Do You Have a Brain Disease? If So, Can You Get Over It?

Like many other diseases, including COVID-19, most people recover from addiction

Posted Dec 17, 2020

In 1997, Alan Leshner, then director of the National Institute for Drug Abuse, wrote an article entitled “Addiction Is a Brain Disease and It Matters.” That eight-word title became the perfect sound bite for the media.  

Not everyone agrees. And that is an understatement. Even Leshner actually said much more: “If we understand addiction as a prototypical psychobiological illness, with critical biological, behavioral, and social-context components, our treatment strategies must include biological, behavioral, and social-context elements.” So addictions are not only a brain disease. 

People are passionate on both sides of the argument. In 2013, Neil Levy, director of Research at the Oxford Centre for Neuroethics, wrote an article entitled “Addiction Is NOT a Brain Disease, and It Matters.” And in the same year, Sally Satel, a psychiatrist in Washington, D.C. and W.H. Brady Fellow at the American Enterprise Institute, authored “Addiction and the Brain Disease Fallacy,” arguing that the very idea has some significant negative consequences for people trying to manage or get over an addiction.

In 2016, Kent C. Berridge, Distinguished University Professor of Psychology and Neuroscience at the University of Michigan, wrote that “neural sensitization changes” may be “problematic enough to be called pathological,” but “arguments of ‘brain disease’ should be put behind us. Our real challenge is to understand addiction and devise better ways to help.” Agreed.           

The fact is, whatever you do — playing the piano, learning to cook great risotto, or drinking a lot of gin — changes your brain. But if you’ve changed your brain, can you change it back? Fifty years of research has established that most people who have an addiction eventually overcome it. 

Sometimes I’m asked, “Do you think I have a brain disease?” I like to respond by asking another question: “Is diabetes a disease?” Most people say yes. I prefer to think of diabetes as a disorder — something in the insulin system doesn’t work right. 

If you have no symptoms of diabetes, have you gotten over it? Most doctors would say, “Definitely not!” But if you moderate your diet and exercise, you may not have any symptoms or have to take any medications for the rest of your life. Have you gotten over it? I would also say “definitely not.” Because if you don’t maintain those changes in lifestyle or take your medications, your symptoms will come roaring back and you may suffer other, related health problems.

Most ex-smokers would not say that they had a disease or even a disorder. Many people who have quit smoking cigarettes will tell you that smoking is no longer an issue for them. They don’t have urges and are completely confident that they will never start up again. Have they recovered? Unlike diabetes, I think we would all agree that they have. They don’t have to be vigilant anymore. Has their brain recovered? I think it is fair to assume that it has.

Some ex-smokers, however, know that, at times, they still feel tempted to smoke, especially if someone starts to smoke near them. AA members use the term “recovering,” never “recovered.” They know that they must continue to be on guard and take care not to slip back into their old habit. Their brain remembers. And likes what it remembers! But if they remain mindful and maintain their new lifestyle, they will remain symptom-free. 

There is absolutely no doubt in my mind that some people cannot interact with ethanol, the active ingredient in alcohol, without getting into trouble. They are often bright, high-functioning people. They have often succeeded at almost everything they have tried to do in life. But alcohol critically affects their ability to control their behavior. They cannot interact consistently with the chemical ethanol and always have acceptable results. They try again and again and fail again and again. They may be able to drink 19 times out of 20 without any significant negative effects, but the twentieth time they will fall down the stairs or drive into a tree. You probably already know if you fit into this group. The same seems true for some people with heroin, cocaine, and marijuana, and some people with such activities as video gaming, watching porn, and gambling.

I am quite confident that we will eventually find that these people differ in some significant way. Perhaps one or more neurotransmitters function differently in their brains. Should this be called a disease? Call it what you want. It’s certainly something that ought to be acknowledged. They cannot do X without getting into trouble. 

Some people hate the “brain disease” idea because they think that means you can’t do something about it, but even if you have “a brain disease,” you can still help yourself do better. 

We now have ample research showing that the brain changes. Neuroscientists and now lay people talk about the “plasticity” of the brain. The brain is malleable. In one famous study, Eleanor Maguire looked at the brains of London taxi drivers. This was before GPS and Google Maps, and wanna-be-taxi-drivers had to study for four years to memorize the wandering, intersecting, variously named streets in the city. Note that they were highly motivated. They wanted to get the license. And they worked very hard for a long time. Voila! Maguire found that a part of their brain, a part of their hippocampus, markedly increased in size.

Some critics said that that was probably due to the stress of driving in London’s streets. Maguire looked at the brains of bus drivers who have a set route, and their brains had not changed. So having to learn the streets of the city seemed to cause a part of their brain to actually grow!

Your brain can also change back once you cut back significantly or stop entirely. Pictures of a brain after someone stops using methamphetamine show dramatic changes back to a more normal brain. Completely? Perhaps not, but often if one part of a brain is injured, for example, in an accident, other parts of the brain start to make up for the loss. The person’s behavior may return to normal or near normal.

Many of you may be familiar with the famous case of Phineas Gage. An iron rod crashed through the front part of Gage’s brain, leaving a very large hole. But he was still alive, and the wound eventually healed. He went on to live a relatively long life. Some aspects of his personality changed. After all, the spike went right through his prefrontal cortex, the center of decision making. Having engaged in an addictive behavior may have changed your brain—as I noted above, anything, including piano playing, does—but not like the hole from Gage’s chin through the top of his skull.

In addition, people with brain injuries from accidents often do many things to speed their recovery. Often they are successful even when the future looks very bleak right after the accident. If you currently have brain changes that can be seen very clearly in a picture, whether you call it a “brain disease” or not, you can probably help your brain recover. 

If thinking of your problem as a “brain disease” helps you take action and stick to your approach, then call it a brain disease. If that doesn’t help you, then think of an addiction as a disorder or behavioral problem or a combination of both. In any case, you have a serious health issue and may want to change some of the old strategies that have not worked so far. 

You can learn more by reading Am I Addicted? 64 Questions and Answers to Help You Change an Addictive or Semi-Addictive Behavior. This blog post is an edited version of the answer to Question 4, Do I Have a Brain Disease?

"There is no good reason why we should not develop and change until the last day we live."  —Karen Horney

References

Berridge, K. C. (2017). Is Addiction a Brain Disease? Neuroethics, 10(1), 29–33. https://doi.org/10.1007/s12152-016-9286-3.

Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278(5335), p. 46.

Levy, N. (2013). Addiction is not a brain disease (and it matters). Frontiers in Psychiatry, 4, 24

Satel, S., & Lilienfeld, S. O. (2014). Addiction and the brain-disease fallacy. Frontiers in Psychiatry, 4, 141.