From a Drinking Problem to a Thinking Problem?

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

 

 

 

They can fuck you up, your mum and dad.

They fuck you up, your mum and dad.
    They may not mean to, but they do.
They fill you with the faults they had
    And add some extra, just for you.

Phillip Larkin – This Be The Verse

Looking back on my own childhood it is easier now to observe the fertile ground from which my genetic seeds of alcoholism started to flourish. I have long maintained that growing up in a dysfunctional family environment did not create my alcoholism but certainly did not help. A family environment were emotional expression was limited and veered between sentimentality and  outright anger.

It is difficult to see how I learnt the essential adaptive skills of emotional regulation then; how to identify, label and express emotions freely without sanction, verbally, and non-verbally. For me emotions where something you cut off, experientially avoided, resisted. The more you did not let them get to you the tougher you were mentally somehow. Emotions were strangely dangerous things almost.

Emotions, having them, made you weak! People who indulged in them were weak.

I also grew up with a father who was a boxer and alcoholic (abstinent, thank God, via the local Church) who insisted emotions had to tolerated like a man, like some tough  hombre in a 1950s Western. I had a host of uncles and a Grandad who agreed and they all set out to toughen me up. I even had boxing matches with cousins at various homes to show how I was progressing!

When I started drinking I found that this tough guy routine was greatly enhanced. Alcohol made me bullet proof. I drank and grew up to manhood in one go. Or so I thought – I didn’t realise that I stayed at that emotionally  impaired 14 years old for nearly three decades later.

The worst effect on my emotional regulation  skills was my relationship with my mother who struggled with valium abuse most of her adult life. This meant she was emotionally distant a lot of the time. Wose than that, she mixed mawkishness with being cold as a stone. It was an insecure attachment.  You were never sure, emotionally, where you were at with her. It made me insecure, anxious and eventually very very angry. Cold blue angry.

But did this also have an effect on my ability to processing emotions. How could maternal emotional deprivation have an effect on my emotional processing skills? Andd how could this emotional processing difficulty affect the amount I craved alcohol??

I recently came across this article (1) which looked at this very question.  I refer widely from it here.

Attachment theory is a widely used framework for understanding emotion regulation as well as alexithymia, and this perspective has also been applied to understand alcohol use disorders. One hypothesized function of attachment is the interpersonal regulation of affective experiences (Shaver & Mikulincer, 2007; Sroufe, 1977).

One hypothesized function of attachment is the interpersonal regulation of affective experiences (Shaver & Mikulincer, 2007; Sroufe, 1977). In the development of alexithymia, attachment theories stress the importance of significant others in childhood (Krystal & Krystal, 1988; Nemiah, 1977; Taylor et al., 1997). Evidence suggests that alexithymia is related to dysfunctional parenting (Thorberg, Young, Sullivan & Lyvers, in press).

Insecure attachment is associated with alexithymia and both harmful drinking and alcohol-dependence (Cooper, Shaver, & Collins, 1998; De Rick & Vanheule, 2006; Thorberg & Lyvers, 2006; Thorberg, Young, Sullivan, Lyvers, Connor & Feeney, 2009). In addition, alcohol abuse has been hypothesized to be a consequence of alexithymia (Taylor, Bagby, & Parker, 1997).

Research on alexithymia (1) has found significant positive associations between alexithymia, difficulties identifying feelings, difficulties describing feelings and alcohol problems (Thorberg, Young, Sullivan, & Lyvers, 2009; Thorberg, Young, Sullivan, Lyvers, Connor & Feeney, 2010). Individuals with alcohol-dependence and alexithymia report more severe alcohol problems compared to those with alcohol-dependence alone (Sakuraba, Kubo, Komoda, & Yamana, 2005; Uzun, Ates, Cansever, & Ozsahin, 2003). They also have poorer treatment outcomes (Loas, Fremaux, Otmani, Lecercle, & Delahousse, 1997; Ziolkowski, Gruss, & Rybakowski, 1995).

Individuals may use alcohol to escape feelings of rejection and establish a “secure attachment base” (Hofler & Kooyman, 1996), given alcohol’s stress and anxiety reducing effects.

In this study (1)  results highlight the importance of alexithymia and difficulties identifying and describing feelings as related to preoccupation, obsessions and compulsive behaviors regarding drinking in those with alcohol-dependence. Or in more simple terms between alexithymia and craving.  In this study 32.4% of this alcohol dependent groups were alexithymic. This is less than previously reported prevalence rates of 45-67% (Thorberg et al., 2009).

In this study (1)  alcohol-dependence severity, alexithymia and insecure attachment were associated with more intrusive and interfering cognitions, ideas and impulses about alcohol, including an impaired ability to control these thoughts and impulses. This cognitively based “craving” as measured by the Obsessive Compulsive Drinking Scale (OCDS; Anton, Moak, & Latham, 1995), which is designed to assess obsessive thoughts and compulsive behavior toward drinking.

Hence there was a demonstrated relationships between alexithymia, craving, anxious attachment and alcohol problems in an alcohol-dependent sample. Higher levels of alexithymia led to a stronger desire for alcohol that was partially explained by an underlying mechanism, anxious attachment. One possible reason for this  it may reflect an impairment in affect regulation.

Findings of the RAAS-Anxiety scale measured insecure attachment as related to a current or previous relationship, these findings may suggest that worries about being rejected, not cared for or unloved lead to an increased craving for alcohol.

One explanation for this mediational relationship may perhaps be that increased relationship stress is associated with a fear of intimacy and anxious attachment that leads to increased craving and perhaps a stronger attachment to alcohol. In other words, the alexithymia of insecure attachment may cause a stress dysregulation which prompts craving particularly as craving is a consequence of dysregulated stress systems. Stress dysregulations is also implicated in increased or more chronic alexithymia as suggested by George Koob in various articles. This has also been observed in other studies – this relationships of negative affect (anxiety, negative mood and emotion) with both alexithymia and craving (Sinha & Li, 2007).

To summarise, the results of this study support important relationships between alexithymia, difficulties identifying and describing feelings in relation to alcohol craving. These relationships extend to significantly higher levels of obsessive thoughts and compulsive behaviors in relation to alcohol use and alcoholism severity amongst individuals with combined alexithymia and alcohol-dependence, compared with alcohol-dependence alone. This study identified anxious attachment as a potentially important mechanism, in the relationship between alexithymia and alcohol craving.

References De Rick, A., Vanheule, S., & Verhaeghe, P. (2009). Alcohol addiction and the attachment system: an empirical study of attachment style, alexithymia, and psychiatric disorders in alcoholic inpatients. Substance use & misuse,44(1), 99-114.

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

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

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

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

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

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

Image

 

 

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

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

 

References 

 

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

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

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

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

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

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

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