Alcoholics Anonymous Part 1: Bali

Bali Cravings
About 4 months into sobriety, I visited Bali with my family (including my parents and mother-in-law). When I got there, a feeling came over me… a peace and tranquillity like I’d never before experienced. Then I got in touch with my spiritual side and found God. Next I saw unicorns flying through the sky whilst pooping rainbows…

NOT!

Yeah OK, that never happened. I mean, I did go to Bali but faaaark me. It was hard. I experienced something that in the lab we refer to as ‘context-induced reinstatement’. Basically, it has been known for sometime, that addictions can be context-specific – one well-known example from real life is when many heroin-addicted soldiers returned home to the United States from the Vietnam war. Surprisingly, once home about 90% of these soldiers were able to shed their addiction, and only 10% remained addicted. However, what this also means is that addictions and can be ‘reinstated’ (i.e. the addict can relapse) when they return to a ‘context’ (place) previously paired with alcohol/drugs, or even visit a new place that is similar to the one associated with alcohol drugs, like a new pub or restaurant etc.

Contextually-mediated relapse in the lab
Similar effects have been shown in rats and mice too. The typical experiment goes something like this: the rat or mouse is first trained to press a lever for alcohol, or cocaine, or amphetamine, or whatever the drug of interest is, in a particular context, usually a skinner box with stripey walls, a grid floor, and vanilla odour. That same rat is then put into a different box with spotty walls, a smooth floor, and a peppermint odour, but in this box, the lever doesn’t earn the drug. In fact, in this box, the lever doesn’t earn anything (known as ‘exinguishing’ the lever press-drug association). If you put that rat back into the ‘extinction’ (lever-no drug) box the next day, s/he will press the lever at a low rates. If, however, you put the rat back in the original box, however, responding will be high again.
In drug addiction, this effect is mediated in the brain by circuits that regulates decision-making generally; structures such as the nucleus accumbens (often reported to be the brain’s hedonic ‘hot spot’, although it does more than just detect pleasure) and its projections to the ventral pallidum and lateral hypothalamus. Further, such ‘relapse’ isn’t only bought on by contexts (places), but can be caused by cues such as the sight of a particular beer label or a wine glass. It makes evolutionary sense for a brain circuit to ‘hold on’ to the knowledge that an action previously earned a reward in a particular place, or to explore whether that action earns a reward in a new place, because if it didn’t the person/animal might miss out on a reward. Unfortunately, however, in drug addicts this effect provides another example of circuitry that evolved to optimise receiving useful rewards, like food or sexual pleasure, going awry and supporting drug-seeking when this is not adaptive.

Contextually mediated relapse in real life
If you are an addict like me, the likelihood is that you have experienced this. You might never experience cravings anymore in your normal surroundings, having ‘extinguished’ the association between walking to your local pub and buying a beer. But then you go on holiday, or into a new environment and see a different pub and the craving comes back to you with full force. Well that’s what happened to me in Bali.
Bali ticked a lot of boxes driving me to drink: 1) it was sunny which I always associate with drinking, 2) I was on holiday so I didn’t have work, 3) my parents were there to be responsible adults and help out with my daughter so I didn’t have to be as responsible, and 4) parents were there being parents (i.e. driving me slightly nuts – love you Mum!). It was very, very, very hard. So I posted in my lovely facebook group about my troubles and so many of them said what I often hear in the group: go to a meeting. And I thought, “actually yeah, why the hell not? So I found the nearest meeting that was on in one hour, started walking there before I lost my nerve, got lost on the way so was a little bit late, but I got there. And it was good.

AA
When I got to the meeting I mentioned straight away that I was a first-timer and I was welcomed with open arms. Then people started to share. To begin with, it was only the men that shared, and they talked about many things. Some talked about how they had ended up in jail, or mental institutions, or how they had lost custody of their children and so on. This was bad. I couldn’t identify with this at all. After several days in Bali with a little voice in my brain (which part of my brain? That I can’t tell you sorry!) telling me I am not really an alcoholic, this was not what I needed to hear. Suddenly that voice started getting louder. “I’ve never experienced consequences like those, so maybe I’m not really an alcoholic?” “Maybe I can get out of here and go drink! And party! Woooo Hoooooo”
But then another voice (in my head) chimed in and asked: “why the hell are you sitting here if you don’t have a problem?” “And if you really don’t have a problem, how come pretty much every area of your life (work, health, fitness, relationships, happiness, anxiety) has gotten so much better since you quit drinking?”. If it wasn’t a problem, that wouldn’t have happened, surely.
So I shared. Can’t remember exactly what I said, but I sat there with my fake tan, thinking that all these people just think I’m some dumb blonde with resting bitch face (oops there’s those self-esteem issues again) and here I am talking about the fact I have a good job, and a loving family, but that alcohol has caused a lot of problems for me, so am I really an alcoholic after all?
But after I spoke up the other women in the group started to speak up. It was at this point that I heard my own story reflected back to me, over and over and over. Being there for your kids but not really being present. Waiting until they go to bed so you can drink. Getting angry with their partners over nothing. Dragging their sorry butts to work hungover and giving a sub-optimal performance. I realise now what I didn’t at the time: that alcoholism seems to manifest differently in men and women. I’m not sure why this is (scientific studies in rodents have by far and away used mostly males, although this is now starting to change). I know that in the human research there have been some differences found in how reactive men and women are to cues, but I’m not sure how that might translate to different manifestations of addiction.
In any case, that meeting saved me from a major relapse. I stayed and had coffee with some of the members afterwards, and they all were so welcoming and lovely and non-judgemental. Noone seemed to judge me for my resting bitch face, or blonde hair. No-one seemed to change their manner immediately and start acting a little self-consciously when I said that I was a behavioural neuroscientist, as often happens when meeting new people. Two of the women gave me their email addresses and numbers, and I messaged them a few times throughout the rest of the trip. And most importantly I didn’t drink.

Returning Home
So you would think that after I returned home after such a positive experience that I would continue to attend AA. Initially I did intend to, I looked up the beginners meeting and there was one nearby. I told my husband I was going to go that night. It was all sorted. Then I got to the evening and I just… didn’t. The cravings certainly dissipated when I returned home (i.e. as I returned to the extinction context), but I knew enough to be wary of this lack of craving, and that it could return at any time. However, I did think long and hard about it, and eventually decided instead to sign up to recovery coaching with the person who runs the podcast I had been listening to instead. In my next post I will elaborate on why.

Narratives and the brain: A Drunk Story

 

pexels-photo-374809.jpegFunny shit

Like most drunks, I have done some fucking dumb shit when I have been drunk. I’ve also done some fucking funny shit. There was the time, during a blackout at a work conference, I was sleeping in the same room as two colleagues (both female) and at some point in the night got up out of the trundle bed in which I was sleeping naked (presumably out of habit as I really don’t know why I was naked!), went to the bathroom, and when I came back tried to get into bed with one of my colleagues. Naked. I have no memory of this of course, but apparently I was very difficult to persuade to go back to my own bed.  So much so that the current occupier of the bed gave up trying to persuade me to, and went and slept in it themselves. The first I knew of any of this was when I woke up in the morning in the wrong bed, naked and totally confused.

Was I mortified? Not really! Slightly. Luckily my colleagues are good friends and forgiving. Did this stop me from doing the same thing a few months later? HELL NO!! In fact, I must have subconsciously decided that I wanted to dial it up a notch, because I couple of months later I did the same thing… TO MY PARENTS!!! It was the night of a Prince concert (R.I.P) and my daughter was about 2 so my parents were staying over to babysit. I drank loads, I remember sweet talking the bar man into selling me more drinks after the bar had closed, then later entered a black out and kicked the side of a bus for no reason whatsoever. Apparently. My poor, ever-suffering husband had to CATCH MY VOMIT IN HIS HANDS in the taxi on the way home so I didn’t get in trouble, and helped me all the way up the stairs. I went to sleep for a couple of hours, and then as some of you might know, your blood alcohol level can actually rise a couple of hours after you stop drinking as your liver can only metabolise a certain amount, and I can only assume this is what happened to me.

The rest I only know from what my husband told me. Apparently, first he woke up to me crouching down in the corner as if I was about to wee. He yelled at me what the hell am I doing? And sent me to the toilet down the hall. Next thing he knows, my mother is screaming for my husband, and he walks in to the room they are sleeping in and there I am, naked again, trying to get into bed with my mother and Step-Dad. Wow. Mortified doesn’t even begin to describe it. Mort. Dead. Deadified.

So let’s get serious

So they are probably the funniest things I did drunk. They certainly weren’t the stupidest, or the meanest, or the most dangerous, but they are pretty funny. The reality behind these stories however, is not that funny. It was still a number of years before I admitted that I had to do anything about my drinking problem, although I had no problem admitting that I was an alcoholic. Step 1: Admit that you are powerless over alcohol. Done and dusted years before entering recovery. Why? Mine was a special kind of denial.

I will never forget visiting a friend’s place about 3 years before quitting drinking. She was also a rather large drinker and quite functional, and I said to her that I had been taking online quizzes to determine whether I was an alcoholic. The answer kept coming up as ‘yes’. She then said “Oh yeah I’m totally a functional alcoholic”, just shrugging it off like it was nothing. And I thought that if she can admit that she’s a functional alcoholic and not be bothered about it, then I can too. I am certainly functional, I have a good job, a family, friends etc. It was as if by admitting that I was an alcoholic, but brushing it aside as if it weren’t a problem, I gave myself permission to carry on doing what I was doing. Who cares? My life is fine! Until it wasn’t.

Fast forward about 3 years, and as many people say, the alcohol just stopped working. I was going through some very stressful times at work (unsurprisingly, being a neuroscientist is highly competitive and stressful, as well as full of rejection so not great for the ol’ self esteem), was severely hungover every weekend so that I was being a shitty mother and wife, and I was bloated and not getting any fitter. Whereas years beforehand I would have drank only on weekends and special occasions, and only when all my responsibilities were taken care of, as my tolerance was increasing I was increasingly able to do everything (even Crossfit) after drinking large amounts the night before. The time that I did spend sober increasingly lost its colour, and I felt like I was always counting down time until I could drink again.

Quitting

I am ashamed to say that originally, the reason I quit drinking for a month was because I was sick of being fat. That month was by far and away the hardest month in my whole sobriety journey and I spent every second counting to the end of the month when I could drink again. I didn’t go out at all, I wasn’t around alcohol, but through sheer force of will, I made it to the end of the month. Then I went out and got wasted, drank so incredibly much I injured my leg, I have no idea how, but I still have a scar from it today. I then spent the next month drinking again, not every day but most, and life was shitty. So I took another month off and life was better. I could concentrate at work again, I had so much more motivation not just at work but at life in general, and I stopped instigating stupid fights with my husband every Friday night so he was happier. I wasn’t hungover every weekend so I could actually spend quality time with my daughter so she was happier. And I lost a few kilos. Hurrah!

But because I never intended to quit drinking forever back then, I always went back. And every time I went back it sucked more than the last. The time I finally decided to quit for good was after going to a work conference, getting absolutely wasted, sleeping through most of the talks and then drinking through my hangover during the next day’s talks when I finally did make it. When I got home I hadn’t seen my family for 3 days, but I was so sick that all I could do was lie in bed even though my daughter had really missed me and wanted me to hang out. My husband just looked at me, sighed and shook his head in disappointment.

Drinking and Recovery

Yet of course, I still drank two days later. Friends came over for lunch, they were going to the movies after. I decided to have a wine because if they were leaving, then I would stop drinking when they left. They didn’t leave, we ended up drinking until late in the night, I ignored my daughter all day again on a Sunday which is often my only day off from work, and drove to work the next morning hungover as fuck. Again. THAT was when I decided no more.

That week I started living and breathing recovery. I decided not to be put off by all the talk of a God and Higher power, to just ignore that stuff and pay attention to the stuff I found relevant. As a scientist it was not easy to ignore the irrationality, but soon the payoffs started to come. It had been so long since I had actually put some thought into life, instead of just bumbling along doing whatever and drinking to numb out the thoughts and emotions. The epiphanies came thick and fast. And here we still are.

The podcasts/memoirs/literature I found most useful were not the self-help podcasts and books, but were the ones that told a story (special shout out to http://theshairpodcast.com/). Listening and reading about the stories of addicts who had gotten sober I found myself identifying with them over and over again, even ones that I expected to have little in common with. This powered me on and gave me new hope that I could get sober, and although I have had a couple of relapses since then, I have been mostly sober for around 9 months. The times I have drunk again I have been able to stop again relatively quickly. The gifts of sobriety just outweigh the gifts of drinking by a million miles, it just seemed crazy to leave that all behind.

Stories and the brain

The epiphanies of sobriety have not just informed my personal understanding of the world and of myself, but of my work. My work had already been part of a movement within the basic behavioural neuroscience world that is increasingly beginning to recognise that even rodents form ‘states’ or contextualise information into ‘situations’ and it is largely the orbitofrontal cortices that carry out this function. This is part of the prefrontal cortex, that sits behind your eyes, hence the name “orbital”. Although it does receive some filtered visual information, however, it does not directly regulate vision. Rather this part of the brain, in conjunction with some subcortical regions such as cholinergic interneurons in the striatum, and centromedian/parafascicular thalamic nuclei, is the part that infers your current location within a task space. In fact this was described elegantly by a close personal friend of mine in a recent article as if your brain has created a kind of ‘google map’ of a task (e.g. to make a cup of tea: if I walk into the kitchen and put the kettle on, then hear the kettle boil so pour out the water… etc) the orbitofrontal cortex provides the ‘pin’ that tells you which part of that map of the task you are currently in.

In other words, the brain constantly constructs a narrative, it is how we are wired. It is my assumption, although untested, that in addicts this narrative gets pushed aside as automated actions take over without much thought. Thus it feels good in sobriety when we start to take control of our narrative once again. Indeed, the OFC has strong reciprocal links with the amygdala, a part of the brain that has been heavily implicated in regulating emotions. Emotions drive, and form part of our narrative.

In short, stories are important to us. In addiction research it is often said that the neural “reward” circuitry gets hijacked by drugs. In normal, non-addicted brains, neurotransmitter responses that are supposed to tell us about intrinsically rewarding outcomes so that we repeat certain actions. When we take drugs/drink, we artificially activate this circuitry so that value becomes attached to the wrong stimuli and destructive actions. Furthermore, dips in this reward circuit are supposed to tell us when expected rewards are omitted or removed, motivating us to seek out how to reinstate them. Therefore, when negative things happen (e.g. we fight with our partner/lose a job etc), our reward circuit can detect this negative outcome and motivate us to do something about it. If, however, we have hijacked this pathway by taking drugs, then we do not experience the same dip in neurotransmitters and are therefore less motivated to do something about it. It is theorised that this is why addicts will continue to drink/use in the face of so many negative consequences.

But encoding reward is not all those neurotransmitters do. Dopamine, for example, is commonly cited as the neurotransmitter that is activated by reward, but it does so much more than that. I would argue that it forms part of our narrative, our story that we tell ourselves. It helps us contextualise events. If, by taking drugs we strengthen the wrong circuit and attach value to the wrong items, this means that our internal narrative also gets skewed. Only in sobriety can we begin to take back control of our narratives. And that is a great feeling, undoubtedly underpinned by the strengthening of new synaptic connections in the brain.

About me

pexels-photo-990819.jpegI am a behavioural neuroscientist, an alcoholic, a mother, a wife, a teacher, a student, and a mentor, among other things, not necessarily in that order. I have thought for a while about writing this blog, and now I have a little time, so here I am. Going through the process of recovery from addiction is often a deeply intense personal journey, and I am no exception. For the first time in so many years I have actually thought about why I feel the way I feel, or think the way I think etc, not just from the perspective of what the underlying neural substrates of those feelings and thoughts are, or how they are behaviourally expressed, as I had for so many years prior through my work.

Prior to entering recovery, I could tell you all about the reward circuit in the brain and how it is hijacked by the use of drugs (hint, it is extremely complicated, there’s still a lot we don’t know, and it doesn’t just involve dopamine and serotonin, although they are involved of course). I could have told you the same information when I was actively drinking, but it didn’t stop me. What I couldn’t have told you is what it felt like to go through the emotions of recovery, things that the recovery community have a pretty good handle on. The initial ‘pink cloud’ during which you come out of the fog of addiction and start to see clearly, then you feel like you can change the world! Then the inevitable wearing off of the pink cloud, and the way in which everything seems to be guiding you towards relapse. The way that social connection is so vital to recovery. This is something I could never have guessed, although I knew very well that taking naltrexone would partially block the pleasurable effect of opioids in the brain and was a relatively effective treatment for alcoholism.

Like most things in life, my discovery is that things are not black and white, but endlessly nuanced and individual. There are, however, so many things the two sides I have been exposed to could learn from each other. Behavioural neuroscience, in my experience, is primarily focused on finding medications that can treat addiction, without much thought to behavioural modifications or interventions, despite these being relatively straightforward to study in the lab. By contrast, the recovery community can be quite narrowly focused on alternatives to medication, particularly ideas derived from alcoholic’s anonymous (AA) and other anonymous programs, although I have noticed that this has started to change a little more recently. In any case, it is clear that the vast wealth of information we have gathered in basic neuroscience research has not made its way through to practise, and by the same token, there is a lot of wisdom in the recovery community that isn’t even considered in the scientific community. This blog is my attempt to bridge that gap.