The Heart of Addiction

How psychology drives addictive behavior.

What Does Dropsy Have to Do With Substance Abuse?

Irrational names lead to irrational treatment.

When doctors don’t know the cause of an illness, they're stuck having to “diagnose” only its symptoms, not the source of the problem. That is just where we stand today with substance abuse, and it’s ruining our chance to treat it effectively.

For example, before we knew the cause of tuberculosis (a bacterial infection), it was named based on one of its symptoms: it was called Consumption because one of its main symptoms was weight loss. Naming the illness as a weight loss problem was not useful for either understanding or treating it. In fact, if doctors had tried to figure out the illness by looking into “weight loss” as the issue, they would never have discovered its true cause. The same thing happened with another commonplace “diagnosis” of the 19th century: Dropsy. This term referred to swelling, often of the ankles. There are several possible causes for this, one of the most common being congestive heart failure. But since doctors didn’t have a clue about this, they stroked their beards and sagely proclaimed that their patients had Dropsy. As with Consumption, the “diagnosis” was not just unhelpful, but thinking of the illness as a swelling problem could never have led to understanding it.

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Today, addiction specialists and nearly everyone on the planet believes that there is something called “substance abuse disorder.” We are again naming a symptom as if it is the problem. Since the focus of an addiction can, and often does, change from one drug to the other, or to non-drug compulsive behaviors like gambling, eating or sex, “diagnosing” a “substance-abuse disorder” is both superficial and harmful. Like Consumption or Dropsy, it misleads us into believing that somehow the problem is about substances. Drugs in fact have absolutely nothing to do with the nature of addiction; they are just one common form of the problem. And like Consumption and Dropsy, use of this misleading term interferes with understanding and treating people suffering with it.

As readers of this blog or my books know, addiction is neither more nor less than a compulsive behavior, identical with other compulsions and understandable in psychological terms. (As always, I am not referring here to either physical addiction, or the biologic illness OCD.) It is certain that true addiction is not a “brain disorder” as I’ve discussed extensively elsewhere, and of course it is also not a moral/spiritual problem. We need to be appreciating addiction as the compulsive behavior it is, and treat people by helping them to understand its psychological roots so they can predict when their compulsive/addictive urges will next arise. With that awareness, and some psychological work, people can effectively manage and ultimately beat their addictions.

It’s hard to buck any entrenched system, but let’s try to keep in mind that people who compulsively use alcohol or any other drug are just like everybody else, just with this particular way of managing overwhelming feelings. They do not have a “substance abuse disorder” because there is no such thing.

Lance Dodes, M.D., is an assistant clinical professor of psychiatry at Harvard Medical School.

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