Why a “Spiritual Solution” to a Neurobiological Disease?

because it says it all! and for our newcomers…

Inside The Alcoholic Brain

In the first in a series of blogs we discuss the topic of why does the solution to one’s alcoholism and addiction require a spiritual recovery.

This is a much asked question within academic research, although the health benefits of meditation are well known and life styles incorporating religious affiliation are known to increase health and span of life.

I guess people are curious as to how the spirit changes matter or material being when it should perhaps be rephrased to how does application of the ephemral mind affect neuroplasticity of the brain. Or in other words how does behaviour linked to a particular faith/belief system alter the functions and structure of the brain. We have discussed these points in two blogs previously and will do so again in later blogs. Here I just want to highlight in a short summary why spiritual practice helps alcoholics and addicts with with…

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What is craving – do neurobiological accounts explain relapse in recovering alcoholics? Pt 2

If you want to drink, you will. It you do not, and depending on your regulation of emotions and stress, you may still relapse, even if one never intended to drink again.

In our previous blog we looked at automatic physiological response to cues that alcoholics appear to experience. These habitual responses are well explained by reinforcement, conditioning or neurobiological models of addiction.

However, do these neurobiological models predict relapse in abstinent alcoholics and addicts? In other words, do recovering alcoholics act and react to cues and have the same attentional bias, i.e. are they lured siren-like to alcohol or drug cues like lemmings to a drink or a drug or are there more  cognitive-affective processes at work in the craving than these models suggest!?

Does the mind play a role in transmuting these physiological urges into “craving”.

When I have seen a new comer to recovery craving they do not seem to walk around like a robot, salivating and rubbing their sweaty hands together. I have seen that when I was in active drinking and was like that innumerable times myself while under the spell of this “fleshy hunger” called having a pathological urge for a drink.

I am not downplaying this urge state, it is quite horrendous, it is like craving a glass of water after days in the desert. It feels like your very life depends on it, in other words. It can be a life or death feeling.

 

PowerPoint Presentation

In recovery, this urge state becomes more complicated and various other brain regions may become involved in this “craving” and there may be a interplay between regions rather than regions simply acting in concert – we will explore this more in series 3 of this theme of “craving”.

For now we examine how well do neurobiological accounts (i.e. accounts which focus primarily on impairments in neurotransmitter and stress systems and brain function in areas which create a cascade of ‘knock on’ impairment and dysfunction in areas of the prefrontal cortex which deals with cognitive control of behaviour with resultant dysfunction in areas which deal with reward, motivation stress and emotional response and more motoric, habitualized action) predict behaviour in abstinent, treatment seeking individuals?

Here we simply consider how well aspects of these theories, such as the ideas relating to craving (urge) via cue reactivity (an attentional bias towards alcohol and drug associated cues in the environment)  and positive memory associations for previous alcohol or drug use, relate to, or are relevent to the experiential reality of everyday recovering alcoholics and addicts.

In simple terms, it is the duty of science to attempt to predict behaviour, so how well do these models, especially the positive reinforcement model, predict the behaviour of treatment seeking abstinent alcoholics and addicts. 

Factors in relapse

Cues, external especially, which is a central part of positive reinforcement models, seem to be only one of various factors in relapse. They are present in a relatively small minority of studies or interact with other variables such as stress and negative affect (NA). So how well does this then validate this theory of addiction, when it is only present in a minor way in relapse and usually alongside stress and NA. Does this mean it plays a role when interacting with these variables of stress/NA. Does it play a role on it’s own?

I forward this question because the looking at an alcohol cue by an alcoholic even in recovery/abstinence invokes stress reactions such as anxiety or negative emotions such as anger, sadness ( ). Can we say there is a non-stress influenced cue-reactivity? Is there a purely dopaminergic cue reactivity? It doesn’t appear so.

In fact moving on from noting this intrinsic stress response in cue reactivity, various studies show that the highest high-risk relapse situations are negative emotions, testing personal control, social pressure, and urge and temptations  (1), that 62 –73% of relapse episodes were due to negative emotion and social pressure. Heroin addicts relapse primarily because of NE and lack of social supports. Mood state, along with social isolation and family factors, was more likely to be related to relapse incidences with a positive correlation between NE and alcohol-seeking behaviour. Thus the most commonly cited reason for relapse was negative mood states, consistent with previous studies of relapse factors (2).  Also reasons for relapse did not differ in relation to the primary drug of dependence (alcohol, methamphetamine, heroin), reflecting the commonality of relapse processes across diverse types of substances.

Marlatt (3,4) , views relapse as an unfolding process in which resumption of substance use is the last event in a long sequence of maladaptive responses to internal or extemal stressors such as negative emotional states, interpersonal conflicts, and social pressures. In fact negative emotional states ….coping, self-efficacy and stressful life events appeared to be of greater import in determining relapse than ‘cues’.

It would appear that cue associated stimuli plays a minor role in relapse, with stress and NA appearing to be a more important determinant of relapse. So conditioning models do not appear to give a comprehensive account of relapse and this may be particularly the case in abstinent, treatment seeking alcoholics.

How does conditioning methodology adequately explain this group?

Attentional Bias

Do treatment seeking alcoholic have the same attentional bias as non treatment seeking active alcoholics?

In fact, studies seem to show a negative attentional bias in alcohol-dependent patients that may be interpreted as an avoidance of alcohol-related stimuli.

Townshend and Duka (2007) propose that treatment seeking individuals have established active avoiding strategies and  are able to disengage their attention from alcohol cues (5). In fact is suggested that a positive attentional bias towards alcohol cues occurs when stimuli were presented shortly (50 ms), followed by a disengagement from alcohol cues in the 500 ms interval of cue presentation. This corresponds with a cognitive model of craving of Tiffany (6) where the 50ms may represent automatic approach before this automatic bias is interfered with by cognitive control, perhaps resulting in ‘craving’.

Does this visual approach–disengagement pattern reflect an  attentional bias which is appetitive or threat based? If there is avoidance are cues similar as  seen as in those with trait anxiety who have attentional bias for threat-related cues (7). A large body of evidence indicates that aversive emotional states are associated with biases in cognitive processing and, specifically, with increased attentional processing of threat-related cues.Is this also how treatment seeking addicted individuals are responding to substance-related cues? It may that stress heightens the salience of attractiveness of the cues so that abstinent individual relapse because of stress based response which makes relapse via internal and external cues a solution to their chronic stress/emotional distress?

Or it may be that relapse is based on difficulties coping with the manifestation of chronic stress, emotional distress and that  relapse  is a more complicated process than simply being lured, siren-like, to relapse via cues.

In most of the relapses we have encountered it has been a ongoing build up to relapse. There has been a period of emotional dyregulation whereby individuals get more and more distressed, often in inter-personal relationships, and have a “to hell with it!” relapse to relieve escalating emotional distress and the distorted thinking that goes with it. It is not due to automatic or motoric proceses, it is mediated via affective-cognitive mechanisms and this is why the information processing model, with some modifications, appears to explain craving and relapse more satisfactorily.

If you want to drink, you will, it you do not, and depending on your regulation of emotions and stress, you may still relapse, even if one never intended to drink again, due to the torturous intrusive thoughts which accompany this cognitive and emotionally based “craving”, more akin to the “mental obsession ” of AA’s Big Book than purely physiological urges.

References

1. El, S., Salah El, G., & Bashir, T. Z. (2004). High-risk relapse situations and self-efficacy: Comparison between alcoholics and heroin addicts. Addictive behaviors29(4), 753-758.

2.  Hammerbacher, M., & Lyvers, M. (2006). Factors associated with relapse among clients in Australian substance disorder treatment facilities. Journal of substance use11(6), 387-394.

3. Marlatt, G.A. (1978) Craving for alcohol, loss of control and relapse: Cognitive behavioural analysis. In: Nathan, P.E., Marlatt, G.A., and Loberg, T. eds. Alcoholism: new directions in behavioural research and treatment. Plenum Press, New York, 271-314.

4. Marlatt, G.A., and Gordon, J.R. (1985). Relapse prevention: maintenance strategies in the treatment of addictive behaviors. Guilford  Press, New York.

5. Townshend JMDuka Attentional bias associated with alcohol cues: differences between heavy and occasional social drinkersPsychopharmacology (Berl)2001;157:6774.

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

7.  Bar-Haim, Y., Lamy, D., Pergamin, L., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2007). Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychological bulletin133(1), 1.

8.  McCusker CG  Cognitive biases and addiction: an evolution in theory and methodAddiction 2001;96:4756.

Euphoria Re-experienced not Recalled?

I never, never want to drink again, I would rather kill myself.

This does not mean I will not drink again however.

A possible relapse is thus not down to desire for a drink, it is because something in my brain and in my heart goes awry.

I remember being in early recovery and thinking the following line from the Big Book of Alcoholics Anonymous was very strange  “Remember that we deal with  alcoholcunningbafflingpowerful! Without help it is too much for us”

What did they mean, alcohol was cunning, baffling, powerful? Surely they meant, alcoholism was cunning, baffling, powerful? Right?

Alcohol itself has not got magical powers? It isn’t a ghost or a spirit that can come and get you lured you back into drinking? Why be wary of a substance?

I suffer from alcoholism not alcohol, don’t I? ISM – I, self, me, the internal spiritual malady treated formerly by alcohol. Right? Alcohol was symptomatic?  “Bottles were only a symbol”

Now what is it to be?

In AA, I used to think alcohol got off light, considering the damage it causes to the brain. I always felt alcohol and it’s comprehensive deleterious neuro-toxic effects on my brain have greatly contributed to my difficulties with emotions and thinking and memory and perception etc. The list does go on and on.

One only has to look at a brain image from a fMRI scan to realise  that the damage to the brain wrought by alcohol is extensive and some of it irreversible although there is extensive repair in certain regions of the brain in recovery. I have felt for some time that alcohol gradually help change, over years,  how I felt and thought and perceived this world.

Alcohol literally moulded my brain. If I emotionally reacted or  thought in the same distorted way as I did while drinking or perceived this world in the same jaundiced way I did while drinking ,but while in recovery, then the same behaviours would soon follow.

I would drink.

Like a lot of alcoholics, I had a terrible sense of self, a very negative self perception in other words. I thought I was the lowest of the low, that I had screwed up my life and squandered my talents, that I didn’t even deserve recovery or to recover. I was not even worth that. It was this shame and guilt-fuelled lack of self esteem, this devalued sense of self that helped drive my drinking and which threatened to ruin any chances of recovery.

But what does this have to do with alcohol being cunning, baffling, powerful I hear you ask? Lots, is the answer. This negative self perception, I have had since early childhood,  well since I could reflect on my self and the product of emotional and mental abuse and traumatic parenting is ingrained in my brain.

Even now when I reflect on myself I have a tendency to think negatively or poorly about myself and my achievements, I have a negative bias in my thinking about me. It could depress me even, if I indulged in thinking about me for too long.

Again what does this have to do with alcohol? Well these negative perceptions, ingrained in neural structures in my brain have had more than a helping hand by alcohol. Alcohol has helped reinforced this faulty image of my self.

Alcohol had helped colour this jaundiced view of my self and this can has serious repercussions in recovery. This distorted view was partly the result of staring at my refection on the warped  glass of a wine bottle or on a glass of beer.  It cemented this view or “concretized” it in my self perception neural networks. Every drink helped dig the grave of my self worth.

I have seen many people in recovery relapse after a period of negative self reflection, after not thinking they are good enough to recover. It is immensely sad, tragic but nonetheless true. That is why they need love more than anything when they come into recovery. Not orders or dictats but love, plain and simple, make them feel part of, that they belong, that they have found their place, their surrogate home.

I have seen countless people who were so severely abused that they could not face the self disclosure at the heart of the 12 step program of recovery. I have seem than unconsciously “choose” to drink rather than take the steps. Part of this is something deep inside whispers a barely audible solution. To drink again.

Why is it barely audible? Because it is. It doesn’t actually have a voice. It is the whisper of a neural ghost (1). It is ghost that lives in the machinery of the brain. As alive as you are. It will probably remain to haunt you as an alcoholic  in some form  and at some time of weakness. Never think otherwise!

It is like a euphoria recalled but also it isn’t!? It may be worse than that; it is actually to a very great extent re-experienced.

Euphoria re-experienced not simply recalled.

Euphoria wasn’t just the pleasure you received but also relief from…negative emotions surrounding the self. Negative self perception, emotional distress and so on. It appears that negative affect (emotions, mood, anxiety) can automatically prompt thoughts of alcohol or drugs (2) and that the neural circuitries of affect, reward, memory and attention are taken over or ‘hijacked’ in the addiction cycle and often prompted into activation by emotional distress so that attention is directed to alcohol to relieve distress, with the resultant ‘craving’ coloured by numerous memory associations ingrained in the brain linked to habitually drinking to relieve negative emotional states.

Also, pertinent to this blog, negative self perception may also prompt relapse. I partly reconcile alcohol being cunning, baffling, powerful and alcoholism by reference to an article I read a while back by Rex Cannon(3).

His observations about a possible role for negative self perception in relapse was based on a study conducted  on recovering alcoholics. It found that by measuring their brain frequencies, when thinking about drinking and when thinking about self perception that there was a change in the frequency of their brain waves. In both cases, thinking about drinking and negative self perception, Cannon et al observed that widespread alpha power increases in the cortex, commonly seen by use of certain chemicals, were also present and in the same areas of a common neural circuitry for his study group during their reports of ‘using’ and ‘drinking’ thought patterns as well as in negative self perception.

These reports of ‘using’ and ‘drinking’ thought patterns as well as in negative self perception which appeared to bring the brain into synchrony, if only for a brief period of time, suggesting this to be the euphoria addicted individuals speak so fondly of and one possible reason for difficulty in treating these disorders.

In relation to using thoughts they suggested that “if the brain communicates and orchestrates the affective state of the individual in response to contents and images relating to self and self-in-experience – it is plausible that a large scale feedback loop is formed involving not only perceptual processes but relative automatic functioning.

This process reinforces the addicted person to become habituated to an aroused cortical state (i.e. increased alpha/beta activity) and when there is a shift to ‘normalcy’ (or recovery/sobriety) it is errantly perceived as abnormal thereby increasing the desire or need for a substance to return to the aroused (perceived as normal (or desired)) state”.

This would surely have a profound impact on addicts attempting to contain normal negative emotions when there is an automatic desire state suggesting, unconsciously, an alternative to wrestling with these torturous sober realities.

I have seen a similar process but over a much longer time frame in some alcoholics in recovery who relapse. They seem to disappear into themselves, right in front of you, like they were being lured by some internal, inaudible siren, into a self drowning.

Letting go of the life boat trying to keep them afloat. I have seen it many times, the dimming of the eye’s light, the turning inwards to the alcoholic darkness. A submerging into this illness.

It may be that indulging in one’s negative self perception recreates a neural based virtual reality. One is almost bodily transported back in time. Back to a drinking period. In a neural sense, back in the drink and not fully in sobriety, however fleetingly.

It does leave a neural taste for it, a torturous transient desire.

I remember it, particularly in early recovery, when the ‘recovery’ script was not written yet and I did not have a habitual recovery self schema to automatically activate, to pull me out of this neural reverie, this most bio-chemical vicarious pleasure.

The problem is that it happens to you without you asking it! You can be invoking a negative self schema automatically without wanting to reawaken this  ghost.

But that is alcoholsim in a nutshell. It happens to you without your express permission. It takes over the brain step by step, while impairing ones’ ability to observe this progression.

That is why we are are the last to know. It is not just denial, it is brain impairment and limited ability to reflect on what has happened to one’s self.

The self has been ‘hijacked’ so it is nigh impossible to figure this out without the help of others.

It is others that lead you out of the fog, as one has become lost to oneself. If nothing else, in early recovery especially, before the steps are done, it is a dangerous place to visit, the self and it is safer to spend as much time as possible outside of it and working with others!

It is a horrible, frightening experience, the limbo between addicted self and recovery self schemas. It is fraught with danger! I remember bumping into people places and things from the past and experiencing the most excruciating cognitive dissonance of literally being caught in between two worlds and not knowing if I was a drinking or a recovering alcoholic; the sense of self as a drinking alcoholic was much stronger than the recovering self. I would hurry to my sponsor or wife to help pull my sense of self as a recovering alcoholic to the surface, out of the neural swamp of my drinking alcoholism.

But it felt alien as Cannon observes, this sober self.  All new, awkward, pained, exposed and frightened.  A constant vacillation between two worlds, that of active use and that of recovery. Recovery had not become “concretized” in my neural networks!

This left an oscillating experiential schism, with one caught in two realities almost simultaneously.

I see people relapse because they have no emotional sobriety and they seem to be emotionally drunk before they are actually drunk. Emotionally drunk seems to be like a virtual drunk, brings up the similar feelings or neurochemical reactions as actual drinking.

The best way to stay sober is to act sober and develop this habitual schema so that it can be retrieved instantaneously, automatically, without thinking. We achieve this schema through our actions, so in a sense is also an action schema. Tiffany (4) states that alcoholics and addicts are prompted to relapse by automatized schemata surrounding drug and alcohol use rituals, so we must have automatized schemata surrounding recovery rituals. Such as ringing a sponsor, mentor, friend, doing a  step ten, praying, meditating, working with others, letting go and letting God, re-appraising distress, regulating emotions, putting thoughts of others before thoughts of ourselves, living outside self.  There are so many automatic schemas in AA and other therapeutic regimes.

Either way, whatever path you choose, make your recovery  tools automatic, so that they come to hand without yourself having to think about them.

 

 

References 

 

1.  Zack, M., Toneatto, T., & MacLeod, C. M. (1999). Implicit activation of alcohol concepts by negative affective cues distinguishes between problem drinkers with high and low psychiatric distress. Journal of Abnormal Psychology108(3), 518.

2.  Cannon, R., Lubar, J., & Baldwin, D. (2008). Self-perception and experiential schemata in the addicted brain. Applied psychophysiology and biofeedback,33(4), 223-238.

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

4.  Adinoff, B. (2004). Neurobiologic processes in drug reward and addiction.Harvard review of psychiatry12(6), 305-320.