In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

Imprinted in the developing brain circuitry of the child subjected to abuse or neglect is fear and distrust of powerful people, especially of caregivers.

In time this ingrained wariness is reinforced by negative experiences with authority figures such as teachers, foster parents, and members of the legal system or the medical profession. Whenever I adopt a sharp tone with one of my clients, display indifference, or attempt some well-meant coercion for her benefit, I unwittingly take on the features of the powerful ones who first wounded and frightened her decades ago. Whatever my intentions, I end up evoking pain and fear.

I have come to see addiction not as a discrete, solid entity—a case of “Either you got it or you don’t got it”—but as a subtle and extensive continuum. Its central, defining qualities are active in all addicts, from the honored workaholic at the apex of society to the impoverished and criminalized crack fiend who haunts skid row.

Addictions, even as they resemble normal human yearnings, are more about desire than attainment. In the addicted mode, the emotional charge is in the pursuit and the acquisition of the desired object, not in the possession and enjoyment of it. The greatest pleasure is in the momentary satisfaction of yearning.

‘Just one more’ is the binding factor in the circle of suffering,” writes the Buddhist monk and teacher Sakyong Mipham.1

Fuck. That God thing again. What God? Ever since I was a child, I’ve been shaking my fist at Heaven.

Bruce Alexander, a psychologist at Simon Fraser University in British Columbia, points out the obvious: laboratory animals in particular can be induced into addiction because they live under unnatural circumstances of captivity and stress.

My colleagues and I built the most natural environment for rats that we could contrive in the laboratory. “Rat Park,” as it came to be called,

By contrast, caged rats consumed up to twenty times more morphine than their relatively free living relatives.

The Vietnam veterans study pointed to a similar conclusion: under certain conditions of stress many people can be made susceptible to addiction, but if circumstances change for the better, the addictive drive will abate. About half of all the American soldiers in Vietnam who began to use heroin developed addiction to the drug. Once the stress of military service in a brutal and dangerous war ended, so, in the vast majority of cases, did the addiction.

Thus, we might say that three factors need to coincide for substance addiction to occur: a susceptible organism; a drug with addictive potential; and stress.

Cocaine’s action may be likened to that of the antidepressant fluoxetine (Prozac). Prozac belongs to a family of drugs that increase the levels of the mood-regulating neurotransmitter serotonin between nerve cells by blocking its reuptake. They’re called selective serotonin reuptake inhibitors, or SSRIs. Cocaine, one might say, is a dopamine reuptake inhibitor. It occupies the receptor on the cell surface normally used by the brain chemical that would transport dopamine back into its source neuron. In effect, cocaine is a temporary squatter in someone else’s home.

Dr. Richard Rawson, associate director of the University of California, Los Angeles’s Integrated Substance Abuse Program, reports that food seeking can increase brain dopamine levels in some key brain centers by 50 percent. Sexual arousal will do so by a factor of 100 percent, as will nicotine and alcohol. But none of these can compete with cocaine, which more than triples dopamine levels. Yet cocaine is a miser compared with crystal meth, or “speed,” whose dopamine-enhancing effect is an astounding 1,200 percent.10

In what was probably the first ideological “War on Drugs” in the New World, the Spanish invaders denounced coca’s effects as a “delusion from the devil.”

Children who have not received the attentive presence of the parent are, as we will see, at greater risk for seeking chemical satisfaction from external sources later in life.

As a result, her OFC has been trained to create a powerful emotional pull toward the drug from the second she even thinks about “fixing.” Addiction research refers to this dynamic as salience attribution: the assignment of great value to a false need and the depreciation of true ones. It occurs unconsciously and automatically.

In this chapter we have seen that the OFC, a central part of the brain system that regulates how we process our emotions and how we react to them, participates in substance dependence in a number of ways. First, it emotionally overvalues the drug, making it the chief concern of the addict—and often the only concern. It undervalues other objectives, such as food or health or relationships. By becoming triggered even at the thought of the drug (or activity) of choice, it contributes to craving. And finally, it fails at its task of impulse inhibition. It aids and abets the enemy.

Brain development in the uterus and during childhood is the single most important biological factor in determining whether or not a person will be predisposed to substance dependence and to addictive behaviors of any sort, whether drug-related or not.

The child needs to be in an attachment relationship with at least one reliably available, protective, psychologically present, and reasonably nonstressed adult.

“maternal contact alters the neurobiology of the infant.”13 (Note that in the human context, “maternal” does not necessarily refer to a female mothering figure or to a biological parent. It can also refer to primary caregivers of either gender.) Children who suffer disruptions in their attachment relationships will not have the same biochemical milieu in their brains as will their well-attached and well-nurtured peers. As a result their experiences and interpretations of their environment, and their responses to it, will be less flexible, less adaptive, and less conducive to health and maturity. Their vulnerability both to the mood-enhancing effects of drugs and to drug dependency will increase.

18 In one study of the EEGs of adults who had suffered sexual abuse, the vast majority had abnormal brain waves, and over a third showed seizure activity.

Addiction is a deeply ingrained response to stress, an attempt to cope with it through self-soothing. Maladaptive in the long term, it is highly effective in the short term.

“I’m working on sifting through my need for extremes in my life,” the gifted writer Stephen Reid, now in jail for bank robbery, told me.

These, then, are the traits that most often underlie the addiction process: poor self-regulation, lack of basic differentiation, lack of a healthy sense of self, a sense of deficient emptiness, and impaired impulse control.

Friedrich Nietzsche remarked, “One cannot get rid of anything, one cannot get over anything, one cannot repel anything—everything hurts. Men and things obtrude too closely; experiences strike one too deeply; memory becomes a festering wound.”

People with ADHD are twice as likely as others to fall into substance abuse and nearly four times as likely as others to move from alcohol to other psychoactive drugs.3 People with ADHD are also more likely to smoke, to gamble,

Scientific findings since then have only confirmed that pre- and postnatal stresses are the most important determinants of this condition. According to one recent study, for example, 22 percent of ADHD symptoms in eight- and nine-year-old children can be directly linked to maternal anxiety during pregnancy.5 Abused children are far more likely than others to be diagnosed with ADHD,

It is the impact of early stress on the brain—maternal depression, for example—that creates vulnerability to ADHD and to addictions.

ADHD and addiction have much in common, both in their characteristics and in their neurobiology. They are both disorders of self-regulation. They both involve abnormal dopamine activity—in fact, the medications used to treat ADHD are stimulants like methylphenidate (Ritalin, Concerta) or amphetamines (Dexedrine, Adderall), whose method of action is to increase dopamine activity in important brain circuits.8The personality traits of people with ADHD and with addiction are often identical: poor self-regulation, deficient impulse control, poor differentiation, and a constant need to find distractions from distressing internal states.