The Addicted Brain
Joseph Vollaro, Ph.D
Assistant Professor of Psychology,
Suffolk County Community College
Executive Director, RES Company, Inc.
DSM –IV Criteria for Substance
Abuse
A. A maladaptive pattern of substance
use leading to clinically significant
impairment or distress, as manifested by
one (or more) of the following, occurring
within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, or home (e.g.,
repeated absences or poor work performance related to
substance use; substance-related absences,
suspensions, or expulsions from school; neglect of
children or household)
(2) recurrent substance use in situations in which it is
physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g.,
arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (e.g.,
arguments with spouse about consequences of
Intoxication, physical fights)
B. The symptoms have never met the
criteria for Substance Dependence for
this class of substance.
DSM-IV Criteria for Substance
Dependence
A maladaptive pattern of substance use,
leading to clinically significant
impairment or distress, as manifested by
three (or more) of the following,
occurring at any time in the same 12month period:
(1) Tolerance , as defined by either
of the following:
(a) a need for markedly increased
amounts of the substance to
achieve
intoxication or desired effect
 (b) markedly diminished effect with
continued use of the same amount of the
substance

(2) Withdrawal as manifested by
either of the following:
(a) the characteristic withdrawal syndrome
or the substance (refer to Criteria A and B
of the criteria sets for Withdrawal from the
specific substances)
(b) the same (or a closely related)
substance is taken to relieve or avoid
withdrawal symptoms
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(3) the substance is often taken in larger amounts or
over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to
cut down or control substance use
(5) a great deal of time is spent in activities necessary to
obtain the substance (e.g., visiting multiple doctors or
driving long distances), use the substance (e.g., chainsmoking), or recover from its effects
(6) important social, occupational, or recreational
activities are given up or reduced because of substance
use
(7) the substance use is continued despite knowledge of
having a persistent or recurrent physical or psychological
problem that is likely to have been caused or
exacerbated by the substance (e.g., current cocaine use
despite recognition of cocaine-induced depression, or
continued drinking despite recognition that an ulcer was
made worse by alcohol consumption)
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Specify if:

With Physiological Dependence:
evidence of tolerance or withdrawal (i.e.,
either Item 1 or 2 is present)
Without Physiological Dependence:
no evidence of tolerance or withdrawal
(i.e., neither Item 1 nor 2 is present)
If drinking is interfering with your work, you're probably a
heavy drinker. If work is interfering with your drinking,
you’re probably an alcoholic.
~Author Unknown
Addiction continues to be a
growing problem in our society!!
– 8% of the population are believed to be users of
illegal drugs (Substance Abuse and Mental Health
Services Administration, 2003), despite numerous
“Wars on Drugs”
Did you know America ranks the lowest in education
but the highest in drug use? It’s nice to be number one, but we
can fix that. All we need to do is start the war on education. If it’s
anywhere near as successful as our war on drugs, in no time we’ll
all be hooked on phonics.
~Leighann Lord
– Even legal drugs and their devastating effects
 Obesity
– 25% of Americans are Obese (Mokdad, et, al, 2003)
 American Obsessions: Caffeine, Television, Internet, Sex,
McMansions
– Even legal drugs and their devastating effects
 Obesity
– 25% of Americans are Obese (Mokdad, et, al, 2003)
 American Obsessions: Caffeine, Television,
Internet, Sex, McMansions
If addiction is judged by how long a dumb animal will sit
pressing a lever to get a ‘fix’ of something, to its own
detriment, then I would conclude that Netnews is far
addictive than cocaine. ~Rob Stampfli
To cease smoking is the easiest thing I ever
did. I ought to know because I’ve done it a
thousand times….~Mark Twain
Addiction is nothing new..it has
been with part of the human
condition from the beginning
of time.. researchers continue
to ask that age-old
question…….Why?
Thou hast the keys of Paradise, oh, just, subtle,
and mighty opium!
~Thomas De Quincey,
Confessions of an English Opium-Eater, Part II
In 1990, George Bush declared
the 90’s the decade of the
brain……leading to an explosion
in the field of Neuroscience
This has lead to an explosion of
knowledge related to how our brain
affects all aspects of our life and
functioning….including in the field of
Addiction
 As our knowledge has progressed, it has
become clear that substances that have
the power to make us feel good seem to
share some remarkable similarities once
they hit the brain
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It is important to note, that the
best explanation of addiction is the
Biopsychosocial Model. As
Lyvers (2000) states:
“ The identification of underlying biological
mechanisms in addiction does not render
psychosocial factors irrelevant, but rather implies
that such factors may interact in important ways
with biology, as it is widely acknowledged in the
currently popular biopsychosocial perspective.”
As providers of services to individuals with
Traumatic Brain Injury (T.B.I.), it is not
uncommon to receive a referral for CIC/IBP
services, or more because:
-Consumer has begun to use a drug
compulsively
-The consumer has lost control of their
behavior
-Use of the substance begins to affect their
decisions, health, finances, and presonal
relationships
Which addiction is a problem for our
society, it is of particular concern in
people with disabilities….
OASAS
(1997)- 22.4% of the clients served had a
coexisting physical/mental disability
Many people believe that this number reflects a great
underreporting!
Why are people with disabilities more likely to experience
Substance use Disorders?
-Unemployment
-Lack of recreational activities
-Social isolation
-Homelessness
-Victimization (i.e. physical, psychological abuse)
THE ADDICTED BRAIN: the
Disease Model of the
Alcoholism:
Addiction is not a character flaw, or a sign
of weakness, but a disease, similar to
other psychiatric diseases, whose etiology
can be better understood by
understanding brain functioning in the
addiction process
At the very center of this model is
the idea of the Pleasure Center
(Olds & Milner, 1954 )
Using the brain stimulation
paradigm, they came to the
following conclusions:
•Electrical Stimulation of the brain could be experienced as
pleasurable or rewarding
•An area known as the Nucleus Accumbens played a
major role in this response
Subsequent experiments have demonstrated
animals will take drugs or choose electrical
stimulation of the brain at the expense of normal
activities (i.e. eating, sleeping) and that they
come to prefer an environment that they associate
with the drug
Led to the formulation of the idea of a brain
“Pleasure Center” which gives new meaning to
the word “To Die for”
Much work subsequent to this has established that
a class of neurotransmitters, known as the
catecholamines, which includes
Norepinephrine, Epinephrine, and Dopamine,
seemed to be involved
Of particular interest, is the neurotransmitter,
Dopamine, whose activation in the area of the
brain known as the Nucleus Accumbens, appears
to be a common denominator in many drugs of
abuse
Newer theories of addiction suggest
that overtime, humans have either
discovered or manufactured
substances that hijack this system,
creating addiction
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A common question that evolves from this
idea is Why would we have such a place
in our brain to begin with? The answer to
this question comes from the theory of
evolution!!
– According to Darwin, our ultimate goal is
survival of the species
– Thus, it is believed this “reward system” has
evolved as a mechanism to reinforce
behaviors that facilitate the survival of the
species (i.e. eating, drinking, sex)
Studies have begun to compare how
different activities affect the level of
stimulation in this system with some
very interesting results!!!!!
Level of Intensity: (from greatest to
least):
–
–
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–
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Addictive Drugs
Sexual Activity
Eating
Exercise
Mediation, Spirituality, Deep thought, Art, Music,
Nature, Socialization
The Addicted Brain: A macro view
The Major brain
areas included
in Addiction
include:
 Nucleus
Accumbens
 Ventral
Tegmental Area
(VTA)
 Prefrontal lobe
 Limbic System
Nucleus Accumbens: release
of Dopamine in this area seems
to be related to the experience
of intense pleasure
Ventral tegmental area:
– When stimulated, sends a
signal (release of
Dopamine) to the Nucleus
Accumbens, and then,
through the process of
reuptake, ends this signal
– Also is involved in what has
become known, as an
Anticipatory signal
 If this anticipation can’t be
fulfilled, it might be replaced
with another behavior
 It is believed many forms of
addiction begin here!
Prefrontal lobe:
– Willed actions are associated with this area, in
contrast to “routine” or “automatic” tasks
– Mediate or inhibit these relatively automatic or “fixed
action patterns”, giving these behaviors certain
flexibility and relative independence from the
environment
– Damage to this area can lead to
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Disinhibited behavior
Perseveration
Failure to assess consequences of ones actions
Apathy
Poor self-monitoring
Limbic system:
– Amygdala; primitive emotional responses (i.e. anger,
surprise, fear, novelty)
 We recall how well we feel when we satisfy the addiction
(i.e. good feelings around Xmas, birthday, Hanukah, many
years later)
 This at times overwhelms our logic!
 This explains why stimuli associated with addiction (i.e. a bar,
friends, neighborhood, drug paraphernalia)
– Hippocampus
 Long term potentiation (LTP): physical process in which
memories are formed- relies on the neurotransmitter
Glutamate
THE ADDICTED BRAIN: THE
MICRO VIEW
Plasticity of brain function: the fact that the
brain changes permanently in regards to
both internal and external stimulation
Psychopharmacology and Plasticity are
beginning to provide an explanation of two
characteristics associated with addiction:
Tolerance and Withdrawal
The mechanisms of how these
drugs exert their effects in the
brain are well worked out. There
are two main ways this occur:
1. Increases the activity of these
systems by mimicking the activity of the
drug:
2. Inhibiting re-uptake of the drug, causes
a longer, stronger signal
– More recent evidence has begun to help
us understand other aspects of addiction
– Tolerance and withdrawal occur, because,
in the initial stages of addiction, frequent drug
use can initially suppress parts of the brain’s
reward system by activating a substance
called dynorphin, whose function it is to loop
back and inhibit (“turn off”) the VTA
 This makes the same dose of the drug less
rewarding
 Also contributes to a growing depression, as the
person begins to experience Anhedonia, failure to
take pleasure in previously enjoyable activities
– The next stage: Sensitization
 Recent work has identified a substance, Delta Fos
B, whose concentration rises in the Nucleus
Accumbens and other brain regions in response
to chronic drug use
 This protein is extraordinarily stable, thus, remains
active in the neurons for weeks and even months
after drug administration
 It is believed that prolonged induction of this
molecule causes animals to become hypersensitive
to drugs
The next step is highly speculative
at this point:
 Prolonged exposure to drugs in animals
has led to additional “sprouting” on the
dendrites of the Nucleus AccumbensDelta Fos B may lead to these changes,
thus, when its’ levels return to normal it
has left a lasting “impression’ on the
brain
ADDICTION AND THE FRONTAL
LOBES
– Some theorists have begun to look at
addiction in a behavioral sense as a loss of
self-control
– Self control, or inhibition, is considered to
be one of the aspects of functioning known as
the Executive Functions:
 Self-control, delay of gratification, drive inhibition,
and anticipation of future consequences
 Environmental dependency syndrome
(Lhermitte, 1986): With those who have frontal
lobe damage, behavior becomes largely a function
of external stimuli
– Evidence now suggests frontal lobe dysfunction is
associated with a host of disorders including Autism,
ADHD, OCD, and Schizophrenia
– There have been a number of studies examining the
effects of Chronic Alcohol use on the brain
 Volkow (1994): Chronic alcoholism is associated with
abnormally low frontal cortical metabolism, more specifically
orbitofrontal areas, which gradually improved with month of
abstinence
 Studies have also indicated that these decreases tend to
outlast the withdrawal phase, despite the initial improvement
 Excessive Dopamine release and overstimulation of
Dopamine receptors in the prefrontal cortex have been
shown to impair prefrontal-cortex dependent cognitive
functions in laboratory animals (Arnsten & Goldman-Rakic,
1998)
 Similar short-term and long-term effects have been found
with other substances, such as, Cocaine and the Opioids
Putting it all together:
In addition to causing the experience of pleasure,
the Dopamine system by virtue of its’ connections
with the frontal lobe, can help explain some of the
behavioral results of long-term substance abuse
It has been suggested that the Mesocortical
Dopamine System serves to take the prefrontal
cortex “off line” during stressful events so that
faster, more automatic or instinctive processes
mediated by the limbic system
o
Acute depression of prefrontal lobe activity due
to excessive inhibitory mesocortical
dopaminergic neurotransmission evoked by
drugs is increasingly accompanied over time by
sensitization of dopaminergic transmission and
perhaps chronic neurotoxic drug or dopamine
actions on the frontal lobes, should significantly
reduce the inhibitory control exerted by
prefrontal cortical areas over posterior cortical
and subcortical systems mediating reinforcement
and automatization of behavior (Tiffany, 1990).
Leads to impaired control over drug use
and behavior in general