I recently had the opportunity to hear Dr Trevor Robbins of Cambridge, an expert on cognitive neuroscience, speak about the neuropharmacology of cognition. His remarks have a lot to say about how Addiction and recovery are affected by and effect cognition.
Dr Robbins divided cognition into three parts: Input, Representation, and Executive Control. Input is exactly what we think it is, being alert and wakeful enough to perceive with our senses the world around us. Representation is what we do with the product of our senses, how we remember perceptions and link them to other perceptions in memory both long and short term. Executive Control, he broke down into three parts: decision making, decision shifting, and anti-impulsivity. Input first.
It is often said that Addiction is a disease of perception, but that’s not exactly correct according to Dr Robbins’ breakdown. We may perceive the stimulus accurately but are perhaps not paying enough attention. It’s not he eyes or ears that lack function in Addiction, but the brain areas that take the perceptions of the senses and process them. With too little dopamine in the midbrain we cannot adequately pay attention to stimuli. Every day I hear people tell me stories of how they thought they did something they didn’t do or did do something they don’t remember. Here’s an example. A man had the key for his AA meeting and was responsible for opening the door. He arrived a few minutes late so there was a crowd at the door. He unlocked it, set the door to be unlocked and went in with the others for the meeting. Several minutes later he was comfortably sitting in the meeting feeling he’d done a good job of unlocking the door when he heard a banging on the windows. The man when outside and found his sponsor standing by the locked door unable to get in. “I thought you had the key,” his sponsor said. “I do. I unlocked the door,” the man replied. “No, you didn’t,” was the obvious answer. The man thought he had unlocked the door. He had intended to unlock the door. He even remembered unlocking the door. Yet, he did not unlock the door. There was nothing wrong with his eyes or hands. But in his haste he did not pay adequate attention to what he was doing and therefore did not lay down an accurate memory of what he had done. This happens on a daily basis with Addiction. If we aren’t awake, alert, and attentive we will not perceive in our brain what our senses perceive of the world.
This example also has to do with memory which is the second part of Dr Robbins’ breakdown of cognition. He discussed representation of what we sense in our memories. Memory has two parts as he described it: working (or short term) and long term. Working memory is sort of what we do when we are figuring something out. We want to see how it works so we have to represent it in our minds, turn it around and see it from a different angle and at the same time keep the old angle in our minds in working memory. It’s what allows us to see the “whole picture” instead of just what’s in front of us. It often happens that people with Addiction cannot remember the other side of something that isn’t in front of them at the moment. That’s one of the reasons that a common AA slogan is, “This too shall pass.” It’s also the origin of some of the quick rush to judgement that people with Addiction exhibit. If all that’s there is what I see, then I know enough to make a decision. If I forget that there is more to it, I don’t see that I don’t yet know enough to make that decision. Long term memory is also impaired when we don’t have enough dopamine. People with Addicition seem to have difficulty with memory and memory of time.
Finally, executive control is, of course, impaired in Addiction. Decision making doesn’t seem to be much of a problem as noted above, but the second two, decision shifting and anti-impulsivity, are. Decision shifting is the mental flexability to change the decision when the inputs change. An example, “Cocaine makes me feel better for a little while, now cocaine has stopped making me feel better and makes me feel worse, but I’m still acting under the old rules using cocaine to try to feel better.” This happens in lots of life area for people with Addiction. Anti-impulsivity is such an obvious problem that it probably doesn’t need to be addressed except to say that it too is a low dopamine phenomenon.
So Addiction is not just a brain disease of “wanting” or “seeking” but also has symptoms and impairments in the cognitive aspects of life. It makes the need for treatment all the more important.
© Howard C Wetsman MD FASAM