In a recent “interview” in The Guardian newspaper Marc Lewis once again forwarded his ideas that addiction is not a disease but a condition of aberrant learning.
His ideas are laid out in more detail in his book The Biology of Desire – a book I have not read and have little intention to do so as I had the misfortune to buy his previous book, Memoirs of an Addicted Brain, which was so badly written I gave up half way through. If there was a category award for writing about drugs badly in the same way one writes about sex badly then Marc Lewis’ book would surely be a contender.
His remembering of his drug experience was punctuated by asides detailing, in terms of neurobiology, what was going on in his brain while he was getting high, e.g. surges of dopamine etc etc.
It was as dry a read on drugs as one good imagine and often quite unintentionally hilarious.
That aside, the fact he is a poor writer does not mean he is not a gifted neuroscientist or that his ideas on addiction are not well researched and presented.
Let’s get to the point – Marc Lewis does not believe the view that addiction is a disease, kinda.
He feels this definition, born of the marriage between medicine and neuroscience, is based on the finding that the brain changes with addiction is not correct.
In the Guardian, he writes “A counter argument is gathering momentum. Many are coming to see addiction as a learned pattern of thinking and acting – a pattern that can be unlearned”. He offers no references or researchers to support this view.
He continues that “As a neuroscientist, I recognise that the brain changes with addiction, but I see those changes as an expression of ongoing plasticity in an organ designed to change with strong emotions and repeated experiences. Similar changes have been recorded when people fall in love, become obese, gamble compulsively, or overindulge on the internet.”
He furthers, “I see addiction as an attitude or self-concept that grows and crystallises with experience, often initiated by difficulties in childhood or adolescence. Indeed, addiction is in some ways like a disease, but that’s only half the story.” Although he, at no point attempts to define the concept, he only half agrees with? Namely he does not define disease as such. So we are not sure what his issue is with the term as he has not operationlised a term around which to debate
He often refers to Johan Hari in his writing – see my recent blog Nearly Everything Hari Thinks He Knows About Addiction Is Wrong – and like Hari there is little or no acknowledgement of the neuroplastic effect abusive upbringing, childhood or trauma (including developmental trauma) has on the brain. There is no mention of altered stress systems in the brain on whether these can be “relearned too”? Or whether they can ever return to “normal” via the effects of learning based neuroplasticity?
He states that for some, without including himself, that “the disease label isn’t just wrong, it’s repugnant – it’s a rationale for helplessness and an obstacle to healing.”
He continues, “I hated being told I had a disease,” wrote a recent commenter on my blog. “I am not diseased… I don’t have a disease. I had past traumas, environmental factors and learned behaviours… I feel I have learned new things… new skills opened up… new pathways that were underdeveloped.”
We are not told which “new pathways” these are? At least we have mention of past traumas. The majority of a addicts, substance and behavioural, seem to have suffer previous trauma and neglect, maltreatment which seems to alter stress systems.
Hari does not mention trauma in his writings on Vietnam vets although many had come back from one of the most traumatic wars ever traumatised and continued to suffer PTSD.
Many continued to suffer from alcohol and substance abuse disorders too. Although Hari fails to mention this?
Like Hari, I find Lewis’ work quite glib and simplistic, superficial almost, particularly on this area of trauma and stress dysregulation.
Trauma alters the brain in such a profound way, in terms of neuroplasticity, that individuals will find in more difficult processing and regulating their emotions, have diminished control over stress and emotion distress, and this has knock on effects in terms of distress based impulsivity and poor decision making.
Lewis mentions a debate with another neuroscientist. He fails to mention it was George Koob who has long researched into how the brain becomes more dysregulated in terms of stress systems during the addiction cycle, how addicted people become more alexithymic – they have difficulty coping with emotions as they find it difficult reading, labeling and articulating emotions into feelings that can be used into a adaptive goal directed manner.
Instead they fail to differentiate emotion and put words to these emotions which means that decisions are not based on conscious reasonable, cortical areas of the brain. Instead most addicted individuals often react to undifferentiated emotions, which are unpleasant and distressing via an urge to relieve this distress via the means normally used to discharge distress, namely via compulsive repetitive behaviours.
These stress and emotion processing (alexithymic) deficits are seen commonly across a wide range of addictive disorders from eating to drug addiction.
So, as Lewis suggests, if addiction is a learning and memory issue, then it is stress and emotion distress doing the teaching.
Lewis believes that learning in the brain is dopaminergic (as is memory, although other neurochemicals like stress chemicals and glutamate are also heavily implicated – in fact is stress chemicals consolidate and prompt implicit memories or habit or schema memories, memories that are activated by stress/distress as in addiction) and does not really consider the reciprocal and interacting relationship between stress chemicals and dopamine throughout the addiction cycle.
To do so is to miss half the story as he muses.
Lewis, in a blog on his website , he mentions a debate he had with Dr George Koob.
Lewis mentions swatting up on some disease model stuff prior to the debate ” lots of stuff on changes to the dopamine system, Berridge’s review of his incentive sensitization model, findings on the desensitization of the striatum and the resultant loss of connectivity with the prefrontal cortex.” This last minute revision does not suggest a person who has thoroughly researched the area he is attacking.
It comes across as a bit sloppy. A bit glib.
Lewis also swats on Koob’s work as well?
I believe that there are limitations in the approach of Lewis in terms of his understanding of brain mechanisms just as I do with Koob or Nora Volkow, the other “high priest of the Disease Church” as Lewis refers to her (is such language helpful?)
In fact I also find Berridge limiting as I do other researchers who concentrate mainly on dopamine networks as the cause of addiction. Dopamine constantly interacts with other neurotransmitters and stress chemicals and does not act in isolation in the brain.
Research shows that stress systems are altered in those with childhood maltreatment and that this altered stress impacts directly on a variety of dopaminergic networks within the human brain. There is no purely dopaminergic phase in the addiction cycle for addicts, in the majority of cases.
It is stress doing the teaching and the learning and the memory, often using dopamine to dig it’s neuro-plastic furrows throughout the brain.
This is a point that most researchers, including Lewis, seem to be missing.
The idea Lewis forwards is that it is dopamine which is involved in reward related learning that eventually causes the habitual behaviour of “addiction” – this is barely a new idea as Stephen Hyman has been discussing the idea of addiction a disease of learning and memory for many years.
Dopamine is also involved in attention, reward, motivation, emotion, stress response and behavioural control as well as in learning and memory.
Even if we said addiction was not a disease, or more correctly a neuro-biological disease or a brain disorder, to quote a recent definition by the the America Society of Addiction Medicine, there is a central point being missed by all these people and organisations.
Namely, that in the majority of addicts, there is a stress based alteration in dopaminergic “extended reward” networks, of above, or “survival networks in the brain. It is altered stress systems which become in charge of survival, however maladaptive.
“We suggest that there is not only direct interaction of dopaminergic and stress systems throughout the addiction cycle, from initial use, via the abusing stage, to the endpoint of addiction, but that this interaction is present prior to initial use. A combination of genetic factors and/or experiences of adversity may result in a stress-triggered sensitisation of dopaminergic networks which is present before the onset of substance use, which cannot be explained solely in terms of dopaminergic (positive) reinforcement.
Rather these processes are best explained by an allostatic model which reconciles aspects of both models of addiction and shows how dopamine/stress interactions become increasingly pathological in the addiction cycle…. A multi-circuit explanation of how this cumulative effect of stress increasingly impacts on dopaminergic networks of reward, affect, attention, memory and behavioural control” can be viewed in this excellent review here (1).
Altered stress systems often cut off cortical parts of the brain or explicit memory parts of the brain in favour of dealing reactively with environmental situations which are perceived as threatening. It does so unthinkingly, implicitly, via subcortical and motoric parts of the brain. In other words it acts in a “fight or flight” way to most basic life challenges. It makes the most innocuous decisions based on a distress prompted impulsiveness. It is thus, we as addicts are never fully in charge of the decision making process. Implicit processes often make the decisions for us.
How do we seek to relearn this then?
Even if you do not agree with the term disease, surely the above could at least be described as a disorder. A disorder of decision making and thinking which are both the product of disordered reacting to distress.
Why not call it an affective disorder which, for some, results in the maladaptive regulation of emotion via external mechanism, namely the taking of substances or engaging in maladaptive, compulsive behaviours.
In order to re-learn more positive behaviours and habitualise these we must first, in terms of treatment, seek to treat that affective disorder, which is based on a neuroplasticity which renders the amgydaloid area of the brain hyperactive.
It is amgydaloid hyperactivity, implicated in the emotion dysergualtion seen in most affective disorders, which cuts of the prefrontal cortex area of the brain in favour of more motoric responding, to relieve distress (which is what compulsion is, automatic behaviours to relieve distress).
One way for treatment would be to quieten this amgydaloid area not only via “spiritual” means like meditation, mindfulness, prayer etc but also to teach as the above commentator mentioned above “new skills”.
These new skills need to revolve around coping with chronic stress reactivity, a reactivity often based on an inherent, often genetically inherited, emotion processing and regulation deficit, which can he treated via emotion literacy, and talking to someone to identify, label, share and process emotion to the extent that neuropalsticity via this improved emotion regulation reconnects with the cortical reasonable part of the brain, to start to regain control over behaviour.
Whatever you call it, limited control over behaviour is at the heart of addiction.
I believe 12 step sponsors and members do this is on a daily basis, across the world. This is one of the reasons 12 step groups work, the sharing of emotions, in order to articulate feeling and make decisions more adaptively based on how we feel.
For decades I had not the foggiest idea of what I was feeling. I could talk about my feelings, just could not feel them enough in order to make the right decisions for me and those around me.
I use the term emotion disease for lyrical reasons as well as because it strikes a cord with those like me who are in recovery from addictive behaviours.
I am not saying it is a disease. Although I don’t mind you calling it that. I don’t call it a spiritual malady although I don’t mind you doing so.
I don’t mind it being called a developmental delay disorder leading to deficits in affective regulation either.
Too often the debate is semantic.
It is what I feel I have is what I recover from. If I feel you have recovered from what I feel I have, then I will listen to how you recover from it.
I feel my feelings, articulate them and make adaptive decisions which not only reduce my impulsive tendencies but which appear to generally benefit me and my loved ones and wider society. This is good enough for me.
If I followed Marc Lewis, Johan Hari, Stanton Peele etc etc I believe I would not be writing this blog as I believe I would be dead. I do not believe a person who suffers what I suffer can stay sober let alone recover via their ideas on addiction.
I have not had an intention to have a drink or drug for a long time, which is good for a recovering addict/alcoholic. Although my distress levels have gotten high enough on occasion to automatically pop the idea of these into my head, they have never been chronic or acute even to send me “out there” compulsively, unthinkingly reactively. It has never got so bad that I have shouted the relapse mantra of “Fuck It!”
The main reason for that is because I share how I am feeling, even the really scary stuff, especially the scary stuff, with loved others and those in recovery who know the score.
I will not be telephoning Koob, Volkow, Hari or Lewis for that. Just those who I know and who know the score.
I hasten to add I have not only benefited from that fatalistic 12 step program co-founded by two “last gasper” drunks like myself but in recent months benefited greatly from EMDR therapy to treat my 45 year old complex PTSD which as greatly reduced the distress out of my bones.
The distress I have partly, if not mainly, as the built up resonating, reverberating unprocessed, undifferentiated soul crushing emotions from the past, which has haunted and provoked my actions, decisions and behaviours for far too long.
Get the distress out of your bones, that is what I suggest, somehow, if you are like me.
- H Johnston, J., EJ Linden, D., & BM van den Bree, M. (2016). Combining Stress and Dopamine Based Models of Addiction: Towards a Psycho-Neuro-Endocrinological Theory of Addiction. Current drug abuse reviews, 9(1), 61-74.
I love you!
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Now that that’s out of my system, there’s an experiment where rats are conditioned to expect a foot shock when they hear a bell. Later they stop administering the shock and the rats gradually decondition. But if the rat’s medial PFC is removed it never deconditions. So the devolved circuit goes: emotional stimulus > sensory thalamus > amygdala > SNS. With deconditioning it goes emotional stimulus> sensory thalamus > medial PFC > amygdala > integration.
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another rat study showed that drug taking rats had dendritic hypertrophy in the dorsal striatum region of he brain (implicated in habitual, automatic and compulsive behaviours) and pronounced atrophy in the prefrontal cortex over time, clearly showing a shift in behavioural control from cortical to subcortical from explicit to implicit, from conscious and considered, to unconscious and reactive.
Hi Paul – We talk a lot on Facebook but I’m not sure if you’re in the US or the UK? I’d like to invite you and friends in southern California to an Oct. 14 film on Trauma-Informed Care in San Clemente, CA. “Paper Tigers” presents key tools for anyone dealing with healing drug and alcohol abuse. Please forward this to colleagues especially people in southern California. If you have a list in south Orange County, CA, I’d be honored to contact them. Please reply to my email you see here or on Facebook so I can send you the Oct. 14 event flier with “What,Where,When” info. – Hugs, Kathy
Thanks for the invite Kathy, I am in the UK. Hope it went well?
I apologize if you’ve written about this and I missed it but have your read Maia Szalavitz’s “Unbroken Brain?”
Hi Lauren and thanks for the link – I agree to an extent that addiction is a development delay disorder particularly in relation to affective regulation. The point I disagree with is the growing out of addiction. I believe via various treatments we can become more healthy in terms of affect regulation but still find over 10 years into recovery that there is a dim and distant siren of addiction still in my brain. Whether this is due to a the effects of a brain that is still I believe allostatic, i.e. there is still a stress dysregulation which prompts a reward dysfunction and a sense of “deficit” and often wanting more than is required in a given situation. This “wanting” more than is required is fundamental to addictive behaviour. I still suffer the effects of C-PTSD although less than before and I still want more than I need at any given time. This suggest a brain that is not Broken (I do not like this provocative type of language anyway) but I do still have a brain that needs to be managed in terms of constantly finding a “balance” as I doubt it does this wholly by itself. The brain is greatly improved via recovery but to say the condition of addiction is outgrown is dangerous and not a view I would support
Thank you for your response. I just reread this blog post and couldn’t agree more with it. I’ve been sober for 29 years but during the first 24 years only briefly used a sponsor to quickly go through the steps (that’s all that I was capable of at the time). Due to my upbringing with an absent father and a Borderline mother, I don’t think that I was capable of trusting a sponsor. I didn’t really get the point of using one. I looked around the rooms and thought, “how can any of these women help me with my problems?”
At around year 17, I started getting really desperate after almost getting fired due to provocatively opposing the administrators at my job (my constant battle with authority). I started going to a lot of meetings, joined a home group, did service, went on Big Book retreats, etc. Finally, 8 years later, I got a wonderful sponsor and really started talking about what was going on inside emotionally.
Previously, I could never figure out why I could read and understand things like “restraint of tongue and pen” but would then react and blow up at all of the usual triggers. It wasn’t until I really started sharing with a sponsor (and now a therapist too), that some of my behaviors started to change to being less reactive and more reasonable. Now, when I go on speaking commitments, this is what I talk about because I’m sure there are others like me who are too traumatized to really trust a sponsor. Of course the other problem is that there are a lot of messed up people in AA who probably aren’t capable of sponsoring effectively (can’t handle your feelings because they can’t handle their own). Anyway, thanks for your wonderful blog. I’ve always been a little uncomfortable with certain aspects of AA, even while intuitively knowing that it was good for me to attend meetings. I love it that you are writing about why things work rather than just taking it on faith. Faith is still pretty foreign to me although I do pray, even if only to remind myself that I cannot control things.
I relate to so much of your story Lauren. The main difference is that I was nearly dead when I came into recovery and had drunk myself to alcoholic psychosis so it was either trust someone or die – it was only under this extreme condition that I chose and trusted a sponsor (someone with a similar troubled, traumatic background as me too which helped enormously). I still have trust issues today even after extensive trauma treatment. I have learnt there are degrees of trust or circles of trust. Very very few get into the inner circle still but that is the way it is. For me AA was the start of the journey not the destination. I have had other help, professional and spiritual from monks, etc and from my wife. Allowing some to know you completely is the greatest therapeutic tonic I have found.
Many in AA do not sponsor effectively because they have not fully come to understand their condition, many have co-morbid conditions like PTSD and so on.
The 12 steps is not enough if you have C-PTSD.
There is no mention of toxic shame in the Big Book but the majority of people in AA suffer this. The 12 steps helps with our guilt from the past but not so much our shame. With trauma we should not be “turning it over” but turning it around ourselves by talking about our emotions in order to fully understand our feelings. We make better decisions when we know how we are feeling. We do not react as much and become more reasonable.
Much of letting go and letting God can become experiential avoidance, something many of us have been doing all our lives. I am not sure this is a full recovery.
We have to learn to live with our feelings and not react to them.
This is what I have learnt so far.
Hi, I miss your articles/posts and I’m hoping that you are doing/healing well.
Hi Lauren, thanks you for your message. I finished treatment last year and suddenly lost the urge/desire to post. I am not sure I will ever start again. I have also struggled to regain any enthusiasm for academic writing either. I will finishe the current article I am writing and that will be it, I think? Although there may still be a book in me somewhere..? The war in my heart seems to at least have been called to ceasefire, if not over. I feel very different to before I started EMDR treatment, kinda feel like a newish version of me. I also started oil painting as the result of treatment and have had an exhibition already, maybe this will be my new passion, art. I am always here to share with or discuss stuff with, just post a message or contact me via my email firstname.lastname@example.org
Best wishes, Paul
This is very Incredible Post. I got most of the answers which i was searching for. Thanks for sharing this informative post.
EMDR is an effective treatment for trauma. Most addicted people have trauma because substance abuse is a coping strategy for unprocessed trauma. In order for a person with unprocessed trauma to be able to remain sober, it is critical that he processes his past trauma. Because EMDR effectively treats trauma, it is not at all surprising that it helps treat addiction – the coping mechanism for the trauma. I’ve been doing research on EMDR treatments, how it helps and exactly what the pros and cons are.
Should anyone else be interested to see how this would help others here’s the page I looked at https://www.pbinstitute.com/emdr-therapy/
Hopefully, this information can assist someone (friends and families) in choosing the best treatment for someone they love.