Your Heart is in Your Own Hands!

Easy Does it…on yourself!

I give myself a hard time, it is a habitual response I have when things go “wrong” or don’t go my way. One of the first words that pop into my head is “idiot!”. It is a lack of distress tolerance borne out of a reducee ability to deal with fristration. This appears in the brain as a distress signal prompting an automatic response rather than an evaluative response. A reaction rather than a reflective action.

It is the consequence of a distress state and in itself distressing. It can also be distressing for those around me. It seems like perfectionism which is also a product of distress.

I believe it is also the product of my upbringing, trauma and insecure attachment which has led to a low self esteem and a lack of self soothing combined with the reality that chronic alcoholism leaves us with an allostatic brain, i.e. the stress systems in the brain are impaired.

It is only recently in recovery, after some years of recovery, that I have started to feel real compassion for myself as someone recovering from alcoholism and various addictive behaviours.

When I look at photos of me in active addiction and in the first years of recovery my heart goes out to that younger, more distressed version of myself.

Compassion is a Latin word that which can be translated as meaning suffer together with. It can also be described as a feeling of empathy for the suffering of other people.

I have always found it easier to have compassion for others more than myself. I practiced Buddhist mediation for a number of years and have often felt at one with the world and it’s people. I have nonetheless always struggled with being compassionate towards myself.

I have somehow found myself undeserving of a compassionate attitude towards my own struggles. I know my God loves me but I have often felt it difficult to love this person that God loves.

Again, this could be a legacy of how ambivalent attachment and how my mother saw and reacted. I sometimes have more time and consideration for others rather than myself.

Ultimately however, how react to the world is a function of how I treat myself and the attitudes I have collected in my negative self schema or the neural responses ingrained in my brain over decades. As the image below shows, my heart is in my own hands, by this I mean the distress I experience in life is the consequence of my own attitudes towards me and my fellow human beings.

I can change my brain and behaviour via neuroplasticity by behaving differently towards myself!

Here we look at one study on self compassion in relation to those who have alcohol use disorders.

It will be a first in a series of blogs about the role of the heart in addiction and recovery.

Why the heart?

I thought this blog was about neuroscience and the brain which is the head? Not completely true. The heart has a role to play in stress and emotion regulation and in craving and helps prompt neuro transmission of various brain chemicals. The heart has a reciprocal relationship with the brain as we will see in later blogs.

We have had a neuroscientific “decade of the brain” so perhaps we need a “decade of the heart”? As we say in recovery circles, recovery is a journey from the head to the heart, which is so true whatever way you care to look at it.

This study (1) looked at “Self-Compassion Amongst Clients with Problematic Alcohol Use”.

“Self-compassion is a topic of growing research interest and is represented by six facets including selfkindness, self-judgement, mindfulness, over-identification, common humanity and isolation. Recent research interest has begun to examine the use of self-focused compassion and mindfulness as a way of alleviating the distress associated with psychological disorders.

Recent research interest has begun to examine the use of self-focused compassion and mindfulness as a way of alleviating the distress associated with psychological disorders.

The self medication hypothesis (Khantzian 2003) suggests that substance addiction functions to self-soothe and to modulate the effects of distressful psychological states (Suh et al. 2008).

Other research has found that experiencing stressful life events significantly predicts the amount and frequency of alcohol consumed (Dawson et al. 2005) and the onset of alcohol dependence (Lloyd and Turner 2008) indicating that stress plays a key part in the development of alcohol use disorders.

Low self-esteem has also been found to pose a high risk for substance abuse (Baumeister 1993; Bushman and Baumeister 1998) and alcohol dependence (Chaudhury et al. 2010,).

Self-compassion does not involve an unrealistic self view, it should be stable unlike self-esteem, which often fluctuates (Kernis et al. 1993). Self-compassion involves being kind and understanding to oneself, awareness that pain and failures are unavoidable common experiences among humanity and a balanced awareness of one’s emotions (Neff, Rude and Kirkpatrick 2007).

Kelly et al. (2010) suggested that the trait of self-compassion promotes adaptive functioning and appears to provide a buffer from emotional distress. Neff (2003a) has also reported that self-compassion was strongly inversely related to psychological health such as depression, anxiety, rumination, thought suppression, self-criticism and neurotic perfectionism. Neff, Kirkpatrick and Rude (2007) found that increased self compassion resulted in reduced depression, anxiety, thought suppression, rumination and self-criticism.

Neff (2003a, b) suggests that there are three main components to self-compassion including self-kindness versus self-judgement, common humanity versus isolation and mindfulness versus over-identification. Self-kindness is being kind to oneself rather than judging harshly or being self– critical. Common humanity is viewing one’s experiences as part of larger human experience and not viewing them as isolating or separating. Mindfulness is paying attention in a particular way involving a conscious direction of awareness (Kabat-Zinn 1994). Neff (2003a, b) describes mindfulness as taking a balanced approach to negative emotions and neither suppressing not exaggerating emotions.

The self-kindness facet represents an alternative to rumination, blaming, self-condemnation and self-criticism.

Common humanity appears to be related to general well-being and Mindfulness represents a state of mental balance with a stance of composure towards difficult and painful thoughts and feelings, therefore suggesting mindfulness may play an important role in adaptive and maladaptive emotion regulation (Van Dam et al. 2011). Self-compassion can be thought of a coping strategy that assists one to remain emotionally balanced when in a stressful situation (Rendon 2007) and provides emotional resilience (Neff 2011).

This study is among the first to examine the self-compassion of people with alcohol dependence, who were currently using alcohol at hazardous levels.

The results indicated that the (alcohol dependnet) participants in this study were significantly lower in mindfulness, common humanity and self-kindness than what would be expected in the general population.

Participants were also significantly higher in over-identification, perceived isolation and self judgement than the norms for general population.

Stress was found to be significantly negatively correlated to the overall score for self-compassion (e.g., the higher the level of stress reported by the individual, the lower the self compassion). Stressed individuals judged themselves more harshly, felt more isolated from others and felt overly responsible for negative events that occurred in their lives.

The results ,taken together, indicated that participants in this study reported a significant increase in self-compassion, mindfulness, common humanity and self-kindness between baseline and 15-week follow-up and involvement in treatment with a Drug and Alcohol Clinical Service.

Additionally, there was a significant decrease in self-judgement, isolation and over-identification. The reduction in self-judgement and isolation was such that at the 15-week follow-up stage, participant scores for these subscales were equivalent to what other research has suggested is representative of the general population.

The change in participant’s stress was found to be significantly associated with self- kindness, self-judgement, isolation and the number of sessions in which meditative practice (which may have incorporated mindfulness-based approaches) was used by clinicians. These results provide support for the notion that significant increases in participant’s overall self-compassion, self-kindness, mindfulness and common humanity can be observed in people with alcohol dependence over a 3-month treatment period.”

This study is useful in that it shows how the emotional distress at the heart of addiction, itself a manifestation of altered stress responding or heightened stress responses in alcoholics, was greatly reduced by self compassion or simply have a more compassionate view of one’s suffering.

It is in taming the distress of the heart that lowers stress chemicals swirling around the brain and which influences our subsequent attitudes and behaviour.

Recovery is in the heart, in the now, in not reacting but acting. Even if that action is just of observing, paying attention to, having compassion for.

After years of being our own worst enemy, perhaps recovery is the process of becoming our own best friend.

References

1. Brooks, M., Kay-Lambkin, F., Bowman, J., & Childs, S. (2012). Self-compassion amongst clients with problematic alcohol use. Mindfulness, 3(4), 308-317.

Forgiving Others is the Number One Healer!?

“Resentment is the “number one” offender. It destroys more alcoholics than anything else… In dealing with resentments, we set them on paper. We listed people, institutions or principles with whom we were angry… The first thing apparent was that this world and its people were often quite wrong. To conclude that others were wrong was as far as most of us ever got. The usual outcome was that people continued to wrong us and we stayed sore. Sometimes it was remorse and then we were sore at ourselves. But the more we fought and tried to have our own way, the worse matters got…It is plain that a life which includes deep resentment leads only to futility and unhappiness…If we were to live, we had to be free of anger. The grouch and the brainstorm were not for us. They may be the dubious luxury of normal men, but for alcoholics these things are poison…We saw that these resentments must be mastered, but how?… (1)”

Later, p.77, it suggests “a helpful and forgiving spirit.”

In the 12 Steps and 12 Traditions, p.78, in reference to step 8 it suggests “why shouldn’t we start out by forgiving them, one and all?

These truncated passages from the Big Book (1) and the 12 and 12 (3) illustrates how resentments cause relapse and that they need to by treated with the antidote of forgiveness.

We suggest also that the myriad of resentments which swirl around our minds in early recovery are also negative emotions unprocessed and thus unregulated from the past. They continually haunt us because we have not put them “to bed” in long term memory.

We have not dealt with them, by clearly identifying, labelling, sharing via verbalising them with others and then by letting go of them via forgiveness. “Letting go” is another emotional regulatory strategy that healthy people use.

res images (42)

Instead of constantly holding on to memories and incidents from the past, endlessly ruminating on them we maturely face up to them and consign them to the past.

We were thus interested in a study which was not using 12 step recovery but which came to the same conclusion but via another route (2).

“Anger and related emotions have been identified as triggers in substance use. Forgiveness therapy (FT) targets anger, anxiety, and depression as foci of treatment. Fourteen patients with substance dependence from a local residential treatment facility were randomly assigned to and completed either 12 approximately twice-weekly sessions of individual FT or 12 approximately twice-weekly sessions of an alternative individual treatment based. Participants who completed FT had significantly more improvement in total and trait anger, depression, total and trait anxiety, self-esteem, forgiveness, and vulnerability to drug use than did the alternative treatment group. Most benefits of FT remained significant at 4-month follow-up.

The levels of anger and violence observed among alcohol and other substance abusers are far higher than the levels found in the general population.

Alcohol and other substance abusers administered the State-Trait Anger Expression Inventory typically have been shown to have higher state and trait anger, to be more likely to express anger to others, and to have less control of their anger.

Reducing levels of anger and its related emotions is now seen as an important feature of recovery programs. For example, according to the Project Match 12-step facilitation therapy manual, “Anger and resentment are pivotal emotions for most recovering alcoholics. Anger that evokes anxiety drives the alcoholic to drink in order to anesthetize it. Resentment, which comes from unexpressed (denied) anger, represents a constant threat to sobriety for the same reason” (Nowinski, Baker, & Carroll, 1999, p. 83).

Marlatt (1985) emphasized the importance of anger and frustration as triggers for relapse in both the intrapersonal and interpersonal domains. He noted that 29% of relapses are related to intrapersonal frustration and anger and that 16% are related to interpersonal conflict and associated anger and frustration.

Litt, Cooney, and Morse (2000) reported that those alcoholics who had urges to use after treatment had higher degrees of alcohol dependence, anxiety, and trait anger than those without such urges.

Forgiveness is an important way to resolve anger and restore hope (Enright & Fitzgibbons, 2000). In helping clients move toward forgiveness, it is essential to differentiate forgiving from condoning, pardoning, reconciling, or forgetting.

Forgiveness is a personal decision to give up resentment and to respond with beneficence toward the person responsible for a severe injustice that caused deep, lasting hurt. FT helps the wronged person examine the injustice, consider forgiveness as an option, make a decision to forgive or not, and learn the skills to forgive.

Findings – Our clients came to the program with trait anxiety and trait anger scores substantially above the published norms for adults; after treatment, however, FT participants exhibited scores comparable to the average. In other words, the treatment did not lead simply to a change in anxiety and anger (particularly the reportedly more stable trait anxiety) but to a change toward normal profiles. In contrast, patients in the alternative treatment condition had anxiety scores well above average, especially in terms of trait anxiety, which showed little change at post test and only minimal improvement at follow-up.

FT did not focus on drug vulnerabilities, whereas the alternative treatment did. Urges to use substances are not necessary for relapse, they are important indicators.

FT treatment is centered more on clients’ thoughts, feelings, and behaviors about someone other than themselves: an offender who hurt them deeply and unfairly. In FT, a potential reason for substance use is examined, that of avoiding painful memories of betrayal, violence, or abuse. When patients are allowed to heal, their motivation to abuse substances may be substantially reduced…(it) is worth considering as a way to address core issues of emotional pain.

resentment

This can lead to a reduction in negative emotions and increases in self-esteem and forgiveness… it moves to the heart of the matter for some clients. Deep hurts borne out of unfair treatment seem to play a part in substance use and abuse. Even when clients have many people to forgive…we find that they seem to know which person is most crucial to forgive first before moving to other offenders. Substance use, from this perspective, is a symptom of underlying resentments and related emotional disruptions.

If we fail to realize this, we may end up treating only symptoms rather than underlying causes. ”

This process seems practically the same as the inventory of Step 4 and the forgiveness implicit to steps 8 and 9. This study also highlights that we through forgiveness we actually tackle the underlying condition of emotional dysregulation. It is this emotion dysregulation (or spiritual disease) which appears to drive addiction so needs to be fundamentally addressed. By addressing these issues via the steps especially step 4 we begin to see how it works!

It was interesting that forgiveness led to higher self esteem, as if being tied to the past was akin to being tied to a former negative self schema, that people from our pained past did actually have the power to control us! Especially how we feel about ourselves. We change how we feel about ourselves and our past by simply forgiving, it is such a powerful tool in recovery.

Importantly by viewing studies like this (2) we get beyond negative views of 12 step recovery to show that the recovery program’s effectiveness is clearly highlighted by the success of other psychological treatments getting the same positive results by using exactly the same strategies.

12 step groups provide a battery of the most profoundly effective psychological therapies for addiction ever contained within one treatment philosophy.

Don’t we all need to re-appraise how we see 12 step recovery?

Can’t we all benefit from stepping to one side and looking via a different angle to see why 12 step recovery is effective?

Reference

1. Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Services.

2. Lin, W. F., Mack, D., Enright, R. D., Krahn, D., & Baskin, T. W. (2004). Effects of forgiveness therapy on anger, mood, and vulnerability to substance use among inpatient substance-dependent clients. Journal of consulting and clinical psychology, 72(6), 1114.

3. Twelve steps and twelve traditions. (1989). New York, NY: Alcoholics Anonymous World Services

What recovers in Recovery? – Cognitive Control over emotions?

In recent blogs we have called for an increase in research into the neurobiology of recovery to add to the extensive research already published on the neurobiology of the addiction cycle.

There has been extensive research into the neurobiology of addiction, most of this has focused on reward and motivation networks of the brain. In effect this suggests there is a pathological wanting in addicts, an excessive motivation towards drug taking over all other rewarding activities.

This view does not fully consider that this pathological wanting is in itself a product of dysregulated stress systems in the brain, many the product of neglect, abuse and maltreatment in childhood. These stress factors are also reflective of the role of emotional distress in the addiction cycle . This distress is we feel a product of the emotion processing and regulation deficits commonly seen in all addictive behaviours such as alcohol and substance addiction, eating and gambling disorders and sex addiction etc (and often reflective of childhood maltreatment).

In fact , this emotion processing and regulation deficit is also apparent in certain children of alcoholics and may be a vulnerability to later alcoholism as these children demonstrate a deficit in impulsivity (common to alcoholics and addicts) and a decision making profile based on choosing now over later (short term gains based) and which recruits more subcortical and motor expressive (compulsive) parts of the brain rather than cortical and reflective/evaluative parts of the brain.

This means they make decisions to alleviate the distress of decisions (as undifferentiated emotions appear to be distressing) not via evaluative processes). This has obvious consequence for decision making over a life span.

This emotion dysregulation is also seen in active addicts and alcoholics and at the endpoint of addiction there is a fairly complete reliance of this compulsive decision making profile, which begs the question, does the decision making deficits seen in at risk children simply get worse in the addiction cycle via the neuro toxic effects of substance abuse?

This emotion (and stress) dysregulation also potentiates reward (makes things more rewarding) so alcohol is seen as more stimulating than for non risk children. This vulnerability may lead to the need to regulate, especially negative, emotions ( and low self esteem ) via the stimulating and highly rewarding effects of alcohol make perpetuate the addiction cycle to it’s chronic endpoint where chronic emotional distress acts as a compulsive stimulus to the responding of chronic alcohol and drug use.

This emotion dysregulation also seems to play a huge part in relapse – so it begs the question does this emotion regulation improve in time via recovery, particularly long term recovery?

In the next two blogs we look at how the emotion regulation areas of the brain become reinforced, strengthened by the process of recovery or in other words we appear to develop the brain capacity for controlling and regulating our emotions more adaptively and this reduces the stress/distress which often prompts relapse.

Personally, I can wholeheartedly say, that the one main aspect I have developed in my recovery has been the awareness and skills in regulating/controlling emotions. Via recovery I have learnt to identify, label, describe by verbalising and sharing with others how I feel. This processes and regulates the emotions that used to cause me so much distress.

I have also developed a more acute awareness of the the emotional expression and needs of yours. These were previously aspects of my life which were completely lacking and frustrating/confusing as a result.

By emotionally engaging in with the world, by becoming more emotionally literate, I can converse with the world in a way that was previously beyond my capabilities.

The research we look at in the next two blogs asks the question – is cognitive control over emotions, lacking in active addiction, one of the main brain functions that improve in recovery?

A core aspect of alcohol dependence is poor regulation of behavior and emotion.

Alcohol dependent individuals show an inability to manage the appropriate experience and expression of emotion (e.g., extremes in emotional responsiveness to social situations, negative affect, mood swings) (1,2). Dysfunctional emotion regulation has been considered a primary trigger for relapse (1,3) and has been associated with prefrontal dysfunction.

While current alcohol dependence is associated with exaggerated bottom-up (sub-cortical) and compromised top-down (prefrontal cortex) neural network functioning, there is evidence suggesting that abstinent individuals may have overcome these dysfunctional patterns of network functioning (4) .

Neuro-imaging studies showing chronic alcohol abuse to be associated with stress neuroadaptations in the medial prefrontal and anterior cingulate regions of the brain (5 ), which are strongly implicated in the self-regulation of emotion and behavioral self-control (6).

One study (2) looking at how emotional dysregulation related to relapse, showed compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence.

Another study (7) which did not look specifically at emotional regulation but rather on the recovering of prefrontal areas of the brain known to be involved also in the inhibition of impulsive behaviour and emotional regulation showed that differences between the short- and long-abstinence groups in the patterns of functional recruitment suggest different cognitive control demands at different stages in abstinence.

In one study, the long-term abstinent group (n=9) had not consumed cocaine for on average 69 weeks, the short-term abstinent (SA) group (n=9) had an average 0f 2.4 weeks.

Relative to controls, abstinent cocaine abusers have been shown to have reduced metabolism in left anterior cingulate cortex (ACC) and right dorsolateral prefrontal cortex (DLPFC), and greater activation in right ACC.

In this study the abstinent groups of cocaine addicts showed more elevated activity in the DLPFC ; a finding that has also been observed in abstinent marijuana users (8).

The elevation of frontal activity also appears to undergo a shift from the left to right hemisphere over the course of abstinence. The right is used more in processing (labelling/identifying) of emotion.

Furthermore, the left inferior frontal gyrus (IFG) has recently been shown to be important for response inhibition (9) and in a task similar to that described here, older adults have been shown to rely more on left PFC (10). Activity observed in these regions is therefore likely to be response inhibition related.

The reliance of the SA group on this region suggests that early in abstinence users may adopt an alternative cognitive strategy in that they may recruit the LIFG in a manner akin to children and older adults to achieve behavioral results similar to the other groups.

In longer, prolonged abstinence a pattern topographically typical of normal, healthy controls may emerge.

In short-term abstinence there was an increased inhibition-related dorsolateral and inferior frontal activity indicative of the need for increased inhibitory control over behaviour, while long-term abstinence showed increased error-related ACC activity indicative of heightened behavioral monitoring.

The results suggest that the improvements in prefrontal systems that underlie cognitive control functions may be an important characteristic of successful long-term abstinence.

Another study (11) noted the loss of grey matter in alcoholism that last from 6–9 months to more than a year or, in some reports, up to at least 6 years following abstinence (12 -14).

It has been suggested cocaine abuse blunts responses in regions important to emotional regulation (15)

Given that emotional reactivity has been implicated as a factor in vulnerability to drug abuse (16) this may be a preexisting factor that increased the likelihood of the development and prolonging of drug abuse

If addiction can be characterized as a loss of self-directed volitional control (17), then abstinence (recovery) and its maintenance may be characterized by a reassertion of these aspects of executive function (18) as cocaine use has been shown to reduce grey matter in brain regions critical to executive function, such as the anterior cingulate, lateral prefrontal, orbitofrontal and insular cortices (19-24) .

The group of abstinent cocaine addicts (11) reported here show elevations in (increased) grey matter in abstinence exceeded those of the healthy control in this study after 36 weeks, on average, of abstinence .

One possible explanation for this is that abstinence may require reassertion of cognitive control and behavior monitoring that is diminished during current cocaine dependence.

Reassertion of behavioral control may produce a expansion (25) in grey matter in regions such as the anterior insula, anterior cingulate, cerebellum, and dorsolateral prefrontal cortex .

All brain regions implicated in the processing and regulating of emotion.

References

1. Berking M, Margraf M, Ebert D, Wupperman P, Hofmann SG, Junghanns K. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. J Consult Clin Psychol. 2011;79:307–318.

2. Fox HC, Hong KA, Sinha R. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Alcohol Clin Exp Res. 2008;33:388–394.

3..Cooper ML, Frone MR, Russell M, Mudar P. Drinking to regulate positive and negative emotions: A motivational model of alcohol use. J Pers Soc Psychol. 1995;69:990

4. Camchong, J., Stenger, A., & Fein, G. (2013). Resting‐State Synchrony in Long‐Term Abstinent Alcoholics. Alcoholism: Clinical and Experimental Research, 37(1), 75-85.

5. Sinha, R., & Li, C. S. (2007). Imaging stress- and cue-induced drug and alcohol craving: Association with relapse and clinical
implications. Drug and Alcohol Review, 26(1), 25−31.

6. Beauregard, M., Lévesque, J., & Bourgouin, P. (2001). Neural correlates of conscious self-regulation of emotion. Journal of
Neuroscience, 21(18), RC165

7. Connolly, C. G., Foxe, J. J., Nierenberg, J., Shpaner, M., & Garavan, H. (2012). The neurobiology of cognitive control in successful cocaine abstinence. Drug and alcohol dependence, 121(1), 45-53.

8. Tapert SF, Schweinsburg AD, Drummond SP, Paulus MP, Brown SA, Yang TT, Frank LR. Functional MRI of inhibitory processing in abstinent adolescent marijuana users.Psychopharmacology (Berl.) 2007;194:173–183.[PMC free article]

9. Swick D, Ashley V, Turken AU. Left inferior frontal gyrus is critical for response inhibition. BMC Neurosci. 2008;9:102.[PMC free article]

10. Garavan H, Hester R, Murphy K, Fassbender C, Kelly C. Individual differences in the functional neuroanatomy of inhibitory control. Brain Res. 2006;1105:130–142

11. Connolly, C. G., Bell, R. P., Foxe, J. J., & Garavan, H. (2013). Dissociated grey matter changes with prolonged addiction and extended abstinence in cocaine users. PloS one, 8(3), e59645.

12. Chanraud S, Pitel A-L, Rohlfing T, Pfefferbaum A, Sullivan EV (2010) Dual Tasking and Working Memory in Alcoholism: Relation to Frontocerebellar Circuitry. Neuropsychopharmacol 35: 1868–1878 doi:10.1038/npp.2010.56.

View Article

13. Wobrock T, Falkai P, Schneider-Axmann T, Frommann N, Woelwer W, et al. (2009) Effects of abstinence on brain morphology in alcoholism. Eur Arch Psy Clin N 259: 143–150 doi:10.1007/s00406-008-0846-3.

View Article

14. Makris N, Oscar-Berman M, Jaffin SK, Hodge SM, Kennedy DN, et al. (2008) Decreased volume of the brain reward system in alcoholism. Biol Psychiatry 64: 192–202 doi:10.1016/j.biopsych.2008.01.018.

View Article

15, Bolla K, Ernst M, Kiehl K, Mouratidis M, Eldreth D, et al. (2004) Prefrontal cortical dysfunction in abstinent cocaine abusers. J Neuropsychiatry Clin Neurosci 16: 456–464 doi:10.1176/appi.neuropsych.16.4.456.

View Article

16. Piazza PV, Maccari S, Deminière JM, Le Moal M, Mormède P, et al. (1991) Corticosterone levels determine individual vulnerability to amphetamine self-administration. Proc Natl Acad Sci USA 88: 2088–2092. doi: 10.1073/pnas.88.6.2088

View Article

17. Goldstein RZ, Volkow ND (2002) Drug addiction and its underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 159: 1642–1652. doi: 10.1176/appi.ajp.159.10.1642

View Article

18. Connolly CG, Foxe JJ, Nierenberg J, Shpaner M, Garavan H (2012) The neurobiology of cognitive control in successful cocaine abstinence. Drug Alcohol Depend 121: 45–53 doi:10.1016/j.drugalcdep.2011.08.007.

View Article

19. Liu X, Matochik JA, Cadet JL, London ED (1998) Smaller volume of prefrontal lobe in polysubstance abusers: a magnetic resonance imaging study. Neuropsychopharmacol 18: 243–252 doi:10.1016/S0893-133X(97)00143-7.

View Article

20. Bartzokis G, Beckson M, Lu P, Nuechterlein K, Edwards N, et al. (2001) Age-related changes in frontal and temporal lobe volumes in men – A magnetic resonance imaging study. Arch Gen Psychiatry 58: 461–465. doi: 10.1001/archpsyc.58.5.461

View Article

21. Franklin TR, Acton PD, Maldjian JA, Gray JD, Croft JR, et al. (2002) Decreased gray matter concentration in the insular, orbitofrontal, cingulate, and temporal cortices of cocaine patients. Biol Psychiatry 51: 134–142. doi: 10.1016/s0006-3223(01)01269-0

View Article

22. Matochik JA, London ED, Eldreth DA, Cadet J-L, Bolla KI (2003) Frontal cortical tissue composition in abstinent cocaine abusers: a magnetic resonance imaging study. NeuroImage 19: 1095–1102. doi: 10.1016/s1053-8119(03)00244-1

View Article

23. Lim KO, Wozniak JR, Mueller BA, Franc DT, Specker SM, et al. (2008) Brain macrostructural and microstructural abnormalities in cocaine dependence. Drug Alcohol Depend 92: 164–172 doi:10.1016/j.drugalcdep.2007.07.019.

View Article

24. Ersche KD, Barnes A, Jones PS, Morein-Zamir S, Robbins TW, et al. (2011) Abnormal structure of frontostriatal brain systems is associated with aspects of impulsivity and compulsivity in cocaine dependence. Brain 134: 2013–2024 doi:10.1093/brain/awr138.

View Article

25. Ilg R, Wohlschlaeger AM, Gaser C, Liebau Y, Dauner R, et al. (2008) Gray matter increase induced by practice correlates with task-specific activation: A combined functional and morphometric magnetic resonance Imaging study. J Neurosci 28: 4210–4215 doi:10.1523/JNEUROSCI.5722-07.2008.

View Article

Recovery: can you feel “Better than Well!”?

Degrees of Recovery?

Better than Well – I love this concept and reality and relate to it myself. This is a reality for many recovery people who feel they had an amplified recovery or in simple terms, people who got better than well!

This people did not simply have the pathology of addiction extracted from their lives. These people did not only go on to recover but went on to live incredibly rich lives in terms of the quality of their lives and the service to their communities.

These are people who talk about addiction and recovery as a blessing! These are individuals who suggest that what they achieved after recovery was not in spite of their recovery but because of the strength they drew out from their addiction recovery.

Their fulfillment of life was greater perhaps than if they had never been addicted and suffered from addiction. Their recovery from addiction gave them a meaning that they may not have had, if they had not been addicts.

I believe I am 25% smarter in recovery (can be proved in terms of exam grades), I understand people now in recovery, I am a more empathetic human being in recovery. My life is immeasurably better than it was before. I have a contentment unknown to me previously. A peace of mind I thought impossible.

My roots grasp a new soil! I feel like I have been reborn.

This kinda fits in also with Bill White’s description of recovery as a method of transcending the self or “getting out of self”. This idea and reality relates to various previous blogs on why we need to live “outside” self regulation” systems of the brain as these appear to have been hijacked by the effects of drug and behavioural addiction.

One way of doing this is by using our self in a different way, to use self to serve others. This way we can use our stories to help others in recovery and improve our own self regulation as it strengthens areas of the brain like the ventromedial pre frontal cortex used in self referential information and emotional regulation.

We can get reward not from drugs or behaviour but by helping others which supplants the depleted dopamine, natural opioids, oxytocin of increased attachment and bonding and the serotonin of well being. It improves our orbitofrontal cortex as we become more empathetic, begin to become emotional literate, reading emotional expression in other’s faces. It reduces stress and distress. Lowers glutamate and increases GABA. We become less fearful and more serene.

Helping others helps us so profoundly. It changes the neurobiology and hence neuroplasticity of our brains.

The video ends with a brief look at the “hot flash” spiritual awakening of recovery a la Bill Wilson and the slower more incremental or “educational” variety of spiritual awakening. For me, spiritual awakening can mean emotional catharsis, sometimes so dramatic that it immediately changes how we think and feel about the world and our place in it or the more experiential, where our views and attitudes to the world gradually change. Each leads to the same goal of long term recovery. The latter being, by far, the most common.

Interpersonal Factors in Relapse – Part 1

“Living life on life’s terms” essentially means living with others.

The majority of relapses I have witnessed have been due to interpersonal factors, e.g. arguments at home with family and loved ones, not being able to cope with relationship breakdowns, perceived rejection by loved ones.

Research itself shows that the majority of relapses are caused by an inability to deal with distress (negative emotions) especially in the context of interpersonal relationship.

While neurobiological accounts of addiction suggest the main cause of relapse is due to responding to alcohol or drug cues, an effect heightened in the presence of stress, it does not allow for the main arena in which this stress/distress occurs i.e. with loved ones or people we are having relationships with, or thwarted relationships . Living with others can be difficult for alcoholics and addicts especially as we often found ourselves living in social isolation from others at the endpoint of our addictions. Especially as many of us, if not the majority, have insecure attachment styles.

So why do addicts and alcoholics and others suffering from a range of addictive behaviours from sex to eating disorders have difficulties with coping with relationships with others?

This point certainly needs addressing as it appears to be a major determinant of relapse!

I do not know about you but there are certain parts of my “personality” that I do not like.

I believe these are mainly do to my insecure attachment – these include the tendency at times to be dismissive, to be needy, look at “me, me me!”, to be wary of others and their motives and to be very rejection sensitive. I have major issues with rejection from others and guard against it. I am also taking action in my personal life to deal with these issues more adaptively, more healthily.

It appears to me increasingly that part of my alcoholism is rooted not only in the genes I inherited from both my parents but in the fertile ground of insecure attachment and childhood maltreatment.

So have any researchers considered these factors? Not many it has to be said but this study (1) certainly did an it is one o the best and most comprehensive studies I have read in relation to these issues.

So in short, is there a sequelae between insecure attachment, rejection issues, low self esteem, interpersonal relationship difficulties and relapse?

“In this article, we review the literature on interpersonal stress and rejection sensitivity and examine how these factors increase the risk of relapse in individuals with alcohol or drug dependence…(to) provide insight into the role of interpersonal stress as a powerful and oftentimes destructive factor that affects individuals in recovery from substance dependence.

Relapse following treatment for alcohol or drug use disorders is a common problem. Studies indicate that 50–70% of patients are unable to remain abstinent during the first year following addiction treatment (1)…(we) review the constructs of rejection sensitivity, insecure attachment, and low self-esteem, integrating these traits and considering how they influence relapse vulnerability…

Next (blog 2), we review the constructs of expressed emotion, perceived criticism, and marital distress, examining how these negative social contexts can contribute to unfavorable outcomes among individuals recovering from substance dependence.

We conclude with the testable hypothesis that there exists a subgroup of substance-dependent individuals with high trait rejection sensitivity that is particularly vulnerable to relapse in the context of a harsh and critical interpersonal milieu. We propose that high trait rejection sensitivity is a unique risk factor for relapse that can inform research in this area.

rejection images (40)

Intrapersonal Vulnerabilities to Addiction and Relapse

Interpersonal stressors are regarded by many as the one of the most severe forms of stress and can affect an individual’s cognition and behavior. Interpersonal stress is a well-known precipitant of maladaptive drug and alcohol use…we will review the extant literature on the related constructs of rejection sensitivity, insecure adult attachment style, and low implicit and explicit self-esteem. Although not identical, all of these constructs contribute to an individual’s compromised sense of self and an inability to interact comfortably and effectively with others. Further, they all share a propensity to increase an individual’s vulnerability to addiction.

Rejection Sensitivity

Rejection sensitivity (RS) is defined as the disposition to anxiously expect, readily perceive and react intensely to rejection. High-RS individuals interpret ambiguous social cues as indicative of rejection (22,23,24). Individuals entering into a romantic relationship with expectations of rejection attribute insensitive behavior by their partners to hurtful intent. RS also causes people to be dissatisfied in relationships and to anticipate that their partners are dissatisfied and want to end the relationship. High-RS individuals react in ways that undermine their relationships, ultimately serving as “self-fulfilling prophecies” (22,23). High-RS people have lower self-esteem and coping skills than those with low RS…and have higher levels of drug use than low-RS individuals (24).

High-RS individuals may quickly activate a defensive motivational system (DMS), which acts automatically and at a nonverbal level (22). The DMS results in rapid execution of automatic behavior aimed at self-protection, whether the threat is physical or social (22). Although the DMS is adaptive when a quick automatic defense to threat is required, it is maladaptive when a response requires higher reflective cognition (22)….

…thwarting a person’s fundamental need to belong produces cognitive dissonance, leading to a failure to self-regulate effectively, which is manifested in self-defeating behaviors (25).

Insecure Adult Attachment Style

Anxiously attached adults lack self-confidence, are extremely sensitive to interpersonal rejection and lack effective emotion regulation skills, while securely attached adults have high self-worth, perceive that other people are accepting and engage in healthy coping skills (28,29,30). The ability to regulate distressing emotional experiences is theorized to develop during infancy in the context of a responsive and available caregiver (27,28,30). A primary function of attachment, therefore, is the interpersonal regulation of distressing emotional states (27,31). Insecure attachment is marked by deficient mood regulation skills and a propensity to use maladaptive coping methods, such as drugs and alcohol, to modulate distressing affect (27,29,30,31,32).

Anxious attachment, therefore, predisposes individuals to heightened interpersonal conflicts due both to their diminished self-worth and their deficits in regulating emotion.

Insecure adult attachment is associated with addictive disorders (27,28,29,31,32). Thorberg and Lyvers (30) found that, compared with control subjects, individuals with a substance use disorder scored lower on the “attachment dimension of close” and the “attachment dimension of depend” and higher on the “anxiety dimension” of the Revised Adult Attachment Scale. These measures reflect the extent to which a person feels comfortable with closeness and intimacy, how much they feel they can depend on others, and how anxious they are of being abandoned or unloved. Those with substance use disorders were also more emotionally reactive than controls (30). Another study by these investigators (31) used the Negative Mood Regulation (NMR) expectancies scale to examine the association between anxious attachment and mood regulation. The NMR measures an individual’s ability to regulate and successfully cope with negative affective states. They found an association between anxious attachment and a diminished ability to regulate negative moods and postulated that substance use represents a “mood regulating coping mechanism” (30).

McNally et al. (27) examined the relations between alcohol-related consequences and adult attachment dimensions. They used the adult attachment style conceptualization of Bartholomew and Horowitz, which is similar to that of Hazan and Shaver except that they differentiated avoidant attachment into “dismissive” and “fearful” attachment. Two dimensions exist in this model: view of self and view of others. Securely attached individuals have a positive view of self and others; anxiously attached (renamed “preoccupied”) individuals have a positive view of others but a negative view of self; dismissive individuals have a positive view of self but a negative view of others; and fearful individuals have a negative view of both self and others. These investigators found that individuals with a negative view of self (i.e., those with preoccupied and fearful attachment styles) reported greater alcohol-related consequences, which were mediated by the individual’s desire to alleviate negative affect. The investigators noted that the “individuals’ global feelings of insecurity in relationships and interpersonal interaction, and in particular, their sense of themselves as both inadequate and undeserving (negative model of self) appear to have a direct effect on the motivated use of alcohol to cope with negative affect, and an indirect effect (mediated by coping motives) on drinking-related problems” (p. 1124).”

Negative reinforcement of social rejection is not the only mechanism increasing high-rejection-sensitivity individuals’ risk for addiction and relapse. Because rejection activates the defensive motivational system, these individuals frequently respond with automatic aggressive behaviors, sometimes assuming a passive form of “going out and getting wasted” to “punish” the person who rejected them. Social rejection also impairs self-regulation, further diminishing the high- rejection-sensitivity individual’s ability to employ the strategies and cognitions necessary to avoid relapse.

I call this a “to Hell With It!” relapse! You reject me and I will reject you back! Again this ties in with the emotional immature reactions that we blogged on before, and the direct consequence, again, of insecure attachment.

In Part 2 we will look at low self esteem and interpersonal vulnerabilities to relapse (particularly in family settings).

To be continued.

References

1. Leach, David, and Henry R. Kranzler. “An Interpersonal Model of Addiction Relapse.” Addictive disorders & their treatment 12.4 (2013): 183–192. PMC. Web. 30 Jan. 2015.

A Message of Hope at Christmas – We Do Recover!!

I have heard various statistics about rates of recovery of the years, especially in AA. Some of the figures were depressing low and often go unchallenged which can be demotivating for those seeking recovery.

Why AAs in particular spread distorted statistics which suggest hardly any one recovers is open to question?

Out of all the people I know who were in treatment before me and in the group after me, as well as with me and who completed the entire course of treatment most of them, i.e. a high majority of at least 3/4s, are still in recovery.

This suggests to me that those who seek treatment, whether 12 step based treatment or via taking the steps, with fearlessness and honesty, do actually recover long term. So why is this sort of statistic not well know?

There can be no greater motivation to recover than knowing that the vast majority of people who do engage in treatment do actually recover!

I recently came across an excellent article on this by Dr. Omar Manejwala, former Medical Director for Hazelden Foundation, one of the nations oldest and largest addiction centers in the US.

I will quote from his blog here.

“…the recent tragic overdose death of Phillip Seymour Hoffman, whom many have noted was reportedly abstinent from alcohol and drugs for over two decades, raises another set of important questions:

Do people who get sober actually stay sober?
Can’t you ever be free of addiction? Are you always at risk of relapse?
Is there some period when, like cancer, you are considered to be “cured”?
Isn’t staying sober for a long time at least somewhat protective?

In my experience treating thousands of addicts, I’ve learned that cases like these can often diminish hope and create a perception that these conditions aren’t treatable, or that addicts can never be trusted.

When is an addict or alcoholic sober long enough to be considered at least relatively safe? Do most people with addiction who have been sober a long time eventually relapse? In scientific terms, what is the natural history of recovery from alcohol and drug addiction?

I’ve seen numerous experts speak up in the wake of Hoffman’s death, but few have offered hard science on what we really know about how a person’s duration of sobriety is related to their chances of being sober in the subsequent years. Fortunately, there are data to support the idea that recovery is durable, and that the vast majority of people who stay sober for a long time will continue to stay sober afterwards.

The most thorough attempt to understand what happens to addicts and alcoholics who stay sober is an eight-year study of nearly 1200 addicts. They were able to follow up on over 94% of the study participants, and they found that extended abstinence really does predict long term recovery. Some takeaways from this research are:

Only about a third of people who are abstinent less than a year will remain abstinent.
For those who achieve a year of sobriety, less than half will relapse.
If you can make it to 5 years of sobriety, your chance of relapse is less than 15 percent.

Of course, there are many people with 10, 20, 30 or even 40 years of abstinence…. My experience is that people with decades of abstinence clearly can and do relapse, but the incidence is very low. Like Hoffman and many others, it’s always heartbreaking when it happens. I’ve seen it triggered by opiate prescriptions, acute pain and other life stressors. Often the people who relapse have stopped engaging in the recovery-oriented practices that served them well during their earlier sobriety.

Every death from addiction is tragic. But cases like Hoffman’s are definitely the exception and not the rule.”

Link/reference

http://www.manejwala.com/#!single-post/cyqt/1

Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.

Gambling Disorder and Emotional Dysfunction

Following on from our recent blog on emotional dysfunction in sexual addiction we continue our series which explores the inherent role of emotional dysfunction in all addictive disorders.

We will explore eating disorders later.

Here we use excerpts from a very interesting article (1) on

Deficits in emotion regulation associated with pathological gambling.

“Pathological gambling is recognized as an impulse-control disorder characterized by a loss of control over gambling, deception about the extent of one’s involvement with gambling, and significant family or job disruption (American Psychiatric Association, 1994). Failures in self-control, therefore, represent a defining feature of pathological gambling. Self-control involves over-riding impulses by substituting another response in its place (Tice & Bratslavsky, 2000), and failures in self-control are primarily associated with the desire for short-term gains despite associated long-term negative consequences (Baumeister, 1997, Baumeister, Heatherton, & Tice, 1993).

Failures in control over gambling are likely to be influenced by individual coping styles. Problem-focused coping includes active and effortful problem solving, while emotion-focused coping includes escape and avoidance behaviours (Lazarus & Folkman, 1984). Scannell, Quirk, Smith, Maddern, and Dickerson (2000) suggested that loss of control over gambling is associated with emotion-focused coping such as avoidance or escape. This suggestionhas been supported by evidence that gamblers demonstrate deficits in coping repertoires (McCormick, 1994) and some rely on gambling to provide an escape from personal or familial problems (Corless & Dickerson, 1989; Lesieur & Rosenthal, 1991). Finally, in a sample of adolescent gamblers, those identified as at-risk for developing pathological gambling behaviours were those who exhibited more emotion-focused coping styles
(Gupta & Derevensky, 2001).

Gambling behaviours, therefore, seem to be associated with a deficit in self-control
processes that may be exacerbated by reliance on coping styles characterized by
avoidance and escape. At a more basic level, difficulties managing emotions effectively may contribute to the use of maladaptive coping strategies and result in failures in self regulation and impulse control. Optimal self-regulation relies on being able to focus on long-term goals in the presence of emotional distress that tends to shift attention to the immediate present (Tice & Bratslavsky, 2000). In addition, struggling with one’s feelings may deplete coping resources and leads to decreased self-control (Baumeister, Muraven, & Tice, 2000), leading to increased risk of disinhibited or impulsive behaviour.

Finally, individuals who are feeling acute emotional distress will likely wish to escape via activities that promise immediate pleasure (Tice, Bratslavsky, & Baumeister, 2001) and pathological gamblers often report using gambling to escape from negative mood states (Blaszczynski & McConaghy, 1989; Getty, Watson, & Frisch, 2000).

Emotion regulation refers to strategies to influence, experience, and modulate
emotions (Gross, 1999). Although there are several factors that influence whether a
certain emotion-regulation strategy is adaptive in a particular situation, certain strategies appear to be costly and maladaptive. For example, suppression or avoidance of emotions is associated with increased negative effect and anxiety, physiological activity, and physical pain (Campbell-Sills, Barlow, Brown, & Hoffman, 2006; Gross & Levenson, 1997; Levitt, Brown, Orsillo, & Barlow, 2004; Masedo & Esteve, 2007). Experimental investigations also support the notion that the effort of suppressing emotions drains mental resources (Richards & Gross, 2000), which could lead to decreased self-control.

Ricketts and Macaskill (2003) investigated several techniques that gamblers use to
modify their emotions, one of which was the technique of ‘shutting off’ or using gambling in order to stop an unpleasant emotional state. Participants receiving treatment for gambling were interviewed or watched during treatment sessions and administered questionnaires. Patients who used the technique of ‘shutting off’ were often the ones who also reported poorly tolerating emotional discomfort (Ricketts & Macaskill, 2003).

According to Baumeister, Zell, and Tice (2007), emotional distress leads to an increase in self-awareness, which consequently leads to a desire to decrease ones self-awareness, but at the cost of self-regulation. If one is unable to self-regulate, this could lead to an addiction or a relapse of an addictive behaviour (Sayette, 2004).

Impulse control represents one of the major behavioural aspects of emotion regulation (Gratz & Roemer, 2004) and has been identified as an important component of addictive processes (Evenden, 1999). More specifically, research has demonstrated that failures of emotion regulation are associated with addictive behaviours (Coffey & Hartman, 2008; Fox, Axelrod, Paliwal, Sleeper, & Sinha, 2007; Goudriaan, Oosterlaan, De Beurs, & Van Den Brink, 2008; Lakey, Campbell, Brown, & Goodie, 2007).

Several recent studies have employed the Difficulties in Emotion-Regulation Scale (DERS), a recently developed and validated measure of emotion regulation, in assessing behavioural addictions (Bonn-Miller, Vujanovic, & Zvolensky, 2008; Fox et al., 2007; Fox, Hong, & Sinha, 2008). The DERS assesses both general deficits in emotion regulation and deficits in specific domains of regulation. It is based on a model of emotion dysregulation that includes: (1) deficits in awareness and understanding of emotional experience (i.e., clarity), (2) minimal access to strategies to manage one’s emotions, (3) non-acceptance of emotions (i.e., reactivity to one’s emotional state), and (4) impaired ability to act in desired ways regardless of emotional state (i.e., impulsivity and an inability to engage in goal-directed behaviour).

The goal of the present study was therefore to examine emotion regulation difficulties among individuals being treated in a specialist gambling clinic and
to compare the use of strategies to a mixed clinical comparison group and a sample
of healthy community controls. Specifically, we investigated the association between
emotion-regulation deficits and gambling pathology using two measures of emotion
regulation, the DERS and the Emotional Regulation Questionnaire (ERQ; Gross & John, 2003). The ERQ examines the habitual use of two specific emotion-regulation strategies, namely expressive suppression and cognitive reappraisal. The use of suppression reduces the outward expression of emotions in the short term, but is less effective in reducing emotions in the long term and is, therefore, considered a maladaptive emotion-regulation strategy (Gross, 1998; John & Gross, 2004). Cognitive reappraisal involves changing the meaning associated with a particular situation so that the emotional impact is altered (Gross, 1999; Siemer, Mauss, & Gross, 2007). Reappraisal is considered an adaptive strategy to regulate one’s internal states and is associated with higher self-reported positive emotions and fewer depressive symptoms (Gross & John, 2003; Mauss, Cook, Cheng, & Gross, 2007).

Discussion

As expected, we found a significant relationship between self-reported problem,
gambling behaviour, and negative effect as measured by the DASS, as well as deficits
in emotion regulation as measured by the DERS.

With respect to group differences, the gambling group reported a greater lack
of awareness of their emotions compared to both comparison groups.

With respect to the overall findings of emotional dysregulation, Blaszczynski and
Nower (2002) proposed a pathway model of the determinants of gambling and identified three separate trajectories into problem gambling. Of relevance to the current study, the authors identified an emotionally vulnerable group of problem gamblers who used gambling as a way to regulate affective states by providing either emotional escape or arousal.

According to the pathway model, once a habitual pattern of gambling behaviours has been established, the combination of emotional vulnerabilities, conditioned responses, distorted cognitions, and decision-making deficits maintain the cycle of pathological gambling. Blaszczynski and Nower (2002) suggest that such emotional vulnerabilities make treatment more difficult in this particular group of gamblers and emphasize the need to address these underlying vulnerabilities in addition to directly targeting gambling behaviours in therapy. It may, therefore, be of therapeutic benefit to specifically assess for and target emotion-regulation strategies in this population of gamblers.

Given the gamblers in the current study demonstrated limited access to effective strategies for managing difficult emotions, it may be important for clinicians to address coping strategies (including emotion-focussed strategies) as a part of any comprehensive treatment package. Gamblers need to be able to recognize and modify unhelpful thinking patterns (both in relation to problem gambling situations and, more generally, to other life stressors).

It is also important that the clinician is aware of any deficits in emotion-regulation strategies to ensure that the client is prepared to guard against relapse, given that the ability to tolerate distress is associated with increased length of abstinence from gambling (Daughters et al., 2005).

. More specifically, given the finding that gamblers were less aware of their feelings, mindfulness strategies may be useful to increase awareness of one’s
emotions. This could potentially be helpful in reducing automatic and habitual responses, particularly in high-risk situations. Decreasing emotional avoidance through mindfulness may also assist pathological gamblers in better understanding the impact of various mood states on their behaviour. Individuals who experience heightened awareness of emotions, and who learn to observe and act in a more aware manner, are less likely to engage in maladaptive behaviours such as gambling (Lakey et al., 2007).”

References

1. Williams, A. D., Grisham, J. R., Erskine, A., & Cassedy, E. (2012). Deficits in emotion regulation associated with pathological gambling. British Journal of Clinical Psychology, 51(2), 223-238.

It Works if you Work It!

Alcoholism takes away your life and then kills you.

We look at a study from 8 years ago to show the extent of premature deaths caused by alcoholism and how membership of Alcoholics Anonymous helps in reducing the risk of premature death from alcoholism.

This study (1) of women and men, over 16 years, observed that those initiating help-seeking careers have better chances of long-term survival. Of the individuals for whom cause of death was known, of the 121 participants known to have died, 76 did so between the 8- and 16-year follow-ups.and 68% died of alcohol-related causes.

Men were more likely to die than were women. When gender was controlled, individuals who were older and unmarried and had more alcohol dependence
symptoms at baseline were more likely to die over the 16-year period.

“It is well documented that the course of alcohol use disorders (AUDs) may end in premature death (Rivara et al., 2004; Room et al., 2005) and …that remission may reduce the risk of premature mortality (Fillmore et al., 2003; Miller, 1999), there is little information about whether an initial course of
professional treatment, or participation in Alcoholics Anonymous (AA), can counteract the connection between AUDs and heightened mortality risk.

To address these issues, we examined mortality in a sample of individuals who had just initiated help-seeking for their AUDs at the start of the study and were followed for 16 years. Specifically, we ascertained the proportions of women and men who died and how these rates compared with matched general population rates…

Data on mortality are much more extensive for treated than for untreated individuals with AUDs. Finney and Moos (1991) reviewed long-term studies of mortality among treated individuals. Overall mortality rates ranged from 15% to 42% and were higher when the duration of follow-up was longer (see also Nielsen et al., 2005).

…Among individuals treated for AUDs, mortality rates were higher for men than for women (Feurerlein et al., 1994; Hurt et al., 1996). In addition, in community samples, rates of mortality due to alcohol use were higher in
men than in women (John and Hanke, 2002; Zureik and Ducimetiere, 1996). Premature death due to alcohol abuse or dependence is particularly more likely among men than among women in young and middle-aged groups (Moller-Leimkuhler, 2003)…

…A more severe and longer duration of alcohol abuse predicts premature death (Liskow et al., 2000; Ojesjo, 1981)…. In an 11-year follow-up, Smith et al. (1983) found that women who developed their AUD early and engaged in binge drinking were more likely to die. Consistently, more alcohol consumption and having recognized at a younger age that drinking was a problem were related to more years of life lost to an AUD (Marshall et al., 1994).

…Mackenzie et al. (1986) found that men who were hospitalized for AUDs more frequently were more likely to die over an 8-year follow-up. Inpatient treatment occurring throughout the course of alcoholism may be a marker for a more severe and chronic disorder because such treatment is sought in response to a relapse (Timko et al., 2000). In a study of inpatients with AUDs, de Lint and Levinson (1975) found that death rates were lower in the first 2 years postdischarge than thereafter. They speculated that intensive outpatient aftercare may delay or prevent the high rate of mortality that often occurs shortly after discharge.

Among individuals treated for AUDs, those who subsequently attended AA were less likely to have died by a 2-year follow-up than those who did not attend (Masudomi et al., 2004)…

… For inpatient care, longer duration appears to be an indicator of greater disorder severity and thus should be associated with higher mortality…However, for outpatient care and help from AA, a longer duration predicts better substance use disorder outcomes and so may indicate continuing motivation to stop drinking (Moos and Moos, 2003a, 2004a). From this perspective, a longer duration of outpatient treatment or AA affiliation should be associated with lower mortality.

…Furthermore, those who relapsed after treatment were 3 to 5 times more likely to die as those who remained abstinent (Bullock et al., 1992; Feurerlein et al., 1994)…

(This study found)…individuals who are just beginning their help-seeking…have a better chance of long-term survival than do women and men with more chronic disorders.
That is, individuals entering an initial episode of help-seeking may be successful at preventing or reducing the harm associated with excessive drinking that is also potentially causal in death. In contrast, repeated episodes of AUD treatment are often a reflection of the chronic and severe alcoholism known to cause premature death. As other studies have found, men were more likely to die than were women (Feurerlein et al., 1994; Hurt et al., 1996; John and Hanke, 2002; Zureik and Ducimetiere, 1996). Of the individuals who died, over two-thirds died of causes related to alcohol use.

…individuals who were olderand had more alcohol dependence symptoms (Finney and Moos, 1992; Liskow et al., 2000) and were unmarried were
more likely to die over the 16-year observation period.
Alcohol-related mortality tends to be lower among married persons (Agren and Romelsjo, 1992; Lewis et al., 1995)…

…continuous abstinence, had a positive effect on the survival of individuals with AUDs. Studies comparing stable abstinence with reduced frequency and
quantity of abusive drinking found that only stable abstinence prevented a higher mortality risk (Bullock et al., 1992; Gerdner and Berglund, 1997). Our results are consistent with those findings…

…Longer duration of AA attendance during the first follow-up year (specifically, attendance for more than 4 months) combined with better 1-year drinking outcomes was associated with a lower likelihood of death in the subsequent 15 years.

Alcoholics Anonymous participation may delay mortality not only by
reducing drinking and drinking-related, including medical,
problems, as outpatient treatment does, but also by increasing social resources and reducing…friendship stressors (Humphreys and Noke, 1997; Kaskutas et al., 2002; Masudomi et al., 2004).

References

Timko, C., DeBenedetti, A., Moos, B. S., & Moos, R. H. (2006). Predictors of 16‐year mortality among individuals initiating help‐seeking for an alcoholic use disorder. Alcoholism: Clinical and Experimental Research, 30(10), 1711-1720.

Are Alcoholics Emotionally Immature?

Concerted attempts have been made to relate personality factors to alcohol dependence.

In fact, for many years, research attempted to define the so-called alcoholic personality. Attempts to do so have dwindled in recent years.

Potential alcoholics tend to be emotionally immature, expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have a low frustration tolerance, and feel inadequate and unsure of their abilities to fulfil expected male or female roles.¹

Although the obvious emotional immaturity often seen in alcoholics seems to cover a number of the more recent findings on bio-psychologcal aspects a alcoholism.

For example, if we partly defined emotional immaturity as containing some of the following, then we appear to be covering a number of much researched and demonstrated aspects of alcoholism. Do these then not come under an umbrella term of emotional immaturity? This list was complied by Psych Central

Dimensions of Emotional maturity

The ability to modulate emotional responses. Addicts tend to have an all or nothing emotional response. When they respond they become overly emotional and take a longer time to return to baseline. They are easily flooded with emotion to the point of impairing functioning.

The ability to tolerate frustration. Addicts tend to respond to frustrating situations as disasters rather than having any perspective.

The ability to delay gratification. Emotionally immature people have trouble planning and working toward goals. The ability to give up immediate gratification is necessary for anyone to go about life in a successful way.

The ability to control impulses. The mature self has the ability to see that feeling the urge to do something is not the same as doing it. The recovering addict has a level of control over his or her behavior and can put boundaries around what is inappropriate to say or do.

The ability to be reliable and accountable. Addicts are often self centered and not good at dealing with the everyday requirements of life like being on time, fulfilling obligations and telling the truth. As they gain emotional maturity they gain the ability to get out of themselves and think about the impact of their actions on others and on their own lives as well.

According to a list drawn up by alcoholrehab.com

If people are emotionally immature, they may exhibit some of the following symptoms:

* Such individuals will often find it hard to deal with the normal challenges of life. When they are faced with problems they feel unable to cope. They may have developed a psychological state known as learned helplessness.

They struggle to develop meaningful relationships with other people. They may appear too needy or a bit overbearing.
* Those people who are emotionally immature will tend to have a pessimistic outlook on life. They may see the future as a threatening and hostile place.
* This type of person will usually have low self-esteem. This means that they do not value themselves highly so will be willing to accept very little in life as being all they deserve.
* They find it almost impossible to live in the present moment. They are either reliving the past or worrying about the future.
* They can easily lose their temper at the slightest provocation. When they are dealing with uncomfortable emotions they will tend to take things out on other people.

* People who are emotionally immature can have unrealistically high expectations. This means that they are frequently disappointed. Such and individual can have impossibly high expectations for other people yet low expectations for themselves.
* Such individuals can suffer from severe mood swings. This instability of mood can make life a bit uncomfortable.
* If people are emotionally immature, they find it much harder to control their own behavior.

Recognize any of these symptoms?

We were completely like this before doing the 12 steps.

We, however, do not think that anyone, alcoholics or otherwise choose to behave in this emotional immature way.

We have already looked at the emotional distress accompanies alcoholism and addiction, and will be examining more in the months ahead and it is difficult not to see the above emotional immaturity as all being products of a distress state.

In the course of addiction the alcoholic in particular grows in emotional distress as the stress and emotional dysregulation associated with addiction increases.

This means the brain “collapses” from more cortical, goal-directed (and emotionally regulated) areas of the brain to more sub-cortical areas which are more automatic, unthinking and compulsive.

Emotional distress activates these areas of habit-like compulsive behaviour, acting as a stimulus response, distress the stimulus and compulsive (unthinking) responding as the response.

This is like a distress based or “fight or flight” reality or a heightened emotional state or “emergency” state. It seems to us that alcoholics live in this region more than cortical regions. They are primed to go off!

They then have a tendency to either run away from situations or to fight “everybody and everything”, to be intolerant of uncertainty, to catastrophize, to be fear-based people to be over reactive, hypervigilant, perfectionist etc These are all distress based states.

Are aspects of the apparent emotional immaturity mentioned above not also not a surface manifestation of these deep subcortical processes?

It is this state of heightened uncertainty and fear that whittles away at the alcoholic psyche. This amount of stress/distress promotes implicit, do, memory, over explicit, reflective, evaluative, memory. Distress makes one act without much thought of consequence, it makes one choose short term over greater long term gain, it makes one want to act impulsively or compulsively to alleviate distress. It is this distress that is in charge of action and emotional behaviour. It calls the shots. A state of emergency has been called in the brain of the alcoholic.

I know it is widely shared at AA meetings that we got stuck in the emotional age of our first drink, in the early teens and never developed our emotional selves or capacity to regulate and process emotions. We are not sure this is completely true as the stress that accompanies alcoholism, as alcohol is literally classified as a pharmacological stressor, not only causes chronic stress dysregulation but also the emotional dysregulation which accompanies this. It is emotional parts of the brain and the cortical areas that are supposed to keep them in check that are most impaired via chronic alcoholism.

Dr. Stephanie Brown (2) has explored these developmental changes in cognition, which lead to “alcoholic thinking.” She states that these changes refer “not only to rationalization, denial and frame of mind, but also to character traits that frequently accompany drinking. These include grandiosity, omnipotence and low frustration tolerance.” (3) These traits appear to be directly associated with the addictive process rather than with the individual’s personality prior to establishing this abusive cycle.

As alcohol becomes more dominant, the need to deny these changes becomes greater. It appears that there is an interaction between physiological changes and psychological defenses which creates emotional immaturity, self-centeredness and irresponsibility. Alcoholism becomes a thought disorder as well as an addiction to alcohol.

This is the consequence we believe of prefrontal atrophy and subcortical hypertrophy caused by chronic alcohol consumption, a constant injection a pharmacological stressor into the brain, wrecking the ability to maturely deliberate and instead rely on “I want it now!” type of thinking.

We firmly believe this progression is to a state of constant distress signal in the brain and a cortical hyperarousal.

The alcoholic may not be emotionally distressed all the time but his brain is never satisfied, it constantly needs more, it finds only transient balance, via allostasis, it never finds true balance, i.e. homeostasis. it is always seeking, never reaching satiety, never completely at rest. This is emotionally exhausting.

It may represent, on superficial observation to some, the “emotional immaturity, self-centeredness and irresponsibility” (4) but is it really this simple, seeing these as the primary defenses and interpersonal style typical of normal development in the first three years of life or to characterize the addictive part of self as a “two-year-old child”?

Isn’t it more apt to say instead of a “two-year-old wounded part of self begins to “drive the bus” and create havoc for all concerned” to say chronic stress manifest as emotional distress “driving the bus”?

Thus a valid question remains for us and we ask it to our normies or earthling friends (i.e. non-alcoholics), wouldn’t you act in a childish if you were this distressed most of the time, having to rely on impaired emotional regulation and processing parts of the brain?

In fact, to all those normies or earthlings who are reading this blog, how well do you think or consider others when in a state of persistent and daily distress? In this heightened anxiety how good is your action outcome memory, goal-directed planning and awareness of future consequence?

Are you ever moody, emotionally volatile and over reactive in this state of high anxiety? Hyper sensitive? Ever strike out unthinkingly at others although you had not intended to? Leading to guilt and shame, and remorse and self pity which can in the fullest of time lead to depression? This is called a transient emotional dysregulation, distress leading to an emotional cascade. This is the brain of an alcoholic all the time. It can lead to dejection and relapse.

In this sate of nauseating anxiety, how well do you consider the consequence, negative or otherwise, or your fear-based decision making? Do you choose the short term answer in these anxiety-filled moments just to simply relieve this distress this unpleasant feeling of doom? So do alcoholics!

It is not enough to call the alcoholic emotional immature or stuck in the “terrible twos”, although let’s face it the evidence for it is compelling at times!! Let’s instead understand the reasons for it. Would you like to be in a state of distress most of the time? It’s not a whole lot of fun!

The 12 steps help solve these issues, there is a solution to emotional immaturity – it leads to emotional maturity or emotional sobriety which is blogged about here also.

The next time the alcoholic is your life acts in an immature way don’t ask them why they are acting that way, ask them how they feel. instead. Get them to identify, label and process their feelings by verbalizing them.

When the anxious amgydala has quelled and it’s feverish responding quietened, get them to an AA meeting where many tens of thousands of alcoholics are doing the same, “sharing”, processing their emotions by talking about them and how they really feel.

Not running away from them or intellectualizing about them, not fighting them. Simply saying in words how they feel.

It is a miracle awakening for us in recovery, the emotional regulation normies and earthlings take for granted.

The age of miracles is amongst us and it starts by opening your mouth, asking for help, getting help and getting real about what you are really feeling.

It is through sharing our deepest feelings that we start to mature and grow up.

References

1. Chaudhury, S.K. Das, B. Ukil, Psychological assessment of alcoholism in males Indian J Psychiatry. 2006 Apr-Jun; 48(2): 114–117. doi: 10.4103/0019-5545.31602

2. Brown S. (1985). Treating the Alcoholic: A Developmental Model of Recovery. New York: John Wiley & Sons, Spring.

3. Brown, S. (1988). Treating Adult Children of Alcoholics: A Developmental Perspective. New York: John Wiley and Sons.

4. http://www.cairforyou.com/alchoholdrugs/alcoholcharacter.htm

Predicting relapse via extent of emotional dysregulation?

by alcoholicsguide

Even the most experienced counselors have difficultly spotting a recovering alcoholic in danger of relapse. Brain imaging scans might do a better job according to a study last year by researchers at Yale University.

They suggested that alcoholics with abnormal activity in areas of the brain that control emotions and desires (reward) are eight times more likely to relapse and drink heavily than alcoholics with more normal patterns of activity or healthy individuals (1)

“These areas in the prefrontal cortex are involved in regulating emotion and in controlling responses to reward,” said Rajita Sinha, the Foundations Fund Professor of Psychiatry and professor in the Child Study Center and of Department of Neurobiology. “They are damaged by high levels of alcohol and stress and just do not function well.”

Or both perhaps, i.e. chronic alcohol use impacting on already impaired emotional regulation networks in the brain.

This graphic highlights areas of the brain where Yale researchers found significant differences in responses to stress and relaxation-inducing stimuli between alcoholics and healthy controls. Alcoholics who exhibited such patterns of activity during fMRI scans were much more likely to relapse than alcoholics that more closely resembled control subjects.

Areas of the brain governing emotional regulation such as the ventromedial prefrontal cortex which suggests chronic difficulties in emotional dysregulation, which potentiates the reward network, lying adjacent, and promotes higher relapse – click image for study.

Ironically, the damage shows up on fMRI scans when alcoholics imagine being in their own most relaxing scenarios, like sitting at the beach listening to the waves, or taking a bubble bath. In non-alcoholics, these brain regions regulating emotion show markedly reduced activity during relaxing imagery, as anticipated. However, in alcoholics most likely to relapse, those brain regions remain hyperactive. On the other hand, when recovering alcoholics imagine their own recent stressful events, these control regions of the brain show little change, while in non-alcoholics, they show marked activation in response to stress. Such disrupted responses in areas of the brain governing emotions and reward lead to high cravings in the recovering alcoholic and an increased likelihood of subsequent relapse.

These brain scans in the future might serve as a diagnostic test to help professionals identify those most at risk of relapsing and suggest specific interventions to normalize brain function and prevent high rates of alcohol relapse, Sinha said.

“The findings show the prefrontal region is important for maintaining recovery for alcoholism,” Sinha said.

This is in accord with much of our writing in this blog – alcoholics, in recovery or otherwise, appear to have profound difficulties in regulating stress and emotion, as if the hyperactivity in the ventromedial pefrontal cortex, seen here, is indicative of a brain that never emotionally shuts off, is always on the go (whether this is the consequence of allostasis, the continual readjustment of the brain to stress needs to be further explored) and is primed to relapse effectively via a “fight of flight mechanism, or a distress based impulsivity.

References

Dongju Seo; R Todd Constable; Kwang-Ik Hong; Cheryl Lacadie; Keri Tuit; Rajita Sinha
Disrupted ventromedial prefrontal function, alcohol craving, and subsequent relapse risk.
JAMA psychiatry (Chicago, Ill.) 2013;70(7):727-39.

	Brittany Palmer on An Addicted Brain but a Recove…
	Richard L Walz-Smith on Acceptance is the Key
	Chapter 10 – R… on “The Bottled Scream” A Disease…
	Chapter 1 “Rock Bott… on Do we have to Hit Rock Bottom…
	Chapter 4 – Wh… on Acceptance is Always the …
	Chapter 5 – My… on Simplifying the Complex?
	Chapter 4 – Wh… on The psychic change as continua…
	Chapter 3 – Th… on 12 Steps
	Chapter 1 “Rock Bott… on Do we have to Hit Rock Bottom…
	“The Bottled Scream”… on Chapter 5 – My Sobering…
	“The Bottled Scream”… on Chapter 3 – The First…
	“The Bottled Scream”… on Chapter 1 “Rock Bottom”
	The First Step Is Th… on “The Bottled Scream” A Disease…
	Don’t They Kno… on “The Bottled Scream” A Disease…
	A Chemical Colonisat… on “The Bottled Scream” A Disease…

The Alcoholics Guide to Alcoholism

Blogging The Language of the Heart

Reasons for Relapse

Your Heart is in Your Own Hands!

Forgiving Others is the Number One Healer!?

What recovers in Recovery? – Cognitive Control over emotions?

Recovery: can you feel “Better than Well!”?

Interpersonal Factors in Relapse – Part 1

Rejection Sensitivity

Insecure Adult Attachment Style

A Message of Hope at Christmas – We Do Recover!!

Gambling Disorder and Emotional Dysfunction

Deficits in emotion regulation associated with pathological gambling.

It Works if you Work It!

Are Alcoholics Emotionally Immature?

Predicting relapse via extent of emotional dysregulation?

Predicting relapse via extent of emotional dysregulation?