In order to establish a new nosology of addictive disorders, the neurobiology of withdrawal and craving are reviewed, followed by a review of the psychoanalytic literature on addictive neuropsychodynamics.
New information allows us to refine our understanding of addiction. One type of addiction is a character type; a second is a biological disorder. Addictive character is a repetitive, stereotyped response to helplessness via compulsive behaviours. Physical addiction is due to an upregulation of the ventral tegmental dopaminergic pathway with lifelong drug craving and drug dreams.
Both disorders have overlapping features including idealization of the addictive behaviour, a denial system, and resort to addictive behaviours under stress. dsm-type diagnostic criteria are proposed.
The nosology helps to clarify the relationship of non-drug to drug addictions.
For example, gambling or shopping addiction exists only as a
psychological addiction, whereas alcohol or opiate addiction can be either psychological or physical or both.
Use of the refined diagnostic concepts aids in treatment planning and in understanding the relationship of addictive disorders to other forms of psychopathology.
Diagnosis is essential in guiding treatment.
This paper will redefine four entities-psychological addiction, physical addiction, addictive character, and addictive personality disorder-using new developments in the psychoanalytic understanding of addiction, and developments in neuroscience.
A clear understanding of the underlying issues involved in these categories of psychopathology will help us organize our understanding of the patients we see and will illuminate the relationship of addiction to other mental disorders.
Psychological Addiction and Physical Addiction:
Literature Review
There has been general agreement that psychological dependence means "a compulsion to use a drug to produce pleasure or to avoid discomfort, despite negative consequences." This is contrasted with physical addiction, where the threat of withdrawal from the drug with its characteristically painful abstinence syndrome militates towards constant use (Pradhan & Dutta, 1977, p. 5; Angres & Benson, 1985; Littleton & Little, 1994; Dodes, 2002).
Cahalan (1988) defined psychological dependence on alcohol as satisfying 2 out of 5 possibilities:
1. Drinking to help when depressed
2. Drinking because of nervousness
3. Drinking to forget everything
4. Drinking to help forget one's worries
5. Drinking to cheer one up when in a bad mood
With the development of increasingly sophisticated models of the neurobiology of craving, this distinction has become unclear and is in need of further clarifi cation: Which phenomena are biological, which are psychological, and how might one be able to tell the difference (Littleton & Little, 1994)?
We now understand that both withdrawal and craving are aspects of neuroadaptation to drug exposure. A brief review here will help clarify the concepts to be explicated later.
Withdrawal
Intoxication is always the opposite of withdrawal. For example, alcoholic drinking causes persistent inhibitory gabinergic hyperactivity, which opposes normal physiologic activity in driving systems such as norepinephrine and glutamate; alcohol slows you down.
Persistent inhibition of these driving systems causes them to upregulate: to increase presynaptic neurotransmitter release, to increase the number of receptors at the postsynaptic membrane, and/or to increase the effi ciency of transmitter/receptor coupling in effecting depolarization of the neuron.
In withdrawal, the removal of alcohol-abetted gabinergic activity from the brain results in noradrenergic and glutamatergic hyperactivity, which accounts for the dysphoric and dangerous withdrawal symptoms (Tsai et al., 1998). The same basic concept is true of all addictive drugs that alter the homeostatic balance of neurotransmitter systems' functioning (Kasser et al., 1997).
The existence of physiological withdrawal may help to differentiate subgroups of addicted individuals. Withdrawal may be a key marker of severity of addiction, distinguishing between high and low abuse-liability drugs and helping to identify individuals in need of immediate treatment (Schukit et al., 1998).
Craving
Craving is the result of a process that affects a distinct system of the brain (Robinson & Berridge, 1993). Animals are endowed with a "wanting" system to ensure survival and procreation through the pursuit of water, food, and sex. The internal demand that animals pursue their goals is mediated through a discrete dopaminergic system, which originates in the ventral tegmentum, a midbrain structure with its most important projections to the nucleus accumbens and frontal cortex (Zhang & Xu, 2001).
With the "incentive-sensitization" model, Robinson and Berridge describe sensitization or "reverse tolerance" in this neural pathway when it is repeatedly exposed to an addictive drug (Robinson & Berridge, 1993).
For example, in a situation where either placebo or small amounts of amphetamine are infused into subjects, there is no difference in eye-blink rate during initial exposure. With subsequent infusions of the same amount of amphetamine, eye-blink rate accelerates. The motor system involved has become sensitized to amphetamine. Thus the same dose of this addictive drug gradually causes an increased response within this pathway (Robinson & Berridge, 2000).
Berridge & Robinson (1998) have shown that wanting and liking are completely separate phenomena. (This division between wanting and liking is similar to the psychoanalytic literature on the motive for addictive behaviours. See Johnson, 1999.)
Upregulation of the ventral tegmental pathway produces urgent wanting (craving) for the drug, which persists in an endless fashion. The onset of craving is accompanied by the onset of recurrent drug dreams (Persico, 1992; Flowers & Zweben, 1998; Johnson, 2001). The same ventral tegmental pathway, which is the motor for craving, is also the motor for dreaming (Solms, 2000).
Unconscious craving can be made conscious by the recognition of the meaning of these dreams as manifestations of continuing irrational urges to use. Drug dreams may help patients stay sober (Persico, 1992; Johnson, 2001).
A new biological drive for addictive drugs is produced by repeated drug exposure (Bejerot, 1972; Shevrin, 1997). Whether or not the experience is pleasant, once people have been repeatedly exposed to a drug, they will urgently want the drug to which they have become physically addicted, whether or not withdrawal is a factor.
The neural system is complex, and objections have been made to the Berridge and Robinson model in a number of ways.
Is the nucleus accumbens a more central structure in this pathway (Cornish & Kalivas, 2001)?
Is serotonin an important neurotransmitter in the craving system (Sora et al., 1998)?
As interrelated as all structures and neurotransmitters are, it seems that upregulation of the dopaminergic system originating in the ventral tegmentum initiates behavioural sensitization to drugs (Gelowitz & Berger, 2001).
The Robinson and Berridge model is becoming a standard in the addiction fi eld (Goldsmith, 2001).
Addictive Personality: Literature Review
Some earlier psychoanalysts asserted that there was an "addictive personality."
For example, Meissner (1980), while not explaining exactly what he meant by "alcoholic and addictive personality" asserted, "Such personalities tend to show a predominance of oral traits and can often be classified under the narcissistic or schizoid character disorders . . . Because of the primitive nature of the addictive character and the predominance of orality, along with its attendant depressive pathology, alcoholic and addictive personalities are frequently poor risks for psychoanalytic treatment."
Reading this description in the 21st century, one is struck by its vaguely derogatory nature: These are "personalities" not people, words like oral, primitive, and poor risk sound distasteful, and psychoanalysts are specifically warned away from treating these patients.
This view has given way to an absolute insistence both within psychoanalysis (Zinberg, 1975; Wurmser, 1995; Dodes, 2002) and in the addictions (Gendreau & Gendreau, 1970; Zimberg, 1985; Ludwig, 1988) that there is no way of delineating differences in the personalities of addicted persons from those of any other person.
As you read this, the concept of "addictive personality" is a dead issue-no one believes in it. Of course, patients constantly say that they have an addictive personality-which makes one wonder why there should be a term in common usage that has no mirror in diagnostic parlance.
There has been an increasing delineation of the psychodynamics of addictive disorders as psychoanalysts engage with patients despite the previous view that analytic treatment was contraindicated. Drug abuse is accounted to have defensive and adaptive functions (Sabshin, 1995; Khantzian, 1999).
While the adolescent is undergoing separation from the family, the choice of addiction is determined by factors involving environment, social class, and gender (Johnson, 1993) and is often a response to underlying problems of psychological comorbidity (Khantzian, 1985, 1997). An "addictive search" ends when an addictive behaviour is chosen that solves a problem of overwhelming anxiety (Wurmser, 1974).
This description of addiction as a set of defences and adaptations that begin in adolescence and persist as an adult adjustment, has many attributes of a character style. The fact that there is an increased incidence of addictions in certain families, and a genetic component to the predisposition to alcoholism (Bohman, Sigvardsson, & Cloninger, 1981; Cloninger, Bohman, & Sigvardsson, 1981) should not dissuade us from positing an addictive character, since adaptation to genetic endowment is accorded an important place in the predisposition to character styles (Shapiro, 1965).
Dodes (1990, 1996) made a breakthrough in the psychoanalytic description of addiction. He was able to explain that addiction is a nearly indistinguishable cousin of compulsion. In his formulation, the addicted individual is predisposed to being overwhelmed by helplessness due to childhood experiences. The addicted person cannot respond directly and effectively.
When the person makes the decision to perform his addictive act, however, he no longer feels helpless, because in making the decision, he has reasserted a sense that he is in control, that he can act to alter his affective state.
In addition, traumatic helplessness is normally accompanied by rage, and Dodes noted that it is this rage at helplessness that both drives addiction and gives to it its powerfully insistent qualities.
Finally, he pointed out that all addictions are displacements, in which a reversal of helplessness is achieved by the indirect, substitute action that is the addiction, instead of by a more direct response to helplessness. The aggressive urge needs to remain unconscious for dynamic reasons (as originally described for compulsive symptoms by Freud, 1909).
Since addictions contain this internal compromise of displacement, Dodes concluded that they are indistinguishable from other symptoms, especially compulsions.
For example, a man who was asked by his boss to do an amount of work he felt was excessive responded by relapsing to alcoholic drinking (Dodes, 2002, p. 17). His drinking was a displaced re-empowerment against an old helplessness. In his associations, he linked this demand for work to childhood experiences where he couldn't go out and play because his parents had made what he considered excessive demands for him to do housework.
Dodes's formulation of the psychodynamics of addiction is a breakthrough because it helps us to understand that addiction does not stand outside our way of understanding people, but rather positions addictive psychodynamics in the mainstream of psychoanalytic psychology. Khantzian's (1985, 1997) "self-medication hypothesis" can be understood as an elaboration of how a sense of helplessness is generated by affects.
Addictive behaviours are often pursued in an expression of the panicked need to escape from this affect-generated helplessness. Terror of aloneness, based on early experiences (Johnson, 1993), is also often responded to with addictive behaviours.
Cloninger (Cloninger, Sigvardsson, & Bohman, 1988) is a non-analytic researcher who has delineated a combination of innate temperament and character structure that predisposes to addictive behaviours. Specifically, children who are prone to addiction show temperamental traits of high novelty-seeking and low harm-avoidance in combination with character traits involving a lack of investment in spiritual/social issues.
Thus, the initial psychoanalytic formulation of addictive character structure, such as the description by Meissner, lacks specifi city, and in addition carries a judgmental avoidance of a signifi cant patient population.
This paper asks if we have thrown the baby out with the bathwater, and whether it might not be more helpful to use our improved resources to reconsider this currently discredited diagnostic category.
Freud's Addiction
One more factor that may contribute to the status of addictive personality is that Sigmund Freud was ostentatiously and lasciviously addicted. In 1884 cocaine became a second problem in addition to his addiction to nicotine.
He wrote to his fianc?e Martha Bernays, And if you are forward (willful) you shall see who is the stronger, a gentle little girl who doesn't eat enough or a big wild man who has cocaine in his body. In my last severe depression I took coca again and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance. (Byck, 1974, pp. 10-11)
In 1886 he wrote Martha regarding his use of cocaine to treat social anxiety, I was quite calm with the help of a small dose of cocaine . . . and accepted a cup of coffee from Mme. Charcot; later on I drank beer, smoked like a chimney, and felt very much at ease without the slightest mishap occurring. (Byck, 1974, pp. 164-165)
Freud introduced the dream of Irma's injection (1895) with the following: I was making frequent use of cocaine at that time to reduce some troublesome nasal swellings, and I had heard a few days earlier that one of my women patients who had followed my example had developed an extensive necrosis of the nasal mucous membrane. (Byck, p. 205)
Of course, Freud's "troublesome nasal swellings" were probably caused by rather than relieved by cocaine insufflation, which by this point he had been practising for 11 years. You will see (below) that he used the same odd kind of denial regarding the irritation that tobacco smoke caused in his mouth.
When Freud stopped his use of cocaine is not known, but he most certainly died from his nicotine addiction. Romm (1983), a psychiatrist and ent surgeon, wrote, Smoking had (by 1900) been traditionally acknowledged as a causative factor in cancers of the head and neck region, and evidence suggests its implication in the genesis of Freud's lesion as well.
Labeled a "heavy" user of tobacco, Freud smoked up to 20 cigars each day. Acknowledging his tendency to form leukoplakic plaques in his mouth-whitish fl at patches with a high propensity to turn cancerous-he still dreaded the prospect of being told to abstain from tobacco. He actually claimed, five years previously, that abstinence from smoking unquestionably caused a sore to appear on his palate, the resolution of which could only be obtained by the resumption of nicotine indulgence.
Despite his doctors' frequent injunction to stop smoking because of the probable connection of tobacco and his disease, Freud evidently still hoped for their indulgence in not prohibiting his beloved habit. In fact, the appearance of leukoplakia seemed to bother him less than the advice to stop smoking.
At the time that basic concepts of hysterical, obsessional, paranoid, narcissistic character types-which have found their way through different versions of the Diagnostic and Statistical Manual into our current conceptualizations of psychopathology - were being formed, the founder of the study of character types was mortally ill with addiction. The possibility that there was a force within psychoanalysis militating against work on a character type that would have fi t Dr. Freud is discussed below.
Toward a Definition of Addictive Character
The concept of addictive character relies on a strict differentiation between psychological and physical addiction. A character type is a style of response to internal and/or external stress during which stereotyped, repetitive defences are employed. The addictive character type is a style of relatedness.
Physical addiction can be created in any human or rat that is repeatedly exposed to an addictive drug. Physical addiction is a physical illness characterized by permanent upregulation of the ventral tegmental pathway, and resultant drug craving.
For personality concepts to be tested empirically, they must fi rst be identified "theoretically" (Westen et al., 2002). I will use the method of Westen and Shedler (1999a) to give a "composite description" of these different diagnoses. I will then give clinical vignettes. DSM refers to the Diagnostic and Statistical Manual of the American Psychiatric Association (1994).
DSM-Style Criteria for Addictive Character
. Has a denial system that allows persistent engagement in the addictive activity despite obvious harm
. Shows evidence of three (or more) of the following:
* Responds with an addictive activity when feeling helpless (includes engaging in the addictive activity when experiencing
intolerance of affect)
* Idealizes1 the addictive activity
* Resorts to addictive activity in preference to interpersonal support
* When engaged in a relationship and confl ict arises, resorts to
addictive activity in place of effective interpersonal communication
If the patient meets criteria for a personality disorder, the diagnosis is "addictive personality disorder." If the patient has a level of functioning above that of a personality disorder, the diagnosis is addictive character, neurotic level of functioning.
DSM-Style Criteria for Physical Addiction
. Has a denial system that allows persistent drug use despite obvious harm
. Persistent (lifelong) craving to use a drug (including alcohol) that has been caused by recurrent drug exposure. If this craving is not conscious, it is manifest in behaviour that heightens the danger of relapse (drinking sodas at a bar, visiting drug-using friends, etc.)
. Craving is intensified by stress
. Has persistent drug dreams
. Idealizes the drug
Withdrawal that results from physical dependence is now regarded as an epiphenomenon of physical addiction; it is important to treat medically during initial abstinence from drugs, but is simply a manifestation of the underlying changes in neurotransmitters and receptor activity.
Criteria for addictive character: Discussion
These descriptions of addictive character and physical addiction are similar. Active addiction is not possible without a denial system: a set of beliefs that facilitate the compulsive urge to act, despite the reality of negative consequences. Addictions are always idealized. Without denial and idealization the dangerous behaviour will stop.
But addictive character (psychological addiction) and physical addiction are completely different in terms of the mechanism that is driving them. An addictive character style is a set of defences that allow one to consistently manage diffi cult situations with aplomb. All one has to do is to displace other potential solutions into an addictive behaviour.
Why would this character style be idealized? The answer is that if one listens closely to patients in psychoanalysis, all character styles are idealized.
People with obsessional neurosis will explain that keeping careful track of things, and counting them constantly, is important. A patient with a hysterical character (described below) explained to me that once one has been married for some years, it becomes a virtue to not discuss sex with one's wife, because you know each other so well that speaking about sex has become superfluous.
Nonetheless, it seems important to include idealization of addictive behaviours in our defi nition, since it is such a striking phenomenon. Patients have told me things such as, "I vomit silently and don't get dental caries," "Doctor, you will never be able to eat as much as me," or, "My friend and I both drank a case of beer, had sex with the same woman, and both got herpes. That is something you could never do."
Idealization is also a part of the denial system that is an absolute requirement for a behaviour to be both self-destructive and appealing.
The denial system is complex and unconscious. There are a number of characteristic components that are different for each person and are adapted to their own life and behaviours. But they are variants of defences that allow the addictive behaviour to continue; defences such as rationalization ("After a day like today, I deserve a drink"), projection of responsibility ("My doctor wouldn't prescribe any more Oxycontin, so I had to start buying heroin"), minimization ("Ecstasy isn't such a bad drug"), denial ("Scratch tickets are cheap, so they really don't count as gambling"), etc.
One notices that in order for one to become "ready" to change, the denial system has to be rendered ineffective. This is the psychodynamic underpinning of the "stages of change" phenomenon (Prochaska, DiClemente, & Norcross, 1992). Clinicians do not have to wait passively for their patients'
denial to mysteriously evaporate. An important part of the treatment of patients with addiction is to help them become conscious of the defences of denial that hold the addictive behaviours in place.
The two addictions now join other phenomena that appear to have both psychological and biological attributes. Depression can be a character style used to manage anxiety (McWilliams, 1994; Akiskal et al., 1980) as well as having possible adaptive advantages (Nesse, 2000). It can also be a biological
disorder requiring treatment with medications. Anxiety can be a useful signal of internal danger (Freud, 1926) or it can be a biological disorder (social phobia, generalized anxiety disorder) treated with medications.
The issue of whether an addictive character is a diagnostic entity different from a biological addiction is exactly mirrored in a controversy over whether a depressive character is a diagnostic entity different from a biological depression. There is a long psychoanalytic tradition of understanding depressive character as a style of adaptation: depression as a way to avoid internally and externally generated anxieties and stresses.
There is no doubt that there is also a biologically mediated endogenous depressive disorder that is ameliorated with medications. However, seeing that similar behavioural characteristics produced by separate mechanisms,
combined with the "factor analytic" method of creating diagnostic categories by grouping symptoms derived from observation alone (and eschewing "theory"), makes it appear untenable to assert that there are separate character and biological disorders (Ryder, Bagby, & Schuller, 2002).
Symptoms of a depressive character and biological depression overlap in the same way as symptoms of addictive character overlap with physical addiction.
This observation that a psychological process and a biological process produce a similar-appearing constellation of behaviours helps us to understand the current confusion over the difference between psychological addiction and physical addiction.
The DSM method of insisting on observing behaviours (symptoms) and renouncing "theory" in establishing diagnostic categories hampers our ability to use our expanding understanding of neurobiology to account for differences among illnesses that have overlapping symptoms.
The similarity between the observed characteristics of psychological addiction and physical addiction renders them impossible to differentiate without reference to their origins (as is true of psychological and endogenous depression). A purely descriptive nosology fails. But a reference to underlying mechanisms allows an essential diagnostic separation.
Criteria for physical addiction: Discussion
As similar as physical addiction is to addictive character style, it has very important differentiating characteristics. It is the counterpart of the relationship of endogenous depression to depressive character style, or anxiety disorder to signal anxiety. There is no need to postulate any particular pre-morbid psychology, although of course addictive character is the most common pre-morbid character style. Rat studies show that character is irrelevant to the induction of this physical illness.
In physical addiction the midbrain is now driving the cortex (this aphorism is a simplification because in reality there are multiple input and feedback pathways). Whether an individual had a predisposing addictive character or simply experimented repeatedly with a drug until the ventral tegmental pathway upregulated, the brain is permanently changed by drug exposure.
This new addictive drive provokes thinking that allows gratification of drive, and yet keeps important aspects of the drive unconscious. The ego (cortex) is responsible for developing a style of thinking (denial, idealization) that overwhelms the conflicting messages about the self-damaging nature of the drug, and allows drive (id) gratification.
Drug dreams will come up occasionally as part of psychological addiction, as would any important activity. But in physical addiction they are constant and persistent, and seem to document, in the standard Freudian manner, the persistent activity of drive on the sleeping brain (Freud, 1900).
The wish for sex or food will come up in dreams. As a consequence of physical addiction, so will the wish for drugs. Dreams are the guardians of sleep (Freud, 1940). One goal of drug dreams apparently is to allow the physically addicted person to sleep on while pursuing her drugs in the delusion of the dream.
Another note on Freud
Returning to the criteria for psychological and physical addiction, one can see that my brief quotes from Freud show that he met the criteria for both disorders. Freud idealized cocaine, and he loved his cigars (as they killed him). One would guess that he was intuitively and unconsciously aware of this. "Sometimes a cigar is just a cigar," must have functioned as a key aspect of his denial system.
It humorously dismissed observers who might have said, "If you know so much about human psychology, why are you using a carcinogen, even in the face of precancerous lesions?" I
believe that what is meant by this aphorism is that the psychodynamics underlying his addiction to drugs were never to be investigated.
Addicted persons often get angry when their denial system is questioned, and early psychoanalysts may have sensed that a realistic exploration of addiction might have incurred Freud's wrath or troubled his advocates.
It is impossible to know for sure if Freud's problems were an important detriment to open consideration of the mechanisms of addiction, but there has certainly been an antipathy in psychoanalysis for considering addictive dynamics until recently.
Khantzian's (1999, p. 375) summary of early psychoanalytic formulations on addiction is stated as "highly speculative and embarrassingly unuseful." How many psychoanalytic articles have considered the dynamics of n
