The Pleasure Principle
When you get right down to it you have to look at alcoholism as pleasure gone berserk. All addictions for that matter fall into this category when you consider the biological basis of addictions. Because in alcoholics and addicts it is the reward – pleasure circuits in the brain that are the focal point for the disease of addictions.
It is this reward system gone awry that has lead so many people down the path of misery, ill health, maladaptive behavior and death. It is because of alcohol and drugs that, we have learned, the brain is as plastic as it is, i.e. it can be reprogrammed from its primary functions as a watchdog for danger and guardian of our personal safety. Yes it is plastic, not the immutable, hard wired organ that it was imagined to be not twenty years ago. And this has come as a great awakening for the medical community, and lifted great a weight off the shoulders of the addicted population freeing them (us?) from the long pointed finger of condemnation for being will-less souls.
But how does addiction occur and why is it so hard to break away from? First off we have to realize that the brain is a much more pliable and mutable organ than we ever imagined. Yet how truly remarkable it seems that could it have been conceived in any other way? How could we have acquired memories, learned right from wrong, stored smells and sights and sounds without something changing, something translating, something metamorphosing at the cellular/molecular level?
And within the past ten years this has been amply demonstrated at the glucose metabolic level or the blood flow level as moment by moment neural traffic flow is measured as it traverses the highways of the neural pathways shown in PET and MRA scanning permitting us to see humans as they are actually thinking, feeling and reacting emotionally. And we can see how a brain changes over time and we can even see how a brain stores the memories of a story from one person to the next.
We can see first how a mind has a baseline of information; then more of some as a story is absorbed. Then we can see how it is learned and we can compare the quality of that learning as it is stored by the quantity of the memory of the energy stored. So we have come a long way in our understanding of physiologic processes of the brain. But how does this help us understand addiction?
Addictions act at the most primitive level of human emotional response, at the survival level. Alcohol and cocaine and all addictions for that matter act on the pleasure centers, a learning area called the meso- accumbens and the nucleus accumbens where good and bad experiences are learned so that they can be recalled quickly.
So if we were to place a finger on a hot stove, and we were naïve to that experience, the memory would be stored and we would become very wary in the future when approaching another stove. Similarly if we find that we like honey, this will also be stored, but as a positive memory for the future. This is part of the survival - pleasure – pain response system, the fight or flight system (in very simplified form).
The major neurotransmitter of this system is dopamine and it serves as the transmitter responsible for positive feeling sensed in these nuclei. What happens when people take cocaine is that it inhibits the release of another neurotransmitter (GABA) which prevents the release of dopamine. So the result is the accumulation of dopamine and the result is a rush of overwhelming positive good feelings. Sometimes these feelings overlap and are sensed as food or sex.
This sensation is so intense that the psychological effect (positive reinforcement) is to want to repeat the experience, which is usually done. And when this is repeated over and over again (as in cocaine addiction), the cocaine short circuits the usually inhibited circuitry and potentiates the dopamine for even more of a high. What is so addicting is that the ‘high’ thus triggered is so far beyond what the body can remotely normally experience that the memory gets tricked into desiring this drug, (cocaine), more and more, (for the dopamine ‘high’ that it can produce).
But the normal body tends to move toward an equilibrium which is called homeostasis or balance. The out of balance response to excessive dopamine calls upon the brain to react to decrease the efficacy of that dopamine in one way or another. In this case, the dopamine receptors become “less efficient” and it takes more and more cocaine (or alcohol) to mount the same high. So when the cocaine binge or alcohol binge is over there is a relative dearth of dopamine with a resulting suppressed mood, resulting in feelings of depression, unhappiness and drug/alcohol craving. Let the interval last long enough in the alcoholic and symptoms of withdrawal will take place.
This accounts for the phenomenon of ‘drug tolerance’, the need for increasing the dose of the drug to produce the same or greater effect. This also accounts for the reinforcing effect that the drug will have on the addict to feel better when the cravings are relieved after resuming the dose. Once again this reinforces the behavior.
This behavioral reinforcement carries over into the triggering of cravings when people or places or paraphernalia find the recovering addict in situations that they cannot avoid. This is the emotional residue and it may last for years. Smokers know how real this is when years after giving up smoking they may have had a particularly satisfying meal and suddenly feel the urge to have a smoke at the end of the meal. This is the result of a sense memory of the satisfaction of smoking in the past after the end of a satisfying meal.
This can be called emotional or contextual memory and this type of recall may never go away. And these conditioned responses to environmental stimuli that set off feelings or desires to have a drink or desire to use are the stimuli that surrounded the environment when we were using. So alcoholics may find urges to drink in bars, at parties, at ballgames and at weddings and social events where the main point of the evening was to drink and get high or drunk. At least for the alcoholic. The alcohol sets up the chemical “reward” in the conditioned response.
With time, when the conditioned response is no longer rewarded with the expected reward (that is when the situation does not present the alcohol) the behavior of craving usually gets ‘extinguished’. And this happens in the higher functioning longer term thinking memory of the mind. But the short term more primitive and reactive memory of the fight or flight mind still, from time to time will be caught unaware and find itself craving the expected reward of the alcohol induced dopamine release which then goes on to release endogenous endorphins which promote the high of alcohol consumption.
It is this long term unconscious memory that is the most difficult to fight and most often is what catches alcoholics and addicts off guard and which they have to be most wary of. When we understand the origin of these feelings and that they are just primitive rattlings of the primitive ‘crocodile’ mind we may be able to get a better handle on our cravings.
The techniques that are introduced through the book “Living Sober” are about learning new behaviors so that they automatically become the instant default practices in any set of circumstances in which our original habit would be to pick up a drink or walk into a bar, a liquor store or to act in a non sober manner. In this way we substitute higher level thinking over the more primitive brain thinking functions. We are trying to get away from those conditioned, Pavlovian responses.
Modern psychosocial psychotherapies of alcohol sufferers are treated with Cognitive-Behavioral Therapy. This centers on the alcoholic identifying specific thoughts, feelings and behaviors in and around the use of alcohol. The therapy is meant to develop skills to identify and manage the thoughts and feelings and outcomes of behaviors that arise out of the behaviors thus identified.
The “Living Sober” book identifies for the alcoholic all the major events common to most alcoholics that he no doubt will run into and suggests generic remedies to help modify these behaviors. So for family get togethers it suggests “go late and leave early.” “Eat something before you go even if food is going to be served”. “Always bring your own car with you so that you can drive yourself home, and make sure that you park well away from all the other cars at the party so that nobody who has been drinking has to move his car out of the way for you.”
During your first year of recovery: “Avoid major life changes in the first year of your sobriety”. This is not an unreasonable challenge since at best our thinking is marginal and clouded during the first six months of becoming sober and it is hardly the time to be making complex and life defining decisions if possible.
So what modern psychiatric practice has adopted as standard practice today has been used since 1978 in Alcoholics Anonymous as suggested ways to get and remain sober. We understand a bit better why the technique works but the technique has been working for the past thirty years even without an official label to it. And we can bend that part of our mind that serves to protect us by informing us subliminally what is inherently good and pleasurable and safe from that which is bad or painful and dangerous. We just have to relearn how to recognize what those things were and not mistake the false pleasures that turn out to be the real dangers.
© res 10/5/11
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