Disorder refers to an abnormal state of the body or mind in which there is a disturbance of normal functioning, or a deviation from the normal structure or functioning of any part or organ, as manifested by a characteristic set of symptoms and signs whose prognosis and pathology may be known or unknown. These characteristic symptoms frequently disorganize the individual and may cause physical and psychological distress and pain.
Addiction refers to a chronic, relapsing condition characterised by compulsive repetition of substance use or a behaviour, increasing tolerance, and psychological and physical dependence. Addiction involves a compulsive psychological and physiological craving of a habit forming substance or any other rewarding behaviour like sex, gambling, medicine, food or religion.
Addiction is a dependence on a substance, such as the drug heroin, or a type of behaviour, such as gambling. The dependence is so strong that it may seem as if the person is unable to break away from the dependence
An addictive disorder is any abnormal state of body or mind which involves a chronic, relapsing disease characterised by compulsive repetition of the behaviour, increasing tolerance, and psychological and physical dependence. Any activity, substance, object, or behaviour that has become the major focus of a person’s life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially is considered an addictive disorder. A person can become addicted, dependent, or compulsively obsessed with anything. All addictive disorders are progressive and are usually characterized by withdrawal syndromes.
What Is An Addiction? A Broad Meaning of Addictions
Addiction has long been understood to mean an uncontrollable habit of using alcohol or other drugs. Because of the physical effects of these substances on the body, and particularly the brain, people have often thought that “real” addictions only happen when people regularly use these substances in large amounts.
More recently, we have come to realize that people can also develop addictions to behaviours, such as gambling, and even quite ordinary and necessary activities such as exercise and eating. What these activities have in common is that the person doing them finds them pleasurable in some way. There is some controversy about which of the “behavioural” addictions constitute scientifically validated “true” addictions, with both professionals and the public failing to reach an agreement. More research is needed to clarify this issue.
So if you can be addicted to anything, what makes it an addiction? Although the precise symptoms vary from one addiction to another, there are two aspects that all addictions have in common. Firstly, the addictive disorder is maladaptive or counter-productive to the individual. So instead of helping the person adapt to situations or overcome problems, it tends to undermine these abilities. For example, a gambler might wish he had more money – yet gambling is more likely to drain his financial resources. A drinker might want to cheer herself up with an alcoholic beverage– yet alcohol use contributes to the development of her depression.
A sex addict may crave intimacy – yet the focus on sexual acts may prevent real closeness from developing. Similarly, relationships are often neglected in favour of the addictive disorder, undermining trust and putting pressure on partners and other family members to cover up and make up for difficulties arising from the addiction. Secondly, the behaviour is persistent. When someone is addicted, they will continue to engage in the addictive disorder, despite it causing them trouble. So an occasional weekend of self-indulgence is not addiction, although it may cause different kinds of problems. Addiction involves more frequent engagement in the behaviour.
But if you still enjoy it, it can’t be an addiction, right? Wrong. Because the media, in particular, have portrayed addicts as hopeless, unhappy people whose lives are falling apart, many people with addictions do not believe they are addicted as long as they are enjoying themselves, and they are holding their lives together.
Often people’s addictions become ingrained in their lifestyle, to the point where they never or rarely feel withdrawal symptoms. Or they may not recognize their withdrawal symptoms for what they are, putting them down to aging, working too hard, or just to not liking mornings. People can go for years without realizing how dependent they are on their addiction.
People with illicit addictions may enjoy the secretive nature of their behaviour. They may blame society for its narrow-mindedness, choosing to see themselves as free-willed and independent individuals. In reality, addictions tend to limit people’s individuality and freedoms as they become more restricted in their behaviours. Imprisonment for engaging in an illegal addiction restricts their freedom even more.
When people are addicted, their enjoyment often becomes focused on carrying out the addictive disorder and relieving withdrawal, rather than the full range of experiences which form the person’s full potential for happiness. At some point, the addicted person may realize that life has passed them by, and that they have missed out on enjoying much other than the addiction. This often happens when people overcome addiction.
What’s the problem if it isn’t doing any harm?
Addictions are harmful both to the person with the addiction, and to the people around them. The biggest problem is the addicted person’s failure to recognize the harm their addiction is doing. They may have denials about the negative aspects of their addiction, choosing to ignore the effects on their health, life patterns and relationships. Or they may blame outside circumstances or other people in their lives for their difficulties.
The harm caused by addiction is particularly difficult to recognize when the addiction is the person’s main way of coping with the other problems they have. Sometimes other problems are directly related to the addiction, for example, health problems, and sometimes they are indirectly related to the addiction, for example, relationship problems.
Some people who get addicted to substances or activities are very aware of their addictions, and even the harms caused by the addiction, but keep doing the addictive disorder anyway. This can be because they don’t feel they can cope without the addiction, because they are avoiding dealing with some other issue that the addiction distracts them from (such as being abused as a child), or because they do not know how to enjoy life any other way.
The harm of addiction may only be recognized when the addicted person goes through a crisis. This can happen when the addictive substance or behaviour is taken away completely, and the person goes into withdrawal and cannot cope. Or it can occur as a consequence of the addiction, such as a serious illness, a partner leaving, or loss of a job.
The costs associated with addiction cannot be calculated. Addictions cause enormous personal harm to not only the addict, but to their families and friends as well. People who become addicted to drugs may develop any number of health problems. They may also experience personality changes and lose the ability to interact with other people socially. Addicts may have trouble staying in school or holding a job. If they do hold a job, they may pose a certain risk to their co-workers, to their customers, and to any individuals with whom they interact. For example, a truck driver who is addicted to alcohol may pose a serious safety threat to other drivers on the road. Addiction is also responsible for a host of societal problems. Because many addictions are very expensive, addicts may turn to crime in order to get the money they need.
The business of providing addicts with the substances and activities they require has become a huge enterprise. Casino operators, tobacco and alcohol companies, and other operations are kept in steady business.
PART ONE:AN OVERVIEW OF ADDICTIVE DISODERS
1.1TYPES OF ADDICTIVE DISORDERS
Addictive disorders are a recognizable psychological and behavioural syndrome that expresses itself in a particular individual in regard to specific substances or processes, but which exhibits a striking similarity and commonality among addicted individuals regardless of their specific circumstances and particular addictions.
An individual can become addicted, dependent, or compulsively obsessed with any activity, substance, object, or behaviour that gives him/her pleasure. Addictions may be subdivided into two: substance addiction and process addiction.
Substance addiction involves use of various illicit and licit drugs, including alcohol. A drug is any chemical substance that interacts with a living organism and brings about noticeable changes in the way an organism functions.
The process of substance addiction is a continuum that starts with abstinence on the one end of the continuum to addiction on the other end of the continuum. There is a progressive increase in use from experimental and occasional use, to regular and inappropriate use. * Experimental use – once a year may be during graduation and with limits * Occasional use – may be every other time there is a holiday and within limits * Recreational use – within limits for recreation
* Inappropriate use – loss of control and preoccupation with the drug emerges. * Addiction – compulsive use emergence of dependence withdrawal syndrome.
Traditionally, the term addiction has been used to describe dependence on substances, such as alcohol and other drugs. More recently, addiction has been applied to a range of behaviours.
Process addiction (also referred to as behavioural addiction) refers to patterns of behaviour, which follow a cycle similar to that of substance dependence. Behaviour addiction is a condition in which a person is dependent on some type of behaviour, such as gambling, food, exercise, computer games, shopping, work, or sexual activity. Whether or not behavioural addictions are “real” addictions is a central controversy within the addiction field.
Process addictions are considered real, in that they follow the same pattern as substance-based addictions. Behaviour addictions begins with the individual experiencing pleasure in association with a behaviour and, seeking that behaviour out, initially as a way of enhancing their experience of life, and later, as a way of coping with stress. The process of seeking out and engaging in the behaviour becomes more frequent and ritualized, until it becomes a significant part of the person’s daily life. When the person is addicted, they experience urges or cravings to engage in the behaviour, which intensify until the person carries out the behaviour again, usually feeling relief and elation. Process addictions result in problems in many areas of the individual’s life. Though negative consequences of the behaviour may occur, the individual persists with the behaviour in spite of this.
1.1.3Relationship between Substance Addiction and Behaviour Addiction There are similarities between physical addiction to various chemicals, such as alcohol and heroin, and psychological dependence to activities such as compulsive gambling, sex, work, running, shopping, or eating disorders.
There is increasing evidence that addiction to behaviours involves similar brain mechanisms to substance-based addictions, although more research is needed to confirm and clarify how this happens. It is thought that behaviour activities may produce endorphins in the brain, which makes the person feel “high.” If a person continues to engage in the activity to achieve this feeling of well-being and euphoria, he/she may get into an addictive cycle. In so doing, he/she becomes physically addicted to his/her own brain chemicals, thus leading to continuation of the behaviour even though it may have negative health or social consequences.
Most physical addictions to substances such as alcohol, heroin, or barbiturates also have a psychological component. For example, an alcoholic who has not used alcohol for years may still crave a drink. Thus some researchers feel that we need to look at both physical and psychological dependencies upon a variety of substances, activities, and behaviours as an addictive process and as addictive disorders. They suggest that all of these behaviours have a host of commonalities that make them more similar to, than different from, each other and that they should not be divided into separate diseases, categories, or problems.
Crossover, switching of addictions, multiple addictions and a changing pattern of addiction are common but not universal features of an underlying addictive illness with recognizable structural features of its own.
In depth understanding of addictive processes must begin with the general and common features of addiction and move to the specifics of the addictive expression in a specific individual. Whether the addiction is single or multiple, substance or process, legal or illegal or an unstable and shifting combination of all the above, certain recurring and recognizable common features distinguish addictive from non-addictive processes.
1.1.4Common Characteristics among Addictive Disorders
There are many common characteristics among the various addictive disorders, which include: 1. The person becomes obsessed (constantly thinks of) the object, activity, or substance (salience, obsession, abnormal or pathological importance of the substance or behaviour). 2. They will seek it out, or engage in the behaviour even though it is causing harm (physical problems, poor work or study performance, problems with friends, family, fellow workers). Relative immunity to adverse consequences and resistance to learned modification of behaviour. 3. The person will compulsively engage in the activity, that is, do the activity over and over even if he/she does not want to and find it difficult to stop.
4. Persistence, rigidity, stereotypy, inflexibility and repetition of the particular addictive disorder. 5. Upon cessation of the activity, withdrawal symptoms often occur. These can include irritability, craving, restlessness or depression. 6. The person does not appear to have control as to when, how long, or how much he or she will continue the behaviour (loss of control). For example, they drink 6 beers when they only wanted one, buy 8 pairs of shoes when they only needed a belt, ate the whole box of cookies, etc. 7. He/she often denies problems resulting from his/her engagement in the behaviour, even though others can see the negative effects. There is invocation of an interrelated system of psychological defences which, like a string of military forts, function in concert to protect the individual from the full realization and acknowledgement of the self- and other- harmful nature of his addiction and hence provide cover and concealment for the continued expression of the addictive process.
8. Person hides the behaviour after family or close friends have mentioned their concern (hides food under beds, alcohol bottles in closets, doesn’t show spouse credit card bills, etc). 9. Many individuals with addictive disorders report a blackout for the time they were engaging in the behaviour (don’t remember how much or what they bought, how much the lost gambling, how many miles they ran on a sore foot, what they did at the party when drinking). 10. Depression is common in individuals with addictive disorders. That is why it is important to make an appointment with a physician to find out what is going on. 11. Individuals with addictive disorders often have low self esteem, feel anxious if they do not have control over their environment, and come from psychologically or physically abusive families.
Addictive fascination and fixity of interest have been justly compared to the more commonly known stage of romantic or infatuated love in which the lover thinks constantly of the beloved and pines and suffers when not in their presence. An individual in such a state of mind is said to be obsessed with their love object and to subordinate every other aspect of their existence, including at times their health, work, and other relationships to the fulfilment of the almost unbearable need and longing to be united with their beloved. And we know from life as well as literature that so passionate and frequently desperate are such lovers that at times they even die as a consequence of or for their love.
Anyone who understands the terrific drive and intensity that underlies and propels well-established addictive illness will not be surprised at the difficulties individuals encounter when attempting to control or terminate their addictive disorders. In such situations the old saying ‘The spirit is willing but the flesh is weak’ is an apt description of affairs once the individual has reached the stage of recognizing his addiction and the need to do something about it. And in many if not most cases, such recognition of harmful addiction may itself come only very late in the course of the addictive process, which has long managed by means of the psychological defences mentioned above to conceal and therefore protect itself from the critical recognition of its host.
1.2THE NATURE OF ADDICTION
Addictive disorder has distinct symptomology, pathology and prognosis (forecast or prediction). According to DSM-IV, the diagnostic criteria for most common disorders includes: description, diagnosis, treatment, and research findings.
Initially, the term “addiction” was used almost exclusively for substance addiction, that is, addicts were people who were totally dependent on drugs such as heroin, cocaine, nicotine, or alcohol. That form of addiction is now known as “substance addiction.” Later, experts also recognize that people can become addicted to certain behaviours. Some individuals may develop a dependence on gambling, shopping, sexual activity, eating, or many other activities. Addictions of this kind are sometimes called “process addiction or behaviour addiction.”
Diagnosis of an addiction may be made by a medical doctor or by a mental health professional. Often, patients go for help because they feel they can no longer deal with their addictive disorder by themselves. Sometimes family or friends intervene and bring the patient for diagnosis and treatment. In some cases, individuals are brought to the attention of professionals because of legal problems related to their addiction.
The standards used for diagnosing addiction include the three symptoms listed under diagnostic symptoms. All forms of addictions have some common symptoms, including:
a. Loss of control: Addicts are unable to manage their behaviour or their use of a substance. They may decide to quit the behaviour or using the substance one day and then fall back into the habit the next day.
b. Tolerance: In most forms of addiction, a person needs more and more of the substance or behaviour over time. Early in an addiction, a person may need only one “hit” of heroin a day. A few months later, he or she may need two, six, or a dozen “hits” to get the same response.
c. Impairment: Addicts often continue to use a substance or demonstrate a behaviour even when they know the undesirable effects it may have. For example, a gambling addict may continue to wager money even though he or she has lost everything in previous gambling experiences.
A person who displays these three symptoms is diagnosed as being addicted to some substance or type of behaviour.
There are many treatments available for people who suffer from addiction. These treatments are designed to deal with one or both forms of addiction: physiological and psychological. Example of treatment approaches for people who are addicted to certain substances include withdrawal therapy, medications, counselling, and alternative treatment.
Withdrawal therapy involves placing patients in a protected area where they have no access to the substance to which they are addicted to and where they are no longer allowed to use it. This form of therapy is sometimes called “drug detoxification.” The term means that the toxins (poisons) in a person’s body system caused by drug addiction are being removed from the body. Withdrawal therapy can be very difficult. The person’s body may still be expecting its daily ration of the abusive substance. When the substance is not provided, the body may react strongly. Nausea, vomiting, pain, and hallucinations are common side effects of withdrawal therapy. In some cases, patients must be physically restrained to help them get through this period.
Medications are also available for treating addictions. Perhaps the best known example is methadone. Methadone is a chemical that has many properties similar to heroin. It is addictive, just as heroin is. But methadone does not have the narcotic effects of heroin. A narcotic is a substance that dulls the senses and makes a person drowsy and sleepy. People who are addicted to heroin may be treated by giving them methadone instead. Ideally, the methadone treatment can very slowly be reduced until the patient is no longer addicted to either drug.
Various forms of counselling are also used to treat addictions. The theory behind counselling is that people become addicts because of serious problems in their lives. If those problems can be resolved, they may be less inclined to depend on addictive substances or behaviour. One counselling option is one-on-one counselling: an addict meets regularly with a counsellor, and the two discuss the client’s life and try to find solutions to problems that may have led to addiction.
Group counselling is another option: people with common addictions may meet with a professional counsellor to discuss their problems. Perhaps the best-known examples of group counselling are the so-called 12-step programs. The original 12-step program was Alcoholics Anonymous (AA). The term “12-step” comes from the stages of recovery through which AA members are expected to pass. The AA 12-step model is now used by other groups working to overcome other types of addiction.
Alternative treatment include acupuncture (a Chinese therapy technique where fine needles puncture the body) used to decrease withdrawal symptoms. Yoga has been suggested to help control behaviour addictions.
Treatments that have been developed to treat substance dependencies have been successfully used to treat behavioural addictions. Addiction professionals are developing competencies to treat a range of addictions, and clinics exist that specialize in treating behavioural addictions.
1.3CRITERIA FOR DIAGNOSIS OF ADDICTIVE DISORDERS
1.3.1DSM-IV Criteria for Substance Dependence
A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance, as defined by either:
a. Need for markedly increased amounts of the substance in order to achieve intoxication or desired effect; or b. Markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either:
a. Characteristic withdrawal syndrome for the substance; or b. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3. The substance is often taken in larger amounts or over longer period than intended 4. There is persistent desire or unsuccessful efforts to cut down or control substance use 5. A great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g. chain smoking), or recover from its effects 6. Important social, occupational or recreational activities given up or reduced because of substance abuse 7. Continued substance use despite knowledge of having a persistent or recurrent psychological, or physical problem that is caused or exacerbated by use of the substance
1.3.2International Classification of Diseases-10 (WHO 1992) Three or more of the following must have been experienced or exhibited at some time during the previous year: 1. Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use 2. A strong desire or sense of compulsion to take the substance 3. Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects
4. Persisting with substance use despite clear evidence of overtly harmful consequences, depressive mood states consequent to heavy use, or drug-related impairment of cognitive functioning 5. Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses 6. A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms
1.3.3Some problems with the DSM and ICD criteria
These diagnostic criteria leave considerable scope for interpretation. For example, how strong does a feeling of desire or urge need to be to count as craving? How severe do effects of withdrawal have to be to count as withdrawal ‘symptoms’? How harmful do the consequences have to be for them to count? The result is that determining whether or not an individual who engages in a behaviour is addicted cannot be specified objectively, but only by reference to judgements made in a clinical interview, or responses that the individual makes on a diagnostic questionnaire.
The arbitrariness is compounded by the specification that only a subset of symptoms is required for the diagnosis to be made. In principle, two ‘addicts’ could have non-overlapping sets of symptoms. However, this use of ‘disjunctive’ symptom sets in diagnosis is essential because some of the criteria have little relevance to some types of addictive behaviour. For example, chronic tolerance is marked in the case of alcohol but less so for cocaine. Giving up activities because of the addiction is more relevant to intoxicating drugs such as alcohol than drugs such as nicotine that do not interfere with normal functioning.
This suggests that the current diagnostic criteria need further revision. That is something to which this book returns in the last chapter. It is worth noting at this point, however, that revision of a set of diagnostic criteria and conceptualisations is not something to be undertaken lightly because it creates a disjunction with the past. This affects prevalence estimates as well as estimates of such parameters as heritability.
13.4Components of the Diagnostic Criteria
Addiction is one of the toughest problems facing our culture today. The growing problems within the family, as well as many other cultural stressors, make addiction a national and international problem that is growing by leaps and bounds. We have promoted a “feel good right now” mentality that tends to feed the addictive process. Addiction is a very complex and it has several elements that must be understood to grasp the true nature of it: tolerance, dependence, withdrawal and compulsion.
Tolerance is the reduced sensitivity or increased resistance to the drug effect. The body tissues adapt themselves to repeated exposure by becoming less sensitive to the drug or behaviour; hence the individual progressively needs a higher dose.
Tolerance means that over time more and more of the behaviour or substance is required to produce the desired effect. More intense sex or more alcohol is required to numb out feelings, or more cocaine is needed to get the heightened sense of excitement and competence. Eventually the intensity of the behaviour or substance needed to produce the high become dangerous in and of itself. Not only does one become an impaired driver in the case of chemical addictions, but an overdose can occur or the liver can fail. In the case of sex one runs the risk of an arrest, loss of a primary relationship or job, or becoming infected with HIV. And in the case of other behavioural addictions such as eating, spending, or gambling more and more intense experiences are required for satisfaction. Eventually even those fail.
Tolerance is not a static condition. With complete abstinence over a period, tolerance will decline and the body will return to its original level of sensitivity to the drug, so that some heroine users easily overdose themselves when they relapse with fatal consequences.
Cross tolerance is the process in which the effect of one drug is reduced or replaced by another drug. For example, alcohol requires more doses of sedatives to produce sedation. Tolerance precedes dependence.
Dependence is state in which the body has become too tolerant to the drug or a behaviour that the presence of a certain level of the drug becomes essential to its “normal functioning”. According to the DSM-IV Substance Dependence Criteria, the condition is manifested by three (or more) of the following, occurring any time in the same 12-month period:
3. The substance is often taken in larger amounts or over a longer period than intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having a persistent physical or psychological problem.
DSM-IV criteria for substance dependence include several specifiers, one of which outlines whether substance dependence is with physiologic dependence (evidence of tolerance or withdrawal) or without physiologic dependence (no evidence of tolerance or withdrawal). In addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3) sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment.
Types of dependence
i) Psychological dependence: Psychological dependence is the mental discomfort a drug abuser experiences in the absence of a drug of addiction. When a person become psychologically addicted to substances and activities, the substance or activity makes them feel happy, more self-confident, or better in some other way. In order to keep experiencing these feelings, they believe they must continue to use the substance or activity that gave them these feelings. It is the psychological withdrawal symptoms which are relieved by repeated use of the drug.
Generally psychological withdrawal symptoms refer to preoccupation with drug seeking behaviour (craving). For example, tobacco users pine painfully for a cigarette and can be irritable, restless and apprehensive. However amphetamine user can be severely depressed and suicidal upon abstaining. While alcoholics can experience delirium tremens (DTs) characterised by agitation, depression, apprehension and hallucinations.
ii) Physical dependence: Physical dependence is a condition in which the presence of a certain level of a drug becomes necessary for normal functioning of the body physiologically. When a person’s body become biologically dependent on the substance or behaviour, the body may begin to need and expect that it will receive a certain substance each day or each hour. If it does not receive the substance, it responds by becoming ill, manifested by withdrawal symptoms. Withdrawals vary in severity from mild to very severe. For example alcoholics who abstain may experience tremors of the hands and at the most severe levels of alcoholism they experience rum fits (seizures) physical.
This explanation has been used for addictive disorder as well as addictive substances. Some types of behaviour cause a person to become very excited. Their body chemistry may actually change as they win a jackpot or make another sexual conquest. Over time, body chemistry may demand repetition of the activities that produced this level of excitement.
There is no boundary between physical and psychological dependence. In many cases, addictions involve both physiological and psychological aspects. Both occur simultaneously.
What causes dependence?
Dependence is caused by substance abuse. According to the DSM-IV Substance Abuse Criteria, substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period: 1. Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; or neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous conditions (such as driving an automobile or operating a machine when impaired by substance use) 3. Recurrent substance-related legal problems (such as arrests for substance related disorderly conduct) 4. Continued substance use despite having knowledge of persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (for example, arguments with spouse about consequences of intoxication and physical fights).
Alternatively, the symptoms have never met the criteria for substance dependence for this class of substance.
Addiction and dependence
It is useful to be able to distinguish between addiction as impaired control and ‘physical dependence’ as a state of physiological adaptation to a drug which then needs to be taken to prevent withdrawal symptoms. Some researchers like to talk about ‘psychological dependence’. This term can be useful if it refers to a state in which an individual, for whatever reason, feels that he ‘needs’ something.
As such it is different in a subtle way from addiction which is a syndrome involving a behaviour and feelings. The problem is that addiction and dependence are often used interchangeably; it is unlikely that we will ever
be in a position where there is a strong enough consensus on the definition of and distinction between these terms to make a play for a formal definition.
Interestingly, in common parlance we tend to use different terminology for different addictions: we say ‘heroin addiction’ not ‘heroin dependence’ but ‘alcohol dependence’ not ‘alcohol addiction’. With benzodiazepines we tend towards ‘dependence’ rather than ‘addiction’. With nicotine and stimulants we feel about equally comfortable with either term. At the risk of using a language that reads rather strangely, this book will consistently use the term ‘addiction’ to refer to the syndrome at the heart of which is impaired behavioural control and try to avoid the term dependence. However, use of language sometimes provides clues to how well underlying concepts fit together and it is worth considering whether the different application of the terms ‘dependence’ and ‘addiction’ to different drugs reflects differences in the phenomenology of the problem.
Withdrawal means that an individual has a very painful physical and/or emotional reaction when the substance or behaviour is stopped. Withdrawal happens in two phases: acute withdrawal and post-acute withdrawal.
Acute withdrawal occurs within hours and days of the cessation of use. Alcohol withdrawal can be accompanied by hallucinations and delirium tremens. After a person has become adjusted to a certain level of the drug/experience removal of it affects the emotional/biochemical balance that has been established. The person then has to readjust to living without the previous level of stimulation, etc.
Post acute withdrawal can last two years or more. It also has emotional and physiological aspects that are very difficult to endure.
Loss of control over substance use or compulsion (the loss of control over whether or not to engage in a given behaviour so that the behaviour is repeated again and again in spite of hazardous consequences). For example, a person who repeatedly has sex with any available man or woman even without any attachment and even if he feels awful, he can’t stop.
Compulsions may involve sex, food, making excessive charitable contributions, caffeine, nicotine, gambling, spending, TV watching, Internet surfing, reading, cleaning, washing, drugs or alcohol. The key point is that the activity is not connected to the purpose it appears to be directed to, and is likely to be excessive. Examples could be a person who is afraid of bonding with a partner choosing to zone out with the TV, or a person who has never had enough love filling up on a gallon of ice cream.
Compulsive activities are rooted in a need to reduce tension caused by inner feelings a person wants to avoid or control. Compulsive activities are repetitive and seemingly purposeful and are often performed in a ritualistic manner.
Addiction differs from compulsion in that it inevitably escalates. A web of deceit, cover-ups, and detachment from a sense of self escalate. Harmful consequences can be a) external, for example, loss of job, car crashes, or b) internal, for example, detachment, depression, lack of ability to feel or concentrate. There may also be physical consequences such as illness, hypertension and memory loss.
Note: From the above it is quite clear that some of the most outstanding characteristics of addiction include tolerance, compulsion, dependence and withdrawal symptoms. As you can see, addiction is an ever-growing downward spiral which has no pleasant ending and why it grows stronger over time. This is not a happy picture.
In addition, addiction is more or less a dependence on a substance, such as the drug heroin, or a type of behaviour, such as gambling. The dependence is so strong that it may seem as if the person is unable to break away from the dependence.