Unlocking Recovery: Exploring Models and Theories of Addiction

You. Hey there everybody, and welcome to today's presentation on theories of addiction and co occurring disorders. I'm your host, Dr. Donnelly Snipes. In this presentation we're going to talk briefly about what co occurring disorders are and then describe a variety of theories that people use to try to explain what causes them to actually happen. So let me start out by saying co occurring disorders or at least co occurring disorder symptoms are the expectation, not the exception. And this is a issue that I see get overlooked far too often in addiction treatment. We rarely see someone who is just presenting with compulsive use. They've got other stuff going on and if we don't address it, we're setting them up for relapse. The mental health disorder or symptoms may have come first and the person may be self medicating with the addiction. So somebody may have had long standing trauma or depression or anxiety or something else and they found the addiction and they found that engaging in the addictive behavior, whatever it is, help them feel better. So okay, we recognize that that happens in a significant portion of people who have addictions. But then there's another big portion of people who may not have had a diagnosable mental health issue prior to beginning use. So what I really want to talk about here is what I call the DSM diagnostic caveats. When you make a diagnosis of something like depression, there's a caveat at the bottom that says this is not better explained by symptoms of a substance use disorder or some other medical or mental health issue. So we often don't diagnose people with concurrent depression or anxiety or PTSD or whatever it is in recovery, because a lot of their symptoms can be attributed to potentially the substance use and the disregulation of their neurotransmitters and the rest of their life as a result of their addiction. However, it's important to not ignore those symptoms. Some of the symptoms that you can see in early recovery, depressive symptoms like hopelessness and helplessness. Think of people you've worked with with addictions. Even if they didn't have pre existing depression, when they come into treatment, there's often a great sense of being overwhelmed, hopeless and helpless. When they are in early recovery, their energy is low, their dopamine levels as a result of the addiction are low, which is going to contribute to low energy. They're often experiencing brain fog as a result of the changes and disruption and the neurochemicals as well as a lot of other stuff that's going on in their body and their life. Intense Guilt. This is not unexpected in addiction recovery. Now in the diagnosis of depression it says inappropriate guilt. And whether the guilt is appropriate or inappropriate, you can really debate in addiction recovery. Someone may have guilt over things they did in their addiction and be holding on to that. And you as the therapist may think that they're being too hard on themselves, quote, unquote, which would be what we might call inappropriate guilt. But a certain level of guilt is kind of expected in early recovery. And then we see ideation for suicide generally. And this isn't common, but it is not uncommon either. So being aware of this, when people's neurotransmitters are out of balance, when their entire life is out of balance, it is not uncommon to see some ideation, some thoughts about self harm. Anxiety is another thing that we often see. One of the things we'll talk about in the video that we do on detoxification and pharmacology is the detox symptoms are often the opposite of the symptoms or side effects, whatever you want to call it, effects of the substance. So someone who has been on anti anxiety medications or abusing them, or they've been abusing opioids, for example, as they start to sober up, their levels of worry, irritability and restlessness may increase a lot. And we'll talk about that more when we get to the video on the impact of addiction on brain chemistry, tolerance and withdrawal. But for this particular presentation, just recognize that we often see a lot of these symptoms in early recovery from addiction. And whether the symptoms predated the addiction or not is sort of irrelevant. If we don't deal with them now, they're going to be relapse triggers, PTSD or complex post traumatic stress disorder. We see people in addiction recovery who've experienced trauma, and that trauma may or may not be related to their addiction. But in many cases, most cases, people encountered things, encountered losses, encountered experiences in their addiction which were traumatic. They have emotional dysregulation. And this is a result of chronic stress causing the nervous system, the HPA axis, to become dysregulated. And addiction itself can lead to emotional dysregulation. It can lead to dysregulation of that HPA axis because addiction itself is a stressor on the body. But we also see that people with addictions often have a lot of other stuff going on that's contributing to their stress and contributing to the overload, if you will, of that stress response system. Hyper vigilance is common after trauma. You don't want to experience that again. So you're looking for threats, you're looking for things that are going to make you unsafe. And people with addictions may also be more hyper vigilant, Expecting bad things to happen, expecting the worst to. To occur. And we call that stinking thinking. Sometimes avoidance and numbing is another common symptom of ptsd, and it's one of the hallmarks of addiction. People don't want to feel that way, so they often engage in behaviors, whether it's dissociation or drunkenness, that may help them try to avoid or numb those memories or feelings or exposures. And finally, personality disorders. We see a lot of people displaying personality disordered behavior in early recovery, But I challenge you to examine the function of that behavior. An unstable self image. Well, they've been acting in their addicted self for months, years, days, decades maybe. So they may not know who they are if they're not using. They may not know what makes them lovable. So they're trying to figure this out. So their self image may be very unstable in early recovery. And interpersonal functioning deficits. Most people who are in early recovery from addiction have experienced interpersonal losses, have experienced problems with other people. Now, whether they grew up in a family where a addiction was prevalent and they didn't learn healthy behaviors to begin with, or if they had problems in their relationships as a result of their emotional dysregulation, There are a lot of reasons that we might see interpersonal functioning deficits. And, and those are the hallmarks of your personality disorders. Each personality disorder manifest these things in slightly different ways. But I encourage you, when you are working with people with addictions or people with mental health disorders, to screen for addictions. But I encourage you to look at the function of the behavior, the meaning behind the symptom, instead of just lumping it in and going, oh, okay, this person also has depression, and let's just give them a laundry list of diagnoses or the opposite end of the spectrum. We're only focusing on addiction, and everything else will just magically resolve itself. It ain't going to happen. So it's important when we're going through addiction treatment to recognize the interaction, recognize the impact of addiction and the impact of every area of a person's life. And I'm kind of jumping ahead to the biopsychosocial model, but let's take a look at some of the models that have come to prominence over the years. And some, like the first one, have thankfully faded. But I think it's important to understand that our understanding of addictions Is still evolving. I'll say it one more time because it's that important. Co occurring disorder symptoms are the expectation, not the exception, and they need to be addressed concurrently. So this is that theory that has fallen out of favor. Thank you. The moral theory. Back in the day, addictive behaviors were seen as a result of moral weakness. They were associated with people being gluttonous or lazy or prideful or, you know, they. They were associated with all of those character defects, so to speak, that people may have been taught In a more traditional society. And the treatment was the use of willpower and discipline and the development of a virtuous lifestyle. You start making the right choices, and your compulsion to use Will just kind of magically go away. Well, no, that's not it. We need to understand the function. So moral theory has pretty much gone by the wayside. But if you're taking a test on addiction counseling, it still may come up occasionally as one of those early models that were was posited to explain addiction. The disease theory is another early model, and it still has an element of truth Today. Diseases are incurable, progressive, and fatal if left untreated. Now, there are certain fatal diseases. But what we're talking about when we talk about the disease of addiction, we're talking about this set of behaviors that will continue to wreak havoc on the person's body and the rest of their life if left untreated. But they can arrest, they can stop the progression of the disease. Addiction is caused by biological and genetic factors that cause a physiological deficit, Making the person unable to tolerate or moderate the drug. So the person uses, and they're like, oh my gosh, I've never felt this good. And from then on, they're kind of chasing that high. And that often is a result of differences in the way the nervous system is wired. So when we say people may be pre. Genetically predisposed to addiction, this can be one of those reasons. We also know that there can be a physiological deficit that leads to compulsive use. Now, that can be the result of genetics. The person doesn't have enough dopamine, the person doesn't. Or their dop Dopaminergic system isn't working well, There can be a variety of genetic underpinnings to it, or the physiological problems could result from excessive use. When per. A person uses excessively and starts to develop tolerance, There are literal changes. Restructuring of the nervous system. So when they're not engaging in the behavior, they don't feel well, they start having cravings. They may Feel more irritable or depressed, and then they reach out to supplement with the addictive behavior in order to get those neurotransmitters back in balance. Based on the new wiring, the new structuring, if you will, imbalances in neurotransmitters like gaba, norepinephrine, dopamine and serotonin can lead to negative emotional energy and pain states. I know this one just says emotional states, but I think it's important to recognize that your neurotransmitters play a role in your energy, it plays a role in your libido, it plays a role in your emotions, it plays a role in your ability to think clearly and remember things. So when your neurotransmitters are out of balance, we may see a variety of different symptoms. When people are engaging in addictive behaviors and, and I keep saying that because it's not just substances, it can be behaviors. And they are increasing dramatically, increasing those levels of dopamine in addition to other neurotransmitters based on whatever they're doing, then you're going to see alterations in the nervous system, which is potentially going to mean when they're not using, they're experiencing those negative emotional states. Additionally, poor nutrition, unsafe environments, and lack of adequate rest, those are all stressors can lead to similar, similar neurochemical imbalances which are improved with use. And this disease theory and self medication hypothesis kind of go hand in hand. But it's important to recognize that when people are under chronic stress, they're feeling chronic anxiety, they're not getting enough sleep, their neurotransmitters will get out of balance. Like I mentioned earlier, their stress response system, the HPA axis, will become disregulated and that will lead to a sense of dysphoria, unpleasant feelings and low energy that often can be improved not healthfully, but improved with use. And I think it's important I didn't mention this back on the moral slide, but I think it's important to really recognize that people with addictions are people who are showing a really strong desire in many cases to try to survive. They're trying to survive whatever that pain is they're, they feel or experience when they're not using, but they don't know how to deal with it otherwise. So it's this spiral of feeling hopeless and helpless and in pain, then using to try to numb that, but using makes it worse. And then they start to feel like, well, I don't, I don't know how to deal with it. And numbing. It's making my life worse. So that's where that hopelessness and helplessness comes in. The social learning or sociocultural theory. I put these two things together because they're related. Both of these say that addiction is learned through observation, or what we call vicarious reinforcement and direct experiences. In social learning, People are learning from observing others. They are learning from their family, they're learning from their peers. They're learning from the media about how to cope with stress or depression, how to feel more relaxed and sociable, how to escape from pain. They get these messages from the, the people around them and from their culture. That's that sociocultural theory. And when they see other people, their friends, their family, or somebody on TV engaging in an addictive behavior and having a positive result, they drink, they feel more relaxed, they use this drug, they magically feel better, whatever it is, when they see that it contributes to what vicarious reinforcement. So the person says, oh, well, that worked for that person. Maybe it'll work for me. And they may try to. And try using. Now, some people can use and not develop addictions. That's one of the places this particular theory falls a little bit short. There are people who can grow up in environments where addiction is prevalent and not develop addictions. So there's something missing from this theory. We do know that people who find relief in a pleasurable behavior are more likely to do that again. So if somebody follows the recommendations that they see from a friend or a family member or whatever, and they go, oh, well, that works for them, maybe I'll try it. They try it, it helps for a minute, then they're going to be more likely to use it again. And that chronic or heavy use is what leads to the changes in the brain chemistry Going back to that disease model that can lead to compulsive behavior. The cognitive behavioral model posits that irrational thoughts and cognitive distortions lead to negative emotions and reactions. Chicken egg. Did the person have irrational thoughts and cognitive distortions that caused them distress, that led them to use, or did they start using and start experiencing negative consequences and subsequently develop irrational thoughts? Don't know. Doesn't matter if they've got them, we need to address them. Over time, people learn or acquire. Acquire certain thinking patterns. So if they start believing that all things are this way or this never works out for me, then they're going to start feeling more hopeless and helpless. They're going to start internalizing that. If they expect that this never works for me. And then when they start trying to do it again, whatever it is, they're going to look for signs of failure. They're going to create what we call a self fulfilling prophecy. Then they'll fail, they'll feel even more hopeless and in more distress, which may lead to them seeking relief behaviors. I mentioned the self medication hypothesis earlier when we were talking about the disease model. So we're not going to do a whole big deep dive into it, but it's important to recognize that people who are in distress seek out relief. You don't want to sit there in pain. You it, it's difficult. And people who are in enough distress where it's intolerable, whether it's because of how long it's going on or how intense it is, they're going to seek relief because they want to survive. And that I keep going back to because it's important to recognize and not pathologize. People who have anxiety or depressive disorders can feel completely overwhelmed by those feelings and physiological symptoms and other symptoms that go along with it. People with ADD or ADHD may have difficulty concentrating, may have difficulty functioning. And a lot of people with ADD and, and, or ADHD experience bullying and problems in interpersonal relationships which can cause distress. They find something that helps them either integrate more effectively and they start abusing that or they may self medicate their distress from the, from the trauma of being bullied or not fitting in which with other substances. Bipolar disorder. Now most people who are in the midst of a manic episode, they're impulsive and they seek out substances and behaviors that are going to often produce a lot of a big rush. So people who are in a manic episode aren't trying to escape from it, they're trying to intensify it. When they're in the midst of a depressive episode, they're trying to escape from it. And it's important to recognize again the, the function of the behavior so we can help them identify alternate ways to meet those needs. People with schizophrenia very often will self medicate with addictive behaviors. Sometimes it's for anxiety, sometimes it's for depression, sometimes it's to help silence the voice. And there are other treatments that are available. But like with bipolar disorder, the treatments for both of these, the medications for both of these can feel very sedating. And so medication compliance is often quite low. And it's important to really advocate for patients who are starting new medications. And if they're not going to be treatment compliant, then they need to talk with their doctor about what could we do instead? And then people who've experienced trauma may seek out relief from the memories, from the pain, from the flashbacks, from whatever it is. It's important to recognize that self medication is a real thing. And the biopsychosocial model, this kind of smooshes everything together. And I use the mnemonic pieces to represent the biopsychosocial model in this slide. We're just going to talk about peace. We're going to leave spiritual for a different video. In addiction, we know that people who have addictions experience neurochemical changes. Now there may or may not be a genetic component with everybody. But we know that when they are in active addiction they have altered their neuroceruitry to in a way that is going to maintain that addiction until they basically rewire it interpersonally. There is a social learning and interpersonal aspect in addiction. People have learned their behaviors in many cases from those around them. They have developed those coping tools. And in addiction, a lot of times healthy coping people, healthy supports may have distanced themselves by the time the person comes to treatment and they're learning and all of their thoughts and beliefs and thinking styles are being reinforced by other people with addictions and negative thinking patterns. So we start to see people in addiction, with addictions experiencing increasing distress and decreasing amounts of healthy social support. Emotional There is a self medication aspect. Whether the emotional dysphoria existed before the addiction or not. The person in recovery, in early recovery is often struggling with a lot of very unpleasant emotions that they're having to deal with. And prior to recovery they're often self medicating that. They're like, I don't know how. This is too big for me to deal with. I don't know how to deal with it. So I'm just going to make it go away at least for a little while. Cognitively, there are irrational thoughts and pessimistic schema or expectations and beliefs about the world. And we talked about those on the cognitive behavioral slide. And e environmentally, whether it's from billboards or the media that you're watching or just stuff that's around in your community, in your culture, in your house, the addictive behaviors are prevalent. And there's an element of learning that can happen even if you're not social learning, even if you haven't seen somebody drink and then experience relaxation. A child who finds alcohol or finds porn and uses it and and says oh that's really interesting feeling may be more likely to use it again. So we need to consider all of the pieces of the puzzle that go into Each individual's development of their addiction. I do want to touch briefly on trauma and addiction because as I said, most people with addictions, even if they didn't have trauma prior to the addiction, they experience trauma during their addiction. And this may not be victimization. This may be trauma from their social supports, their healthy social supports, distancing themselves, their loss of friends, their loss of jobs. There, there are lot, a lot of losses in addiction. But let's take a look at it Physically. People who experience trauma may have symptoms of hypervigilance, so they never feel safe. They're constantly scanning for threats. Sleep impairment, well, if you don't feel safe, you ain't going to sleep well. And circadian rhythm disruption. If you're not sleeping well, your circadian rhythms are going to get out of whack and your neurotransmitters are going to get out of balance as a result of all of that. It's just, just the way it is. Interpersonally. People who've experienced trauma often have difficulty trusting others and may have insecure attachments with the people in their life. It's like, okay, maybe I want you here, maybe I don't. I'm, I'm not sure if you're good or bad or safe or unsafe. Emotionally. People who've experienced trauma often develop a certain amount of emotional disregulation. If that trauma goes on for long enough, if it's not treated, then it can. The person can start developing PTSD or cptsd and then we start to see that emotional disregulation. When people have experienced trauma, they have guilt, grief, depression, anxiety, a lot of different unpleasant or dysphoric moods that they're experiencing. When people have experienced trauma, it alters the way they think about things and they may start thinking in very concrete, all or nothing terms in order to try to figure out how to stay safe again. Trauma, the core of trauma, is causing the person to feel unsafe and powerless. Negativity and pessimism can also develop as a result of trauma. Brain fog. Well, brain fog is kind of a secondary effect most of the time, but it results when the person doesn't feel safe, when they're not getting enough sleep, when their stress response system is constantly on. When they're in fight, flight, fight or flight, most of the time they're not thinking clearly, they're not using their wise mind skills because they can't. Their brain is saying, protect yourself. Don't worry about thinking about it, just protect yourself. So they're in a perpetual state of brain Fog that leads to difficulty with what we're going to learn about in a few weeks Called wise mind skills. Environmentally, the person feels unsafe and triggered. Wherever they look, they see reminders they don't feel safe in their environment. They see things that. Or smell things or hear things that remind them of their trauma. And they start feeling very unsafe and powerless. Okay, so that none of that probably is a surprise to you. But let's look at this in terms of addiction. People who are in active addiction Are often hyper vigilant. They are looking for signs that you are going to take their addiction from them. They are looking for signs that you might know about their addiction. Because on some level, they probably know it's not healthy. They may be hyper vigilant to criticism. They may be very sensitive to that. But that hyper vigilance is a state of the nervous system. A lot of people with addictions also have sleep impairment. Often as a result of the substances in their body or the behaviors they're engaging in. But sometimes it just is a result of their staying up all night long, Playing video games or using or gambling or whatever it is they're doing, which causes problems in their circadian rhythm and neurotransmitter regulation. Because of addiction, a lot of people's social circle changes. And the people that they hoped they could depend on or hoped would enable them. Enable them distance themselves. So they might start feeling insecurely attached. They might not know who they can trust. And there's a lot of ineffective thinking that goes into all of that that can be addressed in treatment. But we do see a lack of trust in others in addiction treatment. Emotional dysregulation and dysphoria. When the person is constantly stressed, it alters that stress response system. So especially when someone is not under the influence of their addiction. Or whether it's their addiction of choice or another addictive behavior, when they don't have their altered levels of neurotransmitters going, Then they're typically going to feel anxious, depressed, angry, irritable. Cognitive distortions, very common in addiction. Negativity and pessimism, especially as it relates to others, very prominent, but also as it relates to self. Because a lot of people with addictions, as they start to recognize it's a problem, they try to quit. They're unable to quit. They start to feel helpless and hopeless. Brain fog is a byproduct of addiction. When dopamine is out of balance, People are going to have difficulty concentrating. Dopamine is one of our concentration neurochemicals. And when people engage in addiction, dopamine surges and then really recedes. So you've got either kind of all or nothing. If you want to think about it that way. It's a little extreme, but so when people are not using, then they don't have enough dopamine to really help them effectively with their cognitive functioning. And people with addictions, just like people who've experienced trauma, often see, hear, smell triggers all around them. Now, whether it's triggers for depression, anxiety, trauma, flashbacks that make them want to self medicate, or if it's triggers for use like seeing alcohol or seeing advertisements, the we need to talk to the person, but they feel unsafe and triggered in their environment, which can contribute to them feeling powerless. It's important that we look at how addiction can actually cause trauma and how trauma can lead to addiction because it is prevalent. It's important that we don't minimize the impact of traumatic events, Even if it's not something that quote, rises to the level of, of what you might give someone for post traumatic stress disorder trauma, however the person experiences it. Trauma is something that overwhelms a person's ability to cope and causes them to feel unsafe and powerless. So we need to examine those because in recovery, people need to feel safe and empowered. So just recap your models of addiction. Your moral model tried to blame people for their use and said all you need to do is make a better choice. We know that it's not that simple. And we know that it's not the result of a quote, character defect. We know that it's a result of something much, much, much larger than that. And people are really trying to survive. The medical, physical or disease model discusses the genetic and physiological underpinnings. And we know that people can have genetic predispositions and not develop addiction. And people can develop addictions even without genetic predispositions. We know this exists. We know that once people start engaging in addiction, they do start to have some physiological changes that maintain the addiction. Social learning and interpersonal goes back to number one, whether a person ever had safe social environments and what they learn from their environment, self medication. Well, when people are in distress, whether it's physical pain, emotional pain, or feeling completely powerless, they may self medicate. They may try to get a respite from that for a period of time because it just feels too overwhelming and they don't have any other tools that are effective enough at helping them tolerate it. Sociocultural and environmental. We really want to look at this in outpatient as well as you know, ongoing recovery, what things in the environment might trigger somebody to think about using to trigger that, those obsessive thoughts and or what might trigger distress in them. Anxiety, trauma, flashbacks, whatever that then subsequently trigger the desire to use an escape. And then the last one is what I call the trauma informed biopsychosocial. Where we really look at all of these things together and say, yeah, all of this explains addiction. No one theory is totally effective at explaining addiction for any one person. But there is a combination of things that has to, that have to happen. Which also means there's a combination of treatments that also have to happen for effective recovery. And that's why it's important I know you're going. Well, why do we need to learn all these models anyway? Because it's important to understand what causes something so then you can fix it. If you hear your brakes grinding, you know, that's great to notice it, but then you have to understand what's causing that in order to fix it. There are a variety of explanations of where addiction comes from. Most people with addictions also have mental health issues and co occurring symptoms. Say it with me, must be treated concurrently. Otherwise you're going to have a person who is depressed and may be clean, but they're likely to use again. That's probably a relapse trigger if they can't get that depression under control. Or you may have a person who may not have those mood symptoms, but they're still engaging in addictions and disrupting every other aspect of their life, their physiology, their interpersonal relationships, their self esteem, their emotions, cognitions, et cetera, cetera. So we need to consider everything and not just be lazy and assume that there's one easy answer that fits every single person that we work with.