"The Biology of Desire: Why Addiction is Not a Disease" by Marc Lewis

Marc Lewis explores the neurobiology of addiction in this short book, with proposed approaches to better understanding and helping people who are struggling with addictions.  

He comes across very clearly as a compassionate person, with a good understanding and personal experience in this area.  Probably someone who would be good to have as a therapist or support in the context of addictive problems.   

The book presents several case stories, which is always a compelling style in describing health care issues.  They could be a source of inspiration that could help people in their own journeys through addiction.  But of course testimonial accounts have only limited value in a scientific study, since they can introduce very strong biases in the reader, if not accompanied by references to large controlled studies.    

He has good reasons for disparaging what he calls "medicalization" of addiction, and emphasizing his opinion that addiction should not be considered a "disease."    Many of these reasons involve emphasis on what most of us would consider "bad medicine," i.e. institutional or even punitive treatment, simple remedies such as drug treatments given without addressing social or psychological issues, etc.    He particularly disparages psychiatrists, as though he thinks all psychiatrists enjoy the narrow or excessive brandishing of labels and dispensing of medications without attending to deep understanding, therapeutic compassion, and a biopsychosocial focus, with patients.  

So I found this part of his message to be tiresome.  Excessive narrow "medicalization" of almost any issue is not good medicine.  Almost any health condition, such as type II diabetes, heart disease, hypertension, and certainly conditions such as anxiety or depression, have spectrums of severity or chronicity; there are very important psychosocial factors, often present for years before the onset of the condition, that influence symptoms, severity, and progression.   There are feedback loops involving behaviour which cause spiralling exacerbations or rapidly accumulating harms in all of these conditions.  And treatments for diabetes or heart disease need to involve understanding and help with lifestyle, social, and economic factors affecting these conditions, with long-term goals in mind.    But it is not necessary to avoid calling diabetes a "disease."  Rather, the approach should be, in my opinion, to recognize that any disease state occurs on a continuum.  In many cases, there is no clear-cut line between disease or non-disease.   The word "disease" does not necessarily imply permanence, or need for invasive, narrow,  or institutional treatments.  For example, we could agree that viral pharyngitis is a disease, but is not one which normally requires medical intervention.  Just as in addiction, many conditions uncontroversially considered "diseases" or at least pathological states, such as pneumonia, COVID, migraine, sciatica secondary to disc prolapse, psychotic episodes, or brain injury, can often  recover on their own without any treatment at all; but for some sufferers of these conditions, the symptoms become relentlessly chronic or more difficult to deal with.    Just because something has the possibility of improving on its own, or through lifestyle improvements, after days, months, or years, does not mean that it shouldn't be considered a disease.  Furthermore, the improvements in many conditions can sometimes be associated with improved perspective or lifestyle, but sometimes the improvements are just random.  Many patients I've seen have engaged in all the healthy perspective-taking and good lifestyle habits you can imagine, but are still afflicted by the same tormenting symptoms.  Other patients somehow recover from severe problems without changing their lifestyles much at all.  

Hypertension is a disease, with multifactorial causes, which often requires medication but always requires attention to lifestyle factors.   Simple, overly reductionistic medical treatments can sometimes help with certain disease states (such as repairing a broken limb) but in many or most disease states, medical treatments are only one branch of helping.  The other branches require attention to lifestyle factors, community or social supports, and possibly an existential focus, to help people regain an awareness and passion for long-term goals.  But this multi-pronged focus is what I consider to be normal medical care.  

Lewis argues that because the neurobiology of addiction features entirely "normal" activations of normal brain pathways, akin to learning or falling in love, addiction therefore should not be considered a disease.  But many conditions in medicine feature activation of normal physiologic functions as a component of their pathology.  For example, inflammatory states resulting from infection (this is a major pathology in COVID) are activations of the body's defenses to fight off pathogens, but the inflammation itself ends up causing severe tissue destruction.  The processes are all "normal" but the circumstances of the disease state (germ + host) cause the reaction to be disastrous.  A clear understanding of disease states, mechanisms, and medical interventions to interrupt this cycle, are indicated to save lives and prevent widespread tissue destruction.  

Addictive states can lead to similar destruction of bodies, minds, relationships, and careers.  Just because the mechanisms involve activations of normal neural pathways does not mean we should avoid diagnostic language.    Problems associated with pathologizing labels, such as stigma (from others or from self) do not mean we have to avoid such labels entirely, but it may mean that the labels should be used with care and humility, rather than in a pejorative manner.  

There is interesting neuroscience describing addictive processes, but sometimes discussion of this can devolve into making overly strong literal claims (e.g. about neuroplasticity), often based on compelling testimonial accounts, without as much robust statistical evidence to back these up.  This is a pitfall I've seen with other authors touching on this, such as Doidge.  The use of the neuroscientific language then becomes a tool of persuasion, which sounds impressive to most people.  But it is much more important in this area to back up claims, especially those based on case studies or testimonial accounts, with careful reference to large controlled studies.   

Lewis has good ideas and a passion for his subject, but his focus on addiction not being a "disease" is needless--it is to some degree a semantic squabble, which subtracts needlessly from the impact of his book.  

The Elephant in the Brain & The Folly of Fools

 Two more books to recommend:  

The Folly of Fools (2011) by Robert Trivers and The Elephant in the Brain (2018) by Kevin Simler & Robin Hanson are both about the human tendency to engage in deception: not only the deliberate deception of others but the deception of self.  

Trivers approaches this issue from the point of view of genetics (he was the first to characterize the evolutionary biology of reciprocal altruism).  The capacity to deceive can be beneficial to survival, as we see in many species of animals, and in many human examples.   But such deception can only work up to a certain point, an equilibrium point in terms of frequency, otherwise the strategy fails.  If deception was too frequent, the evolved strategies to counter deception would render the deceptive strategy ineffective.  Similarly, cheating can be an evolved strategy, but if cheating occurs too frequently in a population, it would no longer be effective due to widespread awareness and countermeasures in the population.    

Trivers goes on to argue that self-deception is a type of advanced deceptive strategy.  The capacity to effectively deceive others is enhanced if we can deceive ourselves.  If you REALLY believe you can win a fight (despite poor objective evidence), you are more likely to convince your opponent that you can win, and therefore are more likely to actually win, even if you utterly lack fighting skills. 

Unfortunately, self-deception leads to many serious problems in society.  Trivers goes through many examples, showing that horrible accidents, wars, biased research, and religious phenomena, are often driven by self-deceptive factors which end up causing disastrous results.  

His chapter called "religion and self-deception" is particularly recommended.  

While I consider this book important and highly recommended, I did find it often to be quite informal in reasoning, punctuated by forays into humour, but this could be a bit problematic when he is wandering into areas (for example about politics, wars, and religion) that many people could be quite sensitive or easily offended about.  There are bound to be sections in this book which could cause people some offense.  

The Elephant in the Brain is quite a remarkable review of ideas from social psychology and behavioural economics.  There is influence from Kahneman, Trivers (The Folly of Fools is referenced), Haidt, and many other leaders in the research of this area over the past decades.  I think it's astounding that these two authors, who are not specialists in these areas, produced such a comprehensive and compelling summary of this research.  

The thesis of this book is that humans have a powerful motive to signal membership in groups.  The tendency to form ingroups is a powerful human trait, evolved over millions of years.  Group membership allows us to trust and collaborate with our group members, for safety, defence, maintaining a food supply, dealing with illness, finding a mate, and raising children.  But unfortunately, this tendency to form ingroups can become such a powerful motivation, often without our awareness, that it overwhelms reason, fosters needless and often terrible conflict with outgroup members, and can become very destructive or at least inefficient.    And the phenomenon tends to perpetuate itself, since members of ingroups (be it political or religious or cultural) tend to socialize, mate, and have children with fellow ingroup members.  

They refer to Bryan Caplan's argument about education, showing that a great deal of education leads to only an indirect signal of skill or competence.  Most people do not use subject matter they learned in university very often if at all in the work they do afterwards.  Instead, the degree and grades serve mainly as a competitive signal to employers about capacity to achieve work, conform stably to demands, etc.  I have reviewed Caplan's book elsewhere (I do have some disagreements about this).  

The authors show that political and religious membership have powerful ingroup effects.  The tendency to form strong beliefs about elements of religious doctrine can be understood as a badge of group membership; if one can engage in successful self-deception about these doctrinal elements, it is all the more effective as a group membership badge.    The beliefs become shibboleths which can allow some feeling of trust with co-believers, and a sense of distrust or frank dislike of outsiders.  Such belief systems can develop independently of rational moral reasoning.  While all religious systems contain positive insights about morality (e.g. "love your neighbour as yourself", "blessed are the meek", "blessed are the peacemakers," "judge not lest ye be judged", "do unto others as you would have them do unto you," etc.), the moral prominence of these beautiful insights is often lost in a cloud of doctrine that becomes more about maintaining an emblem of group involvement, an "us" vs. "them" mentality.  This mentality is a manifestation of an evolved trait pushing all humans towards group involvement, formation of local communities in which we can feel trust and belonging, but with the unfortunate consequence of having outgroups which we would not trust, and which we would treat with less positivity, warmth, and generosity.  

The same phenomena occur in political beliefs.  While there could be core rational beliefs about positions on a political spectrum, with regard to preferred economic strategy, international affairs, management of public works, etc., a great deal of political involvement involves doctrinaire beliefs that are badges of group membership, and which have nothing to do with any understanding of policy.  Most people don't even know what the policy positions are, exactly, of the candidates they vote for.   Many others support their ingroup's politicians even though the associated policies would be harmful to themselves economically or socially.    We have tragically seen this happen during the pandemic.  Extreme beliefs about vaccines, masks, etc. became emblems of political group membership; many people made decisions about these issues not because of rational evidence (which strongly supported vaccine and mask use, for the protection of everyone's health, including the anti-vaxxers' own health and well-being), but because of the beliefs of fellow ingroup members in political or religious factions.  Masks and vaccines have almost nothing whatsoever to do with religion or politics -- they are simply common-sensical public health measures -- but once these issues became badges of group involvement, the issue spiralled into disaster, to the detriment of everyone.  This is an extreme example of the phenomenon shown in the famous children's study, where kids randomly given shirts of a different colour end up forming hostile ingroups, opposed to each other.  In the case of the pandemic, a great deal of anti-vax belief was simply driven by factors akin to having a different shirt colour, just to show difference from an opposing outgroup.  

In both books, reference is made to psychiatric theory as an example of self-deception.  Psychoanalytic theory is basically a set of ideas akin to religious doctrine, with a strong ingroup community of "believers" who couch discussion of psychiatric issues through the lens of a theoretical system which is mostly fictional.  As with religions, there are core beliefs in psychoanalysis which reflect deep insight and wisdom.   For example, the idea of psychological defenses came from psychoanalysis, and is ironically an insight into the tendency for humans to engage in self-deception, with the implication that we should try to become aware of our defences, and to be able to set them aside.   Similar insights warning about self-deception can be found in religious texts.  But most of psychoanalytic theory is arbitrary, based on bizarre inferences made from case reports, coloured by the already biased opinions of the therapists.   But as with religious practices, much of the therapeutic value in psychoanalysis has nothing to do with the literal belief system, it has to do with the practice itself.   Visiting a trusted minister or priest, who would most likely be kind, gentle, understanding, supportive, and wise, could be a wonderfully healthy practice, as could a meditative practice of daily prayer, or visiting a congregation of loving friends.   These healthy and possibly healing effects would occur regardless of the belief system held by the group.  Similarly, the practice of psychoanalysis (or psychodynamic therapy more generally) requires frequent visits with a wise, compassionate, gentle, kind therapist who probably has some useful feedback about life problems, and there would be a healing effect of simply having a stable therapeutic relationship over a long period of time, irrespective of the fictional theoretical belief system held, such as strict Freudianism.  

While we can empathize and even endorse the benefits of ingroup membership phenomena, I believe it behooves us to strive for improved rationality, to guide our knowledge and decisions so as to benefit ourselves, our neighbours, and the world in the most effective way.  Societies across the world have improved in this way over the centuries, as Steven Pinker has shown us (see Enlightenment Now), but we have a lot of work to do to continue progress in building a just, peaceful, prosperous society.  

In both books, we are wisely cautioned to look to ourselves for our own self-deceptions.  It is another human tendency to see self-deception or folly in others, while not noticing our own.  In my case, I recognize this will be a work in progress.   I surely have beliefs or practices that are products of my ingroup or other biases; I hope that I will be able to keep working on better awareness of these issues over time, in service to my patients and to myself.   

Review: Shrinking Violets: The Secret Life of Shyness, by Joe Moran

 Joe Moran's book is a nice exploration of various historical figures (such as authors, poets, and musicians) who had what he calls "shyness."  Moran alludes to his own shyness as well.  

A thematic goal of the book is to understand shyness as a part of the tapestry and variety of human life, as opposed to a pathology that requires treatment, or that is even treatable at all.  

Moran is a good writer--he's an English professor, and it is always a delight to read a book in this type of genre written by someone with a mastery of the language.  

This book is interesting as a historical or biographical journey, but I found it quite limited as a serious study of shyness from a psychiatric point of view.  First of all, "shyness" is a very limited term to describe the many varieties of anxiety, introversion, personality styles, and autistic traits likely present in some of his case studies.  

Near the end of the book, Moran encourages a position of gentle acceptance of shyness, but this acceptance seems to disparage the potential value of attempting to help people manage or change their social anxiety or avoidance using therapeutic techniques.  One chapter is even called "The War Against Shyness," which is a pretty strong condemnation of the therapeutic culture.    

There are many shy people, who have what might be considered social anxiety or autistic traits, who might find therapy helpful, to improve social skills, to find ways of facing fears more comfortably, or even to reduce anxiety a notch (including with the help of medication).   We should always have modest or limited expectations of therapy; also we need to take care to affirm an accepting rather than a pathologizing stance, particularly when social behaviour and experience always exists on a spectrum.  Yet the best of modern therapy is affirming and accepting; it just helps people to suffer a little bit less, to help people have a little bit more freedom in their lives to do things they might find meaningful, enjoyable, or essential for survival or prosperity.  

Review: Blueprint by Nicholas Christakis

 I am happy to have discovered Christakis and his work, in an area I would call “evolutionary sociology” or “mathematical sociology.”  

Blueprint: The Evolutionary Origins of a Good Society is an excellent companion to books by Steven Pinker, Jonathan Haidt, and Richard Dawkins, and even behavioural economists such as Kahneman, looking at issues concerning the genetic components of individual and group behaviour, and the intersection or interplay between “genetic” and “environmental.”     Christakis shares Pinker’s general optimism about human progress, though through a social and anthropological lens rather than a strictly individual, rationality-based one.  Haidt and Christakis both look at dynamics of group differences, Haidt as a psychologist, Christakis as a sociologist.  And Christakis looks at gene-environment interaction on a group level, a continuation or elaboration of Dawkins idea of an “extended phenotype.”  

Near the beginning of the book, there are very interesting case studies presented about small groups that isolated themselves from the rest of society, either through choice (e.g. the Shakers), or through disaster (shipwrecks), then having to develop some means of survival, stability, or happiness.  Some organizational styles were successful, especially when there was some form of effective but not overly rigid leadership, combined with respect for individual differences, and a culture encouraging playful interactions.   Some styles led to failure (a very low survival rate), such as if warring factions developed, “Lord of the Flies” style, or if the community was either too anarchistic, too insular, or too tyrannical.  

Christakis introduces network analysis of groups, which I would like to learn more about.  I consider this to be in the mathematical discipline of “graph theory,” another nice example of pure mathematical concepts and modern data science allowing us a deeply insightful view of aspects of human nature.     I consider this type of analysis especially important in this age of online connectivity, which has the potential to amplify or distort connectivity phenomena, leading to powerful forces of social change, leadership, and spread of ideas or culture.  

After finishing this, I am motivated to finally start Christakis’ next book, Apollo’s Arrow, which is about  the COVID pandemic, again studying it through the lens of sociology and group dynamics.  

A general takeaway point from this book, from my perspective as a psychiatrist, would be to even more strongly value an understanding of social and group dynamics in a person’s life, to understand the nature of connections, connections of connections, group memberships, friendships, communication, and community, in much greater detail, as a component of understanding psychiatric phenomena and strategizing about therapeutic help, rather than stopping at the level of individual psychology only.  

The Urge: Our History of Addiction, by Carl Erik Fisher

The Urge: Our History of Addiction, by Carl Erik Fisher is a good book about the history of addiction, weaved together with a story of the author's own alcohol use problems and rehab.  

The original use of the word "addiction," as Fisher shows us, was more general or broad, referring to situations we might now consider "behavioural addictions," habit problems, or just very strong preferences.    This usage of the word, despite objections from some addictions specialists, may be most accurate from a neurobiological point of view, according to recent evidence.  

He emphasizes many times how addictive phenomena lie on a continuum of severity in different people and within the same person at different points in time, and are influenced strongly by social, economic, and political circumstances.   For some people addiction is a symptom of, or a means of coping with, horrible environmental circumstances.  For others, it is a trap leading to loss of control even when environmental circumstances have improved or are normal.  

Understanding and helping addiction problems has had an interesting history, with some compassionate medical and community help approaches evolving since the 1800s, but often interrupted or negatively influenced by social factors such as stigma or criminalization.  

I agree with his conclusions, that addiction treatments need to be individualized, and that there can be various different causes or problems which underlie addiction for different people.  AA or other 12-step groups can be valuable for many people, but this is not the only effective approach.  Other group styles, such as the "SMART" program, can be preferred.  Abstinence-based models of treatment may be preferred or necessary for some people, but for others it is effective to aim only for moderation without abstinence.  Some people do not want or need peer or group support, and prefer one-on-one counseling.  Others may prefer to manage their addictive problems alone; Fisher cites data showing that many people with addictions can recover without any therapeutic treatment at all.   There are medications that can help, such as naltrexone.  

Fisher acknowledges the importance of loss of control in addiction, and of the phenomenon of denial which delays or prevents many people from seeking help.  

There have been big problems in addiction management that must change.  First, there needs to be much more availability of addiction treatment programs for those who desire or need them.  There should not be economic biases causing some groups to have less access than others.  For opiate addiction in particular, there needs to be easier availability of methadone or buprenorphine maintenance for those who would like to try this approach.  Harm reduction strategies in general have a very strong evidence base.  

Second, public health interventions can be simple and effective, such as restricting the advertising or marketing of addictive products (such measures have been useful for reducing tobacco use in the population).  There is still a big corporate influence on policy (from the alcohol or gambling industries, for example), which should not be allowed to continue.   Third, there should be less focus on prohibition and criminal punishments, which in general have often made addiction problems worse, particularly by focusing expensive social resources on law enforcement rather than on community improvement and rehabilitation.