Addiction is not a "disease" (?)

By Razib Khan | August 16, 2009 7:07 pm

Recently I listened to the author of Addiction: A Disorder of Choice, Gene M. Heyman, interviewed on the Tom Ashbrook show. A lot of the discussion revolved around the term “disease”, which I can’t really comment on, but a great deal of Heyman’s thesis is grounded in rather conventional behavior genetic insights. In short, a behavioral trait can have a host of inputs, and is often a combination of environment & genes developing over a lifetime. Alcoholism is not much of an issue among observant Mormons because of their environment, not their genes. Heyman points out that whereas some behavioral phenotypes, such as schizophrenia or autism, are extremely difficult or impossible to cure through one’s own personal choice (i.e., for schizophrenia you may need medication, while many autistics are what they are no matter the drug or environment), addiction therapy can work and so change the expression of the trait. Additionally he makes some important criticisms of the methodologies of clinical studies of addiction which seem important to me, primarily that there is a strong selection bias in these samples which overstates the inability to control impulse in individuals prone to addiction (similar problems probably resulted in an overestimate of the concordance for homosexuality among twins).
But the bigger issue is the same as the one that crops up with obesity, what role does personal responsibility and public policy play? Many of the critics of Heyman seem to be suggesting that he is reverting to blaming someone with an illness. The fat acceptance movement makes similar arguments. These issues, and the fact that policy and culture revolve around them, mean that we have to begin to rethink our conceptions of free will, choice and decision making. It isn’t about people being good, bad, irresponsible or moral, it is people being who they are, and confronting the cards they’re dealt.

CATEGORIZED UNDER: Cognitive Science, Culture, Health
  • http://uponariver.blogspot.com/ Lisa

    I guess the problem is its virtually impossible to distinguish the relative importance of the environment and genotype for a particular trait. Without being able to distinguish the difference, it’s hard to decide whether it’s better for people to ‘know’ if they have these traits.
    If I found out I had a particular set of genes for fatness, would just having that knowledge increase my chances of becoming obese? At the moment, I think I’m at a good weight (a rare thing for a female to think!) although I think I do eat too many chocolate biscuits. However if I found out I was more predisposed to being fat – would I begin eating more biscuits without realising that I was? I could quite easily have genes increasing the risk of obesity, since most of my relatives on my mothers side are obese and I doubt I’ve been lucky enough in the genetic lottery to only get the genes from my father’s side.
    Would I slowly become fatter and fatter? Maybe I would think it was just ‘meant to be’, rather than because I was in fact consuming more sugar and fat. Perhaps some of my ‘free will’ will be taken away, because I will no longer believe I can resist these foods. Would it then be my fault I became fat? Of course it could have the opposite effect, and I might cut out the biscuits completely (although that would be a sad day!).
    Of course this is all hypothetical since I don’t think we will be in a position to tell someone they’re meant to be fat for a long time! But I do think we are currently in a place where people do realise they may be predisposed to things like obesity, and maybe the state does need to think of ways to deal with this, because it could potentially make the problem worse with people feeling they have no choice in how they turn out.

  • http://scienceblogs.com/gnxp razib

    lisa, if you have a predisposition to X which is not something you want, you should change your environmental inputs, right? i don’t seem to have an issue with alcohol addiction, so i drink regularly/socially without much worry.

  • http://www.nvo.com/hypoism/hypoismhypothesis/ Marcus M
  • craig

    Right, I’m Irish (American) and I grew up knowing several alcoholic relatives who had basically destroyed their lives by drinking — lost marriages, lost careers, lost anybody giving much of a damn about them, etc — so I consciously avoided getting drunk or high out of the fear that I might really like it. I got semi-drunk in college a few times, but otherwise always limited myself to maybe 2 beers at a party. Possibly overly paranoid, but seeing a few lives ruined up close will do that. Drunkard, penniless middle-aged men are very, very sad sights to see.

  • dev

    “Perhaps some of my ‘free will’ will be taken away, because I will no longer believe I can resist these foods. Would it then be my fault I became fat?”
    Regarding free will, I think you have to distinguish between micro-decisions and macro-decisions. At the micro level you may encounter chocolate biscuits and face a decision whether or not to eat just one more, and for genetic reasons you might be indeed be predisposed to eat another (or at least, to do so more often than other people might). However at the macro level, as Razib notes, you are free to take any number of actions that would change your environment and make it less likely that you’d over-indulge in chocolate biscuits. For example, you could buy them only in very small packages, have a friend buy them for you and just give you one or two, or not have them in your house at all.
    Having free will doesn’t necessarily imply that you have (or have to have) total freedom of action on every decision, uninfluenced by your personal genetic makeup. In fact, it may be a more significant exercise of free will to order your life at the macro level so that certain decisions at the micro level are avoided or pre-determined for yourself. Daniel Dennett addresses this question in his book “Freedom Evolves”, and notes that “the policy of preparing oneself for tough choices by arranging to be determined to do the right thing when the time comes is one of the hallmarks of mature responsibility”.

  • jb

    I didn’t follow your remark about “an overestimate of the concordance for homosexuality among twins”. Could you expand on that?
    What I’ve heard is that if one twin is gay there is a 50 percent chance the other will be too. This figure is quoted to argue for a genetic component to homosexuality, which seems fair enough. But then the existence of a genetic component is used to argue in turn that gender preferences are fixed, that you are born that way, and therefore there is no need to worry about children being “turned gay” by greater visibility and social acceptance of homosexuality. Nobody every seems to point out that the 50 percent figure in fact implies that the environment has just as strong an influence as genetics, which would seem to suggest that worries are indeed warranted!
    So anyway, I would be interested if you think the 50 percent figure is inaccurate, and if so how.

  • http://scienceblogs.com/gnxp razib

    What I’ve heard is that if one twin is gay there is a 50 percent chance the other will be too.
    probably 25. the original studies were probably selection biased toward twins who were both gay.
    . Nobody every seems to point out that the 50 percent figure in fact implies that the environment has just as strong an influence as genetics, which would seem to suggest that worries are indeed warranted!
    it doesn’t necessarily imply that one can learn to be exclusively homosexual at all (though it might). consider if homosexual orientation is “fixed” during the fetal stage due to a random developmental switch or infection. twins may have a genetic makeup which makes this more likely, but does not guarantee it. but if there is a random element to this then you’ll have a lot of discordance, that is, where one twin is state X and another is state Y.

  • http://entitledtoanopinion.wordpress.com TGGP

    In Mark Kleiman’s recent diavlog with Virginia Postrel he mocked how the disease-model of addiction has no produced no fruit while cracking down on it like a criminal behavior works.

  • http://skeptifem.blogspot.com nails

    The stigma for mental illness is still going strong, and this is certainly part of it. Disease isn’t the most well defined term in medicine anyway. The fight over the word seems really silly to me. I want to toss in type II diabetes to be debated along with alcoholism to show an interesting contrast in the attitudes people display.

  • http://uponariver.blogspot.com/ Lisa

    I agree that if you find you have a predisposition to something you ‘should’ change your behaviour. However, people don’t always behave how they should – I often see my mother who is diabetic snacking on things like chocolate eclairs, telling herself she’s been ‘good’ today so she can eat them. This is despite the fact my grandmother, died at around the age of 40 essentially because she didn’t control her diabetes. She also mocks my uncle who is diabetic, because he has a much more stricter control over his diet than her.
    I think you may see a similar thing with people who think they have a predisposition to being fat. They eat more food than people with a normal weight, often not realising they are (While not a scientific study, I did watch a television program with someone overweight who thought they ate the same as their underweight friend, and in fact this wasn’t the case). Then they blame the fact they are fat on their poorer metabolism etc. I think in many cases people will do exactly what is bad for them, mainly because they kid themselves it’s not their behaviour that’s the problem. Giving someone another reason to think it’s not their ‘fault’ and it’s just in their genes could make the behaviour worse.
    Then again, if I found out I was diabetic I definitely would stop eating chocolates, so maybe it’s easier to change your behaviour when you KNOW it’s bad. With obesity, it’s easier to think you won’t be the one that gets the health complications. If I found out I was more likely to become fat, I would correctly think that since I’m not overweight at the moment and I do eat chocolate biscuits that stopping that behaviour isn’t necessary. Which could then lead to the scenario of me eating more and more.

  • http://www.molecularfossils.com Dan!

    I don’t think homosexuality is really a discrete trait anyway, so I think you’re asking the wrong type of question. If a person has sex with some one of the opposite sex 499 times and once with a person of the same sex, are they gay? What about 50/50? What about virgins, can their “orientation” truly be determined? Isn’t masturbation “homosexual” in the strictest sense of the word?
    Sexuality is a hugely complex behavioral trait, and its going to be a long time before we understand its genetic and environmental components. I think address it in the gay/straight paradigm isn’t helping understand it.

  • John Emerson

    Herbert Fingarette has written about the disease metaphor. The medicalization and therapization of personal and social problems is one of the weak spots of liberalism.
    Once the argument about “free will” vs. cause-and-effect models of behavior arises, the confusion becomes inpenetrable. The cause-and-effect models statistical analyses are not necessarily much good either.
    I haven’t seen Kleinman’s piece, but I’m not sure that cracking down on alcoholism as criminal behavior works that well either. Sweden has minimized a severe problem by heavy taxation and restrictive laws, though.
    I like Dennett’s quote.

  • jb

    probably 25. the original studies were probably selection biased toward twins who were both gay.
    This would be very interesting! Anything you can link to?
    My own suspicion is that homosexuality — like other forms of deviant sexuality that nobody claims are genetic (S&M, for example) — is to some degree triggered by random influences in childhood.
    I base this in part on memories of my own childhood: My interest in the opposite sex was mostly intellectual (I figured out how the plumbing worked quite early) up until puberty, when all of the sudden I actually started to feel it. It just isn’t all that hard to imagine some random encounter — even some random image in a movie or on TV — sending me down the other path!
    The question of when the random environmental influence occurs still remains, and of course if it’s pre-natal then you can still say that people are “born that way”. But if the true number is really 25 rather than 50 percent, the exclusive “born that way” scenario become that much harder to argue.

  • nonuthin

    You cannot will what you want.

  • DK

    Heyman points out that … addiction therapy can work and so change the expression of the trait.
    He is full of shit. For “bad” addictions (ethanol, morphine, nicotine) addiction therapy does not work. Never did. Unless you count 5% success rate as “working”. Truth is, the long-term abstainers that come out of therapies come in two cohorts: those that were ever only heavy abusers, never truly physiologically addicted and those who are white-knuckling it for some time (suffering every day of their life; most of those eventually relapse). That’s your typical 5%. The rest can’t manage even that over tha course of a single year.
    The “incurability” of many “true” addictions isn’t surprising at all. The hard addiction is an imprinting effect – a newly grown population of neurons with a long-term memory of exposure and axonal connections to the reward circuit. Getting rid of the addiction is similar to unlearning riding a bike. Almost impossible to do – unless you are brain dead! And as long as a slightest shadow of memory remains, the Pavlov’s dog inside you is liable to react to all kind of cues and stresses that poise a relapse.
    All of this obviously has a lot of intercepts with genetics. And, while obvious, most of the details remain totally obscure. Giving enough ground to the self-serving assholes like Heyman to declare
    that, basically, all addictions are life style choices and/or moral defects. Do you think Heyman will ever be willing take up a two months heroin addiction course to prove he is right? Personally, I’d give my house to him for just trying it honestly. LOL. It’s easy for me because I know he won’t. No way! This kind of people people never puts their lives where their mouses are.

  • John Emerson

    DK’s post is 100% assertion with no evidence or argument. Perhaps it’s part of a larger, more intelligent debate, but we can’t knbow that from what he or she has written.
    Recovery is heavily ideologized and there’s tons of money in it, so discussions tend to veer off into dogma.

  • http://tumblr.jsoutofbiblepgs.com Elyse

    Who is this Heyman…I’ve never heard of him. Does he have any qualifications relevant to this topic?
    I believe that the current evidence in the fields of motivational theory, psychopharmacology of drugs of abuse, and neurobiology adds up against this guy.

  • DK

    DK’s post is 100% assertion with no evidence or argument. Perhaps it’s part of a larger, more intelligent debate, but we can’t knbow that from what he or she has written.
    Obviously, I am not going to write a literature review for you here. (Particularly because a better done review would be the size of monograph). Do your research, acquaint yourself with the the basics of primary data. If you do have a very specific question or objection, name it and I will be happy to provide a concrete response.
    For now, let me give you a primer: In global health terms, the worst addiction is to alcohol. The largest and perhaps the best study of the best known therapies so far (some of the best drugs with or without the best shrink approach so far) was “Project Combine”. There are many publications but the main one is JAMA, 2006, 295(17):2003-17. Read it. Table 9, entitled One-Year Posttreatment Drinking Outcomes is probably the most damning. To be crude, the summary: Nothing truly works.
    Recovery is heavily ideologized and there’s tons of money in it, so discussions tend to veer off into dogma.
    That’s exactly right. Except that you got it wrong :-) in that the dogma (prevailing meme) is that interventions work. But the actual evidence that they do is slim to none.

  • DK

    To quote Elyse:
    Who is this Heyman…I’ve never heard of him. Does he have any qualifications relevant to this topic?
    Formally, yes. In reality, no. Heyman is a hack who, while having a tenure at Harvard, has a record of original research thinner than that of any half-decent postdoc. His
    I believe that the current evidence in the fields of motivational theory, psychopharmacology of drugs of abuse, and neurobiology adds up against this guy.
    Of course. Only in something as soft as psychology at Harvard can one survive publishing so few papers with so little insight written so poorly. These days, the guy wouldn’t make it out of any self-respecting graduate school. A total joke every way you look at.
    A sample: “The results showed that the persistence of sweetened-alcohol reinforced responding could not be explained by differences in baseline response rates or the reinforcing properties of saccharin. Rather, the findings were consistent with the idea that the rats were defending baseline levels of alcohol-plus-saccharin consumption.”
    Translation: Rats really like ethanol, and they like it even more when it tastes good.
    Another: “Individuals who smoke cigarettes regularly but do not become dependent on them provide a unique opportunity for studying the factors that inhibit drug dependence. Previous research on this population, sometimes referred to as ‘cigarette chippers’, showed that they did not differ from regular smokers in terms of smoking topography (e.g. puff number and duration) and circulating nicotine levels, but that they did show more self-control according to answers on a questionnaire. We evaluated the generality of this finding using a behavioral choice procedure. …[snip - DK] These findings are consistent with the view that chippers are less impulsive than smokers.”
    Translation: Nicotine addicts really are addicted.
    This is the sort of groundbreaking research that allows Gene Heyman to pretend to be an expert…

  • John Emerson

    Obviously, I am not going to write a literature review for you here.
    Nothing but your own arrogance prevented you from giving us a few titles. People at GNXP welcome documentation.
    I really don’t have a dog in this fight. By your tone, however, you are not someone I would expect to get a good answer from.

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This blog is about evolution, genetics, genomics and their interstices. Please beware that comments are aggressively moderated. Uncivil or churlish comments will likely get you banned immediately, so make any contribution count!

About Razib Khan

I have degrees in biology and biochemistry, a passion for genetics, history, and philosophy, and shrimp is my favorite food. In relation to nationality I'm a American Northwesterner, in politics I'm a reactionary, and as for religion I have none (I'm an atheist). If you want to know more, see the links at http://www.razib.com

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