CHAPTER THREE
PHASES OF THE DISEASE
Testimonial 3
“My life was madness. I had episodes involving alcohol and cocaine every three or four days. I would appear calm, and then thoughts of using would bombard me. This produced tremendous anxiety that ultimately drove me, like a powerful force, to use again. During the episode, the pleasure had disappeared; everything was chaotic, an indescribable frenzy. Once I finally managed to sleep after the episode, depression and an overwhelming sense of worthlessness would follow. Before long, the anxiety to use would begin again. That was how I lived, trapped in hellish cycles. Today I understand why: because my brain was ill and wanted stimulation, because I had developed addictive disease.”
Jhon X, patient. (Fundación Función Futuro, 2008)
FROM THE LATENT TO THE CHRONIC STATE
In this chapter, we will address the phases of the disease that develop from prodromal use, which in itself creates a state of heightened vulnerability to the development of addictive disease. When prodromal use occurs frequently, it can be understood as progressing toward addictive disease through three phases. As previously explained, the process begins with a latent state, which may be described not so much as a phase but as a preaddictive condition, from which the early, critical, and chronic phases are triggered. Each of these follows a characteristic and defined course.
When prodromal use becomes dependence-related use, a need for stimulation has already emerged, and addictive disease begins. It then progresses through stages marked by increasing substance use and deterioration in the individual and their social environments. These phases arise from the European studies of Magnus Huss, who researched alcoholism among people in France, Russia, and the Scandinavian Peninsula. Alcoholism was the first addiction to be recognized as a disease.
These descending and ascending phases or curves can also be applied to other addictions and must be taken into account because addiction, as a chronic and progressive disease, follows a characteristic course. Although variations occur depending on the substance or addictive behavior involved, these phases reveal a set of clearly defined patterns. They are described below on the basis of observations of hundreds of people treated and studied by the Función Futuro team, considered in light of various theoretical approaches and the accounts of people affected by addictive disease.
It is important to clarify that during the early and intermediate phases of the disease, the individual begins to develop tolerance[1] to the substance or to the specific neurotransmitter released by the addictive behavior. As tolerance develops, the person must increasingly stimulate the nervous system and consume more and more to achieve the same effect. During the advanced phases, tolerance thresholds become progressively lower; this is known as reverse tolerance. However, the body has become accustomed to the release of large quantities of specific brain chemicals and becomes dysregulated through the mechanism of anticipatory depletion. This is known as neuronal adaptation to the stimulus and generally persists for a considerable time after the last episode of use.
In conclusion, the brain adapts to substance use and establishes connections that consciously and unconsciously repeat the ritual of the addictive behavior. For this reason, many people with addiction state that they use against their own will. This can be explained by the triggering, at a certain point, of the neurological event associated with the disease. At this stage, the person no longer uses solely for pleasure, but also to escape the tension and anxiety caused by withdrawal. Initially, use is driven mainly by the pursuit of pleasure, or positive reinforcement. During the intermediate phases, it is driven by both pleasure and relief from anxiety, or dual reinforcement. In the most advanced phases, it is driven mainly by the need to reduce withdrawal-related anxiety, or negative reinforcement.
It is essential to understand these phases of development and the latent or preaddictive state. Because this is a chronic disease—that is, a condition that remains permanently present in the individual—its progression and deterioration may be halted through abstinence, but the underlying condition remains chronic. Like most chronic diseases, it may respond appropriately to three types of intervention: primary intervention, involving prevention and intervention during the latent or preaddictive state; secondary intervention, once the neurological component has emerged; and tertiary intervention, involving relapse prevention after secondary treatment. It must also be understood that there are essentially three developmental components, in addition to a spiritual component, because few diseases affect a sufferer’s values and will to the same extent.
The three primary components are biological, understood as addictive kindling; psychological, involving the psychological predisposition and the characteristics addressed in Part Two; and social, which is explained in the corresponding chapter. These components are clearly present during the latent state, are triggered in the first phase, and many of their features persist and intensify as the disease progresses.
It is very important to understand the terms craving, primary priming, secondary priming, and bonding. Cravings are urges that cause a person to lose control over abstinence; the anxiety becomes so intense that, only a few days after committing to abstinence, the addicted person uses again. Primary priming is the substance’s potential to trigger repeated dosing, resulting in a loss of control over use. Secondary priming is the potential for another substance to be used while under the effects of the first. Bonding is the potential of a substance to produce addiction. These phenomena intensify as the disease advances.
PHASES OF ADDICTIVE DISORDERS
In modern times, Magnus Huss (Campos, 1999, para. 5) and E. M. Jellinek[2], renowned researchers of alcohol addiction, pioneered the study of the disease by describing the phases of alcoholism (WHO, 1954, p. 25) and the types of alcoholic disease, which differ from the types of substance use. The phases of the disease describe how risky and prodromal use progress toward pathological use, and how dependence-related use advances through progressive phases, each with clearly defined characteristics.
Because addiction is a disease that encompasses such diverse areas, behaviors, and substances, the phases described below must be adapted to the specific addictive behavior or substance involved. Even so, certain patterns can be applied to all types of addiction, particularly those involving psychoactive substances. According to statistics compiled by Fundación Función Futuro, addiction to psychoactive substances is the most common: approximately 75 out of every 100 patients seek treatment for addiction to such substances (2017). Many aspects of addictive diseases must be reconsidered and rewritten because patterns of use, the age of initiation, and the addictive and psychoactive potency of substances have changed considerably over time. It is therefore essential to consider the current reality and examine these phases as described here in order to improve prevention, intervention, and postvention[3]—interventions carried out after intensive treatment has achieved positive symptom reduction—in the field of addiction.
We emphasize the need to understand that this disease, which has always existed, was long viewed through a biased lens as a “vice” or a “mania for becoming intoxicated.” This prevented it from receiving adequate attention through clinical research. Today, we know that addiction is neither a moral deviation nor an emotional deficiency. It is a disease like any other and can affect people regardless of race, gender, creed, socioeconomic status, or intellectual ability. It should be understood as a condition that may occur and that can be successfully prevented and treated.
The content of this chapter must be adapted to both substance dependence and addictive behaviors. Unlike obsessive-compulsive disorders (OCD) and manias, addictive behaviors, dependencies, and non-chemical addictive disorders involve the overstimulation of brain chemicals consistently associated with pleasure—particularly dopamine—or an overload of the dopaminergic circuit. In OCD, irrational repetitive behaviors are carried out to relieve anxiety; for example, compulsive handwashing may occur in response to the anxiety caused by obsessive thoughts of becoming infected. In the case of manias, there is a clear impairment of impulse control and the presence of inappropriate and irrational behaviors, such as pyromania, dromomania, kleptomania, and toxic-substance manias[4], among other recognized manias. However, these individuals are not seeking an overload of the dopaminergic circuit. Addiction therefore should not be described as drug mania or as an OCD condition. Nevertheless, when these antecedents are combined with substance use, they become prodromal risk factors that require close attention to prevent the development of addiction.
Eating disorders and certain personality disorders share many psychological signs and symptoms with addictions. For this reason, non-chemical addictions and eating disorders can also be understood through the progressive phases or curves that describe the psychological deterioration caused by the disease, as outlined below.
Preadictive or Prodromal Phase
This phase is so named because the person focuses attention on matters carrying a high risk of addiction, minimizing their harmful nature while maximizing their euphoric promise of well-being. This may trigger the disease when combined with an environment in which substances or behaviors are readily offered, genetic risk factors—including a family history of addiction and psychiatric problems—and an attitude favorable to use. The person denies the often devastating consequences of use, justifies experimental behaviors, and greatly idealizes the practice or substance. In many cases, initial use occurs under peer pressure and because the person has a limited sense of personal power when establishing boundaries.
Nearly all experimental use begins with a desire to fit in or belong to a particular social group that has been idealized as a source of affiliation and acceptance. Among people in recovery who have achieved abstinence, this latent phase remains for life, even when they maintain high-quality abstinence. Cigarette addiction is a clear example. At approximately 60 years of age, the brain may erase the connections associated with compulsive use, habit, and dependence; however, even after five years of abstinence, if the person smokes an entire pack again, they may fall back into the grip of the disease. According to what we have documented during 30 years of research, the same applies to addictions involving other substances and behaviors. This is why people with addiction say, “It is the first dose after a period of abstinence that causes the harm.” They also say that “a thousand doses after the first will never be enough” and therefore that “the first is always already too much.”
This phase may also involve dangerous avoidance-based use intended to escape one’s personal reality or the family and social environment in which one lives. The person accepts preaddictive behaviors as a means of escaping reality or seeking new sensations. Some have called this the enchantment or “honeymoon” stage, during which the substance or behavior is heavily idealized. Some beginners even assign a magical or mythical meaning to the ritual of use or to the preaddictive or prodromal behavior. Many people experiment with substances or behaviors, and some eventually become addicted, depending on the extent to which they deny the risk, justify further use, and overidealize the activity or substance.
The disease thus begins with the “siren song,” an analogy that aptly represents what occurs with drugs, other addictive behaviors, and even certain eating disorders (Ortiz, 2008, p. 46). Until the disease—in this case, an obsession with use—becomes anchored in the person’s mind, the individual remains in a preaddictive or prodromal phase. Once obsessive use or behavior emerges, with excessive preoccupation, use at inappropriate times and places, and an inability to stop for sustained periods[5], the disease itself begins, its development accelerates, and the person enters the early phase.
It is important to note that the person is not yet addicted but is prone to developing an addiction. As stated previously, “not everyone who drinks alcohol is an alcoholic, and not everyone who uses drugs is a drug addict.” Nevertheless, when use becomes problematic, it is necessary to determine whether the person has difficulty stopping. This requires an assessment of the person’s ability to maintain abstinence, to stop easily once use has begun, and to control their behavior after becoming engaged in the addictive practice or ritual. These difficulties arise under the powerful influence of deceptive promises of inner fulfillment that, in reality, subject the person to overwhelming excess and loss of self-governance.
The following expands on a passage from Homer’s Odyssey (Spanish trans., 1987). The main character is Odysseus, also known as Ulysses. As he returns home to Ithaca after the Trojan War, he and his crew pass an island inhabited by a goddess and sorceress named Circe, who forces them to remain there. She instructs Ulysses on how to pass the island of the Sirens without dying. The Sirens “sang such beautiful songs” that they lured sailors toward the cliffs, where their ships crashed, so that the Sirens could kill and eat them. Ulysses wanted to hear their magnificent songs, so he ordered his crew to tie him to the ship’s mast and to place wax in their own ears so they could not hear the Sirens’ seductive singing.
In this story, the Sirens’ songs represent the temptations of a substance or behavior—the attractions and false promises of well-being that may lead a person toward the ferocity of addiction. This is how addiction begins during the preaddictive or prodromal phase. Young people are inherently attracted to risk, and it is precisely here that these siren songs create confusion. By presenting risks as manageable, they entice young people to accept them, often with negative consequences. The person’s sense of certainty and awareness of consequences are also impaired.
Prodromal use is not always present during the latent state. The person may simply be in a preaddictive phase or stage, with or without current use, because they are potentially prone to developing addiction. Prodromal use may be absent in the latent state or phase, particularly in cases involving attention-deficit/hyperactivity disorder, personality disorders, schizophrenia, and bipolar disorder. Because of their psychological characteristics, such individuals may already be at substantial risk of developing addiction and, consequently, dual pathology[6].
The progression of this phase toward addiction is related to the person’s poor management of endogenous enabling factors, such as attitudes favorable to use, the social environment, and heredity. It is also influenced by exogenous factors, including dysfunctional families, friends, and society itself with its false stereotypes. The inability to work through problems, together with the failure to establish constructive boundaries that protect personal growth in every area of life, increases the risk of triggering severe addiction. Irrational beliefs must therefore be eliminated, including personal ideologies claiming that psychoactive substances are harmless, that one is immune to the depths into which others have fallen, or that these behaviors relieve existential suffering. Such immediate, fleeting, and temporary pleasures ultimately demand a high price: future well-being.
Other influences on the development of the disease are biological factors, including the addictive power of the substance or behavior[7] and the person’s organic resistance[8] to that addictive power. Drugs therefore do not affect everyone in the same way, nor are addictive behaviors equally pleasurable for all people. As previously explained, environmental factors, psychological position, genetic predisposition, and organic resistance shape a person’s vulnerability or hypersensitivity to a specific form of pleasure and, consequently, the likelihood of developing addiction.
Because an individual’s resistance to a drug is unknown, the most coherent choice is not to become “hooked,” since many people are trapped from the first dose. In purging-type anorexia and bulimia, the initial illusion of well-being accompanies the binge. Although vomiting may appear to “improve the situation” and “temporarily dissipate anxiety,” the anxiety later intensifies. Restriction produces a sense of control and may even seem to create an attractive figure; however, this is an illusion. Dysmorphophobia[9] appears, and vomiting is used once again in an attempt to feel better. In both addictive and eating disorders, these situations begin in a latent phase or state that requires close attention. Because these diseases are chronic, they respond well to specific primary care, with comprehensive programs offering the best approach.
Although the disease can develop at any age, the most vulnerable stages are those during which character is formed: childhood, preadolescence, and adolescence. Certain emotional patterns can be recognized as factors leading an individual toward addictive behavior. Early substance use generally reflects an exaggerated search for acceptance and recognition. Other factors include impulsivity, a demand for immediate gratification, low frustration tolerance or limited resilience thresholds[10], lack of self-acceptance, difficulty adapting, disproportionate emotional responses to pleasant or unpleasant external stimuli, emotional chaos, limited ability to overcome adversity, an extremely defensive attitude, resistance to suggestions, attitudes of superiority or inferiority toward others resulting from distorted self-concept, tendencies toward avoidance and denial, a sense of either insufficient or excessive personal power, identification with stereotypes of addicted people, hypersensitivity to pleasure, negative family examples, difficulty respecting and establishing boundaries (Ortiz, 2008, p. 47), and the proliferation of primary defenses (see the psychological aspects discussed in Part Two).
When these characteristics are combined with limited humility, an inability to follow guidance, little perseverance, an ideology favorable to addictive practices, and an absence of reasonable limits, the development of the disease becomes easier. Adding substance use may produce an addicted individual within a short time. It should also be remembered that the misuse of any addictive behavior or substance substantially increases the possibility of developing the disease, particularly before the age of 25, when full neurobiological development or maturity is reached.
Although the obsessive-compulsive phenomenon has not yet appeared during this phase, the preaddictive individual can be recognized by marked impulsivity across many areas of life and notable anomie[11]. Low self-esteem is particularly important and is almost always accompanied by a basic anxiety in which the person fears not being good enough or sufficiently adequate. During 30 years of observation, we have seen that these features, when combined with any type of substance use, frequently propel a person toward addiction. Most experimental use occurs because of peer pressure and the desire to “shine” or gain recognition, to demonstrate an ability to transgress limits, or to earn the group’s respect and avoid being considered a nerd[12]. It may also arise from spiritual, emotional, and social erosion (Ortiz, 2008, p. 47), preceded by this underlying anxiety.
Consequently, the person begins engaging in recurrent and obsessive addictive behaviors and becomes attached through the substance’s bonding potential[13], losing their sense of reality in interaction with the individual’s kindling vulnerability[14]. The preaddictive person is therefore playing with the extremely serious danger of triggering addiction. Vigilance is necessary to prevent further descent along the course of the disease. An ideology favorable to addictive practices becomes an especially serious risk factor because it allows the disease to progress.
When a close family member has experienced addiction, great caution is required to prevent later addictive situations. It should be remembered that 50 percent of addictions are transmitted genetically (Fonseca, 2017; Sáiz, García-Portilla, Paredes, Bascarán, & Bobes, 2009; Volkow, 2014), while the remainder are attributed to abuse or excessive exposure (Fundación Función Futuro, 2017a). Healthy communication—both in the manner in which a message is delivered and in its content—is therefore essential, as is making the family member feel important and validated. Clear boundaries against substance use, reinforced through example, affection, and support, are equally important and strengthen protective factors.
During the phase of experimental use or behavior, it may become apparent that the preaddictive individual is devoting progressively more time to thinking about using or obtaining substances. Performance, discipline, and commitment to responsibilities consequently decline. The person reaches the critical point of this phase—the peak from which they are propelled into the early phase—when denial begins: “I use them, but I do not need them,” or “I control them.” In contrast to an addicted person, someone with strong levels of acceptance and adaptability does not require a substance or self-destructive behavior to achieve pleasure, personal security, well-being, acceptance from people who truly matter, or a legitimate sense of self-fulfillment.
Fertile ground for the development of this phase is created by poor personal management of precipitating factors, facilitators, and triggers. Precipitating factors are people, places, and situations that cause distress or open the way to substance use and a social narrative favorable to it. Facilitators are those who offer the substance or behavior. Triggers include more than the personal attitudes represented by psychological defenses; they also include irrational thoughts and beliefs that protect or justify substance use or the behavior.
When the family environment creates internal distress, or when family events leave a profound mark on the individual—such as adoption, tyrannical or overprotective parents, parents prone to abandonment or excessive absence, and other family and social circumstances to be addressed in the corresponding chapter—the risk of addiction rises substantially, particularly when avoidance-based use is added as a means of escaping reality. It is therefore essential to develop a strong awareness of consequences by learning from the experiences of others and evaluating the future risks of one’s own actions.
Lastly, sensitivity to the offerings of a hostile and substance-promoting environment encourages and facilitates the disease when a person’s principal self-schemas are insufficiently developed. These include self-knowledge, self-acceptance, self-control, autonomy, and self-esteem. Weakness in these areas, combined with psychological predisposition, may allow the addictive gene to be triggered in the preaddictive individual. Substance use then arises not only through experimentation but also through avoidance and an inability to resolve personal conflicts within one’s reality. This is reflected in the search for highly euphoric behaviors that absorb the individual. Such behaviors are used to compensate for feelings of nonexistence, insecurity, existential emptiness, and either insufficient or excessive personal power, rather than turning to constructive influences on personality, such as healthy and moderate activities including study, sports, reading, outdoor activities, quality films, religious activities, and others.
In any person, the development of the disease may be triggered by a genetic history of addiction, severe tension with parents, conflict within the inner self, or personality-disorder traits combined with substance use. The risk is especially high when the person is under 25 and experiences episodes of brain overstimulation through drug misuse, food binges, or vomiting to expel unwanted food.
Vomiting produces a surge of neurotransmitters in the brain and reflects a highly irrational habit that is discussed more extensively in the section on eating disorders. When substance use is combined with traits of depression, psychosis, suicidal ideation, or bipolar disorder, the behavior is also classified as risky practice during the prodromal phase.
Other factors that may make an individual prodromally addicted include a genetic history of addiction extending to the third generation, cluster personality disorders, sexual abuse, anxiety disorders, bipolar affective disorder, schizophrenia, and depression, among others, when any of these conditions is combined with substance use or abusive or compulsive behaviors aimed at intoxication or narcosis. The risk is particularly high when these behaviors occur before the age of 25. As stated repeatedly, experimental use after the age of 25 is less likely to develop into addiction, except when a genetic component is present.
Many people, particularly young people, enter treatment during this phase. Although they are not yet addicted, their families may become concerned about visible signs of excess and deterioration and arrange treatment. This decision must be carefully considered because, if the young person is not taken to a high-quality rehabilitation setting, they may imitate negative behaviors and learn precisely what they should not learn. The center should provide highly individualized care and specific primary-prevention services. A widespread myth in prisons and behavioral treatment centers is that minors should never receive treatment alongside adults. When care is highly personalized, however, it may even be beneficial for a preaddictive person—often a minor—to be treated with older individuals, whose experiences can provide examples, testimony, and positive modeling in an environment deeply committed to recovery.
Early Phase
The early phase of the disease begins at the precise moment when addictive kindling is triggered. The brain has already undergone changes and begins producing a conscious or unconscious need for stimulation. This phase is characterized by a gradual increase in tolerance levels or thresholds for the substance, behavior, or addictive practice. Because the damage is almost imperceptible, the addicted person begins denying the harm that has already developed, avoiding prolonged periods of abstinence, and creating justifications to protect and arrange future contact with the substance or behavior.
From this phase onward, the addicted person experiences pleasure during contact with the addictive stimulus while simultaneously feeling distress upon realizing that the “addictive episode” is about to end (Ortiz, 2008, p. 48). The first signs of withdrawal appear, along with what we have called the consequence syndrome: clearly marked fear, anxiety, guilt, pain, and sadness arising as a rebound effect after the episode. As the brain becomes dysregulated, it increasingly operates through a mechanism of anticipatory depletion. In other words, during the addictive episode, the brain exhausts the neurotransmitters that create feelings of well-being and pleasure. Even so, use during this phase is driven mainly by positive reinforcement—that is, the person frantically seeks the pleasure created by stimulation. Use intended to relieve withdrawal-related anxiety is not yet the dominant pattern, although it is already present.
During this phase, the quantity, frequency, and potency of the substance or behavior increase and become extremely pleasurable because the brain is flooded with dopamine. These episodes distract the person from confronting and resolving their own reality and draw them away from the sense of purpose and life plan established before entering this phase. The addicted individual feels chemically—but not genuinely—fulfilled and idealizes the substance use. Priming[15] toward other substances frequently occurs at this stage.
In cases of drug addiction, the person experiences great pleasure when possessing a large quantity of the preferred substance and simultaneously fears being without it. When sober during this stage, the addicted person longs for and plans the next episode of use. Compulsive eaters begin anticipating the taste of food and repeatedly savoring it mentally before consuming it in a binge. Poor management of precipitating factors, particularly family situations, leads the person to adopt behaviors that help them escape their own reality. This is where obsession and the planning of “intense but controlled episodes” begin.
At this stage, the addicted person begins losing the capacity for self-criticism—that is, the ability to evaluate themselves and their actions accurately. Conscious and unconscious self-deception increases and becomes part of the denial of the disease. Clear deterioration therefore begins during this phase: the greater the denial, the further the disease progresses. The person’s powerlessness in the face of the behavior also becomes more evident as the obsession with use or the addictive practice grows. Family members and other close contacts begin to criticize the person (Ortiz, 2008, p. 49), normal habits are gradually abandoned, and the addictive ritual or episode becomes increasingly frequent and intense.
In addition, some individuals show the clear emergence of what are known as cross-tolerances. The person begins experimenting with different substances, either separately or layered onto the original drug. Priming is particularly evident when one substance immediately stimulates the desire for another. For example, drinking alcohol may create the urge to smoke cigarettes, as may the combination of cocaine and alcohol. Such cross-tolerances ultimately impair the body’s ability to resist toxic substances. In some cases, the person becomes addicted to two, three, or even four different substances. In primary priming, the substance has the potential—depending on the individual’s addiction—to cause the dose to be repeated compulsively again and again.
Each phase or stage is marked by specific indicators. Just as the preaddictive state is generally characterized by low self-esteem and, in many cases, a distorted sense of self-importance, the early phase is marked by the beginning of a loss of self-control that persists throughout the development of the disease. We have essentially observed the deterioration of three forms of control: the ability to maintain abstinence after promising oneself not to use again; the ability to control the impulse to continue once the addictive episode has begun; and the ability to control behavior while under the influence. These losses correspond to what self-help groups describe as powerlessness. During this initial phase, the person loses personal control over the substance or addictive behavior. Addiction has been born.
The first compulsions occur during this stage, although initially only on occasional occasions. The addicted person may be unable to stop using or performing the behavior, or may simply use in inappropriate situations and become socially inappropriate, marking the beginning of social degradation. The person arranges circumstances that favor the behavior and superficially rejects the suggestion that there is a problem. Denial consequently allows the disease to continue progressing. The individual also supports the behavior with apparently rational arguments used to defend the abandonment of good habits, recreational and family activities, spiritual practices, school, university, sports, work, or healthy friendships.
A process of neglecting personal appearance begins. In some cases, particularly those involving substance use, the person develops a preference for atypical clothing. By this phase, the addicted individual has formed a core group of facilitators, including friends who use substances and dealers, who immerse them in the subculture of use. Depending on the substance, the person gradually adopts personality roles that are not authentic.
As the person begins this self-destructive path and disregards advice from those who point out their mistakes, they become involved with others in the same condition to avoid feeling marginalized by emerging behavior that is typically asocial[16] and, in certain cases, antisocial[17]. The person begins to lose contact with social peers and develops relationships with individuals who do not correspond to their previous social and cultural background. In some cases of drug use, the person becomes dangerously involved in the dark underworld of street-level drug dealing and, in others, in crime or subcultures involving drugs and dangerous, unhealthy sexual behavior. This clearly reflects a departure from primary goals and serious damage to the person’s sense of purpose, as the psychoactive power of the substance distorts interpretations of both personal reality and the surrounding environment.
During this phase, the affected person does not recognize the significant changes occurring in the mind because of substance use, nor its impact on friendships, life plans, personal appearance, and, in certain cases, moral and ethical decisions. The self-destructive process begins. The individual reshapes their social environment downward to protect behavior that degrades personal ethics and moral principles, because they feel less criticized or rejected in lower social circles. Responsibility is gradually lost, and the person fails to fulfill academic, family, occupational, and social commitments.
Throughout this phase, use generally takes place in groups, and the person believes they remain in control of the substance or behavior and of their normal life. Some call this phase the “honeymoon,” while others call it the “pink cloud.” Biological damage may not yet be visible, although the behavior becomes anchored mentally and emotionally. Negative effects then begin to appear, including irritability, emotional instability, withdrawal from previously healthy social environments, and erosion across different areas of development. At the neurological level, connections begin to form as the brain interprets dopamine overstimulation as a reward. Strong conscious and unconscious cravings then arise in an effort to recreate the episode.
Character defects intensify during this phase, while the individual’s virtues and inner values decline. The sense of belonging is severely affected; friends may be viewed as enemies, and conflicts arise with family members. The sense of ownership and regard for personal possessions also erodes. A substantial portion of the person’s money is used to pay for the addiction. Excessive spending, partying with inappropriate people, unwanted sexual encounters, and, in some cases, the first acts of deception and theft occur. A particularly noticeable feature is the increased ability and willingness to lie in order to protect the substance use. The sense of consequence and certainty also deteriorates further. As conscience—the ability to recognize and act upon what is right and wrong—is affected, the person begins to assign negative meaning to what is good and positive meaning to what is harmful. Unless this stops, the descent will continue, accompanied by further justification or denial of the deterioration and decline through irrational meanings and constructs.
Tolerance thresholds begin adapting to increasing use because the body requires larger doses to obtain the same effect and calm the cravings. Most heavy users, including those able to tolerate large quantities without an immediate visible problem, are found at this stage. These individuals generally carry a significant personal supply, unlike social users who consume only circumstantially. Because the damage is not yet highly visible, the addicted person may believe they are invulnerable and develop an arrogant, irresponsible, and reckless attitude toward use.
The self-destructive behavior makes the person feel “fulfilled”; however, this fulfillment is not genuine because it is chemically produced. Disregard for commitments and the loss of control over uncomfortable, extreme, and intense feelings become increasingly evident. This produces problems with communication, adaptation, and commitment to responsibilities as a child, parent, professional, student, and ultimately as a citizen. Post-use pain begins to appear, accompanied by guilt and shame for failing to seek healthy sources of pleasure and for the scenes or abnormal events that occur during the addictive episode.
During the early phase, the addicted person begins mismanaging time and money. When personal effort could be used to build a better future, the person instead devotes time to sources offering fleeting and apparent well-being. The end of this phase can be recognized when the person begins sacrificing personal possessions to cover the costs of addiction, loans, or debts, or frantically seeks money and resources by selling or exchanging personal belongings in order to use the substance or engage in the behavior (Ortiz, 2008, p. 50).
The difficulty of stopping becomes evident near the end of this phase. The person occasionally begins promising others and themselves that there will be “no more,” yet returns to the same behavior within days. Dysfunctional personality traits and maladaptive patterns become more pronounced. Some individuals increasingly isolate themselves, while others become excessively social. Emotional instability and hostility toward anyone who criticizes the substance use become unmistakable. People with anxious temperaments adopt addictive practices as a way of life to dissipate their anxiety. Although this phase may not yet be highly painful for the individual, it is painful for those close to them. Some people begin recovery during this phase and thereby avoid more serious problems.
Intermediate or Critical Phase
Identifying the disease becomes much easier during this phase because tolerance thresholds reach their broadest range. The person requires a large quantity of the substance to feel satisfied. In behavioral addiction, the addictive practice breaks through all of the individual’s limits (Ortiz, 2008, p. 50). Because of the pain and harm already caused, the addicted person begins promising and wishing not to repeat the behavior, usually without success.
Coping structures such as autonomy, self-esteem, and self-control undergo clear deterioration. Stability across the major areas of life is similarly compromised. The person’s autonomy declines while substantial dependence on the substance or addictive behavior develops, accompanied by morning episodes, solitary excesses, and use at inappropriate times. Dual-reinforcement use appears during this phase: the person uses both to seek pleasure, or positive reinforcement, and to reduce the anxiety caused by withdrawal, or negative reinforcement.
People with emotional or social ties to the affected individual notice the abnormal behavior with confusion and may believe that the addicted person has lost sound judgment. They respond according to their own criteria and understanding of the disease and may become either facilitators or obstacles to the addiction (Ortiz, 2008, p. 51). When the family responds appropriately, it helps the person enter treatment. Otherwise, family members may isolate or marginalize the person physically or emotionally, which produces worse results.
Family members who become precipitating factors or facilitators in the development of addiction generally do not understand that, with appropriate treatment, the affected person can resolve cravings and “work through” difficult situations without using again. No one other than the individual ultimately pulls the trigger that initiates another episode. It is essential to emphasize that the family must not facilitate the disease, although it can promote and support recovery. In some cases, however, when the person continues denying the problem and rejects help, separation may be appropriate until they reach a crisis point and accept assistance.
As a result of the loss of control over the disease, the time and resources devoted to use—including money and personal energy—steadily increase. Repeated failures to meet responsibilities emerge as the disease advances. The addictive behavior is used to relieve tension and escape reality, or at least part of it. Character defects, such as aggression toward those who provide affection, become more evident. At this stage, the affected person is clearly becoming a victim of their own defects and excesses. Selfishness, dishonesty, pride, grandiosity, self-indulgence, and continual justification are simply defenses of the disease or immature ways of coping with reality.
Symptoms such as obsessiveness reflect personality deterioration. The problem involves not only the time devoted to the addiction but also the amount of time spent thinking about it. Marked deterioration occurs in occupational, financial, and family life, and a large share of the individual’s financial resources is used to cover the costs of the addiction.
Certain psychological complexes and syndromes appear or intensify, becoming a psychological crutch used to carry out the addictive practice as though it were necessary for survival and to avoid confronting personal fears, sorrows, shame, guilt, and pain. During this phase, the day-after syndrome, or consequence syndrome following an episode of use or addictive behavior, is marked by unwanted conduct and characterized by fear, remorse, and guilt. Its effects are resolved by passing through withdrawal without using again. With prolonged abstinence, the consequence syndrome disappears entirely, provided that effective restructuring work addresses thoughts and beliefs, feelings, affections, and attachments. In other words, the person must learn how to think, how to believe, how to love, and above all, how to feel.
The addicted person becomes highly sensitive and is easily hurt, responding with anger or episodes described as “depression.” Self-destructive behaviors emerge, including self-pity and repeated addictive practices. In cases involving substances, blackouts and episodes of geographical disorientation are frequent. Parties or binges lasting more than one day also occur with some frequency, sometimes referred to as runflas.
In both behavioral and substance addictions, the need for money becomes so great that, in nearly every case, the person resorts to loans that will not be repaid, deception of others, or even criminal conduct such as theft—first within the family and later against others—to cover the costs of the disease (Ortiz, 2008, p. 51). Violations of personal morality become evident. During this phase, the sense of existential orientation and direction, the individual’s life project, and the meaning of life itself gradually dissolve into fantasy.
Unwanted desires and thoughts become increasingly intense. Control over personal spaces, time, and possessions is severely impaired. When the person is not using, they are planning the next episode or addictive behavior. Re-stimulation has a powerful effect during this phase: the addicted person becomes powerless before certain people, situations, objects, and places associated with use or the addictive practice and therefore initiates new cycles. Distractibility and poor academic or occupational performance become dominant. The person repeatedly commits acts contrary to family and social upbringing, behaving “insanely” under the influence of a force that exceeds willpower and self-control. Sound judgment begins to disappear, and the person ends up in places and circumstances they never imagined experiencing (Ortiz, 2008, p. 52).
Degradation, irritability, manipulation, opportunism, apathy, contempt for healthy activities, arrogant and defiant conduct, and lying are among the tools used during this stage to protect the pleasure of engaging in the addictive practice, although at an extremely high cost to quality of life and well-being. The person in this phase is described as critical because most episodes produce a crisis. In the case of cannabis, for example, these may be motivational crises accompanied by substantial deterioration in cognitive abilities.
The person experiences withdrawal crises, and life begins to dissolve amid continued use, producing deep frustration. Resilience declines, and the threshold for frustration is greatly reduced. Tolerance for criticism, rejection, harassment, and similar experiences reaches very low levels, deepening sadness and pain and encouraging further use to escape these emotional realities. Substance use or addictive behavior then becomes a way of life that absorbs increasing amounts of time, energy, and both inner and outward values.
Under these circumstances, people with alcoholism frequently create disturbing scenes, while people addicted to cocaine may spend two or three days isolated and using, generally in motels or brothels. In the case of analgesics, whether taken in drops or injected, doses become enormous because tolerance has reached its highest point. The same occurs with other psychoactive substances. Doses may become so high that they would severely intoxicate or even kill a person without tolerance. The end of this phase is identified by the onset of reverse tolerance: the previous ability to withstand large quantities disappears, and smaller doses rapidly produce an effect. This marks the beginning of the chronic phase.
At the end of this phase, the dopamine discharge is accompanied by pleasure followed by increasingly intense post-use pain, guilt, and feelings of agony. In opposition to their cultural, moral, and material heritage, the addicted person pays for continued use—not only with material possessions. The person may be willing to end up alone, dispossessed, and humiliated in order to maintain contact with the addictive behavior and therefore begins choosing solitary use. They become irritable and almost unreachable when addiction is discussed. Loss of self-control becomes so severe that personal belongings may be sold to pay the material costs of the addiction. Other people are exploited through deception, theft, and broken promises. Accidents and legal problems frequently occur, along with incongruent and irresponsible behavior that pushes the individual into positions of progressively lower responsibility. Existential dynamics consequently deteriorate. Quality of life declines until, unless denial and avoidance end, the person may enter a psychiatric clinic or recovery center, become homeless, go to prison, or die. In every case, the individual becomes stigmatized and excluded from opportunities to develop integral values (Ortiz, 2008, p. 52).
Many so-called problem users are found in this phase—people whose use almost always results in difficulties or scandals. The end of this stage is also marked by solitary use or behavior and the complete loss of control during an episode, which is well recognized in substance-misuse cases. The phase reaches its conclusion when the person deceives and even steals, or pawns belongings to finance the addiction. At this point, serious problems arise from antisocial behavior within the family or on the street, and the individual begins entering detention facilities or addiction-treatment centers. Legal detention may also occur. Most people who ultimately recover begin their recovery through the humble acceptance of this phase and by responsibly embracing their commitment to life (Ortiz, 2008, p. 53).
Chronic Phase
During this stage, the sustained sensation of pleasure throughout the dopamine-release episode has almost entirely disappeared. Use is driven far more by negative reinforcement—relieving anxiety—than by the search for pleasurable stimulation, or positive reinforcement. An intense, frantic, and very brief effect is experienced only at the beginning of the pleasure discharge. The remainder consists of frenzy and a desire to consume more and more, varying with the substance and the pattern of use developed by the individual. Pleasure is felt only at the beginning. The habit is so powerful that behavior is governed more by addictive automatism than by personal will, accompanied by an overwhelming need to continue the addictive practice. Anxiety and anguish become so intense that, in some cases involving drugs, the effects appear even before the addictive behavior begins (Ortiz, 2008, p. 53).
Physical or verbal aggression against anyone attempting to prevent use also intensifies. The affected person irrationally believes that a new cycle will produce different results and that behavior will be controlled during the next desired occasion. Sooner or later, this error leads back to the same depths the person wishes to avoid. They continue using in the hope of finding the pleasure experienced in earlier phases, although it has already disappeared. The person feels sorry for themselves and betrays their own ideals because of the speed with which deterioration follows use. Examples include an older adult who forges a medical prescription to obtain sedatives, a gambler who defrauds the family, a person addicted to drugs who begs in the street, or a person with alcoholism who lies unconscious in a bar or on the floor at home. These situations are highly similar: all are driven by a disintegrating force[18] that exceeds the person’s own will and compels them to violate their integrity in order to satisfy the destructive force called addiction (Rosabel Soler, personal communication, 2000).
As noted, tolerance increased during the previous phase. In the chronic phase, however, tolerance begins to decline rapidly as soon as it has reached its highest point. Progressively smaller quantities produce an intense effect until even a minimal dose creates an overwhelming response. A very small amount may be enough for the person addicted to substances to lose what little sound judgment remained. The body attempts to defend itself against the toxic substance: urinary and fecal incontinence, sweating, vomiting, and tremors occur after use and sometimes immediately before it. The alienation associated with the chronic phase is unmistakable. Death from overdose and episodes of severe mental disturbance are frequent during this stage.
During the chronic phase, the addicted person becomes isolated and marginalized after losing personal values, existential dynamics, and the emotional, occupational, and social environments in which they once functioned. Much of the sense of direction, ownership, and identity disappears. Sound judgment may be lost completely, placing both the individual’s life and the lives of others in constant danger. Recovery remains possible during this stage, although most chronically addicted individuals have already made unsuccessful attempts to control the addiction. The damage is so evident that denial tends to diminish, but avoidance of responsibility for recovery becomes more pronounced (Ortiz, 2008, p. 54).
In this phase, the person acts with a complete loss of control over overwhelming desires and uses without wanting to, automatically and compulsively. They are willing to pay any price for another episode and lose perspective on the value of objects, money, and the affection of loved ones. Their thoughts develop a marked paranoid tendency: they feel watched, alone, humiliated, powerless before life, and discriminated against because of the addictive behavior. The person is a victim of the disease and is entirely overwhelmed by the unwanted effects of withdrawal. Finally, failures of attitude and the loss of assertive thinking create severe problems. The only way out is abstinence (Ortiz, 2008, p. 54).
TYPES OF ADDICTED INDIVIDUALS
We again wish to emphasize that “not everyone who uses a substance is addicted; not everyone who drinks alcohol is an alcoholic; and not every young person who has tried marijuana is addicted.” Having described the phases of addiction, we will now address different types of addicted individuals in order to provide a fuller understanding of the complex disease of addiction. These are cyclical and institutionalized addicted individuals.
The Cyclical Addict
The cyclical addict is characterized by an insufficient assimilation or understanding of the disease. When emotional well-being begins to return, the person feels strongly attracted to substance use and believes that permission to use has been regained. Cyclical addiction occurs when people begin a recovery process and remain abstinent for a period, but later relapse and repeatedly restart recovery, whether in an institution, through support or prayer groups, or independently.
The cycles experienced by this type of addicted person tend to be similar in duration for that individual, although the length of the cycles differs from one person to another. A person is considered a cyclical addict when the intervals between addictive episodes exceed 30 days; otherwise, the individual may be experiencing one of the previously described phases. Recovery is possible when the errors in earlier recovery processes are identified, exposed, and resolved (Ortiz, 2008, p. 54).
With time and abstinence, a chronically addicted person may move back to the critical phase and from the critical to the intermediate phase. However, recovery of tolerance levels for the substance has not been demonstrated; in this sense, the addiction is irreversible. The interval between episodes may change, and the intensity may decrease, provided that use is reduced by more than 95 percent over a three-year period. Even then, there is an extremely serious risk that a new episode will re-establish the pattern of use. Maintaining abstinence is therefore the best course, because each new episode brings back the unwanted symptoms of the addiction and the secondary effects of substance use.
The Institutionalized Addict
The institutionalized addict is a person whose will is severely restricted. Even when attempting recovery, the individual can remain sober for extended periods only when personal freedom is limited through confinement in an institution. It should be remembered that every person with addiction can recover with an effective rehabilitation program (Ortiz, 2008, p. 55).
In summary, cyclical addicts remain abstinent for a period but later relapse and resume the disease at the point where they left it, interrupting the recovery process. Institutionalized addicts, by contrast, are able to achieve a degree of sobriety only while confined in a rehabilitation center.
Special attention must be paid to the treatment provided. Without effective treatment that addresses personality maladjustment, a person with addiction can easily transition from one addiction to another. So-called cross-addictions involve replacing one addiction with another—one substance with another substance, gambling with substance use, gambling with food, attachment to a person with substance use, and many other substitutions. These patterns preserve obsessiveness and the poor management of precipitating factors and facilitators, ultimately triggering irrational, avoidant, and compulsive behavior. Unfortunately, the number of multiple addictions and dual diagnoses being recorded continues to increase.
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Notes
[1] It should be remembered that tolerance consists of a progressive increase in the dose of a drug required to maintain its subjective effects (Terán & Ledo, 2009, p. 223). Withdrawal appears when administration is stopped abruptly (Stahl, 2011), and its symptoms are the opposite of those produced by the drugs (Kuhar, 2012).
[2] Jellinek served as a WHO consultant on alcoholism. At the time of this publication, he was Dean of the Institute of Alcohol Studies at Texas Christian University, Fort Worth, Texas, United States (WHO, 1954, p. 2).
[3] We have adopted this term from psychological interventions used in cases of suicide. It is important for addictology to adopt terms from other specialties as metaconcepts that support clearer understanding. According to the WHO, the term used for a specialist in addiction medicine is “addiction specialist” or “addictologist.” By the late 1980s, “Addiction Medicine” had become the preferred term in the United States for the branch of medicine concerned with alcohol- and drug-related diseases (1994, p. 44).
[4] An irresistible mania or compulsion to consume toxic substances, whether psychoactive or not, including nail polish, soaps, and cleaning products, among others. This does not necessarily mean that the behavior meets the criteria for addiction.
[5] It is important to emphasize the theory of the three forms of control lost through addiction: (1) control over abstinence; (2) control over the ability to stop once use begins; and (3) control over behavior once the person is engaged in the use episode and dopamine release.
[6] Dual pathology is understood as the simultaneous presence of addiction and another significant psychological disorder.
[7] The addictive power of a substance is exogenous because it is a characteristic factor that originates outside the person (Ortiz, 2008, p. 35).
[8] The body’s organic resistance is an endogenous factor because it is part of the individual’s internal constitution (Ortiz, 2008, p. 35).
[9] Also known as dysmorphesthesia, this is the feeling of being particularly ugly, unpresentable, repulsive, or deformed (Galimberti, 2002, p. 339).
[10] These are tolerance thresholds relating primarily to frustration, criticism, rejection, harassment, betrayal, grief, and ridicule (Jaramillo, 2020).
[11] The absence of norms or rules (Galimberti, 2002, p. 84).
[12] This English word became widely known through the film Revenge of the Nerds. The nerds were highly studious, well-behaved, and obedient young people who did everything correctly.
[13] As previously defined in Chapter 1, bonding refers to the addictive potential of a substance or behavior—that is, its power to attach a person to continued use.
[14] As previously defined in Chapter 1, addictive kindling is an individual’s vulnerability to a substance.
[15] Priming is the desire to continue using after taking a small dose of an addictive substance or another substance that produces the same effect on the brain’s reward system (Wikler, 1948, as cited in Rahola, n.d., p. 7).
[16] A person who does not integrate into or form connections with the social body (DLE, 2019).
[17] Conduct that is contrary to the social order (DLE, 2019a).
[18] This force progressively disintegrates the self, character, confidence in oneself, personality, and sense of purpose—broadly speaking, the principal components of human will. This concept is drawn from certain approaches in Cuban psychiatry used in 2000 at the International Clinic for Addictions (Rosabel Soler, personal communication, 2000).
