What Is Addiction? PDF
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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,pleaseemailspecial_sales@mitpress.mit.eduorwritetoSpecialSalesDepart- 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:
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