In the Realm of Hungry Ghosts: Close Encounters with Addiction

by Gabor Maté

My voice loses some of its edge. “I really don’t think you’re in control when you’re that way,” I say. “I don’t believe you’re doing it deliberately.” Claire lifts her eyes to look straight at me. “Of course not,” she says quietly. “But what you do deliberately is that you use cocaine.” “Because I’m addicted to it.” “That’s a choice you’re making,” I reply. Even as the words leave my lips, I know I’m mouthing a platitude. From a certain point of view, everything we do is a choice. From a scientific perspective, though, Claire is closer to the mark. Her explanation that she is addicted—and that therefore her drug use is not the result of thoughtful deliberation—fits with the research evidence. It sounds like a cop-out, but in neurological terms, it’s not.

An abnormally functioning OFC has also been implicated in compulsive behaviours in both human and animal studies. A rat with a damaged orbitofrontal cortex will persevere in reward-seeking, addiction-type activities even after the rewards are removed. As the researchers comment, “these findings are reminiscent of the reports of drug addicts who claim that once they start taking a drug of abuse they cannot stop even when the drug is no longer pleasurable.”13

It is not hyperbole to say that drugs have been the chief source of consolation that Claire, now in her thirties, has ever found. Ever since she began using in adolescence, they’ve offered her relief from searing emotional pain, loneliness, anxiety and a deep-seated fear of the world. 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.

the OFC distinguishes and reacts to angry, disgusted and fearful facial expressions in other people but not to neutral facial expressions.

If our society were truly to appreciate the significance of children’s emotional ties throughout the first years of life, it would no longer tolerate children growing up, or parents having to struggle, in situations that cannot possibly nourish healthy growth. STANLEY GREENSPAN, M.D. CHILD PSYCHIATRIST AND FORMER DIRECTOR, CLINICAL INFANT DEVELOPMENT PROGRAM, [U.S.] NATIONAL INSTITUTE OF MENTAL HEALTH

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 behaviours of any sort, whether drug-related or not.

What is true for vision is also true for the dopamine circuits of incentive-motivation and the opioid circuitry of attachment-reward, as well as for the regulatory centres in the prefrontal cortex, such as the orbitofrontal cortex—in other words, for all the major brain systems implicated in addiction that we surveyed in the previous three chapters. In the case of these circuits, which process emotions and govern behaviour, it is the emotional environment that is decisive. By far the dominant aspect of this environment is the role of the nurturing adults in the child’s life, especially in the early years.

emotional nurturance is an absolute requirement for healthy neurobiological brain development.

As we will soon see, this is particularly so for the brain systems involved in addiction. The child needs to be in an attachment relationship with at least one reliably available, protective, psychologically present and reasonably nonstressed adult.

[An] abnormal or impoverished rearing environment can decrease a thousand fold the number of synapses per axon [the long extension from the cell body that conducts electrical impulses toward another neuron], retard growth and eliminate billions if not trillions of synapses per brain, and result in the preservation of abnormal interconnections which are normally discarded over the course of development.12

Happy, attuned emotional interactions with parents stimulate a release of natural opioids in an infant’s brain. This endorphin surge promotes the attachment relationship and the further development of the child’s opioid and dopamine circuitry.1 On the other hand, stress reduces the numbers of both opiate and dopamine receptors. Healthy growth of these crucial systems—responsible for such essential drives as love, connection, pain relief, pleasure, incentive and motivation—depends, therefore, on the quality of the attachment relationship. When circumstances do not allow the infant and young child to experience consistently secure interactions or, worse, expose him to many painfully stressing ones, maldevelopment often results.

Rats separated from their mothers at an early stage display permanent disruption of the dopamine incentive-motivation system in their midbrains. As we already know, abnormalities in this system play a key role in the onset of addiction and craving. Predictably, in adulthood these maternally deprived animals exhibit a greater propensity to self-administer cocaine.4

And it doesn’t take extreme deprivation: in another study, rat pups deprived of their mother’s presence for only one hour a day during their first week of life grew up to be much more eager than their peers to take cocaine on their own.

Humans hold and cuddle and stroke; rats lick. A 1998 study found that rats whose mothers had given them more licking and other kinds of nurturing contact during their infancy had, as adults, more efficient brain circuitry for reducing anxiety. They also had more receptors on their nerve cells for benzodiazepines, which are natural tranquilizing chemicals found in the brain.6 I think here of my many patients who, on top of cocaine and heroin addictions, have been hooked since their adolescence on street-peddled “benzo” drugs like Valium to calm their jangled nervous systems. For a dollar a tablet, they get an artificial hit of the benzodiazepines their own brains can’t supply. Their need for tranquilizers says much about their infancy and early childhood.

In addition to damaging the midbrain dopamine system, excess cortisol shrinks important brain centres such as the hippocampus—a structure important for memory and for the processing of emotions—and disturbs normal brain development in many other ways, with lifelong repercussions.

A child’s capacity to handle psychological and physiological stress is completely dependent on the relationship with his parent(s). Infants have no ability to regulate their own stress apparatus, and that’s why they will stress themselves to death if they are never picked up.

It’s just as many substance addicts say: they self-medicate to soothe their emotional pain—but more than that, their brain development was sabotaged by their traumatic experiences. The systems subverted by addiction—the dopamine and opioid circuits, the limbic or emotional brain, the stress apparatus and the impulse-control areas of the cortex—just cannot develop normally in such circumstances.

I mentioned abnormalities in the corpus callosum, which facilitates the collaboration between the brain’s two halves, or hemispheres. Not only have the CCs of trauma survivors been shown to be smaller, but there is evidence of a disruption of functioning there as well. The result can be a “split” in the processing of emotion: the two halves may not work in tandem, particularly when the individual is under stress. One characteristic of personality disorder, a condition with which substance abusers are very commonly diagnosed, is a kind of flip-flopping between idealization of another person and intense dislike, even hatred. There is no middle ground, where both the positive and the negative qualities of the other are acknowledged and accepted.

As a result, in intimate relationships and in other areas of life, the afflicted individual fluctuates between idealized and degraded perceptions of himself, other people and the world.

my view of things can be either very positive or highly cynical and pessimistic, and often dogmatically so. When I’m watching the happy channel, my negative perceptions seem like a crazy dream; when stuck in the dejected mode I can’t recall ever having felt joy.

Extreme circumstances breed extremist brains.

Early trauma also has consequences for how human beings respond to stress all their lives, and stress has everything to do with addiction. It merits a brief look here. Stress is a physiological response mounted by an organism when it is confronted with excessive demands on its coping mechanisms, whether biological or psychological. It is an attempt to maintain internal biological and chemical stability, or homeostasis, in the face of these excessive demands. The physiological stress response involves nervous discharges throughout the body and the release of a cascade of hormones, chiefly adrenaline and cortisol. Virtually every organ is affected, including the heart and lungs, the muscles and, of course, the emotional centres in the brain. Cortisol itself acts on the tissues of almost every part of the body—from the brain to the immune system, from the bones to the intestines. It is an important part of the infinitely intricate system of checks and balances that enables the body to respond to a threat.

sapolsky's zebras

researchers defined stress “as a state of disharmony or threatened homeostasis.”23 According to such a definition, a stressor “is a threat, real or perceived, that tends to disturb homeostasis.”24 What do all stressors have in common? Ultimately they all represent the absence of something that the organism perceives as necessary for survival—or its threatened loss. The threat itself can be real or perceived.

Early stress establishes a lower “set point” for a child’s internal stress system: such a person becomes stressed more easily than normal throughout her life.

“A child who is stressed early in life will be more over-active and reactive. He is triggered more easily, is more anxious and distressed. Now, compare a person—child, adolescent or adult—whose baseline arousal is normal with another whose baseline state of arousal is at a higher level. Give them both alcohol: both may experience the same intoxicating effect, but the one who has this higher physiological arousal will have the added effect of feeling pleasure from the relief of that stress. It’s similar to when with a parched throat you drink some cool water: the pleasure effect is much heightened by the relief of thirst.”26

A brain pre-set to be easily triggered into a stress response is likely to assign a high value to substances, activities and situations that provide short-term relief. It will have less interest in long-term consequences, just as people in extremes of thirst will greedily consume water knowing that it may contain toxins. On the other hand, situations or activities that for the average person are likely to bring satisfaction are undervalued because, in the addict’s life, they have not been rewarding—for example, intimate connections with family.

Neglect and abuse during early life may cause bonding systems to develop abnormally and compromise capacity for rewarding interpersonal relationships and commitment to societal and cultural values later in life. Other means of stimulating reward pathways in the brain, such as drugs, sex, aggression, and intimidating others, could become relatively more attractive and less constrained by concern about violating trusting relationships. The ability to modify behavior based on negative experiences may be impaired.

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.

Exposure to stress is the most powerful and reliable experimental manipulation used to induce reinstatement of alcohol or drug use,” one team of researchers reports.32 “Stressful experiences,” another research group points out, “increase the vulnerability of the individual to either develop drug self-administration or relapse.”

The research literature has identified three factors that universally lead to stress for human beings: uncertainty, lack of information and loss of control.35 To these we may add conflict that the organism is unable to handle and isolation from emotionally supportive relationships.

Human children do not have to be reared in physical isolation to suffer deprivation: emotional isolation will have the same effect, as does stress on the parent. As we will later see, stress on pregnant mothers has a negative impact on dopamine activity in the brain of the unborn infant, an impact that can last well past birth.

And would he hit a child, I inquire, if that child “asked for it”? Would he blame that child for “stupid decisions”? Wayne looks away. “I don’t want to talk about that crap,” says this tough man, who has worked on oil rigs and construction sites and served fifteen years in jail for armed robbery. He looks away and wipes his eyes.

Our brains are resilient organs: some important circuits continue to develop throughout our entire lives, and they may do so even in the case of a hardcore drug addict whose brain “never had a chance” in childhood.

“The most important finding of research into a genetic role for alcoholism is that there is no such thing as a gene for alcoholism,” writes the addiction specialist Lance Dodes. “Nor can you directly inherit alcoholism.”

Numerous studies in both animals and human beings have found that maternal stress or anxiety during pregnancy can lead to a broad range of problems in the offspring, from infantile colic to later learning difficulties19

A recent British study, for example, found that children whose mothers were stressed during pregnancy are vulnerable to mental and behavioural problems like ADHD or to being anxious or fearful. (ADHD and anxiety are powerful risk factors for addiction.) “Professor Yvette Glover of Imperial College London found stress caused by rows with or violence by a partner was particularly damaging,” according to a BBC report. “Experts blame high levels of the stress hormone cortisol crossing the placenta. Professor Glover found high cortisol in the amniotic fluid bathing the baby in the womb tallied with the damage.”20

Women who were pregnant at the time of the 9/11 World Trade Center attacks and who suffered post-traumatic stress disorder (PTSD) as a result of witnessing the disaster passed on their stress effects to their newborns. At one year of age these infants had abnormal levels of the stress hormone cortisol. We might wonder if this was not a post-natal effect of the mother’s PTSD. However, the greatest change was noted in infants whose mothers were in the last three months of pregnancy on September 11, 2001. So the fact that the stage of pregnancy a woman was at when the tragedy occurred was correlated with the degree of cortisol abnormality suggests that we are looking at an in utero effect.22 It turns out that during gestation, just as after birth, brain systems undergo sensitive periods of development.

For these reasons, adoption studies cannot decide questions of generic inheritance. Any woman who has to give up her baby for adoption is, by definition, a stressed woman. She is stressed not just because she knows she’ll be separated from her baby, but primarily because if she wasn’t stressed in the first place, she would never have had to consider giving up her child: the pregnancy was unwanted or the mother was poor, single or in a bad relationship or she was an immature teenager who conceived involuntarily or was a drug user or was raped or confronted by some other adversity. Any of these situations would be enough to impose tremendous stress on any person, and so for many months the developing fetus would be exposed to high cortisol levels through the placenta. A proclivity for addiction is one possible consequence.

There is a psychological fact that, I believe, provides a powerful incentive for people to cling to genetic theories. We human beings don’t like feeling responsible: as individuals for our own actions; as parents for our children’s hurts; or as a society for our many failings.

the genetic argument is easily used to justify all kinds of inequalities and injustices that are otherwise hard to defend. It serves a deeply conservative function: if a phenomenon like addiction is determined mostly by biological heredity, we are spared from having to look at how our social environment supports, or does not support, the parents of young children; at how social attitudes, prejudices and policies burden, stress and exclude certain segments of the population and thereby increase their propensity for addiction.

“It’s all in the genes”: an explanation for the way things are that does not threaten the way things are. Why should someone feel unhappy or engage in antisocial behavior when that person is living in the freest and most prosperous nation on earth? It can’t be the system! There must be a flaw in the wiring somewhere.

“A Void I’ll Do Anything to Avoid”

Today he might also include in his sermon: sugar, caffeine, talk shows, gourmet cooking, music buying, right- or left-wing politics, Internet cafés, cell phones, the CFL or NFL or NHL, the New York Times, the National Enquirer, CNN, BBC, aerobic exercise, crossword puzzles, meditation, religion, gardening or golf. In the final analysis, it’s not the activity or object itself that defines an addiction but our relationship to whatever is the external focus of our attention or behaviour.

definition of addiction: any repeated behaviour, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others.

“All addictive disorders, whatever types of behaviors that characterize them, share the underlying psychobiological process, which I call the addictive process.”

There is plenty of evidence for such a unitary view. Substance addictions are often linked to one another, and chronic substance users are highly likely to have more than one drug habit: for example, the majority of cocaine addicts also have, or have had, active alcohol addiction. In turn, about 70 per cent of alcoholics are heavy smokers, compared with only 10 per cent of the general population.3 I don’t believe I’ve ever seen an injection drug user at the Portland Clinic who wasn’t also addicted to nicotine. Often nicotine was their “entry drug,” the first mood-altering chemical they’d become hooked on as adolescents. In research surveys more than half of opiate addicts have been found to be alcoholics, as have the vast majority of cocaine and amphetamine addicts, and many cannabis addicts as well. Both animal and human researches have demonstrated that common brain systems, brain chemicals, and pharmacological mechanisms underlie alcohol and other substance addictions.

All addictions, substance related or not, share states of mind such as craving and shame, and behaviours such as deception, manipulation and relapse. On the neurobiological level, all addictions engage the brain’s attachment-reward and incentive-motivation systems, which, in turn, escape from regulation by the “thinking” and impulse control areas of the cortex.

It’s safe to say that any pursuit, natural or artificial, that induces a feeling of increased motivation and reward—shopping, driving, sex, eating, TV watching, extreme sports and so on—will activate the same brain systems as drug addictions.

For someone with a relative shortage of dopamine receptors, it’s whichever activity best releases extra quantities of this euphoric and invigorating neurotransmitter that will become the object of addictive pursuit. In effect, people become addicted to their own brain chemicals.

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