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I I I I I I I I I I I I I I I I I Chemistry. Craving PERSONALITY, RESEARCHERS REPORT, DETERMINES HOW YOU WILL SATISFY YO UR COMPULSI VE NEEDS. BY HARVEY MILKMAN AND STANLEt' SUNDERWIRTH he term addic• tion was once reserved for dependence on drugs. Today it is applied to a range of compulsive behaviors as disparate as working too hard and eating too much choco- late. The fact is that there are essen- tial biological, psychological, and so- cial common denominators between drug use and other habitual behaviors. Whether your pleasure is meditation or mescaline, cocaine or cults, you are addicted if you cannot control when you start or stop the activity. Although it is commonly accepted that loss of control is a primary fea- ture in all addictive disturbances, there is no generally accepted defini- tion of addiction. We define it as self- induced changes in neurotransmission (a type of brain activity) which result in problem behaviors. This definition encompasses a multidisciplinary un- derstanding of compulsive problem behaviors which involves personal re- sponsibility (they are self-induced), biochemical effects (changes in neurotransmission), and social reactions. Neurotransmission is the mecha- nism by which signals or impulses are sent from one nerve cell to another. The more rapid the transmission in certain pathways of the brain, the more intense the feeling. Individuals repeat a behavior (activity or sub- stance intake) to bring about neuro- transmission consistent with how they want to feel. The desired feeling dif- fers among addicted individuals and determines the activity or substance they choose to abuse. How rapidly neurons fire is deter- mined by the concentration of mole- cules known as neurotransmitters present in the synapse (junction) be- tween neurons: the more neurotrans- mitters in the junction, the faster the rate of firing. Ordinarily, neurotrans- mitters are pumped back into the pre- synaptic neuron and stored there. Cer- tain drugs, however, block this pump and keep the neurotransmitter mole- cules in the synapse, where their pres- ence brings about more rapid neuro- transmission. This creates the elevated mood sought by cocaine us- ; ers, for example. Why do people become addicts? ' Most researchers in the field--even i # PSYCNOLOCS' T0D6PiOfTOBER !!fJ

I I I I I I I I I I I I I I I I I those who disagree about other mat- ters of causation and treatment- agree that low self-regard is a crucial factor in addiction. Manifest or masked, it is basic to most dysfunc- tional lifestyles. One way of coping with feelings of worthlessness is to immerse oneself in mood-altering behavior. Depression, for example, can be lessened through exciting activities. Skydivers are un- likely to experience sadness during the "rush" of being airborne. Such potent emotional shifts are related to chemi- cal alterations in the brain, which the individual learns to recreate, through either commodities (drugs or food), or activity. Workaholics, for example, find temporary relief from loneliness or low self-regard in their jobs; over- eaters find it in chocolate 6clairs. Although these activities provide a brief reprieve from conflict, overindul- gence can lead to progressive physical, social, or economic deterioration. Har- vard psychologist Howard Shaffer calls addiction "a two-edged sword; it serves as it destroys." Whether the gratifying behavior is work, gambling, or chanting, some people lose control and continue despite the consequen- ces. Compulsive runners, for example, may continue jogging despite damage to their knees, ankles and other parts of their skeletal systems. We agree with neuroscientists Nel- son H. Donegan, Judith Rodin, Charles P. O'Brien, and Richard L. Solomon that it is unnecessary to de- velop a separate set of principles to ex- plain how people become addicted to drugs rather than compulsive behaviors. In addition to noting com- mon characteristics in the reinforcing properties of drugs and mood-altering activities, they observed that both types of experience produce an initial feeling of euphoria, followed by a neg- ative emotional state. This post-eu- phoric discomfort leads to a repetition of the rewarding activity. It is now becoming apparent, howev- er, that the type of drug used depends on the user. In a research study at the Bellevue Hospital Center in New York, one of the authors (Milkman) and William A. Frosch found a strik- ing relationship between personality and drug of choice. Those who prefer heroin usually cope with stress through relaxation and isolation. Am- phetamine users are likely to confront a hostile or threatening environment DDICTION.. A A 1 SELF-IND UCED CHANGES IN NEUROTRANSMISSION THAT RESULT IN PROBLEM BEHA VIORS. with physical or intellectual activity. Clinical observations of people who use hallucinogens such as LSD con- firm that they characteristically rely on imagery, daydreaming, and altered thought processes to reduce tension. These three preferred styles of cop- ing, which we call "satiation," "arous- al," and "fantasy," seem to have their origins in the first years of life. We re- gard childhood social learning experi- ences, combined with genetic predispo- sition, as the precursors to adult addictions. The drug group of choice- depressants, stimulants, or hallucino- gens, respectively-is the one that best fits the individual's characteristic way of coping with stress or feelings of unworthiness. In our view, people do not become addicted to drugs or mood-altering activities as such, but rather to the satiation, arousal, or fan- tasy experiences that can be achieved through them. Addicts whose basic motivation is satiation, for example, are likely to binge on food or television-watching or to choose depressant drugs such as heroin. Psychologically, they are try- ing to shut down negative feelings by reducing stimulation from the internal or external world. The life of the "sati- ation" type of addict bears striking similarity to that of a child during the first year of li.fe. The mouth and skin are the primary receptors of experi- ence, and feelings of well-being are de- pendent almost completely on food and warmth. Edward J. Khantzian and Harvard Medical School's Shaffer suggest that depressants provide a pharmacologic defense against the user's own ag- gressive drives. Binge eating or exces- sive television watching may fulfill the same adaptive role by helping individ- uals quiet strong hostile impulses. On a biochemical level, the effect of "sati- ation" activities may be similar to that of opiates. The relationship between opiate ingestion and satiation activi- ties is suggested by the discovery by John Hughes and Hans Kosterlitz at the University of Aberdeen of painkill- ing molecules called enkephalins that exist naturally in the brain. Other re- searchers have shown that enkephalins and related compounds called endorphins seem to behave as opiates in many ways, including the ability to decrease neurotransmission. Growing dependence on such behaviors as overeating and watching television may be analagous, though more subtle, versions of opiate addiction. While addicts of this kind try to avoid stimulation and confrontation, others actively seek it. The behavior associated with the "arousal" mode of gratification includes crime, gambling, risk-taking, and use of stimulant drugs such as amphetamines or co- caine. These addicts seek to feel active and potent in the face of an environ- ment that they view as overwhelming- ly dehumanizing. They are often boastful about their artistic talent, in- tellectual skill, and sexual or physical prowess. Their vast expenditures of mental and physical energy are de- signed to deny underlying fears of helplessness. This posture is reminis- cent of 2- and 3-year-olds coping with the world of giants in which they live. Asked, "Who is biggest or toughest?" they often reply, "I can beat up Dad- dy." They protect themselves through the defense of magic denial: "I am really not helpless and vulnerable; I am powerful and feared." Biochemically, risk-taking or other arousal activities may affect neuro- transmission in much the same way stimulant drugs do. And since sus- tained, self-induced changes in neurotransmission are resisted by the body's biochemistry, taking risks or swallowing amphetamines-actions which increase neurotransmission- are counteracted by a decrease in the level of certain enzymes, protein-like molecules which help bring about chemical reactions in the body. This decrease results in a reduction in the rate of neurotransmission (and thus the user's satisfaction) even while the activity or substance abuse continues 38 P S Y C H 0 L 0 G Y T 0 D A Y i 0 C T 0 B E R t! l J.

I I I I I I I I I I I I I I I I I ADDICTIVE STATES While the brain's limbic system appears to play a major role in the pleasurable sensations of addiction, the cerebral cor- tex influences mental content. Its right hemisphere ma-v be involved in fantasy experiences such as those achieved at the initial level. Therefore, to recreate the desired mood, the addict must increase the level of activity or drug use, producing a spiral of in- creasing dependency. The third type of addict, who uses fantasy as the preferred way of deal- ing with the world, favors repetitive activation of what some researchers refer to as right-hemisphere thinking. Thoughts become dreamlike, with rap- idly shifting imagery and illogical rela- tions between time and space. This style of coping often includes preoccu- pation with day or night dreams, com- pulsive artistic expression, or various forms of mystical experience, some- times expressed as a quest for the feeling of "oneness" or cosmic unity. Individuals who rely on this style par- tially overcome their fears by creating through LSD or other imagination-oriented activities. The heightened sense of reality experienced during compulsive risk-taking or work may be linked to activity in the left hemisphere. fantasies in which they are effective and important. They may travel with extraterrestrials, encounter the "Grim Reaper," or have their body entered by a supernatural entity. These' addicts favor hallucinogens such as LSD, mushrooms containing psilocybin or peyote. Interestingly, the two basic types of chemical com- pounds-variations of indole and phenylethylamine-which are present in nearly all hallucinogens are also found in many molecules that occur naturally in neurotransmitters. For example, dopamine and norepineph- rine have the basic phenylethylamine structure, whereas seretonin has the indole structure. The fantasy aspects of some artistic or spiritual activities may convert the brain's own indole or phenyiethylamine compounds into hal- 39 lucinogenic variations of the chemicals. In addition to producing different patterns of neurotransmission, the three types of addiction seem to in- volve different parts of the brain. Mood shifts appear to be influenced chiefly by the limbic system, located near the middle of the brain. This sys- tem is associated with emotions and with sexual, feeding, and aggressive responses. As arousal decreases, moods may downshift from relaxation Z\Z to tranquility and finally to a state of n blissful satiation. Conversely, in- pp, creases in arousal are accompanied by ~j changes in experience from ordinary Fp, alertness through creativity and ulti- p mately, manic states. © While the limbic system appears to Q play a major role in pleasurable sensa- Q0 tions connected with altered levels of ~ Con4nued an P.,te 44

I tONTEMPORARY I I I I I I 1 I I DRUG STREET NAMES EFFECTS WPCHDRAWAL SYMPTOMS ADVERSE/OYERDOSE REALTIOyS NMt7TtC5: NEl41N N, hoabr+, Apathy, difficulty in eoncen- Anxiety, vomiting, eneezing. Depressed levels of conadous- , 1* :am* trition, slowed speech, de- diarrhea, lower back pain, ness, low blood pressure, ' 414941, Lxw, creased physical activity, watery eyes, runny nose, rapid heart rate, shallow v.p drooling, itching, euphoria, yawning, irritability, tremors, breathing, con.utaiona, coma, aausea panic, chills and sweating, possible death aamps MORMIINE Nnpstora ie*t, ai., first liee, ord COOfINE P13CODAN Puics OEltlElg'Ol NETKADOME Msth SIDAflVE IIYMlOT1CS: NEMiUTAI Y.IIow j.dcNs, Impulsiveness, dramatic mood Weakness, resUessness, nwses Confusion, deae:sed response qdiews swings, bitarre thoughts, and.omiting, headache, night- to pain, shallow respiration, tttONAI Itaks suicidal beharior, slurred oarrs, irritability, depression, dilated pupils, weak and flflNAl Twys• speeth, disorientation, slowed stnte anxiety, hallucinations, rapid pulse, coma, possible MIDI4NARlRRAI mental and physiul function- seizures, poasible death death QtlAAIUDES L.des, 714's ing, limited attention span YA11UM V's UiRIUM EQUANII DRUG iE]QEDtlNE S*wd Increased confidence, eood Apathy, generat fatigue, pro- Elevated btood pressure, in- ekr.tion, senae of energy and {ooaed sleep, depression, dis- Qease in body temperature, bcaDRINE fP"sf slertnest, decreased appetite, erientation, wicidal thoughts, fue-picking, suspiciousness, aasiety, irritability, insomnia, agitated motor actirity, irrita- bizure and repetitious be- 0lSCx'fM fMel, arst.l trtasient drowsiness, delayed bility, bizarre dresms havior, vivid haHucination, o.flwotrias atism oonrulsions, posaib{e death tuNETAA1tNE qaic It..wfies, RlTA1/N PRitUDIN COUlNE t.ic., Wow, fe.t, snow, 4.iy STREET NAMES EFFECTS WTMDRAw'AL SYMPTOMS ADYERSE/OYERDOSE REA(TIOtiS C;o 40 PSYCNOLOGY rODA J' / OCTOBER 1113

I I I I I I I I I I I I I I I I D R U G S 0 F C H 0 1 C E DRUG STREET NAMES EFFECTS 4YPT8DRAWAL SYMPTOMS ADVERSE/OVERDOSE REACTIONS rALLl1C1MOGf1t5: LS 0 E{afrieify, ~, Faadnation with ordinary ob- Not reported Namea, chills; increased pulse, fvser, biofl.r jecfa; heightened esthetic re- temperature, and baood pres- .4 taiveiof, sponses to coior, tesiure, spa- sore; trembiing; slow deep wiiite tial arrangements, contours, breathing, losi of appetite, in- I*Kint tnuaic; vision and depth dis- sosaia, longer, more intense porpl. `u»is tortion; hear colors, see "trips"; bizsrre, dangerous be- music; slowing of time; harior possibly kading to in- heightened sensiti.ity to jM or death faces, gestures: magnified ~ feelings of love, lust, hate, Cj joy, anger, pain, terror, de- ~ spair, etc.; paranoia, panic, ~ euphoria, bliss, impairment of ~ short-term mearorv. projection O of self into drwniike images © 00 MES(~LJME hryofe buftoem Similar to LSD but more Not reported Rwembie LSD, but more" (mefvMl ioras) sensual and peraptual; fewer bodily se.ationa, vomiting ckanges in thought, mood and seme of self; vomiting KILOCY><!N Mrsbreemsa, Similar to LS D but more Not reported R,esembre LSD, but kss siroas, rooms visnal and less intense; more severe euphoria, fewer panic rear- tions. WINAilS: MwIIJAKA Was& kif, Euphoria, rela:ed inhibitions, Hyperactivity, insomnia, de- Se.ere reactions are rare, but NWLSM l.njsi, iept, increased appetite, dis- crea.sed appetite, anxiety include: puiic, paranoia. fa- MW OIL P12s,'.t, oriented behavior tigue, binrre and dangerous o. ~', fm" behavior .. , r~sr k"4r `MIt, M~y r1rl, Mf~, }M MIEMCYCLIDiME 'Q, .p.l iMSt, tr>cres,ed blood pressurc and Not reported Highly variable and possibly ilos, roekN fwi, heart rite; sweating, nauaea., dose-related: disorientation, s.perv. asnbnesa, floating sensation, {oos of recent memory, kthar- pe.ct'iu, dowed rctlcses aftered body fy/ttnpor binrre and violent mi.~inet iotage; altercd perception of behavior, rigidity and immo- hsinqwTax, tiae and space; impaired im- bility; ssstnm, staring, hallu- irst, 6W pizza mediate and reant .e:aory, cinationa and delusions, coma deaeaaed concentration, pi- ranoid thoughts and delusions Adopred fromKoulmon, J. SchoMer. H, and Burgloss. M E. The Clmoco! Assessmenr and Dwgnos+s of Addiaion IIThe B&ological Bosres-Drugs ond Therr EHeas In Broner, T an Fonesr. G fEdsl. Currem Treormem of $ubsionce Abuse ond Akoholism New York: MocMillon Publishing Co 1983 41 PSYCHOLOGY TODA Y/ OCTOBER 1!!J

I I I I ~ I I I I I I I I I I I I I Coeueued from Pare 39 arousal, the convoluted outer brain known as the cerebral cortex is an im- portant determinant of mental con- tent. Excessive activity in the cortex of the right hemisphere may help ex• plain the uncontrolled imagery found in the fantasies of mystics and schizo- phrenics. Similar cortical activity in the left hemisphere may be responsi- ble for the feeling of super-reality indi- viduals report during such high-risk activities as rock climbing and skydiv ing, which require an accurate and log- ical appraisal of one's options. Certain brain enzymes may alsc play a part in the biochemistry of ad- diction. Changes in the levels of these proteinlike molecules are the result of sustained alterations in neuro- transmission. High or low enzyme lev- els are experienced by individuals as a craving for a substance or activity which will relieve feelings of stress. In addition, enzymes are formed ac- cording to individual genetic make- ups; one of the primary functions of certain genes is to direct the formation of particular enzymes. Behavioral ge- neticist Gerald McClearn of Pennsyl- vania State University suggests that the enzyme produced by a given gene might influence hormones and neuro- transmitters in a way that contributes to the development of a personality po- tentially more susceptible than most people to external influences such as peer group pressure. A genetic predis- position of this type may ultimately become an important determinant of how an individual lives his life. Yet identical twins, who possess exactly the same genetic make-up, do not al- ways develop similar patterns of be- havioral excess. We must look at indi- vidual differences in experience to understand more completely the ori- gins and progression of addiction. Differences in neurotransmission, influences from the limbic and cortical systems, and the effects of various brain enzymes all interact with power- ful social forces that can push suscep- tible individuals toward activities that have a high dependency potential. Highly seductive mass advertising and the emphasis the computer age places on immediacy provide the context in which outlets for rapid reduction of tension have evolved. Public lotteries and video arcades are two widely avail- able escapes from routine existence. With this belief in immediate relief and gratification as part of the gener- F T OR THE ADDICT, HE SEX PARLOR AND VIDEO ARCADE BECOME IMPORTANT ISLANDS OF AI,IENATED COMFORT. al social environment, individuals are directed toward particular channels of behavioral excess by their individual experiences. Early in life, a child may possess a subtle yet identifiable char- acteristic (perhaps a genetic predispo- sition) that steers him or her in the di- rection of addiction. Youngsters can be pushed further along the road to addiction when an early sense of low self-worth is relieved through a specif- ic activity. The dejected adolescent may begin to feel potent only through the use of such external reinforcers as drugs, money, or sex. Although parental role models and styles of child-rearing are important contributors to how children learn to cope with life, adolescent adjustment is also closely bound to peer influence. According to sociologist Denise Kandel of Columbia University, the most reliable finding in drug research is the strong relation between a per- son's drug use and use by friends. Eventually, these young people are labeled by those around them as crimi- nals, fatties, drug addicts, or members of some other deviant group.'I'his stig- matization further decreases their sense of self-worth and pushes them more firmly into a pattern of socially unacceptable behavior. As the addict drifts away from stable family and love relationships, he or she inrseas- ingly selects social settings for imme- diate gratification. The sex parlor or video arcade become important is- lands of alienated comfort. Dramatic conflict with the environ- ment often results as repeated person- al failures require increasingly severe efforts to recoup self-esteem through excessive activity such as drugs or crime. The downward spiral frequent- ly culminates in hospitalization or in- carceration on a cyclical basis. What social scientists call "relapses" may simply be episodes in the naturally os- cillating course of the addictive process. Considering the complex biological, psychological, and social forces that promote behavioral excess, it is not surprising that those who attempt treatment for their compulsions usual- ly fail. From 60 to 80 percent of all ad- dicts who attempt abstinence fail with- in six months. It can be excruciatingly difficult to overcome renegade biologi- cal processes that are further encour- aged by powerful social and psycho- logical influences. Yet it can be done. Biologically, the question is:.Can the human brain gain control over inherit- ed impulses that were appropriate for prehistoric man but are inappropriate in the 20th century? We know that ac- tivities that lead to compulsive life- styles are self-induced and are under both cortical and limbic system con- trol. We also know that the cerebral cortex, the center of thought and memory in homo sapiens, is much larg- er in humans than in other animals. With this great reasoning capacity, we should be able to exercise more control over the basic emotions directed by the lower brain centers. A multidisci- plinary understanding of addiction should provide the conflict-solving ability of our cortex the power it needs to control our lives more successfully. The term "dharma" is used in Hindu philosophy to describe a person's free will or ability to control "karma," that which an individual brings into the world when born. In today's terms we may look at "dharma" as cortical con- trol and "karma" as the inner-brain in- heritance. Clearly, humankind has the ability to exercise dharma over karma: We need not be slaves to our compul- sive behavior. r] Harvey Milkman is an associate pro- fessor of psychology at Metropolitan State College in Denver. He has orga- nized a national conference on "The Addictions: An Interdisciplinary Syn- thesis," which will be held in Denver on October 28 and 29. The conference was developed in collaboration with the Department of Psychiatry, the Cambridge Hospital, affiliated with Harvard Medical School. Stanley Sunderwirth is a professor of chemis- try and vice president for academic af- fairs at Metropolitan State College. 44 PSYCHOLOGY rODAY/OCfOBfR 1)tJ