Noteworthy News Articles on Mental Health Topics, August 28-31, 2007

As a former cocaine and heroin addict, these questions have long fascinated me. I want to know why, in three years, I went from being an Ivy League student to a daily IV drug user who weighed 80 pounds. I want to know why I got hooked, when many of my fellow drug users did not.

A bill was introduced in Congress this spring to change the name of the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction, and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) to the National Institute on Alcohol Disorders and Health. In a press release introducing the legislation, Sen. Joseph R. Biden Jr. (D-Del.) said, "By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease."

But opinion polls find weak support for the concept of addiction as a disease, despite years of advocacy by such agencies as NIDA and NIAAA and by recovery groups. A 2002 Hart poll found that most people thought alcoholism was about half disease, half weakness; just 9 percent viewed it wholly as a disease.

So what does science have to say? Addiction research has advanced dramatically since my high school years in the early 1980s, when I began using marijuana and psychedelics, then cocaine, in the hope they would relieve my social isolation. My progression from psychedelics to coke was fed by a definition of addiction that still causes widespread misunderstanding. In 1982 -- around when I first tried cocaine -- Scientific American published an article claiming it was no more addictive than potato chips. This was based on the fact that cocaine users, unlike heroin users, do not become physically sick when they try to stop taking their drug.

Addiction, by this reasoning, is a purely physiological process, one that results from drug-induced chemical changes in the brain and body. Over time, with heroin and similar drugs, the article explained, the user develops tolerance (needs more of the drug to experience the same effect) and eventually becomes physically ill if he doesn't have access to an adequate dose. Addiction, by this theory, is primarily an attempt to avoid physical withdrawal.

I bought into this idea because it was confirmed by my experience: I never had a problem stopping marijuana, LSD or mushrooms, none of which cause significant physical dependence. I expected cocaine to be similar and, therefore, safer than heroin. With no physical withdrawal to avoid, stopping should be a snap. Or so I thought.

By the time I got suspended from college for my involvement with cocaine, I was smoking it, often daily. And because I believed that my suspension meant I'd already ruined my life, I felt I had no reason not to try heroin. I just didn't care.

Heroin became my drug of choice. It calmed me, gave me distance from my obsessions and anxieties. Over time, cocaine made me feel anxious, but heroin always soothed and smoothed. I continued taking both, injecting higher and higher doses.

Today's most widely accepted definition of addiction -- used in psychiatry's latest edition of its diagnostic manual, the DSM-IV-TR -- recognizes that compulsive use of a substance despite negative consequences is key. And that's exactly what I experienced: At least six times, I made it through the physical sickness of heroin withdrawal -- the shaking, diarrhea and vomiting -- only to use again because I wanted the drug. This compulsive aspect helps explain why we can now consider video games and, yes, even potato chips more addictive than we did in the past.

But the DSM retains a focus on physical aspects of addiction: It calls addiction "substance dependence," suggesting that physical need is critical. Tolerance and withdrawal are part of the criteria used to diagnose the condition, even though pain patients taking opioids as directed may experience both and not actually be addicted. Studies find that less than 1 percent of people who take pain medications and don't have a past history of drug problems become addicted. Many pain patients who stop opioids after the source of their pain has been removed even undergo withdrawal without realizing it: It's called "hospital flu." But the vast majority have no difficulty refusing further medication.

As a result, experts -- including NIDA director Nora Volkow -- have called for the official name of the disorder to be changed from "substance dependence" to "addiction" in the next edition of the DSM. They say the confusion between physical dependence and addiction leads to under-treatment of pain: Surveys find many patients, even those who are dying, don't receive enough medication for effective relief. Physicians are even criminally prosecuted for "over-prescribing" when patients with painful conditions become physically dependent on opioid drugs.

But if physical symptoms don't define addiction, does it follow that addiction is a brain disorder? Matters are murky here as well.

While researchers have argued that addiction is a disease because drugs change the brain, the fact is, most users -- even of drugs such as heroin -- do not become addicted. While 50 percent of American soldiers in Vietnam tried heroin or opium, only 10 percent continued to use such drugs after returning home, and just 1 percent became long-term opioid addicts, according to a federally funded study by University of Washington sociologist Lee Robins.

Further, all brain changes are not indicative of disease. Learning itself changes the brain. FMRI brain scans of London taxi drivers and virtuoso violinists show changes that embody the effects of years of practice in relevant brain regions -- however, no one argues that this means they are ill.

As a result, scans alone cannot prove that addiction is a disease. "The idea that fMRIs can explain addiction is based on the same unscientific grounds as phrenology," says psychologist Stanton Peele, a longtime opponent of seeing addiction as a disease and author of the new book "Addiction-Proof Your Child."

In my own experience, I stopped using when addiction threatened my core values. On my last day taking heroin, I found myself considering seducing a man to get drugs. Because I despised this guy and had a serious boyfriend, I was shocked that I would consider it: I knew that that was addictive behavior. At that point, my personal definition of an addict was someone who violates her own principles to get drugs. I sought treatment the next day and never used cocaine or heroin again.

In Peele's view, addiction is a bad habit, a learned behavior that gets out of hand, an exaggeration of the human tendency to put off pain in favor of immediate pleasure. Even, in some instances, a rational choice when life presents little opportunity for connection, purpose or joy.

Volkow disagrees. She has pioneered brain-imaging research on addictions, looking for ways in which they differ from ordinary learning. "Drugs of abuse affect multiple systems, not just those involved with learning and memory," she says, adding that they interfere with regions that put the brakes on unwanted behavior.

"What happens in the brain of the addicted person is equivalent to a state of deprivation. It changes the brain from operating in a situation where someone has a choice and does something because he wants to do it to a situation where it feels like need," she says.

That, too, comports with my experience: Cocaine seemed to affect my motivation, leading me to take more even when I knew it would fuel a burst of paranoia, not euphoria. While at first it brightened and enhanced other joys, over time it sucked the pleasure and color out of my life. But although I could consciously see this, I felt I couldn't stop.

Another relevant factor seems to have been my youth: We now know that the frontal cortex, the seat of judgment, the region that should apply the brakes, is not fully developed until the early to mid-20s. I quit at 23; when I look back on my behavior now, the sheer stupidity of some of the risks I took shocks me. Genetic research also suggests that certain people are more prone to addiction, particularly those with other mental illnesses such as depression, a condition I also have.

So does that make it a disease? Some would argue that my response to treatment proves it. I underwent seven days of detox, 30 days of rehab, then three months in a halfway house and ongoing self-help support. Later, antidepressant medication helped reduce the distress that I'd previously self-medicated with heroin.

As Thomas McLellan, chief executive of the Treatment Research Institute in Philadelphia and professor of psychiatry at the University of Pennsylvania, notes, treatment for addiction is as effective as treatment for other chronic diseases that involve lifestyle change, such as diabetes and asthma.

Just calling it a disease, however, may not reduce the moral stigma tied to addiction -- as some hope. University of Nevada psychologist Steven Hayes is studying people's unconscious responses to words. "Disease" was as stigmatizing overall as clearly pejorative terms such as "drunk," and was more stigmatizing overall than such terms as "addict" and "intoxicated," he says.

Consider the historical treatment of people with epilepsy or "madness." Or the fact that we think "tough" rehabs are good, despite evidence suggesting otherwise -- though we wouldn't even contemplate "getting tough" with diabetics. Says McLellan: "Yes, people with epilepsy were sent to priests and shamans, too -- but that was the 18th century. Addicted people are still told to get religion."

The program I attended, for example, told me that I would not recover if I didn't surrender to a higher power, make amends and pray. This is not how most diseases are treated.

Further, labeling people with a brain disease characterized by lack of self-control can have negative consequences, particularly for adolescent users, most of whom are not addicts, suggest NIDA surveys and other research. In many teen rehabs, youths are told that they have "chronic, progressive" illness with a 90 percent chance of relapse. Forcing teens, whose identity is not fully formed, to accept an "addict" identity can be a self-fulfilling prophecy.

As Peele points out, "Self-efficacy and the image of the ability to control oneself are critical to recovery" -- as they are to maturation. For the same reason, it's a bad idea to tell people that without treatment, recovery is impossible. In fact, most addicts who recover do so without treatment. Among those who relapse, belief in the disease model is predictive of greater severity, research shows.

So is addiction disease or learned behavior? Given its complexity, some experts say, what probably matters most is which view best yields compassionate and effective treatment.

Maia Szalavitz is a senior fellow at Stats.org and the author, with Bruce D. Perry, of "The Boy Who Was Raised as a Dog and Other Stories From a Child Psychiatrist's Notebook" (Basic Books) and the author of "Help at Any Cost: How the Troubled Teen Industry Cons Parents and Hurts Kids" (Riverhead).

Killer's Parents Describe Attempts to Help Isolated Son
Bridgid Schulte, Washington Post- 8/31/2007

Sometimes, Hyang Im Cho would become so frustrated with her son, Seung Hui Cho, that she would shake him. He rarely spoke. And when he did, it was just a few words, barely above a whisper. He never looked anyone in the eye. It was as if he lived walled off in a world of his own. Try as she might -- with countless visits to counselors and psychologists, treatment with antidepressants or art therapy, and attempts to find him friends at basketball camp or taekwondo or church -- no one could break through. Like any mother, she wanted her son to fit in. Like any immigrant, she felt that no sacrifice was too great to make sure he found a place for himself in this new country, even if it meant overcoming the deeply ingrained stigma in Korean culture of admitting mental illness. She knew he was troubled and isolated. But it wasn't until her son killed 32 students and teachers at Virginia Tech on April 16 that she knew just how twisted his private world had become. And how little she knew him.
      Hyang Im Cho, along with her husband, Sung Tae Cho, and daughter, Sun Kyung, spoke about Seung Hui Cho to the panel appointed by Gov. Timothy M. Kaine to investigate the Virginia Tech shootings. The panel's report, formally released yesterday, paints the most complete portrait to date of Cho's frail and sickly childhood; his hopeful middle and high school years bolstered by intensive psychological therapy, medication and a supportive school environment; his misplaced aspirations to become a famous writer; and, as that dream slipped away, his descent into madness.
     The report also provides for the first time some perspective from Cho's family. They were shocked when they learned of his violent writings. Cho had always been so secretive, typing away on his computer but refusing to share what he wrote. They had no idea that he had been briefly hospitalized at a psychiatric institution during his junior year at Virginia Tech and had been declared mentally ill. The son, the hospital and the court never told them. "We would have taken him home and made him miss a semester to get this looked at," the Chos told the panel. "But we just did not know . . . about anything being wrong."
     Until now, the family's only public comment had been a statement of deep remorse in the days after the tragedy. "We never could have envisioned that he was capable of so much violence," they wrote at the time. The Chos, who own a townhouse in Centreville, have been in seclusion since April. Cho's sister, a graduate of Princeton University, has been on leave from her job as a contractor with the State Department. Wade Smith, the Chos' attorney, who released the statement, did not return repeated phone calls yesterday. Smith arranged for the Chos to meet with the panel for a three-hour interview. Sun Kyung translated, as she had for many of her brother's conferences.
     Although the panel said neither it nor the police had uncovered a motive for Cho's rampage, his sister provided a key piece of the puzzle. Cho began his college career as a business information technology major but, by the time he was a sophomore, decided to switch to English, which was one of his weakest subjects. Nevertheless, he was convinced that he could be a great writer. He had written a novel, which he described to teachers as "sort of like Tom Sawyer except that it's really silly and pathetic," the report said. Later that year, after his sister found a rejection letter from a New York publishing house, she noticed that he became increasingly depressed and detached. His English grades ranged from B's to D's, and his rage grew as he felt no one understood him or his talent.
     Life had always been difficult for Cho. As an infant in South Korea, he developed whooping cough and was hospitalized with pneumonia. Doctors told the family that he had heart troubles and, when he was 3, they performed an invasive procedure to examine him. From then on, Cho did not like to be touched. In Korea, Cho had a few friends he played with. But once the family moved to the United States in 1992 to provide a better education for the children, Cho became more withdrawn. If he talked to anyone at all, it was to his sister. Even then, he would never tell her what he was thinking or feeling. She knew he was being taunted for his accent and inability to speak English, as was she. But whenever she'd ask him about it, he would always say he was "okay."
     Even that limited communication disappeared when a visitor came to the home. The family noticed that Cho's palms would become sweaty, he would freeze, would sometimes cry and was able only to nod yes or no. His parents, by then working six days a week at dry cleaners, pressured him to talk. His mother urged him to "have more courage," the report said. When Cho was still in elementary school, the family decided to "let him be the way he is," the report said.
     In 1997, the summer before he entered middle school and on the school's recommendation, the family took Cho to the Center for Multicultural Human Services, where he saw an art therapist and a psychiatrist who diagnosed a severe social anxiety disorder. "It was painful to see," one of the psychiatrists told the panel. The Chos took turns leaving work early to get their son to his sessions every week. In art therapy, Cho made houses out of clay that had no windows or doors. Sometimes, when the therapist explained that his artwork showed how inadequate he must feel, Cho's eyes would fill with tears.
     In 1999, during the spring of eighth grade, the clay houses morphed into disturbing caves and tunnels. Cho wrote in a school assignment about wanting to "repeat Columbine." A psychiatrist diagnosed selective mutism -- the inability to speak in certain circumstances because of profound social anxiety -- and prescribed paroxetine, an antidepressant. The drug treatment was discontinued after one year because Cho seemed much improved.
     When Cho was at Westfield High School in Chantilly, his inability to communicate and lack of social skills landed him in a special education program designed to help him succeed in school. He was excused from participating in class discussions and received language therapy once a week. The plan enabled him to graduate with a 3.52 grade-point average in a demanding honors program. As a junior, he resisted further therapy. "There is nothing wrong with me," he complained to his parents, according to the panel report. "Why do I have to go?"
     When Cho was a senior, his guidance counselor strongly encouraged him to attend a small college close to home. But Cho had his sights set on Virginia Tech, where he was accepted on the strength of his grades and SAT scores. When his school records were sent, as is common practice, there was no mention of the special education provisions or his condition. At Virginia Tech, he became increasingly isolated and behaved in a bizarre manner, stabbing a carpet with a knife at a party and yelling at a teacher who told him to drop a class. His writing likewise became increasingly violent. The night before their once-invisible son would become infamous for the worst mass shooting by a lone gunman in U.S. history, the Chos had their weekly Sunday evening phone call with him. It was typical. He was fine. No, he didn't need money. His parents ended with, "I love you." The report does not say whether Cho answered.