In her new book Maia Szalavitz recalls her behavior as a child in school and at home. Anxious, bright and slightly obsessive, she didn't seem to fit the stereotype of the “addictive personality”. Nevertheless, in college she would become addicted to heroin and cocaine, forcing her to reexamine her assumptions about addiction and its treatment. The following is an excerpt from Unbroken Brain: A Revolutionary New Way of Understanding Addiction, by Maia Szalavitz. Copyright © 2016 by Maia Szalavitz. Reprinted with permission of St. Martin's Press, LLC. All rights reserved.
A weird little girl on the swings engaging in compulsive behavior to soothe herself is probably not what you picture when you think of an addicted person or her background. Our cultural images of addiction tend to be much less likely to engender sympathy. For one, they are racialized—so even though black and Hispanic people are not more likely than whites to become addicted, those with dark skin tend to be pictured in American media stories about addiction. And when whites are shown, we are typically described as not being “typical.” Second, in part as a result of the racism that has driven our drug policies, these images tend to depict people with addictions as “fiends” or “demons” whose debauchery is driven by a ravenous hedonism, not a human and understandable search for safety and comfort. The “addictive personality” is seen as a bad one: weak, unreliable, selfish, and out of control. The temperament from which it springs is seen as defective, unable to resist temptation. Even when we joke about having an addictive personality it’s usually to justify an indulgence or to signal our guilt about pleasure, even if only ironically. To understand the role of learning in addiction and in the temperaments that predispose people to it, we have to examine the relationship between addiction and personality more closely.
Although addiction was originally framed by both Alcoholics Anonymous and psychiatry as a form of antisocial personality or “character” disorder, research did not confirm this idea. Despite decades of attempts, no single addictive personality common to everyone with addictions has ever been found. If you have come to believe that you yourself or an addicted loved one, by nature of having addiction, has a defective or selfish personality, you have been misled. As George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism, told me, “What we’re finding is that the addictive personality, if you will, is multifaceted,” says Koob. “It doesn’t really exist as an entity of its own.”
Fundamentally, the idea of a general addictive personality is a myth. Research finds no universal character traits that are common to all addicted people. Only half have more than one addiction (not including cigarettes)—and many can control their engagement with some addictive substances or activities, but not others. Some are shy; some are bold. Some are fundamentally kind and caring; some are cruel. Some tend toward honesty; others not so much. The whole range of human character can be found among people with addictions, despite the cruel stereotypes that are typically presented. Only 18% of addicts, for example, have a personality disorder characterized by lying, stealing, lack of conscience, and manipulative antisocial behavior. This is more than four times the rate seen in typical people, but it still means that 82% of us don’t fit that particular caricature of addiction.
Although people with addictions or potential addicts cannot be identified by a specific collection of personality traits, however, it is often possible to tell quite early on which children are at high risk. Children who ultimately develop addictions tend to be outliers in a number of measurable ways. Yes, some stand out because they are antisocial and callous—but others stand out because they are overly moralistic and sensitive. While those who are the most impulsive and eager to try new things are at highest risk, the odds of addiction are also elevated in those who are compulsive and fear novelty. It is extremes of personality and temperament—some of which are associated with talents, not deficits—that elevates risk. Giftedness and high IQ, for instance, are linked with higher rates of illegal drug use than having average intelligence.
Whether these extreme traits lead to addictions, other compulsive behaviors, developmental differences, mental illnesses, or some mixture depends not just on genetics but also on the environment, people’s own reactions to it, and those of others to them. Addictions and other neurodevelopmental disorders rely not just on our actual experience but on how we interpret it and how our parents and friends respond to and label the way we behave. They develop in brains designed to change with experience—and that leaves us vulnerable to learning things that create damaging patterns, not just useful habits.
The impact of all these factors together can be seen most clearly in studies that follow participants from infancy into adulthood (which are rare because they take so long to conduct and are thus very expensive). In these types of data, some strong patterns emerge. One of the earliest and best known longitudinal studies related to drug use followed 101 children—mainly middle class, two-thirds white—raised in Berkeley in the 1970s.
Conducted by psychologists Jonathan Shedler and Jack Block, then at the University of California, the research was published in 1990 and its main finding generated much controversy. The authors discovered that the most mentally and psychologically healthy teens were not those who abstained entirely from alcohol and other drugs, but rather the kids who experimented with weed and drinking, but didn’t overdo it. In this study, occasional teen drinking and marijuana use was normal adolescent behavior. However, while it was common, it was typically not problematic.
Unsurprisingly the teens who became frequent users and drinkers had the problems you might expect, like depression, anxiety, and delinquent behavior. Then again, many of the same psychiatric problems were also seen in the adolescents who rejected the idea of drinking and drugs entirely. That’s probably because, in order to avoid any experimentation as a kid growing up around the Berkeley campus in the ’70s (when nearly two thirds of high school seniors nationally reported at least trying marijuana), you’d have to be either a loner with few friends or a person who was unusually fearful and/or resistant to peer pressure. Not using drugs may well have been a wise choice for these youth— but good decisions aren’t always made for healthy reasons.
And indeed, that’s exactly what the study found. The youth who abstained did not tend to do so because they rationally recognized the risks. Instead, they were overly anxious, uptight, and lacking in social skills; some may not have had to say no because they didn’t even get the chance to say yes. Similar data have been published on teen drinking as well. Moderate drinkers—not nondrinkers—are the most well adjusted, at least in countries where drinking is a social norm. The healthiest patterns are found in the middle of the curve, not at the extremes.
To understand how having these outlying traits increases risk for addiction, we have to look at how they affect development. Critically, in Shedler and Block’s data, the traits that marked both abstainers and heavy users could be seen long before drug use began. After all, the authors had started following these children in preschool. Once they knew how the participants behaved in adolescence, they could look back and see what early traits were linked to particular problems.
Longitudinal studies looking at addiction risk have found three major pathways to it that involve temperamental traits, all of which can be seen in nascent form in young children. The first, which is more common in males, involves impulsivity, boldness, and a desire for new experience; it can lead to addiction because it makes it hard for people to control their own behavior. The second, which tends to be seen more in women, involves being sad, inhibited, and/or anxious. While these negative emotions can also deter experimentation, when they do not do so, people may find themselves on a “self-medicating” path to addiction, where drugs are used to cope with painful feelings.
Being bold and adventurous and being sad and cautious seem like opposite personality types. However, these two paths to addiction are actually not mutually exclusive. The third way involves having both kinds of traits, where people alternatively fear and desire novelty and behavior swings from being impulsive and rash to being compulsive, fear driven, and stuck in rigid patterns. This is where some of the contradictions that have long confounded the study of addiction come into play—namely, some aspects seem precisely planned out, while others are obviously related to lack of restraint. My own story spirals around this paradoxical situation: I was driven enough to excel academically and fundamentally scared of change and of other people—yet I was also reckless enough to sell cocaine and shoot heroin.
If we look more closely, however, the paradoxes disappear. All three pathways really involve the same fundamental problem: a difficulty with self-regulation. This may appear predominantly as an inability to inhibit strong impulses, it may be largely an impairment in modulating negative emotions like anxiety, or it may have elements of both. In any case, difficulties with self-regulation lay the groundwork for learning addiction and for creating a condition that is hard to understand. The brain regions that allow self-regulation need experience and practice in order to develop. If that experience is aberrant or if those brain regions are wired unusually, they may not learn to work properly.
The importance of self-regulation is evident in the Shedler and Block data. From the very start, the children in the study who grew up to be heavy drug users were, as they put it, “visibly deviant from their peers, emotionally labile, inattentive and unable to concentrate, not involved in what they do,” and “stubborn.” This is a picture of emotional dysregulation—and it could have described me as a child, except for “not involved in what they do.”
But while such children can be summed up as having “low self-control” or “impulse control problems”—and in the study, these kids tended to have lower grades—this doesn’t account for the compulsive side of addiction. In my case, when it came to schoolwork, I didn’t shirk. Indeed, I was desperate to be a good student and terrified of getting in trouble. Here, I had trouble stopping intellectual engagement, not starting it.
Obsessiveness like this, however, also involves impaired self-regulation—in this case, at the other end of the spectrum. It’s a problem with stopping what has already been started, rather than starting an action that should have been stopped. In other words, while impulsiveness involves too little behavioral inhibition and a failure to prevent reckless behavior, obsession and compulsiveness is a problem with too much inhibition, a difficulty with getting out of a rut, rather than with preventing actions from being initiated. Further, inability to modulate fear and other emotions also involves a reduced capacity to self-regulate.
In their studies, Shedler and Block found that the abstaining youth were “fastidious, conservative, proud of being ‘objective’ and rational, overly controlled and prone to delay gratification unnecessarily, not liked or accepted by people,” as well as “moralistic,” “not gregarious,” and “basically anxious.” Most of that could also have described me as a three-year-old. Indeed, it reads now as a somewhat judgmental description of the key traits of children with Asperger’s.
My own behavior as a young child and elementary school student swung between the poles of being overly controlled to being out of control. Both behavioral extremes, however, result from a failure in self-regulation. And neuroscience now strongly suggests that such dysregulation plays a key role in addiction. In fact, similar brain circuits are involved in both addiction and obsessive-compulsive disorder (OCD): whether the problem is failing to stop an impulsive action or failing to end a habitual routine, many of the same regions are engaged. It is here that addiction is learned.
The relevant areas of the brain include the prefrontal cortex (PFC), which imagines possible futures and plans and makes decisions accordingly. Of particular importance within the PFC is the orbitofrontal cortex, which helps determine the relative emotional and psychological value of your options and, therefore, your level of motivation and your tendency to make particular choices. The PFC works in concert with the nucleus accumbens (NAC), the region famed as the brain’s “pleasure or reward” center. This area is involved in determining the desirability of particular options and how much you want to seek or avoid them. Another region related to reward and motivation, the ventral pallidum, is also part of this brain system, as is the habenula, which seems to be involved primarily in aversion and disliking.
The insula, which processes emotions like lust and disgust and also monitors internal states like hunger and thirst, is another node in this circuitry. So is the anterior cingulate, which looks for conflicts and errors and changes emotion accordingly. The anterior cingulate seems to be especially important for obsessive behaviors, perhaps because it creates a sense that things are “not right” until they are perfect or complete. In OCD, it may wrongly detect errors, which could cause constant anxiety. Finally, the amygdala is also in the loop. While best known for its role in processing fear, the almond-shaped amygdala is also involved in a variety of other emotions, including positive ones.
Together, this whole neural network sets values, priorities, and goals. Crucially, parts of it can also simplify repeated behavior into programs for habits that can be engaged or disengaged with little conscious thought. Indeed, research shows that as a behavior is learned and becomes more automatic, it engages different parts of the striatum, which is the broader area that contains the nucleus accumbens. As a behavior moves from being a conscious choice to a habit, brain activity changes, moving up toward the top or “dorsal” portion of the striatum and away from the bottom or “ventral” area. In addiction and other compulsive behaviors, brain activity that is increasingly dorsal in the striatum seems to be linked with reduced ability of the prefrontal cortex to stop or control the behavior.
One critical aspect of addiction, in fact, is an alteration in the balance between brain networks that drive habitual behavior and those that determine whether or not to execute those routines. Again, all of these regions are made to change with experience and are, as a result, developmentally vulnerable both in early childhood and adolescence. With any activity, as it is learned, it becomes easier, more automatic, and less conscious. This is essential when you are learning to play the piano or throw a ball—and it allows “muscle memory” to develop and hone your skills. However, it’s not such a great capacity to have when you are learning addiction because, by definition, more reflexive behavior is less under conscious control.
It seems that the same regions that gave me my intense curiosity, obsessive focus, and ability to learn and memorize quickly also made me vulnerable to discovering potential bad habits and then rapidly getting locked into them.