Alcohol Use Disorder, Trauma, and the Brain

When you think about alcoholism, what comes to mind?

The answer to this question depends entirely on whether you’ve ever struggled with alcohol use or known someone who did.  It’s also going to depend on how much you really learned about the complexities of alcoholism.

Genetic and Epigentic Factors

Let’s begin by understanding the genetic and epigenetic precursors which we inherit from our families and our environment.  Our genes, the basic unity of heredity, can set us up with greater risk or protective factors for a variety of future challenges – one of which can be our eventual proclivity toward alcoholism.

Research shows that genetics have somewhere between a 40% and 60% influence on addiction, with the brain structures governing our reward pathways being the most directly implicated.  Neuroimaging of the brain’s reward systems, in those predisposed to alcoholism, tend to show a reduced number of dopamine receptors in the brain.  Dopamine is our ‘feel good’ chemical – and gets released to encourage doing things that make us feel good.  If we don’t have enough dopamine receptors or we have other problems with dopamine regulation, we may find ourselves prone to things like impulsivity, heightened pleasure seeking, and addictive patterns of behavior.  All of which is governed by our genetics.

But genetics alone don’t create or foster patterns of alcohol use, misuse, or abuse.  There are also epigenetic factors at work, factors which impact gene expression.  For instance, the environment in which you are raised, the foods you eat, and the things that you are exposed to can have direct, profound impacts on how your genes express – meaning which genes are turned on or off, at any time, further informing and influencing the internal wiring of your body and brain.  The role epignetic factors play actually begin before birth – and reflect a whole host of internal and external variables present in our parents before and during pregnancy.  Then, our genes continue to change over time, from birth through death, due to a variety of factors over which we may have very little real control.

Trauma and Disconnection

Now let us take this roughly 50/50 possibility of inheriting a genetic predisposition toward alcoholism and add trauma to the mix.  Trauma doesn’t just mean experiencing a major traumatic event, it means being negatively influenced in ways that push against our inherent needs for love, connection, and care when we first enter the world as babies.  In other words, the accumulation of subtle micro traumas that influence attachment bonding, stages of development, and formation of the self structure can all play a part in addiction.  One paper, that I wrote in graduate school, called “cumulative micro trauma and formation of the disconnected self” captures it like this:

Cumulative micro traumas, herein defined as chronic and systemic breakdowns in developmental and supportive social structures which, when accumulated over time, condition and reinforce a self-narrative that is defined, governed, and normalized by these very same chronically and systemically unhealthy social mores, tend to create a ‘feedback loop’ of disconnection wherein a false sense of separateness, as a mental formation, is substituted for the innate wholeness of being.  The result of which amounts to our wounding being hidden from us; normalized into acceptance even when its injurious nature has long-lasting impacts on one’s self-concept. It is this tension, between the narratives of a socially defined false self and the deeper impulse to live and openly express one’s innate wholeness, which contributes to much of the suffering we experience in our daily lives; especially in our experiences of stress, anxiety, and depression.  This felt tension represents the disconnected self; that part of the self-structure which perceives itself as separate and apart from the whole that must be protected and defended at all costs, that has been subjected to the effects of cumulative micro trauma and has yet to heal from these experiences at the somatic level of body and the cognitive level of mind. This false sense of separateness creates a myriad of misunderstandings and misdirected angst that can directly lead to feeling anxious and insecure in the world.  When we operate from a place that is wounded, hurting, or injured, we tend to bring those qualities into the relationships that we surround ourselves with, which steps into the social and societal dynamics of how these tensions can impact our daily lives and continue to perpetuate themselves – not just individually, but collectively, becoming a normalized traumatic inheritance that we unconsciously pass on to one another with little to no questioning at all.

A recent video that I came across gives a more succinct explanation, summarizing this phenomena as a conflict between attachment and authenticity.  When we are children, we rely on our caregivers for our survival – which requires healthy attachment bonding.  If the attachment bond is not secure, then the child cannot rely on that bond for ensured survival and grows up with a sense of being unsafe and insecure in relationship.  At the same time that this is happening, we also have a survival need for honoring our own authenticity – to trust ourselves, our experiences, and our inner wisdom as we walk through life, because, if we don’t, then we end up disconnecting from ourselves and our own internal sense of safety and security. 

What happens though when these two needs (attachment and authenticity) conflict?  If I am a young child relying on you as a caregiver, and you are withdrawing the love and connection that is associated with healthy attachment as a way of teaching me “the right way to be”, then I am faced with a mounting dilemma that creates tension between two competing survival needs.  In this competition, my need for attachment is always going to outweigh my need for authenticity because I am entirely dependent upon you, as my caregiver, for basic things like food, shelter, and love – all of which I place at risk if my sense of authenticity doesn’t accord with your expectations or demands.  Therefor I learn to sacrifice my authenticity for acceptance – a pattern that begins to form across all social and relational dimensions.

And what does this kind of trauma do to the body-brain organism?  It puts the whole thing in distress.  My identity becomes split between the me that I present to others and the me that I am inside – but this split creates confusion that results in feeling like we never know who we really are, what we really want, or what we should really be doing.  Furthermore, this split makes us feel like there’s something wrong with us, that we are fundamentally flawed and broken, because we never really feel like we fit in anywhere!  So, we begin to disown the parts of ourselves that we were told we cannot accept, disconnect from our feelings, and hide from our inevitable psychological suffering.

How Alcoholism Sneaks In

So here we are, in this place where genetic and epigenetic factors are already at play, and now we’ve experienced an all-to-common form of relational cumulative micro trauma that has forced us to disowned ourselves – teaching our brains to shape themselves around our perceived failures and insecurities; using the brain’s natural power of neuroplasticity to warp, ingrain, and reinforce how we see ourselves and how we see the world – molding our core beliefs around themes of being unsafe, unworthy, and unlovable.  It’s a very challenging way to live in the world – so our daily thoughts and behaviors warp right along with those core beliefs.  Over time, the pain and suffering can be too much – and we just want it to go away.

What exactly do alcohol and drugs do?  We’ll get to that in a minute – but first let me just say that no one wakes up one day and says “I think I’d like to be an alcoholic”.   Usually, the journey to alcohol use disorder begins innocently enough.  Maybe we have a few drinks as a kid and start to like how it makes us feel, or we find ourselves drinking socially with friends, or we enjoy coming home after a long days work and have a drink or two to take the edge off.  These are all pretty common scenarios for most of us – and for many people this is where it ends…  But for the burgeoning alcoholic, this is just the beginning.

Alcohol use produces pleasurable sensations in the brain by activating opioid receptors in the nucleus accumbens, a part of the basal ganglia that is associated with intoxication. It also causes the ventral tegmental area to send dopamine signals to the nucleus accumbens.  Remember earlier when we talked about dopamine as the ‘feel good’ chemical in the brain?  We also talked about the genetic predisposition of having fewer dopamine receptors in the brain.  Well, when we drink alcohol, we are basically flooding the brain with dopamine, and overwhelming our dopamine receptors.  Neuroplasticity, being as amazing as it is, jumps in to help by expanding the number of active dopamine receptors in the brain – so the more you drink, and the more you teach your brain how ‘great’ drinking is, the more it adapts to accommodate this pleasure seeking behavior.

Let’s say that, on your very worst possible day, your dopamine levels can go all the way down to 40 nanograms per deciliter; and on your very best possible day, they can go all the way up to 100 nanograms per deciliter.  This gives us a standard dopamine reference range of 40-100.  This is our natural rewards system at work, a reward system that is geared to stay within this 40-100 range. Now, when we introduce alcohol into this system, the dopamine production rate can nearly double what our brains are actually supposed to be working with.  In other words, alcohol hijacks the reward system with a pleasure response that is nearly doubly anything else you could possibly do for yourself – even sex (which hovers around 90 nanograms per deciliter).

Repeated use of alcohol slowly but surely leads to a phenomenon call ‘incentive salience’, a motivation for reward that is driven by both a person’s current physiological state and previously learned associations between cues and the reward.  For instance, if you feel stressed (cue) and drink alcohol (reward), your brain begins to crave alcohol as it’s primary reward anytime stress is experienced.  While this is a bit of an oversimplification, the basic point is that continued exposure to alcohol changes the circuitry of the brain’s reward system so that it begins to seek alcohol as its top priority.  Here’s where things shift from use to misuse.  What may have begun innocently enough has induced structural changes to the brain.  To make matters worse, one of these structural changes shifts conscious control of drinking from the prefrontal cortex to unconscious control by the basal ganglia.

In Alcoholics Anonymous, one of the main themes is to admit that “I am powerless over alcohol”. Can you see why?  Now let’s take things even further – because the brain isn’t done changing yet.  Earlier I asked the question ‘what exactly do alcohol and drugs do?’.  Well, in the case of alcohol, it numbs the amygdala.  The amygdala is where our brain stores sense memories – specifically, emotional memories.  It is heavily implicated in trauma, anxiety, depression, and addiction.  There’s a reason why I focus my practice on these four primary conditions – because they are are related across common neuropathways and psychophysiological structures.  When we are in that previously mentioned tension between attachment and authenticity, the amygdala is where the pain of our lost authenticity is stored – along with every sense or emotional memory that taught us that living in our authenticity is unsafe.  If we can dull that part of the brain, then it reduces this tension – at least initially.

The more we drink, the more the brain continues to rely on alcohol to calm itself by reducing functioning in the prefrontal cortex (the thinking mind), reducing amygdala activation (which, in-turn, reduces trauma responses and anxiety in body), and satiates the reward system in a way that nothing else does.  Then, we start needing to drink more and more to get these effects, which is where alcohol tolerance appears.  Now, as the brain and body become dependent on alcohol, we also start to suffer withdrawal symptoms when we stop drinking.  Most people are familiar with things like ‘getting the shakes’ when withdrawing from a substance like alcohol – but that’s just a minor outward manifestation.  The most impactful sign of withdrawal goes back to the hijacked reward system and dopamine production.  Remember when we said that the standard human reference range was 40-100 nanograms per deciliter?  Well withdrawal can take us all the way down to 10 nanometers per deciliter. 

At these tragically reduced dopamine levels, we end up suffering the same kind of symptoms we might while experiencing a deep depression.  We can’t even get motivated enough to climb out of bed.  Our dopamine reward system has become so dependent upon the presence of alcohol that that it can’t regulate itself normally anymore.  By this point, the brain can’t achieve homeostasis or ‘feeling normal’ unless there is alcohol present.  If you were at this point, and desperate to stop drinking, your brain and your body simply wouldn’t let you do so.  They would continue making you feel absolutely terrible, triggering a demand for use by generating powerful urges and cravings, not to mention all of the other common withdrawal symptoms, enticing you to give the brain what it wants – more alcohol.  Even if you were able to stop drinking for a while – these are the mechanisms at work which lead to relapse, again and again, unless there’s been enough time and distance between your brain and alcohol for your brain to heal – which could take up to one to two years (or more).

Treatment Options

If all of this feels familiar and resonates with you, then it’s time to start talking about options for recovery.  AA is usually the first place most people will turn to in hopes of getting better.  While AA is useful for community and support, it is not a treatment approach.  In fact, data from AAs own studies shows that only 27% of members are still sober after one year.  There’s a lot that AA doesn’t cover and it’s abstinence only approach may not be for everyone – especially when you consider what we just covered regarding alcohol use and the brain.  This doesn’t mean you shouldn’t join AA – it means that you should think of AA as part of a larger and more holistic approach to recovery.

One of the most successful treatment modalities, especially in the early stages of recovery, is the use of Medically-Assisted Treatment (MAT).  This approach uses medications that directly address the damage done to the brain by regular alcohol use, misuse, and abuse. Effective MAT for alcohol use disorder and dependence include FDA approved medications such as Naltrexone, Vivitrol, Disulfiram, Benzodiazepines, and Acamprosate.  These are often administered in a safe, detoxification-oriented treatment setting with round-the-clock medical supervision.  Once the pain and suffering of withdrawal are toned down, these medications may continue to play a part in helping to reduce harm or maintain abstinence.  Either way, these medications can make all the difference in the world when it comes to recovery.  Instead of ‘white-knuckling’ it, you can give yourself a fighting chance to really and truly put an end to your alcohol abuse. 

This is just the first step though – and one prong of a multi-pronged approach.  As you emerge from the cloud of intoxication and reenter your life, you are well advised to begin psycho-social treatment for alcohol use disorder and whatever additional mental health challenges you may be facing – like trauma, anxiety, and depression.  This is where finding a treatment center that offers partial hospitalization or intensive outpatient programs can be incredibly helpful.  Consisting of both group and individual therapy, these programs can teach us how to reconnect without ourselves again, learn emotional self-regulation skills, prepare for and prevent relapses, and so much more.  These programs also offer an opportunity to practice vulnerability in a safe setting, encourage connection over isolation, and listen to the perils and progress of others who are struggling with similar challenges. 

There’s a lot more I could say on this topic – but the main point that I want to make is that addiction is treatable, there is a way forward, and hope is possible!  If you think you may have a problem with alcohol, drugs, or mental health, reach out to a provider and begin inquiring into and investigating your options.  In this moment, right here and right now, you are the most important person in your life – and you deserve a chance to make that life into something that serves you, gives you meaning and purpose, nourishes and fulfills your being, and allows you to transform your suffering into loving action in the world.  

All it takes is a phone call to get started!