Habits, Compulsions, Addictions

I came across an article on the neuroscience of gambling addiction today. It was timely as a reader asked me if I knew of any mindfulness-based interventions for pornography addiction.

I do.

Readers who imagine themselves free of addictions might want to read through this. As Eckhart Tolle asserted, "one of the greatest addictions is the addiction to thinking." And most of us are in stage one denial. Drugs, pornography, food, cigarettes, bingeing, gambling, and other distractions are just poor strategies for quieting the noise, numbing the pain, relaxing the body, and finding respite from suffering or boredom, seeking pleasure to avoid pain.

The simple definition of addiction is "continued use despite adverse consequences." This definition stretches to include continued scrolling despite adverse consequences (e.g. compromised attention and sleep), continued shopping despite adverse consequences (e.g. debt), continued outbursts despite adverse consequences (e.g. frayed relationships), continued catastrophizing despite adverse consequences (e.g. needless stress), continued rumination despite adverse consequences (e.g. depression).

Whether one is struggling with alcohol, opioids, cigarettes, or cocaine, wrestling with a an eating disorder, or a gambling, gaming, or pornography addiction, the underlying neural processes are similar and certain pathways in the brain are triggered in the same direct and intense way.

The path of addiction is as legitimate a path as any other and can be the door to awakening. Basic information about how the brain works can help us interrupt the habit loop and take the path of recovery. An objective, non-judgmental, and multi-modal approach to tackling addiction may be more productive than self-blame and shame. So, let's get clinical.

Habits describe behaviors that have become so ingrained that we perform them automatically (James, 1890; Dickinson,1985; Graybiel, 2008; Robbins and Costa, 2017). Habits can become compulsions or addictions. This is in contrast to goal-directed, purposeful behavior, in which an action is explicitly performed to obtain a desired outcome (Lipton, 2019). We can use goal-directed, purposeful behaviors- like mindfulness- to encourage habits that promote well-being and to eliminate those which do not.

Habits are automatic. They can be healthy (e.g. dental hygiene) or unhealthy (e.g. munching on cookies to self-soothe). The brain wires for habit. Habits promote efficiency. We don't have to think to walk for example. By contrast, goal-directed behavior (like learning a new language or learning to play an instrument), is characterized by active deliberation and exacts higher computational costs (Daw et al., 2005). Automaticity allows the brain to free up attentional and decision-making resources. However, automaticity can also be detrimental and lead to bad habits, compulsions, and addictions.

Overcoming bad habits or establishing new ones may be as difficult as breaking an addiction. It takes time to construct and deconstruct conditioned patterns. Addictions are obvious, but habitual conditioned behavior is much more subtle and easier to ignore. We identify with our patterns and mindsets.

Learning unfolds slowly and incrementally. "Failure is subtle," Jim Rohn rightly observed. If we fell severely ill after eating one donut or were diagnosed with cirrhosis after drinking a pint of whiskey or suffered a broken heart after complaining or experienced poverty after subscribing to cable, we would quickly change. But we don't get severely ill after eating one donut; we are not diagnosed with cirrhosis after drinking a pint of whiskey; we aren't heart-broken after complaining to our spouse; we aren't filing for bankruptcy after subscribing to cable. But, just as small, intentional, daily disciplines build good health, wealth, and relationships, so are bad habits gradually shaped, and once formed are devilishly hard to break.

A recent study showed that when doctors tell heart patients they will die if they don't change their habits, only one in seven will be able to follow through successfully- so powerful is our resistance to change!

Dr. Raphael Levey, founder of the Global Medical Forum, observed, “A relatively small percentage of the population consumes the vast majority of the health-care budget for diseases that are very well known and by and large behavioral... Many articles demonstrated that 80% of the health-care budget was consumed by five behavioral issues.” The 5 behaviors that compromise health are: smoking, drinking, poor diet, stress, and lack of exercise.

Dr. Edward Miller, a medical school dean and CEO of the hospital at Johns Hopkins University noted that many patients with severe heart disease could avoid painful and expensive bypass surgery by switching to healthier lifestyles. Yet very few do. “If you look at people after coronary-artery bypass grafting two years later, 90% of them have not changed their lifestyle. Even though they know they have a very bad disease and they know they should change their lifestyle, for whatever reason, they can’t." I'm very interested in exploring why people can't or don't.

If severe heart disease and the prospect of death do not motivate behavioral change, what can? John Kotter, a Harvard Business School professor asserts that, “Behavior change happens mostly by speaking to people’s feelings.”

Emotions color the stories we tell ourselves. That inner dialogue runs constantly and remains largely unexamined. These hidden mindsets block change.

Retraining your psychological immune system requires both time and willingness. Habits, compulsions, and addictions rewire the brain. “The brains of substance abusers tend to show hyperconnectivity between the ventromedial prefrontal cortex and ventral striatum, two key areas of the reward system,” said Stéphane Potvin, a professor in Université de Montréal’s Department of Psychiatry and Addiction. “This could explain the tendency to choose immediate gratification and why the substance’s motivational value increases over time despite the negative impact on other spheres of life.”

“We also see reduced connectivity in certain brain areas involved in decision-making, such as the prefrontal cortex and amygdala,” added Potvin. “This is consistent with the fact that substance abusers can seem indifferent to the harmful consequences of their choices.”

The most original finding is the presence of anomalies in the brain regions associated with habit formation, including the dorsal striatum and premotor cortex. “This hyperconnectivity could explain the compulsive nature of substance abuse,” Potvin noted.

Breaking our habits, compulsions, and addictions also requires a rewiring of the brain. Some brains are more wired for addiction than others. Some have a genetic predisposition for addiction. The kappa opioid receptor (KOP), for example, is implicated in alcohol use disorder. The KOP system controls brain circuits that affect a range of neurological processes, including addiction, emotion, pain and reward, and reward-seeking. Exposure to alcohol- even in moderate amounts- negatively affects this system (Flores-Ramirez, 2024).

The brain's ability to rewire itself is called neuroplasticity. It takes time for new connections to form and for familiar and strong ones to weaken until they are extinguished. The speed of habit formation or extinction differs- from a few weeks to months or years- depending on the habit and other factors (Camerer, 2023). There are 86 billion neurons. Each is connected to thousands of other neurons. The sum is over 100 trillion connections. How brain circuits connect influences the computations the brain can do. Neuroscience hasn't advanced far enough yet to map the connectome.

The more we reinforce any habit, whether good or bad, the more robust the connections. Non-reactivity can also become a habit. This is the first realization. Every time we resist temptation, the weaker those connections become. We may relapse, but if we persist, we can build back a more resilient brain. The brain can heal itself. The brain is a collection of functional modules. If it is compromised or damaged, it can make compensatory modifications and reorganize itself.

Addiction affects the dopamine pathway. Dopamine is a neurotransmitter that helps nerve cells communicate. Dopamine is an important chemical in the brain's reward system. Addicts showed significantly higher levels of excitement when dopamine was released in their brains compared to healthy controls. Dopamine release reinforces addiction. It feels good when the brain is flooded with it which is why the brain seeks it out, that is, outside of itself. The dopamine pathway originates in the ventral tegmental area and projects into the nucleus accumbens. The nucleus accumbens, or reward center, is associated with pleasure, reinforcement learning, reward-seeking, and impulsivity.

Neuroplastic changes begin to occur as the nucleus accumbens hyper-secretes dopamine. Evidence suggests that neurons dump dopamine into extracellular spaces, priming the activation of nearby neurons with dopamine sensing receptors.

Dopamine is tightly regulated in the body. A specific protein in the body, TNK2, acts as a sort of dial, turning up or down the use of certain genes, effectively tuning dopamine levels to optimize neuron function and survival. TNK2 is known to help bring and recycle dopamine into neurons. When, in our ignorance, we muck with our dopamine schedules, TNK2 recycles too much of it, removing dopamine from the space between neurons, called synapses, where it is needed. By depleting synaptic dopamine, we effectively rob the neurons of the dopamine balance needed for normal function.

Overuse of even technology is associated with an overall deficiency in the reward system, related to a reduced dopaminergic activity (Weinstein, A. & Lejoyeux, M., 2015) A previous study showed an altered resting-state glucose metabolism in dopamine projecting brain regions in subjects with Internet game overuse (Park, H. S. et al., 2010).

Genetic regulation of other key genes- oxytocin receptor (OXTR), dopamine transporter (DAT1) and serotonin transporter (SERT) genes- are adversely affected. Significant changes in DNA methylation levels at OXTR, DAT1 and SERT genes are detected in people with strong addiction like habits.

To seek homeostasis or balance, the brain also secretes dynorphin. Dynorphin is also associated with the pain one feels when the high wears off. Dynorphin decreases the dopaminergic function of the reward system, resulting in a decrease of the reward threshold and an increase in tolerance. In other words, you need more of the same stimulus to get the same high, buzz, or thrill. This is a second important insight. What goes up, must come down. The higher the levels of dopamine, the deeper the crash. You will get a 200% increase above baseline in dopamine by snorting cocaine, for example (Lack, 2007). This will be followed by a significant decrease below baseline after the high wears off, prompting cravings for more.

The dopamine pathway connects with other key regions to form a collection of integrated circuits commonly called the reward system. One of these regions is the amygdala. The amygdala is associated with emotional processing, pain processing, and fear conditioning. Once the dopamine flood has run its course, the amygdala is activated. The resulting negative emotional state leads to activation of the sympathetic nervous system and dysregulation of the parasympathetic system. In other words, one may feel more anxious, stressed, restless, or agitated after dopamine levels plummet. Conversely, one may find it much harder to relax or return to a state of calm equilibrium.

A user then experiences strong cravings and aversive feelings like anxiety which triggers the need to return to the stimulus to self-regulate. Drug-withdrawal induced anxiety and the reinstatement of drug seeking behavior are regulated by the same singular pathway- the amygdala midbrain circuit (Tian et al., 2022).

The prefrontal cortex, which is responsible for motivation, self-regulation/self-control, delayed reward discounting, and other cognitive and executive functions, becomes impaired which decreases top-down inhibitory control. In other words, we begin to assume greater risks to satisfy cravings even in spite of punishment or loss.

Habits, compulsions, and addictions involve a shift in activity from the ventral to the dorsal striatum as habit learning progresses, and from the dorsomedial striatum to dorsolateral striatum, as automaticity becomes ingrained (Everitt and Robbins, 2005, 2013, 2016; Graybiel, 2008). The dorsal striatum has a medial aspect, the dorso-medial striatum (DMS), and a lateral aspect, the dorso-lateral striatum (DLS). The DMS is associated with goal-directed behaviors (Yin and Knowlton, 2004; Yin et al., 2005; Yin and Knowlton, 2006), while the DLS is associated with habits (Balleine and Dickinson,1998; Yin et al., 2004; Yin and Knowlton, 2006; Graybiel, 2008; Amaya and Smith, 2018).

There are cue-induced and stress-induced triggers. Interrupting these cues and delaying a response is key to breaking habits. Within the DLS are task-bracketing patterns of activity. In task-bracketing activity, highly-active DLS neurons fire at the initiation and termination of the behavioral routine (Jog et al., 1999; Barnes et al., 2005; Thorn at al., 2010; Smith and Graybiel, 2013). Task bracketing is like a computer algorithm that runs a routine when certain conditions are present- like a cue or a stressor.

public void ExecuteHabit (int cue){

if (cue>x) {

//run routine

}

}

Once that script executes, the habit follows automatically. This is where the recovering addict feels powerless against the addiction. Once the task-bracketed script runs, they lock in torpedo-like despite all the alarm bells, risks, or consequences they know will follow.

Task-bracketing is a subcomponent in a complex series of neural processes (Wadsley, et al., 2022 ), similar, in effect, to the first domino to fall in a domino run.

This process can be interrupted. Terminating the task-bracketed script is like interrupting a domino rally by removing dominoes 2-5 in a sequence:

I IIIIIIIIIIIII

The first one may fall, but it won't trigger a run.

Attending to cues and contexts requires vigilance or mindfulness. Cues can be external (people, places, things associated with prior abuse) or internal (stressors, emotions, and somatic states). Habit formation is exacerbated by stress (Dias-Ferreira et al., 2009).

Wanting to quit is an important first step. Attending to cues and stress-induced triggers is a second step. The recovering addict might relapse often in this stage. They may find themselves quitting for a few weeks then relapsing. Failing forward, they can learn from each relapse. What happened just prior to the relapse? When did it occur? What state were they in? If they can identify cues or triggers, they can run a new script to interrupt the brain just before task-bracketing. It starts with a pause, with a delay, with response inhibition. Response inhibition is key to terminating an unwanted behavior. This response delay terminates the "go" signal. Response inhibition is the space in my simple domino example:

I IIIIIIIIIIIII

Two structures in the brain have been implicated in taking or inhibiting action: the prelimbic cortex (PL) and infralimbic cortex (IL) (Amaya and Smith, 2018).

The prelimbic cortex mediates a “go” signal, driving drug-seeking behaviors, for example. Whereas the infralimbic cortex sends a “no-go” signal, necessary for extinction learning (Moorman et al., 2015; Gourley and Taylor, 2016).

Dr. Judson Brewer, a leading researcher in the field of neuroscience, addiction, and mindfulness, proposes 4 simple steps to interrupt task bracketing.

Step 1: What do I get from this?

Think of the habit you want to break. Really imagine the habit. Then ask yourself: What do I get from this? It may feel good or calm you down. Go deeper. What does it feel like in the body? What sensations, urges, or emotions come to mind? How rewarding is the activity really?

Step 2: Try RAIN. RAIN is an acronym coined by Michele McDonald.

R: Recognize. By practicing mindfulness, we become aware of thoughts, sensations, cravings, and emotions. We become aware of our triggers. During the craving stage, we may be aware of strong sensations in the body, a restlessness of mind, heightened anxiety or other strong emotion demanding to be pacified with this or that. When it comes, welcome it. Sit with that.

A: Acceptance. Allow the unpleasantness to be there without trying to push it away. Relax into it.

I: Investigate. Investigate the sensations? Where are they? How strong are they? Is there a restless quality? Tightness? Tension? Recognize whatever unfolds without reacting to it. Dive deep. Investigate your perceived suffering with curiosity.

N: Non-doing, non-reactivity, non-judgment. Do nothing. Resist nothing. Expect nothing. Anticipate nothing. Don't try to take the edge off of it. Don't try to feel better. Sit with the suck!

The body scan meditation is one of the best techniques for achieving this state of non-reactivity and non-judgment. Different meditation techniques train different attentional styles. The body scan trains interoception. Interoception provides a moment-by-moment snap shot of the body’s internal state (Craig, 2009; Khalsa et al., 2018).

The interoceptive network spans various brain regions, which include the insular cortex, cingulate cortex, the inferior frontal gyrus, and the sensorimotor cortex (Craig, 2002, 2009; Critchley, 2004; Pollatos et al., 2016; Garcia-Cordero at al., 2017). This network also presents multiple connections to the amygdala, hypothalamus, hippocampus, and brainstem (Craig, 2009; Becker et al., 2015; Kleint et al., 2015; Khalsa et al., 2018). The insula is believed to be the key region, which integrates information from the body via the spinothalamic and vagal afferent tracts (Craig, 2002).

With practice, we build up interoceptive accuracy and sensitivity. The sensations are linked to our emotional state. We attach valences to sensations (e.g. strong/weak, pleasant/unpleasant) and react to these with craving or aversion. Interoceptive learning is a complex process that includes updating and integrating information from current body signals with previous body signals and mental models (Craig, 2009; Mehling et al., 2012; Farb et al., 2013). Over time, these connections are strengthened. Learning to redirect attention to the body facilitates cognitive insights, helps us manage stress, and regulate emotions (Bornemann et al., 2015, Gibson, 2019).

If I'm sitting in meditation, for example, scanning the body and an urge arises, I can feel the sensations: tingling as tingling, pulsing as pulsing, an accelerated heartbeat as an accelerated heartbeat, shallow breathing as shallow breathing, etc. There is no storyline, just raw moment-to-moment experiencing. Thoughts and emotions will blend with sensations. With practice and over time, we will see these as discrete processes. I may feel uncomfortable. I may feel aversion to the discomfort. Anticipation may follow. I may want to quit. If, however, I can allow this to arise and be and simply watch and feel and stay with the intensity of it all and embrace the chaos of it all, a different neural process will begin to unfold. If we can learn to attend to sensations with curiosity and not judgment, we develop equanimity, a balance of mind. Over time, the brain will change with incremental practice. The benefits compound when we make these small, daily investments. Meditation promotes anatomical (Lazar et al., 2005; Hozel et al., 2008; Farb et al., 2013; Kang et al., 2013; Fox et al., 2014) and functional brain changes (Farb et al., 2007, 2013; Zeidan et al., 2011; Tang et al., 2012; Fox and Cahn, 2017).

Step 3: Take Action

The first few times you use R.A.I.N., you may feel uncomfortable. You may still relapse. "That's OK," writes Dr. Brewer. "Good actually. But keep it up and you'll soon start to recognize the bodily sensations and emotions that precede the habit loop." Through it all, see if you can maintain presence and awareness. Be with yourself at all times. We're learning to "urge surf." The urges will be there, and they may be powerful. We may fall off the board from time to time. As Jon Kabat-Zinn writes: "You can't stop the waves, but you can learn to surf."

Step 3's recommendation to Take Action could also be stated this way- Take No-Action. Do nothing. Sit with the discomfort. Accept the darkness of the moment and leap into the fire. You must be willing to suffer for self-mastery. You can't wish the demon away, but you can learn how to sit through the temptation. To quote Jim Rohn, "Don't wish it were easier wish you were better. Don't wish for less problems wish for more skills. Don't wish for less challenges wish for more wisdom." To break the back of a habit, be relentless- accept the inevitability of a prolonged and difficult fight. You may lose some battles. "Success consists of going from failure to failure without loss of enthusiasm," asserted Winston Churchill. Be determined to win. "Victory at all costs!" Never give in! And above all never give up!

What we call willpower or tenacity has a biological substrate. Evidence suggests a central role for the anterior mid-cingulate cortex in subserving tenacity. The anterior mid-cingulate cortex acts as a structural and functional hub connecting multiple brain regions that render the experience we call persistence, or will power, or tenacity (Barrett et al., 2020). The anterior mid-cingulate cortex also receives and integrates a wide range of signals from other brain regions to predict energy requirements that are needed for attention allocation, to encode new information, execute physical movement, and facilitate goal attainment (Barrett, Touroutoglou, 2020). It influences and is influenced by rest, memory, emotion, mindset, interoception, etc. Together, they regulate the amount of effort directed toward any potential behavior. What we call tenacity will influence performance particularly wherever there is challenge. Intentionally doing things that suck every day strengthens these networks and structures. The anterior mid-cingulate cortex grows in volume the more we do those things we don't want to do. So, there is great benefit to pushing through resistance. conversely, the anterior mid-cingulate cortex seems to shrink when indulged. This region is smaller in obese people, but grows when they diet. The volume is larger in athletes who force themselves to lace up their shoes at 4 in the morning to get their run in. It's especially large in those with a challenge they've overcome.

Addiction is a challenge to overcome and an opportunity to rewire the brain!

To review, addiction occurs in phases: the initial drug exposure spikes the pleasure/reward center of the brain, repeated use leads to tolerance, and withdrawal leads to anxiety and restless craving, which in turn contributes to reinstatement of drug taking/seeking. Wanting to take the edge off of these negative affective states (anxiety, restlessness, stress) can lead to relapse. The ability to sit through discomfort, however, can promote recovery. Meditation training alters the brain activity associated with anxiety. Practitioners become better at accepting their anxiety as it is.

Someone once said that those addicts who recover are those who leverage their addiction and turn it into a strength. They become addicted to recovery. They apply the same single-pointed focus and intensity toward self-care and healing. I think addiction+recovery is as "spiritual" a path as any other. Many of the most integrated and mature people I know took this path.

Let's return again to the scientific literature to understand how the brain works in order to find solutions that work.

The previously-mentioned prelimbic cortex (PL) and infralimbic cortex (IL) seem to play opposing roles in balancing between goal and habit. The IL supports habitual behavior and the PL supports goal-directed behavior (Smith and Laiks, 2017; Amaya and Smith, 2018). The IL triggers task-bracketing activity and gives the brain a "go" signal. The PL initiates the no-go signal.

To break a habit, we must replace it with something else. If you plan to say no-go to smoking once and for all, you'll need to say go to something else that is more compelling than the temporary relief you got from toking on a cigarette.

Running them in tandem might look like this: Saying no-go to a liquor run and saying go to actually running, to a triathlon, or other goal that will coax out the best in you; saying no-go to porn and beating on congas instead or studying any instrument you've been telling yourself you want to learn; saying no-go to chain-smoking and challenging yourself not to break the chain of abstinence; saying no-go to sweets and go to nutrient-dense meals you learn to prepare yourself; saying no-go to drugs and go to states of mind better than any drug. "What are all the drugs compared to the drug that gave you this most unusual experience of being born and living in sorrow and fear? " asked Nisargadatta Maharaj. "In search of happiness which does not come, or does not last? You should inquire into the nature of this drug and find an antidote."

Instead of tweaking on ice (street slang for getting high on meth), try ice baths. In Dopamine Nation, Dr. Lembke references a 2000 study published in the Journal of Applied Physiology. Participants were submerged in cold water (57°F/14°C) for an hour. Plasma dopamine concentrations increased 250 percent (equivalent to snorting cocaine). Plasma norepinephrine concentrations increased 530%. The increase in dopamine, interestingly, was gradual and persisted over time, unlike drugs which not only cause a spike in dopamine, but subsequent crashes and tolerance over time. Cold showers are free, street drugs are not.

Better than a drug trip, take a trip to a meditation center. There are Vipassana centers around the world that train in interoceptive awareness. They are donation-based. You pay what you can afford. Many were able to break their addictions after attending a ten-day retreat.

Those who struggle with addictions or compulsions will be faced with hard choices. The more we resist our urges, the weaker those underlying neural connections behind the urge become over time. When we must choose, there is an explore-exploit tradeoff we must make (Hogeveen, 2022). When an urge arsies, do we explore some new path or strategy, or indulge in a known reward (exploit). If my goal is to replace a habit, the substitute must be compelling! If compelling, the calculations and predictions the brain makes will motivate the choice to try the new option.

In the Emotional Secrets to Resisting Alcohol, Jeanette Hu, AMFT makes the following key points:

Dr. Lembke offers a few other actionable steps we can take starting with a dopamine fast. For 30 days, take a break from the stimulus: the porn, the bingeing, social media, the marijuana, the alcohol, the sugar, the shopping, etc. This will give the brain a chance to restore the pleasure-pain balance. This approach works for compulsions and habits, not necessarily for addictions. Going cold turkey might require supervision in some cases.

We can promote response inhibition by placing obstacles or limits on the behavior we are trying to change. She suggests 3 binding methods:

The more we train (regardless of the technique or practice we use), the more we strengthen those nodes and networks that promote inhibition. The right inferior frontal gyrus (rIFG), for example, is a key player and regulator within the subcortical response inhibition nodes. It orchestrates top-down cortical-subcortical control (Qian Zhuang et al, 2023). Do techniques like these activate such structures? Neuroscience hasn't gotten there yet, but I hypothesize they do.

Having a strong social network to keep us accountable and to support us is also valuable. The road to recovery may be long and hard. We need not walk it alone.

Psychedelics like psilocybin and ayahuasca hold promise for treating drug addiction (Winkelman, 2014)... a topic for another day.

First published 2/23/22

Edited and republished 12/26/22