Alcoholism is not about making poor choices in relation to drinking. People that are addicted to alcohol do not have free choice about how much they drink or how often; our free will is compromised by a reward system that urges us ever more compellingly to drink and never to avoid it. The demand that we drink comes as feelings rather than words and we get those feelings before our conscious mind is even aware that alcohol is close. As we continue to drink then the urge to avoid drink weakens as the urge to drink strengthens and drinking becomes compulsive rather than chosen. Addiction begins in the reward system and regular and heavy drinking strengthens the urge to drink while diminishing resistance. As we drink more we spend extended periods of time handicapped by alcohol and our brain tries to correct this in an effort to maintain optimum performance. Alcohol has three main effects on our brain; it slows down the processing speed, it artificially alters our mood, and it reduces our readiness for “flight-or-fight”. These are detected as anomalous behaviour and our brain attempts to correct them. But the changes it makes in order to maintain effectiveness alter how we think and feel.
The first issue is the speed at which the brain operates. While we drink our brain is slowed by alcohol and this slowing down lasts for as long as there is alcohol in our bloodstream. If we drink regularly and heavily then this accounts for significant portions of our day which lowers our average brain speed. Alcohol causes the brain to detect less glutamate than was released and to detect more GABA than was released and the brain does the opposite to try and correct this. It releases more glutamate (the accelerator pedal) and it releases less GABA (the brake pedal). This corrects the slowing down we experience while we are drinking and for as long as we still have alcohol in our bloodstream, but the brain applies this the whole time which means that our brain runs faster than normal when we are sober.
Consequence #1: When our brain adjusts its speed to compensate for regular drinking then we have a racing mind when we are sober.
The second change relates directly to mood. The reasons we enjoy alcohol are that it soothes anxiety, makes us happier and makes us more socially engaged. But the extra dopamine and serotonin we get when we drink isn’t summoned by the brain, it is artificially caused by alcohol and the brain recognises this. The brain detects that it is receiving more dopamine and serotonin than it ordered and it responds by reducing their release as well as reducing sensitivity to them (some of the detector points on neurons get turned off). While the brain makes this adjustment to correct a problem that has been detected it has a significant and unwanted impact on how we feel. Like the adjustment for speed this correction is applied ‘across the board’. The influence of both dopamine and serotonin is reduced, and it is not just reduced while we drink, it is reduced the whole time. This reduces the lift in mood we experience when we drink and it makes us feel down when we are not drinking.
Consequence #2: When our brain regulates down the effect of dopamine and serotonin then we become more anxious, less happy, less care-free and less sociable when we are sober.
The third change is to do with the “flight-or-fight” response and involves both neurotransmitters and hormones. Together these control our readiness to respond quickly to danger and when we drink regularly the levels of these are lowered for extended periods (the slowed brain activity also lowers the flight-or-fight response). But having the flight-or-fight response impaired for extended periods of time is dangerous, it threatens our survival and the brain cannot allow this, so it boosts it up. Like the other adaptations this is a wholesale change; the activity of the flight-or-fight response is increased the whole time. More cortisol, adrenaline and noradrenaline are released, and although this reduces the drowsiness, dullness and lethargy that we experience while we drink it means that the flight-or-fight response is over-active when we are sober.
Consequence #3: When we are sober our brain constantly searches for signs of danger, our heart beats faster, blood is diverted from the skin to the large muscles leaving us with a pale complexion, and feeling edgy and restless.
When we drink regularly over an extended period then our brain adjusts the way it operates to minimise the adverse effects of alcohol. This makes us more alcohol-tolerant: we can drink far more before we become mentally and physically incapacitated. In this respect the adjustments the brain makes are successful, but this comes at a large cost because when we are sober we are less happy, we are more irritable and restless, and we lose social confidence. These changes take years rather than months to develop, but they have a profound effect. We were already victims of a reward system in a runaway state, but the changes to how we feel have consequences that guarantee further decline.
Addiction is a “progressive” condition; it always gets worse, never better. But the grip of alcoholism tightens so slowly that we don’t notice anything changing. We don’t notice that the urges to drink are more powerful and more frequent. We don’t notice that we drink more and that we drink more often. But the longer we continue to drink the more severe the condition becomes. Yes, we drink more and we drink more often than we mean to, but these cease to be our main concerns. As our alcohol-tolerance develops then all of the changes that the brain and body make to try and correct the alcohol impairment increase in severity and the emotional consequences of this drive us relentlessly towards deepening anxiety and depression.
Lengthy exposure to alcohol reduces the effect of dopamine and serotonin in the part of our brain that experiences emotion. We become; less happy, lacking social confidence, and more concerned by our troubles. As we continue to drink these emotional changes become more pronounced until we feel miserable, surrounded by problems, and intimidated by social contact. The continued reduction in GABA and the increase in glutamate speed up mental processing even further which leaves our minds racing and churning over all our problems. Our flight-or-fight response continues to raise adrenaline and noradrenaline levels which cause a faster pulse rate, higher blood pressure and temperature, increased sweating, and loss of appetite. We become anxious, fidgety, and restless as our minds constantly search for the danger for which our body has been prepared. But these elevated levels are normally temporary measures to provide us with a quick boost in times of distress and aren’t evolved to be elevated over extended periods. There are side-effects to having a permanently elevated flight-or-fight response and some of these can become quite serious.
Cortisol is a key chemical in the proper regulation of sleep. It controls our transition into and out of the deep-sleep state that is vital for proper brain health, and it also wakes us from sleep. Elevated cortisol levels disturb this pattern making it difficult for us to get to sleep and it prevents us from achieving the deep-sleep state needed for proper rest and recovery. Additionally the gastrointestinal system is very sensitive to cortisol and continuously elevated levels can lead to heartburn, abdominal cramps, diarrhoea, and constipation. Also both adrenaline and cortisol cause the liver to put more glucose (sugar) into the bloodstream, and when their concentration is increased over an extended period then we have a persistently high blood sugar level. This is why heavy drinkers are more likely to suffer from diabetes.
All of these changes in our brain and body bring us down. We feel constantly ill-at-ease, and unhappy. We are socially insecure and shy of contact with other people. We are anxious, our hearts pound, our minds race, and are consumed by our own problems. Without drink we can’t sleep, but when we drink enough to induce sleep then we wake again as soon as our blood/alcohol level drops. We never achieve deep sleep, and we live in a constant state of chronic fatigue propped up by the stimulating effects of adrenaline and noradrenaline. But there is something that will quickly remove all of these problems and restore us to normal, and that is alcohol. When we drink then our dopamine and serotonin levels rise again, our brain slows down, and our flight-or-fight response stands down from high alert; cortisol, adrenaline and noradrenaline levels drop. Once we have become alcohol-tolerant then alcohol becomes the medicine that removes the symptoms that alcohol has caused, but drinking more only increases their severity.
All of this has an extremely serious consequence, and that is that we now need to drink in order to feel normal. The only way that we can now regularise the brain and body is to drink. When we are not drinking we are unhappy, agitated, lonely, restless, anxious and depressed. But all of these symptoms are relieved by drinking. The reward system recognises this and when it does so a serious decline in our mental well-being becomes inevitable.
At first our addiction was driven by the reward system. It built drinking triggers relating to our daily routines; the time of day, where we were, people we were with and so on, and these triggers were strengthened each time we acted on them. But once our mood is changed by our alcohol-tolerance then the reward system takes on a new dimension with regard to alcohol. It recognises that our anxiety is eased by drinking, that our depression is lifted by drinking, that our loneliness is relieved by drinking, that our roaring minds are calmed when we drink, and it creates drinking triggers for them all. The reward system keeps adding and strengthening emotion-based triggers and over an extended period our first and immediate response to feeling any distress at all becomes to have a drink. Tired? -> drink, lonely? -> drink, angry -> drink, hungry -> drink, stressed -> drink, anxious -> drink. All of these emotional states acquire drinking triggers and we constantly crave alcohol when we are not drinking. Being continuously triggered to drink also means that alcohol is constantly brought to the forefront of our mind. Any time we are not drinking then we are thinking about it and even our waking thoughts are of alcohol; when we will get some and where. As we wake from a drinking session our blood/alcohol level is in decline. We may still be hung-over but as soon as the blood/alcohol level drops significantly then all the problems caused by alcohol-tolerance return. As we come around we start to feel agitated by the excessive noradrenaline activity and our reward system responds with a craving. As we move on with the day we become lonely, frustrated, and anxious and all of these bring on cravings. We think about alcohol the whole time we are not drinking and this too launches cravings. Once we become alcohol-tolerant then our position is dire; we are triggered to drink by the consequences of being sober.
At the other end of the day we have to drink to be able to sleep. If we go to bed sober then our flight-or-fight response is so elevated that our minds race, our heart beats fast, we overheat, and the elevated cortisol level explicitly prevents sleep. If we want to sleep then we must drink first.
The times of day that we drink are extended, we drink to excess far more frequently, and our alcohol-tolerance adapts even further. Our minds race while we are not drinking, churning over and over all our problems. We become increasingly anxious and depressed and are intimidated by social contact. We are agitated and restless and have a persistent sense of impending doom. We rationalise that we are drinking because our lives are difficult, or stressful, or unsatisfying, but in reality most of the reason we are drinking is because our brain demands that we do. We are not drinking in response to our personal circumstances but because our brain is directing us to do so, but we don’t know this. What we know is that we are drinking a lot but we are oblivious to the extent to which our brain is automatically driving this. Over time the consequences of alcohol-tolerance become so severe that it is impossible to drink enough to overcome them and alcoholics often report that “alcohol stopped working for me”. It becomes impossible for us to drink enough to become happy. It doesn’t matter how much we drink we can no longer achieve the care-free happiness we once did. We are so insensitive to dopamine that this is no longer possible. What initially made us happy now locks us in inescapable hopelessness and the most we can achieve is a partial and temporary relief from it, but that relief only worsens our position in the longer term.
Our addiction begins with an unbalanced reward system that encourages us to drink more often than it encourages us to avoid it. We accumulate many powerful drinking triggers and very few drink-avoiding triggers. This is the driver behind our addiction but it is alcohol-tolerance that locks it into place. Alcohol-tolerance leaves us with negative emotions whenever we are sober. Drinking relieves these emotions and we develop powerful drinking triggers for them. When we first began drinking our triggers were related to people, places, events, and times of the day, but the negative emotions of alcohol-tolerance now trigger cravings whenever we are sober. Once we have become alcohol-tolerant then the demand to find alcohol becomes continuous so we drink more and this further strengthens triggers and deepens the emotional consequences of drinking. It is a self-feeding downward spiral. None of this escalation from having a few drinks a long time ago to becoming completely driven by alcohol is chosen. The whole process happens without our permission, involvement or awareness. We have no idea that the problem has formed, we have no idea the problem is escalating, and by the time we suspect we actually have a problem it is too late; we are already completely trapped.