Your Brain and You

Or, to be politically correct, Are you a person with addiction? That, at any rate, is the phrase used in a new Public Policy Statement: Definition of Addiction, put out by the American Society of Addiction Medicine, dated August 15, 2011.

Definitions are supposed to help their recipients correctly apply (and withhold) the defined terms. Since this document runs to eight pages, you might wonder how useful it will be in serving its implied purpose. You would be right to do so: in fact, the Statement itself says that one needs a professional to determine the presence of addiction. (Look in note 2. I’d quote the relevant sentence, but ASAM prohibits excerpting any part of the document without prior permission.)

What the Statement actually is, is an essay that makes many significant claims about addiction. I welcome this statement, because I have long found the concept of addiction to be unclear. What, for example, is the difference between being addicted to something, and just liking it a lot? One occasionally hears the phrase “sex addict”: Can one really be addicted to sex? If one goes to great lengths to obtain it, is one addicted? Or does one just greatly enjoy it? Romeo and Juliet are portrayed as suffering for their love, and as not refraining from expressing it behaviorally even though severe consequences were known to them. Were they addicted to each other?

For all its problems as a definition, the Statement does repay reading, and I encourage readers to do that. But eight pages worth of information is a lot to carry around in one’s head.  Here, I’m going to try to identify, and make a few comments on, the points that I think will be most memorable.

The most important claim comes right at the beginning: Addiction is a disease of certain parts of the brain. The reward system is one of the affected parts, but there are others. This disease of the brain has many effects. Behavior – using a substance or engaging in a behavior such as gambling –  of course, is among them. But other effects include cognitive and emotional ones. Addicts are likely to have different opinions than others about the seriousness of consequences or the causes of their behavior; and they often have unusual emotional reactions.

Here is a limitation of what is offered in the Statement. Parts of it go into considerable detail about some of the neural pathways that may be involved in reward and related functions, identifying connections between several brain areas and specific neurotransmitters. But there is no description of just what kind of difference in the operation of these pathways constitutes the difference between those with addictions and those without. In short, the disease that addiction is said to be is never specified in neural terms.

How, then, do certified professionals identify whether they are dealing with a person with addiction, or not? What makes the subject so complex – the reason why we need certified professionals for diagnoses – is that there is no small set of indicators that are always present.

There are, however, some signs that stand out, to me at least, as particularly important. These are (1) Persistence of a behavior despite accumulation of problems that are due to it. (2) Inability to refrain from a behavior even when undesired consequences of it are acknowledged. (3) Cognitive difficulties in accurately recognizing the relation between a behavior and problems in one’s life.

The classification of addiction as a disease is controversial partly because it forces upon us a question of responsibility. Because the Statement does not identify the nature of the disease in neural terms, it is unlikely to be of much help in resolving that question. Those who incline toward diminished responsibility will point out that one is not responsible for being sick, or for the consequences of having an illness. They may draw comfort from the Statement’s observation that genetic inheritance makes a large contribution to the origin of the disease.

Those oppositely inclined, however, are likely to feel that an addicted person still has control over whether to use a drug, or engage in a behavior, on each particular occasion on which an opportunity presents itself. Being addicted is not being out of control of one’s actions, in the way one would be if one were having a seizure.

In this context, it becomes clear why point (3) is of particular importance. People do not set out to misunderstand. But if they misunderstand the causes of their problems, they will be likely to act in ways that worsen them, or, at the very least, fail to solve them. If being addicted causes false beliefs about the causes of feelings of stress, for example, or causes mistakes in estimating the seriousness of consequences of addictive behavior, then people can be in control of the immediate action of, say, snorting a drug, yet lack the normal resources of reasoning about whether that is something they should do.

It’s as if their brains had a hidden agenda, favoring one set of desires by, in part, hiding from them the ways that satisfying those desires frustrates the satisfaction of other desires.

That kind of failure is disturbing, but we have to face up to it. Clearly recognizing the possibility of cognitive deficit will, I think, affect our attitude toward people with addictions. Even without understanding the underlying neural operations, we can see that admonishment is not well suited to fixing a cognitive problem. A treatment model that aims to restore accurate understanding of causes and consequences seems more appropriate to a condition in which such understanding is impaired, irrespective of how one’s cognitive processes came to be undermined.

[The Statement can be found at http://www.asam.org/DefinitionofAddiction-LongVersion.html .]