I am interested in the cultural trope that addiction is a brain disease - what that means, how it affects diagnosis and treatment, how professionals and lay people make use of this idea in their lives.

I always ask, "Is addiction diagnosed by brain scans or measuring neurochemicals or other biological markers? Or is the diagnosis made on the basis of observed and self-reported behavioral symptoms and life impacts connected with substance use?"

The answer is always the latter.  The substance dependence criteria listed in DSM-IV, according to which all diagnoses in the United States (worldwide) are made, describe a person's reaction to a substance and, mainly, the way use of the substance hurts the person's life.  In fact, we would have no idea of how to measure addiction in terms purely of neurochemicals or PET scans.  None, despite great claims being made in this area by the National Institute on Drug Abuse and others.

In other words, no medical center, laboratory, or rehab would know what kind of brain measurements to take, and how to interpret these, in order to conclude, "Aha - this human being is addicted."  They make that diagnosis instead by asking the person questions about his or her substance use and its effects.

And no one expects this to change.  (Show me one.)  I have commented on striking developments in DSM-5, including the return to the term "addiction" that had been abandoned, and the inclusion of (so far) one "behavioral addiction" (gambling).

But the use of observed life and behavioral criteria remain the same between DSM-5 and DSM-IV. Since DSM-5 will only be implemented in 2014, these same criteria will be in use decades from now. There seems to be no hurry - to say the least - to activate the idea that addiction is a brain disease.  This, even though the head of DSM-5's substance-related disorders work group, psychiatrist Charles O'Brien, is a strong "addiction-as-brain-disease" advocate.

Given all this talk about dopamine, brain pleasure centers, and the medial forebrain (cf. Dr. Drew) in addiction, you might think there would be some incorporation of these things into the addiction assessment process -- at least at some projected point in the foreseeable future.

No such luck.

Do you think that this is because no knowledgeable observer really believes that addiction is due to, explained or described by, or addressed best, as a brain dysfunction?  Like by measuring gambling addiction by watching parts of the gambler's brain light up, rather than noting when he gambles all night instead of going home, or mortgages his home to be able to gamble more?  Or by treating his addiction by finding ways to tone down those brain synapses firing, rather than examining and modifying the addict's feelings, relationships, life?

Do they actually believe, like me, that such ideas are nonsensical?

After all, they're probably sensible people.

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