Video Transcript: Marc Lewis Presentation on Addiction

There's three regions you have to think about. First is the prefrontal cortex. And in particular, the dorsal lateral prefrontal cortex is the most sophisticated region up here. And it's responsible for judgment, decision making, perspective, taking self regulation, all that good stuff. And you can think of that as the bridge of the ship. That's where we steer our behavior that says where we steer ourselves from. So there's that region and then there's the striatum, the which the ventral striatum is sometimes called the nucleus accumbens, you'll see that a lot in the addiction literature. And we can call that the motivational engine. So the striatum evolved as part of the motor system, and it actually gets, smells, to act and to basically pursue goals because that's what we do. And we act we pursue goals, the goal might be getting away from something. But in this case, let's focus on getting toward something. And it also generates the motivation for doing that. So mammals. like unlike frogs, need a push to get them to do something and then a motive or an emotional drive. You know, we don't just flick out our tongues when a fly goes by, we have to have feel some kind of attraction. And that is generated by the striatum. So you can see that that's an important region of the brain when it comes to addiction. And then the the this part of the midbrain, the ventral tegmental area, is, you can call it, a dopamine pump. It manufactures dopamine, which is a neurochemical, you'll often read about in addiction studies. And what dopamine does is it basically does a lot of things but it partly it energizes the striatum, it turns on all the cells in the striatum and it gets the striatum to focus on the goal. So it narrows the beam of attention. And it drives behavior toward the goal. That's what it does. It focuses and drives behavior and allows you to follow a sequence of steps that leads to the goal that you're after, the particular goal.

So what happens in addiction is that you get a lot of dopamine coming up from the midbrain, to the striatum in the presence of drugs, or booze, or gambling, or sex, or porn or pizza, whatever it is, that you're addicted to. The striatum is activated and becomes focused on the goal. And that happens again and again and again. And it happens in response to cues or stimuli that are connected to the activity of choice, the thing that you want. Okay, so then, the other issue is that there is naturally a balance between striatal activation and prefrontal cortex activation, because you need to control these impulses. And we do, you know, all the time, every moment of our waking life, pretty much there's some kind of balance between impulse and control . self regulation, modify behavior in favor of better consequences in the long run. And in addiction, what happens is that this bundle of fibers that connects these two regions, it becomesless crosstalk so there is a reduction in the communication between the striatum and the prefrontal cortex. And what happens over time is that these two systems become less connected. You can even think of them as being somewhat  disconnected from each other. When in the presence of drugs, or cues or other other stimuli associated, it doesn't mean that this disconnection is always there. Because you can live a very normal life and do very normal and well planned things  that require judgment and logic, but when those cues are around, when you're driving by, walking by the pub, or the liquor store, or you know, your your dealer calls, that's when this disconnection occurs, time and time and time again. So that's the problem, right? There's a big problem, we all agree that it's a big problem. So this is what this is a graph showing what happens when people take drugs like cocaine, alcohol and heroin. Yes. For some period of time, and over time, what you get in certain regions, according to a number of different labs, you get actual reduction in gray matter volume in some of these regions of the prefrontal cortex, dorsal prefrontal cortex, that's a very closely related region called the anterior cingulate cortex are very connected. And what this shows is that gray matter volume drops with the duration of the addiction. Okay, so this dotted line is the population baseline, the normal population that people who've never been addicted, this line shows what happens with addicts. And the loss of gray matter volume means that they're losing synaptic density, they're losing synapses are not brain cells are not dying, you're not cells are not dying, but the connections you're losing the density of connections is decreased over time. Okay, so that's, that's a pretty important finding. And well, it sounds like a disease, right? It sounds like it's something is really going wrong with the brain. So why not call it a disease? Well, because that's what the rest of the talk is. It's the because so here, and that's my book, which is available in the lobby only here in the UK, the cover is white. It's a big difference. And it's also in paperback.

Okay, so what I want to do is not to challenge the neural data, but to reinterpret it and to try to figure out what's wrong with the interpretation. The data are pretty solid. So the first point is, I'm a developmental psychologist by training, and I've thought about changing brains throughout most of my career. If you study child development, of course, it's an obvious thing that brains change radically from infancy through through adolescence into adulthood. I mean, that's how we learn language and communication and everything else we learned, the brain is obviously changing. That's what it's for. It's a flexible organ, it's not designed to stay the same like a liver or a heart or a kidney. But so the question would be that, if brains change with learning and development, then brain change by itself doesn't necessarily mean bring in disease. So the next question is, and by the way, brains don't stop changing at the age of 20. But they probably change less after that age, after things kind of solidify. So, so the question is how do bralns change with development. And this, this cute little movie shows an average of MRI scans of different kids at different ages from the age of four to the age of 20. And what we're looking at is the density, the thickness of the of the cortex, the actual thickness and synaptic density in the cortex. And we want to see how does it change from the age of four to the age of 20. So it's an eight second movie, so you have to pay careful attention. But I'll show it again, though. So take a look first, to get a sense of it.

It's pretty. So you see, what happens is the brain turns blue, this development. Okay, I, I was hoping that would go over with a British audience because I thought it's sort of a Monty Python-esks type of type of line. So I'm glad it worked. Okay, no, it doesn't really change blue, he turned blue. Here's the scale. And it is a scale showing gray matter amount of gray matter density. And if we go back here, the the, the the light colors, yellow, and green, and so forth shows thicker, the thicker cortex, and the blue and purple color show thinner cortex. So as the brain gets more blue and purple, it's getting thinner, the cortex is getting thinner. And this is counterintuitive to some people, you might expect the opposite. So here we go, starting in infancy. And it's losing synapses, it's losing 20 to 50% of its synapses, because there's a huge overabundance of synapses in infancy. It's why infants are so confused. And so, you know, they're, I mean, well, they're just kind of out of it, right? Because they have too many synapses. And so what happens was development is that you get this change and what's going on, we call it synaptic pruning, and what's going on is that different regions at different times.,Okay, so here's 4, 6, 8, 10. Let's catch the brain right there. So now the sensory motor strip is now pruned and matured, the orbital frontal cortex, the bottom of the prefrontal cortex is matured, because that's really important for processing emotional information. But this part, and this part, these are Association cortex are more sophisticated, more advanced regions of cortex, and they're not finished pruning yet. And I want you to see that this is the last part to go, this is the dorsolateral prefrontal cortex in charge of judgment and perspective taking, okay, just watch it, and you'll see that it's the last to prune up. Okay, and finally, it does. So that means that by the time you're 20, you can actually think straight, but not before. Okay, so that's the brain change was developed. And just to give you an idea of what what it looks like to see, to see what pruning looks like the big picture and development. But development and learning are actually very similar. They're almost almost synonymous. And they simply involve two processes, two mechanisms. One is synaptic growth, and one is synaptic pruning, you get a proliferation of synapses, or synaptogenesis. And then you get pruning of synapses, which I just showed you. And the balance of those two mechanisms is development in the brain in the cortex, that's development, there's nothing else. And I think of it as being kind of like the ivy on the garden wall, which starts off you know, quite chaotic and disorganized. And then that would be parallel to synaptic growth, and you get novelty and new associations and increasing knowledge and skills and you learn to play new keys on the piano and you learned to be whatever he learned all these new skills. And then with development, you get more and more pruning. So you get consolidation, more efficiency and habit formation. That's what pruning is for us, to make the brain more efficient. So the focus is so that several, the really important pathways, become entrenched. They become myelinated. They convert and send signals much more rapidly and the unimportant synapses just fade and disappear. 

So if you think about, if you think about addiction, in terms of synaptic pruning, then this decrement in prefrontal and in the density of synapses in certain prefrontal areas, this decrease in synapses can be thought of as part of a bigger picture. And then we shouldn't be surprised if that's a developmental progression. We shouldn't be surprised by further synaptic change if people stop. And in fact, that's what this particular study found. is that with abstinence from from both alcohol and heroin, you get an increase in gray matter volume. In very similar areas, they're not exactly the same, the brain never actually goes backwards. In development, that just doesn't happen. But it goes forward. And there's increasing growth and increasing synapses and new regions that are closely related. And they're probably very much involved in self regulation, impulse control, because that's what people need to learn when they start taking drugs. And notice that within within one year or so, the curve the line crosses the non addicted average, the baseline. And so you actually get increasing synaptic density over and above the general population in those regions that seem to be responsible for self control. That's what happens when people quit. And by the way, I should just note that addicts generally do quit, not everybody knows that. But the majority of addicts for any kind of substance and even heroin end up quitting. And it varies the timeframe and the proportion varies with the substance. With cocaine, the average duration of an addiction is four years with marijuana, if you smoke it compulsively, it's six years; with alcohol, it's 15 years. And with tobacco, it's 25 years. So that's a really evil one. On average, if you start smoking today, on average, you will stop in 25 years. Good thing.

Okay, so, lots more change happens when people's habits changed, when their behavior changes, when they stopped taking whatever it is they're taking. So I would say that addiction is sort of a kind of skill. The addicts brain learns to efficiently identify and aim behavior, there's less prefrontal activation, because it's the same behavior or routine repeating itself day after day, hour after hour. There's very highly consolidated habitualized, ritualized forms of behavior in place of having to wonder and think and judge and consider and compare and all that stuff that most of us do most of the time. It's a strange way to think of addiction. But I think it really is like that, it's a kind of a skill, a very nasty one, obviously, but still. And then we should recognize that new skills, or the formation of deep habits, always change the brain. It's not just addiction. So what are some examples? Well, driving a taxi in London is one of the classic ones. You've probably heard that London cab drivers have a hippocampus that's in part of the brain in charge of, of memory, certain kinds of memory, which is 20%, more dense, or more heavy than normal people. Why? Because they have to learn the location of like 1000s, 10s of 1000s of streets: will probably not anymore if they just have GPS. This this finally came came from a few years ago, and it's been replicated many times. So that's kind of cool. And we know other things about the hippocampus, that it's actually decreased in volume from post traumatic stress and, etc. But let's move off the hippocampus and talk about falling in love.  When you fall in love, there are all kinds of changes to the brain, there's increased dopamine to the striatum, there's more activation of the ventral striatum. There's more synaptic patterns. And of course, those patterns represent the loved person. This is like an addiction, in the sense that you have repeated behavior, day after day, in which the emotional appeal of that other person is highlighted is emphasized. All you can think about is their good points at first. Kind of like with heroin. And there's there's lots of research research showing that not just humans, but even with rodents, Prairie voles, you get increasing dopamine flow to the to the ventral striatum, when they are mating when they're in the process. Prairie voles are studied because they are monogamous, and one of the few monogamous mammals. So their romantic habits have been studied in some depth, because that's supposed to be like humans, but it's up for debate.

Okay, so falling in love and mindfulness meditation practice changes the brain. There's been a lot of research on that in the last 10 years. If you're a brain nerd, you might be interested in the default mode network, which is a network which processes information that has to do with self reflection. Thinking about your past, thinking about your future and rehearsing patterns that have to do with your own activity in your own self and is mindfulness meditation, reduces activation in the default mode network. Okay becomes it becomes muted. activation because there's just not as ego involved. And you know this is like a fascinating area of research. All these other behavioral addictions change the brain, I'll get to that in a minute: binge eating, binge drinking, binge anything, binge shopping, change the brand. And psychotherapy changes the brain. I started looking at this just recently, I thought, well, I'm talking about brain change. And I'm saying everything changes the brain, anything that's important. And that really changes the way you function in the world is going to change the brain in a more measurable, recognizable way. And so psychotherapy should do it. And in fact, I found lots of literature on that, their studies with CBT, their studies with other forms of psychotherapy, showing brain change. And then I thought, wait a minute, I used to study that! I was an old academic. I used to do research with kids who had problems with anxiety and aggression. And we would we would look at their brains with what's called dense array EEG, you know, EEG is a dense array means there's like 128 channels, so you can get kind of a pretty good picture of the spatial, the anatomical story, as well as the temporal story of brain activation. And so we put nets on these kids before and after this three months period of treatment. And I think, well, the ones who improve should show brain change, and then do they? They do, I'm not even gonna bother trying to interpret that, it's too difficult. That's what average ERP eg looks like. It's an event potentials or event related potentials. But here's the gist of the story. This graph shows, pretreatment, post treatment, this is mean activation in the ventral region, this is right tucked down in the ventral part of the prefrontal cortex and the close by areas and probably the amygdala, you can't get quite that fine with with EEG, even with source analysis. But what we see here is that the those who did not improve behaviorally, who got the same scores for aggression and anxiety after the treatment, showed no change. Those who did improve showed a pretty significant drop in the activation of these areas. Well, what does that mean? That means they're not using this part of their brain as much as they used to. And that's a good thing. Because when you're using this part of your brain to modulate your interactions with other people, then they're tinged with anxiety and defensiveness. And you can then just flash into into anger if you're provoked.

So so a lot of stuff changes the brain. These are other slides. Other pictures we got from that study, this just kind of gives you an idea of a topographical map of EEG, for younger kids and older kids. And the loss of the reduction in activation with age looks fairly similar. With the loss of activation with successful treatment is a complicated story. I just wanted to give you a sense of it, just a glimpse of it. Okay, so the other interesting thing is that not only addictions to substances, but also behavioral addictions change the brain in almost exactly the same way as substance addictions. I've been to conferences on that; there've been a few in the last few years. The International Society for Behavioral addictions has a conference every couple of years. And it's amazing, but all the brain changes that people associate with substance abuse, you find them in gambling, porn, sex, addiction, and binge eating disorder and obesity as well, that Nora Volkow the head of NIDA, who's who's actually one of the most powerful spokespeople for the disease model, she has written a number of articles showing the incredible parallels between brain change due to drug use and brain change due to obesity and binge eating. There's a lot of parallels. So what's that about?

Well, here's some examples of the things I just mentioned. These are the things that people are studying, internet or gaming addiction, Internet gaming, psychiatrists don't know what to do about this. But it's now entered the DSM, there's now a category for conditions that are under discussion. And people are starting to call this an addiction. And you know what I mean, if you have a teenage child, or  if you know anyone who has a teenage child,  and people can spend a lot of time on the internet, it gets much more serious when they're when they're adults. Well, if the parents don't control them, it could be quite serious in childhood too. But they read people can spend up to 18 hours a day on the internet, and it really screws up their life. So I wanted to find an example of brain change an internet addiction and the first paper I looked at, there's another one. The first paper I looked at, showed something quite remarkable. We'll see if I can read this. Gray Matter abnormalities and internet addiction a voxel based Morphometry Study. It basically means fMRI. And so this study aims to investigate brain gray matter density. Yeah, gray matter density changes in adolescents with internet addiction. So again, gray matter density. So that's because that looks like the most serious thing is this loss of gray matter to the loss of synaptic density in the prefrontal cortex. So we are talking about the internet, we're not talking about heroin here. Okay. So this is what it looks like, I found their graph, and it looks like this. That little yellow spot is the region in the brain that shows a reduction in synaptic density for people who spend more time on the internet. And go back to the brain picture that I showed you before for heroin, cocaine, alcohol addicts. It's exactly the same spot. See that? I just think that's so cool. I convinced myself that I was right. When I found this, that spot actually is not prefrontal cortex. It's  the dorsal anterior cingulate, but it's a part that's very closely linked to the dorsal lateral prefrontal cortex, it's kind of like a convergent zone for decision making and conflict resolution. So it's pretty much connected. So there it is.

So in other words, the the proposition that drugs cause addiction has to be completely wrong: drugs do not cause addiction. They don't. Internet gaming causes addiction and falling in love causes addiction. But sort of, you know, being a sports fan, and being a jihadist being, whatever, all of these things have seen the sort same sorts of fundamental properties. Okay, so I'm going to move on and say, given all that, we have to still understand what addiction is. And especially we have to understand, why is it so hard to stop? It's not just sufficient to say that it's not a disease, what is it? And that's what I'm going to spend the rest of this talk talking about, What is it? Why is it so hard to stop, and there's three points that I want to make. First one is that addiction is based on a strong attraction to something, to a substance or a behavior, which is repeated many times, and which leads to deep learning or accelerated learning. That's the first point. The second point is this mechanism called 'now appeal' or 'delayed discounting," which I'll talk about. And then last is something called ego fatigue, or ego depletion, which is basically the loss of self control. If you try too hard to control things, you actually lose the capacity to do so efficiently.

Okay, so I'm gonna go through those three points. The first one, this is the basic picture, I see addiction as a feedback cycle. It's a self reinforcing, self-perpetuating feedback cycle. And we could think of it simplistically as craving leads to more drug imagery, and more drug imagery leads to craving and round and round it goes and it builds on itself. And that can happen in five minutes or a half an hour or half a day, or whatever it is. And finally, when it gets intense enough, you go and you get some, or you do something, or you drink some, or whatever it is, you smoke some. Okay, so that's the feedback cycle. Now, let's start to think about that in terms of what's going on to the brain. Here's a simplistic cartoon. But we'll start here with the trigger phase. And there's always some kind of perceptual trigger: it can be looking at paraphernalia or booze commercials or whatever it is, but it could be finding a half a pill on the bathroom floor, or it could be having an intense dream about getting high, or whatever it is, all of these things are triggers or cues. So what so they are, they are inputted or whatever, perceived through the back of the brain, so the posterior regions of the brain, and then you've got all these associations that are kind of mediated by the temporal lobes here, the part that's associated with memory, and all these images come up. And as they do, the midbrain sends dopamine up to the striatum. And the striatum generates desire, which addicts call craving for good reason. Because this desire for something that's not immediately available, we call that craving, same thing of love.

And then the striatum sends messages back to the midbrain and says more dopamine, please. And there's a little feedback cycle right there between those two parts of the brain, and the craving increases and imagining increases. And of course the prefrontal cortex becomes activated and now you're planning, where am I going to get and how am I going to pay for it? Am I really going to do it? I was going to wait until Tuesday. I was going to wait till the weekend. I was going to wait until I could share it with my friend, but no, I guess I could probably borrow some money from my aunt and then I could... And all that stuff is strategizing, which is going on in the PFC, which is connecting, of course, to do the elaboration of imaging in the in the association areas, and those parts grow on each other. And finally, during this process, you're sending commands to the motor cortex. And the motor cortex does what you tell it to do. And you go and you get the stuff or you get higher, you get sex, or you get porn, or you gamble, and then you feel better. And then it's done. It's finished. It is sad. You had such a good time. And now it's over. And that's really the point. And in this addictive spiral, this feedback cycle is that when it's over there is always loss, there's often depression, there's often shame, self contempt, remorse, all that stuff, which of course, makes you feel like doing it again. So that's the feedback cycle at another scale the scale of day to day, day to day, day to day; with cocaine, it could be hour to hour.

So what's really going on here is that I want to trace this feedback cycle and show you how it plays out over development. There's the trigger the cue leads to craving. Craving leads to imagining, imagining leads back to I'll just say more perception of the intended activity. And that's an intensification cycle, it goes on for a while. And finally, when it gets intense enough, you go get some, and you do some--that's the using part. And now you get high or whatever, get drunk. What does that do? It has three effects. The first effect is relief, relief for pleasure. And, you know, in learning theory, that's just positive reinforcement. That's positive reinforcement. So it reinforces the behavior and entrenches it further. So that's learning. And then comes loss. And then the cycle repeats itself, like I just said, so you get relief, learning, anf loss. And then you do it again, think about every time this cycle go, every time you go through this cycle in your mind and your brain, what you're doing is activating particular synapses in a particular synaptic configuration that you've been building up over occasions, maybe weeks, months, or years, and you're reinforcing those synaptic synaptic connections. Every time you're reinforcing those synaptic connections, because the IV, you're reinforcing, which means you are developing some synapses, and you're pruning the synapses that aren't involved. And so you are actually sculpting and consolidating the synaptic configuration that makes you an addict. So you do that time after time, day after day, week after week, month after month. And that's development. That's the development of a habit of a very intense habit, an emotional habit, a strongly compelling habit, but it is still a habit. It's a learned habit. And again, think about the IV. Think about as this is happening, you're pruning synapses, you're losing some synaptic connections in the prefrontal cortex, and you're consolidating the addictive pattern.

Okay, so that's that's the first point. That's a general learning model of the development of addiction. Second, is this phenomena that I call now appeal that the psychologists called delayed discounting. This is you might be familiar with this from the famous marshmallow test, where they get three or four year old kids in a room and a nice lady comes in and says, Would you like to have one marshmallow now? Or, or would you like to wait for a few minutes, and we'll be back in three minutes. And then you could have two marshmallows, and three year olds sit there when the woman leaves the room and they twitch? They agonize, because the marshmallow is sitting right in front of them, they really want that marshmallow, and some of them caress it, some of them kiss it. There's, a movie on YouTube, which is just fantastic. Just look up marshmallow task. It's the first thing that comes up on YouTube. There's one for adults too, by the way. I'm sure you can imagine. So, so yeah, so this is this is how it works. Dopamine focuses attention on the immediate goal, and that produces craving and it's the immediacy, that's the issue. So all mammals have delayed discounting. They have a tendency to overvalue immediate available rewards over more distal rewards or long term benefits to their detriment, because if they weren't if they wait In a little while, they'd have a bigger net gain. And all mammals do it, even pigeons do it. And the point is that you sort of know that we mammals kind of know that, but we do it anyway, because it's built into the striatum, it's built into the dopamine system, you go for the low hanging fruit, it's very fundamental mechanism. 

Here's an example. These are called discounting curves. And this on the x axis, we have time, and on the y axis, we have the perceived value of the reward, well, here's the reward, it's a piece of cake. That's a reward that's immediately available. But if you didn't have that piece of cake, in a month, you could have you could lose five pounds, you're gonna have a slimmer, nicer body or something like that. So the question is, why is that man going after the cake? And what these discounting curves show is that the rise in the perceived value of the award goes up quite suddenly, it's not just an exponential curve, it's a hyperbolic curve. It's a sudden curve, when you get close to the immediate reward, the perceived value suddenly goes up. These things are graphed mathematically by people in behavioral economics, if they're buying models based on these these mathematical curves, there's a whole bunch of people working on these things right now. When the blue curve rises above the yellow curve, that's when you're done and going after that cake, whether you get fat or not. So he's going after that cake, because it seems worth more than imagined future happiness at this point right now, right here. And that's because the dopamine system is tuned to the cake, to do the immediate reward. So the consequences are, I think, fairly obvious, there's an immediate goal, which seems worth a lot more than the long term goal. And so you blow it off, whether you're gonna be out of money, +whether your girlfriend's gonna leave you, whether you're gonna get in trouble with a cough, whether you're gonna lose your job, those are future events. All you can really think about is whether or not I'm gonna get high tonight, or today. You never hear people say, Let's get high and next week. It's just not going to hear, Let's get high next Tuesday. No. Its let's get high now. Tonight, today. So yeah, immediate goal outweighs the imagined future. And that's just the way it works. Here's this study, which I think is kind of cool. Because it recreates, itIt simulates this in the lab. These are tests in which the participant looks at a screen, and they are offered small immediate rewards, so that smaller sooner rewards, they can click that button, or larger later rewards, which means I can get  one euro today versus five euros next week, or I should say, pounds, or I don't know what currency you guys are going to be using. But that's that's the task and you sit there and everybody has the kind of ratio, a built in ratio between immediate, smaller, sooner and long term benefits. We have a sort of part of our personality. And so the thing is that when you put this machine on the participants head, this is TMS transcranial magnetic stimulation, and what it does is it discombobulated the prefer the area of cortex that it's right over, it just disorganized so it loses its function. And this happens to be over the left dorsolateral prefrontal cortex, which is my favorite area of the brain. And so when you turn on the machine, guess what happens? The the discounting curve, the ratio between shorter sooner and longer later rewards changes, you are less able to hold on for later rewards, and you are more impulsive and going more after the immediate things, you see what I'm saying? Right? Become more impulsive, more compulsive, and so forth. And that's really, I think, parallels what we see when we see the loss of a connection between the striatum and the prefrontal cortex and addiction. That's exactly what we're seeing, that loss of connection and here we can produce it in the lab. Luckily, it's it's only temporary.

Okay, so that's, that's now appeal. The next phenomenon is this phenomenon of ego depletion or ego fatigue. And this is also a completely normal psychological mechanism. One of the earliest experiments I think, expresses at best that, this is Baumeister's work, what they would do is they would bring participants into the lab, and they would say you can't have eaten in the last eight hours so they come in hungry, and you have a bowl of freshly baked chocolate chip cookies and a bowl of radishes. And psychologists love these kinds of studies because they're perfect. Simply balancing control half the sample is said, you can eat all the radishes you want, but no cookies. And the other half says you can get all the cookies you want, but no radishes, this perfect experiment sat deeply satisfying the psychologists and all of us. And what happens is that the the after 10 or 15 minutes of the situation, the people who have to suppress the impulse to eat the cookies, or do not do as well, a series of cognitive tasks, so they're given a bunch of cognitive tasks, and they just don't do as well. These tasks require cognitive control or executive control, and you've kind of lost some of that it's become fatigued, you've worn some of it out, well, this is a phenomenon, it's very difficult to try to figure out exactly why. it's been examined for many years now. And there's recently been challenges in some ways. But the point is that you can't keep trying not to do something, that's the point. You can't keep trying to suppress an immediate impulse, it's like holding your arm out to the side, you can do it for five minutes; try doing it for an hour. This machinery isn't built for that. So addicts have a really hard time with that, an extremely hard time, because they have to suppress, control, inhibit their impulses for hours at a time, days at a time. weeks at a time, they're told in their age group, you can never drink again. And they're told that their addiction is doing push ups to the parking lot. And they'd have to be on their guard all the time. And that's really, really difficult. It's so difficult that most of them fail and success rate and 5-8%. So one of the problems is they're accused everywhere. This is my home country for now. And especially with alcohol is particularly difficult,  also smoking, because accusers are all around us. So it continues to turn on the dopamine system, focus your attention on the anticipated reward. And then you have to say no, I'm not doing that. So the the response to this recommended by the the executive cortex of the United States of America was just say, No, this is Nancy Reagan. I don't know how many of you remember Nancy Reagan, the wife of Ronald Reagan. And she was one of the spokespeople for the war on drugs. One of many keeps going on and hurt. They were counseling and urging young people, just say no to drugs. Well, okay, here's an example of what happens when you just say no, in this study, participants watched a terribly sad movie clip. So that shows a little kid with his father and the father dies and the kid's all alone, and it's very sad. And half the group is told to suppress their emotions in their expressions. Don't feel it don't show it. And the other half of the group is told to think about the film to think about what the film is trying to portray to intellectualize it. In other words to reappraise it. It's a very different way of dealing with it. And in this particular study, what we see is that this is the suppression group. This is the reappraisal This is the reappraisal so these guys are told not to show or express any emotions, these guys are told to think about what the what the film is trying to convey. And this is a control group. And this blip here, this ERP is called the, the error related negativity, it's what it shows, it's a little ERP, blip, , that represents cognitive control, the attempt to control, to overcome an error, okay? And that blip is smaller for the suppression group, those who are told to not show any emotion that show a reduced reduced activity in that region of cortex that produces this response. That is how we control our impulses. So that's pretty significant. We're seeing now that actually, just trying to say no to yourself for a short period of time is already enough to change the functioning of the cognitive control part of the brain. And if that happens on any one occasion, you can imagine what happens occasion after occasion after occasion, that set circuitry is changing and starting to become less effective over time. And that's really serious for addicts.

So just saying no is not the right answer, suppressing those impulses, saying no isn't what works. What works is to reappraise the situation to think about well, if you take this as a parallel, think about what your addiction is about, think about why I do some counseling with addicts over Skype, and I never tried to tell him that you have to stop. I know better. I don't say you have to stop taking drugs or drinking. I say you know, let's talk about how you're feeling and let's talk about what you want to do and if we're gonna get high. Okay, that's fine. Well, let's talk about that. and just take all that pressure off so that you're not making that kind of demand on the system, I'd rather start to think about what's going on in your life and what's going on in your past and what's going on. And what does this drug or substance do for you? And that's the way to start to change how the system functions. Okay, so in some brain change with addiction. 

Just a summary of what I what I said before, here's the PFC in charge of judgment. Here's the striatum in charge of attraction, desire craving. And here is the dopamine system. And dopamine goes to the striatum and sets up that little feedback cycle. So you get more and more and more, and then the striatum becomes sort of hyper activated in the presence of cues. And then you get that mechanism of now appeal, that narrowing of attraction to the immediate reward and the loss of everything else. The other stuff falls off the radar. And then the, the connection between the PFC and the striatum starts to become compromised, you get ego fatigue, and the prefrontal cortex simply becomes less efficient, less effective at control. The model. Now in the book, by the way, it's not full of neuroscience. In the book, I tell the story of five addicts. One is a heroin addict, one's a meth addict, one was addicted to pharmaceutical opiates. The fourth one was a British man who was alcoholic, very serious alcoholic. And the fifth one was the eating disorder person. And each of these people I interviewed for many, many hours over Skype, they're from all over the world. And I chose people who could talk about their addictions, because they were articulate and honest. And they were able to think about it. And remember it, clearly, I wasn't cherry picking them. And their stories all had a very kind of similar profile to them; the addiction would progress and it would become more and more difficult to control. And it would come to a point where it was really screwing up their lives in a very serious way. And then the attempt to stop would start happening. And there would be a number of failures. This was the case for me when I was an addict. It's a very typical profile. And finally, things get serious enough that people get really, really determined to stop, and that determination starts to change the picture. The guy who was an alcoholic, was very, very close to death. Actually, he was he was very close to death through alcohol or suicide, whichever came first. And he would have these as these four hour days, he would get up, he would wake up, he goes straight to the fridge and and pour a bunch of rum in his coke and start drinking it before he got to the toilet. Actually, he would finish the first one by the time he finished peeing. And then you go back to the second one. And he kept doing this. And  he got drunker and drunker. And finally, after three or four hours, he would become sort of comatose, fall on the floor, and not be able to walk and crawl into his bed and get in his bed and then wake up and start the cycle again. So he didn't have normal days, he had four hour days. And this went on for some period of time until he managed to get the help that he needed and to quit. And I'm going to talk about recovery now. And to talk about how this happens, because for each of the people in my book, they actually did find a way out of addiction, as people generally do. It takes time, it takes effort, but people do find a way out. Most people, not everybody. Some people,  it's a dead end, but the percentage is small.

So what I want to say is the disease model is not helping these people, the disease model of addiction isn't just wrong, it's also harmful. And one way you can get to this conclusion is just by looking at the stats on on conventional rehab programs. Conventional rehab programs have very poor success rates. Usually people relapse anywhere from two to 10 times. It's the revolving door phenomenon, I'm sure you've heard about it, they go from program to program to program, they get kicked out, they get they get court mandated to other programs, they get on waiting lists for state funded programs, which are universally crappy. In the US, they spent all their money and all their family's money in this process. And these are rehab centers; their main banner is the disease model: you have a disease and we're going to help you. This is a really big calling card for addicts and a lot of addicts kind of welcome that. They say well, okay, I have a disease, that's why I do these things and I can't help myself and that's really bad. It explains that I have a disease, okay, but that's not necessarily beneficial. What disease model advocates say is that this reduces stigma and shame and you know, contempt and guilt and all that stuff. Because if you have a diseasek you shouldn't be blamed, right? So it's supposed to make you feel better. But I don't know, if someone told you you have a chronic brain disease that makes you do horrible things, would that make you feel better? I think the logic is really flawed. And the many addicts that I talked to, of course, not all addicts talk to me. And some people probably don't want to talk to me. But but the ones that I talked to say, I never felt like I had a disease, I never felt like I had an illness. But when I was in AAA, I kept getting told that I have this lifelong illness, and I have to guard against it with all my might. And it never felt right to me. And it never made sense to me, and blah, blah, blah, and finally, they left or they went somewhere else, or they did something else. And finally, they quit. So a lot of addicts don't feel good about the disease model, they don't find that it's helpful. But the outcome stats themselves are bad enough. The other problem is that these rehab facilities, these addiction treatment centers, 85% of them in the US are based on the disease model, 85%. And an almost overlapping 85% uses 12 step methods as their primary primary intervention method. Well, you know, that's hard to actually figure out because medicine is this and twelve steps has very little to do with medicine, it's kind of based on our religious orientation, it came from the notion that you are powerless, and you have to give your power away to God. And that's the only way you're ever going to get better. And this is really kind of strange, a confluence between that model and the medical model. But the thing they have in common is the idea that addiction is for good, that it's a fundamental flaw, it's an essential characteristic of the person, and it's not going to go away, it's chronic. So you have to continue to do what we tell you. That's the real commonality, you have to do what we tell you, not what you think you should do, because that's not working, you have to do what we tell you. That's the big problem. So I would say that the disease model fails addicts. Because the disease model calls for medical treatment as the primary intervention, although 12 step methods are deeply deeply conflated with it. And medicalization, the whole setup makes addicts into patients and patients hand over control to professionals. That's what you do when you're patient, you do what you're told, which causes an increased belief that you're a chronic, that's belief and chronicity. There's this loss of empowerment The first of the 12 steps: I am powerless, admit that you're powerless. And this sense of fatalism and surrender, which for many addicts, is actually a ticket to increased relapse rates. I can't help it, I can't stop it. And that's why I keep doing it. In fact, there's a number of studies that show, I know of two and three of them, one about alcohol, one of methamphetamine, that shows that belief in the disease model itself is a predictor of relapse. Those who believe in the model relapse more frequently, and more, and sooner than those who don't. So that in itself is quite telling.

I know, I sound a bit like a zealot on this. Well, every time I sort of calm down and think well, you know, there is there is room for overlap, there is a gray area, there are disease like aspects of addiction, if that part is true. And I should also say that I'm not saying that doctors should be out of the picture entirely. Not at all. There are some addictions for which medical intervention is really, really helpful. The main one is opiate addiction, addiction to heroin and other opiates. Because when you get off heroin, you have these nasty withdrawal symptoms. And for two or three weeks, you're highly vulnerable to relapse because you feel like shit. So if you are given methadone or buprenorphine, which is sometimes called Suboxone, these are opiate substitutes, they will reduce the withdrawal symptoms or completely eliminate them. And then you might be able to have a more tapered trajectory into quitting. Of course, sometimes that doesn't happen, and people will often stay on opiate substitutes for long periods of time, sometimes for life. So that's considered to be problematic, but it's not as problematic as dying on the street because of a heroin overdose. So I'm certainly not saying that these kinds of interventions should not be should not be available; they should be available. But that's not useful for meth addicts or coke addicts, or addicts to a whole bunch of other things, all the behavioral addictions, there's no drug that helps you get over gambling, or sex addiction or porn addiction, or eating disorders, except you know, methamphetamine-- that's why it was prescribed years ago is for people who ate too much. You take a bunch of speed and you stop eating. So, yeah, but for all these other addictions, there really are not appropriate drugs. For alcohol, there are some drugs that help to a certain degree. There's their stuff like antabuse, which makes you sick when you drink. So that can be very effective, because that tends to make you not drink until you stop taking your antabuse, because you really want to drink. So it's really a bit of a flawed treatment strategy, but it does work for some people. And nowadays, we're talking about baclofen which apparently helps reduce cravings for alcohol and for opiates. And if that works, great, let's use it.  not in any way adverse to that. But none of these things touch on the psychological mechanisms that get people into addiction, and that make it so incredibly resilient. And those psychological mechanisms have to be dealt with. And doctors don't have the tools for that. They just don't have the tools or are trained in that. Usually.

Okay, so I'm going to end by saying, how do we help addicts? Well, I'm gonna go back to the two things that I've emphasized: first, how do we help addicts feel empowered, rather than disempowered, which is a potent antidote to ego fatigue, to feel empowered, I can do it, okay. And I think that we need to help them own other goals, it's really important to replace the addictive goal with something else, you can't just spend all your time not doing something, you have to do something, there has to be an attraction to something for me, when I quit around the age of 30. I was doing meditation and Tai Chi, I did Tai Chi in the park every night for an hour; that was great. And so I had something else to do, which really helped me. And that's generally the case, help them own other goals. But when I say there has to be other goals, your goals, you have to formulate those goals, they can't be handed to you by a group or by a physician, or by a sponsor. And I think of it as like what happens when you give the wheel of the car to your teenage kid. Up until that time, they don't care how much gas is in the tank, or how much air is in the tires or if there's a few scratches, they don't care much about the car. Once they get behind the wheel. It's a whole different thing, then they care. And that's where  you have to capture that motivation, that sense of ownership. Okay, that's really empowerment. And that's coming from, well, the striatum in part. So that's the first thing.

The second thing is we have to help addicts envision a future. Because 'now appeal' actually cuts off the ends of the temporal dimension, it cuts off the past and it cuts off the future; you can only think about today, you can only think about getting high.You're now stuck in this kind of eternal present tense. That's really serious. Because you can't even imagine a future, you don't want to think about next week, you can't think about next week, you don't want to think about the past. It's all too awful and disgusting. And how did I get like this? And how did I you know, a marriage breakup, and I lost contact with my kids. And that's not nice to think about. So you're just stuck in this eternal present. So you need to help addicts think about the past and the future and get that back into their mindset. So I think one way to think about that is to see life as a narrative, to see your life as a story, which is moving on, I come from there, this is what happened to me, I myself, I went to a crappy boarding school for two years, got very depressed, came out to Berkeley, got stoned a lot, became addicted to certain things that are not, Now I'm here. And now I'm going to do this and become a psychologist and have a good life. So I was able to put the strands together. And addicts are not able to do that. Sometimes they need help. And so I think that's what professionals and family members and friends and lovers and lots of other people can do help them think about where they come from, and where they're going to. And you put those two things together. And that's the magic formula. I think it's not that simple. It's not a simple thing, but that's certainly a part of it. So what you're doing basically is reconnecting the striatum: that's empowerment. With the prefrontal cortex, you're reconnecting the motivational engine with the bridge of the ship. And that's happening in the brain. And it has to happen in the mind. So treatment works by connecting or reconnecting empowerment to the sense of a future self, self and time. Which is like connecting the striatum back to the prefrontal cortex, which is like connecting the self with the social world. These are all overlapping things, you're rejoining parts of the brain, and you're rejoining parts of the mind. There's the choice: conventional disease model rehabs, which is pharmaceuticals plus the good book. And that's one choice. And the other choice, I think, are all the psychological tools, psychological interventions that are out there that are available that need to be funded, explored and extended: cognitive behavioral therapy dialectical behavior. Therapy motivational interviewing. psychoanalytic therapy works for some people, mindfulness meditation, lots of really good results with using mindfulness meditation to help addicts, which I think is very exciting. Contingency management, another psych approach and compassion, focus therapy, social support, scaffolding, all those things can be very, very useful. And that particular recipe has to be determined according to the individual and his or her needs. And remember, the brain never stops changing. That's it. Thank you