What is Addiction?

Addiction is a condition marked by behavior that is difficult to control and continues despite adverse consequences. The behavior stimulates reward centers of the brain, and the intensely pleasurable effects create a progressively compelling incentive to repeat the activity, often displacing everyday behaviors to the point of disrupting relationships, livelihood, health, and other pillars of normal life.

A number of psychoactive substances have addictive potential, and while they differ pharmacologically one from another, what they have in common is direct activation of the brain’s reward system. Changes in the reward pathways of the brain they induce set the stage for intense cravings at the same time they weaken pathways involved in the ability to control behavior.

There was a time when addiction was thought to be a property residing within substances themselves, like morphine, heroin, alcohol, and other psychoactive agents. Eventually, it was understood that aspects of both the person (including the larger environment a person dwells in) and the substance contribute to the possibility of addiction. But over recent decades, science has offered a compelling case to include under the addiction umbrella not only substances but behaviors, prime among them excessive gambling. Evidence indicates that gambling behaviors can directly activate brain reward systems in similar ways as drugs of abuse and produce behavioral effects similar to those seen in substance use disorders.

With the publication of the Diagnostic and Statical Manual of Mental Disorders, the American Psychiatric Association formally revised the definition of addiction to include compulsive gambling, creating a new category of behavioral addictions. The criteria for diagnosis parallel those for substance use disorders. Much debate rages about including other behaviors taken to problematic extremes—video gaming, internet use, porn use, to name a few. According to DSM-5, the research on behavioral conditions other than gambling is less clear. What is clear is that technology is reshaping modern life in ways that create the potential for addiction-like disruption by numerous activities.

By itself, repeated use of a psychoactive substance or gambling is not an addiction—unless use is beyond the person’s ability to control, even when wanting to cut down use, and impairing functioning at school, work, or home. Another marker of addiction and criterion for diagnosis is that the person spends a great deal of time involved with the substance/behavior—ob-taining it, using it, or recovering from its effects.

In addition, craving for the substance/activity occurs and can be intense, to the point where the person is not able to think of anything else, especially in places where the substance/activity was obtained or used in the past. What also signifies addiction is the risk attached to the use of the substance/behavior —whether using in hazardous situations or developing physical or psychological problems as a result of use.

Other common signifiers of addiction are the development of tolerance, marked either by a need for increased amounts of the substance to have an effect or diminished effect of the same amount of drug—and withdrawal, the experience of physical and psychological distress for a period after abruptly stopping the drug.

How are all addictions alike? The common denominator of all addictions is compulsion. Behavioral and substance addictions arise from the same brain processes. The brain becomes less capable of controlling itself. All addictions act directly on the reward center of the brain to create the intense burst of pleasure known as a “high,” which involves an outpouring of the neurotransmitter dopamine. Addictions of all types are a shortcut to the sense of reward, which is normally obtained by working hard toward and eventually achieving some type of goal.

In addiction, nerve pathways of attention and motivation change in ways that cause a person to preferentially notice, desire, and seek the psychoactive substance or behavior. Activity in the brain’s decision-making center weakens, so that what started as a choice becomes a compulsion. In addition, those addicted generally lose the capacity to respond to life’s normal rewards.

Are all addictions treated the same?The aim of all addiction treatment is to return a person to health, restore their ability to control their own behavior, and rebuild the life that was interrupted. That typically starts with removing access to the substance or activity, which ushers in a period of acute physical and psychological distress—withdrawal—that can last days or weeks. Withdrawal from most addictions is accompanied by extreme discomfort, but with some substances (especially severe, long-term alcohol addiction) withdrawal can be life-threatening and requires medical supervision.

Once withdrawal subsides, real treatment begins. That's when individuals must address the underlying vulnerabilities that made the substance or activity so appealing. There is no one way to do that. Some people make use of clinical services ranging from individual or group psychotherapy to residential care at a “rehab” facility. Others prefer the support of peers and join self-help groups like Alcoholics Anonymous. Many do it on their own. However it is accomplished, recovery must address a person’s emotional state, the nature and quality of their relationships, their stress reactivity, coping skills, their education, and job skills.

In short, all addiction treatment aims to help people find healthy new ways of handling life’s difficulties and rebuild the life that was derailed by addiction. Overcoming addiction usually entails finding meaningful goals to pursue, to provide the brain with rewards more naturally. Over time—usually months—successful treatment reverses the changes in brain circuitry that make substance use hard to control.