| "Addictive" redirects here. For the 2002 R&B single by Truth Hurts, see "Addictive (2002 song)".
Addiction is an uncontrollable compulsion to repeat a behavior
regardless of its negative consequences. A person who is addicted is sometimes called an addict.
Many drugs or behaviors can precipitate a
pattern of conditions recognized as addiction, which include a craving for more of the drug or behavior, increased physiological tolerance to exposure, and withdrawal symptoms in the absence of the stimulus. Most drugs and behaviors that
directly provide either pleasure or relief from pain pose a risk of dependency. Addictions can also be formed due to opponent process reactions. For example the terror of
jumping out of an airplane is rewarded with intense pleasure when the parachute opens. Because of opponent process criminal
behavior, running, stealing, violence, acting, test taking can become habit forming.
Varied forms of addiction
The medical community now carefully distinguishes between physical dependence (withdrawals) and psychological addiction (or simply addiction). Addiction is now narrowly defined
as "uncontrolled, compulsive use despite harm"; if there is no harm to the patient or another party, there is no addiction. The
obsolete term physical addiction is deprecated because of its pejorative connotations, especially in modern pain
management with opioids where physical dependence is nearly universal but addiction is rare.
Physical dependency on a substance is defined by the appearance of characteristic withdrawal symptoms when the drug is suddenly discontinued. While opioids, benzodiazepines, barbiturates,
alcohol and nicotine are all well known for their ability to induce physical dependence, other drugs share this property that are
not considered addictive: cortisone, beta-blockers and most antidepressants are examples. Also, some highly addictive drugs, such
as cocaine, induce relatively little physical dependence. So while physical dependency can be a major factor in the psychology of
addiction, the primary attribute of an addictive drug is its ability to induce euphoria while causing harm.
Some drugs induce 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, most notably Effexor and Paxil, as they have quite short half-lives, so stopping them abruptly causes a more rapid change in the neurotransmitter balance in the
brain than many other antidepressants. Many non-addictive prescription drugs should not be suddenly stopped, so a doctor should
be consulted before abruptly discontinuing them.
Psychological addictions are a dependency of the
mind, and lead to psychological withdrawal symptoms. Addictions can theoretically form for any rewarding behavior, but typically
only do so in individuals with emotional, social, or psychological
dysfunctions, taking the place of normal positive stimuli not otherwise attained (see Rat Park). The distinction between the two kinds of addictions, however, is not always easy to make. Addictions
often have both physical and psychological components.
There is also a lesser known situation called pseudo-addiction, where a patient will exhibit drug seeking behaviour reminiscent of psychological
addiction, however in this case, the patients tend to have genuine pain or other symptoms that have been undertreated. Unlike
true psychological addiction, however, these behaviours tend to stop as soon as their pain is adequately treated.
Not all doctors do agree on what addiction or dependency is. However, researchers, doctors, and popular literature discuss
many addictions, including those to alcohol, tobacco, drugs, gambling, food, and even sex, pornography, computers work, and
shopping / spending.
While eating disorders, like other behavioral addictions, are
usually considered primarily psychological disorders, they are sometimes treated as addictions, especially if they include
elements of addictive behavior. Sufferers may experience withdrawal or withdrawal-like symptoms if they alter their diet
suddenly. This suggests that some common food substances, especially chocolate,
caffeine, and sugar, may have the potential
for addiction.
The speed with which a given individual becomes addicted to various substances varies with the substance, the frequency of
use, the means of ingestion, and the individual. Some alcoholics report they
exhibited alcoholic tendencies from the moment of first intoxication, while most people can drink socially without ever becoming
addicted. Nicotine is considered by many to be the most addictive substance in the
world.
Methods of care
Early editions of the American
Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders described
addiction as a physical dependency to a substance that resulted in withdrawal symptoms in its absence. Recent editions, including
DSM-IV, have moved toward a diagnostic instrument that classifies such conditions as dependency, rather than addiction. 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
according to clinical assessments in six areas, including:
- Acute intoxication and/or withdrawal potential
- Biomedical conditions or complications
- Emotional/behavioral conditions or complications
- Treatment acceptance/resistance
- Relapse potential
- Recovery environment
Some medical systems, including those of at least 15 states of the United States, refer to an Addiction Severity
Index to assess the severity of problems related to substance use. The index assesses problems in six areas: medical,
employment/support, alcohol and other drug use, legal, family/social, and psychiatric.
While addiction or dependency is related to seemingly uncontrollable urges, and may have roots in genetic predisposition,
treatment of dependency is always classified as behavioral medicine. Early treatment of acute withdrawal often includes medical
detoxification, which can include doses of anxiolytics to reduce symptoms of
withdrawal. In chronic opiate addiction, a surrogate drug such as methadone is
sometimes offered as a form of opiate replacement
therapy. But treatment approaches universally focus on the individual's ultimate choice to pursue an alternate course of
action.
Therapists often classify patients with chemical dependencies as either interested or not interested in changing. Treatments
usually involve planning for specific ways to avoid the addictive stimulus, and therapeutic interventions intended to help a
client learn healthier ways to find satisfaction. Clinical leaders in recent years have attempted to tailor intervention
approaches to specific influences that effect addictive behavior, using therapeutic interviews in an effort to discover factors
that led a person to embrace unhealthy, addictive sources of pleasure or relief from pain.
| Treatment Modality Matrix |
| Behavioral Pattern |
Intervention |
Goals |
| Low self esteem, anxiety, verbal hostility |
Relationship therapy, client centered approach |
Increase self esteem, reduce hostility and anxiety |
| Defective personal constructs, ignorance of interpersonal means |
Cognitive restructuring including directive and group therapies |
Insight |
| Focal anxiety such as fear of crowds |
Desensitization |
Change response to same cue |
| Undesirable behaviors, lacking appropriate behaviors |
Aversive conditioning, operant conditioning, counter conditioning |
Eliminate or replace behavior |
| Lack of information |
Provide information |
Have client act on information |
| Difficult social circumstances |
Organizational intervention, environmental manipulation, family counseling |
Remove cause of social difficulty |
| Poor social performance, rigid interpersonal behavior |
Sensitivity training, communication training, group therapy |
Increase interpersonal repertoire, desensitization to group functioning |
| Grossly bizarre behavior |
Medical referral |
Protect from society, prepare for further treatment |
| Adapted from: Essentials of Clinical Dependency Counseling, Aspen Publishers |
Diverse explanations
Several explanations (or "models") have been presented to explain addiction:
- The moral model states that addictions are the result of human weakness, and
are defects of character. Those who advance this model do not accept
that there is any biological basis for addiction. They often have scant sympathy for people with serious addictions, believing
either that a person with greater moral strength could have the force of will to break an addiction, or that the addict
demonstrated a great moral failure in the first place by starting the addiction. The moral model is widely applied to dependency
on illegal substances, perhaps purely for social or political reasons, but is no longer widely considered to have any therapeutic
value. Elements of the moral model, especially a focus on individual choices, have found enduring roles in other approaches to
the treatment of dependencies.
- The opponent-process model generated by Richard Soloman states that for every psychological event A will be followed
by its opposite psychological event B. For example the pleasure one experiences from heroin is followed by an opponent process of
withdrawal. This model is related to the opponent process color theory. If you look at the color red then quickly look at a gray
area you will see green. There are many examples of opponent processes in the nervous system including taste, motor movement,
touch, vision, and hearing.
- The disease model holds that addiction is an illness, and comes about as a
result of the impairment of healthy neurochemical or behavioral
processes. While there is some dispute among clinicians as to the reliability of this model, it is widely employed in therapeutic
settings. Most treatment approaches involve recognition that dependencies are behavioral dysfunctions, and thus involve some
element of physical or mental disease.
- The genetic model posits a genetic predisposition to certain behaviors.
It is frequently noted that certain addictions "run in the family," and while researchers continue to explore the extent of
genetic influence, there is strong evidence that genetic predisposition is often a factor in dependency. Researchers have had
difficulty assessing differences, however, between social causes of dependency learned in family settings and genetic factors
related to heredity.
- The cultural model recognizes that the influence of culture is a strong
determinant of whether or not individuals fall prey to certain addictions. For example, alcoholism is rare among Saudi Arabians, where obtaining alcohol is difficult and using alcohol is
prohibited. In North America, on the other hand, the incidence of gambling
addictions soared in the last two decades of the 20th century, mirroring
the growth of the gaming industry. Half of all patients diagnosed as alcoholic are born into families where alcohol is used
heavily, suggesting that familiar influence, genetic factors, or more likely both, play a role in the development of
addiction.
- The blended model attempts to consider elements of all other models in developing a therapeutic approach to
dependency. It holds that the mechanism of dependency is different for different individuals, and that each case must be
considered on its own merits.
- The habit model proposed by Thomas Szasz questions the very concept of "addiction." He argues that addiction is a metaphor, and that the
only reason to make the distinction between habit and addiction "is to persecute somebody." (Szasz,
1973) (http://www.szasz.com/drugsandfreedom1973.html)
Physiological basis
Although the term addiction is sometimes often used loosely rather than as a medical classification, there are some
physiological conditions related to everyday behaviors that are also related to the more commonly recognized mechanisms
associated with addiction. Pleasurable activities cause the release of endorphins, and this endorphin-rush can conceivably become 'addictive'. Evolutionary biologists have suggested
this process of attentuating pleasure pathways is part of the brain's natural system for ensuring that humans develop abiding
interests. Since human societies depend on enduring attachments, many theorists suggest such addictions are not necessarily a
problem. Other views, such as the those summarized in Buddhist concept of tanha, suggest
trivial attachments are at the root of much human suffering.
The pathways oriented to endorphins, sometimes called pleasure centers originated in small organisms such as insects,
which rely on the neurological system to help them find familiar sources of food.
Endorphins stimulate activity of the neurotransmitter dopamine after initially activating opioid receptors earlier in the nervous circuit.
Increased dopamine activity is often met by a decrease in the number of receptors sensitive to dopamine. This process is called downregulation. The decreased number of receptors tends to result in reduced electrical activity along
post-synaptic nerve pathways, unless some behavior or substance causes a continued high level of dopaminergic stimulation. The
absence of a pleasurable sensation in conditions that were formally sufficient can cause a mild feeling of let-down after
receptors have been downregulated. The increased requirement for dopamine to
maintain the same electrical activity is the basis of both physiological tolerance and withdrawal associated
with addiction.
The middle striatal reward pathway has been most strongly linked with addictive and reward behavior. This pathway utilizes
dopamine as a neurotransmitter and receives presynaptic input (from earlier in the circuit--it gets signals from these earlier in
the circuit cells) from cells that respond to cannibinoids, nicotine (receptor subtype is nicotinic), and from cells that respond
to endogenous opioid substances such as endorphins or enkephalins. Cells that are said to respond to a particular
neurotransmitter (or agonists) contain, at the postsynaptic end (receiving area of the cell) receptors for that
neurotransmitter.
In cases of physical dependency on depressants of the central nervous system such as opioids, barbiturates, or alcohol, the absence of the substance sometimes leads to symptoms of
severe physical discomfort and withdrawal can even result in death from alcohol and barbiturates (but is generally only very
uncomfortable in the case of opioids despite media disinformation to the contrary). In these cases, a body has become so
dependent on a chemical that it has stopped producing the necessary neurotransmitters required to maintain a comfortable
status.
Opioids present extreme risks of dependency because they are chemically similar to
endorphins, causing an upregulation of dopaminergic receptors without stimulation of the endorphin systems. Cocaine and amphetamines also pose risks
associated with physical attenuation, in both cases because they cause increasees in the levels of the neurotransmitters dopamine
and norepinephrine which acts indirectly to stimulate dopaminergic
pathways in the brain.
Casual addiction
The word addiction is also sometimes used colloquially to refer to something a person has a passion for. Such "addicts"
include:
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