Willpower and Substances: A follow-on from Are You Addicted?

Previously I posted on addiction. This consisted of my working through the DSM-5 and how Substance-Use Disorder (SUD) might relate to the everyday you and I. Or, how we have the potential to abuse substances given our circumstances, and the propensity towards diagnosis. That's not to say that psychiatrists or psychologists are trigger-happy maniacs that diagnose every chance they get (some might be, who knows?), but rather that a diagnosis can be an end result where a number of criteria are satisfied.

This post is about a topic that I find remarkable. It's about the basic human's ability to exert willpower in any given situation. It's inspired by the ABC's All in the Mind program, and an interview with research psychologist Roy Baumeister on willpower.

Baumeister discusses willpower and substance use in summary when prompted by the show host, and this is where things get interesting. Not only in understanding the effect a lack of willpower has on people that are substance users, but also on understanding what the exercise willpower actually means for the everyday person (Baumeister & Malcolm, 2014, 29 June).

For example, did you know that in the morning after a good breakfast our biological makeup is at its optimum in engaging in tasks and high-order decision making related to one's willpower? The carbohydrate, glucose, which is essential for the practice of willpower and self-control, according to Baumeister, is at its best after the consumption of food. As it's linked to one's ability to exert control and engage in activities centred around the exercise of willpower, a practical application would be that of eating prior to engaging in a significant decision-making process. If you're company's future is the topic in point, maybe don't make any rash decisions on a friday afternoon when you hadn't had a good night's rest and haven't eaten properly.

Relating this to substance users, we can look again at glucose. Female users that are in their menstrual cycle and suffering from premenstrual syndrome (PMS)  have highly elevated amounts of glucose in their systems. Since this glucose is being used at higher levels during PMS, it's harder for a female user to exert self-control over using their preferred substance given that not as much glucose is available as prior to PMS. Throw is a user that's dieting and going through their menstrual cycle, now the therapist's got a lot more to deal with in terms of relapse prevention!

What's important to remember for substance users isn't that the cravings are the culprits that instigate relapse, but rather the willpower of the person. Cravings fluctuate, and are stronger at some times as opposed to others. Willpower, given it's controlled through the amount of glucose in the person as they're deciding what they want to exert control over, needs to be considered at greater length. 

For the everyday person that's not substance using and wants to diet, then it should be noted that willpower is extremely important in effective dieting. Some studies show that when an organism diets the first time then there's observable weight loss. When they try it a second time, weight loss is more difficult. The cycle continues until there's basically no difference from where one's dieting and eating junk. When we understand our metabolism, willpower, glutamate levels, and areas in our life where we need to exert control, we begin to get a bigger picture as to where we can succeed and where it's more difficult to succeed.

Returning to substance use, I'll speak a little about the implications understanding one's willpower might have on relapse prevention.

1. Understand the sex differences (if any) in glucose distribution in substance users, especially during PMS

2. Understand the current commitments of the clients, and where they want to make change

3. Understand sleeping patterns and current dietary commitments

4. Gage how many times client tried to quit

5. Look at the the above holistically, and work towards a relapse prevention plan (a plan that will be the subject of a later post) that takes into account willpower as a primary factor.

To sum up, willpower is not only important in the exertion of control of everyday activities and changes, but of extreme importance when taking into consideration substance users. Looking at and understanding the inner-workings of willpower for the individual is intrinsic in getting anything important done at all. Rest, diet, load of commitments, and all things in between must be taken into consideration through the lens of willpower-orientation (including an understanding of glucose levels on tasks and biology). This allows us as humans to make an in-depth and informed decision, and better prepares us in succeeding!

References

Baumeister, R., & Malcolm, L. (2014, June 29). Willpower. All in the Mind Podcast. Transcript retrieved from http://www.abc.net.au/radionational/programs/allinthemind/willpower/5552818#transcript.

Images retrieved from:

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Are You Addicted?

I'm sure if you're reading this and you actually are an addict your answer to the above question is almost certainly an adamant NO! That's sort of the irony of addiction, in the beginning we're in the pre-contemplation stage; that is, we're in denial that we actually have an addiction.

Doesn't matter what the addiction is, the basic premise is that you're letting it get the better of your life. You could be addicted to Facebook, sex, ice cream, cannabis, heroin, riding ponies..., amphetamines, or alcohol. The addictions we struggle with on a daily basis have so overtaken us that we've barely developed the ability to keep the urges bottled away. I guess that's the point of it isn't it? They're not called addictions for nothing.

Even though I joke a little about the nature of some addictions (who do you know that's addicted in the clinical sense to riding ponies?) for some it's no joking matter. Families have been torn apart because of some addictions. Some have been murdered. Others have lost their 'sanity' (but then again, who's 'sane' these days?). The consequences spread far beyond the simple taking of a substance. There're entire macro-level repercussions to some addictions (think of the numerous legislations put forth to tackle the 'problem' of addiction).

Today I'm going to focus on illicit (e.g. amphetamines, heroin, etc.) and licit (alcohol, caffeine, nicotine, etc.) substances for the most part. That's because I'm a little familiar with the latter given some experience working in the drug and alcohol field, and delivering psychoeducational substance use and abuse sessions to clients that would satisfy the diagnostic criterion for Substance-Use Disorder.

Where to start? It seems like quite a task, but I don't think we can begin without defining our terms.  The DSM-5 discusses substance use disorder through the use of required criterion. However, before we get to the discussion of DSM-5 diagnosis there are a few other terms that I think we should look into. These terms are as follows:

1. Substance use: where a person uses a substance sporadically (e.g. every now and then at a party), but it's not causing any significant problems in their life and functioning

2. Substance misuse: where a pattern is beginning to be observed in a person's substance use. This pattern has proved to cause some observable harm to the person using, and the people around them (e.g. the person might become more violent or aggressive when on the substance, thereby leading to behaviours and verbalisations that often get them into trouble)

3. Substance abuse: this is similar to substance misuse, however it's got a lot more negative repercussions and effects. When a person abuses a substance he or she has established a pattern of use that's proved to cause significant psychological, physiological, social, occupational, and interpersonal distress.

4. Substance dependence: similar to substance abuse, however the user has built up a tolerance to the substance of choice so that more and more is needed to achieve the same effects as before. Also, withdrawal effects or symptoms are evident when the person attempts to stop using the substance. These effects are many and varied, and are specific to the substance of choice. In the treatment of substance-use disorder, withdrawal effects are taken into consideration when rearing a user off of the chosen substance as some of these symptoms can get so intense so as to cause death.

Now you might see the above described in various ways, but when I'm speaking with my clients I find the above formulations helpful to use given their straightforward applications.

Now to the DSM-5 and substance-use disorder (after all, that's what this series is about anyway!).

In order to be diagnosed with substance-use disorder, a person must present with the following symptoms, or satisfy the following criteria:

1. Person's use has persisted and usage increased for longer than intended

2. Person must've had multiple unsuccessful attempts to cut down or quit the substance

3. Person spend significant time obtaining the substance, using, and recovering from its effects

4. Intense cravings must be present when without the substance for a period of time (this craving activates specific areas of the brain)

5. Failure to fulfil major obligations and activities such as work, school, or home

6. Continues using substance despite its negative effects and the appearance of problems caused by its use

7. Social, occupational, or recreational activities reduced or given up because of substance use

8. Continued use even when it's hazardous

9. Continued use even though person understands it's detrimental to mental and physical health. Problems are continually being exacerbated by use

10. Higher dosages needed to get the same effect as before

11. Withdrawal effects evident

A person must satisfy at least two of the above criteria in order to be considered for diagnosis of substance-use disorder. Substances are also specified, and each substance carries with it differing specification for a diagnosis.

If you're using a substance in an excessive manner, you're not only putting your own mental and physical health in jeopardy, but also the mental and physical health of those that are around you. If you are struggling with using any substances at this moment, please consult your GP in order to qualify for a mental health plan and/or advice on how to minimise your usage, and eventually become abstinent.

Images retrieved from:

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Are You Depressed?

Ever felt sad, down, in the dumps? Have things gotten so dark that you've felt like giving up? It's not an uncommon sight with almost 460,000 Australians aged 16 to 60 suffering from an affective disorder (disorders centred around mood, including Major Depressive Disorder (MDD)) of some kind at one point in their lives.

It's said that in Australia roughly one in four people have suffered from anxiety-related symptoms at some point within the last year, and about one in 20 have suffered from depression-related symptoms in the same time frame. Again, it's not an uncommon sight.

Let's get things straight, when we're talking about depression what do we even mean? Well, the term depression is actually an Anglo-French word (depressio) that came about in the 14th century. It's noted as meaning to be "pressed down".

What have some people identified as feeling when they're depressed? You got it, 'down'. We hear that word tossed around without understanding its inception, but that's beyond the point of this post. What I'm going to focus on here is what depression actually means in the clinical sense, and how it might apply to you!

The DSM-5 notes that affective disorders have a number of common features: feelings of sadness, emptiness, irritability, all accompanied by physiological and cognitive (i.e. pertaining to our thought processes) changes that limit the person's capability to function (APA, 2013). What differs between these disorders are their temporal duration, timing, and presumed cause.

But what are these disorders? We've already mentioned MDD, but surely there are others. After all, the DSM doesn't do things half the velocity... 

You'll see a list of just a few of them below:

1. Disruptive Mood Dysregulation Disorder (a new addition to the DSM-5 that has come under scrutiny given the potential to diagnose temper tantrums as mental disorders)

2. Dysthymia (a prolonged period of depressive symptoms)

3. Premenstrual Dysphoric Disorder (basically the mood swings that include depression-like symptoms when a female's on her period)

You can see why everyone's not too convinced with the DSM's way of pathologising behaviour. But that's fodder for another post (I've summarily discussed some changes in the new DSM and the scrutiny they've endured in a previous post). 

In all seriousness I'm now going to run through the new DSM requirements for the diagnosis of MDD, an increasingly lethal disorder.

In order to be diagnosed with MDD, the person needs to satisfy at least five of the following criteria over a two-week period:

1. Depressed mood observable to others and/or self

2. Decreased interest in activities you once found enjoyable

3. Weight loss or weight gain

4. Insomnia or hypersomnia

5. Motor agitation (observable agitation in terms of movement in the body)

6. Fatigue

7. Worthlessness and guilt

8. Lessened cognitive ability

9. Recurring thoughts about death and suicide (a clinician's guide to suicide risk assessment can be found here)

In terms of making a diagnosis, the clinician will attempt to ascertain a plethora of other details (e.g. whether there are psychotic or melancholic features), but for this post's purposes, the latter criteria is sufficient.

Depressive disorders have been associated with a largely increased suicide risk (although there are many factors involved to determine that risk), therefore if a person identifies with the latter criteria it'll be in their best effort to seek professional help, wherever they reside.

It's my advice that if you've read this post and have found these symptoms in yourself or somebody that you care about, seeking local medical and psychological/psychiatric help would be something to consider seriously. 

I'm sure you've heard somebody respond 'I'm fine!' with agitation in their voice when asking them how they are. What I like to remind people is that when some of us say that we really mean 'I'm frustrated, insecure, neurotic, and emotional!'. A little acronym that just about sums up this post.

References

American Psychiatric Association (APA). (2013). Diagnostic and Statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Images retrieved from:

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Suicide Risk Assessment for Clinicians

I remember undertaking my first suicide risk assessment. It included a client that came to the organisation I worked with at that moment and I was scheduled to perform the intake session. 

Details were collected, substance use history documented, and finally we get to a triage type mini suicide risk assessment section (an area that asks the clinician to briefly detail past and current suicidality and thus determine the risk).

The client had lost his job, drank excessively, and described that he had some suicidal intent. To his absolute credit, he'd come for the intake from across town, a journey that also included a 45 minute walk. He was determined to get help.

I was a little shaken (though not visibly I'm told) when he'd described that he'd had the means (a shotgun) and has called off prior attempts to take his life. This man obviously was ambivalent towards dying.

I determined that he was a medium to high risk suicide client, and went to a colleague to consult. After consultation and my colleagues assistance in negotiating with the client, we set him up for counselling sessions, and determined his suicidality as medium risk.

So that's the extent of my initial contact with a suicidal client. After that, I'd familiarised myself with the literature, and have consulted with others about how to best approach these clients. And so I came across the SIMPLE STEPS Suicide Risk Assessment formulated by Dr Jason M. McGlothlin. In his book Developing Clinical Skills in Suicide Assessment, Prevention, and Treatment, he describes this assessment model for suicidal clients. 

In his interview with Rebecca Daniel-Burke of the American Counseling Association (ACA) he looked into these steps along with treatment options at greater length. It's those steps (similar but more expansive than the American Association of Suicidology's IS PATH WARM acronym to suicide risk assessment) that I'm going to list in this post.

The acronym is as follows:

S: Suicidal
I: Ideation

M: Method

P: Perturbation

L: Loss

E: Earlier Attempts

S: Substances

T: Troubleshooting

E: Emotional Diagnosis

P: Parents and Family

S: Stress and Life Events

Basically we want to ask, (1) Is the client suicidal? If they're younger clients you might want to look into what they actually know about the meaning of suicide, and their ideas about death. If the client tiptoes around this question you might want to probe them a little deeper, but what we need as clinicians is a thorough understanding as to whether the client shows any signs that they are or have been at risk of suicide.

Next we look at ideation. (2) What are the client's thought processes like around suicide? How are their thoughts structured? Measuring on an ordinal scale rather than numeral scale might be helpful. For example, does the client want to live and not die? Does the client not care whether they die, but they don't want to take their life? Does the client want to take their life? And, does the client want to take their life and they know how to?  We also look at the clients responses in a temporal way. For example, we might ask them: On a scale of 1 to 10 how likely are you to commit suicide in the next 72 hours? That gives us a sense of how serious the situation is for the client, and how far they're willing to take it.

Method looks at the means of completing suicide. (4) Does the client have access to the means in which they want to take their own life? Remember, we're not assessing for the lethality of of the means, but rather we're assessing the client. If the client thinks that their chosen method of suicide might be lethal (say, taking 7 valium) it's not up to us to determine whether it actually is lethal, but rather the clients intent and access to the means. Does the client have access to the valium? A gun? Bullets? Etc.

Perturbation is basically assessing the pain that the client's in. (5) What makes you want to take you life? This question of pain accompanies the question of how likely the client is to complete suicide using a scaling question. If we ask how likely are they out of 10 to complete suicide and they rate themselves a 3 or 4, then we could look at what it might take for them to reach a 5 or 6. Little steps in determining the client's level of pain might be the key to knowing how to proceed in being a helper.

Loss is next. (5) What's your experience around loss, both perceived and actual? What this question might serve with the assessment - though it could definitely (as with the others) be formulated in a different way - is to find what precipitating factors might serve the client in their thoughts of suicide. The clinician must keep in mind that perceived loss might actually be more debilitating than actual loss. Perceived loss refers to the anxiety around losing something. Whether it's a partner, job, health, or life, it's a loss that's not certain. It's an anxiety about what might be to come and thus there's no sense of closure. Contrast this to actual loss we see that there's the possibility of achieving a sense of closure and working on from there. Once we've understood the client's sense of loss we can begin to understand how this relates to their thoughts an potential actions towards suicide.

Looking for earlier attempts at suicide is next. (6) Have you attempted suicide in the past? This question can prompt the client to discuss the circumstances around any prior attempts. The more attempts the more potential to complete suicide. As the clinician gages the severity of prior attempts, how long ago, and the number of prior attempts, he or she could open a dialogue around the circumstances prior to attempting suicide and seeing how this might relate to treatment.

Substance use is next. (7) Are you currently on any substances or medications at the moment? That question attempts to understand whether the client's use of certain medications or substances (whether licit or illicit) might be contributing to his or her considerations towards suicide. Seeing whether the client is medicine compliant (i.e. actually taking their medications) might serve to find whether any prescriptions that might be helping them handle a diagnosed mental illness are actually serving their purpose. If not, then the clinician could see whether discussion around this might be useful with the client. Understanding the content and frequency of illicit or licit substance use with the client could also serve to gage what probable contribution this might have to the client's ideation. For example, if the client is using a depressant (e.g. alcohol) they could be more likely to commit suicide when they're in their low mood. Using illicit substances that alter brain chemistry and functioning could also increase the client's attempts towards completing suicide.

(8) How are your problem-solving skills? Understanding what a client's troubleshooting skills are like serves to determine the trajectory of suicidal behaviour. For example, if the client accidentally trips over and straight away thinks of suicide they could be more prone to actually completing suicide. When problem-solving skills aren't there then the brains capacity to think of other solutions to what could ultimately end in taking one's own life is compromised. Furthermore, knowing what immediately preceded the client's thoughts of suicide could assist to determine how adequate their problem-solving skills actually are. This could also be an area that the clinician and client could collaborate on in terms of a treatment context; to work on one's troubleshooting skills.

Emotions. These get us into a whole lot of trouble, and if handled suboptimally one could be headed towards a dark place. (9) What emotions are you experiencing when you feel suicidal? Working towards an emotional diagnosis assists the clinician in understanding what contributors could be at work in the intricacy of suicide. What's usually spoken of in this context is when the client's are experiencing a sense of worthlessness, helplessness, hopelessness, loneliness, and/or depression. If the client identifies with one or more of those factors, the clinician will be better equipped to know how to proceed.

Asking question about family history and suicidality or mental illness is also beneficial in the process of suicide risk assessment. (10) Have your parents, or anybody else in your family suffered with anything similar to what you're suffering through? Studies have found that parental depression can contribute to a number of negative outcomes including less than ideal parenting practices and children suffering from similar symptoms, symptoms that could lead to suicidal ideation. Genetic factors also contribute towards a number of diagnoses of mental illness. Therefore as a clinician progresses through an assessment, questions oriented towards understanding family history are essential.

Finally, we want to get a sense of the way stress and life events have contributed to the client's behaviours. (11) How have you been able to handle stress in the past? In a previous post I've detailed important ways that'll hopefully help a person overcome their negative ruminations. Clients that are so focused on the anxieties and stresses of life given certain life events haven't been able to manage their stress levels to the best of their ability. That way, when a clinician's enquiring about the client's stress levels he or she will get a sense of how the client normally reacts to life events. Being able to capture and slow these thoughts about various life events that are perceived negative might wok well in a therapeutic context.

So there we have it, a very valuable resource to aid with suicide risk assessment for the clinician!

Note: The SIMPLE STEPS model presented in this post is a summarised version of what's presented in the ACA interview with Dr. McGlothlin noted earlier

Images retrieved from:

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Are You a Narcissist?

In a prior post I spoke about the narcissism that's seemingly ubiquitous in social media. It's all about me, me, ME! Well, isn't it? Don't we have our profile for a reason - to post about ourselves? Maybe. But that's not what this post is about. It's not a rant against the self-centredness of social media, but an attempt to question you...

Are YOU a narcissist?

James Doty's a professor of neurosurgery, and has founded the Center for Compassion and Altruism Research and Education at Stanford University. Given he's founded such a centre you mightn't call him a narcissist would you? Well, in his lifetime he's racked up tens of millions of dollars and has given it away. But before then he was living for the penthouses, fast cars, and the rich life. It was about his 'wants' being satisfied rather than the selfless needs of others. Does that necessarily make him a narcissist? Or a reformed-narcissist? It depends on how you define the term. 

The term narcissist comes from the story of Narcissus, a super handsome hunter found in Greek Mythology. It's said that he was walking by a pool of water and saw his reflection. "Damn I'm good lookin'" he thought to himself. With that thought, he fell head-over-heels in love with himself. 

If we define being a narcissist that way - a person that's truly in love with themselves - then we'd probably won't find as many people to call narcissists as we once thought (or maybe you might). 

Taking it a step further, let's look at a psychiatric understanding of the term narcissist. Now, in psychiatry and psychology we've put together a term to describe a disorder that's narcissistic in nature. It's called narcissistic personality disorder (NPD). With it comes a conglomeration of symptoms and signs that are potentially damaging to the personality of the beholder. It' the latter that I'm going to focus on today.

So what's NPD? Let's find out.

The DSM-5 (2013) describes NPD as "a pattern of grandiosity, need for admiration, and lack of empathy." What's that mean? It's basically saying that when you think you're all that, when you want others to notice you, and when you can't put yourself in the shoes of others, you could be suffering from NPD. 

That's probably all teenagers right? Not too convincing...

Well, let's break it down a little bit more. In order to be diagnosed with NPD a person's got to satisfy five criteria.

1. Inflated self-importance

2. Fantasies of limitless success

3. Sees self as only associated with "special" people of high regard

4. Craves admiration

5. Sense of entitlement

6. Exploits people

7. Lacks empathy

8. Envious

9. Arrogant

If you've got any of those five, you might be in the running of being labelled a narcissist. But wait! There's more! 

To actually be considered a prime candidate for the diagnosis of NPD you must qualify for significant disturbances in your life (for the most part). So, if you're 'symptoms' are causing duress for yourself or others. Having a significant impact on your family life, career prospects, relationships with others, and so on, you might very well be 'suffering' from NPD.

So how do you treat it?

Well you could admit yourself to hospital and get a team of specialists to take a look at you (only in the extreme cases though), or you could - and this is my preferred method - seek individual psychotherapy. 

The latter could address your sense of self. Why you need to be seen in such an inflated manner. Get to the bottom of thoughts, emotions (if there are any), and behaviours. 

But then again, since you probably know the best, you might end up becoming the therapist, right?

References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Images retrieved from:

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