From a Drinking Problem to a Thinking Problem?


In early recovery I was amazed that some people in recovery said they never thought about alcohol after a few weeks into recovery. Or rather than thoughts related to alcohol rarely drifted across their minds.

I was alarmed by this as thoughts of alcohol rarely left my mind in early recovery.

They came to me rather than me actively going to retrieve thoughts about alcohol myself, consciously or deliberately.

I now realise that this was due to two main reasons.

First of all, fear of drinking is a distress which activates thoughts of alcohol as distress and negative emotions (and negative self perception/schema) seem to automatically retrieve thoughts of alcohol as there has been some habitual fusion of negative emotion with urge to drink in the alcoholic brain.

This is because my alcoholism resulted in compulsive drinking, i.e. my drinking was mainly to do with relieving distress, and that is what compulsion is, automatic behaviours that relieve distress.

Secondly and tied to this point, is that this compulsive drinking in itself is also linked to how chronic my drinking became.

I was completely addicted to alcohol at the end of my drinking so my alcoholism is very chronic.

In terms of neuroscience this means any distress activates a motoric part of my brain, the dorsal striatum,  a part of the brain that deals with stimulus response or automatic response the internal stimulus of distress, which activates an automatic approach or preparation of movement towards getting a drink.

This is expressed in terms of instruction in the brain as automatically occurring intrusive thoughts about drinking alcohol. This is also called an alcohol use schema because as a schema it is procedural way to deal with distress, i.e. have distress automatically deal with it by drinking.

I still find it fascinating that even automatic behaviours have thoughts that accompany them. Although nothing is completely automatic and we have a brief period of time in which to react or not.

By not reacting or acting on this thoughts they appear to lessen in intensity.  The more we do not react the less intense these thoughts become. Finding new ways to cope with distress lessens their grip on us too and eventually they practically disappear.

I have found I have to be very very distressed in recovery for thoughts of alcohol to come revisiting my mind.

This involuntary retrieval of drug related thoughts is thus a hallmark of addicted populations as it happens automatically, implicitly without you having to consciously and explicitly retrieve these thoughts and associated images from your memory banks. They just pop up without your permission.

The intensity of obsessive thoughts about alcohol is said to predict relapse rates (1), with addicts motivated to use drugs to “silence” obsessive thoughts (2).

The idea that abstinence automatically decreases alcohol-related thoughts is challenged by research (3) and supported by clinical observation that among abstinent alcohol abusers, alcohol-related thoughts and intrusions are the rule rather than exception (4).

Modell and colleagues (1992) highlighted symptomatic similarities between addiction and obsessive compulsive disorder with subjective craving for drugs or alcohol characterized as having obsessive elements. (eg, the compulsive drive to consume alcohol, recurrent and persistent thoughts about alcohol, and the struggle to control these drives and thoughts) similar to the thought patterns and behaviours of patients with obsessive-compulsive illness (5).

Modell et al. also point to the potential similarities in underlying neural pathways implicated in the two disorders, suggesting that they may share a similar aetiology.

The Obsessive Compulsive Drinking Scale (OCDS) implies that as the severity of this illness progresses, so does the intensity of the obsessive thoughts about alcohol and the compulsive behaviours to use alcohol.

Kranzler et al. (1999) showed relapsers who scored higher in ‘obsessions’ craving measured by the OCDS predicted relapse in the 12 months after treatment completion (6).

This may also be a reflection of addiction severity too! As addicts and alcoholics become more addictive brain imaging shows a shift in “reward processing” from the ventral striatum to the dorsal striatum.

The DS as stated above is in charge of more automatic, compulsive reaction.

This shift from VS to DS  may also be marked by an increased emergence of automatic thoughts, which the authors also suggested as the cognitive thoughts and images of automatized drug action schemata (2).

In fact, this is demonstrated by correlations indicating that dorsal striatum activation is lowest in participants with low OCDS scores. And vice versa, highers OCDS scores with increased DS activation.


This means, in simple terms, that more severe addiction may be associated with more intrusive/obsessive thoughts and less severe with less thoughts.  

So if you are in a meeting or in other treatment environments and someone in recovery says they never have any obsessive thoughts or intrusive thoughts consider the possibility that their addiction did not become as severe as your addiction?

Either way these thoughts are not your own but the automatic thoughts of addiction so be careful not to react to them.

They are frightening at first, but gradually becoming irritating and annoying before occurring less and less as recovery and your non reaction progress.

If you learn to habitually not to react emotionally to them they start to lose their grip and become less severely intrusive.

Most days I do not have any intrusive thoughts. This is because my recovery has progressed.

In many ways, recovery usually goes in the opposite direction to addiction.


1.. Bottlender, M., & Soyka, M. (2004). Impact of craving on alcohol relapse during, and 12 months following, outpatient treatment. Alcohol and Alcoholism39(4), 357-361.

2. 6. Tiffany, S. T. (1990). A cognitive model of drug urges and drug-use behavior: role of automatic and nonautomatic processes. Psychological review97(2), 147.

3. Caetano, R. (1985). Alcohol dependence and the need to drink: A compulsion? Psychological Medicine,
15(3), 463–469.

4. Hoyer, J., Hacker, J., & Lindenmeyer, J. (2007). Metacognition in alcohol abusers: How are alcohol-related intrusions appraised?. Cognitive Therapy and Research31(6), 817-831.

5. Modell, J. G., Glaser, F. B., Mountz, J. M., Schmaltz, S., & Cyr, L. (1992). Obsessive and compulsive characteristics of alcohol abuse and dependence: Quantification by a newly developed questionnaire.
Alcoholism: Clinical and Experimental Research, 16, 266-271.

6. Kranzler, H. R., Mulgrew, C. L., Modesto-Lowe, V. and Burleson, J. A.
(1999) Validity of the obsessive compulsive drinking scale (OCDS): Does craving predict drinking behavior? Alcoholism: Clinical and Experimental Research 23, 108–114.

7. Vollstädt‐Klein, S., Wichert, S., Rabinstein, J., Bühler, M., Klein, O., Ende, G., … & Mann, K. (2010). Initial, habitual and compulsive alcohol use is characterized by a shift of cue processing from ventral to dorsal striatum.Addiction105(10), 1741-1749.




One from the Heart

I have started a page on my other blog on the role of trauma and post traumatic stress disorder (PTSD) in addictive behaviours. This is a condition very close to my heart, literally.

For me PTSD is one “co-occurring” condition which has greatly contributed to  my overall alcoholism and the severity of my alcoholism.

It greatly contributed to my initial drinking especially via the effect alcohol had on me.

My traumatic incidents in early to middle childhood mixed with my insecure attachment to my mother meant I was always wary of people. I always left distinct from other people, even my immediate family.

I was wary and anxious, paranoid that people were thinking and talking about me. I never felt I could be myself around others even my best friends from childhood.

I was always holding something back, always left like I was protecting some invisible wound. I now believe that invisible wound was an emotional wound oozing shame.

Then I found alcohol. I felt I had come across the elixir of life.

It made me more me, a better me, a friendlier, warmer, less dismissive, less fearful me.

A me that got on great with others, effortlessly, even others I had not particularly liked before.

I became the life and soul of the party. I never classed alcohol as a drug because I thought drugs took you away from yourself whereas alcohol almost brought me home to myself.

I fitted my skin better and felt more comfortable in it after drinking alcohol. I loved that warm golden glow, the liquid bliss.

It made me go “phew!” and allowed me to escape myself.

A lot of this I believe was trauma mixed with insecure attachment mixed with an abnormal reaction to alcohol.

Trauma and insecure attachment alters the stress parts of the brain which heightens the effects of alcohol. It allowed me to connect with people. Gave me that “comfort and ease” which was illusive in everyday life.

In recovery this connection with people is essential too. We recover with the help of others, we learn the program via others.

We have to trust another person. So what happens when we lose that trust or never gained that trust. And don’t we have to trust in a God of our understanding?  Faith seems to  be about trust too?

The reality folks, is I don’t have a lot of trust period.

I love and trust my wife absolutely. After that…?

I have a lot of trust for various others such as some members of my family a few friends but generally my childhood has left me fearful  and mistrusting. All my immediate family and beyond love me but there is expressing love and there is demonstrating love, they are very different I find.

The worse thing is I also take over from God in many ways because I am not trusting enough to let Him get on with running the show.

This weekend proved to me I need additional help with trust, with my PTSD.

I mean I have come to the realisation I need outside help, professional help, EMDR help for my trauma – the two major issues I have in recovery and which act as my most likely relapse triggers scenarios are both to do with trauma.

This weekend I convinced myself that my unintentional actions had indirectly upset someone in recovery.

I had not real proof of this. I was kinda paranoid about it more than anything.

My head eventually went into a tail spin as a result of thinking I may inadvertently have caused harm in another recovering person. I was full of shame and anguish as my head immediately went into catastrophic thinking, thinking the worse, that his person might take it so bad that they may even relapse, and might even die!!

My thinking was constantly trying to convince me the worse case scenario was about to happen and it would be my fault. This is called PTSD thinking.

When I as a child something terrible happened and someone caused me trauma via a life threatening situation.

I blamed myself for this trauma, convinced myself that it was somehow my fault that this had happened. This was me dealing with my helpfulness and hopelessness in the face of extreme trauma. Trying to somehow control the uncontrollable.

Somehow I could have adverted this if I had acted differently? This is trauma in a nutshell, thinking one is guilty for something beyond one’s control.

In retrospect this seems insane to think I as a child could have any control over this incident. It had nothing to do with me.

Years later this incident (and others) had burnt into my brain and my heart. When I unintentionally hurt  (or otherwise think I have) who is vulnerable like someone in recovery I have this terrible reaction that they may relapse or die.

It is irrational but it is there and it has to be treated professionally.

Someone else’s adult life is not in my control, only my adult life is in my control (and I get a lot of help with that)!

In order to be in more in charge of this adult life I have to deal with that traumatised child, and via professional means.

The problem has become clear, it has become a broken record in my head. The scales have fallen from my eyes.

Action is required.

Recovery is about taking action, not thinking about taking action.

My PTSD and alcoholism got fused into one condition, although they each have different voices in my head.

There is other voices too – the trauma voice, the OCD voices, the insecure attachment voice/ the less than voice/ the not good enough voice – mostly voices of shame provoked by childhood trauma.

There is also the addict voice of the chronic malcontent, nothing is good enough and too much is never enough.

So there you have it, one definitely  from the heart.

That is where recovery has to happen ultimately.

This is where I hope the still voice of recovery will eventually reside.

Intolerance of Uncertainty and Distorted thinking About the Future

Another common area I feel addiction has with obsessive compulsive disorder (OCD) is intolerance of uncertainty (IU).

In fact it is also associated with post traumatic stress disorder (PTSD)- there is actually a high co-morbidity  (at least around 40% comorbidity) with addiction and PTSD and it is one so-called co-morbidity that does not naturally dissipate like some others months into recovery such as Generalized Anxiety Disorder or Depression (the 14% rates of depression and GAD in recovery people are the same as for a normal population) but remains and often makes the symptomatic manifestations of addiction more severe, especially the tendency to engage in “fight or flight” reactions” to uncertainty and ambiguity.

I will blog more on this co-morbidity in later blogs.

The study we cite today in fact looks at IU in addicts who have suffered trauma (1).

Intolerance of uncertainty is a term that refers to a certain way in which some people perceive and respond to situations that are uncertain, and it has been found to be associated with the experience of PTSD symptoms.

Individuals who respond to uncertain or unpredictable situations in this way are considered to have an intolerance of uncertainty. People who are intolerant of uncertainty may begin to experience constant worry about what could happen in the future.

One study (1) demonstrated that negative emotion regulation strategy and intolerance of uncertainty can significantly explain the craving beliefs in addicts (especially those who have suffered a traumatic experience).

This result is consistent with that of Asadi Majareh, Abedini, Porsharifi and Nilkokar (2013) and Nasiri Shushi (2011).

Nasiri Shushi (2011) revealed that there is a significant difference among substance abuse and intolerance of ambiguity and tolerance of uncertainty in two groups of drug abusers.

The other results of this study showed that addicts have less tolerance of ambiguity and tolerance of uncertainty. In the implications of these results it should be expressed that tolerance of uncertainty is associated with cognitive features and addicts when they are faced with difficult situations act in very low levels of performance in terms of decision-making.

Studies carried out to investigate the characteristics of drug abusers suggest that they use substances to regulate a wide range of cognitive events. Undoubtedly unpleasant emotional states, particularly anxiety, depression and stress in addicts are associated with the cognitive consequences.”

The authors suggest that “Drug abusers are not able to tolerate the unpleasant situations and uncertainty in the stressful conditions and their sensitivity leads to mental and emotional problems, therefore, they more turn to substances to regulate their own cognitive experiences (Spada, Nikčević, Moneta, Wells, 2007).

The results of a study showed that individuals with lower tolerance to ambiguity find the ambiguous situations threatening… Many of them may find the substance use in the face of difficulties the only solution and therefore are not able to think or consider other solutions.”

“….While, those with high tolerance to ambiguity in face of unpleasant situation and uncertainty try to find a good solution to get rid of this condition as soon as possible…those with a low tolerance to ambiguity and uncertainty cannot find an appropriate solution…and consequently turn to undetected compromise strategies such as the use of the substance (Ahmadi-Tahoorsoltani and Najafy, 2012).”

I can relate to this study. As I still suffer from intolerance of uncertainty (IU) in recovery, and some years into recovery, it is safe to assume that I suffered form IU in addictive addiction also, if not more so?

For me dealing with an uncertain future can still provoke anxiety. In recovery groups, like AA, we often hear sensible suggestions such as do not “project into the future”, which basically means do not attempt to control future events by thinking about them because this is not only impossible but also anxiety inducing.

The main reason why I think me and other alcoholics cannot project into the future and reasonably reflect and deliberate possible outcomes is because we may have an intrinsic impairment in this regard.

We, or some of us, especially those who have suffered trauma in earlier years, may have IU, like OCD sufferers.

The number of times I rang my sponsor in early recovery to help me with projecting into the future was legion.

Having some one else to talk and share with helps us recruit the pre frontal part of the brain so that we can either see the sense in not not projecting into an unknown future or get help in reasoning through what is likely to occur then.

The difficulty I had and can still have is that my projection into the future is still negatively biased, it is still prompted by distress based cognitive distortions.

As we will see in later blogs these types of cognitive distortions proliferate across a wide range of addictive disorders such as eating disorders which we consider in our next blog.

Among this cognitive distortions is catastrophic thinking which is also distressed based. I will also blog on this at a later date. My head can still run away with itself and convince itself about something which is patently not the case. It can persuade me that this is person or that is doing this or that for these reasons. All of which on reflection are usually nonsense. For me this is like a type of delusion. It is a part of my condition that my head can trick me into believing a whole range of ideas that are delusional. Sometimes I realise this only weeks and months later.

And some people wonder why we turn our lives over to a power greater than ourselves!!?

All this distorted thinking is distressed based.

Which means there is chronically excessive stress chemicals like glucocorticoids being synthesized and whirling around one’s brain. If you give some one enough glucocorticoid there is a good chance they will end up in psychosis. In the 1950s glucocorticoids were used as an anti depressant until people started ending up in psychosis.

Ultimately when we engage in this negatively biased and distorted thinking we have potentially taken the first steps in a walk to relapse because that will eventually seem a whole lot better idea than psychosis?

These cognitive distortions (and there are many)  may even be at the heart of this condition of addictive behaviour.

They are also the consequence of an impaired ability to process emotions (and to avoid) them and thus regulate them. This leads to a tendency to fight or flight which only leads to an heightening of this anxiety, and an increased proliferation of distressing thoughts about future possiblilities, all of which can seem to become more and more catastrophic. How much these thoughts are specifically linked to trauma has to be further explored by research.

For me IU and thought action fusion, especially in early recovery caused as many problems as so-called defects of character. The only difficulty is that they are not mentioned in AA literature, or the Big Book. That does not mean that they do not exist simply because they were not discussed as psychological manifestations commonly known to alcoholics in the 1930s.

They are however known now, which is why I write this blog. To add to our sum of knowledge about this strange illness…

That is not to say having a reassuring sponsor and taking inventory cannot deal with these issues. It is useful however to be aware of them and to realise that not every one in recovery has suffered traumatic incidents. Those who have can have additional requirements in terms of recovery.

I always found it comforting to have a sponsor in the early days who was there and who could also relate to the trauma side of my alcoholism and addiction. It helped soothe me when I could not self soothe. Helped me realise I was not alone in this, that I could recover like this other trauma sufferer could. We can do stuff we can’t do alone.

Ultimately with such an impaired ability to see things reasonably and to make decisions rationally it is imperative to evoke a cardinal recovery rule for me, Accept, Let Go and Let God.

The most profound way to regulated emotions. To Let it Be.

I also used a thing I borrowed and rephrased from Jeffey Schwartz, a leading expert on OCD, how suggested OCD sufferers when in the grip of some obsession to say to themselves “It’s not me it’s my OCD”.

So if your head gets into a downward spiral over some event your head distorts into being and likely to happen in the dark, threatening, Gothic never never world of the future, say to your self “It’s not me it’s my illness.”

In the UK it is called the fanatic in the attic.

It does the thinking for you, if you allow it. Guaranteed.




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.



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.