The Neuroscience of Addiction - with Marc Lewis

I can adjust jump right into it I used to have a slide that said you know addiction can be defined in all these different ways as a disease as a choice as a self medication as a societal or social definition and so forth but now I'm just going to cut to the chase and say the prominent the dominant definition of addiction these days is that it is a disease and that's a definition that's grown up over the last well more than half a century I kind of came from a confluence between the 12-step movement the AAA movement from the 30s and medicine on psychiatry in particular in the 50s and 60s these these two strange bedfellows joined and ever since the addiction treatment world and the psychiatric view of addiction has been as a disease as a chronic disease you know a a defines it as kind of it's a permanent as essential feature of people and that's why they have to be very careful forever for the rest of their lives so and that kind of evolved into the current definition through the recent advance in neuroscience and neuroscience technology and findings which is of course been enormous and now people talk about addiction as a brain disease okay so it's defined as a brain disease and here are the main constituents of the definition from NIDA the National Institute on Drug Abuse oh this is I'm sure there's a parallel organization here but this is part of the the NIH the National Institutes of Health in the u.s. who actually fund 90% of the addiction research in the world in the world it's a lot and National Institutes of Health while they obviously have a medical orientation so this is this is the definition they come up with I might need my glasses to this yeah could you please make it out to another stiff neck um there we go addiction is defined as a chronic relapsing brain disease that is characterized by compulsive drug-seeking and use despite harmful consequences so emphasized chronic relapsing brain disease brain imaging studies from drug-addicted individuals show physical changes in the areas of the brain that are critical for judgment decision-making learning a memory and behavior control all the good stuff and and again physical changes in the brain is this is often a website it's on all of their literature publications talks and articles and and finally the last important point is that in vulnerable individuals the disease of addiction is produced by chronic administration of the drugs themselves in other words the drugs cause the addiction that's been part of the the hegemony that the dominant view for a long time ok so here's the model um and and yeah I'm just going to give you the simplified straight version of VAL model and it's not a model that I disagree with by the way it's pretty well is pretty well researched and well defended and there's been a lot of studies that converge on this kind of model of addiction there's there's three regions you have to think about first is the prefrontal cortex in a particular the dorsal lateral prefrontal cortex is the most sophisticated region up here and it's responsible for judgment decision-making perspective-taking self regulation all that good stuff and you can think of that as the bridge of the ship that's where we steer our behavior that says for we steer ourselves from so there's that region and then there's the striatum the which the ventral striatum is sometimes called the nucleus accumbens you'll see that a lot in the addiction literature and we can call that the motivational engine so the striatum evolved as part of the motor system and it actually gets us mammals to act and to basically pursue goals because that's what we do when we act we pursue goals the goal might be getting away from something but in this case let's focus on getting toward something and it also generates the motivation for doing that so mammals like unlike frogs need a push to get them to do something and in a motive or an emotional drive you know we don't just look out our tongues when a fly goes by and we have to you have feel some kind of attraction and that is generated by the striatum so you can see that that's an important region of the brain when it comes to addiction and then the the this part of the midbrain the ventral tegmental area is called a dopamine pump it manufactures dopamine which is a neural net it partly it energizes the striatum it turns on all the cells in the striatum and it gets the striatum to focus on the goal so it narrows the the the beam of attention and it drives behavior toward the goal and yeah that's what it does it focuses and drives behavior and allows you to follow a sequence of steps that leads to the goal that you're after the particularly so what happens in addiction is that you get a lot of dopamine coming up from the midbrain to the striatum in the presence of drugs or booze or gambling or sex or porn or pizza whatever it is that you're addicted to and so the striatum is activated and becomes focused on the goal and that happens again and again and again and it happens in response to cues or stimuli that are connected to the activity of choice the thing that you want okay so then the other issue is that there is naturally a balance between striatal activation and prefrontal cortex activation because you need to control these impulses and we do you know all the time every moment of our waking life pretty much there's some kind of balance between impulse and and control self-regulation modifying behavior in favor of you know better better consequences in the long run and in addiction what happens is that the this bundle of fibers that connects these two regions it becomes it becomes less crosstalk so there's a reduction in the communication between the striatum and the prefrontal cortex and what happens over time is that these two systems become less connected and you can even think of as being somewhat well disconnected from each other when in the presence of drugs or cues or other other stimuli associated it doesn't mean that this disconnection is always there because you can live a very normal life and do very normal and well-planned things that are that require judgment and logic but when those cues are around when you're driving by the walking by the pub or the liquor store or you know using your your dealer calls that's when this disconnection occurs time and time and time again so that's the problem right that's a big problem we all agree that it's a big problem um okay so this is what this is a graph showing what happens when people take drugs like as a cocaine alcohol and heroin yes for some period of time and over time what you get in certain regions according to a number of different labs you get actual reduction in gray matter volume at some of these regions of the prefrontal cortex dorsal prefrontal cortex and that's a very closely related region called the anterior cingulate cortex server connected and what this shows is that gray matter volume drops with from year with the duration of the addiction okay so this dotted line is a population baseline the normal population of people who have never been addicted this line shows what happens with addicts and the loss of grey matter volume means that they're losing synaptic densities they're losing synapses they're not brain cells are not dying you're not cells are not dying but the connections you're losing the density of connections is decreased over time okay so that's that's a pretty important finding and well it sounds like a disease or it sounds like it's something is really going wrong with the brain so why not call it a disease why not call it a disease well because that's what the rest of the talk is it's the because so here and this that's my book which is available in the lobby only here in the UK the cover is white it's a big difference and it's also in paperback um okay so what I want to do is not to challenge the neural data but to reinterpret it and to try to figure out what's wrong with the interpretation is the data are pretty solid so the first point is I'm a developmental psychologist bike by training and I've thought about changing brains throughout most of my career if you study child development of course it's an obvious thing that brains change radically from infancy through throughout lessons into adulthood I mean that's how we learn language and communication and everything else we learn the brain is obviously changing that's what it's for it's a flexible Oregon it's not designed to stay the same like a liver or a heart or a kidney um but so the question would be that if brains change with learning and development then brain change by itself doesn't necessarily mean brain disease so the next question is and by the way brains don't stop changing at the age of 20 but they probably change less after that age after things kind of solidify so um so the question is how do brains change with development and this this cute little movie shows um an average of MRI scans of different kids at different ages from the age of four to the age of 20 and what we're looking at is the dense the thickness of the cortex the actual thickness the synaptic density in the cortex I want to see how does it change from the age of four through the age of 20 so it's a it's an eight second movie so you have to pay careful attention but I'll show it again though so take a look first to get a sense of it yeah it's pretty huh so you see what happens is that the brain turns blue miss development okay I I was hoping that would go over with a British audience because I thought it's sort of a Monty Python ask type of type of line so I'm glad it worked okay now it doesn't really change blue here at turn blue here's the scale and it is a scale showing gray matter amount or grey matter density and if we go back here the the the light colors yellow and green and so forth shows Fichter the thicker cortex and the blue and purple colors show thinner cortex so as the brain gets more blue and purple it's getting sinner the cortex is getting sinner and this is counterintuitive to some people you might expect the opposite so here we go starting in infancy and it's losing synapses it's losing twenty to fifty percent of its synapses because there's a huge overabundance of synapses in infancy that's why infants are so confused and so you know they're I mean well they're just kind of out of it right because they have too many synapses and so what happens with development is that you get this this this change and what's going on we call it synaptic pruning and what's going on is that different regions at different times okay here's like I can't stop this thing stare stop no won't stop oh I know I should click that and try that again okay so here's four six eight ten let's catch the brain right there so now the sensory motor strip is now pruned and matured the orbital frontal cortex the bottom of the prefrontal cortex is matured because that's really important for processing emotional information but this part and this part these are association cortex are more sophisticated more advanced regions of cortex and they're not finished pruning yet and I want you to see that this is the last part to go this is the dorsal lateral prefrontal cortex in charge of judgment and perspective-taking okay just watch it and you'll see that it's the last to prune up okay and finally it does so that means that by the time you're 20 you can actually think straight but not before okay so that's the brain change with development just to give you an idea of what it looks like to see to see what pruning looks like the big picture and development but developments on learning are actually very similar they're almost almost synonymous and they simply involve two processes two mechanisms one is synaptic growth and one is synaptic pruning you get a proliferation of synapses or synaptogenesis and then you get pruning of synapses which I just showed you and the balance of those two mechanisms is development in the brain in the cortex that's development there's nothing else and I think of it as being kind of like the ivy on the garden wall which starts off you know quite chaotic and disorganized and then that would be parallel to synaptic growth and you get novelty and new associations and increasing knowledge and skills and you learn to play new keys on the piano and you know you learn to be whatever you learn all these new skills and then with development you get more and more pruning so you get consolidation more efficiency and habit formation that's what pruning is for is to make the brain more efficient so that it focuses so that several the really important pathways become entrenched they become myelinated they become yeah they become they they convert and send signals much more rapidly and the unimportant synapse is just fade and disappear so if you think about if you think about addiction in terms of there's the last stage if you think about addiction in terms of synaptic pruning then this decrement in in prefrontal in in the density of synapses in certain prefrontal areas this decrease in synapses can be thought of as part of a bigger picture and then we shouldn't be surprised if that's a developmental progression we shouldn't be surprised by further synaptic change if people stop and in fact that's what this particular study found is that with students from from Cote alcohol and heroin you get you get an increase in gray matter volume in very similar areas they're not exactly the same the brain never actually goes backwards and development that just doesn't happen but it goes forward and there are this increasing growth and increasing synapses and new regions that are closely related and they're probably very much involved in self-regulation impulse control because that's what people need to learn when they stop taking drugs and notice that within within one year or so the curve the the line crosses the non-addicted average baseline and so you actually get increasing synaptic density over and above the general population in those regions that seem to be responsible for self-control that's what happens when people quit by the way I should just note that people that addicts generally do quit not everybody knows that but the majority of addicts for any kind of substance and even heroin end up quitting and it varies the timeframe and the proportion varies with the substance with cocaine the average duration of an addiction is four years with with marijuana if you smoke it compulsively it's six years with alcohol it's fifteen years and with tobacco it's 25 years so that's the really evil one on average if you start smoking today on average you will stop in 25 years it's not really a good thing okay so lots more change happens when people's habits change when their behavior changes when they stop taking whatever it is they're taking so I would say that addiction is sort of a kind of skill the addicts brain learns to efficiently identify and aim behavior there's less prefrontal activation because it's the same behavioral routine repeating itself day after day hour after hour there's very highly um consolidated habitual eyes dribble eyes forms of behavior in place of having to wonder and think and judge and consider and compare and all that stuff that most of us do most of the time is a strange way to think of addiction but I think it really is like that it's a kind of a skill a very a nasty one obviously but still um and then we should we should recognize that uh new skills or the formation of deep habits always change the brain it's not just addiction so what are some examples well driving a taxi in London is one of the classic ones you've probably heard that London cab drivers have a hippocampus that's part of the brain in charge of memory certain kinds of memory which is 20% more dense or more heavy than normal people why because they have to learn the location of like thousands tens of thousands of streets or probably not anymore as there's no GPS but this this finding came came from a few years ago and it's been replicated many times so that's kind of cool and we know other things about the hippocampus that it's actually decreased in volume from post-traumatic stress and etc but let's move off the hippocampus and talk about falling in love when you fall in love there are all kinds of changes to the brain there's increased dopamine to the striatum there's more activation of the ventral striatum there's more synaptic patterns and of course those patterns represent the loved person this is like an addiction in the sense that you have a repeated behavior day after day in which the emotional appeal of that other person is highlighted is emphasized all you can think about is their good points at first yeah kind of like with heroin and there's there's lots of research research showing that not just humans but even with rodents prairie voles you get increasing to nap so dopamine flow to the to the ventral striatum when they are mating when they're in the process of prairie voles are studied because they are monogamous and one of the few monogamous mammals so they're they're romantic habits have been studied in some depth because that's supposed to be like humans but it's up for debate okay so falling in love and mindfulness meditation practice changes the brain there's been a lot of research on that in the last 10 years if you're if you're a brain nerd you might be interested that the default mode network which is a network which processes information that has to do with self-reflection thinking about your past thinking about your future and rehearsing patterns that have to do with your own activity in your own yeah self and it's mindfulness meditation reduces activation in the default mode Network okay it becomes it becomes muted that activation because you're just not as ego involved and I you know this is like a fascinating area of research um all these other behavioral addictions change the brain I'll get to that in a minute binge eating binge drinking binge anything been shopping change the brain and psychotherapy changes the brain I just I just wanted to I started looking at this just recently I thought well I'm talking about brain changed and I'm saying everything changes the brain anything that's important and that's you know that really changes the way you function in the world is going to change the brain in a more measurable recognizable way and so psychotherapy should do it and in fact I found lots of literature on that their studies with CBT their studies with other forms of psychotherapy showing brain change and then I thought wait a minute I used to study that I suppose you when you're an old academic I used to study that I used to do research with kids who had problems with anxiety and aggression and we would we would look at their brains with what's called dense array EEG you know what EEG is a dense array means there's like 128 channels so you can get kind of a pretty good picture of the spatial the anatomical story as well as the temporal story of brain activation and so we put nets on these kids before and after this three months um a period of treatment and I figure well the ones who improve should show brain change and indeed they they do I'm not even bother trying to interpret that it's too difficult that's what averaged erp EEG looks like it's an event potential event-related potentials but here's the gist of the story um this graph shows pretreatment post treatment this is mean activation in the ventral region this is rate tuck down and the ventral part of the prefrontal cortex and the closeby areas and probably probably the amygdala you can't get quite that fine with with EEG even with source analysis but what we see here is that the those who did not improve behaviorally who got the same scores for regression and anxiety after the treatment showed no change those who did improve showed a pretty significant drop and the activation of these areas well what does that mean that means they're not using this part of their brain as much as they used to and that's a good thing because when you're using this part of your brain to modulate your interactions with other people then they're tinged with anxiety and defensiveness and you can then you can then just flash into into anger if you're if you're provoked so so a lot of stuff changes the brain these are other slides with other pictures we got from that study this just kind of gives you an idea of that's a topographical map of EEG for younger kids and older kids and the loss of the reduction in activation with age looks fairly similar with the loss of activation with successful treatment it's a complicated story I just wanted to give you a sense of it just a glimpse of it okay so the other interesting thing is that not only addictions to substances but also behavioral addictions change the brain in almost exactly the same way as substance addictions I've been to conferences on that have been a few in the last few years the International Society for behavioral addictions has a conference every couple of years and it's amazing but all the brain changes that people associate with substance abuse you find them in gambling porn sex addiction and binge eating disorder and obesity as well fat Nora Volkow the head of NIDA who's who's actually one of the most powerful spokespeople for the disease model she she has written a number of articles showing the incredible parallels between brain change due to drug use and brain changed obesity and binge eating there's a lot of parallels so what's that about well um here are some examples of other things I just mentioned these are the things that people are studying Internet or gaming addiction internet gaming psychiatrist don't know what to do about this but it's now entered the DSM there's now a category for conditions that are under discussion and people are starting to call this an addiction and you know what I mean if you have a teenage child or if you ever you know if you know anyone has a teenage child right and people can spend a lot of time on the Internet it gets much more serious when they're when they're adults well if the parents don't control limit to be quite serious in childhood too but they root people can spend up to 18 hours a day on the Internet and it really screws up their life so I thought I wanted to find I wanted to find an example of brain change an Internet addiction the first paper I looked at there's another one the first paper I looked at showed something quite remarkable um see if I could read this gray matter abnormalities and Internet addiction a voxel-based morphometry Morpho I don't even know how to say that word morphometry study ah it basically means fMRI and so this study aims to investigate brain grey matter density yeah grey matter density changes in adolescence with Internet addiction using yeah the rest of that stuff so again grey matter density so that's because that looks like the most serious thing is this loss of grey matter there's a loss of synaptic density in the prefrontal cortex so we are talking about the internet we're not talking about heroin here okay so this is what it looks like I found their graph and it looks like this that little yellow spot is the region in the brain that shows a reduction in synaptic density for people who spend more time on the internet and go back to the brain picture that I showed you before for heroin coke and alcohol addicts it's exactly the same spot see that that cool as I said that's so cool I convinced myself that I was right when I found this that spot actually is not prefrontal cortexes it's the dorsal anterior cingulate but it's a part that's very closely linked to the dorsal lateral prefrontal cortex it's kind of like a convergent zone for decision-making and conflict resolution so it's it's pretty much connected so there it is it's these these behavioral so in other words the that the proposition that drugs cause addiction has to be completely wrong drugs do not cause addiction they don't um internet gaming causes addiction falling a love causes addiction but so you know being a sports fan being a jihadist being a whatever all of these things have same the sort same sorts of fundamental properties okay so I'm going to move on and say given all that we have to still understand what addiction is and especially we have to understand why is it so hard to stop it's not just sufficient to say that it's not a disease what is it and that's what I'm going to spend the rest of this talk talking about what is it why is it so hard to stop and there's three points that I want to make first one is that you addiction is based on a strong attraction to something to a substance or a behavior which is repeated many times and which leads to deep learning or accelerated learning that's the first point the second point is this mechanism called now appeal or delayed discount II which I'll talk about and then last is something called ego fatigue or ego depletion which is basically the loss of self-control if you try too hard to control things you actually lose the capacity to do so efficiently okay so I'm going to go through those three points the first one this is the basic picture I see addiction as a feedback cycle it's a self reinforcing self self-perpetuating feedback cycle and we could think of it simplistically as craving leads to more drug imagery and more drug imagery leads to crazy and round and round it goes and it builds on itself and that can happen in five minutes or half an hour or half a day or whatever it is and finally when it gets intense enough you go and you get some or you do some or you drink some or whatever it is you smoke some okay so that's the feedback cycle ah now let's try to think about that in terms of what's going on to the brain here's a simplistic cartoon but we'll start here with the trigger phase and there's always some kind of perceptual trigger it can be you know looking at paraphernalia or booze commercials or whatever it is but it could be finding a half a pill in the bathroom floor or it could be you know having an intense dream about getting high or whatever it is all of these things are triggers or cues so what so they are they are inputted in whatever perceive through the through the back of the brain through the posterior regions of the brain and then you've got all these associations that are kind of mediated by the temporal lobes here the part that's associated with memory and all these images come up and as they do the mid brain sends dopamine up to the striatum and the striatum generates desire which addicts call craving for good reason because this desire for something is not immediately available we call that craving same thing in love and then the striatum sends messages back to the midbrain and says more dopamine please and there's a little feedback cycle right there between those two parts of the brain and they're craving increases and imagining increases and of course the prefrontal cortex becomes activated and you're planning where am I going to get it how am I going to pay for it am I really going to do it I was going to wait until Tuesday I was going to wait until the weekend I was going to wait until I could share it with you know my friend but no I guess you know I could probably borrow some money from my aunt and you know then I could and all that stuff is strategizing which is going on in the PFC which is connecting of course to the the elaboration of imaging in the in the association areas and those parts grow on each other and finally the of course during this process you're sending commands to the motor cortex and the motor cortex does what you tell it to do and you go and you get the stuff or you get higher you get sex or you get porn or your Gamal and then you feel better and then it's done it's finished out I'm not really crying I just have something in my eye but it is sad you had such a good time and now it's over and that's really the point and this addictive in this addictive spiral this feedback cycle is that when it's over there is always lost there's often depression there's often shame self-contempt remorse all that stuff which of course makes you feel like doing it again so that's a feedback cycle at another scale the scale of day to day day to day day to day I was cocaine it could be hour to hour so what's really going on here is that I want to trace this feedback cycle and show you how it plays out over development there's the trigger the cue leads to craving craving leads to imagining imagining leads back to I was just say more perception of the intended activity and that's an intensification cycle and it goes on for a while and finally when it gets intense enough you go get some and you do some that's the using part and now you get high or whatever get drunk and what does that do it has three effects the first effect is relief relief or pleasure and you know in learning theory that's just positive reinforcement that's positive reinforcement so so is so it it reinforces the behavior and entrenches it further so that's learning and then comes loss okay and then the cycle repeats itself like I just said so you get yeah so you get you get relief learning and loss and then you do it again now think about every time this cycle go every time you go through this cycle in your mind and your brain what you're doing is activating particular synapses in a particular synaptic configuration that you've been building up over occasions maybe maybe weeks months or years whatever it is and you're reinforcing the synaptic the synaptic connections every time you're reinforcing the synaptic connections think of the ivy the ivy you're reinforcing which means you are developing some synapses and you're pruning the synapses that aren't involved and so you are actually sculpting and consolidating the synaptic configuration that makes you an addict so you do that time after time day after day week after week month after month and that's development that's development that's the development of a habit of a very intense have it an emotional habit a strong strongly compelling habit but it is it is still a habit it's a learned habit and again think about the IV think about as this is happening you're pruning synapses you're losing some synaptic connections in the prefrontal cortex and you're consolidating the addictive pattern okay so that's that's the first point that's a general learning model of the development of addiction second is this phenomenon that I call now appeal that the psychologists called delay discounting this is you might be familiar with this from the famous marshmallow test where they take this came from was it Michela yeah they get three or four-year-old kids in a room and a nice lady comes in and says would you like to have one marshmallow in our or would you like to wait for a few minutes I'll be back in three minutes and then you could have two marshmallows and three-year-olds sit there when the woman leaves the room and they twitch they agonize because the marshmallow is sitting right in front of them they really want that marshmallow and some of them caress it some of them kiss it you there's a there's a movie of this on YouTube which is just fantastic just look up marshmallow task it's the first thing that comes up on YouTube there's one for adults too by the way and I'm sure you can imagine so so yeah so this is this is how it works dopamine focuses attention on the immediate goal and that produces craving and it's the immediacy that's the issue so all mammals have delay discounting they have a tendency to overvalue immediate available rewards over more distal rewards more long term benefits to their detriment because if they went if they waited a little while they'd have a bigger net gain and all novels do it even pigeons do it and the point is that you sort of know that we mammals kind of know that but we do it anyway because it's built into the striatum it's built into the dopamine system you go for the low-hanging fruit it's it's a very fundamental mechanism and here's an example uh why is these are called discounting curves and this on the x-axis we have time and on the y-axis we have the perceived value of the reward well here's the reward it's a piece of cake that's a that's a reward that's immediately available and but if you didn't have that piece of cake you could in a month you could have you lose five pounds you can have a slimmer nicer body or something like that so the question is why is that man going after the cake and what these discounting curves show is that the rise in the perceived value of the award goes up quite suddenly it's not just an exponential curve it's a hyperbolic curve it's a sudden sudden curve when you get close to the immediate reward the perceived value suddenly goes up and when that so these things are graphed mathematically by people in behavioral economics if you there they're buying models based on these these mathematical curves there's a whole bunch of people working on these things right now and so when the blue curve rises above the yellow curve that's when the guy that's when you know you're you're done going after that cake whether you get fat or not so he's going after that cake because it seems worth more than imagine future happiness at this point right now right here right there and that's because the dopamine system is tuned to the cake tune it to the immediate reward so the consequences are I think fairly obvious there's an immediate goal which seems worth a lot more than the long-term goal and so you blow it off whether you're going to be out of money out of weather your girlfriend's going to leave you whether you're going to get in trouble with the cops whether you're going to lose your job those are future events and all you can really think about is whether or not I'm going to get high tonight or today you never hear people say let's get high next week it's just you're not going to hear let's get high next Tuesday No so let's get high now tonight today so yeah the immediate goal weighs the imagined future and that's just the way it works here's a study which i think is kind of cool because it recreates it simulates this in the lab these are tests in which the the participant looks at a screen and they are offered small immediate rewards so that smaller sooner rewards they can click that button or larger later rewards which means they can get you know you know like one-year-old today versus five euros next week or I should say pounds or I don't know what currency you guys are going to be using thanks but but that's that's the task and you sit there and everybody has the kind of ratio a built-in ratio between immediate smaller sooner and long-term benefits we have a part of our personality and so the thing is that when you put this machine on the participants head this is TMS transcranial magnetic stimulation and what it does is it discombobulates the the pre front the area of cortex that it's right over it just dis organizes it so it loses its yeah its function and this happens to be over the left drawer so lateral prefrontal cortex which is my favorite area of the brain and so when you turn on the machine guess what happens the the discounting curve the ratio between shorter sooner and longer later rewards changes you are less able to hold on for later rewards and you are more impulsive and going more after the immediate things that the the yeah less delays that's sorry yes less yeah you see what I'm saying right you become more impulsive more compulsive and so forth and that's really I think parallels what we see when we see the loss of a connection between the striatum and the prefrontal cortex interdiction that's exactly what we're saying that loss of connection and here we can produce it in a lab luckily it's only temporary okay so that's that's now appeal the next phenomenon is this phenomenon of ego depletion or ego fatigue and this is also a completely normal psychological mechanism the one of the earliest experiments I think expresses it best that what what this is Baumeister's work and what they would do is they would bring participants into the lab and they would say you can't have eaten in the last 8 hours so they come in hungry and you have a bowl of freshly baked chocolate chip cookies and a bowl of radishes and ha you know psychologists love these kinds of studies because they're perfectly balanced and control half the sample is said you can eat all the radishes you want but no cookies and the other half says you get all the cookies you want but no radishes this perfect experiment right it's at deeply satisfying to the to the psychologists in all of us and what happens is that the the after 10 or 15 minutes of this situation the people who have to suppress the impulse to eat the cookies or do not do as well on a series of cognitive tasks so they're given a bunch of cognitive tasks and they just don't do as well these tasks require cognitive control or executive control and you've kind of lost some of that it's become fatigued you've worn some of it out this is the phenomenon and it's very difficult to try to figure out exactly why that's that's it's been examined for many years now and there's recently been challenged in some ways but the point is that you can't keep trying not to do something that's the point you can't keep trying to suppress an immediate impulse it's like holding your arm out to the side you can do it for five minutes try doing it for an hour the machinery isn't built for that okay it's not built for that so addicts have a really hard time with that an extremely hard time because they have to suppress control inhibit their impulses for hours at a time days at a time weeks at a time they're told in their a a group you can never drink again and they're told that their addiction is doing push-ups in the parking lot and you have to be under guard all the time and that's really really difficult it's so difficult that most of them fail and success rate in AAA is 5 to 8% so the of course one of the problems is they're accused everywhere this is my home country for now and especially with alcohol is particularly difficult because also is smoking the accuser are all around us so it continues to turn on the dopamine system focus your attention on the anticipated reward and then you have to say no I'm not doing that oh so the the response to this recommended by the the executive cortex of the United States of America was just say no this is Nancy Regan I don't have it if you remember Nancy Reagan was the wife husband wife of Ronald Reagan and and she was one of the spokespeople for the war on drugs one of many as keeps going on and her yeah she they were counseling and you know urging young people just say no to drugs just say no to drugs well ok here's an example of what happens when you just say no in this study participants watched a terribly sad movie clip so there's like you know a little kid with his father and the father dies and the kids all alone and it's very sad and half the group is told to suppress their emotions and their expressions don't feel it don't show it and the other half of the group is told to think about the film to think about what the film is trying to portray to intellectualize it in other words to reappraise it it's a very different way of dealing with it and in this particular study what we see is that this is the suppression group this is the reappraisal this is the reappraisal so these guys are told not to show or express any emotions these guys are told to think about what the what the film is trying to convey and this is a control group and this blip here this ERP is called the the error related negativity it's it's what it shows it's a little erp blip eg blip that represents cognitive control the attempt to control too to overcome an error okay and that blip is smaller for the suppression group those who are told to not show any emotions show a reduced reduce activity in that region of cortex that produces this response that is how we control our impulses so that's pretty significant we're seeing now that actually just trying to say no to yourself for a short period of time is already enough to change the functioning of the cognitive control part of the brain and if that happens on any one occasion you can imagine what happens occasion after occasion after occasion that set circuitry is changing and starting to become less effective over time and that's really serious for addicts so just saying no is not the right answer suppressing those impulses saying no isn't what work what works is to reappraise the situation to think about well if you take this as a parallel think about what your addiction is about think about why I do some counselling with with with addicts over over the Skype and I never tried to tell them that you have to stop I know better I don't say you have to stop taking drugs or drinking I say you know let's talk about how you're feeling let's talk about what you want to do and if you're going to get high okay it's fine well let's talk about that and just take all that pressure off so that you're not making that kind of demand on the system and rather start to think about what's going on in your life and what's going on in your past and what's going on and what does this drug or substance do for you and that's the way to start to change how the system functions okay so in some brain change with addiction just a summary of what I what I said before here's the PFC in charge of judgment here's the striatum in charge of attraction desire craving um and here is the the dopamine system and dopamine goes to the striatum and sets up that little feedback cycle so you get more and more and more and then the striatum becomes sort of hyper activated in the presence of cues and then you get that mechanism of now appeal that is narrow wing of attraction to the immediate reward and the loss of everything else the other stuff falls off the radar okay and then the the connection between the PFC and the striatum starts to become compromised you get ego fatigue and the prefrontal cortex simply becomes less efficient less effective at control okay so that's the model now in the book by the way I it's not full of neuroscience in the book I tell the story of five addicts one is a heroin addict one's a meth addict one was addicted to pharmaceutical opiates the fourth one was a British man who was an alcoholic very serious alcoholic and the fifth one was an eating disordered person and each of these people I interviewed for many many hours over Skype they're from all over the world and I chose people who could talk about their addictions because they were articulate and honest and they had were able to think about it and remember it clearly I wasn't sherry cherry-picking them and their stories all had a very kind of similar profile to them the addiction would progress and it would become more and more difficult to control and it would come to a point where it was really screwing up their lives in a very serious way and then the attempt to stop would start happening and there would be a number of failures this was the case for me when I was an addict it's a very typical profile and finally things get serious enough that people get really really uh determined to stop and that determination starts to change the picture the the guy who was an alcoholic was very very close to to death actually he was he was very close to death through alcohol or suicide whichever came first and he would have these as these four-hour days he would get up he would wake up he'd go straight to the fridge and and pour a bunch of rum in his coke and start drinking it before he got to the toilet actually he would finish the first one by the time you finished peeing on and then you go back the second one and he kept doing this and he well he got drunker and drunker and finally after three or four hours he would become sort of comatose fall on the floor and not be able to walk and crawl to his bed get in his bed and then wake up and start the cycle again so you didn't have like normal days you get four hour days and this went on for some some period of time until he managed to get the help that he needed and to quit now I'm going to talk about recovery now and talk about how this happens because for each of the people in my book they actually did find a way out of addiction as people generally do it takes time it takes effort but people do find a way out most people not everybody some people it's a dead end but the percentage is small okay so what I want to say is the disease model is not helping these people the disease model of addiction isn't just wrong it's also harmful and one way you can get to this conclusion is just by looking at the stats on on conventional rehab programs conventional rehab programs have very poor success rates usually people relapse anywhere from two to ten times it's you know the revolving door phenomena I'm sure you've heard about it they go from program to program to program they get kicked out they get they get court-mandated to other programs they get a waiting list for state funded programs which are universally crappy they in the u.s. they spent all their money and all their family's money in this process and these are rehab centers that have a you know they're the main the the banner is the disease model you have a disease and we're going to help you this is a really really big calling calling card for addicts and a lot of addicts kind of welcome that they say well okay I have a disease that's why I do these things and I can't help myself and that's really that explains it I have a disease okay but that's not necessarily beneficial what disease model advocates say is that this reduces stigma and shame and you know can content and guilt and all that stuff because if you have a disease where you shouldn't be blamed right so that's supposed to make you feel better but I don't if someone told you you have a chronic brain disease it makes you do horrible things would that make you feel better and I just I think the logic is really flawed and the many addicts that I talked to of course not all addicts talked to me and some people probably don't want to talk to me but but the ones that I talked to say I never feel like I had a disease I never felt like I had an illness but when I was in AAA I kept getting told that I have this lifelong illness and I have to guard against it with all my might and it never felt right to me and it never made sense to me and bla bla bla and finally they left or they went somewhere else so they did something else and finally they quit so a lot of addicts don't feel good about the disease model they don't find that it's helpful but the outcome stats themselves are bad enough the fact that these the other problem is that these rehab facilities these addiction treatment centers they they they claw 85% of them in the US are based on the disease model eighty-five percent and an almost overlapping 85 percent uses 12-step methods as their primary primary intervention method well you know that's hard to actually figure out because medicine is this and twelve steps have very little to do with medicine it's kind of based on a religious orientation it came from the notion that you know you're powerless and you have to give your power away to God and that's the only way you're ever going to get better and this is a really kind of a strange a confluence between that model and the medical model but the thing they have in common is the idea that addiction is for good that it's a fundamental flaw it's an essential characteristic of the person and it's not going to go away it's chronic so you have to continue to do what we tell you and that's the real commonality you have to do what we tell you not what you think you should do because that's not working you have to do what we tell you that's the big problem so I would say that the disease model fails addicts because okay the disease model calls for medical treatment as the primary intervention although 12-step methods are deeply deeply conflated with it and medicalization the whole setup makes addicts into patients and patients hand over control to professionals that's what you do in your a patient you do what you're told which causes an increased belief that you're a chronic that's belief in chronicity there's a loss of empowerment the first of the 12 steps I am powerless admit that you are powerless and this sense of fatalism and surrender which for many addicts is actually a ticket to increased relapse rates I can't help it I can't stop it and that's why I keep doing it in fact there's a number of studies that show I know of two and three of them one about alcohol one of methamphetamine that shows that belief in the disease model itself is a predictor of relapse those those who believe in the model relapse more frequently and more and sooner than those who don't so that in itself is quite telling I know I sound a bit like a zealot on this well and I just every time I sort of calm down and think about you know there's and there is there is room for overlap there is a gray area there are disease like aspects of addiction if that part is true and I should also say that I'm not saying that doctors should be out of the picture entirely not at all there are some addictions for which medical intervention is really really helpful the main one is opiate addiction addiction to heroin and other opiates because when you get off heroin you have these nasty withdrawal symptoms and for two or three weeks you're highly vulnerable to relapse because you feel like you really really feel like so if you are given methadone or buprenorphine which is sometimes called suboxone these are opiate substitutes they will reduce the withdrawal students or completely eliminate them and then you might be able to have you know a more tapered trajectory into quitting of course sometimes that doesn't happen if people will often stay on opiate substitutes for long periods of time sometimes for life so that's considered to be problematic but it's not as problematic as dying on the street because of a heroin overdose so I'm certainly not saying that these kinds of interventions should not be should not be available they should be available but that's not useful for meth addicts or coke addicts or addicts to a whole bunch of other things all the behavioral addictions there's no drug that helps you get over gambling or sex addiction or porn addiction or eating disorders except you know that's amphetamine you know that's how that's why it was prescribed years ago is for people who ate too much take a bunch of speed and you stop eating so yeah but for all those other addictions there really are not appropriate drugs for alcohol there are some drugs that help to a certain degree there's there's stuff like antabuse which makes you sick when you drink so that can be very effective because that tends to make you not drink until you stop taking your antabuse because you really want to drink so you stop taking antabuse and then you drink so it's really a bit of a flawed treatment strategy but it does work for some people and nowadays are talking about baclofen never heard of baclofen it's a it's a benzodiazepine which apparently helps reduce cravings for alcohol and for opiates and if that works great let's use it I am NOT not in any way adverse to that but none of these things touch on the psychological mechanisms that get people into addiction and that make it so incredibly resilient and those psychological mechanisms have to be dealt with a doctors don't have the tools for that they just don't have the tools they're not trained in that usually okay so I'm going to end by saying that how do we help addicts well I'm going to go back to the two things that I've emphasized how first how do we help addicts feel empowered rather than disempowered which is a potent antidote to ego fatigue to feel empowered I can do it okay and I think that we need to help them own other goals it's really important to replace the addictive goal with something else you can't just spend all your time not doing something you have to do something there has to be an attraction to something for me when I quit around the age of 30 I was doing meditation and Tai Chi I did Tai Chi in the park every night for an hour was great and so I had something else to do which really helped me and that's generally the case help them own other goals but when I say on I mean it has to be your goals you have to formulate those goals they can't be handed to you by a group or by a physician you know or by a sponsor and I think of it as like what happens when you give the wheel of the car to your teenage kid up until that time they don't care how much gas is in the tank or how much errors in the tires or if there's a few scratches they don't care much about the car once they get behind the wheel it's a whole different thing then they care and that's what you have to that's what you have to capture you have to capture that motivation that sense of ownership okay that's really empower Minh that's coming from well the striatum in part so that's the first thing the second thing is we have to help addicts envision a future because now appeal actually you know cuts off the ends of the temporal dimension it cuts off the past and it cuts off the future you can only think about today you can only think about getting high you're now stuck in this kind of eternal present tense that's really serious because you can't even imagine a future you don't want to think about next week you can't think about next week you don't want to think about the past it's all too awful and disgusting and how did I get like this and how did I you know my marriage break up at I lost contact with my kids and that's not nice to think about so you're just stuck in this eternal present so you need to help addicts think about the past and the future and get that back into their their their yeah to the mindset so I think one way to think about that is to see life as a narrative to see your life as a story which is moving on I come from there this is what happened to me I myself I went to a crappy boarding school for two years got very depressed came out to Berkeley got stoned a lot became addicted to certain things that it or not now I'm here and now I'm going to do this and become a psychologist and have a good life so I was able to put the strands together and addicts are not able to do that sometimes they need help and so I think that's what professionals and family members and friends and lovers and lots of other people can do help them think about where they come from and where they're going to you put those two things together and that's the magic formula I think it's well it's not that simple it's not a simple thing but that's it's certainly a part of it so what you're doing basically is reconnecting the striatum that's empowerment with the prefrontal cortex you're reconnecting the motivational engine with a bridge of the ship and that's happening in the brain and it has to happen in the mind of course it's so I think this is my last slide okay so treatment works by connecting or reconnecting empowerment to the sense of a future self self in time which is like connecting the striatum back to the prefrontal cortex which is like connecting the self with the social world these are all overlapping things you're kind of you know rejoining parts of the brain and you're rejoining parts of the mind and the way to do that well you know there's the choice conventional disease model rehabs which is pharmaceuticals plus the good book and that's one choice and the other choice I think are all these psychological tools psychological interventions that are out there that are available that need to be funded explored and extended cognitive behavioral therapy dialectical behavior therapy motivational interviewing psychoanalytic therapy works for some people mindfulness meditation lots of really good results now with using mindfulness meditation to help addicts which i think is very exciting contingency management another psycho proach and compassion focus therapy social support scaffolding all those things can be very very useful and the particularly has to be determined according to the individual and his or her needs and remember the brain never stops changing that's it thank you you

Channel: The Royal Institution

Views: 327,573

Rating: 4.8360109 out of 5

Keywords: Ri, Royal Institution, Neuroscience, addiction, science, lecture, talk, marc lewis, drugs, alcohol

Id: aOSD9rTVuWc

Length: 60min 48sec (3648 seconds)

Published: Sat Dec 10 2016

Reddit Comments

[u/[deleted]]

I mean, it really depends on how you want to define a disease. Some people are predisposed to compulsive behavior; does that make compulsive behavior a disease? I don't know, maybe not-- but it's important to note that not everyone has an equal playing field. The personality and pathological behavior that you've come to cultivate through a life-time probably also plays a large part.

[u/loveyum]

There are issues with the disease model, yes, but a main benefit is that treating it as a disease allows for the allotment of significant governmental research funds to be allocated to the study of it much like other diseases.

[u/Adarkes01]

For any recovering people browsing this I wanna throw out my two cents. Some studies are saying post acute withdrawal symptoms can last months or even years. Some suggested brain chemistry can be permanently altered. 6 years after addiction my interest in things was low, and I wasn’t sad or not entertained, but I was never content. Very neurotic. High anxiety. Low motivation to make social connections. Just get into long down times that would last a few months regularly.

Stumbled across a random study that changed my life years later. I started taking supplements, mostly GABA and Theanine that made me feel like a human being again - and this was 6 years after being clean. I think from experience the damage we do to our brains chemistry in making dopamine is understated in addiction research. This probably causes a lot of relapses.

[u/geri73]

My dentist prescribed me 3 refills of percs. Got hooked on one of the bottles for a good month. Half way through the bottle I decided to check side affects and realised that I need to just say no. I decided to not get those other refills. I did finish the rest of the bottle. I can see how you can get caught up in that shit. Also I had no clue your dentist can prescribe those type of drugs. Not to mention all the refills.

[u/mrgedman]

I think the topic deserves debate. It is shortsighted to shut down either side- both have merits. See the south park episode from a few seasons ago. It had some valid points, and perhaps some not so valid ones.

Some treatment involves monitoring behavior, and suggests it is not a disease but a problem with personal control - 'you are the one that got yourself into it, only you can get yourself out of it by being mindful of your behavior.

Then there is the other treatment, like AA for example. 'You have a horrible disease and are completely powerless to control it.'

I come from a line of behaviorists, and we likely all say it is a disease, but perhaps an alternate definition that does not mesh well with other diseases.

I think AA offers abstinence Only, and I think that's not right for everyone- when you fall off the wagon, you fall hard cause you have little experience with self control. It's different for different people though. Some people should really never ever touch the sauce.

Edit:

A lot of people ITT are thinking that those critical of AA recommend people should not go there. No one has said that, I hope.

My attitude is "thank God we have AA, but a different free treatment program would almost certainly serve addicts much better". I am very critical of AA as I have lost many friends and family to addiction. If you are in AA, please, please keep going, or replace it with an appropriate social support program.

[u/HumblingSitting]

Enjoyed listening to his opinions and jokes, although he surely did make it seem like they were only his opinions and based on his first person experiences. Surely got me to agree, but I think there's this other side we are completely forgetting. Like some studies. Google addiction is like a disease.

[u/cyneverdie]

TLDW...someone please?

[u/SullyBrr]

As a recovering addict in NA with 5 1/2 years clean, I couldn’t agree more with him. He’s right on the mark with the majority of this. The problem is, where do people like me go who are aware of the major flaws in the disease model, but have no other place to turn to. I wish his solution was a little more in depth. I agree focusing on your future and setting goals is imperative to staying clean. I myself have gone back to school and will be graduating with my bachelors in 3 days and will attend grad school this fall for my masters. A lot of me staying clean has been my ability to stay laser focused on my long term goals. I constantly see “in the rooms of recovery” people who wholeheartedly believe they are powerless and that only god can remove their defects through prayer, and they stay stuck in the same place in life and eventually relapse. The good thing about NA/AA is the ability to get around like minded individuals and receive that identification we so desperately need to feel not alone. There is no other outlet for people like us where we can go and share our crazy thoughts and everyone there understand exactly what you’re talking about and then listen to their experience on how they got through it. It’s such a complex issue and we are very far off from finding a resolution, but I do know that it needs to be founded in psychology and not in “God”.

[u/YOUNGJOCISRELEVANT]

Type 2 diabetes is a disease brought on by eating too much sugar. Diabetics did that to themselves, and they need their medicine to make them function. Substitute the word diabetes with addiction. That’s the most common comparison made when going through rehab. Addiction is a disease and only people who don’t understand it claim that it’s not one