Addiction: disease or learning disorder?

How should we approach the concept of addiction? Leocadio Martín tells us.

When we talk about addictions, we are still somewhat burdened by a moral vision, which points to the addicted person as a selfish being, a liar and prone to committing crimes. We believe that, in a way, he or she has brought this on himself or herself and does not deserve compassionate treatment..

In contrast to this prejudiced approach, addiction has been added to the list of mental illnesses to be treated in a health care setting for many years now. It is understood that the addict's brain has replaced its "natural" mechanisms with external substances or behaviors that make him totally dependent. And we must "cure" it, so that the individual can be reintegrated into society. This second option is much more in line with what we know about the addicted brain.

However, the transition between these two conceptions is not complete, and in some ways they are sometimes intertwined, as in 12-step programs, those provided by religious communities or opportunistic gurus with miracle herbs. Increasingly, a different conception is gaining momentum, in which the nature of addiction is related to a learning problem..

Generating dependence through learning

The consensus reached by the scientific community is that addiction is associated with distorted learning systems in which pleasure is overvalued, risk is undervalued and learning fails after repeated mistakes. Addiction alters an unconscious brain to anticipate exaggerated levels of pleasure or Pain reduction (when dependence is consolidated).

What we know about addiction has changed over time. The way in which a drug user becomes an addict or develops a mental pathology is not clear.

In fact, a report by the United Nations Office on Drugs and Crime (UNODC), reports that only 10% of users end up having problems with these substances.. It is true that this seems intuitive, since if all the people who report using alcohol and drugs ended up being addicted, the number of patients attending treatment centers would multiply exponentially.

We are forgetting the whole learning process, which makes the individual progressively substitute his interests and affections for his addiction. Fortunately, along the way, many people discover or learn many other experiences that are much more gratifying than substance use. Our interest, from the psychological point of view, focuses on those who, despite the existence of other more attractive rewards and despite the harm caused by their addiction, persist in their behavior and become dependent.

The neurobiology of addictions

We are talking about a disorder based on the functioning of the brain.which in addicted people functions abnormally. But it is not an irreversible degenerative disease; at least, not in most cases. It is a learning disability that changes the way the brain functions, altering its connections through new mechanisms of reward, motivation and punishment. Like other learning disorders, it is also influenced by genetics and the environment throughout our evolutionary process.

As Maia Szalavitz states in her book Unbroken Brain, "science has studied the connection between learning processes and addiction, recognizing which brain regions are related to addiction and in what way. These studies show how addiction alters the interaction between midbrain regions such as the ventral tegmentum and nucleus accumbens, which are linked to motivation and pleasure, as well as parts of the prefrontal cortex, which help make decisions and set priorities."

One of the functions of these systems, called dopaminergic, is to influence the decisions we make, converting them into rewards, if necessary, increasing the perceived value of them, causing expectations about them Dopamine, the chemical messenger of pleasure in our brain, responds to primary rewards such as food, water or sex. But it also does so to secondary rewards such as money. In the latter case, our expectations play an important role in our brain's response to stimuli. Addiction makes us learn that, if we continue, for example, to gamble, the probability of winning will increase.. A random negative reinforcement is produced where, in spite of almost never obtaining the anticipated reward, the behavior (gambling) is consolidated. In spite of losing a lot of money.

The brain altered by the drug

In non-addicted people, the dopamine signal is used to update the value assigned to different actions, resulting in choice and learning. Learning occurs when something unexpected happens. Nothing focuses us more than surprise. We learn by trial and error.

With addiction, this learning process is disrupted.. The signals surrounding the addictive experience are overvalued, causing the dopaminergic systems to assign an excessive value to the surrounding contexts. Dopamine continues to be released, through the artificial signal produced, for example, by psychoactive substances.

This causes a disproportionate desire for the drug, cravings that go far beyond the pleasure or pain relief it may actually produce. In short, thanks to the distortion in the appraisal system of addicted people, their dependence seems to increase desire without increasing the enjoyment of the object of addiction.

As individuals and as a species it is these brain systems that signal to us what we care about and what we do not care about.and what does not, being associated with feeding, reproduction and our survival. Addiction distorts these life goals, replacing them with the object of addiction, drugs, gambling, sex or even money. It is, in essence, a self-destructive behavior. We could compare it to the engine of a car that we gradually degrade its fuel with, for example, water. The car will run with increasing difficulty, and no one will understand why we continue to fill it with adulterated gasoline.

Understanding the context of addiction

If to an addicted brain, characterized by the focus on a simple source of satisfaction, we add the social pressure to consume drugs, for example, or the use of drugs that help us regulate our emotions or our affective deficiencies, we will understand how, little by little, the person who suffers from an addiction is trapped in it. It is their life, in a way, their comfort zone. However terrible it may seem to us from the outside.

To understand all kinds of self-destructive behaviors, we need a broader conception than the simple idea that drugs are addictive. Addiction is a way of relating to the environment and those who inhabit it. It is a response to an experience that people get from an activity or an object. It absorbs them because it gives them a series of basic and necessary emotional rewards, even if it damages their life with the use of it.even if it damages their life over time.

There are six criteria by which we can define an addiction.

1. It is powerful and absorbs our thoughts and feelings

2. It provides essential sensations and emotions (such as feeling good about oneself, or the absence of worry or pain).

3. It produces these feelings temporarily, for the duration of the experience.

4. Degrades other commitments, implications or satisfactions.

5. Is predictable and reliable

6. As people get less and less out of life without addiction, they are forced, in a sense, to return to the addictive experience as their only form of satisfaction.

It is, as we can see, a full-blown learning process. Y understanding addiction from this perspective changes things a lot.It also changes the approach to health intervention quite a bit.

Reversing the learning process

In no case are we suggesting that, for example, a drug addict cannot become a patient with a dual disorder. It does happen, sometimes. Let's say that the brain has been hacked so much that it is no longer possible to reinstall the original operating system. But until you get here, the drug addict travels a long road where the learning and consolidation of new pathways in his brain can be modified..

Therefore, although the leap from vice to disease was an important advance in the approach to addictions, treating all people who use drugs or are addicted to certain behaviors as patients may be achieving the opposite effect. To treat a learning disorder, such as a phobia, the active participation of the person is essential. It is also essential to know in detail how the disorder has occurred in order to deactivate it.

The same applies to the psychological treatment of an addictive disorder. We have in front of us a person who must replace a harmful behavior with another that is not harmful. And in order to do this it is essential to be involved in it from the beginning..

The classic health approach, by classifying all addicts as sick, does not need the collaboration of the addict, at least at the beginning. In the case, for example, of drug addiction, the patient is asked not to fight, to let himself be done, in order to detoxify.

Then we would move on to psychosocial rehabilitation which, until not so long ago, was considered an accessory part of treatment. In a way, to the brain of the drug addict, we are telling him that the solution is still coming from outside and that we are going to provide it with more psychotropic drugs. Fortunately, we have been evolving towards a treatment that approaches addiction as a learning disorder with biopsychosocial components that with biopsychosocial components that are at least equally important.

Conclusion

Trying to understand why a person continues to self-destruct even though it has been a long time since the pleasure that his addiction provided him disappears is much better explained as a neuroadaptive learning process, rather than based on the classic disease model.

It is a parallel process of unlearning and relearning that requires the active participation of the individual to ensure its success.. If not, in a sense, we are reproducing what the addicted brain thinks: that there is a quick, external solution to its discomfort.

The implications of this new approach to treatment are profound. If addiction is like unrequited love, then companionship and changes in relational dynamics are a more effective approach than punishment. Treatments that emphasize the addicted person's agency in his or her recovery, such as cognitive therapy, with a strong motivational component, or the newer Mindfulness-based treatments, work much better than traditional rehabilitations in which patients are told that they have no control over their addiction.

In short, if we have known for a long time that only a few people who gamble, consume alcohol or drugs become addicted, is it not time to consider studying why this happens and to move away from maximalist approaches? It is more important to know what protects these people to the point that they end up moving away from the easy solutions that addictions provide. This will make us design better prevention programs and help us understand where we should direct treatment processes.