Addiction
Problem 1
What is addiction?
1. What is addiction?
a. How do we define addiction?
Source: What is addiction? In:, G. Stanghellini (Eds.), Oxford Handbook of Psychiatry
It is not easy to define addiction. There is a wide variation in who is addicted, what they
are addicted to and the precise form, health effect and motivation for the addiction.
People can be addicted to illegal drugs, legal drugs and forms of behaviour as an
addiction.
Withdrawal symptoms can also vary a lot:
- heroin bad flu
- cocaine depression, with loss of energy and interest
- alcohol (most severe) hallucinations, delirium tremens and death.
Addiction is positive correlated with low SES, low IQ, adolescence and early childhood,
childhood abuse, stress, psychiatric disorders (personality disorders in specific) and
religion.
Source: Lecture 1_opening lecture 2020-2021
There are a lot of different definitions, but they all have central parts:
Addictive substances
- psycholeptica supress CNS i.e. alcohol, GHB, opiates
- psychoanaleptica stimulated CNS i.e. nicotine, coffee, cocaine, XTC
- psychodysleptica causes hallucinations i.e. LSD, paddo’s, cannabis
Getting high
Severe negative consequences
- individual
- social
Compulsion
Loss of control, unable to stop
The definition according to the WHO: repeated use of a psychoactive substance or
substances, to the extent that the user (referred to as an addict)
- is periodically or chronically intoxicated
- shows a compulsion to take the preferred substance(s)
- has great difficulty in voluntarily stopping substance use
- exhibits determination to obtain psychoactive substances
Tolerance is prominent and a withdrawal syndrome frequently occurs when substance
use is interrupted.
The life of the addict is dominated by substance use to the exclusion of all other activities
and responsibilities.
b. How do we diagnose addiction, based on DSM-5?
Source: What is addiction? In:, G. Stanghellini (Eds.), Oxford Handbook of Psychiatry
The DSM-4:
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,A maladaptive pattern of substance use, leading to clinically significant impairment or
distress as manifestated by three (or more) of the following, occuring at any time within
the same 12-month period:
The difficulty is that the polythetic nature of this definition means that very different
patterns of substance use will all count as addiction. This limits this definition’s capacity
to fulfill another core clinical purpose of diagnosis, namely, to establish prognosis and
indicate treatment course. In short, because of the polythetic nature of the diagnostic
criteria, the DSM-4 does not offer a unified set of diagnostic criteria for addiction.
‘An addiction is a strong appetite’ (Foddy and Savulescu)
This definition is too narrow, because they seem to require that addicts both
(strongly) like and (strongly) want to use drugs (which is not always the case).
This definition is too broad, because it fails to distinguish addiction from heavy
use based on strong desire. (a passionate golf player can also be an addict with
this definition)
An appetite is a disposition that generates desires that are urgent, oriented toward some
rewarding behaviour, periodically recurring, often in predictable circumstances, sated
temporarily by their fulfilment, and generally provides pleasure.
Control
What is the difference between heavy use and addiction? A natural answer is: control.
The importance of control in understanding addiction is reflected in three of the
diagnostic criteria:
3) using more than was intended
4) persistent desire or unsuccessful efforts to control use
7) continued use despite knowledge of resulting persistent or recurring physical or
psychological problems.
So what is control? Two accounts are common. One focuses on wants and claims that an
agent has control over a type of action if and only if:
1) If they want overall to perform that type of action, then usually they do it; and
2) If they want overall not to perform that type of action, then usually they don’t do it.
Use of ‘usually’ is necessary because they might fail in doing what they want (car breaks
down).
Use of ‘overall’ is necessary because desires can conflict (stronger desire for another
activity).
Can conflict with… - First-order desires (golf)
- Second-order-desires (swimming)
Such want-based accounts of control contrast with reasons-responsiveness accounts. On
this kind of account, an agent has control over a type of action if and only if:
1) If they have a strong overall reason to perform that type of action, then usually they
do it; and
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,2) If they have a strong overall reason to not perform that type of action, then usually
they don’t do it.
These account might seem very close. However, these accounts come apart in various
cases that are relevant to addiction:
1) if agents have no reason to fulfill some desires, then those agents can act on their
desires without being responsive to reasons. (having a strong desire to drugs even
though they no longer like them or get any pleasure from them) if that’s the case,
agents seem to have control over their drug use based on the want-based account
because they take drugs when they want to, but such users would lack control on
reasons-responsiveness accounts if they continue to use drugs because of their strong
wants even when they know that they have little or no reason to use drugs.
It is not completely clear which of these accounts of control is most appropriate for a
definition of addiction.
These factors correspond to the kinds of factors that reduce control over drug use:
First, the desire to use drugs can become strong and habitual
Many drugs directly increase levels of synaptic dopamine, which over time, may affect
normal processes of associationist learning related to survival and the pursuit of rewards.
Once the drugs-related pathways are established, cues associated with the drug use
cause addicts to be motivated to pursue the reward of drugs to an unusually strong
extent. There is increasing evidence that as drug use escalates, control devolves from
the prefrontal cortex to the striatum, in line with a shift from action-outcome to stimulus-
response learning. Drug use then becomes increasingly habitual; more wanted than
liked, more automatic than deliberately chosen. Acting against strong and habitual desire
requires willpower; an active attempt to resist the pull of the drug.
Second, it takes effort and resolve to keep exercising willpower
The longer willpower is exercised, the more depleted (uitgeput) resources may become.
This is one reason why many clinical interventions require addicts to remove themselves
from their habitual environment, or at least identify and as much as possible steer clear
of drug-related triggers.
Third, attention and cognition affect the capacity for long-term control
Addicts overestimate the benefits of using drugs and the costs of not using; and
underestimate the harms of using and the benefits of not using.
Fourth, an addict who resolves to stop using drugs will still experience some motivational
conflict with the appetite that constitutes their addiction
We can now add control to the definition of addiction: addiction is a strong and habitual
want that significantly reduces control. Though it is important to remember that the
strong and habitual want is usually only part of what causes the reduction in control.
Harm
This definition of addiction still might seem to lack an essential element. Desire and loss
of control are often associated with romantic love. Nonetheless, love differs in at least
one crucial way from drugs and behaviours that many count as addiction. Addictions
typically cause harm to self. But how would we diagnose people who have the symptoms
of an addict but do not harm themselves? There are three possibilities:
1) Sue and Joe are not addicts because they are not harmed by their behaviour.
2) Sue and Joe are addicts, but, because they are not harmed by their behaviour, that
shows that addictions are not all harmful
3) Sue and Joe are addicts, who are harmed by their conditions, despite their happiness
and successes in business and gambling.
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, Diminished control thus brings a substantial risk of further harm if it avoids harm only in
a very narrow environmental niche. This risk of harm can itself arguably count as a harm.
Nonetheless to be explicit, a more precise definition will be:
‘addiction is a strong and habitual want that significantly reduced control and leads to
significant harm’.
Conclusion
Control and harm come in degrees.
Another long-standing debate is over whether addiction is objective or subjective. This
debate can also be resolved by recognizing that, even if degrees of control and harm
exist independently of our purposes, our purposes can still determine where we should
draw a line between significant and insignificant harms and losses of control and hence,
between addicts and non-addicts (like optometrists).
It is demanded that we recognize that control and harm come in degrees and
that judgements about where to draw the line between addicts and non-addicts
can be made only relative to particular contexts and purposes.
Source: DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale
The DSM-4 criteria for substance abuse and dependence are as follows:
Dependence was
diagnosed when
three or more
dependence criteria
were met.
Abuse was diagnosed
when one or more
abuse criteria were
met.
In Dutch:
c. Are there changes in the DSM-5 and DSM-4? (lecture about diagnosis also helps)
Source: DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale
The DSM-4 was published in 1994 and the DSM-5 in 2013. In 2007, a multidisciplinary
team of experts were gathered (the DSM-5 substance-related disorders work group), to
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