We have spent much of the last two weeks at AddictionNews summarizing chapter-by-chapter the book, A New Approach to Addiction and Choice: Akrasia and the Nature of Free Will, by Dr. Reinout W. Wiers, professor of developmental psychopathology at the University of Amsterdam. It would be fair to say Dr. Wiers’ preferred theory of addiction, “biased choice,” is a challenge to the chronic brain disease model of addiction prevalent in the United States and other countries.

Biased choice argues that brain damage occurs from addictive behaviors and substances, but the majority of addicts are able to overcome their afflictions without professional assistance — and do so at some point in their lives. Therefore, while it damages the brain, the damage can be reversed to some degree. The decrease in function of such things as working memory, impulse control, and delay discounting can be restored to a measurable degree. People can learn to put their long-term goals above their short-term impulses and curb their use of harmful substances and behaviors.

Dr. Wiers’ final chapter, “Meat Addiction,” is a grab bag of takes on different forms of akrasia, or self-injury, such as compulsive meat-eating, sex addiction, smartphone addiction — even climate change. In climate change, he sees akrasia in our inability to correctly assess the long-term costs of our short-term appetites for such things as air travel and air conditioning. He places his hopes on commonsense solutions arrived at by large groups of random citizens. They have a track record of recommending policies with overwhelming popular support, such as lowering the speed limit and phasing out combustion engines. 

Unfortunately, as Dr. Wiers points out, governments ignore these solutions, largely because governments serve the interests of powerful entities who benefit from the current (lack of) climate policy. It is likely easier to get a heroin addict to “kick the habit, find alternative rewards, and build a different life,” to paraphrase Dr. Wiers, than to persuade governments to give up corporate funding and forgo economic growth in order to reverse climate change.

There is a fascinating discussion of smartphone addiction in the last chapter that could have been built into a chapter by itself, the data is so compelling. Smartphone addiction makes the case that perhaps all addictions are behavioral addictions. Excessive use of the device, which can be omnipresent in the lives of even casual users, can quickly damage physical health and mental health, sometimes severely. It can even have life-threatening consequences, whether distracting drivers and pedestrians, or leading to suicidal ideation and suicide. It turns out you can overdose on a smartphone.

Smartphone addiction supercharges other behavioral addictions that can have lifelong consequences, including gaming addiction, gambling addiction, and sports betting. Apps are engineered to capture the brain’s reward system: They use unexpected rewards and social pressure to command attention and punish nonuse. Dr. Wiers refers to the result as “an attention crisis.” As he repeatedly stumbles across the Unified Theory of Addiction, Dr. Wiers writes:

[T]he question becomes what is special about addiction to substances, in comparison with engaging in other (short-term) rewarding activities, like eating, gambling and gaming.

Yes, indeed: What is special? “[W]hat about ‘eating addiction’?” Dr. Wiers writes, exactly hitting the nail on the head without elaborating. Yes, obesity is the result of eating addiction, not food addiction, not addiction to ultra-processed foods, but an addiction to the behavior of eating as a form of stress management that becomes compulsive and is enhanced by ultra-processed foods. That is the opinion of Dr. Robert Pretlow, a Fellow of the American Academy of Pediatrics, and an expert in childhood obesity. Dr. Pretlow is also the publisher of AddictionNews, precisely with the goal of exploring the implications of his Unified Theory of Addiction.

Dr. Pretlow describes the common trigger behind both behavioral disorders and substance use disorders: stress. In particular, the desire to alleviate stress through displacement. The stressful situation may be poverty, food insecurity, housing insecurity, a dysfunctional family, school bullying, trauma, abuse, anxiety, boredom, fear… Even affluence may be a source of stress, as “deaths of despair” occur at a higher rate in wealthier countries.

After the stress is displaced through behavior or substance use, that behavior and/or substance use can become compulsive. Abstaining from the behavior itself becomes a source of stress, which is self-medicated through the behavior in a vicious cycle of addiction that is difficult to get out of. According to Dr. Pretlow:

The displacement mechanism may serve as the basis for a unified theory of addiction. A universal treatment for all addictions may be feasible.

A universal treatment for all addictions — wouldn’t that be nice? Some say it is cognitive behavioral therapy (CBT), a common ingredient in possibly all effective therapies for behavioral disorders or substance use disorders. Some say it’s Ozempic, because GLP-1 agonist drugs tend to prove the Unified Theory of Addiction by impacting both behavioral disorders and substance use disorders. If you stop taking the Ozempic, however, you are likely to resume the behavior or substance abuse without CBT.

Next week, we’ll take a longer look at the optimal design of an addiction treatment intervention based on what we’ve learned from Dr. Wiels’ thought-provoking book and related studies. What does a Universal Treatment for Addiction look like? Next week on AddictionNews.

Written by Steve O’Keefe. First published September 19, 2024.

Sources:

A New Approach to Addiction and Choice: Akrasia and the Nature of Free Will, by Reinout W. Wiers, to be published by Routledge in 2025.

“Macron’s ‘direct democracy’ to be tested as citizens’ panel on climate wraps up,” France 24, January 3, 2021.

“A Unified Theory of Addiction, Preprint 5” by Dr. Robert Pretlow, March 2023.

Image Copyright: kcw1939, used under Creative Commons license.