Addiction vs Compulsion

Addiction refers to a persistent and intense urge to use a psychoactive substance or engage in a behavior which produces natural rewards, barring its detrimental consequences. An individual when consumes a particular substance or engages in an activity, activates the brain’s reward circuit, thereby attaining pleasure. Substance-related disorders in DSM-5 have been categorized into six divisions namely – depressants, stimulants, opioids, hallucinogens, other drugs and gambling disorder. Substance abuse of any of these drugs leads to addiction. Prevalence of substance-use disorder is 1-1.5% in India.

Dopamine is responsible for pleasure, motivation and elevation of mood. Involving in substance abuse or activities which induces the dopamine pathway to seek pleasure creates a dependence for the same over a prolonged period of time. As this pathway becomes more reinforced, an individual’s tolerance to the substance or activity rises, leading to physiological symptoms as the body starts craving more. The amount that once produced pleasure no longer has the same effect, causing an increase in consumption.

Addictive behavior comprises of a voluntary and rational decision preoccupied with the substance or activity. When a person refrains from consuming the substance or engaging in the activity, they experience an intense urge to do so, often manifested through physiological reactions called as withdrawal symptoms like sweating profusely, vomiting, nausea, hallucinations, fatigue, appetite and sleep disturbances.

Additionally, addicts often engage in self-destructive behaviors that involve a degree of risk or harm, driven by the belief that the perceived benefits outweigh the potential costs. A lack of control sets the stage for the use of psychoactive substances or engagement in risky behaviors. However, this doesn’t mean that addicts cannot be convinced to quit. When they start attributing their behavior to circumstances rather than personal choices, they may feel compelled to stop the addictive activity or substance.

Compulsions are repetitive behaviors that individuals get involved in due to relieve themselves of the anxiety caused by obsessions – unwanted and irrational thoughts. Compulsions are a characteristic feature of obsessive-compulsive disorder (OCD). The prevalence of OCD is 0.6% in India. These actions are driven by the desire to alleviate the discomfort caused by irrational fears or thoughts.

Orbital frontal cortex is responsible for primary urges regarding sex, aggression and hygiene. These urges are further filtered by caudate nucleus and passed onto thalamus. Thus, the impairment of cortico-basal-ganglionic-thalamic circuit results in repetitive behaviors or compulsions. The individual recognizes the irrationality of their thoughts or fears but feels helpless, leading them to engage in certain behaviors to alleviate the anxiety.

These compulsive behaviors are involuntary rituals to control obsessions, thus reducing the distress caused by the same. A person with a fear of contamination may engage in compulsive washing and cleaning to reduce the anxiety caused by their irrational fear, while someone with safety-related anxiety might repeatedly check if doors are locked or electrical appliances are switched off. A person refraining from engaging in ritualistic compulsive behaviors to ease the distress caused by their obsessions, might intensify their anxiety, negatively impacting their physiological, social, and psychological well-being.

Association of Addiction and Compulsion:

In the disease view, addiction can be a form of compulsion, driven by irresistible desires. They are constrained to ingest certain substances pertaining to bodily sensations or execute behaviors merely due to a lack of choice. Thus, compulsive behaviors are signified by defect of the will (Wallace, 2003). As addictive behaviors are compulsive it causes dissociation of the decision making ability of the addict and is led by motivation or external cues like stress, emotional states or environmental stressors. Furthermore, pleasure is associated with addiction, whereas relief is what one anticipates in case of compulsions.

Negative consequences of addiction:

• Low self-esteem
• Suicide ideation
• Health – related issues like chronic fatigue
• Legal consequences pertaining to risky behaviors
• Financial crisis as substances are expensive
• Unemployment due to impairment in cognitive abilities like judgment and reasoning

Negative consequences of compulsion:

• Poor interpersonal relationships
• Social isolation
• Difficulty maintaining employment
• Substance-use disorder
• Negative affect on education

Addicts lack a sense of insight due to cognitive impairments in areas related to memory, judgment and reasoning. As a result, their recovery is delayed because the critical stage of recognizing the negative consequences is absent. Although intrusive thoughts lead to compulsions, individuals recognize their irrationality, they feel unable to control them.

Interventions for addiction:

• Withdrawal therapy: Detox or abstinence is the key aspect of this therapeutic intervention where it focuses on withdrawal symptoms and relapse.
• Self-help groups: Alcohol Anonymous and Narcotics Anonymous help decrease the stigma related to relapse.
• Cognitive-Behavioral Therapy: CBT helps change the maladaptive behavior into positive ones with the help of logical reanalysis.
• Group and family counseling: Caters to improvement of interpersonal relationships and problematic behaviors.
• Substance Abuse and Mental Health Services Administration (SAMHSA): Helpline for information about treatment facilities in India
• Medications: Dilsufiram (Antabuse- prevents consumption), Naltrexone (helps stop addiction), Valium (for withdrawal symptoms).

Interventions for compulsion:

• Group therapy or self-help groups: They inform affected individuals about the disorder, build social networks and destigmatize the same.
• Exposure therapy and relapse prevention: Exposing individuals to stimuli that increase obsessive thoughts and controlling their compulsive actions that they perform regularly in order to reduce anxiety/fear associated with it.
• Cognitive-Behavioral Therapy: CBT helps change the maladaptive behavior into positive ones with the help of logical reanalysis.
• Anxiety management techniques like – box-breathing, muscle relaxation, visualization and grounding techniques helps control one’s anxiety.
• Medications: Prozac, Anafranil – initially increases serotonin levels but if administered for 6-12 weeks reduces the same.

For addicts, the focus should be on helping them recognize the negative consequences of their problematic behavior, which can initiate the recovery process. Studies on addiction in the general population reveal that most addicts stop using drugs by their mid-30s, often without seeking help which depicts their resilience (Foddy B, 2006). For compulsive behaviors, one can engage in refocusing one’s attention in order to delay the urge to perform the ritualistic behavior. Moreover, maintaining a journal to keep a track record of obsessions and the compulsive response patterns help ease the urge to initiate the same.