Your perspective on the brain disease model of addiction

[DynamicDidactic]

I finally got around to reading (listening) to Brainwashed: The Seductive Appeal of Mindless Neuroscience by Satel and Lilienfeld and they dedicate an entire chapter to the fallacy of addiction as a brain disease. There was a bit more historical information (e.g., NIDA and funding) then I knew about but I was already very cynical of this perspective. I understand that, in part, this is a perspective that counters the moral failings associated with addiction in the past. However,

I am curious what the forum thinks of this perspective. More helpful or more harmful nowadays?

---

Members don't see this ad.

 

[Ollie123]

I finally got around to reading (listening) to Brainwashed: The Seductive Appeal of Mindless Neuroscience by Satel and Lilienfeld and they dedicate an entire chapter to the fallacy of addiction as a brain disease. There was a bit more historical information (e.g., NIDA and funding) then I knew about but I was already very cynical of this perspective. I understand that, in part, this is a perspective that counters the moral failings associated with addiction in the past. However,

I am curious what the forum thinks of this perspective. More helpful or more harmful nowadays?

Haven't read the book (been on my list for a while but barely have time for imminently necessary reading right now) so can't comment specifically about their take on it. However, if Lilienfeld's name is attached to it odds are good I'll agree with ~95% and the 5% I disagree with is nuanced academic nitpicking of little ultimate consequence.

I think "Addiction as a brain disease" perhaps needed to happen for the historical reasons you stated. I also think "Addiction is a brain disease" is an outrageously stupid statement to make in an academic context and always has been. To be clear, I say this as someone who has largely built his career on studying neurobiological effects/manifestations of addiction. All but one of my extramural grants has been to study some intersection of addiction and neurobiological measures. Looks like I'm about to land my first R01...focused on using fMRI to assess potential treatment response for novel therapeutics for addiction. I say all this just for context to show that I'm not some fluffy "neuroscience could never capture the real true depth of the human experience" guy.

Key thoughts that sum up my perspective:
- The brain is almost certainly the final pathway, in the sense that addiction ultimately hinges on behavioral actions and the brain directs said behavior. That is very different from what most people mean by "brain disease" though. Whether you think that constitutes a "brain disease" is a philosophical issue that I think is of little importance.
- fMRI is honestly not a great research tool right now and a lot of addiction neuroscience is built on it. It might be one day. It isn't right now for many reasons. I use it because its the best we have for some things. Doesn't mean I can't admit it has huge problems.
- The whole notion that any mental health issue operates at a single level of analysis is absurd. I <might> be able to be convinced for an exceedingly small set of very specific disorders (e.g. developmental disorders). I think even trying to frame things like dementia as purely a "brain disease" is foolish given we know there are myriad behavioral factors that contribute to at least some forms of it, let alone bread & butter mental health disorders.
- We're scientists. We should be able to handle complexity. This includes acknowledging multiple causes, multiple manifestations and that all these things interact in ways we don't currently understand.
- Drugs of abuse are simply not as powerful as many pretend. They're just not. Yes, they have neurobiological effects. So does exercise. And cookies. Yes, these drugs have psychoactive effects that spur escalating use in varying ways.
- I'm hard pressed to think of a serious funded investigator in addiction science who would disagree with anything I stated above. Literally just saw a panel with Koob and Volkow - obviously too of the leading "brain-focused" researchers who spent a fair bit of a time discussing the role of environment on addiction was discussed. There's surprisingly little controversy among actual scientists - its the laypersons who think we need to pick one penultimate approach.

These days, I see more harm than good coming from the view, but only because it has outlived its usefulness and I think we're ready for something new. Some of this relates to the issues we see with many mental health problems related to reduced agency over one's actions. I think that's a trivial issue in the grand scheme of things though. I think the bigger issue is that it has reduced our political interest in restructuring our environment to be less conducive to addictive behavior.

 

[DynamicDidactic]

I'm hard pressed to think of a serious funded investigator in addiction science who would disagree with anything I stated above.

The practice and advocacy side of the issue seems to think very differently. Anecdotally, I have seen psychology faculty that reinforce this perspective at the undergrad level.

I think the bigger issue is that it has reduced our political interest in restructuring our environment to be less conducive to addictive behavior

This will likely be the follow up thread 😐

 

[DynamicDidactic]

if Lilienfeld's name is attached to it odds are good I'll agree with ~95%

FWIW, most of the book is not clinically relevant. I could get about halfway through the chapters about neuromarketing and neurolaw. While interesting, not a whole chapter worth of interesting.

 

[Fan_of_Meehl]

I finally got around to reading (listening) to Brainwashed: The Seductive Appeal of Mindless Neuroscience by Satel and Lilienfeld and they dedicate an entire chapter to the fallacy of addiction as a brain disease. There was a bit more historical information (e.g., NIDA and funding) then I knew about but I was already very cynical of this perspective. I understand that, in part, this is a perspective that counters the moral failings associated with addiction in the past. However,

I am curious what the forum thinks of this perspective. More helpful or more harmful nowadays?

I think it becomes more compelling the more severe the usage (e.g., someone engaging in problematic drinking of a six pack every other weekend is different than someone who has been drinking a fifth or more of hard liquor daily for years). That is, the biological factors maintaining the usage are probably more powerful the deeper one goes into addiction/use and certainly genetic differences in how alcohol is processed and affects the nervous system are relevant. But the very concept of behavioral 'diseases' is rooted in certain philosophical and epistemological assumptions that one either accepts (or not) prior to even trying to make sense of the data.

 

[Ollie123]

The practice and advocacy side of the issue seems to think very differently. Anecdotally, I have seen psychology faculty that reinforce this perspective at the undergrad level.

Oh, you certainly see this perspective. I do think its extremely rare among the....shall we say....more intellectually-inclined....members of the field? At least brain disease in the sense of "You have no agency, this is a neurobiological defect, etc." Practitioners and advocates are gonna do what they're gonna do. Some will be great, some will just repeat a talking point they heard 25 years ago. I worked with a nurse during a VA practicum who gave a cringeworthy presentation to patients on how "the dopamines" was responsible for their addiction full of statements that are flat out untrue. We had a chat afterwards and there was clearly just no flexibility in thinking around the topic. These "true believers" are certainly out there, but generally not taken seriously by the academic crowd.

 

[WisNeuro]

Well, the "brain disease" aspect is just comforting and fits within the current social norms. There's a current feeling that when it's prosocial behaviors, personal agency is all that matters, but when it's a deleterious health behavior, it is 100% percent out of your control and 0% of it is your fault. The all or none thinking doesn't help much and hinders making policy decisions that take a more nuanced approach into account that could actually lead to some change.

 

[Sanman]

Well, the "brain disease" aspect is just comforting and fits within the current social norms. There's a current feeling that when it's prosocial behaviors, personal agency is all that matters, but when it's a deleterious health behavior, it is 100% percent out of your control and 0% of it is your fault. The all or none thinking doesn't help much and hinders making policy decisions that take a more nuanced approach into account that could actually lead to some change.

Pretty much. The current addiction problem in this country involves legal drugs and whit people, so I imagine that ascribing it to personal moral failings a la the crack epidemic of the 80s-90s will be unpalatable for many. The reality is obviously more complex.

 

[Ollie123]

If I had to describe my own view, I'd describe it as a multi-level behavioral economic/neuroeconomic view. Addicts choose to use drugs, but do so because a vast array of biological, behavioral and environmental factors work in concert to bias that choice (i.e. its not a "fair fight"). Whether addiction is a choice, a moral failing, a brain disease, etc. I view as irrelevant silliness that legal/political simpletons need to cope with the fact that they can't handle complexity or nuance. Any explanation that requires picking one of the above is doomed to fail eventually.

 

[bcliff]

If I had to describe my own view, I'd describe it as a multi-level behavioral economic/neuroeconomic view. Addicts choose to use drugs, but do so because a vast array of biological, behavioral and environmental factors work in concert to bias that choice (i.e. its not a "fair fight"). Whether addiction is a choice, a moral failing, a brain disease, etc. I view as irrelevant silliness that legal/political simpletons need to cope with the fact that they can't handle complexity or nuance. Any explanation that requires picking one of the above is doomed to fail eventually.

As a non-expert on SUD, my training has emphasized behavioral and economic models of SUD.

I struggle with "disease" models of addiction. Colleagues with greater expertise in SUD have explained to me that substance use and addiction can cause changes in the brain, which is the "disease" of addiction... That explanation has always felt a little funny to me though.

I've found Bickel's work on this topic really useful and interesting:

 

[R. Matey]

I read Brainwashed in grad school and it was phenomenal, especially as an introduction to Lilienfeld's work. On the subject of addiction and books: Does anyone have an opinion on Unbroken Brain? The central premise suggests that addiction might be a learning disorder.

 

[cara susanna]

Not an addictions expert by any means, but I like the public health model for addiction.

 

[Ollie123]

I read Brainwashed in grad school and it was phenomenal, especially as an introduction to Lilienfeld's work. On the subject of addiction and books: Does anyone have an opinion on Unbroken Brain? The central premise suggests that addiction might be a learning disorder.

Actually hadn't heard of it. Addiction as a learning disorder isn't remotely new though, that's been a hot topic dating back to at least the 90's (Di Chiara, G. (1999). Drug addiction as dopamine-dependent associative learning disorder. European journal of pharmacology, 375(1-3), 13-30. - and this is certainly not the earliest article offering that perspective). Disordered learning plays a role, but again it all depends on how you define things. Does exploiting an accessible reward because environmental constraints preclude access to most others equal learning disorder as most would understand it?

 

[Sanman]

Actually hadn't heard of it. Addiction as a learning disorder isn't remotely new though, that's been a hot topic dating back to at least the 90's (Di Chiara, G. (1999). Drug addiction as dopamine-dependent associative learning disorder. European journal of pharmacology, 375(1-3), 13-30. - and this is certainly not the earliest article offering that perspective). Disordered learning plays a role, but again it all depends on how you define things. Does exploiting an accessible reward because environmental constraints preclude access to most others equal learning disorder as most would understand it?

This. We, as a society, put up barriers that do not allow access to other means of managing financial, emotional, social, and physical ills for those without the money. Drugs are awesome and provide an easily accessible means of pain avoidance and short-term relief from real problems. Eventually, the coping mechanism (drugs) becomes its own problem if not addressed with better long-term solutions.

I wonder where we would be as a society if instead of drug dealers at every corner in poor neighborhoods, we had access to social work and healthcare? Where would we be in the treatment of mental health if we paid SWs and LMHCS as we do nurses and psychologists as we do physicians and then allowed a free annual screening/check-up as we do for physical health conditions?

 

[cara susanna]

I mean, isn't it pretty much scientifically demonstrated that people will stop using substances if you pay them money? But that's something we could never, ever implement as as society because too many people would resist it. Same with solving homelessness by giving people housing.

 

[Ollie123]

This. We, as a society, put up barriers that do not allow access to other means of managing financial, emotional, social, and physical ills for those without the money. Drugs are awesome and provide an easily accessible means of pain avoidance and short-term relief from real problems. Eventually, the coping mechanism (drugs) becomes its own problem if not addressed with better long-term solutions.

I wonder where we would be as a society if instead of drug dealers at every corner in poor neighborhoods, we had access to social work and healthcare? Where would we be in the treatment of mental health if we paid SWs and LMHCS as we do nurses and psychologists as we do physicians and then allowed a free annual screening/check-up as we do for physical health conditions?

Hey - save it for the follow-up thread Dynamic alluded to above

But yes - agreed. Criminal justice is another one that always comes to mind. Felony drug charge? Goodbye legal options for gainful employment. So....guess selling drugs is your only option to take care of your family so good luck with that. But don't do it. Starve. And let your kids starve. No don't let your kids starve, that's a crime too. Do they "deserve it?" Well.....maybe....but that's really besides the point? If we think punishment is too light, let's fix the judicial system and not create additional punishments outside it (not that I advocate for harsher sentencing...quite the opposite...I just think there are more than a few gaps in the thought process here). At the same time I completely get that businesses don't want to hire felons. I'd be hesitant myself. That's where we need structural supports that make it easier to pursue that path rather than harder. There is some serious logical inconsistency with our societal approach to these things.

Again though, I just really fail to understand the "pick one" approach to addiction or any other mental health issue. Certain individuals may have a genetic mutation that alters drug metabolism and heightens the alluring effects of drugs, drugs themselves may bias Q learning parameters by overriding striatal dopaminergic signaling and our legal system may contribute to increased drug use by restricting access to non-drug reinforcers. I see zero reason why all of these cannot be true simultaneously.

 

[Ollie123]

I mean, isn't it pretty much scientifically demonstrated that people will stop using substances if you pay them money? But that's something we could never, ever implement as as society because too many people would resist it. Same with solving homelessness by giving people housing.

I'd go a step beyond pretty much to "100% yes with stronger treatment effects than we see for most anything we do in this field." Though still noteworthy I've never seen contingency management with a success rate approaching 100% (again, pointing to this being complicated). The hardcore CM folks will argue that's just because the contingencies weren't high enough for that person, but I think that's delusional.

 

[Sanman]

Hey - save it for the follow-up thread Dynamic alluded to above

Oh, I'm just getting started

 

[futureapppsy2]

Personally, I think there are strong behavioral and economic factors that play into the start and maintenance of SUDs, but I do think that we too often fail to discuss that a lot of people become addicted to certain substances because they are biologically addictive. A massive reason that we had/have the opioid crisis is because opioids are incredibly addictive biologically and easily build increasing physiological dependence and intense withdrawal symptoms. I have to disagree with @WisNeuro here that whether or not we think of something as a moral failing or disease or something in-between makes no difference, because it makes a huge one in terms of treatment and funding allocation. See, for example, the lack of research on treating pedophiles, because no funder wants their name associated with that.

 

[WisNeuro]

Personally, I think there are strong behavioral and economic factors that play into the start and maintenance of SUDs, but I do think that we too often fail to discuss that a lot of people become addicted to certain substances because they are biologically addictive. A massive reason that we had/have the opioid crisis is because opioids are incredibly addictive biologically and easily build increasing physiological dependence and intense withdrawal symptoms. I have to disagree with @WisNeuro here that whether or not we think of something as a moral failing or disease or something in-between makes no difference, because it makes a huge one in terms of treatment and funding allocation. See, for example, the lack of research on treating pedophiles, because no funder wants their name associated with that.

I never claimed it makes no difference. I claimed that all or none type approaches often lead to ineffective solutions as you are not correctly conceptualizing the actual problem and mechanisms of action.

 

[futureapppsy2]

I never claimed it makes no difference. I claimed that all or none type approaches often lead to ineffective solutions as you are not correctly conceptualizing the actual problem and mechanisms of action.

That's a fair enough point, though I might argue if you give policymakers/insurance companies an inch of "this is a choice" when it comes to addiction/mental health, they'll take a mile of denying services/care on that basis.

 

[Ollie123]

I actually think it was me that said that (or implied that, anyways). I don't disagree with you per se, I just think its important to distinguish between reality and what the best sales pitch for additional funding might be to the caricature "esteemed congressman from Texas" who firmly believes addiction would go away if y'all just believed in Jesus as hard as he does. I think being able to clearly delineate between these two things is important in many health-related subfields right now

Addiction as a brain disease emerged in part from exactly what you stated. I think we've now moved to a point where it now does more harm than good, but the pendulum may need to swing back and forth on this.

 

[WisNeuro]

That's a fair enough point, though I might argue if you give policymakers/insurance companies an inch of "this is a choice" when it comes to addiction/mental health, they'll take a mile of denying services/care on that basis.

Persuasion with lawmakers is one thing, lying to patients is another. From personal experience, though, we've still had very good luck explaining the reality of things to lawmakers when we need them to sign on to bills. We have not had to resort to simplistic extremes to get them on board. This is at both the federal and state levels. If the message isn't getting through, you need better lobbyists. As far as @Ollie123 intimated, with some lawmakers, it really doesn't matter what your message is, they've already decided on a stance.

 

[futureapppsy2]

Persuasion with lawmakers is one thing, lying to patients is another. From personal experience, though, we've still had very good luck explaining the reality of things to lawmakers when we need them to sign on to bills. We have not had to resort to simplistic extremes to get them on board. This is at both the federal and state levels. If the message isn't getting through, you need better lobbyists. As far as @Ollie123 intimated, with some lawmakers, it really doesn't matter what your message is, they've already decided on a stance.

I'd argue that it goes beyond lawmakers--anything that includes a mix of personal choice and not personal choice can be a hard sell to the general public, because it's a bad sound bite. I see this all the time with debates around ABA, for example--you have people in the autistic communities arguing that it is de facto abusive and bad and always will be, and people in ABA communities arguing that it's unethical not to use it. The truth is probably somewhere in the middle--that ABA can be used in ways that are beneficial and it can also be used in ways that are both immediately and longitudinally iatrogenic, but neither side will acknowledge that dialectic at all, so conversations get nowhere,

 

[WisNeuro]

I'd argue that it goes beyond lawmakers--anything that includes a mix of personal choice and not personal choice can be a hard sell to the general public, because it's a bad sound bite. I see this all the time with debates around ABA, for example--you have people in the autistic communities arguing that it is de facto abusive and bad and always will be, and people in ABA communities arguing that it's unethical not to use it. The truth is probably somewhere in the middle--that ABA can be used in ways that are beneficial and it can also be used in ways that are both immediately and longitudinally iatrogenic, but neither side will acknowledge that dialectic at all, so conversations get nowhere,

When working clinically, this is our job, it's what we signed up for. It does no good for me to just tell my patients that their dementia is due to their APOe genes or family historyand shuffle them out the door. It's a convenient explanation, but it's simply incorrect on many levels. We can be effective communicators without resorting to simplistic explanations for clinical phenomena. I can explain to this person that their history of poorly controlled vascular risk factors, uncontrolled diabetes, untreated sleep apnea, etc are contributory to their current presentation. And, we can discuss recommendations for the different aspects of contributory factors. This is what we do, it doesn't help our patients to treat them like idiots and assume they can't handle nuance. It's our job to make that nuance palatable enough to lead to some sort of meaningful change, or in some cases, insight and understanding into their condition.

 

[Sanman]

I actually think it was me that said that (or implied that, anyways). I don't disagree with you per se, I just think its important to distinguish between reality and what the best sales pitch for additional funding might be to the caricature "esteemed congressman from Texas" who firmly believes addiction would go away if y'all just believed in Jesus as hard as he does. I think being able to clearly delineate between these two things is important in many health-related subfields right now

Addiction as a brain disease emerged in part from exactly what you stated. I think we've now moved to a point where it now does more harm than good, but the pendulum may need to swing back and forth on this.

He also seems to believe that Jesus is in Cancun despite his rhetoric about building a wall to keep Mexicans out. Let's not confuse rhetoric with actual belief.

 

[WisNeuro]

He also seems to believe that Jesus is in Cancun despite his rhetoric about building a wall to keep Mexicans out. Let's not confuse rhetoric with actual belief.

Yeah, I don't for a minute believe that Cruz believes more than half of what he actually says. But, I do believe that he knows hos to stay in office and easily increase his wealth while doing so.

 

[PsyDr]

1) There is clearly some neurological underpinnings. People like different substances. Dopamine agonists precipitate pathologic gambling in some gambling naïve individuals (theorized to represent a phenotype) .
2) Treating the addiction as a standalone has more credibility than other treatment modalities. The self medication literature has indicated that treatment of presumed underlying psychiatric illnesses doesn't stop "addiction". Efficacy rates of standalone treatment of "addiction" show substantially superior efficacy rates when compared to dual diagnosis treatments. Disulfiram, naltrexone and topiramate have also demonstrated efficacies of varying degrees in the treatment of "addiction".
3) There remains some environmental determinants, including infant attachment, environmental availability, and socioeconomic status.
4) Regardless, the morality is based upon relative group identification.

 

[Shiori]

I have done a few SUD rotations and have seen this video regularly shared with staff and patients. I have appreciated the perspectives presented in the thread so far! I am wondering what others think about the video.

 

[erg923]

I have done a few SUD rotations and have seen this video regularly shared with staff and patients. I have appreciated the perspectives presented in the thread so far! I am wondering what others think about the video.

Well, Grandmas and grandpas can certainly get addicted to opiates after their hip surgeries.

 

[WisNeuro]

I don't watch or read journalists talking about science. Gladwell and others ruined that for me. What are the Cliffs notes of this video?

 

[thebalmofhurtminds]

I did want to mention that, although it can be comforting to pull on external models ("brain disease"), we've seen the negative consequences of this in other areas on patients. For example, the all-or-nothing belief about depression as a "chemical imbalance" has been shown to actually deter patients from evidence-based treatments for depression. Not the same model, of course, but externalizing reasons does impact buy-in for therapy.

 

[Shiori]

I don't watch or read journalists talking about science. Gladwell and others ruined that for me. What are the Cliffs notes of this video?

Quite fair!

Most people don't get addicted to drugs even with heavy and frequent use. He talked about Rat Park and Portugal's approach to drug use. The part that was interesting to me was the emphasis on connection, meaning, and community integration. The hardest part of working in a SUD clinic is the intensity of the misery of my patients, so it is alluring to think that just helping them have better quality lives would "fix" the addiction as a byproduct.

 

[WisNeuro]

Quite fair!

Most people don't get addicted to drugs even with heavy and frequent use. He talked about Rat Park and Portugal's approach to drug use. The part that was interesting to me was the emphasis on connection, meaning, and community integration. The hardest part of working in a SUD clinic is the intensity of the misery of my patients, so it is alluring to think that just helping them have better quality lives would "fix" the addiction as a byproduct.

I mean, yeah, increasing certain QoL indicators generally improves many health outcomes. Are they arguing for something specific to SUD?

 

[Shiori]

I mean, yeah, increasing certain QoL indicators generally improves many health outcomes. Are they arguing for something specific to SUD?

He is arguing that we adopt something closer to Portugal, I believe. That, or at a more basic level that isolating and penalizing drug use isn't effective for getting people to stop. Maybe try something different. I'm now going down the rabbit hole of examining outcomes for Portugal's drug policies and the messiness of expansive cultural and legal changes. I'm between trauma clients today and read substance use articles for fun!

 

[WisNeuro]

Drug policy of Portugal - Wikipedia for surface level reference

Well, we're starting to slowly decriminalize in certain jurisdictions or for certain drugs. It's going slowly. As for MH, preaching to the choir. I don't know many psychologists who don't favor decriminalization and expansion of diversion programs focused on treatments. Convincing certain politicians on the other hand...

 

[DynamicDidactic]

Drug policy of Portugal - Wikipedia for surface level reference

Well, we're starting to slowly decriminalize in certain jurisdictions or for certain drugs. It's going slowly. As for MH, preaching to the choir. I don't know many psychologists who don't favor decriminalization and expansion of diversion programs focused on treatments. Convincing certain politicians on the other hand...

My cursory googling tells me that this hasn't done much to reduce substance abuse but has reduced criminalization (obviously), HIV infections, and stigma. Anyone know more about the outcome of this movement for actually helping people stop using? Or is this just making using less problematic (harm reduction) without any reduction in use (which is not necessarily a poor outcome). How has this affected other crime, economics, and social issues related to substance use?

 

[WisNeuro]

My cursory googling tells me that this hasn't done much to reduce substance abuse but has reduced criminalization (obviously), HIV infections, and stigma. Anyone know more about the outcome of this movement for actually helping people stop using? Or is this just making using less problematic (harm reduction) without any reduction in use (which is not necessarily a poor outcome). How has this affected other crime, economics, and social issues related to substance use?

I kind of thought that as well, though it seems one of the issues is that Portugal hasn't been tracking and documenting drug use all that well until like the last decade, so it may be hard to draw many accurate conclusions as you're looking at a fairly narrow window.

 

[clausewitz2]

Very sensible editorial by a clinician/philosopher of psychiatry this year in Psychopharmacology that I think is particularly thoughtful about this exact question:

Is addiction a brain disease? A plea for agnosticism and heterogeneity - Psychopharmacology

Rationale Although increasingly subject to criticism, the brain disease model of addiction (BDMA) remains dominant within addiction science. Yet few advocates or critics of the BDMA have provided an account of what a brain disease is. The aim of this review is to conceptually clarify what it...

link.springer.com

 

[clausewitz2]

I think it becomes more compelling the more severe the usage (e.g., someone engaging in problematic drinking of a six pack every other weekend is different than someone who has been drinking a fifth or more of hard liquor daily for years). That is, the biological factors maintaining the usage are probably more powerful the deeper one goes into addiction/use and certainly genetic differences in how alcohol is processed and affects the nervous system are relevant.

I knew a guy who was very high-functioning in a profession that involved a lot of customer contact and interpersonal skills who also travelled everywhere by bike to avoid getting DUIs. He did not sleep for more than 3-4 hours at a time because of the need to drink to stave off withdrawal symptoms, and he would go to social events at breweries and sneak in his own fifth of vodka because he simply could not drink beer fast enough to meet his alcohol need. He was recruited for a research study by one of his medical specialists due to the rapidity with which he metabolized alcohol. He never really appeared intoxicated outwardly.

That guy is probably dealing with a different sort of beast than someone who kills a sixer every time they feel some type of way.

 

[clausewitz2]

1) There is clearly some neurological underpinnings. People like different substances. Dopamine agonists precipitate pathologic gambling in some gambling naïve individuals (theorized to represent a phenotype) .
2) Treating the addiction as a standalone has more credibility than other treatment modalities. The self medication literature has indicated that treatment of presumed underlying psychiatric illnesses doesn't stop "addiction". Efficacy rates of standalone treatment of "addiction" show substantially superior efficacy rates when compared to dual diagnosis treatments. Disulfiram, naltrexone and topiramate have also demonstrated efficacies of varying degrees in the treatment of "addiction".

These factors definitely interact, cf. this study purporting to demonstrate efficacy of topiramate for binge-drinking depends on whether or not a certain genetic polymorphism is present (at least in European-descended individuals):

Psychiatry Online

ajp.psychiatryonline.org

 

[PsyDr]

These factors definitely interact, cf. this study purporting to demonstrate efficacy of topiramate for binge-drinking depends on whether or not a certain genetic polymorphism is present (at least in European-descended individuals):

Psychiatry Online

ajp.psychiatryonline.org

Of course they interact. Biological vulnerability is meaningless until the substance becomes available in the environment of the individual (e.g., lactose tolerance). It's the individuals biological vulnerability to the substance, availability of the substance, and exposure to the substance. When we treat the former, we can modify the latter. This is one of the reasons why the self medication hypothesis is cruel nonsense.