rumination

Alcoholics Anonymous and Reduced Impulsivity: A Novel Mechanism of Change

Posted on by alcoholicsguide

Impulsivity or lack of behaviour inhibition, especially when distressed, is one psychological mechanisms which is implicated in all addictive behaviour from substance addiction to behaviour addiction.

It is, in my view, linked to the impaired emotion processing as I have elucidated upon in various blogs on this site.

This impulsivity is present for example in those vulnerable to later alcoholism, i.e. sons and daughters of alcoholic parents or children  from a family that has a relatively high or concentrated density of alcoholics in the family history, right through to old timers, people who have decades of recovery from alcoholism.

It is an ever present and as a result part of a pathomechanism of alcoholism, that is it is fundamental to driving alcoholism to it’s chronic endpoint.

It partly drives addiction via it’s impact on decision making – research shows people of varying addictive behaviours choose now over later, even if it is a smaller short term gain over a greater long term gain. We seem to react to relieve a distress signal in the brain rather than in response to considering and evaluating the long term consequences of a decision or act.

No doubt this improves in recovery as it has with me. Nonetheless, this tendency for rash action with limited consideration of long term consequence is clearly a part of the addictive profile. Not only do we choose now over then, we appear to have an intolerance of uncertainty, which means we have difficulties coping with uncertain outcomes. In other words we struggle with things in the future particularly if they are worrying or concerning things, like a day in court etc. The future can continually intrude into the present. A thought becomes a near certain action, again similar to the though-action fusion of obsessive compulsive disorder. It is as if the thought and possible future action are almost fused, as if they are happening in unison.

Although simple, less worrying events can also make me struggle with leaving the future to the future instead of endless and fruitlessly ruminating about it in the now. In early recovery  especially I found that I had real difficulty dealing with the uncertainty of future events and always thought they would turn out bad. It is akin to catastrophic thinking.

If a thought of a drink entered into my head it was so distressing, almost as if I was being dragged by some invisible magnet to the nearest bar. It was horrendous. Fortunately I created my own thought action fusion to oppose this.

Any time I felt this distressing lure of the bar like some unavoidable siren call of alcohol I would turn that thought into the action of ringing my sponsor. This is why sponsees should ring sponsors about whatever, whenever in order to habitualize these responses to counteract the automatic responses of the addicted brain.

I think it is again based on an inherent emotion dysregulation. Obsessive thoughts are linked to emotion dysregulation.

My emotions can still sometimes control me and not the other way around.

Apparently we need to recruit the frontal part of the brain to regulate these emotions and this is the area most damaged by chronic alcohol consumption.

As a result we find it difficult to recruit this brain area which not only helps regulate emotion but is instrumental in making reflective, evaluative decisions about future, more long term consequence. As a result addicts of all types appear to use a “bottom up” sub-cortical part of the brain centred on the amgydala region to make responses to decisions instead of a “top down” more cortical part of the brain to make evaluative decisions.

We thus react, and rashly act to relieve the distress of undifferentiated emotions, the result of unprocessed emotion rather than using processed emotions to recruit the more cortical parts of the brain.

Who would have though emotions were so instrumental in us making decisions? Two parts of the brain that hold emotions in check so that they can be used to serve goal directed behaviour are the orbitofrontal cortex and the ventromedial prefrontal cortex.

120px-Orbital_gyrus_animation_small2

 

These areas also keep amgydaloid responding in check. Unfortunately these two areas are impaired in alcoholics and other addictive behaviours so their influence on and regulation of the amgydala is also impaired.

This means the sub cortical areas of the amgydala and related regions are over active and prompt not a goal directed response to decision making but a “fight or flight” response to alleviate distress and not facilitate goal directed behaviour.

128px-Amyg

 

Sorry for so much detail. I have read so much about medication recently which does this or that to reduce craving or to control  drinking but what about the underlying conditions of alcoholism and addictive behaviour? These are rarely mentioned or considered at all.

 

We always in recovery have to deal with alcoholism not just it’s symptomatic manifestation of that which is chronic alcohol consumption. This is a relatively simple point and observation that somehow alludes academics, researchers and so-called commentators on this fascinating subject.

Anyway that is some background to this study which demonstrates that long term AA membership can reduce this impulsivity and perhaps adds validity to the above arguments that improved behaviour inhibition and reducing impulsivity is a very possible mechanism of change brought about by AA membership and the 12 step recovery program.

It shows how we can learn about a pathology from the recovery from it!

Indeed when one looks back at one’s step 4 and 5 how many times was this distress based impulsivity the real reason for “stepping on the toes of others” and for their retaliation?

Were we not partly dominated by the world because we could not keep ourselves in check? Didn’t all our decisions get us to AA because they were inherently based on a decision making weakness? Isn’t this why it is always useful to have a sponsor, someone to discuss possible decisions with?

Weren’t we out of control, regardless of alcohol or substance or behaviour addiction? Isn’t this at the heart of our unmanageability?

I think we can all see how we still are effected by a tendency not to think things through and to act rashly.

The trouble it has caused is quite staggeringly really?

Again we cite a study (1) which has Rudolf H. Moos as a co-author. Moos has authored and co-authored a numbered of fine papers on the effectiveness of AA and is a rationale beacon in a sea of sometimes quite controversial and ignorant studies on AA, and alcoholism in general.

“Abstract

Reduced impulsivity is a novel, yet plausible, mechanism of change associated with the salutary effects of Alcoholics Anonymous (AA). Here, we review our work on links between AA attendance and reduced impulsivity using a 16-year prospective study of men and women with alcohol use disorders (AUD) who were initially untreated for their drinking problems. Across the study period, there were significant mean-level decreases in impulsivity, and longer AA duration was associated with reductions in impulsivity…

Among individuals with alcohol use disorders (AUD), Alcoholics Anonymous (AA) is linked to improved functioning across a number of domains [1, 2]. As the evidence for the effectiveness of AA has accumulated, so too have efforts to identify the mechanisms of change associated with participation in this mutual-help group [3]. To our knowledge, however, there have been no efforts to examine links between AA and reductions in impulsivity-a dimension of personality marked by deficits in self-control and self-regulation, and tendencies to take risks and respond to stimuli with minimal forethought.

In this article, we discuss the conceptual rationale for reduced impulsivity as a mechanism of change associated with AA, review our research on links between AA and reduced impulsivity, and discuss potential implications of the findings for future research on AA and, more broadly, interventions for individuals with AUD.

Impulsivity and related traits of disinhibition are core risk factors for AUD [5, 6]. In cross-sectional research, impulsivity is typically higher among individuals in AUD treatment than among those in the general population [7] and, in prospective studies, impulse control deficits tend to predate the onset of drinking problems [8–11]

Although traditionally viewed as static variables, contemporary research has revealed that traits such as impulsivity can change over time [17]. For example, traits related to impulsivity exhibit significant mean- and individual-level decreases over the lifespan [18], as do symptoms of personality disorders that include impulsivity as an essential feature [21, 22]. Moreover, entry into social roles that press for increased responsibility and self-control predict decreases in impulsivity [16, 23, 24]. Hence, individual levels of impulsivity can be modified by systematic changes in one’s life circumstances [25].

Substance use-focused mutual-help groups may promote such changes, given that they seek to bolster self-efficacy and coping skills aimed at controlling substance use, encourage members to be more structured in their daily lives, and target deficits in self-regulation [26]. Such “active ingredients” may curb the immediate self-gratification characteristic of disinhibition and provide the conceptual grounds to expect that AA participation can press for a reduction in impulsive inclinations.

…the idea of reduced impulsivity as a mechanism of change…it is consistent with contemporary definitions of recovery from substance use disorders that emphasize improved citizenship and global health [31], AA’s vision of recovery as a broad transformation of character [32], and efforts to explore individual differences in emotional and behavioral functioning as potential mechanisms of change (e.g., negative affect [33,34]).

Several findings are notable from our research on associations between AA attendance and reduced impulsivity. First, consistent with the idea of impulsivity as a dynamic construct [18, 19], mean-levels of impulsivity decreased significantly in our AUD sample. Second, consistent with the notion that impulsivity can be modified by contextual factors [25], individuals who participated in AA longer tended to show larger decreases in impulsivity across all assessment intervals.

References

Blonigen, D. M., Timko, C., & Moos, R. H. (2013). Alcoholics anonymous and reduced impulsivity: a novel mechanism of change. Substance abuse, 34(1), 4-12.

Forgiving Others is the Number One Healer!?

Posted on by alcoholicsguide

“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

Processing the Past via the action steps, 4-12!

Posted on by alcoholicsguide

 

 

Processing the Past via the actions steps, 4-12!

by alcoholicsguide

How The Alcoholics Anonymous’ program of action helps with emotional dysregulation.

When I first came into recovery I was surprised how much more time I spent embroiled in thinking about past incidents and how I had numerous murderous resentments  about people who had supposedly done me wrong, than I did thinking about drinking.

The thought of drinking terrified me rather than enticed me. Fortunately it also made be nauseous and fortunately still does. A full year of vomiting on an empty stomach, throughout each and every interminable day and night, has had some aversion like effect.

I had literally hundreds of thoughts and negative emotions about the past streaming through and around my aching head and piercing my heart. They were like toxic mind darts that flipped my guts and almost made me physically ill. Even thinking back now makes me feel queasy.

It was a constant state of emotional distress, those early days of recovery.

I was shocked as the weeks trudged on painfully that I seemed to have problems other than the drink. I was reassured by many other AAs in meetings when they shared about how difficult life was on life’s terms – how they struggled with resentments and fears and their “emotional disease”. I was was glad it wasn’t just me.

I had finally found a club where I fitted in! After all these years. In fact most people I drank with were also alcoholic! So I have always sought the company of my own. I thought we could only be found in pubs! And here we had rooms of them talking about trying to stay “emotionally sober”. It wasn’t just sobriety it had to be emotional sobriety. I was, through my fading eyesight and mercifully abating alcoholic psychosis, greatly intrigued by this. My life, and their lives, had become unmanageable, they said,  not just because of the drink, but because of some underlying condition.

I was especially interested in why I was so cursed by memories of my past. Why hadn’t they gone away? Why had they come back so prolifically in early recovery. The alcohol must have keep some of them suppressed, at bay. Now they were teeming through, poisoning my mind just as effectively as any alcoholic withdrawal or rattling hangover ever did. It was difficult not to somehow see these rampant, rampaging negative thoughts and emotions as akin to a disease. When they spoke of spiritual disease, it seemed to describe what was happening in my head.

I have “done” the steps three times and each time has offered more insight into this spiritual malady which I call an emotional disease. Why? Well because the sure sign of a spiritual malady, I believe,  is the expression and lack of control over negative emotions. The emotional lability and volatility. The bad temperedness, the indignition at life’s flaws, the perfectionism, the need to control, the righteous anger. We sin via these negative emotions. Have you ever heard of someone sinning via positive emotions? “Yes he wronged me by being so kind and generous, thoughtful and loving, to hell with that man!” So why are we so scared of the e word, emotion.

We sin via, or have defects of character which are, negative expressions of emotion. Intolerance, or impatience, selfishness, fear based dishonesty and so on. All expressions of distress. A fear based illness?  I like the term defect of character because it suggests sometime intrinsic to alcoholics. I call this inherent aspect of this condition called alcoholism, emotional regulation and processing difficulties.

In this blog I will attempt to explain how the 12 steps of AA, principally the action steps 4 through to 12, have not only connected me with a power greater than myself  but they continue to treat, on a daily basis, my unmanageability.  An  unmanageability caused inherently by my difficulties processing and regulating emotions.

 

12 steps pic

 

I have looked hard for supporting evidence to substantiate what I am about to write and found this link to an interesting piece on the use of EMDR and other therapies in treating the unprocessed emotions caused by emotional dysregulation in those who suffer from trauma. I have used aspects of this to make it applicable to alcoholics. I believe profoundly that steps 4-12 facilitate a profound alteration in our ability to regulate and process emotions.

Steps 4 -7,  in particular help us to embed the numerous unprocessed memories from childhood onwards, that all seem to have been tied together in a terrible mnemonic mesh by aspects of emotional dysregulation such as resentments.  It is in addressing all these that we finally process these associated negative emotions in our memory banks and finally embed all these memories in long term memory.

In short, the Steps allow us to adaptively and healthily process our disturbed pasts. They also allow us to maintain a health and adaptive emotional regulation  on a daily basis and via steps 10-12 in particular allow us to greatly improve our emotional regulation.

I am not rewriting the Big Book of AA here, only to add another angle to understanding it and how it works, so that others in related therapeutic fields can have some insight into how it may work and those who need help feel more inclined to come to AA for help.

http://www.thebody.com/content/art48754.html   – Refer also to the work of Francine Shapiro (1) and her work which shaped development of the EMDR therapy which treats trauma (PTSD) and other disorders. I know it works for PTSD as my wife suffered PTSD after a car accident, and was greatly helped by this type of treatment. It is Shapiro’s insight into the role of unprocessed emotions in causing emotional volatility and a “volcano of unresolved distressing effects” (2) and that  chronic dysfunctional perceptions, responses, attitudes, self-concept, and personality traits are all symptoms of unprocessed memories (3) that shapes my thinking, partly, on how the steps allow us to put the past to bed.

I have to add also that I believe myself to be a sufferer of PTSD also. I have stressed that alcoholism is a psychiatric disorder in it’s own right but would never be silly enough to suggest it does not have co-occurring disorders such as PTSD, as the result of abuse and trauma in earlier life experience. Especially as there as up to 2/3s of dependent people may have had abuse in their early lives and that PTSD sufferers have up to a 50 % co-morbidity with alcoholism and addiction. Perhaps this is why this work by Shapiro strikes a cord with me. I think it is naive to say that abusive early life does not play a role in alcoholism and addition and that this environmental influence on genetic inheritance (alcoholism has a a generic heritability of some 50 – 70% making one of the most inheritable disorders). In other words, some 50 – 70% of alcoholics have alcoholism in their genes.

Throughout our lives, we all experience significant events that impact our perceptions of the world and determine how we interpret and respond to future experiences. These moments represent painful experiences so severe that they overwhelm our ability to cope with the rush of thoughts and feelings they elicit and If left unresolved, these feelings can persist for years in unprocessed emotions.

As a general rule, anything destructive that is left untreated — disease, trauma, stress, psychological disorders, addiction — can become progressively worse over time. Coming to terms with the past is often referred to as “integration,”  of these errant unprocessed emotions and achieving resolution. One way this resolution can be accomplished is by verbally and somatically (by being aware of how they affect one bodily) reprocessing these, like in step 5 when discussing one’s inventory, and the rewards can be transformative.

Mental networks contain visual images of the previous experiences  as well as related thoughts, emotions, and sensations. Previous experiences — including every physical sensation, every emotion, and every perception or interpretation — are encoded and stored in the brain and throughout the body. The processing of information about previous events may be incomplete, perhaps because the person has not developed the emotional or mental faculties to effectively manage or correctly interpret the situation (often the case with children who have faced abuse, trauma, insecure attachment to caregivers) or because processing is hindered by strong negative feelings (such as shame, helplessness, and denial) which I believe may be the consequence of emotional dysregulation.

images (3)

 

The memory of the previous experiences can  therefore be improperly stored without appropriate associative connections and with many elements still unprocessed. This incomplete processing prevents the forging of connections with more adaptive information or new learning which might help the person release the abusive, traumatising, misrepresented, resented, emotionally dysregualted and unprocessed experiences from the past. Finally when we do process these experiences then we can consign them to, embed them, happily in long term memory.

In a previous blog we say how one maladaptive emotional regulations strategies that of self elaboration, where one regulates a negative emotional experience by filtering in through the self and then elaborating on this in a ruminating manner, i.e. only seeing an event in relation to themselves, in self- reference (similar to a resentment)  and that our minds in early recovery are thus filled with these unprocessed memories as the consequence of this type if emotional dysregulation which filtered everything through a self centredness. In many cases we began to see in our step 4 inventory that it was often our emotional dysregultation that caused others to act in certain ways which we interpret, whether for valid reasons or not, in a self centred and distorted way which was base on emotional reasoning. These unprocessed emotions and memories thus lingered on in our minds for decades, festering as resentments and fuelling our drinking and drug use.

Doesn’t Step 4 allow us to record these unprocessed memories, get them down in black and white, with the unprocessed emotions, the resentments and other negative unprocessed emotions, such as anger, fear, selfishness, self-centredness, dishonesty and son on.  Doesn’t it let us use our proper reasoning to see through our purely emotional reasoning?

Don’t we start to process these emotions and thus the attached memories by verbalizing them in a therapeutic sense to our sponsors, mentors, respected religious or spiritual guides, counsellors etc? Don’t we learn to see what has kept us enslaved in feelings of injustice, resentment, of being wronged? Doesn’t it help us see how our emotional dysregulation distorts our perception of reality, and leads to a negative bias in our thinking about life and the people in it? Doesn’t it show us our underlying problem, our underlying psychiatric condition, which the steps helps us then to manage, to help us become manageable. We are not powerless over alcohol when we manage our negative emotions.

The Steps 6 and 7 allow us to have these removed. I believe God remove my many previous unprocessed emotions and memories, helped me consign then to the past and my long term memory. They did not go into ether as i fist thought, but into were processed in long term memory. This is no way lessens the Grace of God or his mercy.  He helps me do what i cannot, He goes deep! Steps 8 and 9 process these emotions even more via making amends for our wrongdoings and getting rid of the potential distress associated with unresolved situations from our past.  The final recognition of the effects our emotional dysregulation has had on our wider community.

Aren’t the steps, primarily to help us manage our emotional dysregulation?

Isn’t this what was unmanageable? Wasn’t it this which gave King Alcohol power over us? Doesn’t the AA program of action help us in a similar way EMDR does with trauma victims?

Step 10 helps us on a daily basis look out for manifestations and examples on how we hurt others with our lack of control over our negative emotional response, our dysfunctional emotional response. It gives us a way to examine and process these emotions and to take action to apologise to those who experienced this emotional volatility. It helps encourage positive, healthy, adaptive emotional expression.

Step 11 helps us self soothe and this helps our emotional regulation, meditation improves  and strengthens the very brain areas which regulate emotion, the dlPFC and ACC, which help control our anxious amygdala, the very the heart of all distress.  And via Step 12 we regulate our emotions in one of the most profound ways possible by helping others. By showing love. There is little dyregulation in love, the most healthy of human  emotional expression. ..and in all our affairs! We do not become intolerance of other is upholding “Principles not personalities”

Love contains the positive assets hopefully also listed in your inventories; selfishness, consideration, patience, tolerance etc  – the aspects of healthy emotional being. Perhaps this is another reason why Step 12 is so profound in helping us manage the unmanageability of our emotional dysregulation.

And fellowship itself, gives us an “earned attachment” especially when many of us had insecure attachments with our parents, grew up in dysfunction, disrupted families, in abuse or trauma. It helps us finally “belong”.  Fellowship  allows us perhaps to express our emotions fully for the first time, allows us to verbalize our concerns and feelings, label them for the first time, regulate and process them. Provides a safe environment in which to emotionally mature. The list goes on and on. AA gives us loving feedback, nurtures us, nourishes us.  Home groups with regular members over many years obviously aid this process of caring and mutual self growth.

It has become more clear while writing this how AA manages this emotional disease we call alcoholism.

The AA program of action helps us change how we feel and think about the world.

References

1. Shapiro, F. EMDR Therapy: Adaptive Information Processing, Clinical Applications and Research Recommendations.

2. Courtois, C. A., & Ford, J. D. (Eds.). (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York, NY: Guilford Press.

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

Some references to follow.

Do you have Emotional Regulation Difficulties!?

Posted on by alcoholicsguide

Emotions have always troubled me! I have always found them frightening, always had difficulties labeling and controlling them. I have always seemed to put in an extra effort to keep them in check.

I have recently read a very good chapter from a book (1) which looks at emotional regulation and the role it seems to play in psychopathology. In fact, it is my view that emotional dysregulation  lies at the heart of alcoholism, initiates, sustains and perpetuates this chronic disease state.

It was thus illuminating to see that emotional dysregulation is cited as being present in some 75% of disorders listed in The Diagnostic and Statistical Manual of Mental Disorders, DSM-5.

Alcohol Dependence in the DSM has a narrow definition, I believe, of alcoholism as mentioned in previous blogs. It relegates all manifestation of emotional, mood, impulse difficulties to that of “co-morbidities” which means it thinks there is a difficulty with unregulated drinking but the unregulated thinking, emotions and impulsive behaviour it relegates to being the consequence of a co-occurring condition such as anxiety disorder, depression, post traumatic stress disorder and so on. This is not to say that some of these conditions do not co-occur with alcoholism. PTSD and alcoholism co-occur quite frequently.

What I am saying is that a number of conditions/disorders attributed to alcoholism as a co-morbidity may not be co-morbidities at all, for some. They may be aspects of this psychiatric disorder I call alcoholism.

Although the relationship of these psychiatric symptoms with addiction is very close, substance abuse may modify pre-existing psychic structures and lead to addiction as a specific mental disorder, inclusive of symptoms pertaining to mood/anxiety, or impulse control dimensions, decision making difficulties or, as we suggest, the various characteristics of emotional dysregulation.

See blogs for more An Emotional Disease? and Current Definitions of Addiction – how accurate are they?

I do not want to rehash arguments mentioned elsewhere on this blog (especially as I want to discuss some emotional regulation difficulties I find are very pertinent to my alcoholism and maybe to yours?) Particularly “self elaboration” which seems to be at the heart of my alcoholism and appears very similar to the alcoholic mentioned in the Big Book of Alcoholics Anonymous.

Emotions are important in readying behavioral, motor,

and physiological responses, in facilitating decision making, in enhancing memory for important events, and for negotiating interpersonal relationships.

But emotions can also hurt as well as help! Emotions are  not always helpful!

Psychopathology is largely characterised by excessive negative emotion.  In those with emotional dysregulation,  emotional regulation strategies helpful in childhood are now unhelpful in adulthood,  such as use of an avoidant coping style where they down play threat and suppress feelings. This may have helped in surviving an abusive childhood but is not conducive to intimate adult relationships.

Another difficulty is not allowing a primary emotional response to proceed but instead suppressing it or resisting it e.g it is not okay for me to feel angry at my dying mother. Thereby, creating a maladaptive secondary emotional response e.g. guilt.

Secondary responses for resisted emotions coming from emotions
are experienced as anxiety producing, as reflected in rigid attentional
processes, lack of acceptance, and the activation of negative beliefs about emotions.

In order to ascertain if your emotional regulation is adaptive answer the questions below (and refer perhaps to your early recovery too!)

Do you not immediately react to the external situation or to one’s internal primary emotional response, but pause for a moment and give oneself some breathing room? Thus allowing  space for the emotion to begin to arise free of immediate avoidance (e.g., cognitive, behavioral, or emotional avoidance), immediate resistance (e.g., “I shouldn’t want to feel this way”), or impulsive behavioural reaction (e.g reacting angrily or fearfully)?

Are you aware of your primary emotional response and be able to identify what emotion one is having in order to effectively control it?

Can you determine how controllable the situation that
caused the emotion is and how controllable one’s internal reaction to the situation?

For situations or internal thoughts or emotions that are out of one’s control, adaptive regulation is to accept the situation and experience . This is common to most therapeutic regimes.

Finally,  how well do you  inhibit/control inappropriate or impulsive behaviors when experiencing negative emotions?

All of the above, from a personal perspective, have improved the longer I have been in recovery. Although tiredness, or distress can prompt a quick return to emotional dysregulation.

Emotion regulatory strategies

The two regualtory strategies are two that most apply to me as an alcoholic. Attentional Deployment and Cognitive Change

See if they relate to you too, or to a loved one.

Attentional Deployment

Specific forms of maladaptive attentional deployment include rumination, distraction and worry.

Rumination typically involves repetitive attentional focus on feelings associated with negative events, along with a negative evaluation of their consequences. It has been associated with increased levels of negative emotion. Rumination is constantly implicated in alcoholism.

We discuss this and catastrophizing in later blogs.

Cognitive Change

Before a situation that is attended to gives rise to emotion, the situation needs to be judged as important to one’s goals (i.e., appraisal).This stage of imbuing a situation with meaning can be influenced if one wishes to change the trajectory of the emotional response.

Cognitive change refers to changing how we appraise a situation to alter its emotional significance.

Two categories of reappraisals associated with psychopathology are (1) self-elaboration (e.g. “Others must think poorly of me”) and (2) emotional resistance/non acceptance of one’s current emotional experience (e.g., “I shouldn’t feel bad” ).

I personally find this “self elaboration” very applicable to myself as an alcoholic,  this ” the self in reference to a situation can substantially increase the duration and complexity of emotional responses.” 

For example, instead of my negative thoughts and feelings being processed and put to bed, they can be reignited throughout the day and can leave me feeling negative for hours afterward rather than just for the period following whatever incident provoked this emotional response initially.

This and other maladaptive emotional regulation strategies like rumination are shared with other disorders such as depression but this doesn’t mean they are the same disorders or that they co-occur. They are disorders which share common emotional dysregulation but ultimately have different behavioural manifestation.

They are not co-morbid but similar in certain ways but not all.

Back to self elaboration  –  Following my lack of appropriate emotional response above, I may feel negative the rest of the day, I may decide to ruminate, or complain  or bitterly gossip with others,  I may exhibit all the “defects of character” that came out in my step four inventory, such as pride, arrogance, intolerance, self-centredness, selfishness, anger, resentment, fear, dishonesty and so, all of which I feel are secondary emotional responding or emotional cascades. In fact, I believe step four through to seven helped me process the various episodes of emotional dysregulation I had running around my head and tearing at my heart for the thirty odd years prior to doing the steps.

The more I gossip and backbite, the more I think the person who “wronged me” is incompetent, it’s all his fault, my feelings are down to him! He caused this distress didn’t he?  The injustice of it all!! These thoughts will reignite other emotions and thoughts – I should have stuck up for my self – guilt and this situation could be serious – fear.  And so the cascade continues.

“I wonder if others think the same way about me, perhaps they don’t like me, perhaps I am not very popular!? – shame, self pity and  maybe I am just not very lovable – despair ” and then it can delve into my distant past to my childhood, “well this is how my mother acted sometimes, maybe it is just me ! I’m the problem!”

It is difficult not to see this self-assassination as anything other than emotional dysregulation. My thinking, based on negative emotions, running away with themselves and increasing these negative emotions which then increased by distorted thinking, until “to hell with it, I’m not worth it, let’s get drunk!”

My emotional dysregulation is linked to a heightened reward sensitivity, I really like things that soothe my emotions like drink and  drugs and I used them to regulate my emotions. I did not ruminate forever as in depression, I fixed it my external means, I consumed things and they change how I felt.

This makes my condition different to depression although plenty of depressives drink and abuse drugs. For me this heightened reward sensitivity meant I enjoyed them a whole lot more, got a whole lot out of them and decided that they would be part of how I dealt with things, emotions, life.

Our abnormal rejection to drink and drugs is a big part of our condition, our psychopathology, our psychiatric disorder. It has similarities with other conditions based on emotional dysregulation but it is also very different, That is why it demands a different treatment.

The wrong treatment will not Work!

The self elaboration means that I would consider many  imagined scenarios all in relation or in reference to my self.  The self has to be involved. Unfortunately this elaborates the meaning of my emotional responses and the emotional responses. All of a sudden  there is a soap opera running in my head, a committee of wrongdoings, soon becoming a psycho drama. A friend of mine in AA calls it travelling via his intergalactic armchair!

Ruminating on things that did not occur as we think, will not occur as we think and have only caused a temporary insanity.

How is this not a psychiatric disorder!?

The emotions get increasing intense and proliferate. A many headed monster.

All usually because of my initial misperception of something that probably did not occur!

 

References

Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework.

How do resentments become the Number one Offender!?

Posted on by alcoholicsguide

Research suggests (1) suggest individuals with poorly regulated emotions often turn to alcohol to escape from or down-regulate their emotions, creating a risk for diagnosable problems in relation to alcohol  difficulties as this impairment in emotion regulation is associated with alcohol-related disorders  and substance-related disorders (2).

Experiential avoidance of thoughts, emotions, sensations,memories, and urges can lead to a variety of negative outcomes such as problems with substance use, because it paradoxically increases negative thoughts (3)

Thus risk factors include suppression (including both expressive suppression and thought suppression), avoidance (including both experiential avoidance and behavioral avoidance), and rumination.

Emotional distress, which is chronically higher in people with emotion dysregulation, appears to potentiate (heighten) reward systems in the brain (1), and this potentiation may be even greater in individuals high in reward sensitivity, increasing the chances they will turn to alcohol. Intake of alcohol will be reinforced both by the satisfaction of high appetitive drives and by the reduction of negative emotions these individuals otherwise cannot regulate. Thus, the combination of emotional dysregulation and high reward sensitivity should be a potent risk factor for the development and/or maintenance of substance abuse and eating disorder.

Emotion dysregulation may occur if emotions are experienced as intense and overwhelming, when individuals have not learned how or when to apply effective strategies, when strategies are not applied flexibly, when the strategies fail, or when strategies are overused, emotion regulation patterns may interfere with the ability to successfully achieve goals. Emotion dysregulation still involves attempts at regulation, but the process leads to maladjustment rather than adjustment. For example, emotion dysregulation may result in poor interpersonal relationships, difficulty concentrating, feeling overwhelmed by emotions, or inability to inhibit destructive behaviors.

Components of emotional dysregulation include a tendency for emotions to spiral out of control, change rapidly, get expressed in intense and unmodified forms, and/or overwhelm both coping capacity and reasoning. (4)

Self regulatory deficits like these may emerge from an interaction of intrinsic biological factors as well as from chaotic or stressful early life experiences, particularly child abuse and problematic attachments with caregivers.

Emotional Dysregualtion may be present in  overly restricted emotional expression and avoidance or excessive emotionality and excitement seeking. This research (4) highlighted that the idea that emotional dysregualtion is a distinct construct, related to but not reducible to negative effect (anxiety, mood, negative emotions) and may be seen as the result of the developmental capacity to adaptively regulate emotions being disturbed by early disruptive experiences. In other words, abuse in early childhood can help determine how we cope with our emotions.

Maladaptive cognitive emotion regulation strategies such as rumination    (5 ) and thought suppression (6) have been linked to a number of negative psychological outcomes. Binge-eating (7), and other impulsive behaviors (8) may all be a result of emotion dysregulation.

Selby (9 ) addresses the issues of why does emotion dysregulation appear to result in behavioral dysregulation?  The connection may lay in the use of certain cognitive emotion regulation strategies (cognitive emotion dysregulation) that actually increase the intensity of negative emotions and cause an individual to engage in maladaptive behavioral emotion regulation strategies (behavioral dysregulation) in order to down-regulate these intense emotions.

In essence, the way we regulate our emotions may actually cause us to lose control of them. These are often  considered “impulsive” behaviors, without premeditation. While not a behavioral emotion regulation strategy per se, urgency may be part of what causes certain individuals to engage in behavioral dysregulation. Individuals who exhibit high levels of urgency, feeling the need to act when faced with emotional distress, may be more likely to engage in maladaptive behaviors such as substance abuse as a result of emotion dysregulation.

The best characterized cognitive emotion regulation strategy is rumination. Rumination (5) is the tendency to repetitively think about the causes, situational factors, and consequences of one’s emotional experience.  Rumination is an important risk factor for substance abuse (10)

Thought suppression is another emotion regulation strategy as is catastrophizing (11) the tendency to continuously think about how bad a situation is and the negative effects that the current situation has on the future. Using catastrophizing as an emotion regulation strategy has been found to increase emotional distress (12)

All of the cognitive emotion strategies discussed (rumination, thought suppression, and catastrophizing) appear to have a common theme: they all focus attention on emotionally relevant stimuli, usually negative.

Furthermore, evidence has shown that ruminative processes tend to amplify the effect of negative affect.

Yet the tendency to ruminate on negative emotional thoughts increases levels of negative affect, and in turn the increase in negative affect increases levels of rumination followed by a flood of racing negative emotional thoughts, which in turn increase levels of negative affect in a vicious, repetitive cycle – an emotional cascade.

As a recovering alcoholic, this rumination and catastrophizing is very similar to what we call resentments the constant resending of negative emotions and accompany thoughts, each cycle making the emotions and thoughts more distressing.

Mixed with the self elaboration we discussed in another blog, then more has a heady cocktail of distressing resentments.

As the Big Book of Alcoholics Anonymous says “resentments kill more alcoholics than anything else”

It is thus difficult to see alcoholism as anything other than a disorder of emotional regulation.

References

1. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review, 30(2), 217-237.

2. Berking, M., Margraf, M., Ebert, D., Wupperman, P., Hofmann, S. G., & Junghanns, K. (2011). Deficits in emotion-regulation skills predict alcohol use during and after cognitive–behavioral therapy for alcohol dependence. Journal of consulting and clinical psychology, 79(3), 307.

3.  Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

4.  Bradley, B., DeFife, J. A., Guarnaccia, C., Phifer, J., Fani, N., Ressler, K. J., & Westen, D. (2011). Emotion dysregulation and negative affect: Association with psychiatric symptoms. Journal of Clinical Psychiatry, 72(5), 685-691.

5. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal
Psychology, 100(4), 555–561.

6. Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality
and Social Psychology, 53, 5–13.

7.  Anestis, M. D., Selby, E. A., Fink, E., & Joiner, T. E. (2007). The multifaceted role of distress tolerance in dysregulated eating behaviors.
International Journal of Eating Disorders, 40, 718–726.

8. Whiteside, S. P., & Lynam, D. R. (2001). The five-factor model and impulsivity: Using a structural model of personality to understand
impulsivity. Personality and Individual Differences, 30, 669–689.

9. Selby, E. A., Anestis, M. D., & Joiner, T. E. (2008). Understanding the relationship between emotional and behavioral dysregulation: Emotional cascades. Behaviour Research and Therapy, 46(5), 593-611.

10. Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of abnormal psychology, 116(1), 198.

11. Garfnefski, N., Kraaij, V., & Spinhoven, P. (2001). Negative life events, cognitive emotion regulation, and emotional problems.
Personality and Individual Differences, 30, 1311–1327.

12.  Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The pain catastrophizing scale: Development and validation. Psychological
Assessment, 7, 524–532.