What Is Addiction?

461 Pages·2010·1.7 MB·English

what is addiction?
EDITED BY
Don Ross, Harold Kincaid, David Spurrett, and Peter Collins
Ross_pb.indd 1 1/13/10 2:58 PM
What Is Addiction?

What Is Addiction?
editedbyDonRoss,HaroldKincaid,DavidSpurrett,andPeterCollins
ABradfordBook
TheMITPress
Cambridge,Massachusetts
London,England
(2010MassachusettsInstituteofTechnology
Allrightsreserved.Nopartofthisbookmaybereproducedinanyformbyanyelectronicorme-
chanicalmeans(includingphotocopying,recording,orinformationstorageandretrieval)without
permissioninwritingfromthepublisher.
MITPressbooksmaybepurchasedatspecialquantitydiscountsforbusinessorsalespromotional
use.Forinformation,[e-mail]Depart-
ment,TheMITPress,55HaywardStreet,Cambridge,MA02142.
ThisbookwassetinStoneSerifandStoneSanson3B2byAscoTypesetters,HongKong.
PrintedandboundintheUnitedStatesofAmerica.
LibraryofCongressCataloging-in-PublicationData
Whatisaddiction?/editedbyDonRoss...[etal.].
p. cm.
‘‘ABradfordbook.’’
Includesbibliographicalreferencesandindex.
ISBN978-0-262-51311-1(pbk.:alk.paper)
1.Substanceabuse. 2.Compulsivebehavior. 3.Cognitiveneuroscience. 4.Neurosciences—
Socialaspects. I.Ross,Don,1962–.
RC564.W497 2010
616.86—dc22 2009014712
10 9 8 7 6 5 4 3 2 1
Contents
Introduction:WhatIsAddiction? vii
DonRossandHaroldKincaid
1 NeuroeconomicsofAddiction:TheContributionofExecutiveDysfunction 1
WarrenK.BickelandRichardYi
2 NeurobiologyofPathologicalGambling 27
JenniferD.BellegardeandMarcN.Potenza
3 GeneticInfluencesonAddiction:AlcoholismasanExemplar 53
JamesMacKillop,JohnE.McGeary,andLaraA.Ray
4 AddictionasaBreakdownintheMachineryofDecisionMaking 99
A.DavidRedish
5 EconomicModelsofPathologicalGambling 131
DonRoss
6 Addiction:ALatentPropertyoftheDynamicsofChoice 159
GeneM.Heyman
7 AddictionandAltruism 191
HowardRachlin
8 TheCoreProcessinAddictionsandOtherImpulses:HyperbolicDiscountingversus
ConditioningandCognitiveFraming 211
GeorgeAinslie
9 MeasuringDispositionstoBundleChoices 247
DavidSpurrettandBenMurrell
10 NeuralRecruitmentduringSelf-ControlofSmoking:APilotfMRIStudy 269
JohnR.Monterosso,TraciMann,AndrewWard,GeorgeAinslie,JenniferBramen,Arthur
Brody,andEdytheD.London
vi Contents
11 AnticipatoryProcessingasaTransdisciplinaryBridgeinAddiction 291
MarkS.Goldman,JackDarkes,RichardR.Reich,andKarenO.Brandon
12 ImpulsivityandItsAssociationwithTreatmentDevelopmentforPathological
GamblingandSubstanceUseDisorders 335
NancyM.Petry
13 MedicalModelsofAddiction 353
HaroldKincaidandJacquelineA.Sullivan
14 AddictionandtheDiagnosticCriteriaforPathologicalGambling 377
NeilManson
15 IrrationalActionandAddiction 391
TimothySchroeder
16 DefiningAddictionandIdentifyingthePublicInterestinLiberal
Democracies 409
PeterCollins
Contributors 435
Index 437
Introduction: What Is Addiction?
DonRossandHaroldKincaid
In Western culture, the addict has been a stock cultural figure for many years. Con-
sider,forexample,thebook(1949)andfilm(1955)versionsofTheManwiththeGolden
Arm. The central character, played in the film by Frank Sinatra, is introduced as a for-
merheroinuserwhohasshakenoffhisdependencewhileinprison.Heexpectshisre-
lease from jail to mark a new beginning for him as a musician. However, encounters
withandpressuresfromhisexploitativeoldcronies,andhismorallyconfusedandde-
ceptive wife, lead him to relapse. In short order his virtues, ambitions, and judgment
evaporateinthefaceofhisdesperationtoobtainandusehisdrug.Hesteals;heblows
his carefully cultivated musical opportunity; he has brushes with the law and is ulti-
mately(falsely)accusedofmurder.Intheendhefindsathirdchanceatawell-ordered
life, thanks to the intervention of an angelic woman; but first, at her insistence, he
mustundergoaharrowingordealofwithdrawal.
The Man with the Golden Arm is comparatively optimistic. In many subsequent, less
sentimental, popular depictions of addiction, there is no suggestion of redemption.
The superb film of 2000, Requiem for a Dream, pursues its heroin-entrapped characters
fromheightsofromanticjoyandtendernesstodisfigurement,degradation,self-hatred,
and psychic collapse. They are last seen in fetal positions, one following the amputa-
tionofhisinfectedarminaprisonhospital.
Addictiononthiswell-rehearsedconceptionisapitintowhichanyheedlessperson
mightfall.Itrepresentsamoralfailingtotheextentthatlackofcautionismoralized.
Butwearetypicallyaskedtosympathizewithaddictedcharactersfortworeasons.First,
the punishmentisoutof proportiontothe sin;merefecklessness is notusuallytaken
to justify humiliation and personal destruction. Second, the addicts’ stupidity is cor-
rected by new knowledge as their condition overwhelms them, but their enlighten-
ment comes too late—addiction is nemesis. Thus the more recent of the addiction
narrativesdescribedabovehasthearcofclassicaltragedy.
Scientificknowledgetendstounderminedramaticpurity.Nothingmoreexoticthan
statistically careful prevalence studies were needed to determine that the overwhelm-
ingmajorityofpeoplediagnosedasaddictseventuallybreaktheirdependencewithout
viii D.RossandH.Kincaid
ever seeking clinical assistance, let alone angelic salvation. The supposedly relentless
grip of addiction has typically been explained in later twentieth-century artistic treat-
mentsbyinvokingthedogmaof12-stepprograms,1accordingtowhichaddictionisa
‘‘disease’’ that can be kept at bay but never cured. This, however, has contributed to
undermining the nemesis image, as a side effect of sweeping medicalization of less
terrifying patterns of experience. Popular usage in some countries—certainly in the
United States—now has it that anything anyperson does more often than is thought
reasonable from the reference point of the describer is ‘‘addicted’’ to the behavior in
question.Itisofcoursepossibletoimaginesomeone’slifedevouredbyan‘‘addiction’’
to(forexample)buildingmodeltrains,butitwouldrequirerareskilltodosowithout
mixingelementsoffarceintothetragedy.
Thusinthelesscredulouscornersofcontemporaryculturetherehasbeendeflation
in theimport, and even theplausibility, ofthe idea ofaddiction. The psychiatric pro-
fessionhasgenerallyrevertedtothealternativeconstructof‘‘dependence,’’whichdis-
tancesclinicalresponsefromboththetragicimageandtheskepticalbacklash.
Doubtsthat addictionmightbeanythingotherthanaculturalorganizingprinciple
forstorytellingcanbephilosophicallymotivated(Fingarette1988).Skepticismisoften
expressedaboutwhetheraddictioningeneralhasanycommonobjectivestructure.Per-
haps, for example, all cases of nicotine dependence are neurochemically similar, but
‘‘addictions’’totobacco,cocaine,andgamblinghavenothingincommonexceptjudg-
mentsbyobserversthatthe‘‘victims’’oftheseconditionssmoke,snort,andbetmore
oftenthantheobserverdeemsprudent.Thefactthatmanyputativeaddictionsfollow
similar behavioral courses doesn’t necessarily impress the skeptic, who might in re-
sponseciteIanHacking’s (1999)workoninteractiveor‘‘looping’’ kinds.Hacking sur-
veys a range of cases in which social construction of a certain kind of person induces
somepeopletoconformtotheexpectationsbuiltintotheconstruction,whichfurther
stabilizes the construction, and so on, in a self-reinforcing spiral. As Hacking would
emphasize,ifthisgoesoninthecaseofaddiction,itisnotgroundsforconcludingthat
addictsdon’treallyexist—quitethecontrary.2However,itwouldimplythataddiction
isinthefirstplaceasocialkindratherthanabiomedicalone.Inmanypeople’sview,
this is directly relevant to the question of whether people who conform to the type
shouldberegardedmainlyasvictimsormainlyasauthorsoftheirownconditions.
With the exception of the final three chapters, this is not a book of philosophical
essays. It is instead devoted mainly to presenting the range of available scientific evi-
denceonwhichopinionsaboutthephilosophicalissuesshouldbebased.Theevidence
inquestioncomesfromarangeofdisciplinaryperspectives:neuroscience,genetics,be-
havioral psychology, behavioral economics, and psychiatry. All of these perspectives
are represented here. Only following these surveys do we turn to discussions of their
philosophicalimport.
Introduction ix
Some readers may be surprised by the degree of attention devoted in the book to
pathologicalgambling.Thisreflects thegrowing statusofthat conditionasa testcase
for claims about addiction as a unitary phenomenon (Ross et al. 2008). No scientific
evidence links intense interest in sex or shopping to the ‘‘classic’’ drug addictions.
Thus these phenomena are consistent with the view that the popular addiction con-
cept simply metaphorically extends the real dependence of individuals on exogenous
sources of certain biochemicals. However, this is not true of pathological gambling
(or,morerecently,overeating).Herethereisnodependenceonexogenoussubstances;
yetthereisstrongbehavioralandneurobiologicalevidencethatpathologicalgambling
andsubstancedependenceshareacommonsetoffeatures.
The chapters by Bickel and Yi, Bellegarde and Potenza, Redish, Ross, and Petry all
adhere to the perspective that there is a shared set of characteristics common to sub-
stancedependencesandpathologicalgambling.Ontheotherhand,noneofthemde-
fendstheviewthataddictionasgenerallyconceivedhasasimpleunifyingstructure.In
particular, Redish surveys evidence for multiple neurodynamical and neurochemical
vulnerabilities that partly cut across the different addictions, but also partly divide
them. Ross argues that although the popular idea of addiction is indeed overly liberal
initsextension—withpotentiallyproblematicimplicationsforpublichealth—thereis
acoreneurochemicalsignaturethatcharacterizesdrugdependenciesandpathological
gambling(andprobablyovereating).
Addiction could have a unifying basis even if that basis is not a localizable neural
dysfunction. This is the view defended directly in the chapter by Heyman, according
towhichaddictionfollowsastandardbehavioralcoursebecauseitisanaturalhuman
vulnerability generated by the structure of evolved human decision-making disposi-
tions. These same structural properties, according to Heyman, explain why and how
most addicts recover on their own as they get older, unless they are afflicted with co-
morbid psychiatric disorders. Goldman et al. survey a broad literature on anticipatory
processing—the psychological states that precede action—and argue that this focus
integrates cognitive and information processing perspectives with motivational/
emotional approaches. They then discuss a range of addiction studies and show how
theirapproachshedslightonthesefindings.ChaptersbyRachlin,Ainslie,andSpurrett
and Murrell extend and enrich this perspective. Monterosso and coauthors, however,
close the distance (as does Ross’s chapter) between behaviorally grounded and neuro-
scientifically grounded accounts. The chapter by Kincaid and Sullivan reemphasizes
the importance of social context in framing addiction, while in no way denying the
relevanceofneuroscientificorgeneticfindings.
Wecansketchinsomewhatmoredetailthecontentsofthechaptersbyfocusingon
thelevelsorkindsoffactorstowhichtheirauthorsturninexplainingaddiction.They
differintheextenttowhichtheyemphasizethefollowingcausalinfluences: