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South African Responsible Gambling Foundation

Addiction

  • Introduction
  • Terminology
  • Diagnosis
  • Causes
1) Introduction

The term “addiction” is very much a part of modern parlance. We commonly refer to people who spend excessive amounts of time, energy or money, on the pursuit of one thing, as “addicts” employing the suffix “holic” to identify addicts of various types. Thus we refer to alcoholics, spendaholics, workaholics, chocoholics and so on. We also refer to people as being addicted to pornography, the internet, gambling, and so on. .A glance at popular culture, as evidenced by reality TV shows, seems to indicate that we are fascinated by people who indulge in pursuits like spending money to excess. So we have programmes that look at Spendaholics, programmes that detail celebrity rehab, programmes that examine pathological over-eating and under-eating and programmes that show interventions in the lives of addicts in gritty detail.

This should immediately alert us to the fact that we are dealing with a topic that has been popularised to the extent that most people have an opinion on what constitutes addiction. In reality, addiction theory is a highly contested terrain in psychology and psychiatry. The term itself, as we shall see in the next section, is problematic and used (and significantly not used) in a wide variety of medical and social contexts. The mainly taken-for-granted “disease model” of addiction, especially as applied to substances, which postulates that an addict is in the grip of a pathological compulsion that controls his or her life is, in itself, open to debate and has a complex history dating from its first use in 1784 by Benjamin Rush, the Surgeon General in George Washington’s revolutionary armies.

Any historical look at the definition and treatment of addiction is also a look at the history of the definition and treatment of alcoholism as well as narcotics The word itself has morphed from its original meaning of “devoted to” to one which implies that addiction is a pathological enslavement to a pastime or substance over which the addict has no control.

It was a Swedish physician, Magnus Huss, who first applied the term alcoholism to the syndrome of excessive inebriation in the late 1800’s. Many initial cures for alcohol abuse included doses of potentially habit forming opiates. Freud was one such leading figure who suggested this approach combined with psychoanalysis. Interestingly of course, Freud notoriously prescribed cocaine for patients as well. So the initial field of addiction studies revolved around alcohol excess.  Later as substances such a morphine (originally sold over the counter) and opium were seen to be habit forming in a problematic manner; the term addiction was applied to narcotics as well.

Contrary to popular belief, the medical or disease model, is not the model initially adopted by Alcoholics Anonymous (AA) the largest international self-help group for addicts, whose founders in fact saw alcoholism as a form of “spiritual and emotional maladjustment”. The Minnesota Model (disease or medical model) of addiction was developed at the Yale Summer Institute using the alcohol industry’s money. post World War II  This is interesting in that it marked the shift away from the focus on alcohol per se being problematic as conceptualised by most moral and religious regeneration movements, to highlighting individual addiction to alcohol as being defined as the problem. This, one could see somewhat cynically, as being eminently more acceptable to the alcohol industry.  If the problem is only with a few late stage drinkers who suffer from a medical problem, then there is little sense in pushing for the outlawing of all alcohol. Interestingly, in certain countries such as South Africa and Australia this approach has also been adopted by the gaming industry who to a large extent, is involved in defining and dealing with problem gambling.

An interesting site that details the long and complicated history of how alcohol addiction treatment and recovery has developed is the review of the book, “Slaying the Dragon” by WL White at:
http://lifering.org/empowering-excerpts/

At the end of his encyclopaedic book on the history of addiction treatment, Slaying the Dragon, William L. White has this to say:-

“Above all, recognize that what addiction professionals have done for more than a century and a half is to create a setting and an opening in which the addicted can transform their identity and redefine every relationship in their lives, including their relationship with alcohol and other drugs. What we are professionally responsible for is creating a milieu of opportunity, choice and hope. What happens with that opportunity is up to the addict and his or her god. We can own neither the addiction nor the recovery, only the clarity of the presented choice, the best clinical technology we can muster, and our faith in the potential for human rebirth."

William L. White. (2002) Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, Ill.: Chestnut Health Systems

Point to Ponder
In the 1800’s and early 1900’s in the USA the take on alcohol abuse was that it was morally reprehensible and that the substance itself was to blame. The Temperance Movements emphasised that no-one should drink and Prohibition was introduced in the 1920’s. Why do you think the shift away from banning alcohol to viewing those who have a problem with alcohol as the main focus for treatment and attention would suit the alcohol industry?  What about the gambling industry? Why would a “medical model” of pathological gambling suit the gaming industry?

An Anti-Medical Model Approach
The therapist Dr Stanton Peele is a prominent proponent of the anti-medical model. He believes the continual search for physical causes of addiction, particularly into substances is a waste of resources. To him all activities engaged in to excess are as addictive as each other. In addition he has written a book on why the AA Twelve Step programme should be resisted. The Stanton Peele Website is at:
http://www.peele.net/

“Stanton Peele has been investigating, thinking, and writing about addiction since 1969. His first bombshell book, Love and Addiction, appeared in 1975. Its experiential and environmental approach to addiction revolutionized thinking on the subject by indicating that addiction is not limited to narcotics, or to drugs at all, and that addiction is a pattern of behaviour and experience which is best understood by examining an individual's relationship with his/her world. This is a distinctly nonmedical approach. It views addiction as a general pattern of behaviour that nearly everyone experiences in varying degrees at one time or another.”

If one views addiction in this light, it is not seen as an unusual condition although he does acknowledge that it can become debilitating in the sense of taking over someone’s life. However he emphasises, unlike the proponents of the Minnesota Model, that this is not a medical issue but “a problem of life”. He believes many people successfully overcome addictions and that the failure to do so is the exception and not the rule. Those who do fail do so because they have not learnt effective coping skills and do not deal with the world in a functional manner. Thus better self esteem and better coping skills will help prevent and stop addiction. Peele goes on to state:-

"Addiction is a way of coping with life, of artificially attaining feelings and rewards people feel they cannot achieve in any other way. As such, it is no more a treatable medical problem than is unemployment, lack of coping skills, or degraded communities and despairing lives. The only remedy for addiction is for more people to have the resources, values and environments necessary for living productive lives. More treatment will not win our badly misguided war on drugs. It will only distract our attention from the real issues in addiction."

Stanton Peele, "Cures depend on attitude, not programs" Los Angeles Times, March 14, 1990.

From this brief introduction to a complex subject we can see that in order to understand more about the field of addiction, as variously defined, we need to look carefully at various topics such as terminology; how psychiatric definitions are determined., issues around labelling and the latest research into causes of addictive behaviour.

 

Video This is an academic discussing the setting
in which the use and abuse of intoxicants occurs
 

 

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2) Terminology

2.1 Addiction
In the first Diagnostic and Statistical Manual of Mental Disorders (DSMI) which is the definitive text on classifiable psychiatric disorders, produced by the American Psychiatric Association, in 1952, the term “addiction” was used to describe excessive consumption as part of a broader definition of Social Pathology. Early editions of the DSM thus described addiction as a physical dependency to a substance that resulted in withdrawal symptoms in its absence. By the 1980’s the World Health Organisation was using the term substance dependence in preference to addiction, in order to avoid the social stigma related to addiction. By the time the DSM IV TR (Text Revision) was published in 2000, there was no mention of addiction and excessive consumption of substances is currently classified as substance abuse and substance dependence.

So, in the United States, physical dependence, abuse of, and withdrawal from drugs and other substances is outlined in the  (DSM-IV TR), in a section about Substance dependence:

"Substance dependence: When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders.

DSM-IV & DSM-IV-TR: Substance Dependence
The American Society of Addiction Medicine recommends treatment for people with chemical dependency based on patient placement criteria (currently listed in PPC-2), which attempt to match levels of care that will be required according to clinical assessments by professionals, in six areas, namely:-

  • Acute intoxication and/or withdrawal potential
  • Biomedical conditions or complications
  • Emotional/behavioural conditions or complications
  • Treatment acceptance/resistance
  • Relapse potential
  • Recovery environment

Despite the omission of the term addiction from the DSM, there is a fairly broadly accepted use of the word amongst those dealing with substance abusers which may be described thus:

Addiction, also known as substance dependence … is a chronically relapsing disorder that is characterized by three major elements:

  • compulsion to seek and take the drug,
  • loss of control in limiting intake, and
  • emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug is prevented.

Koob, G., Paolo Sanna, P., and Bloom, F. (1998). Neuroscience of addiction. Neuron 21: 467-476.

You will have noted that so far we have only used the word addiction in relation to substances, and not pertaining to behavioural activities such as gambling, shopping, using the Internet and so on. As we know, in popular use the term is extended to incorporate these activities and we will examine the validity of this below.

Let us now compare the DSM IV TR criteria for substance abuse (not addiction) with the AA self test checklist which does refer to addiction.

“A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

  • Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
  • Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  • Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)“

DSM IV TR (2000)
Due to the fact, as mentioned above, that many professionals working in the field of substance abuse, routinely refer to addiction, it is thought that the forthcoming DSM V due in 2010 may use the term addiction when describing the criteria above as changes are made on the basis of canvassing the opinions of practising mental health professionals. (As we shall later see this probably will happen )

Now let us look at how Alcoholics Anonymous, the largest self-help group for those dependent on alcohol, defines addiction, a term they apply to all those in their programmes.

Who Is An Addict?
Most of us do not have to think twice about this question. WE KNOW! Our whole life and thinking was centred around our addiction in one form or another - always scheming and plotting to find ways to feed our addictions. We lived to use and used to live. Very simply, an addict is a man or woman whose life is controlled by a substance or action. We are people in the grip of a continuing and progressive illness whose ends are always the same: jails, institutions, illness, poverty, and death.

Only you can decide if you have an addiction, and whether or not a 12 step recovery program can help you. The following questionnaire may help you make this decision. If you answer YES to four or may questions, you may have a problem that can be helped by the steps. See how you do. Remember that there is no disgrace in facing up to the fact that you have a problem! "

Answer YES or NO to the following questions.

  1. Have you ever decided to stop drinking for a week or so, but only lasted for a couple of days?

  2. Do you wish people would mind their own business about your drinking-- stop telling you what to do?

  3. Have you ever switched from one kind of drink to another in the hope that this would keep you from getting drunk?

  4. Have you had to have an eye-opener upon awakening during the past year?

  5. Do you envy people who can drink without getting into trouble?

  6. Have you had problems connected with drinking during the past year?

  7. Has your drinking caused trouble at home?

  8. Do you ever try to get "extra" drinks at a party because you do not get enough?

  9. Do you tell yourself you can stop drinking any time you want to, even though you keep getting drunk when you don't mean to?

  10. Have you missed days of work or school because of drinking?

  11. Do you have "blackouts"?

  12. Have you ever felt that your life would be better if you did not drink?

Did you answer YES four or more times? If so, you are probably addicted. Why do we say this? Because thousands of people in recovery have said so for many years. They found out the truth about themselves — the hard way.”

http://www.recoveryzone.org/docs/whois.htm

As you can see, AA places addiction firmly in the disease model.  As you will also see later, these questions are employed by numerous other self-help groups who refer to a range of substance ingestion and behaviours as addictions. Before we debate whether this is merely a semantic point or does indeed have relevance for society as a whole and policy makers, we will look at how the DSM defines behaviours which are seen as out of control.

Point to Ponder
Can you find similarities between the DSM criteria for substance dependence and the AA Questionnaire? Remember that the DSM criteria are assessed by a professional whereas the AA questions are self administered. Do you think self administered questionnaires are reliable? What possible problems do you think there might be with them?

 

Video This is an interesting look at the role of the ego in addiction
and how the 12 Step Programme deals with this issue
 

 

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2.2 Impulse Control Disorders
Impulse Control Disorders are a clearly defined group of impulsive behaviours that have been accepted as psychiatric disorders under the DSM-IV- TR and include some that many practitioners would describe or operationalise as addictions. Although they have been placed together in this particular category, there are both similarities and differences amongst the disorders.

An Impulse Control Disorder can be generally described as the failure to resist an impulsive act or behaviour that may be harmful to oneself or others In terms of this definition it is assumed that the impulsive behaviour or actions are not premeditated and are ones over which the individual has little or no control.

The ICD is different in quality to merely an impulsive act of which all individuals are capable and indicates a pathology of sorts. ICD may be combined with other psychiatric diagnoses. When more than one disorder is present in an individual one refers to co-morbidity.

2.2.1 Different types of Impulse Control Disorders
There are six categories under this general diagnosis in the DSM IV TR; namely : Trichotillomania, (compulsive hair pulling),  Intermittent Explosive Disorder, Pathological Gambling, Kleptomania, Pyromania, and Not Otherwise Specified. The first five are the most prevalent and common Impulse Control Disorders.

Impulse-control disorders are thought to have both neurological and environmental causes and are known to be exacerbated by stress. A proportion of professionals working with people thus classified believe that several of these disorders, such as compulsive gambling or shopping, should be regarded as addictions. In impulse-control disorder, the impulse action is typically preceded by feelings of tension and excitement and followed by a sense of relief and gratification, often, but not always, accompanied by guilt or remorse. The last two emotions are also closely associated with substance abuse and dependence. Those who work in this field also make a case that rather then guilt, the emotion an addict feels is one of overwhelming shame, to an extent which adds to the sense of helplessness to control behaviour.

Below is a brief description of the ICD listed in the DSM IV TR:-

  • “Pyromania. This disorder is diagnosed when a person has deliberately started fires out of an attraction to and curiosity about fire. In order to meet the criteria for this diagnosis , the firestarter cannot seek monetary gain or be trying to destroy evidence of criminal activity, or be trying to make a political statement or improve one's standard of living.
  • Trichotillomania. This disorder is characterized by compulsive hair-pulling.
  • Intermittent explosive disorder. This diagnosis is indicated when a person cannot resist aggressive impulses that lead to serious acts of assault or property destruction.
  • Kleptomania. The recurrent failure to resist the urge to steal, even though the items stolen are not needed for personal use or for their monetary value, is required for diagnosis of this disorder.
  • Pathological gambling. This form of persistent gambling disrupts the affected individual's relationships or career.
  • Impulse-control disorders not otherwise specified. This category is reserved for clinicians' use when the clinician has established that a patient's disorder is caused by lack of impulse control, but does not meet the criteria for the disorders listed above.”

www.minddisorders.com/Flu-Inv/Impulse-control-disorders.html

This website goes on to discuss the fact that some professionals in the field believe that repetitive self mutilation should also be listed as an ICD. This is because like other ICDs it is a habitual and harmful behaviour which sufferers claim is addictive in that they cannot control it and it is also accompanied by feelings of excitement and that it reduces or relieves negative feelings such as tension, anger, anxiety, depression, and loneliness. It can worsen over time (as does addiction when framed in the Medical Model – it is seen as a progressive disease) and may culminate in suicide.

www.minddisorders.com/Flu-Inv/Impulse-control-disorders.html

An interesting site that looks at the legal implications of Impulse Control Disorders, as well as giving details on causes of ICDs, some of which are summarised below is:

www.forensicpsychiatry.ca/impulse/overview.htm

Although there is no apparent single "cause" of ICD, impulsive behaviour seems to exhibit an underlying predisposition which may or may not be related to existing mental health or medical conditions. Recent research has stressed the substantial co-morbidity of Impulse Control Disorders with mood disorders, anxiety disorders, eating disorders, substance abuse, personality disorders, and with other specific impulse control disorders.

In particular cases, it may be clinically difficult to separate one from another, with the result that the impulsivity at the core of the disorders is obscured. whist the other more “obvious” behaviour is foregrounded. Increasingly this fact has led to calls for a more integrative approach when treating patients with obvious or less obvious co-morbidity.  

Some disorders, such as compulsive buying, compulsive sexual behaviour, and repetitive self mutilation appear to show considerable similarities with other more traditional impulse control disorders and indeed may be more common.

Point to Ponder
Looking at the description and diagnostic criteria for Impulse Control Disorders, can you see why some professionals believe that these disorders could be re-classified as addictions, in a manner similar to substance addiction or dependence?

2.3 Common terms
In the literature relating to addiction, many terms are frequently used, sometimes interchangeably, such as addicted, dependent, withdrawal, tolerance, sensitised and so on. In this section we will attempt to clearly delineate what is meant by each term in as accurate a manner as possible. At various times in the development of the study of addiction, these terms have assumed greater and lesser significance.

2.3.1 Dependence: Physical
Physical dependence is the state in which an individual takes a drug over a certain period of time and unpleasant physical symptoms will result when the drug is stopped or taken in a smaller quantity. For physical dependence to occur a person has to be a chronic user of the drug in question to the extent that a level of tolerance to the drug is developed. This dependence can occur with relatively low doses of therapeutic medications as well as the use and abuse of recreational drugs, such as alcohol and heroin. The greater the dose, the higher the tolerance and the more severe the withdrawal will be.

Both physical and psychological symptoms may be displayed with physical dependence, as this type of dependence is caused by physiological adaptations in the central nervous system and brain, caused by continual exposure to a chemical substance or drug.

2.3.2 Dependence:-Psychological
Previously much was made about the difference between physical and psychological dependence. Marijuana and cocaine for example were viewed as psychologically addictive but not physically so. In other words although an habitual cocaine user may experience irritability and anxiety if she stops using cocaine suddenly, she will not experience classic physical symptoms such as excessive sweating, goose pimples, nausea, headache etc, experienced by those who suddenly stop using heroin or alcohol.

Increasingly however the term psychological dependence is losing popularity with addiction professionals. The reason for this is that as scientists and addiction professionals learn more about addictions and dependencies of various kinds there is increasing evidence that they all seem to relate to changes in brain chemistry that involve certain neurotransmitters and receptors that create pleasurable feelings and that can be stimulated by external factors, whether these are drugs and alcohol or activities such as shopping or gambling. Many of these activities seem to act on the dopaminegeric circuit just as chemical dependencies do, and thus dependencies that do not involve actual chemical stimulation of the brain increasingly fall under the same umbrella. . Thus, “psychological dependence" is becoming just another less than completely accurate term for some addictions.

Let us look at two views – one an objective one; the next a subjective one on this issue.

“1) Many people, both psychology professionals and laypersons, now feel that there should be accommodation made to include psychological dependency on such things as gambling, food, sex, pornography, computers, work, exercise, spiritual obsession (as opposed to religious devotion), cutting and shopping so these behaviors count as 'addictions' as well.. Although, the above mentioned are things or tasks which, when used or performed, do not fit into the traditional view of addiction and may be better defined as an obsessive–compulsive disorder, withdrawal symptoms may occur with abatement of such behaviors. It is said by those who adhere to a traditionalist view that these withdrawal-like symptoms are not strictly reflective of an addiction, but rather of a behavioural disorder. However, understanding of neural science, the brain, the nervous system, human behavior, and affective disorders has revealed "the impact of molecular biology in the mechanisms underlying developmental processes and in the pathogenesis of disease. Modern research into addiction is generally focused on Dopaminergic pathways. There is great and sometimes heated debate around the definition of addiction with parties falling into two main camps:- the Disease model of addiction and the behaviourists”

http://en.wikipedia.org/wiki/Addiction

“2) When you are an addict, it's hard to tell the difference between a psychological dependence and a physical dependence. A lot of people (experts, doctors, etc) love to go on and on about the differences between the two... ask any cocaine addict, and they'll tell you psychological dependence is just as difficult to deal with as physical dependence. I think that psychological dependence might actually be worse than physical dependence - since, for instance, there is a finite amount of time (during physical withdrawal) that you'll be subjected to symptoms. With psychological dependence, there is no time limit to how long you can suffer for that. Also, there is more "help" out there for those with physical dependence - very little for those with psychological dependence”

By jaidgrifter on October 29th, 2008; www.answerbag.com/q_view/977573

An academic article by Michael Lyvers that looks at these issues in detail is downloadable at:-

http://epublications.bond.edu.au/hss_pubs/15/

Below is the abstract of the article:- 

“Physical-dependence-based theories of addiction regard compulsive drug taking as the behavioural manifestation of a desperate need to relieve aversive autonomic withdrawal symptoms. In the present article, the withdrawal-relief paradigm, or opiate model of addiction, is critically examined in the light of recent experimental and clinical evidence for various addictive drugs. It is concluded that contrary to the opiate model, the constellation of pathological behaviors defining addiction (compulsive drug use, craving, loss of control, and a persistent tendency to relapse) does not primarily reflect a need to relieve actual or conditioned autonomic withdrawal symptoms. Recent theories of addiction emphasize the positive reinforcing properties of drugs and sensitization of brain dopamine systems rather than negative reinforcement or drug-opposing neuroadaptations. Despite the failure of the opiate model, recent evidence suggests that persistent drug-induced changes in the physical brain may underlie addictive behavior, consistent with the general notion of addiction as a physical disease.”

2.3.3 Withdrawal
Many illicit drugs and chemicals, including medications, produce withdrawal symptoms when their use is discontinued.

Withdrawal in this context is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation or a decrease in dosage of the intake of medications, or recreational drugs, including alcohol. In order to experience the physiological symptoms of withdrawal, one must have first developed a physical dependence or chemical dependence on the substance. This type of physical dependence will occur over a period of time and will also vary according to the amount and type of substance used. For example, the prolonged use of an anti-depressant will cause a reaction if abruptly discontinued but this withdrawal will be different to the sudden cessation of an opioid, such as heroin. There are also different stages of withdrawal.. In general, symptoms associated with withdrawal will worsen, then level out and finally begin to dissipate.  Depending on the length of use and the quantity used, sudden withdrawal can be physically dangerous and in some rare cases, even result in death, therefore withdrawal is ideally a state which should be medically monitored. The term “cold turkey” is applied to sudden cessation of a substance – this is because goose-flesh often accompanies withdrawal, particularly of heroin.

Since all dependence has a physical and psychological component it is not surprising that withdrawal will lead to both psychological and physiological symptoms. Below is a list of the two types of withdrawal which may be experienced.

Emotional Withdrawal Symptoms

  • Anxiety
  • Restlessness
  • Irritability
  • Insomnia
  • Headaches
  • Poor concentration
  • Depression
  • Social isolation
Physical Withdrawal Symptoms
  • Sweating
  • Racing heart
  • Palpitations
  • Muscle tension
  • Tightness in the chest
  • Difficulty breathing
  • Tremor
  • Nausea, vomiting, or diarrhoea

www.addictionsandrecovery.org/withdrawal.htm

2.3.4 Tolerance
Tolerance is one aspect of physical dependence. It's basically when your body gets used to a medication or a chemical and you no longer get the same amount of pain relief or desired result from a given dose of the substance. A person needs to continue to increase the dose of the substance in order to get the same effect. It is the phenomenon by which the body becomes increasingly resistant to a drug or other substance through continued exposure to the substance.

Medically therefore, physiological dependence requires the development of tolerance leading to withdrawal symptoms.

Tolerance to a drug and physical dependence are not defining characteristics of addiction, although they typically accompany addiction to certain drugs. Tolerance is a pharmacologic phenomenon where the dose of a medication needs to be continually increased in order to maintain its desired effects.  For instance, individuals with severe chronic pain, taking opiate medications (like morphine), will need to continually increase the dose in order to maintain the drug's pain-relieving effects.

Some substances lead to physical dependence or physiological tolerance - but not addiction - for example many laxatives, which are not psychoactive; nasal decongestants, which can cause rebound congestion if used for more than a few days in a row; and some antidepressants. Tolerance then is not a defining quality of addiction or substance abuse. As with addictive substances, however, many non-addictive prescription drugs should not be suddenly stopped.

From the above there should be a clearer understanding of terminology employed in the field of addiction study. What will also be apparent however is that like addiction itself, the terminology is at times contested terrain and different schools of thought put forward various ideas about what terms should be used.

3 Diagnosis

As we noted earlier, currently much treatment and “taken-for granted” views about substance dependence and abuse are based on the psychiatric Bible – the DSM currently the DSM IV TR. version. We also noted that some working in the field of addiction, such as Dr Stanton Peele are critical of these diagnostic criteria. The DSM V is due for publication by the American Psychiatric Association in May 2013 and will substantially change the way “addiction” and “dependence” are viewed and probably treated. The proposed DSM V eliminates the disease categories for substance abuse and dependence and replaces it with a new "addictions and related disorders".

3.1 Reasons for proposed changes
In the words of Charles O’ Brien M.D., Ph.D., Chair of the APA's DSM Substance-Related Disorders Work Group:

"The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system. On the other hand, addiction is compulsive drug- seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding”.

In addition O’Brien noted that there was unanimous agreement that there will be substance abuse disorders for each of the major types of drugs that that are problematic, such as alcohol. Further under the draft DSM V the category “discontinuation syndromes” to accurately assess symptoms of withdrawal from psychoactive substances, including caffeine will be added.
The proposed DSM-V is also set to add a new category of "behavioural addictions" which will contain a single disorder: gambling addiction. Internet addiction was also considered for this category, but work group members decided there was insufficient research data to justify this currently.

O’Brien however added that, it is intended to include sex and Internet addictions in an appendix to DSM-V which will encourage additional research that could lead to their inclusion in future editions.

Stanton Peele, whose ideas we looked at previously commented that the APA has gone back and forth between the terms dependence and addiction.  He further makes these points:

“Every book I've written has the word "addiction" in the title, so I'm glad the term will now be recognized. But the change back may make us wonder whether we will have to reconsider every twenty years or so whether it is more beneficial or harmful to use a word loaded with cultural meanings ("addiction"), or a more neutral term ("dependence")."

The net effect is that the term "addiction" would now be officially applied to more than alcohol and other drug related disorders.  O’Brien further stated:-
“There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system. Both are related to poor impulse control and the brain's system of reward and aggression.”

As we shall see when looking at the research and thesis of the authors of The Midbrain Mutiny, there is indeed compelling evidence that demonstrates that gambling is a ‘pure” addiction.  There are still some professionals in the field, like Stanton Peele who urge that the category be extended beyond even those behaviours included in the DSM V Appendix.
www.jointogether.org/news/features/2010/dsm-v-draft-includes-major.html
www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399

3.2 Issues related to labelling
Why is it important that certain ‘troublesome” behaviours are classified so definitively? The most benign answer would be that behaviours which are problematic for individuals need to be classified so that those suffering are given appropriate help and assistance, as well as recognition that their experience is a reflection of well defined symptoms , rather than a failure of will or moral turpitude.

A more cynical view is that health insurers will not pay for treatment of generalised unhappiness that is not in some manner officially determined and clearly delineated. That the DSM can only reflect the current wisdom of the time is axiomatic – not too many years ago homosexuality was classified in the DSM as a paraphila (perversion).

The issue of sexuality, even more than that of addiction is obviously going to be affected by current views and mores. In the DSM V for example, gender identity disorder (GID) is being slated to change to gender incongruence, (GI). This is because it is seen as pejorative to label intersex individuals as having a disorder but here is an explanation by Jack Drescher as to why GID was first added to the DSM III in 1980:

“At the time, most psychiatrists didn't believe that there was such a thing as a transsexual as a phenomenon where the treatment is reassignment. So the actual motivation for putting it into the diagnostic manual was to try to create access to care. The guiding principle in medicine is first, do no harm; the harm of retention of the diagnosis is stigma, and the harm of removal is potential loss of access to care," So that's the dilemma, how to create a situation where access can be not only available but increased, and discrimination can be reduced. How we'll resolve that remains to be seen."
www.medscape.com/viewarticle/703312

An extremely interesting and lively debate around issues relating to the labelling of GID and GI is at
http://questioningtransphobia.wordpress.com/2010/02/10/dsm-v-draft/

What the above shows very clearly is how the entire enterprise of diagnosing psychiatric disorders is contentious and open to debate and cultural influences. In removing the category of “being in trouble with the law” for example, currently used in substance dependence disorders, (DSM IV TR) the APA is acknowledging that although intended only for use in the USA, the DSM is used internationally and thus the issue of legality can be too culturally bound to be internationally useful or significant.

Point to Ponder
In the treatment of physiological disorders or diseases, it is clearly critical that diagnostic criteria are absolutely rigidly correct. The implications of for example confusing bronchitis with pneumonia would be immense and possibly fatal. Do you think the same applies to diagnostic criteria of psychiatric disorders? When might it be more or less significant to be totally accurate? How severe could the consequences of a psychiatric misdiagnosis ever be?

3.3 Medical vs Legal Distinction of Terms
In legal terms, it is very important to distinguish between disorders and illegal acts. This is another contentious issue – does suffering from a known, labelled psychiatric disorder exempt one from legal responsibility? Let us look at the issue of ICD.  It is important to distinguish between the diagnosis of an Impulse Control Disorder and the impulsive act.

The diagnosis is a psychiatric condition. The act that results from the disorder is often a criminal behavior. In the case of repeated stealing, for example, Kleptomania and Shoplifting are sometimes used interchangeably but one is a medical diagnosis (DSM IV TR) and the latter is a legal term for a criminal act. An individual who shoplifts does not necessarily have kleptomania.  Indeed as we can imagine, by their very nature, some Impulse Control Disorders can result in illegal or criminal behavior as in the example given above of kleptomania. Similarly, pyromania that results in setting a fire that destroys property or injures people is a criminal act. At the other end of the scale are the ICDs, such as trichotillomania, that may result in harm to the individual but not in criminal acts.

Pathological gambling, while usually not a criminal act in itself may escalate to the point where the individual must resort to illegal or criminal acts in order to support the behaviour. This aspect is sometimes in fact one of the criteria for defining pathological gambling. Intermittent Explosive Disorder is also obviously potentially going to lead to criminal acts such as physical abuse.

Adapted from
www.forensicpsychiatry.ca/impulse/overview.htm

A further potentially very controversial issue, again relating to sexuality, labelling, and legality is that of introducing to DSM V a new category: - Paraphilic Coercive Disorder. Currently it is set to be defined thus:

“Paraphilic Coercive Disorder
A. Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion.

B. The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occasions.

C. The diagnosis of Paraphilic Coercive Disorder is not made if the patient meets criteria for a diagnosis of Sexual Sadism Disorder.”

 www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=416

To many people, not only gender activists, this definition sounds very similar to rape. Predictably this issue is being hotly debated – people are invited to submit comments on proposed changes to the DSM by the end of April 2010.

 

Point to Ponder 5
What do you see as potential problems with the proposed diagnosis  of Paraphilic Coercive Disorder? Do you think suffering from a recognised disorder in anyway exempts an individual from responsibility for his or her actions?  In the hands of a skilled defence lawyer how easy would it be to get someone referred for psychiatric treatment as opposed to serious jail time?

 

3.4 Stigma
A further issue attached to labelling, of any psychological condition, not only addiction, is the degree of stigma, perceived or real, attached to the label. This is affected by many different factors – in some cultures, such as the highly psychologised USA, psychological disorders are seen as “acceptable” – to the extent that in some sub-cultures seeing a therapist is almost obligatory. In other less sophisticated or jaded cultures, to be diagnosed with a psychiatric disorder could be viewed as shameful and lead to ostracisation.

A broad overview of this topic looking specifically at the labelling of addicts can be found at: http://www.associatedcontent.com/article/2560599/the_stigma_of_drug_and_alcohol_addiction.html?cat=72

As we have previously mentioned, addiction, which is a chronic and disabling disorder, is also often thought of as a moral deficiency or lack of willpower on the part of the individual thus afflicted, therefore there is a reluctance to be labelled. There is often the attitude that individuals can just decide to stop drinking or using drugs if they want to. The study of the effects of stigma on substance use disorders is still a fairly undeveloped area, but research is revealing that social stigma and attitudes towards addiction are preventing people from seeking help.

The general medical profession itself is not immune from the silence of stigma. More than 40% of family doctors, who are in a good position to detect substance abuse problems early, admitted in a recent USA survey that they find the topic difficult to talk to patients about—more than double the discomfort they admit feeling for depression. This indicates that addiction has a very specific stigma attached to it.

The reality of discrimination based on negative stigmatisation has a very direct and real effect on the course and treatment of a person's mental illness or substance abuse problem. The results of the most recent Canadian Community Health Survey indicated that less than a third of people who have symptoms of mental disorders or substance dependencies sought professional assistance. Prejudice and discrimination have also been shown to influence treatment behaviour, from attendance at self-help or therapy groups to compliance with medication.

The negative stigma can also affect people's access to treatment for substance use problems. Someone with a problem may be reluctant to seek help (even through "anonymous" support groups) for fear of society's reaction if they were found to have a substance use problem. Another example is if someone commits a petty theft to get money to buy drugs or alcohol: the criminal behaviour is usually the focus, when what the person really needs is treatment for their addiction.

There is also evidence to suggest that community attitudes and discriminatory behaviours toward mental disorders and addictions may help determine a person's degree and speed of recovery. For example, researchers have found that schizophrenia has a better prognosis, or outcome, in developing nations not because of better medical treatment but because of societal reaction and integration of the person into the community. In other words in a culture where there is less stigma attached to psychiatric disorders this attitude is in itself helpful to the addict or patient.

(The research cited above was retrieved from:
www.heretohelp.bc.ca/publications/factsheets/stigma )

An excellent educational kit which can be used to good effect with carers and addicts alike in order to explore the entire topic of stigma and how to deal with this phenomenon is available at:
www.camh.net/About_Addiction_Mental_Health/Concurrent_Disorders/beyond_the_label_toolkit05.pdf
Here is an overview of the aim of the package:
Intended audience
Those of us who provide addiction and mental health services have a critical role to play in addressing stigma. We know only too well the barrier that stigma creates when someone is trying to access treatment or support. Yet ironically, we often hold unexamined prejudices or misconceptions of our own. Beyond the Label is intended to support people working in the fields of mental health and/or addiction treatment by providing them with an interactive framework to discuss, learn, understand and reflect on the impact of stigma on people living with concurrent mental health and substance use problems.

3.5 Social control
Addiction is undoubtedly viewed as a form of deviance. Deviance is clearly a social construct – an act can only be viewed as in some way deviant if it is seen by the majority of society as problematic. Killing in war for instance can be viewed as state sanctioned murder or an act of patriotic heroism depending on one’s stance.

The idea that being labelled as in some way deviant is a form of social control was first mooted in the 1960’s by sociologists such as Howard Becker. Deviance, like beauty, is in the eye of the beholder and once society labels one, to a certain extent one is controlled by stereotyping at the very least.  This does not mean that being labelled is all negative. At times, as we have already seen, medical assistance is only forthcoming for those who are labelled or diagnosed. The problem is when the label becomes all-defining – an individual is viewed solely as an addict and other aspects of the person are ignored – this is known as the deviant act and resulting label of deviant, assuming Master Status.  Addicts are therefore at risk once they are labelled as such of being seen in a one dimensional manner by society at large and indeed the very professionals who are sanctioned to assist them.

The psychology and sociology of deviance and labelling theory is a complex and fascinating one. The following two web pages provide a detailed and intriguing overview of this subject.
www.goldenessays.com/free_essays/4/sociology/labelling-theory.shtml
www.accessmylibrary.com/article-1G1-174595743/drug-addiction-between-deviance.html

As with all labels it is possible to subvert the process and in effect define oneself as an addict, thus wresting back a measure of control over one’s own life. Some adherents of 12 Step Recovery Programmes in effect do this. We can thus see that the entire area of labelling as with so much in addiction is a multi-faceted issue in which there are no simple answers.

“Throughout history, the prevailing attitude toward addiction has been one of disapproval, even repugnance. Addiction was seen as a personal failing, one that resulted from moral weakness and a lack of discipline. At best, addiction was a bad habit, at worst, a sin.

Although addiction has not entirely lost its stigma, an increasing body of scientific research has improved people’s understanding of and sympathy for the problem. One major development in addiction research is the theory that addiction is primarily a biological phenomenon.”

www.enotes.com/addiction-article

 

Video This video looks at the reality of living as a heroin addict  

 

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4. Causes of Addiction

As we said in the Introduction, the field of addiction is contested terrain. This is not only with regard to labelling and terminology. This debate continues when looking at the causes of addiction. As with many psychiatric conditions and psychological constructs, there has been an on-going debate around Nature versus Nurture when it comes to establishing an etiology of addiction. As we might imagine there are those working and theorising in the field who come down heavily on either one side or another. The two extremes postulated can be crudely described as purely physiological or purely environmental. However the most productive view seems to be one which caters for both.

The major drug-addiction-research institutes, such as the National Institute on Drug Abuse (NIDA) in the United States, regard drug addiction as a disease of the brain that may eventually be treated by various pharmacological methods. This approach is certainly more progressive than those that treat addicts as delinquents who must be punished.

But the phenomenon of drug addiction is far broader than its neurobiological corollaries alone. Even just to define it, its psychological and social dimensions must also be considered. For example, the problem with methadone treatments for heroin addicts lies not so much in the pharmacology of methadone as in the fact that patients perceive the system that provides these treatments as rigid, controlling, and oppressive. Drug addicts’ social isolation also makes it hard to reach them, earn their trust, and ultimately, offer them pharmacotherapy; see, for example:

The Canadian Institute of Neurosciences, Mental Health and Addiction
http://thebrain.mcgill.ca/flash/a/a_03/a_03_p/a_03_p_par/a_03_p_par.html#2

 

Video This video explains the theory of the role chemicals play in addiction  

 

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4.1       Theories of Addiction
Increasingly, as we shall see, research indicates that the causes of addiction, particularly substance dependence, are deeply connected with the dopaminergic reward system. Before we look at this theory in more detail, let us briefly outline some of the main theories about the causes of addiction. These have been developed primarily by looking at substance dependency; as we shall see there is increasing evidence that other addictions may follow similar patterns. In the theories that follow there is general agreement that even substance abuse comprises both physiological and behavioural strands.

4.1.1   Pleasure vs. Pain
In this theory, the underlying principle is that of hedonism which postulates that people seek pleasure and avoid pain. Such theorists believe that that dependency develops via positive reinforcement (a behaviourist term) as people take substances in order to replicate a pleasant experience. The theory had its heyday in the 1980’s and was based on research done on self-stimulation in the 50’s. Limitations have become apparent with this theory in later developments.

4.1.2   Negative Reinforcement
This is another theory based on behaviourist principles in which it is claimed that avoidance of the negative experience of withdrawal, i.e. the wish to alleviate the suffering caused by withdrawal is the prime reason addicts continue to use substances compulsively. The problem with this theory is that patients, who are prescribed opiates for physical pain, seldom develop severe withdrawal when the prescription protocol is followed. A further limitation of this theory is that even addicts who have experienced the full horror of severe withdrawal from a drug such as heroin will relapse, despite the fact that they know they will probably have to experience withdrawal again at some point in their lives.

4.1.3   Opponent Process and Environmental theory
This theory, developed originally by Solomon and Corbitt, in the 1970’s, combines the hedonistic search for euphoria with the avoidance of the pain of withdrawal. Following on this other researchers have posited that addiction is aberrant learnt behaviour in which the very powerful habit of reward stimulus response is pursued. This is based on the discovery that the reward circuit is involved in learning particularly with regard to recall of pleasurable rewards. Whilst this is useful in that it accounts for the undoubted effect of environmental dependencies, it too has limitations.

This theory states that drug dependent addicts are afflicted with a dysfunction or impairment of the systems of the frontal cortex of the brain which normally regulates decision making. This system also imposes the inhibition of certain behaviour. When the system is impaired, altered judgement and impulsiveness are the result. There is research that shows that the brains of risk-takers function differently to those of non-risk takers. In high novelty-seeking individuals the brain is less able to regulate dopamine, and this may lead these individuals to be particularly responsive to novel and rewarding situations that normally induce dopamine release

4.2       The role of Dopamine
In terms of neurological research, the most interesting and plausible theories are based on the role that the brain neurotransmitter dopamine plays in the pursuit of addictive behaviours. We will look briefly at three theories based on this and then go on to look at a specific piece of research which whilst incorporating the dopaminergic system, is new and cutting edge and posits addictive gambling  as the epicentre of the addiction debate.

(Adapted partly from: http://en.wikipedia.org/wiki/Dopamine)

4.2.1   Dopamine and reward seeking
Dopamine is a neurotransmitter that, amongst other things, plays a role in reward and motivation. One approach to addiction theorises that the mere presence of a possible reward, even one which is not immediately accessible, can cause the dopaminergic system to start producing more dopamine. Experiments with animals show that simultaneously with this increase in production, the animal begins to exhibit approach-type behaviour to the reward. This led some researchers to declare that this demonstrates that drug-seeking behaviour can be disassociated from the satisfaction that drugs provide. In this view, drug addicts have an exacerbated desire for their drug of choice, and the pleasure that it actually provides them with becomes secondary. This theory actually proposes that dopamine drives only the drug-seeking activity, while the experience of pleasure is triggered by other neural pathways.

4.2.2   Dopamine levels
One hypothesis focuses on the idea that individuals’ attitudes toward drugs depend essentially on whether the baseline activity of the dopaminergic neurons in their brains is above or below a certain level. If it is above this level, the individual experiences satisfaction. If it is below, the individual experiences a craving. There is an interesting analogy here with theories that individuals perceive and assess the intensity of pain by comparing it with subtler but related sensations experienced earlier.

4.2.3   Dopamine and risk taking
There is a theory which states that drug dependent addicts are afflicted with a dysfunction or impairment of the systems of the frontal cortex of the brain which normally regulate decision making.  This system also imposes the inhibition of certain behaviour. When the system is impaired, altered judgement and impulsiveness are the result. As already stated, there is also research that shows that the brains of risk-takers function differently to those of non-risk takers. In high novelty-seeking individuals the brain is less able to regulate dopamine, and this may lead these individuals to be particularly responsive to novel and rewarding situations that normally induce dopamine release. This could include addictive behaviours which are risky.

 

For a much more detailed description of Dopamine and how it functions in the body you can look at:
http://en.wikipedia.org/wiki/Dopamine

 

4.3       Dopamine and Neuroeconomics

An intriguing book which combines the description and analysis of much research into the study of addiction, particularly gambling addiction, with neuroeconomic theory is Midbrain Mutiny: The Picoeconomics and Neuroeconomics of Disordered Gambling (2008) by Don Ross, Carla Sharp, Rudy E. Vuchinich, David Spurrett ; MIT Press London.
(also available as an e-book at: http://mitpress-ebooks.mit.edu/product/midbrain-mutiny-picoeconomics-neuroeconomics-disordered-gambling.)

Briefly Neuroeconomics can be described as the study of decision making:
Exploration into the criteria on which we base our decisions concerning the utilization of resources and the processes by which we compare new information with outcomes of past decisions incorporates elements of economics and psychology. When these realms of human behavior are combined with neuroscience, there emerges neuroeconomics.”
http://www.britannica.com/blogs/2009/07/neuroeconomics-studying-how-we-make-decisions/

The book outlines addiction in neuroeconomic terms as chronic disruption of a chronic nature between the balance of the midbrain dopamine system and the prefrontal and frontal serotonergic (another neurotransmitter linked to the pleasure sensations) system. Most significantly for those interested in addiction, it provides a very comprehensive review of much recent research related to addiction in general and gambling addiction in particular, as well as evidence from trials testing the effectiveness of anti-addiction drugs. The authors make a compelling case that pathological gambling is a true addiction and that addictive gambling is the basic form of addiction, which reveals the essential character of all addiction. As we saw earlier, the DSM V compilers likewise equate gambling with addiction in the same manner as previously reserved for substance dependence.

As the authors state:

We think that recent neuroscience strongly suggests that addiction is an internally governed kind of state that, in addicts, sufficiently dominates ecological variables as to be behaviourally stable and salient across ecological (including social) contexts. We all argue that this is particularly evident when one understands addictive responses by reference to the neuroeconomic model of the dopaminergic reward system. (pg14)”

Later in the Introduction, the authors explain the title of their work thus:
(We) then present(s) the structure of and empirical evidence for the emerging neuroeconomic model of addiction as a distinctive pathology afflicting a functionally and chemically specifiable part of the brain, known as the dopamine reward system. In consequence (probably) of interacting contributions from genetically inherited vulnerability and developmental contingencies, this system can usurp control of the motivational, attentional, and even cognitive and conscious aspects of the whole person. In effect, this midbrain circuit commits mutiny against the normal personal control apparatus. For reasons explained by the neuroeconomic model, the dopamine mutineer, considered as an economic agent, then maximizes its utility by relentlessly pursuing goods with certain properties that the targets of addiction all share.
It is often supposed that these properties must be, or must reside in, exogenous (external) chemicals that addicts introduce into their bodies by ingesting substances. The best evidence that this is not the case comes from empirical application of the neuroeconomic model of addiction to pathological gambling … Pathological gambling, we conclude, is not only genuine addiction in the neuropsychiatric sense … it is the variety of addiction which, by involving minimal incidental effects on other brain processes of the sort brought about by exogenous  (external) chemicals, provides the cleanest window on addiction as an endogenous neuroeconomic / neurochemical phenomenon. Simply put, pathological gambling is the basic form of addiction, the form on which drug addictions are then special complications for purposes of general understanding. (pg 16) “

Although some social scientists might feel that the role of neuroeconomics is overstated in this book, we believe it is worth serious attention by those interested in the field of addiction not least because it resolves some of the tension between behaviourism and physiological arguments by incorporating both and because it represents a very viable and fruitful model for further research.

In their own words this comprehensive and meticulously researched text offers a way forward in an arena at times mired in either/or heated debates. Thus:

The view to which we have been led by consideration of empirical evidence fits neither the neat model of addiction as an endogenous disease nor the clinically defeatist model of addiction as an irredeemably complex social syndrome enmeshed in so many layers of cultural and moral construction that it is better handed over from scientists to novelists and oral historians. We are convinced that addiction is complicated, but comprehensible, subject to some robust generalizations, and potentially much more effectively treatable than is usually assumed in popular discussions. “(pg 10)

As we might imagine, the supposed or hypothesised causes of addiction will often determine the preferred or recommended treatment option.

Point to Ponder
What do you imagine some powerful environmental factors leading to substance abuse might be? From time to time, as currently in the Western Cape, entire communities seem to be affected by massive substance abuse problems, in this case “tik”. What circumstances do you think there might be in a community that would lead to this level of abuse? Remember that a large number of these people using will not be addicts in the narrowly defined sense of the word but will certainly be problem users or abusers.