Addiction and behaviour Robert West University College London

Addiction and behaviour Robert West University College London @robertjwest 1

Aim of this talk To develop a new way of thinking about addiction and behaviour that can help develop the science and clinical practice 2

Topics Addiction definitions Processes involved in addiction An ‘ontological’ definition of addiction 3

What purpose is served by having the label ‘addiction’? 4

It provides a label to refer to a commonly occurring class of entity It draws attention to important characteristics of that entity It promotes thinking and talking about the entity It promotes acting on the entity 5

Definitions, diagnostic criteria, and descriptions 6

Definition • A brief description of something that conveys its essential features in a way that enables it to be identified and distinguished from similar things Diagnostic criteria • A set of characteristics that are used to determine whether a condition is present and differentiate it from other conditions Description • A statement or series of statements that characterise something 7

Existing definitions of addiction 8

dictionary. com 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 9

Cambridge Dictionary The need or strong desire to do or to have something, or a very strong liking for something. An inability to stop doing or using something, especially something harmful 10

Psychology Today Addiction is a condition in which a person engages in use of a substance or in a behaviour for which the rewarding effects provide a compelling incentive to repeatedly pursue the behaviour despite detrimental consequences. 11

American Society of Addiction Medicine Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours. 12

Recurring themes A Google Scholar review of 52 articles with ‘addiction’ and ‘definition’ identified five themes: 1. engagement in the behaviour to achieve appetitive effects 2. preoccupation with the behaviour 3. temporary satiation 4. loss of control 5. suffering negative consequences Sussman S & Sussman A. Int J Environ Res Public Health. 2011 Oct; 8(10): 4025– 4038. 13

Related constructs 14

Substance use disorder Alcohol Use Disorder Tobacco use disorder Drug dependence Drug abuse Problem gambling Harmful drug use Excessive drug use 15

Problems with existing definitions 16

As stated, prevailing definitions do not adequately serve their functions because they are ambiguous about what kind of entity they refer to This causes confusion, unnecessary disagreement and fruitless debate 17

Is addiction …? • A process • A disposition • A quality Does addiction inhere in …? • People • Behaviours • Substances • Society 18

Process • Brain mechanisms leading to loss of control • Mental processes leading to feelings of craving Disposition • Tendency to experience craving • Tendency to prioritise a given behaviour Quality • Experience of craving • Experience of loss of control 19

Behaviour • Tobacco use • Injecting drug use People • Prevalence of tobacco addiction • Diagnosis of opiate addiction Substances • Tobacco is addictive • Heroin is addictive Society • Addiction is a social construct • Society is addicted to money 20

In all addiction definitions there is an implicit assumption about quantity How strong the desire? How frequent the behaviour? How prolonged the behaviour? How harmful? How ‘out of control’? 21

What does addiction involve? 22

Processes believed to be involved in Addiction Processes Description Cost-benefit analysis The benefits of the addictive At least some people addicted behaviour are judged by the addict to to alcohol believe that the outweigh the costs benefits in terms of anxiety relief and mental escape are worth the financial, social and health costs Repeated exposure to addictive drugs Smoking crack cocaine leads to sensitisation of brain feelings of craving in situations pathways that generate feelings of similar to those where this has ‘wanting’ in response to drug cues occurred, independent of feelings of ‘liking’ feelings of euphoria produced by the drug Incentive sensitisation Example 23

Processes believed to be involved in Addiction Processes Description Example Reward seeking Addicts learn that addictive Methamphetamine users seek behaviours provide positive feelings the ‘rush’ provided by the drug of enjoyment and euphoria Attachment Addicts become emotionally attached Smokers often report feeling a to drugs or addictive behaviours sense of bereavement during because these have been reliable the early stages of stopping sources of comfort or gratification smoking: like they have lost a cherished friend or family member 24

Processes believed to be involved in Addiction Processes Description Drive reduction Repeated engagement in an addictive Repeated use of nicotine alters behaviour results in development of brain physiology so that an acquired drive, which is abstinence results in an experienced as craving, after a period acquired drive state, of abstinence. experienced as craving Distress avoidance Addicts learn that addictive behaviours relieve mental and physical distress caused by mental health problems, life circumstances, and/or withdrawal symptoms Example Repeated use of heroin results in changes in brain chemistry leading to adverse mood and physical symptoms when concentrations of the drug fall below certain concentrations in the brain 25

Processes believed to be involved in Addiction Processes Description Example Social influence Cultural, sub-cultural, peer group Family and peer group are and/or family norms promote or are important factors influencing permissive of addictive behaviour the development of smoking and alcohol consumption Impaired control Addictive behaviours develop, and are maintained by, pre-existing or acquired inefficiencies in brain systems required for impulse control Use of stimulant drugs leads to impairment in frontal lobe functioning required to inhibit impulses to continually repeat the use leading to bingeing 26

Processes believed to be involved in Addiction Processes Description Example Classical conditioning Repeated pairing of stimuli (cues) associated with effects of addictive behaviours leads those stimuli to generate anticipatory reactions to those effects Lights, images and sounds are used by gaming machine manufacturers to promote high rates of use of those machines Operant conditioning Addictive behaviour are followed by powerful positive or negative reinforcers (rewards or offset of aversive stimuli) in the presence of discriminative stimuli (cues), so that those stimuli come to provoke a strong impulse to engage in the behaviour Use of psycho-stimulants is maintained by the positive reinforcing properties of these drugs 27

Ontologies and addiction 28

Ontologies In information science, they are systems for representing knowledge in the form of: Entity ns h lat io Entity p Re hi ns io 3. Specification of relationships between them (‘is a’, ‘part of’, ‘positively influences’ …) lat 2. Labels and definitions for these Re ip 1. A set of unique identifiers of ‘entities’ Relationship Entity Arp R, Smith B, & Spear AD (2015). Building ontologies with basic formal ontology. Cambridge: MIT Press.

What ontologies can do 1. 2. 3. 4. Improve clarity of thinking and reporting Generate new ideas and testable hypotheses Identify information gaps and promotes lateral thinking Facilitate interoperability across domains of knowledge and knowledge representations 5. Provide a powerful and intuitive basis for automated querying and reasoning

Basic Formal Ontology 31

Entity Continuant Occurrent Arp R, Smith B, & Spear AD (2015). Building ontologies with basic formal ontology. Cambridge: MIT Press. 32

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An ontological definition of addiction Addiction Is a type of Has addiction target Is a property of Is realised as Results in Results from An enduring disorder Activity type Mental functioning of people Abnormal craving Impaired self-regulation Significant actual or risk of harm Learning Addiction to a given activity is an enduring disorder of mental functioning in which, as a result of learning, the sufferer experiences abnormal cravings and impaired self-regulation in relation to that activity resulting in significant actual or risk of harm 35

What benefits does this definition confer? 36

Scientific It makes clear what type of entity addiction is construed as It makes clear how addiction relates to other entities It specifies what entities need to be the focus of ‘threshold’ debate It differentiates addiction from similar entities It captures expert usage of the label It provides a systematic way to link addiction to relevant domains 37

Pragmatic It draws attention to a serious issue that needs to be addressed It directs attention to the full range of potential countermeasures It promotes countermeasures that are in accordance with civilised values It provides a way of avoiding either trivialising or medicalising the construct 38

Reading West, R, Christmas, S, Hastings, J, & Michie, S Developing general models and theories of addiction. In Pickard, H & Ahmed, S (Eds) (2018) The Routledge Handbook of Philosophy and Science of Addiction. London: Routledge p 160 -172. @robertjwest 39