurch out into the cold of early morning or late night, seeking, searching, there’s got to be a way. There’s got to be a sequence of steps. If I can only figure out where the path starts, I know, I just know, that there will be drugs at the far end.

That’s called compulsion. The drive to act, to do something, without thought or reason.

I promised last post to continue the model of addictive behaviour I was working on.  I’ve been reading more neuroscience papers, and there is a final state in the sequence of states I outlined. A final stage that I think is applicable to most people and most addictions: When addiction tightens its grasp, impulse turns to compulsion, and that’s when you just can’t stop – or so it seems.

There’s a distinct neurobiological change when this happens. I have focused a lot of attention on the ventral striatum or nucleus accumbens. That’s where attraction and focus suddenly converge to create the impulse to go after the thing you crave. But the striatum has another whole subsystem within it, higher up in the brain, which we can call the dorsal striatum. When impulsive drug-seeking behaviour turns to compulsive drug-seeking behaviour, it’s the dorsal striatum that gets activated. This is a definite change in how the brain processes cues – and when I say cues I mean the thoughts, memories, withdrawal symptoms, or reminders out there in the world that call your attention to the thing you’re addicted to. Now, the action sequence, the set of steps, the behavioural response, One_of_Pavlov's_dogswhatever you want to call it, is suddenly resonating, vibrating with life. You are plunged into action, forced into action by the wiring of your dorsal striatum. Much like Pavlov’s dog, who starts to salivate when he hears the bell. There’s nothing to think about, no more reflection on whether it’s worth it or not. You just have to act. Which means: you just have to get some.

I’ll say more about compulsive addictive behaviour next post. For many experts in addiction neuroscience, compulsive drug-seeking is the definition of addiction, and it’s worth our attention. For now, I feel a bit compelled to get this post up. (I’ll probably revise it more later). Jaqueline’s story, so resonant with Janet’s memoir and so searing a reminder of my own crazy drug days, got my fingers going until this post was done.

Now I’ll go see what’s up with the family.



44 thoughts on “The final stage: compulsion

  1. Richard Henry February 12, 2013 at 6:59 am #

    Thanks for sharing Marc
    I find this subject very interesting.
    I use a little trick when I feel the compulsion come on to seek out drugs, to end the compulsion before it turns into an impulse, becoming almost to late to stop it.
    I will go to the mirror and look straight at myself and say leave me alone, and if you quit bugging me, I will give you some ice-cream later. I usually laugh and get over it, but always reward myself with ice-cream or chocolate later. I’m not sure how this works but I do know humor for me, plays a big part in disrupting that pathway.
    Regards Richard

    • Marc February 15, 2013 at 5:21 pm #

      Hi Richard. Humour is such a great way to outsmart that addictive persona. I mean, it’s really so dumb, so stupid, to just want to do it again and again. Humour seems to jump up in the air and distract you from that rut, like an act in a very cool circus, like Cirque de Soleil. When your attention comes back to earth, it’s different: light-hearted and wise at the same time.

  2. Chinagrrrl February 12, 2013 at 7:16 am #

    I very much look forward to hearing more about this dorsal striatum and its tightening effect. I know I have been having difficulty in my own work describing the “full-metal jacket” assault on the fascia tissue in my body when I attempt to write on how the compulsive nature of addiction takes over my will. Ten years later and I still break out in a cold sweat when I think of how addiction took over me body and soul, and turned me into something more like a machine with one prerogative. Get and use more drugs: At all costs.

    • Marc February 15, 2013 at 5:30 pm #

      Hello you! The reference to Pavlov’s dog wasn’t metaphorical. The dorsal striatum or “caudate nucleus” is much more involved than the ventral striatum once a behaviour sequence is deeply learned. Once it is, the cue just triggers the behaviour. The system is no longer on the lookout for reward….it no longer evaluates whether the act is worth it or not. In other words, Pavlovian conditioning has commandeered your brain, and good old operant (Skinnerian) conditioning (you think that was mechanical? Watch this!) becomes nested within it.

      In still other words, Pavlov’s dog might have been the wrong poster child. His response was just to salivate, which is reflexive and very simple. In fact, long sequences of behaviour — learned, not innate — can be triggered in Pavlovian conditioning. This is certainly the case in obsessive-compulsive disorder (OCD). The main thing is that the stimulus (the bell, in the dog’s case) is directly linked to a response sequence. Hence the sense of acting like a machine. That’s exactly what you’re acting like. And yet…you’re still not quite a machine.

      More soon….

  3. Elizabeth February 12, 2013 at 8:57 am #

    I’m a big fan of this characterization! Yay! Thanks for posting!

    I’ve often thought that in my own recovery, working to break down the compulsive, “habit like” response by trying to delay engaging, or becoming an “observer” of my engagement through mindfulness-based practices, worked on this aspect of addiction. By becoming more aware of what I was doing, I was able to start to see how cues may be involved in triggering the compulsion. I also think I was starting to recruit the more ventral parts of my striatum again. I started to be able to evaluate the “value” or potential outcomes of what I was doing. Over time, I could decide whether engaging in my “addiction” was worth it or not, eventually leading to being able to stop behaviors whenever there is that nervous, anxiety-like twinge to start.

    • Marc February 15, 2013 at 5:51 pm #

      Very interesting!! I don’t know whether the ventral striatum changes teams quite like that. My thought is that it becomes virtually a slave of the dorsal striatum. I actually found this idea (as I interpret it) in the paper you sent me by Belin et al, 2008 (Parallel and interactive learning processes within the basal ganglia: Relevance for the understanding of addiction). For example:

      ” [the dorsal striatum receives…] inputs from the sensorimotor and associative cortex [16], and its dopamine innervation, [and] supports habitual, or stimulus-response, learning mechanisms.

      “These parallel systems involve some overlap between the neurobiological structures that mediate Pavlovian and instrumental learning mechanisms. Pavlovian and instrumental learning mechanisms mainly overlap through the [nucleus accumbens) and its dopamine innervation. Thus the [accumbens] provides Pavlovian control over instrumental responding, a function that is consistent with its earlier suggested role as an interface between emotion and action…”

      Have to read more and get back to you.

      But the point about mindfulness and “evaluation” is well taken! It’s really powerful to think about mindfulness as a way to get in between the cue and the compulsive act…a moment to slow down and actually insert some insight into an otherwise mechanical process.

      • Elizabeth February 15, 2013 at 6:08 pm #

        Honestly, my interpretation of the effects of mindfulness are completely speculative. To my knowledge, I don’t think anyone has looked into whether mindfulness practice during engagement with habits will, over time, result in a downward shift to more ventral parts of the striatum and reverse the “ventral dorsal” shift that occurs over long-term substance use. I know that there is evidence that changes in receptor levels can recover over periods of protracted abstinence in the striatum. Whether that correlates with changes in compulsive behavior? I don’t know.

        • Marc February 17, 2013 at 6:58 pm #

          So…let’s keep speculating! I just found the following:

          “Many neurons in the basal ganglia begin to show activity before movement actually takes place. These have been termed “getting set cells.””

          This reference is to the caudate, the dorsal striatum. My question: is the caudate only involved in overlearned behaviour? Is it completely divorced from operant learning? It doesn’t seem to receive direct projections from the amygdala, whereas the ventral striatum certainly does. So…continuing to think speculatively, where does the dorsal striatum get its emotional charge? If it is not linked to the anticipation of reward, then perhaps its only emotional stake is in the blockage of (compulsive) behaviour….

          This is only too well known to people with OCD. It’s when you are blocked in your ritualistic outputs that you start to get really upset. The emotion is certainly anxiety… but where does that come from? What part of your brain starts to panic when you can’t DO the thing you need so badly to do? Does the emotional charge come back through the amg-to-ventral striatum loop? I think it must… Does that point to a potential source of voluntary redirection?

          I’m thinking aloud too, Elizabeth, but if you have any concrete data that applies here, I’d be very grateful!

          • Elizabeth February 18, 2013 at 12:00 am #

            I’ll have to check into this more when I get back into town, but there is some speculation that, when drug use is compulsive, the Amygdala (specifically central nucleus) may be more involved in negative affective states and may influence the activity of the Substantia Nigra. The dopaminergic projections from here feed forward to the striatum and encourage habitual behavior, especially in negative affective/stress states. I heard about this from a short course I took with George Koob. I’m sure there is some elaboration of this theory under his name. So, yes, there must be some emotional connection there via the ventral striatum, but that activity precedes the initiation of habitual behavior?

  4. Janet February 12, 2013 at 10:17 am #

    I wish I’d known about the “compulsion” when my beloved son was going to places, both actual and emotional, that I just simply couldn’t understand. I have learned so much. Especially through all of you here. When I stopped trying to understand through my own brain which was full of my own “compulsions” as a desperate parent, I got better. I am no longer afraid of the things I can’t understand. And a deeper understanding and peace has grown from that on it’s own. Like new soil.

    • Marc February 15, 2013 at 5:55 pm #

      Hi Janet.

      What we are learning about brain-based emotional processes should help us understand many of the mysteries — and patent absurdities — of being human. Addiction is a big one, but it’s not the only one.

      That’s one reason why I love brain science. It’s not that there’s no dogma involved, but whatever axe one might have to grind soon fades to insignificance in the flood of new knowledge.

      • Janet February 15, 2013 at 6:39 pm #

        You are so brilliantly correct. I have never “used” in my life but I have walked that “worn path” as much as anyone. And everyone.
        Thank you, Marc. This human experience is shared. For sure. Janet

  5. peter sheath February 12, 2013 at 12:10 pm #

    Hi Marc
    As always great post and it resonates so well with me and my experiences. As I have mentioned before there does seem to be a mental health continuum with lots of overlaps and very similar symptomatology. I don’t know if you have come across Daniel Seigel? I’m just reading his book mindsight, transform your brain with the new science of kindness. He talks about “windows of tollerance”, which throughout life become dominated by chaos and rigidity and subsequently shrink to a point whereby our whole world becomes tiny and fraught with difficulty. In an effort to deal with the chaotic situations we find ourselves in we surround ourselves with the rigidity of obsession and compulsion.
    He uses a mnenomic FACES to describe how we need to work to reprogramme ourselves; Flexibility, Adaptability, Cohesiveness, Energised and Stability, and thereby widen our “window of tollerance.”

    • Marc February 13, 2013 at 4:15 pm #

      Hi Peter. I read an earlier book of his, The Developing Mind, in which he shows how problems with attachment lead to all kinds of serious emotional endgames. I also met him one evening in Los Angeles…..he’s a smart guy with a real dedication to linking neuroscience, developmental psychology, and clinical practice. I admire him.

      The core idea you mention strikes the chord. The chaotic, unpredictable jabs of everyday life do seem to send us scurrying back to our rigid ruts of safety — however ineffective they may be. This seems to get at the same paradox I’ve been trying to capture in the last couple of posts. I think Shaun nailed it when he said: addiction is like coming back to the same well-worn path again and again whenever you get lost in a field of tall grass (part way down in the comments on this page:

      We are blind men, but we are somehow finally coming to see the elephant.

  6. John Hill February 12, 2013 at 6:00 pm #

    Dear Marc:

    Thank you so much for all the fine work you have done. Your clear and bravely honest approach to addiction is, I am sure, of immense help and comfort to many people.

    It is so important to have accurate information to help dispel the prevailing general atmosphere of ignorance, fear and prejudice about addiction in our society Thank you for providing hope, and new tools and insights, to help the millions of people still struggling and suffering and dying from addictions – and all the people they affect (i.e. all the rest of us).

    You are doing what I should have done (and often thought of doing) myself – writing up your own experiences and adding the results of your research – and, most importantly, got the message out to people effectively.

    I would just like to add that all your major observations have the ring of truth to me, and help confirm my own observations and findings after almost 40 years of work and research in the field.

    Congratulations, and thanks again!

    John Hill

    • Marc February 13, 2013 at 3:47 pm #

      Thank you very much, John. Your words make me feel confident in what I’m doing, and that is (for me) a very helpful, very important, echo back from the virtual unknown. The “ring of truth” is especially helpful, because, if it didn’t have that, my writing would be another shot in the dark. We are all trying to find answers, and there’s just no roadmap worth relying on. So…thanks for helping to light up the terrain. This is clearly a communal effort.

  7. AnonymousRon February 13, 2013 at 1:23 am #

    Hi Marc,

    Great piece.

    I have lost touch with you again for a while. New email(again). The “From the Federal Marshalls to the statistics exam guy” has become the Working Classic Guy.

    Glad to be back in the loop again.

    Great things going with the SMART Recovery Group. Would love to share or put you in touch with my mentors for insight into the program.

    Ron Henderson

    • Marc February 15, 2013 at 5:58 pm #

      Hi Ron. Nice to hear from you! It sounds like your feet are on the ground and you’re involved in some exciting stuff. It is always good to hear what’s going on in SMART recovery. Please do share whatever is relevant, as we forge onward and upward. Cheers, Marc

  8. Nicolas Ruf February 13, 2013 at 9:57 am #

    Agree 100%. That switch hits the ‘save’ button setting for the behavior. Now there’s no need for amygdala or NAcc input. The whole program is remembered and triggered by reintroduction of the substance or behavior, cue, or stress and acquires a life of its own.

    • Marc February 13, 2013 at 11:46 am #

      Well said! My battery is at 3% so I’ll leave it at that. Who knew that the Swiss have their own style electric socket?

    • Marc February 15, 2013 at 6:00 pm #

      P.S. Of course the Swiss have an adaptor, available at the front desk. This whole country has a reputation for being adaptive. Nice place to visit…

  9. Megan February 13, 2013 at 1:34 pm #

    Great post, as always! You have found a way to resonate with my life once again. I am currently enrolled in a Biological Foundations of Psychology class…which I love! I read this yesterday, and today the topic of compulsive behaviors came up in my class discussion. I have mentioned you, your book, and your work numerous times in this class. (I’m hoping some of my fellow classmates will catch on and buy your book!) Anyway, we were discussing the possibility of baclofen being used to treat addiction, and it’s potential for reducing or eliminating compulsive thoughts and behaviors in addicts.

    Sometimes I find it hard to discuss the idea of compulsive behaviors with people who have never dealt with addiction. They can’t possibly comprehend how someone could lose themselves to an addiction so badly that they are no longer in control of their thoughts and behaviors. I have not told my class that I have a recovering addict. I’m sure some have picked up on it, but I am afraid that they will disregard my 5 years sober and only hear the part about my addiction. I am interested in becoming a certified drug and alcohol counselor, and I tell them my passion stems from a lot of personal experiences involving close friends and family. It’s a shame I still live in fear of being labeled an addict, I wonder if I’ll ever come to terms with it.

    Thanks again for encouraging me with your words,

    • Marc February 17, 2013 at 7:23 pm #

      HI Megan. I lived with that fear for at least 10 years. I had made it to tenured assistant professor and was in the final stages of clinical certification….and still waiting to get nailed.

      I never did get nailed. As time went on, I got more and more respect for the distance I’d travelled: from where I’d been to where I’d gotten to. People became increasingly willing to listen. I was finding a way to make use of my experience to become a better clinician and even a better theorist. After a while, I no longer had to hide it. It became a part of my CV, so to speak. You’ll see: it’s probably already starting to happen.

      Regarding baclofen: I’m just starting to understand the drug and the controversy surrounding it. It’s just another GABA agonist…so what’s the big deal? It calms you down. So do the benzodiazepines. It reduces cravings and withdrawal symptoms. So do the benzodiazepines. It appears to be less addictive in itself than the benzos — but nobody knows for sure because nobody is doing the definitive research. Why? Because the drug companies don’t have any profit to gain from a drug that’s been off-patent for ages already. So psychiatrists — who generally play it safe for good, conscientious reasons — but, I think, for narrow selfish reasons as well — don’t want to prescribe it for alcoholics/addicts. Even though the ravages of end-stage alcoholism/addiction are so damn obvious. It’s a bit of a mess.

      You’ve now got dual citizenship. You “get it” so much more deeply than your colleagues. That knowledge will set you apart. And you’ll start to use it as it becomes safe and comfortable to do so. No need to hurry…

  10. Jeff Skinner February 13, 2013 at 2:19 pm #

    This is precisely the thing which most citizens can’t understand about addiction: The state where the will is overpowered by compulsion. It is nowhere in their frame of reference.

    The monkey on the back is a very good metaphor. You just have to remember that the monkey in question is not some cute, Curious George Disney monkey. It is a 200 lb fury with sharp teeth and claws a ravening craving for drugs and no respect for civilization,

  11. nik February 13, 2013 at 3:45 pm #

    I think the term ‘compulsion’ has many meanings, one of which is focussed on by Marc. “overpowering desire or urge”. one that ‘compels’ one, irresistibly to do something.

    Just speaking as a ‘behavioral addict’ (in the area of sex), I don’t think those occasions are, for me, key to my ‘disease.’ In particular, I don’t find most ‘actings out’ are preceded by such overpowering desires. Indeed, lots of incidents happen with minimal desire.

    Perhaps the ‘overpowering urge’ does fit the chemical dependencies and alcoholism. If so, assimilating the broader categories of addictions/compulsions may be a mistake. There is, in addition, some reason to doubt that moments of ‘overpowering desire’ are key (at least for some chemical dependencies), even in these instances, though I have no first hand experience. As
    Charles Bukowski once said,

    “That’s the problem with drinking, I thought, as I poured myself a drink. If something bad happens you drink in an attempt to forget; if something good happens you drink in order to celebrate; and if nothing happens you drink to make something happen.”

    Another piece of evidence:

    [B] Heroin in Vietnam: The Robins Study [/B]

    Origins of the Disease Model of Addiction (Part 2).

    ///In 1971, under the direction of Dr. Jerome Jaffe of the Special Action Office on Drug Abuse Prevention, Dr. Lee Robins of Washington University in St. Louis undertook an investigation of heroin use among young American servicemen in Vietnam. Nothing about addiction research would ever be quite the same after the Robins study. The results of the Robins investigation turned the official story of heroin completely upside down.

    The dirty secret that Robins laid bare was that a staggering number of Vietnam veterans were returning to the U.S. addicted to heroin and morphine. […]

    After she had worked up the interviews, Dr. Robins, who died in 2009, found that almost half—45 per cent—had used either opium or heroin at least once during their tour of duty. 11 per cent had tested positive for opiates on the way out of Vietnam. Overall, about 20 per cent reported that they had been addicted to heroin at some point during their term of service overseas.[…]

    “Perhaps our most remarkable finding,” Robins later noted, “was that only 5% of the men who became addicted in Vietnam relapsed within 10 months after return, and only 12% relapsed even briefly within three years.” What accounted for this surprisingly high recovery rate from heroin, thought to be the most addictive drug of all? As is turned out, treatment and/or institutional rehabilitation didn’t make the difference: Heroin addiction treatment was close to nonexistent in the 1970s, anyway. “Most Vietnam addicts were not even detoxified while in service, and only a tiny percentage were treated after return,” Robins reported. It wasn’t solely a matter of easier access, either, since roughly half of those addicted in Vietnam had tried smack at least once after returning home. But very few of them stayed permanently readdicted. ///

    I think in a broad sense a ‘compulsion’ or addiction is a self destructive pattern, which one is ‘stuck in’. This ‘stuckness’ is complex and determined by both internal and situational factors. It’s a feature of the whole. Some of the internal factors are not seeing or trying alternatives. Others may be loneliness, anxiety, despair over life’s meaninglessness. Situational factors includes thing like what one’s friends are doing, available avenues and alternatives. In a word, in my opinion, the ‘stuckness’, resistance to change, is not to be explained by simply looking at individual occurrences and the accompanying desires and subjective states.

    The ‘grip’ of the pattern is not, in my opinion, primarily based on the person’s being, in most moments of acting, in the terrible grip of an overpowering desire experienced as absolutely compelling, although we have all had moments when this is certainly the case. I think there is much evidence, in Marc’s fine memoir that the above holistic approach is plausible, notwithstanding the desperate moments he’s now highlighting. But perhaps I misread him.

    • Marc February 18, 2013 at 11:10 am #

      Yes, Nik, I agree that there is a “whole pattern” that addiction is often a part of. Even if the pattern is almost solely built around the addiction itself — as in the case of living on the street — there is still the pattern, the context, the cast of characters, etc, etc. That was the big lesson with Vietnam vets.

      But I still think that compulsive urges can be a lynchpin in that pattern, even for, maybe especially for, behavioural addictions. Many people with eating disorders describe their addictive eating (and/or purging) as the epitome of compulsion.

      I wouldn’t necessarily call compulsion desire, either. Desire is the province of the ventral striatum. Compulsive behavioural urges are generated by the dorsal striatum. The proof of that pudding is that you feel very little emotion as long as the behaviour is allowed to be actualized. It’s only when the behaviour is blocked that you start to feel something, and what you feel is anxiety…..maybe lots of it. This is not the same as attraction/desire.

      I see compulsive eating in my 6-year-old, Ruben. He is a healthy normal kid, but like many little boys, he hardly tastes his food. He just wolfes it down. The only emotion he shows is when you try to stop him: Ruben! Finish swallowing before you take another bite! etc…

      The anxiety of not completing the act is no different than that of the OCD person who is blocked from his or her ritual. All thanks to the automaticity of the dorsal striatum.

      Does any of that sound familiar?

  12. MB February 15, 2013 at 9:42 pm #

    Hi Marc,

    I came to this blog by way of a comment you left under my post on a blog where I spoke of my 20 year old recovering addict son’s positive experiences with NA despite his intellectual rejection of some of NA’s basic tenets. He is an atheist who does NOT believe in the addiction = disease premise and does not believe he’s powerless over drugs, but that drugs are very powerful and best avoided.

    The progression from impulsive to compulsive behavior as a critical component of addiction has intrigued me because my other, older son experienced onset of OCD when he was around 19 years old. He experienced very significant cycles over a 2 year period, and lapsed into a major depressive episode at the prospect of living as an OCD sufferer. He was attending one of our country’s finest universities in Chicago, so lived away from us. We could only wring our hands and offer support and suggestions when he sought them. I helped him find a therapist, but it was really my son’s research into and vigilant application of CBT techniques over a 2 year period that helped him achieve a reasonable and enjoyable level of functioning.

    When my younger son became an addict at just about the same age (he also lived away from us at university), the possibility of a connection hit me like bricks. This son seemed an unlikely candidate to become an addict. He was the child who could delay gratification for seemingly impossible lengths of time. We joked through his childhood and adolescence that in an earlier age, he would have been an ascetic and that perhaps we might buy him a hair shirt and whip for his birthday.

    What happened? Was there a late adolescent shift in brain chemistry or was there a latent expression of some pre-existing abnormal wiring/chemistry for both of my sons? I have read that imaging of the anterior cingulate cortex and orbitofrontal cortex differ significantly in a neutral or non-stimulus state. They are hypoactive in the addict and hyperactive in the OCD sufferer, but when provoked they are abnormally hyperactive in both. Are my sons expressing similar (compulsive) responses to a differing, structural brain abnormality?

    Interestingly, my older son describes his OCD as something always present, like a muted buzzing in the back of his brain. During times of stress at work or in relationships, it becomes emboldened and tries to emerge, but he redoubles his techniques and returns it to its little spot in the recesses of his brain. My younger son is still in early recovery (6 months), and this is a topic we have not discussed, but I wonder if that’s what his addiction feels like or will feel like (if he stays in recovery).



  13. nik February 16, 2013 at 1:34 pm #

    Fascinating stuff, MB, about the links of OCD and addiction. “Compulsion” in the sense of *having* to get things, just right, obsession with detail– **having** to stick to an exact pattern. This ‘porn addict’ has been known to spend a couple hours retouching a photo.

    It might be mentioned that the substance of many 12 step meetings, is reading exact wordings (scripts), which in some cases make sense–as legal disclaimers, injunctions to confidentiality, etc. But in other cases seem like pure OCD. For example, there was a newcomer at a meeting, and the chairperson was looking for the ‘welcome’ message–to be read word for word. Some of us just said, “welcome to the meeting.’

    Other parts of a greeting could, of course, be stated loosely, such as ‘come to a few meeting before you make up your mind.’ But there is an official script that says the exact words, and specifies 4-6 meetings, etc.

    This all raises the interesting idea of ‘counter compulsions’ that one might learn to counteract those connected with harmful substances. Indeed, perhaps there is a reason, in many cases, NOT to pursue some ‘therapeutic’ goal of health or flexibility, but rather simply to insure that a ‘compulsive’ or inflexible connection with a harmful substance or activity is replaced by a compulsive pattern w/o ill effects, say (I am not making this up), of attending 10, 12 -Step meetings per week. And of course in this case, the presence of social connections, replacing connections with despairing abusers is an added plus.

  14. MB February 18, 2013 at 10:42 am #


    Replacing undesirable activities with other, more acceptable or beneficial activities is not confined to addicts or people with compulsions. We all do it. We are trained to do it from an early age. Your kid picks his nose and you hand him a tissue or your kid reaches for a cookie and you hand her an apple as a substitute. You experience intense anger but instead of punching the wall you strap on your running shoes and hit the street for a run.

    We all *know* that we can retrain our brains and make an end-run around an undesirable action by hopping on a different neural path. Humans have been doing this since the inception. Sometimes it takes more conscious effort than simply moving your hand toward the celery instead of the cake, particularly when the choice is taking the benzo in someone’s outstretched hand or walking out the door. you need to be fully aware and mindful because the alternative is not a tangible item you can grab, feel, chew – it’s the absence of a pleasurable experience. But if you are in touch with all the sensations stored in your memory, it’s also the
    negation of a desperately painful path that led you to lose friends, commit a felony and lie.

    My son currently attends ~10 meetings a week, so I suppose he is compulsively substituting one activity for another. I don’t expect he’ll attend this many meetings for the rest of his life. The bulk of folks in long-term recovery I’ve spoken to tapered off over time. Here’s the thing – it doesn’t bother me because my son is not an “automaton,” which I’ve noticed is a term that some people ascribe to the NA program and its adherents. We are a family of true skeptics. My husband and I were raised atheists. He grew up in Berkeley, CA and I was raised in a working class family that was paradoxically anti-union and libertarian. We raised our children to question every thing and accept nothing at face value. My sons are particularly skeptical, but they are also receptive to ferreting out the “positive” attributes in concepts that may be antithetical to their attitudes and beliefs. My son cherry picks at NA, and where we live, NA allows him to choose the fruit.

    So, what does he get from NA? Well, attending a meeting and socializing with the group members at the local diner or coffee shop after is an alternative to taking a cash advance on the maxed out credit card and then texting the dealer for your next hit. Seeing newcomers’ faces etched with arrogance, pain, sorrow or confusion reminds you both of where you were and how far you’ve come. Sharing a relevant story gives you the chance to help another, but also stimulates introspection as you relay that life event. Looking down the road, he’s built a strong network of long-time recovering addicts who will be there to help divert him should he start walking down that other path.

    As for strictly following the traditions, my work experiences and my associations with all-volunteer groups tell me that an organization can devolve or dissipate quickly without a strong structure. I would guess an all volunteer organization of addicts might be even more challenged without a strong structure. (Ouch – is that insensitive?)

    I know that NA doesn’t work for everyone, but I am grateful that it is beneficial for my son. Peace…!

    • Marc February 25, 2013 at 4:13 am #

      Hi MB. Welcome to the blog. Tonight I am to give a lecture to medical students on addiction. Actually I’m sharing the podium with a psychiatric researcher/clinician — i.e., a doctor — and we plan to have a debate about whether addiction should be classed as a disease or not. You can imagine who’s taking which side.

      I want to use the first two paragraphs of your comment, above, as an argument as to why addictive choices are not qualitatively different from the other choice points we constantly grapple with in our lives. It’s hard to imagine how giving in to impulses can be classed as a disease unless we include cookies vs. celery in the equation.


      But when it comes to compulsions, the argument is more challenging. My six-year old gobbles his food compulsively, despite all arguments and reason, and I don’t see that as a disease. But your story of your two sons both succumbing to different forms of compulsive behaviour problems at the same age — that does have the ring of a biologically prespecified condition, which can be seen as something like a disease, or at least a “disorder”.

      I also see the parallel you mention between the two boys as being very significant. And there’s no doubt that compulsivity figures largely in both your sons’ developmental struggles. That could mean that both have a tendency for learning (conditioning) to shift in style from operant to Pavlovian when it comes to powerful rewards/concerns — which means that, after a while, you do things because of the potency of a stimulus to evoke behaviour, rather than because of the expectancy of a reward (or the avoidance of a negative outcome). This does indeed involve pathways in the striatum, as I’ve written about. But whether these can be construed as variants of a disease? I’m still not comfortable with that.

      What you say about the OFC and anterior cingulate is true. But all it basically means is that these brain regions, very involved with anticipation and planning, are underactive when there’s nothing on the radar — which is the case for addicts when the substance is not present or potentially present. For the OCD sufferer, of course, there is always something on the radar, hence the ongoing hyperactivation.

      Thanks for this very thoughtful contribution, and good luck to both your sons.

  15. MB February 25, 2013 at 8:46 am #

    Thank you for your response. I’m delighted at the prospect of your using my first two paragraphs in your lecture. I had the opportunity to see our OCD suffering son this weekend in Northern Ohio, which is the midpoint between our homes. I mentioned this blog and some reading I had done suggesting a possible connection between OCD and addiction. Interestingly, he told me that conversing about his OCD would cause it to “spike.”

    I panicked a bit and expressed concern and dismay that I may have triggered a cycle. He assured me that he would be okay. He would apply his different techniques and manage it. He tells me that he challenges himself with certain thoughts periodically to “practice” managing his OCD.

    Just a couple of days prior, I had spoken with my addicted son about why he was so quiet about picking up his 6 month key tag. He went up to his room and brought down one of the tags he had picked up during the week for me to keep. He told me that he was low key about the 6 months because he had learned from other addicts with many years of recovery that their clean time anniversaries trigger thoughts of using. For these 10, 15 and 20 year clean addicts, conversation at meetings or among family and friends about the impending anniversary stimulates thoughts that they may not have had for the other 11 months of the year. My son finds that evidence enough for practicing the “just for today” philosophy, because today it is a “space” that he finds easier to manage.

    Both sons are actively managing their minds to just stay afloat in this world. Thank you for your well wishes.

    • Marc March 6, 2013 at 12:41 pm #

      Wow, these observations are compelling and disconcerting. I can imagine what your OCD son might be experiencing. Once you are hypersensitive to certain cues, and then cues relating to those cues, it makes sense to build a strategy for keeping your distance. I have heard this from a lot of addicts as well. In fact, I’ve gotten emails from people saying they couldn’t read much of my book because of the associations it induced.

      The point about “anniversaries” is also well taken. But sad. It is like a photographic negative of a “using” cue. I can imagine that as well.

  16. Emilie auto July 6, 2017 at 7:49 am #

    Beautiful man…

  17. Yorkies December 13, 2021 at 9:06 am #

    I mean, it’s really so dumb, so stupid, to just want to do it again and again. Humour seems to jump up in the air and distract you from that rut, like an act in a very cool circus, like Cirque de Soleil.

    • Marc December 20, 2021 at 2:13 pm #

      Distraction is brilliant, Yorkies. Compulsion is quick, totally illogical, intrusive and bull-headed. Distraction is a superb weapon against it.

  18. obedience training December 14, 2021 at 7:45 am #

    By becoming more aware of what I was doing, I was able to start to see how cues may be involved in triggering the compulsion. I also think I was starting to recruit the more ventral parts of my striatum again.

    • Marc December 20, 2021 at 2:17 pm #

      The ventral striatum can propel us toward any goal, quickly and thoughtlessly. That includes the wish to be free.

  19. Snuffle Bowl January 6, 2022 at 7:50 am #

    In still other words, Pavlov’s dog might have been the wrong poster child. His response was just to salivate, which is reflexive and very simple. In fact, long sequences of behaviour — learned, not innate — can be triggered in Pavlovian conditioning.

    • Marc January 7, 2022 at 11:22 am #

      Very good point. I’ve often been bothered that salivation is supposed to epitomize a “behaviour” that becomes (automatically) triggered by cues. I don’t think it’s a behaviour at all, at least not in the normal sense of the word.

      But I think you mean poster puppy….?

  20. prodotti per animali domestici February 25, 2022 at 11:39 am #

    I can imagine what your OCD son might be experiencing. Once you are hypersensitive to certain cues, and then cues relating to those cues, it makes sense to build a strategy for keeping your distance.

  21. pomeranian boo March 4, 2022 at 11:03 am #

    I know that there is evidence that changes in receptor levels can recover over periods of protracted abstinence in the striatum. Whether that correlates with changes in compulsive behavior.

    • Marc March 6, 2022 at 10:57 am #

      I have seen evidence of increased grey matter density in the dorsal PFC and anterior cingulate corresponding with weeks of abstinence. See Connolly, Bell, Foxe, & Garavan. PLOS ONE, vol. 8, 2013. If you have more recent data on cortical or striatal changes corresponding with abstinence, please send me some citations or links. As you see, my familiarity with this literature is seriously dated. Thanks for your contribution.

      You can reach me through the Contact link on the right.

  22. lisa April 16, 2022 at 10:25 am #

    His response was just to salivate, which is reflexive and very simple. In fact, long sequences of behaviour — learned, not innate — can be triggered in Pavlovian conditioning.Cat Breeders

  23. lisa April 23, 2022 at 11:52 am #

    I had spoken with my addicted son about why he was so quiet about picking up his 6-month key tag. He went up to his room and brought down one of the tags he had picked up during the week for me to keep. main coon for sale

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