In this first in a series of blogs addressing the similarities between addiction and obsessive compulsive disorder (OCD).

This blog looks at the nature of obsessive thoughts about alcohol. It brings to focus the great sense in your sponsor suggesting the reason you may be having thoughts about alcohol, especially in early recovery, is because you are an alcoholic. Alcoholics have obsessive thoughts about  alcohol. Normal, healthy people don’t!

The other interesting thing about this study (1),  in addition to echoing that these thoughts are a natural occurrence to alcoholics, is that the authors explain how the nature of these thoughts are similar to those experienced in OCD, such as thought-action fusion. It also looks at how Metacognition which refers to higher order thinking which involves active control over the cognitive processes can be important to how we appraise our alcohol related thoughts and ultimately how we react to them.

 

“… the idea that abstinence will automatically also decrease alcohol-related thoughts might be too optimistic. Empirical research contradicts this expectation, demonstrating instead that alcohol-related thoughts can resemble obsessive-compulsive thinking (Caetano, 1985; Modell, Glaeser, Mountz, Schmaltz, & Cyr, 1992). This finding is also supported by clinical observation and leads to the expectation that among abstinent alcohol abusers, alcohol-related thoughts and intrusions are the rule rather than the exception.

Relatively little is known about how alcohol abusers appraise their alcohol-related thoughts. Are they aware that alcohol-related thoughts occur naturally and are highly likely during abstinence? Or do they interpret these thoughts in a negative way, for example, as unexpected, shameful, and bothersome? Finding answers to these questions has implications for relapse prevention, because misinterpretations of naturally occurring thoughts may be detrimental for abstinence (Marlatt & Gordon, 1985).

Metacognitive theory provides a theoretical context for analyzing these open questions about alcohol-related thoughts. It focuses on the role that beliefs about one’s thoughts and appraisal of these thoughts play in the development and persistence of psychological disorders (Nelson, Stuart, Howard, & Crowley, 1999; Purdon & Clark, 1999; Wells, 2000; Wells & Matthews, 1994).

A number of conceptual papers and empirical studies have shown that individuals’ appraisal of their intrusive thoughts as detrimental and potentially out of their control may lead them to dysfunctional and counterproductive efforts to control their thinking. These efforts to control can explain the development and maintenance of various disturbed cognitive processes, including those seen in generalized anxiety disorder (Wells, 1999), obsessive-compulsive disorder (Purdon & Clark, 1999; Rachman & Shafran, 1999), depression (Teasdale, 1999), hypochondriasis (Bouman & Mijer, 1999).

Although these disorders clearly differ from one another in their clinical presentation, the basic assumption unifying the metacognitive models for each of them is that ‘‘metacognitive beliefs are always involved in guiding the content and nature of cognition that modulates emotional disturbance’’ (Wells, 2000, p. 31).

If alcohol abusers do experience alcohol-related thoughts that they metacognitively monitor and evaluate on the basis of metacognitive knowledge, they are likely to use various metacognitive strategies in an effort to control the thoughts.

Alcohol-related thoughts cause an individual to experience strong emotional reactions; however, alcohol abusers will increase their efforts to control their thinking only when they have negative metacognitive knowledge structures and beliefs that are activated. For instance, spontaneous positive memories about alcohol (‘‘It was so nice to hang out at parties and to drink with my buddies’’) may be appraised—and misinterpreted—as ‘‘the first steps toward a relapse’’ and as ‘‘a bad sign’’…or as documenting the person’s inability to stay away from alcohol.

Such an appraisal of one’s thoughts about alcohol as problematic may instigate thought suppression and other efforts to control the thoughts. Because these efforts must be assumed to be counterproductive (Fehm & Hoyer, 2004), they will predict rather than prevent negative feelings, and they may even demoralize alcohol abusers who are trying to remain abstinent.

If …alcohol-related thoughts are not appraised as problematic but as a normal part of abstinence, the awareness of these thoughts would be a neutral mental event, or might even lead to the selection of more adaptive coping responses, which could help to reduce the risk of relapse

The analysis of metacognitive appraisal of alcohol-related thoughts may also help to solve a core theoretical problem in craving research (Drummond, 2001): The validity of craving for predicting relapse is ambiguous. The assumption that metacognitive variables mediate reactions to alcohol-related cues may help to explain why craving does not inevitably lead to relapse.

 

Based on the results of two samples of alcohol abusers receiving cognitive-behavioral treatment in this study, the Metacognition Questionnaire for Alcohol Abusers (MCQ-A) was developed and refined and preliminary validation was conducted. The latest version of the MCQ-A measures two factors identified in Study 1 and replicated in Study 2. They were named Uncontrollability/Thought-Action Fusion and Unpleasantness. A third dimension of metacognition about alcohol-related thoughts was examined in Study 2. It is called Subjective Utility of the Thought was developed through theoretical and clinical considerations.

These factors covered the following:-

Factor 1: Uncontrollability/Thought-Action Fusion.

This thought is stronger than my will. I cannot stop this thought once I have it in mind. This thought has too much impact on me. I can control this thought.  I cannot push away this thought. This thought increases my desire to drink. This thought stimulates craving for alcohol.  This thought can really make me drink.

Factor 2: Unpleasantness

I feel bad when this thought comes up. This thought makes me lose my good mood. It is unpleasant to have this thought. I get annoyed at this thought. This thought disturbs me. I wish I could stop thinking this thought. I do not want to have this thought. It is annoying that this thought always returns.

Factor 3: Subjective utility

This thought can be of help by waking me up. This thought serves as a warning signal for me. I can use this thought when I understand it as a warning sign. This thought can warn me. I can learn something through this thought.

…nearly all of the alcohol abusers in both studies indicated having experienced intrusions and thoughts about alcohol during the prior weeks. This result is not surprising considering that research has suggested that craving is associated with enhanced processing of alcohol-related episodes and recollections. Thus, the result confirms the relevance of studying the role that alcohol-related thinking plays in the process of abstinence.

Uncontrollability/Thought-Action Fusion and Unpleasantness scales were positively correlated, as expected, with detrimental social-cognitive variables, such as craving and thought suppression, and negatively with drug-taking confidence.

The study clearly showed that metacognitive appraisal of alcohol-related thinking can be measured in alcohol-abusing patients. The appraisal is linked to symptoms such as craving and may lead to counterproductive coping efforts, such as thought suppression.”

I cite this study because the factors it identifies are the types of reactions to thoughts I experienced myself in early recovery.

As I am mentioned it is a cognitive-affective reaction to these naturally occurring thoughts via e.g thought suppression that gives rise to “craving”. If we remain mindful of them and accept them as being natural, a neutral event, they can pass without prompting a craving episode.

One aspect that is not mentioned in this article but which is a part of OCD type thinking is the notion of ego dystonic thoughts.

I believe that thoughts about alcohol move from being egosyntonic in active drinking to egodystonic in recovery.

Egosyntonic is a psychological term referring to behaviors, values, feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image.

Egodystonic (or ego alien^[1]) is the opposite of egosyntonic and refers to thoughts and behaviors (e.g., dreams, impulses, compulsions, desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego, or, further, in conflict with a person’s ideal self-image.

Hence we may react to these thoughts because we feel they are not longer consistent or are threatening to our new found sense of self as a recovering person.

 

As we shall see in the next few blogs there are similarities between OCD and addiction.

 

References

1.  Hoyer, J., Hacker, J., & Lindenmeyer, J. (2007). Metacognition in alcohol abusers: How are alcohol-related intrusions appraised?. Cognitive Therapy and Research, 31(6), 817-831.