Substance Abuse: Self-Destructive Behavior

 "The surest way to humility is humiliation” ~ commonly heard saying at Catholic 12-Step meetings in Ireland

 

It seems like the debate over whether or not substance abuse is a “disease” is never ending, as described recently by fellow blogger George Dawson. I really don’t want to get into the particulars of that, because the debate is almost always a waste a time due to the multiple definitions of the word disease that get employed and continually conflated in such debates.

 

I’d rather focus on one main issue: How much control do most addicts have over their drug use? My opinion is that the question can best be answered by re-classifying most, though maybe not all, substance addiction behavior as self-destructive behavior. Voluntary. If it were not voluntary, addicts would have next to no control over when and under which circumstances they chose to not indulge, no matter the consequences. Almost no addict is using 24/7 unless they are actively suicidal.

 

Now, some people might argue that substance abuse might be a form of obsessive-compulsive disorder. When people with OCD who have compulsions do not engage in their compulsion, their anxiety level skyrockets. This may be due to clearly abnormal firing of some nuclei in their brain. While they can certainly choose to let their anxiety skyrocket, this choice is indeed very difficult.

 

However, skyrocketing anxiety can have another cause besides the clearly pathological firing of brain nuclei. It can also be caused by panic over anticipated consequences of engaging or not engaging in a particular behavior. If doing so might lead to massive invalidation by everyone a person knows and cares about, then doing so becomes very difficult because of kin selection and tribalism, two subjects I have previously blogged about extensively.

 

Although, due to our current state of knowledge about the brain – literally the most complicated object in the known universe – there is no way of knowing for certain if most substance abusers indulge because of feared consequences of not indulging, or because of abnormal brain firing of some sort. And of course there may be two different types of addicts, so either or even both possibilities may be true depending on which addict one is dealing with.

 

Based on my clinical experience with all sorts of self-destructive and self-defeating behavior in my psychotherapy patients, I’m going to come down on the side of feared consequences for most of them. So am I saying an addict’s family system needs them to continue to be addicts in some way? Well yes, that’s exactly what I am saying.

 

If this is the situation, it does not make sense to ask the question of whether or not the addict wants to be an addict, because in fact they would be ambivalent about it (intrapsychic conflict, the primary concept in psychoanalysis – what a novel idea!). While some substance use in moderation in some contexts is indeed pleasurable, the life of an addict is anything but. They hate what the drug does to them. Many no longer even get high from cocaine after extended use, for example. And if getting high really made them feel so good, then why aren’t addicts the happiest people around instead of some of the most miserable? The problem is that the feeling of existential terror due to kin group invalidation feels even worse. So they indulge. Self-destructively.

 

Now, the family groupthink issue which triggers any given family’s need to have an addict in their mist to remain stable is not always the same, so each family has to be evaluated individually on its own terms. But let me discuss the most common example of such an issue: Puritanism.

 

Puritans on the whole believe, to put it bluntly, that we are nothing but sinful piles of crap in God’s eyes, and that we have to be sinners because, well, all people are sinners who must therefore ask for God’s forgiveness. So, as clearly stated in the 12 steps, which are based on Protestant conversion techniques, our will must be a problem. If we are willful, we simply must come to a bad end. The only way out is to renounce our will and turn it over to a “higher power” - which is actually the group to which we belong. And do what they want us to.

Did someone mention willfulness there?

I’ve heard docs from 12-Step programs give talks at medical meetings during which they would tell the most humiliating stories about their own crazy behavior when they were using – a public version of what they do in meetings. Essentially, these folks are substituting a less harmful form of self-abasement for a more harmful one. Just like the Irish slogan at the top of this post says rather overtly. I suppose that’s the better of the two options, but it’s still self-destructive. But it makes their conflicted parents feel better about not acting on their own forbidden impulses. While having already received vicarious satisfaction of these very impulses watching their children indulge. Heaven forbid anyone might feel good about doing something selfish.

More Stories from the Journal of Obvious Results

As I did on my posts of  November 30, 2011,   October 2, 2012, September 17, 2013,  June 3, 2014,  February 24, 2015,  December 15, 2015,  September 13, 2016 and March 15, 2017, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the later. 

The journals honor the tradition of The Golden Fleece Award, an award given to public officials in the United States for their squandering of public money, its name sardonically derived from the actual Order of the Golden Fleece, a prestigious chivalric award created in the late-15th Century, and a play on the word fleece, as in charging excessively for goods or services. The late United States  Senator William  Proxmire  began to issue the Golden Fleece Award in 1975 in monthly press releases.

My comments are in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

3/17/17. Because substance abuse is an indicator of being satisfied with your life. US Veterans With Substance Abuse Problems May Have Higher Risk Of Suicide Than Veterans Without Such Problems, Study Suggests. HealthDay  reported, “US veterans with substance abuse problems have a higher risk of suicide than veterans who don’t,” researchers found after examining data on “more than four million veterans.” The findings were published online March 16 in the journal Addiction.

5/24/17. Because having a potentially fatal illness is so exhilarating. Lung Cancer Diagnosis May Increase Suicide Risk, Study Suggests. HealthDay (5/23, Mille) reports that research suggests individuals “with lung cancer have a strikingly higher-than-normal risk of suicide.” Investigators looked at “data from over 3 million patients during a 40-year period.” The research indicated “that a lung cancer diagnosis raised the odds of suicide by over four times compared to people in the general population.” The findings were presented at the American Thoracic Society meeting.

5/30/17. Because most people adjust instantly when uprooted from their entire way of life by a bloody war. Syrian Refugee Children Living In The US Reported High Levels Of Anxiety, Small Study Suggests. MedPage Today (5/28, Visk) reported, “Syrian refugee children living in the US reported high levels of anxiety,” researchers found. Specifically, “based on self-reported test scores, more than half of children had a probable anxiety diagnosis, and more than 80% had probable separation anxiety,” the 59-child study revealed. The findings were presented during a poster session at the American Psychiatric Association’s annual meeting. Healio (5/26, Oldt) also covered the study.

8/17/17. Cheaters are prone to cheat? Will wonders never cease? Serial Infidelity Across Subsequent Relationships (Arch Sex Behav; ePub 2017 Aug 7; Knopp, et al ).  Prior infidelity emerged as an important risk factor for infidelity in next relationships, according to a recent study. Researchers addressed risk for serial infidelity by following adult participants (n=484) longitudinally through 2 mixed-gender romantic relationships. Participants reported their own extra-dyadic sexual involvement (ESI) (ie, having sexual relations with someone other than their partner) as well as both known and suspected ESI on the part of their partners in each romantic relationship.

9/6/17.  And I thought most elderly people who fall fall out of bed. For nursing home residents, mobility increases risk of fracture. Reuters (9/5, Rapaport) reports a new study published in The Journals of Gerontology: Series A found that for nursing home residents, “risk factors for fracture included the ability to walk independently, wandering the halls, dementia and diabetes.” The study was based on data from “419,668 nursing home residents, including 14,553 who experienced hip fractures.” Lead author Sarah Berry, MD, of the Institute for Aging Research and Harvard Medical School in Boston said, “Frail nursing home residents that are still mobile and independent have opportunity to fall.”

9/6/17. People prone to diseases get them more often than those who are not? Genetic variants linked to health problems appear less frequently in people who live longer, study indicates. Newsweek (9/5, Osborne) reports genetic research published in PLOS Biology used data from over 200,000 people to show humans “appear to be evolving to hit puberty later and those who start at an older age live longer.” Researchers also discovered that “genetic variants linked to heart disease, obesity and high cholesterol appear less frequently in people who live longer.”

9/8/17. Because major depression has a genetic component, and depressed mothers may have attachment issues or altered parental behavior, ya think? Children Whose Mothers Took Antidepressants During Pregnancy May Be At Increased Risk For Psychiatric Illnesses Themselves, Research Indicates. HealthDay (9/7, Preidt) reports, “Children whose mothers took antidepressants during pregnancy may be at increased risk for psychiatric disorders themselves,” researchers concluded after reviewing “data from more than 905,000 children born in Denmark between 1998 and 2012,” whose “health was followed for up to 16.5 years.” The findings were published online Sept. 6 in the BMJ. According to Medscape (9/7, Brooks), the authors of an accompanying editorial “say that reporting absolute risks, as the researchers do in this study, is important to facilitate communication between clinicians and pregnant women.”

9/8/17. Maybe cuz they’re the ones who are eating again? Young Women With Anorexia Nervosa Who Resume Menstruation By End Of Treatment May Experience Greater Improvement In Psychological, Physiological Well-Being Than Those Who Do Not, Small Study Suggests.

Medscape (9/7, Davenport) reports, “Young women with anorexia nervosa (AN) who resume menstruation by the end of treatment experience greater improvement in both psychological and physiologic well-being than those who do not,” researchers found after studying 39 women with AN and 40 women with bulimia nervosa. The findings were presented at the European College of Neuropsychopharmacology Congress.

9/8/17.  Why would you need doctors for people to have healthcare? I just don’t understand. ACA Plans With Narrow Networks May Provide Less Access To Mental Healthcare, Study Indicates. Reuters (9/7, Rapaport) reports that according to a new study conducted by researchers at the University of Pennsylvania Perelman School of Medicine in Philadelphia, “narrow-network insurance plans created by the Affordable Care Act (ACA) offer only limited access to mental health care.” The article says these plans seem to have substituted lower costs for less access to mental healthcare.

9/11/17. Self destructive kids study less? High school students with poor grades more likely to have unhealthy behaviors, CDC study indicates. The Atlanta Journal-Constitution (9/8, Hart) reported, “There’s a link between unhealthy behavior and bad grades, according to a new study of high school students by the US Centers for Disease Control and Prevention.”  HealthDay (9/8, Preidt) reported the study suggests US high school students with poor grades are “much more likely to have unhealthy behaviors – including illegal drug use – than teens at the top of the class,” researchers concluded after “analyzing data from a 2015 government survey.” The findings were published in the CDC’s Morbidity and Mortality Weekly Report.

9/15/17. Because as we all know the incidence of health problems decreases with age. Risk For Health Anxiety May Be Increased In Older Adults, Study Suggests. MD Magazine (9/14, Warren) reports, “The risk for health anxiety...a disorder characterized by a preoccupation with physical health and/or somatic/body symptoms, is increased in older adults,” researchers found after assessing “538 primary care patients” ranging in age from 18 to 90. The findings were published online June 24 in the Journal of Anxiety Disorders.

9/29/17. They thought infectious disease occur spontaneously, I guess. Babies with older siblings may be at higher risk of hospitalization for influenza, researchers say. In “Well,” the New York Times (9/28, Bakalar, Subscription Publication) reports, “Having older brothers and sisters puts infants at higher risk for being hospitalized” for influenza, researchers concluded after studying “1,115 hospital admissions of children under two born in Scotland from 2007 to 2015.” The findings were published in the European Respiratory Journal.

10/2/17. Because listening to people talk about the voices in their heads is so relaxing. Caregivers of Individuals With Schizophrenia Experience High Levels of Distress, Study Finds. Psychological distress among family or friends who provide unpaid support to people with schizophrenia or schizoaffective disorder is much higher than the general population, reports a study published today in Psychiatric Services in Advance.

 

10/4/17. I didn’t know PTSD had anything to do with being traumatized. PTSD Particularly Common Among People Exposed To Mass Shootings, Studies Indicate. The AP (10/3, Tanner) reports that people who survived this week’s shootings in Las Vegas may be at risk for post-traumatic stress disorder (PTSD). Also at risk for “psychological fallout” are first responders, medical staff, eyewitnesses, and bystanders. Studies indicate “PTSD is particularly common among people exposed to mass shootings versus other types of trauma, with rates as high as 90 percent reported” by some researchers.

10/25/17. Because being abused as a child is good for your mental health. Young Adults Who Recall Being Maltreated May Have A Particularly Elevated Risk For Psychopathology, Researchers Say.   A study to be published in the January issue of the Journal of Psychiatric Research (10/24, Newbury, Arseneault, Moffitt, Caspi, Danese, Baldwin, Fisher) “explores the validity and utility of retrospective self-reports versus prospective informant-reports of childhood maltreatment.” Study data “were obtained from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative birth cohort of 2,232 children followed to 18 years of age (with 93% retention).” Researchers evaluated “childhood maltreatment” through “prospective informant-reports from caregivers, researchers, and clinicians when children were aged 5, 7, 10 and 12,” and via “retrospective self-reports of maltreatment experiences occurring up to age 12, obtained at age 18 using the Childhood Trauma Questionnaire.” The study revealed that “young adults who recall being maltreated have a particularly elevated risk for psychopathology.”

More Surprising Findings from the Psychiatry Literature

As we did on my posts of November 30, 2011 and October 2, 2012, it’s once again time to look over the highlights of the latest issues of my two favorite medical journals, Duh! and No Sh*t, Sherlock. 

As I pointed out in those posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

So, we have a lot of academics weighing in with studies on the obvious. Literally weighing in. Since academic promotions are often based on the quantity of papers, rather than their quality, schools might measure faculty members' progress towards tenure by calculating the physical weight of the paper on which their authored articles have been written. 

If Albert Einstein had only published his two papers on relativity - which literally changed the entire field of physics forever - that obviously would not have been anywhere near enough for him to get tenure at most universities these days.

So here we go with more fantastic additions to our knowledge base.

 

Early Drinking Associated With Problem Drinking Later

MedPage Today (8/16, Petrochko) reports, "Students who started drinking and getting drunk at an early age were more likely to engage in frequent heavy drinking and associated problems by senior year of college," according to a study published online Aug. 15 in the journal Alcoholism: Clinical and Experimental Research. "A longitudinal analysis of incoming college freshmen showed a significant association not only between younger drinking age and heavy drinking, but also with difficulties in work and school, blackouts, vomiting, and other problems by senior year (P<0.001 for all)," researchers reported.

So self destructive behavior has its roots in childhood experiences, eh?  Someone please tell the psychoanalysts.

And on a related note:

Youth With Conduct Disorder More Likely to Abuse Substances

5/15/13.   A longitudinal study of youth with and without conduct disorder (CD) finds that the former are significantly more likely to abuse substances. The findings are published in the May Journal of the American Academy of Child and Adolescent Psychiatry. Researchers from the University of Colorado prospectively followed 1,165 community-dwelling adolescents without CD, 194 youth in the community with CD, and 268 youth who were in treatment for CD. They were re-interviewed during young adulthood, and self-reports on age of substance initiation for 10 substance classes were analyzed.

Gee, I wonder if family problems and adverse childhood environments lead to both antisocial behavior AND substance abuse? That just never occurred to me before. 

Depression, Mania In Bipolar Disorder Have Differential Social Adjustment Effects

1/23/12.  Medwire (1/23, Cowen) reports, "Results from a UK study show that depression and mania symptoms have specific and differential effects on social adjustment in patients with bipolar disorder (BD). Richard Morriss (University of Nottingham) and team found that depression symptoms have a negative effect on performance and interpersonal behavior, while mania symptoms increase interpersonal friction."

And to think that I used to be under the impression that other people would react to hyperactive, impulsive, hypersexual people in exactly the same way as they would to someone who doesn’t even want to get out of bed or have sex with someone lying naked in the bed next to them.

High Doses of Opioids May Impair Driving

Drivers taking 20 mg of morphine or more per day, or the equivalent, are up to 42% more likely to be involved in road trauma than drivers taking the lowest doses of opioids, according to a new study from the Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Higher doses of intoxicants lead to more impairment than lower doses?  Who knew?

Anger Due To Delusions May Explain Violent Behavior In Patients With Psychosis

In print and in its "Well" blog, the New York Times (3/11/13) reports that "a new study finds that anger, coupled with psychotic delusions, may be the most significant factor in violence committed by people with mental illness." Medwire (3/12, Piper) reports, "Anger due to delusions appears to be a key factor explaining violent behavior in patients with acute psychosis," according to the results of the 458-patient East London First Episode Psychosis Study published online March 6 in JAMA Psychiatry.  

So people with paranoid delusions that make them feel angry or threatened are more likely to become violent than when they are not experiencing those reactions. So are such people actually psychotic if they act just like everyone else would?

Handling Stress Poorly May Increase Long-Term Risk For Anxiety/Mood Disorders

USA Today (4/4/13) reports that handling "stress poorly...may put you at greater risk for anxiety disorders and other mental health issues 10 years later," according to a study published online in the journal Psychological Science. Researchers from the University of California-Irvine "analyzed data on 711 men and women, ages 25 to 74, who were interviewed two times 10 years apart." Investigators found that "people who responded to stress with more anxiety and sadness than the average person were much more likely to have self-reported anxiety/mood disorders and psychological distress 10 years later."

Oh I get it now! Anxiety is caused by stress. That’s a remarkable insight.

And on a related note:

Association Between Mood and Alcoholism

The Los Angeles Times (5/2/13) A study that was published May 1 in JAMA Psychiatry, found that individuals "who drank 'to alleviate mood symptoms' were three times more likely to become dependent on alcohol than were those who did not use alcohol to calm themselves down or improve their mood."

And mood symptoms are also related to stress, leading to abuse of a psychoactive substance!?!  Even more remarkable.

.................

And we also just learned that actively trying to solve problems rather than just ignoring them is the better way to go. Now that’s counter-intuitive:

Small Study: Way Of Dealing With Emotions Linked To Anxiety Levels

The Time (5/13/14) "Healthland" blog reports, "When faced with a challenge, whether you deny the problems it poses or dive in to solve them in a positive way may determine how much anxiety you feel overall," according to research published in Emotion. The investigators "found that the participants who regularly reframed what was happening to them to view their situation in a better light reported less severe anxiety than the participants who suppressed their emotions in trying situations."

And finally, the question of whether or not the prospect of dying or of someone you love dying leads to psychological distress has at long last been settled by two recent studies.

Parents of Children with Cancer Show High Psychological Distress

5/17/13. A group of researchers associated with several pediatric oncology treatment facilities has published one of the first studies to describe the experience of distress in parents of children with advanced cancer. The researchers found that psycho­logical distress was associated with par­ent perceptions of prognosis, goals of therapy, their child's symptoms/suffer­ing, and financial hardship.

 

   Anxiety May Be Common Among Cancer Patients, Spouses

7/12/13.  The New York Times (7/12, Hoffman) “Well” blog reports that an analysis published in the Lancet Oncology indicates that “within two years of a cancer diagnosis, the pervasiveness of depression in patients and their spouses tends to drop back to roughly the same levels as in the general population, only to be replaced by another mind-demon: anxiety, which can even intensify as time passes.”