Addiction: Not a Brain Disease, Nor a DSM Diagnosis
A leading psychiatrist examines the unprecedented rejection of his profession's new diagnostic system by the federal mental health research establishment. His conclusion? A plague on both their houses.
The DSM-5’s new approach to “substance use disorder” diagnoses is little more than an irrelevant tweak to a fundamentally flawed view of addiction. In the current debate between the American Psychiatric Association (producers of the DSM) and the National Institute of Mental Health (which has just rejected the DSM-5 as a guide for NIMH research), I believe that they both miss the essential element of addiction.
Addiction is neither a matter of what a substance does to a person (DSM) nor a matter of what a substance does to a brain (NIMH). Both views offer neat but inaccurate explanations for addiction’s true nature as a psychological process, akin to other compulsive behaviors, caused by meaningful emotional factors that must be explored and treated in psychotherapy. We do a disservice to our patients and make recovery less likely by locating addiction external to the person.
Granted, the DSM-5’s inclusion in the addiction category of the first behavioral disorder—compulsive gambling—is a useful advance. It makes sense to affirm that compulsive behavior is compulsive behavior, whether it is betting or taking drugs. But the DSM-5 could go much further. It could recognize that addictions are neither more nor less than psychological symptoms, as are other compulsions. (The diagnosis “Obsessive-Compulsive Disorder” is an exception: These compulsions are biologically triggered, have no psychological meaning, and can be treated with SSRIs.)
That addictions and compulsions are, at their root, identical processes is highlighted by the fact that people often switch addictions, halting the compulsive use of one substance only to take up another substance or a new behavior. A woman I treated stopped her addictive use of Percodan only to begin cleaning her house with a Q-tip. Was this some mysterious new diagnosis? Of course not. She and I quickly appreciated that the focus of her compulsion had simply shifted. Not only did we not need a new DSM diagnosis to describe her, it would have interfered with understanding the very nature of her problem to give this new focus of her compulsive behavior a new name.
The proper way to treat addiction is to help people understand how this psychological compulsion operates, anticipate and manage the drive to repeat it, and work out the underlying issues that are being temporarily solved by this symptom.
The idea that addiction is a “brain disease”—increasingly promoted by neuroscience—is hampering progress in treatment no less than the DSM’s diagnostic focus on the substance or behavior. While the label “disease” has helped to lessen the shame associated with addiction, it has given currency to the “chronic disease” model of addiction—a model that, in my view, has no validity.
This model arose from various “landmark” studies of rats in which drug-seeking behavior was precipitated by chronic exposure to high doses of a drug like cocaine. The rats’ brains were permanently changed, making them hyper-responsive to environmental cues associated with the drug. This behavior was caused by the release of dopamine in the brain’s nucleus accumbens, leading the rats to run around seeking the drugs to which they had become sensitized. The lab researchers extrapolated from these results claiming that human addiction is caused by similar brain changes.
Of course, MRIs and other imaging technology have shown that human brains are altered by substance use. However, these brain changes do not “cause” addiction. We have known this for over 40 years, since Lee Robins and her group wrote their celebrated paper, "The Vietnam Drug User Returns," and numerous follow-ups showing that a majority of heroin-addicted soldiers were able to quit use when they returned from Vietnam and were physically detoxed. By contrast, many stateside heroin addicts were unable to stop. This paper demonstrated that a person does not become a heroin addict simply by taking heroin for a long time in high doses.
This conclusion gave strong support to the theory of the psychological nature of addiction. The difference between the groups lay not in the drug but in the people: The soldiers had used heroin to manage a temporary psychological state caused by prolonged exposure to enormous stress. When the soldiers left the war zone, they no longer needed the drug. By contrast, the other group used heroin to manage psychological problems connected to an ongoing internal “war zone.” Their use was compelled not by the powerful effects of the drug, which they shared with the veterans, but because they had a powerful emotional need to use. Unlike the veterans, it didn’t matter where they were.
Addiction is a psychological process, akin to other compulsive behaviors, that must be explored and treated in psychotherapy.
The Robins study refutes the “brain disease” idea of addiction. The soldiers’ long-term use of heroin may have caused permanent brain changes, but these changes did not cause the soldiers to develop addiction. (There are countless other counterexamples of the “brain disease” theory: People who quit smoking after long-term exposure to the addictive drug nicotine, for example, and those medically treated with narcotics for pain who remain drug free after being discharged from the hospital.)
Human addiction looks nothing like the “automatic behavior” of rats exposed to cues related to drugs. When people have the thought of repeating their addictive behavior, they often plan and wait and can be rather calm. People who run around seeking a drug are those in acute physical withdrawal, which is not usual addictive behavior. Addictive behavior in people is precipitated by psychologically meaningful events or feelings. (The exception is in the case of physical dependence, where transient withdrawal symptoms may induce drug seeking.)
While humans may share a reward pathway with rats, we have a big brain on top of it and a complex psychology. We have psychological defenses, conflicts and other elaborate mechanisms to manage our feelings.
Many professionals of all stripes in the field of addiction, not to mention the general public, have become accustomed to simplistic explanations and labels for complex human psychological behavior. Now that the DSM-5 has been published, and with the debate over its validity ongoing, those of us who advocate for the view that addiction is compulsive behavior and compulsions are a psychological symptom of emotional distress that requires psychotherapy should make our voices heard.
Lance Dodes, MD, is a training and supervising analyst at the Boston Psychoanalytic Society and Institute and an assistant clinical professor of psychiatry at Harvard Medical School. He has been the director of the addiction treatment unit of Harvard’s McLean Hospital, of the alcoholism treatment unit at Spaulding Rehabilitation Hospital and of the Boston Center for Problem Gambling. He is the author of The Heart of Addiction and Breaking Addiction: A 7-Step Handbook for Ending Any Addiction. His website is here.