Биология желания. Зависимость — не болезнь

by Marc Lewis, Марк Льюис

Почему люди так легко на все подсаживаются? У современного человека много зависимостей. Мы сидим в социальных сетях, играем в компьютерные и азартные игры, тратим на покупки намного больше, чем собирались, пьем, курим или фанатично занимаемся спортом. Но почему тогда психиатры и психологи называют болезнью только алкогольную или наркотическую зависимость? А, например, не безответную любовь, которая тоже является зависимостью с печальными последствиями?

Наш мозг ищет удовольствий и расслабления в мире, который не отвечает ему взаимностью. Мозг непрерывно перестраивает себя, обучаясь и развиваясь. Как только у нас появляется какая-то зависимость, этот процесс резко ускоряется, ведь нашему мозгу регулярно предлагаются весьма привлекательные "призы". Марк Льюис — когнитивный нейробиолог и бывший зависимый — объединяет простые истории человеческой жизни с четким научным объяснением. «Биология желания» дает надежду каждому, кто либо борется с зависимостью сам, либо помогает бороться другим.

Genres: Psychology, Nonfiction, Addiction, Science, Health, Neuroscience, Biology

304 pages, Hardcover

First published May 26, 2015

About the author

Marc Lewis is a neuroscientist and professor of developmental psychology, recently at the University of Toronto, where he taught and conducted research from 1989 to 2010, and presently at Radboud University in the Netherlands. He is the author or co-author of over 50 journal publications in psychology and neuroscience, editor of an academic book on developmental psychology, and co-author of a book for parents. More recently he has written two books concerning addiction.

Reviews

[Morgan Blackledge · Rating 4 out of 5]

When it comes to addiction. It seems like everyone has a different (deeply held, strongly defended) opinion.

Religious people call it a moral failing and they say we just need to pray to Jesus more.

Conservatives call it a failure of willpower. They tell us to "Just say no" and to "DARE" to abstain.

Liberals tell us it's a symptom of social inequities. They tell us we need to provide the urban poor with equal access to healthcare and human services.

AA people tell us it's a spiritual disease and a character defect. They want us to "work the steps", spend our lives at meetings and chant slogans.

Doctors tell us it's an incurable brain disease. They tell us to go to AA or rehab.

Therapists tell us it's because we don't cry enough. They want us to talk about when uncle Roy touched us where our bathing suit covers.

Shrinks tell us it's because your mom and dad didn't love you or what ever. And then they give you pills that make you feel like a zombie and get fat.

So What (exactly) is addiction:

Pretty much everyone uses the term. People commonly think they know what it means. Most people are actually deeply confused about it.

Marian Webster defines addiction as:

"the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma".

That's seems like a pretty straightforward definition of very common word.

But if we deconstruct the concept of addiction as it is represented in this definition, we uncover some interesting and highly problematic assumptions.

So let's take this thing apart and see what happens. Let's break it into the following parts and examine each one:

(1) the state of being enslaved to a (2) habit or practice or to something that is (3) psychologically or physically (4) habit-forming, as narcotics, to such an extent that its (5) cessation causes severe trauma".

Ok. Here goes:

1: "the state of being enslaved"
- this implies that some of us are "enslaved" by our "habits" and some of us are not.

The implication is, that if you're not one of those "addicts", than the things that you do, and the reasons that you do them are categorically different from the things that "addicts" do and the reason that they do them.

You are free to choose to do all of the virtuous things that you do and those addicts are enslaved by their vices.

Never mind the fact that you would rather die than go a day without coffee.

Never mind the fact that you intended to loose 35 pounds this year, but just couldn't keep away from the cookie butter.

You're free to choose your virtuous behavior.

Those addict people are enslaved by their vices.

Denial anyone?

Furthermore; when we say "enslaved" what are we really saying?

In America (the land of the free), the word slavery has a certain psychosocial charge. It's a loaded term.

Slavery invokes images of our most shameful historical chapter, including sociopathic, often sexually repressed plantation men getting off on savagely bullwhipping cowering (but proud and determined) Africans chained to a fence post.

To be a slave or a slave driver is not a pretty thing. And to be liberated and free. Well that's pretty much the American raison d'être.

So what kind of person willingly becomes a slave to a drug?

Who does that?

When viewed in this light, it's clear that there is a pretty harsh judgment built into the very definition of the word addiction.

And we're only just getting started.

2: "a habit or practice"
- this implies that some of our behaviors are habitual and some are not?
- so which of our behaviors are habitual and which are not and how do we know which is which?

Have you every tried to stay absolutely mindful and intentional of everything you do for an entire day?

Not many people have. But anyone who has gone on a mindfulness meditation retreat has tried to do some variant of this practice.

One small version of this is the practice of always entertaining a room with your left foot.

What that entails is mindfully pausing every time before you cross the threshold of a door and intentionally stepping into the room with your left foot.

Does that sound easy?

Not even highly trained Buddhist monks and nuns can do it perfectly.

Why?

Because it's a highly automatic, habitual behavior.

Bringing it out of inflexible automaticity and into flexible intentionality is tremendously difficult.

What you immediately discover when you do these types of exercises is that 99.9% of your behavior throughout the day is automatic and habitual.

That's not a bad thing. That's a really good thing. Imagine if you had to concentrate in order to do things like eat and walk. It would be inconvenient no?

If your ancestors had to concentrate on walking instead of scanning the environment for saber toothed tigers, let's just say they probably wouldn't have had the opportunity to become an ancestor.

The fact that almost all of your behaviors needed for daily living are on autopilot is a huge feature not a flaw. You'd be fucked if it were any other way.

But what about bad habits?

We all know that some habits are good and some are bad.

Some are even filthy.

What kind of person maintains a bad or filthy habit and why don't they just quit?

For the same fucking reason you have a hard time quitting all of your bad habits. Once a maladaptive habit has become automatic (or "over learned") it's really, really fucking hard to change it.

Particularly if quitting (what ever it is you're into) comes with some aversive withdrawal effects (discussed later).

3: "psychologically or physically"
- this implies that there is a clear distinction between the psychological and physical.
- if we consider our subjective "mental" experience to be emergent from biological substrates i.e. from embodied brains, than how exactly do we distinguish between physical and psychological?

Countless examples demonstrate that when you alter a persons brain, you alter their perceptions, thought processes, feelings, personality and even their ability to inhibit (some really reprehensible) behaviors.

One (extremely disturbing) example I'd like to bring your attention to is the case of a 40-year-old married schoolteacher who had no previous history of sex offenses, who suddenly became sexually obsessed with children.

His wife evicted him from the family home after discovering he had made sexual advances to young children.

If you're appalled, well of course you are, that makes you and me both.

But hold on, the story gets better.

The evening before he was due to go to prison, he went to hospital complaining of a headache and saying he was afraid he would rape his landlady.

Wow right?

Hold on, it gets even better.

An MRI scan revealed he had an egg-sized brain tumour in the right lobe of the orbifrontal cortex (the part of the brain responsible for judgement, impulse control and social behaviour).

The tumor was removed and the mans sex crazed pedophilic ideation and behavior completely remitted.

After what must have been some really interesting couples therapy, the marriage was restored and the man was once again living at home.

In October 2001, he complained of headaches and started to secretly collect child pornography again.

Another MRI scan revealed that the tumour had regrown. It was removed and his behaviour disappeared.

Ok. I'm sure we all agree that this is absolutely inexcusable behavior and we as a society must do everything in our power to protect our children form this type of abuse.

But it's kind of hard to call this a moral failure.

If you're not convinced, consider what would happen if you your self were magically transported into this dudes body, with the same brain, and brain tumor.

If you think your behavior would have been any different. Let's just say that your opinion is absolutely contrary to all of the scientific evidence.

Pretty much everyone who legitimately studies the subject agrees. You are your brain. Change your brain, change your you, maybe even change your behavior for the worse.

Even if you still don't agree, and you think that there is some magical (non biologically determined) essence of you that somehow effects your behavior outside of the condition of your brain, and you think that "you" would have (somehow) behaved differently with that particular brain condition.

Than I guess you're special and better than that guy.

But just thank your higher power that you don't have that particular brain condition to fight against.

And say high to Dumbledor and Gandalph for me while your at it.

4: "habit-forming, as narcotics"
- lets just cut to the chase here
- by narcotics we're essentially talking about heroin.
- heroin is among the most stigmatized drugs in our culture
- when you say addict, the archetypical image is that of the black clad gutter junky slamming dope in a trash strewn alleyway or in a filthy cold water flat in some nondescript urban environ.

Junkies are shady characters.

The deep implication is that only certain types of people become "junkies" or "meth heads" or "wineo's" or "crack heads" or what ever.

Nice people, strong people, good people, they don't become junkies.

But the fact of the matter is this that particular issue (addiction) effects all kinds of people irregardless of their character (what ever that even means).

5: "cessation causes severe trauma"
- here's the real kicker.
- cessation causing severe trauma is a euphemism for what is colloquially referred to as getting "dope sick".
- media renditions of heroin withdrawal depict a prolonged, agonizing, hallucinogenic, feverish madness.
- analogous images depict crack heads breaking your windshield for five bucks worth of change and meth heads stripping houses for copper wire. Just to get one more hit.
- these images go hand in hand with stories of week willed individuals who are driven by their agony to commit atrocious and violent crimes in order to get their daily fix.

I'll be the first to admit that there is some truth to these stereotypes. But just as with other media clichés. It's important to remember that they are distorted caricatures that fail to capture the complexity of reality.

So if we snap the pieces together here, when we say addict, were often essentially talking about willingly enslaved, morally bankrupt, habitually controlled zombies, compelled by feverish madness to score dope at any cost, even if it means committing heinous crimes like mugging old ladies for their grocery money.

That's an image of a tortured soul damned to a hell of their own making that Dante himself couldn't have surpassed.

And similar to Dante's masterwork The Inferno, it's also an antique, moralistic fiction that belongs to a previous era, but certainly shouldn't pass for the truth in the age of modern science.

So what does modern science have to say about addiction?

Well, for starters, the term addiction is not preferred by serious researchers for all of the afore mentioned reasons.

The preferred term is Substance Dependence, defined as:

"an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use"

The Diagnostic and Statistical Manual of Mental Disorders 5th addition (DSM-5), which is essentially the bible of psychiatric diagnosis defines substance dependence disorder via a cluster of biopsychosocial symptoms, typified by (a) increased drug tolerance (b) withdrawal effects on cessation (c) drug seeking and using behavior that persists despite negative ramifications and/or the desire to quit.

Furthermore:

The DSM-5 puts certain compulsive behaviors (such as compulsive gambling) in the same category as substance use disorders due to neuroscience findings that confirm that brain structures associated with pleasure, reward and compulsion are equivalently active in both substance dependence and behavioral "addictions".

So that's a little window into how modern science defines what we commonly refer to as "addiction" aka Substance Dependence Disorder.

I don't know about you, but that definition and terminology sounds so much more precise than the other definition.

But if we deconstruct this definition, we uncover some more subtle, less insane and ignorant, but still potentially problematic assumptions.

The Medical Model:
The medical view of addiction is that it's a brain disease. Which is a HUGE step in the right direction.

But the medical model is incomplete. At least in its current from.

So what is the best way to view addiction or substance dependence if it's not a disease?

In The Biology of Desire, neuroscientist (and former hella, super duper druggy) Marc Lewis asserts that addiction is not in fact a disease.

"Addiction, whether to drugs, alcohol, gambling, food, sex, or cigarettes, is rather a developmental learning process resulting from the normal functioning of the human brain".

Defects of Character:
A common 12-Stepism is that people use drugs and alcohol due to what they call Charater Defects.

The idea is that by prayer and meditation, a higher power will "remove the defects of character" and liberate the addict from the disease of addiction.

Dr. Lewis proposes that people use drugs for similar reasons as we do everything else. Because (a) our brain responds to the behavior as rewarding on some level, and (b) because our brains have become conditioned (due to exposure) to crave or otherwise expect said rewards.

Conditioning not Character:
Animals (including people) are born hardwired to seek rewarding stimuli and avoid aversive stimuli.

Certain behaviors lead to rewarding short term consequences, others lead to unfavorable short term consequences.

Over time, the rewarding behaviors are reinforced and become more likely to reoccur and the unpleasant behaviors become less likely to reoccur.

This changes the individuals brain In the sense that now they associate behavior (x) with reward, and therefor seek out opportunities to do behavior (x).

Certain things like food and sex are neurologically preprogrammed (via evolution) to be extra rewarding due to their survival and reproduction benefit.

Ideally, behavior (x) is healthy. But in the modern world, a lot of very unhealthy stuff is interpreted by your brain as extremely desirable due to our evolutionary history.

For example salt, fat and sugar are all highly rewarding based on the conditions of scarcity we evolved in.

Junk food is high in salt, fat and sugar, so our stone aged brains think it's the extra best thing for us. You eat it. You get a HUGE blast of pleasurable neurochemistry e.g. dopamine.

Your brain loves it and rapidly adjusts its expectations.

And suddenly, all you ever want to eat is a Big Mac and carrot sticks seem pretty fucking boring and tasteless in comparison.

Lots of things trick your brain like this. Internet porn, gambling and video games can do it. But some substances cut strait to the chase and stimulate your pleasure and reward centers directly. No particular behavior necessary.

Your brain becomes conditioned to crave and use these substances very rapidly. Additionally, your brain adjusts its chemistry and suddenly nothing else seems rewarding.

Now your brain is conditioned to crave and use the substance.

And now you are ummmm how you say....fucked?

Neuroplasticity:
Refers to changes in neural pathways and synapses due to changes in behavior, environment, neural processes, thinking, and emotions.

The catch phrase for neuralplasticity is:

"Neurons that fire together, wire together".

Referring to the fact that when you exercise cognitive functions, neuronal connections get created and strengthened.

The rest of the catch phrase is:

"Use it or loose it"

Referring to the fact that when you don't exercise neuronal connections, they tend to weaken over time.

In other words.

Learning is a matter of stimulating neuronal activation and growth (SNAG). When you study for a test or practice piano, or learn any information or skill, you're actually just SNAGing your brain.

You're stimulating neuronal activation and growth. The neuronal connections that get exercised, get stronger. And when strong neuronal pathways are cut, than you just learned something.

The stronger the neuronal connections and pathways, the "deeper" the learning.

In other words, learning is a kind of "rewiring" of you brain, and conversely, rewiring your brain is a kind of learning.

This is important in regards to addiction in the sense that repeated exposure to drugs of abuse rewire i.e. SNAG the fuck out of your brain.

For reasons discussed later. Drugs create MONSTER strong neuronal pathways. Once your brain is modified in this way. It's really fucking hard (but not impossible) to recondition that thing.

Repetition:
Doing something over and over is one way to learn. Watch guys practicing skateboard tricks. They will try over and over to stick that sick boneless goofy foot flip side bean plant (not actually skateboard tricks but close enough).

The associated neuronal pathways become stronger with each repetition until at last. You get it.

But learning via repetition is definitely the hard, slow way to go.

It SNAGs your brain. But it makes neural pathways the way walking in a jungle makes a trail. Slowly, slowly over time, lots of foot traffic cuts a little dirt trail.

Neurochemistry:
When you do something you love, or that's rewarding or frightening or terrifying, these emotions fast track the learning process.

The big doses of neurochemistry (dopamine, serotonin, cortisol etc.) that gets released when you're feeling excited (or feeling anything for that matter) accelerates the learning process by SNAGing the brain above and beyond mere repetition.

Making neural pathways with the assistance of large doses of neurochemistry is like laying down a superhighway of learning.

This is significant for the case of addiction because the levels of neurochemistry that you're subjecting your brain to way way way exceed normal.

Doing cocaine or heroin or other heavy duty drugs of abuse is like bombing your brain with hella high doses of neurochemistry, and basically tricking your brain into super learning.

The only problem is, the thing that you're learning is how to do drugs, who to get them from, where to do them, that kind of thing.

Developmental Theory of Addiction Recovery:

Substance dependence recovery can often entail learning some really basic and fundamental skills like emotional monitoring and modulation, affect tolerance and behavioral activation.

You can always learn and change. It just takes work. But fortunately the work is really rewarding.

And when people do the work. They get to places of self mastery and acceptance and wisdom that normies (addict slang for people who have never done hard drugs or have gone through recovery) may never approach.

Recovering from addiction is not about unlearning, it's about learning more.

It's about developing new capacities to not just how to surrender to living life on life's terms, but also to accept what arises as we commit to creating a life worth being sober for.

So what about the book?

Dr. Lewis's work is really great but unfortunately this book isn't. It starts out great but quickly gets bogged down in tedious case study examples that try to double as teachable moments.

Love the man, love his work, ambivalent about this book. Read it. But consider you're self informed.

4 stars :-|

[Brenda ~The Sisters~Book Witch · Rating 5 out of 5]

I found The Biology of Desire to be a powerful, enlightening and interesting read that gave me a good understanding of addiction, how the brain works, why it changes and why addiction should not be considered a disease. Marc Lewis helped me understand what can work to overcome addiction.

I followed this book after reading his book Memoirs of an Addicted Brain: A Neuroscientist Examines His Former Life on Drugs.

I highly recommend both for readers who have a passion or interest in understanding addiction. For me The Biology of Desire gives me hope.

[Ali · Rating 4 out of 5]

The strength of this book lies in how well it ties various strands together - it is part introduction to neuroscience, part polemic and part compelling storytelling. Lewis fails at none of these things, does all of them very well, and if he fails to be truly great at any of them, it hardly seems worth a complaint. Except of course, that there are glimpses that he could be really great, and I haven't read a punch-the-air-great book in months... so basically, I want him to write more.
My interest here was more strongly on the neuroscience angle, but even saying that is disingenuous, as the strength of the book these approaches are woven together. Lewis includes, for example, the distressing details of his case studies emotional lives as addicts, material you can find in many how-I-found-hope-again memoirs. Here, rather than function as a morality tale or schadenfreude fodder, the detail is included to explain what is happening in the brain, how our brains are designed to drive us towards things we want, which meet fundamental emotional needs, and then to create deep seated patterns very quickly (which is after all, efficient), and how this combination of processes can create an unbreakable drug/alcohol/eating or gambling habit.
The interaction between what we think of as personality and human nature, and how that translates into how human brains creates connections and pathways are is just fascinating stuff, so easily and lucidly explained. This is a tale of how our experiences create our biology, the gift and the curse of the mammal.
Lewis is fuelled by fury at ineffective treatments he believes are underpinned by a mistaken view of addiction. I was drawn to this book in large part because of my shock when I realised through casual reading that there is, in fact, no scientific evidence that 12-steps programs actually *work*, yet we have made orthodoxy out of the fact that addicts need to go into rehab, abstain completely, attend meetings frequently. To suggest otherwise is heresy, considered akin to sentencing someone to a life of spiralling devastation. I don't mean to sound flippant here, like almost all of us, I have had addicts in my life, and I would have done anything to help them break free: hence my sense of betrayal at the dirty little secret that actually, the AA orthodoxy helps just as many addicts as no intervention does.
Lewis has a nuanced view - his perspective is really involved in identifying the neurological connections that need to change in order to move through addiction. In this sense, he is neither pro- nor anti-AA - he speaks, for example, of the connection to others experiences that AA can facilitate and how that can rebuild use of neurological networks that help addicts to strengthen concious control. He is opposed, absolutely, to rehabilitation programs which decrease the addicts control and power, as his thesis revolves around the necessity of strengthening the use of addicts long-term planning, and concious control segments of the brain - making residential, patronising and "just say no"" approaches counterproductive in the long run.
There is some great stuff here on willpower, by the way, and why simply trying resist impulses (as opposed to reframing the desire through thinking differently about what you want and why) not only depletes the individuals capacity to make decisions, but weakens the brain connections between higher-level planning/decision making and the impulse/compulsive/desire parts of the brain, creating a vicious cycle of abstinence and compulsive indulgence.
Perhaps the weakest parts of the book, are firstly, that Lewis doesn't effectively distinguish between the neuroscience that there is consensus around and where he is bringing his own research to the fore - this ends up weakening his argument about the importance of refuting the disease theory, as it simply isn't clear what the scientific theory he is critiquing actually is (as opposed to the popular conception). Secondly, the final chapter, with some ideas for effective treatment felt tacked on and not well thought htrough, particularly given the passion and certainty of the rest of the book, it was tentative and unassured. It wasn't a great surprise in the acknowledgements to learn that it was the editor who insisted upon it, for good reason, critique without solution around an issue this paralysing and distressing isn't ideal, but I don't think the work solved that problem.
Overall though, a great and insightful read, which has sent me off chasing more books on the topic.

[Dina · Rating 2 out of 5]

Two stars for gripping storytelling and a nice explanation of some brain anatomy. Minus three stars for crappy arguments and huge scientific inaccuracy.

The author tries to argue why we shouldn’t call addiction a “disease”, and yet his only reasoning repeated in each chapter (speaking of compulsions…) is that addiction is based on a brain mechanism that’s playing role in other areas of our life that’s considered normal. I have several problems with and several arguments against this idea and reasoning.

Firstly, no one calls addiction a disease, at least in the professional community. Most problems treated in psychiatry are called “disorders” which is a whole different term with its own definition, and largely it’s used exactly because we cannot put a strict line between where mental health becomes mental illness. The book implies that an idea of not over-medicalizing mental health problems and removing treatment options from context is innovative, whereas it’s been the view in medicine and any other related field for decades if not more. The mere fact that the author is simply explaining possible causes and neurobiological mechanisms of addiction as the same theories he tries to criticize but under another name doesn’t even deserve comment.

Second, the fact that addiction is developing through a universal brain mechanism doesn’t prove that it’s not a disease. All diseases are explained through mechanisms occurring in our body — it’s the definition of pathophysiology: it is not the fact that it is an unnatural process but rather the dysfunction and distress following this process what qualifies a certain condition to be pathological, a “disease”. Tumors are based on a universal mechanism in our body — cells live to reproduce and some unfortunately end up producing the cells we don’t want — so should we not count tumors as diseases? The author somehow uses this argument to claim addiction is not a disease while depression somehow is, even though depression — like any other mental health condition — has the same brain circuits that function in any human, but in some people and under a combination of certain biological and environmental factors, they function in such a way that lead to certain symptoms that cause distress. In fact, many mental disorders in their less severe stages are not considered pathological in certain communities or individuals despite qualifying the diagnostic criteria; this doesn’t automatically make depression less of a problem for other people suffering from it. The change of name and a neurobiological explanation of its mechanism doesn’t solve the problem, so what is the point of the whole idea then?

Third, the book is filled with horrible scientific inaccuracies, such as calling the highly-debated ego depletion theory “indisputable” or cherry-picking preclinical studies to prove a point about humans. The last drop for me was when the author explained that the study in his example had biased methods and yet interpreted the findings as very convincing based on a large effect size in the results. Sir, this is not how statistics and research in general works: poor methodology asks for attention exactly because it means you cannot treat the study results as trustworthy evidence, no matter how compelling they feel to you.

Fourth, the stories from the book all have a common cause for addiction which the authors keeps amplifying — childhood trauma. Whereas it is undoubtedly one of the possible reasons for someone to be at risk for substance abuse, this set of examples seems more like cherry picking to prove his ungrounded opinion. Some people are more prone to substance use than others as determined by their genes even outside traumatic exposures and some don’t develop problematic addictions even after suffering years of abuse. Moreover, the argument that keeps on appearing in these stories is that everyone can overcome addiction by simply wishing for it, or as the author called it — “learning”. This is a very dangerous assumption since — even when calling addiction “learning” or “habit” and not disease — suggests that all addicts need is not professional help and years of work but a lucky life lesson that suddenly rewires their brain circuits. I also really doubt the “fact” that was given in the first chapters about most problems with substance abuse resolving on their own with time without any intervention: firstly, this is the kind of data hard to obtain since most addicts are only systematically registered by health professionals when diagnosed, and second, it is hard to believe given the chronic nature of addiction which makes it not only hard to give up but also more likely to relapse.

Thus, the author’s claims aren’t grounded neither in logic nor in sound research evidence. Even though explaining science requires a lot of simplification where important nuances get lost, it is no excuse for the author to use obviously biased statements to influence an opinion on such societally important topics. Honestly, the whole narrative felt more like a sophisticated way to explain why the author’s own addiction was not a problem but a natural progression of his life choices, and hence that should apply to the whole population.

[Nancy Patrice · Rating 1 out of 5]

Five people is hardly a disease model.

[Sarah · Rating 4 out of 5]

MY NOTES/QUOTES/AND USEFUL BITS:

The debate may hinge on the issue of control. If you don't have control over your substance use, then you have a disease, and if you do have control (but aren't using it), then addiction is a choice. The leak in the logic is the assumption that choice is a deliberate, rational function we can apply at will. But choice is nearly always irrational - which is only to say that it is executed by the same brain that gives rise to hope, need, fear, and uncertainty, a brain that's highly sensitive to learned associations and contextual cues, a brain that forges new connections based on the activation of existing connections and the strong emotions they render. So when I argue against the disease model, I'm not arguing that addictive behaviors are fueled by voluntary choice.
p22

People often take drugs to solve a problem that has no better solution. To alleviate an ache that won't go away, an ache that others may never see, that they themselves can't name.
p66

...the term "recovery" no longer made sense to me. "Recovery" implies going backward, becoming normal again. And it's a reasonable term if you consider addiction a disease. But many of the addicts I've spoken with see themselves as having moved forward, not backward, once they quit, or even while they were quitting. They often find they've become far more aware and self-directed than the person they were before their addiction. There's no easy way to explain this direction of change with the medical terminology of disease and recovery. Instead of recovering, it seems that addicts keep growing, as does anyone who overcomes their difficulties through deliberation and insight.
p 115

Then why should we reject the disease model?
The main reason is this: Every experience that is repeated enough times because of if its motivational appeal will change the wiring of the striatum (and related regions) while adjusting the flow and uptake of dopamine. Yet we wouldn't want to call the excitement we feel when visiting Paris, meeting a lover, or cheering for our favourite team a disease. Each rewarding experience builds its own network of synapses in and around the striatum (and OFC), and those networks continue to draw dopamine from its reservoir in the midbrain. That's true of Paris, romance, football, and heroin.
...
So even though addictive habits can be more deeply entrenched than many other habits, there is no clear dividing line between addiction and the repeated pursuit of other attractive goals, either in experience or in brain function.
p163

One of the greatest blows to the current notion of addiction as a disease is the fact that behavioral addictions can be just as severe as substance addictions. The party line of NIDA, the AMA, and the American Society of Addiction Medicine remains what it has been for decades: addiction is primarily caused by substance abuse. But if that were so, why are addictions to porn, sex, Internet games, food and gambling so ubiquitous? And why do "disorders" characterized by too much of any of the above show brain activation patterns that are nearly identical to those shown in drug addiction (e.g. overactivation of the striatum when cues are present and anticipation is high, and deactivation of some prefrontal regions when indulgence take the lead)?
p165

People pursue certain activities repeatedly, often with little control, because those activities are highly attractive. That description can cover anything from spending sprees to helicopter parenting to jihadism, and so on and so on. But there is one very normal human endeavour that most of us recognize as the epitome of blind desire and recurrent pursuit: falling in love. Lovers think obsessively about their love object, exaggerate his or her positive qualities, and avoid thinking about future repercussions.
p 166

If addiction is a disease, then so, apparently, is love.
p168

So, what exactly is addiction? It's a habit that grows and self-perpetuates relatively quickly, when we repeatedly pursue the same highly attractive goal. Or, in a phrase, motivated repetition that gives rise to deep learning.
p173

Often, emotional turmoil during childhood or adolescence initiates the search for addictive rewards, which can provide relief and comfort for a while. But there are other points of entry too. Addiction is a house with many doors. However it is approached, and however it is eventually left, addiction is a condition of recurrent desire for a single goal that gouges deep ruts in the neural underpinnings of the self.
p174

So, perhaps sadly, maybe ironically, pleasure is a small part of the common experience of eating, even when you're eating something delicious. Desire and expectancy make up most of the experience: the approach is by far the main act. But this disproportionate relationship makes perfect sense. The evolutionary requirement to focus on pleasure is almost nil. Once the food is in your mouth, there's really nothing more you have to do to improve your odds of survival and procreation. But the evolutionary requirement of getting the food to your mouth, as driven by desire, is immeasurable.
p175

I've compared addictions to love affairs and shown that they share many psychological and neurological features. Both addictions and love affairs are ignited by attraction - highly rewarding until they start to cause more trouble than they're worth. They are both amazingly difficult to walk away from until their consequences become intolerable. And they both satisfy potent emotional needs or they simply would not be so captivating.
pp176-7

People learn addiction through neuroplasticity, which is how they learn everything. They maintain their addiction because they lose some of the plasticity. As if their fingers had become attached together, they can no longer separate their desire for well-being from their desire for drugs, booze, or whatever they rely on. Then, when they recover, whether in AA, NA, SMART Recovery, or standing naked on a thirty-third-floor balcony of the Chicago Sheraton in February, their neuroplasticity returns. Their brains start changing again - perhaps radically.
p197

Failures in recovery - and so-called relapses - can easily be explained by the exhaustion of self-control, when now appeal and ego fatigue work together and the bridge of the ship becomes harder to access from the motivational engine room. Attempts to suppress the attraction of immediate rewards amplify ego fatigue, so we give in to desires we might otherwise circumvent. Yet addiction takes time, carves its ruts deeply, and builds on existing mental habits. So addiction is an aspect of personality development, often an extension of patterns formed by failed attempts to deal with negative emotions from childhood. In fact, addictive patterns aren't just an outcome of personality development; they're a continuation of that development. Addicts continue to grow and modify their self-image, generally for the worse, and so addiction becomes part of the self, characterized by the imprint of earlier failures.
p199

Until addicts begin this kind of reflection, their preoccupation with the immediate is locked in by dopamine's tide. They are caught in a rapidly cycling spiral of desire and acquisition, wanting and getting, getting and losing. Now appeal is not just a devaluation of future goodies; in the case of addiction, it's a gorge carved across the continuum of a person's life, dividing personality development into an unexamined past and an unimagined future. It's a place where people can live for a long time. In fact, they can die there. Or they can find a way out. That requires connecting the jagged halves of one's life - past and future - by discovering and recounting the story of one's own development, and extending that developmental route beyond the next few hours, into the months and years ahead.
p202

To me the message is clear: humans need to be able to see their own lives progressing, moving, from a meaningful past to a viable future. They need to see themselves as going somewhere, as characters in a narrative, as making sense. In addition, the relentless preoccupation with immediate rewards carves a small burrow out of the potential richness of time.
p204

Addicts experience something breathtaking when they can stretch their vision of themselves from the immediate present back to the past that shaped them and forward to a future that's attainable and satisfying. It feels like shifting from momentary blobs of experience to the coherence of being a whole person. It feels like being the author and advocate of one's own life. It feels like being real.
pp206-7

The trick to overcoming addiction is thus the realignment of desire, so that it switches from the goal of the immediate relief to the goal of long-term fulfillment.
p208

[Muhammad Hazem · Rating 4 out of 5]

The biology of desire is a powerfully scientific book that tackles the mainstream notion of addiction being a disease in a very interesting sense. The author presents a solid case of how addiction works, using captivating narratives of addicts, eloquently illustrating their suffering while shedding a spotlight on the underlying reasons using neuroscience.

The book is not for those who are seeking recovery, in my opinion, but for those who want to gain a solid understanding of a globally troubling phenomenon that people have a hard time labeling, or maybe for addicts who want to be able to explain why they are doing what they are doing. Is it a problem of self-control, a purely chronic disease or something in between? How should we view the addict and how are we to hold him accountable for his behaviors, or not at all?

The book also clearly explains why some strategies for recovery simply do not work and why others do. It's a powerful, heavy book that needs a thoughtful read inspired by a passion for understanding addiction in a logical, evidence-based sense.

While I disagree with its purely scientific theme that ignores aspects of addiction that can only be addressed with spirituality and more abstract approaches, yet I understand that this might not be the kind of book for that.

In summary, it's a powerful read and I passionately recommend it.

[Atila Iamarino · Rating 4 out of 5]

Um neurocientista e ex-dependente explicando como o desejo funciona no nosso cérebro e como se dá a dependência. Ele passa pelas formas de entendimento de vício (por falta de uma palavra melhor do meu vocabulário), como doença ou como hábito, por exemplo, sem dar um veredito final de qual a forma mais certa. Destacando o que elucidam e onde erram.

Me marcou principalmente a diferença entre desejo e prazer. Como o vício tem muito mais a ver com o desejo por algo, mesmo que aquilo não desperte mais prazer. E para chegar nesse ponto, passamos pelos ciclos de desejo, uso, alívio, habituação e repetição que fazem o vício se tornar o foco do cérebro e tornam o auto-controle só um dos ingredientes para a saída. Para explicar cada passo desses, ele usa entrevistas e relatos de ex-dependentes.

[Sarah · Rating 5 out of 5]

This is an absolutely fascinating book. As a mental health professional, I’ve always been a little uncomfortable with the push to identify addiction as a disease. There are clearly benefits to doing so; insurance companies are more likely to offer coverage for medical conditions as opposed to behavioral health conditions, for instance. The disease model also offers relief from stigma and feelings of moral/character failure on the part of the person struggling with addiction, which is often quite helpful in attempting to re-establish health and wellness. Even so, I’ve never felt that “disease” fit quite right, and this book has finally clarified that gut feeling I’ve had for so long.

Marc Lewis is a neuroscientist and he uses his expertise to explore the ways in which our brains are set up to respond to various stimuli, particularly desire, goal pursuit, and restraint. There’s a lot of scientific jargon involved, but Lewis does an excellent job of presenting information in a way that’s mostly digestible to those of us lacking a heavy scientific background.

Essentially, Lewis’s argument boils down to this: Addiction is not a disease. It’s not a disease because the addicted brain is functioning normally, in the way that it was designed to function, in the face of strong desire and goal pursuit. The brain changes that accompany the development of a powerful habit are actually evidence of normal neuroplasticity in response to learning, as opposed to disease or dysfunction. In fact, Lewis points out a number of times that the brain generates identical responses and patterns to all strong desires, be it love, sports, or heroin. Does that mean that love is a disease, too? I think most people would argue that it’s not.

This isn’t to say that addiction is healthy or that we shouldn’t attempt to treat those struggling with it. It also doesn’t suggest inherent character flaws or moral failures on the part of the addicted person. The brain is powerful and once such a strong, established habit is formed, it’s incredibly difficult to change (i.e. the addicted person cannot always “just choose” to stop using; it’s not necessarily a matter of willpower or choice once brain pathways have been laid and buttressed so thoroughly over the course of time).

Like any bad habit, we all know that consequences of addiction can cause a lot of serious damage; physically, psychologically, socially, financially… And for these reasons, it’s important for professionals to recognize addiction for what it is, and to develop models of treatment that honor the fact that the addicted brain isn’t diseased or broken, but working incredibly well and must be effectively redirected to establish healthier habitual pathways in relation to desires, motivations, and goal pursuit.

Interesting stuff, folks. I recommend the read!

[Matthew Liberio · Rating 5 out of 5]

An examination of what addiction is and what it might not actually be. Lewis argues that the common opinion that addiction is a brain disease is actually a poor model for explaining what's actually happening. He argues that it's actually about desire and how the human brain behaves during addiction.

"The trick to overcoming addiction is thus the realignment of desire, so that it switches from the goal of immediate relief to the goal of long-term fulfillment." (P 208)

This was written for the layperson, like me. I still only tracked with about 75% of it, which is a good challenge for me. Lewis embeds five testimonials that help reveal how different addictions function in the brain and for the person. I like that element. It helped me understand the complexity of addiction science by making it personal.

[Tatiana Shorokhova · Rating 5 out of 5]

Много нейробиологии, но главный вывод: мы сами творцы своего пиздеца. Выбираем сиюминутное наслаждение, не думая о будущем. Все проблемы из головы - пока не пролечишь голову, ничего не выйдет.

Как человек, зависимый от еды, читала и расстраивалась. Но закончила книгу с ощущением, что выход есть.

[Shaun Shelly · Rating 5 out of 5]

This book is really amazing. Marc Lewis combines the narrative experience of "addiction" and the neuroscience and explains in a very accessible manner why addiction is not a disease. This is one of the few books on addiction that is both accessible and robust in terms of the science. Marc Lewis also explains what is needed to best assist those with problematic drug use. A must read for anyone interested in addiction.

[Sergei_kalinin · Rating 4 out of 5]

Довольно любопытная книга, в которой автор пытается соединить "объективный" (нейрофизиологический) и "субъективный" (психологический) подход к пониманию зависимостей, и к избавлению от них. Книга начинается со смелого заявления о том, что "медицинский" подход, в рамках которого зависимости понимаются как тяжкая и с трудом поддающаяся лечению "со стороны" (врачами и медикаментами) болезнь - устарел.

Автор формулирует главный вопрос: если (на психологическом уровне) болезнь = вредная привычка (т.е. выученная и повторяющаяся схема неадаптивного поведения), то чем принципиально зависимость отличается (уже на нейрофизиологическом уровне) от любого другого научения, в т.ч. адаптивного?

И второй вопрос: если зависимость ничем не отличается от обычного научения, то насколько "страшными и необратимыми" на самом деле являются изменения мозга при зависимостях? Можно ли, опираясь на нейропластичность мозга, и используя активное переобучение, избавиться от зависимости?

Разрушу интригу :)) и сразу скажу, что по мнению автора ответы на все эти вопросы положительные: формирование зависимости мало чем отличается от обычного научения, поэтому (при соблюдении определенных условий), человек может (в том числе самостоятельно!) избавиться от навязчивых поведенческих схем, и в т.ч. "вырастить" в мозгу новые здоровые нейросети.

"Плюсы" книги:

1) Очень цепляющие истории реальных наркоманов - отличные кейсы о том, как формируется зависимость, и каким образом люди от неё избавились.

2) Понятно и системно рассказано о нейроанатомии, нейрохимии и нейрофизиологии зависимого мозга. Для меня часть информации была знакомой, но всё равно очень познавательно!

3) Много ссылок на современные научные исследования зависимости. Некоторые очень любопытные (например, про родство зависимостей с депрессиями и компульсивными расстройствами).

4) Системный, целостный подход. Автор затрагивает все аспекты зависимого поведения: от нейронных структур мозга до "Я-концепции" и социальных связей личности.

Из "минусов":

1) На мой взгляд, книга слабовато структурирована. Понятно, что это не учебник, но в силу широты охваченного материала иногда при чтении довольно трудно удерживать в голове логику автора (и это я ещё себя считаю подготовленным читателем :) ).

2) Есть некоторые спорные моменты. Например, автор пишет про т.н. "истощение эго", хотя в последнее время эту модель много критикуют.

3) На мой взгляд, в книге маловато практических рекомендаций. Автор успешно доказывает свои начальные посылки (о том, что каждый в состоянии перерасти свою зависимость), вдохновляет на подвиги :) , но что именно делать - не говорит. Упоминаются некоторые работающие по мнению автора методики психотерапии; а создавать какую-нибудь собственную методику автор и не собирался.

Вывод: в целом очень качественный науч.поп (скорее всё же науч-поп, а не self help), к прочтению однозначно рекомендую!

[Robert · Rating 3 out of 5]

Marc Lewis is not the greatest writer, but he is intelligent and has passion for the subject. You can tell like he just really, really wanted to find a way to express a few good ideas in the long form of a book, and he does so through some decent but slightly contrived case studies. Fairly typical for a Phd who is likely more used to annotating research papers. He does well to include his knowledge of neuroscience, and doesn’t belabor his own experience with addiction -which he has a whole other book about. But I guarantee you will be skimming a lot of this book if you read it. The bulk of the book is in the 5 case studies, but the important material is all in the last couple chapters where he tries to tie it all together. Felt a bit bloated but the most critical thing to say about it is that it lacks a decent flow - important ideas appear disparate and in various parts, and he fails at focusing decently on one thing at a time so there is a real sense of bits flying off everywhere.
That said, his idea of ego fatigue was nothing short of awesome to me, and it is a fabulous concept that ties together very practical knowledge from ACT, 12-step work, and mindfulness (though he didn’t quite make that connection, as far as I recall. You missed that one, Marc!).

He states on page 199: “Failures in recovery – and so-called relapses – can easily be explained by the exhaustion of self-control, when now appeal and ego fatigue work together and the bridge of the ship becomes harder to access from the motivational engine room. Attempts to suppress the attraction of immediate rewards amplify ego fatigue, so we give in to desires we might otherwise circumvent.”

I think that this is a very good way to articulate what in ACT we might call “control strategy failures”. Clearly this is WAY important in addiction and I hope to be able to communicate that to clients better in the future.

Another good quote is this summative statement from p. 208: “the trick to overcoming addiction is thus the realignment of desire, so that it switches from the goal of immediate relief to the goal of long -term fulfillment.”
Obviously an over-simplification but I like the emphasis on the big problem of instant gratification that is clear but so often overlooked in addiction treatment.

I’ll read more of what Lewis writes but it’s not going to be study or purchase material that inspires me like G.Mate or M. Szalavitz. Recommended for a lay-reader since there is nothing really wrong with the book, but that’s about as far as I’d go.

[Forest]

OMG... Discovering that this is coming out in 2015 has just completely made my day. Maybe even my year. It goes without saying that I am very excited for this! I don't know how I'm gonna wait for the release date to arrive. Marc Lewis rules.

[Illysa · Rating 5 out of 5]

I loved the weaving of neuroscience with biographies of individuals who have personal experiences with addiction. Thoughtful exploration of what occurs in the brain with addiction and ways we can help fight it.

[Ammara Abid · Rating 4 out of 5]

I read this book in dribs and drabs as I'm not into neuroscience but finally I did. yayyyy Coming to the book it is Interesting, informative, time-consuming and mind swirling ( just kidding,,, no, no, I'm serious, for me it is) first 40 pages are hard for me, the starting wasn't impact full at all. But as the book progressed it became interesting. Apart from the neurological mechanisms what makes this book worth reading is the relationship of the addicts Natalie, Brian, Donna, Jhonny & Alice with their addictions heroine, meth, alcohol, bulimia respectively. What's going on in the brain of the addict? Why addiction is not a disease? What aggravates the addicts to take more? What's the Relationship between addict & addiction and how the side effects ruin their health family and work? & last but not the least how addiction becomes desire? If you ever want to know all this, go for it.( Otherwise it's not a book for you)

As I dare to read this one, so here are the keynotes of it :)

~ What fires together wires together and what fires apart wires apart. That's how brain works.

~Dopamine is the fuel of striatum.

~ Striatum is the source of desire, of craving. It is a spiral of tissue near the centre of the brain that first identifies an action to be pursued, a goal to be attained then generate the motivation to go after it.

~ Accumbens is the centre of the whirlpool, rapidly forms connections with its close neighbour the amygdala, which triggers emotional responses and the OFC where the value of goals registered. I have called this network the "motivational core" of the brain. Whether the addiction is meth, coke, tobacco or heroine, some grey matter volume in some prefrontal areas has been thought to decrease by as much as 20%. Degree of loss appears to correspond with length and severity of the addiction.

~ When habits lose their strength, when synaptic traffic finds old and new routes between the striatum and cortex, it's not that self control suddenly appears, it's that self control changes character from an imposition to a desire, from a heartless reflex to a heartless wish.

[Edward Taylor · Rating 5 out of 5]

As a person recovering from an opioid-based addition, I always found it interesting to see what people think of the issues I was facing at the time of my darkest moments. I had been crippled and partially paralyzed by a spinal cord injury, I was living with an undiagnosed case of major depressive disorder and PTSD from both my military career and years of child abuse at the hands of my parents. My issues, though products of my environment were my own and I never blamed anyone else because of them. I separated myself from the war and the soldier I was, I forgave my parents, I got help for my crippling depression but I never did anything other than drown myself in Dilaudid and bourbon for my spinal agony (and it was and continues to be just that) - I took more than 1200 pills (8-24mg at a time) over 3 years (based upon what was prescribed to me) and I still could not make it go away (the pain) - I was addicted not to feel the rush or the high, but the numbness that I needed to take the edge of the growing neuropathy that was spreading uncontrolled through my lower body.

Marc Lewis is a bright man, someone who has helped me in ways that I will never be able to fully express to him as he sat me down and told me, page by page how I felt without ever getting to meet or know my story. His words, the tales he told of the people suffering from pain and solitude, not a disease but of demons of the mind and body have given me more hope than my psychiatrist, therapy group and those around me who have suffered from my addiction.

If you have an addiction or if you have a family member or a friend who suffers, please read this, and try to help yourself understand what they are going through so you can help them get something other than a fix, but to be fixed instead.

[Gigi · Rating 5 out of 5]

thanks to my cousin for lending this to me ur a real one

[Arjun · Rating 4 out of 5]

Marc Lewis lays down a strong argument against the disease model of addiction. And he does make sense. Even though the disease model (and the henceforth pharmaceutical overlords) has come up with medical interventions, the disease model robs people of their volition. I believe we need both the choice and the disease model to go hand in hand to develop reasonable interventions and solutions that can be catered to people in need and NOT a magic pill that solves all. Why four stars then? I think Mr. Lewis didn't do a good enough job on designing interventions. Even though he points to some excellent programmes like the ROR and lays down some theoretical ideas for further thinking, he does not reach a concrete level ground of current therapeutical inventions and future solutions.

[Dolly Ye · Rating 5 out of 5]

Former-drug-addict-turned-neuroscientist Marc Lewis wove state-of-the-art neuroscience research into the heroic narratives of five people struggling with various kinds of addictions. He frames addiction as misguided learning and illuminates on the paths to reshape a brain. It is one of the most illuminated book I’ve read on addiction. And I’ve read a lot of books on this unique human phenomenon. I recommend The Unbroken Brain, Memoir of An Addicted Brain (also by Marc Lewis), For the Love of Money: A Memoir ,The Chemistry Between Us Love, Sex, and the Science of Attraction and Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked.

[Aaron Oda · Rating 5 out of 5]

Addiction recovery is the realignment of our desire and the ability to envision our future selves and goals as more attractive than our short term ones. If addiction is the natural, accelerated albeit, motivation towards short term goals and the natural changing of the brain to do so, plasticity, then what was done can be undone: We can change our brains, create new pathways, and slowly the old pathways will have no use and decay. Desire is the key. Highly recommend.

[Darla · Rating 5 out of 5]

Finally! A different approach to a difficult subject. This resonates with everything in my own personal experience with the people I’ve known who have suffered from addiction. This is invaluable knowledge; Thank You!

[Jonn · Rating 5 out of 5]

Other than Addiction: A Disorder of Choice, the best book on addiction I've read and one that convincingly argues that it is not a disease from a neurological and scientific basis.

[Scribe Publications]

A courageous and much needed voice in rethinking addiction — Lewis takes addiction out of a disease model and reframes it as a negative outcome of neuroplasticity. This model provides realistic hope, given that what has been learnt can be unlearnt by harnessing the principles of neuroplasticity. Through his intimate personal and professional knowledge of addiction, Lewis reframes our understanding of its mechanisms and nature in a way that is empowering.
Barbara Arrowsmith-Young, Author of the international bestseller The Woman Who Changed Her Brain

Clear, insightful, and necessary.
Johann Hari, Author of Chasing the Scream

Marc Lewis provides a wonderful mix of biography, psychology, and neuroscience to explain desire and addiction in a new way. It will stimulate thinking about our approaches to addiction and desire. His writing is accessible, personal, and captivating.
David Roland, Author of How I Rescued My Brain

This is the real story of “this is your brain on drugs”, but one that provides a refreshing, convincing alternative to the widespread traditional disease-model view of addiction. Through compelling stories of real people who struggled with various addictions, Lewis lucidly makes the case for a new science-based understanding of what causes and sustains addiction. Most important, it offers far more positivity about ways out of addiction than those offered by traditional treatment, providing hope for those struggling as well as for their loved ones.
Anne M. Fletcher, MS, RD, Author of Sober for Good and Inside Rehab

Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a primary brain disease. A bracing and informative rebuke of the muddle that now characterizes public and professional discourse on this topic.
Dr. Gabor Maté, MD, Author of In the Realm of Hungry Ghosts: Close Encounters with Addication

Highly readable and plausible illustration of current ideas about addiction from behavioural neuroscience and clinical perspectives by the use of vivid case histories.
Trevor Robbins, Head of Psychology Department, Cambridge University

Marc Lewis’s new book neatly links current thinking about addiction with neuroscience theory and artfully selected biographies. Ex-addicts, we learn, are not “cured”, rather they have become more connected to others, wiser, and more in touch with their own humanity. This is a hopeful message that has, as Lewis demonstrates, the advantage of also being true.
Gene Heyman, Author of Addiction: Disorder of Choice

Whether you are looking for a foundation in the neuroscience of addiction, guidelines for recovery or just hope that recovery is possible, it’s all here. The scientific information is presented in the context of day-to-day behavior and the lives of individuals you will come to care about. You’ll learn more about neuroscience (and human development and psychology) than you may have thought possible. Informed by this book, you’ll see how neuroscience explains addiction as a part of life, rather than a mysterious entity only experts can understand.
Tom Horvath, President of Practical Recovery and Smart Recovery, and Author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions

[L]ooks at how addiction and brain science collide, and how understanding our brains can help addicts get out of the abyss … [A] very readable, often touching, gateway into the universe of neuroscience and the shadowland of addiction.
Richard Ferguson, Sydney Morning Herald

[The book's] success lies in its ability to communicate complex ideas in a way that will engage you and move you and sometimes make you laugh … a very readable, often touching, gateway into the universe of neuroscience and the shadowland of addiction.
Esperance Express

The most important study of addiction to be published for many years.
The Spectator

[Rachel · Rating 4 out of 5]

I found this book immensely useful, both for my personal and professional life. Lewis is certainly shadow-boxing with an opponent who isn’t me. As he himself admits, the ‘disease’ model of addiction is far more humane than the ‘moral failing’ model, even if it doesn’t capture the complexity. And what he’s talking about – the Birmingham model or individualised psychotherapy – is in fact out of the remit of acute medicine, at least as it’s practiced in Ireland. Treating an acute detox with benzodiazepines does work, short-term; but he’s right in saying there’s way more to it than that. Some of the biological basis for his arguments seems a bit stretched – the left side of the pre-frontal cortex stuff in particular – but I also acknowledge that a lot of psychological disorders aren’t readily captured in the traditional, revered quantitative research so beloved of ‘evidence-based medicine’. The thinking in this book will certainly be informing and re-forming my approach.

Facts I learned:

Personality can be thought of as a consolidation of personal habits.

‘[Addiction] can surely be seen as self-medication, but the anxiety and shame that have to be medicated result more and more from the addiction itself.’

‘It seems that evolution devoted a lot more real estate to desire than to the end state – pleasure or relief – it sometimes achieves.’

‘Natalie had to find a self before she could find self-control.’

‘In fact, what we see is a brain that is in the throes of strong emotion, while making is way in a social world characterised by conflict and contradiction. [...] The triumvirate of the amygdala OFC, and accumbens – the motivational core of the brain – evolved precisely for the purpose of linking cognition with emotion, thought with feeling and then putting the best available plan into action.’

Addiction shifts over time from impulsive to compulsive.

Ego depletion or self-control depletion coupled with now preference leads to the addictive cycle.
There’s also difficulty with the linear sense of time: ‘Future well-being can only be pursued if the future can be imagined.’

‘In addiction, the relentless preoccupation with immediate rewards carves a small burrow out of the potential richness of time. [...] The addict’s life is lived in the tomb of the present, dead because it has lost its connection from the story from which it came.’

Birmingham Model and SMART therapy.

Needing to know yourself before you can control it, ego depletion, and the loss of linear time in particular are concepts that I found revelatory.

[Sherif Gerges · Rating 2 out of 5]

While a nice and intuitive qualitative overview of the neurobiological and behavioral processes that undergird addiction, Lewis is essentially arguing that addiction is not a disease in the strictly biological sense, but rather the product of a feedback loop between repetitive behavior (which can include drug use) and the synaptic plasticity that reinforces said behaviors.

To my eyes, he doesn’t establish this argument comprehensively, at least not in the case of hard drugs like cocaine and heroin. Importantly, I feel it would be necessary to buttress the thesis of the book with substantial data (which I am not intimately familiar with). Instead, this book is more like a hodgepodge of matter-of-fact references to what I can assume, but not confirm, is established fact in the field. Of course, he doesn’t touch on the genetic aspects of addiction, which are slowly pointing to the putative perturbation of neurons as being etiologically connected to addiction of cigarettes, for example. I would not be shocked if other genes or their respective DNA regulators (perhaps opioid receptors?) are connected to drugs as acetylcholine is to smoking.

That being said, it seems intuitive that a kernel of truth lies in what Lewis is saying. In particular, I agree with his criticism of the neurobiological view of psychiatry; which has attempted to codify a nosology that essentially tethers every dimension of human behavior to pathology. But these are low hanging fruit, as the DSM has invoked the ire of psychiatrists and psychologists alike.

[Jo · Rating 4 out of 5]

Wow. Definitely a paradigm shifting type of book in a way that shook me up a little. The neurology/literature review portions were a little dense but legible and the personal story narratives were really easy to read and I flew through the rest of the book.
I think the book also does a good job of sticking to relevant conclusions about what addiction is and isn't, exploring various perspectives but without venturing too far into prescribing precise and indelible solutions, though I often found myself wanting precisely that. While this book had really precise notions about how personal narrative and empowerment can change the trajectory of addiction patterns, I really would have loved more information and exploration on the experience of moving forward from addiction in community especially corresponding neurological research about brain patterns and communal settings of culture making and healing. But that's probably more than one book and perspective can provide.
It really resonates with the places I've grated against disease classification of addiction and I found it really mindful actually to learn about the biology of the brain when it comes to building patterns of habit, in a similar way to how meditation teaches non-judgmental observation of the mind and body.
Would definitely recommend and also am looking forward to literature that expands on this framework especially in the kinds of methods of recovery that exist.

[Pasha · Rating 5 out of 5]

Professor Marc Lewis initially captivated my attention with his TED talk where he told his story of recovered opioid addict becoming professor of neuroscience. His path to recovery and advises that he provided to addicts were substantial different from paradigms employed by “faith-based” organizations, such as AA and NA. Later, I’ve read his article in which he argued that addiction is not a disease. This view is different from position take by mainstream addiction researchers, NIDA and rehabs recovery centers.
There are three major views on addiction. Disease model suggests that addictive behavior comes from a diseased brain. Addictive behavior further rewires certain brain systems and makes such behavior “ingrained” in neural circuits. These changes in the brain are well documented on all levels. Substantial body of scientific literature describes both “high-level” behavioral alterations such as inability to delay gratification and submission to the temporal discounting and anatomical changes in specific brain regions accompanied by “low-level” phenomena such as changes in expression of certain receptors. Hence, addiction is considered to be similar to heart or liver disease, which are manifested with pathological changes.
The concept of addiction as a choice comes from behavioral economics. In this model, an addict is considered a rational decision maker, who performs cost analysis and makes conscious choice in favor of addictive behavior disregarding other alternatives. This model implies that addiction is an “immoral” characteristic of personality since addict acts are based on his/her free will and conscious choice. While this model makes treatment of addiction harder, nevertheless, it provides better explanation on how addicts quit.
Lastly, self-medication model suggests that addictive behavior is used to compensate for some deficiency that is caused by another disease, such as PTSD, depression or anxiety. This model is in agreement with noticeable correlation between frequency of psychiatric conditions and tendency for addictive behavior.
Model of addiction as a disease is a mainstream view implemented in US healthcare. One of the major proponents of this model is Dr. Nora Volkow, director of NIDA. Also, “addiction as a disease” model declared in official documents issued by US Senate. The practical reality of US healthcare is one of the reasons for this approach. In this reality “medicalization” of addiction is the only way to have insurance coverage for the treatment as well as to warranty profitability of addiction treating enterprises.

Dr. Lewis outlines his argument by taking a closer look into brain anatomy and demonstrates that brain changes all the time and under many circumstances that are considered “normal”, such as a period of rapid development during adolescence or during highly emotional moments such as falling in love. He argues that brain evolved to be “plastic”, so analogy with liver or heart, when change equals to pathology is incorrect. Changes in brain do not always have pathological nature, but rather just steps in its normal development. He goes further into evolutionary psychology and explores the roots for this plasticity and their origins from the “survival of the fittest”, when traits that contribute to plasticity involved in addiction were important for survival and passing the genes to the next generation. The brief summary of reinforced learning is provided with focus on Hebbs rule and outline of brain regions fueled by dopamine that are major players in formation of addictive behavior.
Next, Dr. Lewis tells five stories of addicts and compliments narratives of their experiences with a vivid description of neurological changes in their brains. The main pattern that is present in all these stories is disconnection between dorsolateral prefrontal cortex, “the bridge of the ship” that is the key region for conscious decision making from the deeper, limbic dopaminergic structures that are involved in impulsive, and compulsive behavior and processing of emotions.
Besides low-level anatomy, there are a few high-level behavior phenomena that responsible for formation of addictive behavior. First, “ego fatigue” or exhaustion of “willpower” due to continues exposure to the “cues” and constant need in applying self-control. It coincides in decline in self-awareness Second, “now appeal” or temporary discounting, when small reward that is available immediately means much more than large reward, but delayed in time. Additionally, Dr. Lewis argues that addicted brain has cyclical perception of time, rather than linear, when the long-term outcomes associated with avoiding addictive behavior are hard to imagine and use in decision making.
After telling these stories, Dr. Lewis takes on “addiction as a disease” model. His main argument is that the processes in the brain involved in addiction are based on reinforced learning, which is not something “unnatural” for the brain, but evolutionary evolved schemes that are activated during such events as falling in love, traveling to desired exotic destination or cheering for favorite sport team. Basically, addiction is a form of love affair, and tendency for it to happen is an innate feature of human brain. He states that addiction is rather desire than a disease and this “desire” is frequently becomes disconnected from “pleasure”, when addictive behavior turns into fully compulsive pattern.
If addiction is similar to love affair, why some people spiral into addictive behaviors, while other seems to avoid it even after being exposed addiction-forming experience? Addiction form as a process of brain development and frequently it establishes itself in people, who had some sort deficiency due to adverse childhood experiences such as sexual or emotional abuse, parental substance abuse and neglect or parental depression. The brain “growth” into addicted brain and path to recovery requires “growing” past this experience. In all five stories, recovery from addiction happened not as a come back to “normal state” before the addiction, but in to a different, healthier state when another compensatory mechanisms for past psychological wounds have been developed.

[Scott Wozniak · Rating 4 out of 5]

This is an excellent book on what's happening in the brain during addiction. The author is good at explaining the complex brain science to non-scientists. What I liked most was how he deliberately intertwined the personal experiences from therapy with the chemical/biological factors. Most people are one or the other, ignoring the other field.

To be clear, it's not a book on how to help addicts break free, but there are some thought provoking examples of others who are doing good work in this area.

The most unique part of the book is the subtitle. I have to admit that I was convinced. There are disease-like elements to addiction, but it is fundamentally different than disease when you get up close. There are brain changes that create problems and these need to be dealt with. But it's not disease. If you'd like to learn the difference (and why it really matters) then I'd suggest you read the book. :)