mindfulness

How Mindfulness could help Recovery?

Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence.

Posted on May 7, 2015 | Leave a comment

Yesterday we looked a how low heart rate variability in alcoholics (active and in recovery) may influence self, emotion and stress regulation, and have a limited effect on impulsivity, and result in a “locked in” attention to alcohol-related cues, all of which have obvious consequences for relapse.

Here we cite and use excerpts from an article by Eric Garland et al (1) which addresses the effects of mindfulness  meditation on those with alcohol dependence.

Although Garland suggest mindfulness could be an alternative to other treatment and recovery programs, I suggest that it can be used most effectively with other treatment and recovery programs, e.g. with step 11 of 12 step programs.

I believe the consequence of emotion dysregulation  over many years of addiction leaves behind numerous unprocessed emotions which have not been consigned to long term memory and as a result float around the mind as resentments, shame and guilt based memories etc.

Emotion dysregulation has not allowed us to consigned them properly to the past (the so-called wreckage of the past) or long term memory and only an intensive process of emotional processing these e.g. via step 4 or 5 or via an alternative stock taking of our pasts seems to resolve this problem.

I know from my previous experience of intensive meditation involving various 10 day intensive courses and meditating on a very regular basis, before realising I am an alcoholic, would always result in relapse via the distress of the past being resurgent in my mind.

Some method of addressing all of these past behaviours, which invariably have hurt someone, need to be addressed and processed, even making amends to those hurt by our previous behaviours,  before we profoundly ease the distress of the past and help facilitate a greater recovery and more effective meditation practice.

Anyway, that’s my vies, on with the article…

“When attention is fixated on visual or olfactory alcohol cues, alcohol dependent individuals exhibit significant psychophysiological reactivity (Carter & Tiffany 1999). In turn, this alcohol cue-reactivity may lead to increased craving, which can trigger alcohol consumption as a means of reducing distress. Many persons recovering from alcohol use disorders attempt to suppress cravings, which, paradoxically, can serve to increase intrusive, automatic alcohol-related cognitions (Palfai, Monti, Colby, & Rohsenow 1997), dysphoria, and autonomic arousal (Wenzlaff & Wegner 2000). Indeed, among alcohol dependent persons, thought suppression is negatively correlated with vagally-mediated heart rate variability (Ingjaldsson, Laberg, & Thayer 2003), a putative index of emotion regulation and parasympathetic inhibition of stress reactions (Thayer & Lane 2000).

As thoughts of drinking intensify and are coupled with psychobiological distress, the impulse to consume alcohol as a form of palliative coping may overcome depleted self-regulation strength (Muraven, Collins, & Nienhaus 2002; Muraven & Shmueli 2006) leading to relapse. The attempt to avoid distress or allay its impact through compulsive alcohol consumption results in negative reinforcement conditioning that may perpetuate this cycle by further sensitizing the brain to future stressful encounters via allostatic dysregulation of neuroendocrine systems (Koob 2003). Components of this risk chain may be especially malleable to targeted behavioral therapies.

One such intervention, mindfulness training, which originates from Buddhist traditions but has been co-opted by Western clinicians, has recently gained prominence in the psychological and medical literatures for its salutary effects on stress-related biobehavioral conditions (Baer & Krietemeyer 2006; Ludwig & Kabat-Zinn 2008). Mindfulness involves self-regulation of a metacognitive form of attention: a nonreactive, non-evaluative monitoring of moment-by-moment cognition, emotion, perception, and physiological state without fixation on thoughts of past or future (Garland 2007). A growing body of research suggests that mindfulness affects implicit cognition and attentional processes (e.g., Jha, Krompinger, & Baime 2007; Lutz, Slagter, Dunne, & Davidson 2008; Wenk-Sormaz 2005) as well as heart rate variability indices of parasympathetic regulation (Tang et al. 2009).

 

Mindfulness treatments may enhance clinical outcomes in substance-abusing populations.

Bowen et al. (2007) found that mindfulness training of incarcerated inmates reduced post-release substance use, substance-related problems, and psychiatric symptoms to a greater extent than standard chemical dependency services offered at the prison. Other pilot studies of mindfulness-based interventions with substance abusers have found significant reductions in distress, negative affect, stress-related biomarkers, and substance use (Marcus, Fine, & Kouzekanani 2001; Marcus et al. 2003;Zgierska et al. 2008).

To that end, a randomized, controlled design was used to compare the therapeutic effects of a mindfulness-oriented recovery enhancement (MORE) intervention to those of an evidence-based alcohol dependence support group (ASG).

We hypothesized that, relative to ASG, MORE would result in significantly greaterdecreases in perceived stress, impaired alcohol response inhibition, craving for alcohol, psychiatric symptoms, and thought suppression and significantly greater increases in mindfulness and in heart rate variability (HRV) recovery from stress-primed alcohol cues.

 

MINDFULNESS TRAINING REDUCES STRESS AND THOUGHT SUPPRESSION

Among recovering alcohol-dependent individuals, mindfulness training appears to be a potentially effective stress reduction technique. MORE reduced perceived stress to a greater extent than did ASG, which is noteworthy given that social support reduces stress reactivity and buffers deleterious effects of stressful life events (Christenfeld & Gerin 2000). The stress reduction effects of mindfulness training among nonclinical populations are well known in the literature (Grossman, Niemann, Schmidt, & Walach 2004), but it is notable that significant effects were obtained in a sample of clinically-disordered, alcohol-dependent adults with extensive trauma histories who may be more vulnerable to stress-precipitated relapse due to allostatic dysregulation of neural stress circuitry (Valdez & Koob 2004).

Like stress, thought suppression significantly decreased over the course of ten weeks of mindfulness training. In turn, decreases in thought suppression among MORE participants were significantly correlated with decreases in impaired alcohol response inhibition, raising the possibility that participants who improved their ability to regulate drinking urges may have done so via reductions in thought suppression.

In the context of alcohol dependence, thought suppression seems to enhance the conscious awareness of alcohol-related cognitions and affective reactions. MORE, with its emphasis on nonjudgmental, metacognitive awareness of present-moment experience, appeared to counter this deleterious cognitive strategy and therefore may have prevented post-suppression rebound effects from exacerbating negative affect and intrusive alcohol-related cognitions that can promote relapse.

CONCLUSION

In sum, the unwitting attempts of recovering alcohol dependent persons to suppress appetitive cognitive-emotional reactions towards alcohol may obscure these responses from consciousness only to perpetuate and intensify them within the cognitive unconscious. In the domain of unconscious mental life, automatic processes run smoothly and efficiently uninhibited by volitional control (Kihlstrom 1987). Hence, by shunting appetitive reactions into the unconscious, the alcohol dependent individual may increase the very appetitive response towards alcohol he or she is trying to suppress and exacerbate psychophysiological reactivity to alcohol cues. Mindfulness training may serve to undo this process, making unconscious responses conscious. Thus, practice of mindfulness may promote the recovery of alcohol dependent persons through: a) deautomatization of alcohol use action schema, resulting in diminished attentional bias towards subliminal alcohol cues and increased craving as a result of disrupted automaticity; and b) decreased thought suppression resulting in increased awareness of alcohol urges over time, increased HRV recovery from alcohol cue-exposure, and improved ability to inhibit appetitive responses.

Accordingly, mindfulness training may be a tractable means of promoting enduring behavior change. Although brief motivational interventions may be highly effective at impelling the desire towards sobriety, participants of such motivational enhancement therapies remain prone to eventual relapse; indeed, relapse is often a part of the recovery process. As such, interventions that consolidate short-term treatment gains into broader lifestyle change are of major significance to the addictions treatment field. During the gradual practice of mindfulness, one learns to work with negative emotions in a metacognitive context, resulting in nonreactivity to difficult mental contents and improved self-regulation in the face of stressors. The developmental process of cultivating and embedding mindfulness principles into all aspects of one’s life may solidify gains made in prior treatment and provide an effective, long-term approach to coping with stress-precipitated relapse.

Despite evidence suggesting that stress appraisal and attentional biases are key components of alcohol dependence, the form of addictions treatment most available to poor and marginalized persons, social support groups, does not target these pathogenic mechanisms directly. In contrast, practice of mindfulness may attenuate stress reactivity and thought suppression while disrupting addictive automaticity, resulting in increased awareness of craving and greater ability to cope with and recover from alcohol urges in stressful contexts. Hence, mindfulness training may hold promise as an alternative, targeted treatment for stress-precipitated alcohol dependence among vulnerable members of society.”

Equally mindfulness meditation may be used alongside other treatment regimes. For example, it can be used in a daily manner as part of step 11 in the 12 step program. It is also used as part of DBT, for example.

I think that there are ideas out there, is so-called different treatment regimes, which can simply compliment each other. Whatever works, works.

I personally meditate using both  Christian and Buddhist meditation techniques.

Sometimes appreciating the therapeutic strengths of different treatment philosophies and practice can augment one’s own main treatment and recovery program.

References

1.  Garland, E. L., Gaylord, S. A., Boettiger, C. A., & Howard, M. O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: results of a randomized controlled pilot trial. Journal of psychoactive drugs, 42(2), 177-192.

Christianity_Jesus_meditating_golden_light

How it (Mindfulness) Works? (Part 4)

“Mindfulness Training Ameliorates Addiction by Targeting Neurocognitive Mechanisms

EXPOSURE AND EXTINCTION

Individuals in early recovery from addiction often attempt to suppress craving for drugs and alcohol as a means of maintaining abstinence. However, these suppression attempts often backfire, resulting in depletion of self-control resources (1, 179) and a consequent rebound of substance-related thoughts (50, 51). Critically, attempted avoidance of substance cue-reactivity may prevent extinction learning from occurring, which requires inhibition of conditioned responses in the presence of conditioned stimuli. In contrast, mindfulness training provides an effective alternative to suppressing unwanted substance-related thoughts, emotions, and urges by promoting acceptance of and exposure to these mental experiences. By learning to tolerate aversive psychological events through acceptance rather than avoidance, mindful exposure to substance-related thoughts and cues may prevent the post-suppression rebound effect and facilitate desensitization to conditioned stimuli (78). When engaged over time, this practice might result in extinction learning of previously conditioned associations between substance cue-reactivity and addictive behaviors.

In support of this hypothesis, changes in thought suppression have been shown to partially mediate effects of mindfulness training on alcohol use and drinking consequences (180). Furthermore, Mindfulness-Oriented Recovery Enhancement treatment led to significant reductions in thought suppression which were associated with improved capacity to inhibit drinking urges, decreased alcohol attentional bias, and increased HRV recovery from stress and alcohol cues (7). Relatedly, among a sample of persons in long-term treatment for co-occurring psychiatric and substance use disorders, individuals with higher levels of dispositional mindfulness exhibited less craving for substances and were less likely to develop post-traumatic stress symptoms in response to trauma (66). Thus, MBIs may reduce the tendency to suppress aversive psychological experiences, thereby allowing urges that had been previously suppressed to become accessible to explicit cognitive control. As suppression decreases, controlled cognitive processing can be more effectively deployed to inhibit and counter addictive responses.

The effects of MBIs on cognitive regulation of extinction learning might be measured by combining neuroimaging, self-reported craving, and self-reported emotion regulatory strategy during a drug cue-reactivity paradigm. Pre- and post-mindfulness training, addicts could participate in cue-exposure sessions (e.g., a smoker might be asked to handle cigarettes, ashtrays, and lighters without smoking for a limited period of time, followed by an ad libitumsmoking session) in which skin conductance, heart rate, and craving responses could be measured throughout. If mindfulness enhances cognitive regulation of extinction learning, cue-elicited skin conductance, heart rate, and self-reported craving would be reduced following mindfulness training relative to an active control intervention, as would drug-use following the cue-exposure session.

Although we have described the aforementioned therapeutic mechanisms of mindfulness-centered regulation as discrete processes linked in a sequential, linear fashion, in actuality they often run in parallel and may be linked in a recursive, self-reinforcing system of positive feedback loops. Figure 2depicts the hypothesized interactions between these processes and therapeutic targets of MBIs.

 

Conclusion

In contrast to mindfulness, which leads to cognitive and behavioral flexibility, addiction may be characterized by mindlessness, i.e., habitual or scripted responses that are often deployed automatically without conscious volition or regard for goodness-of-fit with present goals or the socioenvironmental context. Although procurement of many psychoactive substances requires significant planning and intentionality, the appetitive drive that motivates drug seeking may emerge in a context of mindlessness, manifested as obsessional thoughts of using and compulsive urges that seem to arise in an unbidden and intrusive fashion in direct contradiction to rational decision making. Moreover, the behavioral routines involved in the ritual of drug administration can become automated and executed mindlessly in much the same was as other complex repertoires can be engaged without conscious volition by conditioned contextual cues (26). Hence, individuals treated for substance dependence with higher levels of mindlessness tend to experience higher levels of craving (66) and consume larger quantities of addictive substances than their more mindful counterparts (1). These findings suggest that habitual, reflexive responding can confer vulnerability to individuals in recovery. Conversely, greater attention to and awareness of one’s reactions to substance-related cues predicts less substance use among persons in recovery from addiction (111). In light of Tiffany’s (20) proposal that automaticity drives appetitive addictive responses, mindfulness of one’s automatized reactions would presumably allow for greater self-regulation of mindless reactions elicited by drug-cues, and increase proactive cognitive control over substance use.

Addiction involves deleterious neuroplastic changes in frontal-striatal-limbic circuitry that results from chronic drug-use. We hypothesize that this drug-induced neuroplasticity may be remediated through participation in MBIs. Specific knowledge of the neuroplastic alterations underpinning dysregulated circuit-function in addiction may inform treatment development efforts to drive the next generation of MBIs. For example, in light of evidence that dopaminergic salience networks involved in normal human learning and reward become usurped during the addictive process and biased in favor of drug-relevant stimuli, MBIs should be explicitly tailored to address reward processing deficits by emphasizing skills that enhance savoring of natural, non-drug related rewards. Though most current MBIs have underemphasized this potential treatment target, one novel MBI, Mindfulness-Oriented Recovery Enhancement (6–8) places a special emphasis on providing training in mindful savoring as an approach to restoring natural reward responsiveness. Concomitantly, a growing recognition of the role of attentional bias in addiction points to the potential clinical utility of focused attention forms of mindfulness practice as means of strengthening lateral frontal (dlPFC)-parietal networks involved in attentional (re)orienting from drug-cues; in that regard, recent ERP analyses of EEG data suggest that regular, brief mindfulness practice of focused attention on respiratory sensations strengthens electrophysiological indices of enhanced attentional control (181). Conversely, open monitoring forms of mindfulness meditation that target medial frontal (ACC)-parietal-thalamic regulation of striatal circuits might be most useful for generating awareness of cue-elicited activation of drug-use action schemas and could enable the practitioner to regain conscious cognitive control of automatized addictive behavioral routines. Thus, translating findings from the leading edge of neuroscience into the treatment development process may result in ever more specialized and efficacious MBIs targeted to meet the unique challenges of addictions treatment.

Importantly, although various drugs of abuse do share some common neurobiological underpinnings, there is also variability in the circuit-level function associated with different psychoactive agents. Similarly, while addiction to drugs may share overarching neural substrates with some behavioral addictions [e.g., food addiction, (182)], there may be important differences in the functional connectivity or node strength of neural networks involved in these various forms of addiction. Despite these differences, given our assertion that MBIs strengthen domain-general neurocognitive resources that can be used to target common transdiagnostic processes (i.e., automaticity, attentional bias, appraisal, emotion regulation, cue-elicited craving, stress reactivity, and extinction learning) we hypothesize that MBIs would have similar efficacy across a wide range of addictions. In contrast, the efficacy of MBIs may be moderated by key individual differences – an, important understudied area of research crucial to understanding the path from drug initiation to dependence to recovery. For instance, we hypothesize that extant MBIs may be less effective for individuals lacking motivation or readiness to change, because current programs do not integrate motivational components with mindfulness training, and evidence suggests that mindfulness alone may not facilitate readiness to change (Garland et al., submitted for publication). Similarly, MBIs may be more effective for individuals in early to late abstinence as opposed to individuals in active addiction; exposure to ubiquitous drug-related cues and an environment that affords ready access to drugs may promote a more automatized form of drug-use (20) that does not allow a novitiate of mindfulness (whose prefrontally mediated executive functions have atrophied due to years of drug-use) to marshal proactive cognitive control via mindfulness practice. In contrast, inpatient treatment settings may provide respite from cue-elicited craving and contextual triggers of striatally mediated habit responses, and therefore allow a fledgling mindfulness practitioner the opportunity to exercise PFC functionality in a safe environment until it has reached sufficient strength to allow the person to navigate a socio-cultural context beset by stressors and conditioned appetitive stimuli. Thus, mindfulness training may have heterogeneous effects across individuals depending on the natural history and trajectory of their addiction and treatment process.

The conceptual framework we have outlined in this paper may also have utility in developing temporally sequenced descriptions of neurocognitive processes targeted by MBIs. We offer the following speculative, hypothetical account based on our clinical and research experience using MBIs to treat persons diagnosed with substance use disorders. When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up appetitive urge. Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration. During this process, as sensations of craving arise, the individual may engage in metacognitive monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone and foster neuroplasticity in brain areas subserving increased dispositional mindfulness.

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges. The neurocognitive framework we have presented is intended to stimulate future research and facilitate the optimization of MBIs for the treatment of addiction. The tools of modern science have only begun to elucidate the many ways in which mindfulness training targets the risk chain of addiction at the attention-appraisal-emotion interface.”

I will critique this very interesting model in due course.

References

1. Garland, E. L., Froeliger, B., & Howard, M. O. (2013). Mindfulness  training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Frontiers in psychiatry, 4.

How it (Mindfulness) Works? (Part 3)

“Mindfulness Training Ameliorates Addiction by Targeting Neurocognitive Mechanisms

In the third part of this excellent review paper  (1) we look at the empirical evidence is presented suggesting that MBIs ameliorate addiction by enhancing cognitive regulation of a number of key processes.

EMOTION REGULATION

When individuals are unable to marshal effective problem-solving to resolve a stressor, lack of a favorable resolution may lead to deployment of emotion regulation efforts to manage the emotional distress elicited by the stressful circumstance. Neuroimaging research has provided evidence for a reciprocal, dual-system neural network model of emotion regulation comprised of a dorsal brain system (e.g., dlPFC, dACC, parietal cortex) subserving top-down cognitive control, and a ventral brain system (e.g., amygdala, striatum) subserving bottom-up emotional impulses (133–135). Top-down engagement of proactive cognitive control mechanisms regulates negative affect and attenuates the effects of emotional interference on cognition (135–138), and is associated with increased activation of PFC which in turn attenuates amygdala activation (139, 140). Research suggests that dysregulated emotional reactions occur when the reciprocal balance between the relative activation of bottom-up and top-down neural circuits becomes tipped in favor of bottom-up processes (141). A number of studies suggest that mindfulness training may counter this imbalance and augment emotion regulation [for reviews, see Ref. (78, 142)] by restructuring neural function in favor of context-dependent top-down control processes. For example, Goldin and Gross (143) demonstrated that individuals with elevated negative affect at baseline who later received mindfulness training exhibited increased emotion regulatory capacity coupled with greater recruitment of attentional control resources and reduced amygdala activation during exposure to negative, self-relevant stimuli. Thus, by enhancing top-down cognitive control over emotional responses in a context-dependent fashion, MBIs may reduce drug use precipitated by negative affective states.

Importantly, MBIs provide training in cultivating a state of mindful awareness and acceptance of the extant emotional response as a precondition for emotion regulation. While acceptance of aversive mental experience may itself result in reduced negative affect (144), mindfulness training may also exert downstream facilitative effects on cognitive regulation of emotion following the acute state of mindfulness. For instance, mindfulness training may promote cognitive reappraisal, the process by which the meaning of a stressful or adverse event is re-construed so as to reduce its negative emotional impact (125). One theoretical model posits a multi-stage process of mindful emotion regulation (1, 145). According to this model, during an adverse experience mindfulness practitioners first disengage from initial negative appraisals into the metacognitive state of mindfulness in which cognitions and emotions are viewed and accepted as transitory mental events without inherent veridicality. Subsequently, the scope of attention broadens to encompass a larger set of previously unattended information from which new situational appraisals may be generated. By accessing this enlarged set of contextual data, present circumstances may be reappraised in an adaptive fashion that promotes positive affect and behavioral activation. For instance, a newly abstinent alcohol dependent individual might reappraise an affront by a former “drinking buddy” as evidence of their need to build new, sober relationships. In support of this model, recent studies indicate that mindfulness during meditation predicts enhanced cognitive reappraisal (146), which in turn mediates the association of mindfulness and reduced substance craving (147). This context-dependent use of prefrontal regulatory strategy represents a “middle way” between hypo- and hyper-activation of cognitive control resources, thereby preventing resource depletion and untoward rebound effects.

Speculatively, this “mindful reappraisal” process may involve spreading activation in a number of brain networks. Generating the state of mindfulness in the midst of a negative affective state may activate the ACC and dlPFC (148, 149), which could facilitate metacognitive monitoring of emotional reactivity, foster attentional disengagement from negative appraisals, and regulate limbic activation. In so doing, the acute state of mindfulness may attenuate activation in brain areas that subserve self-referential, linguistic processing during emotional experience (e.g., mPFC) while promoting interoceptive recovery from negative appraisals by increasing activation in the insula (113). Metacognitive disengagement from the initial negative appraisal may result in non-elaborative attention to somatosensory information, thereby facilitating the set shifting process of cognitive reappraisal, as brain activations shift from posterior to anterior regions of cortex centered on the node of the OFC. During this process emotional interference is attenuated while alternate appraisals are retrieved from memory and evaluated for goodness-of-fit to situational parameters and demands (150).

The effects of mindfulness-centered regulation of negative emotion might be measured with a standard emotion regulation paradigm [c.f. (137)], in which participants are instructed to use reappraisal to reduce negative affect in response to exposure to aversive visual stimuli [e.g., images from the International Affective Picture System; (151)]. In this task paradigm, mindfulness practitioners may exhibit enhanced reappraisal efficacy, as evidenced by reduced self-reported and psychophysiological responses to aversive stimuli on reappraise relative to attend trials. In that regard, a study employing ERP analysis found that when compared to controls, meditators exhibited significantly greater reappraisal efficacy as evidenced by significantly larger attenuation of brain activity during reappraisal of stressful stimuli in centro-parietal regions subserving attentional and emotional processing (152).

STRESS REACTIVITY

In addition to pro-regulatory effects on emotion, mindfulness training may facilitate neurocognitive regulation of the effects of stress on the autonomic nervous system. As addicts in treatment develop dispositional mindfulness through mindfulness training, they may be more able to engage prefrontal cortical modulation of the sympathetic “fight-or-flight” response via parasympathetic nervous system activation of the “vagal brake,” resulting in increased HRV and heart-rate deceleration in the face of stress or addictive cues (153, 154). Thus, increasing dispositional mindfulness may be reflective of greater neurovisceral integration and flexibility in the central autonomic network (67). This network is comprised of neuroanatomic and functional linkages between central (e.g., PFC and ACC) and autonomic (e.g., vagus nerve) nervous system structures which coordinate the self-regulation of attention, cognition, and emotion while exerting regulatory influences over perturbations to visceral homeostasis (155), such as those that might be evoked in abstinent substance dependent individuals exposed to stressful and/or substance-related stimuli. Mindful individuals may have greater capacity for contextually appropriate engagement and subsequent disengagement of neurocognitive resources in response to the presence and absence of stress and drug-cues. Such autonomic flexibility (156) engendered through mindfulness training may help persons in recovery from addiction adapt to situational demands without succumbing to a stress-precipitated relapse.

This hypothesis is consistent with evidence of the effects of mindfulness on neural function in dlPFC and ACC (149, 157), key structures involved in central autonomic regulation of HRV via downstream influences on the amygdala and hypothalamus (158, 159). Congruent with such findings, MBIs increase parasympathetically mediated HRV to an even greater extent than relaxation therapy (160,161), and decreases sympathetically mediated indices of stress (8), including blood pressure (162), heart rate (163), skin conductance responses (161), and muscle tension (164). These effects of mindfulness-centered regulation on autonomic function may result in improved ability to manage substance cue-reactivity. In support of this hypothesis, a Mindfulness-Oriented Recovery Enhancement intervention for alcohol dependence increased HRV recovery from stress and alcohol cue-reactivity (7). Congruent with this finding, relative to their less mindful counterparts, alcohol dependent individuals with higher levels of dispositional mindfulness exhibited greater attentional disengagement from alcohol cues which predicted the extent to which their HRV recovered from alcohol cue-exposure levels (67). Lastly, persons participating a mindfulness-based smoking cessation intervention who exhibited increased HRV during mindfulness meditation smoked fewer cigarettes following treatment than those who exhibited decreased HRV (165). Thus, addicts who develop dispositional mindfulness through participation in MBIs may become better able to regulate appetitive responses by virtue of enhanced neurocognitive control over autonomic reactivity to stress and substance cues.

The effects of MBIs on cognitive regulation of autonomic cue-reactivity might be measured with a stress-primed cue-reactivity paradigm, in which participants are first exposed to a laboratory stress induction [e.g., aversive IAPS images, c.f. (7); or the TSST, c.f. (132)], then exposed to substance-related cues (either in vivo, imaginally, or images of alcohol or drugs), and finally asked to use mindfulness skills to downregulate the resultant state of autonomic arousal.

References

1. Garland, E. L., Froeliger, B., & Howard, M. O. (2013). Mindfulness  training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Frontiers in psychiatry, 4.

How it (Mindfulness) Works? (Part 2)

“Mindfulness Training Ameliorates Addiction by Targeting Neurocognitive Mechanisms

ATTENTIONAL BIAS

Given that drug-use action schemas may be evoked by cues associated with past substance use episodes, activation of addictive habits may be interrupted by re-orienting attention from substance-related stimuli to neutral or salutary objects and events. MBIs may be especially efficacious in that regard. Focused attention and open monitoring mindfulness practices capitalize on attentional orienting, alerting, and conflict monitoring – the fundamental components of attentional control (89, 90). Consequently, studies indicate that mindfulness is linked with enhanced attention regulation (61, 91). For instance, mindfulness training is associated with strengthening of functional connectivity within a dorsal attentional network (92) and MBIs can increase attentional re-orienting capacity, i.e., the ability to engage, disengage, and shift attention efficiently from one object to another subserved by dorsal attentional systems (93, 94). Other studies demonstrate that long-term mindfulness training strengthens alerting (93,95), i.e., a vigilant preparedness to detect and attend to incoming stimuli, subserved by the ventral attentional stream. In addition, dispositional mindfulness is positively associated with self-reported attentional control (68) and behavioral indices of sustained attention capacity (70). Recently, data from a randomized controlled trial indicated that 8 weeks of Mindfulness-Oriented Recovery Enhancement led to significant reductions in attentional bias to pain-related cues in a sample of opioid-misusing chronic pain patients (96).

MBIs may target addiction attentional bias by facilitating attentional disengagement from substance-related stimuli. In support of this hypothesis, a study of alcohol dependent adults in residential treatment identified a significant negative correlation between dispositional mindfulness and alcohol attentional bias for stimuli presented for 2000 ms that remained robust even after controlling for alcohol dependence severity, craving, and perceived stress (1). Hypothetically, alcohol dependent persons higher in dispositional mindfulness might exhibit increased capacity for attentional disengagement from alcohol cues by virtue of enhanced PFC and anterior cingulate cortex functionality, as these brain structures have been implicated in addiction attentional bias (97–99). Concomitantly, the degree to which alcohol dependent individuals higher in dispositional mindfulness were better able to disengage their attention from alcohol cues than their less mindful counterparts predicted the extent of heart-rate variability (HRV) recovery (an index of prefrontal-autonomic regulation) from stress-primed alcohol cue-exposure (67). Mindfulness training may also affect attentional orienting to substance-related cues. Among a sample of alcohol dependent adults in inpatient treatment, Mindfulness-Oriented Recovery Enhancement was found to result in significant effects on alcohol attentional bias for cues presented for 200 ms (7), indicating modulation of automatic initial orienting to alcohol cues [c.f. (23)]. In individual difference analyses, reductions in attentional bias following Mindfulness-Oriented Recovery Enhancement were significantly associated with decreases in thought suppression, which were, in turn, correlated with increases in HRV recovery from alcohol cue-exposure and improvements in self-reported ability to regulate alcohol urges.

Hence, mindfulness training may strengthen the capacity to regulate attention in the face of conditioned stimuli associated with past substance use, countering attentional biases by refocusing attention on neutral or health-promoting stimuli (e.g., the sensation of one’s own breath or a beautiful sunset). Repeatedly redirecting attention from substance-related cues toward innocuous stimuli may foster extinction of associations between substance-related cues and drug-use action schema. This potential mechanism may explain how attentional bias modification among addicts leads to decreased substance use and improved treatment outcomes (100,101). Future research could evaluate the effects of mindfulness training and MBIs on addiction attentional bias with the use of a dot probe task alone or coupled with eye tracking and analysis of event-related potentials (ERPs) to determine at what stage of attentional selection (initial orienting vs. later attentional disengagement) training has significant effects.

CUE-ELICITED CRAVING

The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli which have been conferred incentive salience, and is magnified by negative affective states. Several studies demonstrate that MBIs can produce significant reductions in craving (4,8,102–105). However, other studies have failed to identify significant reductions in craving among participants of MBIs (7, 106–108).

Mindfulness-based interventions may positively influence craving-related processes in several ways. First, mindfulness training may decrease bottom-up reactivity to drug-related stimuli, as mediated by reduced activation in the subgenual anterior cingulate cortex and striatum during exposure to substance cues (105). Second, mindfulness training may decouple negative emotion from craving. Although negative emotion is a common precipitant of craving and subsequent relapse (109), mindfulness training may extinguish this association, such that an addict experiencing sadness, fear, or anger could allow these emotions to arise and pass without triggering an appetitive reaction. Indeed, substance dependent individuals participating in Mindfulness-Based Relapse Prevention were less likely to experience craving in response to depressed mood, and this reduced craving and reactivity to negative emotion predicted fewer days of substance use (110).

MBIs may also produce therapeutic effects by increasing awareness of implicit craving responses. Tiffany (20) proposed that conscious craving occurs when an activated drug-use action schema is blocked from obtaining the goal of drug consumption. As such, persons in acute withdrawal, persons unable to obtain drugs (e.g., due to lack of funds or availability), or persons attempting to maintain abstinence in the face of triggers may experience an upwelling of craving for substances. In contrast, according to this theory, addicts who are able to obtain and use drugs in an unimpeded fashion would not experience craving. Similarly, persons in long-term residential treatment who are isolated from drug-related cues are unlikely to be conscious of craving. Without awareness of craving, the addict may unwittingly remain in high-risk situations and thus be especially subject to relapse. Indeed, lack of awareness of substance craving has been shown to be predictive of future relapse (111). MBIs may increase conscious access to the appetitive drive to use substances by virtue of their effects on increasing interoceptive awareness (78, 112). In that regard, mindfulness training has been shown to increase activity in the anterior insula during provocations by emotionally salient stimuli (113, 114). The anterior insula subserves interoception and awareness of the physical condition of the body, among other related processes (115). Increased neural activity in the insula during mindfulness meditation may index heightened access to interoceptive information.

In synthesizing the findings regarding attentional bias and cue-induced craving, we suggest that MBIs may restructure attentional bias away from drug-related reinforcing stimuli (e.g., drug-cues, negative affective stimuli) and facilitate the addict’s attempts to deal with associated cravings. We posit that mindfulness-centered regulation of cue-elicited appetitive responses occurs as a result of strengthening frontal-executive circuit-function and enhancing neural communication to the hippocampus and thalamus through formal and informal mindfulness meditation practices. The hippocampus is critical for context-dependent learning and memory – with reciprocal connectivity to brain regions that code for reward (ventral striatum), interoception (insula), affect (amygdala), and thalamus. In turn, the thalamus, a complex structure that is generally considered to serve as a relay station between limbic, striatal, and cortical circuits, contains efferent and afferent projections with striatal, limbic, somatosensory, ACC, lateral and medial PFC, and OFC. Thus, the recovering addict may utilize mindfulness training to become aware of which cues are under the spotlight of attention, and become more sensitive to how those cues may trigger changes in body state and motivation drive.

Hence, mindfulness may increase awareness of craving and thereby facilitate cognitive control of otherwise automatic appetitive impulses. In that regard, a recent study found that participation in Mindfulness-Oriented Recovery Enhancement was associated with decreased correlation strength between opioid craving and opioid misuse, suggesting that mindfulness training may have decoupled appetitive responses from addictive behaviors (8). This mechanism may explain the disparate findings vis-a-vis the effects of mindfulness on craving: because of potential underreporting of baseline levels of craving among individuals with impaired insight into their addiction (34), this increased awareness may confound researchers’ attempts to measure the impact of mindfulness training on craving, resulting in an apparent lack of change in craving over time.

The effects of mindfulness on cognitive regulation of craving might be measured by utilizing neuroimaging methodology (e.g., fMRI) to investigate neural circuitry function while participants attempt to regulate their craving response to salient drug-cues. For example, cognitive regulation appears to decrease cigarette craving concomitant with increased activity in dACC (116) and prefrontal regions coupled with attenuated activity in striatal regions (117). A complementary approach to probing the effects of mindfulness on regulating craving may be to utilize real-time fMRI (rt-fMRI). rt-FMRI involves providing subjects with real-time feedback of the BOLD signal within a brain region of interest (ROI) while they attempt to regulate the response within that ROI. This approach has been used to manage pain (118) and reduce cigarette cue craving in nicotine dependent smokers during smoking cessation (119). Evaluating the effects of mindfulness-centered regulation of craving-related neural circuitry in real-time may include a number of benefits including: (a) directly measuring which circuits are being effectively modulated and which are not; (b) feedback to the subject that will help guide mindfulness efforts; and (c) identifying individual differences associated with differential effects of MBIs on specific neural mechanisms.

COGNITIVE APPRAISAL

Insofar as stress evokes automatic responses and impairs prefrontally mediated cognitive control functions (120), exposure to socioenvironmental stressors may render addicts in recovery vulnerable to relapse (1, 22, 121). Mindfulness training may allay stress-induced relapse by virtue of its stress-reductive effects (122). Although early theorists believed that mindfulness meditation reduced stress primarily by evoking a generalized relaxation response (123), modern research indicates that mindfulness practice may also attenuate stress by targeting cognitive mechanisms (1, 124). One potential target of mindfulness is cognitive appraisal, the process whereby stimuli and their environmental context are evaluated for their significance to the self (125). Appraisals of threat or harm elicit negative emotional reactions coupled with activation of stress physiology. When recurrent, such emotional reactivity biases perception, leading to exaggerated, overestimated appraisals of threat and underestimations of self-efficacy (126), and ultimately, sensitization to future stressors (127).

In contrast, mindfulness, which has been conceptualized as a non-reactive form of awareness (128) may enable the individual to cognitively appraise his or her present circumstances with less emotional bias, and to more accurately assess his or her ability to cope with present challenges (60). Thus, MBIs may impact both primary (rapid and implicit) and secondary (slow and explicit) appraisal processes (125). In partial support of this hypothesis, a recent neuroimaging study revealed that, in contrast to a meditation-naive control group, mindfulness meditation practitioners exhibited decreased reactivity to briefly presented negative emotional cues in frontal-executive brain regions (i.e., dorsolateral PFC) and less deterioration of positive affect in response to cue-elicited amygdala activation (31). These data suggest that mindfulness training may alter the allocation of cognitive resources during appraisal of negative emotional stimuli and attenuate the influence of limbic reactivity on mood state. Other research demonstrates that mindfulness training minimizes emotional interference from unpleasant stimuli [e.g., Ref. (129)]. In so doing, mindfulness training may reduce biases toward negative emotional information processing. Among persons with a history of depression, Mindfulness-Based Cognitive Therapy reduces overgeneral memories (130) and cognitive bias toward negative information (131). Among individuals suffering from chronic pain, Mindfulness-Oriented Recovery Enhancement decreases cognitive bias toward pain-related cues (96). Together, these findings suggest that MBIs may decrease negative emotional bias in initial cognitive appraisal processes, thereby reducing the downstream effects of stress on addictive behavior. As mindfulness-centered regulation enhances cortico-thalamic-limbic functional connectivity, the recovering addict becomes more aware of relations between attention, emotional state, and motivation. This awareness provides an opportunity to deploy cognitive strategies to respond to the environment in a more adaptable context-dependent manner, rather than responding from a pattern of overlearned reactive behaviors.

References

1. Garland, E. L., Froeliger, B., & Howard, M. O. (2013). Mindfulness  training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Frontiers in psychiatry, 4.

How it (Mindfulness) Works? (Part 1)

Following on from our previous blog Neural mechanisms of mindfulness meditation we now use abbreviated excerpts form a very good researcher Eric Garland into how possible mindfulness helps repair, via meditation based neuroplasticity, those areas and networks of the brain which are impaired or do not function adaptively  in the addicted brain.

In this review paper, they described how mindfulness-based interventions (MBIs) may target neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface.

“Mindfulness Training Ameliorates Addiction by Targeting Neurocognitive Mechanisms

Empirical evidence is presented suggesting that MBIs ameliorate addiction by enhancing cognitive regulation of a number of key processes, including: clarifying cognitive appraisal and modulating negative emotions to reduce perseverative cognition and emotional arousal; enhancing metacognitive awareness to regulate drug-use action schema and decrease addiction attentional bias; promoting extinction learning to uncouple drug-use triggers from conditioned appetitive responses; reducing cue-reactivity and increasing cognitive control over craving; attenuating physiological stress reactivity through parasympathetic activation; and increasing “savoring” to restore natural reward processing.

Although mindfulness is an English term linked with a set of contemplative practices and principles originating in Asia over 2500 years ago…

MBIs are centered on practices designed to evoke the state of mindfulness, a mindset characterized by an attentive and non-judgmental metacognitive monitoring of moment-by-moment cognition, emotion, perception, and sensation without fixation on thoughts of past and future (60, 61)…During focused attention, attention is sustained on an object while the practitioner alternately acknowledges and lets go of distracting thoughts and emotions. Objects of focused attention practice can include the sensation of breathing; the sensation of walking; interoceptive  feedback about the body’s internal state etc…

Focused attention practices are often the precursor to open monitoring forms of mindfulness meditation. During open monitoring, a state of metacognitive awareness is cultivated wherein mental contents are allowed to arise unperturbed without suppression or distraction while the quality of awareness itself remains the primary focus of attention (61)

Putatively, focused attention and open monitoring emphasize or differentially activate different cognitive capacities during the mindful state, including attentional vigilance, attentional re-orienting, executive monitoring of working memory, response inhibition, and emotion regulation (62).

Engaging in these practices repeatedly over time may induce neural and cognitive plasticity (7); recurrent activation of the mindful state during meditation may leave lasting neurobiological traces that accrue into durable changes in the dispositional propensity to be mindful in everyday life even while not meditating (64).

Germane to the current discussion of neurocognition in addiction, dispositional mindfulness is significantly inversely associated with addiction attentional bias (1) and craving (66), positively associated with autonomic recovery from stress and substance cue-exposure (67), and correlated with various indices of cognitive control (68–70). MBI-related increases in dispositional mindfulness might be mediated through neuroplasticity stimulated by experience-dependent alterations in gene expression (71, 72).

Indeed, cross-sectional studies have demonstrated significant differences in gray matter volume between meditation practitioners and meditation-naïve controls, particularly in regions of PFC that instantiate cognitive control (e.g., inferior frontal gyri) and higher-order associative processing (e.g., hippocampus) (73–77). Moreover, longitudinal research has shown that participants in an 8-week MBI evidenced increased gray matter density in posterior cingulate cortex, temporo-parietal junction, and cerebellum, compared to controls (78), and reduced amygdala volume that correlated with the degree of stress-reduction achieved from mindfulness training (79).

Through focused attention and open monitoring forms of meditation, MBIs exercise a number of neurocognitive processes believed to go awry in addiction. Indeed, MBIs may be fruitfully conceptualized as means of training or exercising prefrontally mediated cognitive control networks which have become atrophied or usurped in the service of drug seeking and use. By strengthening PFC functions and the ability of the PFC to modulate other brain networks in a context-dependent manner, MBIs may provide the global benefit of enhancing neurocognitive flexibility…(e.g., cognitive regulation of automaticity, attention, appraisal, emotion, urges, stress reactivity, reward processing, and extinction learning).

These processes do not operate in isolation; they are linked in mutually interdependent, interpenetrating, recursive networks [for reviews, see Ref. (2, 3)]. MBIs may restructure dysregulated processes by strengthening functional connectivity and efficiency of prefrontally mediated self-regulatory circuits (see Figure2). Below, we propose a number of hypothetical neurocognitive targets that could mediate the therapeutic effect of MBIs on addictive behavior.

FIGURE 2

 

Figure 2. Mindfulness-centered regulation: the central tenet of this model posits that mindfulness-based interventions (MBI’s) may remediate dysregulated habit behaviors, craving, and affect primarily by way of strengthening functional connectivity: (1) within a metacognitive attentional control network (PFC, ACC, Parietal); and (2) between that metacognitive attentional control network and the (a) habit circuit, (b) craving circuit, and (c) affect circuit.

HABIT RESPONSES

Substance dependent individuals typically experience euphoria during initial stages of drug-use. Yet, as experience with the drug increases, the reward associated with drug-taking becomes dramatically attenuated. Despite diminishing returns in positive emotional experiences resulting from substance use, dependent users continue to use their drug of addiction. Undergirded by neuroplastic changes in striatal circuitry, habitual drug-use becomes an overlearned process that can become automatized (12, 80).

Though more investigation is needed to elucidate effects of mindfulness on brain-behavior relations subserving drug-use action schemas, early research on the effects of mindfulness on behavioral measures of automaticity has emerged [e.g., Ref. (82)]. Such research provides a theoretical foundation for the potential efficacy of MBIs for interrupting drug-use action schemas. Hypothetically, mindfulness training may increase awareness of the activation of drug-use action schemas when triggered by substance-related cues or negative emotion, thereby allowing for the disruption of automatized appetitive processes with a controlled coping response.

As posited in our model of mindfulness-centered regulation (Figure 2), mindfulness training may enhance functional connectivity in a cortico-thalamic loop including prefrontal, cingulate, parietal, and dorsal thalamus nodes, strengthening an executive regulatory circuit providing feedback to the striatum and medial temporal lobe. This feedback process is theorized to allow for greater consciousness of thoughts and behaviors that were previously enacted with little conscious awareness.

The practice of mindfulness in daily life is focused on developing awareness of automatic behavior. Indeed, many MBIs prescribe informal mindfulness practices where individuals are instructed to engage in everyday, repetitive tasks (e.g., washing the dishes) with full consciousness of the sensorimotor aspects of the activity. Such informal mindfulness practices are designed to reduce mind-wandering and strengthen conscious control over automaticity.

Potentially as a result of such practices, mindfulness training has been shown to decrease habit behavior (83) and reduce rigid adherence to scripted cognitive responses (82). These findings accord with early theoretical accounts which conceptualized mindfulness meditation as a form of “deautomatization,” whereby patterns of motor and perceptual responses which had been rendered automatic and unconscious through repetition are reinvested with conscious attention (84).

Thus, is plausible that mindfulness training may deautomatize habitual addictive responses through both formal meditations focused on regulating automatic appetitive impulses as well as informal mindfulness practices designed to increase generalized awareness of automaticity. In light of findings suggesting that conscious cognitive control disrupts automatic processing (20, 85–87), mindfulness training may interrupt drug-use action schemas by augmenting top-down control via a frontoparietal metacognitive attention network, facilitating the strategic deployment of self-regulatory processes to reduce or prevent substance use. The effects of mindfulness training on inhibition of habit responses might be indexed with performance on an Emotional GoNoGo task (88), where subjects would be asked to withhold automatized “go” responses in the context of emotional interference from a drug-related (i.e., a drug-related background image) or negative affective stimulus (i.e., an aversive background image).

To be Continued…

References

1. Garland, E. L., Froeliger, B., & Howard, M. O. (2013). Mindfulness  training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Frontiers in psychiatry, 4.

Neural mechanisms of mindfulness meditation

Mindfulness is simply paying attention to thoughts, emotions, and body sensations in a non-judgmental manner.Meditation is a platform used to achieve mindfulness. This practice originated from the idea of mindfulness in Buddhism and has been widely promoted by Jon Kabat-Zinn.

Components of mindfulness meditation

Although several components for mindfulness meditation have been proposed, four components have found to be common among most: attention regulation, body awareness, emotion regulation, and change in perspective on the self.[1] All of the components described above are connected to each other.

Attention regulation

Attention regulation is the task of focusing attention on an object, acknowledging any distractions, and then returning your focus back to the object. Some evidence for mechanisms responsible for attention regulation during mindfulness meditation are shown below.

  • Mindfulness meditators showed greater activation of rostral anterior cingulate cortex (ACC) and dorsal medial prefrontal cortex (MPFC).[2] This suggests that meditators have a stronger processing of conflict/distraction and are more engaged in emotional regulation. However as the meditators become more efficient at focused attention, regulation becomes unnecessary and consequentially decreases activation of ACC in the long term.[3]

  • The cortical thickness in the dorsal ACC was also found to be greater in the of gray matter of experienced meditators.[4]

Body awareness

Body awareness refers to focusing on an object/task within the body such as breathing

  • Meditators showed a greater cortical thicknesss [8] and greater gray matterconcentration in the right anterior insula.[9]

 

 

The insula is responsible for awareness to stimuli and the thickness of its gray matter correlates to the accuracy and detection of the stimuli by the nervous system.[11][12] Since there is no quantitative evidence suggesting that mindfulness meditation impacts body awareness, this component is not well understood.

Emotion regulation

Cognitive regulation (in terms of mindfulness meditation) means having control over giving attention to a particular stimuli or by changing the response to that stimuli.The cognitive change is achieved through reappraisal (interpreting the stimulus in a more positive manner) and extinction (reversing the response to the stimulus). Behavioral regulationrefers to inhibiting the expression of certain behaviors in response to a stimuli. Research suggests two main mechanisms for how mindfulness meditationinfluences the emotional response to a stimuli.

  • Mindfulness meditation regulates emotions via increased activation of the dorso-medial PFC and rostral ACC.[2]
  • Increased activation of the ventrolateral PFC can regulate emotion by decreasing the activity of the amygdala.[13][14][15] This was also predicted by a study in which they observed the effect of a person’s mood/attitude during mindfulness on brain activation.[16]

Lateral prefrontal cortex (lPFC) is important for selective attention while ventral prefrontal cortex (vPFC) is involved in inhibiting a response. As noted before, anterior cingulate cortex (ACC) has been noted for maintaining attention to a stimulus. The amygdala is responsible for generating emotions. Mindfulness meditation is believed to be able to regulate negative thoughts and decrease emotional reactivity through these regions of the brain.

 

Changing your Mind, Emotions (and brain) via Mindfulness

Apart for the 12 step program of recovery, the other reasons for me still being alive today are my wife and mindfulness meditation.

All the periods I have struggled in my recovery have coincided with me not meditating properly.

I spent a number of years learning and practicing Vispassana meditation, learning the techniques in a fairly expert way at various 10 day retreats.
Vispassana is also referred to as insight meditation  and forms the basis of the western version of Mindfulness meditation developed by people like Jon Kabat Zin.
What meditation does to the brain has just started to be be fully explored in the last couple of decades.
I can only speak form my own experience. When I meditate I regulate my emotions than when I do not. My emotions seem more modulated, their intensity is manageable and they are much shorter in duration. My stress and distress levels are also greatly reduced and I have better facility for living in the moment, the now.
In the next few blogs I will be further exploring the use of meditation in the treatment of addictive behaviours.

I would urge every one in recovery to at least explore a meditation class to see if it can benefit their recovery too.

Life is much easier when I meditate, less so when I don’t.
The video below is an introduction to the work of  Jon Kabat Zin and The Centre for Mindfulness in Medicine who have been  a visionary force and global leader in mind-body medicine for thirty years and more, pioneering the integration of mindfulness meditation and other approaches based on mindfulness in traditional medicine and health through patient care, academic medical research and vocational training, and in society in general through various outreach initiatives and public service.

 

Appraising Alcohol-Related Thoughts

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.

 

 

Getting out of “self” via Prayer and meditation

When I first came into recovery I constantly heard the refrain about “getting out of self” – in fact steps 10-12 help one do so. Step 12, by helping others in recovery and step 11 which encourages prayer and mediation.

Can we get out of “self” by prayer and mediation? I will be dedicating a number of blogs to mediation so will just briefly consider prayer here.

In one study Franciscan nuns had their brains imaged via SPECT which looked at blood-flow in their brains while they were engaged in a type of mystic union called  ‘centring prayer’ which involves opening themselves to being in  the presence of God (and not in “self”).

In centring prayer the nuns had a “loss of usual forms of space  During prayer there was demonstrated increase in blood flow in the PFC inferior parietal and inferior frontal lobes  and a decreased flow in the superior parietal lobe, which is related to feelings of “self”.

Centering-prayer

I mention this type of meditation, also because it is a meditation/prayer that I do myself. Click here for more information on this wonderful prayer technique and how it is used by Fr Frank Keating and 12 step groups  –

I alternate with this and vispassana meditation

which also makes one feel like they are no longer in “self”, that the self is an ephemeral reality, always changing so not static, fixed – the self is thus an illusion in a sense as it is constantly changing. Regardless, of their different origins, both when practiced can transport one to a place seemingly beyond feelings of being in self. The self seems to blend into a widen sense of consciousness without parameters or boundaries such as limited by self.

In this state of being, one can view the fleeting images  of the self dispassionately, not being moved by them or reacting to them. Images of the self dissolve like into snow flakes in snow.

As we we will see in other blogs, meditation also reduces stress, improves neurotransmission in neurostransmitters effected by chronic addiction, e.g. GABA and strengthens neural regions of the brain that are very important to recovery.

The findings of these and other studies of prayer bear some similarity to studies in meditators such as on Tibetan Buddhist meditators (1) so I would not get hung up on the apparent religiosity  or non-religiosity of these ways of meditating. to me they achieve something very similar. It they work they Work!

The meditative and spiritual experiences are partly mediated through deactivation of the superior parietal lobe which normally helps to generate the normal sense of “self” (2)

Christianity_Jesus_meditating_golden_light

A  beautiful and enriching respite from self regulation and a profound sense of wholeness, and connection with something beyond self whatever that being beyond self is.  Therapeutically we have to somehow move beyond a reactionary self to a mindful one. From an emotional distressed one to a serene one. The brain is healthier after mediation than before.

 

As mentioned in other blogs, without emotional distress this condition can be quite dormant.

 

References

1.  Newberg, A. B., & Iversen, J. (2003). The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations. Medical hypotheses, 61(2), 282-291.

2. d’Aquili, E. G., & Newberg, A. B. (2000). The neuropsychology of aesthetic, spiritual, and mystical states. Zygon®, 35(1), 39-51.

From Hijacking the Brain

Maintaining emotional sobriety (and sanity) via Steps 10-12

When I have did my steps 4-7, noting the situations, the people, the institutions  that have caused persistent resentments in me, then examining what parts of my self have been affected,  I also, thanks to one sponsor was asked me to,  put down exactly what “sins” or defects of character I also experienced during these resentments. This jotting down of the exact sins I was in during these resentments  has proved to be very useful in my recovery ever since.  What I noticed was that I had the same array of sins or negatively (immaturely) expressed emotions in relation to all resentments regardless of the situation or the person I had the resentment, the same web of sins was weaved in every situation.  For me this shows clearly how I do not process and regulate my emotions properly, how it has a canalized form of reaction.

I have found increasingly in recovery that when I want someone or something to be the way I want it and it doesn’t go that way or I want something to stay a certain way or I believe someone is threatening to interfere or take away something that I have (when I am controlling basically), I find I respond by either being dependent or dominating of the person or situation. This is what Bill Wilson also found out in ten years or so of psycho-analysis with Harry Tiebout.

Immature emotional response I call this, followed by emotional reasoning. I rarely react in a balanced manner to these prompts. The situations invariably provoke a fear based response in me which somehow also leads to me suddenly becoming dishonesty in my thinking. It is as if this self centred fear as cut me off from the truthful sunlight of the spirit and I am suddenly in the dark shadow of dishonesty. In fact, according to Father Ralph honesty comes from the Greek to be at one with God funnily enough.

Then I feel shame as the result of my pride being hurt, which can lead to self pity it if I let it. I may also feel guilt. Then I may decide to strike back via being arrogant, impatient or intolerant, in behaviourally expressed sometimes as putting others down to elevate one self. Again immature emotional response. I am obviously also being self centred and selfish while in this process. I can also be envious or jealous of others in the midst of this for taking what I wanted or threatening what I have, like a child in the park or playground with friends. Other ways of fixing my feelings rear their heads and I can be gluttonous as a reaction or become greedy. Eat too much or go on a shopping frenzy. All instead of processing the emotions which are driving this behaviour I react, act out of distress based impulsivity. I can be so distressed that I can tend towards procrastination, which is sloth in five syllables. These sins or negatively expressed emotions truly grip me and these sins seem to  hunt in packs.

I found this fascinating when I first discovered this during my steps. It seemed to map the reactions of my heart when I react via resentments to the world. They describe accurately how I relate to the world especially when the world does not give me what I want or I have stood on it’s toes.

What else is this but an immature emotional reaction based not just on me being the same age as I started drinking  but also on the fact that the regions of the brain which govern emotional regulation in the brain of the alcoholic are immature, are smaller, not connected as well or do not function as well as healthy folk.  This is according to many academic studies and also seen in the brains of children of alcoholics, so our emotional brain regions may never have worked properly and thanks to years of alcohol abuse have gotten a whole lot worse.

When I am not in charge of my emotions they are in charge of me, in other words. They are controlling me and not the other way around. This type of emotional immaturity happens throughout the day sometimes. So there is no point waiting to the end of the day to do a step 10, to see when have I been fearful, dishonest, resentful or selfish. I have to do it continuously throughout the day to maintain my spiritual and emotional equilibrium, because it needs constant attention and maintenance, because I have no naturally maintained balance. I have to manage it. I impose homoestasis to an allostatic system. There is not naturally resting place. I am in charge of my serenity.

So I spot check continuously to ensure my emotional sobriety. Another word for sober is sane. I ike this because  while I am in emotional dysregulation or immaturity, I am far from sane. In fact, I am strangely deluded, distinct from from any reasonableness. I need to do my step ten to be restored to sanity.

The other problem with this emotional lability and dysregulation is that it send streams of distorted thinking into my head. I remember ringing my sponsor in early recovery, a few months in, with the startling relevation, to me,  that my thoughts were all leading me to a place of emotional pain. My emotional dysregulation leading to cognitive distortions which leads to further emotional dyregulation etc.  Spot the negative emotions underpinning these thoughts and they disappear like wispy evaporating clouds. This has similarities here with the practice of mindfulness.

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I do this all in a very simple way – I simply ask God to remove my sins, which are usually fear, dishonesty, pride, shame,guilt, self pity, leading to intolerance, arrogance and impatience and so on, warmed in a dendritic spreading across my heart and polluting of my mind with stinking thoughts.

It is interesting that in the 5th century a religious man called Evagrius Ponticus suggested that one gets rid of troublesome thoughts by pinpointing the negative emotions which were somehow underpin then and weight these thoughts in one’s mind, like anchors weighing down lassoed clouds. I do the same effectively.

I ask God to remove these emotions after I have first identified them and offered them to Him for help in removing. What I am doing, in a sense, is also identifying, labelling and letting go (processing) of the negative emotions that have kept these thunderous grey black clouds of thoughts in my head, and striking my heart with forked pain. I am asking God to help me do what I cannot do for myself it seems; namely emotional regulation.

People outside AA often wonder how this spiritual program can help people recover. As  I blogged about recently recently it does so, I believe partly, because it helps us learn how to practice identifying, labelling  and processing emotions (often by verbalising them to someone or via step 10)  in a way that is not only healthy and adaptive but in a way I was seemingly never able to do prior to coming into AA.  Or had never been taught to do.

I have learnt all these development skills not in my childhood but in my surrogate home of AA.  How many of us have come home in AA?