From a Drinking Problem to a Thinking Problem?

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

 

 

 

Who Wants to be an Alcoholic?

The social stigma of being an alcoholic prevents many from coming into recovery and treating their illness. And it is an illness but it takes time to realise that – a physiological, psychological, emotional, cognitive, behavioural and spiritual disease. It is as profound an illness as one can have.

It is the only illness that actively tells you that you do not have it!

How cunning, baffling and powerful is that!?  

In fact stigma, particular prevalent in the UK as compared to the US, helps kill alcoholics.

We all have ideas of tramp on park benches supping on bottles of alcohol when we think of alcoholics.

I know I did. When I went to my first meeting I thought I would be greeted by park tramps with strings holding their trousers up with food encrusted beards, no teeth and hygiene problems.

I wasn’t greeted by anyone like this.

I was greeted by a teacher, a lawyer, a counsellor, a business man, a builder, a nurse, an actress, among others.  Alcoholism effects every area of life, no strata of life is immune, there are recovering alcoholics everywhere.  The second man to have stepped on the moon is in recovery for alcoholism!

These shiny AA people were not drinking and some had not drank for decades!

Imagine not drinking for ten years and more? I could not imagine ten minutes…but now I am coming up to my tenth birthday in AA.

 

“Most of us have been unwilling to admit we were real alcoholics. No person likes to think he is bodily and mentally different from his fellows” (1)

Neuroscience has demonstrated repeatedly how the brain is taken over by the actions of alcohol and other substances which leave the brain severely restricted in it’s choice of behaviours. Self will has become so compromised we barely have any!?

We become so comprised in our own ability to make decisions that we are often “without mental defence against” drinking.

Alcohol via the alterations in stress and reward (survival) systems in the brain means our illness has literally taken over our brain and calls the shots, does the thinking which leads to the drinking.

We have a thinking disease as well as drinking one by the time we get into recovery.

It is the thinking of this illness, which we mistake for our own, quite understandably, as these thoughts are happening in our own head, that tells us we do not have an alcoholic problem, we do not need to go to an AA meeting, or when we have gone, that we do not need to stay, that we are different to the people at the meeting – that they need this recovery thing not me. I can work this out myself.

Why does it do this?

Why is it constantly chittering away between our ears. It has to be us, surely? Our thoughts can’t have been taken over like some 1960s episode of Star Trek where Captain Kirk and crew are struck down by some thought virus??

If you are new to recovery don’t bend your head over this stuff!

All you have to do is twofold. Get to a meeting and see if your experience of drinking tallies with those there and two, watch out for that motivational voice of alcoholism trying to get you far away from these people.

This is my test to see if you are alcoholic.

This voice of the illness is similar to the voice of OCD and other anxiety disorders which talk to us in thoughts which are contrary to our well being and health. Why?

Because our survival networks in the brain have gone so haywire that these conditions think they are helping us survive by suggesting certain actions which we previously used to reduce distress, i.e.compulsive behaviours, but which take us increasingly into even greater emotional distress and unhealthy behaviours.

They are like an Olympic coach training us to get chronically unwell.

They persist because they have ingrained in our brains unfortunately, possible forever. They are the torturous whispers of our neural ghosts!

They refuse to die but in time these voices become more manageable, the volume on them can be turned down or ignored altogether.

Turning down the distress signal that feeds them is at the key.

You are not alone – “Every natural instinct cries out against the idea of personal  powerlessness.” (2)

This powerlessness led me to surrendering. Paradoxically to win this war we must first surrender.

Surrendering to the idea that I may, possibly, be an alcoholic.

Acceptance of this possibility is the first step.

 

References

 

  1.  Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Services.
  2. Twelve steps and twelve traditions. (1989). New York, NY: Alcoholics Anonymous World Services.

 

Is the “mental obsession” of the Big Book relative to how severe your addiction is?

Involuntary retrieval of drug related thoughts is a hallmark of addicted populations.

Intensity of obsessive thoughts about alcohol predict relapse rate (1), with addicts motivated to use drugs to “silence” obsessive thoughts (2).  The idea that abstinence automatically decreases alcohol-related thoughts is challenged by research (3) and supported by clinical observation that among abstinent alcohol abusers, alcohol-related thoughts and intrusions are the rule rather than exception (4).

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

Modell et al. also point to the potential similarities in underlying neural pathways implicated in the two disorders, suggesting that they may share a similar aetiology. The Obsessive Compulsive Drinking Scale (OCDS) implies that as the severity of this illness progresses, so does the intensity of the obsessive thoughts about alcohol and the compulsive behaviours to use alcohol.

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

Image

 

 

This may also be a reflection of addiction severity too! As addicts and alcoholics become more addictive brain imaging shows a shift in “reward processing” from the ventral striatum to the dorsal striatum. The DS is in charge of more automatic, compulsive reaction.  This shift from VS to DS  may also be marked by an increased emergence of automatic thoughts, which the authors suggested as the cognitive thoughts and images of automatized drug action schemata (2).

In fact, this is demonstrated by correlations indicating that dorsal striatum activation is lowest in participants with low OCDS scores. This means, in simple terms, that more severe addiction may be associated with more intrusive/obsessive thoughts and less severe with less thoughts.  

 

References 

 

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

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

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

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

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

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

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