Chapter 2 – “Things Can Only Get Better”

This is part of a series called “The Bottled Scream” A Disease of Self – Understanding Addiction and Recovery. To go back to the introduction click here.

Addiction

Chapter 2

Things can Ony get Better

It was only when my wife withdrew from me after she had exhausted all possibilities to try and help me—taking me to mental health professionals but with no success—that I asked her for the first time for help. It was the first time I had directly asked for help. Well sort of asked for help. I was in the bathroom under the pretext of having a bath, something I had not done in many months (I had also developed an actual phobia of water, not uncommon in alcoholics). I stood there in front of her, half naked and asked her if she thought I was a bit jaundiced, in an unusual moment of understatement.

Her face retracted with shock, she hadn’t seen me in many weeks as I lived as a crazy recluse in the attic and we rarely saw each other – other than talking through doors and written reminders to buy wine and lots of it! She could hear me clicking bottled wine glass and tins of beer against my teeth as I tried to drink and this had added to her general sense of revulsion and despairing helplessness. Workaholism and fitness addiction had kept her petrified mind together these last months. Most days she would retrun from work wondering if this was the day, the day in which I had finaly killed myself? What unbearable and intolerable strain she must have lived under?

“Jesus, you’re…!” she exclaimed…

“I thought so” I replied. I looked like Homer Simpson with a heavy suntan! With a massive green discoloration snaking around my neck. I already knew I was jaundiced three months earlier when the local shop owner couldn’t contain himself and shouted “look at you, are you ill man!” which is partly why I didn’t go out, the excruciating shame of that and it’s probable repeat and the increasing psychosis, of course. Plus I could barely walk anymore. I knew I was jaundiced I just wanted Emma to know how bad it was and in realising how bad it was, offer to somehow help in a way that had yet to show itself. Or in a direction we had yet to exhaust. We had already tried various therapists to no avail. I was pretty desperate by this stage. Beyond desperation.

Plus, I also couldn’t rely on my half working eyes anymore and anyway, I needed absolute verification. God damn it, I needed help! Needed it months ago! Things were very much worse than I thought. Which, somehow, by this stage, seemed impossible. Emma seemed spurred into action and suggested going to the GP tomorrow. The GP? I was still in psychosis and wondered if he could do a home visit?He couldn’t and the next day in the late afternoon we would drive over the surgery. Getting out of the house had become impossible I lived in fear of someone coming to our home and kept a hammer and monkey wrenches by every door and window, proclaiming to my future imaginery intruders that I was ready for them. Paranoid psychosis isn’t a lot of fun. But it is thorough and leaves you well prepared. Emma had even tried to get me sectioned, put into a mental health institution but they only accepted after suicide attempts or attempted murder and given my current weak physical state, these two scenarios seemed remote. Plus all medicines had long since been stored away by Emma, for obvious reasons.

The GP did, however, make allowance for my deteriorating mental health by suggesting I turn up after practice hours and sneak in through the back doors? This was a blessed relief not having to face the public and their horrified looks. I drank two bottles of wine and slurped down a couple of tins of the strong and disgusting German lager in the car, trying not to throw up, as we waited to be sneaked in to the surgery via the tradesman’s entrance. Emma helped me walk to and in through the back of the surgery where the GP met us.

He listened in some incongruity to us explaining how my drinking had got out of hand, probably spurred on by my tough childhood, my mental health problems and so on. He seemed defensive, his arms across his chest. He was resisting our prognosis. He listened but didn’t seem convinced by our reasons for my drinking so much and bluttered out quite brutally.

“You are an alcoholic man! “Plain and simple, and if you keep drinking like this, you will be dead in a few months!”

Emma and I looked at each other. Of course, he was right. It seems so obvious now but at the time it was an epiphany. Of course I was a bloody alcoholic. I was physically addicted to alcohol, for some that would have been a bit of a giveaway but strangely not me, or, even more strangely, not Emma? A strange fog had settled on her thinking too. The panic attacks and the physosis and muddied the water. How come we hadn’t worked this out ourselves? It was now so obvious.

I wondered why the Drug and Alcohol Centre hadn’t released this too? I had turned up to the noon meeting having drunk two bottles of wine? Some would have seen this as a clue to potential alcoholism? More important than those underlying conditions, they kept talking about. Or the two therapists I had seen over the last three years. One who had seen me for two years and then when I returned subsequently for therapy, told me I didn’t have enough brain left to continue therapy (and how later would say me in recovery if I had suddenly decided to be a good boy when she learnt of my recovery!) and another who insisted I listen to white noise around the clock to treat the trauma that was obviously leading to my excess drinking. Obviously, it increased my drinking. Didn’t people know anything about alcoholism or addiction? How could the therapeutic world be so ignorant. Almost willfully ignorant!

Another terrible irony of this whole scenario, is that the GP I saw was only filling in for my usual local GP, who had failed in seven years to realise I was alcoholic, choosing instead to treat me with anti depressants for my depression and anxiety! If he had been there that day, I wouldn’t be here today. That is the terrible truth! He would not have said what this GP had just said, that I was an alcoholic! He probably would have tried to give me more medication. In the months that followed, he would try to dissuade me going to a local 12 step facilitated treatment centre because he thought it was too draconian. Not as draconian as chronic alcoholism though!? He, like most of the so-called professionals I saw, would treat me for something other than alcoholism, wondering if my drinking was linked to some other mental health issue.

They all failed to see that the mental health issue that I was suffering from, and that was going to kill me quicker than any other possible disorder, was my chronic alcoholism, my chronic addiction. I wouldn’t have any chance of treating any other mental health issue unless I dealt first with my addiction to alcohol. I still contend today that those individuals with addiction do not get any less addicted when they have treated other co-occurring conditions. The severity and complexity of their addiction may alter but they will remain addicted people in recovery.

As I show later treating these other conditions helps tremendously with recovery form addiction. I hope to explain, one condition feeds into another and they all have to be treated in the whole. Starting with addiction first! Start with the condition most like to kill you, and work backwards from there!

Chapter 1 “Rock Bottom”

This is part of a series called “The Bottled Scream” A Disease of Self – Understanding Addiction and Recovery. To go back to the introduction click here.

Addiction

Chapter 1

Rock Bottom

My alcoholism almost killed me. I had spent the last nine months in alcoholic psychosis, the so-called DTs (delirium tremems) hallucinating, drinking and vomiting, repeat.

I could hardly get the drink to my mouth with my violently shaking hands. Tin and glass, cracking against my teeth. I was so jaundiced my neck had turned a dark sickly shade of copper green! My eyesight deteriorated to such an extent, that it was about like straining to see through scratched plastic glass. Eyesight is linked to liver and my fatty liver had reduced by eyesight by half.

I was so weak from drinking, not eating, a 8 and half stone weakling, who had to stop on the stairs, every three steps, to rest and start again. Sleep had been replaced by twenty minute snoozes, awoken by terror and the dripping sweats. How the hell had it come to this?

I had planned none of it. I thought of death and of suicide. There was a place worse than dying and I had somehow ended up there. All plans on killing myself foundered on my angrily held assertion to myself that I hadn’t asked for any of this. None of this was my fault! That indignation was as close as I could get to hope, which had recently left home. I drank because of my bloody tough upbringing, didn’t I, and that wasn’t my fault either? Many had had similar upbringing and they weren’t slipping down the plughole along with my stomach-heated up wine? Why me? Why the hell was I in this hellish hole of despair and utter defeat?

Worse still the drink had stopped working, only staving off the full horror of the hallucination and preventing me from having the alcoholic fit that would kill me.My wife would travel to the shops, reluctantly buy grates full of cheap Spanish wine and almost undrinkabe German lager that tasted like liquid Gorgonzola, unwittingly keep me alive. We were both ignorant of the reality that any prolonged period without drink could have killed me. That a diversion from the straight road home, after shopping , or a car accident, or some other unavoidable occurrence that slowed the delivery of my alcohol, could have killed me via an alcoholic seizure.

My wife hated spending all that money on drink that rarely stayed long in my stomach. People would shout over to her as she waited at the till “Having another party!?” Little did they ever know how far they were from the truth.

Read more about Rock Bottom in my earlier Blog Post from 2016 “Do we Really have to Hit Rock Bottom to Recover?” here

“The Bottled Scream” A Disease of Self – Understanding Addiction and Recovery

Introduction

Getting To the Root of All Our Troubles

I was born into trauma and know no different.

Trauma, with a helping of genetic disposition, gave birth to addiction and alcoholism which it then used to try and kill me. It led be to a place that I strongly believe was worse than dying. Eventually it has led to a place, and a way of life, which I would have scarcely believed existed.

This is a book about my journey though alcoholism, addiction, complex PTSD ( and related OCD) and my continued recovery from these conditions, via 12 step recovery and treatment centres, neuroscientific research and trauma therapy. It is about how I have survived addiction and, at times, recovery.

Recovery can kill you too; other peoples’ views and understanding of alcoholism has a bearing on whether you live or die. Their lack of understanding about co-occurring disorders can too. This may be unpalatable to some but it doesn’t make it less true. These people can include fellow recovering people and recovery groups (while acknowledging their crucial role in recovery), medical professionals, those working in treatment, your loved ones and many other professionals who deal with addicted individuals on a daily basis and the media.

The more each of these groups know more precisely the nature of addiction, what caused it and how this can be recovered from, via specific and appropriate, sometimes individualised, treatment, the better they can help people in recovery.

We tend to blame addicted individuals for not recovering rather those helping to treat them or giving medical advice. Or those whose responsibility it is to provide clear understanding into the nature of addiction. Society continues to create stigmas in the absence of a common knowledge about these conditions. Stigmas blossom in ignorance.

Clarity of understanding leads to a compassion that simply wilts in it’s absence.

I have experienced much of this ignorance in my own recovery and have been moved to challenge it now in this book. I have found medical and treatment professionals and those in recovery to be lacking in precise definitions and the consequences are profound. It seems that the precise definitions of other chronic diseases, seen elsewhere in medicine, is somehow not as important in addiction, a condition that remains one of the worst killers.

So let’s start here with a clear definition of addiction and what causes it and then show how this manifests in the life of one alcoholic/addict.

Addiction is the progressive impairment of self control (regulation). This can be mapped in the brain and addiction has a brain signature.

It is driven, to endpoint addiction, by the effects of emotion/stress dysregulation (which itself is often prompted and often sustained by negative self schema, often post traumatic ) on reward (motivation) dysfunction.

In simple terms, most addicted individuals cannot process emotion properly and this causes them to flee feelings by substituting unpleasant, undifferentiated, feeling states with more controllable feelings of pleasure and relief from aversive feeling states. It represents the “fixing of feelings” externally, outside of self, as opposed to emotions being processed internally, in the brain . This is negative and positive reinforcement combined at the very onset.

This represents a defective and disordered survival network, an embryonic neurobiological disease state, as it represents a disorder of function, emotion processing, which will eventually create a distinctive group of neurobiological changes, and thus, unwittingly, create the fertile ground for later addictive behaviour.

As emotion/stress dysregulaton escalates, the inital prompting of impulsive behaviour increasingly becomes compulsive addictive behaviour as increasing and continual levels of distress increase reward dysfunction and a patholical wanting (needing) results.

At the endpoint of addiction, the rewarding and relieving effects of addictive behaviour diminish in relation to chronic distress levels and even increasing levels of addictive behaviour no longer have sufficient effect on what often becomes compulsive behaviour; this automatic behaviour to relieve chronic distress yields increasingly diminished returns.

The addictive behaviour as “solution” profoundly diminishes while the “problem” of chronic emotion/stress dysregulation escalates.

Recovery is often particularly viable at this point and needs to address the cessation of the former “solution” with treatment of the underlying problem – emotion/stress dysregulation, the pathomechanism of this addictive behaviour.

This emotion disorder and thus impairment of self regulation, often born out of genetic disposition and/or environmental trauma, is the pathomechanism that drives addictive behaviour, not only in substance addiction but also in behaviour addictions. It can be diagnosed, it can be tested for. It need not be shrouded in mystery.

It need not be endlessly argued over. It is inherent in most addictive behaviour and it can be easily treated.

In this book, I will show how I came to be in recovery after almost dying from alcoholism. I will show my struggles in recovery and with the recovery programmes I have followed.

Leaving the 12 step recovery that saved my life, and which still offers me a template of recovery today, was very frightening but I felt I had no choice. Through neuroscientific research and, eventually, trauma therapy, I have been like a detective piecing the clues together to better understand my condition. To understand how I ended up the way I did. It has not only helped me more clearly understand my addiction, and the trauma that partly underlies it, but it has often saved my life.

The outside help I received in addition to 12 step recovery has not been an adjunct to addiction but has shown me the fertile soil in which my addiction grew. It showed me what partly fuels my addiction today, seventeen years into recovery. It shows me why my addiction still continues to be progressive, even in recovery.

Recovery has been discovery, often thrilling, often terrifying. It continues to be so today. Let me take you on that journey from despair to hope, from ignorance to understanding.

Let me take you through my traumatic childhood and life, through alcoholism and addiction to recovery. Through 12 step recovery and treatment to the research and trauma therapy to a new understanding that reconciles all treatment and arms it with greater clarity and understanding.

Structure of this project This book is split into three distinct parts – Addiction, Trauma and Recovery. These can be read separately, in order, or not, or concurrently. They interweave in their influence on my addiction and recovery. One feeds into the other, as in real life. In both parts I will marry my anecdotal and neuroscientific research into the nature of my addiction.

In this first part I will share my journey into recovery from chronic alcoholism, looking at what happened to bring me into recovery and what has happened in the seventeen years of my recovery

In recovery, I have journeyed through six years of 12 step recovery and AA anecdotal wisdom about addiction and recovery to twelve years of neuroscientific research into understanding how the brain changes as a result of addiction and what, in addition to substances, accounts for this dramatic change in how the brain controls our behaviours.

Via this research where early understandings of addiction have been both complemented and challenged, resulting in a clearer insight into how addiction can effectively be treated.

Although this research gradually saw me gradually move away from 12 step recovery (although I still follow the steps on a daily basis) , my research also shows, in a more profound way, how this type of recovery is key to helping addicted individuals recover.

Finally the experiential wisdom of 12 step recovery has become more effectively married to the most recent neurosicentific research so I believe it is time, as Bill Wilson, co-founder of Alcoholics Anonymous, once declared, to be “friends with our friends”.

In fact, Bill Wilson has been a constant inspiration for me in my research, he was constantly striving learn more about addiction via his work with academics and would be, no doubt, fascinated by what neuroscience has unearthed about this strange illness of mind and body. He was also worried that 12 step recovery was based on a book “frozen in time”; I hope to unfreeze some of our understanding in this book. In the Big Book of Alcoholics Anonymous it also suggests people in recovery should get “outside help” for conditions other than alcoholism, or co-occuring conditions as they are called today.

After ten years, I found that I needed to get treatment for Complex PTSD and attachment trauma as they were threatening my recovery. Thus the second part of this book is dedicated to Trauma and starts with my experience of trauma from childhood onwards until I started treatment for it at the age of 48 years old, ten years after seeking recovery from chronic alcoholism.

I will then explain the treatment I had before taking you on part of the actual therapeutic journey I undertook to get more healed. This is the part of my “experience , strength and hope” sharing how trauma, in the fertile soil of family addiction, led to my later chronic alcoholism. The complexity and severity of my alcoholism was caused by Complex PSTD and it’s treatment has greatly reduced the severity and complexity of my alcoholism while in recovery.

Although alcoholism and trauma are two tributaries running into the same river, I hope by clearly delineating them, the reader, and those who suffer from similar co-occuring conditions, can more clearly see how they influence each other and how they may need, at times, separate, and common, treatment in recovery. The treatment of one affects the recovery of the other has been my experience. This is my message of hope to you.

This is a work in progress and I am adding chapters all the time. I’m afraid that my chapter numbers might change or just be plain wrong as I revise the text. I will try an keep up double checking the indexing but organisation is a weak point of mine, so please bear with me!

Here a few links to posts on the following:- Addiction, Trauma and Recovery.

There is a map of Emotional Responding Tattooed on my Heart.

When I was doing my step four inventory as part of my 12 step programme of recovery I did it pretty much as suggested in the Big Book.

My sponsor at the time asked me to do an additional part that is not explicitly mentioned in the Big Book.

He said to list all the negative emotions (or defects of character) that I had been in the grip of and exhibiting in relation to my various misdemeanors and the resentments I had held against various people and institutions over the preceding decades.

This turned out to be a brilliant idea for two reasons.

First it showed me that I held a multitude of resentments because I had a problem of emotion regulation.

I did not realise that the engine driving this emotion dysregulation was chronic shame.

I realised when doing my step 4 that that I had not previously been able to leave various supposed slights and abuses from my past in the past because I did not have the emotional maturity to look at these episodes reasonably and objectively.

In other words, I had not processed these episodes emotionally and embedded these events in my long term memory like healthy more emotionally mature people do.

Hence when I came into recovery I had hundreds and hundreds of resentments swirling around my mind, poisoning my thoughts and sending constant emotional daggers into my heart.

My past constantly assailed me emotionally, randomly attacking my mind.

My step 4 and then 5 showed me that I did not have the natural ability to deal with my negative emotions.

Secondly, listing all the negative emotions I had when I held a resentment against someone was very revealing in that when I held a resentment, any resentment, and against a wide variety of people, the negative emotions listed where generally the same! In fact they were all interlinking in a pattern of emotional reacting, one activating the other. It was like a emotion web that ensnared one in increasingly frustrating states of emotional distress and inappropriate responding.

This was quite a revelation!? That I respond in exactly the same way to my sense of self being threatened?

That there was a map of emotional responding tattooed on my heart.

I was drawing up a web of my emotional dysregulation, a route map of all the wrong ways to go, to emotional cul de sacs.

It was a list of the negative emotions which appear always when I felt anger and resentment against someone for hurting me and my feelings.

Just as revealing where the negative emotions listed which clearly showed how I react, and can still react to people who I believe have caused my hurt or rejection.

In fact it seems now that I treat all insult, intentional or otherwise, in a very similar way.

I have spent years trying to work our why?

I got as far as deciding it was an inherent problem with processing negative emotions, which it is.

However, there seems to be a problem specifically with a patterned mesh of negative emotions which are activated when someone upsets me.

In fact I think this pattern of interlinked negative emotions occurs simply because of inability to identify, label and share the simple fact that I have been upset by what someone has said or acted towards me.

“Shame is a fear-based internal state being, accompanied by beliefs of being unworthy and basically unlovable. Shame is a primary emotion that conjures up brief, intense painful feelings and a fundamental sense of inadequacy. Shame experiences bring forth beliefs of “I am a failure” and “I am bad” which are a threat to the integrity of the self. This perceived deficit of being bad is so humiliating and disgraceful that there is a need to protect and hide the flawed self from others. Fears of being vulnerable, found out, exposed and further humiliated are paramount. Feelings of shame shut people down so that they can distance from the internal painful state of hopelessness.”

“… unacknowledged thoughts and feelings become repressed and surface later through substitute emotions and dysfunctional behavior. Other emotions are substituted to hide the shame and maintain self esteem. Anger, exaggerated pride, anxiety and helplessness are substituted to keep from feeling the total blackness of being bad. The buried shame is expressed through defense mechanisms that shield negative unconscious material from surfacing.

Anger responses are modeled and learned in some families. The anger response is more comfortable than feeling the shame for some individuals. Families where coercive and humiliating methods of discipline are used develop children who are shame prone. Behavior become driven by defenses that function to keep from feeling bad. Reality becomes distorted to further protect the self from poor self esteem. The transfer of blame to someone else is an indicator of internal shame.

Children who live with constant hostility and criticism learn to defend against the bad feelings inside and externalize blame on others. External assignment of blame is a defense against shame. People who are super critical have a heavy shame core inside.”

I was working with someone last year and we had a disagreement and this guy said to me “I am upset” and “You have hurt my feelings” I was taken aback. I thought I never say things like that. This guy was an Olympic champion at expressing how he feels compared to me. I never say I am upset because it also seems to be an undifferentiated emotion that I have trouble accessing, mentalising and expressing.

I have not been taught as a child or since to simply say I am upset.

Instead of acting on my upset by saying to someone, you have hurt my feelings I do the opposite, I react and attack them in my head, my thoughts, my words and sometimes in my actions. Sometimes I “get them back” somehow. I make them pay in some way.

Honesty is the heart of recovery and I am being honest. The years of recovery reveal many different things, some of them not so palatable.

I grew up in a family that did not express emotions like the ones I had mentioned. We reacted via anger and put downs hence I have grown up to be dismissive.

My dismissiveness and my arrogance are parts of defence mechanism against rejection, they guard my inherent sense of shame. I am full of shame, more so than fear, although these two overlap. Shame is in fact fear evoking.

I hide my shame away under an anger of emotional hostility, stay away or else! I will get you back somehow. Sometimes I am in shame and offend via my attitudes.

I also have other ways of reacting in an emotionally unhealthy way that my step 4 showed.

If someone hurts me, according to my step 4, my angry resentment of what they have said or done makes me ashamed. This can quickly prick my sense of self pity (uselessness and hopelessness) which is something I have always rage against (rage is an essential part of shame plus I rally against this feeling of powerlessness) and I retaliated via excessive pride (I am better than you, I will put you down and see how you like it!) I put you down in my mind or through the words uttered from my mouth by arrogance, dismissiveness, impatience and intolerance.

I do so because I am being dishonest and fearful.

I do some because I am self centred and selfish.

These are all parts of my emotionally entangled web that is spun when I react to some sense of rejection.

Sometimes the shame persists for some time and I try to relieve it by behavioral addictions, too much shopping, too much eating, too much objectification of the opposite sex.

Not enough action, or effort to change my feelings in a healthy manner.

My step 4 showed me this is the unhealthy fruit of my greed, gluttony, my lust, my sloth.

My spiritual malady.

Add in perfectionism because that is the quick way to do nothing, a fear of failure that paralyses.

These are my main negative emotional reactions to the world that often scare me and make me feel ashamed.

I have felt powerless via your comments so try to to steal some power back by making my self seem more powerful over you.

I respond to feelings of humiliation by humiliating you, I react to my chronic shame by attempting to created shame in you.

Some days I react more adversely than others.

For example, this family have just moved into my neighbourhood, they seem wild and out of control.

I am not only fearful (leading to dishonesty in my thinking, catastrophizing, intolerance of uncertainty about how they will behave etc) I have reacted to their arrival via shame based defence mechanisms and reactions. I am shamed and disgusted that my neighourhood has come to this. I am dismissive of them, intolerant, impatient and arrogant towards them. All shame based reactions.

Last night the police were called to their home and one of them was handcuffed and put in the back of the police van.

My head went “I told you so!”

It was a very shameful scene for the whole family.

When things had died down and calm restored I spent the evening not in my fear or shame but in empathy and compassion.

How embarrassing for them how shameful.

I relate to them as they are out of control, my family was at varying times completely out of control too, traumatic and this is what has created a chronic shame in me, even still now after 10 years of recovery!

My shame responded and related to their shame.

Nobody wants to be out of control, to be teetering on the verge of the next disaster, the next moving of home, the next calling of the police, the next swirling carousel of unmanageabiilty.

No one.

I related and all my negative emotions retreated to source like a evening tide on a beach.

I relate to my fellow human beings when I am not in fear or shame.

When I am in fear and shame the same pattern of negative reactions entrap my heart in its’ poisonous grip and I react in a way I would not choose to, if more reasonable.

This is what the heart of my alcholism looks like. Not a pretty sight some days.

The most beautiful thing about me most days is the fruits of my recovery.

Now at least I can see how I react and can take steps to deal with it.

I have a spiritual tool kit that deals with this emotional disease.

Whether I stay in fear or shame is now my choice. A choice I once did not seem to have.

This is what recovery has given to me.

I do not have to cultivate my own misery through blind reaction.

Via an Amazing Grace I can now see what ails me.

Via AA I now have the tools, never taught to me in my family or in my troubled home environment.

I have gone home in AA. I learnt an attachment to those in AA and others.

I share my feelings of shame with those who know what that feels like.

Together we share our pain and we recover.

Reference

1. http://www.angriesout.com/teach8.htm

How Far Have We Come In Understanding this “Spiritual Malady” of Alcoholism?

In our previous blog we wondered if some commentators, who have co-occurring disorders may be puzzled at how having a “spiritual malady” could be related in any way to have a co-occurring condition?

This is a pretty valid question?

In fact this may be at the heart of the issue in many cases of feeling the need to take medication for so-called co-occurring conditions?

Seeing alcoholism as partly the product of a spiritual malady, instead of the affective disorder I believe it to be, may influence certain AAs to seek additional help for supposed additional conditions when the manifestation of these conditions may actually be part of the emotional disorder of alcoholism?

It is at least worth considering?

For me sometimes there is a confusion with what is perceived to be a spiritual malady?

I do not believe I have the same type of spiritual malady as my wife for example who is an normie, earthling, normal person (whatever that is?) I believe, if any thing I have a super enhanced, at times turbo-charged, spiritual malady, often fuelled by stress/distress, as the result of my alcoholism.

I do not believe I have the same spiritual malady as other normal people such as those people who were in the Oxford Group.

That is not to say that normal people cannot be full of sin – a cursory look around the work and it’s events will soon confirm this is the case. What I am saying is that they do not have the emotion dysregulation or fear based responding that I seem to have which often prompts “sin”.

By sin I mean negative emotions that cause distress to me and others.

For example, false pride, intolerance, impatience, arrogance, shame, lust, gluttony, greed. Yes these all create distress.

The spiritual principles of AA and the 12 steps in particular were drawn from the 4 absolutes of the Oxford group, via initially the 6 steps and the idea of a spiritual malady is also borrowed from the Oxford group.

I have for several years wondered if the spiritual malady described in the Big Book adequate or accurate enough in describing what I suffer from.

I believe others have difficulties in reconciling the spiritual malady of the Big Book with their own alcoholism, addiction and co-occurring conditions?

Part of the problem may lie in not being specific enough about what alcoholism is.

It may be that research and the world have not progressed far enough to give a comprehensive account of what alcoholism is. Also the spiritual malady concept of AA has for 80 years helped millions of people recover from this most profound of conditions? So why change it if it’s not broke?

That is a good point? I am not advocating changing anything, I hope AA recovery remains as it is for 80 more years and much more years. I would not change one word in the first 164 pages of the BB.

However, many AAs ignore the spiritual malady thing completely, or do not do the steps, so, in my opinion, they often do not properly understand what they suffer from?

The magic of the the steps is that they seem to reveal the patterns of behaviour that our actions have prompted over the course of our lives. Maladaptive behaviours I should add. It helps us see ourselves and our condition of alcoholism and how it effects us and others.

It shows the areas of behaviour and attitudes that can be treated by working the steps. It shows us how our approach to life can possibly be transformed for the better.

For me personally it often showed a pattern of emotional responding to events that do not go my way!!?

As Bill Wilson once wrote we suffer when we cannot not get what we want or others seem to prevent us getting what we want.

My inventory of steps 4/5 showed me that my long lists of resentments were mainly the product of emotional immaturity and responding in an immature manner to not getting my way.

My inventory showed me also that I did not seem to have the facility previously to emotionally respond to the world in a mature way. As the world dominated me.

My recovery has thus since been about “growing up” a bit, however unsuccessful I am in this pursuit on occasion.

I have often written that this inherent emotional immaturity may even be linked to the possibility that the areas of my brain that regulate emotions have not matured properly as alcoholic seem to have different connectivity, functionality and morphology (size/volume) in this emotion regulation circuit/network to healthy normal people.

Alcoholics seem not to be able to fully process emotional information externally, i.e reading emotion expression of faces accurately, or internally reading what emotions we are having, or even whether we are hungry or tired!

So we have issues with emotions and somatic/body feeling states. This is perhaps compounded by most of us having experienced abuse or maltreatment which can also lead to alexithymic characteristics such as not being able to label or describe, verbally, emotional states we are experiencing – although we can be good at intellectualising these emotions – which is not the same as processing them.

Alcoholics and children of alcoholics have a tendency to avoid emotions (use avoidant coping strategies) in fact and to use emotional reasoning when arguing a point.

These emotion processing deficits also appear to make us more impulsive, and to choose lesser short term gain over greater long term gain in decision making. It can lead to a distress feeling state that can make us fear based, perfectionist, have catastrophic thoughts, intolerance of uncertainty, low frustration and distress tolerance, be reactionary, moody, and immature in our emotional responding.

But how has any of this got anything to do with the so-called spiritual malady we are suppose to suffer from?

I believe the spiritual malady mixed with the ancedotal evidence throughout the BiG Book hints at these emotional difficulties as being an intrinsic part of our alcoholism, “We were having trouble with personal relationships, we couldn’t control our emotional natures, we were a prey to misery and depression, we couldn’t make a living, we had a feeling of uselessness, we were full of fear, we were unhappy…”

It was 80 years ago, so our knowledge base has moved on greatly from when the Big Book was written. Hence I believe we should appreciate that this definition of our condition has been updated by research into emotions especially in the last 20 years.

I am happy to say a spiritual malady is what we suffer from, as the steps provide a solution to my emotion disorder by treating it as a spiritual malady but I do not think it is the straightforward spiritual malady adopted by AA from the Oxford Group, mainly because in the majority of situations I do not choose to sin, the sinning seems to happen to me. In other words it is the consequence of my fear based condition, this affective disorder.

The Oxford Group explain a general spiritual malady that all people can have. I do not think alcoholics are like all people. We are human beings, but extreme versions of human beings. I believe, even when I try my best to be virtuous and holy, I could sin at the sinning Olympics for my country. I am that naturally good at it!

I sin so naturally, effortlessly and usually without even trying. I believe my so-called defects of character are linked to my underlying emotional disorder of alcoholism.

Sins I believe are the poisoned fruit of fear, often helped along in alcoholics by false pride, shame and guilt. These defects are related to me being an alcoholic, they are intrinsic to my condition.

In order to illustrate how I believe my spiritual malady is the consequence of my emotional disorder, called alcoholism/addiction first let’s go back to where this idea of spiritual malady came from.

According to a wonderful pamphlet “What is the Oxford Group” written by The Layman With a Notebook ” Sin can kill not only the soul but mind, talents, and happiness as surely as a malignant physical disease can kill the body…

Sin is a disease with consequences we cannot foretell or judge; it is as contagious as any contagious disease our bodies may suffer from. The sin we commit within this hour may have unforeseen dire consequences even after we have long ceased to draw living breath…

…Like physical disease Sin needs antiseptics to prevent it from spreading; the soul needs cleaning as much as the body needs it…

Unhappiness to us and others, discontent, and, frequently, mental and bodily ill health are the direct results of Sin.

…Morbidity of mind must affect the physical health. If we can be absolutely truthful to ourselves we can analyse our sins for ourselves and trace their mental and physical effects. Sins can dominate us mentally and physically until we are their abject slaves. We cannot get rid of them by deciding to think no more about them; they never leave us of their own accord, and unless they are cut out by a decided surgical spiritual operation which will destroy them, roots and all, and set us free from their killing obsession, they grow in time like a deadly moss within us until we become warped in outlook not only towards others but towards ourselves….”

One can see how this concept of sin disease or in other words spiritual malady could be and was applied to early AA and incorporated into the Big Book of AA.

However, it is equally stating, I believe, that alcoholics suffer from the same spiritual malady as other people but our spiritual malady has led to chronic alcoholism, this is the manner in which sin has dominated “mentally and physically until we are their abject slaves”.

In fact the Big book’s first chapters look more at the manifestation of this malady, problem drinking, than the malady. It suggests that there is more than this malady, there is also a physical reason for alcoholism- an allergy (or abnormal reaction) to alcohol. So this is a departure from the Oxford Group as it clearly states that alcoholism is more than a spiritual malady. It is not simply the consequence of this spiritual malady although this malady may contribute. So is this saying some of us are spiritually ill while also having an abnormal reaction to alcohol?

In the foreword The Doctor’s Opinion suggests that “the body of the alcoholic is quite as abnormal as his mind.” and a first mention of a disorder more than “spiritual” is suggested, “It did not satisfy us to be told that we could not control our drinking just because we were maladjusted to life, that we were in full flight from reality, or were outright mental defectives. These things were true to some extent, in fact, to a considerable extent with some of us. (my emphasis)

“The doctor’s theory that we have an allergy to alcohol interests us…as ex-problem drinkers, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account.”

“the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker.”

Here we have an abnormal reaction to alcohol and for some alcoholics a maladjustment to life.

For me this maladjustment to life is not exactly the same as the spiritual disease mentioned in the Oxford Group pamphlet.

All of my academic research in the last 6 years has explored the possibility that this “maladjustment to life” is more than a spiritual malady, i.e. it is not simply the consequence of Sin but the result of abnormal responding, emotionally (which has obvious consequences for sinning) to life.

This emotion dysregulation, as I name it, has consequences for how we feel about ourselves, how we interact with people, how much we feel we belong, how rewarding alcohol and drugs are, how much these substances make us feel better about ourselves (fix our feelings ) and how they turn off the internal critic of maladaptive and negative self schemas.

In fact our first “spiritual” wakening was probably the result of drinking as it transformed how we felt about ourselves and the world in which we lived. I know it did for me. In fact, I felt “more me” when I drank, it was like I escaped a restrictive sense of self to be a more expansive, people loving self. I had a connection with the world I could not generate myself, when sober.

I was a “spirit awakening” if nothing else? It is interesting that a common definition of “spiritual” as it relates to AA, is a sense of connection with others.

As the BB states “Men and women drink essentially because they like the effect produced by alcohol. The sensation is so elusive that, while they admit it is injurious, they cannot after a time differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks—”

For me this section is saying our emotion dysregulation leads to feelings of being “restless, irritable and discontented” which prompt a return to drinking.

The Doctor’s Opinion even offers some classifications of alcoholics “The classification of alcoholics seems most difficult, and in much detail is outside the scope of this book. There are, of course, the psychopaths who are emotionally unstable… the manic-depressive type, who is, perhaps, the least understood by his friends, and about whom a whole chapter could be written.”

This section would appear to be stating clearly that there alcoholics who have other (co-occurring) conditions or conditions appearing as co-occurring?

I contend that alcoholism is an emotional disorder which results in chemical dependency on the substance of alcohol. However in order to treat it we have to first contend with the symptomatic manifestation of this disorder, chronic alcohol use, as it is the most life threatening aspect of this disorder when we present our selves at AA.

What we used once to regulate negative emotions and a sense of self has eventually come to regulate our emotions to such an extent that any distress leads to the compulsive response of drinking. Alcoholics had become a compulsive disorder to relief distress not to induce pleasure.

The “spiritual malady” of the Oxford group seems enhanced in me, I believe I sin more than normal people because of my emotional immaturity and reactivity. My “loss of control” over drinking is also linked to emotion processing difficulties as it prompted impulsive, uninhibited drinking.

This emotional immaturity is referenced throughout the Big Book I believe.

“… He begins to think life doesn’t treat him right. He decides to exert himself more. He becomes, on the next occasion, still more demanding or gracious, as the case may be. Still the play does not suit him. Admitting he may be somewhat at fault, he is sure that other people are more to blame. He becomes angry, indignant, self-pitying. ”

“Whatever our protestations, are not most of us concerned with ourselves, our resentments, or our self-pity? Selfishness—self-centeredness! That, we think, is the root of our troubles. Driven by a hundred forms of fear, self-delusion, self-seeking, and self-pity, we step on the toes of our fellows and they retaliate. ”

“So our troubles, we think, are basically of our own making. They arise out of ourselves…”

“…Our liquor was but a symptom…”

“Resentment is the ”number one“ offender. It destroys more alcoholics than anything else. From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick.”

For me this is saying that out of my emotion dysregulation “stem all forms of spiritual disease”.

It then talks of the fear that “was an evil and corroding thread; the fabric of our existence was shot through with it. ”

The list of emotional difficulties continues throughout the Big book’s first 164 pages.

One of the earliest studies on AA members concluded that they were linked in commonality by two variables, emotional immaturity and grandiosity! I would contend that grandiosity is a part of emotional immaturity. I also contend that our “maladjustment to life” is based on emotional immaturity which is in itself a function of emotion regulation and processing deficits.

A book titled Matt Talbot by Morgan Costelloe has cites this reference – “American authorities on alcoholism hold that the following psychological traits are commonly found in alcoholics:

> 1. A high level of anxiety in interpersonal relations
> 2. Emotional immaturity
> 3. Ambivalence towards authority
> 4. Low frustration tolerance
> 5. Low self-esteem
> 6. Perfectionism
> 7. Guilt
> 8. Feelings of isolation”

The list is almost word-for-word identical with one in Howard Clinebell’s
“Understanding and Counseling the Alcoholic” p 53 of the revised edition of 1968 (the original edition appeared in 1956), the only difference being that Clinebell included grandiosity and compulsiveness.

Years after the Big Book Bill Wilson wrote about this emotion immaturity in the guise of discussing emotional sobriety, for me what he is saying that our emotional difficulties are present in long term recovery and need to be addressed – in other words there is more to alcoholism than sinning and drinking. What we are left with after the steps is ongoing and underlying difficulties with living life on life’s terms because we are emotionally immature. This I believe also preceded our drinking, for many of us anyway?

For many recovering alcoholics this may be another unpalatable truth, that they have issues with emotional responding, with being emotionally mature. If further validation is required I suggest a frank conversation with a loved one, wife, husband, child, parent, etc.

Here is what Bill Wilson wrote ” Those adolescent urges that so many of us have for top approval, perfect security, and perfect romance—urges quite appropriate to age seventeen—prove to be an impossible way of life when we are at age forty-seven or fifty-seven. Since AA began, I’ve taken immense wallops in all these areas because of my failure to grow up, emotionally and spiritually”. (my emphasis)

Bill continues “Suddenly I realized what the matter was. My basic flaw had always been dependence – almost absolute dependence – on people or circumstances to supply me with prestige, security, and the like. Failing to get these things according to my perfectionist dreams and specifications, I had fought for them. And when defeat came, so did my depression.”

” Emotional and instinctual satisfactions, I saw, were really the extra dividends of having love, offering love, and expressing a love appropriate to each relation of life… I was victimized by false dependencies… For my dependency meant demand—a demand for the possession and control of the people and the conditions surrounding me.”

For me this is emotional immaturity, regulating ones emotions and distress via external dependencies on others, demanding in an immature manner that others do one’s bidding?

I would suggest in relation to the issue of co-morbidities that one try to deal with these alcoholism related issues and then see if there are any other to deal with afterwards. For me, as someone who has been treated for anxiety and depression prior to recovery the 12 steps appear to have treated these as emotional consequences of my underlying condition of emotion dysregulation which I call alcoholism.

I think part of the issue is whether doctors, who know in my experience often know next to nothing generally about alcoholism, can always properly diagnose depression and anxiety in someone suffering from alcoholism?

I also think the issues are complicate because alcoholism have some many similarities to GAD, MDD, OCD, and so on. They all may be similar but different.

This is why we need a satisfactory definition of what alcoholism and addition is? Rather than describing these conditions in terms of the manifest symptoms, i.e chronic substance abuse or, at times, vague “spiritual maladies”.

For example, one variable I believe is slightly different in alcoholism to other affective disorders is distress based impulsivity which leads to maladaptive decision making, it leads to always wanting more of that…that anything.

These may be specific to addictive behaviours.

It may also be that we feel we have a co-occurring disorder because the underlying distress states prompt similar reactions in various differing disorders.

My distress feeds perfectionism, and catastrophic thinking as with other anxiety disorders like OCD, does that mean I have OCD too?

Maybe or maybe not? My tendency to not regulate emotions has caused a distress state since childhood, it feeds into perfectionism and many other manifestations like always wanting just one more…?

It is the always wanting one more that makes my affective disorder that of addiction and not another disorder.

My affective disorder via various neural and cognitive – affective mechanisms leads to chronic substance use and dependency of these substances.

GAD, MDD, OCD have different manifestations and different mechanisms.

If we start by trying to recover from alcoholism and addiction and find we still have other issues then obviously address these with outside professional and specialist help.

I believe we can unwittingly complicate our treatment of alcoholism by believing we have (and treating) other conditions we see as distinct from alcoholism but which are in fact part of this condition called alcoholism.

I never fully knew what alcoholsim was until I did the 12 steps. Only then did it become clear what I suffered from?

I have suggested clearly in previous blogs how I think AA’s 12 recovery programme helps specifically with problems of emotion dysregulation.

How the Alcoholics Anonymous-12-step-program of recovery helps with emotional dysregulation

Maintaining Emotional Sobriety (and sanity) via the steps 10-12.

These illustrate how the 12 step programme can help with an emotion dysregulation disorder.

I end, however, with some words from a doctor who seems to be suggesting that AA works because it makes us more emotionally healthy. For me she is saying how AA treats emotional illness.

An article by Dr. Jacqueline Chang’s paper given to the National Workshop for Health Liaison in York in 1998 and published in the Winter 1999 edition of the AA News suggests that

“The principles of the programme of Alcoholics Anonymous are scientific and closely follow all the helping therapies which lead people to emotional well-being.

AA proposes living “ One Day at a Time”. It is emotionally healthy to live in the day … in the here and now. Professional therapists teach people to live in the present. AA encourages members to share their experience, strength and hope with other members. It is emotionally healthy to accept our past experiences, however painful, as past events and move on to a richer, more fulfilling future.

Step 1 in the AA programme is “ We admitted we were powerless over alcohol – that our lives had become unmanageable”. It is emotionally healthy to surrender and accept things over which we have no control.
“God grant us the serenity to accept the things we cannot change, courage to change the things we can and the wisdom to know the difference” is the Serenity Prayer used at every AA meeting. It is emotionally healthy to prioritise problems. The Serenity Prayer is the greatest exercise in prioritisation.

It is emotionally healthy to accept that we cannot change a particular situation but we can change the way we react to it.

It is emotionally healthy to accept yourself as you are.
It is emotionally healthy to recognise your environment and interact with it as it is, not as you wish it would be. It is emotionally healthy to associate or be in contact with other human beings.

It is emotionally healthy to be altruistic – to help others without question or expectation.
It is emotionally healthy to anticipate – to plan for future discomfort or crises. This is the function of the AA Step programme. ”

AA provides many ways of becoming more emotionally well, which ultimately means more emotionally mature.

Intolerance of Uncertainty and Distorted thinking About the Future

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

All this distorted thinking is distressed based.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

Fizollahi, S., Abolghasemi, A., & Babazadeh, A. THE ROLE OF EMOTION REGULATION, DISSOCIATIVE EXPERIENCES AND INTOLERANCE OF UNCERTAINTY IN THE PREDICTION OF CRAVING BELIEFS IN DRUG ABUSERS WITH TRAUMATIC EXPERIENCE.

Alcoholics Anonymous and Reduced Impulsivity: A Novel Mechanism of Change

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.

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.

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.

Eating Disorders based on a Body “Feeling State” Confusion?

Here we look at emotion processing deficits in eating disorders and whether the extent of these difficulties can predict treatment outcome three years later. This would demonstrate the ongoing role of emotion processing, as conceptualised as alexithymia, plays an ongoing role in the pathomechanism driving eating disorders.

This article also had a very good description of the somatic/emotional confusion which creates that unpleasant feeling state we have referred to before which appears to end in compulsive reactive behaviour rather than goal-directed, adaptive, evaluative, action-outcome thinking.

As we have shared before this is due to emotions not be labelled and used as guides to recruit goal directed parts of the brain but rather in their emotionally undifferentiated state they appear to compel us to react rather than consider our long term actions and their consequences.

“Several cross-sectional studies have reported high levels of alexithymia in populations with eating disorders.

However, only few studies, fraught with multiple methodological biases, have assessed the prognostic value of alexithymic features in these disorders. The aim of this study (1) was to investigate the long-term prognostic value of alexithymic features in a sample of patients with eating disorders.

The Difficulty Identifying Feelings factor of the Toronto Alexithymia Scale (TAS-20), often used to assess levels of alexithymia, emerged as a significant
predictor of treatment outcome. In other words, the results of this study indicated that difficulty in identifying feelings can act as a negative prognostic ( meaning predictive of something in the future) factor of the long-term outcome of patients with eating disorders.

The authors of this study also suggested that professionals should carefully monitor emotional identification and expression in patients with eating disorders and develop specific strategies to encourage labeling and sharing of emotions.

The identification of variables that predict treatment outcome in patients with eating disorders is critical if we are to increase the degree of sophistication with which we treat eating disorders…Among the several psychological features that have been proposed to predict treatment outcome in patients with eating disorders, alexithymia has attracted special interest.
Alexithymia is a personality construct characterized (partly) by a difficulty in identifying and describing feelings.

Several arguments, namely, factor analyses and longitudinal studies, have supported the view that alexithymia is a stable personality trait rather than a state-dependent phenomenon linked to depression or to clinical status [3,4].

Several studies have reported high levels of alexithymia in patients with eating disorders, especially in individuals with anorexia nervosa [5–8]. There are several reasons to believe that this construct could play a major role in the illness course of eating disorders: due to their cognitive limitations in emotion regulation, alexithymic individuals with eating disorders may resort to
maladaptive self-stimulatory behaviors such as starving, bingeing, or drug misuse to self-regulate disruptive emotions.

The results of our study indicate that one of the facets of the alexithymia construct, the difficulty in identifying feelings, is a negative prognostic factor for the long-term outcome of patients with eating disorders. Patients with the
greatest difficulties at identifying emotions at baseline are more often symptomatic at follow-up and show a less favorable clinical improvement.

There are several ways in which alexithymia can affect the clinical outcome of eating disorders: via the negative influence it exerts on the clinical expression of the disorders and on the response to therapeutic interventions.

First, the difficulty in identifying feelings may reduce the capacity of patients with eating disorders to adapt to stressful situations [28]. Such situations generate an emotional overflow that alexithymic subjects apprehend less by emotional and cognitive features than by their associated somatic indexes[29]. This uncertainty between feelings and bodily sensations reminds us of the interoceptive (a sensitivity to stimuli originating inside of the body) confusion proposed by Hilde Bruch [30,31].

Luminet et al. [32] have experimentally observed a dissociation of the components of the emotional response of alexithymic subjects (a physiological hyperreactivity to emotional stimuli associated to a deficit at the level of the cognitive experience), which illustrate the functioning of patients with eating disorders.

Faced with the physiological arousal induced by emotional demands, these patients may show poor adaptive strategies. They may resort to restricted patterns of repetitive and automated behaviors, such as the hyperactivity of anorexic individuals or the binges/purge cycles of bulimic subjects, which temporarily relieve their feeling of discomfort and restore their inner equilibrium [33,34] but generate, in the long term, a positive reinforcement of the eating disorder.

Second, alexithymia may be related to a chronic course of eating disorders by its relationship with other pathological behaviors, especially with addictive disorders. We have shown in previous studies that alexithymia is associated
with addictive behaviors in patients with bulimia [35].

Patients with eating disorders may resort to addictive behaviors to relieve the anxious and depressive feelings elicited by their negative perceptions of themselves [36].”

Thus to conclude, eating disorders appear to have the same emotion processing and regulation deficits as other addictive behaviours, particularly emotional differentiation, a difficulty in knowing exactly what one is feeling.

Interestingly eating disorders seem also to be driven by the same negative self perception we have seen in other addictive disorders.

References

1. Speranza, M., Loas, G., Wallier, J., & Corcos, M. (2007). Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study.Journal of psychosomatic research, 63(4), 365-371.

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.

Different addictive behaviours all centre on the same inherent difficulties.

by alcoholicsguide

Commonalities across all addictive disorders.

There are those, and some in treatment centres, who maintain that addiction is addiction is addiction. I have not always been convinced by this, mainly because I see differences in temperament and personality among different types of addicts (i.e alcoholics often appear different to heroin addicts in my mind) but these supposed and perhaps superficial distinctions may be masking inherent similarities or commonalities in the aetiology of all addictive disorders. There seems to be commonalities in particular between alcoholics, sex addicts, gambling addicts and those with eating disorders. This commonality may also help explain “cross addiction” – the tendency to become addicted to various things, whether substances or behaviours.

I personally have become” addicted” in very short periods of time to chocolate and many other substances and behaviours, such as constantly having to watch my workaholic behaviour. By addicted I mean I have quickly suffered addictive behaviour symptoms such as excessive consumption, pathological craving, physiological withdrawals from the substance or behaviour and the gamut of negative emotions surrounding my shame and despair at these obsessive compulsive behaviours. I can’t take it or leave in relation to many things in my life. Period!

There seems to a “manic hamster on the treadmill” mechanism in me that gets ignited by my engaging in what appears to be the most innocuous behaviour. Suddenly, whatever it is, leads me to want more, more, MORE of it!

I have an addicted brain and a recovering mind.

What is this intrinsic mechanism in my brain? What trips the switch towards addictive behaviour? This is the heart of the question.

How does the brain tumble towards unbridled wanting. What leads our brain to suddenly say I NEED THIS! rather than simply wanting it?

Why does the most simple behavioural decision suddenly seem life or death, urgent, most necessary? Why a such a sudden recruitment of this emergency state? For us it is due to the limbic and subcortical areas, the “fight or flight” areas of the brain being recruited to make the most simple decision urgent. Even the most simple decisions seem to involve feeling about our very survival. As we have blogged about before in “Why a “Spiritual Solution” to a Neurobiological Disease?” survival becomes the domain of these emergency parts of the brain so we do everything like there is no tomorrow, It is everything or nothing NOW. We need these things. Our survival regions have become extreme and constantly react, not act.

Our very survival has become habitually and compulsive governed as if our brains are constantly under siege.

These commonalities centre on the fundamental role we believe emotional processing and regulation deficits have in these various types of addictive disorder. It may be these deficits that are present in all addictive behaviours and it may suggest that they are fundamental mechanisms in driving addictive behaviours forward.

In a previous blog we showed how these areas of emotional dysfunction may even be inherited in many, so it is tempting to conclude that the vulnerability, or some of the major vulnerabilities that addicts and those with addictive behaviours inherit are the impaired ability to process and regulate emotions which leads to fundamental decision making difficulties and distress-based impulslivity (as the lack of processing emotions represents as distress signals act to relief these states not guide reflective decision making) which combine to shape the rest of their lives.

The encouraging aspect is that at an affective-cognitive level it may be possible to target these deficits in children at risk via prevention programs.

It illustrates what addicts of various types have said about their illness, however, that they suffer from an emotional disease.

The solution may be prevention and/or intervention to shore up these difficulties which is primarily what various treatments do without explicitly saying so. We first need to state categorically this is what we think drives addictive behaviours and then use complementary therapeutic strategies to specifically address these vulnerabilities.

We have to relearn emotions, how to identity, label, verbalise, process and subsequently regulate our emotions so that we become less impulsively driven and ultimately make better decisions in our lives.

We have in previous blogs discussed how substance addiction seems to have emotional processing and regulation deficits at the heart of their manifestation and act as pathomechanisms in propelling these disorders to eventual chronicity.

In the next series of blogs we will be discussing whether fundamental emotional processing and regulation deficits are common to (or intrinsic to the aetiology of) other addictive disorders too).

First up, we discuss emotional (or otherwise known in research as affective) dysregulation in those with Hypersexual Disorder or more commonly know to lay persons as sexual addiction.

Hypersexual Disorder – the proposed diagnostic criteria that were given consideration for the Diagnostic and Statistical Manual of Mental Disorder Fifth Edition (DSM-5) characterize hypersexual disorder (HD) (1) which is commonly known as sexual addiction.

This study (1) states that HD is a phenomenon involving repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning(Bancroft, 2008; Kafka, 2010; Kaplan & Krueger, 2010; Marshall & Briken, 2010; Reid, Garos, & Fong, 2012).

Patients seeking help for HD typically experience multiple unsuccessful attempts to control or diminish the amount of time spent engaging in sexual fantasies, urges, and behaviors in response to dysphoric mood states or stressful life events (Kafka, 2010).

Personality characteristics such as proneness to boredom (Chaney
& Blalock, 2006), impulsivity and shame (Reid, Garos, & Carpenter, 2011), interpersonal sensitivity, alexithymia, loneliness, and low self-esteem also have been observed in association with hypersexual behavior (Reid, Dhuffar, Parhami, & Fong, 2012; Reid, Stein, et al., 2011; Reid, Carpenter, Spackman, & Willes, 2008). Collectively, these characteristics create significant challenges for hypersexual patients.

The importance of finding effective treatments for HD cannot be underestimated given the gravity of its consequences (Reid, Garos, et al., 2012): Hypersexual patients are at increased risk for loss of employment, legal problems, social isolation, higher rates of divorce (Reid & Woolley, 2006; Reid, Carpenter, Draper, & Manning, 2010; Zapf, Greiner, & Carroll, 2008), and sexually transmitted infections (Coleman et al., 2010; Dodge, Reece, Cole, & Sandfort, 2004; Rinehart & McCabe, 1997, 1998).

This study found (1) significant associations between unpleasant emotions, impulsivity, stress proneness, and hypersexuality replicating findings
noted in other studies (Reid et al., 2008; Reid, 2010). The findings in this study also offer some support for the DSM-5 proposed classification criteria for HD (Kafka, 2010). Specifically, stress and emotional dysregulation have been hypothesized as precipitating and perpetuating risk factors for hypersexuality, and, accordingly, correlations to reflect this relationship, were consistent with findings of this study (1).

Another study (2) looked at investigating alexithymia, emotional instability, and vulnerability to stress proneness among individual seeking help for hypersexual behavior. Findings (2) provide evidence for the hypothesis thatindividuals who manifest symptoms of hypersexual behavior are more likely to experience deficits in affect regulation and negative affect (including
alexithymia, depression, and vulnerability to stress).

An increasing number of individuals are seeking help for hypersexual behavior related to a constellation of symptoms that reflect difficulties in regulating sexual thoughts, feelings, and behaviors.

This study’s (2) conceptualization of this phenomenon keys onbehavior dysregulation as manifest through exaggerated frequency and focus on sexual behavior (from sexual activity with partners, to use of pornography, sexual fantasy, or other erotic stimuli, to excessive masturbation).

Hypersexual behavior may include a sense of being out of control or a history of failed attempts at increased control, and it encompasses elements common to other psychiatric dysfunctions, such as impaired functioning in aspects of daily living, subjective distress, and deficits in coping strategies for addressing uncomfortable affective experiences (e.g., anxiety reduction), usually because of over reliance on sexual behavior as a means of affective regulation and relief. Many patients presenting with hypersexual behavior also report incongruence between their values and beliefs and their sexual behavior.

This study, used the definition of Reid and Woolley (2006) was used
to operationalize hypersexual behavior as: difficulty in regulating (e.g., diminishing or inhibiting) sexual thoughts, feelings, or behavior to the extent that negative consequences are experienced by self or others. The behavior causes significant levels of personal or interpersonal distress and may include activities that are incongruent with personal values, beliefs, or desired goals.The behavior may function as a maladaptive coping mechanism (e.g., used to avoid emotional pain or used as a tension-reduction activity)…. (p. 220)

“It may be that such persons possess deficits in affective regulation similar to those encompassed by the constructs of alexithymia and neuroticism. . It
is plausible that such deficits would influence exaggerated sexual behavior
in some persons (e.g., in the absence of other coping strategies for successful affective monitoring and regulation, the stress-reduction aspects of sexual behavior as a substitute may be powerfully reinforced).

Adams and Robinson (2001), as well as others (e.g., Schwartz & Masters,
1994; Wilson, 2000), have theoretically postulated thathypersexuality represents a compensatory behavior that attempts to alleviate symptom distress associated with problems of affect regulation. A similar theory among individuals with eating disorders was advanced by Heatherton and Baumeister (1991), who argued that motivation for binge eating emerged as an attempt to escape from negative appraisals associated with self-awareness and unpleasant mood states triggered by stressful events.
It can be reasonably argued that sexual activity provides a mood-altering experience enabling individuals to disassociate from uncomfortable, awkward, or unpleasant emotions (Quayle, Vaughan, & Taylor, 2006).

The power of sexual experience to shield one from negative emotions, then, probably arises from sexual arousal’s inherent ability to create intense focus on the competing state of pleasurable arousal, as well as the release of tension associated with orgasm. Furthermore, some individuals may find that fantasizing about sexual activity provides a greater distraction than partnered activity because it encourages—and maybe even requires— disconnect from relationships with their inherent problems, challenges, and complexities.

One plausible way to understand hypersexuality is seeing behaviors associated with reward, distraction, or soothing—such as overeating, exaggerated focus on somatic complaints, substance abuse, or hypersexuality—as being particularly likely in those for whom emotional distancing has high priority. This need for emotional distance can arise from increased stress proneness, negative affective states, emotional pain associated with unresolved trauma, or the inability to develop and form secure attachment bonds.

Our clinical impressions of patients displaying hypersexuality, as defined above, are consistent with those of other researchers who have suggested that alexithymic individuals seek tension reduction from uncomfortable or unpleasant emotions (Keltikangas-Jarvinen, 1982; Kroner & Forth,
1995; Zimmermann, Rossier, de Stadelhofen, & Gaillard, 2005), thereby contributing to their eating disorders (Corcos et al., 2000; Larsen, van Strien, & Eisinga, 2006), substance abuse (Haviland, Hendryx, Shaw, & Henry, 1994),
and the like. Our rationale for suggesting associations of stress vulnerability, emotional instability, and alexithymia with hypersexual behavior also stems, in part, from our own observations of poor affect regulation and deficits in stress management among these patients.

Research supports some associations between alexithymia and stress. For instance, high, as compared to low, alexithymic individuals show different cardiovascular response to stress (e.g., Linden, Lenz, & Stossel, 1996).

The findings support our hypothesis that alexithymia, emotional instability,
and vulnerability to stress are associated with the severity of hypersexual
behavior. More specifically, it appears that patients who present with more
profound levels of hypersexual behavior are more depressed, alexithymic,
and prone to stress.

These findings are consistent with our theoretical conceptualization of
emotional instability among individuals with hypersexual behavior. Our clinical impressions suggest this population struggles with uncomfortable, awkward, or unpleasant affective states, and in fact, these data indicate that they also experience the prevalence of such emotions in greater proportions than those found in normal populations.

Many of the subjects in the present study displayed emotional deficits and a paucity of emotional awareness. Queries about feelings in therapy would often elicit a response such as “I don’t know” or “I’m not feeling anything.” – otherwise know as emotional differentiation and discussed recently in another blog.

Our clinical impressions of hypersexual patients suggest that many of
these individuals habitually entertain negative self-appraisals that are likely
influenced by attention bias which seeks evidence in daily experiences to
confirm irrational beliefs (I’m unlovable, worthless, etc.). Additionally, many
of these patients devote time to maintaining facades and implementing strategies of impression management that may further disconnect them from their authentic self, including their genuine emotions. Patients desperately desire external validation by others and privilege such adulation while marginalizing subjective positive perceptions about the self. Unable to control and predict the reactions of others, patients vacillate along a continuum of emotional instability. Negative appraisals by others become threats to their sense of self-worth, and such criticisms often result in disavowing aspects of the self. Specifically, the patients disconnect from undesirable emotional states.

The function of sexual activity in these instances is stress reduction and escape from or avoidance of uncomfortable and unpleasant affective experiences attributable to difficulties in their interpersonal relationships and other challenges in daily living.

References

1. Reid, R. C., Bramen, J. E., Anderson, A., & Cohen, M. S. (2014). Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. Journal of clinical psychology, 70(4), 313-321.

2. Reid, R. C., Carpenter, B. N., Spackman, M., & Willes, D. L. (2008). Alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior. Journal of Sex & Marital Therapy, 34(2), 133-149.

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The Alcoholics Guide to Alcoholism

Blogging The Language of the Heart

emotional dysregulation

Chapter 2 – “Things Can Only Get Better”

Chapter 1 “Rock Bottom”

“The Bottled Scream” A Disease of Self – Understanding Addiction and Recovery

There is a map of Emotional Responding Tattooed on my Heart.

How Far Have We Come In Understanding this “Spiritual Malady” of Alcoholism?

Intolerance of Uncertainty and Distorted thinking About the Future

Eating Disorders based on a Body “Feeling State” Confusion?

Gambling Disorder and Emotional Dysfunction

Deficits in emotion regulation associated with pathological gambling.

Different addictive behaviours all centre on the same inherent difficulties.