Hi again. Last post I argued that the growth of addictive behaviour takes place at several scales. A “real-time” scale of minutes or hours, approximately, and a much slower scale that we can properly call “development” — something that takes place over months or years. And perhaps other scales as well.
I realize now, as then, that the picture I painted was not only dense and abstract but also incomplete. I fleshed out the real-time scale, but not the others.
Since most of us have been or still are “addicts,” the real-time scale is probably the most familiar and the most upsetting and frightening to contemplate. Here’s how I summarized it last post:
Attraction leading to craving, leading to pursuit, leading to…a brief period of pleasure or relief, followed by more attraction and craving. In other words, wanting leading to getting, leading finally to loss or emptiness, which leads once more to wanting.
I didn’t cover it last post, but I think there is an even faster scale of addictive cycling, which we particularly see with certain drugs (e.g., cocaine), with binge eating, and probably with gambling. For these addictions, the “reward” is not long-lasting, so the whole cycle of craving, doing, and loss can repeat itself every 10-20 minutes. This may also describe addictive drinking, when the satisfaction of the last drink rapidly fades and the urge for the next one rapidly grows.
We’ve also talked about the rapid brain changes that take place when we are in the clutches of this spiralling pattern — for example the shift from default mode activation to the rapidly rising activation of the ventral striatum (v.s. or nucleus accumbens), fueled by dopamine from the VTA (the ventral tegmental area in the midbrain), and accompanied by lots of action in the prefrontal cortex (PFC, especially orbitofrontal/ventral regions) and the amygdala (that almond-shaped repository of emotional associations).
But what about the developmental scale? That’s where the big picture of addiction gets drawn, first in broad brush strokes and then with the details more and more fleshed out. What changes over months and years, as we become addicts? Does this process really show the same sequence of states we can trace in real time? Do brain changes really follow the same pattern? The answer, I think, is yes, and this is a very important issue.
Many prominent addiction neuroscientists theorize about developmental changes in the brain. And many of them point to those changes as evidence for the argument that addiction is a disease. As you know, I don’t call addiction a disease, but it is like a disease in some ways, and the slow, insidious sequence of brain changes bring us face to face with this perplexing definitional challenge.
So here’s a rough sketch of the developmental changes in brain and mind that take place as we become addicts:
1. At the start, like most other people, we spend a lot of our time in the default mode network, daydreaming, rehearsing things we’d like to say and do, imagining our lives, past and future. In other words, our brains start out “normal,” except that addicts spend more and more time in the default mode, as focused attention gives way to fantasy. Over weeks or months, we find ourselves indulging in fantasies of getting or doing that one special thing. We find ourselves floating away more often on unbidden thoughts — “what if…?” — while we’re supposed to be reading, writing, calculating, buying, selling, or whatever it is.
2. As time goes by, and we keep going back to that special “pastime,” we find that the drugs, drink, food, or gambling isn’t just fun anymore. It’s more than fun. It makes us feel better than we could have felt doing anything else — so it seems. Now the fantasies — the thoughts, memories, images, and stimuli related to our thing of choice — become more and more compelling. They take on unprecedented power to switch our thinking from a daydreaming mode to a highly focused mode, where sharp attention and motivational thrust join forces, and we start to crave and to make plans.
The brain change associated with this stage is called incentive sensitization. Our brains become more and more sensitized to specific cues and reminders that rapidly trigger the incentive to go, do, get, score, acquire…. I’ve written about this in detail elsewhere. In a nutshell, a whole lot of cells in the nucleus accumbens (NAcc, or ventral striatum) are getting more and more strongly linked to the the cells in perceptual (posterior) cortex that represent coke, or sex, or booze, and many of those linkages run right through the amygdala, which records the hot flush of emotional potency that goes with them. Now those specific synapses in the NAcc, and between the NAcc and the prefrontal/orbital cortex, and between the NAcc and the amygdala, start to multiply. Those synapses, those hundreds of millions of connections, are all shouting “cocaine!” or “sex!” or “vodka!” more and more loudly as they grow fatter and stronger — by sucking up the dopamine that was designated for alternative synapses, representing other goals, other wishes, now fading in comparison.
3. The period of increased craving/planning and procuring, of increased desire and demand, may continue to grow for weeks, months and even years, before impulse turns to compulsion. It’s not that I really want to, it’s that I really have to. Now the anticipation of the “drug reward,” or “drink reward,” or whatever, is actually replaced. Now what’s driving our thinking and behaviour is the enormous anxiety of a need that has to be fulfilled. Attraction, anticipation, planning, and behaviour have already been set in motion, and now any doubts or drawbacks feel like temporary obstacles — “temporary” because they have to be overcome. It becomes paramount to complete the behavioural sequence. To leave it hanging feels like being trapped in suspended animation: nowhere else to go, nothing else to do.
The brain changes that takes place when impulsive turns to compulsive have been worked out in animal research, and powerful new models are appearing in the literature. The striatum — whose job it is to initiate behaviour — has a dorsal region and a ventral region, which you can imagine as a northern region and a southern region. The dorsal region is in charge of automatic behaviour sequences triggered by a stimulus. This is not where new learning takes place. Rather it’s where old learning gets packed into habit, and habit gets triggered by cues or stimuli, from inside our heads or from the outside world. As synapses in the dorsal striatum start to become sensitized to addictive cues, they join in a network with the nucleus accumbens/ventral striatum and the amygdala. They suck up additional dopamine — now from another little dopamine factory called the substantia nigra — a factory designed to power behaviour directly, without having to wait for the rest of the brain to come on board.
So you see? There is a direct parallel — a self-similarity — between the developmental changes that take place in the structure of these systems and the real-time progression that takes place as these systems get activated, one after another.
Kinda scary. These brain changes are real, at both scales, and the underlying structural “wiring” may never be completely reversible. But we do have the power to overcome these biological processes, along with the feelings and actions they generate. Next post, I’ll show how self-control, and the brain changes that power it, also evolve with time, changing our lives for the better.
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
“Come to the root of the root of yourself” said Rumi.
(We’re getting to the juicy bits now, Marc, and I am very excited.)
Me too!
Hi Marc
I just love these posts, it really helps bring clarity to my understanding of how it works. When I share your post on my Facebook page I write “Knowing is half the battle” I quit drinking 5 or 6 years ago, I mean, I have a beer with my son on an occasion, but alcohol is do longer part of my daily diet. Having overcome the daily use of alcohol has opened up my mind, it’s like I was starving for input for so long, now I can’t get enough. For me knowledge is power, the power of understanding, and you have played a big part in helping me regain that power. I look forward to your next post…
Thanks Marc
Thanks, Richard. Hey check out the new Guest Memoir I just published. Somehow this person’s recovery reminded me of you — not sure why. It’s a great memoir anyway.
Thank you for shedding more light. It was so over my head before and I thought I just simply couldn’t get the academic aspect of it. Thanks for opening the door wider…
I’m in. Off to read the new memoir.
Marc, EXACTLY!
You have even described the micro-scale I alluded to in a previous comment. What I think is important though, is that at some point along this Macro-Path, we switch a (until research finds it) metaphorical switch, from user/abuser to addict. At this point the using moves from being a means to an end to an end in itself. Or, in different words, from drug use being a “cure” to a symptom to an underlying condition, to drug use becoming the symptom of the new condition: Addiction.
Not everyone will make this transition, but those of us with the right(wrong) genetics, combined with environmental influences(macro and micro) discover, too late, a momentum that pushes us over the edge, into the abyss.
Basically, as the Macro scale moves along, the real-time scale travels through it’s cycle more frequently and the micro scale kicks in on each using occasion with a vengeance second to none.
This has important implications for treatment: First, we need to interrupt the real-time and micro cycles (Think 8 week declines in deltaFosB) – then we need to treat the addiction – the macro scale you talk about – then we need to address the original reasons for drug use. These are not clearly defined stages or “steps” but happen on different overlapping levels and time -frames. There are many ways that this can happen, but I believe that every story of recovery I have heard fits this process in one way or another.
Interestingly, due to learned behaviour, drug expectation etc, even after prolonged abstinence, these cycles are shorter second time round, and shorter third time round etc etc!
My two cents worth!
Thanks, as usual, for the discussion.
Shaun, I agree with much of what you say. There is usually a progression from “self-medication”, by which drugs actually relieve the effects of earlier traumas, to the stage at which drugs themselves BECOME the trauma. So be it. In classical treatment models, they call these “iatrogenic” effects. Please see my post on this: https://www.memoirsofanaddictedbrain.com/connect/self-medication-or-not/
Now if you can get in there and treat the micro-cycles BEFORE things get out of hand, then more power to you (Higher or not). However, as you say, there is a physical, biological momentum that takes hold with repeated substance use. In previous posts I’ve referred to this as “kindling”.
So….you are sort of putting up your therapist’s weapons against the armaments of runaway biology. Not an easy struggle, and hardly an even playing field!
I admire your vision. The pragmatic issue is that you hardly ever see “clients” before they are in the throes of addiction. Because, up until that point, they seem to be handling their torment in the best possible way. It’s only once the developmental structuration starts to change, as a result of addiction, that people lose the edge of their “self-medication”. And by then, it’s not easy to bet on the hand you’ve been dealt.
Yes, you are right. They have already flicked the metaphorical switch in 8/10 cases before they have sought help, and so what I am saying is that we first have to 1) interrupt the micro cycle, 2) then treat this thing called addiction – help create new neural pathways (or strengthen alternative “non-using” ones), reverse the macro process as much as possible and then 3) teach new coping mechanisms or treat the underlying condition to prevent re-initiation.
Where most treatment programs fail is that they only address the first of these, or at best the second, if they are long term.
Aviel Goodman describes these stages as (he has four) 1) behaviour modification, 2) Stabilization, 3) Character Healing 4) Renewal.
Some of us, the majority according to research, manage this outside rehab. Some of us manage this without any outside influence at all. But in some way or another we follow this process.
In terms of the self-medication, although some addicts are clearly self-medicators, many are not, at least not on a conscious level. What causes the initial drug use is usually external to self – more environmental. What causes continued use is usually internal or biological, and this internal engine gathers momentum as we repeat and learn the behaviour.
I find what you say about shame in your “self-medication” post very interesting. In the centre I run we are busy with an analysis of what is and isn’t working. What we are finding is that the therapists dealing with shame are getting the best results. We are going to be taking a closer look at this over the next little while, and hopefully I will have some data to support this position in the near future.
Very interesting. What you say makes a lot of sense. Indeed, many people become addicted without having come from nasty upbringings. And many, as you say most, addicts do manage to recover without formal treatment. These are important factoids. And I suppose they support the notion that addiction is its OWN problem, over top of what ever other problems MAY have helped to generate it.
But your sequence of treatment steps is right on target: start with real-time behaviour, which is most “available” to alter, then move on to the neurocognitive entrenchment at the root of the addiction, and then move on the the personality issues that often — but no always — contributed to the addiction to begin with.
“I would be interested in knowing whilst all this addiction learning is going on in the brain, does it mean other learning is pushed out, or reduced or lost? (You may have talked about this already but I can’t remember).
For example, I sometimes wonder, why i can’t have it all? Why can’t I drink and also be fit and healthy (eating healthy, running for exercise). It seems reasonable to think that my brain is capable of learning good habits alongside my bad ones; but it usually doesn’t seem to work that way. I can’t seem to be both drinking and living a healthy life.
Is there something in the brain chemistry that is being pushed out so that this isn’t possible? (Or is it just me)”
The short answer is “yes”. There is something in brain chemistry that works against “having it all”. Dopamine’s job is to focus the striatum on a single goal. As a result, other goals — competing goals — pale in comparison. That functional story gets transformed into a structural story over months and years. The goals that lose attractiveness in the moment also lose their significance over the lifespan.
The long answer is: read my book! It explains it all, and I think it’s a rather gripping story too. (at least it was for me)
I am stuck with this crazy, dominant image of gears and gear ratios, as seen in a child’s plastic toy. The large gear, representing development, is turned by smaller gears that continually decrease in size. What I’m having trouble with is does the decreasing size of the gears represent diminished time cycling as the addict moves toward and drives deeper into compulsion or is it reversed? Does the increased sized of gears represent the ratio of life’s time spent servicing the addiction? Perhaps it’s bi-directional. And what is the actor – the hand that turns the crank? Is the hand that turns the crank the substance or the brain on substance?
Omigod, I thought I was abstract! There are many ways to see it. I think the simplest way is to say that increasing frequency in the real-time cycle corresponds with more rapid structural changes in the developmental cycle. That’s straightforward. But as to the causal direction? Well it has to go both ways. Structural brain changes, the more advanced they are, will give rise to more rapid cycling in real time. And real-time cycling, the more rapidly it goes, will contribute increasingly to structural brain changes.
I don’t believe there is some kind of cosmic hand/mind behind all this. I just think that the universe works through feedback cycles — at multiple levels of scale. That’s why we see things like repetition, redundancy, self-similarity, fractal geometry, and a host of other phenomena. It’s just the way things work. And…we’re lucky that’s how things work, because life itself is an outcome of this formula.
Sadly, so is addiction.
Marc, I like this post, and I’d like to check with you and see if I’m following you when you write addiction is “like a disease in some ways.” Does this mean that there is a physical substrate to the repeated addictive actions, i.e. brain pathways that give addiction a physical correlate?
Once these pathways are sufficiently established, the person just needs to take a first step along the pathway, and he or she may go zipping down, like going down a slide.
The choice was at the very beginning, but once decided at the top to enter the slide and let go, then the rest takes place (habits, predispositions, etc.). [The AA saying, “The person takes a beer, the beer takes a beer, the beer takes the person.”]
So the addiction has become “like a disease” in that brain and neurological pathways have been established that are real, and predispose the person to an addictive outcome.
George, no, I don’t see it that way. As a neurobiologist, I take it as a given that all cognitive and emotional learning involves physical changes in the brain. That’s just the way it works. That does not mean that one act seals your fate! Although I believe whole-heartedly in biology, I don’t believe in biological determinism.
I think that when you fall head-over-heals in love with someone, your brain changes to the same extent as when you become alcoholic. Why don’t people realize this? Does that mean that love is a disease? Or that once in love you can never stop loving, or start loving someone else? I don’t think so.
No. We have to see, not only how developmental/structural changes in the brain affect our thoughts and our actions, but also how our thoughts and actions affect structural changes in the brain. That is the big picture I’m trying to get across.
Thanks. I’ll chew on this. In other words, it’s not a one-way street!
I was thinking of this, from your Compulsion topic, recent blog:
” 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, whatever 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 see your point, George, and I admit that this is where things can get controversial.
But, granted that compulsive behaviour involves brain change, does that grant us the authority to call compulsive behaviour “diseased”?
Typical three-year-olds will gobble their food, pick their nose, or poo in their diapers long after we think they should stop. Why? Because a stimulus evokes a response that has a power of its own. This was Pavlov’s contribution to learning theory: humans are subject to stimulus-response conditioning. Regardless of any real or perceived reward!
That’s all I’m saying. That’s how the brain is structured. That’s how we are constructed. Biting your fingernails or picking your nose at the age of 4 or 5 is not likely to wreck your life. But compulsively snorting, smoking or shooting cocaine is.
I just don’t know exactly where I would draw the line!
But without understanding this, I don’t think we’ll ever fully understand addiction.
Your two comments are helpful in pointing to the need to distinguish between compulsion, brain pathways, and disease.
Now I’m more curious to learn what you were alluding to when you referred to addiction as “like a disease in some ways.”
Well, nothing too mysterious there. For one thing, a lot of addicts perceive themselves as having a disease because they feel they can’t control it — it has control over them. That corresponds with much of the AA model. Second, the medical/psychiatric community has DEFINED addiction as a disease. Though I don’t see it that way, those people are not idiots. They are tracking biological changes that may be irreversible, and, if you’re medically minded, that smacks of disease. Third — check the Net. There’s a huge amount out there about addiction as a disease: the hijacked brain model, etc, etc. And last, addiction really is hard to get rid of. Um, that’s why it’s called addiction. But in that sense it does seem LIKE a disease — even to me.
Thanks, Mark, for identifying key disease related characteristics.
Your posts are continually informative, as well as the subsequent discussion.
Will be particularly interested in the posts you will be sending when you attend the Dalai Lama meeting.
I’m currently attending classes at Berkeley’s Dharma College on Buddhist related approaches to how the mind works.
I’ve shared some of your postings with fellow classmates, since the ideas often dovetail.
Here’s link: http://www.dharma-college.com
Marc,
As a casual reader of your blog, I initially read it out of general curiosity. These last sequences of dialogue have tipped me onto my rapidly increasing dependence on wine
Now I m going to take steps to supplant that stimuli with an innocuous but enjoyable substance like mineral water.
Mary.
Here’s my take on this from a meta-perspective: humans, like all animals, come into the world with certain “wiring” or predispositions or instincts, whatever you want to call that which evolution has bred into us so that we have a shot at surviving. For humans, that means not just getting food, safety and mates, but above all fitting into a group. Since civilization has gotten so big and complicated, fitting in has too.
Ideally, our neurochemicals serve to give us rewards when we are successful in functioning within our group, when we are approved of, accepted and loved. But if the environment we find ourselves in isn’t ideal and we don’t get what our wiring drives us to seek, we’re left craving something we don’t even know how to look for.
Meanwhile, our more primitive reward systems are still there, the ones that respond to various “highs” from substances (including foods) and/or behaviors, things that make us feel good for the moment. So, in the absence of an experience of getting the more desired societal approval (which we also experience as self-esteem), we are left extremely vulnerable to “getting high.” Once that gets going, it is self-reinforcing. The more we do it, the less we pursue more productive avenues and we move farther and farther away from that which evolution has actually designed us to seek.
When damage starts to result, people come into treatment or others recognize that there’s a problem. But I think most of us muddle through at some level of less than optimal development, maybe not ever causing serious enough damage to recognize or seek help or not having access to it even if we wanted to.
And there are a million ways to fail or lose one’s way along the path of “ideal” development. By ideal I mean without ever engaging in some sort of counterproductive, self-defeating, damaging “feel good” activity whether that includes substances or just behaviors.
So all this talk about what’s an addiction and how to “treat” it sounds somewhat misleading to me, Granted, what you are calling “addictions” can and do cause all kinds of damage including death. I have engaged in some pretty seriously myself. But the way I see my own path is that I faced some very difficult challenges growing up and did not have the tools to meet them head on. I fell into some long and winding detours but always somehow figured there was some rhyme and reason to my struggles. I never wanted to accept the label of addiction because that seemed to negate what was really going on. I was just trying to grow up, plain and simple.
My neurochemicals were still driving my behavior but what they were meant to drive me towards is everything we call growing up or maturing. I can’t say I’ve got it all figured out but it has helped immensely to focus on what I’m trying to go towards, finding people, ideas, situations, etc., which support me going in that direction rather than focusing on having an addiction and how do I get rid or over it. I get over it by growing up and along the way I try to minimize the damage.
I love this discussion and your providing the forum and open mindedness, thanks Marc!