Monday, 17.05.2021

Peter R. Martin: Historical Vocabulary of Addiction




      According to the current electronic version of the Oxford English Dictionary (OED), the noun aggression is partly a borrowing from French and Latin.  The French aggression is derived from the classical Latin aggressiōn-, aggressiō.  Both of these were formed originally as the combination of the past participial stem of aggredī (“to attack”) and -iō -ion (a suffix which is used to form a noun from a verb).  The first use in the English language of the word aggress which is found in both noun and verb forms preceded that of the noun aggression.

      The noun aggress was first used in the English language as exemplified by an entry in The Acts of the Lords Auditors of Causes & Complaints dating originally to 1475, edited by Thomas Thomson (1773–1852), a Scottish physician and chemist (1839): “In the mein tyme he to haue aggress [to] Malcom Fleming for quham he is bundin.”  This meaning of the noun agress (“access, approach”) is now obsolete, replaced by one that designates motivated antagonism (“An attack, an act of aggression”) as in (Fletcher 1677): “The 3d. and last aggress was managed by Salmanasser… who in the 9th of Hoshea sweeped the Land of its inhabitants.”  An example of the first appearance of the verb aggress occurred in a book by Thomas Preston (1537-1598), playwright and college head (1569): “Beholde I see him now agresse and enter into place.”  This meaning (“To approach, march forward; to progress”) is also considered obsolete; it has been supplanted by one that denotes ferocious fighting (“To make an attack; to commit the first act of violence, to provoke conflict.”), as for example by Edmund Arwaker the elder (?1660–1730), an Irish poet and cleric (1708): “The Man's Son, thro' Wantonness, aggress'd, And with a rude Assault provok'd the Beast.” 

      The original meaning of aggression in the English language (“An unprovoked attack; the first attack in a dispute or conflict; an assault, an inroad”) is exemplified by (Sheldon 1611): “Who is ignorant how that same furious aggression and censure of Boniface the VIII. vpon Philip the Faire, how little it profited?”  Then the meaning of aggression shifted (“The practice of attacking another or others; the making of an attack or assault”), as for example (Lord 1630): “They renewed their battell by fresh Aggression and Onset, till darknesse did prohibit the vse of Armes.”  The progression of meanings evolved from military to more political contexts until aggression came to be viewed as an attribute (“Feeling or energy displayed in asserting oneself, or in showing drive or initiative; aggressiveness, assertiveness, forcefulness”).  An example is from Gustav Adolf Lindner (1828–1887), the Czech pedagogue, sociologist, psychologist and philosopher, in his book Manual of Empirical Psychology as an Inductive Science (Lindner and De Garmo 1890): “The great secret of their aggression and efficiency is to be found in the fact that they [sc. the Herbartian school] have a vital psychology.” 

      Eventually, the word aggression came to be used in psychology: “Behaviour intended to injure another person or animal; an instance of this.”  An example of this meaning was in a paper entitled The Gambling Impulse (France 1902): “[In gambling] we find arising emulation, aggression, the instinct of domination, with the love of humiliating one's opponent.”  Analogously, aggression became closely linked in the psychodynamic literature with sexuality as for example by Freud (1910): “The sexuality of most men shows a taint of aggression.”  Also, aggression emerged as having a substantial role in neuroticism, whereby physical force is not needed or practiced but domination is accomplished with the emotional quality of profound passivity (Adler 1917): “The neurotic succeeds in... this new line so skillfully as to manage to set up an aggression which enables him to dominate and torture others.”  Eventually, the blending of pleasure and aggression evolved such that these constructs could be discussed in very similar terms by Charles Anthony Storr (1920–2001), an English psychiatrist and psychoanalyst, in his book Human Aggression (1968):

      “Once we can bring ourselves to abandon the pleasure principle, it is easy to accept the idea that the achievement of dominance, the overcoming of obstacles, and the mastery of the external world, for all of which aggression is necessary, are as much innate human needs as sexuality or hunger.”

      This quotation seems to predict that aggression could be considered a vital drive with the potential to go awry and manifest characteristics of an addictive disorder. 

      Aggression has long been recognized as a common consequence of alcohol/drug use (Spain, Bradess and Eggston 1951; MacAndrew and Edgerton 1969; Virkkunen 1974; Kalant and Kalant 1975; Nurco and DuPont 1977).  Even recreational use of drugs and alcohol has been directly linked to aggression and violence, mediated by personality characteristics (Tomlinson, Brown and Hoaken 2016), especially in those with a previous history of aggressive behavior (Ritter, Lookatch, Schmidt and Moore 2019).  However, out-of-control use of drugs/alcohol in those suffering from addiction is additionally punctuated by the pressure of distressing symptoms of craving and withdrawal.  Attempts to overcome such urges by obtaining, often from illicit sources at hard-to-afford cost, the substance(s) to which an individual is addicted, frequently involves criminality and aggressive behavior, albeit mediated by personality, sex, family history, other psychiatric diagnoses and multiple socioeconomic factors (Guze, Woodruff and Clayton 1974; Cloninger, Christiansen, Reich and Gottesman 1978).  When the addicted individual succeeds in obtaining the abused substance, intoxication can often wreak havoc, implicated in a large proportion of all assaults, rapes, homicides and violent deaths. 

      Aggressive behavior is a distinct response to self-administration of alcohol/drugs influenced by interindividual genetic and experiential differences, much as is susceptibility to other manifestations of intoxication such as sedation, ataxia and blackout (Brown, Goodwin, Ballenger et al. 1979; Schuckit 1980; Pihl, Smith and Farrell 1984; Lappalainen, Long, Eggert et al. 1998; Moeller, Dougherty, Lane et al. 1998; Hingson, Simons-Morton and White 2016).  Intoxication may release deep-seated anger, the basis of aggression, that would otherwise be distressing and incompatible with one’s personality (Snell, Rosenwald and Robey 1964); repeated use under these circumstances can eventually progress to alcohol/drug use disorder.  This situation is quite analogous to self-medication of pain, insomnia or anxiety/depression and (Martin, Weinberg and Bealer 2007). Nevertheless, the significant association between aggression and substance use disorders does not specify direction of any linkage. 

      Aggression may have an etiologic role in addiction beyond simply an association with phenomenology of the addiction syndrome that characterizes substance use disorders.  This concept originates from Thompson (1963) demonstrating that aggression can serve as a positive reinforcer in its own right in male Siamese fighting fish (Betta splendens).  Subsequently, it was shown that access to aggression can be conditioned using the paradigm of nose pokes in mice as an operant response on ratio- and time-based reinforcement schedules (May and Kennedy 2009) and heightened by various agents such as alcohol (Fish, DeBold and Miczek 2002b) and the neurosteroid allopregnanolone (Fish, De Bold and Miczek 2002a) but diminished by NMDA antagonists.  Delineation of modulators of aggressive behaviors have led to predictions of the underlying neural circuits (Covington, Newman, Leonard and Miczek 2019).  Furthermore, in non-human primates, McClintick and Grant (2016) demonstrated that baseline aggressive temperament and behavior were associated with increased risk of higher ethanol self-administration and intoxication when ethanol and water were concurrently made available.  The interaction between alcohol and aggression seems to be recapitulated across the animal kingdom as alcohol potentiates pheromone signaling tied to nutrition and reproduction in the fruit fly Drosophila melanogaster (Park, Tran, Scheuermann et al. 2020).   The breadth of these convergant findings have lent support to the substantial contribution of operant conditioning to aggression, along with other fundamental drives.    

      The well-accepted and robust association between addiction and aggression that so profoundly affects society, previously examined primarily from ethological (Dollard, Miller, Doob et al. 1939) and social (MacAndrew and Edgerton 1969) perspectives might, therefore, be further elucidated using theories of conditioning, a heuristic model for understanding addiction.  Accordingly, disturbances in the biological drive of aggression may join the family of addictive disorders termed behavioral addictions, e.g., gambling disorder and perhaps problematic hypersexuality and over-eating (Ragan and Martin 2000; Martin and Petry 2005; American Psychiatric Association 2013).   Although aggression seems to stoke the fires of substance use disorders and vice versa, under this conceptualization, pathological aggression may progress to an addictive disorder per se with or without co-occurring drug/alcohol use disorder.  A transitory episode of an all-encompassing emotion like aggression can serve as a distraction, a reprieve from or a manner of coping with potentially distressing symptoms of an underlying medical or psychiatric disorder.  Thereby, aggressive behaviors can be used in an analogous manner to self-medication, frequently employed to avoid feeling primary medical or psychiatric symptoms such as pain or anxiety/depression.  If this means of coping is momentarily beneficial and repeatedly practiced, it may eventually progress to development of pathological aggression.

      Current pathogenetic, phenomenological and nosological concepts related to out-of-control aggressive behavior manifest striking lacunae with respect to the potentially rewarding nature of these behaviors.  Classically, aggression has been described as defensive, premeditated or predatory and impulsive or nonpremeditated; only impulsive and predatory aggression are considered pathological (Coccaro 2012).  Attempts to understand and classify impulsive aggression have culminated in the American Psychiatric Association’s  DSM-5 term intermittent explosive disorder (2013).  Beginning in adolescence or early adulthood in about 5% of the population, this disorder consists of either infrequent very intense outbursts of aggression or repeated less severe outbursts.  Nosologic conceptualization of this disorder has swung over time between attributing these impulsive aggressive outbursts either to a psychological response style based on personality structure or to disruption of neurobiological underpinnings of the expression of anger (Coccaro 2012).  These developments in clinical phenomenology and classification have focused predominantly on impulsiveness and resultant harm to the self and others, paying little attention to compulsiveness based on reinforcement and learning. 

      As impulsive aggression became clinically more reliably characterized (Coccaro 2012), etiopathogenesis drifted towards establishing an association with abnormal metabolism of brain biogenic amines, predominantly serotonin (Brown, Goodwin, Ballenger et al. 1979; Linnoila, Virkkunen, Scheinin et al. 1983; Kolla and Bortolato 2020).  This idea originated from observations by Åsberg, Träskman and Thorén (1976) that a subgroup of depressed patients with low concentrations of 5-hydroxyindoleacetic acid (the major metabolite of serotonin) in the cerebrospinal fluid (CSF) were more likely than depressed patients with normal 5-HIAA to have attempted or completed suicide using particularly violent means.  This observation was eventually generalized to a trait in various disorders such as intermittent explosive disorder, personality and other psychiatric disorders which frequently co-occur with impulsive aggression (Coccaro, Lee and Kavoussi 2010).  Of relevance to addiction, low CSF 5-HIAA was also found associated with a tendency to repeated, impulsive violent behavior which can be directed towards oneself (suicide) as well as others (murder) and with early onset alcohol abuse (Lappalainen,  Long, Eggert et al. 1998).   Nevertheless, the route to intense impulsive episodes of aggression can be via other than serotonergic mechanisms, e.g., temporal lobe seizures (Bach-Y-Rita, Lion and Ervin 1970; Woermann, van Elst LT, Koepp et al. 2000), mood disorder and various other neurocognitive causes (Blair 2001). 

      Unravelling the neurobiological foundations of pathological aggression has led to mechanisms relevant to salience, conditioning and learning and emergence of the term compulsive aggression.  This perspective allows specific forms of pathological aggression to be viewed as a behavioral addiction.  Golden, Jin, Heins and colleagues (2019) investigated appetitive aggression using a novel mouse model of aggression self-administration and relapse, in combination with immunohistochemistry, in situ hybridization, and chemogenetic manipulations to examine how nucleus accumbens cells are recruited for, and control, operant aggression self-administration and aggression seeking in early abstinence. They found dopamine receptor 1-expressing neurons that act as a critical modulator of operant aggression reward and aggression-seeking suggesting involvement of addiction-related reward circuits.  Labonté, Abdallah, Maussion et al. (2020) identified and characterized a novel long noncoding RNA, acting as a regulator of the monoamine oxidase A gene in the brain of suicide completers, regulated by a combination of epigenetic mechanisms, suggesting that variations in DNA methylation regulate impulsive-aggressive behaviours.  This mechanism of modulating aggressive behavior parallels previous findings showing the role of epigentic modifications following stress exposure (Guillemin, Provençal, Suderman et al. 2014) and in expression of  addiction- and depression-related behaviors (Heller, Cates, Peña et al. 2014).  These most recent findings are compatible with the proposal that appetitive forms of pathological aggression are neurobiologically closely related to out-of-control and self-destructive drug self-administration as well as other behaviors that characterize alcohol/drug use disorders and behavioral addictions, respectively.  



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April 22, 2021