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.