Archive for the ‘Addiction and substance use/abuse’ Category

What do you want? A three part question.

June 6, 2010

Many years ago, when I was a young psychiatry resident, I went through a period of great confusion, in my personal life and as a neophyte professional. A trusted friend, a psychologist who was older and wiser than me, looked me straight in the eyes and demanded my full attention before asking me, in a tone fraught with meaning, “What do you want?”  I sat there in stunned silence, my mind suddenly clear of the jumble of racing thoughts that had prompted her question.  Instead, I had only one thought, echoing in my mind and making my head hurt:  What, indeed, did I want?

Now, decades later, I often think of that moment and smile at the simplicity of the question and the obviousness of the answer.  But it took me years of trial and error to really grasp the import of the question.  What I want depends on the unstated part of the question:  Right now, in this moment?  Or, in the near future?  Or, in the long run?

For example, if I am at a restaurant surrounded by people I enjoy and having a grand time, do I really want to order another martini?  It would taste good, and the rush would certainly feel good.  But, past experience tells me I would not sleep well that night, and would feel less than my best the next day.  In the long run, if I regularly doubled my alcohol intake, I might put on some unwanted pounds and suffer other negative consequences.  I have never regretted NOT having a second martini, but have often regretted having one.  So the answer is obvious: No, I do not want another martini, thank you.

Little decisions mount up to big ones.  And big ones, of course, may come at us all at once, as in “Do I want chemotherapy?  Do I want to marry this person? Do I want a divorce? Do I want to adopt a baby?”  I contend the same three parts apply: immediate gratification, short range implications, long term likelihoods. We may have to delay the decision pending some research, or the counsel of others.

What makes this point worth writing about is that so often, in my psychiatric practice and in my life, I have seen people fooled into thinking what they WANT is immediate gratification.  The denial of that (saying “No, thanks” to the offer of a second martini) is not seen as what they want, but as what they SHOULD do, or what they KNOW, but not what they WANT.  That, to me, is ridiculous, because there is no reason to define what we want, really-honestly-deeply want, as simply what is tempting in the moment.

Stating our decisions as what we WANT is a way of taking full responsibility for ourselves. That is why I say so often in this blog that the secret to happy, healthy living (at least that part we control) is re-framing our thinking from what we should do, to what we want to do — in the moment, for the short term, and for the long run.  Striking a balance among the three versions of “want” can be tricky; no one promised it would be easy.  Do you WANT that bag of french fries, or don’t you?  What about that puppy?

Ending overeating

July 7, 2009

Kessler overeating

A very important new book (The End of Overeating: Taking Control of the Insatiable American Appetite by David Kessler) accurately describes major factors contributing to the obesity epidemic: cleverly formulated manufactured food designed to seduce us into overeating, addictive ingredients (salt, sugar and fat) which act like nicotine in cigarettes to keep us coming back for more, a profit driven system of marketing and government subsidies which works against our best interests, and the loss of boundaries limiting when and how much we eat. It is indeed frightening to think that a 2-year-old’s appetite “knows” to shut down when enough calories have been consumed, but by the time that child is four (in our culture) there is often a loss of that self-control mechanism.

Kessler’s solutions include re-training our minds to devalue unhealthy processed foods loaded with the Big Three (salt, sugar, fat); reforming our policies and practices which encourage this vicious cycle; and doing much more to educate people as to what they are consuming (such as requiring nutritional information in restaurants).

I agree with all this, but take issue with some of the concepts Kessler promotes. My main complaint is he oversimplifies the issue of food containing salt, sugar and fat by using an addiction model. Too much of these ingredients is indeed unhealthy, but a simple addiction model will not work.

Another problem is his use of the term “real food” (see NPR interview) which is a vague concept, at best. Many seemingly real foods contain salt, sugar and fat (either naturally, or because of the way they are produced), and not all “manufactured” foods are bad (e.g., some fish farmed in a sustainable way are better for us than some “wild-caught” fish). I can buy a chicken that has been doctored with added salt and fat, or I can buy one (usually smaller and more expensive) which has been grown almost organically. To the average consumer, both seem “real.” Also, I can buy “sea salt” and “unrefined real sugar” and think I am getting something healthier than standard table salt and corn syrup, but the bottom line (sodium and calories) may be exactly the same.

Finally, he promotes a black vs. white dichotomy between a disease-like state we cannot directly control (“conditioned hypereating”) and old fashioned willpower, telling us “it is not our fault” that we overeat. Fault, per se, may not be the issue; rather, we should learn ways to increase our resistance to external cues and marketing, educate ourselves about nutrition and portion size, and practice coping skills to enhance self-regulation. I have written about this at length elsewhere.

Something to keep a bloodshot eye on.

November 20, 2008


Usually, I don’t post about preliminary research findings, and this one only applies to rats, but I think it is interesting. Beyond that, no comment.

Puff-a-Day Marijuana Dose Helped Older Rats Remember (Update1)

By Rob Waters

Nov. 19 (Bloomberg) — A daily puff of a compound like marijuana, the plant blamed for ruining potheads’ recall, might help maintain memory in old age, researchers who tried it on rats reported today at a neuroscience meeting.

Here is the full story.

The power (and controversy) of self-change

August 4, 2008

I have written before (here) about self-change and its relevance for adopting a healthy lifestyle. This recent article in Scientific American Mind summarizes the issues (and controversy) quite well. In case the link to the article goes away, here is the article:

Do-It-Yourself Addiction Cures?

Former drug and alcohol users can show impressive results without professional treatment, through the phenomenon of self-change

By Hal Arkowitz and Scott O. Lilienfeld

July 31, 2008

“To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times.”—Mark Twain

Samuel Clemens (Twain was his nom de plume) humorously mocked his inability to end his nicotine-fueled habit. But he might have gone for Quitting Round 1,001 had he had the benefit of recent research.

In 1982 Stanley Schachter, an eminent social psychologist then at Columbia University, unleashed a storm of con­troversy in the addic­tions field by publi­shing an article showing that most for­mer smokers and overweight people he interviewed had changed successfully without treat­ment. He also cited a study that repor­ted even higher rates of recovery among heroin users without treatment.

A particularly controversial finding was that the success rates of his so-called self-changers were actually greater than those of patients who underwent professional treatment. Schachter discussed two possible explanations. First, treatment seekers may be more severely addicted than self-changers. Second, studies typically examine only one change endeavor, whereas his interviews covered a lifetime of efforts. Perhaps it takes many tries before a person gets it right, he suggested.

Schachter’s findings were met with intense skepticism, even outright disbelief, particularly by those who believed in a disease model of addiction. In this view, addictions are diseases caused by physiological and psychological factors that are triggered by using the substance (drugs or alcohol); once the disease is triggered, the addict cannot control his or her substance use, and complete abstinence is the only way to manage the disease. Proponents of this model did not believe that so many people could change their addictions at all, let alone without treatment. Other criticisms came from researchers who questioned the scientific value of Schachter’s work because it was based on a small and selective sample and relied on self-reports of past behavior, which often are not accurate pictures of what really happened. Nevertheless, his findings served as a catalyst, encouraging many researchers to study self-change in addictive behaviors. Let us examine what the research tells us about how widespread successful self-change is for problem drinking and drug addiction.

Rates of Success
Psychologist Reginald Smart of the Center for Addiction and Mental Health in Toronto recently reviewed the findings on the prevalence of self-change efforts among problem drinkers. We draw the following conclusions from his review and from our reading of the literature:

  • Most of those who change their problem drinking do so without treatment of any kind, including self-help groups.
  • A significant percentage of self-changers maintain their recovery with follow-up periods of more than eight years, some studies show.
  • Many problem drinkers can maintain a pattern of nonproblematic moderate use of alcohol without becoming readdicted.
  • Those who do seek treatment have more severe alcohol and related problems than those who do not.

Although fewer studies of self-change in drug addiction exist, the results generally mirror those for problem drinking. In summary: self-change in drug addiction is a much more common choice for solving the problem than treatment is; a substantial percentage of self-changers are successful; a significant percentage of those who were formerly addicted continue to use drugs occasionally without returning to addiction-level use, and they maintain these changes fairly well over time; and those who seek treatment usually have more ­severe problems than those who do not.

The experiences of Vietnam veterans are especially instructive. Sociologist Lee N. Robins, then at the Washington University School of Medicine in St. Louis, and her associates published a widely cited series of studies beginning in 1974 on drug use and recovery in these veterans. While overseas, about 20 percent of the soldiers became addicted to narcotics. After discharge to the U.S., however, only 12 percent of those who had been addicted in Vietnam were found to be in that state at any time during the three-year follow-up. Fewer than 5 percent had overcome their addiction through therapy. Additional findings from Robins’s studies suggested that abstinence is not necessary for recovery. Although nearly half the men who were addicted in Vietnam tried narcotics again after their return, only 6 percent became readdicted.

The results of Robins’s studies suggest the power of self-change in drug addiction, but they also have been the target of many criticisms. For example, most men who became addicted in Vietnam had not had that problem before their tour of duty, suggesting that they may be unrepresentative of the general population of drug addicts. Moreover, their drug use may have been triggered by the stress of serving in Vietnam, making it easier for them to stop when they returned home. This last criticism is weakened, however, by the finding that most men who continued using some narcotics after discharge did not become addicted and by the fact that the return home was also very difficult because of the popular sentiment against that war in the U.S.

Next Steps
We need more and better research on the potential for self-change to conquer problem drinking and other addictions. Studies suffer from differences in the definitions of important terms such as “addiction,” “treatment” and “recovery.” The use of reports of past behavior and relatively short follow-up periods are problematic as well. We also do not know of any studies on self-change with prescription drug addiction. Finally, we need to know if recovery from drug addiction leads to substitution with another addiction. At least one study revealed that many former drug addicts became problem drinkers. Because of these caveats and others, the percentages we have reported should be taken only as rough estimates.

Although we have reviewed some encouraging initial results from the literature, it is our impression that many addictions professionals do not view self-change as very effective. Their conclusion may be largely correct for those problem drinkers and drug addicts to whom they are typically exposed—treatment seekers.

Generalizations from those who seek treatment to the population of problem drinkers and drug addicts as a whole may be incorrect for two reasons, however. First, those who seek treatment have more severe problems than those who do not; second, they may overrepresent those who have failed repeatedly in their attempts at self-change.

We may learn a great deal from people who successfully change addictive behaviors on their own. Whatever they are doing, they are doing something right. In addition to the work with problem drinkers and drug addicts, we are beginning to make headway in the study of self-change in other problem areas, such as problem drinking, smoking, obesity and problem gambling. Greater knowledge about self-change and how it comes about might be used to help people who are not in treatment find ways of shedding their addictions as well as to enhance the effectiveness of our treatment programs.

Note: This story was originally printed with the title, “D.I.Y. Addiction Cures?”.

Hal Arkowitz and Scott O. Lilienfeld serve on the board of advisers for Scientific American Mind. Arkowitz is a psychology professor at the University of Arizona, and Lilienfeld is a psychology professor at Emory University

Body shape is as important as weight

May 31, 2008

Are you an Apple, or a Pear?


Several recent studies and articles have highlighted how important WHERE we store fat is to our health. Excess weight is generally stored either in the abdominal area or in the hips, thighs, and buttocks, giving rise to the descriptive terms “Apple” and “Pear.” If you are an Apple (and these shapes appear to be partly determined by genes), you tend to have more visceral fat (fat around the abdominal organs) and this can lead to various diseases (type 2 diabetes, some types of cancer, heart problems, urinary problems, dementia, hypertension, and stroke). The only benefit to the Apple shape is lower risk of osteoporosis. Overweight men and post-menopausal women tend to be Apples. Also, smoking is associated with abdominal fat accumulation.

Pears are not as much at risk for the serious diseases listed above, but are more likely to suffer from osteoporosis, varicose veins, and cellulite. While a Pear can become an Apple, Apples do not morph into Pears.

The good news? Here is a quote from an excellent article on this topic in the U. C. Berkeley Wellness Letter (June, 2008):

While abdominal fat tends to accumulate faster than other fat, it also tends to come off faster. [More good news:] losing just 2 inches from the waist reduces coronary risk by 11% in men and 15% in women, according to one recent study.

Further information from Weight Management for Your Life:

Some research indicates that elevated waist circumference (Men: equal to or greater than 40 inches; Women: equal to or greater than 35 inches) is a more specific risk factor for some diseases, such as prediabetes, than weight or BMI. An increasing waist-to-hip ratio may be a better indicator of coronary artery calcification than either waist circumference or BMI.  Therefore, weight distribution, as opposed to weight alone or BMI, must be taken into consideration; belly weight (abdominal obesity, “visceral fat,” or “central adiposity”) is of most concern. [see also here]

Just asking — 4 questions to ponder

May 27, 2008

One of the strongest influences on weight management and healthy lifestyle is drinking alcohol. I am not referring to the fact that moderate drinking has been shown to have some health benefits (cardiovascular). Rather, too much drinking adds unwanted pounds and negatively affects the brain, liver, and most other organ systems. So, how do you know if you drink “too much?” One of the simplest ways to begin to find out is to take a screening test, such as the RAPS4. Here it is:

RAPS4 (Remorse–Amnesia–Perform–Starter):

1. During the last year have you had a feeling of guilt or remorse after drinking?
2. During the last year has a friend or a family member ever told you about things you said or did while you were drinking that you could not remember?
3. During the last year have you failed to do what was normally expected from you because of drinking?
4. Do you sometime take a drink when you first get up in the morning?

A “yes” answer to at least one of the four questions suggests that your drinking is harmful to your health and well-being and may adversely affect your work and those around you.

If you answered “no” to all four questions, your drinking pattern is considered safe for most people and your results do not suggest that alcohol is harming your health.

You also may have a problem if alcohol is causing or aggravating any specific health problem or lab test.

Here is a more detailed online test, developed by Johns Hopkins University Hospital.

What should you do if you think you might be drinking too much? Well, you can cut down by setting an upper limit of drinks per day and days per week. Or, you can try going alcohol free for 2 months or so and see how you feel after this experiment before deciding whether and how much to drink in the future. If either of these experiments is too difficult, strongly consider getting an evaluation from an alcohol counselor or therapist.

To end this post on a lighter note, here is a comprehensive review of cures for hangovers, from The New Yorker magazine (May 26, 2008). Bottom line: there is little scientific evidence to support any of the claims, but it seems alternating alcoholic drinks with glasses of water helps in several ways: less alcohol consumed, fewer calories consumed, less chance of dehydration (which alcohol consumption can cause).

The power of social networks to improve health

May 22, 2008

Quitting smoking and losing weight (if you are overweight) are perhaps the two most important behavior changes you can make to improve your health. A new article in today’s New England Journal of Medicine confirms what a previous article has shown: people we interact with in our social network (friends, spouse, co-workers, etc.) strongly affect our behavior when it comes to smoking and weight gain or loss. We also affect the other people in our network. Today’s article is titled “The Collective Dynamics of Smoking in a Large Social Network” by Christakis NA, Fowler JH (NEJM, Volume 358:2249-2258). The earlier article, and similar research, is described in Weight Management for Your Life (p. 79):

In 2007, an article appeared in the New England Journal of Medicine with the title “The Spread of Obesity in a Large Social Network over 32 Years” [N Engl J Med. 2007 Jul 26;357(4):370-9] The same day the article was published it made front page news. No previous research had focused so intensively on “the obesity epidemic” as a social network phenomenon. The main finding of this elaborate study was that friends have a highly significant influence on our weight, specifically whether we become obese. The effect of friendship was surprisingly large and exceeded the influence of siblings and spouse (whose influence was also significant). … The editorial in the NEJM accompanying the article put it this way: “As the article by Christakis and Fowler [the researchers] shows, … networks, in this case those that pertain to social influence, may have just as strong an impact on the development of obesity as the otherwise strong genetic effects.”

These studies provide exciting and compelling evidence in favor of the bio-psycho-social model for disease and wellness, meaning that biological (e.g., genetic), psychological (e.g., coping) and social (e.g., interpersonal and cultural) factors interact to produce health problems and all must be addressed in reversing or treating these problems.