Understanding Addiction

Hi from Hungary. I’m at a conference on behavioral addictions. Two days of talks by experts — psychologists, neuroscientists, psychiatrists, clinical researchers, etc. — who want to understand behavioral addictions. These include compulsive gambling, eating disorders, hypersexuality or sex addiction, and internet or gaming addiction.  And I am really high on the flood of information, insight, commitment and good intentions, knowledge, creativity, blah blah blah, not to mention that I happen to be in Budapest, which looks like a magical kingdom from some angles and a Communist-bloc relic from others.

I knew so little about Hungary, I actually forgot the name of my destination when checking in for my flight in Amsterdam. I was standing at one of those automatic check-in terminals, had entered my passport information, and then when the prompt asked me for the first three letters of my destination, I blanked out. I asked the guy next to me, which was kind of embarrassing as he was deep in a conversation with someone else: What’s the capital of Hungary? He thought about it for awhile and then said “Bucarest”. I typed in BUC, and then realized that’s where my wife, Isabel, was born — and she’s Romanian, not Hungarian. It finally came:

Budapest

Coming in from the airport by cab, we crossed into another dimension. Mile after mile of hulking, dilapidated rectangular buildings, looking like they were last used 70 years ago to make bomb parts for the war. There was this stale ghost of leftover Communism everywhere. Everything looked shut down, grey slabs of concrete under a grey sky. This was Budapest?

My first surprise came when the driver demanded 5,450 for the ride. What? This could be trouble. But it turned out that 5,450 whatevers translated to 20 euros. Whew.  My next surprise was how beautiful the inner city turned out to be. At some invisible line the Communist-era shabbiness rolled back to reveal a land of Oz: Enormous but gorgeous monuments to a thousand years of changing architecture — churches, castles, museums, fountains — with elaborate arches and elegant turrets, tapering to slender needles pointed at the sky. All connected by wide avenues, full of shoppers, and bridges that appeared to be held up by steel lace. History oozing out of every stone in every facade.

The third surprise was that the talks were so riveting I was hardly tempted by the marvels just outside the door. In two days I learned so much, met so many amazing people, discovered new research strategies, new devices, new recovery tools. For example, today I chatted for an hour with a man named Robert Pretlow, who spent two years — full-time — developing a cell-phone app, and a couple of decades studying child and adult eating disorders. This app (displayed on the right — so far only available for research) lets you chat with other recovering individuals, warns you about addictive triggers, reminds you about your own effective coping strategies, records your progress day by day. It’s like having a treatment centre in your pocket. Dr. Pretlow is using it to study eating disorders, but it seems that it could be applied to many other addictive problems as well. Bob agrees, but there is a lot of work to be done.

I learned about the hidden dangers in sex and gambling. This was not one of those conferences where you have to douse yourself with coffee to keep awake. I learned about the diversity of eating disorders — from binging, which looks a lot like substance addiction, according to Marc N. Potenza at Yale  — to anorexia — which looks more like over-control. A lot of talks focused on OCD, obsessive-compulsive disorder, and quite a few speakers connected the compulsive nature of OCD with that of addiction. People talked about stages in the development of addiction (not far from the stages I listed the last couple of posts), and compared them with stages in the development of OCD. One guy showed how the addictive progression of stages coverged with the OCD progression — starting out in different places but ending up almost completely overlapping.

And these people weren’t just talking about behavior. There were neuroscience data in half the talks. The striatum was the overwhelming star of the show — the ventral striatum and its role in craving, and the dorsal striatum responsible for compulsion. It appears that OCD sufferers talk about their compulsions a lot like addicts talk about their addictions. I don’t want to stop it. I know it’s bad for me, but it makes me feel better. And their brains light up in almost all the same places! In fact, their brains show changes in synaptic density (some areas getting more connected, other areas getting less connected) that look exactly like what you see in addicts, over the same time frame, as they get worse — or better.

In just two days I learned so much, met with so many experts, exchanged email addresses, got books and papers handed to me…enough to keep me busy for quite a while.

And to keep you busy! In the next few posts I’m going to try to synthesize what I’m learning about behavioral addictions — gambling, sex, food, and internet — how they develop, how they stabilize, and most of all how the same or at least overlapping brain changes underlie them all.  And here’s the clincher: I’m going to show you, as I continue to digest it myself, how similar ALL addictions are. When it comes to substance addictions versus behavioural addictions, there’s just not much difference in what the brain is doing.

So, it might seem counterintuitive, but heroin addicts, codependent partners, gaming addicts, and sex addicts are very, very much alike. In other words, you don’t have to be a heroin addict or an alcoholic to wreck your life. You can wreck it just as well by spending 18 hours a day on the internet, while the bills pile up, the unemployment cheques fizzle out (and you didn’t notice), and your wife starts packing, not only her stuff but the kids’ stuff too. You might reply: yeah, sure, but substance addiction can kill you! Behavioral addiction? That’s pretty wimpy in comparison. If you believe that, as I did until yesterday, I’ve got news for you. According to the stats, obesity (a result of food addiction) causes 4 – 5 times more “preventable deaths” in the U.S. than the number caused by alcohol.

The conference just ended. I’m going to go out and check on Budapest now — gaze at statues and absorb some culture. But stay tuned for a deeper look at the core processes underlying  behavioral and substance addictions — in other words all addictions. Coming up next.

Last post I said I’d review schools of psychotherapy that promise to target addiction, and ACT and IFS were at the top of my list. I’ll get to these, but I thought I’d spread the net a bit wider. So I’m starting this series with a look at “psychodynamic” or psychoanalytic psychotherapy. I think the underlying concepts of this tradition are crucial for understanding and overcoming addiction.

Psychoanalysis (think Freud and his followers) is the mother of all psychotherapies. No matter what you’ve heard, no matter how much people scoff at penis envy and other outdated concepts, Freud was a genius. He was the first (as far as I know) to develop a “talking cure” for serious emotional difficulties, and he was the first to bring the idea of unconscious wishes and motives into public parlance. Sure, psychoanalysis — on the couch, four times a week, for fifteen years (?!) — hasn’t lived up to expectations, and I believe it’s correctly pushed aside by more focused, present-tense-oriented, and evidence-based treatment models.

But its offspring, psychodynamic psychology, isn’t so easily ignored. So my goal for this post is to tell you how this approach tends to frame addiction and how it can help, directly or indirectly.

The person who first comes to mind (and to Google) when you put “psychoanalytic” and “addiction” in the same search is Lance Dodes. His 2015 book “The Sober Truth” purports to debunk 12-step methods as riding on bad science. I have mixed feelings about this book. If “Science” with a capital S is to be our lodestone, then psychoanalysis doesn’t look so hot either. But, okay, Dodes is inspiring, he’s developed his methods over decades, he’s come down strongly on “resort” rehabs (great video!) like those spawning in Malibu, California. So I want to touch on his perspective.

This is how Dodes conceptualizes addiction, and it captures core features of the psychodynamic insight:

“[E]very addictive act is preceded by a feeling of helplessness or powerlessness (an overwhelming of the capacity to manage [one’s moods or feelings] without feeling emotionally flooded). Addictive behavior functions to repair this underlying feeling of helplessness. It is able to do this because taking the addictive action (or even deciding to take this action) creates a sense of being empowered, of regaining control over one’s emotional experience and one’s life. This reversal of helplessness may be described as the psychological purpose of addiction.”

Of course we know that this temporary “empowerment” leads to further helplessness, but the initial rush of self-determination is not to be denied. More broadly, psychodynamic approaches always look at present problems in the light of one’s early development. A realistic and increasingly popular spin-off of this position is the emphasis on childhood trauma, most famously highlighted by Gabor Maté, as featured in this clip. Whether a specific trauma is discovered or not, psychodynamic psychotherapy works to get people to rediscover and reinterpret their early struggles. The assumption is that addiction is an ineffective resolution to conflicts and defeats that were never fully accepted or resolved.

There are addiction treatment centres (e.g., Caron Treatment Centers) that expressly tap psychodynamic psychology in their approach. Other organizations combine aspects of psychodynamic psychology with other traditions. Andrew Tatarsky’s Center for Optimal Living in New York offers a harm-reduction approach that has psychodynamic psychology (and thus individual psychotherapy) built into it. I particularly like Tatarsky’s model (I spoke there and met him last June) because it is fundamentally empathic and humanistic, honouring individual differences and working with them.

What’s most interesting to me is how psychodynamic ideas provide a foundation underlying many current schools of psychotherapy. With respect to addiction, ACT and IFS (my favourites — see last post) are all about bringing the past into the present and dealing with it. What seems to be missing from our lives? When did that start? Where does the depression come from? What messages do we repeatedly give ourselves that make us feel hopeless or despicable, so there seems little opportunity for relief except our addiction? Where do contradictory self-statements, like yes, this is what I want and I hate doing this! actually come from?

My own training in psychotherapy was entirely psychodynamic. I learned and practiced with children and adolescents, and my mentors were pretty classical by today’s standards. But what I do now, and what I think most psychotherapists do, is blend different approaches, revising and refining our methods until we find what works best. And what works best appears at the interface of our own personality and knowledge base, our style of connecting with others, and the particular problems (in my case, mostly addiction) that come our way.

The problem with “pure” psychodynamic therapy is that it spends too long reinterpreting past events without connecting them intimately and acutely with current issues. As a result, pure psychodynamic therapy can take too long and never really get to the here-and-now. Yet the here-and-now mustn’t be put off when it comes to addiction. Addiction is self-perpetuating and it involves synaptic changes. Psychodynamic therapy ignores the fact that deep habits are neurally encoded and their momentum doesn’t derive from…any one thing. What’s more, people with addictions are truly miserable. They may live their lives on the cliff edge of self-destruction. So, for me, the psychodynamic approach works best as a platform on which to devise and enrich more direct interventions. Yes, we have to understand where we come from, but mostly as a means for understanding where we’re at now and where we’re going next.

So many of you have asked how it went last night, I thought I’d try to give you my take on it, right here.

In a nutshell, it went very well.

After working for days (sweating, obsessing, etc) on my Powerpoint presentation, Isabel forced me (don’t ask me exactly how) to redo the whole thing yesterday morning before she left for work. Isabel is a really skilled speaker, and she’s developed a style for “inspirational” talks that make intellectual and scientific points digestible, entertaining, accessible, and potent. I’m just a stodgy old academic, so I still tend to put a lot of text on my slides. Trying to make sure I cover everything and include the necessary facts and figures, even at the risk of boring or losing some of my audience. So…I’ve learned enough to do what she says.

It took the whole day, but I finally got it done: a lean, mean, presentation. Slides with few words, mostly titles and bullet points, lots of cool animation, and a step-by-step breakdown of what the “disease model” of addiction gets wrong (in my opinion) and how to adapt/replace it with a more effective way to understand addiction and help those who suffer. I’ve printed all my slides below.

We were almost late and…there was a certain amount of anxiety involved. Parking in a highly questionable spot, racing through the train station to platform 11. Isabel had generously offered to go with me, essentially to hold my hand. I was kind of nervous but not too bad. And somewhat magically, the nervousness just evaporated when we got on the train.

I edited my slides obsessively during the trip, hardly noticed changing trains in Utrecht, and I babbled to myself all the way. What might Nora Volkow say to this, and to that, and did it matter? And how to deliver what I needed to deliver without being overbearing or attacking or…too wimpy.

It was a cold night in Amsterdam, but everything glittered: the magnificent structures of the old city interspersed with modern buildings that were also imaginative and beautiful in their own way. All of it reflected off the canals. We found the venue, about a ten-minute walk from the station: a beautiful and very modern library, and in it a classy theater that could seat about 250. Isabel looked fabulous. I looked dowdy. I guess we averaged out okay.

So…there was Nora Volkow, in the flesh, We had a friendly enough greeting. She was there to receive an honorary PhD from the University of Amsterdam. I asked her how many PhDs she had now. She said she truly didn’t know. She is the most renowned and probably the busiest addiction scientist in the world. She’s earned her stripes. But of course she’s just a person, looking a bit tired and no doubt jet-lagged on this particular night.

By the time we started, the theater was completely packed. She got up on the stage and did her thing: energetic, committed, sure of herself, convinced that neuroscience was the main act when it comes to understanding addiction. She showed some colourful brain MRIs, talked about dopamine a lot, and…well if you want to know more about her message, go to the NIDA website.

One thing that did impress me (and others) was that she talked a bit about recovery from addiction. For many years, the NIDA party line has been that addiction is a chronic brain disease. People don’t recover from chronic diseases. So…maybe that’s progress. Maybe the addiction neuroscientists are starting to listen to our messages about the experience of addiction, its developmental time course, the enormous individual differences in process and outcome, the gradations in levels of intensity…and the very important issue of free will — something that Nora has long claimed gets wiped out by drugs. The hijacked brain. In my talk I emphasized that addicts do not lose their willpower — in fact they have a great deal of it. Rather, they have a hard time making choices that are good for them in the long run. And choice is not a simple thing — for anybody.

Maybe the brain scientists, including Nora Volkow, are tuning into the personal and social and societal foundations of addiction. I hope so, and I hope that those in the “psychosocial” camp start listening to the brain scientists as well. These are all pieces of the same puzzle.

Nora talked for about 20 minutes, then I went up there and did my spiel. It was a good talk. If I was a religious person, I’d say the power moved in me…or something like that. I was hardly conscious of what I was saying. It was that thing they call “flow.” But man, it felt good, because I could tell it was coming out just right, and Isabel sat in the third row and smiled hugely every time we made eye contact. And then, lots of applause — especially for the Dutch — and then a debate between Nora and me with input from a panel of three experts and the audience.

And so on and so forth. I won’t try to capture any more of it for now. The evening was recorded, and I think the talks and debate will all show up on YouTube before long. I’ll let you know.

Meanwhile, here are my slides. I’ve inserted blue arrows to try to give you a sense of what words and images appeared partway through the slides (via animation). I’ve also included some “speech balloons” to approximate the things I said that don’t appear on the slides. A lot is missing, I know. As per Isabel’s instructions, there was less to read and more just to speak.

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.

Several posts ago I started a discussion of “the pivot point” — the moment when we give in to our cravings and dive for the drugs or the booze. I emphasized a few things about this event, many of which resonated with readers’ experiences — in fact many of which came from readers:

-it can begin with a change in your internal dialogue, like my humming to myself in the rat lab, when you already know, without full consciousness, that you’re going to do it

-at the final moment, it feels like you are throwing off control, not just surrender but also triumph

-there is often a feeling of great relief, abandon, or escape from suffocating self-control — one reader called it the sense of free fall

We then discussed the pivot point in more detail, getting into the psychology of ego fatigue and the underlying brain dynamics: the weakening of the will as the anterior cingulate cortex (ACC) runs out of fuel, and the final snapping of the branch. The dialogue concluded with the notion of an 11th commandment: Avoid Temptation. Because you can’t inhibit your impulses, actively, for a very long time. Your brain can’t take the strain.

In this post I want to go a step further and explore the relief that comes at the pivot point. There is still an untapped mystery here. Sure, you’ve been craving, and now you allow yourself to get the thing you’ve been craving. Dopamine feels like desperate desire when the goal is out of reach. But it feels like a headlong rush when you’re suddenly “allowed” to go get it. That’s a part of the relief.

Yet there’s a lot more to it. During periods of self-restraint, there can be an ongoing struggle that often takes the form of an internal dialogue: Don’t do it. No, just stop. But it would be so nice… Stop thinking about it. But I want… Shut up! Just stop! And it can get quite a bit more vicious than that: Stop, you self-indulgent baby. But it’s just one last time. That’s what you always say, you hopeless cretin. So? Everyone’s got their problems. You don’t deserve sympathy.  But I’m so depressed…  No wonder you disgust people. Etc, etc. If you’ve ever heard a (usually unspoken) dialogue  like this, going on in your head, then you’ve probably gotten to the point of saying “Fuck it.” And you know that the relief you get is not only from the drug/drink, or the anticipation of the drug/drink. It’s also the blissful shutting off of that nasty voice of self-rebuke.

Think about it this way: When are you more likely to yell at your kid? When she is playing safely in the playground, or when she’s wandering out into the street? When your kid is approaching an oncoming truck, or a cliff edge, is when you lose it and scream: Stop! Go back! I told you NEVER to do that!

So what’s going on in the brain during this state? Picture your ACC, sitting near the top of the brain, trying to keep control, but finding it slipping, slipping. Two floors down there’s the amygdala, the organ of emotional colouring. As your ACC starts losing it, your amygdala begins to panic. Not only because of the longterm suffering you’re about to contract, but also because the internal “parent-like” voice is getting more and more harsh, nasty, and punitive.

With the ACC losing control and the amygdala responding with waves of anxiety, the two voices in your head, the childish self and the scolding parent, become more desperate, and more desperately at odds with each other. There is no consensus on where internal voices are generated in the brain, but we do know that anger is associated with the left prefrontal cortex (PFC) and fear with the right. The left PFC, being involved in planning, logic, and making sense, has also been associated with moral judgment. The right PFC is more “childish” — it develops rapidly in infancy, before the left — and it’s more closely connected with raw emotion. In fact, some neuroscientists claim that an important job of the left PFC is to regulate the right. That often means inhibiting impulses. So now you’re losing control, the amygdala is blaring anxiety, and the “childish” right hemisphere is being suffocated by the moral authority of the left.  This is no picnic. It’s a major family argument in the privacy of your own brain!

And then comes the pivot point. The ACC is finally too “fatigued” to keep controlling impulses. So here’s what I think happens next:

Without the ACC to help keep the ship on course, the left-based punitive “voice” loses its authority. The right PFC is suddenly free to take the emotional path of least resistance. Left-hemisphere reasoning now switches over to become allied with its old friend, the ventral striatum (the engine of goal-pursuit), which has silently toppled the ACC in terms of cortical supremacy. In fact the whole frontal brain becomes unified behind one exalted goal: LET’S GET HIGH. And the left PFC does its part by planning (its specialty) — how to get it, how to pay for it, how to hide it. The amygdala is suddenly passing along waves of excitement rather than anxiety, and you are cruising, rudderless, in a tide of pure intention.

This kind of brain modelling needs to be verified by research, and we’re just starting to acquire the tools to go there. For example, recent research (in a related model) shows that, when the inner voice of restraint is coming from brain regions that represent other people (not oneself), we stop listening, and we stop acting responsibly.

So there it is: a (speculative) brain-based model of the relief that comes from escaping self-restraint. But I’m not recommending it! (Don’t try this at home, kids.) That relief is real, both psychologically and neurologically, but it is a temporary flash of positive emotion at the start of a long dive into negative emotion. This is part of the siren song, the fool’s gold, of substance use. It doesn’t last long, and it leaves you empty and gasping when it’s gone.

I know this post is a little dense. I wanted to get these ideas down before leaving for the US book tour — in less than two days. But please post your comments or questions, I’ll check in while I’m on the road, and I hope to unpack some of these themes in the near future.