The Addicted BrainThe Addicted Brain

Joseph Vollaro, Ph.DJoseph Vollaro, Ph.D

Assistant Professor of Psychology, Assistant Professor of Psychology, Suffolk County Community CollegeSuffolk County Community College

Executive Director, RES Company, Executive Director, RES Company, Inc.Inc.

DSM –IV Criteria for DSM –IV Criteria for Substance AbuseSubstance Abuse

A. A maladaptive pattern of A. A maladaptive pattern of substance use leading to clinically substance use leading to clinically significant impairment or distress, as significant impairment or distress, as manifested by one (or more) of the manifested by one (or more) of the following, occurring within a 12-following, occurring within a 12-month period: month period: 

(1) recurrent substance use resulting in a failure to (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance (e.g., repeated absences or poor work performance related to substance use; substance-related related to substance use; substance-related absences, suspensions, or expulsions from school; absences, suspensions, or expulsions from school; neglect of children or household) neglect of children or household) (2) recurrent substance use in situations in which it (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance or operating a machine when impaired by substance use) use) (3) recurrent substance-related legal problems (e.g., (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) arrests for substance-related disorderly conduct) (4) continued substance use despite having (4) continued substance use despite having persistent or recurrent social or interpersonal persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights) consequences of Intoxication, physical fights) 

B. The symptoms have never met the B. The symptoms have never met the criteria for Substance Dependence criteria for Substance Dependence for for

this class of substance.this class of substance.

DSM-IV Criteria for Substance DSM-IV Criteria for Substance Dependence Dependence

A maladaptive pattern of substance A maladaptive pattern of substance use, leading to clinically significant use, leading to clinically significant impairment or distress, as impairment or distress, as manifested by three (or more) of manifested by three (or more) of the following, occurring at any time the following, occurring at any time in the same 12-month period: in the same 12-month period: 

(1) Tolerance , as defined by (1) Tolerance , as defined by either of the following:  either of the following: 

(a) a need for markedly increased (a) a need for markedly increased amounts of the substance to amounts of the substance to achieve intoxication or desired effect achieve intoxication or desired effect 

(b) markedly diminished effect with (b) markedly diminished effect with continued use of the same amount of continued use of the same amount of the substance the substance 

(2) Withdrawal as manifested (2) Withdrawal as manifested by either of the following: by either of the following: 

(a) the characteristic withdrawal (a) the characteristic withdrawal syndrome or the substance (refer to syndrome or the substance (refer to Criteria A and B of the criteria sets Criteria A and B of the criteria sets for Withdrawal from the specific for Withdrawal from the specific substances) substances)  (b) the same (or a closely related)  (b) the same (or a closely related) substance is taken to relieve or avoid substance is taken to relieve or avoid withdrawal symptoms withdrawal symptoms

(3) the substance is often taken in larger amounts or (3) the substance is often taken in larger amounts or over a longer period than was intended over a longer period than was intended 

(4) there is a persistent desire or unsuccessful efforts (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use to cut down or control substance use 

(5) a great deal of time is spent in activities (5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its substance (e.g., chain-smoking), or recover from its effects effects 

(6) important social, occupational, or recreational (6) important social, occupational, or recreational activities are given up or reduced because of activities are given up or reduced because of substance use substance use 

(7) the substance use is continued despite knowledge (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or of having a persistent or recurrent physical or psychological problem that is likely to have been psychological problem that is likely to have been caused or exacerbated by the substance (e.g., caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol recognition that an ulcer was made worse by alcohol consumption) consumption) 

SpecifySpecify if:  if:  With Physiological Dependence:With Physiological Dependence:

evidence of tolerance or withdrawal evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) (i.e., either Item 1 or 2 is present) Without Physiological Without Physiological Dependence:Dependence: no evidence of no evidence of tolerance or withdrawal (i.e., neither tolerance or withdrawal (i.e., neither Item 1 nor 2 is present) Item 1 nor 2 is present) 

If drinking is interfering with your work, you're probably a heavy drinker. If work is interfering with your drinking, you’re probably an alcoholic.

~Author Unknown

Addiction continues to be a Addiction continues to be a growing problem in our growing problem in our

society!! society!! – 8% of the population are believed to be users 8% of the population are believed to be users

of illegal drugs (Substance Abuse and Mental of illegal drugs (Substance Abuse and Mental Health Services Administration, 2003), despite Health Services Administration, 2003), despite numerous “Wars on Drugs”numerous “Wars on Drugs”

Did you know America ranks the lowest in Did you know America ranks the lowest in education but the highest in drug use? It’s nice to be education but the highest in drug use? It’s nice to be number one, but we can fix that. All we need to do is start number one, but we can fix that. All we need to do is start the war on education. If it’s anywhere near as successful the war on education. If it’s anywhere near as successful as our war on drugs, in no time we’ll all be hooked on as our war on drugs, in no time we’ll all be hooked on phonics.phonics.

~Leighann Lord~Leighann Lord

– Even legal drugs and their devastating effectsEven legal drugs and their devastating effects ObesityObesity

– 25% of Americans are Obese (Mokdad, et, al, 2003) 25% of Americans are Obese (Mokdad, et, al, 2003) American Obsessions: Caffeine, Television, Internet, American Obsessions: Caffeine, Television, Internet,

Sex, McMansionsSex, McMansions

– Even legal drugs and their devastating Even legal drugs and their devastating effectseffects ObesityObesity

– 25% of Americans are Obese (Mokdad, et, al, 25% of Americans are Obese (Mokdad, et, al, 2003) 2003)

American Obsessions: Caffeine, Television, American Obsessions: Caffeine, Television, Internet, Sex, McMansionsInternet, Sex, McMansions

If addiction is judged by how long a dumb animal If addiction is judged by how long a dumb animal will sit pressing a lever to get a ‘fix’ of something, will sit pressing a lever to get a ‘fix’ of something, to its own detriment, then I would conclude that to its own detriment, then I would conclude that

Netnews is far addictive than cocaine. ~Rob Netnews is far addictive than cocaine. ~Rob StampfliStampfli

To cease smoking is the easiest thing I To cease smoking is the easiest thing I ever did. I ought to know because I’ve ever did. I ought to know because I’ve

done it a thousand times….~Mark done it a thousand times….~Mark TwainTwain

Addiction is nothing new..it Addiction is nothing new..it has been with part of the has been with part of the human condition from the human condition from the

beginning of time.. beginning of time.. researchers continue to researchers continue to

ask that age-old ask that age-old question…….Why? question…….Why?

Thou hast the keys of Paradise, oh, just, subtle, and mighty opium!

~Thomas De Quincey, Confessions of an English Opium-Eater, Part II

In 1990, George Bush In 1990, George Bush declared the 90’s the declared the 90’s the

decade of the brain……decade of the brain……leading to an explosion in leading to an explosion in the field of the field of NeuroscienceNeuroscience

This has lead to an explosion of This has lead to an explosion of knowledge related to how our brain knowledge related to how our brain affects all aspects of our life and affects all aspects of our life and functioning….including in the field of functioning….including in the field of AddictionAddiction

As our knowledge has progressed, it As our knowledge has progressed, it has become clear that substances has become clear that substances that have the power to make us feel that have the power to make us feel good seem to share some good seem to share some remarkable similarities once they hit remarkable similarities once they hit the brainthe brain

It is important to note, that the It is important to note, that the best explanation of addiction is best explanation of addiction is the the Biopsychosocial Model. Biopsychosocial Model.

As Lyvers (2000) states:As Lyvers (2000) states:

“ “ The identification of underlying biological The identification of underlying biological mechanisms in addiction does not render mechanisms in addiction does not render psychosocial factors irrelevant, but rather psychosocial factors irrelevant, but rather implies that such factors may interact in implies that such factors may interact in important ways with biology, as it is widely important ways with biology, as it is widely acknowledged in the currently popular acknowledged in the currently popular biopsychosocial perspective.”biopsychosocial perspective.”

As providers of services to individuals As providers of services to individuals with Traumatic Brain Injury (T.B.I.), it is with Traumatic Brain Injury (T.B.I.), it is not uncommon tonot uncommon to receive areceive a referral for referral for CIC/IBP services, or more because:CIC/IBP services, or more because:

-Consumer has begun to use a drug -Consumer has begun to use a drug compulsivelycompulsively-The consumer has lost control of their -The consumer has lost control of their behaviorbehavior-Use of the substance begins to affect -Use of the substance begins to affect their decisions, health, finances, and their decisions, health, finances, and presonal relationshipspresonal relationships

Which addiction is a problem for Which addiction is a problem for our society, it is of particular our society, it is of particular

concern in people with concern in people with disabilities….disabilities….

OASAS (1997)- OASAS (1997)- 22.4% of the clients served had a 22.4% of the clients served had a coexisting physical/mental disabilitycoexisting physical/mental disabilityMany people believe that this number reflects a Many people believe that this number reflects a great underreporting!great underreporting!Why are people with disabilities more likely to Why are people with disabilities more likely to experience Substance use Disorders? experience Substance use Disorders?

-Unemployment-Unemployment-Lack of recreational activities-Lack of recreational activities-Social isolation-Social isolation-Homelessness-Homelessness-Victimization (i.e. physical, psychological abuse)-Victimization (i.e. physical, psychological abuse)

THE ADDICTED BRAIN: THE ADDICTED BRAIN: the the Disease Model of the Disease Model of the

Alcoholism:Alcoholism:

Addiction is not a character flaw, or a Addiction is not a character flaw, or a sign of weakness, but a disease, sign of weakness, but a disease, similar to other psychiatric diseases, similar to other psychiatric diseases, whose etiology can be better whose etiology can be better understood by understanding brain understood by understanding brain functioning in the addiction processfunctioning in the addiction process

At the very center of this At the very center of this model is the idea of the model is the idea of the

Pleasure CenterPleasure Center (Olds & (Olds & Milner, 1954 ) Milner, 1954 )

Using the brain Using the brain stimulation paradigm, they stimulation paradigm, they

came to the following came to the following conclusions: conclusions:

•Electrical Stimulation of the brain could be experienced as pleasurable or rewarding

•An area known as the Nucleus Accumbens played a major role in this response

Subsequent experiments have Subsequent experiments have demonstrated animals will take drugs or demonstrated animals will take drugs or choose electrical stimulation of the choose electrical stimulation of the brain at the expense of normal activities brain at the expense of normal activities (i.e. eating, sleeping) and that they come to (i.e. eating, sleeping) and that they come to prefer an environment that they associate prefer an environment that they associate with the drugwith the drug

Led to the formulation of the idea of a brain Led to the formulation of the idea of a brain “Pleasure Center” “Pleasure Center” which gives new which gives new meaning to the word “To Die for” meaning to the word “To Die for”

Much work subsequent to this has Much work subsequent to this has established that a class of neurotransmitters, established that a class of neurotransmitters, known as the known as the catecholamines, catecholamines, which which includes includes Norepinephrine, Epinephrine, Norepinephrine, Epinephrine, and Dopamineand Dopamine, seemed to be involved, seemed to be involved

Of particular interest, is the neurotransmitter, Of particular interest, is the neurotransmitter, Dopamine, Dopamine, whose activation in the area of whose activation in the area of the brain known as the the brain known as the Nucleus Nucleus AccumbensAccumbens, appears to be a common , appears to be a common denominator in many drugs of abusedenominator in many drugs of abuse

Newer theories of Newer theories of addictionaddiction suggest suggest that overtime, humans have either that overtime, humans have either discovered or manufactured discovered or manufactured substances that hijack this system, substances that hijack this system, creating addictioncreating addiction

A common question that evolves from A common question that evolves from this idea is this idea is Why Why would we have such a would we have such a place in our brain to begin with? The place in our brain to begin with? The answer to this question comes from answer to this question comes from the theory of the theory of evolution!! evolution!! – According to Darwin, our ultimate goal is According to Darwin, our ultimate goal is

survival of the speciessurvival of the species– Thus, it is believed this “reward system” Thus, it is believed this “reward system”

has evolved as a mechanism to reinforce has evolved as a mechanism to reinforce behaviors that facilitate the survival of the behaviors that facilitate the survival of the species (i.e. eating, drinking, sex)species (i.e. eating, drinking, sex)

Studies have begun to compare Studies have begun to compare how different activities affect the how different activities affect the level of stimulation in this system level of stimulation in this system

with some very interesting with some very interesting results!!!!!results!!!!!

Level of Intensity: (from greatest to Level of Intensity: (from greatest to least):least):

– Addictive DrugsAddictive Drugs– Sexual ActivitySexual Activity– EatingEating– ExerciseExercise– Mediation, Spirituality, Deep thought, Art, Mediation, Spirituality, Deep thought, Art,

Music, Nature, SocializationMusic, Nature, Socialization

The Addicted Brain: A macro The Addicted Brain: A macro viewview

The Major brain The Major brain areas included areas included in Addiction in Addiction include:include:

Nucleus Nucleus AccumbensAccumbens

Ventral Ventral Tegmental Tegmental Area (VTA)Area (VTA)

Prefrontal lobePrefrontal lobe Limbic SystemLimbic System

Nucleus Accumbens: Nucleus Accumbens: release of Dopamine in this release of Dopamine in this area seems to be related to area seems to be related to the experience of intense the experience of intense

pleasurepleasure

Ventral tegmental area:Ventral tegmental area: – When stimulated, sends a When stimulated, sends a

signal (release of signal (release of Dopamine) to the Nucleus Dopamine) to the Nucleus Accumbens, and then, Accumbens, and then, through the process of through the process of reuptake, ends this signalreuptake, ends this signal

– Also is involved in what Also is involved in what has become known, as an has become known, as an Anticipatory signalAnticipatory signal If this anticipation can’t be If this anticipation can’t be

fulfilled, it might be fulfilled, it might be replaced with another replaced with another behaviorbehavior

It is believed many forms of It is believed many forms of addiction begin here!addiction begin here!

Prefrontal lobe:Prefrontal lobe:

– Willed actions are associated with this area, in Willed actions are associated with this area, in contrast to “routine” or “automatic” taskscontrast to “routine” or “automatic” tasks

– Mediate or inhibit these relatively automatic or Mediate or inhibit these relatively automatic or “fixed action patterns”, giving these behaviors “fixed action patterns”, giving these behaviors certain flexibility and relative independence certain flexibility and relative independence from the environmentfrom the environment

– Damage to this area can lead toDamage to this area can lead to Disinhibited behaviorDisinhibited behavior PerseverationPerseveration Failure to assess consequences of ones actionsFailure to assess consequences of ones actions ApathyApathy Poor self-monitoringPoor self-monitoring

Limbic system:Limbic system:

– Amygdala; Amygdala; primitive emotional responses (i.e. primitive emotional responses (i.e. anger, surprise, fear, anger, surprise, fear, novelty)novelty) We recall how well we feel when we satisfy the We recall how well we feel when we satisfy the

addiction (i.e. good feelings around Xmas, birthday, addiction (i.e. good feelings around Xmas, birthday, Hanukah, many years later)Hanukah, many years later)

This at times overwhelms our logic! This at times overwhelms our logic! This explains why stimuli associated with addiction This explains why stimuli associated with addiction

(i.e. a bar, friends, neighborhood, drug paraphernalia)(i.e. a bar, friends, neighborhood, drug paraphernalia) – HippocampusHippocampus

Long term potentiation (LTP): Long term potentiation (LTP): physical process in physical process in which memories are formed- relies on the which memories are formed- relies on the neurotransmitter neurotransmitter GlutamateGlutamate

THE ADDICTED BRAIN: THE ADDICTED BRAIN: THE MICRO VIEWTHE MICRO VIEW

Plasticity Plasticity of brain function: the fact of brain function: the fact that the brain changes permanently in that the brain changes permanently in regards to both internal and external regards to both internal and external stimulationstimulation

Psychopharmacology and Plasticity are Psychopharmacology and Plasticity are beginning to provide an explanation of beginning to provide an explanation of two characteristics associated with two characteristics associated with addiction:addiction: Tolerance and Tolerance and Withdrawal Withdrawal

The mechanisms of how The mechanisms of how these drugs exert their these drugs exert their

effects in the brain are well effects in the brain are well worked out. There are two worked out. There are two

main ways this occur:main ways this occur:

1. Increases the activity of these systems by mimicking the activity of the drug:

2. Inhibiting re-uptake of the drug, 2. Inhibiting re-uptake of the drug, causes a longer, stronger signalcauses a longer, stronger signal

– More recent evidence has begun to More recent evidence has begun to help us understand other aspects of help us understand other aspects of addictionaddiction

– Tolerance and withdrawalTolerance and withdrawal occur, occur, because, in the initial stages of addiction, because, in the initial stages of addiction, frequent drug use can initially frequent drug use can initially suppress suppress parts of the brain’s reward system by parts of the brain’s reward system by activating a substance called activating a substance called dynorphin, dynorphin, whose function it is to loop back and inhibit whose function it is to loop back and inhibit (“turn off”) the (“turn off”) the VTAVTA This makes the same dose of the drug less This makes the same dose of the drug less

rewardingrewarding Also contributes to a growing depression, as the Also contributes to a growing depression, as the

person begins to experience person begins to experience Anhedonia, Anhedonia, failure failure to take pleasure in previously enjoyable to take pleasure in previously enjoyable activitiesactivities

– The next stage: The next stage: Sensitization Sensitization Recent work has identified a substance, Recent work has identified a substance,

Delta Fos B, Delta Fos B, whose concentration rises in whose concentration rises in the the Nucleus AccumbensNucleus Accumbens and other brain and other brain regions in response to chronic drug use regions in response to chronic drug use

This protein is extraordinarily stable, thus, This protein is extraordinarily stable, thus, remains active in the neurons for weeks and remains active in the neurons for weeks and even months after drug administrationeven months after drug administration

It is believed that prolonged induction of this It is believed that prolonged induction of this molecule causes animals to become molecule causes animals to become hypersensitive to drugshypersensitive to drugs

The next step is highly The next step is highly speculative at this point:speculative at this point:

Prolonged exposure to drugs in Prolonged exposure to drugs in animals has led to additional animals has led to additional “sprouting” on the dendrites of the “sprouting” on the dendrites of the Nucleus AccumbensNucleus Accumbens- Delta Fos B - Delta Fos B may lead to these changes, thus, may lead to these changes, thus, when its’ levels return to normal it when its’ levels return to normal it has left a lasting “impression’ on has left a lasting “impression’ on the brainthe brain

ADDICTION AND THE ADDICTION AND THE FRONTAL LOBESFRONTAL LOBES

– Some theorists have begun to look at Some theorists have begun to look at addiction in a behavioral sense as a loss addiction in a behavioral sense as a loss of self-controlof self-control

– Self control, Self control, or inhibition, is considered or inhibition, is considered to be one of the aspects of functioning to be one of the aspects of functioning known as the known as the Executive Functions:Executive Functions: Self-control, delay of gratification, drive Self-control, delay of gratification, drive

inhibition, and anticipation of future inhibition, and anticipation of future consequences consequences

Environmental dependency syndromeEnvironmental dependency syndrome (Lhermitte, 1986): With those who have (Lhermitte, 1986): With those who have frontal lobe damage, behavior becomes frontal lobe damage, behavior becomes largely a function of external stimulilargely a function of external stimuli

– Evidence now suggests frontal lobe dysfunction Evidence now suggests frontal lobe dysfunction is associated with a host of disorders including is associated with a host of disorders including Autism, ADHD, OCD, and SchizophreniaAutism, ADHD, OCD, and Schizophrenia

– There have been a number of studies There have been a number of studies examining the effects of Chronic Alcohol use on examining the effects of Chronic Alcohol use on the brainthe brain Volkow (1994): Volkow (1994): Chronic alcoholism is associated Chronic alcoholism is associated

with abnormally low frontal cortical metabolism, more with abnormally low frontal cortical metabolism, more specifically orbitofrontal areas, which gradually specifically orbitofrontal areas, which gradually improved with month of abstinence improved with month of abstinence

Studies have also indicated that these decreases Studies have also indicated that these decreases tend to outlast the withdrawal phase, despite the tend to outlast the withdrawal phase, despite the initial improvementinitial improvement

Excessive Dopamine release and overstimulation of Excessive Dopamine release and overstimulation of Dopamine receptors in the prefrontal cortex have Dopamine receptors in the prefrontal cortex have been shown to impair prefrontal-cortex dependent been shown to impair prefrontal-cortex dependent cognitive functions in laboratory animals (Arnsten & cognitive functions in laboratory animals (Arnsten & Goldman-Rakic, 1998)Goldman-Rakic, 1998)

Similar short-term and long-term effects have been Similar short-term and long-term effects have been found with other substances, such as, Cocaine and the found with other substances, such as, Cocaine and the OpioidsOpioids

Putting it all together:Putting it all together:

In addition to causing the experience of In addition to causing the experience of pleasure, the Dopamine system by virtue of pleasure, the Dopamine system by virtue of its’ connections with the frontal lobe, can its’ connections with the frontal lobe, can help explain some of the behavioral results help explain some of the behavioral results of long-term substance abuse of long-term substance abuse

It has been suggested that the It has been suggested that the Mesocortical Dopamine SystemMesocortical Dopamine System serves to serves to take the prefrontal cortex “off line” during take the prefrontal cortex “off line” during stressful events so that faster, more stressful events so that faster, more automatic or instinctive processes mediated automatic or instinctive processes mediated by the limbic system by the limbic system

o Acute depression of prefrontal lobe activity Acute depression of prefrontal lobe activity due to excessive inhibitory mesocortical due to excessive inhibitory mesocortical dopaminergic neurotransmission evoked by dopaminergic neurotransmission evoked by drugs is increasingly accompanied over time drugs is increasingly accompanied over time by sensitization of dopaminergic by sensitization of dopaminergic transmission and perhaps chronic neurotoxic transmission and perhaps chronic neurotoxic drug or dopamine actions on the frontal drug or dopamine actions on the frontal lobes, should significantly reduce the lobes, should significantly reduce the inhibitory control exerted by prefrontal inhibitory control exerted by prefrontal cortical areas over posterior cortical and cortical areas over posterior cortical and subcortical systems mediating subcortical systems mediating reinforcement and automatization of reinforcement and automatization of behavior (Tiffany, 1990). behavior (Tiffany, 1990). Leads to Leads to impaired control over drug use and impaired control over drug use and behavior in generalbehavior in general