I was delighted to be asked and honored to take part in one of the excellent “The Hope Interviews” with Steve Jones for the recovery newspaper “Keys to Recovery” – our interview is on page 9 and it was a experience strength and hope type interview from both a 12 step recovery and a neuro-psychological perspective, showing how these perspectives are very compatible and how we need a spiritual solution to a neuro-psychological problem.
In early recovery I was amazed that some people in recovery said they never thought about alcohol after a few weeks into recovery. Or rather than thoughts related to alcohol rarely drifted across their minds.
I was alarmed by this as thoughts of alcohol rarely left my mind in early recovery.
They came to me rather than me actively going to retrieve thoughts about alcohol myself, consciously or deliberately.
I now realise that this was due to two main reasons.
First of all, fear of drinking is a distress which activates thoughts of alcohol as distress and negative emotions (and negative self perception/schema) seem to automatically retrieve thoughts of alcohol as there has been some habitual fusion of negative emotion with urge to drink in the alcoholic brain.
This is because my alcoholism resulted in compulsive drinking, i.e. my drinking was mainly to do with relieving distress, and that is what compulsion is, automatic behaviours that relieve distress.
Secondly and tied to this point, is that this compulsive drinking in itself is also linked to how chronic my drinking became.
I was completely addicted to alcohol at the end of my drinking so my alcoholism is very chronic.
In terms of neuroscience this means any distress activates a motoric part of my brain, the dorsal striatum, a part of the brain that deals with stimulus response or automatic response the internal stimulus of distress, which activates an automatic approach or preparation of movement towards getting a drink.
This is expressed in terms of instruction in the brain as automatically occurring intrusive thoughts about drinking alcohol. This is also called an alcohol use schema because as a schema it is procedural way to deal with distress, i.e. have distress automatically deal with it by drinking.
I still find it fascinating that even automatic behaviours have thoughts that accompany them. Although nothing is completely automatic and we have a brief period of time in which to react or not.
By not reacting or acting on this thoughts they appear to lessen in intensity. The more we do not react the less intense these thoughts become. Finding new ways to cope with distress lessens their grip on us too and eventually they practically disappear.
I have found I have to be very very distressed in recovery for thoughts of alcohol to come revisiting my mind.
This involuntary retrieval of drug related thoughts is thus a hallmark of addicted populations as it happens automatically, implicitly without you having to consciously and explicitly retrieve these thoughts and associated images from your memory banks. They just pop up without your permission.
The intensity of obsessive thoughts about alcohol is said to predict relapse rates (1), with addicts motivated to use drugs to “silence” obsessive thoughts (2).
The idea that abstinence automatically decreases alcohol-related thoughts is challenged by research (3) and supported by clinical observation that among abstinent alcohol abusers, alcohol-related thoughts and intrusions are the rule rather than exception (4).
Modell and colleagues (1992) highlighted symptomatic similarities between addiction and obsessive compulsive disorder with subjective craving for drugs or alcohol characterized as having obsessive elements. (eg, the compulsive drive to consume alcohol, recurrent and persistent thoughts about alcohol, and the struggle to control these drives and thoughts) similar to the thought patterns and behaviours of patients with obsessive-compulsive illness (5).
Modell et al. also point to the potential similarities in underlying neural pathways implicated in the two disorders, suggesting that they may share a similar aetiology.
The Obsessive Compulsive Drinking Scale (OCDS) implies that as the severity of this illness progresses, so does the intensity of the obsessive thoughts about alcohol and the compulsive behaviours to use alcohol.
Kranzler et al. (1999) showed relapsers who scored higher in ‘obsessions’ craving measured by the OCDS predicted relapse in the 12 months after treatment completion (6).
This may also be a reflection of addiction severity too! As addicts and alcoholics become more addictive brain imaging shows a shift in “reward processing” from the ventral striatum to the dorsal striatum.
The DS as stated above is in charge of more automatic, compulsive reaction.
This shift from VS to DS may also be marked by an increased emergence of automatic thoughts, which the authors also suggested as the cognitive thoughts and images of automatized drug action schemata (2).
In fact, this is demonstrated by correlations indicating that dorsal striatum activation is lowest in participants with low OCDS scores. And vice versa, highers OCDS scores with increased DS activation.
This means, in simple terms, that more severe addiction may be associated with more intrusive/obsessive thoughts and less severe with less thoughts.
So if you are in a meeting or in other treatment environments and someone in recovery says they never have any obsessive thoughts or intrusive thoughts consider the possibility that their addiction did not become as severe as your addiction?
Either way these thoughts are not your own but the automatic thoughts of addiction so be careful not to react to them.
They are frightening at first, but gradually becoming irritating and annoying before occurring less and less as recovery and your non reaction progress.
If you learn to habitually not to react emotionally to them they start to lose their grip and become less severely intrusive.
Most days I do not have any intrusive thoughts. This is because my recovery has progressed.
In many ways, recovery usually goes in the opposite direction to addiction.
1.. Bottlender, M., & Soyka, M. (2004). Impact of craving on alcohol relapse during, and 12 months following, outpatient treatment. Alcohol and Alcoholism, 39(4), 357-361.
2. 6. Tiffany, S. T. (1990). A cognitive model of drug urges and drug-use behavior: role of automatic and nonautomatic processes. Psychological review, 97(2), 147.
3. Caetano, R. (1985). Alcohol dependence and the need to drink: A compulsion? Psychological Medicine,
4. 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.
5. Modell, J. G., Glaser, F. B., Mountz, J. M., Schmaltz, S., & Cyr, L. (1992). Obsessive and compulsive characteristics of alcohol abuse and dependence: Quantification by a newly developed questionnaire.
Alcoholism: Clinical and Experimental Research, 16, 266-271.
6. Kranzler, H. R., Mulgrew, C. L., Modesto-Lowe, V. and Burleson, J. A.
(1999) Validity of the obsessive compulsive drinking scale (OCDS): Does craving predict drinking behavior? Alcoholism: Clinical and Experimental Research 23, 108–114.
7. Vollstädt‐Klein, S., Wichert, S., Rabinstein, J., Bühler, M., Klein, O., Ende, G., … & Mann, K. (2010). Initial, habitual and compulsive alcohol use is characterized by a shift of cue processing from ventral to dorsal striatum.Addiction, 105(10), 1741-1749.
In our previous blog we wondered if some commentators, who have co-occurring disorders may be puzzled at how having a “spiritual malady” could be related in any way to have a co-occurring condition?
This is a pretty valid question?
In fact this may be at the heart of the issue in many cases of feeling the need to take medication for so-called co-occurring conditions?
Seeing alcoholism as partly the product of a spiritual malady, instead of the affective disorder I believe it to be, may influence certain AAs to seek additional help for supposed additional conditions when the manifestation of these conditions may actually be part of the emotional disorder of alcoholism?
It is at least worth considering?
For me sometimes there is a confusion with what is perceived to be a spiritual malady?
I do not believe I have the same type of spiritual malady as my wife for example who is an normie, earthling, normal person (whatever that is?) I believe, if any thing I have a super enhanced, at times turbo-charged, spiritual malady, often fuelled by stress/distress, as the result of my alcoholism.
I do not believe I have the same spiritual malady as other normal people such as those people who were in the Oxford Group.
That is not to say that normal people cannot be full of sin – a cursory look around the work and it’s events will soon confirm this is the case. What I am saying is that they do not have the emotion dysregulation or fear based responding that I seem to have which often prompts “sin”.
By sin I mean negative emotions that cause distress to me and others.
For example, false pride, intolerance, impatience, arrogance, shame, lust, gluttony, greed. Yes these all create distress.
The spiritual principles of AA and the 12 steps in particular were drawn from the 4 absolutes of the Oxford group, via initially the 6 steps and the idea of a spiritual malady is also borrowed from the Oxford group.
I have for several years wondered if the spiritual malady described in the Big Book adequate or accurate enough in describing what I suffer from.
I believe others have difficulties in reconciling the spiritual malady of the Big Book with their own alcoholism, addiction and co-occurring conditions?
Part of the problem may lie in not being specific enough about what alcoholism is.
It may be that research and the world have not progressed far enough to give a comprehensive account of what alcoholism is. Also the spiritual malady concept of AA has for 80 years helped millions of people recover from this most profound of conditions? So why change it if it’s not broke?
That is a good point? I am not advocating changing anything, I hope AA recovery remains as it is for 80 more years and much more years. I would not change one word in the first 164 pages of the BB.
However, many AAs ignore the spiritual malady thing completely, or do not do the steps, so, in my opinion, they often do not properly understand what they suffer from?
The magic of the the steps is that they seem to reveal the patterns of behaviour that our actions have prompted over the course of our lives. Maladaptive behaviours I should add. It helps us see ourselves and our condition of alcoholism and how it effects us and others.
It shows the areas of behaviour and attitudes that can be treated by working the steps. It shows us how our approach to life can possibly be transformed for the better.
For me personally it often showed a pattern of emotional responding to events that do not go my way!!?
As Bill Wilson once wrote we suffer when we cannot not get what we want or others seem to prevent us getting what we want.
My inventory of steps 4/5 showed me that my long lists of resentments were mainly the product of emotional immaturity and responding in an immature manner to not getting my way.
My inventory showed me also that I did not seem to have the facility previously to emotionally respond to the world in a mature way. As the world dominated me.
My recovery has thus since been about “growing up” a bit, however unsuccessful I am in this pursuit on occasion.
I have often written that this inherent emotional immaturity may even be linked to the possibility that the areas of my brain that regulate emotions have not matured properly as alcoholic seem to have different connectivity, functionality and morphology (size/volume) in this emotion regulation circuit/network to healthy normal people.
Alcoholics seem not to be able to fully process emotional information externally, i.e reading emotion expression of faces accurately, or internally reading what emotions we are having, or even whether we are hungry or tired!
So we have issues with emotions and somatic/body feeling states. This is perhaps compounded by most of us having experienced abuse or maltreatment which can also lead to alexithymic characteristics such as not being able to label or describe, verbally, emotional states we are experiencing – although we can be good at intellectualising these emotions – which is not the same as processing them.
Alcoholics and children of alcoholics have a tendency to avoid emotions (use avoidant coping strategies) in fact and to use emotional reasoning when arguing a point.
These emotion processing deficits also appear to make us more impulsive, and to choose lesser short term gain over greater long term gain in decision making. It can lead to a distress feeling state that can make us fear based, perfectionist, have catastrophic thoughts, intolerance of uncertainty, low frustration and distress tolerance, be reactionary, moody, and immature in our emotional responding.
But how has any of this got anything to do with the so-called spiritual malady we are suppose to suffer from?
I believe the spiritual malady mixed with the ancedotal evidence throughout the BiG Book hints at these emotional difficulties as being an intrinsic part of our alcoholism, “We were having trouble with personal relationships, we couldn’t control our emotional natures, we were a prey to misery and depression, we couldn’t make a living, we had a feeling of uselessness, we were full of fear, we were unhappy…”
It was 80 years ago, so our knowledge base has moved on greatly from when the Big Book was written. Hence I believe we should appreciate that this definition of our condition has been updated by research into emotions especially in the last 20 years.
I am happy to say a spiritual malady is what we suffer from, as the steps provide a solution to my emotion disorder by treating it as a spiritual malady but I do not think it is the straightforward spiritual malady adopted by AA from the Oxford Group, mainly because in the majority of situations I do not choose to sin, the sinning seems to happen to me. In other words it is the consequence of my fear based condition, this affective disorder.
The Oxford Group explain a general spiritual malady that all people can have. I do not think alcoholics are like all people. We are human beings, but extreme versions of human beings. I believe, even when I try my best to be virtuous and holy, I could sin at the sinning Olympics for my country. I am that naturally good at it!
I sin so naturally, effortlessly and usually without even trying. I believe my so-called defects of character are linked to my underlying emotional disorder of alcoholism.
Sins I believe are the poisoned fruit of fear, often helped along in alcoholics by false pride, shame and guilt. These defects are related to me being an alcoholic, they are intrinsic to my condition.
In order to illustrate how I believe my spiritual malady is the consequence of my emotional disorder, called alcoholism/addiction first let’s go back to where this idea of spiritual malady came from.
According to a wonderful pamphlet “What is the Oxford Group” written by The Layman With a Notebook ” Sin can kill not only the soul but mind, talents, and happiness as surely as a malignant physical disease can kill the body…
Sin is a disease with consequences we cannot foretell or judge; it is as contagious as any contagious disease our bodies may suffer from. The sin we commit within this hour may have unforeseen dire consequences even after we have long ceased to draw living breath…
…Like physical disease Sin needs antiseptics to prevent it from spreading; the soul needs cleaning as much as the body needs it…
Unhappiness to us and others, discontent, and, frequently, mental and bodily ill health are the direct results of Sin.
…Morbidity of mind must affect the physical health. If we can be absolutely truthful to ourselves we can analyse our sins for ourselves and trace their mental and physical effects. Sins can dominate us mentally and physically until we are their abject slaves. We cannot get rid of them by deciding to think no more about them; they never leave us of their own accord, and unless they are cut out by a decided surgical spiritual operation which will destroy them, roots and all, and set us free from their killing obsession, they grow in time like a deadly moss within us until we become warped in outlook not only towards others but towards ourselves….”
One can see how this concept of sin disease or in other words spiritual malady could be and was applied to early AA and incorporated into the Big Book of AA.
However, it is equally stating, I believe, that alcoholics suffer from the same spiritual malady as other people but our spiritual malady has led to chronic alcoholism, this is the manner in which sin has dominated “mentally and physically until we are their abject slaves”.
In fact the Big book’s first chapters look more at the manifestation of this malady, problem drinking, than the malady. It suggests that there is more than this malady, there is also a physical reason for alcoholism- an allergy (or abnormal reaction) to alcohol. So this is a departure from the Oxford Group as it clearly states that alcoholism is more than a spiritual malady. It is not simply the consequence of this spiritual malady although this malady may contribute. So is this saying some of us are spiritually ill while also having an abnormal reaction to alcohol?
In the foreword The Doctor’s Opinion suggests that “the body of the alcoholic is quite as abnormal as his mind.” and a first mention of a disorder more than “spiritual” is suggested, “It did not satisfy us to be told that we could not control our drinking just because we were maladjusted to life, that we were in full flight from reality, or were outright mental defectives. These things were true to some extent, in fact, to a considerable extent with some of us. (my emphasis)
“The doctor’s theory that we have an allergy to alcohol interests us…as ex-problem drinkers, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account.”
“the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker.”
Here we have an abnormal reaction to alcohol and for some alcoholics a maladjustment to life.
For me this maladjustment to life is not exactly the same as the spiritual disease mentioned in the Oxford Group pamphlet.
All of my academic research in the last 6 years has explored the possibility that this “maladjustment to life” is more than a spiritual malady, i.e. it is not simply the consequence of Sin but the result of abnormal responding, emotionally (which has obvious consequences for sinning) to life.
This emotion dysregulation, as I name it, has consequences for how we feel about ourselves, how we interact with people, how much we feel we belong, how rewarding alcohol and drugs are, how much these substances make us feel better about ourselves (fix our feelings ) and how they turn off the internal critic of maladaptive and negative self schemas.
In fact our first “spiritual” wakening was probably the result of drinking as it transformed how we felt about ourselves and the world in which we lived. I know it did for me. In fact, I felt “more me” when I drank, it was like I escaped a restrictive sense of self to be a more expansive, people loving self. I had a connection with the world I could not generate myself, when sober.
I was a “spirit awakening” if nothing else? It is interesting that a common definition of “spiritual” as it relates to AA, is a sense of connection with others.
As the BB states “Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that, while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks—”
For me this section is saying our emotion dysregulation leads to feelings of being “restless, irritable and discontented” which prompt a return to drinking.
The Doctor’s Opinion even offers some classifications of alcoholics “The classification of alcoholics seems most difficult, and in much detail is outside the scope of this book. There are, of course, the psychopaths who are emotionally unstable… the manic-depressive type, who is, perhaps, the least understood by his friends, and about whom a whole chapter could be written.”
This section would appear to be stating clearly that there alcoholics who have other (co-occurring) conditions or conditions appearing as co-occurring?
I contend that alcoholism is an emotional disorder which results in chemical dependency on the substance of alcohol. However in order to treat it we have to first contend with the symptomatic manifestation of this disorder, chronic alcohol use, as it is the most life threatening aspect of this disorder when we present our selves at AA.
What we used once to regulate negative emotions and a sense of self has eventually come to regulate our emotions to such an extent that any distress leads to the compulsive response of drinking. Alcoholics had become a compulsive disorder to relief distress not to induce pleasure.
The “spiritual malady” of the Oxford group seems enhanced in me, I believe I sin more than normal people because of my emotional immaturity and reactivity. My “loss of control” over drinking is also linked to emotion processing difficulties as it prompted impulsive, uninhibited drinking.
This emotional immaturity is referenced throughout the Big Book I believe.
“… He begins to think life doesn’t treat him right. He decides to exert himself more. He becomes, on the next occasion, still more demanding or gracious, as the case may be. Still the play does not suit him. Admitting he may be somewhat at fault, he is sure that other people are more to blame. He becomes angry, indignant, self-pitying. ”
“Whatever our protestations, are not most of us concerned with ourselves, our resentments, or our self-pity? Selfishness—self-centeredness! That, we think, is the root of our troubles. Driven by a hundred forms of fear, self-delusion, self-seeking, and self-pity, we step on the toes of our fellows and they retaliate. ”
“So our troubles, we think, are basically of our own making. They arise out of ourselves…”
“…Our liquor was but a symptom…”
“Resentment is the ”number one“ offender. It destroys more alcoholics than anything else. From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick.”
For me this is saying that out of my emotion dysregulation “stem all forms of spiritual disease”.
It then talks of the fear that “was an evil and corroding thread; the fabric of our existence was shot through with it. ”
The list of emotional difficulties continues throughout the Big book’s first 164 pages.
One of the earliest studies on AA members concluded that they were linked in commonality by two variables, emotional immaturity and grandiosity! I would contend that grandiosity is a part of emotional immaturity. I also contend that our “maladjustment to life” is based on emotional immaturity which is in itself a function of emotion regulation and processing deficits.
A book titled Matt Talbot by Morgan Costelloe has cites this reference – “American authorities on alcoholism hold that the following psychological traits are commonly found in alcoholics:
> 1. A high level of anxiety in interpersonal relations
> 2. Emotional immaturity
> 3. Ambivalence towards authority
> 4. Low frustration tolerance
> 5. Low self-esteem
> 6. Perfectionism
> 7. Guilt
> 8. Feelings of isolation”
The list is almost word-for-word identical with one in Howard Clinebell’s
“Understanding and Counseling the Alcoholic” p 53 of the revised edition of 1968 (the original edition appeared in 1956), the only difference being that Clinebell included grandiosity and compulsiveness.
Years after the Big Book Bill Wilson wrote about this emotion immaturity in the guise of discussing emotional sobriety, for me what he is saying that our emotional difficulties are present in long term recovery and need to be addressed – in other words there is more to alcoholism than sinning and drinking. What we are left with after the steps is ongoing and underlying difficulties with living life on life’s terms because we are emotionally immature. This I believe also preceded our drinking, for many of us anyway?
For many recovering alcoholics this may be another unpalatable truth, that they have issues with emotional responding, with being emotionally mature. If further validation is required I suggest a frank conversation with a loved one, wife, husband, child, parent, etc.
Here is what Bill Wilson wrote ” Those adolescent urges that so many of us have for top approval, perfect security, and perfect romance—urges quite appropriate to age seventeen—prove to be an impossible way of life when we are at age forty-seven or fifty-seven. Since AA began, I’ve taken immense wallops in all these areas because of my failure to grow up, emotionally and spiritually”. (my emphasis)
Bill continues “Suddenly I realized what the matter was. My basic flaw had always been dependence – almost absolute dependence – on people or circumstances to supply me with prestige, security, and the like. Failing to get these things according to my perfectionist dreams and specifications, I had fought for them. And when defeat came, so did my depression.”
” Emotional and instinctual satisfactions, I saw, were really the extra dividends of having love, offering love, and expressing a love appropriate to each relation of life… I was victimized by false dependencies… For my dependency meant demand—a demand for the possession and control of the people and the conditions surrounding me.”
For me this is emotional immaturity, regulating ones emotions and distress via external dependencies on others, demanding in an immature manner that others do one’s bidding?
I would suggest in relation to the issue of co-morbidities that one try to deal with these alcoholism related issues and then see if there are any other to deal with afterwards. For me, as someone who has been treated for anxiety and depression prior to recovery the 12 steps appear to have treated these as emotional consequences of my underlying condition of emotion dysregulation which I call alcoholism.
I think part of the issue is whether doctors, who know in my experience often know next to nothing generally about alcoholism, can always properly diagnose depression and anxiety in someone suffering from alcoholism?
I also think the issues are complicate because alcoholism have some many similarities to GAD, MDD, OCD, and so on. They all may be similar but different.
This is why we need a satisfactory definition of what alcoholism and addition is? Rather than describing these conditions in terms of the manifest symptoms, i.e chronic substance abuse or, at times, vague “spiritual maladies”.
For example, one variable I believe is slightly different in alcoholism to other affective disorders is distress based impulsivity which leads to maladaptive decision making, it leads to always wanting more of that…that anything.
These may be specific to addictive behaviours.
It may also be that we feel we have a co-occurring disorder because the underlying distress states prompt similar reactions in various differing disorders.
My distress feeds perfectionism, and catastrophic thinking as with other anxiety disorders like OCD, does that mean I have OCD too?
Maybe or maybe not? My tendency to not regulate emotions has caused a distress state since childhood, it feeds into perfectionism and many other manifestations like always wanting just one more…?
It is the always wanting one more that makes my affective disorder that of addiction and not another disorder.
My affective disorder via various neural and cognitive – affective mechanisms leads to chronic substance use and dependency of these substances.
GAD, MDD, OCD have different manifestations and different mechanisms.
If we start by trying to recover from alcoholism and addiction and find we still have other issues then obviously address these with outside professional and specialist help.
I believe we can unwittingly complicate our treatment of alcoholism by believing we have (and treating) other conditions we see as distinct from alcoholism but which are in fact part of this condition called alcoholism.
I never fully knew what alcoholsim was until I did the 12 steps. Only then did it become clear what I suffered from?
I have suggested clearly in previous blogs how I think AA’s 12 recovery programme helps specifically with problems of emotion dysregulation.
These illustrate how the 12 step programme can help with an emotion dysregulation disorder.
I end, however, with some words from a doctor who seems to be suggesting that AA works because it makes us more emotionally healthy. For me she is saying how AA treats emotional illness.
An article by Dr. Jacqueline Chang’s paper given to the National Workshop for Health Liaison in York in 1998 and published in the Winter 1999 edition of the AA News suggests that
“The principles of the programme of Alcoholics Anonymous are scientific and closely follow all the helping therapies which lead people to emotional well-being.
AA proposes living “ One Day at a Time”. It is emotionally healthy to live in the day … in the here and now. Professional therapists teach people to live in the present. AA encourages members to share their experience, strength and hope with other members. It is emotionally healthy to accept our past experiences, however painful, as past events and move on to a richer, more fulfilling future.
Step 1 in the AA programme is “ We admitted we were powerless over alcohol – that our lives had become unmanageable”. It is emotionally healthy to surrender and accept things over which we have no control.
“God grant us the serenity to accept the things we cannot change, courage to change the things we can and the wisdom to know the difference” is the Serenity Prayer used at every AA meeting. It is emotionally healthy to prioritise problems. The Serenity Prayer is the greatest exercise in prioritisation.
It is emotionally healthy to accept that we cannot change a particular situation but we can change the way we react to it.
It is emotionally healthy to accept yourself as you are.
It is emotionally healthy to recognise your environment and interact with it as it is, not as you wish it would be. It is emotionally healthy to associate or be in contact with other human beings.
It is emotionally healthy to be altruistic – to help others without question or expectation.
It is emotionally healthy to anticipate – to plan for future discomfort or crises. This is the function of the AA Step programme. ”
AA provides many ways of becoming more emotionally well, which ultimately means more emotionally mature.
I remember when I was in the first days, weeks and months of early recovery I used to give myself such a hard time when my attention was drawn to some alcohol-related cue, like someone drinking ,or finding it difficult not dealing with some reminder of people places and things from my alcohol abusing past; finding that I found it nigh on impossible dragging my attention away from these and related memories associated with my drinking past.
It was as if I was entranced by it, in some of tunnel vision. It used to scare the life out of me.
I rarely found these thoughts appetitive but if I dwelt on these thoughts or trained my attention on cues I would find that the adverse, fearful things would turn to more desire based physiological reactions like salivating and so on.
I took these to mean that I actually wanted to drink and not stay sober. My sponsor at the time said two things which helped – a. I have an alcoholic brain that wants to drink period, 2. cues from my past may always have this effect on me. Accept it, don’t fight it.
That was what I had been doing in fact. Fighting it, these cues reminders and their automatically occurring intrusive thoughts about the past. It is in fighting these thoughts that they proliferate and then become “craving”.
Years later after much research I found that all alcoholics seem to have an attentional bias towards alcohol-related cues which leads to a cue reactivity.
Originally I thought this meant that I simply wanted to drink but found out that in any manifestation of urge to drink (which is slightly different from a craving which requires an affective response on the part of the alcoholic in order to become a craving similar to mental obsession of the Big Book ) there is a stress reponse like the hear beat quickening, differences in galvanic skin conductance, increased saliva production etc .
Thus this cue reactivty seems to involve not only appetitive or desire states, i.e. it activates the reward system in the brain to motivate one to drink but also contains a stress based reactivity.
Any so-called “craving” state also manifests as either an anxiety state in simple cue reactivity e.g. the sight of alcohol or in negative emotions such as fear, anger and sadness in terms of a stress based craving.
Together, i.e. a cue based reactivity in the face stress/distress leads to a greater urge to drink than by either alone. By reacting to these one is increasing the stress/distress.
To the alcoholic brain having a drink or the desire to drink is the brain suggesting to us as alcoholics that this is the best way to attain transient homeostasis from an allostatic state of distress because this is how we used to balance the effects of emotional distress when we were drinking. We experience distress and automatically had thoughts about drinking. Thus alcoholism is a distress-based condition. We think it is us wanting the drink but it is the distress prompting the wanting of the drink!!
The distress does the drinking for us, itgets us out of our seats and down the street to the bar, it gets us on the bar stool….We may think it is our actions as we use rationalisng and justifying schemata afterwards to justify behaviour that had, in fact, been automatic or compulsive, compulsive meaning to relieve a distress state.
As a schema, which is implicit, i.e. it is automatically prompted and activated by distress also. We are not even in charge of this. We feel and think that we are in control over behaviour bit this is not the case as self control has become so impaired and limited it is distress doing the action and the subsequent rationalising.
The compusive part of the brain, the dorsal striatum, is the only part of the brain that requires us to make a post hoc rationalisation of why we did an action that was essentially automatic and compulsive.
We have become passengers in our own lives. Distress is now doing the driving.
So the brain thinks it is simply telling us the best way to survive this distress or in other words to regulate this distress. Thus it is an incredibly impaired way to regulate stress and emotional distress.
I want to further explain how some of this is linked to low heart rate variability. If we have low HRV we find it difficult inhibiting automatic responses and in changing behaviour. We become behaviourally rigid, and locked into attending to things like cues when we don’t really want to.
This is often the result of distress reducing the ability of the heart rate variability to inform and change our responses.
I cite and use excerpts form one of my favourite articles again by co-authored by Julian Thayer (1).
“The recovering alcoholic must face the difficulty of having his or her ambition to remain abstinent challenged in various situations in which memories about the pleasurable effects of alcohol are activated and the striving for abstinence no longer seems meaningful (Anton 1999; Marlatt and Gordon 1985). The odds for successful coping with such temptations are related to numerous factors, such as one’s subjective affective state and the ability to shift one’s focus from the automatic impulse to drink toward a cognitive reconstruction of the situation (Palfai et al 1997b; Tiffany 1990). Despite the importance of attentional flexibility in effectively modulating such “highrisk” situations, research on the topic is scarce.
Thayer and Lane (2000) suggested that the interplay between positive (excitatory) and negative (inhibitory) feedback circuits in the nervous system (NS) allows for flexible and adaptive behavior across a wide range of situations. The uniqueness of this model lies with its emphasis on the importance of inhibitory processes in effective modulation of affective experience. In short, these researchers propose that the defects in neurovisceral regulation of affective experience seen in various psychiatric conditions (e.g., anxiety disorders) may be better explained by faulty inhibitory function in the NS than by unitary arousal models.
Tonic heart rate variability (HRV) may be a physiologic indicator of such inhibitory processes (Friedman and Thayer 1998a; Porges 1995). Heart rate variability refers to the complex beat-to-beat variation in heart rate produced by the interplay of sympathetic and parasympathetic (vagal) neural activity at the sinus node of the heart.
Importantly, heart rate (HR) is under tonic inhibitory control via the vagus nerve (Levy 1990). These neural connections to the heart are linked to brain structures involved in goal-directed behavior and adaptability (Thayer and Lane 2000). Compelling evidence now exists to show that high levels of HRV are related to cognitive flexibility (Johnsen et al 2003), modulation of affect and emotion (see Bazhenova 1995, cited in Porges 1995), and increased impulse control (Allen et al 2000; Porges et al 1996).
The hypothesis that reduced HRV is related to defective affective and emotional regulation has been supported in recent research in which reduced HRV was present in clinical disorders such as generalized anxiety disorder (Thayer et al 1996), panic disorder (Friedman and Thayer 1998b), posttraumatic stress disorder (Cohen et al 1997) several scientific arguments suggest that impaired inhibitory function may play a role in chronic alcohol abuse.
First, alcoholics have repeatedly been shown to have problems shifting attention and directing their attention away from task-irrelevant information (Johnsen et al 1994; Setter et al 1994; Stormark et al 2000). Second, frontal areas of the brain are most affected by the acute and chronic effects of alcohol, and these structures are of crucial importance in inhibitory functioning and self-control (Lyvers 2000). Third, acute effects of alcohol ingestion result in reductions in HRV, implying that chronic alcohol ingestion may result in a long-lasting impairment of the vagal modulation of HR (Reed et al 1999; Weise et al 1986)
Fourth, severely dependent alcoholics show a sustained phasic HR acceleration when processing alcohol information, indicating defective vagal modulation of cardiac function (Stormark et al 1998). Tonic HRV has similarly been found to be a useful measure of physiologic activity in challenging situations (Thayer and Lane 2000). Appropriate modulation of HRV (increases, decreases, or no change) depends on the type of challenge and the characteristics of individuals as they interact with specific contextual manipulation (Friedman and Thayer 1998a; Hughes and Stoney 2000; Porges et al 1996; Thayer et al 1996).
For example, during attention demanding tasks, healthy individuals show appropriate reductions in HRV (Porges 1995). In general, high tonic levels of HRV allow for the flexible deployment of organism resources to meet environmental challenges. With respect to attention, it is suggested that high levels of HRV reflect flexible attentional focus, whereas low HRV is related to “locked in attention” (Porges et al 1996). Moreover, increased tonic vagal activity is related to adaptive development and lack of behavioral and emotional problems (Hughes and Stoney 2000; Porges et al 1996).
Furthermore, it has been demonstrated that increases in vagal activity during challenging tasks discriminates between individuals who have experienced traumatic events and managed to recover from them and those who still suffer from chronic symptoms of posttraumatic stress (Sahr et al 2001). Such increases in vagal activity during challenging tasks are particularly interesting because studies on alcohol abusers have found increases in HRV after exposure to alcohol-related cues (Jansma et al 2000; Rajan et al 1998).
One could speculate that such enhanced vagal activity could be a sign of compensatory coping aimed at taming automatic drinking related processes (Larimer et al 1999). Such an interpretation is in agreement with cognitive theories predicting that alcoholics and other drug users do not simply respond passively to exposure to drug-related cues, but, on the contrary, in such situations conscious processes are invoked, inhibiting execution of drug-related cognition (Tiffany 1990, 1995). If this explanation is correct, alcoholics who have more effective coping resources should show stronger increases in vagal activity during such challenging exposure than alcoholics who express greater difficulty in resisting drinking-related impulses.
Also general differences in HRV between alcoholics and nonalcoholics are interesting indicators of defective inhibitory functioning, a measure of rigid thought-control strategies and lack of cognitive control should be an important indicator of defective inhibitory function and “positive feedback loops” reflected as low HRV (Wegner and Zanakos 1994).
Linking these measures to the physiologic index of HRV makes a stronger case for attributing reduced vagal tone (HRV) to a defective regulatory mechanism resulting in unpleasant affective states and maladaptive coping with psychologic stressors
The main results of our study may be summed as follows. First, as expected, alcoholic participants had lower HRV compared with the nonalcoholic control group. Second, the imaginary alcohol exposure increased HRV in the alcoholic participants. Third, across the groups, an inverse association was found between HRV and negative mood and a positive association between positive mood and HRV. Fourth, HRV was negatively correlated with compulsive drinking during the imaginary alcohol exposure in the alcoholic participants. Fifth, within the alcoholic group, HRV was negatively associated with chronic thought suppression (WBSI).
Generally, these findings are in agreement with the neurovisceral integration model and the polyvagal theory that suggests HRV is a marker of the level of cognitive, behavioral, and emotional regulatory abilities (Thayer and Lane 2000).
The fact that the alcoholic group had generally lower tonic HRV compared with the nonalcoholic control group indicates that such reduced HRV may also be a factor in alcohol abuse; however, such group differences in HRV provide only indirect support for the theory that low HRV in alcoholics may be related to impaired inhibitory mechanisms
Because HRV is related to activity in frontal brain areas involved in cognition and impulse control (Thayer and Lane 2000), we speculated that tonic HRV would be an index of nonautomatic inhibitory processes aimed at suppressing and controlling automatic drug-related cognitions. To test this hypothesis more directly, the association between HRV and problems with controlling drinking-related impulses were studied.
Consistent with this hypothesis, the compulsive subscale of the OCDS was found to be inversely associated with HRV in the alcohol-exposure condition, thus suggesting that HRV may be an indirect indicator of the level of impulse control associated with drinking. These findings are therefore consistent with Stormark et al (1998), who found that sustained HR acceleration (lack of vagal inhibition) when processing alcohol-related information was related to compulsive drinking and “locked-in attention.”
Post hoc analysis further suggested that alcoholics who expressed a relatively high ability to resist impulses to drink (OCDS) had the clearest increase in HRV under the alcohol exposure this study suggests that alcoholics may actively inhibit or compensate for their involuntary attraction to alcohol-related information by activation of higher nonautomatic cognitive processes (Tiffany 1995). Such conscious avoidance has previously been demonstrated in studies on attentional processes in alcoholics (Stormark et al 1997) and by the fact that frontal brain structures involved in inhibition and control of affective information are often highly activated in the processing of alcohol related cues (Anton 1999). Furthermore, this interpretation is in agreement with other studies suggesting that high HRV during challenging tasks is associated with recovery from acute stress disorders (Sahr et al 2001).
Several studies have indicated that low HRV is associated with impaired cognitive control and perseverative thinking (Thayer and Lane 2002). Consistent with these reports a negative association was found between HRV and chronic thought suppression. The WBSI assesses efforts to eliminate thoughts from awareness while experiencing frequent intrusions of such “forbidden” thoughts and thus represents an interesting and well-validated measure of ineffective thought control (Wegner and Zanakos 1994). Thought suppression has been found to be an especially counterproductive strategy for coping with urges and craving (Palfai et al 1997a, 1997b) and may even play a causal role in maintaining various clinical disorders (Wenzlaff and Wegner 2000).
To our knowledge, this is the first time a link between physiologic indicators of a lack of cognitive flexibility (low HRV) and chronic thought suppression has been demonstrated.
Thayer and Friedman (2002) have reviewed evidence indicating that there is an association between vagally mediated HRV and the inhibitory role of the prefrontal cortex. Consistent with Thayer and Lane (2000), this study suggests that impaired inhibitory processes are significantly related to ineffective thought control.
The fact that this association between HRV and WBSI was only found in the alcoholics may be related to the fact that only this clinical group shows signs of such faulty thought control.
Wegner and Zanakos (1994) suggested that thought suppression is particularly ineffective when the strategic resources involved in intentional suppression are inhibited or blocked (Wegner 1994). Consistent with this hypothesis, our findings show that those reporting high scores on WBSI show signs of impaired inhibitory functioning as indexed by low vagally mediated HRV.”
This excellent article fro me is also alluding to the fact that those with increased HRV was related to successfully related to regulating negative emotion, stress/distress and affect, not just the thoughts that these affective states gave rise to .
Thus any strategies that help with improving the ability to increase HRV will likely have positive results in coping with cue associated materials.
We look at one of these therapeutic strategies next…that of mindfulness meditation.
1. Ingjaldsson, J. T., Laberg, J. C., & Thayer, J. F. (2003). Reduced heart rate variability in chronic alcohol abuse: relationship with negative mood, chronic thought suppression, and compulsive drinking. Biological Psychiatry, 54(12), 1427-1436.