by Adam Alter
The most striking thing Szalavitz told me was that addiction is a sort of misguided love. It’s love with the obsession but not the emotional support. That idea might sound fluffy, but it’s grounded in science.
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In 2005, an anthropologist named Helen Fisher and her colleagues placed infatuated lovers in a brain scanner. She described their findings in an article titled “Love Is Like Cocaine”:
I felt like jumping in the sky. Before my eyes were scans showing blobs of activity in the ventral tegmental area, or VTA, a tiny factory near the base of the brain that makes dopamine and sends this natural stimulant to many brain regions . . . This factory is part of the brain’s reward system, the brain network that generates wanting, seeking, craving, energy, focus, and motivation. No wonder lovers can stay awake all night talking and caressing. No wonder they become so absent-minded, so giddy, so optimistic, so gregarious, so full of life. They are high on natural “speed.” . . . Moreover, when my colleagues re-did this brain scanning experiment in China, their Chinese participants showed just as much activity in the VTA and other dopamine pathways—the neurochemical pathways for wanting. Almost everyone on earth feels this passion.
In the 1970s, a psychologist named Stanton Peele published Love and Addiction, explaining that the very healthy attachment we feel toward people we love can also be destructive. This same attachment could be directed toward a bottle of vodka, a syringe of heroin, or an evening at the casino. They’re impostors because they soothe psychological discomfort in the same way that social support makes hardship easier—but they soon replace short-term pleasure with protracted pain. The capacity for love is the result of millennia of evolution. This makes people well-designed to raise offspring and to shepherd their genes into the next generation—but also susceptible to addiction.
Destructiveness is a critical part of addiction. There are many ways to define addiction, but the broadest definitions go too far because they include acts that are healthy or essential for survival. In a 1990 editorial in the British Journal of Addiction, a psychiatrist named Isaac Marks claimed that, “Life is a series of addictions and without them we die.” Marks titled the editorial “Behavioral (Non-Chemical) Addictions,” and he was being provocative for good reason. Behavioral addictions were relatively new to the field of psychiatry:
Every few moments we inhale air. If deprived of it, within seconds we strive to breathe, with immense relief when we succeed. More prolonged deprivation causes escalating tension, severe withdrawal symptoms of asphyxiation and death within minutes. On a longer time scale, eating, drinking, defaecation, micturition and sex also involve rising desires to perform an act; the act switches off the desire, which returns within hours or days.
Marks was right: breathing seemed to mirror the properties of other addictions. But the idea of addiction isn’t interesting or useful if it describes every single activity that plays a role in our survival. It doesn’t make sense to call a cancer patient an addict because she needs her chemotherapy medication. Addictions should, at the very least, leave our chances of surviving unchanged; as soon as they mirror the life-sustaining properties of breathing, eating, and chemotherapy drugs, they’re no longer “addictions.”
Stanton Peele linked love and addiction in the 1970s, arguing that love drove addiction when it was misdirected and turned toward dangerous targets. Like Marks fifteen years later, Peele was also arguing that addiction went beyond illegal drugs. That had been the position of scientists for decades, so much so that few of them were willing to accept that nicotine was addictive. Since smoking was legal, by their logic, its component parts couldn’t possibly be addictive. The term “addiction” had become so stigmatized that it was reserved for a small, closed set of substances. But the term wasn’t sacred to Peele. He pointed out that many smokers leaned on nicotine in the same way that heroin addicts relied on heroin as a psychological crutch, although heroin was more obviously damaging in the short-term. Peele’s perspective was heretical in the 1970s, but the medical world caught up in the 1980s and 1990s. Peele also recognized that any destructive crutch could become a source of addiction. A bored white-collar worker who turned to gambling for the thrill he lacked in the real world could develop a gambling addiction.
I approached Peele in researching this book, but he bristled when I mentioned behavioral addiction. “Sure,” he told me, signaling that he’d be happy to talk, “except I’ve never in my life used the term ‘behavioral addiction.’” To Peele the term was heretical, because it implied there was a meaningful difference between behavioral and substance addictions, a distinction he argues doesn’t exist because addiction isn’t about substances or behaviors or brain responses. Addiction, to Peele, is “an extreme, dysfunctional attachment to an experience that is acutely harmful to a person, but that is an essential part of the person’s ecology and that the person cannot relinquish.” That’s how he defined it decades ago, and that’s how he sees it today. The “experience” is everything about the context: the anticipation of the event, and the behavior of carefully lining up the needle, the charred spoon, and the lighter. Even heroin—an addictive substance if ever there was one—makes its way to the body via a chain of behaviors that themselves become part of the addiction. If even heroin addiction is to some extent “behavioral,” you can see why Peele avoided the term altogether.
Peele may not have used the term “behavioral addiction,” but for decades he has separated addictive behaviors and addictive substances in his books. For example, the sixth chapter of Peele’s book, The Truth About Addiction and Recovery, written with psychiatrist Archie Brodsky in 1991, is titled “Addictions to Gambling, Shopping, and Exercise.” Peele and Brodsky asked, “Can one be addicted to gambling, shopping, exercise, sex, or love in the same sense that one is addicted to alcohol or drugs?” Their answer was yes—that “any activity, involvement, or sensation that a person finds sufficiently consuming can become an addiction . . . addiction can be understood only in terms of the overall experience it produces for a person . . . and how these fit in with the person’s life situation and needs.” Peele and Brodsky were also quick to dismiss the idea that any pleasurable, endorphin-producing activity was an addiction. “Endorphins don’t make people run until their feet bleed or eat until they puke,” they argued. Just because runners experience a “high” doesn’t make them addicts. They refused to call gambling, shopping, and exercise compulsions “diseases,” but they allowed that those activities were capable of inspiring addictive behaviors.
Peele was marginalized for decades. He railed against abstinence and Alcoholics Anonymous, and wrote again and again that addiction wasn’t a disease. Rather, it was the association between an unfulfilled psychological need and a set of actions that assuaged that need in the short-term, but was ultimately harmful in the long-term. Peele was often inflammatory and always provocative, but his central message was unchanged: that any experience could be addictive if it seemed to soothe psychological distress. Peele’s ideas have slowly drifted to the mainstream. Though the American Psychiatric Association (APA) still considers addiction a disease, four decades after Peele first linked love and addiction, the APA has acknowledged that addiction isn’t limited to substance abuse.
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Every fifteen years or so the APA releases a new edition of its bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM catalogs the signs and symptoms of dozens of psychiatric disorders, from depression and anxiety to schizophrenia and panic attacks. When the APA released the fifth edition of the DSM in 2013, it added behavioral addiction to its list of official diagnoses, and abandoned the phrase substance abuse and dependence in favor of addictions and related disorders. Psychiatrists had been treating behavioral addicts for years, and now the APA was catching up.
The APA also made clear that merely depending on a substance or behavior wasn’t enough to warrant a diagnosis of addiction. Many hospital patient
s depend on opiates, for example, but that doesn’t make all hospital patients opium addicts. The missing ingredients are the sense of craving that comes from an addiction, and the fact that addicts know they’re ultimately undermining their long-term well-being. A hospital patient who relies on morphine while he recovers from surgery is doing what’s best both in the short-term and the long-term; a morphine addict knows that his addiction combines short-term bliss and long-term damage. A number of current and former behavioral addicts told me the same thing: that consummating their addictions is always bittersweet. It’s impossible to forget that they’re compromising their well-being even as they enjoy that first rush of gratification.
The APA is only now endorsing the link between substance addiction and behavioral addiction, but isolated researchers have been making similar claims for decades. In the 1960s, even before Peele began publishing his ideas, a Swedish psychiatrist named Gösta Rylander noticed that dozens of tormented drug addicts were behaving like distressed wild animals. When confined to small spaces, animals soothe themselves by repeating the same actions over and over again. Dolphins and whales swim in circles, birds pluck their own feathers, and bears and lions pace within their enclosures for hours. By some reports, 40 percent of caged elephants march in circles and rock back and forth in a desperate quest for comfort.
These are universal signs of distress, so Rylander was worried to see similar behavior in regular amphetamine users. One patient collected and arranged hundreds of rocks by size and shape, and then jumbled them so he could begin the process from scratch. Dozens of motorcyclists in a gang of amphetamine users rode around the same suburban block two hundred times. A man picked at his hair incessantly, and a woman filed her nails for three days until they bled. When Rylander asked them to explain what they were doing, they struggled to concoct sensible answers. They knew they were behaving strangely, but they felt compelled to continue. Some of them were driven by an intense pathological curiosity, while others found the act of repetition soothing. Rylander reported what he saw in a journal article, where he labeled the behavior punding, a Swedish word that means blockheadedness or idiocy. Most interesting to Rylander, though, was that for these patients there was no line between drug addiction and behavioral addiction. One bled into the other, and they were similarly harmful, soothing, and irresistible.
Rylander died in 1979, but left a significant legacy. A growing circle of doctors and researchers reported punding in cocaine addicts and other drug users, and Rylander’s paper was cited hundreds of times. Punding behaviors are often bizarre, but they affected exactly who experts might have predicted: heavy drug users. That was true, at least, until the early 2000s, when a small group of neuroscientists began to see punding and other odd repetitive behaviors in the least likely of suspects.
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In the early 2000s, Andrew Lawrence, a neuroscience professor at Cardiff University, and some of his colleagues noticed a range of strange addictive behaviors in people suffering from Parkinson’s disease. There’s almost no overlap between the stereotypical personalities of heavy drug users and Parkinson’s patients. Where drug users are young and impulsive, Parkinson’s patients tend to be elderly and sedate. More than anything, they hope to enjoy the final decades of their lives without suffering through the muscle tremors that are typical of the disease. The only overlap, in fact, is that these Parkinson’s patients were using a very strong drug to treat their tremors. “Parkinson’s results from a dopamine deficit, so we treat the disease with drugs that replace dopamine,” Lawrence said. Dopamine is produced by a number of brain regions, and it produces a wide variety of effects. It controls motion (hence the tremors in Parkinson’s patients) and plays a major role in shaping how people respond to rewards and pleasure. Dopamine targets Parkinsonian tremors, but also happens to introduce a form of pleasure or reward. Many patients, left to their own devices, develop addictions to dopamine replacement drugs, so neurologists monitor their dosages very closely. But that wasn’t what fascinated and troubled Lawrence most.
“Patients were hoarding their medication, and we happened to notice that some of them were also displaying behavioral addictions,” Lawrence said. “So they would report problem gambling, problem shopping, binge-eating, and hypersexuality.” In 2004, Lawrence catalogued some of these symptoms in a staggering review paper. One man, an accountant who had been a dedicated and careful saver for half a century, developed a gambling habit. He had never gambled before, but suddenly he felt drawn to the thrill of risk. At first he gambled conservatively, but soon he was gambling a couple of times a week, and then every day. His hard-won retirement savings shrank slowly at first, and then more quickly, until he went into debt. The man’s wife panicked and asked their son for money, but their son’s contribution merely fueled the man’s addiction. One day his wife found the man rummaging through the garbage, hoping to retrieve the lottery tickets she’d torn up earlier that day. Worst of all, the man couldn’t explain the change in his character. He didn’t want to gamble, or to squander his life savings, but he couldn’t help himself. When he fought the tendency to gamble it occupied his every thought. Only gambling seemed to relax him.
Other elderly patients developed sexual fetishes, and pestered their husbands and wives for sex throughout the day. One man, a lifelong fashion conformist, took to dressing up like a prostitute. Others developed addictions to Internet pornography. Lifelong health nuts binged on candy and chocolates and put on mountains of weight in a few short months. Strangest of all, perhaps, was the man who couldn’t stop giving away his money. When his bank account was empty, he began giving away his possessions instead. When Billy Connolly, the celebrated Scottish comedian, developed Parkinson’s in his late sixties, he began taking dopamine replacement drugs. He, too, succumbed to behavioral addictions and had to stop treatment. “The doctors took me off the medication, because the side effects were stronger than the effects,” Connolly told Conan O’Brien on a late-night talk show appearance. “I asked what the side effects were, and they said, ‘an overriding interest in sex and gambling.’” Connolly makes light of the anecdote on TV, but without treatment his tremors are becoming increasingly severe. The drugs are so strong that up to half of all patients seem to develop some of these side effects.
Lawrence argued that these patients were simply enacting whatever behaviors came to them most naturally. These behaviors, called stereotypies, depend on “individual life histories,” Lawrence wrote. “For example, office workers stereotypically shuffle papers, a seamstress will collect and arrange buttons.” A sixty-five-year-old businessman repeatedly dismantled and reconstructed pens, and tidied an already immaculate space on his desk. A fifty-eight-year-old architect tore down and reconfigured his home office over and over again. A fifty-year-old carpenter collected hardware tools and unnecessarily felled a tree in his yard. These familiar actions became a source of comfort because they came so fluently and demanded very little thought.
Lawrence and Rylander before him were witnessing the blurred line between substance addictions and behavioral addictions. Like drugs or alcohol, stereotypies offered just one more route to soothe a tormented psyche. Lawrence pointed out this overlap by noting that many of the patients who were stuck in a behavior loop also overdosed on their dopamine-producing medication. Those with aggressive Parkinson’s were often fitted with a small pump that administered the drugs internally. Though they were told to obey a schedule, they could push a button to administer a fresh dose of the drug when their symptoms flared. Many of them began by following the schedule, but they soon learned that the drug also made them feel good. Some of the patients who became addicted to the drug also developed behavioral addictions, and they would jump back and forth between the two. One day they might take a few extra doses of the drug, and the next they might shuffle papers for several hours in the morning before collecting and arranging rocks from the garden in the afternoon. Sometimes they’d do both at the same time, self-
medicating with both drugs and soothing behaviors. There was no material difference between these two routes to addiction; they were essentially two versions of the same malfunctioning program.
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In the 1990s, a neuroscientist at the University of Michigan named Kent Berridge was trying to understand why addicts continued using drugs as their lives deteriorated. One obvious answer was that addicts get so much pleasure from their addictions that they’re willing to sacrifice long-term well-being for a jolt of immediate bliss—that they fall in dysfunctional love with a partner that destroys them in return. “Twenty years ago we were looking for mechanisms of pleasure,” Berridge said. “And dopamine was the best mechanism of pleasure out there, and everybody knew it was involved in addiction. So we set out to gather more evidence to show that dopamine was a mechanism of pleasure.” To Berridge and many other researchers the link seemed obvious—so obvious that he expected to find it quickly so he could move on to answer newer, more interesting questions.
But the result turned out to be elusive. In one experiment, Berridge gave rats a delicious sugary liquid and watched as they licked their lips with pleasure. “Like human infants, rats lick their lips rhythmically when they taste sweetness,” Berridge said. Rat researchers learn to interpret different rattish expressions, and this one was the gold standard for pleasure. Based on his understanding of dopamine, Berridge assumed that each rat’s tiny brain was flooding its host with dopamine each time it tasted the sweet liquid, and this rise in dopamine drove the rat to lick its lips. Logically, if Berridge stopped the rat from producing dopamine, it should stop licking its lips. So Berridge performed a kind of brain surgery on the rats to stop them from producing dopamine, and fed them the liquid again.