A nationally recognized expert on compulsive behaviors explains the phenomenon of craving and gives us tools to achieve freedom from our seemingly insatiable desires by changing our actions to remap our brains.
When we find ourselves wanting something strong enough, we’ll do just about anything to get itsometimes at the expense of our bodies, brains, bank accounts, and relationships. So why do we sometimes have the irrepressible feeling that we need somethingsuch as food, cigarettes, alcohol, or sexthat we really just want? And how do we satiate that feeling without indulging it?
In Craving, Omar Manejwala, M.D., translates the neurobiology of this phenomenon into real and accessible terms, explaining why we just can’t seem to get enough. He then gives us tools and guidance to find satisfaction without giving in to our cravings.
Dr. Manejwala explains: how and why our brain drives behavior; how to change the part of our brain that fuels our cravings; the warning signs that craving is evolving into addiction; why craving is the most difficult component of addiction to address; and why self-help and spiritual groups that use models like the Twelve Steps are so effective at changing behaviors, receiving encouragement, and remaining accountable.
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The Tenacity of Craving
“What is allowed us is disagreeable, what is denied us causes us intense desire.”
-Ovid Many of the people I have worked with over the years point out how stubborn cravings are. They will often describe the sense that something has sunk its teeth into them and is not letting go. The harder they tug to try to remove it, the deeper the bite. Many of my patients describe this as wanting what they cannot have. Psychologists refer to our response to perceived constrained freedom as reactance.
But we don’t always want what we can’t have. Studies in the late 1970s demonstrated that when heroin addicts were given the drug Naltrexone, which blocks the effects of heroin and other opiates, their cravings actually went down. Once the addicts were aware that they couldn’t get high, they were less likely to crave! This finding persisted even when they were around other heroin addicts who were actually getting high.
When are we more likely to want what we can’t have? In a classic reactance experiment by Paul Cherulnik and Murray Citrin, one hundred and eighty college students were shown four posters and asked to rank which was their first, second, third, and fourth choice. They were told they would get their first choice poster. Cherulnik and Citrin measured the students locus of control using a validated scale that established whether their locus of control was internal (i.e. they tended to believe that they control their own lives) or external (they tended to believe that their lives were controlled by external factors beyond their own control).
Two days later, they divided the students into three groups: one group that was told they lost their third choice because of a shipment problem (impersonal reason). A second group was told that their third choice poster arrived in limited quantities and that their third choice was removed as an option for them on the basis of personal reasons (an assessment of their scholastic records). Finally, a third group was a control group and was simply asked to re-rate their choices.
The results were fascinating. The students with an internal locus of control showed an increased desire for the unavailable third choice poster when the reason for elimination was personal. On the other hand, the students with an external locus of control showed an increased desire for the unavailable third choice poster when the reason for elimination was impersonal. What does this mean, and what does this have to do with cravings?
What it means is that it turns out it’s not always true that you want what you can’t have. What this study shows is that what you believe about the reason you can’t have something affects whether or not you want it. If you believe that the primary power that controls your life is also the primary reason you can’t have something, you want it more. This has significant implications when it comes to cravings, because it means that if you can develop a different perspective about why you are experiencing cravings, you may be able to reduce the depth of the bite. In my successful patients who believe in a higher power, when they experience cravings, they don’t blame God. They simply describe it as a facet of their illness that will respond to discussion with others and practice of their program. By separating the locus of control, they achieve success and a reduction in their desire. We’ll explore these concepts further in chapters seven and ten.
The Vicious Craving Cycle
Thus far in this chapter we’ve seen how distortions and bias in thinking can lead to problems in how we handle cravings, resulting in more cravings because we cannot see clearly enough to address them. However, there is another force that drives cravings: cravings themselves. To see how this works, consider this example:
Tom is driving home from a particularly hard day of work after successfully quitting smoking for four days. He begins to crave a cigarette again but manages to resist the craving. He notices that his gas tank is down to less than a quarter full. There is enough to get home, but he may not have time tomorrow morning to fill it so he decides to stop at a gas station. When paying for his gas, he notices the cigarette display. He decides he is only going to have one cigarette, but of course they aren’t sold individually. So he purchases a pack with the intention of throwing the rest away. After purchasing the pack, he thinks to himself, “Throwing these away would be a waste of money. I’ll just give the rest to my coworker tomorrow who is a smoker.” By the time he goes to bed he has smoked the entire pack.
By now, you are skilled in picking up some of the cognitive biases evident in his thoughts, and there are several. But there is another force at play here: The craving itself led to a behavior (purchasing a pack of cigarettes and saving them) that also was a setup for further cravings. Most smokers who are attempting to quit will tell you that if there are any cigarettes hidden anywhere, the thought of those cigarettes can be downright overwhelming. The behaviors that result from acting out on cravings are themselves a setup for further cravings. (This example also contains a great example of attentional bias where the addict preferentially notices the cigarette display and turns his attention away from all the other displays and towards the cigarettes. Several researchers have posited a relationship between attentional bias and cue-related craving).
There are countless examples of this phenomenon. I usually tell my patients to delete the telephone numbers from their cell phones of anyone that they don’t need to contact unless they want to act out on their cravings. Now, if you think about the phone numbers in your cell phone, you probably don’t know most of them. You rely on your cell phone to find and dial the number for you. But when it comes to cravings, these numbers have a funny way of getting into your memory, where it’s much harder to “delete” them. The result is even more cravings. The craving led to a behavior (not just calling a co-conspirator, but focusing on and remembering the number) that ultimately led to more cravings.
Beyond these superficial examples of cravings-leading-to-behaviors-that-drive-cravings is a deeper cycle, driven by the emotional consequences of acting out on cravings. This phenomenon was described in 1939 in Alcoholics Anonymous:
They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinksdrinks which they see others taking with impunity. After they have succumbed to the desire again, as so many do, and the phenomenon of craving develops, they pass through the well-known stages of a spree, emerging remorseful, with a firm resolution not to drink again. This is repeated over and over, and unless this person can experience an entire psychic change there is very little hope of his recovery.
The sense of remorse and shame that follow acting out on addictive behaviors can be powerfully debilitating. No discussion about cravings is complete without addressing shame. As a psychiatrist, I unfortunately know of many cases where a patient’s last words were remorse over acting out on a craving of some sort or another. Common sense would suggest that when people engage in self-destructive actions, particular those that are socially unacceptable or hurtful to others as well, that shame would be common.
Much has been written on the topic of shame when it comes to addictive or self-destructive behaviors, and unfortunately very little of it has been in the academic/research literature, but one thing is clear: shame appears to be extremely common in people who struggle with cravings. In fact, in John Bradshaw’s book Healing the Shame that Binds You, he describes the experience, hypothesizing that acting out on eating disorders is essentially a substitution for shame-bound interpersonal needs. In other words, in these people, the desire to be loved, nurtured, and cared for is unacceptable, and inexorably bound up with shame. Food is therefore substituted. However, as Bradshaw writes:
Food can never satisfy the longing and as the longing turns into shame, then one eats more to anesthetize the shame. The meta shame, the shame about eating in secret and binging, is a displacement of affect, a transforming of the shame about self into the shame about food.
Although people sometimes use the terms guilt and shame interchangeably, from a psychological or treatment perspective we think of them quite differently. Also, most people seem to sense this difference, even if they don’t express it. In addiction treatment circles, we view shame as the sense that you are flawed, particularly in some fundamental way that renders you bad or unworthy of love. With shame, the core thought is “I am a bad person.” On the other hand, guilt is the sense that you’ve done something wrong. The core thought here is “I’ve done something I shouldn’t have.” In this way of looking at shame and guilt, guilt does not threaten a person’s core identity. Shame, however, is devastating to the all-important sense of worth and value that people need in order to navigate their lives with dignity and integrity.
Culturally, our sense of shame has changed over the last few decades. Some groundbreaking work by Thomas Scheff of the University of California Santa Barbara has demonstrated that western societies tend to suppress shame.
However, in that same research, Dr. Scheff also found that the threshold for shame in western societies has been decreasing. What that means is that we are both more likely to experience shame and more likely to suppress it which should be considered a recipe for disaster. As the gap between what we experience and what we can express grows, we get sicker.
Sometimes people with addiction are so disconnected from their emotions as a result of acting out, that they present with what psychologists call neurotic defenses such as emotional detachment rather than overt shame. This appears to be more common in men. In those cases, people who are experiencing shame may actually come across as an “emotional wall.” To an observer, they may look as though they aren’t experiencing any emotions at all. They may seem unflappable, as if they are numb or immune to situations that would cause most people to experience (and express) profound emotions. It’s very easy to look at people who are expressing self-pity or self-loathing and see that they are dealing with shame. It’s much more difficult to see the shame behind the tough exterior and detachment of those who seem emotionally numb. In both cases, however, dealing with shame is critical if there is to be any relief.
Because shame is uncomfortable, many people tend to avoid it, or pretend it isn’t there, and psychotherapists are not immune to that either. I’ve also seen many cases where therapists treated shame in a very superficial way, often because of their own discomfort with the topic. At any evidence or expression of shame that a person might show, the therapist pulls away, tries to redirect, or glibly explains away the notion. One way that this can look is that a patient can express a shameful thought or belief (either verbally or nonverbally), and the therapist immediately jumps in and attempts to convince the sufferer that it isn’t true that really they are a good person. The result is that the patient’s experience is not validated, the real issues are avoided, and the shame grows covertly.
In my clinical experience, for many people who suffer from cravings, trauma, addiction or any of a number of self-destructive behaviors, shame plays a key role in fueling addiction. Thus shame seems clinically to be both a contributor to addictive behaviors as well as a result of addictive behaviors.
Table of Contents
Chapter 1 Craving: why it matters
Chapter 2 Beyond neurotransmitters: The real brain science of craving and decision-making
Chapter 3 How cravings drive self-defeating behaviors and the tenacity of craving
Chapter 4 Addiction is addiction: how gambling, food, sex, alcohol and drug addiction are related
Chapter 5 Plasticity: How thoughts, actions, experiences (and drugs) actually change your brain
Chapter 6 Spirituality and recovery: How 12-step recovery and other spiritual approaches reduce cravings
Chapter 7 You can’t do it alone: why groups can improve urges and behaviors that individuals can’t
Chapter 8 The naïve perception of immunity
Chapter 9 Apparently Irrelevant Decisions (AID) and how simple actions can reduce craving
Chapter 10 Joy, hope and recovery
Appendix: A Field Polarized: The Uncomfortable Gap Between Cognitive Therapies and Twelve Step Programs
About the Author