Craving and Approaching – Avoidance

A Step Essential to the Understanding of Craving

By Mary Jo Breiner M.S., Werner G. K. Stritzke, Ph.D., and Alan R. Lang, Ph.D.

Craving is only one component of the mental processes that influence drinking behavior.

Alcohol-related cues (ARCs) can set in motion a dynamic competition between inclinations to approach drinking and inclinations to avoid drinking. Craving can thus be integrated into a comprehensive model of decision making in which ambivalence or conflict is a key element.

The relative strength of each component of the ARC reaction can fluctuate over time as well as in response to both subjective states and environmental circumstances.

Simultaneously and independently evaluating these opposing responses puts clinicians in a better position to influence the relative weight that the patient assigns to the positive and negative outcomes of alcohol consumption.

Alcohol Research & Health Vol. 23, No. 3, 1999

Objective: The aim of this study was to evaluate the impact of chronic alcoholism on cognitive functions and social disability.

Method: Forty-one chronic alcoholic men and forty control subjects of comparable age and forty control subjects of comparable age and education level were evaluated. The patients received the neuropsychological tests and social disability scale after a 3 week period of abstinence. Each subject was given an extensive battery of neuropsychological tests assessing language skills, attention, memory and cognitive functions related to frontal regions of brain. Two groups were compared regarding the results of Wisconsin Card Sorting Test (WCST), Line Orientation Test (LOT), Visual Auditory Digit Span Test (VADST), Stroop Test, Mini Mental State Examination, and Hamilton Depression Scale. Social disability level was determined by the administration of the Short Form General Health Survey of Medical Outcome Study (SF-MOS). The symptoms and the symptom severity of alcohol dependent patients were evaluated by using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN), a semi-structured instrument for clinical interview and symptom rating.

Results: Alcoholic patients showed a significant impairment on auditory part of VADST. Similarly LOT results were significantly different between alcoholics and control group. The following WCST subscores were statistically different between the two groups: Total answer, total error, total perseverative responses, perseverative errors, percent of perseverative errors, nonperseverative errors, number of categories completed, and conceptual responses. Stroop Test results showed no statistical difference between the two groups. Social disability scores were significantly higher in alcoholic patients compared with the control group. 63.42% of the forty-one patients, had severe disability. Statistical analysis failed to show any significant correlation between the neuropsychological test results and disability scores.

Conclusion:

Alcohol dependent patients displayed significant neurocognitive impairment and high levels of social disability compared with healthy controls.

Social disability levels did not appear to be correlated with neurocognitive dysfunction.

Research report; Cognitive Functions and Social Disability in Alcohol Dependency. Dr. Sibel MERCAN, Dr. Berna ULU?, Dr. Ahmet GÖ?Ü?. Turkish J of Psychiatry, 1999; 10(1): 3-12

The Role of Thiamine Deficiency in Alcoholic Brain Disease

A deficiency in the essential nutrient thiamine resulting from chronic alcohol consumption is one factor underlying alcohol-induced brain damage.

Thiamine is a helper molecule (i.e., a cofactor) required by three enzymes involved in two pathways of carbohydrate metabolism.

Because intermediate products of these pathways are needed for the generation of other essential molecules in the cells (e.g., building blocks of proteins and DNA as well as brain chemicals), a reduction in thiamine can interfere with numerous cellular functions, leading to serious brain disorders, including Wernicke-Korsakoff syndrome, which is found predominantly in alcoholics.

Chronic alcohol consumption can result in thiamine deficiency by causing inadequate nutritional thiamine intake, decreased absorption of thiamine from the gastrointestinal tract, and impaired thiamine utilization in the cells.

People differ in their susceptibility to thiamine deficiency, however, and different brain regions also may be more or less sensitive to this condition.

Research; The Role of Thiamine Deficiency in Alcoholic Brain Disease, Peter R. Martin, M.D., Charles K. Singleton, Ph.D., and Susanne Hiller-Sturmhöfel, Ph.D. Alcohol Research & Health; Vol. 27, No. 2, 2003

Obstetricians Often Overlook Alcohol Consumption In Pregnancy, says the Australian And New Zealand Journal Of Obstetrics And Gynaecology

One in every two pregnant Australian woman still consume alcohol during pregnancy, according to a study in the Australian and New Zealand Journal of Obstetrics and Gynaecology. The responsibility of providing accurate information about the harmful effects of alcohol and its lifelong effects on the child falls on obstetricians and other health professionals.

And yet, almost half of the obstetricians interviewed said they did not routinely ask about alcohol consumption in pregnancy.

An editorial by Professor Elizabeth Elliot from the University of Sydney titled “Alcohol and Pregnancy: the Pivotal Role of the Obstetrician”, discusses the state of awareness about the adverse effects of alcohol consumption during pregnancy and the obstetricians’ participation in educating against maternal drinking.

Only 16% of the obstetricians routinely provided information about the consequences of alcohol in pregnancy, while only 5% gave advice which were consistent with the latest guidelines of The National Health and Medical Research Council of Australia (NHMRC) – which states that, for pregnant women, ‘no drinking is the safest option’.

Professor Elliot says, “Failure to provide information about the dangers of alcohol consumption in the antenatal consultation represents a lost opportunity. Accurate recording of antenatal alcohol exposure will help identify children who require pediatric assessment, since the effects of alcohol may not be obvious at birth.”

“More importantly, identifying the women who are unable to stop drinking provides an important opening for the management of problem drinking and prevention of exposure to alcohol in future pregnancies,” added Professor Elliot.

Alcohol consumption during pregnancy has been associated with increased risks of miscarriage, stillbirth, intrauterine growth restriction, pre-term birth and low birth-weight. However, the best known adverse effect of alcohol exposure on the fetus is the fetal alcohol syndrome (FAS) – which is associated with a wide range of birth defects and ongoing educational, behavioral and psychological problems.

This paper is published in the June 2008 issue of Australian and New Zealand Journal of Obstetrics and Gynaecology (Vol. 48, Issue 3, 2008).

See also;

1. Facial features of fetal alcohol syndrome
2. Alcohol and Pregnancy
3. Alcohol Free Pregnancies
4. Alcohol intervention may help.
5. Brief-TSF can assist patients cease alcohol consumption.

Multiple psychiatric disorder risk for families with alcohol dependence

First-degree relatives of people dependent on alcohol are not only at increased risk of becoming addicted to alcohol and other drugs such as cocaine, but also of developing psychiatric disorders such as depression and panic disorder, study findings indicate.

Noting that alcohol dependence tends to aggregate within families, John Nurnberger (Indiana University School of Medicine, Indianapolis, USA) and colleagues analyzed data from the family collection of the Collaborative Study on the Genetics of Alcoholism to assess whether other psychiatric disorders may be also be more common in families with a history of alcoholism.

Data were available for 8296 relatives of people with alcohol dependence and 1654 individuals with no family history of alcoholism.

The rate of DSM-IV alcohol dependence was 28.8% for relatives of people with the condition, compared with 14.4% for controls.

Overall, relatives of alcoholics were twice as likely to become addicted to alcohol as people without a family history of alcohol dependence.

Relatives of alcohol-dependent individuals were also at an increased risk of becoming addicted to other drugs, including cocaine, marijuana, opiates, sedatives, and stimulants. The greatest risk was for cocaine dependence, with relatives of individuals with alcoholism more than three times as likely as those without a family history of alcoholism to become dependant on the drug.

Moreover, relatives of alcoholics had a higher risk of depression, panic disorder, post-traumatic stress disorder, and antisocial personality disorder than controls.

“The aggregation of antisocial personality disorder, drug dependence, anxiety disorders, and mood disorders, suggests common mechanisms for these disorders and alcohol dependence within some families,” Nurnberger et al write in the Archives of General Psychiatry.

This represents a “shared specific genetic vulnerability,” they say, which puts people at risk of a number of psychiatric disorders if they have a family history of alcohol dependence.

Research Source: Arch Gen Psychiatry 2004; 61: 1246-1256

Illicit drugs alcohol, and addiction in human immunodeficiency virus.

Drug and alcohol use complicate both the prevention and treatment of human immunodeficiency virus (HIV) infection.

Substance use is one of the major engines driving HIV transmission, directly, through the sharing of injection drug use equipment and indirectly, through increasing risky sexual behaviors.

Drug and alcohol dependence compromise effective HIV treatment by influencing both access and adherence to antiretroviral therapy.

Exposure to addictive substances may have direct immunosuppressive effects independent of their impact on access and adherence to treatment.

Measures effective at minimizing HIV transmission attributable to drug and alcohol use include HIV testing and referral to treatment, syringe and needle exchange programs, opioid replacement therapy (i.e., methadone and buprenorphine), and behavioral interventions targeting HIV risk behaviors among both HIV-infected and HIV-uninfected people.

Measures effective at optimizing HIV treatment among alcohol and drug-dependent patients include HIV testing with referral to treatment and substance use treatment that is linked to or integrated into HIV treatment.

Due to the intertwining problems of substance use and HIV infection, physicians and other health care providers must address the issues of illicit drugs and alcohol use as mainstream medical problems in order to provide optimal care for HIV-infected patients.

Research; Samet JH, Walley AY, Bridden C. Illicit drugs alcohol, and addiction in human immunodeficiency virus. Panminerva Med. 2007 Jun;49(2):67-77.

Alcoholism is a multigenerational disease as evidenced by this report.

Abstract; To test the hypothesis of a sex-linked factor influencing the occurrence of alcoholism and alcohol abuse, alcoholism or abuse rates were compared for 136 sons of the sons vs 134 sons of the daughters of 75 alcoholics. No substantial difference between the groups of grandsons was found in frequency of officially registered alcoholism or alcohol abuse, or both, which suggests no sex-linked factor is involved. The total sample was also used to calculate the risk of such registration for the grandson; the rate of registration by the grandsons’ fifth decade of life was 43%, approximately three times that of the general male population, and even higher than the equivalent rate in brothers of alcoholics. This result is incompatible with an assumption of a recessive gene being involved in the occurrence of alcoholism, though it fits with the assumption of a dominant gene.

L. Kaij and J. Dock. Grandsons of alcoholics. A test of sex-linked transmission of alcohol abuse. Arch Gen Psychiatry. Vol. 32 No. 11, November 1975.

“I’ll never touch it again, doctor!” – harmful drinking after liver transplantation.

Alcohol relapse can negatively influence the outcome after liver transplantation (LT).

The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT.

A total of 387 consecutive patients (23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated.

• Mean +/- SD age was 51.3 +/-7.5 years. Follow-up time was 61.2 +/- 47.5 months.

Alcohol consumption relapse and potential factors associated with it were studied.

• The relapse rate of harmful alcohol consumption after LT was 11.9%.

In univariate analysis, alcohol relapse was significantly associated with

• age greater than 50 years,
• year of LT 1995 or earlier,
• duration of abstinence less than 6 months,
• presence of psychiatric comorbidities,
• presence of a life partner, and
• a high score on the High-Risk Alcoholism Relapse (HRAR) scale.

Multivariate logistic regression disclosed the following independent factors of relapse:

• duration of abstinence of less than 6 months;
• presence of psychiatric comorbidities; and
• HRAR score higher than 3.

In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively.

In a large cohort of patients undergoing LT for alcoholic cirrhosis,

• a duration of abstinence of less than 6 months before wait-listing for LT,
• the presence of psychiatric comorbidities, or
• an HRAR score higher than 3

was associated with relapse into harmful drinking.

The presence of more than 1 factor dramatically increased this risk over 50%.

In the pre-LT evaluation in this setting, these factors should be accurately determined.

Research; Haber PS, McCaughan GW. “I’ll never touch it again, doctor!” – harmful drinking after liver transplantation. Hepatology. 2007 Sep 25;46(4):1302-1304.

Liver Transplantation & the Alcoholic Patient: Medical, Surgical and Psychosocial Issues by Michael R. Lucey, Robert M. Merion, Thomas P. Beresford Read more about this title…

A qualitative study of Alcoholics Anonymous members and South Asian men.

The spiritual aspect of recovery for people with drinking problems was explored in a comparative analysis of South Asian men recovering from drink problems and white members of Alcoholics Anonymous (AA).

In-depth semi-structured interviews were carried out with participants to explore significant factors that assisted recovery. Interviews were analyzed using grounded theory. Ten participants in total were interviewed; 5 were South Asian men receiving individual and/or group counseling with South Asian therapists either in an NHS or non-statutory specialist alcohol treatment service, and 5 were white members of AA.

Models of recovery for the two groups were developed and are presented.

Spirituality and religion played an important role in the experiences of recovery described by AA and South Asian participants respectively.

For AA participants their experiences reflected those described in AA’s Big Book although concepts such as that of a Higher Power were complex and multilayered, with spirituality just one, albeit significant, aspect.

South Asian participants generally underwent a re-affirmation of existing beliefs rather than the conversion type of experience described by AA participants.

The findings are discussed in relation to implications for service delivery and development and directions for future research.

Morjaria, A.; Orford, J. Role of religion and spirituality in recovery from drink problems: A qualitative study of alcoholics anonymous members and South Asian men. Addiction Research and Theory, 10(3):225-256, 2002.

The Spirituality of Imperfection: Storytelling and the Search for Meaning by Ernest Kurtz, Katherine Ketcham Read more about this title…

Helping other Alcoholics and Relapse

The specific mechanisms of Alcoholics Anonymous (AA) that mobilize and sustain behavior change are poorly understood.

This study examined the relationship between helping other alcoholics in AA and relapse in the year following treatment for alcohol use disorders. Data were derived from a longitudinal investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence (Project MATCH). Probabilities of time to alcohol relapse were calculated using Kaplan-Meier survival estimates. Proportional hazards regressions, with control for number of AA meetings attended, were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics.

those who were helping other alcoholics . . . were significantly less likely to relapse in the year following treatment

Age was the only demographic characteristic that distinguished participants involved in helping other alcoholics; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics and were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended.

Thus recovering alcoholics who help other alcoholics (mutual-help) maintain long-term sobriety after formal treatment are better able to maintain their own sobriety.

The authors conclude that clinicians who treat substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober.

Research report; Pagano ME, Friend KB, Tonigan JS, and Stout RL. Helping other alcoholics in alcoholics anonymous and drinking outcomes: Findings from Project MATCH. Journal of Studies on Alcohol 65(6):766-773, November 2004.