“Staying in Action” Part 3

In this third part of our blog on the gambling addicts version of “dry drunk” we look at further “symptoms” of this. We hasten to add that a good 12 step program would soon iron out  most of these emotional and behavourial manifestations and maintenance of our “emotional sobriety” via steps 10-12 keep them in manageable order.

Nonetheless, this article (1) gives us good insight into the emotional malady we suffer from without a therapeutic solution, and which can creep up on us in many ways even when trying to “work our program” .

Other manifestations of “Staying in Action” –

Flooding

Gamblers who rely on avoidance as a defense mechanism are frequently flooded with feelings and memories when they become abstinent. This can occur in several ways. Most commonly the gambler becomes overwhelmed with guilt as he or she remembers things that were done, people that were hurt, episodes of lying and cheating. A common refrain is “I can’t believe I did that.”

A similar experience is the sudden realization of time wasted. During the years they had been gambling, their lives had gone on and they are now older. There is an acute sense of lost opportunities, and of lost youth and innocence. Disappointment becomes self-pity and there is an impulse to give up or to punish oneself by a return to gambling or some other self-destructive behavior.

A third kind of flooding involves the sudden remembrance of painful and traumatic memories of childhood—physical or sexual abuse, extreme neglect, disturbed parents. This may occur when the patient stops gambling or quits other addictive behaviors.

(( we dealt with these ourselves in steps 4 through to seven, followed up with amends 8-9)  As we have already blogged on previously the steps 4-7 in particular allow one to process memories from the past via the adaptive processing of emotions attached to these memories as well as the realisation they we were in the grip of a profound affective and addictive disorder.   Also as the Big Book states “No matter how far down the scale we have gone, we will see how our experience can benefit others. That feeling of uselessness and self pity will disappear. We will lose interest in selfish things and gain interest in our fellows. Self seeking will slip away. Our whole attitude and outlook upon life will change. Fear of people and of economic insecurity will leave us. We will intuitively know how to handle situations which used to baffle us. We will suddenly realize that God is doing for us what we could not do for ourselves.”

This transforms our self pity and sense of wasted years into a powerful transformative tool for helping others. It is no longer wasted but the most precious thing we possess in helping others, in sharing our experience, in being there for others because we know what it’s like to feel the way they do, to be where they are at. )

Boredom

According to the description in DSM-IV, as well as the writings of most clinicians (for example, Custer & Milt, 1985, p. 52), the typical pathological gambler is “restless, and easily bored.”  This proneness to boredom has been the focus of two studies (Blaszczynski, McConaghy, & Frankova, 1990; Elia, 1995) that compared pathological gamblers to normal controls; boredom scores were significantly higher for the pathological gamblers.

(Again this ties in with alcoholics without a recovery as per the BB ” being restless, irritable, and discontented”, page xxvi).

For early onset male gamblers, particularly if there have been decades of gambling activity, the gambling was typically how they defined themselves. Without their identity as a gambler, they do not know who they are. Giving up gambling leaves a large vacuum or hole in their lives. They have no other interests, and there are few activities that can compete with the excitement of gambling.

As already noted, boredom can mean understimulated. when they stop gambling and “get off the roller coaster” of strong sensations and self-created crises, they may find the underlying restlessness unbearable.

Patients who are manic also need time to adjust to being normal. What others regard as normal feels like being in slow motion to them, or as if something is missing. They describe it as strange and uncomfortable.

Boredom can mean that individuals cannot be alone because of problems in self-soothing. Boredom can mean that they are left alone with intolerable feelings, such as depression, helplessness, shame, or guilt. There is a need to escape, to get away from themselves.

(as an alcoholic the main reason I gave for drinking was “to get away from myself!”) 

For some, being alone means an intolerable state of emptiness or deadness. Those individuals who did not bond in infancy may carry within themselves an image of parental rejection or disgust, or affects engendered by an overwhelmed mother. Being alone and quiet means experiencing these intolerable affects, which they instead try to externalize through addictive substances and behavior.

Problems with intimacy and commitment

By the time the gambler is in treatment and has stopped gambling, spouse and family members are aware of the debts and depleted finances, the pattern of lying, and other problems. The response is usually one of anger, helplessness, and betrayal. Not infrequently, it is only after the gambling has stopped that the brunt of the spouse’s anger is expressed. This is often difficult for the gambler to understand. The anger is often proportional to the fear of being hurt and betrayed again. Holding on to the anger is a way for family members to protect themselves.

Mistrust of the gambler continues longer than it does with other addictive disorders because a relapse can be so devastating in terms of a family’s financial situation, and also because it is so much more difficult to recognize. As frequently stated, gambling is not something that a wife can smell on her husband’s breath nor observe by his gait or coordination. Nor are there blood or urine tests so that one can detect it with certainty. What we need to emphasize with both patient and family is that reestablishing trust will take time, and that if treatment is successful there will be observable changes in personality as well as behavior.

There are usually problems with intimacy that precede the gambling, in which case they will be there after the individual has stopped. Pathological gamblers often have difficulty being open and vulnerable and depending upon others in a meaningful way.

(I can relate to all of the above too – waking up to an awkward and at times profoundly troubling and distressing emotional illiteracy  is perhaps the last thing one needs in the early days of prolonged withdrawal and feelings of almost overwhelming emotional distress that can sometimes accompany the early weeks and months of recovery)

They have learned to suppress their feelings and to detach from potentially painful situations. Much of the work in therapy has to do with identifying emotions and learning how to express them.

Family members have their own issues which if not dealt with may sabotage the gambler’s recovery (Heineman, 1987; Lorenz, 1989). For example, some of the wives of recovering gamblers will admit that they miss the gifts they received when their husband came home after winning. They confess to a wish that he could have just one more big win, which would allow them to pay off their debts. They may realize they had been living vicariously through him, particularly if he was an “action” or “high stakes” gambler. His optimism and grandiosity were contagious. Initially they may have been attracted to him because he was a man with big dreams, a risk-taker, and big spender. According to Heineman (1987) and others, many wives of compulsive gamblers are adult children of alcoholics or of compulsive gamblers. Living from crisis to crisis may be familiar and exciting for them. In some cases there is a need for the gambler to remain “sick” so that they can take care of him.

Many pathological gamblers were brought up in a home in which intimacy was lacking.  They tolerate financial indebtedness far better than they do emotional indebtedness. Many experience claustrophobia in their personal relationships (Rosenthal, 1986), in fact in any meaningful situation. Commitment is experienced as a trap. They have difficulty saying no, or setting limits. This is related to an excessive need for other people’s approval and validation. When they say they feel trapped by another person, what they mean is that they feel trapped by their own feelings about the other person. They may have projected various expectations or demands on to the other, so that they are overly concerned about disappointing them, or about not being adequate to the task.

Excessive reliance on these projective mechanisms leaves them uncertain as to their boundaries, between inner and outer, self and other. A question they frequently ask themselves: what am I entitled to?

Male gamblers, in particular, are preoccupied with power games (Rosenthal, 1986). Power, as opposed to strength,3 is defined in relation to others, and is invariably gained at someone’s expense.

Relationships take on a seesaw quality, with the gambler battling for power and control.

Due to unresolved guilt about his gambling, a patient felt “onedown” in relation to his wife. He felt unworthy of her and not entitled to be treated decently. He did not verbalize this, but instead provoked fights at home. Similarly, his self-esteem was based on material success. When they had to scale down their lifestyle, he felt diminished. Again feeling like a failure, he blamed others and took it out on those closest to him. Compulsive gamblers are often good at “turning the tables,” so that it is the spouse who feels helpless and inadequate or is apologizing to the gambler and seeking forgiveness. For male gamblers, particularly action seekers, relationships are typically adversarial.

In light of the above, it is not surprising that there are frequent sexual problems (Daghestani, 1987; Steinberg, 1990, 1993). Adkins, Rugle, and Taber (1985) found a 14 percent incidence of sexual addiction within a sample of 100 inpatient male compulsive gamblers. When “womanizing” patterns are investigated, the incidence is closer to 50 percent (Steinberg, 1990, also personal communication). The excitement associated with the pursuit and conquest of women resembles the excitement and “big win” mentality of gambling.

In treating early onset male gamblers, in particular, one typically encounters two patterns of aberrant sexual behavior: (1) celibacy or a kind of phobic avoidance of sexual relationships, and (2) compulsive sexual behavior consisting of promiscuous womanizing, or compulsive masturbation related to various forms of pornography. The two patterns may be mixed.

Success

A closely related problem has to do with difficulties handling success. It may be blown out of proportion. For example, in some parts of the country a GA birthday is a cross between a bar mitzvah and a Friar’s Club roast. Gamblers compete with each other in seeing how many people will attend and who will receive the most glowing testimonials. It is a critical time, in that the achievement of a year’s abstinence, or some other landmark, poses an immediate risk for relapse.

There frequently are unrealistic expectations of what success will mean, so that its achievement leads to disappointment and depression. Sometimes the gambler abstained in order to prove something to someone, in effect to win a mind bet. Sometimes they were doing it for their family or for the therapist, so that after a period of abstinence they feel justified in saying “Okay, I was  good for a year. Now I feel something is owed me so I’m going out to have some fun.” Fun, in this case, of course, means gambling.

 

compulsioncartoon

 

Sometimes their successes are attributed to omnipotent parts of the personality (Rosenthal, 1986). Success can trigger mania.

They get high on their success and grandiosity takes over. Some gamblers are fearful of success, and there is a subset of gamblers with masochistic character disorders. Some of them feel more alive when they are in debt and having to work hard to pay creditors. A critical time is when they are just beginning to get in the black, when they can start to have something for themselves.

The gambler’s relationship with reality may be adversarial, persecutory, or humiliating. The gambler may want to see himself as an exception—exceptional among people, and an exception to the rules. Not wanting to be pinned down, he is looking for “an edge,” or for loopholes. This search for “freedom” is often what gets him into trouble.

Once initial problems have been dealt with and abstinence established, gamblers are often at greatest risk when life starts becoming predictable. Meeting responsibilities and living a “normal” life leads to a feeling of being trapped for those gamblers who have not yet internalized a value system based on facing responsibility. Rather than viewing their new life as a self determined one, gamblers are more likely to see such behavior as externally imposed. Feeling controlled by their own schedule, they experience a need to rebel.

Conclusion

Staying in action is, for the pathological gambler, equivalent to the alcoholic’s dry drunk. It is a way to maintain attitudes and behaviors associated with gambling while superficially complying with treatment and Gamblers Anonymous. After the patient has initially achieved abstinence, it is important to look for more covert forms of gambling and other ways in which the patient may still be in action.

Lasting abstinence requires personality change. At a minimum, there is a need to identify and confront whatever it is from which the gambler is escaping. This would include the intolerable situation and feelings as well as the mechanism of their avoidance. Honesty means more than not lying to others about one’s gambling; it means being honest with oneself about one’s feelings. One learns to take honest emotional risks, rather than those based on the need to manipulate or control external events.

As is true for all addicts, gamblers at the beginning of treatment cannot trust themselves. Self-trust requires self-knowledge, which in turn requires curiosity about oneself. Stated differently, “The key to building self-trust” (Kramer & Alstad, 1993, p. 252) “is the ability to utilize one’s own experience, including (one’s) mistakes, to change.”

(This article (1)  is worthy in addressing the oft unspoken realities of abstinence/sobriety when the emotional dysfunction and emotional immaturity once solely regulated via addictive behaviours seeps into sober life also and the formerly habitualised compulsive approaches to life re-surface in abstinence. There can be quick and profound self transformation in recovery but many of the habitualised behavioural patterns continue to stalk our every day lives, as we ” trudge the road of Happy Destiny”. They are there waitng to resurface. They are normally the consequence of reacting to the world as opposed to acting responsibly in it.

I have an addicted brain and a recovering mind, they do not always mix very well. They pull me in opposite directions and have sometimes heated arguments in my head.

I have to manage my illness. It hasn’t gone away. The drink did not make me ill. It didn’t help but it did not solely make me an alcoholic, some emotional dysfunction worsened by alcohol, drugs and other addictive behaviours did. I had a vulnerability and a propensity to later addictive behaviours. I was primed to go off. If alcohol or drugs were the sole problem I quite simply would have given them up. As I did with cigarettes etc

If I do not try to remain manageable or emotionally sober I can still react and “still go off on one”, on temporary, fleeting dry drunks.

Hey I appear even to have many  “stay in action” similarities and I haven’t gambled since I was 14 years old. Perhaps these emotional and behavioural manifestations have certain commonalities among addictive disorders?  A spiritual malady or emotional dysfunction which activates “old patterns of behaving” ?  

Then again I only gave up gambling on poker machines because I was losing all my drinking money on gambling machines!!))  

 

References

1. Rosenthal, R. J. (2005). Staying in action: The pathological gambler’s equivalent of the dry drunk. Journal of Gambling Issues.

 

 

 

 

Why we need to be more accurate in diagnosing co-morbidity.

In this blog we have repeatedly queried whether the co-occurrence of so-called co-morbidities with substance use disorders (SUDs) is as high as reported in many studies (1).

In a blog from yesterday Are most co-morbidities really substance-induced disorders?  that diagnosis is often flawed in many studies and that the so-called diagnosis of co-morbidity is not borne out long term with many presumed co-morbid disorders disappearing in time.

In an recurring example given, the author uses the high prevalence of so-called comorbidity with mood disorders to illustrate how alcoholics and addicts appear to have a similar range of mood disorders as that of a normal population sample, i.e. as normally in society, around 15%.

This is in keeping with our ancedotal evidence of attending numerous AA meetings over a number of years has shown that in the vast majority of individuals the symptoms of a supposedly co-morbid disorder such as General Anxiety Disorder (GAD) or major depression (MD) appear to dissipate after some weeks.

This either means that there 12 step program of recovery outlined in mutual support groups like AA can provide profound therapeutic effect on other disorders (which they very well may do) or that the co-morbidities highlighted in many studies is greatly exaggerated.

This exaggeration has two major consequences. The study of and research into SUDs is hampered by relegating affective dimensions to that of co-morbidity while not exploring the specific emotional dysregulation at the heart of SUDs ( in particular dyscontrol over subcortical/amgydaloid emotional responding appears at the heart of most of these psychopathologies so they have common neural substrates and mechanisms but they may not manifest in the same behavioural responses – in other words there may be common emotional dysregulatory mechanisms but different pathomechanisms)

Burden of Addiction Graph

 

That is not to say that co-occuring disorders can not exaggerate the trajectory of a SUDs as disorders such as post traumatic stress disorders may, for example, add to distress based responding and may also require further and more specific treatment in addition to that for a SUD.

Also research needs to not only to predict behaviour e.g. in the case of addiction, relapse, but also to help prevent conditions arising. Thus it is imperative that research more fully informs prevention and intervention in children and adolescents at risk from later SUDs.

Thus the specific aspects of emotional dysregulation specific to a SUD such as, for example, a tendency to act rashly or impulsively under distress may be addressed by considering whether this is also the function of emotional processing deficits which mean emotions are “avoided” rather than processed by cortical areas, resulting in more reactive sub-cortical responding which has consequence for a decision making profile which is more based on alleviating this distress state, this unpleasant feeling state, than it does the recruiting via effective emotional processing and regulation of more cortical areas of the brain. All of which has ramifications for a more accurate study of the aetiology of addiction per se and it’s prevention.

For example, teaching at risk children how to identify, label, and verbalise their emotions at an early age will help them learn how to process and regulation them; to then use these feeling states to guide goal-directed adaptive behaviour rather than and  recruiting more subcortical emotive-motor parts of the brain to flee these distress states resulting in more reactive  decision making and emotional management. It would also help with reducing the effect that initial alcohol use has on adolescents as  emotional dysregulation potentiates reward, so distress/stress make the rewarding effects of drugs and alcohol heightened. It may also mean heart rate variability is also higher so that the smoothing, calming effects of alcohol are not as exaggerated. It would help put some neural brakes on increasingly out of control behaviour.

It would help tackle the premorbid distress at the heart of vulnerability to later addiction at its source, its manifestation as emotional reactivity.

It would return us to a theoretical conception of addicts as suffering human beings not neurobiological machines, which can be tweeked by this neurochemical or that!

This leads me onto the second short point. If we relegate the anxiety, impulsivity mood  and affective dimensions of a SUD to co-morbidity we limit our understanding of the overlapping and interlinked roles of emotional processing and regulation deficits on reward processing for example.

There is a tendency in some researchers to see addiction purely in terms of neurbiological processes, usually dopaminergic, equating addiction to the effects that a drug or alcohol has on the neurobiology and neuro-anatomy of the brain, and not to see how these deficits may not be simply drug induced but also linked to stress dysregulation which itself is linked profound and pre-existing impairments in emotion processing and regulation.

A chronic addict is emotionally distressed most of the time, who do dopaminergic models explain this emotional response or the fact that most relapse is stress or emotional distress based and prompted.

Or the effects of maltreatment or abusive childhoods, or economic deprivation or deviant peers. Observing addiction as a inherited emotional regulation and processing deficit, exaggerated by sometimes dysfunctional  parenting  (especially if the parents are also addicts and alcoholics) and persistent stress allows us to observe how genes in certain individuals are influenced by environment and manifest in behavioural undercontrol, emotion lability and reactivity and impaired, impulsive decision making in those at risk from later addiction. It may be important to study what is impaired before the neurotoxic effects of chronic drug and alcohol use profoundly aggravate these “pre-morbid”  impairments.

To conclude, there is “overlap of the biological substrates and the neurophysiology of addictive processes and psychiatric symptoms associated with addiction”

Pani et al suggest the “inclusion of specific mood, anxiety, and impulse-control dimensions in the psychopathology of addictive processes.”

We suggest these can be accommodated under the umbrella of emotional regulation and processing deficits as the above and additional deficits seen in alcoholics and addicts are more satisfactorily covered by this nosology.

We agree with Pani et al, that “addiction reaches beyond the mere result of drug-elicited effects on the brain and cannot be peremptorily equated only with the use of drugs despite the adverse consequences produced.”

We infer that emotional dysregulation is at the “very core of both the origins and clinical manifestations of addiction and should be incorporated into the nosology of the same, emphasising how addiction is a relapsing chronic condition in which psychiatric manifestations play a crucial role.”

We agree that “addictionology cannot be severed from its psychopathological connotations, in view of the undeniable presence of symptoms, of their manifest contribution to the way addicted patients feel and behave, and to the role they play in maintaining the continued use of substances.”

References

Pani, P. P., Maremmani, I., Trogu, E., Gessa, G. L., Ruiz, P., & Akiskal, H. S. (2010). Delineating the psychic structure of substance abuse and addictions: Should anxiety, mood and impulse-control dysregulation be included?. Journal of affective disorders, 122(3), 185-197.