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When I was young, I used to spend hours looking at all of the football results and the league tables. I would analyse them endlessly. Actually, I still do. I look at current form, home and away performance, goal scorers, attendances – the whole thing. In fact, I do it all of the way down from the Premier League to so-called grassroots non-league football. I carried this fascination for statistics into financial markets. Now I can sit all day watching the colours flashing on the screen, analysing the charts, trying to discern trends and turning points. If I'm doing it at home then my wife laughs at me because she says it’s the way I've always been. There is something addictive about this type of behaviour, of course. When you put working in financial markets together with alcohol and drugs then it’s potentially quite a toxic mix. Trading involves risk-taking, the sense of a high, the craving for more, and withdrawal symptoms - what do you do with yourself when it’s a bank holiday or a weekend and the markets are closed? All of these behaviours characterise the alcoholic. I've known many alcoholics in my life in the City. In fact, I became one of them but I perhaps managed to hide it better than some. Like many, I began a pattern of drinking at a young age in my early teens. When I started work, I found that I could mix business with pleasure, so to speak. It started out with the long ‘liquid lunches’, which often carried on until the end of the day. These were deemed socially acceptable at one time because they ‘oiled’ the wheels of business. At the outset, it’s fun. The camaraderie and bravado of traders provides for shared stories of how you’ve taken on the rest of the world and won, or for drowning sorrows until another day. But what started as a pleasurable way of handling stress turned into loss of control, binges and blackouts. When I look back, where was the fun in wandering around foreign cities in blackout in the early hours of the morning or waking up on the floor of hotel bathrooms? You’re putting your job at risk, obviously, but on reflection, with the wisdom of sobriety, even your life at times. But I learned something with maturity about markets and with my background in economics. There is no point in being sucked into every ‘tick’ – every movement of the price. We call it ‘screen watching’. It’s not worthwhile trying to find significance in every micro move when there is none to be found. You get a better perspective if you stay out, reflect on the bigger picture, and talk to other people. Calm rational analysis is better than impetuosity and false bravado. The same principles are at work when the alcoholic turns around and starts setting out on the path to recovery in treatment. You begin to realise that you've been locked into doing something for the sake of it. Reaching for the next drink is like wrongly believing that you always need to have a trading position. In reality, you're at risk of making things worse. You need to step back and have the humility to ask for the help of others. The world of the financial markets trader is both global and local at the same time. You are a ‘citizen of the world’ – plugged into world events for twenty four hours a day – but often with a very narrow focus on a specific area of activity. As an economist, I can see that all parts of the global economy are interconnected to a greater or lesser extent. When responsible only for trading the Euro/dollar exchange rate, however, it’s easy to lose sight of the significance of events in some distant part of the world like China. The danger for the trader is a retreat into self-isolation with a loss of broader perspective. The irony is that a trader can become very lonely, especially when things are going wrong. It’s the same for an alcoholic. What starts as a social activity can easily slide into self-centred behaviour. Most of my heavy drinking was done alone. Turning around is all about becoming a team-player and having the support of others around you. The same principles are at work for all of us, and especially for alcoholics in recovery. We all belong to something much bigger in life in relation to others and to the world around us but often become enslaved by our own self-obsessions. Being an alcoholic is lonely. Just as the trader needs to lift his head and take a broader perspective of the world around him, the alcoholic in recovery needs to come out of self-isolation and find his true place in the world.

Attention to spiritual health on the path to recovery in alcohol treatment is about encouraging openness. It’s about letting go of inward obsession with a false sense of self-identity and turning outward. Spiritual health is about finding our place in the world. It’s about finding meaning, purpose and truth in a community of shared lives. We find this community in the first instance in those closest to us – the family and other loved ones. The alcoholic takes the first step toward recovery by acknowledging to self and to others that he has lost control of his drinking. He needs to confess because this first step is about being honest to self and to others. This is a necessary first move toward opening up and moving forward. If we cannot be honest and open to others then how can we rebuild relationships? Honest acknowledgment of the need for help is cleansing and liberating. Alcoholics have a hard time confessing. Based on my own experience, there was a long downward spiral of blackouts and repeated attempts to stop drinking before being prepared to admit to myself or to anybody else that I needed help. We need somebody to hear the confession properly as we enter treatment. This is likely to be somebody in our closest circle. It might be a trusted colleague at work or a friend. In moving from inward to outward, the family is usually the closest in the immediate circle. But sometimes it is difficult to turn to family and admit to a deep problem of personal behaviour. I started to acknowledge to others that I had a problem long before I entered formal treatment. When I look back, I knew that I could no longer control my drinking but perhaps I didn’t say it loudly enough or others didn’t take it seriously enough to make a difference. The first people I told were work colleagues. But I was reluctant to tell my family. Why? It might have been that I feared being judged by those closest to me. It was probably also because I didn’t want to hurt them. We need somebody to share the burden of recovery. Committing to a programme of recovery is hard work. It means self-sacrifice, obviously, but it also involves others because you are no longer able to do the same things together. It also involves pain because there are setbacks. The path requires mutual understanding between the recovering alcoholic and the support group. The family usually, but not always, knows the suffering alcoholic more intimately than anybody else. The family needs to understand and commit to the recovery path. The alcoholic in recovery has a better chance of success if others have knowledge of what is trying to be achieved. There needs to be a common framework for all of those supporting the recovering alcoholic. Ideally, this will involve a common understanding of the process, shared responsibility and a common aim – restoration of health in body, mind and spirit. The spiritual path is about helping the recovering alcoholic to find a proper sense of belonging in the world. It is about encouraging him to come out of himself, in some sense, to find a deeper source of meaning and purpose to his life. We do this in relation to others and the world around us. This is how we find our true sense of self-worth – a proper sense of self-identity in relation to a broader community – living in communion. The spiritual perspective is that life is communion and communion is love. What does this mean? It means that authentic human life is found in the interrelatedness of all things. The nature of the reality in which we live is a connectedness of giving and receiving. True community is love. Love is unconditional – it asks for nothing in return. We find our ultimate sense of self-worth and identity as human persons in a communion of love. The family is the immediate embodiment of this communion of life and communion of love. We never love perfectly. The family never loves perfectly. Sometimes we find it easier to take than to give. Alcoholics often care more about the next drink than others. The love of family has an important role to play in helping the recovering alcoholic on the path to spiritual recovery.

Do we have three brains? Now we know that in the early century XX neuroscientists were able to understand the roots of some of Jon’s symptoms, mostly those related to very basic primitive behaviours, hiding deep inside the human brain because they were one of the first brain structures to develop during the evolution process. They first appeared in reptiles and other species with relative simpler brain structures. The so called Reptile brain. Those structures can explain basic human instinctive short lasting reactions, with no elaborate emotions and feelings involved, nor long lasting memories of it. The lizard inside us all. As decades went by, extraordinary events occurred. Some 140 million people were killed within a 30 year period (1914-1945). WWI resulted in 40 million deaths, WWII in 75 million deaths, and a further 20 million also died as direct or indirect consequence of the Russian Revolution. And we say Coronavirus is lethal… What about humans? Well, that’s exactly what many people wondered at the time, and that was what prompted, along with new scientific advances in neurobiology, neurology, neurosurgery, psychiatry and psychology, a new age of research and discoveries in human brain and human mind. No doubt we are intelligent, but why do we behave in such aggressive ways? How can humans be capable of such cruelty? Not even the Reptilian part of our brain can explain such destructiveness, unheard of in the animal kingdom, supposedly inferior to humans… But that was exactly the nature of the paradox. We have a reptilian brain but also human intelligence as well. That combination of intelligence and animal instinct makes us dangerous. We were able to create increasingly elaborate means of destruction, driven by the basic aggressive instincts deep in our brains. When the more developed parts of our brain work together with the most primitive ones, intelligence and basic aggressive instincts get their way. That’s how during WWI for the first time industrial revolution engineering was applied to war waging, to create killing machines. Savage animals are very capable of killing, but the concept of torture and vengeance upon their victims does not seem to exist. And that applies not just to sadistic behaviours, but masochistic as well. It is not just the stimulation of deep structures in our brains by drugs that induce self-destructive behaviours, but the damage to our most evolved parts (pre frontal cortex) as well. That could explain the loss of humanity fuelled by hard drugs. The forebrain turns servant to the Reptilian Brain. During those WWI years Freud's ideas and theories flourished and became the new trend in psychology. The concepts of unconscious primitive drives (psychological) / instincts (biological) taking over the human psyche became popular because humans have proven to be a lot less rational than they thought they were. In the early century XX Freud's and Jung's psychoanalytic theories led the way to understanding human behaviour and treating its “deviations” with psychotherapy. Their theories and ideas were supported by little or almost non-existent empirical evidence, although they did provide a rational framework for professional psychological treatment. Something similar happened with Psychiatry, where pragmatic interventions using a few medications and medical procedures were utilized, sometimes resulting in very negative outcomes. Neurobiological sciences continued developing at a steady but slow pace in relation to the acute need for evidence based treatments of mental disorders. By the mid-50s there was a much better understanding of brain development and how it works, and by 1964 Paul MacLean, an American clinician and neuroscientist, proposed the evolutionary Triune Brain theory. Communicators such as Paul Koestler and Carl Sagan made his theory more understandable to the public, captivating their imaginations. MacLean’s Triune Brain (TB) resembles a neuroanatomical correlate to Freud’s tripartite view of the mind: id, ego and superego. We know today that the TB theory has many flaws and many recent discoveries in neuroscience contradict the model, however when it was launched some 60 years ago it was widely accepted by scientists and clinicians. MacLean's theory provided a relative simple integration of central nervous system phylogenetic evolution, neuro-embryologic development, and mature brain structures with different levels of function. Now we know it is not that simple, but the TB model was appealing (it still is) and not too difficult to understand. The TB consists of three independent, conscious, sequential structures resulting from evolution. These brain structures develop like a Russian doll. The most internal parts are the most ancient ones, first to appear in amphibia. The intermediate structures (midbrain) appeared for the first time in vertebrates, and the outer dorsal ones in superior mammals. Following MacLean's ideas, we could say that in some way, we have three brains that have evolved over eons to become one. What makes human brain different from the rest of superior mammals, is a much more developed pre-frontal brain cortex, bigger in size and neural complexity when compared to primates. It is very important to understand the brain structures, how they work and how they interact, if we are to provide a rational evidence based treatment for mental health disorders, including addictions. Dr Oscar D'Agnone, MD, MRCPsych. Medical Director

Being still is difficult. Being in isolation is even more difficult - for everybody, but especially for alcoholics in recovery. Lockdown still presents a severe challenge, although we are slowly re-emerging. People are responding to the lockdown in different ways. Some are using it to tackle things that have been postponed for months if not years, like clearing out the house or the garage. Long queues formed at the public recycling centres when they re-opened. Others are painting the house from top to bottom or designing a new garden. No doubt, it is an opportunity to do some of those things. Forming a plan of activity helps to bring order to our lives. Getting things done provides us with a sense of achievement. This is all positive. But is it not also a sign that some people feel the need to be always doing something? Are we not already often overly busy in our lives? What is wrong with using the opportunity of lockdown to be still? I used to be a very driven person, and no doubt sometimes I still am. For years, I was completely exhausted. My job took me all over the world. I was either permanently jet-lagged or hung over from alcoholic binges. It all came crashing to an end, of course. After I'd been dry for some considerable time, and stopped running around, somebody told me how much better I looked. Alcohol treatment therapy helped me to take care of both my physical and spiritual health. Why are we uncomfortable being still? We strive hard to make a success of our lives and provide for our families and loved ones. This provides a sense of purpose. But some people keep pushing themselves well beyond this basic need and never achieve happiness. Is it because we lack a sense of self-worth and deeper meaning to our lives? Some people are overly busy because they are not really comfortable in their own skin. This is not good for our well-being. We need occasionally to take a deep breath and take stock of what really matters in our lives. Mindfulness is what we are doing when we sit and be still. We need to focus on the present moment. Don't keep looking back full of regret. The past has gone. Yes, it is part of who we are as persons. Our genes, family, education, friends and work have all contributed to who we are today. But we can’t change any of that. It already happened. Similarly, our futures are not mapped out in front of us in some predetermined fashion. So don’t be anxious about what the future holds. We will make choices, of course, and we will do our best. But some things will happen that are beyond our control. Some things will be good and, unfortunately, yes, some things will be bad. That’s life. Remorse and fear feed anxiety. This is bad for our emotional and spiritual well-being. Some then turn to alcohol as a way to cope. Unfortunately, what starts as a pleasurable way of coping with stress sometimes turns into habit, which then becomes necessity. Loss of control leads to a downward spiral and despair. Mindfulness is part of a strategy to restore spiritual health. Buddhists use mindfulness or meditation as a practise to let go of craving and false impressions of the self. Others think of mindfulness like prayer, but it’s not about asking, it’s about listening. It’s about letting go of who said what to whom in the workplace or plotting about how to climb above others. It’s about finding your true place in the world. Some of us are fortunate enough to have peace and quiet during lockdown. When I close my eyes and breathe deeply, I can hear birdsong with real clarity. I can hear the trees moving in the wind. It makes you realise that you are part of something much bigger, the flow of life. Mindfulness is a tough spiritual discipline to follow, especially for the restless alcoholic in recovery, but it helps provide a pathway to peace. Just to be clear, we do need to get back to meeting other people and carrying on with our lives. We are social beings and we need community. We all need a return to something like normality. But we also need space and time to have clear heads. Ask yourself - who am I? What really matters in life? How am I going to use my recovery? Lockdown is an opportunity to Be Still.

Spiritual well-being has an important role to play in recovery from alcoholism. That is because spirituality, when properly understood in its broadest sense, is integral to self-identity and self-worth. Spiritual awareness is part of what it means to be a human person. The role of spirituality in recovery is increasingly recognised in alcohol rehab treatment therapies. My own spiritual journey started with psychotherapy in rehab, and led to thirty years of studying the human condition. Human beings are a composite of body, mind and spirit, or soul if you prefer. We know that we need to look after both the body and the mind to be healthy. But do we pay enough attention to our spiritual health? What do we mean by spirituality and how does this relate to the alcoholic in recovery? Philosophers have long recognised that what is distinctive of human beings is the ability to use our capacity for reasoning when we think and act in the world. We share sensory perception – sight, hearing, touch, taste and smell – with the other animals. But we also have self-awareness, the ability to reflect on our situation in self-consciousness. The ability to transcend ourselves, in some sense, both individually and in communion with others, is what we mean by spirituality. The modern world has re-discovered the Greek philosophers’ concept of well-being. We all desire to be happy. We are happy, or “living well”, when we direct our desires and act in accordance with our true nature as human beings. Our well-being depends on our spiritual health. Spiritual awareness gives us a sense of belonging in the world. It is how we find value, meaning and purpose on a shared life journey in hope with others. Spirituality is a process of discovery. It is about openness to new experience, acceptance of things we cannot change and the courage to act when we can. (I needed courage to walk down the street again and go back to work). Ultimately, it is about finding out who we really are and what matters to us. In contrast, the descent into alcoholism is a turn inward away from others and the world. The fall into blackouts and dependency undermines the alcoholic’s rational capacity. The alcoholic creates and inhabits another parallel reality. Rather than find self-worth through relationship to others and the world around us, the alcoholic becomes enslaved by a mind-altering substance. The obsession to drink overcomes commitment to work, family, and friends, whether one is a so-called functioning alcoholic or not. The desire or craving to get drunk becomes overriding. This compulsion fractures relationships, undermines our self-identity in relation to others and is ultimately self-destructive. The alcoholic is not unaware of the damage being done. It is devastating to realise the loss of control, the inability to turn back, and the impact this is having, not least on one’s own health. Loss of self is living in despair. Crisis, however experienced (the personal “rock bottom” of the user), provides a potential turning point toward recovery. But this is a situation of both vulnerability and opportunity. Being sober, perhaps after alcohol detox, and entering treatment initially heightens the sensitivity of the alcoholic in a form of awakening. I recall that feeling of being wide awake. It was like stepping into bright sunlight and I have never forgotten an almost strange awareness of colour. The alcoholic is vulnerable at this stage because he is still locked into self-interest. He is more aware than ever of his illness. He is frightened. Therapy is perhaps questioning his deep self, his history, and the psychological background to his behaviour. The easiest solution to the discomfort and fear is to flee back into drinking. That is why alcohol rehab treatments pay so much attention to craving and the risk of relapse. I was paralysed by fear after brief hospitalisation, quite literally struck down by panic attacks. The turning point also provides an opportunity for healing, however, for transformation of the mind, and a path to lasting recovery. For this to be effective, we need attention to body, mind and spirit. Alcohol treatment has many aspects but needs to bring about a spiritual awakening to encourage the alcoholic to turn from inward self-obsession to outward personal growth. Treatment needs to encourage openness for the alcoholic to find a sense of self-worth, and his place in the world as a human being. How do we start this journey of spiritual awakening? Alcohol rehab treatment shows empathy and unconditional regard for the suffering addict to stimulate a spark of spiritual awareness. First, the alcoholic should be encouraged to admit openly his loss of control and express a genuine desire to stop drinking. Second, he should be brought to acknowledge that he is unable to get well on his own and needs support from a power beyond himself. Third, he needs to show contrition for the suffering his actions have brought to others. Fourth, he needs constantly to reflect on his recovery, perhaps through meditation (mindfulness). Finally, he should be encouraged to engage with fellow sufferers, to nurture love for others and to re-discover his self-worth. These structures of confession, repentance, and mindfulness or prayer are found in organised religions. These share common beliefs and practises which provide for the regular habit of actions to support spiritual growth. But religion need not be a barrier to atheist and agnostic alcoholics. The broad concept of spirituality and appeal to a source of spiritual health or power outside of ourselves, however understood, is found in various psychotherapies and in the long-standing 12-step programme of mutual help groups. For anybody embarking on this path, the one single piece of advice that I give is to read about, or listen to, the stories of those in recovery. This is the start of finding your true self in others and asking yourself – wouldn’t you like to have what they’ve got? Spirituality encourages new ways of thinking and acting in the world, helping the alcoholic to build lasting recovery. It is about stepping from darkness into light. In my case, it was about standing up and walking out of a dark room into a new life. In putting the precepts into practise, the sufferer is transformed to find new enjoyment in life, to become truly a person to love and to be loved in the fellowship of other human beings. *Andrew Bevan is a voluntary mentor. He is a recovering alcoholic who has been sober for more than 20 years. He has worked in international finance for more than 40 years and is currently a partner of an asset management company in London. Following treatment, he developed an interest in psychotherapy and psychology. He subsequently studied philosophy and theology. He holds a PhD in Economics from City University, London and a PhD in Theology from Kings College, London.

Reptilians Among Us Late in the morning in April 1899 Christfried was crossing the cobbled central square of Erlangen, in Bayern. His pace was fast, firm and resolute. He had finally made his decision and like a man on a mission, he knew exactly where he was going. He will be heading south, far, far away south. The air was fresh and everything seemed to be as bright as his mood was. The river Regnitz was also flowing fast, as if in a rush to meet the Schwabach towards the Rhine. Christfried Jakob [1] had accepted the position of director the neurobiology laboratory of the Hospicio de las Mercedes in Buenos Aires, Argentina. It had been a bold decision to leave the security of his current position as first assistant to professor Adolf von Strumplell at the University of Erlangen, where he trained as a doctor, published his first books, then went on to teach Neurology to the new generation of doctors to be. But his boldness was fuelled by his youth and the opportunity as well. He would be the boss now, the captain of his ship. His main line of work and passion was to study the anatomy and physiology of the human brain, and in order to continue his research he needed more specimens. He needed more bodies to perform autopsies and study the brains. So, strange as it sounds, one of the main motivators for making his decision was the access to around 300 autopsies per year. Far more that he could have ever dreamt in Erlangen. It was a centre of excellence for medicine and technology, and Christfried also decided to make a name for himself at the same time that Flechsig, Kölliker, Nissl, Brodmann, Vogt made theirs in Germany, Ramon y Cajal in Spain, Camillo Golgi in Italy, Dejerine in France, Hughlings Jackson and Sherrington in the United Kingdom and were laying the foundations of modern neurobiology and clinical neurology. Christfried was 32, young and confident. He had published two brain maps [2] [3] that included detailed drawings of the internal brain structures and neural pathways. These maps were widely known in Paris, Vienna and other medical centres of excellence in Europe. Professor Strumpell had forwarded his first book edited in 1985 before he even turned 30. No doubt Christfried Jakob was a great promise in the field. A chilly winter morning he arrived in Buenos Aires to take over his position as lead of the neurobiology laboratory, but also as full professor of biology at the Faculty of Philosophy. Yes, philosophy. Christfried was an intellectual of his time, versed not just in neurobiology but also in philosophy, arts and a skilled pianist as well. It was a time where scientists, philosophers, and writers looked at the brain, the same way we look at the cosmos today. They were looking for answers to the same old questions: who are we? Where do we come from? Where are we going? Who would have thought that seventy years later I would train as a psychiatrist in the same laboratory by disciples who cherished and preserved his legacy. These days Jakob is known mostly for his contribution to the discovery of Creutzfeldt-Jakob (CJD) disease [4] [5] (spongiform encephalopathy) also known as mad cow disease. His complete works include twenty books and over 180 scientific papers. Jakob stated that amphibia are the first species in which a primitive cortex appear, culminating the evolutionary process in the human cortex.[6] He thought that the supreme level was what he called the neoneuronal, which includes two sectors: the limbic cortex (mostly related to internal systems activity), and the lateral cortex (processing environmental stimuli). The lateral cortex (new brain in picture) integrates external and internal stimuli as individual experience. It is where the ego and personality reside. As early as in 1911 Jakob claimed that “Love and hunger arise from the limbic cortex.” Visceral sensations reach mamillary bodies through the brain steam, and from there via Vicq D’Azyr fascicle project to the Thalamus to finally end in the Cingulate cortex. It is amazing to know that back then, Jakob described clearly the basic concepts of the limbic system functions, some 27 years before James Papez, and 45 years before MacLean’s Triune Brain [7] evolutionary theory changed Jakob’s “visceral brain” to Reptilian Brain. At a time when fancy positron scans, computerised tomographic scans, artificial intelligence, not even phones or computers existed, good old Jakob would have known exactly where Jon’s deep emotions, instinctive reactions and impulsivity were coming from. Same as Jon, we all have gut feelings at some point in our lives. The difference is that most of us are not guided just by “gut feelings” or intuitions, but by some sort of rational thinking. Sort of rational I said… That strong instinctual feeling, that intuition, the one for which we don’t have no words, but we know it is coming from deep inside. [8] 110 years ago, no doubt Jakob would have related Jon’s gut feeling based decisions were linked to his “Visceral or Reptilian Brain”. Perhaps he would have said that Jon’s reptilian brain was taking over, and the most highly evolved human part of it (neocortex) has been damaged by cocaine. So the Reptilians are among us after all… Dr Oscar D'Agnone, MD, MRCPsych. Medical Director References: [1] Orlando. J. C., La vida y obra de Christofredo Jakob. Electroneurobiología 2 (# 1) pp. 499-607, 1995 [2] Atlas der Gesunden und Kranken Nervensystems nebst Grundriss der Anatomie, Pathologie und Therapie desselben. Mit einem Vorwort von Prof. Dr. Ad. v. Strümpell. Lehmann, München, 1895. [3] Atlas der Klinischen Untersuchungsmethodem nebst Grundriss der Klinischen Diagnostik und der speziellen Pathologie und Therapie der inneren Krankheiten. J. F. Lehmann. München. 1897. [4] https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Creutzfeldt-Jakob-Disease-Fact-Sheet [5] Manix, Marc; Kalakoti, Piyush; Henry, Miriam; Thakur, Jai; Menger, Richard; Guthikonda, Bharat; Nanda, Anil (2015-11-01). "Creutzfeldt-Jakob disease: updated diagnostic criteria, treatment algorithm, and the utility of brain biopsy". Neurosurgical Focus. 39 (5): E2. [6] Lazaros C. Triarhou, Centenary of Christfried Jakob's discovery of the visceral brain: An unheeded precedence in affective neuroscience. Neuroscience & Biobehavioral Reviews 32 (# 5), pp. 984-1000, 2008 pmid= 18479750 [7] The embodied brain: towards a radical embodied cognitive neuroscience. Julian Kiverstein and Mark Miller, Front. Hum. Neurosci., 06 May 2015 | https://doi.org/10.3389/fnhum.2015.00237 [8] Since biblical times it was believed that the stomach or the heart were the seat of emotions, and Jakob in 1911 showed where about it resonate in our brains.

I want to vs I have to You know what you have to do, but you can’t help doing the opposite. How many times have you been there? Don’t worry, we all have. It is a very human thing. It is probably what makes you a real human. Internal conflict. The “have to” element is the more rational one, since it implies some level of reasoning. If you know what you have to do, this is because you have pondered the options. Acting on the “have to” implies some degree of will power or mental energy investment. It is not a “let go”, it is going in the direction you want to go. The “want to”, is a more immediate thought coming from the inside. It’s almost an instinctive reaction to a situation. Acting on the “want to” doesn’t require will power, it is just a “let go” situation, and usually results in instant gratification, usually some kind of physical sensation (but it can be emotional as well). This sensation may be also followed by some sense of guilt or unease afterwards, if what we did was not what we were supposed to do. The reason for this duality is rooted in two different parts of our brains, that have developed over eons of human evolution. The “want to” is usually related to the more internal, ancient parts of the brain, and the “have to” is rooted in the frontal cortex, the highest level of brain evolution. This part is what differentiates the human brain from the rest of the mammals. Hence, the conflict between the “want to” and the “have to” is the essence of human being. Jon is a 47 year old man, happily married to his third wife 20 years his junior. But he’s alright. Apparently. He lives fast. Doesn’t waste time in eternal ruminations or vacillations. He is a self-made man of action. Flourishing business, two daughters and a teenage boy he adores. Jon is fit and well, perhaps too well. He spends two hours in the gym he built in his big home, every day including weekends. So he is in a good shape and looks younger. Some people say he uses his dominant physique to bully people and get what he wants in business and life in general. But Jon strongly disagrees, and I tell you he is not the kind of person you want to have an argument with. Jon has a problem though. He snorts cocaine. Lots of it. I mean, like 7 grams a day. That makes him lose control sometimes, becoming abusive. Emotionally, but physically too. In the past, this has been a problem for others, not for him, but now he is getting older and realizing that he can lose things he won’t be able to recover as easily as he did before. Time is becoming a precious commodity for him. Now, after snorting a few grams he becomes verbally abusive and occasionally violent. The last two episodes were witnessed by his children and he feels guilty about it. Jon is, believe it or not, very religious. He loves Jesus. He regrets being abusive with his children, beating his wife or smashing the face of an employee who challenged him in front of others. He knows he is losing control and he doesn’t like it. Jon is somewhat aware that he has a personality problem that is fueled by cocaine, and steroids he used to inject until recently. He’s not stupid. He’s an intelligent man, but he is also frequently driven by impulses and gut feelings, instinctive reactions. Jon admits that cocaine for him is like a demanding lover he can’t leave. Even worst than a lover, because he had many in the past, and leaving them cost him money, but was never a big deal. But he can’t do the same with cocaine. That’s what he sees as his main problem. That is the conflict destroying his mind, consuming his nights, giving no hope. There is something inside he can’t control. “This is not me. This is not the one I want to be, the one I have to be. This is killing me.” This is not a Dr Jekyll and Mr Hyde made up story. This is real life. That man, and many like him exist. I am pretty sure a few familiar names or faces come to mind. They may use other drugs, alcohol or are about to lose everything that is left after years of betting and gambling. They are not stupid; they are all intelligent, but the big personal decisions they make are incoherent and irrational, plagued by inconsistencies and ludicrous justifications. They know what they have to do, they know why they have to do it, but they can’t help doing otherwise. Who is the real Jon? Who is Jon actually? Internal conflict and anxiety is as old as the moment we became humans, and we have been trying to solve this conundrum ever since. There are no straightforward answers to these essential, existential questions, but every generation adds a new twist to this story, in different and more complex settings of its age. Over eons of time our brains have evolved and we finally became humans. We call it evolution and progress, but the conflict remains and sometimes some people seem to regress in time. The conflict between the want to and the have to, is the essence of human thinking. It is the trademark of being human. It defines us. I personally do not trust much those who pretend to be conflictless. If you have problems, you are alive! Dr Oscar D'Agnone, MD, MRCPsych. Medical Director

Introduction In 2014, SAMHSA revealed that approximately 7.9 million people experienced concurrent addiction and a mental health disorder. That’s nearly 40% of the entire population who experienced addiction through that year. NIDA statistics on co-occurring disorders reveal people with mood-related mental health disorders or anxiety are twice as likely to succumb to a drug disorder – and similarly, patients with substance use disorders are approximately twice as likely to be diagnosed with those types of mental health disorders. - Approximately 50% of individuals with severe mental health disorders are affected by substance abuse. - 37% of alcohol abusers and 53% of drug users also have at least one serious mental illness. - Of all the people diagnosed with a mental illness, 29% abuse either alcohol or drugs. What are Co-occurring Mental Health Disorders? Dual diagnosis (also known as co-occurring disorders) is a term that refers to individuals who experience a mental illness and a substance use disorder simultaneously. Each of these—substance use or mental disorder—can develop first. Individuals experiencing a mental health disorder may resort to abusing alcohol or other drugs as a mode of self-medication to improve the mental health symptoms they experience. However, research reveals that alcohol and other drugs worsen the symptoms of mental disorders. The professional fields of substance use and mental health recovery have dissimilar cultures, so finding an integrated plan of care can be a huge challenge. Two entwined problems – What Should You Expect with a Dual Diagnosis? Co-occurring disorders tend to be difficult to diagnose. Symptoms of substance abuse or alcohol addiction can mask symptoms of mental disorder, and symptoms of mental illness can be muddled with addiction symptoms. Individuals with mental health disorders occasionally do not address their substance use since they don't believe it to be relevant to their illness. However, here are some typical patterns that emerge with co-occurring disorders: A worsening course of mental health symptoms even while getting treatment. People diagnosed with mental illnesses often use substances to attain emotional satisfaction. People with anxiety may seek something to make them feel calm; people with depression may abuse a substance to make them feel more animated; people having specific phobias may seek something to make them feel less inhibited and more relaxed; and people suffering from psychological pain may seek substances to make them feel numb. Alcohol Addiction or the use of other drugs not only results in treatment failure for the mental disorder but also prevents the patient from developing sufficient coping skills, creating satisfying relationships, and making peace with themselves. Alcohol also interferes with the drugs prescribed for mental health disorders. Briefly, drug and alcohol use worsens any mental health disorder. Substance or alcohol use problems that seem treatment-resistant. Individuals with co-occurring disorders may stop abusing alcohol or other drugs, but they will experience difficulties as their mental health disorders symptoms persist. Treatment centres, clinicians and addiction specialists may not be well-equipped to address the co-existence of both conditions. And some conventional peer recovery groups may advocate abstinence from all forms of drugs – even the prescription medications for mental health disorders. Resultantly, people with co-occurring disorders find it challenging to treat their substance-use disorder simultaneously with their mental health disorders. Why is it Important to Devise a Coherent Treatment Plan? The association of Co-occurring AUD and MHCs with poorer outcomes, like increased relapse rate, use of emergency services, as well as the use of psychiatric services, when compared to individual disorder – is the biggest factor that calls for an integrated intervention. Co-Occurring disorders were not increasingly recognised until the 1980s and 1990s, and patients presenting for SUD or mental health treatment frequently were not evaluated for a co-occurring disorder, or they were prescribed treatment plan without addressing the co-occurring disorder. Since neither of these disorders is likely to show clinical improvement if treated in isolation without acknowledging the influence or presence of the co-occurring disorder, different treatment approaches were developed to counter co-occurrence, inclusive of parallel, sequential, and integrated treatments. Sequential treatment refers to assessing or treating one disorder before the other one. While in parallel treatment, each disorder is addressed separately by different clinicians or treatment teams. The integrated treatment refers to an approach where the same provider or treatment team addresses both disorders simultaneously. What are the Types of Integrated Therapy? In addition to diagnosing the presence or absence of co-occurring AUD or MHCs, elucidating the nature, chronicity, scope, and effect of the primary disorder and the co-occurring ones is critically significant for creating an effective recovery and treatment plan. The heterogeneity among co-occurring AUD and MHCs, calls for individualised treatment plans that account for the severity of each disorder and patient preference when it comes to devising interventions The integrated therapy should consist of: Behavioural therapy Behavioural therapies, consist of cognitive behavioural therapy, motivational enhancement therapy, contingency management, and 12-step facilitation – referred to as the standard of care for individuals with AUD and consolidating a chief part of a treatment plan for patients with co-occurring AUD and MHCs. Behavioural therapy for AUD – commonly consisting of motivational enhancement therapy or cognitive behavioural therapy, is offered to all participants in most randomised controlled trials that assess pharmacotherapy for patients with AUD and an MHC. When it comes to AUD-focused therapies delivered to patients with MHCs, the plan of delivery needs to be adapted to account for the MHC. Pharmacotherapy Owing to the global literature on pharmacotherapy for co-occurring AUD and MHCs, the argument can be constructed that that medication in the absence of treatment interventions may not be sufficient to stabilise both conditions. Nonetheless, medication remains a treatment option in patients with co-occurring disorders. Initial stabilisation and maintenance with disorder-specific medication are specifically required in more serious mental illness, like bipolar disorder and psychotic disorders. For MHCs, like anxiety and depression with mild to moderate impairment and AUD with mild impairment, the clinical guidelines suggest medication or therapy as first-line treatment options. However, medication is more strongly indicated for individuals who have a greater impairment. Community support Peer-led mutual help organisations can be another constituent of a treatment plan for individuals with co-occurring AUD and MHCs. Dealing with a dual diagnosis can feel isolating and challenging. Support groups or Alcohol rehab clinics enable members to share frustrations, celebrate successes, find specialists referrals, find the best community resources and exchange recovery tips. They also offer a space for forming healthy relationships filled with encouragement to stay sober. Here are some groups NAMI likes: - Double Trouble refers to a 12-step fellowship for individuals managing a co-existing mental illness and substance abuse. - 12-step groups like Alcoholics Anonymous Narcotics Anonymous, for individuals recovering from alcohol or drug addiction. - Smart Recovery – a sobriety support group for people with a variety of addictions that is not based on faith. All these groups follow the 12 phases or traditions of 12-step organisations, but they contain modifications addressing the co-occurring MHC. The Verdict? According to The Journal of the National Institute on Alcohol Abuse and Alcoholism: “Evidence-based practices for integrated treatment programs for individuals with substantial impairment and low functioning because of AUD and a serious mental illness, such as schizophrenia or bipolar disorder, include incorporating interventions that match an individual’s stage of readiness for treatment engagement and involve assertive outreach, motivational interventions, and counseling to build cognitive and behavioral skills. Evidence-based practices also include strengthening an individual’s connection with social supports that encourage recovery, a comprehensive approach that addresses AUD and MHCs in all aspects of the program, including social services, and takes a long-term, community-based perspective on recovery. Cultural sensitivity and competence are also crucial aspects of integrated treatment programs.” References: https://www.arcr.niaaa.nih.gov/arcr401/article07.htm?utm_source=GovD&utm_medium=Email&utm_campaign=Issue-401-Article-7 https://www.mdedge.com/familymedicine/article/207657/mental-health/caring-patients-co-occurring-mental-health-substance-use https://www.samhsa.gov/ Image references: https://www.mentalhelp.net/content/uploads/2015/09/1-mental-illness-new.png

Introduction Deep research into the grounds of psychopathology has extensively focused on two chief etiologic categories: genetic vulnerability and environmental factors. A crucial role for heritable/familial factors in the aetiology of a broad range of psychiatric disorders was established well before the modern era of genomic research. In this article, we will focus on the genetic basis of three disorder categories—major depressive disorder (MDD), the anxiety disorders, and posttraumatic stress disorder (PTSD)—for which stress responses and environmental stressors chiefly contribute towards pathogenesis. Each of these disorders runs in families and have been revealed to be moderately heritable. We will also reveal the possible connections between the three disorders based on the neural phenotypes as assessed by the functional MRI of the affected individuals and control population. What is Anxiety? Anxiety is your body’s natural response to stress. It’s a feeling of fear or worry regarding what’s to come. Anxiety disorders refer to a group of mental illnesses, and the distress they cause can keep you from carrying on with your life normally. The umbrella includes Generalised Anxiety Disorder, Specific Phobias, and Social Anxiety Disorder. What is depression? Depression (major depressive disorder) is a serious psychological disorder that negatively impacts your emotions, how you feel, your thought process and thus, your actions. However, it is treatable in most cases. Depression is characterized by feelings of grief and/or a loss of interest in daily activities (that were once enjoyed). Leading to a variety of physical and emotional symptoms, depression can decrease a person’s ability to function at work and at home. What is PTSD? Post-traumatic stress disorder (PTSD) is a mental disorder that's triggered by a terrifying incident — either witnessing it or experiencing it. Symptoms may include nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event. What are Neural Phenotypes? Evaluating the Genetic Basis of Psychiatric Disorders Psychiatric disorders are prevalent, complex, and severe disorders that affect the core of an individual: their emotions, intellect, and ability to self-regulate. The diverse research in this topic reflect various opinions and approaches in the field of neuropsychiatric genetics and neurodegeneration and could be understood as innovative responses to the challenges in the research on common complex disorders. Neurogenetics collects aspects from both the studies of neuroscience and genetics, focusing in particular how the genetic code of an organism affects the traits it expresses. Neurological diseases, behaviour and personality are all studied in a neurogenetic context. There is a significant overlap between the symptoms of post-traumatic stress disorder (PTSD), anxiety disorders, and mood disorders — like major depressive disorder and bipolar disorder. For example, someone with a generalised anxiety disorder might exhibit depressive symptoms, and someone with the major depressive disorder might experience excessive anxious states. Family Studies Evaluating the influence of genetics towards psychiatric disorders (as with other complex disorders) typically involves a series of questions and study designs. The first question remains, whether the disorder is inherited in families. Family studies are typically conducted to compare the prevalence of illness among first-degree relatives of affected individuals. Association Studies For multifaceted disorders, association studies remain more powerful for recognising risk loci and have become the dominant strategy for genetic studies of psychiatric disorders. Association studies typically utilise a case-control design to determine whether specific genetic variants (alleles) are more common among affected (cases) than among unaffected individuals (controls). Association studies have been used to assess different classes of DNA variation pertinent to psychopathology. The genetic makeup of a phenotype refers to the entire complement of underlying genetic risks factors including their number, allele frequencies, and effect sizes of contributing variants. Use of Brain Imaging to Connect the Dots Between Anxiety Disorder, PTSD, and Mood Disorders According to the JAMA study: "Up to 90% of patients with an anxiety disorder meet criteria for a concurrent mood disorder, and as many as 70% of individuals with mood disorders meet criteria for an anxiety disorder during their lifetime." What do these 9000 functional brain scans imply? The overlap of symptoms in these comorbid conditions infers that there have to be neurological similarities between the two conditions. To elucidate the findings, 9000 functional MRI’s from both diseased and control population were evaluated to unlock inner pathophysiology underlying these interconnected neurological disorders. Hypoactivation of Inhibitory Areas The clusters of hypoactivation were found in the following areas: · Prefrontal cortex/Insula · Inferior parietal lobule · Putamen These regions represent the right-dominant brain system which is chiefly involved in the contextual shifting and stopping of brain impulses and behavioural responses. The right inferior prefrontal cortex is exceedingly relevant when it comes to inhibition of contextually inappropriate affective, cognitive, and motor responses. This phenomenon is generally known as Salience. Neurocognitive studies in mood and anxiety disorders also indicate a general disruption in cognitive control because they consistently report deficits of large effect size in stopping and shifting responses in a range of tasks. These hypoactive areas correspond to the symptoms that we observe in these patients, like the inability to switch between tasks or particular emotions. “Locked in” states may also be explained very well through this finding as this is exactly what lack of salience can lead to. Clusters of Hyperactivation 3 chief clusters of hyperactivation were found - The left amygdala/parahippocampal gyrus (involved in emotional memory formation and retrieval) - The left thalamus, - The perigenual/dorsal anterior cingulate cortex (involved in regulatory influence for appraisal and emotional experience as well as generation of internal autonomic and their associated expressive emotional responses) The relative hyperactivation points towards the notion that these individuals have lower thresholds to arousal in response to stress factors. However, it could not be ruled out if these factors can/can't be attributed to the stress related to fMRI scans. Conclusion The study concluded that In this transdiagnostic study for mood disorders, posttraumatic stress disorder, and anxiety disorders, the most consistent abnormalities were found in the task-related brain activity in the regions that are primarily associated with inhibitory control and salience processing. This revelation regarding significant overlap in functional MRIs of these interconnected psychological disorders gives way for future interventions that can be directed towards these pathways and prevent morbidity in these affective studies. References https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2753513 https://www.psychiatry.org/patients-families/depression/what-is-depression https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294215/ Image references http://ww1.prweb.com/prfiles/2015/01/14/12440056/christinaveselak-mentalhealthnutrition-pressrelease-canstockphoto.jpg https://media.springernature.com/full/springer-static/image/art%3A10.1038%2Fmp.2016.89/MediaObjects/41380_2016_Article_BFmp201689_Fig1_HTML.jpg

Understanding Opioids Over the past few decades, much has been revealed about opioid dependence that has shaped our comprehension of addiction as a chronic disease. Opioid drugs activate specific opioid receptors (mu, kappa, and delta in the spinal cord and GIT system. Initially, when heroin or other opioids derivatives are consumed, activation of these receptors in the human body induces euphoric effects. Subsequent doses will quickly lead to tolerance – the need for increasingly higher doses to produce the same effect – and physical dependence. Currently, the studies reveal that tolerance is a result of a reduction in either the number or the responsivity of opioid receptor What are Opioids? Opioids are a class of drugs naturally occurring in the opium poppy plant and that act on the endogenous receptors in the human body to produce a variety of effects, including the relief of pain, euphoria and GIT effects. What do opioids do? The opioid drugs, characterised by morphine, can potentially produce profound analgesia, physical dependence, mood changes, tolerance along with a hedonic ('rewarding') effect which may lead to dependence or compulsive drug use. The receptors for opioids are found both in the central and peripheral nervous systems. Within the central nervous system, opioid receptors are widely spread in the spinal cord. In the peripheral nervous system, opioid receptors are located within the wall of the gut– responsible for the powerful constipating effects. Receptors in peripheral tissues such as joints seem to regulate inflammation. Mechanism of Opioid Dependence Opioid dependence is a neurobehavioral disorder characterised by a repeated, compulsive seeking or use of opioid medication. The predisposition for developing opiate addiction depends on the complex interaction between genetics, environmental factors, and the pharmacological effects of opiates. Environmental factors like availability of opiates from an early age, perceived risk of opiate use, psychosocial factors, and learned coping strategies all regulate the risk of developing an opiate addiction. Researchers also reveal an association between post-traumatic stress disorder and opiate addiction with an over-representation in the prevalence of this disorder in opiate addicts compared to the control population. Opioid dependence is accompanied by well-described physical dependence with withdrawal syndrome and tolerance. Opiate addiction includes not only abuse of illicit heroin and other opium derivatives, but also the less commonly recognised problem of misuse and chronic abuse of prescription opioid pain relief medications, such as oxycodone, hydrocodone, codeine, etc. Drug dependence is referred to a drug-induced clinical state in which, in which drug cessation results in physical and/or psychological withdrawal symptoms. Like many definitions, this is a blurry one. Underpinnings of the behavioural disease state of opioid dependence One addiction theory, including that of Robbins, Everitt, Wise, Berridge, Kalivas, Robinson, and Piazza stems from many decades of addiction research. This theory proposes the 3 steps model for the development of opioid dependence: 1st step: development of a reward learning process with drug consumption. 2nd step: escalated drug use in vulnerable individuals with hypo-dopaminergic systems and impaired prefrontal cortex inhibitory control. 3rd step: This step leads to the addiction phenotype, is described as a result of allostatic drug-induced changes in reward circuitry in your neurons which result in a strong desire for drugs (incentive-sensitisation). This model emphasises positive reinforcement. The driver for addiction seems to be the modified reward circuitry and loss of inhibitory control, with the inference of altered plasticity of synapses in cortical-striatal neuronal circuits and switching from goal-directed to habitual circuitry. Opioid withdrawal syndrome – What are the symptoms? Short-acting opioids (e.g. heroin): withdrawal symptoms ensue within 8-24 hours after last use; the phase lasts for 4-10 days. Long-acting opioids (e.g. methadone): withdrawal symptoms ensue within 12-48 hours after last use; the phase lasts for 10-20 days. Symptoms include: Nausea and vomiting Anxiety Insomnia Hot and cold flushes Perspiration Muscle cramps Watery discharge from eyes and nose Diarrhoea What is Opioid Maintenance Therapy? The primary driver of ongoing drug use is the negative reinforcement of withdrawal symptoms. Several strategies to relieve opiate withdrawal symptoms have been evaluated. An integrated global therapeutic approach towards pharmacotherapeutic decisions for opioid dependence should be adopted. This will include psychosocial support, focusing on the individual’s functional recovery. In this respect, Opioid Maintenance Treatments (OMTs) remains the gold standard medication for opioid dependence. While opioid medications are generally indicated for treating pain, when used as OMTs, they have their specific indication and their particular criteria of use. Methadone, buprenorphine, and naltrexone are each approved for the long-term treatment of opiate addiction. Prolonged-Release buprenorphine Buprenorphine has more recently emerged as an efficient treatment for opioid dependence. It has been marketed only since the 1990s for this use. In 2018, it was administered to 220,000 patients in Europe, and it was the most frequently prescribed OMT in the following 8 countries, including France, Sweden, Norway, Finland, and Greece. Prolonged-release depot injection and implantable formulations of buprenorphine are extremely recent novel developments in the treatment of opioid dependence. Such formulations remove the need for daily dosage and offer patients sustained concentrations of buprenorphine over weeks or months. Let’s explore the 2 case studies authored by our Medical Director Prof. Oscar D’Agnone: “Successful Treatment of Opioid Dependence with Flexible Doses of Injectable Prolonged Release Buprenorphine”, published in Case Reports in Psychiatry recently. [1] Case Study 1 Summary: A 52-year Caucasian male with a history of 22-years of intermittent heroin (injectable) use was started on prolonged release buprenorphine OMT. The patient was shifted from the initial treatment plan of oral buprenorphine to prolonged released buprenorphine due to daily intake challenges and work-life balance. The patient was started on 24 mg Buvidal®, subcutaneous injection after appropriate evaluation. At the 1st-week follow-up visit, the patient was stable, upon which he was administered a further dose of 96 mg buprenorphine for the following month. Three months of continuous therapy resulted in complete abstinence of all drugs, including alcohol and tobacco – with a complete absence of cravings and improvements in all aspects of his life. His relationships with friends and family improved significantly. Case Study Summary 2: A 56-year-old Caucasian female with an extensive 25 years’ history of heroin use, chose prolonged-release buprenorphine treatment as a part of a care plan for OD. The patient relapsed on her initial treatment of oral methadone of 60 ml per day. The patient was selected for prolonged-release buprenorphine and was started on oral buprenorphine one week prior to starting the treatment. During the 4 months of therapy there were no signs on relapse, and the patient appeared stable, happy and content. In fact, according to the patient, it was the first time in her life that had been successful in maintaining abstinence. Misconceptions Around the Use of OMT: Since maintenance medications (methadone and buprenorphine) are opioids themselves and are able to produce euphoria in individuals who are not drug-dependent, many people perceive that this form of treatment just substitutes a new substance use disorder instead of an old one. This belief has, unfortunately, stalled the acceptance of these effective treatments. Previously, even some inpatient treatment programmes that were otherwise evidence-based did not allow patients to use these medications, in favour of an "abstinence-only" viewpoint. Although it is possible for people who don’t have opioid dependence to get high on methadone or buprenorphine, these medications affect people who have developed a high tolerance to opioids in a different way. At the recommended doses, and as a result of their pharmacokinetic and pharmacodynamic properties (the way they attach and affect opioid receptor sites and due to their property of being slowly metabolised in the body), these drugs do not produce a euphoric effect but instead minimise cravings and withdrawal symptoms. This allows the patient to achieve stability and function normally, fulfil school or work responsibilities, and participate in other forms of treatment or support group recovery services to help them become free of their opioid dependence over time. References [1] Oscar D’Agnone, The OAD Clinic: Successful Treatment of Opioid Dependence with Flexible Doses of Injectable Prolonged Release Buprenorphine, Case Reports in Psychiatry, Volume 2019, Article ID 9381346, 4 pages, https://doi.org/10.1155/2019/9381346 Image references https://njmonthly.com/wp-content/uploads/2017/11/OPIODS-IN-THE-BODY.jpg https://www.abcam.com/ps/CMS/Images/066_12_KB-Opioid-Receptor2-400x300px.jpg https://www.zubsolv.com/wp-content/uploads/2014/12/brain-diagram.gif