How Self-Regulation Builds Recovery Success

Emotions are powerful.  From emotions come passions, wild and driving, which spur us to create or to destroy.

Evidence about decision-making through neuroscience suggests that most decisions are determined not by logic, but by emotion.  Neuroscientist Antonio Damasio discovered that his patients with damage to the part of the brain that controls emotion have difficulty making decisions.  Later, a 2006 study by De Martino et al. found that people undergoing an fMRI while presented with gambling options made their decisions emotionally.

“Emotions move us. The word, ’emotion,’ derived from the Latin, literally means ‘to move.’ The ancients believed that emotions move behavior; in modern times we say they motivate behavior. They energize us to do things by sending chemical signals to the muscles and organs of the body; they prepare us for action.”
Steven Stosny, Ph.D. on Psychology Today

It is not surprising, then, that emotion regulation or dysregulation has been shown to have profound effects on human behavioral patterns throughout life.
Awareness gives me a chance to change

Several studies (Nikmanesh et al. 2014, Gerra et al. 2014, Banducci et al. 2014) have found a connection between emotion dysregulation due to childhood trauma, and behaviors such as gambling, eating disorders, substance use disorders, and violence.  They indicate that the ability to regulate one’s emotions is not innate, and can be severely compromised by emotional and physical trauma incurred in childhood.  Teaching emotion regulation skills to a child, and particularly to victims of trauma, is imperative to help the individual avoid substance use disorders and other behavioral disorders later in life.

Emotion regulation is the ability to assess and change one’s emotional state, particularly in cases of extreme distress.  In a broader sense, emotion regulation is a set of skills and abilities that keep one’s emotional system healthy and functioning.  This introductory article suggests that emotion regulation encompasses the following skills:

  • Recognizing one is having an emotional response.
  • Understanding what the emotional response is.
  • Accepting the response, rather than becoming afraid.
  • Assessing and choosing strategies to reduce the intensity of the emotional response.
  • Engaging in goal-directed behavior toward these strategies.
  • Controlling impulsive behaviors during the emotional response.

Emotion regulation also helps one to align one’s actions with one’s deepest values.  It begins with awareness of one’s emotional state.  Without awareness of emotions, there can be no clear awareness of decisions as decisions are made.  Perhaps this is why a choice to drink or use drugs becomes a habit of drinking or using, which insidiously becomes an addiction without one knowing exactly when the shift took place.

Substance use disorders are strongly linked to emotion dysregulation in the literature (Nikmanesh et al. 2014, Fox et al. 2008, Matthias et al. 2011, Axelrod et al. 2011, Dishion et al. 2011).  It has been proposed that substance use begins as an effort toward emotion regulation or self-regulation, but that if it leads to addiction it only worsens one’s ability to self-regulate.  This is known as the self-medication hypothesis of addiction, an older hypothesis which is still supported by scientific literature.  The perceived need to self-medicate begins when emotions become intolerable, and when an individual is unable to regulate those emotions. In fact, “negative affect,” or unregulated, negative moods such as anger, frustration, and depression, is the primary predictor of relapse for addicted individuals.

Yet it would be monumentally unfair to call this difficulty in emotion regulation a moral failing.  Emotion regulation is a skill set, which can be compromised by severe or repeated trauma and stress.  If a person had never thrown a ball before, or perhaps had had an injury in that arm that impaired throwing accuracy, one would not condemn that person even if they messed up and threw the ball directly into someone’s face.  One would have compassion for that person’s compromised ability, and perhaps work with them to improve their throwing.

And fortunately, there are approaches to building emotion regulation skills that are supported by the literature.

Cognitive Behavioral Therapy is a form of talk therapy in which a therapist actively guides a person in examining the relationships between thoughts, feelings, and actions.  The therapy focuses on discovering and changing the thoughts and feelings that lead to detrimental behaviors.  Cognitive Behavioral Therapy, particularly when combined with acceptance, tolerance, and active modification of negative emotions, has been shown to be effective training for emotion regulation.

Dialectical Behavioral Therapy has even more support in the literature for cultivating emotion regulation (Linehan et al. 1999, Neacsiu et al. 2014).  It is another form of talk therapy, originally developed to treat people with borderline personality disorder.  DBT is similar to CBT, but with the focus on acceptance of the negative thoughts and emotions that trigger detrimental behaviors.  Through acceptance, people are able to see change as actually possible and so engage with the therapist in planning a gradual change for recovery.

Mindfulness Training is a rising star in talk therapy, derived from the Buddhist meditation practice anapanasati.  In essence, mindfulness training cultivates a person’s ability to be exactly in the present moment, aware of one’s breath, feelings, thoughts, perceptions – everything.  Mindfulness practice inserts a pause of awareness between one’s internal reaction to something and one’s actions.  This pause is essential for one to assess one’s self and to temper emotional decisions with one’s deepest values.  Mindfulness training is simply an Eastern, meditation approach to cultivating this pause.  Mindfulness is supported in the literature as a promising approach to cultivating emotion regulation.

It is clear that emotion regulation is a fundamental skill set for assuming autonomy and control over one’s decisions and actions.  Without emotion regulation, people are at higher risk for many detrimental behaviors and disorders, including substance use disorders. Emotion regulation training is an important element for professionals to consider when developing recovery programs for people with substance use or process disorders.  This training is a direct and influential measure one can take toward recovery success.

Update: The section beginning “Substance use disorders are strongly linked to dysregulation in the literature” was last updated 5/3/16.

Laurel Sindewald is a writer, researcher, and editor.

The content of this post is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

On Anhedonia: A Lasting Effect of Addiction

By Laurel Sindewald

Much of the battle of recovery is a hidden, quiet affair. After the shakes subside and a person is considered stable enough to have survived acute withdrawal symptoms, the person in recovery from addiction has a hard slog ahead.

The experience has not been studied enough for it to be considered official, but people who have seen or experienced it have given it a name anyway: post-acute withdrawal syndrome or PAWS. SAMHSA has taken note of the condition and has published an article with helpful details on how PAWS affects people recovering from different substance addictions. Symptoms of PAWS can include depression, anhedonia, loss of concentration, craving, sleep disturbances, stress sensitivity, anxiety, and guilt.

While post-acute withdrawal syndrome has not been studied extensively as a whole, anhedonia is a lasting effect of substance use disorders. Anhedonia refers to a physical loss of one’s ability to experience pleasure. Though drug cues continue to elicit craving and the promise of that elusive pleasure, natural sources of pleasure will feel as if they’ve utterly lost their charms. This condition occurs in several neuropsychiatric disorders, most notably major depression and schizophrenia in addition to substance use disorders. It is unknown what exactly causes anhedonia. Yet whether anhedonia causes addiction, addiction causes anhedonia, or anhedonia is caused by other things than addiction and simply co-occurs with addiction, we know that anhedonia occurs upon abstinence from the addictive substance.

Anhedonia is the result of changes in the dopaminergic mesolimbic and mesocortical reward circuit, involving the ventral tegmental area, the ventral striatum, and part of the prefrontal cortex. The inactivation of dopamine in these areas is proposed to lead to anhedonia, though more research is needed to be certain. A recent study (2012) by Robert Malenka of Stanford University found that the nucleus accumbens, part of the ventral striatum, does not work properly when anhedonia occurs. He found that the melanocortin transmitter may have a more specific and relevant role in producing anhedonia in rats under chronic stress than dopamine.

The evidence of anhedonia’s link to addiction is well documented. One study (2009) presented pleasant pictures to a control group and to a group of people addicted to heroin and found that heroin users had reduced responsiveness to these natural reinforcers, “across a range of psychophysiological measures.” They found that, furthermore, their subjective ratings of the pleasant pictures predicted future heroin use.  Another study (2005) found that anhedonia occurred with withdrawal symptoms and was especially associated with craving.  Other studies have also documented that anhedonia occurs (Cook et al., Zijlstra et al., Hatzigiakoumis et al., Leventhal et al.) and persists (Stevens et al., Martinotti et al.) in people in recovery. Anhedonia is more pronounced in people recovering from multiple addictions, and several studies emphasize that anhedonia is a significant indicator of relapse (Koob and Le Moal, Volkow et al., Garfield et al.).

Anhedonia is known to follow cocaine, amphetamine, tobacco, alcohol, cannabis, and especially opiate substance use disorders, though according to SAMHSA its occurrence and intensity does vary from person to person. It is also documented to be long-lasting, though how long is uncertain. A study (2008) of 102 people diagnosed with alcohol use disorders found that anhedonia persisted for the duration of their 12 month study.

It is likely anhedonia can persist longer than a year, but the duration of the condition has not been investigated. A meta-study (2013) of 32 research articles from three different databases has been conducted, intending to discover the average duration of anhedonia among other questions, but the abstract did not report a single study in which the duration of anhedonia after abstinence was studied.

There are some treatments that have had success in treating anhedonia. fMRI studies of Behavioral Activation, a behavioral therapy used to treat depression, have revealed “BOLD responses of the striatum during reward anticipation,” suggesting that Behavioral Activation therapy may be a helpful treatment.

Pharmacological treatments have been developed, specifically targeting the activation of the dopaminergic reward system. These are commonly psychostimulants, dopamine agonists, and bupropion (a norepinephrine/dopamine reuptake inhibitor), thought most treatments were developed to treat anhedonia in depressed patients rather than specifically substance use disorders. A recent study (2011) by Martinotti et al. found that intravenous administration of the drug Acetyl-l-Carnitine accelerated the improvement of anhedonia in detoxified alcohol dependent subjects. Martinotti et al. (2009) also found that aripiprazole was as efficacious as naltrexone in reducing craving in alcohol dependent subjects, and more effective at treating anhedonia. Subjects receiving aripiprazole also remained abstinent for longer periods of time than those receiving naltrexone. More tentatively, in 2008 Martinotti et al. found that the drug quetiapine decreased alcohol consumption, craving, and psychiatric symptoms such as anhedonia in alcohol dependent subjects with comorbid mood disorders.

Even more encouraging, Robert Malenka has had a breakthrough in research regarding anhedonia, which may lead to better pharmacological treatments in the future. He studied rats that had been kept under conditions of chronic stress and who had shown a reduction in preference of sugar water over regular water, as well as significant weight loss. The rats’ conditions improved after he inhibited the release of melanocortin, a transmitter that functioned to reduce the activity of neurons in the nucleus accumbens during periods of chronic stress.

For those who prefer alternative therapies, clinical trials are reported to be underway for the effectiveness of acupuncture in treating drug addiction by influencing the reward system. It is yet to be seen whether acupuncture can be demonstrated to help anhedonia.

Exercise may be beneficial as physical activity has been shown to be inversely related to both depression and anhedonia and regular exercise reduces anhedonia and depression. Regular exercise and a diet tailored to recovery from the drug of abuse may be two immediate treatments for anhedonia, and likely for other PAWS symptoms as well. As research on the exact mechanisms behind anhedonia continues, treatments will undoubtedly improve.

Laurel Sindewald is a writer, researcher, and editor.

The content of this post is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

This post was last updated on 10/20/16.

On Relapse Rates and Sobriety Goals

Relapse in substance abuse is far from failure. Not only does relapse provide an individual with a chance to change, but it provides valuable information about the effectiveness of treatment. Even better, relapse rates may be able to provide addicts with a timeline of sobriety goals to aid in recovery.

Addicts need to know if, and how, their chances for success increase over time. An opiate addict is likely to hear that he or she has an 85% chance of relapse. While this is valuable for evaluating the effectiveness of treatment, hearing one’s likelihood for failure doesn’t exactly bolster confidence.Solutions for Extreme Conditions = Experience + Innovative Thinking

A more fruitful statistic for an addict would be, “Opiate addicts are ___% less likely to relapse after one year following treatment.” One year becomes a benchmark, a goal, for the recovering addict to achieve. Phrased as sobriety goals, statistics on relapse rates could potentially be very helpful for recovering addicts.

This is simple enough to say, but the data is complicated.

Relapse rates are usually reported specifically per substance, and many compare relapse rates between treated and untreated individuals for a substance. This is further complicated in that different treatment methods might be used in different studies, and individuals don’t always remain in treatment for comparable amounts of time.

The following statistics give one an idea of these difficulties, as well as an idea of relapse rates for alcoholism:

  • According to this source updated in 2014, 80% of patients with alcohol addictions relapse within the first year. After 2 years, however, this relapse rate drops to 40%. Patients are 40% less likely to relapse after two years of sobriety. This rate drops even further after 5 years, though a statistic is not provided.
  • This 2006 study found that by year 3, 62.4% of individuals in a treated group were remitted in addition to 43.4% in the untreated group. Unfortunately, in year 16, the number of sober individuals in the treated group dropped to 35.6% and 17.1% in the untreated group. According to this study, patients are about 26.3% more likely to relapse in year 16 than in year 3.

The information above illustrates the difficulty in determining reliable relapse rates even within one addiction such as alcohol. Patients referenced in the first source were likely given different treatment than the second source. Furthermore, the time frames are completely different; the first source informs us of the change from year 1 to year 2, and the second details the change from year 3 to year 16.

What is ultimately needed is a detailed meta-study focused on providing addicts with benchmark statistics, specific to their addiction, to encourage them to last just one year, two years, five years longer. Addicts need to know when the temptation to use will get easier to refuse. Descriptive statistics such as these would also be the lowest-cost means of tracking progress each year of sobriety.

More recent research may offer more personalized estimates of relapse risk, though potentially more expensive. According to an article published in February of 2011 the extent of grey-matter deficits in alcoholics, particularly in the part of the brain regulating behavioral control and decision making, predict the likelihood of relapse.

“Hazard ratios indicated that, for each 1ml reduction in grey-matter volume in the medial frontal cluster and in the parietal-occipital cluster, there was a 48% increase in risk of earlier relapse. After further adjustment for years of alcohol use and total alcohol consumed in the 90 days before treatment, smaller grey-matter volume in these two clusters predicted shorter time to relapse to heavy drinking, by 44% and 45% respectively.” –Rando et al.

Rather than searching for generalized averages to indicate a person’s risk of relapse, doctors could analyze an addict’s grey-matter volume in the parts of the brain mentioned above to determine risk level.

Furthermore, if an addict is introduced to a program that helps increase grey-matter volume, he or she could see his or her risk level drop as the program progressed. Perhaps, for each 1ml increase in grey-matter volume, there is a 48% decrease in risk of earlier relapse. Mindfulness practice has been shown to cultivate an increase in grey-matter density.

Measuring grey matter may be one of the most accurate predictors of relapse risk, but most addicts don’t have the money for such a detailed and personalized consultation. The above study is also specific to alcoholism, leaving other addictions in the dark.

Fortunately for addicts and families alike, research on addictions continues to expand. Data on relapse rates is currently scattered and disparate, but with careful analysis a series of meta-studies could piece the patterns together. There is a need for more positive analysis of relapse patterns. What’s needed are descriptive statistics to give addicts hope, and goals.

Laurel Sindewald is a writer, musician, philosopher, and biologist.