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Most of us know someone who has struggled with a drug or alcohol problem. Nearly 20 million Americans currently have a substance-use disorder, and millions more have battled addiction at some point in their lives.

Addiction is common. But it’s also complicated. What can devolve into dependency for one person may, for another, be manageable in moderation. Moreover, addiction doesn’t always look the way it’s depicted in the media: Not everyone who has a problem crashes and burns, or goes into treatment — or even recognizes he or she has a problem, for that matter.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes addiction as a “pathological pattern of behaviors” related to use of a substance. But how does one come to develop that pattern? And where do we draw the line between normal and pathological in the first place? After all, there’s an enormous gulf between enjoying a glass of wine with dinner and having an alcohol problem.

Identifying an addiction starts by understanding how it works. Generally speaking, the path of addictive behavior follows a gentle slope before heading steeply downhill. Along the way, both physiological and psychological mechanisms feed what may ultimately turn into an unhealthy dependency.

Addiction and the Brain

Drugs, alcohol, nicotine, even caffeine alter how we feel, and like all feelings, they generate in the brain. While different substances spark their own unique interaction with neurotransmitters — stimulants like cocaine make us feel more alert; alcohol, a depressant, tends to relax and disinhibit — all trigger the release of dopamine, which ultimately makes us feel good (at least temporarily). But more important, that hit of dopamine makes us want more.

Plenty of things generate a rewarding neurochemical response but don’t lead to addiction. A 2011 study showed that simply stroking a dog can boost oxytocin, yet few people become compulsive pooch petters.

Drugs and other addictive substances are different because their impact on the brain extends beyond momentary bliss by forging structural changes in our neurochemistry. The brain naturally generates dopamine and other feel-good chemicals; drugs essentially open the floodgates. The constant rush of dopamine causes the brain to produce fewer dopamine receptors on its own, leaving the user with a deficit when the drug surge subsides. In time, the brain requires greater and greater amounts of the substance to make up the difference. This is what’s known as tolerance.

Not only does the addicted individual need to use more of a substance to reap the same reward, they’re likely to feel depressed, irritable, or — depending on the frequency and intensity of their addiction — in physical pain when they aren’t using. This is withdrawal.

Tolerance and withdrawal act as complementary levers of reinforcement in the brain’s reward center, making it difficult or even dangerous for addicts to stop using once they’ve passed a certain threshold of dependency.

A Toxic Relationship

Over time, excessive substance use can cause significant harm to both brain and body. But the toll addiction takes on a user’s family, friendships, and other aspects of life can be just as consequential.

Here’s where the psychological component of addiction comes in. Aimee Murray, PsyD, an assistant professor of psychiatry at the University of Minnesota who works with individuals struggling with addiction, likens the condition to a toxic relationship in which the individual with addiction becomes preoccupied with his or her “partner” to an unhealthy degree.

“That relationship becomes the center of everything,” Murray explains. “Someone who’s addicted to alcohol might spend inordinate amounts of time throughout their day agonizing over their hangover from last night’s binge, while at the same time obsessing about when they’ll be able to have their next drink and where they’ll go to get it.”

In other words, it’s not just the consequences of using a substance but the outsized role it plays in a person’s life that can lead to problems. The addiction overshadows work, hobbies, health, and family. Relationships, in particular, are liable to fray in the face of addiction. “Support systems deteriorate.” Murray says. “The substance use interferes with the individual’s ability to stay connected with other people.”

Addiction to Habits

For decades, addiction research, treatments, and general awareness have centered on substance use. But it’s also possible to become addicted to a behavior.

Gambling is currently the only behavioral addiction recognized by the American Psychological Association. The DSM-5 criteria for Gambling Disorder doesn’t look that different from substance-use disorders, characterized by preoccupation, repeated unsuccessful attempts to quit or cut back, continued use despite negative consequences, and tolerance.

Experts are beginning to explore whether other behaviors can lead to a similar pattern.

Of particular interest is technology use. Recent studies have demonstrated that our phones’ electronic notifications trigger dopamine hits similar to those associated with cocaine and other addictive substances, and some have suggested that Facebook, Twitter, and other social-media sites were purposely designed to encourage compulsive use. (In fact, former Facebook vice president Chamath Palihapitiya publicly apologized for creating these addictive “dopamine-driven feedback loops”).

What’s more, there’s growing evidence that we can develop a toxic relationship with tech not unlike that of substance addicts. South Korean researchers found that roughly one-third of the 1,824 middle-school students who participated in a study on smartphone use demonstrated an addictive relationship to their device, endorsing questionnaire items such as “My school grades dropped due to excessive smartphone use,” “Family or friends complain that I use my smartphone too much,” and “I panic when I cannot use my smartphone.”

Other behaviors that are normal or even healthy in moderation may also become problematic after a point. Even exercise. What might start as a healthy habit can morph into an obsessive fixation on calories burned or miles logged. A compulsive exerciser may skip out on social or family obligations in order to get their fitness fix, or force themselves to hit the gym even when they’re suffering from a strained muscle. Exercise becomes the “toxic partner,” taking precedence over everything else.

Ultimately, notes Murray, it’s still not clear whether all behavioral addictions operate with the same underlying mechanisms as substance addictions. But there’s a growing push to ground theories in hard data, and Murray expects more research to emerge. “I think we’ll have a lot more conclusive evidence around how those types of addictions work in the years ahead,” she says.

In the meantime, it’s worth taking an honest inventory of your relationship with substances or behaviors that run the risk of turning addictive.

Do you have an addiction problem?

The checklist below is based on substance-use-disorder criteria from the DSM-5. If you check three or more of these boxes, you may have an unhealthy relationship with a substance or behavior.

  • You frequently use or do more than intended.
  • You have attempted many times to cut back or quit but haven’t been able to stick with it.
  • Even when you aren’t doing or using it, the substance or behavior is on your mind (this could include recovering from the last time or planning the next time).
  • Your use or behavior has had negative consequences on work, school, relationships, or other important parts of your life.
  • You continue to do or use despite those negative consequences.
  • You have given up or de-prioritized things that used to be important to you in order to do or use.
  • You need more of the substance or behavior than you used to in order to feel good.
  • You feel depressed, irritable, or otherwise bad when you aren’t doing or using the behavior or substance.

This originally appeared as “Understanding Addiction” in the July/August 2019 print issue of Experience Life.

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