Sex, Drugs, and No Control

Sex as Addiction and the Treatment Thereof
There is much controversy around the use of the term "sex addiction." This article gives a brief overview of the arguments against this term, and then shows some of the aspects as to why sex may indeed be an addiction and how it may be treated. There is certainly a need for further research in this area before anything definitive can be proclaimed, but perhaps the study of behaviours that present as addiction can give us further insight and understanding of exogenous addictions.
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According to the DSM-V Sex Addiction is not a diagnosable condition. Sexual addiction was mentioned in the DSM-III-R, but disappeared in the DSM-IV, threatened a come-back in the DSM-V but has now been discarded. Sex, however, has long been described as addictive. In the late 1800s Freud described masturbation as the “original addiction.” Rado in the 20’s described addiction as “compulsive” and made the reward/pleasure/sex link. We saw words such as nymphomania (Ellis) and the clumsy “Don Juanism”(Stoller). In the 70’s Mac Dougall spoke of “addictive sexuality”. It was originally proposed that sex be included under the heading of addiction in the DSM-V, and then that was discarded and the idea of hyper-sexuality was introduced as a possibility. Eventually none of these proposals was accepted, and so sexual addiction has ceased to exist, according to the DSM, that is.

Sex Addiction Doesn’t Exist?

There are many others who say that there is no such thing, or at the very least, call it a misnomer. Thomas Szasz (Humanist Psychiatrist and author of The Myth of Mental Illness) said: "Masturbation: the primary sexual activity of mankind. In the nineteenth century it was a disease; in the twentieth, it's a cure." Is it this paradigm shift that has moved us to become more tolerant of sexual excess and discard the notion of sex addiction? Certainly one of the common arguments against the label of sex addiction is that we are pathologising the “different” as determined by a set of arbitrary parameters. This could at times be true, and we do need to be careful. For example Dr Martin Kafka, a Harvard professor and a member of the APA sexual disorders workgroup describes men who have 7 or more orgasms a week for 6 months or more as hypersexual. This was in a 2009 paper. Some may rather call this behaviour “first year at varsity”! 

On the other side of this coin, there are those who argue against the term “sexual addiction” because it “pathologises deviance” and thereby creates a convenient label that enables the individual to abdicate responsibility. This is the view often taken by our self-appointed defenders of morality.

I feel that both of these views fail to understand the true definition of addiction. 

A third argument against the use of the term sex addiction, which has been presented by Coleman, is that the term “addiction” is so stigmatised that “there seems to be more uncertainty and potential harm” to use the term addiction. Coleman preferred the term “compulsion”, and there is indeed good reason to use the word compulsion, but in many opinions it does not fully encompass the severity of the condition called sexual addiction. 

The bottom line is that with anything of a sexual nature, society has both a fascination and avoidance. There are few topics that are so tainted by personal experience and upbringing.

So Does Sex Addiction Actually Exist?

St Augustine said “Inter Faeces et Urinam nascimur”, but for some of the population “Inter Faeces et Urinam mortimur!”  There are undoubtedly patients who have problematic sexual behaviours, and these behaviours will, if left untreated, be the death of them. If we take the current DSM criteria for addiction and apply it to sexual behaviours, we would find that it would fit the behaviour of many of the patients I have mentioned above:

  •  Tolerance (marked increase in amount; marked decrease in effect)
  • Characteristic withdrawal symptoms; sexual activities undertaken to relieve withdrawal
  •  More sexual behaviour in larger amount and for longer period than intended
  •  Persistent desire or repeated unsuccessful attempt to quit
  • Much time/activity to obtain, use, recover
  • Important social, occupational, or recreational activities given up or reduced
  • Use continues despite knowledge of adverse consequences

So, what behaviours characterise sexual addiction? I would argue it is foolish to try and list specifics of behaviour and quantify these behaviours to try and diagnose sex addiction. It is not the behaviour, but rather the pattern and consequences of the behaviour. It is here that I would differ with Carnes – considered by many to be the spokesman of sex addiction after the publishing of his 1983 book “Out of the Shadows” - who describes “levels” of addictions. He starts with Level 1 behaviours, which include what many would classify as “normal” sexual behaviours: Masturbation, homo and heterosexual relationships, pornography, strip shows, prostitution. He then describes Level 2 behaviours as exhibitionism, voyeurism and indecent phonecalls, while Level 3 is reserved for the behaviours most of us would classify as abhorrent – paedophilia, rape and the like.  I would argue that the paraphilias have nothing to do with sexual addiction, but would rather be a co-occurring disorder co-existing with sex addiction in some cases.

If addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships or activities, then sex addiction is when our relationship with sex is more important than our relationship with the person with whom we are (or are not) having sex.

The Evidence for Sex as Addiction

If sex is an addiction, it should present as an addiction in the same ways as other addictions. It is my belief that addiction is an underlying syndrome which may manifest itself in many different ways. This model has also been proposed by Shaffer (Shaffer, La Plante, La Brie, Kidman, Donato, & Stanton, 2004), and he describes all addictions as having similar etiology but varied expressions. In my terminology I often describe addiction as similar to those that suffer from it: “all are unique, but none is different”.

I explain addiction as something that takes place on three planes: The thought-behaviour plane, the neurobiology-neurochemistry plane and the macro/micro-system or environmental plane. These three influence each other over time, and any addiction brings about fundamental changes in each of these areas, and that in turn amplifies the effects on each plane individually and collectively. Therefore, for something to be an addiction it must be demonstrated to some or other degree in each of these planes.

Behaviour – Compulsive, Impulsive or addiction?

As stated earlier, Coleman suggests the use of the term “sexual compulsivity”. Compulsive disorders, according to the DSM IV, reduce anxiety or distress, even though the act is not pleasurable or gratifying. The purpose of the act is to reduce the anxiety of the obsession, rather than find pleasure in the action itself. It could be regarded as negative reinforcement. 

The impulsive disorders would be the (apparently) immediate satisfaction of cue-based desires despite negative consequences. This could be considered a form of positive reinforcement.  Although I have used the terms negative and positive, these two states should not be seen as diametrically opposed. The relationship between the two is far more complex. 

Addiction seems to include aspects of both compulsive and impulsive behaviour types. I would suggest that it may start as impulsive and move towards being compulsive, often vacillating between the two. Similarly, sexual addiction both gratifies and repulses the patient, often giving the briefest moment of respite after hours, or even days, of obsession and ritual, shortly followed by deep shame and repeated promises of “never again!” 

In the film Shame, Michael Fassbender portrays a sex addict living in New York. The film graphically shows just how unfulfilling sex can be, and how when sex is an end in itself, all normal boundaries seem to dissolve - a “not yet” list quickly becomes “done that and more” confession. Just like with substance addiction. It is at this point that we see how closely sex and drug addiction are intertwined and it becomes difficult to see what fuels what – it is for this reason that syndromal models seem to carry weight.

Behaviourally we see the addict engaging in increasingly dangerous and uncharacteristic behaviours in spite of extreme consequences. Cognitively we see the move towards less-helpful patterns of thinking. Wrong (from the patients original point-of-view) becomes right, the cognitive distortions become more obvious, and have a greater effect which is increasingly catastrophic. 

Neurology

This tragic photo shows Didier Jambert with his wife Christine at a press conference after he was awarded damages because his ReQuip tablets turned him into a “hypersexual, gay, cross-dressing gambling addict.” The apparent cause of this sudden and unprecedented change in behaviour was dopamine. Dopamine is certainly one of the usual suspects when it comes to drug addiction, and similarly it has been shown to have a role in behavioural addictions. There certainly seems to be significant correlation between dopamine levels and behavioural addictions, including sex addiction. However, the reward system is not enough to explain addiction. 

One of the more useful theories of addiction is the iRISA theory of Goldstein and Volkow (Goldstein, 2002). Basically this says that addiction can be considered an impairment of inhibition and/or an over exaggerated drive or motivation. During drug use there is a repetitive cycle of salience attribution, craving, bingeing and withdrawal. Each of these phases involves different brain regions and neurotransmitters and neuropeptides. Similarly Carnes describes a cycle of sexual behaviour in the addict, although I found earlier references of this process in the work of Reed and Blaine from a 1988 paper. I would like to propose that these could possibly be corresponding and that the underlying neurology may be similar:

iRISA
Carnes/Reed & Blain
Possible underlying Neurobiological processes
Salience Attribution
Pre-occupation
hDA levels in limbic brain regions particularly NAcc, evidence of hDA levels in frontal regions.
Drug Expectation
Ritualisation
Likely involvement of Amygdala, PFC and Hippocampus. Activation of Thalamo-orbitofrontal circuit and anterior cinculate.
Impaired Inhibition
Compulsive Behaviour
Loss of top down control DA, 5-HT & Glutamate play active role
Depression
Depression
Disruption of frontal cortical circuits. iDA  i5-HT

For more detail on this, check out this article of mine: The Neurobiological Underpinnings of Addiction
 
Like drug addiction, sex addiction breeds tolerance, and like drug addiction “real-life” becomes less rewarding neurologically and experientially. There is evidence that low levels of pre-addiction serotonin are also linked, like in other addiction, with behavioural and sexual addictions (Grant, Brewer, & Potenza, 2006)

Also, what must be noted, is that addiction-like sexual behaviours, as well as paraphilias, can be the result of brain lesions or underlying organic conditions. This, I believe, shows us that addiction is a lot more than a simple choice process, and that brain dysfunction has a significant role to play.

The System

The Micro-environment

A study by Carnes in 1991 suggested that 82% of the sex-addict subjects had experienced childhood sexual abuse. This figure is incredibly high, but is supported to some degree by other studies. Not only does this point to the psychology of the sex addict, but also to the biology. We know that early childhood abuse has major effects on the pre-frontal cortex circuitry, and we see reduced size in the left-hippocampus and a corresponding set of dissociative symptoms in adulthood. It should also be noted that these abnormalities were seen in cocaine addicts (Ersche, Jones, Williams, Smith, & Bulmore, 2012). We also see less left-right brain integration with corresponding opposing views of the world in which they live, and to further complicate this we see alterations in oxytocin and vasopressin mediated sexual arousal.

There has long been the proposed link between the lack of early attachment and addictive disorders. It may be that the corresponding drop in dopamine and noradrenaline may drive the individual to seek behaviours or drugs that boost levels just so they can feel “normal”. What means they choose may have a lot to do with the broader eco-system in which they find themselves, rather than with direct conscious choice. We also see the imprint of childhood trauma on the limbic system, leading to a hypersensitive amygdala, which may contribute to impulsivity and this adds credence to the idea that for the sex addict, sex is not merely pleasure seeking, but survival seeking.

Undoubtedly, like with other addictions, but more so, the neurological effects of childhood abuse and attachment issues move the individual towards a predisposition for sexual behaviour that presents as addiction.

The Macro-Environment

In the world of the internet we have what is referred to as the triple A-engine: affordability, accessibility and anonymity. The availability of sexual images at ever decreasing ages has certainly fuelled what Carnes calls the Tsunami of sexual addiction. The estimated first age of exposure to pornography is 11 in the United States (Bryant & Brown, Pornography: research advances and policy considerations).

I alluded to the effect of this macro-system or ecosystem in that it may push the addiction prone individual towards a particular manifestation of the underlying condition or need. In a world where sex, drugs and rock and roll are the norm we will get more addicts of the drug and sex type than in a more conservative society, where we may get religious addicts – which is arguably a more acceptable manifestation – it doesn’t mean the individual isn’t sick, it just means that they aren’t being as harshly judged for their particular symptoms!

The Treatment of Sex Addiction

The first thing to remember is that the majority of patients who have sex as addiction issues do not usually present with an obvious sexual addiction. Because of the shame surrounding sexual issues the patient will often present with other issues, sometimes even because of a lack of sex with a romantic partner. Often there may be anxiety, depression, suicidality, substance abuse or criminality. It is only later, once a good therapeutic relationship has been built, that the sexual behaviour is discussed.

So how would we treat sex that presents as addiction? Well, in much the same way as we would an addiction. We need to examine three main areas: The system: past, present and future; the immediate thoughts and behaviours; and the neurobiology and neurochemistry. Like all addictions all these planes of treatment should be considered to ensure that an effective treatment plan is formulated. The treatment of sex addiction is hard. Like with all addictions we are expecting the individual to move from instant gratification with delayed (possible) consequences to instant turmoil with future (possible) satisfaction. This is a difficult task. Goodman proposes an outline that I have found useful: He proposes 4 stages of treatment (Goodman, 2001):
  • Behaviour Modification
  •   Stabilisation
  • Character Healing
  •   Self-Renewal
These should not be seen as hard and fast individual processes that happen independently of one another, but should rather be seen as interrelated aspects of the recovery process.

The biggest challenge is that when it comes to sex addiction, all treatments, except in the case of a few co-occurring paraphilia, are essentially harm reduction and not abstinence based. It is important to help the patient define healthy sexual behaviours as opposed to unhealthy behaviours, and facilitate the move away from pathological behaviours. Having said this, many of those that treat sexual addiction may suggest an initial period of abstinence to help establish initial behavioural modification.

Psycho-social interventions:

Most searches on the internet when it comes to treatment for sex addiction invariably lead to 12 step programs. In the local context we see SLA – Sex and Love Addicts anonymous. While many have described these groups as very helpful in overcoming the sense of shame and isolation that many sex addicts experience, these groups should not be seen as treatment, but rather as an adjunct to treatment. It should also be borne in mind that these groups are also filled with sex addicts, and as such can be a trigger for the recovering sex addict.

Another problem with this approach, especially in the treatment setting, is that many 12-step based treatment plans are confrontational and expect the sharing of one’s deepest and darkest secrets in the group setting. If we consider that the majority of sex addicts have a history of being sexually abused this could be extremely counterproductive. We need to tread carefully, and above all, non-judgementally.

For this reason, sexologists would immediately feel that the treatment of sexual addiction falls firmly into their field, however many of those seeking treatment for sex addiction feel that they need less therapy and more treatment. According to Robert Weiss, one of the major complaints received from patients is that therapists don’t understand how destructive their behaviour is. Many may also misconstrue the source of the shame felt by sex addicts. While it may be caused by some of the activities they engage in, it is often more about the levels of salience they have attributed to the pursuit of their sexual behaviours (Hall, 2011) at the expense of the ones they love and the values they consider important.

The types of psycho-interventions that have shown to benefit sex addicts are cognitive behavioural therapies, particularly in the stages of behaviour modification and stabilisation, and then a gradual move towards psycho-dynamic psychotherapy which is often essential to long-term recovery and the process of character healing. I would also like to see more research on the use of Dialectical Behavioural Therapy due to the similar aetiologies of Borderline Personality Disorder and Sex Addiction.

In managing the environmental aspect of the addiction, it is also helpful to include the spouse, although this, I would suggest, be left till later in the process. Dealing with constant relapse within the couples therapy environment is difficult and can be damaging to the process, and until there has been some demonstrable changes in behaviour, the partner is more likely to be oppositional than reconciliatory.

Pharmacological Interventions

Most of the limited research revolves around the SSRIs. There have been limited successes, and a few double blind trials, which have tended to be focused on very specific target groups, and have had limited research value. Both Citalopram and Fluoxetine (Prozac) has also been shown to have some effect in the reduction of acting out with sexual behaviours (Garcia & Thibaut, 2010).

Naltrexone, the opioid antagonist that has been used across a multitude of addictions, has also been shown to have some effect on compulsive sexual behaviour (Raymond & Grant, 2010) (Bostwick & Bucci, 2008).
Topiramate, originally used as an anticonvulsant, and more recently approved for weight loss, has, in one case report (Khazaal & Zullino, 2006) shown to possibly mediate the cue effect in sexual addictions. Interestingly a 2010 Cochrane Review concluded that there was evidence supporting the use of Topiramate in the treatment of borderline personality disorder, which I have suggested earlier could have a similar origin to sex addiction. Topiramate has also shown some success in the treatment of cocaine addiction in clinical trials (Kampman KM, 2004) as well as alcohol (Johnson, 2005). Topiramate increases cerebral GABA levels and inhibits glutametergic activity.

There is also literature regarding the use of antiandrogen medications for nonparaphilic sexual behaviour, but, personally, I have some unresolved ethical issues surrounding this and so won’t discuss this here.

Conclusion

It is obvious that whether or not we buy into the term “Sex Addiction” there are significant similarities with addictive disorders when it comes to pathological non-paraphilic sex. We need to keep in mind that the only reason we seek to label is so that we can identify a treatment path. Certainly there needs to be a lot more research into what I have termed sex addiction: the neurobiology, chemistry, behaviours, and biopsychosocial interventions to bring some level of comfort to those who find themselves suffering from this particular manifestation of addictive disorders.

Even once we have achieved some measure of clarity there will always remain the unanswered key question in the world of sex addiction: “Is Tiger Woods a sex addict or not?”

Bibliography

Bostwick, J., & Bucci, J. (2008). Internet sex addiction treated with naltrexone. Mayo Clinic Proceedings, 83(2):226-230.
Brenhouse, H., Lukkes, J., & Anderson, S. (2013). Early life adversity alters the developmental profiles of addiction related prefrontal cortex circuitry. Brain Science, 143-158.
Bryant, J., & Brown, D. (Pornography: research advances and policy considerations). Use of pornograph. Hillsdale (NJ): Erdbaum.
Carries, C., & Delmonico, D. (2007). Childhood abuse and multiple addictions: Research findings in a sample of self-identified sexual addicts. Sexual Addiction and Compulsivity, 3(3):258-268.
Davis, J., Loos, M., Sebastiano, A., & Brown, J. (2011). Lesions of the Medial Prefrontal Cortex Abolish Conditioned Aversion Associated with Sexual Behavior in Male Rats. Biological Psychiatry, 67(12):1199-1204.
Ersche, K., Jones, P., Williams, G., Smith, D., & Bulmore, E. (2012). Distinctive Personality Traits and Neural Correlates Associated with Stimulant Drug Use Versus Familial Risk of Stimulant Dependence. Biological Psychiatry.
Fong, T. (2006). Understanding and Managing Compulsive Sexual Behaviours. Psychiatry, 51-57.
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Goldstein, R. V. (2002). Drug addiction and its underlying neurobiological basis: Neuroimaging evidence for the involvement of the frontal cortex. American Journal of Psychiatry, 159(10): 1642-1652.
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4 comments:

  1. Nik Wrote this about the above post on Marc Lewis's blog: Memoirs of an Addicted Brain

    Hi Shaun

    Thanks for the link. Your article seems well written and has several good points, e.g. about Carnes’ too easy equation of antisocial acts and paraphilias as the ‘extreme’ of sex addiction. I think it’s a remnant of the old AA doctrine of “the progressive nature of the disease”, which has some truth, for some cases, but in my opinion fails as a generalization because of poor foundation in the evidence (of the global picture, not just of those who turn up at AA meetings).

    It was interesting that you present 12-step “S” meeting as adjuncts to therapy.
    I’ve got over 150 under my belt, and find they claim the exact opposite: therapy is the adjunct to peer supported, self-instituted life changes. Is there any way to adjudicate claims, here. Is it only a turf war?

    It’s appropriate to mention the ‘neither’ option, both here and below, based on data such as Fletcher’s ‘Sober for Good.’ People do move past problems, quite often w/o therapy or ‘treatment’. I must say ‘treatment’ gives me some chills, and causes reservations about excuses: I’m thinking of articles that say, “Celebrity X, after crashing his car into another and nearly killing several people, has been cleared of all charges with the understanding that he will seek ‘treatment’ for…”

    One passage of yours is rather puzzling, in that it seems at first to agree with ‘less therapy’ and ‘more treatment’, and to believe in some such distinction. A few sentence later, though you’re recommending “cognitive behavioral therapy”! Are you implying it’s not ‘therapy’ and is more ‘treatment’. Does the distinction make sense? To take an analogue, is not ‘physiotherapy’ a ‘treatment’ of some physical or functional problem?

    shaun //many of those seeking treatment for sex addiction feel that they need less therapy and more treatment. According to Robert Weiss, one of the major complaints received from patients is that therapists don’t understand how destructive their behaviour is. [..].

    The types of psycho-interventions that have shown to benefit sex addicts are cognitive behavioural therapies, //

    =======

    You say, //The treatment of sex addiction is hard. Like with all addictions we are expecting the individual to move from instant gratification with delayed (possible) consequences to instant turmoil with future (possible) satisfaction. //

    Something like this was/is surely the general goal of psychoanalysis and ‘dynamic psychotherapy.’ In Freuds famous phrase: //Wo Es war, soll Ich werden.” // Certainly, as you say, ‘a difficult task’.

    I think you laid out some of the issues around compulsivity, impulsivity and ‘addiction’ and thank you for drawing my attention to the APA’s ultimate rejection of ‘hypersexual disorder’– presumably having already rejected ‘addiction’ and ‘compulsion.’ There are lots of foundational issues, here, including the more basic, what is [psychological] disorder?

    I find myself leaning *away* from the term ‘addiction’, esp. where it takes on a life of its own as ‘disease’ (and further ‘disease requiring “treatment” ‘. Having listened to dozens of ‘sex addicts,’ the presence of underlying issues is quite striking, as you yourself mention. Hence in many cases, for example, it seems plausible to say, the main disorder is depression; there is an associated, derivative syndrome of sexually compulsive ‘acting out.’ There is, here, as you say, a harm to be curbed– like wandering dark alleys at night– but not exactly a ‘disease’ or ‘disorder’ to be treated for as such.
    (All the later DSM’s confound these matters.)

    There are many issues, not all of which are immediately relevant to this thread or Marc’s blog which possibly could be discussed in outside avenues.

    Thanks again for your post and article.

    ReplyDelete
  2. Thanks for your comments Nik, you've given me a bit to think about. I presented this as a talk, and so I was able to spend some time clarifying some points, which isn't reflected in this piece. I'll try and provide some of my opinions around the questions you ask. At this stage most of this is simply my understanding as there is little concrete research:

    Are 12-step programs an adjunct or a treatment? Well, I was presenting this to a group of medical professionals working in the addictions field, and in all too many "recovery programs" rely on the 12-step approach as "treatment". I have a major problem with this in that I see this as the hi-jacking of a free community resource. Of course, it very much depends on the individual as to where the life-changes take place. I tend to see support groups as filling the role of shame reduction, and creating new relationships and for the fostering of hope. If the individual works their "steps" diligently, this can, indeed, be the most important aspect of their recovery. That would be my personal experience. However, this is not treatment. It is self-healing, and I believe there are some for whom this is beyond their grasp, and they need a more intensive professional treatment.

    As for the "neither" option, the sheer discomfort of the addictive disorder eventually becomes to uncomfortable, and often people "self-heal" through some informal, private means of change.

    I hear what you say about treatment. This is one of the big sources of debate when it comes to addiction. However, to imply that just because of illness there is no responsibility is simply not true. With acknowledgement comes the responsibility for treatment.

    The puzzling passage is a result of my using the word "treatment" in a slightly different context. What Goodman is referring to is that many people seeking help want some concrete actions to take - they want a literal or metaphorical pill to swallow that can result in short-term behaviour modification, as opposed to the longer term psychodynamic approach. I see the CBT as providing that, and this is more in the realm of addictions therapists, rather than sexologists (generally speaking!)

    I am very conflicted about the disease notion of addiction. I am firmly on the fence at this stage. I do see lots of support though that there are certainly brain dysfunctions in addicts, and there is support that these were preexisting, as well as being catalyzed by addictive behaviours.

    There is so much more I could say, but I will leave it there for the moment. I will be writing more on many of these subjects over the next few months, and hopefully we will have more discussions around these issues.

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  3. Very interesting stuff, Shaun. I am most intrigued by the parallels between sex addiction and other addictions, and I'm glad you emphasize that link. In this regard, it's particularly important what you say about shame. Shame is not about the behaviour per se, but about the strength of the feelings that drive one to do it again and again. People are astonished at themselves and deeply ashamed, when they see how much they continue to give up in order to permit themselves "yet another" episode of whatever it is they're addicted to.

    I'm also interested in the neuroscience. I looked up that story about Didier Jambert and ReQuip -- wow! If anyone still has the misconception that dopamine is responsible for pleasure, just send them a link to that story. It makes if very clear that dopamine (too much, phasic, flooding particular brain regions) is the source of craving and desire -- and that's not fun at all.

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  4. Thanks for your comment Marc. I think we have a lot to learn about exogenous addictions through the study of behavioural addiction. I am sure there is something in the dopamine thing that makes certain types of dopamine release in certain areas for certain individuals "Toxic" in some way - there is no science to back this up, but somewhere I have this uneasy feeling!

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