The Neurobiological Development of Addiction

An Overview

By Aviel Goodman, MD | August 28, 2009

DAT1. Adolescents (age 15) who were homozygous for either of 2 variants of the DAT1 gene and who grew up in psychosocially adverse familial conditions were found to exhibit significantly more impulsivity, hyperactivity, and inattention than did adolescents with other genotypes or those with the same genotypes who grew up in less adverse family conditions.¹⁰⁷ Variants of DAT1 had no significant main effects on these ADHD-like traits, which suggests that the DAT1 risk operates through its effect on susceptibility to risk environments. These findings are relevant to the development of addictive disorders because “neurobehavior disinhibition” (these same ADHD-like traits plus affect dysregulation) at ages 10 through 12 and 16 was found to differentiate boys at high average risk for a substance use disorder (SUD) from boys at low average risk. In addition, the neurobehavior disinhibition trait score mediated the association between both father’s and mother’s lifetime SUD and the son’s SUD.¹⁰⁸

Clinical implications

This overview concludes with a glance at the implications of the reviewed findings that are relevant to clinical psychiatry.

Diagnosis. A wealth of neuroscience research has converged to provide a neurobiological foundation for the theory that all addictive disorders share an underlying biological vulnerability. This neurobiological understanding complements the clinical and theoretical arguments for defining addiction as a chronic condition in which a behavior that can function both to produce pleasure and to reduce painful affects is used in a pattern that is characterized by 2 key features: recurrent failure to control the behavior, and continuation of the behavior despite significant harmful consequences.^109,110

The critical diagnostic issue with respect to addictive disorders is not so much the specific name that designates the disorders or the superordinate category that includes them but rather that they are recognized to be disorders and are grouped together in the same category. Recognizing them to be addictive disorders identifies them as medical syndromes rather than moral failings. It directs attention and energy toward treatment, collaborative fostering of health, and prophylaxis, rather than toward exhortation, punishment, and fostering of guilt and shame. Grouping the conditions together directs clinicians to look for comorbid addictive disorders in patients’ past and current histories, and in their family histories. It also alerts clinicians to the possibility that as one addictive disorder becomes stable or enters remission, a comorbid addictive disorder might flare up, or addictive patterns of engaging in another behavior might emerge for the first time.

Treatment. If the various disorders that fit the definition of addiction share an underlying biological process, then a treatment approach, modality, technique, or agent that is effective with one of the addictive disorders has a better-than-average likelihood of being effective with one or more of the other addictive disorders. The treatment of one addictive disorder could potentially benefit from the lessons learned in treating other addictive disorders.

An implication for treatment that relates more specifically to the developmental issues that were discussed here concerns the potential value of psychodynamic psychotherapy in addressing addiction-prone impairments that are related to maternal deprivation or pathogenic caregiving during infancy or to traumatic experiences during childhood. In the envisioned treatment system, psychodynamic psychotherapy would not replace psychiatric medication or cognitive-behavioral therapies but would complement them, and each treatment modality would enhance the efficacy of the other two.^110,111

Prevention. A theme that weaves through the preceding discussion is that stress and the associated increase in glucocorticoid levels at any phase of development can potentiate an addictive process. A corollary of this theme is that interventions at any phase of development that reduce stress or (better yet) prevent it from arising are likely to lower the probability that an addictive disorder will develop. The section on maternal gestational stress suggests that, from a public health perspective, the program for prevention of addictive disorders with the highest rate of return on investment could be providing psychiatric care and social support for pregnant women.

This overview of the neurobiological development of addiction indicates that the addiction diathesis develops as a result of some combination of genetic, prenatal, infancy, and childhood factors. Symptomatic expression of an addictive disorder is then initiated in response to stress in (most typically) adolescence or young adulthood. Drug addiction is not caused by exposure to drugs, any more than pathological gambling is caused by exposure to gambling. A scientific, empirically based understanding of how addiction develops suggests that reduction and prevention of drug addiction would be more likely to result if the resources that currently are allocated to the “war on drugs” were instead invested in treatment, research, and targeted social support.

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by Rajendra Trivedi | April 15, 2010 7:32 AM EDT

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Rajendra Trivedi,M.D.

CCA and Pain Center

Also in this Special Report

Pathological Gambling: Update on Assessment and Treatment

Smoking Cessation During Substance Abuse Treatment

Successful Treatment of Physicians With Addictions

The Neurobiological Development of Addiction

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The Neurobiological Development of Addiction

An Overview

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