Thursday, March 19, 2009

Is Addiction Merely a Personality Disorder?

An article from a couple of days back in Psychology Today's blog section suggests that addiction is a personality disorder - and only a personality disorder. Stephen Mason taught psychology at the university level for years, including time at Lehigh University, Penn State, and the University of Miami.

Sadly, however, at least in this case, he is perpetuating nonsense. Comments from me below the article.

The Addictive Personality

A major misconception involving addiction is the idea that certain substances are, all by themselves, addicting. That a drug can captivate an unwary victim is an idea popularized in the 1936 film Reefer Madness. In that movie, it took just a few puffs of marijuana to turn a gentleman into a slobbering dope fiend; his health shattered; his life ruined. While such heavy-handed propaganda might be met with less credulity today, the fact remains that most Americans still believe the basic message - Just Say No or you'll wind up hooked. What makes this truly odd is that, according to numerous national surveys, most Americans have tried marijuana and didn't become dope fiends. Indeed, several years ago, a group of US congressmen attempted to come forward, admit their prior pot use and put an end to a draconian system that confiscates property and puts people in prison for years. But the electorate clearly wasn't ready for any such reappraisal of the drug laws and the movement quickly died.

But how is it, you ask, that all those congressmen that were candid about their drug use didn't get hooked Reefer Madness style? The reason is because addiction depends, first and foremost, upon having an addictive personality. Such people, estimated at perhaps 10%-15% of the population, simply don't know when to stop. Do you enjoy a glass or two of wine with dinner? If so, why not have ten or twenty? Did you ever buy a lottery ticket on your birthday? If so, why not sell your house and buy 100,000? How about going to church on Sunday? Does it make you feel good? If so, why not go every day twice a day? The point here is simple: Too much of a good thing can be bad. And yet people with addictive personalities will get hooked on alcohol and gambling and religion. Believe it or not, being addicted is nothing more than an out-of-control habit. The difference between that 10%-15% and everyone else is the difference between using and abusing.

During the Vietnam War, drug use was endemic among troops serving in Southeast Asia. And yet, returning veterans suffered addiction rates that were no higher than those found in the general population. It would be difficult to think of a more perfectly designed experiment to show, once and for all, that dependence is mostly a matter of personality. And yet, when it comes to winning hearts and minds, the War in Vietnam was as nothing when compared to the War on Drugs. Although this second battle has completely failed in reducing illegal drug use, it has succeeded brilliantly in convincing Americans that they need to be saved from themselves. It's a belief that was sold so well that hardly anyone noticed that Drug Czar Bill Bennett was an addictive personality hooked on both food and gambling.

Look At It This Way
The problem with the War on Drugs is that it creates far more harm than it eliminates. If drugs can't be kept out of prisons, how can you possibly keep them out of a mostly free society? The "War" won't go away because by now it's become a major industry. It creates jobs on one side of the law and provides the opportunity for huge financial rewards on the other. But, like Prohibition before, making a law that can't be enforced does little more than erode the public's respect for the law. When alcohol was illegal, the upper classes had theirs imported while the common folk drank it from bathtubs. No one so inclined went without. And nothing has changed. Bush turned (supposedly) from drugs and alcohol to religion, thus substituting one addiction for another. Clinton told us, with a straight face, that he never inhaled. So here's a simple question: Would either of these gentlemen be better off today if they had been sentenced to long prison terms? If so, why not provide them with a belated opportunity to serve time? If not, then why should the kid down the street be put away for doing the same thing?

Asking such simple questions should make it plain to anyone with any common sense that the truth regarding drugs and addiction is concealed behind so many layers of ignorance and emotion, deception and special interests that it will remain a major problem for a long time to come.

I agree that the "war on drugs" is wrong-headed and destructive. Agreement stops there.

While it is true that some addicts have a personality disorder, often resulting from trauma or abuse in their childhood, the truth remains that addiction has a brain chemistry etiology as well as a personality dysfunction (and it's not a habit control issue, as he suggests - it's an escape from pain issue).

For a little balance, here is an explanation of the neurological aspects of addiction, from a treatment center specializing in addictions:
Neurochemistry of Addiction

Addiction is a complex disease of drug chemistry, brain chemistry, thought processes and social interactions. Research has shown that addiction involves the reward centers in the brain belonging to the limbic system, which is emotionally driven and recently shown involvement of the frontal cortex; our rational, conscious brain area.

Much focus on addiction centers on the brain chemical dopamine. Dopamine has shown to increase in concentration in the limbic (middle) brain regions when abusive drugs are consumed. As the magnitude of drug-induced dopamine increases, the reports of reinforcing properties (the “high”), appear to decrease. Thus, the addict must use larger amounts of the drug over time, to achieve their original “high” state.

This reaction implies that dopamine involvement in drug addiction is likely mediated by functional and structural changes in the neural circuits. Some of the structural changes observed recently are decreases in volume of the frontal lobe with certain drug use.

Research has demonstrated frontal lobe volume losses in abusers of cocaine, heroin and alcohol. With the frontal cortex being involved in rational, conscious thought, reduced function impairs these top-down processes causing a loss of self-directed, willed behavior. Thus the addicted loses their inhibitory controls and defaults to stimulus-driven behaviors, facilitated by the drugs.
The cycle of addiction can be broken down into 4 main areas; drug intoxication, drug craving, drug bingeing, and drug withdrawal.

As stated previously, drug intoxication involves higher extra cellular dopamine concentrations in the limbic as well as frontal regions of the brain.

Drug craving is a learned response involving social and environmental cues. Memory for the drug experience is housed in the amygdala and hippocampal regions, and involves activation of the thalamo-orbitofrontal and anterior cingulated areas to manifest the craving experience. Blood sugar metabolism has been shown to be intimately linked in the craving stage. Compulsive drug administration (bingeing) involves a loss of inhibitory processes and has been shown to involve dopamine, serotonin and glutamine circuitry in the thalamo-orbitofrontal and anterior cingulate gyrus areas.

Drug withdrawal results in disruption of behavioral circuits, culminating in dysphoria, dysthymia and irritability. These changes have been shown to involve frontal cortical circuitry, and the neurochemicals dopamine, serotonin and corticotrophin-releasing factor. It has also been noted that the dopamine receptor (D2) availability decreases with increased drug exposure. The D2 receptor pathway involves reward circuits in the brain, and thus with decreased receptor availability, a potential for increased risk of addictive behavior ensues.
If we want to successfully treat addicts, we need to acknowledge the integral nature of the disease, the biological, psychological, and cultural elements of the disease. To write it off as simply a personality disorder is ignorant and best, and dangerous at worst.

1 comment:

Anonymous said...

I agree that - especially for soft drugs - criminalizing does not help. Instead schools should properly inform teenagers of the dangers and there should be help for those who are addicted. But how can that be expected in the US where a similar problem exists with regard to pregnancy. And where the healthcare system is least accessible to those most likely to get addicted.