Psychological dependency is a dependency of the mind, and leads to psychological withdrawal symptoms (such as cravings, irritability, insomnia, depression, anorexia, etc). Addiction can in theory be derived from any rewarding behaviour, and is believed to be strongly associated with the dopaminergic system of the brain's reward system (as in the case of cocaine and amphetamines). Some claim that it is a habitual means to avoid undesired activity, but typically it is only so to a clinical level in individuals who have emotional, social, or psychological dysfunctions (psychological addiction is defined as such), replacing normal positive stimuli not otherwise attained (see Rat Park).

It is considered possible to be both psychologically and physically dependent at the same time. Some doctors, and especially scientists in related fields, make little or no distinction between the two types of addiction, since the result, substance abuse, is the same, and in terms of scientific as opposed to magical thinking, the "psychological" dependence is entirely due to physical effects of the drug on the brain.

Psychological dependence does not have to be limited only to substances; even activities and behavioural patterns can be considered addictions, if they become uncontrollable, e.g. gambling, Internet addiction, computer addiction, sexual addiction / pornography addiction, reading, eating, self-harm, vandalism, drug addiction or work addiction.

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Addiction and drug control legislation

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Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, hallucinogens (tryptamines, LSD, phencyclidine(PCP), psilocybin) and a variety of more modern synthetic drugs, and unlicensed production, supply or possession may be a criminal offense.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, whilst others rarely cause any form of compulsive need whatsoever. Typically nicotine (in the form of tobacco) is regulated extremely loosely, if at all, although it is well-known as one of the most addictive substances ever discovered.

Also, although the legislation may be justifiable on moral grounds to some, it can make addiction or dependency a much more serious issue for the individual. Reliable supplies of a drug become difficult to secure as illegally produced substances may have contaminants. Withdrawal from the substances or associated contaminants can cause additional health issues and the individual becomes vulnerable to both criminal abuse and legal punishment. Criminal elements that can be involved in the profitable trade of such substances can also cause physical harm to users.

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Methods of care

Early editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) 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 arguably could have roots in genetic predispositions, treatment of dependency is conducted by a wide range of medical and allied professionals, including Addiction Medicine specialists, psychiatrists, and appropriately trained nurses, social workers, and counselors. Early treatment of acute withdrawal often includes medical detoxification, which can include doses of anxiolytics or narcotics to reduce symptoms of withdrawal. An experimental drug, ibogaine,^[15] is also proposed to treat withdrawal and craving. Alternatives to medical detoxification include acupuncture detoxification. In chronic opiate addiction, a surrogate drug such as methadone is sometimes offered as a form of opiate replacement therapy. But treatment approaches universal 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 affect 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

From the applied behavior analysis literature and the behavioral psychology literature several evidenced based intervention programs have emerged (1) behavioral maritial therapy (2) community reinforcement approach (3) cue exposure therapy and (4) contingency management strategies.^[16][17] In addition, the same author suggest that Social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious.

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Diverse explanations

Several explanations (or "models") have been presented to explain addiction. These divide, more or less, into the models which stress biological or genetic causes for addiction, and those which stress social or purely psychological causes. Of course there are also many models which attempt to see addiction as both a physiological and a psycho-social phenomenon.

• The disease model of addiction holds that addiction is a disease, coming about as a result of either the impairment of neurochemical or behavioral processes, or of some combination of the two. Within this model, addictive disease is treated by specialists in Addiction Medicine. Within the field of medicine, the American Medical Association, National Association of Social Workers, and American Psychological Association all have policies which are predicated on the theory that addictive processes represent a disease state. Most treatment approaches, as well, are based on the idea that dependencies are behavioral dysfunctions, and, therefore, contain, at least to some extent, elements of physical or mental disease. Organizations such as the American Society of Addiction Medicine believe the research-based evidence for addiction's status as a disease is overwhelming.

• The pleasure model proposed by professor Nils Bejerot. Addiction "is an emotional fixation (sentiment) acquired through learning, which intermittently or continually expresses itself in purposeful, stereotyped behavior with the character and force of a natural drive, aiming at a specific pleasure or the avoidance of a specific discomfort." "The pleasure mechanism may be stimulated in a number of ways and give rise to a strong fixation on repetitive behavior. Stimulation with drugs is only one of many ways, but one of the simplest, strongest,and often also the most destructive" "If the pleasure stimulation becomes so strong that it captivates an individual with the compulsion and force characteristic of natural drives, then there exists...an addiction" ^[18] The pleasure model is used as one of the reason for zero tolerance for use of illicit drugs

• 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, many researchers argue that there is strong evidence that genetic predisposition is often a factor in dependency.

• The experiential model devised by Stanton Peele argues that addictions occur with regard to experiences generated by various involvements, whether drug-induced or not. This model is in opposition to the disease, genetic, and neurobiological approaches. Among other things, it proposes that addiction is both more temporary or situational than the disease model claims, and is often outgrown through natural processes.

• 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, or the terror of jumping out of an airplane is rewarded with intense pleasure when the parachute opens. 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. Opponent-processes occurring at the sensory level may translate "down-stream" into addictive or habit-forming behavior.

• The allostatic (stability through change) model generated by George Koob and Michel LeMoal is a modification of the opponent process theory where continued use of a drug leads to a spiralling of uncontrolled use, negative emotional states and withdrawal and a shift into use to new allostatic set point which is lower than that maintained before use of the drug.^[19]

• 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. What also needs to be noted is that when people don't gain a sense of moderation through their development they can be just as likely, if not more, to abuse substances than people born into alcoholic families.

• 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 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."^[20] Cf also the life-process model of addiction.

• Finally, 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.

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Neurobiological basis

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The development of addiction is thought to involve a simultaneous process of 1) increased focus on and engagement in a particular behavior and 2) the attenuation or "shutting down" of other behaviors. For example, under certain experimental circumstances such as social deprivation and boredom, animals allowed the unlimited ability to self-administer certain psychoactive drugs will show such a strong preference that they will forgo food, sleep, and sex for continued access. The neuro-anatomical correlate of this is that the brain regions involved in driving goal-directed behavior grow increasingly selective for particular motivating stimuli and rewards, to the point that the brain regions involved in the inhibition of behavior can no longer effectively send "stop" signals. A good analogy is to imagine flooring the gas pedal in a car with very bad brakes. In this case, the limbic system is thought to be the major "driving force" and the orbitofrontal cortex is the substrate of the top-down inhibition.

A specific portion of the limbic circuit known as the mesolimbic dopaminergic system is hypothesized to play an important role in translation of motivation to motor behavior- and reward-related learning in particular. It is typically defined as the ventral tegmental area (VTA), the nucleus accumbens, and the bundle of dopamine-containing fibers that are connecting them. This system is commonly implicated in the seeking out and consumption of rewarding stimuli or events, such as sweet-tasting foods or sexual interaction. However, its importance to addiction research goes beyond its role in "natural" motivation: while the specific site or mechanism of action may differ, all known drugs of abuse have the common effect in that they elevate the level of dopamine in the nucleus accumbens. This may happen directly, such as through blockade of the dopamine re-uptake mechanism (see cocaine). It may also happen indirectly, such as through stimulation of the dopamine-containing neurons of the VTA that synapse onto neurons in the accumbens (see opiates). The euphoric effects of drugs of abuse are thought to be a direct result of the acute increase in accumbal dopamine.^[21]

The human body has a natural tendency to maintain homeostasis, and the central nervous system is no exception. Chronic elevation of dopamine will result in a decrease in the number of dopamine receptors available in a process known as downregulation. The decreased number of receptors changes the permeability of the cell membrane located post-synaptically, such that the post-synaptic neuron is less excitable- i.e.: less able to respond to chemical signaling with an electrical impulse, or action potential. It is hypothesized that this dulling of the responsiveness of the brain's reward pathways contributes to the inability to feel pleasure, known as anhedonia, often observed in addicts. The increased requirement for dopamine to maintain the same electrical activity is the basis of both physiological tolerance and withdrawal associated with addiction.

Downregulation can be classically conditioned. If a behavior consistently occurs in the same environment or contingently with a particular cue, the brain will adjust to the presence of the conditioned cues by decreasing the number of available receptors in the absence of the behavior. It is thought that many drug overdoses are not the result of a user taking a higher dose than is typical, but rather that the user is administering the same dose in a new environment.

In cases of physical dependency on depressants of the central nervous system such as opioids, barbiturates, or alcohol, the absence of the substance can lead to symptoms of severe physical discomfort. Withdrawal from alcohol or sedatives such as barbiturates or benzodiazepines (valium-family) can result in seizures and even death. By contrast, withdrawal from opioids, which can be extremely uncomfortable, is rarely if ever life-threatening. In cases of dependence and withdrawal, the body has become so dependent on high concentrations of the particular chemical that it has stopped producing its own natural versions (endogenous ligands) and instead produces opposing chemicals. When the addictive substance is withdrawn, the effects of the opposing chemicals can become overwhelming. For example, chronic use of sedatives (alcohol, barbiturates, or benzodiazepines) results in higher chronic levels of stimulating neurotransmitters such as glutamate. Very high levels of glutamate kill nerve cells, a phenomenon called excitatory neurotoxicity.

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Criticism

Levi Bryant has criticized the term and concept of addiction as counterproductive in psychotherapy as it defines a patient's identity and makes it harder to become a non-addict. "The signifier 'addict' doesn't simply describe what I am, but initiates a way of relating to myself that informs how I relate to others."

A stronger form of criticism comes from Thomas Szasz, who denies that addiction is a psychiatric problem. In many of his works, he argues that addiction is a choice, and that a drug addict is one who simply prefers a socially taboo substance rather than, say, a low risk lifestyle. In Our Right to Drugs, Szasz cites the biography of Malcolm X to corroborate his economic views towards addiction: Malcolm claimed that quitting cigarettes was harder than shaking his heroin addiction. Szasz postulates that humans always have a choice, and it is foolish to call someone an 'addict' just because they prefer a drug induced euphoria to a more popular and socially welcome lifestyle. Therefore, being 'addicted' to a substance is no different from being 'addicted' to a job at which you work everyday.

Szasz and Bryant are not alone in questioning the standard view of addiction. Professor John Booth Davies at the University of Strathclyde has argued in his book The Myth of Addiction that 'people take drugs because they want to and because it makes sense for them to do so given the choices available' as opposed to the view that 'they are compelled to by the pharmacology of the drugs they take'.^[22] He uses an adaptation of attribution theory (what he calls the theory of functional attributions) to argue that the statement 'I am addicted to drugs' is functional, rather than veridical. Stanton Peele has put forward similar views.

Experimentally, Bruce K. Alexander used the classic experiment of Rat Park to show that 'addicted' behaviour in rats only occurred when the rats had no other options. When other options and behavioural opportunities were put in place, the rats soon showed far more complex behaviours.

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Casual addiction

The word addiction is also sometimes used colloquially to refer to something for which a person has a passion, such as books, chocolate, work, the web, running, or eating.

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See also

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Notes

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Further reading

• Lende, D. H. & Smith, E.O., (2002). Evolution meets biopsychosociality: an analysis of addictive behavior. Addiction 97: 447-458.
• Ornstein, C., (2005-11-14). Quitting meth pays off. LA Times.

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External links

Addiction at the Open Directory Project [Addiction]

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