CENTER ON BEHAVIORAL MEDICINE
Behavioral Genics: Related Paper
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An “Organism” Predisposed to Alcoholism, Current Theory and Treatment
George M. White
Alcohol itself is a depressant. It depresses the central nervous system. It causes 5-10 times more dopamine to be released to the nucleus accumbens where D2 receptors are located and where “reward” is experienced (depending on the drug). It also causes endorphins to be released throughout the brain, most likely the mu opiod system is most affected. The exact receptor sites for alcohol have not been identified (LeDoux, 2002). The endorphin receptors in the mid brain, the amygdala, the thalamus and hypothalamus are flooded with endorphins, hence the sedative-body-effect, muscle relaxation, motor impairment, speech impairment, etc. “Normal” people don’t find getting drunk attractive, learn their lesson quickly, and stop. “Addicted people just get started,” the genetic reduction of D2 receptors causes a different mental, emotional response, the person “lights up,” feels better than ever and at that moment “saliency” occurs. Pleasure, whereas little or none was experienced before, now is felt, the feeling is novel and unexpected. (This example is directed towards early use.) In the addicted person, there is a continued drive for pleasure. It is the compulsion, the continuation despite negative consequences. Natural reinforcers become no longer salient. As dopamine is depleted by continued use and the potential reduction of D2 receptors occurs, neuro adaptation occurs on the dopamine two receptors as well as the mu opiod receptors. The process is drug liking, drug abuse and drug dependence. It is important to distinguish between true addiction, the genetic lack of D2 receptors and dependence spurned by abuse of the drug, creating physiological dependence. Does true addiction create dependence? Probably yes. However, not always. Is dependence addiction? Some say yes, however most neuroscience oriented addictions people say no.
Withdrawal from alcohol is a result of norepinephrine release increase due to lack of alcohol, which causes anxiety, shaking and agitation. Thinking is impaired due to increase of norepinephrine to the frontal cortex as well as immune system relaxation caused by cortisol. The negative effects of alcohol in the predisposed people are devastating. Loss of control, compulsion, repeated negative behaviors, etc., are hallmarks of alcohol’s effect on mental, emotional and behavioral realms. It certainly has the potential to create poor judgment in anyone, whether there is predisposition involved or if they are early abusers with negative consequences.
Alcohol’s effects on executive functioning (mental), is noted to negatively effect frontal cortex responsibility of logic, reason, judgment, decision, integration, etc. Euphoria is created which, depending on the person, may or may not be an issue. All sensory information terminated in the thalamus (except smell). The thalamus sends information to the frontal cortex, the hippocampus, the hypothalamus and the amygdala. Alcohol impairs and changes perception. In short term memory, the hippocampus, which also stores new long-term information, up to 3-5 years by some reports (Carlson, 2004, LeDoux, 2002), records solutions to situations under the influence effecting current and later frontal cortex evaluation of new experiences (LeDoux, 2002). Alcohol stimulates endorphins throughout the brain, helping keep the amygdala calm, the hypothalamus relaxing the body and influencing the thalamus in the information sending to the frontal cortex. State dependent learning is a term known today as the brain’s learned events under influence and operating normally under influence versus non-influence and the potential “agitation” or not able to work at capacity without the drug.
The cause of alcoholism, its etiology, is still debated heavily today. As stated, alcohols positive reinforcement comes from the release of dopamine to the nucleus accumbens. The cause of lack of D2 receptors in the nucleus accumbens is considered to be due to genetics, experiences, environment, intelligence, etc., which may be the “cause” of the underlying deficits in the brain. Alcohol also enhances the action of GABA at GABAa receptors and interferes with the transmission of glutamate at the NMDA receptors (Carlson, 2004). Thus, abnormalities in the mesolimbic dopaminergic pleasure pathway, from the ventral tegmental area to the nucleus accumbens and the frontal cortex. The number of D2 receptors or the lack of dopamine being stimulated, the increase of endorphins release on the mu opiod receptors, the facilitation of GABA, the interference of glutamate, all factors in the cause of alcoholism. Depending on the individual’s brain and its uniqueness, the cause of alcoholism is therefore unique to the individual. Whatever caused the lack of D2 receptors in the nucleus accumbens is probably for that person the reason they have an addiction to alcohol.
Causative agents and factors
regarding alcoholism are numerous and profound.
How is one organism alcoholic and another not? The DMS-IV clearly
distinguishes the criteria for abuse versus dependence. It does
address “addiction.” It addresses criteria, behavioral criteria,
not neuroscience. Therefore the causative agent and factors
to alcoholism are under current, intense research. Neurobiology,
specific to brain systems, genetics, the specific gene for alcoholism
or possibly now known, the individuals specific brain makeup,
experiences, memories, insight, are all factors. A person raised
in an alcoholic home, with possible chaos, abuse, neglect, physical,
emotional or sexual abuse, poor nutrition, poor spiritual foundation,
of structure, morals, values and ethics, would certainly be a factor in
the organism’s predisposition. Addiction, if seen from attachment
disorder, is a consequence of the impaired ability to establish and
maintain healthy attachment
relationships (Flores, 2004). The lack of pleasure and the
damage to or of the pleasure pathway via potential influences is noted
above. The perception of self, the equation of ones validity in
surroundings and the ability to express, communicate and belong, are
factors if a chemical is introduced which in itself is a brain changing
Discussion of alcohol etiology must include comorbidity and multiple disorders, which are more common in people who abuse, are dependent and/or addicted to alcohol. Research literature today is full of articles sharing the likelihood of substance abuse in psychosis, bipolar spectrum and anxiety disorders. I have written in numerous papers the high probabilities of substances, self-medication attempts, in the disorders noted above. Also reported is the high use of substances by personality disorder people. I see in group therapies what is being understood and presented recently that, people who’s addiction is opiods/opiates, rage is being suppressed; people who’s addiction is barbiturates, alcohol and marijuana, are settling anxiety; people who’s addiction is stimulants are trying to calm ones self down or are trying to lift oneself up from depression (Harvard, The Addictions: Treatment approaches, 2004). The newest presentations of addiction via the above mentioned conference, also Addiction Medicine: Evidence-based strategies, Harvard Medical School, Oct. 22-23, 2004, are presenting it in a way that the addiction field will not like. Again, understanding neuroscience, brain systems, is in my opinion, the etiology of addiction. In understanding alcohol’s sedative, calming effect, one can understand how it can help calm voices, fear, anxiety, mood disturbance, switching, anger, loneliness and pain. Addiction, alcoholism, is considered chronic and a long-term condition.
It is absurd to believe that six to eight sessions or 28 days is the answer. It is understood today that treatment modalities for addiction do not work (Schaffer, 2004). Emphasis today is how our expectations as therapists dramatically influence patient outcome (Schaffer, 2004). The relationship developed between therapist and patient is highly emphasized today. The focus that the therapist has, understanding comorbidity, addictions, neurobiology, brain systems, etc., has everything to do with outcome. It is estimated that only one-third of patients see will “buy in” to the concept of therapy (Harvard, March 2004). “We do what we can” (Berk, 2004). It is extremely rare in any treatment modality today, to just see a substance disorder on Axis I. Is a schizophrenic’s compulsive use of alcohol about the alcohol or about the attempt to calm the voices? I worked in a state hospital for 3 years in the Department of Rehabilitative Services. My caseload was with primarily schizophrenic patients being discharged. My job was to help them re-enter the community. I secured housing and a job, paid for 1 month of groceries, medicines, etc. A large percentage of these patients stopped medicines, became delusional/psychotic, used alcohol heavily and other drugs, especially marijuana, requiring legal/safety interventions resulting in rehospitalization. I also have seen people discharged recently, with the best of stated intentions, medicines, appointments, meetings, all set up before discharge, only to return to previous dysfunctional behaviors when faced with stress, sadness or anger.
Anxiety in itself is incredibly important to understand. When the amygdala is activated, it dominates working memory (LeDoux, 2002). Background, understanding the patient’s anxiety versus focus on the chemical – it’s negative effects, etc., etc., is more effective. I have stated in other papers that if a person is so anxious and knows how to self-medicate, it is very difficult to get them to endure pain and misery. Dependence is the avoidance of discomfort and withdrawal. It does have compulsive behavior. Addiction is about misery and pain. There can be anxiety in both. It is important to know which one or both are being medicated.
Within the context of comorbidity and etiology, medical problems such as illness, physical discomfort, physical pain, arthritis, malformation, pre and post surgery, etc., all can involve the use of alcohol. Alcohol is effective in numbing paid. The mu opiod system, responsible for paid reduction does so via endorphins. Alcohol also involves endorphins on the mu opiod receptors. I have worked with many adults who’s physical injuries leading to inactivity and/or physical pain, sought alcohol and often drugs to relieve the paid, only to become dependent physiologically with “pathological dependence,” which by some, equals addiction (Erickson, 2004). It is therefore very important to accurately assess a patient’s physical status and refer to appropriate treatment when indicated. Rational thinking and logic are often discarded when faced with pain. Intent focuses on alleviation of pain. Alleviation of pain takes many forms. What works tends to be what is done. What works depends on the person.
Pain tolerance per individual is biological and/or psychological, but can also be learned. Etiology of alcoholism can also include environment. As Berk has illustrated in her book “Child Development” immediate environment is family. Genetics are indeed a factor, however learned behavior, simulation, and influence, etc., effects children dramatically. Ericksons psychosocial stages of development are remarkedly accurate. The effects of the environment, what is given or not, the child’s perception of being wanted and loved, the effects of abuse, are all so influential. Early experiences influence brain plasticity and the neuronal pathways ability to adapt and develop new receptor sites. Extreme negativity via environment hinders pleasure pathway development, increases the likelihood of fear conditioning and bring about anxiety (LeDoux, 2002). Low self-esteem, poor boundaries, executive functioning disruption, rage, fear, etc., results from negative environment. I have worked with many adolescents from horrible homes, no structure, no rules, no expectations with abuse, violence, drug abuse etc., who’s use of nicotine, alcohol and marijuana were all attempts to medicate self-blame, shame, hurt and anger (Berk, 2004). Often these types of homes are located in impoverished areas. Low income, poor, addicted, defeated and often intellectually limited people procreate with horrible results. Children who feel shame, when the eyes turn inward and the child sees themselves as bad, meet other children who perhaps see themselves the same way, may discover effective but inappropriate ways to feel better.
Social ineptness, one of the criteria for addiction, is a predisposing factor. If a child is socially inept, without reference or example on appropriate behaviors, and finds inappropriate, illegal and unacceptable ways as satisfying, then in effect, this is predisposisng. I have worked with adolescents from horrible backgrounds who had physiological dependence of alcohol at age 16. I have also worked with adolescents who had the ability at age 14 to drink in excess of 14 beers in one occasion, not get sick, pass out or have and extreme hangover. Not all impoverished homes produce children as I have described, as there are exceptions to every rule. I have worked with adolescents from very good homes, neither parent a user of nicotine, drugs or alcohol. However their having an alcoholic parent or grandparent predisposes the adolescent to be a heavy drinker with high tolerance, but showing no immediate physical problems. In this case genetics are dominant.
Spiritual bankruptcy is also a factor in predisposition. Negative produces negative. The environment I have described can destroy hope. Jeff Georgi describes hope, belief, desire and motivation as elements of spirituality. When a person’s spirit is broken, especially a child’s self-belief and ability to see the future or have hope inside, the spirit is diminished. I hear many patients, adolescent and adult, who via abuse, mental disorder, trauma and stress that have given up. People who have little ego strength, who are fear conditioned, who see life as threatening, etc., are predisposed to addiction. Addiction known today as a brain disease is just beginning to be understood in all elements of addicted people. Spirituality, which includes values, morals, ethics, religion, love or whatever an individual holds as, in my opinion, what can be referred to as “self.” I have discussed sense of self. This perception comes from many experiences with many memories and a place where one stands and how they see themselves to their surroundings. This certainly has influence on decisions but also is a factor in predisposition. Many patients I have worked with, because of severe abuse, physical or sexual, hate themselves, blame themselves and are prone to irrational behaviors and thinking, will continually perpetuate their negative self-concept. Their “externalized behaviors,” reflect low intelligence, learned behaviors and attitudes, severe depression and substance abuse, all of which are predisposing elements of addiction. Spirituality therefore is a very complicated entity. Spiritual bankruptcy can begin very early. As Erickson so accurately pointed out, abuse, neglect and abandonment can begin in infancy (as well as prenatal) and that the results affect numerous elements of being human, and that predisposition is multifaceted and very complicated.
Biological vulnerability, psychological liability, social ineptness and spiritual bankruptcy are the known etiology of addiction today (Georgi, 2002). Perhaps today in 2005 and with constant research, particularly in FMRI by Dr. Nora Volkow, we will come to greater understandings of alcohol addiction’s etiology. I believe it is far too complicated to focus on the simplicity of “using a drug causes addiction.” I have discussed this earlier and in numerous papers and will continue to differentiate drug liking, drug abuse, drug dependence and drug addition. Etiologies for each can be different as well as very similar.
There are many ways alcoholism is assessed today. They are well known and there are many accurate assessment techniques, questionnaires, guidelines, etc. being used. Today, as presented by Harvard, current methods of trying to help addiction have fallen short.. Assessment by the professionals on the problem seems to be the easy part. Assessment of the patient, what they want, what they are willing to do, try or change, is the hard part. In my opinion, assessment of addiction is a delicate, every changing balance that is there for a reason, has been for a time, and will not easily go away. Treatment for alcoholism, medically, has followed a necessary path. Withdrawal from alcohol can be fatal, benzodiazipine and barbiturates often must be used to “mimic” alcohol in the brain and decrease risk of seizure.
In the latest edition of Addiction Professional, Dr. Volkow notes how science is shaping services. She also states that medical interventions need flexibility. In her presentation at The Addictions: Treatment approaches, March 5-6, 2004, Harvard Medical School, she strongly emphasized the importance and need to medicate appropriately. I have noted in other papers that her plea was to give the brain what it needed. She proposed Adderall as a treatment for addictions or drugs or alcohol. Scientifically, this makes sense. She has demonstrated via FMRI a lack of D2 receptors in people addicted. Drugs and alcohol increase dopamine to this area. Why not treat with Adderall? Fear, lack of knowledge or not being current or willing to adapt and change to new ways of treatment are the answers. In two recent patient cases of severe alcoholism, after 7-15 inpatient admissions, the standard caveat of medication interventions – SSRIs, Benzos, atypical antipsychotics, severe depressive symptoms were reported by both, so they drank. Both reported it was the only way they knew to lift themselves up. Despite AA, knowledge of alcoholism, sponsors, and one failed marriage, they both drank when in this deep depression. After attending Harvard in March and hearing Dr. Volkow, I initiated treatment (only one psychiatrist agreed to try this initially) with Adderall and Topomax for these two patients while inpatient. The results are amazing. There have been no incidents of drinking or inpatient admissions. Both (being inpatient at different time periods) reported recently, dramatic increase in functioning, thinking, focus, no depression and no desire to drink. The dose of Adderall was 10mg a.m. and 10mg at noon. One patient actually cut the second dose in half to assist sleep. The psychiatrist and I are quite pleased with these results.
This specific body-mind problem, the predisposition for alcoholism, addiction is more than just genetics. There are many facets, predisposing factors as Jeff Georgi and many others, particularly those at Harvard, are presenting. Knowledge is power. Lack of knowledge is unfortunate; it hinders progress and increases suffering.
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