Dr. Ellis discusses how addiction excels at keeping people around it off balance and in doubt. He then describes 4 common signs of addiction that should help you decide if you need to take action.
At the core of all addictions lies a spiritual void. This void most often is the result of unaddressed, or inadequately addressed, trauma. Into the void comes the drink, pill, or needle promising an immediate relief with no mention of the very high cost. Eventually, the drug-use produces an ever-increasing craving for an ever-diminishing pleasure. In the end, there is no pleasure. The addict will use or drink simply to try to feel normal. Addiction drains the spirit and gives nothing in return.
The spiritual void is the end-result of a physiological process. So the key question in recovery, for the alcoholic and the family, is simply this: is alcoholism a disease? The success of an intervention and treatment can hinge on your answer.
If you, and members of the intervention team, regard your loved one’s drinking as a bad habit or weakness of will, then blame, shame, and guilt are going to weigh heavily on the meeting. The alcoholic, already feeling persecuted by the world, is more likely to simply dig in and fight back.
We need a change of viewpoint where we begin to see the alcoholic not as a bad person that needs to be punished, shamed, or shunned but a sick person that needs treatment. This shift changes the entire tone of the gathering.
I’m not for a moment saying that the alcoholic has not done some very bad and harmful things. This disease comes with a load of awful consequences. But our focus in intervention is on getting the alcoholic to a place where he can heal. In an effective recovery, the alcoholic will learn how to properly take responsibility for his behavior and make appropriate amends. While in active addiction, the alcoholic literally cannot maintain clear thinking. An intervention is simply not the time to deal with a litany of grievances, attempts to assign blame, or elicit confessions. We have a unified goal of getting the patient into treatment and helping the family to begin healing.
So again, the key question concerns how you view alcoholism. Is it a disease? To answer this question, we need to look at the brain and how addiction affects it.
The brain is a combination of wondrous complexity, fragile balances, and remarkable resiliency. It performs truly incredible tasks. It can get sick, and it can heal. That’s good to know when we’re talking about addiction. The addicted brain can heal.
For the purpose of understanding addiction, we begin with a basic description of the three-part brain:
The Hindbrain controls breathing, heart, rate, blood pressure and countless other things that we need to stay alive but do not think about. It’s autonomic and has little to do with addiction except for the opioid receptors present in the medulla oblongata that controls breathing. Opioids (heroin and all the narcotics) bind to these receptors and depress breathing. Too much of the drug and we pass out or die. All opioid overdose deaths result from the essential shutting down of the areas that automatically control our breathing.
The Midbrain processes much of our vision, hearing, motor control, alertness, and temperature. Too much alcohol results in clumsiness, blurred vision, and passing out. This area also has a vital role in the “pleasure pathway” that gets distorted in addiction. The Limbic System is primarily located here and serves a vital role in survival matrix. Here we find the fight or flight response. It also motivates a great deal of our sexuality desire to eat, protection, etc.
The Forebrain, or cortex, is a rather recent evolutionary development in the brain, appearing to rapidly expand in primates about half a million years ago. This is the external part of the brain with all of the folds. It makes us human in the highest sense. The prefrontal cortex in particular, right beneath our foreheads, is particularly important. It’s where wisdom originates. In this area we weigh decisions, anticipate consequences, process higher love and higher spiritual experiences. It’s also the part of the brain that exercises an “executive function.” It keeps the less developed parts of our brains in check and prevents us from acting impulsively and unwisely. It is the last part of our brains to come fully “on-line.” This explains a great deal of risky and even bizarre adolescent behavior.
In a normal functioning brain, the prefrontal cortex executes choices and serves as a governor to more primal drives. Thus, we do not seek to have sex, or eat, or fight all of the time. It essentially keeps us from acting irresponsibly on limbic impulses for pleasure. The prefrontal cortex makes the final decision as to how these drives are fulfilled.
In addiction, this delicate balance is destroyed.
A human being is a combination of the dust of the earth and the breath of heaven. There is something spiritual and eternal about every person. Discussions of the soul and matters of the spirit are critical to understanding how we live and find meaning in life.
However, science has helped draw back the curtain on the human mind and how we think and conceive of the world, seen and unseen, around us. Brain scans, a major leap forward in brain study, help scientists see and chart the areas responsible for various thoughts, emotions, and actions. Essentially, the brain is a carefully tuned chemical and biological matrix of neurons and neurotransmitters generating electrical circuits that enable us to, among other things, read this sentence and remember it.
The two main neurotransmitters in regard to addiction are: Dopamine and Glutamate.
Dopamine is the pleasure neurotransmitter. When an experience is pleasurable the Midbrain releases dopamine initiating a cascade of responses that tell the brain “this is good and desirable.” This is also called the pleasure circuit, or mesolimbic pleasure pathway.
Glutamate is the memory neurotransmitter and the most abundant neurotransmitter in the brain. When the Midbrain releases dopamine it says, “this is good, and I want it.” The Cortex then releases glutamate to say, “remember this and go get it.”
Again, when this delicate balance works properly it enables us to enjoy life appropriately. Our desires and instincts (from the Midbrain) are necessary for survival and neutral in terms of morality. The Cortex enables us to seek and enjoy pleasures in a good, helpful, and balanced manner. Addiction wrecks the balance.
A normal pleasurable event begins with a stimulus. I see my young granddaughter and her very appearance gives me a warm experience of joy. Her smile, her eyes, her calling me “Gandy” all trigger a series of events in my brain that creates a “pleasure construct.” We have countless pleasure constructs, triggered by stimuli such as food, sex, a football team, a favorite perfume, and even spiritual experiences. The perception of these pleasures all begins with the Ventral Tegmentum Area (VTA) of the Midbrain. The VTA then stimulates the Nucleus Accumbens of the Limbic System to release dopamine and thus we feel pleasure. The Cortex then releases glutamate to engrave the memory of the pleasurable event.
Drugs initiate a massive release of dopamine, perhaps 10x more than typical pleasurable events, certainly more than the brain was ever intended to accommodate. The Midbrain tells the rest of the brain that this drug is irrationally good and floods the pleasure circuit with dopamine. Then something very critical occurs in about 15% of the population, sometimes quickly and sometimes over longer periods of time: addiction.
In addiction, the Midbrain hyper-prioritizes the drug. In its primal way, with its massive releases of dopamine, the midbrain says to the rest of the brain that the drug is more important than anything else; food, sex, health, family, God, etc. The drug becomes the primary focus of the brain.
The two brains, the Cortex and Midbrain, should work in concert, with the Cortex in charge. In addiction, however, the Midbrain takes over and overrides the critical thinking areas of the Cortex. This disconnect explains the destructive, tragic and often incomprehensible behavior of the alcoholic.
An alcoholic’s behavior has been likened to a whirlwind. He or she brings chaos into the family, work place, and into every other relationship. They are unpredictable, except in their capacity to disappoint. They leave emotional, and often physical, wreckage in their wake. Everyone around the alcoholic struggles to comprehend this chaos.
The external chaos is simply a reflection of the chaos inside an alcoholic’s brain.
Addiction breaks down every area of brain processing. It is a biological dysfunction in which the alcoholic’s ability to think is tragically compromised. Even the alcoholic often struggles to comprehend the chaos. They likely will recognize the chaos they bring but are powerless to explain it or permanently change it.
So why don’t they choose to stop? Why do they choose to continue down a path of destruction? The answer is uncomfortable and disturbing, but undeniably true: they have lost the ability to choose freely.
They are at the mercy of a primal brain drive that is saying the drug is the most important thing in life. This experience is often just as maddening and frightening to the alcoholic as it to the family and friends of the alcoholic.
This explanation is not an excuse. It’s simply an explanation of what is happening. It underscores the absolute necessity of treatment where the freedom to choose can be restored.
Everyone who has ever taken a drink has chosen to do so, and we usually drink because we like taste and/or the effect alcohol produces. Alcohol in any amount is never beneficial to the brain, but many people who drink experience nothing harmful or wrong with that slight dopamine surge, at least initially.
A person genetically predisposed to addiction, however, experiences the surge, and that pleasurable sensation gets locked in by other areas and structures of the brain in ways a non-addict does not experience. The misguided power of the Midbrain surges through the entire pleasure circuitry of the brain and alcohol or drugs become the dominant drive.
For the alcoholic this experience is overwhelming and sometimes terrifying. His brain has become wired for alcohol. It has built a pleasure construct around the use of alcohol. The Cortex has engraved sights, sounds, and smells into this warped alcoholic pleasure construct. A party or ball game becomes a trigger to drink. A type of music becomes a trigger to drink. A smell, such as cigar smoke or even a barbecue become a trigger to drink. Certain people become triggers to drink.
This is an unconscious brain drive that takes over the life of the alcoholic.
What began as a disorder of pleasure ends in a catastrophically impaired ability to choose. Note which came first. The tragically bad choices are the result of underlying brain dysfunctions. The brain is diseased, broken, at some very fundamental levels. Addiction has wrecked the freedom of choice.
We can clearly see the effects of the breakdown of the decision-making system of the brain in three phenomena: Craving, Denial, and Pleasure-blindness.
Craving describes both the physical compulsion to drink and the mental obsession about drink. The alcoholic’s life revolves around alcohol. Even when she is functioning in a fairly normal way, i.e. taking care of normal daily tasks, she is still thinking about alcohol. This obsession may take the form of longing and planning for the next drink or binge, or even wrestling with the desire to not drink. It’s all a form of craving.
Most people use the word craving to describe a desire for chocolate for example. The craving in addiction is much more severe, overwhelming, and debilitating. Imagine not eating for three days and then trying not to think about food. At that point, your Midbrain would be screaming for food! The addict has the same obsession with his drug, every day, because the Midbrain has declared the drug to be #1.
Denial is often the most maddening part of addiction to the outsider. Everyone around the alcoholic sees the bad behavior and bad consequences. The alcoholic often does not see it that way at all, or, if she does,
only fleetingly and through a haze. Denial is why the alcoholic is usually the last person to recognize the depth and seriousness of a problem.
It’s a terrifying statement, but it is true: Addiction owns the brain. For this reason, addiction fights for its life.
Again, this is a reflection of what is happening in the brain. The pleasure circuitry of the brain is desperately trying to protect its unobstructed access to the drug. Alcoholics often appear to have a relationship with alcohol, as if it is their best friend. Essentially that is what their brains are telling them.
Pleasure blindness (anhedonia) is the inability to enjoy formerly pleasurable experiences. Alcoholics can get to the point where they feel depressed and utterly numb to ordinary and important pleasures; like family, hobbies, art, music, and beauty in nature. Those on the outside are painfully puzzled as to why their loved one no longer seems to take joy in them or anything truly worthwhile.
This is an outward reflection of the twisted inner chemistry of the brain. In a normal brain, typical dopamine surges, such as enjoying a granddaughter, “reach” the pleasure threshold and register as enjoyable events. However, repeated massive dopamine surges from drinking have raised the threshold so impossibly high that only drinking provides any sense of fleeting pleasure. Ironically, in later addiction no amount of alcohol brings pleasure. The alcoholic then begins to drink in a desperate attempt to feel normal (e.g. vodka in the morning coffee to stop jitters and get moving), or simply to feel nothing.
So again, we can see how lower brain dysfunctions have compromised the higher functions of choice. The Cortex, that executive part of the brain that polishes our humanity, has been set aside.
We’ve waded through a lot of complicated material to arrive at a simple answer: yes, addiction is a disease.
Dr. Kevin McCauley offers this definition of addiction as a disease: “Addiction is a combined genetic and stress-induced defect in the midbrain and prefrontal cortex dopamine/glutamate reward-learning system, resulting in symptoms of decreased functioning, namely (1) Loss of control (2) Craving and (3) Persistent use of the drug/behavior despite negative consequences.”
Understanding the devastating effects of addiction on the brain should help you understand why “choice” alone is inadequate. In fact, you can take away alcohol from the alcoholic and all you’ll have is an angry alcoholic. He will still crave alcohol, and that is truly a miserable experience.
Treatment gets to the underlying brain dysfunctions. It helps the alcoholic manage stress. The normal pleasure circuitry comes back “online.” True freedom of choice will be restored.
Remember why consideration of this question is so important. An intervention can be an emotionally charged event, but if the alcoholic senses genuine caring then chances of success are much higher. The shift we’re looking for initially in an intervention is to view the alcoholic as a patient, in need of treatment, and deserving of love.