CASE 1: WHAT IS “ADDICTION”?
LD:
1. What aspects are central in defining addiction?
It’s not easy to define addiction. There is a wide variation in:
- Who is addicted
o Occurs across levels of socioeconomic status, intelligence and education
Still, rates of addiction are positively correlated with: low SES, low IQ,
adolescence and early adulthood, childhood abuse, stress psychiatric
disorders and religion
- What they are addicted to
- The precise form
- Health effects
- Motivation for the addiction
o Goals of non-addictive consumption:
Improved social interaction
Facilitated sexual behaviour
Improved cognitive performance
Coping with stress
Alleviating psychiatric symptoms
Novel perceptual and sensory experiences
Hedonia or euphoria
Improved physical and sexual appearance
o Further, once addicted, people may use drugs to maintain normal functioning and
avoid withdrawal
There are various kinds of definition of addiction.
Precising definitions are judged in large part by their usefulness, relative to a particular purpose.
The precising definition should serve several purposes:
- Clinicians: need to decide whom to treat
- Health insurance companies: need to decide for whom they’re willing to pay for treatment
- Law courts: need to decide whether a defendant is criminally responsible and so should be
held straightforwardly accountable, or whether they should be remanded to treatment
- Scientists: need to collect data in ways that enable precise scientific generalizations
- Individuals: need to decide how to think and feel about others who are addicted
Philosophical definitions of addictions tend to be pithy. “An addiction is a strong appetite”.
- Appetite: “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 provide pleasure”
- This definition does not restrict addiction to substances
- It enables scientists to seek the neural bases and psychological mechanisms for such strong
appetites, and philosophers to ask whether people are responsible for what they do as a
result of such strong appetites
- Nonetheless, this definition is too narrow; Theory of incentive sensitization
o Distinction between liking and wanting
We engage in some activities because we like them
We also engage in some activities because we are motivated to do them
regardless of whether we expect to get any pleasure or reward from them:
we want to do them, but not because we like to do them
, o In the case of addiction: addictive wants are triggered by drug-related cues that have
become associated through sustained, heavy use with consumption
They don’t like it, but nonetheless, they want it very much
Having difficulty quitting when there is a good reason to do so
Causes significant personal harm or risk of harm
- This definition of appetite seem to combine liking with wanting
o It seems to require that addicts both (strongly) like and (strongly) want to use
This double requirement is a problem: some extreme addicts report no
longer liking the drugs that they nonetheless want
- This definition is also too broad, because is fails to distinguish addiction from heavy use
based on strong desire
o Difficulty quitting? Causing significant harm?
The difference between heavy use and addiction: control
- What addicts normally mean when they claim to lack the ability to stop is the lack of good
enough reason to quit – not the physical and psychological ability
o Psychical and psychological ability to control use is reduced: they lack the degree of
control that we normally expect people to have over their behaviour
- What is control? Two accounts are common:
o One focuses on wants and
Claims that an agent has control over a type of action if and only if:
If they want overall to perform that type of action, then usually they
do it; and
If they want overall not to perform that type of action, then usually
they don’t do it
The qualification of “usually” is necessary because occasional lapses do not
prove lack of control
The qualification of “overall” is necessary because desires can conflict
o One focuses on reasons-responsiveness
Claims that an agent has control over a type of action if and only if:
If they have a strong overall reason to perform that type of action,
then usually they do it; and
If they have strong overall reason not to perform that type of action,
then usually they don’t do it
o It is not completely clear which of these accounts of control is most appropriate for a
definition of addiction
Here we will usually talk in terms of what the agent wants overall
o With this rough account of control, we can now see how various factors can remove
or reduce control
- Factors that reduce control over drug use – these factors in combination show how or why
control can be reduced in addiction:
o The desire to use drugs can become strong and habitual
Immoderate long-term drug use can change neural mechanisms
Once drug-related pathways are thus established, cues associated
with the drug use cause addicts to be motivated to pursue the
reward of drugs to an unusually strong extent
Moreover, 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 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
o It takes effort and resolve to keep exercising willpower
Exercising willpower depletes its strength in the short term but can increase
in the long term
So, the need for addicts to persevere in resisting the desire to use
drugs, especially in the face of strong associations and cues, may
weaken their willpower, potentially to depletion
o Attention and cognition affect the capacity for long-term control
In addition to affecting strength of desire and habit, drug associations and
cues may cause intrusive, incessant, obsessional drug-related thinking
This in turn may make it very difficult for addicts to recall and attend
to non-drug-related desires and values or to the positive
consequences of abstinence and the negative consequences of use
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
They also seem to discount the future in extreme ways: hyperbolically
Some addicts fail to take in or use information about fictive losses – losses in
what they would have gained if they had acted differently – that is relevant
to rational choice
o An addict who resolves to stop using drugs will still experience some motivational
conflict with the appetite that constitutes their addiction
Wanting to stop doesn’t mean the desire for drugs thereby disappears
Abstinence for many addicts requires undergoing withdrawal symptoms
For many addicts drug use may provide relief from life’s various miseries
There can also be positive consequences associated with addiction
Such as the possibility of status within an drug culture and network,
and the corresponding construction of a positive self-conception
- For all these reasons, even if heavy users want overall (and recognize strong reasons) to
abstain, they still might not usually abstain, and then their control is understandably
diminished
o Addiction: a strong and habitual want that significantly reduces control
To say that the strong and habitual want causes the reduction in control is
not to say that it is the sole cause: multiple factors, in combination, often
contribute to diminished control
The strong and habitual want is usually only part of what causes the
reduction in control
Willing addicts: who endorse their addiction & never try to control their use
Willing: they want overall to use drugs; so they do what they want
overall to do when they use.
o Addicts because if they no longer wanted to use, they would
still use at least usually
- Control comes in degrees, depending on the range of situations in which the agent acts in
accordance with wants or reasons
o Control can thus be reduced without being extinguished completely. For addiction,
the reduction or loss must be significant
This significance cannot be captured in a purely descriptive statistical way,
the notion of significance is pragmatic
This degree of control can be differentiated to each purpose of defining
addiction: is the reduction in control significant in the context?
, This definition of addiction still lacks an essential element.
Desire and loss of control are also often associated with romantic love. Nonetheless, love differs in at
least one crucial way from drugs and behaviours that many count as addictions.
Addictions typically cause serious harm to the self.
- The loss of control will already ensure risk of harm at a minimum
o Nonetheless, addiction: a strong and habitual want that significantly reduces control
and leads to significant harm
As before, the want and reduction in control cause harm, but that doesn’t
mean that they are the sole causes. Many factors typically contribute to the
harms of addiction
- Harm – in this definition – includes: death, pain, distress, dysfunction or substantial risk of
these within a normal environment
o Like control, harm comes in degrees, and disagreement may occur as to when the
degree of harm of risk of harm counts as significant
In some cases it will be unclear, as when reduced control creates or
constitutes risk of unhappiness
o It distinguishes addictions from other extreme forms of behaviour
Addiction: a strong and habitual want that significantly reduces control and leads to significant harm.
- Control and harm come in degrees
o Addicts have some control over their choices and actions, but not full or normal
o This allows us to move forward: addiction is a form of compulsion to the degree that
an addict lacks control
o Our purposes can still determine where we should draw a line between significant
and insignificant harms and losses of control and between addicts and non-addicts
This variation in where the line between addicts and non-addicts should be
drawn may be confusing if the rationale behind it is not explicit. But there is
nothing illegitimate about drawing the line at different places for different
purposes
We simply need to be explicit about what we are doing and avoid the
temptation to ask and answer overly simplistic questions about
whether or not a person is really an addict
- Instead, we must ask about
o The degree of diminished control and harm they suffer
o Whether or not, given the particular context and what is at stake, we are justified in
counting a person an addict
- Good practice in all contexts where questions of addiction arise – from the courts to the clinic
– demands 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
2. What are the DSM-V criteria for diagnosing addiction?
3. How were the DSM-V criteria for addiction developed and how do they differ from the DSM-IV
criteria?
The criteria in the last version, DSM-IV-TR, were first published in 1994. Since then, knowledge about
psychiatric disorders, including substance use disorders, has advanced greatly. To take the advances
into account, a new version, DSM-5, was published in 2013.
- In 2007, APA convened a multidisciplinary team of experts, the DSM-5 Substance-Related
Disorders Work Group, to identify strengths and problems in the DSM-IV approach to
substance use disorders and to recommend improvements for DSM-5
- Using a set of 2006 reviews as a starting point, the work group noted weaknesses,
highlighted gaps in knowledge, identified data sets to investigate possible solutions,
