It would be nice if addiction could talk, or rather, speak in a language we could understand clearly. It would be great if it would just say, “Excuse me, I’m a little low on dopamine tone, please see your doctor for this problem.” Even a dashboard light would be enough, maybe a little red LED under our thumbnail that would light up to tell us we need professional attention. It would be nice, but it doesn’t happen, so we’ll probably have to learn the language addiction does use: symptoms.
Symptoms, I’ve found, come in two varieties. The first are primary (sorry, no pun intended) symptoms directly caused by the neurobiology of lowered dopamine tone in the midbrain reward system. The second are secondary symptoms caused either by secondary neurobiologic changes or that are learned. I’ll give examples of the primary and secondary neurobiologic symptoms I usually see but it’s the learned symptoms I want to get into in greater depth.
I’ve mentioned in other entries what the primary symptoms are: poor attention, poor memory, inability to attach to others, relative anhedonia, restlessness, and feeling like there’s something missing or we don’t have enough. These cause secondary symptoms directly from the neurobiologic changes or by the way we interpret them and translate them into our social and family environment. Examples of secondary biological symptoms are low motivation, feeling inadequate and irritability. What I’d really like to spend some time on are the translated or learned symptoms, basically what our brain learns to say to try to get the message across.
If you think of the midbrain as someone who speaks a different language and the cortex as a translator this may start to make a little sense. The midbrain doesn’t speak English; it speaks Symptom. But the people around us who could be of any help at all are all speaking English (at least in my case) so we try to get the cortex to translate. How that translation sounds depends on a lot of things. Age at onset of the disease, social background, cultural influence, family illness history are all some but not all of the influences on this translation. Think about it this way. If you’re hearing Arabic translated into English, might you not get a different translation from a native speaker than from someone who learned Arabic as a adult. And might you get a different translation from someone born in Indonesia than from someone born in Morocco? So let’s take a look at some of these factors and how they may change the translation we hear.
Age at onset
What I mean here is not age of onset of drug use but age of onset of the primary symptoms. Of course that onset is usually followed immediately by frantic efforts to raise dopamine tone but the first of these is rarely drug use if the onset is in childhood. So what would someone use to raise dopamine tone at the age of three or four? An incomplete list includes: foods high in sugar or fat, getting someone to show us praise, novel stimuli, and feeling more powerful than those around us. So those could get expressed as a sweet tooth, people pleasing, bullying, or thrill seeking for instance.
Of course drug use does occur in very young children. I grew up with someone who was exposed very early to paregoric, an opioid preparation that used to be used for colic and upset stomach in children. He very much liked the effect produced by the paregoric and complained of intestinal problems a great deal. Of course his mother, not understanding he was asking for increased dopamine took him to the pediatrician who didn’t understand he was asking for increased dopamine and treated a spastic intestine that didn’t exist. The midbrain quickly learned that when it needed more dopamine it should have a stomach ache. More about learned symptoms later.
As we lose dopamine tone with age, many people can get the symptoms after they become an adult. By that time they’ll have learned words that express some of the events in the midbrain. They may be able to say they’re anxious or depressed. They may be able to say their feeling picked on because they don’t have enough of anything. In general, they’ll have more resources to express verbally what’s happening in the midbrain, but, of course, they won’t be able to say, “Doctor I have a low dopamine tone in my midbrain.”
How could social status or background matter? Here’s one I’ve noticed. Most kids who can’t pay attention well get pretty sick and tired of getting kicked around for it. “Why can’t you do anything right?” “You never follow directions.” “Your brother doesn’t leave his things laying around.” Who wouldn’t get sick of that? So kids react differently in different situations. The child of two professional who prize educational achievement above all else may learn to compensate with obsessive neatness and note-taking. If you can’t order your mind, at least order your external world so you can’t forget much. The same child born to a family that doesn’t prize education or that can’t afford to support the obsessive reaction will have to develop a different strategy. That’s probably why when I meet a low dopamine person who is obsessive they are almost always from an upper middle to upper class family with highly educated parents. It has nothing to do with the child’s intelligence or attributes, it’s just an epiphenomena of their social environment.
Different cultures will allow different expressions of the symptoms. For instance that kid that had to have stomach cramps to get paregoric would have had to find a different way in a more stoic culture or one that didn’t have access to modern medication. Some cultures will allow the kinds of drugs that kids in our culture can get pretty early, caffeine, nicotine, sugar. Others will not allow those drugs for children. Some behaviors will be acceptable and others not. So while the family is the basic unit of culture, the culture at large can have an effect on the developing illness equal to or greater than that of the family.
Family Illness History
It’s probably easier to be an alcoholic if you grow up in an alcoholic home. Your parents are more likely to see drinking as acceptable and you observe people using alcohol to medicate their emotional state early on in your life. However family illness history doesn’t just predispose to the use of a particular drug or behavior; in some cases it can protect against it. Another boy I grew up with grew up in a home where his mother chain smoked. He’s never picked up a cigarette in his life, not because he had normal dopamine but because he was so disgusted by his mother’s use of the drug. I can’t tell you how many people I meet using heroin or cocaine who’s fathers were alcoholic and who never drank. They hated the idea of turning into their father and thought if they only avoided his drug they’d avoid the outcome. Of course, it didn’t work like that but still that’s their thinking.
So once you see addiction in terms of a biological brain disease you have to start noticing things more subtle than what we usually term a drug. In about 80% of the people I see we can identify something they were using to increase dopamine tone before they picked up the first thing society would call a drug. I think this has important implications for treatment. Up to now, most treatment programs have focused on “drugs or alcohol” to the exclusion of other drugs like nicotine. So a person with addiction may just leave treatment using a drug that will progress his illness more slowly but still progress his illness. It also effects “relapse” rates. It’s been shown that people who stop smoking in rehab go back to using their primary drug less than those who continue to smoke.
While the issue of nicotine and, to some extent, sugar and overeating are becoming more recognized in treatment programs, some of the earliest behaviors are considered part of the patient’s underlying personality and not addressed at all. I think we, as a field, would improve our service to our patients and society if we addressed these early rewarding behaviors as drugs in treatment. We’d get a more complete treatment and a more sober patient. Once we make the decision to address these issues, of course, we’re going to have to go looking for them, rather than wait for the patient to identify them. It would be easier if addiction could only talk.
© Howard C Wetsman MD FASAM