Craving (11 page)

In fact, there is significant overlap between process addictions and chemical addictions. About 6 percent of people with alcohol use disorders also meet criteria for OCD, and over 11 percent of opiate addicts meet criteria for OCD; that’s much higher than the general population. Impulse control disorders are also more common among people with addiction, and over a third of patients with OCD also have another impulse control disorder.
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From a brain science perspective, although clearly understudied, some similarities emerge between impulse control disorders and substance use disorders. For example, attempting to resist the urges in OCD, the impulses in impulse control disorders, and the cravings in chemical addictions all result in activation of the orbital prefrontal cortex. Furthermore, activation of symptoms in OCD and impulse control disorders, and activation of cravings in chemical addictions all result in increased activity in the striatum—a deep brain structure that also contains the nucleus accumbens, important in addictions. And we learned that these brain regions were involved by studying patients with the imaging technique functional MRI, which can, in real time, tell us what parts of the brain are more active. There are also some brain chemistry similarities that, while not definitive, do suggest some shared processes in these disorders.
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Critics of this view note that many of these findings also occur in conditions that are clearly not addictive. These critics, therefore, are reluctant to consider these compulsive and impulsive disorders as fundamentally addictive disorders. Nevertheless, while these disorders don’t have identical neurobiological processes (nor would we expect them to), they do have some clear similarities, both biologically and, especially, clinically.

As an example, let’s look at kleptomania. For years, I have seen a link between compulsive shoplifting, bulimia, and (eventual) benzodiazepine addiction. (Benzodiazepines are antianxiety medications such as Valium, Ativan, and Xanax.) I’ve treated many women with all three conditions. There isn’t very much literature on this triad. I’ve even spoken with store owners who note that over-the-counter diet pills are a commonly stolen item. When I interview these women, they often tell me that they don’t understand why they steal or why they like benzodiazepines, except to say that these behaviors provide “relief.” Further investigation sometimes reveals a chain of reactions—the women feel a profound sense of shame that is anesthetized by the sense of control they gain by stealing, which in turn causes guilt that they suppress by bingeing, which leads to shame that they primitively “undo” by vomiting, resulting in distress that they alleviate by benzodiazepine use. You can imagine any permutation of the above. The end result is a complex knot that often defies unraveling.

Research has confirmed some of these connections. For example, immediate family members of kleptomaniacs are more likely to have alcohol use disorders and psychiatric disorders.
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Jon Grant, from the University of Minnesota, has noted that imaging data supports a link between kleptomania and addiction.
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He has also pointed out some similarities between chemical addictions and kleptomania in the brain’s dopamine and serotonin systems, and has published data that supports using naltrexone—an effective medication in the treatment of alcoholism—to help those with kleptomania.
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Gambling addicts also share some characteristics with people who are chemically dependent, including some clinical features and related brain changes. For example, people addicted to gambling show low levels of metabolites of serotonin in their spinal fluid (just as other addicts do). We’ve previously reviewed the importance of dopamine in the brain’s reward pathway and its relationship to chemical addictions. When problem gamblers are given amphetamine, which affects reward-system dopamine, their motivation to gamble increases. For example, the ventromedial prefrontal cortex is involved when drug addicts make decisions about risk and reward. Imaging studies show a reduction in activity in this same region when gambling addicts are presented with gambling cues. In fact, the brain changes that occur with gambling addiction are so similar to what happens during chemical addictions that researchers have proposed that its classification should be changed from an impulse control disorder to an addictive disorder, and I strongly agree.
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Close (first-degree) relatives of people with drug addiction also have an increased risk of developing gambling problems compared to the general population.
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In terms of behavior, gambling addiction seems in many ways to be virtually indistinguishable from chemical addictions. Craving, tolerance, withdrawal, unsuccessful efforts to control the behavior, frequent promises to quit, significant deterioration in the major areas of life function—these and many more characteristics typically seen in chemical addictions are also hallmark features of gambling addiction. When it comes to treatment and recovery, Twelve Step approaches are effective for gambling addicts (just as they are for chemical dependency), and some of the medications used to treat chemical addictions also show some benefit in gambling addicts, most notably the opiate-blocking drug naltrexone.

Similar brain findings have been noted for people who struggle with binge eating. Binge eating involves eating a large amount of food, often to the point of feeling uncomfortably full, and while experiencing a loss of control. Many of the binge-eating patients I have treated describe a trancelike high during the episode and a release from care and worry or a reduction in stress while they are bingeing. Dr. Gene-Jack Wang from the University of Florida found that when obese bingers are compared to obese non-bingers, the binge eaters release more dopamine in the brain’s reward pathway. People with obesity also have higher rates of attention deficit disorder (ADD) and Alzheimer’s disease, suggesting the possibility of some overlapping brain mechanisms.

Obesity has been linked with smaller cortical brain volumes. Of course, obesity can cause other medical conditions that might be confounding variables, but even in physically and otherwise medically healthy obese people, higher body mass index (BMI) has been associated with lower cognitive functioning.
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Wang recently released a study in which he and colleagues found reduced prefrontal cortex activity in study participants who had a higher BMI; he was able to correlate those findings with reduced executive functioning and memory.
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As a reminder, the prefrontal cortex is the part of the brain that was severely damaged in the railroad worker Phineas Gage, resulting in his difficulty with planning and judgment. (See our discussion of Phineas and the prefrontal cortex in
chapter 2
.) The takeaway here is that obese binge eaters may experience many of the same neurobiological issues as people with chemical addictions, further suggesting that these compulsive overeaters may have a form of addiction.

Finally, it’s important to note that cultural factors can influence the expression of all addictions, especially food addictions. For example, some evidence suggests that rice cravings are more common in Asian females.
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When it comes to overeating and food cravings, it appears that the environment you were raised in, the food you grew up on, and the foods you saw others eating around you may play a role in your specific cravings.

Another behavior with addictive features is compulsive or addictive exercise. Many of the people I’ve treated who struggle with this also had bulimia or another eating disorder, or they struggled with a profoundly distorted self-image. In the professional athletes I’ve treated, it can be very difficult to differentiate between healthy behaviors and addictive behaviors, especially when the career itself may have been selected for very unhealthy reasons. (For example, someone with an eating disorder may choose to pursue running to lose weight and act out on the eating disorder.) The people I’ve helped with this problem often describe experiencing a sense of tolerance; that is, they need to increase the intensity or time spent exercising to achieve the same effect they previously attained with less exercise. They describe irritability when they miss an exercise session and often will tell me (especially once they are “detoxed”) that they were exercising specifically to alter their mood or to escape reality. They describe exercise as the most important thing in their lives, and they have usually experienced conflicts with their loved ones over how much and how often they are exercising.
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Research also shows that compulsive exercisers tend to be independent high achievers with the strong “internal locus of control” that we discussed earlier—they have a strong sense that they can control their life experiences. They are frequently dissatisfied with their lives and their body image, they tend to isolate, and they do not enjoy their free time
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The thought of stopping exercise, even for a brief period, is terrifying to them. One researcher of these exercisers enrolled 200 people into a study, but when they were told that the study required them to stop exercising for three days, 178 of participants withdrew, leaving only 22 to complete the study.
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Sometimes when I describe this condition to audiences, members will say, “I
wish
I were addicted to exercise!” This reaction is an example of a cognitive bias (which we learned about in
chapter 3
) called focusing effect. This bias causes people to focus excessively on one aspect of a situation, ignoring others, resulting in decisions that don’t achieve their own goals. I’ll usually counter by asking something like, “So you’d like to compromise your job, your marriage, lose time with your kids, and develop a sense of life that is so distorted that exercise becomes more important than everyone and everything you love?” Often the person’s response will be “Umm…no…. I’d just like to exercise more and not hate it so much.”

This also brings up the problem with our pop-culture approach of calling everything addiction: the United States is “addicted” to oil, that woman is “addicted” to lip gloss, my cousin is “addicted” to a certain HBO series. The problem with using “addiction” in this way is that it softens the severity of the term and thereby moderates true addictions in our mind; this also reinforces the types of bias and distortion that allow someone to say, “I wish I were addicted to exercise.”

Much like with other addictions and other drivers of the reward pathway, the brain science of exercise implicates dopamine, with mouse and rat studies showing increased dopamine levels in the nucleus accumbens with exercise (think rodents running on a treadmill).
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Many people with exercise dependence also suffer from eating disorders, and some evidence points to shared neurobiology and hormonal effects between these conditions.
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No discussion of craving would be complete without exploring passionate craving. Of course, poets and writers have frequently compared love to addiction. Although “love addiction” or “passion addiction” are not currently scientifically accepted disorders (nor are they very clearly defined), there is little doubt that these conditions do share features with chemical addiction. People with love addiction are addicted to relationships or the feeling of love. They may experience extreme neediness in relationships; they fall in love extremely quickly, are unable to end unhealthy relationships, and spend nearly all of their time fantasizing about their partner, the “love object,” or about the relationship. This type of addiction can also produce physical symptoms, as with chemical addiction.
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For example, euphoria and intoxication-like effects are often experienced when the person is in the presence of the love object, and sleep disturbance, agitation, and withdrawal-like features occur in the absence of the love object. Increasing intensity is often needed to experience relief (tolerance), and the object is pursued at significant, usually self-destructive personal cost. Some of the neurobiological changes that occur in addiction (which we reviewed in
chapter 2
) also occur in passion, sex, and love, including activation of the dopamine-based mesolimbic reward system.
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People can even experience an addictive “high” from grieving, which can make it hard to stop grieving. Perhaps you may know someone who seems chronically attached to their grieving and simply cannot stop. As miserable as it is, they continue to grieve. As with the later stages of drug addiction, the act of grieving is not pleasurable, but rather offers some sense of relief. Indeed, intense, enduring grief can stimulate this dopamine pathway, and some experts propose that the rewarding aspect of such grief actually interferes with the successful navigation of the grieving process.
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So the body of evidence demonstrating similarities between various addictive disorders is strong and growing. This explains the popularity of Twelve Step approaches for managing behaviors that are not yet medically defined as addictions (Gamblers Anonymous, Sex and Love Addicts Anonymous, Overeaters Anonymous, and many more). Furthermore, the core similarities between various chemical addictions are a key principle of the Narcotics Anonymous (NA) program. The pamphlet
Welcome to Narcotics Anonymous
states:

It is not important which drugs you used; you’re welcome here if you want to stop using. Most addicts experience very similar feelings, and it is in focusing on our similarities, rather than our differences, that we are helpful to one another.
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