Addiction is not a lack of will: why does science classify it as a mental disorder?

WHAT CHANGES IN THE BRAIN

To understand addiction it is necessary to talk about dopamine. This neurotransmitter plays a central role in the brain's reward system: it regulates motivation, learning, pleasure and decision making. When we consume an addictive substance, there is a massive and artificial release of dopamine much greater than that generated by natural experiences such as eating or interacting with others.

Studies with positron emission tomography (PET) have documented the changes that occur in the dopaminergic system of people with addiction: alterations in dopamine synthesis, in its transporter and in postsynaptic receptors (Hou et al., 2014). The brain responds to this overstimulation by reducing its own dopamine receptors (a kind of defense mechanism), which generates tolerance: needing more and more amounts to feel the same effect. But the damage is not limited to the reward system.

THE BRAIN IN IMBALANCE: THREE AFFECTED SYSTEMS

Researchers such as Noël, Brevers and Bechara (2013) propose a model of three neural systems that explains why a person with addiction makes decisions that seem irrational from the outside:

1. The impulsive system (amygdala-striatum) becomes overactive. This system operates automatically and prioritizes immediate gratification. In people with addiction, this system responds exaggeratedly to stimuli related to consumption, a smell, a place, a person, an emotional state.

2. The reflective system (prefrontal cortex) becomes hypoactive. This region of the brain is responsible for impulse control, long-term planning, and decision making. Its weakening explains why it is so difficult to "just stop": the brake we all use to regulate our behaviors is damaged.

3. The insula (which integrates the body's signals with emotions and decisions) helps make craving (the intense desire to consume) feel like an urgent physical need, not a preference.

This neurological imbalance is not a metaphor. It is measurable, observable and documented.

ADDICTION AS A CHRONIC DISEASE: THE DEBATE AND CONSENSUS

For years there has been academic debate about whether addiction should be classified exclusively as a brain disease or whether behavioral, social and contextual factors should also be considered. This debate is legitimate and enriching.

However, a comprehensive review published in Neuropsychopharmacology by Heilig and collaborators (2021) concludes something fundamental: denying that addiction has a neurobiological basis is a harmful position, because it reduces access to medical and psychological treatment, and perpetuates the stigma that those who suffer from it already face.

The authors recognize that addiction does not determine a person's destiny (recovery is possible and occurs) but point out that the brain is the biological substrate from which both addiction and the capacity for change emerge. To ignore that is to ignore the evidence.

What we do know clearly is that addiction shares characteristics with other chronic diseases such as diabetes or hypertension: there is a partial genetic basis, lifestyle influences, relapses are part of the process, and treatment works, although not always the first time (Mao et al., 2023).

WHY DO THEY RELAPS IF THEY HAD ALREADY STOPPED?

More than 60% of people in recovery from a substance use disorder relapse within the first year (Mao et al., 2023). This information is usually interpreted as a failure of the treatment or the person. But from a clinical understanding, relapse is part of the pattern of any chronic illness, not proof that the person "doesn't want to."

The factors most associated with relapse are conditioned stimuli: situations, emotions, people or places that the brain has learned to associate with consumption. When the person is exposed to them, the impulsive system is activated almost automatically, while the reflective system (already weakened) fights to maintain control.

This explains why treatment cannot be limited to detoxification. It requires sustained work on the thought patterns, emotions, social context and specific triggers of each person.

RISK FACTORS: WE DON'T ALL START FROM THE SAME POINT

Addiction does not occur in a vacuum. Aguilar Bustos (2012) identifies at least four groups of risk factors that interact:

1) Individual: genetic vulnerability, neuropsychological characteristics, presence of another mental disorder (anxiety, depression, trauma). 2)Family members: history of consumption in the family, parenting patterns, relational dynamics. 3)Social: access to substances, group pressure, normalization of consumption in the environment. 4)Educational: school difficulties, absenteeism, integration problems.

This also explains why two people exposed to the same level of consumption do not develop the same degree of addiction. It's not a question of willpower: it's a complex interaction between biology, personal history and context.

WHAT THIS MEANS FOR TREATMENT

Recognizing addiction as a mental disorder has direct consequences on how it is treated and how those who experience it are supported.

First, eliminate guilt as a therapeutic tool. Guilt doesn't help you recover; In fact, it is usually a factor that maintains the consumption cycle. What does work is a structured intervention, based on evidence, that addresses both the neurobiological and psychological and relational aspects.

The most scientifically supported approaches to addiction treatment include Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), relapse prevention, and (when there is a co-occurring mental disorder) a dual diagnosis approach that addresses both conditions simultaneously.

Second, place the focus where it belongs: on the process, not the person. The question is not why you can't stop, but what do you need to be able to do it?

IF YOU OR SOMEONE YOU KNOW IS GOING THROUGH THIS

Addiction has treatment. Recovery is possible. And asking for help is not giving up, it is the first real step towards change.

If you are in Tijuana, Rosarito or looking for care online, I can accompany you in that process. I treat addictions, co-occurring disorders and families who live with the consumption of a loved one.

Schedule a first session here or write to me directly by WhatsApp at 664 418 6900.