Month: September 2019

What is alcohol use disorder?

Most of us drink alcohol. A large survey showed that about 78% of Canadians drank alcohol in the previous year, 21% exceeded low-risk consumption guidelines and about 6% drank heavily at least once a month (five or more drinks per occasion for men and 4 or more drinks per occasion for women).

Many people who misuse alcohol have occasional problems in their lives because of alcohol such as social/family, health, legal, or financial difficulties. Some people experience so many problems because of their drinking that they can be considered to have an Alcohol Use Disorder.

Alcohol use disorder occurs when there are ongoing negative consequences from drinking. For people with alcohol use disorder their drinking commonly results in significant distress and problems functioning in their daily life. Alcohol use disorder ranges from mild to severe, but anyone who is experiencing problems from their alcohol use should seek help to avoid the problem escalating.

In a recent survey of Canadians, approximately 18 % of the population met the criteria for some level of alcohol use disorder with the prevalence being higher for men than for women.

What are the symptoms of alcohol use disorder?

The number of symptoms a person meets is used to determine the severity of the disorder. Those who experience 6 or more of the symptoms below are considered to have a severe alcohol use disorder. However, a person who is experiencing any of these symptoms may benefit from professional help.

Alcohol is often taken in larger amounts or over a longer period of time than was intended.

• There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
• Craving, or a strong desire or urge to use alcohol.
• Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
• A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
• Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
• Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
• Recurrent alcohol use in situations in which it is physically hazardous.
• Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
• Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or b) A markedly diminished effect with continued use of the same amount of alcohol.
• Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Is alcoholism a disease?

Some experts believe alcohol use disorder is a medical disease that cannot be cured, just like diabetes. This is known as the medical model. They believe that people with alcohol use disorder have no control over their alcohol use and that their disease can only be managed by avoiding alcohol altogether.

Other experts argue that alcohol use disorder is a psychological disorder rather than a disease. They do not believe that alcoholism is an incurable disease. Experts from this perspective believe that people attempting to recover from alcohol disorders can choose to stop drinking altogether or can learn to drink moderately instead.

Who is at risk for developing alcohol use disorder?

If a person has a biological parent with alcohol use disorder, that person is at increased risk. Children may also learn patterns of heavy drinking from their parents.

Those in cultures or social groups where heavy drinking is accepted (e.g., those working in bars) are at increased risk. Also people’s attitudes and beliefs are important (e.g., believing alcohol has lots of positive effects). However, it is still very difficult to predict precisely who will develop alcohol use disorder.

What psychological approaches are used to treat alcohol use disorder?

The best known treatment for alcohol use disorder is Alcoholics Anonymous (AA). The AA approach is consistent with the medical model and includes a strong spiritual component. Abstinence (no drinking at all) is the treatment goal. Research has shown AA is effective for those who stick with it. One of its strengths is peer support and encouragement. However, AA has high dropout rates.

Two common psychological treatments have similar effectiveness to AA.

Cognitive Behavioural Therapy (CBT) helps a client change his/her drinking as well as their risky attitudes and beliefs. The goal of CBT can be either no drinking or moderate/controlled drinking (i.e., harm-reduction). CBT helps the client identify his/her own unique high-risk situations for heavy drinking. Then, they develop plans and skills that are alternatives to heavy drinking in these situations.

CBT also increases the client’s confidence about his/her ability to resist heavy drinking. Because alcohol abuse/dependence has high rates of return to heavy drinking, CBT often includes relapse-prevention.

Motivational Interviewing (MI) is another effective psychological treatment. MI is based on the fact that people with alcohol problems are at different stages of readiness to change their drinking.

Some are completely ready and simply need help to change. Others are thinking of changing but are not quite ready. Still others are not even considering changing or deny they have a problem.

MI helps clients move to a stage where they are more ready to change their alcohol use. For example, the therapist might encourage the client to really examine the pros and cons of continuing versus changing their current drinking patterns.

Severely dependent clients may be treated in a detoxification program in the initial stages to provide medical supervision of withdrawal from alcohol. Detoxification can precede treatments such as CBT, MI and AA.

There are also medications that may help people quit drinking. However, they only work while people take them, and they can cause side effects. Thus, MI and CBT are seen by some as safer, or as producing longer-lasting benefits than medications. Sometimes psychological interventions are used with medications to maximize benefits. For people who have problems with their alcohol use they should consult with their doctor to find out what the best treatment approach is for them.

Where do I go for more information?

More information regarding alcohol abuse and dependence can be found at the website of the Centre for Addiction and Mental Health at http://www.camh.net and the website of the Canadian Centre on Substance Abuse at http://www.ccsa.ca.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology go to http://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Drs. S.H. Stewart and Cheryl D. Birch, Dalhousie University.

Revised: September 2019

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

Bereavement is the state of loss when a loved loved one such as a parent, child, spouse, or close friend has died. Grief refers to the psychological reaction to the bereavement. Grief can occur due to various losses:

• Spousal death: Under the age of 55 about 1% of adults are widows, but by age 85 the majority of people are widowed. Spousal death after decades of marriage can be an enormous shock and adjustment.
• Anticipatory grief: When a spouse is experiencing a debilitating illness like Alzheimer’s or is admitted to a personal care home, grief may occur prior to the physical death. This is sometimes referred to as “anticipatory grief” but is in many ways is a full grief. At the same time that one is experiencing “caregiver stress” for taking care of a debilitated spouse, one is also grieving the loss of the marital companionship and affection.
• Death of a child: Death of a young child can be an emotionally painful parental experience. We all find the death of a child disturbing. Health care workers such as physicians and nurses working in pediatrics can experience significant grief distress when witnessing the deaths of their young patients. About one in ten of older people over the age of 65 will experience the death of one of their adult-aged children, a loss that can significantly deplete the family support network as they age.
• Cumulative bereavement: This refers to the reality that older adults will experience a number of losses of family and friends, often very close together. As we age, our social network can grow smaller and smaller as friends die, and we need to be able to re-build it, sometimes over and over again. Maintaining and rebuilding social networks is one of the essential tasks required for successful aging.
• Pets: Research shows that the death of a family pet can result in significant grief.

Many life changes can possibly also trigger an adjustment reaction similar to a grief response, including loss of health (amputations), retirement and loss of career identity, divorce.

While many aspects of this discussion of grief can apply to younger adults and children, much of our understanding of grief comes from the psychological study of middle aged and elderly bereavement, especially death of a spouse.

What is grief?

Grief is normal. Grief, especially for the death of a child, has been observed in many intelligent social animals such as dolphins and elephants. Creating social bonds and attachments is necessary for the survival and well-being of many species. When that bond is severed, grief is a normal reaction.

When death occurs for a person who has been a constant companion and with whom we have had a close emotional attachment, many changes in our life must be assimilated. Over many years of a close relationship, our self-concept can become defined by the relationship and this identity now must be reshaped. C S Lewis, the author of the well-known Narnia books, wrote of his own experience: “grief comes from the frustration of so many impulses that had become habitual.” Lewis observed in himself that many daily thoughts, feelings, and actions focused on the loved one as their object, “but now there’s an impassable frontierpost across it.”

Patterns of grief reactions

What is the normal intensity and length of grief? Are there stages or phases to this experience? There are many different reactions to grief and no one single pattern that fits most people.

About 30% or more, one in three people, experience a relatively mild distress in response to the death of a spouse, are able to quickly accept the loss of a loved one and resume normal activities. These people do not typically experience a delayed grief, and have good health outcomes. On the other hand about 30% experience waves of high distress. And another 30% or so falls in between these extremes and experience a moderate distress. Another 10% of people appear to experience a slightly delayed grief about 6 months after the bereavement. These estimates are approximate as different studies have found slightly different results.

The idea that grief occurs in stages is a common one, and was implied by Charles Darwin in 1872: “after the mind has suffered from an acute paroxysm of grief, and the cause still continues, we fall into a state of low spirits; or we may be utterly cast down and dejected.”  Some people experience an initial stage of shock or numbness, followed by a period about 3 months after the death of an increased depressed mood and yearning for the loved one. Generally, as acceptance of the death increases towards the end of the first year, the yearning, sadness, and anger gradually diminishes.

The experience of grief

The normal grief response can be very intense. For the 30% who experience an intense grief, symptoms may include waves of sadness, sleeplessness, fatigue, poor concentration, and loss of appetite. There will be a strong yearning for the lost loved one. Death of a close life partner may lead to sensing the presence of the dead spouse, such as briefly hearing their voice; this is very common and can last for over a year. Many people find hearing the voice of a spouse or dreaming of the spouse reassuring if they are aware that it is normal.

An intense grief experience may closely resemble the symptoms of a depression. Indeed, grief can be more intense than a depression. DSM-5, the diagnostic manual of the American Psychiatric Association, indicates that a careful clinical judgement by a professional is sometimes required to differentiate a normal intense grief from a depression.  DSM-5 suggests that grief can be differentiated from depression in that grief comes in waves of emotion, whereas in a clinical depression the mood is more constantly negative. In grief, the individual usually maintains a positive self-esteem and the focus of the grief experience is specific to the loss of a loved one, whereas depression includes a much broader negative view of the self.

How long does grief last?

How long is grief expected to last? There is no straightforward answer to this question. The answer varies by person, circumstance and culture. We are not meant to forget the deceased loved one, and memories of that person may be painful for years to come. Increasingly, grief experts suggest that a sense of a “continuing bond” and relationship with the deceased is quite normal and healthy. The resolution of grief does not mean forgetting the deceased person, or lessening our affection for them. But one is expected to resume normal activities.

Many events during the first year can be difficult such as the first family dinner, first birthday, first wedding anniversary, first major religious holiday, or first anniversary of the death. After the first anniversary of the death, the intensity of grief reactions has typically subsided with the individual having returned to everyday activities and normal daily mood. However, even after many years, brief waves of grief may still occur, especially at anniversaries.

When is prolonged grief considered a problem?

At the time of the bereavement, most grief reactions of varying intensities, even intense reactions, are generally considered normal. Grief is typically only considered a mental health issue if it becomes excessively prolonged. About 7% of people experience a prolonged high level of grief.

In a prolonged or “complicated” grief, the individual stops making progress in recovering from the bereavement stress and remains overly focused on past memories for many months and years. In a prolonged complicated grief, the individual continues to yearn for the deceased and remains withdrawn from resuming normal social activities. Everyday thoughts and memories of the deceased continue to be accompanied by severe emotional spells. There may be pervasive feelings of numbness towards others, loneliness, emptiness, meaninglessness, regret, and difficulty acknowledging the death. There may be a continuing avoidance of places that are reminders of the deceased person including family gatherings, social groups, the church where both attended, medical facilities, and other funerals. Some degree of these symptoms may occur from time to time in most grieving people; it is only when these prolonged symptoms are excessive and interfere with normal everyday functioning that the grief is seen as problematic.

A prolonged grief may depend on many factors. Grief may be complicated by the circumstances of the death, such as being unexpected, accidental, by suicide, or after a difficult and painful illness. Death of one’s child at any age is difficult to accept. Life factors may contribute to the development of a complicated grief, such as a lack of support from family and friends. The personality style of the grieving person can also lead to complicated grief. For example, if the individual has been overly dependent on the now-deceased spouse or parent, the grief process may be more difficult or prolonged.

How long is too long? There is much debate and controversy as to the length of grief that should be required as the minimum to consider a prolonged grief as warranting a mental health diagnosis. The World Health Organization (ICD-11) uses a diagnostic category of Prolonged Grief Disorder which can be considered at a minimum of 6 months following the bereavement. Prolonged Grief Disorder is conceptualized within ICD-11 as a stress disorder, similar to an Adjustment Disorder. The American Psychiatric Association’s DSM-5 proposes a similar diagnostic category of Persistent Complex Bereavement Disorder, which is considered only after 12 months post bereavement. These different recommended minimums for a prolonged grief disorder need to be viewed as arbitrary. Expecting an adjustment to a severe grief reaction of at least 12 months post bereavement more closely matches the normal course of grief. There are many varying circumstances, and a great variety of grief reactions.

When and how is pronged complicated grief treated?

Grief is a normal response.  Grief is not an illness and usually does not require medication or psychological treatment unless safety issues emerge. Treatment of grief should be approached with caution. It is not necessarily desirable to eliminate grief, which is part of a normal emotional adjustment to the death of a lifelong partner or loved one.

Preventative approaches immediately following the death have not received evidence of a lasting effectiveness. Early grief interventions such as bereavement groups can provide useful social support and reassurance if conducted carefully, but appear to have only a temporary positive effect and little evidence of long-lasting benefit. Bereavement groups may potentially be harmful if they convey to the individual that their grief is unhealthy, or undermine the person’s normal coping by forcing onto them an intense emotional grief focusing.

Psychological interventions are best reserved for a prolonged complicated grief. When psychological intervention is provided to a prolonged grief, at least 6 months following the bereavement, there is evidence of moderate but lasting benefit. For prolonged grief there is also some evidence of greater benefit using an individual format rather than group interventions.

Cognitive-behavioural therapy (CBT), cognitive processing therapy, interpersonal psychotherapy, brief psychodynamic or other effective psychotherapies can be used to help the person engage in activities and think about and understand the impact of the loss. Some individuals may need to work through some of the complicating aspects of their relationship to the deceased. Regret resolution can be important. For example, it may be useful to revisit past relationship hurts and forgive past faults, regrets, anger, and guilt.

Cognitive behavioral interventions are used to help people gradually return to their daily routines.  An important component of a psychological treatment for traumatic aspects of grief is to help the individual to return to situations they are avoiding because of the fear of the distressing memories. Continued avoidance of these situations increases the sensitization to grief emotions, whereas only by entering these situations does the excessive distress gradually dissipate. Cognitive behavioural strategies to overcome avoidance have been shown to be more effective than supportive counseling.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to https://cpa.ca/public/whatisapsychologist/PTassociations/.

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lorne Sexton, Psychology Program Site Manager at St. Boniface General Hospital, Winnipeg Regional Health Authority, and Associate Professor, Department of Clinical Health Psychology, University of Manitoba.

Revised: September 2019

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657

What is irritable bowel syndrome?

Symptoms of Irritable Bowel Syndrome (IBS) include pain or discomfort in the lower abdomen (below the belly button area) and changes in bowel habit that involve frequent, urgent diarrhea or constipation. Bloating is another common symptom. IBS is a medical disorder of the lower ‘gut’ (the small and large intestine) which is one part of the gastrointestinal (GI) tract.

It is understood to be a problem of the functioning of the gut. It is thought to occur because of communication problems between the brain and the gut. Research suggests that people with IBS experience abnormal gut motility (changes in the rate of contractions of the gut muscles) and enhanced visceral sensitivity (an increased sensitivity to gas or sensations from routine activities that occur in the bowel).

It is not clearly understood what causes IBS. For some people it begins in childhood with a ‘sensitive stomach’ that develops into more intense symptoms as an adult; for others, the GI problems start suddenly during a period of stress or persist after an infection in the bowel. IBS is diagnosed based on the presence of the symptoms described above in combination with the absence of other ‘red flag’ symptoms (such as weight loss or bleeding).

IBS is very common. It is estimated to affect up to one in five Canadians. It often starts in young adulthood and occurs much more frequently in women than men. It is the second most common reason for missing work and is one of the most common reasons that people visit their doctor. In Canada, IBS has been estimated to cost over $350 million in direct and over $1 billion in indirect health care and productivity costs each year.

While the impact on society is quite significant, IBS can be very challenging for the individual. Pain, cramping or urgent trips to the washroom may interfere with work and home activities. The bloating, gas and urgency can be embarrassing, so people often suffer in silence.

Many people think certain foods must be the culprit but there is no evidence to support the idea that IBS is related to food allergies or food sensitivity. Once IBS develops, however, the bowel is over-reactive to or easily triggered by a variety of things including diet, stress, emotional state, and even hormone fluctuations.

Stress does not cause IBS, but it does appear to play a particularly important role in triggering IBS symptoms, likely because of the close communication via nerves and chemical pathways between the brain and the gut. In fact, two-thirds of healthy individuals without IBS report GI symptoms of pain or bowel upset in response to stress and the numbers are even higher for people with IBS.

Research suggests that both ‘acute stressors’ such as deadlines, exams, job interviews, or conflict with others as well as ‘chronic stressors’ such as financial concerns, time pressures, or family issues can aggravate the gut.

Can psychology help?

Absolutely. For those with milder IBS symptoms, use of over-the-counter medications and changes in lifestyle that ensure more regular eating and sleep routines, a healthier diet with increased fibre and water intake, as well as more regular aerobic exercise are usually sufficient to provide some relief.

However, for those with moderate to severe symptoms, medical and psychological treatments are recommended. These treatments usually target specific symptoms (like pain, diarrhea, or constipation) or aim to decrease the triggers (such as stress) that aggravate the symptoms.

Conventional medical treatment has included fibre supplements, antispasmodics, gut motility agents, and medications that act on biochemicals such as serotonin in the GI tract and central nervous system. At this point, reviews of the effectiveness of the medication treatments have concluded that they are helpful for small subsets of people with IBS, but have been disappointing overall in their impact. For the most up-to-date information on medication treatments as they apply to your situation, you are encouraged to discuss the use of these medications with your family doctor.

Several specific psychological treatments have been found to be effective in providing relief of IBS symptoms as well as reducing the distress and coping difficulties that often occur when dealing with a chronic illness. These psychological therapies focus on ways to decrease stress and cope differently so that the stress does not ‘go to the gut’.

What psychological treatments are effective??

Four approaches have been carefully evaluated over the past number of years and have been found to be of benefit. These treatments are provided by professionals trained in psychological interventions for health problems.

Relaxation training teaches ways to relax the body and mind.

Cognitive Behavioural Therapy (CBT) incorporates a number of steps aimed at changing behaviour to improve health and coping. It often involves providing information to ensure a better understanding of the illness (to help with fears and worries), teaching strategies to change thinking patterns that can contribute to strong emotional and physical reactions, teaching skills to deal with challenging or stressful situations that can trigger the gut, and goal setting to establish optimal health habits. CBT typically includes relaxation training.

Hypnotherapy uses mental imagery and hypnosis instruction to specifically reduce gut sensations and develop a state of calmness and relaxation.

Brief Dynamic Therapy focuses on significant personal relationships. The emphasis is on identifying and dealing with challenging interpersonal situations and interpersonal stressors that can trigger the gut.

Cognitive behavioural therapy is the most commonly available type of psychological treatment for IBS in Canada and the United States. Evaluation studies have shown that psychological treatments can lead to greater improvement than the usual medical treatment. As well, the psychological therapies have long lasting effects months to years after treatment was completed.

Medication treatments, in contrast, tend to cease to have an effect when patients stop taking the medicine. Some research suggests that the amount of improvement relates in part to the effort and time the individual contributes to working with the strategies.

Where do I go for more information?

For more information about irritable bowel syndrome and steps you can take based on these psychological therapies:

• Breaking the bonds of irritable bowel syndrome: A psychological approach to regaining control of your life. (2000) Barbara Bolen. New Harbinger Publications Inc.
• IBS Relief: A complete approach to managing irritable bowel syndrome. 2nd edition (2006) Dawn Burstall, T. Michael Vallis, Geoffrey Turnbull. John Wiley & Sons Inc.
• Controlling IBS the drug-free way. A 10-step plan for symptom relief. (2007) Jeffrey Lackner. Stewart Tabori & Chang.

For general information about IBS and similar gastrointestinal disorders please visit the International Foundation for Functional Gastrointestinal Disorders at http://www.iffgd.org.

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, click https://cpa.ca/public/whatisapsychologist/PTassociations/.

 

This fact sheet has been prepared for the Canadian Psychological Association by Dr. Lesley Graff, Associate Professor with the Department of Clinical Health Psychology, Faculty of Medicine, University of Manitoba and staff psychologist at Health Sciences Centre, Winnipeg, Manitoba. Dr. Graff’s clinical work and research is primarily in the area of chronic pain, stress, and gastrointestinal disorders.

Revised: September, 2019

Your opinion matters! Please contact us with any questions or comments about any of the Psychology Works Fact Sheets:  factsheets@cpa.ca

Canadian Psychological Association

Tel: 613-237-2144
Toll free (in Canada): 1-888-472-0657