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Many chronic illnesses involve dysfunction in the systems that keep our bodies in healthy balance. Heart disease involves dysfunction in the cardiovascular system whereby the fine balance between high density lipoproteins and low-density lipoproteins becomes skewed and results in a gradual restriction of the small blood vessels. Diabetes involves an imbalance between the sugars we take in and the insulin we produce to facilitate storage of this important energy source.

One of our biological regulatory systems is our motivational system, a system that regulates voluntary behavior and helps us to live according to a healthy set of priorities. There are two main brain areas involved in motivational regulation—the executive system (controlled by the prefrontal cortex) and the survival  (or limbic) system. These systems hold one another in balance to facilitate healthy motivational functioning. The executive system orients us toward mid-range and long-term rewards. We use it to plan, strategize, and think through the possible consequences of our behavior. The survival system orients us to immediate rewards and dangers, helping us to survive by securing important resources and protecting us from immediate threat.

We’ve all had a common cold though few of us have had life-threatening pneumonia. Likewise, we’ve all experienced motivational problems but few of us have suffered from addiction. Common experiences of motivational dysfunction include eating dessert when we had been dieting, rolling over and going back to sleep when we know it will make us late, or saying something in anger that we would never say when we are calm. More severe motivational problems include engaging in adultery when we had intended to remain faithful or being dishonest in business when we know that it’s wrong to do so. What all these problems have in common is that we choose a form of immediate gratification that compromises our principles, priorities, or longer term goals. In short, we experience limbic system override of our self-control and self-determination.

The everyday tensions between our long-term goals and immediate desires provide a framework for morality. We struggle against bad habits and temptations to live out moral values.  We make sacrifices in the short term to achieve the things we want but that only come with work and patience. We don’t always live up to our ideals or principles, but we learn from our mistakes, offer and receive forgiveness, and do the best we can.

In addiction, the moral tension that guides our lives becomes profoundly imbalanced. The limbic system attachment to a drug or behavior is so overpowering that there is little or no moral tension left and no chance that we will be able to exert sustained self-control over our cravings or sacrifice short-term gratification for long-term goals. Unless a person has been addicted, it is difficult to imagine such a complete loss of self-control. But we are all capable of it, and we can all understand it if we consider this: The limbic system, designed to help us survive, is also designed to override all rational thinking when survival is on the line. Perform the following thought experiment to get a felt sense of what addiction might be like:

Imagine that you are in the military and have been captured by the enemy. You are trapped in a locked cell. It is winter but your cell has no heat. Heat deprivation is one of the ways that the enemy guards are trying to break you down.

The door of the cell opens and a guard reaches a blanket through the door. “Go ahead and use this blanket, you sorry sap. A prisoner died in it last night—of smallpox. It’s your choice really—you can die of cold or die of smallpox. It makes no difference to me.”  The guard throws the blanket into the middle of the cell.

Freezing from cold, you pace around the room, warily eyeing the blanket. You stop, look at the blanket, and a stream of thoughts goes through your mind.

“Maybe the guard was just tormenting me. Maybe he was lying about the smallpox. I mean does smallpox even exist anymore?”

“But I don’t want to take the risk. When I was coming in here I saw a man who had small welts all over his body.”

Pace, pace, pace. You stop and shiver.

“How much longer can I take this. It’s so cold in here. I may have to use the blanket whether I want to or not.”

“No I can wait it out a bit longer.”

Pace, pace, pace. You stop and shiver.

“You know, maybe I can use the blanket without catching whatever that man died from. I mean really, I won’t touch it to my face. I’ll just warm my lower body….”

Pace, pace, pace. You stop and shiver.

How long will you be able to resist?

In our day-to-day lives, we don’t encounter real survival events very often. How many of us know hunger or cold? How many of us have faced life-threatening danger? In situations of survival, our limbic system takes over and overrides any rational resistance to the survival drive. Eventually, if we became cold enough, most of us would use a blanket to try to stay warm, smallpox or no smallpox.

As our resolve to avoid the blanket wore down, we would find ourselves coming up with reasons to use it. Most of the reasons would center around two ideas:

  1. I have no choice–I need to use it; and
  2. Maybe it won’t be so bad.

These are the same rationalizations that persons with addiction use as their resolve to stay sober breaks down: “I’ll just use it one more time. No one will know. It won’t be a big deal.” Or “I have to use. I can’t get through this day without using.” Addiction is a disease of the motivational system whereby a drug or behavior achieves survival salience in our brains and the limbic generated cravings override a person’s principles, goals, values, and rational thinking.

Limbic system cravings act quickly in the face of immediate reward or threat, but they also work gradually. The piece of cake in the fridge might wear down a dieter over the course of several hours. Recent research has shown that executive functioning is a limited commodity that must be replenished with rest and recuperation. The more we use our executive functioning to repress limbic system impulses, the more we deplete our capacity for self-control. “Decision fatigue” results from making hard decisions over and over again–from saying “no” to the cake each time it presents itself to the conscious mind. That is why addiction recovery is not a matter of just exercising free will. In order to prevent relapse, a person with addiction must maintain careful relapse prevention plans that prevents the triggering of strong or frequent cravings that can overpower or wear down conscious resolve.

Ned Presnall

Ned is Executive Director of Clayton Behavioral and Adjunct Professor at Washington University in St. Louis, Missouri. He presents widely on the topics of addiction, mental health, and Medication Assisted Treatment. Ned is passionate about reducing the stigma against persons with addiction and against Medication Assisted Treatment through discourse and public engagement.


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