Barriers to Recognition
It is no longer surprising when a movie star, a politician, or a sports hero reveals to the news media a personal struggle with the perils of addiction. The disease is common; we now know that it afflicts an estimated 10% of the population. In the U.S., this would equate to 30 million individuals who will develop addiction in their lifetime. Alcoholics Anonymous, the oldest and largest self-help group for addiction recovery, reports more than 53,000 A.A. meetings in the U.S. Addiction specialists use the term "addiction" to refer to alcohol, drug and many behavioral addictions such as gambling. In this article, when I use the word addiction, I will be referring to all of these types of addiction.
While these numbers are remarkable, most troublesome number is that of the addicts and alcoholics who continue to suffer with their disease. Addiction continues to be misunderstood, and the consequences of this misunderstanding are gravest for the addicts themselves. The most formidable barrier to a rational understanding of the disease is the mental image people have of addicts, based on nothing more substantial than prejudice. When people think "alcoholic" or "addict," they envision a down-and-out street person cradling his bottle in a torn brown paper bag. Despite the celebrity confessions and the odds that most of us have a family member, colleague, or neighbor with chemical dependence, this image persists in the back of our minds and interferes with awareness of our own addictive behavior. We struggle instead with the more palatable idea that next time, by handling our drinking or drug use differently; we will prove ourselves immune from this haunting mental image. Family members are blinded to addiction as well. When discussing their spouse's addiction I commonly hear: "He could not be an addict, he goes to work every day!"
Addiction to alcohol or drugs is a final common pathway illness. That is to say, many factors propel an individual along the road toward becoming an addict; once there, however, research and clinical experience shows that the addicted individual cannot go back to the days when alcohol or drug use was casual and voluntary. One of the most powerful factors leading to addiction is genetics. This does not mean that people inherit addiction, but that they inherit the propensity to become addicted. Whether they go on to develop an addiction depends not only on genetics but on the repeated consumption of addicting substances or addicting behaviors. In addition to genetics, addiction has other factors that stimulate its appearance. Family structure, personality, other psychiatric disease and environment all play a part in the etiology of addiction. Children who have grown up in an atmosphere of shame experience a high incidence of addiction. People who tend to be anxious and driven or who have other psychological problems seem especially vulnerable to addiction. Childhood trauma-whether intentionally inflicted, like sexual abuse; or unintentionally inflicted, like the death of a parent-can result in an emotional injury that leaves one susceptible to becoming addicted later in life. Stress can also lead a casual substance user along the road to compulsive use of chemicals. Each of these factors link in various combinations to reach the final common pathway: the disease of addiction. Regardless of the particular combination of contributing factors, once a person has developed an addiction, complex alterations in the brain's chemistry make it impossible to return to an earlier phase of moderation and control. Unfortunately, addicted individuals spend a lot of time and energy trying to return to a relationship with mood altering chemicals that is no longer possible.
Another barrier to recognizing chemical dependence is that people addicted to drugs tend to misinterpret the source of the chaos in their lives. Alcoholics and addicts invariably define their problem as something external to themselves: a nagging spouse, hormones, a stressful job, or the drug itself, which they have come to love, crave, and hate. Research during the last decade has revealed that many individuals suffer from more than one addiction-6o% of people with bulimia nervosa are also alcoholic, 8o% of gambling addicts are addicted to chemical substances. Addiction Medicine physicians understand addiction as a disorder in the brain that creates a distorted relationship between the brain and the substance or behavior.
Whatever the addictive substance or behavior, symptoms of addiction are the same. One of the primary symptoms is denial, which makes it very difficult for the addict to seek help. Denial is the subtle reorganization of reality that occurs in the addict's mind that keeps him or her from seeing their problems as arising from their addictive disease. This is why the alcoholic is often the last to know they have a problem. Other manifestations of chemical dependence include physical dependence and increasing tolerance for the drug. Once the person is under the sway of addiction, what began as apparently harmless and voluntary social drinking or occasional drug use becomes the ruling passion of his life. Nothing is as important, not the entreaties of his wife, tears of his children, loss of a job, or even skirmishes with the law appear to get through to him.
What Happens to the Brain in Addiction?
Understanding how addiction affects the brain helps explain these perplexing symptoms. To appreciate how things go haywire in the addict, it is helpful to visualize the basic structure of the brain. The cortex is the part of our brain in which conscious thought occurs, and the part of the brain that makes us distinctively human. The cortex is also called the "new brain" because from an evolutionary point of view, it appears in more highly evolved species such as lower primates and humans. The cortex houses the superior mental faculties-memory, learning, and judgment-of which we are understandably proud; it is, in fact, the part on which all conscious thought is based.
Despite its amazing properties, however, the human cortex is baffled by addiction. To see why, we must look at another part of the brain, the midbrain. The midbrain is the seat of the basic drives: hunger, thirst, the fight or flight reaction, sex, and pain regulation. No conscious thought occurs in the midbrain; instead, pressure from the midbrain is transmitted to the cortex, where it registers as conscious thought ("I'm hungry"). Although the cortex may appear to be running the show, the midbrain wields deceptive power. Several times in life-at puberty, for instance-the midbrain totally rearranges the way we see the world.
From the perspective of addiction, the midbrain is where the action is. In people who develop addiction, the midbrain takes on a sixth activity in addition to the five basic drives delineated above. This sixth activity is a primitive push for the addictive substance or behavior, which feels to the individual exactly like a basic drive. But there are two fundamental differences between this sixth function and the basic drives. The sixth (addictive) function eventually grows so powerful that it eclipses all the drives. And whereas the drives push the individual toward self-preservation, the sixth "drive," the pressure to get drunk or high, leads ultimately to self-annihilation.
The midbrain sends its signals to the cortex through the motor cortex, which controls movement. The pressure from the midbrain drives action, a motor event. For example, the midbrain transmits pressure for alcohol. The alcoholic turns into the liquor store parking lot. Only then do what cortical neurophysiologist Michael Gazzaniga has labeled the "Interpreter" kicks in to analyze the action. "You deserve a drink," it whispers. The interpreter tries, in retrospect, to make sense of the action triggered by the midbrain and carried out by the motor cortex.
Such an assessment mechanism is doomed to fail because of the discrepancy between the raw drive for a drug and the individual's rational functioning. Errors in interpretation multiply, entrenching the person in denial. These misperceptions and rationalizations are the hallmark of addictive thinking.
Implications for Treatment
For treatment to be effective, the brain must be educated about the errors in circuitry by which it has been baffled. From our current understanding of the subtle changes in chemistry that occur in the brain during addiction, two important corollaries emerge:
1) You Can't Think Your Way Out of Addiction
Treatment helps the addicted person reconcile the basic conflict between the cortex and the midbrain, or the old brain and the new brain. The critical role of the midbrain in preserving the organism, Homo sapiens, underscores why even the most sophisticated analytical thinking cannot lead a person out of his addiction. Instead, one needs the retraining and cooperation of the midbrain, which is the common denominator not only of our humanity but also our relation with the rest of humanity.
A tragic error in addiction treatment early in the 20th century was the mistaken belief that if the addict could develop enough insight into his problems and feel better about himself through psychoanalysis or another form of psychotherapy, he could stop the addictive behavior. Sadly, the relapse histories of countless patients proved this type of approach to be a critical and often fatal error. To the addict, no amount of insight about underlying causes is enough to overcome the craving for chemical relief that occurs when one is actively using drugs and alcohol. In order to recover, the addict needs to stop the behavior first.
2) Recovery Takes Time
When a drug is introduced to the body of a person who will become addicted, it leads to a surge of euphoria that is quicker and more intense than any "high" the body can produce through natural means. This artificial activation of the brain's reward system increases the release of chemical substances that mediate the euphoria, however, this surge of euphoria does not last. After the body develops tolerance, larger quantities are needed; the addict begins to need the drug not to feel high but to feel normal. The brain's chemistry develops tolerance for the artificial surge produced by addiction. When the drugs and behaviors are withdrawn in treatment, it takes the body a while to resume production of substances that make the person feel a sense of calm and well-being. This process of detoxification and normalization of thought takes time, meaning months or years.
Once detoxified, the individual in recovery must hack through the thicket of excuses and rationalizations by which his brain has attempted to make sense of his bizarre behavior. This also takes time. When the addict finally and deeply understands the havoc wrought by drug use in the brain's natural chemistry, the midbrain essentially gives up. When treatment occurs and the addict or alcoholic engages in a specific set of actions (called working a program of recovery), the individual is set free from the compulsion to drink or use drugs.
The Nature of Treatment Today
Based on our current scientific knowledge about addiction, the treatment process at all recovery centers occurs in four distinct phases:
1. Behavioral Intervention: The first step in treatment involves behavioral containment, stopping the drug from entering the body. Once the individual feels the tug of addiction as a primitive drive, no further improvement can occur until he stops taking the drug. Acute detoxification usually takes several weeks; it may take months before the brain's chemistry returns to normal. During this early phase, alcoholics and other addicts often feel like they have lost their best friend or lover and experience enormous grief and/or anger, as well as depression.
2. Cognitive Insight: The phase of cognitive insight is the "Aha!" phase, during which the recovering person begins to recognize and make sense of his formerly perplexing behavior. This usually occurs in a series of fits and starts over a period of about a week.
3. Emotional Integration: During the phase of emotional integration, the recovering person begins to rediscover his feelings. This process takes weeks; feelings may have been buried for a long time, and they are usually covered in shame. Among the most destructive cultural attitudes toward alcoholism and drug addiction is the notion that the addicted person is morally weak and lacks self-discipline. When internalized, this attitude interferes with the alcoholic's realization that he has a disease and with his understanding of the insidious disease process. We sometimes call the phase of emotional integration the "Ugh" phase because it is difficult work-work that requires courage and perseverance. Most people who do not recover from chemical dependence give up or attempt to sidestep this painful phase.
4. Transformation: Transformation is the last stage of change-the transition into recovery. Transformation does not mean changing one's mind about using drugs. It means nothing less than seeing the world in a different way. The transformation phase is what recovering addicts often describe as a spiritual experience. Some patients describe the increasingly unfamiliar way they were before, as if they had been looking at life from atop a strange mountain. Others discover a new or rediscover a past spiritual or religious practice. To the individual entering this phase everything and everybody looks different, though it is in fact he who has changed. People who make it to the transformation phase generally lock in their recovery and go on to live life free of drugs and filled with an inner peace that often surprises them and those around them.
Effective treatment is based upon the 12 Steps of Alcoholics Anonymous and Narcotics Anonymous. We add individual and group therapy, training in intra and interpersonal skills and family components to produce a good outcome. Treatment is matched with long term monitoring; the marriage of treatment and continuing care produces excellent remission rates for this chronic disease.
Our society provides us with an increased exposure to addiction though the media. Despite this exposure, many people still do not understand the complex nature of the brain disease called addiction. Addiction affects so many aspects of a person's life and our culture and, as such, is difficult to tease out from the fabric of that culture. Recent science has clearly established this is a disease of the brain that affects the emotions, heart and soul of the afflicted and his or her family. The recovery process is slow and occurs in phases, each one helping the addict or alcoholic transition into a life of meaning and peace. Despite this, treatment is remarkably effective-as effective or more so than any other chronic disease.