Unbroken Brain: A Revolutionary New Way of Understanding Addiction

by Maia Szalavitz

Stimulant withdrawal also doesn’t make you physically ill like heroin or alcohol withdrawal does; nearly all of its signs can be dismissed as “psychological” rather than “physical” and include things like ir...

Addiction was generally depicted at that time as an ongoing fight against withdrawal—so if it didn’t lead to visible withdrawal sickness, a drug shouldn’t be too addictive. Hence marijuana, amphetamines, and cocaine were seen as nonaddictive, while heroin and alcohol could create real addicts. Physical symptoms were seen as real and measurable; psychological symptoms were minimized and not to be taken seriously.

addiction isn’t just a physical need for a substance to avoid withdrawal, though that doesn’t help matters any.

Physical withdrawal symptoms are nothing compared to psychological desires: what matters in addiction is what you want or, yes, believe you need, not whether you feel sick or even how sick you feel.

the question of whether body or mind matters more—and where the boundary between mind and brain, mental and physical is—runs through most of the key issues and fault lines in addiction.

What makes drug withdrawal hard to take is the anxiety, the insomnia, and the sense of losing the only thing you have that makes life bearable and worth living, not the puking and the shaking. It’s the mental and emotional symptoms—the learned connection between drugs and relief and between lack of drugs and pain—that matter.

the meaning of pain profoundly affects how it is felt, and the more worry and fear involved, the worse the suffering.

Pain that is viewed as life threatening literally feels more intense and agonizing than pain with a known, nondangerous origin or time frame; studies find that people who believe a particular type of pain means that worse is to come actually rate it as more severe on pain scales than they do if they have the exact same physical experience but can be reassured that it’s nothing to fear.

The psychology and the experience of pain are inseparable. Moreover, no matter whether the source of pain is obviously “physical” or “just psychological,” the unpleasant aspect of the experience is processed by many of the same parts of the brain.

I needed to understand what drugs had given me and what addiction had taken away.

Other aspects relate to the “defects of character” unfortunately claimed by some promoters of 12-step programs like Alcoholics Anonymous to typify all addictions, such as dishonesty and selfishness.

Many people think this definitional debate is only seen around addiction. But the same is true in schizophrenia, bipolar, autism, depression, and all the other conditions in psychiatry’s diagnostic manual. In none of these diagnoses has a single pathology, present in all affected people and absent in others, been found. In fact, once a specific genetic profile or a unique physiology can be detected reliably, it may be redefined as “neurological” rather than psychiatric and removed from the manual, which leaves psychiatric diagnosis open to ongoing controversy.

getting people to understand that a condition is real and not just a “choice”—quite tricky. Addiction is the classic case of this problem, and failing to see it as a learning disorder has contributed to that.

addiction is best understood as compulsive use of a substance or compulsive engagement in a behavior despite ongoing negative consequences.

fundamentally, addiction is a learning disorder. There are three critical elements to it: the behavior has a psychological purpose, the specific learning pathways involved make it become nearly automatic and compulsive, and it doesn’t stop when it is no longer adaptive.

I want to stress that I do not mean that there is no biology involved, nor do I mean to imply that medical treatment—including medication—is not often useful and sometimes critical. I also don’t mean to imply that addiction is driven by ignorance.

The problem with our current understanding of addiction is that by ignoring the role of learning, we have tried to slot it into a category of medical illness or moral failing where it doesn’t quite fit and then tried to ignore the round peg forced into the square hole.

Our society doesn’t deal well with conditions that cross boundaries between mind and body, medicine and education, psychology and ...

Consider the difficulty parents have in determining whether to call a doctor, a tutor, or a therapist when a child has ongoing behavior problems that affect academic achievement.

In the addictions world, the word disease itself is an ideological front line, weighed down with far too much historical and moral baggage. I’d like to stop fighting over language (if you want to say it’s both a learning disorder and a disease, I won’t try to stop you, nor do I mind if you want to see these notions as completely distinct). Instead, I want to focus on how learning and development can allow us to stop trying to square circles.

From this perspective, like schizophrenia, depression, and autism, addiction has neurodevelopmental roots: some brains are more vulnerable to it than others as a result of genetic predispositions, which affect development in utero and beyond.

Predispositions to addiction also tend to carry risk of other mental illnesses and developmental disorders: at least half of people with addictions also have another condition, like depression, anxiety disorders, bipolar, ADHD, and schizophrenia, with some studies finding rates of co-occurring disorders as high as 98%;...

All of these propensities interact with early life experience, particularly trauma, over time to produce risk. Addictio...

as with other psychiatric and developmental disorders, addiction it...

But more so than with conditions like schizophrenia and autism, it does involve choices made both consciously and unconsciously as children and adolescen...

Consequently, it is profoundly affected by cultural factors and by the way individuals perceive their own experience, particularly very early in life. This means that while addiction can certainly impair moral decision making, it does not eliminate free will, and the level of impairment varies widely...

During my addiction I frequently made choices about using—for example, I never did so in court or where the police could see me—but my values were certainly skewed toward prioritizing it over school and relationships, which I ordinarily would have valued mo...

Further, as a developmental disorder, addiction is more likely to appear in some st...

the typical case of depression begins in one’s early 30s.

In addiction, adolescence is the high-risk period because this is when the brain changes to prepare for adult sexuality and responsibilities and when people begin to develop ways of coping that will serve them for the rest of their lives. For example, the odds of alcoholism for those who start drinking at age 14 or younger are nearly 50%—but they drop to 9% for those who start at age 21 or later.

If you manage to make it through adolescence and young adulthood without developing an addictive coping style, your odds of developing one later, while not nonexistent, are dramatically reduced.

Addiction, then, is a coping style that becomes maladaptive when the behavior persists despite ongoing negative consequences. This persistence occurs because “overlearning” or reduced brain plasticity makes the behavior extremely resistant to change. Plasticity is the brain’s ability to learn or change with experience. Lowered plasticity means this ability is compromised, and when a pattern of activity is locked in, it is “overlearned.”

The capacity for such overlearning is a feature of the brain’s motivational systems, which evolved to pro...

virtually all psychiatric disorders—including schizophrenia, bipolar disorder, personality disorders, and yes, addictions—have been found to be profoundly shaped by learning during development, and so these, too, are now under the neurodevelopmental umbrella.

Brain development cannot progress properly without experience; therefore, almost any disorder that affects mental functioning in childhood and adolescence will have a learned component.

Since most brain development depends on experience, environmental influences in childhood ranging from parents and peers to chemical exposures can determine whether wiring differences become disorders, disabilities, advantages, or some mix of all three.

timing matters in learning disorders. Because healthy development unfolds in a precise pattern, the sequencing of environmental influences, particularly social ones, is of critical importance. Missing an experience may be trivial at one stage of development but can derail it at another.

The two main sensitive periods in human brain development are infancy and adolescence. When specific input that is important at one of these stages is missed, it is difficult for someone to catch up later.

because development is sequential, well-timed intervention can change its course.

Before infant screening for deafness became widespread, early hearing loss was commonly misdiagnosed as intellectual disability. Because deaf children didn’t learn language when their brains were most responsive and receptive to it, they appeared to have innate difficulties with grammar and other skills, even in sign language. Many wound up in institutions because their hearing prob...

As with deafness and intellectual disability, some of the social disabilities seen in autism may be linked not with lack of capacity but with lack of exposure to appropriately timed developmental experience.

If you can intervene effectively during a sensitive period in a developmental disorder you may entirely prevent problems that previously were seen as intrinsic to it but that actually result from missing important developmental experiences.

the importance of sequencing in all developmental disorders cannot be overstated. Later aspects of development often rely on the previous stage being successfully completed. If you don’t have a foundation, proceeding with the rest of the building process will obviously not be successful.

At certain times, in systems that have sensitive dependence on initial conditions, tiny things can have a massive and disproportionate domino effect.

For instance, once a device like the QWERTY keyboard becomes popular, overcoming the enormous inertia of large systems and making the huge number of alterations in training and equipment needed to try something different becomes virtually impossible or simply not worth the effort, even if it would ultimately produce a superior technology.

the phenomenon is called “path dependence.”

In any area where these kinds of sequencing effects are seen, it is almost impossible to understand the present state of a system without knowing its particular...

In a story of his alcoholism, The Who’s guitarist Pete Townshend noted, “Most people for whom alcohol becomes a problem are running away from something.… Usually, what they are running away from is feelings and the inability to deal with the intensity of their feelings.”

The particular symptoms that people use drugs to cope with may be infinitely varied, but the desire to feel accepted and secure when you typically feel alienated, unloved, anxious, and in danger is common.

As a learning disorder, addiction results from a dysfunctional coping style in a way that is profoundly affected by development.