Thursday 10 January 2019

Evidence-based puritanism

As the paternalistic state expands, it is shifting its attention from substances to behaviours. In the 2020s, the focus of the nanny state is likely to move beyond alcohol, nicotine, drugs and food and start targeting video games, social media, sex and shopping. It has already begun by speciously redefining gambling as a public health issue.

The rhetoric will be the same. Consumers will be portrayed as dupes and addicts. The blame will be placed on advertising and availability. The solution will be bigger government. As I argued in Killjoys, the great trick of the paternalist is to take freedom away in the name of making people free.

An article in The Guardian yesterday illustrated this nicely. It comes at a time when the World Health Organisation is trying to classify 'gaming disorder' (video games, not gambling) as a bona fide disease. The article's basic argument is that 'from sex to sugar to social media, people are in the grip of a wider range of compulsive behaviours'.

Before we begin, here are four propositions, all of which I am inclined to believe.

Firstly, every society has a minority of people who are so unhappy that they will seek pleasure to an extent that can become seemingly self-destructive and irrational. Unconcerned about the future, they discount future costs heavily - sometimes entirely - in pursuit of short-term benefits. They engage in pursuits which most people enjoy without developing a problematic relationship, eg. drinking alcohol, taking drugs, gambling, having sex, playing video games, eating food, shopping.

The activity can be almost anything and it is often several activities at once. It is not the activity per se that causes the problem, as evidenced by the fact that the vast majority of consumers do not develop an unhealthy relationship with the product. It is the person's circumstances. When the circumstances change or the person changes, the excessive consumption will stop.

Secondly, every society has a minority of people who feel moral revulsion towards frivolous or risky pursuits (puritans) and a majority of people who feel moral revulsion towards at least one frivolous or risky pleasure. They portray the people mentioned above as addicts and the activities listed above as inherently addictive, undesirable and harmful. They use addiction as an excuse to clamp down on activities that displease them, but they are not bothered about compulsive behaviour per se. They don't mind people getting addicted to hill-walking, hoarding or Hollyoaks. Their true aim is to extinguish the activity, not free the individual. 

Thirdly, genuine addiction - ie. physical addiction and withdrawal symptoms - is real but it is relatively rare and is only possible when the addiction involves substances (as opposed to behaviours).

Fourthly, the psychiatric and pharmaceutical industries have a huge incentive to medicalise normal human behaviour and have been doing so for years.

Now let's look at the Guardian article (by Amy Fleming)...

Addiction was once viewed as an unsavoury fringe disease, tethered to substances with killer withdrawal symptoms, such as alcohol and opium. But now the scope of what humans can be addicted to seems to have snowballed, from sugar to shopping to social media. The UK’s first NHS internet-addiction clinic is opening this year; the World Health Organization (WHO) has included gaming disorder in its official addictions diagnosis guidelines.

The first glimmer of this shift was in 1992, when tabloids reported that Michael Douglas – Hollywood royalty, fresh from starring in the erotic thriller Basic Instinct – was holed up in an Arizonan rehab facility with sex addiction. No matter that, to this day, Douglas stringently denies ever suffering from the condition – the way we perceive addiction had begun to unfurl.

Back then, the broadening of the term was often viewed in medical circles as lazy appropriation; however, neuroscience has now largely accepted that it is the same brain chemical, dopamine, driving these irrepressible cravings. What’s more, our 21st-century world is so heavily baited with cues and stimuli – from stealthy marketing to junk food, not to mention the nagging lure of online life – that it appears to be rigging our dopamine systems to become “hypersensitised”.

A great deal of nonsense is talked about dopamine. You will often hear campaigners claim that a pleasurable activity, such as eating sugar, 'hijacks' the brain by stimulating dopamine in the same way as cocaine. But there is no pleasure without dopamine and the whole point of dopamine from an evolutionary perspective is to encourage things like procreation and energy consumption. The brain is not being 'hijacked' when it releases dopamine in response to the consumption of high-calorie food. It is doing exactly what it is supposed to do. The fact that cocaine produces a similar reaction artificially does not mean that everything which stimulates dopamine is like cocaine.

Peter Gray explained this nicely in an article about 'gaming addiction' last year:

The research that Kardaris referred to demonstrates that certain pathways in the forebrain, where dopamine is the neurotransmitter, become active when people are playing video games, and drugs like heroin activate some of these same pathways. What Kardaris’s and similar articles leave out, however, is the fact that everything that is pleasurable activates these pathways. These are the brain’s pleasure pathways. If video gaming didn’t increase activity in these dopaminergic pathways, we would have to conclude that video gaming is no fun. The only way to avoid producing this kind of effect on the brain would be to avoid everything that is pleasurable.

As gaming researchers Patrick Markey and Christopher Ferguson (2017) point out in a recent book, video gaming raises dopamine levels in the brain to about the same degree that eating a slice of peperoni pizza or dish of ice cream does (without the calories).  That is, it raises dopamine to roughly double it’s normal resting level, whereas drugs like heroin, cocaine, or amphetamine raise dopamine by roughly ten times that much.

Back to the Guardian...

“The range of what people are getting addicted to has increased,” confirms Michael Lynskey, a professor of addiction at King’s College London. “For my parents’ generation, the only options were tobacco and alcohol. Now there are more drugs, including synthetics, along with commercialisation and ways – especially online – of encouraging prolonged use of different things.”

This is the first of many bald assertions that do not stand up against the facts. Did previous generations only have alcohol and tobacco to get 'addicted' to? No. Many of the activities that are now being medicalised, from gambling and shopping to sugar and sex have been around for a very long time.

Gambling is the longest established behavioural addiction, having been medically recognised since 2013.

Wow, all the way back in 2013. The olden days.

“I see gambling students who drop out of university because they can’t stop,” says Henrietta Bowden-Jones, the consultant psychiatrist behind the forthcoming NHS internet-addiction clinic. “I see people with shopping compulsions who are in so much debt because they couldn’t stop themselves from buying three dresses in different sizes, that in the end their businesses and families suffer.”

Sometimes, she says, compulsions flit between different vices – for example, a young man seeking refuge from family problems might toggle between gaming and porn. “I saw [a gaming disorder patient] yesterday,” she adds, “who then went on to spending money on objects and clothes. You can somehow shift the behaviour but it’s an illness we don’t yet know enough about.”

If it is an 'illness' for young men to be playing video games, looking at porn and spending money on 'objects and clothes', we're going to have to build a lot of hospitals. But I guess that would suit someone who is about to open an NHS-funded 'internet-addiction clinic'.

Not everyone agrees with defining these new disorders as addictions – after all, you can’t overdose on them. Gambling and gaming are the only ones to have made it on to the WHO list of addictions. However, a paradigm shift in understanding addiction is in motion.

It certainly is.

Take sex addiction. Seeking treatment for this controversial condition has, in cases such as that of the golfer Tiger Woods, been criticised as a cynical shortcut to redemption for philanderers.

That's exactly what it is and everybody knows it.

On the other hand, neuroscientists who have been able to study the brains of people with debilitatingly compulsive obsessions with sex witness similar responses to those they have observed in drug addiction cases.

But the article the Guardian links to says in the first paragraph that 'the researchers caution that this does not necessarily mean that pornography itself is addictive'.

The first factor is that our modern environment is stuffed with craving-inducing stimuli. “People don’t appreciate the power of cues that have been associated with rewards, be it a drug or sex or food, in generating motivational states.” In fact, addicts can start liking the cues more than the end goal, such as the rigmarole of scoring drugs and so on. “The amount of cues associated with highly palatable foods are everywhere now,” he says. “Drugs, sex and gambling as well, and that has changed quite a bit over the years and could be leading to more problematic use.”

This is difficult to square with the decline in drug use and - apparently - sex among millennials. Drugs and sex are not advertised so I'm not sure which 'cues' are being referred to, but since gambling advertising was legalised in 2005, there has been no rise in problem gambling or gambling participation in the UK.

Lynskey agrees, adding “some of the marketing and design of gambling machines is a step ahead of all of us academics in devising ways to attract users and boost dopamine and retain them”. The “like” button, quantifying approval and igniting a compulsion to check social media, is a similar example.

I don't buy this brain-hijacking, dopamine-boosting, hidden persuaders bullshit. When you break it down, all it means is that companies make products and services that people enjoy instead of things that they don't. If Twitter wants to hijack my brain by having a feature that lets me know when someone likes my tweet, that is absolutely fine. It's a social network, after all and there is nothing remotely sinister about it. Get a grip.

There is an underlying puritanism at work here. Anything that produces pleasure (and therefore dopamine) is immediately regarded as suspect. The implication is that companies should make their products and services less enjoyable so people stop using them and do something more spiritually uplifting or economically productive. This is an incredibly dangerous attitude and 'killjoys' is exactly the right term for those who promote it. 

Robinson’s second consideration is dosage. Our liking of sweet tastes suited us when we were hunter-gatherers, helping us choose ripe energy sources. Now, we have high-fructose corn syrup, which blows our minds with unnatural levels of glucose.

As a general rule, you can ignore any journalist who claims that British people are hooked on high-fructose corn syrup. EU quotas mean that HFCS is a negligible part of the British diet. Moreover, HFCS doesn't have high levels of glucose. It has (relatively) high levels of fructose. Normal sugar is 50% fructose, 50% glucose. HFCS is 55% fructose, 45% glucose. The clue is in the name, for goodness sake.

In any case, there's no reason to think that this marginal difference in fructose content 'blows our minds' any more than regular sugar.

His final factor is simply access. “Food, sex, gambling and drugs – availability these days is much greater than it was in the past.” (Sex addiction can include consuming porn, sexting, compulsive masturbation, exhibitionism and chemsex.)

Notice how similar these three factors are to what the 'public health' lobby calls the Three As: advertising, affordability and availability.

Let's face it, if you're complaining about something being affordable, advertised and available, you are really complaining about it existing. You don't think people should be engaging in a certain activity and so you blame the industry that facilitates it.

It's a way of being judgemental without appearing overtly judgemental, as I argued in Killjoys...

By switching attention from the buyer to the seller, they portray the individual as victim and the industry as aggressor. And since society tolerates a higher degree of regulation for companies than it does for individuals, legislation that is paternalistic in intent can be presented as protecting consumers from injuries inflicted by companies.

To take a typical example, an Australian professor of public health has written about the ‘ubiquitous availability, accessibility, advertising and promotion of junk foods that exploit people’s vulnerabilities’. Given this supposedly predatory behaviour by big business, she argues that it is ‘important not to blame victims for responding as expected to unhealthy food environments’ (Lee 2016).

Since advertising and promotion are much the same thing, and accessibility is the same as availability, it appears that the crimes of the food industry in this instance amount to putting products on the shelves and telling people about them. To suggest that people are ‘victims’ because they have been given options and information is undiluted paternalism; it treats adults like children. 

Back to the Guardian again...
Major risk factors for addiction, such as deprivation and childhood trauma, are still important predictors for how easily your dopamine system can be hijacked, says Robinson...

Now we're getting near the truth; I refer you to my first proposition at the start of this post. But is it really the case that unhappiness makes the dopamine system easier to 'hijack' or could it be, as Gary Becker argues, a more rational process in which the unhappiness changes the costs and benefits? Doesn't the very fact that these 'disorders' are strongly influenced by personal circumstance - and often disappear when the circumstances change - suggest that they are not really diseases at all?

 ....“but you have laden on top of that ubiquitous cues, more potent formulations and increased availability”.

Well, maybe, but that is a theory that could be tested empirically. If strong empirical evidence exists to support it, it is not cited in this article.

Despite the increase in the range of addictions, says Lynskey, there are still probably fewer addicted people than there were 30 years ago because the level of nicotine dependency – the most deadly one – has dropped from 50% to less than 20% in the UK. 

This is likely true, but it rather undermines the rest of the article. We are, supposedly, surrounded by addictive products which are more available than ever before, not least via our ubiquitous mobile phones, and yet overall rates of addiction have fallen because just one of them - nicotine in cigarettes - has become less popular. At the very least, this suggests that the other activities mentioned in the article are much less addictive than cigarettes.  

However, updates to diagnosis guidelines mean that people who sit lower on the addictive spectrum can now be seen as having problematic dependencies.

As an admission that the goalposts are in the process of being moved to medicalise a whole bunch of normal, everyday activities, this is as candid as it gets.

“There is a spectrum,” he says, “whether it’s alcohol or drug dependence or shopping addiction and people have become a bit happier with placing the point at which behaviour becomes problematic at a lower level of use.”

No kidding.

“There are fantastic blocks to put in place that can stop you from watching porn, gambling and indeed anything to do with the behaviour you have an issue with, except for gaming,” says Bowden-Jones. 

You only need to think about this for a few seconds to realise that it is not true. Smoking? Drinking? Sex? Eating? Drugs? Are there even blocks you can put in place to stop you watching porn? Maybe there are, but self-exclusion from gambling is the only one I've heard of.

“We need to get to a position where, in the cold reality of your day, you can say: ‘I don’t need to spend more than two hours a day doing this, so I will block myself after two hours [of play].’” 

It's called self-control.

This responsibility, she says, lies with the gaming industry.

Of course it does. If there's one thing we've learned from the cod science of neo-addiction, it's that there's no such thing as personal responsibility.

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