By Vera Tarman MD, ABAM
Is addiction a disease or learned behaviour? How about both?
Many people seem to feel that addiction and learned behaviour are two separate entities. The battle between psychologists who use the operant conditioning model and physicians who use a biological model of disease seem to be arguing for different phenomenon of behaviour. However, I contend that they are actually talking about the same behaviour, just using a different language and a different explanation for the same dynamic.
Essentially, the psychological dimension is the behaviour we see (i.e. actions), and the biological is the brain neurology (to execute the action) – in other words, it is the road map behind that action.
The premise behind operatant conditioning is that if you reward behaviour with either positive or negative consequence, you can encourage or discourage behaviour. The bell rings, and the dog, who has already learned the bell means a treat, starts to salivate in anticipation.
Under this model you can learn or extinguish (ie unlearn) behaviour by no longer rewarding that behaviour. Stop giving the treat when the bell rings and the dog will stop salivating. Stop eating sugar whenever you smell the baked goods, and you can walk by the bakery without bolting into the store.
Or you might be able to offer a more powerful reward i.e. connection to community, family, a coveted job, which may be more powerful than the reward of a drug. You may want to baked good, but you actually prefer the allegiance to a community of abstinent supporters.
What is Disease?
Medical doctors call anything that impairs function a disease. Thus learned behaviour can become a disease if the severity of malfunction the learned behaviour has created is high. Or the person has been unable to extinguish or retrain the learned behaviour to a ‘better’ outcome despite repeated attempts.
Note: Any disease (even a testable health conditions such as diabetes) does not have to be reflected by lab tests. A diabetic who is taking their meds or is eating a proper regime may have good sugar control – but they are still affected by the disease of diabetes. Give that diabetic a poor diet and their sugars will soar out of control in a way that would not occur for a non-diabetic. Similarly a food addict. Eat properly and the symptoms are in remission, but give the trigger of sweet and the symptoms revive, sometimes worse than before. The disease is always there, but may be in remission.
What is Addiction?
Addiction: this is a functional definition. Since there is no lab test that can diagnose this, addiction is determined by questions that determine the level of impairment that the obsession / cravings can cause a person. There are lab tests (SPECT scans) to illustrate how one addiction can look like another i.e. cocaine and sugar, but these can not capture the level of severity. That is only done by our questions i.e. history taking.
One easy definition of addiction is the ABAM criteria i.e. the ABCDEs of addiction – the dynamics of addiction (or obsession or strong craving)
Abstain – can you?
Behavioural control – can you control the behaviour?
Craving – how strong is the obsession?
Diminishing the negative consequences – Do you deny the consequences?
Emotional – are emotions are affected in a major way?
Or, you can use the 20 questions (i.e. are you an alcohol, a food addict etc) to measure these attributes or more formally the DSM-V.
We use the DSM-V inventory to determine the gradient from 1 to 12 that determines the severity of the obsession (from mild, moderate or strong addiction) and how it impairs the person in their life, their physical and mental health.
People have levels of addiction – some being addicted but not so impaired and others very impaired.
When Impairment of Learning becomes Disease:
Where people cross the line from being able to control use to no longer having control reflects the level of brain adaption to the exaggerated stimuli (i.e. the drug’s dopamine spike).
We see that some people can eat tons of sugar, suffer extremes of carcinogens and not get diabetes and cancer, while others can not. Some people can retrain their behaviour with better and safer rewards and other can not. How come?
We understand the concept of learned behaviour (stimulus – associations – response) through the concept of neurons that “fire together wire together” (this is how habit is formed) – in the reward pathway of the brain. If behaviour has been rewarded repeatedly and strongly enough (multiple dopamine spike to the Nucleus Accumbens) as with drug use, the pathways are solidified via uptake of receptors, further protein development etc. The brain has changed itself and now this surging of dopamine has become the ‘new normal’ or the default expectation. Thus, learned behaviour has it biological corollary in the neurology of neurons that have fused together into strong associations.
It is only when the default or ‘new normal’ (the adaptation to an usual circumstance ie the ‘super’ natural spike of pleasure / dopamine that drug use provides) the changes lead to malfunction – in the normal world where this spike of pleasure is not expected or healthy in the long term. After all, we can not run on ‘superdrive’ forever, our bodies, neurons, receptors, will not hold out.
Receptors will start to degrade, our neurochemistry will fall behind on the production of the higher dopamine levels we now need…. Here is where impairment and disease starts. Addiction is the final stage of this maladaptation of learned behaviour. The system needs what we can no longer provide or withstand.
Abstinence versus Moderation:
Will power, control of desire, or the ability to redirect desire MAY work in a system that has not been permanently altered. If the person has not been bombarded or supercharged their reward system with too much alcohol, drugs, tobacco, food, it may be possible to stop and then to retrain the maladaptive fledgling associations towards moderate use.
It might be possible. The person who beat cancer at early stages, provided they have a strong immune system, or the pregnant women who gets gestational diabetes, might get better. Though often – years later, these conditions do come back.
Full recovery depends on the stage of a person’s addiction and how robust the reward pathway still is. But addiction is progressive. Over time, the constant bombardment of drugs (or the substitution of one drug for another which continues the bombardment in another fashion), or aging, hormones, stress etc can wear down the resiliency of the reward system’s ability to recover fully. Full recovery to non addiction may occur in early stages of addiction.
And… let’s not forget relapses. The number of relapses appear to be very disadvantageous in that they seem to step up this progression of the addiction.
Furthermore, if the use of drug was enough to engage the survival instinct (the fundamental driver of ANY learned behaviour) it gets harder and harder to retrain or extinguish this learning. Think PTSD – once a person has made the association that the whistle of a bomb leads to catastrophic death, that whistle will cause impairment in normal life where there are no longer any bombs. A whistle leads to hyper-vigilance, and can be intrusive in dreams, into normal life even years later. And you can not ‘will’ your way out of this fear / survival reaction.
Similarly, an association such as drink, food, any intoxicant that leads to relief of anxiety, depression or makes a person feel euphoric (pos / negative reinforcement) will later bring on a craving for the substance when restimulated (triggered). The slight smell of a donut, the flick of a lighter, the glint of an ice cube will cause a hyper-response (ie craving for food, crack, alcohol) to that trigger – since those substances once ensured survival. Very hard to extinguish PTSD or even retrain it. It takes years and years of therapy and patience.
Moderation will certainly not work if the drug use was extreme. The ’trauma’ or the heightened reinforcement / dopamine spike of the drug, food or drink may have been too severe. Any use will only retraumatize a system that is no longer robust enough to withstand any blunt onslaught of dopamine. The over-abundance of dopamine has caused damage to the receptors (from the blunt force of too much dopamine on the receptors – like a drug, or sugar).
We see a similar process with Diabetes 11 – the glucose receptors are no longer robust enough to absorb the excess sugar. Once a diabetic, always a diabetic, even if in remission.
To further explain this: The reward / dopamine system is no longer robust enough to withstand any trigger, slight or strong. It has become highly sensitized, kindled (think like fire kindling). We often call this ‘allergic’. One drink or one bite and the system is flared into hyper-responsiveness (i.e. craving) of dopamine. Dopamine is the neurochemical of want, of desire, of craving.
It is the same with seizure activity – once a person has had one seizure, their ‘seizure threshold’ has been changed so that they are now more likely to have a seizure again but to a lesser provocation. This seems to be the same with dopamine. Addiction is a dopamine threshold gone awry leading to a hyper-responsive or allergic response of craving or obsession to the point of impairment.
When this has happened, only abstinence, avoidance of any trigger, is the solution. Avoid retraumatizing the system.
The goal of sobriety / serenity is to allow the reward pathway to heal itself to the point where normal rewards are sufficient for life, i.e. connection, job, family, healthy foods. One ‘recovers’ the ability to enjoy normal rewards. But the overpowering effect of sugar, booze, drugs will likely always tear down any healing that has occurred. Serenity is lost as the overpowering cravings return.
BYW, processed foods are not normal – not to our biological body. Sugar, alcohol, cocaine are all manufactured to produce euphoric highs far more than our biological body (built to enjoy produce, meats, fats, fruits) has been programmed to expect or endure. To suggest that sugar in a cake or candy is normal is to buy into the sugar industry conception of normality.