Part 2

A Brief History of Addiction as Affective Disorder

Cheetham and others are not the first, however, to suggest an affect centred view of addiction.

Rado in 1933,  described substance use as a way of coping with excessively difficult states of emotions (3). Others have interpreted addiction as a maladaptive way of fighting against stress, anxiety, and depression (4-6).

Krystal and Raskin (1970) emphasized the role of undifferentiated and archaic, somatically manifested, emotions of persons suffering from addictive disorders (7). They suggested these emotions are fixed at this level owing to the early traumatic nature of many addicted individuals.

This point is pertinent considering the extent of childhood maltreatment in addicted populations. One study of clients in a treatment centre showed 84% of them had suffered abuse etc.

There is also a high incidence of insecure attachment within these clinical groups which has been shown to effect emotion processing and regulation.

McDougall (1984) also highlighted the importance of overflowing emotions in the case of people with addictive disorders (8), identifying substance use as a compulsive way of canalizing these overflowing emotions.  In these theories, addictive behaviours are an instrument to regulate emotions.

According to Wurmser (1974), people with addictive disorders are unable to regulate their undifferentiated feelings, impulses, and pervasive internal stress, and so they turn to psychoactive substances (9). Their substance use can thus be recognized as an attempt at “self-treatment.” The self-medication hypothesis of Khantzian (1985) posits the self medicating of overwhelmingly painful emotions.

Relevant to our discussion is Wurmser’s connection between undifferentiated feelings and impulses.

Clinical observations also highlight primarily the presence of undifferentiated, overflowing, dominantly negative and painful feelings, and difficulties in emotional expression and emotional regulation.

Besides clinical observations (21), empirical studies have also shown that people with addictive disorders— such as alcoholic patients or those diagnosed with eating disorders—have difficulties with the verbalization and expression of their feelings, and the incidence of of alexithymia is much higher than in the normal population (22-24).

The prevalence of higher alexithymia in alcohol use disorders is between 45 to 67% (36, 37) and up to 50% in patients with other substance use disorders (SUD) [5] and [6].

Finn, Martin and Phil (1987) investigated the presence of alexithymia among males at varying levels of genetic risk for alcoholism, finding that the high risk for alcoholism group was more likely to be alexithymic than the moderate and low genetic risk groups (38).

Thus the unpleasant “undifferentiated emotional” experience of early theories, and associated with alexithymia, is supported by present day neuroscientific study which states this might prompt individuals to engage in maladaptive addictive behaviors in an effort to regulate emotions (41).

One study of eating disorders demonstrated evidence of a global emotion-processing deficit independent of affective disorders, such as anxiety and depression (the so-called comorbidities of DSM V).

This study on eating disorders demonstrated that emotions were not integrated and so remain global and undifferentiated, which leads to an incapacity to use affects to guide the selection of an adapted (goal directed) behaviour.

It was also noted that neither the level of emotion processing as measured by emotional awareness scores or alexithymia scores were correlated with the duration of illness which suggests that this impoverishment internal emotional life was not due to the severity of the disorder.

Thus part of the vulnerability to these and other addictive behaviours may a deficit predating  the occurrence of the disease, as with alcoholism, as  some authors who consider alexithymia (and possibly emotion awareness) to be a predisposing factor in addictive behaviours (Taylor, 1997a, 1997b).

Based on genetic and familial influence, a higher percentage of alexithymia may be expected in parents and other family members of alexithymic patients.

As part of an often shared environmental or familial mechanism, problems with alcohol in parents could result in neglecting their child’s emotional states, leading to emotional self-regulation deficits, such as alexithymia.

In line with this, a disturbed family functioning could be said to relate to the development of alexithymic characteristics [21].  Similar findings were observed for a history of neglect or sexual abuse, regardless of whether it occurred within the family [22],[23] and [24].

Also high alexithymic substance use disorder patients were more likely to have fathers or both fathers and mothers with alcohol problems compared to low alexithymic SUD-patients.

Interestingly paternal family history of alcoholsim (FHA) may also relate to the degree of alexithymia, independent of disturbed family functioning.

The relationship between alexithymia and these substance abuse symptoms suggests that the high baseline alexithymia score can at least partially be interpreted as a state phenomenon [4] and [34].

Emotional Dysregulation

As mentioned earlier there is a reciprocal relationship between emotion processing and emotion regulation as effective emotion regulation skills include the ability to be aware of emotions, identify and label emotions, correctly interpret emotion-related bodily sensations, and accept and tolerate negative emotions (2,3)

Emotion dysregulation may occur if emotions are experienced as intense and overwhelming, spiral out of control, change rapidly, get expressed in intense and unmodified forms, and/or overwhelm both coping capacity and reasoning. (4-8)

This emotional dysregualtion has been demonstrated be common to all addictive behaviours.

In fact the  Difficulties in Emotion Regulation Scale (DERS) distinguishes emotional dysregulation among different addictive behaviours and psychiatric disorders – in fact it is worth noting that emotion dysregulation is central to 75% of axis I and II disorders in DSM (but not clearly stated in relation to substance dependence).

Bradley et al demonstrated that emotional dysregulation could even be independent of negative affect. Thus this reciprocal relationship between emotion processing deficit and emotion dysregulation may be a mechanism at times independent of negative emotions. It may represent a more universal impaired self regulatory system.

One study (3) using DERS found emotion regulation difficulties in treatment-engaged alcohol dependent (AD) patients, with the period of early abstinence marked by an overall distress state, with this distress contributing to particular difficulties with emotional awareness and impulse control.

This had been replicated also in cocaine-dependent individuals who also report emotion regulation difficulties, particularly during early abstinence (4), and particularly concerning emotional clarity and awareness.

This lack of emotion differentiation or granularity is also seen in gambling disorder, hypersexual disorder and eating disorders ().

How do emotion processing deficits prompt impulsivity?

Selby is one of many researchers who addresses the issues of why emotion dysregulation results in behavioral dysregulation by referring to “impulsive” behaviors, without premeditation, which cause certain individuals to engage in behavioral dysregulation.

Impulsivity is a complex multifaceted construct which has resulted in numerous additional definitions such as, “the tendency to react rapidly or in unplanned ways to internal or external stimuli without proper regard for negative consequences or inherent risks” (Shin et al., 2012), or “the tendency to engage in inappropriate or maladaptive behaviors” (de Wit, 2009).

A common behavioral measure of impulsivity is the delay discounting task which measures the degree of temporal discounting.

Participants are faced with the choice of a small immediate reward, or a larger delayed reward; choosing the smaller immediate reward indicates a higher degree of impulsivity. Increased discounting of larger delayed rewards has been found in heroin (), cocaine- (), and alcohol () -dependent individuals.  It has also been observed in other addictive disorders such as gambling, eating and hypersexual disorders respectively.

This inherent decision making profile also appears vulnerable to the effects of stress. Another behavioural test, the Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. A stress induction, using the Trier Social Stress Test, was shown to produce a significant deterioration in IGT performance in long term abstinence and newly abstinent heroin users, but not in comparison subjects.

This decision making deficits in these clinical groups deteriorate further under stressful conditions, which may be analogous of the increasingly stress dysregulation of the addiction cycle.

Selby concluded that individuals who exhibit high levels of negative urgency, feeling the need to act when faced with emotional distress, may be more likely to engage in maladaptive behaviors such as substance abuse as a result of emotion dysregulation.

Another study suggests that this negative urgency (or distress based impulsivity) was also linked to alexithymia scores.

An impaired ability to identify or describe emotions (as with alexithymia), appears to create a confusing affective experience may be quite upsetting, and could lead to negative urgency, or a tendency to act rashly.  At certain earlier phases in the addiction cycle, lack of emotional granularity may prompt rash behaviour prior to the escalating negative affect associated with the progression of the addiction cycle.

Thus it may be that the emotional confusion inherent in alexithymia (emotion processing deficits) prompts a “distress” based impulsivity to engage in dysregulated behaviors.

Others have conceptualised this distress as a feeling state confusion. This is obviously heightened in stressful situations that generate an emotional overflow with alexithymic individuals apprehending less by emotional and cognitive features than by their associated somatic indexes.

This uncertainty between feelings and bodily sensations is similar to the interoceptive confusion proposed by Hilde Bruch, so when faced with the physiological arousal induced by emotional demands, these individuals may resort to restricted patterns of repetitive and automated behaviors which temporarily relieve their feeling of discomfort and restore some form of inner equilibrium [33,34] but generate, in the long term, a reinforcement for this type of behaviour.

This has been demonstrated to be the opposite of individuals who experience their emotions with greater differentiation or more granularity ( ). These individuals are less likely to resort to maladaptive self-regulatory strategies upon experiencing intense distress. This granularity and the subsequent, more elaborate emotion regulation may divide those who are protected against and those who are vulnerable to later addictive behaviour.

To support this view, one 30-day timeline follow-back study revealed that people with intense negative emotions consumed less alcohol if they were better at describing emotions and less reliant on global descriptions.

It has been stated that the experience of emotion facilitates action, thus emotional processing appears to prepare the body for action. In fact, to emote means, literally, to prepare for action ().

It may that without adequate words to describe various neurophysiological stimuli associated with emotion, addicted individuals cannot feel (identify and describe) them accurately and precisely, and thus have difficulties regulating behaviors that follow these emotions.

Thus the reduced ability to make fine-grained distinctions regarding negative emotions in particular prompts impulsivity.

Without adequate words to describe various neurophysiological stimuli underpinning emotional states,   alexithymic individuals cannot feel (identify and describe) them accurately and precisely, and have difficulties regulating our behaviors that follow these undifferentiated emotions.

Lane & Schwartz, 1987 have suggested individuals with alexithymia are considered to be on the first two levels of emotional awareness (i.e., sensorimotor reflexive and sensorimotor enactive) as their abilities to cognitively identify various feelings precisely by recognizing specific physiological signs of emotions are not fully developed.

This lack of cognitive representations for neurophysiological stimuli may make individuals with alexithymia distressed…and thus they may use substances lie alcohol to alleviate their discomfort; relying on reflexive affective (emotional) processes rather than on reflective cognitive processes, to lead their behaviours.

Thus deficits in deficits in the cognitive representation of emotional experience may contribute to impulsive action when emotionally aroused, perhaps illustrating why alexithymia has been identified as a risk factor for many psychological problems that involve emotional and behavioral regulation deficits.

To more fully  understand why unprocessed emotion leads to a distress type impulsivity that prompts further endpoint emotion and distress dysregulation requires further elucidation of brain regions and neural mechanisms implicated in adaptive goal directed decision making and how their impairment can result in maladaptive rash decision making.

TBC

References (to follow)