In which Sci is rightfully reprimanded

I posted last night (you can tell this is serious, I really am blogging on the weekend!) about the concept of “Prozac withdrawal”. I drew a little heat from Drugmonkey about this, due to the distinction I used between “physical” and “psychological” addiction. I’ll repost what he said here:

Physical addiction should be distinguished from psychological addiction…. almost all addictive drugs are a mixture of physically and psychologically addictive.
Awww, sciC why’dya have to go and add this to such a fantastic* post? This notion is complete and utter bollocks and even worse is demonstrably harmful to the goal of getting those suffering from addiction disorders the medical treatment they need.
The trouble is that you delving into dualistic nonsense as if the “psyche” was not entirely a result of the structure and function of the body, mostly the brain. What you term “craving” is just as assuredly a “physical” effect of drug abstinence after chronic exposure as is constipation. Second, the connotation is ALWAYS that so-called “psychological” dependence issues are less important and less real. Which dredges up the notion that people should just get over it, cure themselves with will power or morals, etc. Acutely harmful, that. Thirdly, this mental set keeps us from understanding that the real problem at hand in drug abuse is indeed (long term) craving. The acute stages of withdrawal? We can deal with that relatively easily and cheaply. Life long proclivity to relapse to drug taking? Not so much.

Drugmonkey is absolutely right, and Sci considers herself justifiably spanked. So I’m feeling sheepish, and I think I need to try and rectify this situation, and get myself all better in the eyes of Drugmonkey, so I don’t have to cower in his presence the next time I see him, and then he won’t buy me drinks, and then I’ll cry. And more importantly, I want to be a better scientist than I was last night. So here it goes.

Drugmonkey is right, the idea of “physical” vs. “psychological” addiction is an outmoded concept, and is very liable to make people think the wrong things. First, if you differentiate between physical and psychological addiction, you get people thinking that one or the other is “better” or “worse”. People will think, for example, that psychological addiction is about failures in willpower, which simply is not the case, and that physical addiction is therefore more deserving of treatment. And secondly, it’s an outmoded concept in that the “psyche” IS a part of your physiology. To someone like me with the training I have received, we look at “psychological” and think brain chemistry, and I guess this is part of where I have gone wrong, but excuses aside.
“Psychological addiction” was considered merely the presence of craving and the absence of definable withdrawal features, other than generally feeling like crap. Now that we know more about the brain, we know that “psychological addiction”, such as addiction to cocaine or amphetamines (withdrawal from amphetamines won’t kill you, btw, but overdosing on them certainly will), is due to changes in the chemical levels and neuronal physiology of the brain. These are not “psychological” changes, they are physical changes. Your neurons are changes, the levels of chemicals coming from them and where they are going are changed. So “psychological addiction”, even in the absence of physical symptoms, is still the result of physical changes to your brain. Psychological addiction IS physical addiction, even if it doesn’t mean you’re throwing up everywhere or having seizures. Nowadays, most people do not even distinguish between physical and psychological addiction, and just call it addiction (probably to stop themselves from running in to the problem wall I just hit). And craving as a result of being off an addictive drug is just as much a problem in need of treatment as any seizures you may be having. It may even be MORE important. The physical withdrawal symptoms (by which I mean cold sweats and seizures and throwing up and constipation) will pass, but the craving sensation remains, and can return after years and years of being clean, coming back at the mere memory of a place where someone once did their drugs. And this craving feeling is just as physical in origin as any constipation.
Based on those criteria, you could say that Prozac is, in a sense, addictive. It changes your brain physically, and results in a withdrawal syndrome that is characteristic. BUT. So do a lot of things. Like oral contraceptives, which change your body, and your body can require some time to get over the different levels of hormones when you go off them (as pointed out by leigh, thanks for the great example! We need to get together during ScienceOnline!!) Just because things change your brain or body does not necessarily mean that those things are bad and addictie, but it does mean that your body gets used to the chemicals being there, and will react to their absence. So Prozac has a withdrawal syndrome, but that does not mean that Prozac is addictive in the traditional colloquial sense. And neither are oral contraceptives. But until we can dissociate the word “withdrawal” from the word “addiction”, the things you suffer when going off Prozac are “SSRI discontinuation syndrome”. But I don’t think we should be ashamed to call it withdrawal.

11 Responses

  1. I was wondering when DM would show up on that one…

  2. There is, however, a huge difference — psychologically, if you will — between a dependency on a drug where the subject knows the relationship between the withdrawal symptoms and one where the subject doesn’t. And, yes, “knowledge” is also a physical reaction, but life gets tedious when we insist on discussing everything in terms of the underlying quantum mechanics rather than at higher levels of abstraction.
    It took me freaking forever to figure out that those miserable days-long headaches were the result of caffeine withdrawal. The coffee didn’t do anything for me except taste good, you see, but if I went without I was wide-awake but the day after I did without coffee I had a killer headache.
    Likewise with the SSRIs — the “withdrawal” symptoms just aren’t associated closely enough with the drug that people are likely to tie the two together, and the drug itself doesn’t provide sufficiently immediate benefits that they tie them to the drug, so the behavioral connection that causes addicts to seek out their next “fix” never gets established.
    That’s absolutely the opposite from the situation with the fast-acting dopaminergic drugs, to name the most obvious example.

  3. Sci is surrounded with monkeys and still blogs with eloquence. This is a great follow-up and expansion on the original post. If a bit of Drugmonkey chastisement spurred this quality of response on other blogs, sb would rock even more than it already does.
    Asking more questions rather than getting comfy in outdated notions is somewhere near the heart of science, isn’t it? As there is a never ending supply of unanswered questions,every scientist’s vocational addiction can be handled without fear of missing a fix.

  4. I think the spanking over physical vs psychological addiction as you used it is a bit over the top but I agree with the underlying idea without the absolutist framing. Raising awareness is useful, and on that score I get it.

    Thirdly, this mental set keeps us from understanding that the real problem at hand in drug abuse is indeed (long term) craving. The acute stages of withdrawal? We can deal with that relatively easily and cheaply. Life long proclivity to relapse to drug taking? Not so much.

    So, the argument that making the distinction (asserted as bullocks) as demonstrably harmful to getting needed “medical” treatment seems excessive since I know of no purely pharmacological treatment for such people over the long term. What barrier to getting “medical help” does making the distinction between 2 different classes of effects, one on the reward centers vs. one that just trashes your body for a time? Until we can understand precisely how the brain works in this regard, we will still need people to use their thinking/will etc, to compensate as best they are able (with help). The pragmatic distinction is important for treatment, no matter how you frame the ultimate origin which we all would agree is physical in the technical sense, but we haven’t reached a purely physical (i.e. “drugs/surgery”) treatment (yet). We certainly wouldn’t want to tell them it’s hopeless until we find a pill to fix them without side effects that are nearly as bad on some level.
    Try this semantic game: The effect of talk therapy (i.e. “just get over it” as an unfair simplification) could be construed as a “physical treatment” much like occupational therapy is to stroke patients. I think it’s arguable CBT can be a useful tool against depression (for example) as well as some drugs.
    Therefore, the idea that employing something other than drugs to the problem is hardly invalidated and the distinction of the two classes of symptoms is reasonable. I may be responding to something you aren’t saying, namely the idea of the necessary “medical” help being “only” drugs.

  5. Drugmonkey is right, the idea of “physical” vs. “psychological” addiction is an outmoded concept, and is very liable to make people think the wrong things. First, if you differentiate between physical and psychological addiction, you get people thinking that one or the other is “better” or “worse”
    This is a problematic road to go down. Soon we’re back to the pop cultists with there ‘video game addiction’, or ‘tv addiction’ or ‘internet addiction’, or ‘sex addiction’. What prevents extending this to ‘French pastry addiction’, or ‘sunny day off addiction’.
    When you run with the politically convenient idea that confuses real physical addiction (caused by actual harm when the substance is removed) and that which simply finds the user undergoing unpleasant, but perfectly normal reactions, you really are getting out into la la land.
    Sadly the ‘reason’ for eliminating this distinction seems to be more a matter of political correctness or social engineering, trying to define words to control popular attitude. (and science should NEVER be determined by how the results might affect things like medical insurance)
    You were closer the first time.

  6. jay, not so. not so at all. Start with the proposition that not all use of recreational or clinical drugs with the potential to cause addiction (i.e., in some individuals) does produce dependence in all individuals. This is in fact the case and one of my favorite papers to reference for this is briefly described here. An amazing fraction of 10+ cig per day over at least 10yr population apparently do not meet diagnostic criteria for nicotine dependence.
    By analogy, to postulate gambling, TV or internet addictions does not say anything about the frequency of diagnosable dependencies or addictions that are morphologically similar to substance dependencies. Not identical, similar.
    Furthermore, drug abuse science has provided quite good evidence for final-common-pathway type mechanisms involved in dependence of many classes of recreational drugs. Drugs which have very distinct mechanisms of primary pharmacological action. These final-common-pathways also tend to respond in a similar way to what we term the naturalistic reinforcers- food, access to receptive sexual partner, etc in animal models. The overall theory being that there are defined common mechanisms that mediate responses to rewarding or reinforcing stimuli. Gambling, TV, novels, etc certainly qualify as just such stimuli in humans. Given this, it is quite possible to understand how such non-drug reinforcers in humans may gain control over behavior to the extent that a behavioral diagnosis of a dependency can be made, see SciC’s other post for the outline of clinical diagnosis of dependence. It is a behavioral or symptom based diagnosis.
    This logical possibility, nay probability, that naturalistic and non-drug reinforcers can induce dependencies or addictive patterns of behavior is just a starting place. From there we turn to both clinical and nonclinical research to further determine if such patterns of behavior do indeed exist. There I’ve exhausted my knowledge of the literature but it would only take a bit of work on Pubmed to determine the approximate scope and current status of evidence.
    Until one has delved into this literature, one’s gut-feeling that gambling addiction is ridiculous is just an anti-science reflex based on introspection.

  7. Thanks for taking the time to comment. I hope I am understanding your comment as you meant it.
    I still see a serious problem with equating pleasure response (even pleasure response that has gotten out of control) with behaviors caused by chemicals introduced into the body that directly modify brain chemistry. Some aspects may be similar, and indeed there may be some area of overlap, but in many ways they are very different animals (a cold and the flu have many similar mechanisms, but they’re not the same disease), including likely method of treatment (psycho therapy vs medical approaches that may involve the need for blockers, and for intensive medical supervision during withdrawal because of potential damage). Behaviors that are specifically caused by a pleasure response issue can often (at least in early stages) be helped by counselors and therapists. This is rarely true of a physical addiction.
    One is not less real than the other (a perception you seem to be worried about). To insist on mixing the two does a disservice to people dealing with actual chemical caused addiction as well as people whose problem is an out of control pleasure response (trivializing the former, lowering expectation and motivation for success the latter). One of the results of this ignoring the gorilla in the room, is that there is a mass market of people willing to be told by some hot new author that their behavioral problems are an addiction and ‘not their fault’. (I know this is not what you are saying, but there is a problem when you try to expand a word that had a very specific connotation).
    I am concerned two by the political implications of this ‘blending’. As a firm believer in personal liberty, I am concerned that politicians will take this as license to equate activities considered too seductive (gambling, erotic or other ‘dangerous literature’, even calls for vid game control for youngsters) needing (justifying in their view) government restriction, much as they’ve restricted recreational drugs. While philosophers suspect ‘free will’ is at some level an illusion, it’s an illusion that is part of our evolution and actually enables us to function.
    [next on Oprah: people who are addicted to watching Oprah] ;}

  8. Thanks so much for responding, Drugmonkey! I was hoping you would. 🙂
    Jay: I understand your issues with equating “pleasure” with behaviors caused by chemicals introduced into the body. The problem is that these chemicals highjack what is normally a natural pleasure response (to be really simple about it I’m just going to use the dopamine system, though that’s certainly not the whole story), increasing neurotransmitter levels beyond what you would normally ever get with a natural reward. So when it comes right down to it, drugs and food are causing the same physiological response, and the same chemical changes. Methods for treatment are often extremely similar. The issue with things like, say, food addiction or binge eating is that people with these problems still NEED to eat, so it’s a matter of controlling intake rather than quitting cold turkey. I don’t really understand how this means that one or the other addiction could be trivialized.
    It’s true that you often need medication and medical treatment to care for the physical effects of things like opioid withdrawal. However, there are still strong cravings associated with these drugs, and therapy is still often necessary. People will go back to the drug due to craving even if the “physical” withdrawal issues are resolved. This is the other reason that the physical vs psychological model doesn’t work: most addictive drugs are strong mix of both, and when you add in the fact that changes to “psychology” are changes to brain chemistry and physiology, the distinction just can’t hold.

  9. People will go back to the drug due to craving even if the “physical” withdrawal issues are resolved. This is the other reason that the physical vs psychological model doesn’t work: most addictive drugs are strong mix of both, and when you add in the fact that changes to “psychology” are changes to brain chemistry and physiology, the distinction just can’t hold.

    Are we having a disconnect over whether “psychology” necessarily implies some sort of mind/body dualism?
    The last time I looked into the subject [1] the behavioral science of psychology requires no such assumption, any more than the science of chemistry requires the assumption that “chemicals” have properties not describable by quantum mechanics [2]. Both are, as far as I’ve been able to determine, simpy higher-level abstractions for the rather messy details of the more precise models.
    [1] OK, it was a couple of years ago when one of my children was studying towards her undergraduate degree in psychology. I’m biased, but what is the underlying neurophysiology of that bias? Should we refrain from using terms like “bias” since they also imply some sort of “mind?”
    [2] Or, in my own field, the assumption that there is such a thing as “software” independent of the transistors (etc.) that actually change state in a computer.

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