Understanding Addiction - The Roles of Impulsivity and Compulsivity

Addiction is a persistent and complex brain disease that’s characterized by a diminished ability to control drug or alcohol use and by episodes of relapse, after even prolonged periods of abstinence.

Has your history of drug and alcohol use caused brain changes?

Well, if so, you’re in good company with millions of other Americans, and though addiction makes behavioral regulation difficult, you can learn strategies to retake control and you can manage the situation so it doesn’t diminish your health and quality of life (there's good cause for hope and optimism!)

To aid in this process, it’s useful to learn all you can about exactly how brain changes lead to addiction, such as how impulsivity and compulsivity team-up as two component pieces of the complex puzzle of addiction.

Understanding Impulsivity

Impulsivity = Acting quickly and without adequate thought or planning in response to internal or external stimuli. A predisposition to accept smaller immediate rewards over larger delayed gratification and an inability to stop a behavior toward gratification once it’s set in motion.¹

A behavioral example of impulsivity could be:

• Running into a friend in the street and accepting a sudden invitation to get drunk/high even though you need to be up early in the morning for an important work presentation.

Understanding Compulsivity

Compulsivity = Behaviors engaged in to ward off negative feelings. These behaviors persevere even in the face of adverse consequences; repeating the same acts over and over again even though they cause negative results. Compulsive behaviors are often habitual in nature.²

A behavioral example of compulsivity could be:

• You feel anxious and tense before work so you feel a strong need to get high beforehand to function normally, even though getting high at work has caused you repeated problems in the past.

Impulsivity Vs. Compulsivity

• Impulsive – Seeking pleasure
• Compulsive – Avoiding pain

Impulsive acts are generally driven by pleasure-seeking – spontaneous or ill-considered actions driven by hedonistic principles and positive reinforcement. You feel arousal or tension in the build-up to the act and pleasure, gratification and release after committing the act.

Compulsive behaviors, in contrast, are driven by a desire or ‘need’ to avoid discomfort and by feelings of anxiety and stress that precede a habitual compulsive act and feelings of relief from stress after committing the act. Compulsive behaviors are habitual and negative-reinforcement driven.¹

Impulsivity and Compulsivity in Addiction

Addiction is considered a brain disease because changes to the brain’s structure and functioning lead to a loss of behavioral control and to using drugs or alcohol even in the face of great personal consequences. The increased impulsivity and compulsivity seen with addiction result from changes to the cortex and to a reduced ability to regulate behavior, override negative impulses and make use of top-down controls to achieve long-term goals in the face of short-term costs. 

Both impulsivity and compulsivity play a role in the development and perpetuation of addiction, though impulsivity is more influential in the first stages of abuse/addiction and then later stages are characterized more by a combination of compulsive and impulsive acts.

Early Addiction – Characterized by Impulsivity

As we repeatedly overload reward and motivation circuits of the brain with excessive dopamine (getting drunk or high repeatedly, over a period of time) these systems can become dysregulated and start to malfunction. Two consequences of this neural dysregulation are:

1. A diminished capacity to regulate impulsivity.
   
2. A broken motivation system that’s been rewired to seek out drug rewards over all other rewards of normal life.

As abuse transitions into the early stages of addiction, you become increasingly focused on getting the pleasures of drugs or alcohol and increasingly unable to resist your impulses to get drunk or high.

So the early stages of addiction develop around pleasure-seeking and the impulsivity that allows for continued pleasure-seeking.

Mid to Late Addiction – Compulsion and Impulsivity

Over time, as the social, physical and psychological consequences of drug or alcohol use mount and as use gets more habitual/ritualized (late-afternoon cocktails), the primary motivation for use tends to shift away from pleasure-seeking (though that’s still there) and toward avoiding the negative consequences of not using (feeling like you don’t just want a drink, you NEED a DRINK!)

In mid to late addiction, periods between use are characterized by increasing withdrawal symptoms, anxiety and stress. By this point, people use primarily to relieve stress, anxiety and physical discomfort, while still also seeking pleasure as a secondary motivation.

Responses to stress and anxiety also become very habituated and you come to feel like you need to drink or use drugs in certain situations/times or else you’ll face negative/unbearable consequences.³

Demonstrating Compulsivity’s Role in Addiction

Recent animal-model research (April 2013) illustrates how significantly brain changes to the prefrontal cortex influence the ability to resist cocaine compulsions.⁴

Just like with humans, not every rat that uses cocaine ‘recreationally’ gets strongly addicted. What protects some rats and humans alike may be differences in the way the prefrontal cortex responds to repeated cocaine use.

The Experiment

1. A group of rats were given 2 months of unrestricted access to cocaine (delivered by the pushing of a lever). All rats became heavy users.
2. After 2 months, the researchers changed the protocol so that pushing the lever delivered cocaine 70% of the time, and 30% of the time it earned the rats a mild electric shock.
3. By 4 days of this new shock protocol, 70% of the rats had stopped trying for cocaine entirely, but 30% of the rats (the addicted rats) continued to seek cocaine, even at the expense of repeated electric shocks.

Why Did Some Rats Continue to Seek Cocaine?

When the researchers looked at the brains of the 2 different groups of rats, they found that the addicted rats had less active neurons in the dorsal lateral prefrontal cortex – an area of the brain that regulates behaviors by inhibiting actions that may have greater negative than positive consequences.

• So though an addicted rat may ‘know’ that pressing the lever could be painful, the brain area that’s responsible for stopping harmful behaviors isn’t working well enough and the rat isn’t able to stop itself.

To further demonstrate the role of brain-damage induced compulsivity in addiction, the researchers were also able to induce addictive behaviors (compulsive use of cocaine even at risk of electric shock) in rats that had previously avoided the shock lever by dampening neuronal firing in the dorsal lateral prefrontal cortex. Conversely, and more significantly, they were also able to extinguish addiction by increasing neuronal activity in that same brain area.

Take Home Message

Some people are far more susceptible to changes in areas of the brain linked to behavioral control and compulsivity. Once these areas start malfunctioning, it becomes very hard to resist compulsive acts. This helps to explain why people continue to take drugs even when they should be able to see that the negative consequences of use outweigh any possible rewards.

Overcome Impulsivity and Compulsivity

The value of addiction treatment….

If you’re already addicted, you might wonder – beyond general interest - what’s the point of learning about mechanisms beyond my conscious control? How can knowing about brain damage help my situation now?

Well, fortunately, though nothing but time will reverse addiction-related brain changes (and some of these are likely permanent) you can learn skills and tools that help you to compensate for your diminished behavioral control.

Addiction alters your brain so you can’t rely on determination and good intentions alone like you once could, but when you learn compensatory skills and tools, you can achieve the same level of behavioral control – and at the end of the day, how you control your behaviors doesn't matter, so long as you can control them.

Most addiction treatment programs focus on teaching compensatory strategies to help people achieve behavioral control. Some examples of these strategies include:

• Learning to recognize cues that trigger impulsive or compulsive impulses. Trying to reduce your exposure to such triggers and learning coping strategies for minimizing  their impact.
• Making a plan for dealing with cravings (when I get a craving I call my sister). This way you don’t have to count on controlling your impulses, you just have to follow your plan.
• Learning strategies to delay acting on your impulses. For example, deciding to delay acting on any impulse to drink or use drugs for at least half an hour (by half an hour most urges dissipate on their own.)
• Learning cognitive behavioral thinking strategies to change the way you think about compulsive urges. For example, “I don’t need a drink I just really want one. I won’t die if I don’t have a drink right now, that’s just my addicted brain trying to get me to fall back into relapse.”
• Learning mindfulness strategies that can help reduce perceived stress and anxiety – by staying in the moment what was unbearable without alcohol becomes manageable sober today.
• Learning to take better care of your physical and emotional health so you’re strong enough to battle your negative impulses. A classic acronym that illustrates this is AA's H.A.L.T. – to avoid succumbing to impulse or compulsion, avoid getting too Hungry, Angry, Lonely or Tired.

Brain changes make it exceptionally hard to stop addiction once it gets a toe-hold. Though determination plays a role, you can’t will-away addiction any more than you could decide to quit diabetes. Fortunately, you can learn strategies that help you to compensate for your diminished capacities – and the millions of people who stay happily in recovery every day are testament to the possibilities of change and a better life.