The Roots of All Our Troubles!?

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Most of my distress and emotional pain in recovery comes from wanting stuff, and not getting my way or not accepting things as they are.

As Bill Wilson noted, we seem to get distressed when we don’t get what we want or feel people or trying to take away what we have.

This was his observation after a decade of psycho analysis with the psycho analyst Harry Tiebout.

A decade of therapy also showed Bill Wilson he has two default settings in his relationship to other human beings – he either tried to dominate them or he became dependent on them for his sense of self and emotional well being. In other words, he became dependent on others, on external means for approval and elevating his self esteem.

This is similar to relying on external means, i.e. alcohol, drugs, addictive behaviours to regulate our emotions and bolster our low self esteem.

We are in a sense co-dependent on other people for our sense of esteem.  We rely on others in terms of how we feel about ourselves.

As a result we are guarded against those that we perceive will reject us or be negative to us, harm us in some way and we seek to dominate these folk or we are dependent on those who are kind to us, help us and care for us. We swing at times between these extremes.

Some of us are “people pleasers”, some of us are dismissive towards others. I can be a dismissive person more than a people pleaser. It is all manipulating our interaction with others to our selfish ends.

Some of these tendencies are the result of our childhoods and how closely attached we were to our parents.

Some of us have this knawing feeling of not being good enough, have a hole in the soul which we are/were kinda always unconsciously trying to protect, shield from the world.

It is a strange feeling of not wanting to be found out of being less than, not good enough. “If people realise what the real me is like, they will reject me!” type thinking although a lot of this is unconscious and does not pop in to our minds as thoughts but is an unconscious self schema that shapes our behaviours.

In simple terms we manipulate via people pleasing or we push people away via being dismissive and putting others down, we guard against any threat of perceived rejection or threats to the self via defense mechanisms such as projecting what we do not like about ourselves on to others.

We often do not like traits in others because they somehow mirror traits in ourselves although we are not always conscious of this.

We have difficulties in our relationships with others, these relationships are often unhealthy and ill.

Some of this is touched on in the Big Book of Alcoholics Anonymous, but much of it comes from later observations by Bill Wilson after the publication of the Big Book and my and others’ observations since.

I have seen in myself how fear and shame seem to drive most of my maladaptive behaviour.

My illness of addictive behaviours.

I have an illness of chronic malcontent, things are rarely good enough and I am rarely good enough, according to my “out of kilter”  thinking which  I usually try to ignore, turn over to God or on occasion challenge via reasoning and sharing with other people.

My thoughts are often not my friends, they are often not in the service of my ongoing well being, quite the opposite in fact.

This is how a mental health disorder manifests itself as distorted fear based thinking which appear, if acted upon, to make one’s situation a whole lot worse.

We can not rely on our thoughts and feelings or, in other words, our Self Will. Our self will has become impaired and is no longer in the service of our successful survival.

I have found over the last decade in recovery that when I turn my Will over to the care of the God of my understanding that I am restored to sanity and my thoughts are sound, they are on a higher plane as the Big Book tells me.

I can become the fullest expression of me in the God, not the ill, deluded version while running under my own self will. That has been my experience.

It is only with God’s help that I get restored to sanity or reasonableness.

When I have a fear of not getting stuff and this is linked to insecurity, as mentioned in the Big Book, it is usually in relation to my pocket book, financial insecurity, personal relationships, self esteem etc.

I will now look at this fear based reaction to my security which is mainly to do with stuff out  there (external) such as work, people and how they affect my sense of self before looking at how my internal sense of self, based on the fear based emotion of shame seems to play a pivotal role in my relationship with others and the world around me.

I am assailed externally by fear of what other’s think about me and internally about what I think of me – when these two line up it can have a powerful and damaging effect on my psyche.

Desiring stuff seems at the root of my fear based stuff – the exquisite torture of desire which soon loses it’s so-called relish and just becomes torturous.

Alcoholics do not seem want stuff like normal folk, but have a pathological wanting, an all consuming need to get stuff regardless of it’s worth or value.

We seem to compulsively seek to relieve an inherent distress of not having what we set out to get. Our decision making seems fueled at times by this need to relieve distress rather than the intrinsic value of what we are seeking.

We seem to become manic in our pursuit of things and end up overdoing whatever we are doing via this stress-based manic activity.

This seems compounded by not always being able to read our emotions or somatic states.

One of my own difficulties is realising I am hungry or tired and I can often end up exhausted by over-doing stuff especially manual work around my house. My stop button broke a long time a ago and probably did not work very well to begin with.

So we have  stress-based compulsive need to do something and very limited brakes in the brain stopping us and very little emotional feedback going on, a limited consideration of  “aren’t we overdoing this a bit?”

Desire obviously runs contrary to the idea of being in God’s will, in fact it is being in Self Will that seems to create distress in many people with addictive behaviours.

I would add to this that I also get distress via fears of rejection from others, I suffer from fear based shame to a chronic extent.

Shame, also the consequence of being in Self Will, was not really mentioned in the Big Book of Alcoholics Anonymous, mainly because it was not really known about as a psychological or psycho-therapeutic concept then.

Much of the Big Book was influenced by  psycho-analysis which did not consider shame, but rather guilt, in psychological disturbance.

In fact, it has only started considering the role of shame in the last few decades.

So I would add fear of not getting what we want or having something taken away is also complemented by shame-based fears of being rejected.

For example there is an undercurrent in fear of things being taken away, of it being because we are not good enough, deserving enough, have failed in some way, which are shame based reactions.

In fact the Big Book gives me a good idea of the “sins” or “defects of character” I have when I have a resentment but does not explain why I have resentments in the first place.

It explains this as selfishness, self centredness… the root of all our troubles.

It does not, for me, clearly explain why we resort to these selfish, immature, emotional reactions or why we persist with resentments?

It does not explain the emotional immaturity at the heart of alcoholism,  this spiritual malady of inappropriate emotional response to the world around us?

Bill Wilson was struck himself, when he started working with other alcoholics, how much they were plagued constantly by various resentments. How they were haunted by memories of situations in the past, how they swirl around and pollute their minds in the present. How they could not let go of events in their past?

For me he was seeing the root of this spiritual malady, this emotional disease.

For me we engage futilely and distressingly in resentment because we have an inability to process and control our emotions, they overwhelm us and we often react by people pleasing (shame) or react via various defense mechanisms (also shame based).

Defense mechanisms are central to psycho-analytic thought – such as projection etc, the idea that we  expel “out of ourselves what we do not like about ourselves onto others.

Sometimes others expel the same negative emotions on to us. I have found this a fairly common trait among male alcoholics in recovery settings and meetings.

I was discussing this with a newcomer last week, how people who seek to “put us down”  do so out of shame and induce in us all the negative emotions they are experiencing themselves!

The newcomer gave me an example of a resentment he was experiencing after this guy at a meeting said “get off your pink cloud” a phrase that refers to the sometimes  mildly ecstatic feelings of early recovery.

This made the newcomer ashamed that he could have been so stupid for being on this pink cloud, as if this was a selfish indulgence!?

I explained to him that his pride had been hurt, he was in shame and his “apparent” depression every since was simply prolonged self pity.

If we leave self pity to fester long enough it becomes depression, that is my experience anyway.

I said the other guy was probably “hurt” to see a newcomer having such a good period of recovery (God does want us to be happy, joyous and free after all) – I said his false pride was hurt too, that he was not having the recovery experience at present of the newcomer (possibly because he wasn’t putting the effort in) and was in shame (not good enough) and self pity. This mesh of negative emotions can link up fairly instantaneously I find.  It is the web my spiritual malady seeks to ensnare me in.

The guy was probably in guilt too as he could been working on his recovery more.

As a result this guy put the newcomer down to alleviate his own sense of self, his low self esteem.

He “had to” react with arrogance, dismissiveness, impatience and intolerance, because his shame, which is a fear based emotion, made him fearful of his own recovery and fear makes one strangely dishonest (at times deluded), This is my experience.

All because a newcomer had the temerity to be enjoying his recovery?

Not completely, this is half the answer.

The other part is that this guy, if an alcoholic like me, has real difficulties accessing in his heart and mind how he actually “feels” at any particular time. Or rather what emotions he is experiencing at any particular time.

This guy could have been experiencing guilt or shame for example.

Instead of saying to himself I am feeling guilt that my recovery is flabby  compared to this newcomer or that I am being an arrogant “know it all”, putting this newcomer in his place because  he had been in recovery longer – although being in recovery and being sober are different things I have found.

Either way, if he could perhaps of had the ability to say this is how exactly I am feeling he could have acted on this emotional information rather than reacted to it.

What do I mean by this?

Well, if I was feeling guilty about this newcomer it would cause a disturbance in me because I have difficulties processing my emotions.

It would have turned up therefore as a resentment of someone having something I do not have and as them taking away the illusion that my recovery was going OK?

I would have found this threatening to my sense of self so I would have reacted via defense mechanisms. I would have strangely blamed this person for making me feel the way I did! Even if this person had no such intention of hurting my feelings I would blame him nonetheless via my defensive reactions.

It is as if my emotional well being is dependent on other people and their behaviours, this is my spiritual malady, my emotional disease.

As I would have had a resentment, it would have had a wolf pack of negative emotions attached.

In this instance I might have have acted differently.

If I had been in God I would have been more sane for a start and had more loving tolerance for a newcomer.

I would have been acting not reacting. I would have had empathy for where the newcomer  “was at in his recovery” as I had been there once too.

This love and tolerance for the newcomer evolves the displaying of virtues (the opposite of defects are virtues).

What virtues? Well as the newcomer was relatively new I would attempted to be patient, empathetic, kind, gentle, tolerant, considerate  etc. These prevent the defects occurring I find.

If we practice virtues instead of defects then the brain changes for the better and we recover quicker. Our positive loving, healthy behaviours change us and our brains via neuroplasticity for the better.

Attempting to live according to God’s Will (which is a state of Love) also helps me not react but to act with Grace.

In Grace we can still experience negative emotions but God allows us to see them for what they are and not react. His Grace takes the distress out of thee negative emotions. This is my experience.

This allows me to do a quick inventory of my negative emotions and a prayer to God to have them removed. My experience is that they are always removed and that we are immediately restored to sanity.

I do not necessarily have to react to my feelings of negativity about myself, someone else does not need to experience the consequence of my resentments.

I can manage my spiritual malady or emotional dysfunction, I have the tools to do so.

I also impressed upon the newcomer that what the other guy was experiencing and was reacting is also how he, the newcomer, reacts and how I react too.

It is what our spiritual malady looks like I believe, it is the map of my impaired emotional responding.

I also impressed upon him that mostly I can manage this emotional dysfunction but often I fail to and get into a resentful anger.

This is why I have to forgive the other guy as I have been forgiven but also to forgive myself (or ask God to forgive me my shortcomings) for my reactions.

We are not perfect, far from it. We are far from being Saints but have a solution Saints would approve and achieve a kind of transient sanctity in this 12 step solution of letting go and letting God.

We have to show love and tolerance for each other as we suffer the same illness/malady. Dismissing others like us for having what we have and acting as we do is like a form of self loathing. We have to forgive ourselves and each other for being ill. Self compassion allows us to be compassionate  towards others.

Also we need to be aware what we project on to other alcoholics is the same thing as they project on to use and sometimes we project if back.

So we have two main ailments, distressed based wanting which results in the same negative emotions as being in a shame- based fear of rejection.

I can get out of the distress of wanting/needing stuff by asking God to remove those negative emotions which block me off from Him.

For example, if I really want something and feel someone is preventing me getting that thing or that they are taking this thing away from me I have a hunting pack of negative emotions running through by heart and pulsating through my veins, propelling me to want that thing even more! As if my very life depended on it?

These feelings are translated as “how dare you take that thing/stop me getting that thing” – False Pride – followed by fear of being rejected – Shame (this is because I am not good enough)  and possible Guilt (for something I must have done wrong as usual) – then leading to “poor me” and feelings of Self pity, all because I am in Self, so I am being Self Centred and not considering someone else’s view so I am Selfish.

I retaliate via by “I”ll show you/I’ll get you” emotions of Dismissiveness, Intolerance, Arrogance and Impatience – my “I’ll put you down to make me feel better!”

All because I am fearful that you are taking away something from me or rejecting  me –  Fear and Fear is always accompanied by dishonesty.

I will act out on these somethings, if I do now use my spiritual tools and let Go and Let God, usually by eating too much, Gluttony, having a shopping spree, Greed, engaging  sexual fantasy/activity Lust of “freezing” through fear in the subltle sin of Sloth (procrastination).

A perceived slight or a rejection can have an incredible emotional effect on me

This is all emotion dysfunction and immaturity. I have resentments because they are a true sign of emotion dysfunction.

The mature way to to access, identfiy and label how one is feeling and use this information to reasonably express how one is feeling. This way we do not retaliate, fight, flee or freeze. Instead our emotions do what they are supposed to do. They are suppose the tell the fronts of our brains to find words for our feelings. Not to tell the bottom of our brains to fight back or run or freeze.

Let me use an example.

I had an argument with a guy once who suddenly proclaimed he was upset by what I had said. I was amazed as this guy was reading his emotions, identifying verbalising/expressing them to me in a way I have never been able to do.

My alcoholism is rooted in an impaired ability to read, identify, label and express my emotions (otherwise called emotion processing) – as a result my emotions have always troubled me and been so troubling in their undifferentiated state that I have always either avoided them or ran away from them.

I have sought refuge from my negative emotions in alcohol, drugs and other addictive behaviours. It is this that propelled my addictions, this inability to deal with my negative emotions. I dealt with them externally via addictive behaviours, not internally via emotion processing.

My emotions became wedded in time to being undifferentiated arousal states that prompted me to seek an external way to deal with these troubling emotional/arousal states.

Today when I engage in the above emotion dysfunction, engage in the above web of defense mechanisms it is because I have not been able to locate in me what feeling is disturbing me ?

On occasion it is, as the guy above said, because I am upset. I have not learnt the ability to say that I am upset etc. The words for these feeling states somehow can continue to elude me unless I am in God’s Grace.

God does for us what we can not do for ourselves!

Finding out what is really going on with us emotionally is at the heart of recovery. That is why we have to constantly share how we are feeling with others so that we can find out what we are feeling.

Unless, we let Go and Let God and ask God to remove these negative emotions/sins/defects of character we end up in a futile increasingly distressed spiral of negative emotions.

We end up cultivating much greater misery.

As soon as you can, let Go and Let God.


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.




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.


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 [811]

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.


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.

eating_disorder_by_ttonny-d2yezty (1)


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.


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).

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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).”



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.

images (34)

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.



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.

Understanding Emotional Processing Deficits in Addiction – Guest Blog

Understanding Emotional Processing Deficits in Addiction

by alcoholicsguide

We recently blogged on how alcoholics, and children of alcoholics, have difficulty with recognizing and differentiating external signs of emotions such as facial emotional expressions, now we will consider increasing evidence that alcoholics have difficulties with identifying and differentiating internal emotional states also.

Both these areas of research point to real difficulties in alcoholics in relation to the processing of emotion.

As we shall explain below, this deficit in emotional processing has real consequence for decision making capabilities and this has an important role to play in the initiation and maintenance of substance abuse and eventual addiction.

Alexythymia and Addiction

Effective emotion regulation skills include the ability to be aware of emotions, identify and label emotions, correctly interpret emotion-related bodily sensations, and accept and tolerate negative emotions (2,3).

Alexithymia is characterized by difficulties identifying, differentiating and expressing feelings. The prevalence rate of alexithymia in alcohol use disorders is between 45 to 67% (4,5)

Finn, Martin and Pihl (1987) investigated the presence of alexithymia among males at varying levels of genetic risk for alcoholism. They found that the high risk for alcoholism group was more likely to be alexithymic than the moderate and low genetic risk groups (6).

Higher scores on alexithymia were associated poorer emotion regulation skills, fewer percent days abstinent, greater alcohol dependence severity (7). Some studies have emphasized a right hemisphere deficit in alexithymia [8,9] based on the hypothesis that right hemisphere plays a more important role in emotion processing than the left [10, 11].

Dysfunction of the anterior cingulate cortex has been frequently argued, e.g., [12], and others have focused on neural substrates, such as the amygdala, insula, and orbitofrontal cortex (see the review in [13]). All different components of the the emotional regulation  network.

These models may interact with each other and also map onto the brain region morphological vulnerability mentioned as being prevalent in alcoholics.

Magnetic resonance imaging and post-mortem neuropathological studies of alcoholics indicate that the greatest cortical loss occurs in the frontal lobes, with concurrent thinning of the corpus callosum. Additional damage has been documented for the amygdala and hippocampus, as well as in the white matter of the cerebellum. All of the critical areas of alcoholism-related brain damage are important for normal emotional functioning (14) .

One might speculate that thinning of the corpus collosum may render alcoholics less able to inhibit negative affect in right hemisphere circuits.

Alcoholics are thus vulnerable to thinning of the corpus collosum and perhaps even to emotional processing difficulties (15 ). The inability to identify and describe affective and physiological experiences is itself associated with the elevated negative affect (16) commonly seen in alcoholics, even in recovery (17.

Thus, this unpleasant experience might prompt individuals to engage in maladaptive behaviors, such as excessive alcohol consumption, in an effort to regulate emotions, or, more specifically, cope with negative emotional states (18 )

One neuroimaging study (19) looked at and compared  various models of alexithymia showing people with alexithymia showed reduced activation in the dorsal ACC and right anterior insula (AI), and suggested individuals who exhibit impaired recognition of their own emotional states may be due to a dysfunction of the ACC-AI network, given these regions’ important role in self-awareness. These studies suggest alexithymics may not be able to use feelings to guide their behaviour appropriately.

The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice (20).

ep neg

The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level, similar to the study on children of alcoholics and thus may represent a vulnerability.

The function of the caudate is to regulate or control impulsivity and disinhibition. Individuals with alexithymia may work on the IGT impulsively rather than by using emotion-based signals. This IGT study suggests that individuals with alexithymia may be unable to use feelings to guide their behavior appropriately.

Alexithymic individuals thus may be unable to use emotion for flexible cognitive regulation. Thus, there may be dysfunction in the interaction of the aspects of the emotional response system in alexithymia with greater activation in the caudate (basal ganglia) and less activation in the mPFC in alexithymics during the IGT.

Thus alexithymics show weak responses in structures necessary for the representation of emotion used in conscious cognition and stronger responses at levels focused on action. This ties in with the blog on an emotional disease? and also  so how is your decision making? which suggested that alcoholics do not use emotion to guide decision making and rely on more motor, or automatic/compulsive parts of the brain to make decisions.

Consequently, alexithymics experience inflexible cognitive regulation, owing to impairment of the emotion guiding system. These dysregulated physiological responses over many years may result in untoward health effects such as drug addiction.

To illustrate this, one study demonstrated that patients with cocaine dependence had higher alexithymia scores compared with healthy control subjects (21).

In a study of 46 inpatients with alcohol abuse or dependence, the total TAS (Toronto Alexithymia Scale) score was significantly higher among those who relapsed after discharge than among those who did not, even when depressive symptoms were taken into account(4)

Cocaine-dependent patients also failed to activate the anterior cingulate and other paralimbic regions during stress imagery, suggesting dysregulation of control under emotional distress in these patients (22).

Instead, cocaine-dependent patients demonstrated greater craving-related activation in the dorsal striatum, a region that has been implicated in reward processing and obsessive–compulsive behaviours. The greater activation associated with alexithymia in men in the right putamen during stress is broadly consistent with earlier studies implicating the striatum in emotional motor responses.

This also corresponds to  the study of  children of alcoholics show significantly more activation in the left dorsal anterior cingulate cortex and left caudate nucleus a region associated with impulsive choice, illustrating perhaps in children of alcoholics a bias in brain decision-making systems as an underlying  elevated risk for alcoholism.

We have also suggested previously a ‘compulsive’ emotional  habit bias in endpoint addiction which reflects a stiumulus response or automatic behaviour in the face of emotional distress, which then influences an automatic decision making profile. This may be the effect of chronic drug use impacting on an inherited emotional expressive-motor decision making vulnerability seen in children of alcoholics.

In simple terms, these vulnerable individuals may recruit more automatic rather than goal-directed areas of the brain when making decisions. This would result in impulsive/compulsive decisions which do not fully consider consequences, negative or otherwise, of their decisions and resultant actions. This decision making profile would then have obvious consequences in terms of a propensity to addiction.


References (to be finished)

1. Naqvi, N. H., & Bechara, A. (2009). The hidden island of addiction: the insula.Trends in neurosciences32(1), 56-67.

2. Berking M, Margraf M, Ebert D, Wupperman P, Hogmann SG, Junghanns K. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. Journal of Consulting and Clinical Psychology. 2011;79:307–318

3. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment.2004;26:41–54

4. Loas G, Fremaux D, Otmani O, Lecercle C, Delahousse J. Is alexithymia a negative factor for maintaining abstinence? A follow-up study. Comprehensive Psychiatry. 1997;38:296–299.

5. Ziolkowski M, Gruss T, Rybakowski JK. Does alexithymia in male alcoholics constitute a negative factor for maintaining abstinence. Psychotherapy and psychosomatics. 1995;63:169–173.

6.  Finn PR, Martin J, Pihl RO. Alexithymia in males at high genetic risk for alcoholism.Psychotherapy and Psychosomatics.1987;47:18–21

7.  Moriguchi, Y., & Komaki, G. (2013). Neuroimaging studies of alexithymia: physical, affective, and social perspectives. BioPsychoSocial medicine7(1), 8.

8. Miller L. Is alexithymia a disconnection syndrome? A neuropsychological perspective. Int J Psychiatry Med. 1986;7:199–209. doi: 10.2190/DAE0-EWPX-R7D6-LFNY.

9. Sifneos PE. Alexithymia and its relationship to hemispheric specialization, affect, and creativity.Psychiatr Clin North Am. 1988;7:287–292.

10. Buchanan DC, Waterhouse GJ, West SC Jr. A proposed neurophysiological basis of alexithymia. Psychother Psychosom. 1980;7:248–255. doi: 10.1159/000287465.

11. Shipko S. Further reflections on psychosomatic theory. Alexithymia and interhemispheric specialization. Psychotherapy and psychosomatics.

12. Lane RD, Reiman EM, Axelrod B, Yun LS, Holmes A, Schwartz GE. Neural correlates of levels of emotional awareness Evidence of an interaction between emotion and attention in the anterior cingulate cortex. J cognitive neuroscience. 1998;7:525–535. doi: 10.1162/089892998562924.

13. Wingbermühle E, Theunissen H, Verhoeven WMA, Kessels RPC, Egger JIM. The neurocognition of alexithymia: evidence from neuropsychological and neuroimaging studies.Acta Neuropsychiatrica. 2012;7:67–80. doi: 10.1111/j.1601-5215.2011.00613.x.

14. Oscar-Berman, M., & Bowirrat, A. (2005). Genetic influences in emotional dysfunction and alcoholism-related brain damage.

15. Sperling W, Frank H, Martus P, et al. The concept of abnormal hemispheric organization in addiction research. Alcohol Alcohol.2000;35:394–9.

16.  Connelly M, Denney DR. Regulation of emotions during experimental stress in alexithymia. Journal of Psychosomatic Research. 2007;62:649–656

17. Stasiewicz, P. R., Bradizza, C. M., Gudleski, G. D., Coffey, S. F., Schlauch, R. C., Bailey, S. T., … & Gulliver, S. B. (2012). The relationship of alexithymia to emotional dysregulation within an alcohol dependent treatment sample.Addictive Behaviors37(4), 469-476.

18.  Thorberg FA, Young RM, Sullivan KA, Lyvers M, Hurst CP, Connor JP, Feeney GFX. Alexithymia in alcohol dependent patients is partially mediated by alcohol expectancy. Drug and Alcohol Dependence. 2011;116:238–241

19. Moriguchi, Y., & Komaki, G. (2013). Neuroimaging studies of alexithymia: physical, affective, and social perspectives. BioPsychoSocial medicine7(1), 8.

20.  Kano M, Fukudo S. The alexithymic brain: the neural pathways linking alexithymia to physical disorders. BioPsychoSocial medicine. 2013;7:1. doi: 10.1186/1751-0759-7-1.

21.  Li, C. S. R., & Sinha, R. (2006). Alexithymia and stress-induced brain activation in cocaine-dependent men and women. Journal of psychiatry & neuroscience,31(2).

22.  Sinha, R., Lacadie, C., Skudlarski, P., Fulbright, R. K., Rounsaville, B. J., Kosten, T. R., & Wexler, B. E. (2005). Neural activity associated with stress-induced cocaine craving: a functional magnetic resonance imaging study.Psychopharmacology183(2), 171-180.

Do alcoholics drive through life with Faulty Brakes!

There has been a lot of debate in the last thirty – forty years about genetic inheritance – with at least half of children of alcoholic families at risk for later alcoholism. What is less known is what exactly is inherited in our genes? What marks us out for later alcoholism? Prior to drinking are there aspects of our behaviour, personality or emotional responding that marks us out compared to so-called normal healthy types.

Recently research has looked at brain systems which overlap in decision making such as cognitive control over impulsive behaviour and also emotional processing. Children from alcoholics seem to have difficulties with both these overlapping circuits in the brain – they are not only impulsive but also do not seem to process emotions in the same way their “health” peers do. Research has also begun  to show that emotional processing is indeed important to making decisions, as is the ability to inhibit impulsive responses.

It seems  young alcoholics in the making, are not using our emotions  to make decisions and  are also prone to being impulsive. This difficulty with making decisions must shape all other future decisions ?

Youth for families with a history of alcoholism (FH+) are more likely to engage in early adolescent alcohol use (1), they may be more prone to experience the neurotoxic effects of alcohol use during adolescence.


Heavy alcohol use during adolescence is related to poorer neuropsychological functioning, including response inhibition (2), working memory (3-5), and decision-making (6).

Neuroimaging studies have shown that alcohol abusing teens have atypical grey matter volume in the PFC (7,8), and subcortical structures, such as the hippocampus (9,10) OFC and the amgydala.

Further, they have reduced integrity of white matter pathways, in both long-range connections between frontal and parietal brain regions as well as in pathways connecting subcortical and higher-order brain areas (11,12).

FMRI studies have found reduced BOLD response in adolescent alcohol abusers
in brain regions important affective decision-making (13).

The raging debate in research has been to whether these deficits are a consequence of heavy alcohol use or if genetic and environmental factors, such as family history of alcoholism, may contribute.

Risk Factor for Alcohol Use Disorders (AUDs): Family History of Alcoholism

The observation that alcoholism runs in families has long been documented
(14-16). Over the past few decades, adoption (17,18) and twin (19)
studies have suggested that there is an increased likelihood of individuals with a family history of alcoholism to develop the disorder themselves (20, 21).

These studies indicate that familial alcoholism is one of the most robust predictors of the development of an AUD during one’s lifetime. Furthermore, this risk factor appears to be stable over time, since it also predicts the chronicity of alcohol dependence at multiple time points (22).
This indicates that higher familial density is often associated with greater
risk (23), with genetic vulnerability accounting for about 30-50% of
individual risk (24-26).


One of the best characterized findings in individuals with familial alcoholism are greater impulsivity and difficulties in response inhibition which are commonly seen in this population (27,28), and FH+ individuals are less able to delay reward gratification compared with their peers (29).

Emotional processing and its relationship with executive control has received much less
attention in FH+ individuals.

Alcohol Use Disorders and Emotional Processing

Emotion Recognition and Affective Processing – Research suggests that alcohol use disorder (AUDs)  are associated with deficits in emotion recognition
(30-33), which may be related to atypical brain structure and functioning observed in the
limbic system among alcoholics (34-37).

Alcoholics not only tend to overestimate the intensity of emotions seen in faces  but they also make more negative emotional attributions and often confuse one emotion for another, such as mislabeling disgust as anger or contempt (32). Additionally, these deficits seem to be specific to alcoholism, since alcoholics, both recently abstinent and long-term abstinent, perform poorer on emotion recognition tasks than individuals with other drug abuse history (38). Alcoholics have also been shown to have slower reaction time when recognizing emotions (39).
Furthermore, poorer accuracy on emotion recognition tasks in alcoholics does not improve across the duration of the task, even though better performance is seen over time with other drug abusers (38).

Polysubstance abusing adults, the majority of whom were alcohol abusers, showed emotion recognition deficits on angry, disgusted, fearful, and sad faces (40). Based on the evidence of emotion recognition deficits in alcoholics, it is necessary to determine whether similar difficulties are present in FH+ youth that could be disruptive to emotional functioning and may contribute to the ultimately higher prevalence of alcohol abuse in this population.

Ultimately we may be observing here external emotional processing difficulties in the same manner we observed “internal” emotional processing difficulties in those with alexithymia, the reduced ability to “read” internal emotions of which a majority of alcoholics appear to suffer.

In summary, alcoholics and children of alcoholic families appear to have both external, i.e. recognition of other people’s emotions as well as their own and these may relate to immature development of brain regions which govern emotional, processing, recognition and regulation, which appears to contribute greatly to the initiation and progression of alcohol abuse.


In addition to emotional processing deficits, alcoholics have various structural
and functional abnormalities in affective processing brain regions. Studies of the limbic system have found reduced volume in subcortical structures, including the amygdala, thalamus, ventral striatum, and hippocampus among adult alcoholics (41,42). Alcoholics with smaller amygdalar volumes, are more likely to continue drinking after six months of abstinence (37).

Marinkovic et al. (2009) alcoholics exhibited both amygdalar and hippocampal hypoactivity during face encoding, and when recognizing deeply encoded faces, alcoholics had significantly reduced amygdalar activity to positive and negative emotional expressions compared with controls (35). These results help explain findings in behavioral studies of alcoholics that have found considerable evidence for emotion recognition deficits in this population.

Furthermore, during emotion identification, alcoholics showed comparable
performance to controls, but had reduced brain response in the affective division of the
anterior cingulate cortex (ACC) to disgust and sadness, with this lack of affective response to aversive stimuli believed to underlie disinhibitory traits in AUDs (36).

There is also evidence to suggest that non-alcohol abusing FHP individuals
share similar deficits in affective systems to alcohol abusers, including reduced
amygdalar volume, less amygdalar activity in response to emotional stimuli, and high
rates of internalizing symptoms such as anxiety and depression (37; 45-47).

Furthermore, research examining the relationship between emotional
processing and cognition has found that poor inhibition in individuals with co-morbid
substance and alcohol abuse is associated with atypical arousal in response to affective images (48), and affective measures in FH+ alcoholics also relate to deficits in executive functioning, e.g impulsivity (47).

This suggests that familial history of AUDs may put individuals at greater risk for problems with emotional processing and associated disruptions in executive functioning (47), which could, in turn, increase risk for alcohol abuse (49).

As we suggested previously, in relation to decision making profiles, in those at risk, those with alexithymia and also with cocaine addicts, decision making often involves more emotion expressive-motor areas of the brain like the caudate nucleus which is more of a “feel it-do it” type of reaction to decision making or a emotionally impaired or distress-based impulsivity. If there is a difficulty  processing emotions, these emotions can not be used as a signal to guide adaptive, optimal decisions. Decisions appear more compulsive and short term.

It may be this tendency to act now, rather than later,  that defines the vulnerability in FH+ children. It is like driving through life with faulty brakes on decision making, which sets up a chain of maladaptive choices such as alcohol abuse which then damages these affective based decision making regions of the brain even more, with increasing  deleterious consequences as the addiction cycle progresses until the endpoint of addiction of very limited choice of behaviour as emotional distress acts eventually as a stimulus response to alcohol use.  Emotional processing usurped by compulsive responding.



Main reference – Cservenka, A., Fair, D. A., & Nagel, B. J. (2014). Emotional Processing and Brain Activity in Youth at High Risk for Alcoholism. Alcoholism: Clinical and Experimental Research.

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At Risk Adolescents have Emotional Dysregulation?

Following up from our previous blog on the abnormalities in the ventromedial prefrontal cortex  (vmPFC) in alcoholics,  brain regions which govern emotional regulation, we came across another study which appears to show that adolescents at increased risk for later alcohol use disorders (AUDs) may also be showing an emotion regulation difficulty.

This emotional regulation difficulty may be a biomarker for later alcoholism, which is in keeping with our previous proposals that an emotional processing and regulation difficulty or disorder underpins the aetiolgy of of alcoholism. In order words it is part of the pathomechanism – or the mechanism by which a pathological condition occurs- of later alcoholism.




The area in this study, the vmPFC,   showed relatively increased cerebral blood flow (CBF) in bilateral amygdala and vmPFC and relatively decreased CBF in bilateral insula, right dorsal anterior cingulate cortex (ACC) and occipital lobe cuneus of high-risk adolescents. This suggests that adolescents at relatively high-risk for AUD exhibit altered patterns of resting CBF in distributed corticolimbic regions supporting emotional behaviors.

The authors’ hypothesized that the relatively increased amygdala and ventromedial prefrontal CBF may contribute to increased emotional reactivity and sensitivity to environmental stressors in these individuals while diminished insula/occipital cuneus and dorsal anterior cingulate cortex (ACC) CBF may lead to poor integration of visceral and sensory changes accompanying such emotional stress responses and top-down regulation of amygdala reactivity.

Thus we see our model in a snapshot even in adolescents potentially.  The emotional processing deficits we have discussed previously implicate the insula and ACC, as there appears to be a difficulty in alcoholics in reading emotional or somatic signals/states and integrating these signals into the identifying, labelling and processing of emotions. Equally there appears to be a hyperactivty in the vmPFC and amgydala as with alcoholics which implies emotional dysregulation, a hyper reactive emotional response and a tendency perhaps to a more “fight or flight” response, distress based impulsivity and short termist decision making, wanting it NOW rather than later.


References Lin, A. L., Glahn, D. C., Hariri, A. R., & Williamson, D. E. (2008). Basal Perfusion in Adolescents at Risk for Alcohol Use Disorders. In Proc. Intl. Soc. Mag. Reson. Med (Vol. 16, p. 60).

How far have we come in understanding this emotional disorder?

A constant thread throughout our blogs so far has been an assertion that alcoholism and addiction are primarily emotional regulation and processing disorders.

So we were thus  very interested to find this article (1) which describes how we are not the first to view alcoholism and addiction this way.

Here we use this article to present a  brief history of research, dating back to the 1930s, that has viewed alcoholism and addiction in a similar way to we do now in 2014.


“Life, as we find it, is too hard for us; it brings us too many pains, disappointments and impossible tasks. In order to bear it we cannot dispense with palliative measures. (…), intoxicating substances, which make us insensitive to it” (Freud, 1930, p. 75).


Rado (1933) was the first to describe substance use as a way of coping with excessively difficult states of emotions (3).

Others subsequently interpret the phenomena as a maladaptive way of fighting against stress, anxiety, and depression (4-6). Krystal and Raskin(1970) emphasize the undifferentiated and archaic, somatically manifested, emotions of persons suffering from addictive disorders (7).

These emotions are fixed at this level owing to their early traumatic nature.

Later, McDougall (1984) also highlighted the importance of overflowing emotions in the case of people with addictive disorders (8). He identified substanceuse as a compulsive way of canalizing these overflowing emotions. Conclusively, we can see that in all of these mainly psychoanalytically oriented theories, substance use is present as an instrument to regulate emotions.

This approach is elaborated unequivocally in the theories of Leon Wurmser and Edward J. Khantzian. According to Wurmser (1974), people with addictive disorders are unable to regulate their undifferentiated feelings, impulses, and pervasive internal stress, and so they turn to psychoactive substances (9). Their substance use can thus be recognized as an attemptat “self-treatment.” The self-medication hypothesis of Khantzian (1985) also highlights emotion regulation in the background of addictions (10).

He asserts that drug use in fact emerges as the common result of psychopharmacological functioning and overwhelmingly painful emotions. Like Wurmser, Khantzian also points out that the choice of substance is specific to the person’s self-regulation and affect-regulation problems, as well as his/her personality dysfunctions (11).

More recently we have had Cheetham’s affect- centred theories of addiction (12).

Apparently, clinical observations highlight mainly those dimensions in the background of psychoactive substance use—primarily the presence of undifferentiated, overflowing, dominantly negative and painful feelings, and difficulties in emotional expression and emotional regulation—which appear to be basic components of the later Emotional Intelligence (EI)  construct (13). For instance, according to Mayer and Salovey (1997), the main components of EI are: (1) the perception, appraisal, and expression of emotions; (2) the emotional facilitation of thinking; (3) understanding and analyzing emotions, and employing emotional knowledge; and (4) the regulation of emotions.

The most important empirical findings regarding our topic may be those studies, which attempted to explore the relationship between addictions and alexithymia.

The concept of alexithymia (14) was created by Ruesch (1948) but the definition of Nemiah and Sifneos is more widely known (15,16).

The four main characteristics of alexithymia are: (1) difficulty identifying feelings and distinguishing between emotions and corresponding bodily sensations; (2) difficulty describing feelings to others; (3) constricted imaginal life and fantasies; and (4) externally oriented cognitive style (17).

The relationship between alexithymia and emotional consciousness or emotional intelligence was confirmed by several studies (18-20). These studies pointed out that a low level of EI correlates with a high level of alexithymia.

These results are hardly surprising, given that the ability to identify and express emotions is an important component of EI.

Besides clinical observations (21), empirical studies have also shown that people with addictive disorders—mainly alcoholic patients or those diagnosed with eating disorders—have difficulties with the verbalization and expression of their feelings, so in their case the problem of alexithymia is more frequent than in the normal population (22-24)

One study looking at a meta analysis of research into emotional aspects of addiction (1) found – 12 of these studies solely measured the ability to identify emotions – Oscar-Berman and colleagues (1990) were the first to draw attention to the fact that alcohol addicts, especially those suffering from Korsakoff‘s syndrome, have difficulties in identifying and decoding emotions mediated by facial expressions (25).

Underlying the inaccuracy of decoding is the overestimation of intensity of emotions, especially negative ones, characteristic of alcohol patients (26-29). They also tend to associate negative emotions more often with each of the presented facial expressions (30). Furthermore, Kornreich and colleagues have pointed out that the ability to identify emotions is tightly and negatively associated with interpersonal problems, and these problems seem to be a mediating factor between emotional identification deficits and alcoholism (31). All of these findings may relate to results stating that people with alcohol addiction tend to interpret facial expressions, like sadness or disgust, falsely as emotions describing interpersonal conflicts, like anger or contempt (32).

This latter result is also supported by an Italian study (33). A further important outcome of these investigations showed that alcohol-addicted patients, in spite of their weaker capacity, rate these emotion-decoding tasks at the same difficulty level as do people from the control groups. It therefore seems as though they are not aware of their difficulties in identifying emotions.

At the same time, however, this distortion in the subjective ratings is not only characteristic of alcohol addiction, but is present in the case of opiate-addicted people as well (34,35). These studies also highlighted that alcoholism is associated with poorer emotion-decoding  abilities than compulsive use of opiates.



We have discussed emotional processing deficits in alcoholics and addicts in another blog.

The prevalence rate of alexithymia in alcohol use disorders is between 45 to 67% (36,37). Finn, Martin and Phil (1987) investigated the presence of alexithymia among males at varying levels of genetic risk for alcoholism. They found that the high risk for alcoholism group was more likely to be alexithymic than the moderate and low genetic risk groups (38).

The inability to identify and describe affective and physiological experiences is itself associated with the elevated negative affect (39) commonly seen in alcoholics, even in recovery (40). This latter study also highlighted the link between alexithymia and the emotional dysregulation inherent in addictive disorders.

Thus, the unpleasant “undifferentiated emotional” experience of early theories might prompt individuals to engage in maladaptive behaviors, such as excessive alcohol consumption, in an effort to regulate emotions, or, more specifically, cope with negative emotional states (41).

We now see how neurobiological models can marry statisfactorially wih psycho-analytic theories. This will be especially the case when we blog about alexithymia, addictive and theories of attachment.

We have thus moved from a mainly clinical perspective on the role of emotional difficulties in addiction to providing some neuroscientific evidence that these theories were actually on to something, namely these theories were pointing the way to further conceptualisations of addiction as a disorder of emotional regulation and processing. 



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