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The 2012 study involved no brain measurements, just DSM criteria. Yet no one is ever sent to rehab because of a brain scan. People are treated because of life problems and distress they have experienced. That's how the DSM-5 is written. Psychiatry's bible includes no defining criteria that refer to brain scans for the simple reason that there are no such defining criteria. Contrary to the claims of neuroscientific enthusiasts such as Charles O'Brien, Howard Markel, and Nora Volkow, you cannot see addiction on an fMRI.
The 2013 UCLA study rejected sex addiction because addicts did not show measurable brain reactions to sex like those cocaine addicts show in response to cocaine. But brain imaging studies of cocaine addiction do not find differences between experienced cocaine users who were addicted and those who were not. In other words, as in the case of sex addiction, a brain scan cannot indicate whether the subject is an addicted or controlled consumer, to what extent he might be addicted, or whether he is ready and able to cut back or quit.
A 2011 New York Times profile of Volkow, aptly headlined "A General in the Drug War," describes her scientific obsession this way: "She must say it a dozen times a day: Addiction is all about the dopamine." Dopamine is the neurochemical graphically imagined to mediate the pleasure centers of the brain, so that people become dependent on dopamine-producing experiences-which include, along with sex and eating, seeing a child smile, meditation, and being in love. But another obvious factor affects addictive behavior: self-restraint.
In a highly publicized 2012 study reported in the journal Science, Cambridge University researchers examined 47 addicted people along with 49 of their nonaddicted siblings. They found that the brains of both the addicted and nonaddicted siblings differed from those of 50 unrelated, nonaddicted people. Here is how Volkow described the results in an accompanying commentary: "The inferior frontal gyrus is really one of the main 'brakes' of our brain. [The drug users and their siblings] have less connections that are linking the rest of the brain with the inferior frontal gyrus that form a network that allows you to inhibit responses." But how does that explain why one sibling is addicted and the other isn't?
Covering the study in Time, Szalavitz made an observation that raises further questions: "Interestingly, the authors note, these connectivity problems are similar to those seen in the brains of teenagers, a group that is characterized by impulsive behavior. It is almost as if the brains of addicts are less mature. Perhaps that helps explain why some addiction wanes with age. Studies find that most people who struggle with alcohol and other drugs in their 20s [age out] of their problems by their 30s, typically without treatment." How is it that the overwhelming majority of people outgrow this brain disease, which the study suggests is inherited?
I'm an Addict, Not a Patient
There is a difference between saying a person with a life-disrupting attachment to something is addicted to it and saying he has a disease. In addition to arguing against unjustifiably restricted definitions of addiction, I have long resisted the excessive medicalization of human problems. This tendency can hurt the very people it is intended to help, as Szalavitz noted in a June 2013 Time essay.
Arguing that "defining obesity as a disease may do more harm than good," she drew an analogy to heavy drinking: "When alcoholism is seen as a disease, doctors and patients are also more likely to believe that overindulging can't be stopped without professional help or attending groups like AA-and that it must be treated with total abstinence. The disease concept wound up creating a ghettoized treatment system aimed only at severe cases, with few options for the vast majority of people with alcohol problems who don't require such extreme measures."
In addition to the question of whether it is helpful to call compulsive eating or drinking a disease, there is the question of whether it is accurate. Some critics of the DSM argue that the lack of biological tests for the disorders it lists undermines psychiatry's putative status as a branch of medicine. Thomas Insel, director of the National Institute of Mental Health, hopes further research will remedy the DSM's "lack of validity." As a May 2013 New York Times article explained, Insel wants to "reshape the direction of psychiatric research to focus on biology, genetics and neuroscience." But as the Times noted, "Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions."
When it comes to addiction, this is not a temporary inconvenience. It's the nature of the beast. Addiction can be defined only in terms of people's experiences and behaviors. There is nothing more scientific about how attached people become to an addictive object-whether heroin, alcohol, sex, eating, video games, or shopping-than to understand how subjectively captivating and powerful it is for them. That's not to say these things are usually or permanently addictive. Addiction is a specific involvement a person forms in a particular period in his life. Nothing more scientific can be said than that.