Diagnosis: Towards Validity and Consistency

Thanks again for your comment Scott. Rather than rehash what I wrote last time – your main question Scott was whether we have to make a leap to attribute traits like “distress based impulsivity and short term decision making” to “emotional processing and regulation difficulties which are pertinent to this disorder”. No, I wouldn’t say this was a leap at all. Let me provide another example to illustrate what I mean. Those with emotional processing difficulties as seen in individuals with alexithymia also have a similar decision making profile as alcoholics and even in those premorbidly. This similar decision making profile appears to recruit a more motor-expressive area of the brain, part of the basal ganglia. Thus if one cannot process (e.g. label, define) or regulate an emotion it can appear somatically as an unpleasant feeling state that prompts more automatic (compulsive) decision making to relieve this “distress” signal. Why is it a distress signal? It is a distress signal because has not been processed or regulated. It creates an “affective imperative” which prioritises dealing with this distress state (via negative urgency) above all other other considerations, such as prefrontal and goal-directed, or action-outcome thinking based decision making. It is like an emotional decision making rather than reasoned decision making profile which has been demonstrated in alcoholics and addicts in many Delay Discounting tasks were short term (now!) gain is invariably chosen over longer term greater gain. Again the interesting aspect of this is that those with a premorbid vulnerabilty may have decision making deficits or bias which can lead to maladaptive choices. This is important to prevention also as well as treatment. This bias towards maladaptive choices when mixed with heightened reward sensitivity, which has been demonstrated to be linked with emotional dysregulation, is then a potent cocktail in the initiation and continuation of alcohol abuse. Alcohol abuse worsens not only decision making ability by also heightens the effects of emotional distress which is known to greatly worsen during the addiction cycle. I hope this clarifies a potential connection between vulnerabllity and aetiology. In simple terms the, situation often starts off bad and then gets a whole lot worse! I have blogged about this in various blogs and in covering different areas of this theory in my two blogs –
http://alcoholicsguide.wordpress.com/ and http://insidethealcoholicbrain.com/ It would be great to hear your comments on there too.

Comment by alcoholicsguide — June 28, 2014 @ 10:23 am

Thanks again Paul for the explanation. Here’s what puzzles me: the differences noted by Gratz’ profile are interesting, but we have to make a leap to attribute traits like “distress based impulsivity and short term decision making” to “emotional processing and regulation difficulties which are pertinent to this disorder”. And those are premorbid to substance use? Could these be a risk factor rather than part of the etiology of a disorder?

Thanks for your patience.

thanks Scott for your comment. Emotional dysregulation is evident in up to 75% of psychiatric disorders so it is becoming a common theme to look at aspects of this, which is encouraging. There are a number of ways to define emotional dysregulation. I tend to favour one by Gratz and used by her in developing the Difficulties in Emotional Regulation Scale (DERS) which is a repeatedly validated scale and which has shown different emotional dysregulation scores for different disorders such as PTSD and Borderline Personality Disorder, GAD, MD and SUDs etc which is fascinating. It also appears to illustrate gains in emotional regulation and processing as the result of treatment also which is informative too. It also differentiates, via subscales, between different disorders. Addictive disorders tend to show a emotional dysregulation profile which has distress based impulsivity and short term decision making at it’s core. I believe these are the result of emotional processing and regulation difficulties which are pertinent to this disorder. This suggests addicted individuals have difficulties with regulating acute emotional distress and act impulsively in relation to it, often via relapse to previous drug or alcohol use. Treatment thus needs to specifically cater for this. It may be that the emotional coping strategies in treatment may have similar utility among with other disorders. What I am forwarding is to suggest these difficulties are not only particular to addicts and alcoholics but appear to be there pre-morbidly and are not necessarily the consequence of the increasing anxiety and depression often seen in the addiction cycle as the result of years of neuro toxins and increasingly impaired stress systems. There is a pre-morbid vulnerability which is based on emotional processing and regulation difficulties. In fact children of alcoholics have been shown to have the same recruiting of motoric parts of the brain to make decisions (perhaps to avoid a distress signal) as seen years later in chronic alcoholics. The low resting heart rate variability ( a putative index of emotional dysregulation) is also evident in children of alcoholics.
This emotional dysregulation also appears to be linked to actual brain impairments in areas of the brain governing emotional regulation, with morphological differences demonstrated, in volume, for example. . These difficulties, may often be genetically transmitted and are obviously worsened by environmental conditions such as abusive childhoods and insecure attachments to caregivers etc. I am thus trying to profile a clear distinct aetiology. This is not to say that there is still not a co-occurrence of other disorders e.g. GAD or PTSD in some cases. However, it is important to delineate disorders accurately as they appear to have different behavioural manifestations such as addiction having commonly a distress based relapsing to prior use of drug and alcohol. For example, a recent study showed that so-called co-morbidities in chronic alcoholics were not correlated, positive or negatively, to craving which activated the dorsal striatum in a brain imaging study. This is a stimulus response part of the brain, an implicit memory part of the brain. This suggests to me that the automatic craving state is independent of the influence co-morbidities in this case. It may be the combination of emotional dysregulation, pre-morbidly, which has subsequently interacted with chronic consumption to alter the brain so that it has an automatic reward and emotional response to cues, internal and external, not seen in other “co-morbidities”. Equally this chronic consumption may have been simply impacting on processes which are present pre-morbidly (biomarkers of vulnerability) and worsened with responding made more severely acute and automatic by the effect of excessive neurotoxins in the chronic consumption of drugs or alcohol in the addiction cycle. Particularly as emotional distress in children links with later pathological gambling disorder.

Comment by alcoholicsguide — June 27, 2014 @ 1:44 pm

Hi Paul — nice piece. One thing occurs to me — ’emotional dysregulation’ is a characteristic of a whole range of disorders, not just addiction. I mean, DBT is built around identifying and addressing the regulation of emotional states. Anyway, that seems like a challenge for differential diagnosis. Second, it’s not all that easy to closely define something like emotional dysregulation, which leaves a lot of room for interpretation (as it does with those other disorders), and that’s no friend to validity.

Anyway, enjoyed it.

Thank you Joyce. Very gratifying to read your comment.

Comment by alcoholicsguide — June 23, 2014 @ 9:44 am

This is probably the most intelligent, forward-logical, rational approach to addiction as I have ever read. It supports all the neurophysiological treatises on emotion/dopamine/serotonin regulation of emotion and behavior I have seen published.

Let’s take moral failings and character defects out of addiction discussions and treatment and show people how to not drink.

Comment by Joyce Goodale — June 23, 2014 @ 8:51 am