Signs & Symptoms
Addiction Series copied from Psychology Today
Whether the substance involved is crack cocaine or alcohol or a behavior such as gambling, the common denominator of all addictions is continued use despite the development of negative consequences—whether to self, relationships, finances, school or work performance—and the inability to control use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which shuns the term addiction (but nevertheless, confusingly refers to addictive disorders), instead prefers the term substance use disorder, and categorizes 10 distinct such conditions depending on type of drug involved—for example, Alcohol Use Disorder; Stimulant Use Disorder, including use of cocaine; Opioid Use Disorder, including heroin. The DSM notes that all 10 “produce such an intense activation of the reward system that normal activities may be neglected.”
How each type of drug acts in the body is different, but the behavioral symptoms, including those associated with gambling, all overlap. Another common feature is the persistence of changes in brain circuitry beyond any detoxification period; studies show that it can take months or more after stopping use for the brain to rewire itself to respond to normal rewards.
Signs of Addiction Substance use is not, by itself, a disorder. According to DSM-5, widely used as a roadmap to diagnosis, it becomes a disorder when use eludes control and interferes with functioning. Substance use disorder is marked by a pattern of pathological behaviors related to use of the substance.
What are common behavioral signs of addiction? Substance use disorder is marked by a pattern of pathological behaviors related to use of the substance. As listed in the DSM, they include:
• Being unable to stop taking a substance, even when wanting to cut down or regulate use or having tried several times • Worrying about the next dose or getting a consistent supply of the substance • Experiencing intense cravings at any time, but especially in places where the drug was once obtained or used • Devoting considerable time to getting, taking, or recovering from drug • Neglecting roles and responsibilities such as work, school or home obligations • Experiencing interpersonal problems as a result of substance use • Changing social patterns, withdrawing from family, friends and activities in order to use a substance • Facing risky situations to become intoxicated or maintain a supply of drug • Using a substance despite knowing it causes physical or psychological harm to oneself • Developing tolerance, requiring more drug to get an effect; a common but not invariable feature of addiction, sometimes called adaptation • Developing the unpleasant physiologic symptoms of withdrawal—shakiness, sweating, queasiness or vomiting, headache—when unable to take the substance. Withdrawal is a highly variable sign of addiction; it occurs with use of some drugs (alcohol, for example) but not others (cocaine); however, it often drives continuing use. Withdrawal can require medical treatment when a person abruptly stops heavy substance use.
Along with the diagnostic signposts of addiction, those addicted typically display a number of other behavioral characteristics: • Secretiveness about activities and relationships as well as private space, to conceal drug use • Sudden changes in activity patterns, refusing participation in activities once enjoyed • Lying about whereabouts, absences, consumption habits; making excuses for unusual behavior • Loss of energy or motivation • Neglect of appearance • Stealing to support drug purchases.
What are the psychological signs of addiction? A cardinal sign of addiction is not being unable to control consumption of alcohol/drug—even when wanting to. In addition, addiction is typically marked by urges or craving—wanting a substance so badly it becomes difficult to think about anything else. Intoxication has its own distinctive psychological manifestations—from belligerence and mood lability to impaired judgement and “absent presence.” They result from the effects of the substance on the central nervous system. Those who are high also display perceptual disturbances, problems with attention, disrupted thinking patterns and easy confusion, as well as difficulties relating to others.
In the grand scheme of things, addiction is considered an attempt—a nonproductive attempt—to solve a problem; it offers relief from shyness, relationship difficulties, shortage of opportunities, losses and failures of any kind, and much more. From that perspective, it is a sign of inability to cope with a stressor; behind the psychology of addiction is a sense of powerlessness, and it always a sign that better stress-management skills are needed.
The Experience of Addiction At some point, addiction becomes a trap of endless repetition that loses whatever allure it once held. As addiction progresses, the psychological and life problems it causes tend to increase—and the trap can feel too deep to climb out of. However, it is almost always possible to stop use and begin recovery.
Do you have to be addicted to experience problems? The experience of problems is central to the diagnosis of addiction. As repeated use of a substance accelerates motivation to seek out and use the agent, people typically suffer negative physical and psychological consequences and, in neglecting roles and responsibilities, experience difficulties and disruptions in their family, social, and work lives. They may also face increasingly dangerous situations in pursuit of a substance supply. Independent of the addictive process, problems can also develop from the taking of any chemical substance.
Illegal drugs pose special risks of toxic contamination and/or accidental overdose as a result of substitution with underground agents of unknown potency. The recent rise in opioid deaths, for example, is attributable to a shift from prescription painkillers to the cheaper and often more readily available street drug heroin. Unbeknownst to users, illicit drug manufacturers often adulterate heroin (and the stimulant cocaine, and many other substances of abuse) with the synthetic painkiller fentanyl, which is not only cheaper but 30 to 50 times more potent than heroin, increasing the likelihood of respiratory problems. According to the U.S. Centers for Disease Control and Prevention, fentanyl is the drug most often involved in fatal overdoses in the U.S.
While consumption of any illicit drug can be dangerous from a toxicological perspective, it can also create problems from a behavioral perspective. Intoxication with alcohol is a major cause of traffic accidents and violence to others.
What does physical dependence mean? There is considerable confusion even among professionals about many of the terms relating to addiction, in part because many terms are used broadly in popular culture but have more specific clinical meaning, and also because, historically, the psychiatric diagnostic bible, the DSM, has used various terms, including dependence, to mean addiction, with the intent to avoid the stigma attached to addiction.
There is an important distinction between drug addiction vs. drug dependence. The term dependence refers to the fact that the brain has adapted physiologically to the substance of abuse. That adaptation, achieved through changes in brain receptor sensitivity and neurotransmitter balance, is manifest in tolerance—requiring larger doses of the agent for effect—and in withdrawal, the onset of any array of unpleasant symptoms when the substance is abruptly discontinued. Dependence specifically refers to the effects of the process of neural adaptation to a psychoactive substance. It is a common feature of addiction, but not the totality of the more complex disorder.
It is possible to be dependent on a substance without being addicted. Physiological dependence can occur with many different kinds of substances, including common medications. It’s also possible to be addicted without being dependent. Tolerance and withdrawal are not universal features of substance use disorder; hallucinogens, for example, do not create tolerance or withdrawal symptoms.
Does psychological dependence exist? Psychological dependence is a term sometimes used to indicate the mental processes of addiction, but it has no real meaning given current understanding of the way the brain works. There is no real difference between physical addiction and psychological addiction. Addiction is one of those conditions that demonstrates it is not possible to distinguish between physical and psychological aspects of behavior.
Nevertheless, some people erroneously believe that processes such as withdrawal are distinctly physical while other feature of addiction, such as drug cravings or the inability to stop using a substance, are purely psychological. In fact, inability to regulate use results from a physiological process—progressive weakening of the neural circuitry in the brain’s executive control center in response to repeated use of a dopamine-activating substance. Cravings, or deep desire for a substance, arise from alterations in reactivity patterns of nerves in the brain’s reward center.
Confusion arises in part because of historical misunderstanding: It was once thought that withdrawal was the defining feature of addiction and every other aspect of addiction did not reflect physical processes. It is now known that withdrawal symptoms are not an invariable feature of addiction—they do not occur with addiction to hallucinogens, for example—and that all facets of addiction reflect physical changes in brain circuitry, and those changes are reversible after substance use stops.
What do drug cravings mean? Cravings are intense desires for a substance and motivate the repeated seeking of the substance and its effects. They are typically viewed as a sign of entrenchment of the addiction process. Cravings intrude on thought processes, create considerable distress, and focus attention on immediately satisfying the desire for the substance. Cravings can be seen in brain imaging studies as areas of heightened activity in the reward center of the brain in response to specific environmental signals that have been connected to drug use through experience.
Cravings occur when the brain remembers drug use. They can be set in motion by past memories or current environmental cues relating to substance use and are thought to be a force behind relapse, although they are not a clinically consistent predictor of relapse. Any cue with emotional significance registers on the brain's amygdala, which then activates the nucleus accumbens and its dopamine neurons. Their activation gives rise to the sense of motivation, experienced as a highly focused urge to seek the substance.
There is no objective measure of the strength of cravings, but they are highly dynamic and fluctuate, varying in intensity and duration in any individual throughout the course of a day. They naturally rise and fall over several minutes, and many treatments for addiction train people in techniques for outsmarting cravings or distracting themselves from drug cravings until they lessen in intensity.
Do all drugs create withdrawal symptoms? Withdrawal symptoms occur when drug use is abruptly stopped or the dosage is sharply diminished. They occur because the brain is an adaptive organ (which permits learning of all kinds), and in response to the repeated presence of a psychoactive substance, the brain undergoes changes in neurotransmitter activity and receptor sensitivity in various systems. When use of that substance stops abruptly, cessation disrupts all the adaptations to that substance the brain has made; over time, it will adapt to absence of the drug—but that process takes time.
The clinical manifestation of abrupt cessation of a substance of abuse is withdrawal. Symptoms of withdrawal range from sweatiness, shakiness, tremors, and seizures to upset stomach, diarrhea, and vomiting. Irritability, agitation, restlessness, and sleep disruption are common withdrawal symptoms for many drugs as are muscle cramps, headaches, and changes in blood pressure and heart rate. Drug cravings can be fierce, and fear of withdrawal symptoms often drives continued drug use.
Withdrawal symptoms do not occur with all substances; for example, stopping hallucinogens or marijuana does not typically lead to withdrawal symptoms. Further, the intensity of withdrawal depends on the amount of drug usually taken and the duration of its effects. Withdrawal from such drugs as heroin, painkillers, alcohol, and benzodiazepine tranquilizers can be life-threatening, and medical supervision is generally advised.
Why do I feel like I’ll never be able to stop? Substances of abuse deliver an intense sensation that creates a neurochemically driven motivation to repeat the experience again and again. At the same time, the repeated use of a substance that delivers the intense (if short-lived) reward of a chemical high weakens the decision-making and impulse-control centers of the brain, making it difficult to resist cravings. Many drug users have made many promises to themselves to stop—and broken them as well, leading them to believe they are incapable of stopping. Users, too, commonly experience negative life effects of addiction—whether to relationships, work, or in other domains, and the painful feelings of self-disappointment and shame trap them in negativity that further erodes hope and finds fast relief in the drug high.
What is the course of addiction? Addictive disorders, including alcohol use disorder, most often begin during late adolescence and early adulthood, when there is increased risk of use of many psychoactive substances. Many people “mature out” of addictions by their 40s. According to the DSM, addictive disorders are often wrongly perceived as intractable conditions because those who present themselves for treatment typically have a long history of use and failed attempts to control substance use.
Statistics indicate that most people experiencing addiction achieve complete recovery and do so without seeking clinical services. According to the latest U. S. National Survey on Drug Use and Health, more than 75 percent of people addicted to alcohol or drugs recover. Increasing age is associated with decreased prevalence. Addiction is often marked by multiple periods of abstinence and relapse. It is common for people to make many attempts at recovery before succeeding, and many experts in fact view relapse as a normal part of the recovery process.
Next in the Series: Causes of Addiction
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SOURCE: Addiction | Psychology Today (Clickable Link)