ASAM’s Definition of Addiction: Frequently Asked Questions (2011)

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COMMENTS: This set of frequently asked questions accompanied ASAM's new definition of addiction. A few of the Q & A's address sex addiction. It's quite clear that the experts at ASAM view sex as a real addiction. We see sex addiction (real partners) as quite different from Internet porn addiction (a screen). Many who develop Internet porn addiction would never have developed a sex addiction in the pre-Internet era.

Two articles we wrote:


ASAM’s Definition of Addiction: Frequently Asked Questions (August, 2011)

 

1. QUESTION: What’s different about this new definition?

ANSWER:

The focus in the past has been generally on substances associated with addiction, such as alcohol, heroin, marijuana, or cocaine. This new definition makes clear that addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry. We have recognized the role of memory, motivation and related circuitry in the manifestation and progression of this disease.

2. QUESTION: How is this definition of addiction different from previous descriptions such as DSM?

ANSWER:

The standard diagnostic system has been the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. This manual lists hundreds of diagnoses of different conditions, and the criteria by which one makes a diagnosis. The DSM uses the term ‘substance dependence’ instead of addiction. In practice, we have been using the term ‘dependence’ interchangeably with addiction. However, it is confusing. The method that psychiatry has relied upon has been the patient interview and outwardly observable behaviors. The term that is used most often is ‘substance abuse’--some clinicians use this term interchangeably with ‘addiction’ which also causes confusion. Therefore, ASAM has elected to define addiction clearly, in a way that accurately describes the disease process that extends beyond overt behaviors such as substance-related problems.

The editions of the DSM published since 1980 have been very clear that the DSM approach is “atheoretical” – a diagnosis does not depend on a particular theory of psychology or a theory of etiology (where a disease comes from). The DSM just looks at behaviors you can see or symptoms or experiences that a patient reports through an interview. The ASAM definition of addiction does not exclude the role of environmental factors in addiction – things such as neighborhood or culture or the amount of psychological stress that a person has experienced. But it definitely looks at the role of the brain in the etiology of addiction – what is happening with brain functioning and specific brain circuitry that can explain the outward behaviors seen in addiction.

3. QUESTION: Why is this definition important?

ANSWER:

Addiction, almost by definition, involves significant dysfunction in a person – their functional level at their job, in their family, in school, or in society in general, is altered. Human beings can do all sorts of dysfunctional things when they have addiction. Some of these behaviors are frankly antisocial – doing certain things can be a violation of social norms and even societal laws. If one simply looks at the behavior of a person with addiction, one may see a person who lies, a person who cheats, and a person who breaks laws and appears to not have very good moral values. The response of society has often been to punish those antisocial behaviors, and to believe that the person with addiction is, at their core, “a bad person.”

When you understand what’s really happening with addiction, you realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function. Addiction is not, at its core, just a social problem or a problem of morals. Addiction is about brains, not just about behaviors.

4. QUESTION: Just because a person has the disease of addiction, should they be absolved from all responsibility for their behaviors?

ANSWER:

No. Personal responsibility is important in all aspects of life, including how a person maintains their own health. It is often said in the addiction world that, “You are not responsible for your disease, but you are responsible for your recovery.” People with addiction need to understand their illness and then, when they have entered recovery, to take necessary steps to minimize the chance of relapse to an active disease state. Persons with diabetes and heart disease need to take personal responsibility for how they manage their illness--the same is true for persons with addiction.

Society certainly has the right to decide what behaviors are such gross violations of the social covenant within a society that they are considered criminal acts. Persons with addiction may commit criminal acts, and they could be held accountable for those actions and face whatever consequences society has outlined for those actions.

5. QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting?

ANSWER:

Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-V) will list gambling disorder in the same section with substance use disorders.

The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This the first time that ASAM has taken an official position that addiction is not solely “substance dependence.”

This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction.

6. QUESTION: Who has food addiction or sex addiction? How many people is this? How do you know?

ANSWER:

We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors. So, anyone who has addiction is vulnerable to food and sex addiction.

We do not have accurate figures for how many people are affected by food addiction or sex addiction, specifically. We believe it would be important to focus research on gathering this information by recognizing these aspects of addiction, which may be present with or without substance-related problems.

7. QUESTION: Given that there is an established diagnostic system in the DSM process, won’t this definition be confusing? Isn’t this competing with the DSM process?

ANSWER:

There is no attempt here to compete with the DSM. This document does not contain diagnostic criteria. It is a description of a brain disorder. Both this descriptive definition and the DSM have value. The DSM focuses on outward manifestations that can be observed and the presence of which can be confirmed via a clinical interview or standardized questionnaires about a person’s history and their symptoms. This definition focuses more on what’s happening in the brain, though it does mention various outward manifestations of addiction and how behaviors seen in persons with addiction are understandable based on what is now known about underlying alterations in brain functioning.

We hope that our new definition will lead to a better understanding of the disease process that is biological, psychological, social and spiritual in its manifestation. It would be prudent to better appreciate addictive behaviors in that context, beyond the diagnoses of Substance Dependence or Substance Use Disorders.

8. QUESTION: What are implications for treatment, for funding, for policy, for ASAM?

ANSWER:

The major implication for treatment is that we cannot keep the focus just on the substances. It is important to focus on the underlying disease process in the brain that has biological, psychological, social and spiritual manifestations. Our long version of the new definition describes these in more detail. Policy makers and funding agencies need to take notice that treatment must be comprehensive and focus on all aspects of addiction and addictive behaviors rather than substance specific treatment, which may result in switching of pathological pursuit of rewards and/or relief by using other substances and/or engagement in other addictive behaviors. Comprehensive addiction treatment requires close attention to all active and potential substances and behaviors that could be addictive in a person who has addiction. It is common for someone to seek help for a particular substance but comprehensive assessment often reveals many more covert manifestations that would be and are often missed in programs where the focus of treatment is substances only or substance specific.