The American Association of Addiction Medicine outlines a clear definition of Addiction and clarifies the range of factors and issues associated with both the development and treatment of Addictions:
Short Definition of Addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.
Addiction is characterised by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Factors Influencing Addiction:
Genetic factors: account for about half of the likelihood that an individual will develop addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioural and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.
Other factors: that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:
- The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviours which enhance reward function are preferred and sought as reinforcers
- The repeated engagement in drug use or other addictive behaviours, causing neuro-adaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviours
- Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception
- Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies
- Exposure to trauma or stressors that overwhelm an individual’s coping abilities
- Distortion in meaning, purpose and values that guide attitudes, thinking and behaviour
- Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
- The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviours.
Characteristics of Addiction:
- Inability to consistently Abstain
- Impairment in Behavioural control
- Craving; or increased “hunger” for drugs or rewarding experiences
- Diminished recognition of significant problems with one’s behaviours and interpersonal relationships
- A dysfunctional Emotional response.
The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviours, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviours associated with these past experiences.
Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviours (such as gambling or spending), or exposure to other external rewards (such as food or sex), a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.
Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to rewarding substances and behaviours, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.4
In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviours despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviours, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviours, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.
Addiction is more than a behavioural disorder. Features of addiction include aspects of a person’s behaviours, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.
Behavioural manifestations and complications of addiction, primarily due to impaired control, can include:
- Excessive use and/or engagement in addictive behaviours, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioural control
- Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviours, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work)
- Continued use and/or engagement in addictive behaviours, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviours
- A narrowing of the behavioural repertoire focusing on rewards that are part of addiction
- An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems
Cognitive changes in addiction can include:
- Preoccupation with substance use
- Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviours
- The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction
Emotional changes in addiction can include:
- Increased anxiety, dysphoria and emotional pain
- Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result
- Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia)
The emotional aspects of addiction are quite complex. Some people use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”). Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement”. Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviours. The state of addiction is not the same as the state of intoxication. When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviours such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.
Over time, repeated experiences with substance use or addictive behaviours are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviours, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs. While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”–but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behaviour in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal. Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.
As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.
Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviours of the individual and contingency management, sometimes including behavioural consequences for relapse behaviours, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.
The qualitative ways in which the brain and behaviour respond to drug exposure and engagement in addictive behaviours are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent. As is the case with other chronic diseases, the condition must be monitored and managed over time to:
- Decrease the frequency and intensity of relapses
- Sustain periods of remission
- Optimize the person’s level of functioning during periods of remission
In some cases of addiction, medication management can improve treatment outcomes. In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives.
Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.
Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.
Contact us now in confidence at Arduna @ (01) 833 2733 to discuss making an appointment with one of our therapists who works with addiction.
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