Risk factors for addiction

DEFINITION: The underlying risks for drug abuse and addiction involve a complex mix of biological, psychological, and environmental factors. Medically, addiction is recognized as a chronic, recurrent brain disease expressed in the form of compulsive behaviors. Addiction is characterized by loss of control, craving or preoccupation with the addictive substance or activity, and continued use despite consequences. It is also a developmental disease that usually begins in adolescence.

The Addictive Personality?

Solving the addiction problem is much more complex than “just saying no,” as the antidrug campaign popularized by former First Lady Nancy Reagan encouraged. A major misconception about addiction is that certain substances, by themselves, can turn the unwary into “dope fiends.” Because substance misuse involves problems with impulse control, some researchers have asserted that dependence is mostly a matter of personality, speculating that there may be a certain addictive personality profile that puts people at risk for addiction. However, most research indicates that there is no single "addictive personality," and substance use disorders are a complex, highly individualized condition.

The National Survey of American Attitudes on Substance Abuse, an annual survey conducted by the National Center on Addiction and Substance Abuse at Columbia University, states that “every child in America is at risk of using drugs, regardless of race, ethnicity, or economic status.” People of all racial and ethnic groups can develop addictions, and around half of American adults have tried marijuana, according to a 2023 Gallup poll, but most do not become addicted. According to the Substance Abuse and Mental Health Services Administration, one in ten people who use marijuana develops an addiction. However, among those who begin using in adolescence, this rate is one in six.

Why does addiction affect only some people and not others? The answer appears to lie not so much in a person’s personality but more in a person’s vulnerability to drug abuse and addiction. Vulnerability is a product of the interaction of a person’s environment, age, and biology. The common denominator is body chemistry and how the brain reacts to addictive substances. The addictive process shares common elements and influences, although the pathways will differ from person to person.

The American Addiction Centers reported in 2022 that the concept of an "addictive personality" is a myth. No single set of psychological characteristics fits all addictions. Such characteristics include depression, anxiety, dependent or antisocial behavior, and difficulty formulating long-term personal goals.

While certain personality traits play a role in addictive behavior, most behavioral experts concur that the triad of social factors, psychological factors, and physiological components is at the core of the addiction process, but the exact nature of their interplay is complex.

Psychological Risk Factors

Addiction comprises psychological conditions involving biological processes and genetics that have physical, environmental, and neurochemical aspects. Impulsivity and sensation-seeking are the psychological characteristics that have been commonly reported as factors associated with a higher risk for addiction. Also considered is how a person perceives risk. Persons with a low-risk perception tend to focus on potential benefits and do not or cannot see the adverse consequences in situations of uncertain outcome.

The prevalence of substance use disorder is higher in persons with a comorbid mental health condition. According to the National Institutes of Health, around 35 percent of Americans with substance-related disorders also have comorbid psychiatric conditions, such as major depression, bipolar disorder, anxiety disorders, attention deficit hyperactivity disorder (ADHD), personality disorders, and schizophrenia. Some personality disorders are marked by impairments in impulse control, which increases one's risk for addiction. This is especially true for antisocial and borderline personality disorders. Antisocial personality disorder is a pervasive pattern of disregard for and violation of the rights of others and an inability or unwillingness to conform to social norms. Such persons are impulsive, have deficits in attention, are unable to reflect, and lack sensitivity. Borderline personality disorder is a pervasive pattern of instability in interpersonal relationships, self-image, affect regulation, and impulse control.

People with anxiety disorders are at increased risk for developing addictions because they may use substances to reduce their anxiety and control their symptoms. A National Epidemiologic Survey on Alcohol and Related Conditions found that any anxiety disorder of the Diagnostic and Statistical Manual of Mental Disorders, diagnosed in the year of the survey, was associated with a 13.02 percent prevalence of alcohol use disorder, which increased with a diagnosis of two coexisting disorders.

A later study of patients from three urban, university-affiliated outpatient clinics investigated the association of individual anxiety and mood disorders and drinking patterns, defined as three drinks, two or more times a week for heavy drinking and four or more times a week for frequent drinking. Overall percentages were 6.19 percent for heavy drinking and 8.31 percent for frequent drinking. Post-traumatic stress disorder was associated more with heavy drinking and panic disorder more with frequent drinking (but with less heavy drinking). No significant relationship was found between alcohol use and two or more coexisting disorders.

Persons with ADHD, in general, are at higher risk for addictions because one of the primary features of ADHD is impulsivity, which involves premature, risky behavior and poorly conceived actions. Aside from impulsivity, people with ADHD can have difficulty recognizing risks or associating them with negative consequences; they can lack sound judgment and become frustrated easily, making them highly susceptible to addictive behavior.

Approximately 10 percent of people will develop an eating disorder at some point, and one in five teenagers exhibits disordered eating behaviors. While not strictly an adolescent disorder, the age of onset for most eating disorders is between twelve and twenty-five. However, an article published in the Journal of Eating Disorders in 2020 noted that the age of onset for anorexia nervosa decreased in the early twenty-first century. Eating disorders manifest as intense preoccupations with food, weight, and body image, but are complex conditions involving physical, psychological, interpersonal, and social issues. Like other addictions, eating disorders have patterns, although no one factor causes an eating disorder.

Risk factors for anorexia include fear of growing up, inability to separate from the family, need to please or be liked, perfectionism, need to control, need for attention, lack of self-esteem, high family expectations, parental dieting, and family discord. Risk factors for bulimia include difficulty regulating mood, impulsive acts (such as shoplifting and substance abuse), sexual abuse, and family dysfunction.

Biological Factors

Since the early 1990s, scientists have amassed a wealth of data about the neurophysiologic processes and biologic mechanisms that underlie the triggering of pleasure, reward, and addiction, resulting in the classification of addiction as a biological brain disease. These neurochemical changes and genetic influences, which account for up to 40 to 60 percent of the predisposition to addiction, along with family history of addiction, age, and gender, are all biologically based risk factors that affect a person’s vulnerability to addiction.

The prefrontal cortex (the gray matter of the anterior part of the frontal lobe) is part of the cerebral cortex, the convoluted outer layer of gray matter of the cerebrum that coordinates sensory and motor information. The prefrontal cortex is involved in behavior control through executive functioning (EF)—abstract thinking, motivation, planning, and inhibition of impulsive responses. The prefrontal cortex is highly developed in humans, but is not fully developed until adulthood. Thus, certain groups, such as people with ADHD and antisocial personality disorder, and adolescents, who have deficient, dysfunctional, or immature EFs, will be predisposed to impulse control problems and have a higher risk for substance abuse and addiction.

With chronic substance abuse, the brain’s ability to control impulses becomes further compromised because addictive substances reduce functioning specifically in that area. Simply put, this initiates a vicious cycle of impulse control problems leading to dangerous behavior that perpetuates the impulsivity.

The limbic system controls basic emotions, drives, and behaviors, and affects motivational and mood states. Because it links certain brain structures that regulate people’s ability to feel pleasure, the limbic system is essential to the brain’s reward circuitry.

The neurotransmitter dopamine has long been known to become activated and to regulate feelings of pleasure, and it now appears to also be key in determining the motivational state. With chronic drug use, the persistent release of dopamine programs the limbic brain regions and the prefrontal cortex to embed drug cues into the amygdala (one of the limbic system structures), a process that floods the brain’s reward system, enhances the motivational state, and creates the obsessive craving for drugs. Hence, there is an inherent risk cycle of reinforced drug taking that leads to addiction. This compulsive drive toward drug use is exacerbated by deficits in impulse control and decision making.

Personal relevance, the state of being able to relate internal and external stimuli to establish a sense of belonging, is important in personality development. The bilateral caudate nucleus (BCN) and pregenual anterior cingulate cortex (PACC) are both known to be active in this process. BCN is a medial basal ganglia involved in motor control. PACC is found in the frontal part of the cingulate cortex surrounding the corpus callosum; it is involved in emotional aspects of brain function and linked to anhedonia.

Another brain region, the bilateral anterior insula (BAI), not previously reported to be active in personal relevance, was investigated specifically during personal relevance in an experiment into neural responses evoked by reward and the attribution of personal relevance. BAI is typically involved in empathy, compassion, and interpersonal phenomena, as well as in decision-making in complex and uncertain situations. Based on analyses, the response to personally relevant stimuli depends on the novelty-seeking personality trait, and the neuronal responses of BAI, BCN, and PACC may predict addiction risk.

Other studies have found evidence of additional biological risk factors. Deficient cortisol reactivity to a variety of stressors has been implicated as a risk factor for alcohol and nicotine dependence. In addition, persons with alcohol and drug-abusing parents who show preexisting alterations in frontal-limbic interactions with the hypothalamic-pituitary-adrenocortical axis may be more vulnerable to addiction. Task-based activation in the inferior frontal gyrus and right insula has been associated with risk aversion, and activation in the nucleus accumbens and parietal cortex has been associated with both risk seeking and risk aversion. According to the investigators, these findings indicate that individual differences in attitudes toward risk taking are reflected in the brain’s functional architecture and may have implications for engaging in real-world risky behaviors.

Children and adolescents who exhibit aggressive behaviors, who demonstrate a lack of self-control, and who have a difficult temperament may be at risk for drug addiction, especially if they have been physically abused or have parents who are dependent on drugs or alcohol. These children and adolescents usually view authority with disrespect and feel out of control. Those who have been abused may be consumed by feelings of violence and may turn to drugs to suppress the anger, anxiety, and aggression caused by earlier trauma.

Risk Factors Related to Age and Gender

Because the prefrontal cortex is the last part of the brain to develop, thirteen- to nineteen-year-olds tend to use other parts of the brain (for example, emotional areas) when making decisions and are at high risk for substance abuse and addiction. Adolescent characteristics are predictors of adult alcohol use and abuse, and their effect varies as a function of age and type of alcohol outcome.

According to the Substance Abuse and Mental Health Services Administration, twelve- to seventeen-year-olds who smoke are more than eight times more likely to use illegal drugs and more than seventeen times more likely to drink heavily than their peers. In the same age group, those who used marijuana weekly were nine times more likely than their peers to experiment with illegal drugs or alcohol.

There is a robust association between age at first drink and risk of alcohol use disorder, reflecting willful rather than uncontrolled heavy drinking. Heavy episodic drinking is a measure of higher-risk drinking. Substance abuse prevalence is greatest among eighteen- to twenty-five-year-olds and more common in men than in women, but the relative risk of marijuana use is approximately equal for men and women. Hazardous alcohol use among older adults became an area of increasing concern in the early twenty-first century as America's population aged.

Environmental Factors

Environmental risk factors are those characteristics in a person’s surroundings and everyday life that increase their likelihood of becoming addicted to drugs. These characteristics include one’s family dynamics, social and cultural surroundings, housing, school, employment status, economic status, education level, and peer group.

Risk of drug abuse increases substantially during times of transition—changing schools, moving, divorce, and puberty. One of the biggest factors contributing to drug abuse risk is having friends who engage in addictive behavior. Teens are six times more likely to use marijuana when they believe that all or most of the students in their grade use drugs.

Lackadaisical family attitudes about drugs and alcohol, family substance use, dysfunctional parenting, and parental abuse (physical, emotional, or sexual) are contributing risk factors to substance abuse and addiction. If parents use alcohol, tobacco products, or other substances, their children are more likely to use them too.

Excessive deprivation or overindulgence in early life and inconsistencies in parental behavior, such as too much or too little love or discipline, or frequent instances of sudden switching from unrealistic praise to destructive criticism, can make a child more likely to use drugs or alcohol. Studies have found that children who are regularly left home alone are four times as likely to get drunk as those with more parental supervision. Children who have the least amount of adult monitoring start using drugs at earlier ages, which is linked to an increased likelihood of developing a substance use disorder.

Cultural beliefs, availability of drugs in the community, and acceptability of use within a person’s social environment and peer group contribute to drug use. People living in urban communities are more at risk for illicit drug and alcohol abuse than those living in rural communities. Those living in rural areas, however, are at greater risk of becoming addicted to prescription pain medication, binge drinking as adolescents, and using tobacco products of any kind. Among rural inhabitants, low socioeconomic status and isolation are risk factors of note.

Academic failure, particularly in later elementary years, is a risk factor for addictions because it begets low self-esteem. Teens are more likely to smoke, drink, or use illegal drugs if they have a negative attitude, difficulty adapting to change, and an inability to “go with the flow.” Teens at risk are those with changing family structures; easy access to alcohol, tobacco, or illegal drugs; adverse peer pressure; little adult supervision; unsafe places to learn, play, and socialize; and no good role models.

Perspectives

Resolving the monumental problem of substance abuse and addictive disorders will require education about addictive substances, recognition of susceptible personality traits and risk factors associated with addiction, and a better understanding of the complex interactions of psychological, environmental, and biological factors that contribute to the development of addiction.

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