Free Will Black Swans and Addiction

Authors: Ted Fenton Reinout W Wiers

Publish Date: 2016/11/21

Volume: 10, Issue: 1, Pages: 157-165

PDF Link

Abstract

The current dominant perspective on addiction as a brain disease has been challenged recently by Marc Lewis who argued that the brainchanges related to addiction are similar to everyday changes of the brain From this alternative perspective addictions are bad habits that can be broken provided that people are motivated to change In that case autonomous choice or “free will” can overcome bad influences from genes and or environments and brainchanges related to addiction Even though we concur with Lewis that there are issues with the brain disease perspective we also argue that pointing to black swans can be important that is there can be severe cases where addiction indeed tips over into the category of brain disease but obviously that does not prove that every case of addiction falls into the disease category that all swans are black We argue that for example people suffering from Korsakoff’s syndrome can be described as having a brain disease often caused by alcohol addiction Moreover the brain changes occurring with addiction are related to choicebehaviour and the related notions of willed action habit formation and insight hence essential mental abilities to break the addiction We argue for a more graded perspective where both black swans severe brain disease which makes recovery virtually impossible and white swans unaffected brain are rare and most cases of addiction come as geese in different shades of grayThere is no question that addictive behaviours can have negative effects for the individual including social problems physical harms and premature death But that in itself does not imply that it is best described as a brain disease the current dominant perspective in biomedical sciences clearly stated by the influential scientist and president of the National Institute on Drug Abuse NIDA Nora Volkow 1 in line with her predecessor Alan Leshner in an influential paper in Science 2 Addiction is related to choices that are potentially beneficial in the shortrun at the expense of longterm positive outcomes a facet of impulsivity known as delaydiscounting 3 However association does not imply causation and indeed there is both evidence that impulsive traits can become more pronounced through engaging in addictive behaviours and that impulsivity is one of the riskfactors for the development of addiction 4 5 Increased impulsivity is a first example of brainchanges that can occur with the development of addiction others include changes in the systems underlying habit 6 7 salienceprocessing 8 selfinsight 9 and increased negative affect and stresssensitivity aptly called “the dark side of addiction” 10 Most neurobiologicallyoriented scientists adhere to a model now including all these different changes in different phases of addiction where initially there is increased reward and salience of drugcues positive reinforcement stage followed by more automatized habitual responding compulsive phase and in later stages by anhedonia and drug use to counter negative effects of previous use negative reinforcement 7 11 12 Note that in addition to different phases these responses may differ from substance to substance 13 and from person to person related to personality characteristics 14 Further people typically take multiple substances which may further complicate the exact nature of the brain changes 15 The question here is whether these brainchanges should be called a braindisease In his wellwritten book and accompanying paper Marc Lewis argues against this perspective 16 17 What are his argumentsFirst Lewis argues that the brain changes all the time when we learn a new cognitive ability eg a new language a new skill eg skateboarding or any new habit Lewis here cites Doidge “there’s nothing more fundamental to the human brain than its plasticity” and adds “Yet neuroscientists who study addiction seem to have missed the point” We doubt whether the neuroscientists really missed this point or merely emphasize that the brain changes are more profound and longlasting than brainchanges in learning everyday habits In fact Lewis agrees that “we must still ask whether there is something special about addiction that makes it hard to overcome” and then lists “three mechanisms that accelerate our attraction to addictive rewards and entrench addictive activitieswithout making it a disease” 17 ms P 10 This appears to be an empirical question to what extent brain changes related to substance use disorders are similar to those related to falling in love or habits involving rewards gambling gaming and there appear to be both commonalities and differences 18 19 In fact parallels in brain functioning in pathological gamblers and people with substance use disorders was an important argument to include pathological gambling in the addictions cluster in the DSM5 Of course that does not prove that both or neither are a brain disease but does point to a perspective where some brainchanges are more longlasting and severe than othersA related point concerns the question to what extent brain changes associated with addiction are more longlasting than those related to other bad habits or again falling in love Here Lewis points to some recent research showing increases in grey matter after prolonged abstinence 20 That is a nice and positive finding but there are also numerous studies showing some return of function in some areas but not in others as recently reviewed 21 In fact many studies in this area report no full return of function after abstinence because the abstinent expatients don’t reach normal levels of functioning However without a baseline measurement of functioning before the addiction it cannot be ruled out that the suboptimal functioning may have been a premorbid factor rather than an effect of the substance use 21 Recent evidence not only points to excessive use as a cause of brain damage but also to the number of detoxifications which was shown to be related to functional damage in shifting in a reward task 22 23 24 In summary it seems fair to say that there can be some return of functioning after breaking with an addiction but clearly there is also evidence for the opposite pattern and this should be investigated further ideally with baseline measures of functioning which might happen with recent large scale longitudinal studies underway 25A second argument is that the braindisease perspective may be demoralizing for individuals That may be true for some and indeed there is some research pointing in this direction for example smokers who viewed smoking as an addiction had more troubles in quitting than smokers who viewed it as a bad habit 26 When you believe you have lost your free will you can more easily shrug your shoulders because you are actually not to blame However one could also argue the opposite and in his introduction Lewis points to this as well the braindisease perspective freed addicted people and their families from some of the social stigma related to the moral perspective on addiction When addiction is a brain disease immoral behaviours are less accountable than when it is the consequence of one’s immoral choices But in the end this is not a central argument the central question is whether addiction can best be seen as a brain disease or not given the current state of the scientific knowledge The secondary question is then how this is best transmitted and what the societal impact is of either messageWhat is addiction then according to Lewis Is it the same as any other result of our ever learning and changing brain Lewis proposes that addiction is a bad habit which is in line with current neurobiological theories that emphasize the gradual change in addiction from motivated choice to compulsive behaviour which is accompanied by a change in control from neural circuits involving the ventral striatum to circuits involving the dorsal striatum 6 7 The beautifully portrayed cases in Lewis’ book show that contrary to popular belief you can stop your addiction with enough willpower without any special treatment And in fact that’s what many people with addictions do Just like when you fall in love drug use is a motivated repetition that gives rise to deep learning Desire is the number one emotional state that drives learning Lewis then describes three specific mechanisms that make addiction exceptionally hardtoovercome habitsThe first is a narrowed beam of attention for immediate reward and delaydiscounting According to Lewis this is exactly the state addicts find themselves in again and again This is related to cognitive biases which have indeed been related to addiction and the good news is that they can be overcome through specific targeted training methods 27 28 29 30 The second mechanism is that addictive rewards enlarge motivation Our synaptic patterns get reinforced with every repetition leaning a language cooking smoking and the best way to do that is by boosting that repetition with strong motivation Moreover addictions have shortlasting rewards and are often followed by negative affect which can elicit the need for new stimulation Or in Lewis’ own poetic style “Addictive rewards whet the appetite and leave frustration loss and depression in their wake” ms P 11 Third the addictive habit converges with other habits that thicken our personality as in the crystallization of depressive or anxious traits And indeed there is evidence for increased impulsivity with adolescent addictive behaviour 5 All in all addiction is a habit that grows more quickly and becomes more deeply rooted in our neural circuitry than other habits because of the intensity of the motivation of wanting to repeat them This may sound a lot like a brain disease but the difference is that Lewis’ perspective is the dynamic and developmental emphasis and the alternative remedy of further growth as the salivating answer rather than repairing the “broken brain” in addiction as the disease model would suggest

Keywords: