The '5H's' Leading to Addiction

President of Üsküdar University Psychiatrist Prof. Nevzat Tarhan, participated online in the panel “Combating Substance Addiction” organized in cooperation with Karabük University and Can Sağlığı Foundation, within the scope of June 26, International Day Against Drug Abuse and Illicit Trafficking. Under the title “Psychological Resilience Protecting Youth from Addiction and The Power of the Family”, Tarhan drew attention to the 5H's leading to addiction — ‘Speed, Pleasure, Whim, Impulse, Greed’ — stating that these 5H's, which cause what we call hedonic adaptation, lead to excessive dopamine secretion in the brain, thus locking people into pleasure and turning them into slaves of the substance. 

“Addiction impairs the function of the brain's frontal region”

Speaking about the treatment process of addiction, Psychiatrist Prof. Nevzat Tarhan said; “In addiction treatment, there are three types of therapy and one clinical treatment. In other words, we can talk about four stages regarding addiction treatment. The first is clinical treatment. The patient is hospitalized, detox is performed, brain chemistry is corrected, and a crisis period is overcome. This is generally a three-week process and is often sufficient for this stage. The frontal region of the brain includes functions such as attention, orientation, short and medium-term memory, patience, planning, judgment, reaction control, being organized, problem-solving, learning from mistakes, understanding and expressing emotions, empathy, common sense, morale, and motivation. All of these are functions impaired by addiction. In other words, addiction impairs the function of the brain's frontal region. All the qualities that make a human being human, the abilities that enable a person to build civilization, are severely damaged after substance use. The person loses their human qualities under the influence of the substance at that moment.”

“Addiction is a brain disease”

Tarhan noted that the 5 H's leading to addiction are: ‘Speed, Pleasure, Whim, Impulse, Greed’, and stated that ‘these 5H emotions, which cause what we call hedonic adaptation, lead to excessive dopamine secretion in the brain, locking people into pleasure and creating individuals enslaved by the substance.’ Emphasizing that reward pathways turn into highways in addicted individuals, Tarhan said; “When we look at the neurobiology of addiction, the frontal region of the brain and the reward system come into play here. Substance use or stimulating factors such as insomnia, certain behavioral stimulants, and even natural stimulants like exercise activate the brain's reward system. This system works particularly through the mesolimbic region. Here, chemicals such as dopamine, endorphin, and serotonin are involved. In the neurobiology of addiction, during the treatment process, we consider the receptors associated with these chemicals. Furthermore, different receptor systems are also active in addiction. There can be cannabinoid receptors, or glutamate receptors. With the activation of these receptors, various signals are transmitted to the brain. Consequently, addiction is a brain disease. While normal brain pathways are like a footpath, in addicted individuals, reward pathways turn into a highway. Our primary goal in treatment is to ensure that this structure, which should be a footpath, returns to normal. It is necessary to reorganize these intensified pathways formed due to excessive dopaminergic activity. This process varies between six months and one year. Therefore, if we keep a patient in the treatment process for six months after hospitalization, we observe that a 60-70% recovery rate can be achieved in addiction.”

“Personalized planning is carried out through genetic measurements”

Speaking about the importance of personalized treatments, Tarhan said; “In addiction treatment, primary prevention consists of efforts to ensure healthy individuals do not fall ill. At this stage, psychological resilience, social connections, and meaningful relationships are emphasized. The concept we call psychological resilience is particularly strengthened here. In secondary prevention, risk groups are identified. For example, risk-bearing groups such as individuals who occasionally use stimulants or illicit substances within their social circle are identified, and rehabilitation programs are implemented for them. Tertiary prevention is clinical treatment, and the fourth stage is rehabilitation therapy. Protocols for clinical treatment have been determined, and the appropriate protocol is applied according to the patient. Ideally, nowadays, medication alone is not sufficient; in addition, addiction protocols affecting receptor sensitivity in the brain and neuromodulation therapies are also used. If psychosis has developed in the person due to substance use, i.e., a schizophrenic picture has emerged, more advanced treatments come into play. Because newly emerging illicit substances, in particular, can disrupt serotonin and dopamine gene expressions in individuals with predisposition genes in the brain, and can even shut down gene function. These genes are actually structures that can be turned on and off. Under stress, with substance use, or prolonged sleep deprivation, these genes can be turned off in individuals with genetic polymorphisms. For this reason, nowadays, by conducting genetic measurements, treatments are being planned in a personalized manner.”

“Certain features of the Internet facilitate addiction”

Speaking about conditions that may arise with a decrease in dopamine levels, Tarhan said; “On the other hand, there are behavioral addictions and virtual addictions. Internet addiction is one of them. Certain features of the Internet facilitate this addiction: being accessible 24/7, its immersive nature, offering validating content, being convenient and inexpensive, not evoking a sense of threat, and also being rewarding. All these features have nowadays replaced some substances. The dopaminergic system in the brain is also affected by this process. When a person picks up a tablet or phone, they don't notice how hours pass. This situation leads to the production of cheap dopamine in the brain, and a dopamine cycle forms. Over time, a condition we call dopamine drought develops in the brain. When dopamine levels decrease, the person feels tired, unhappy, and exhausted. As a result, many depressive symptoms and psychiatric conditions may emerge. Excessive stimulation of the dopaminergic system, in particular, makes this process even more pronounced.”

“Young people tend to gravitate more towards risk-containing stimuli”

Stating that adolescence is a period of intense change, Tarhan said; “Adolescence is a period of identity search where a person asks ‘Who am I, where do I belong, what am I living for?’ For this reason, young people are in a higher risk group due to their age and particularly need to be focused on. Adolescence is an intense period of change and can, in some respects, be considered a temporary crisis. During this period, sudden emotional shifts, outbursts, and defensive behaviors can be observed. This situation is largely natural and is also a process where learning and cooperation develop. In this process, the forebrain is not yet fully developed. Development generally continues until the age of 22. The maturation of the corpus callosum also continues until this period. In some individuals, this process may extend further, and adolescent characteristics can be carried into older ages. In these individuals, impulse control may be weak because the ‘stop-think-act’ mechanism is not sufficiently developed; behaviors such as doing whatever comes to mind and believing the last thing they heard may be observed. For this reason, young people are in a risk group. Furthermore, the brain reacts more strongly to negative emotions than to positive ones. Therefore, young people tend to gravitate more towards stimuli involving excitement, action, and risk. EEG and neuroimaging studies also show that these emotional responses are stronger.”

“We aim to create a jury mechanism in the frontal lobe”

Referring to the importance of the mental jury in healthy decision-making, Tarhan said; “We try to teach young people the metaphor of a mental jury. When a wrong thought or the urge to use a substance comes to mind, we assume there is a jury in the person’s mind. This jury consists of five members. The first is the president, who decides whether the event is real or not. The second is the scientist, who verifies and falsifies, and tests. The third is morality, who distinguishes between good and evil. The fourth is the aesthetician, who evaluates what is beautiful and ugly. The fifth is the operator, who performs a cost-benefit analysis. The judge here makes the final decision. However, for a healthy decision, it is necessary to consult all other jury members. This also develops fast and controlled thinking skills. This is not an innate characteristic; it is learned later. In fact, we aim to create such a jury mechanism in the frontal lobe.”

“Learning to be happy with ordinary things is the most fundamental skill”

Speaking about gratitude and thankfulness modules, Tarhan said; “We talk about positive psychology as a weapon for achieving happiness. According to Seligman, there are two basic concepts here: flexible optimism and authentic happiness. Flexible optimism is not Pollyannaism. It is more about learning and developing positive cognitions and thought patterns. Authentic happiness, on the other hand, is pure and true happiness, but it can only be achieved with effort and endeavor. The thought ‘I would be happy if I had this, I would be happy if I had that…’ frequently emerges at this point. True happiness is tied to internal reasons. A person needs to learn to be happy with ordinary things. Instead of trying to change the world and others, it is important to be able to change ourselves. Because a person who is constantly trying to change the world and others cannot be happy. Learning to be happy with ordinary things is the most fundamental skill. For this reason, in positive psychotherapy, the gratitude and thankfulness module is worked on. A person going and doing good to someone who did good to them in the past creates a very deep and meaningful bond for them. Or, a person focusing on the values they possess rather than what they don't have when they wake up in the morning is part of this process.”

“What protects a person from evil is accountability”

Stating that the self-management diagram must function correctly to achieve psychological resilience, Tarhan said; “A person who is not their own leader and does not know how to manage their brain cannot be happy, nor can they possess psychological resilience. Psychological resilience is the holistic functioning of logical intelligence, bodily intelligence, social intelligence, emotional intelligence, and spiritual intelligence. This is a type of self-management diagram. IQ is logical intelligence; it works like a program in a computer. It analyzes, thinks, strategizes, can think outside the box, and tries to foresee the future. EQ is emotional intelligence; it is the capacity to manage emotions. It enables one to be hopeful, optimistic, courageous, and empathetic. It uses humor and aesthetics, produces passionate projects, and supports self-confidence. PQ is physical (kinesthetic) intelligence; it is the ability to manage the body. It instills discipline, enables focus on goals, teaches resistance to distractions, and develops determination and dedication. SQ is social intelligence; it is the ability to manage relationships. It enables one to be compassionate, embracing, and open to cooperation. It can manage crises, is an active listener, is solution-oriented, and strengthens family bonds. VQ is spiritual (conscientious) intelligence; it is the capacity to listen to one's inner voice and for accountability. It makes a person principled, responsible, and honest. What protects a person from evil is not just good intentions or religiosity, but accountability. A person who knows they can account for their actions does not commit hidden evil.” Tarhan concluded.