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General Theory of Addiction

While researching gambling addiction and I came across this critique (National Research Council, 1999) of Durand Jacobs (1986) “General Theory of Addictions” which calls for a “credible and testable theory of addiction that acts as an overriding conceptual framework for addiction that would address the causes and course of addictive behaviors (Jacobs, 1987, 1988; Shaffer et al., 1989a).”

I think that it is worth exploring what Jacobs has to say to see how it compares with my own theory, that addiction is not only intimately related to trauma but that addiction is also is a trauma and an act of dissociation in its own right. The excerpts of the critique of Jacobs’ work are in italics and quotation marks.

“Jacobs has proposed an interactive model of addiction, defining it as a dependent state that is acquired over time by a predisposed person in an attempt to relieve a chronic stress condition.”

A “predisposed person…relieving a chronic stress condition” sounds like trauma to me. Tell me more.

“Using pathological gambling as the prototype addiction, he posited that two interacting sets of factors (1) an abnormal physiological arousal state and (2) childhood experiences resulting in a deep sense of personal inadequacy and rejection.”

This is literally part of the criteria for PTSD (Diagnostic Statistical Manual of Mental Health Disorders, 2013). Criteria A: Experienced, witnessed, or heard about the death or serious life-threatening injury which causes an arousal state and alterations in moods, which we now know can also cause a shutdown response i.e. dorsal vagal shutdown often labeled as depression. Interestingly enough, some common traumas that are not identified as traumas still fit these criteria i.e., birth, medical surgeries, use of medicines, illness, sickness, stressful pregnancies, family history of loss, generational and cultural trauma, and parenting styles performed over time. Furthermore, Criteria A is implying that the life-threatening event that was experienced, witnessed, or heard about was conscious, but my question is "what about the threats to our body or our unconscious system like drug use?" My answer is that these would be retained as well because they have value to the survival brain. Criteria B: Strong negative beliefs and cognitions about oneself as a result of the experience.

The critique continues: “…[A] conducive environment may produce addiction to any activity or substance that possesses three attributes: (1) it blurs reality by temporarily diverting the person's attention from the chronic aversive arousal state, (2) it lowers self-criticism and self-consciousness through an internal cognitive shift that deflects preoccupation from one's perceived inadequacies, and (3) it permits complimentary daydreams about oneself through a self-induced dissociative process.”

Overall, I like the train of thought so far. It is the closest thing that I have found that directly highlights that trauma or adverse life experiences create the “conducive” conditions for addictive behaviors to thrive and quantifies why addictive behaviors make sense. Lastly, it directly identifies the dissociative process as it is referenced in each of the attributes i.e., “blurs reality” “cognitive shift that deflects” and “daydream.” However, I have one point of contention with a “self-induced dissociative process.” This needs more contexts in order to help accurately provide a sustainable general theory of addiction.

The next part of the excerpt states…

“The general theory holds that a given individual's addictive pattern of behavior represents that person's deliberately chosen means for entering and maintaining a dissociative-like state while indulging.”

I am not in agreement here. A “self-induced” or “deliberately chosen” choice goes against the definition of addiction because addiction is the removal of choice. I would agree with “self-induced” or “deliberately chosen” if the general theory identifies that an unconscious survival process in the primitive and limbic areas in the brain is making the choice, which is what we now know is happening. The qualifier of “maintaining a dissociative-like state while indulging” negates the experience of the unconscious survival process. What if the “while indulging” was an unconscious dissociative survival process like re-enactment based on what parts of the self have previously experienced? I believe that a process of re-enactment is happening unconsciously and is not deliberate but can become conscious, however, THIS IS NOT GOING TO STOP THE UNCONSCIOUS PROCESS! It would be like trying to stop someone from falling in love with you.

To add more context: Your survival brain makes decisions all the time that you are consciously unaware of, like maintaining blood pressure, cell repair, and performing digestion, because it has to. You cannot cognitively process all things that your body needs to do to survive hence you are at the whim of the unconscious process. Similarly, the unconscious processes are at the whim of the choices you make like what you put into your body but even that too is influenced by the unconscious, which is attracted to experiences that provide certain value or boosts the chances of survival. It is easier to see these as intimate processes that work together in an effort to create homeostasis within a system.

We have to understand addiction in relation to brain/body’s survival functioning and the psychological parts of self that are often represented in our survival actions. There are parts of the brain that specialize in performing different tasks, which, if you attribute them to who you are as a whole person or your cognitive/conscious self, you miss the fact that those parts make up the whole. All states of addiction are altered and dissociative. To the point where I suggest that they mimic the disorders of dissociation (I also suggest that continued use of addiction behaviors cause dissociative disorders.) While decisions made in these states make sense at the time they do not hold the same value socially because they are based on information that is survival only and fueled by the unconscious processes in the brain rather than a conscious, deliberate choice. In dissociative disorders, this is called trance logic (Howell, 2011) and in addiction/self-help terms it is “addict logic” and both are ultimately based on survival decisions where the ideas and concepts make sense in that state of being.

Furthermore, if you made previous decisions to survive (traumas) then you are going to use those methods again because your survival brain knows that they work. You can make a conscious choice in a dissociative state, but by definition, a dissociative choice is not a part of the conscious whole and/or by societal standards and/or can be both conscious and unconscious because different parts of the brain functioning are consciously influencing the decision-making process. The process of going between different states is environmentally dependent but also reference-dependent depending on individual history. The same is true in the addiction process that produces shifts in personality.

In Dissociative Identity Disorder (DID) there is the experience of switching in which the part that is driving the conscious bus is placed in the backseat. This can be likened to the “hijacking” of the brain in addiction. There can also be co-consciousness where the parts that are conscious are working together. If addictive states mimic psychosis then they can mimic DID, which in addiction terms, this is the Dr. Jeckyl and Mr. Hyde but it is all based on the survival fear-based brain being activated, just not in the typical fight, flight, freeze, and appease response. I think that we have to look at the pleasure side of the fence and when we do we can add the love-based survival mechanisms of strive, provide, and enjoy the ride. These pleasurable survival responses have the same value to our survival needs as do the fear based ones. To understand more about dissociation and addiction more please consider reading Dr. Jamie Marich and my work on Demystifying Dissociation: A clinician’s guide (Marich and O’Brien, 2018).

Lastly, in the phrasing, “dissociative-like” I would drop the “like” from it because it is a dissociative state in its own right because addictive behaviors produce dissociative states and leave traces of the experience in the form of memories. Even though trauma, addiction, and dissociation are conditional and ultimately temporary, the impact of them is not from a body and memory perspective because all experiences leave a mark. It is a paradox but something that did not happen did happen. The aftermath is what people suffer from and the memory of the experience creates the symptoms. Dissociation, PTSD, and addictions are diagnoses that can go into remission and for this reason, I am in favor of having addiction be categorized as Trauma and Stress-Related Disorder, under the main heading of Dissociative Disorders because it is more philosophically and diagnostically accurate (even though addiction is induced, it is the inducing that is the trauma). It is important to note that the act of dissociating utilizes the natural opiate and cannabinoid system in the brain (Lanius, Paulsen, & Corrigan, 2014), which suggests to me that this is why addictive behaviors feels good or right and that this experience is what fuels the process of re-enactment in the memory systems that creates the habit. The process of re-enactment can come in many different forms and deserves a blog of its own.

The critique of Jacobs work continues… “Jacobs also characterizes this feature as a type of self-management or self-medicating strategy (Khantzian, 1985); that is, the person's addictive behavior represents the best solution to the stresses generated by longstanding underlying problems.”

After reading this section, the next train of thought for me is... when the solution turns into the problem and the addiction has developed i.e., the toxic relationship to the solution-oriented behavior has reached a state of dependence; the addiction becomes traumatic because the relief is causing pain. This is critical to understanding the idea of the trauma-addiction on the dissociative spectrum that I am advocating for because it highlights the cyclical nature of the relationship between these experiences (also represented in the cycle of abuse i.e. honeymoon, escalation, abuse/fallout, make-up/honeymoon (). Also, to link this back to the re-enactment idea stated above, the “longstanding underlying problems” is trauma/pain and what is being re-enacted and the reason why it is being re-enacted is an attempt to resolve it.

“Testing this theory on pathological gamblers, persons with other kinds of addictions, and normal control subjects, Jacobs and others have found principally through self-report research, that similar dissociative states are reported by pathological gamblers, alcoholics, and compulsive overeaters (Kuley and Jacobs, 1988; Marston et al., 1988). However, others have found that, although his work represents an important step toward the development of multidimensional models, Jacobs has largely ignored the importance of the social setting factors (Lesieur and Klein, 1987; Rosecrance, 1988; Zinberg, 1984) that influence the development, maintenance, and recovery from addictive behaviors (Shaffer et al., 1989).”

As to Jacobs “largely ignoring the importance of the social setting factors,” this may be true in his work but it seems to me that “two intersecting factors” of a heightened arousal state (trauma), strong negative beliefs, as well as chronic stress (trauma) happen in the context of relationships, therefore, cannot be created in social isolation. Maybe he did not state it directly but I believe that it is implied. This critique of his work does not identify the word trauma. In 1986, that would make sense since seminal work of Judith Herman (1992) in Trauma and Recovery was not published yet, PTSD was still an “abnormal response to an abnormal event,” polyvagal theory was being formulated, and the influence of a decade of brain research into trauma had yet to take place.

So where does this lead us…?

My point of view is that Jacobs gets a lot right; namely, he identified trauma and dissociative processes that are infused in the development of addictions. But since we now use the word trauma or adverse life experiences to highlight a lot of what he was identifying we can use that trauma framework to provide a general theory of addiction. I think it is critical for clinicians and people in general to understand the role that addiction plays in creating trauma. Furthermore, if one can be addicted to pleasure then one can become addicted to pain. The process is so intimate that it cannot be separated and should be viewed on a spectrum because they are intimately related to one another.

So, borrowing from trauma theory to support a general theory of addiction, the symptoms of traumatic experience are based on are traumatic memories, which is my over-arching theory of addiction. Addiction is a series of stuck memories. To put it more succinctly, addiction is the result of a series of stuck memories that cause strong beliefs, affect dysregulation, and intrusive reminders. This causes the need to self-regulate with coping skills that provide temporary relief, which become habitual and progress like a disease. A disease/allergy is the closest analogy or metaphor that we have for this is that addiction is, however, disease or allergy is really a form of memory. Diseases come in many different forms and so I agree that addiction acts like a disease and kills like a disease but ultimately, from a more psychological and philosophical perspective: addiction based on a series of stuck memories that create habitual dependence.

At the end of the day, memories and how the memory systems interact is the conceptual framework for all reality so they can also be for addiction. But the fact remains that you cannot have trauma without dissociation. Similarly, you cannot have an addiction without dissociation and you cannot have either without a break in trust or attachment, which is traumatic. So, we have to examine the intimate relationship that exists between these events in order to truly understand the context in which these conditions thrive. This is where qualitative analyses are critical in understanding addiction. One interesting current state of affairs that I think undermines the understanding of addiction is the denial of Developmental Trauma (and stress related) Disorder (DTD) in the DSM5 (van der Kolk, 2014). Having the category of Developmental Trauma-Related Disorder (DTRD) would help accurately define addiction. To me, addiction is the poster child for this disorder.

I continue to see the need for clinicians, people who are in a state of active addiction, medical doctors, families, and communities to have an accurate definition of addiction in order to comprehend what addiction truly is. Having an overarching framework that helps clinicians and researchers identify fertile grounds or “conducive environments” will generate effective therapeutic interventions. However, it means that the environment has to change as well. Borrowing from traumatology is way easier and more accurate but we have to come to some realizations about trauma that particularly challenges cultural mores and values, family and traditional beliefs, and medical and legal norms. Since trauma is subjective it can be dismissed when these institutions are the perpetrators. I believe that my definition of addiction as a series of stuck memories holds the validity needed to provide appropriate treatments for this condition once the stigmas and resulting judgments of and from these institutions have matured.

Resources

Diagnostic Statistical Manual for Mental Disorders DSM-5 5th ed. (2013). Washington D.C.: American Psychiatric Publishing.

Herman, J. (1992). Trauma and Recovery: The aftermath of violence from domestic violence to political terror. New York, NY: Basic Books.

Howell, E. (2011). Understanding and treating dissociative identity disorder: A relational approach. New York, NY: Routledge.

Jacobs, D. (1986). A General Theory of Addictions: A Theoretical Model. Journal of Gambling Behavior. Vol. 2(1), Spring/Summer. Human Sciences Press.

Jacobs, D.F. (1987). Evidence for a common dissociative-like reaction among addicts. Journal of Gambling Behavior 4:27-37.

Jacobs, D. (1988). A general theory of addictions: Rationale for and evidence supporting a new approach for understanding and treating addictive behaviors. Pp. 35-64 in Compulsive Gambling: Theory, Research and Practice, H.J. Shaffer, S. Stein, B. Gambino, and T.N. Cummings, eds. Lexington, MA: Lexington Books.

Jacobs, D. (1989a). Illegal and undocumented: A review of teenage gambling and the plight of children of problem gamblers in America. In Compulsive Gambling: Theory, Research and Practice, H.J. Shaffer, S.A. Stein, B. Gambino, and T.N. Cummings, eds. Lexington, MA: Lexington Books.

Jacobs, D. (1989b). Special issue: Gambling and the family. Journal of Gambling Behavior5(4).

Khantzian, E.J. (1975). Self-selection and progression in drug dependence. Psychiatry Digest 36:19-22.

Kuley, N., and D. Jacobs (1988). The relationship between dissociative-like experiences and sensation seeking among social and problem gamblers. Journal of Gambling Behavior 4:197-207.

Lanius, U., Paulsen, S., & Corrigan, F. (2014). Neurobiology and treatment of traumatic dissociation: Toward an embodied self. New York, NY: Springer Publishing Company.

Lesieur, H.R., and R. Klein (1987). Pathological gambling among high school students. Addictive Behaviors 12:129-135.

Marich, J., and O’Brien, A. (2018). Demystifying dissociation: A clinician’s guide. Addiction Professional Fall 2018 Vol. 16. No. 4.

Marston, A.R., D.F. Jacobs, R.D. Singer, and K.F. Widaman (1988). Characteristics of adolescents at risk for compulsive overeating on a brief screening test. Adolescence 23(89):59-65.

National Research Council. (1999). “Gambling Concepts and Nomenclature." Pathological Gambling: A Critical Review. Washington, DC: The National Academies Press. doi: 10.17226/6329. https://www.nap.edu/read/6329/chapter/4#40

Rosecrance, J.D. 1985 Compulsive gambling and the medicalization of deviance. Social Problems 32:275-284.

Shaffer, H.J. (1986). Assessment of addictive disorders: The use of clinical reflection and hypotheses testing. Psychiatric Clinics of North America9(3):385-398.

Shaffer, H.J., S.A. Stein, et al., eds. (1989). Compulsive Gambling: Theory, Research, and Practice. Lexington, MA: Lexington Books.

van der Kolk, B. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York, NY: Penguin Books.

Zinberg, N.E. 1975 Addiction and ego function. Psychoanalytic Study of the Child 30:567-588.

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