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 Cochrane Library has evidence that can help

Acupuncture? Nicotine patches? Telephone therapy? Antidepressants? Cognitive behavioural therapy?

Which work? Which have no effect? Which are dangerous? Confused?

Over 40 Cochrane reviews analyse the evidence.

For example, one systematic review (CD000146) shows how nicotine patches can double the odds of successful quitting. Another (CD000031) concludes that the antidepressants bupropion and nortriptyline aid long-term smoking cessation, but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not. Yet another (CD006103) revealed that varenicline (recently approved in the UK by NICE), increased the odds of successful long-term smoking cessation more than threefold compared with pharmacologically unassisted quit attempts.

Ever since Sir Richard Doll and others used careful analysis to show that smoking was a key cause of cancer, there has been pressure to find ways of reducing dependency on tobacco. Richard Doll’s work also showed the importance of putting critical analysis and high quality research at the heart of good decision making.

“With changes in the law providing fresh impetus for smokers to quit, the catalogue of reviews in The Cochrane Library is a great source of the knowledge needed by people wanting to make well informed decisions. The reviews provide reliable evidence on the strengths and weaknesses of many different types of therapy. They should help guide policy-makers who are looking for ways to increase the chances that people who want to stop smoking succeed in putting their cigarettes down for good,” says Director of the UK Cochrane Centre, Professor Mike Clarke from the University of Oxford.

They can all be found at http://www.thecochranelibrary.com or visit http://www.eurekalert.org/images/release_graphics/pdf/Cochrane_Smoking_Cessation_Reviews.pdf

Smoking Cessation Therapies — Cochrane Reviews:

A summary of all treatments designed to help people stop smoking that have been reviewed by The Cochrane Library. Simply click on the URL under the review title to see the abstract and if you wish to see the full review.

Also; Nicotine Anonymous: The Book

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

The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive disorders.

We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers.

This scale and the measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs.

Findings on these patient groups were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees.

These suggest that, for certain patients, spiritual orientation is an important aspect of their recovery.

Furthermore, the relevance of this issue may be underestimated in the way treatment is framed in a range of clinical facilities.

Research; Galanter M, Dermatis H, Bunt G, Williams C, Trujillo M, Steinke P. Assessment of spirituality and its relevance to addiction treatment. J Subst Abuse Treat. 2007 Oct;33(3):257-64.

See also;

• The Most Effective Form of Harm Reduction
• What About This Spiritual Awakening Thing?

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.

Difference in medical history classified by ICD-10 between male and female alcoholics.

The drinking history and current medical history of patients with alcohol dependence were surveyed in Japan and they were analyzed by demographics; gender, age and changes with time (2 stages).

The results showed that in the course of continued habitual drinking by patients with alcohol dependence, a wide range of physical complications occurred.

The main complications

• in men were gastrointestinal diseases and
• in women were mental and behavioral disorders, showing a gender difference in the medical history.

This result suggested that there is a high possibility that this will contribute to early discovery and early measures against alcohol related problems in women, which are difficult to bring out into the open.

Better alcohol education including mental health is important from an early age.

Nihon Arukoru Yakubutsu Igakkai Zasshi. 2008 Feb;43(1):25-34. Difference in medical history classified by ICD-10 between male and female alcoholics. Shinoda R, Mizukami Y, Nakagawa Y, Maruyama K.

See also;

• Brief-TSF is designed to address these issues.
• 12-Step Treatment More Effective than Alternative
• Subscribe to BriefTSF by e-Mail

Counseling the Culturally Diverse: Theory and Practice by Derald Wing Sue, David Sue Read more about this title…

Cannabis use and risk of psychotic or affective mental health outcomes

Background; Whether cannabis can cause psychotic or affective symptoms that persist beyond transient intoxication is unclear. We systematically reviewed the evidence pertaining to cannabis use and occurrence of psychotic or affective mental health outcomes.

Methods; We searched databases from their inception to September, 2006, searched reference lists of studies selected for inclusion, and contacted experts. Studies were included if longitudinal and population based. 35 studies from 4804 references were included. Data extraction and quality assessment were done independently and in duplicate.

"we conclude that there is now sufficient evidence to warn young people
that using cannabis could increase their risk of developing a psychotic illness later in life."

Findings; There was an increased risk of any psychotic outcome in individuals who had ever used cannabis (pooled adjusted odds ratio=1·41, 95% CI 1·20-1·65). Findings were consistent with a dose-response effect, with greater risk in people who used cannabis most frequently (2·09, 1·54-2·84). Results of analyses restricted to studies of more clinically relevant psychotic disorders were similar. Depression, suicidal thoughts, and anxiety outcomes were examined separately. Findings for these outcomes were less consistent, and fewer attempts were made to address non-causal explanations, than for psychosis. A substantial confounding effect was present for both psychotic and affective outcomes.

Interpretation; The evidence is consistent with the view that cannabis increases risk of psychotic outcomes independently of confounding and transient intoxication effects, although evidence for affective outcomes is less strong. The uncertainty about whether cannabis causes psychosis is unlikely to be resolved by further longitudinal studies such as those reviewed here. However, we conclude that there is now sufficient evidence to warn young people that using cannabis could increase their risk of developing a psychotic illness later in life.

Theresa HM Moore, Stanley Zammit, Anne Lingford-Hughes, Thomas RE Barnes, Peter B Jones, Margaret Burke and Glyn Lewis. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. The Lancet 2007; 370:319-328

Life With Hope: A Return to Living Through the Twelve Steps and Twelve Traditions of Marijuana Anonymous

What does the Brief-TSF model look like?

How does the Brief-TSF model work?

Defining the Brief-TSF processes

This model brings together three people to achieve sobriety in one of them. These are the;

• experiential contributor (AA Peer Sponsor) and
• professional care (Twelve Step Facilitator) to collaborate in facilitating self help recovery for the
• alcoholic (normally known as the patient or client).

Each of the three people brings to the intervention knowledge’s and functions known as ‘domains of praxes’. Within each domain are the constituents of experience, training, perceptions, goals and capabilities.

Functional Domain

The Brief Twelve Step Facilitator facilitates self-assessment by the patient, introduces them to a ‘Peer Sponsor’ and facilitates understanding of the ‘Program of Recovery’. In addition the healthcare worker assesses and addresses or refers the patient for any co-morbidities.

The Peer Sponsor shares their ‘experience, strength and hope’ with the patient, provides initial resources to attend meetings, introduces the ‘Newcomer’ to Alcoholics Anonymous members and explains the program of recovery from drinking.

The patient chooses what, when, and how they can use information, from each of the providers. This is true Self help within a paradigm of mutual help.

Additionally, the patient is supported in seeking professional treatment/therapy for other issues.

Recovery Domain

Each participant maintains their integrity and independence within their domain.

The primary goal of Brief-TSF is affiliation with Alcoholics Anonymous as described in the Stages of AA Affiliation.

Recovery includes attending AA meetings and other activities, stopping drinking, ‘working’ the program of recovery and consulting with a peer sponsor within an affiliation scheme.

The whole facilitated process producing a ‘Domain of Recovery’.

Disease Domain

Alcoholism is a primary, chronic, progressive three fold disease – mental, physical and spiritual. Alcohol dependence is fatal if not arrested by abstaining from alcohol.

Each participant has a hand in recovery

Due to their high prevalence in the general population, alcohol use and abuse can be associated with hepatitis B and C virus infections and it has been demonstrated that alcohol plays a role as a co-morbid factor in the development of liver disease.

There is evidence that alcohol abuse accelerates the progression of liver fibrosis and affects the survival of patients with chronic hepatitis C. The mechanism by which alcohol worsens hepatitis C virus-related liver disease has not been fully clarified, but enhanced viral replication, increased oxidative stress, cytotoxicity and impairment of immune response could play a relevant role.

Alcohol abuse also seems to reduce both sensitivity to interferon and adherence to treatment.

It sounds reasonable to presume that the mechanisms enhancing liver damage in patients affected by hepatitis B are similar to those involved in hepatitis C virus infection.

However, more studies are warranted to improve our knowledge about the interaction between alcohol intake and hepatitis B virus infection.

In conclusion alcohol abuse is associated with an accelerated progression of liver injury, leading to an earlier development of cirrhosis, higher incidence of hepatocellular carcinoma, and higher mortality.

Abstinence from alcohol could reverse some of these deleterious effects.

Research report; Gitto S, Micco L, Conti F, Andreone P, Bernardi M. Alcohol and viral hepatitis: a mini-review. Dig Liver Dis. 2009 Jan;41(1):67-70. Epub 2008 Jul 3.

See also;

• Helping an Alcoholic is Possible in Right Circumstances
• Hep C Factsheet
• Hepatitis B
• If you have healthcare training this manual may help.

The Alcoholic