Aside from the psychological strategies of cognitive-behavioral therapy, which prepare our minds for change, we can use three primary physical strategies to prepare our bodies for change: getting exercise, improving our sleep, and using medication to break tunnel vision.

Would you like to hear about how exercise helps with overcoming addictions?

How often do you currently get cardiovascular exercise (as opposed to weight training)?

This section may be especially helpful for you! I hope that I can convince you to step up your frequency (if you have poor health or significant medical problems, be sure to consult your primary care physician before starting or stepping up your exercise regimen).

You're doing pretty well. Still, you may see that things get easier if you step up your frequency a bit.

That's great to hear! Hopefully this section will help you maintain your commitment to frequent exercise.

While exercise has many ways of boosting your self-control (see the excellent book "Spark" by Dr. John Ratey for a full discussion), I think that there are two that are particularly important: it increases neuronal arborization, and ramps up the activity of your parasympathetic nervous system. That is to say, it makes your thinking clearer, and lets you "digest" cravings more efficiently.

Let’s talk first about arborization, which refers to the shape and extension of your neurons.  The ideal neuron looks like a tree in the winter, without any leaves, that is full of many tiny branches and twigs. The more branchy and twiggy the tree is, the healthier the tree; and it is the same with neurons. We want them to be very branchy and twiggy, since the neurons use these tips for communicating with each other. 

What do you think is the effect of stress (e.g., the kind of stress that a chronic addiction brings) on the branchiness and twigginess of neurons in your upper cortex?

Sometimes you can guess the right answer by putting yourself into the position of the questioner. In this case, you could ask yourself, "Would he really be asking me this if the answer was that there's no effect?"

Sorry, the correct answer is "C: Stress decreases their arborization."

We need our upper cortex to be in good shape if we are to resist the strong cravings and impulses that come from our lower cortex. Stress is taxing on our upper cortex, causing the neurons to lose their arborization. This makes it harder to think clearly and inhibit impulses.

That's right! We need our upper cortex to be in good shape if we are to resist the strong cravings and impulses that come from our lower cortex. Stress is taxing on our upper cortex, causing the neurons to lose their arborization. This makes it harder to think clearly and inhibit impulses.

Stress decreases how branchy and twiggy your neurons are in the parts of your brain that help you focus, control your impulses, think flexibly and remember well. It's as if the neuronal "tree" had a dial at its base that controls its branchiness and twigginess: the stress hormone called cortisol turns that dial down, so that you first lose the little twigs, then smaller branches, and so on. Your neurons get more stubby and your cognitive abilities decrease.

At the same time, chronic stress leads to the "over-arborization" of neurons in your amygdala (i.e., it turns the "dial" too far "up"); this may boost the power of your amygdala to trigger cravings, making the cravings more powerful and making automation more likely to set in. 

So the effect of stress is two-fold: it makes your thinking more cloudy by affecting your memory center, and it makes your amygdala more responsive to triggers. Both of these effects tend to tip the scales in favor of the vicious cycle of addiction.

See Vyas, A., Bernal, S., & Chattarji, S. (2003). Effects of chronic stress on dendritic arborization in the central and extended amygdala. Brain Research, 965(1-2), 290–294.
The good news is that exercise powerfully reverses the effects of stress on arborization. When we exercise, our body responds with a surge in a hormone called "Brain-Derived Neurotrophic Factor," or "BDNF" for short.

In animal models, even one session of intense cardiovascular exercise was enough to fully arborize the neurons that had their dials turned "down" by stress. (We would expect that it would also return to normal those neurons in the amygdala that had been "overarborized" by the stress.) The effects seem to last for a couple of days, meaning that you will keep your neurons in the best shape possible if you get exercise at least every other day.

Regular cardiovascular exercise has been shown to particularly increase the size of your prefrontal cortex, leading to improved cognitive control of behavior, improved attention and flexibility, improved working memory and faster processing speeds. Exercise brings clarity and control to your upper cortex.

These benefits appear to be dose-dependent: the more exercise you get, the greater the improvement.

See Gomez-Pinilla F, Hillman C (January 2013). "The influence of exercise on cognitive abilities". Compr Physiol 3 (1): 403–428.
Intense exercise turns on your sympathetic nervous system, the part of your nervous system involved in the fight or flight response, which gets chronically over-activated when you’re under stress. While you exercise, you get a boost of adrenaline, the main hormone of this system. 

All that changes when you stop exercising. At that point your parasympathetic nervous system turns on; this turns off your sympathetic system and gives your body a chance to restore itself. Parasympathetic activation undoes the effects of stress, helping you to “rest and digest.”

We are now coming to understand that parasympathetic activation helps you to not only “rest and digest” physically, but also mentally and emotionally. It helps you to focus your attention on one single task, and it also allows you to “rest your amygdala” and “digest your cravings” — without acting on them. 

When you are in the throws of an addiction, your amygdala is chronically hyperactive, looking for potential trigger, and firing off quickly when they are detected. Having a higher amount of parasympathetic activity keeps your amygdala nice and quiet.

Exercising regularly also increases the effectiveness of any mindfulness practice you might do by priming your parasympathetic nervous system to turn on more powerfully. Mindfulness itself turns on your parasympathetic nervous system, as is measured by the drop in your heart rate as you exhale; see the previous module on mindfulness to see how you can measure this at home.

If you exercise before mindfulness practice, your primed parasympathetic nervous system will give an even greater boost to your focus and self-control. This makes it easier for you to see trials as opportunities, and to use to your attention to work through cravings intentionally when they come (e.g., “digest” them). For this reason, the best time for exercise in first thing in the morning.

Would you like to hear about improving your sleep?

In general, there is a link between addictions and sleep disorders. Sometimes people use addictive drugs or behaviors to help them fall asleep; they think a permissive thought like “I’ll just get this over with” to justify giving in to the cravings. Other times, the sleep disturbances come only when a person tries to stop giving in to the addiction. Either way, you will benefit from hearing a few tips from the cognitive-behavioral treatment of insomnia. 

Which do you think is the best strategy for improving sleep?

Sorry, that's actually bad sleep advice. Try again!

Correct! These strategies are all terrible at improving sleep, and yet, they are all commonly used by people with insomnia. Now let’s discuss each of them.

The first principle of behavioral therapy for insomnia is that you need to reduce the time you spend in bed while not sleeping. You want to improve what is called sleep efficiency, defined as the number of hours spent sleeping divided by the total number of hours spent in bed, times 100. Anything less than 90% is considered insomnia. It's best to remove the TV from the bedroom, read somewhere else (e.g., a nearby chair), and avoid long conversations.

The second principle of behavioral therapy for insomnia is that you need to fix your daily wake-up time, and not vary it at all in response to the amount of time you actually spent sleeping (and your weekend wake-up time shouldn’t be more than an hour later than your weekday wake-up time). 

This might mean that initially you have less sleep and are more tired during the day; gradually, however, you will find it easier to fall asleep at the right time at night, and you will maintain better sleep through the night. You should generally aim at not getting less than seven hours of sleep, and not getting more than eight. When the alarm goes off, immediately get out of bed, before it has time to become a struggle. It's never easier than at that first instant!

The third principle is that you should only get into bed when you are feeling sleepy. Researchers call the "force" that pushes you into sleep "sleep pressure." Reading a boring book before bedtime increases sleep pressure. So does working hard during the day, exercising (earlier in the day), and avoiding naps. On the other hand, caffeine, intense TV shows or movies, emotional discussions and computer screens all decrease sleep pressure; these should be avoided close to bedtime.

Finally, behavioral therapy for insomnia teaches that, if you find yourself awake in bed and it has been around twenty minutes, you should get out of bed and engage in a non-stimulating activity until you feel sleepy (e.g., read that nonfiction book). Once you get a wave of drowsiness you can go back to bed and allow sleep to set in. Do not try to fall asleep: sleep effort is paradoxically stimulating (it reduces sleep pressure). Sleep has to just come on its own. 

One important caveat: this assessment needs to be done without looking at a clock: you should never have a clock visible from the bed, nor should you check the time on your phone. Clock-checking worsens sleep. Sleep shouldn't be monitored or measured too closely, lest you start worrying about sleep, and fearing insomnia. Insomnia often comes from having a phobia of insomnia.

Studies suggest that just knowing and following these guidelines is enough to significantly improve sleep for most people with chronic insomnia. If you have more serious sleep problems (e.g., you are not getting even six hours of sleep at night, and these recommendations do not help) you would likely benefit from seeing a psychiatrist or sleep disorder specialist.

See Buysse DJ, Germain A, Moul DE, et al. Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults. Arch Intern Med. 2011;171(10):887-895.
Would you like to hear about how a medication can help to break vicious cycles?

As a psychiatrist and behavioral therapist, I approach the topic of using medications with some caution. Too often people expect the medication to do all the work, and end up being disappointed with the results. 

My understanding of the role of medications is that they help to transfer momentum from vicious cycles to virtuous cycles.

For instance, propranolol is often used to help people with their fear of public speaking. Propranolol blocks the effects of adrenaline outside of the central nervous system, making them externally feel calm. As a result, they can experiment more with speaking in public, and grow in confidence: the vicious cycle of avoidance gets broken, and the virtuous cycle grows as they gain mastery in public speaking. The propranolol dose is then cut in half, and then the medicine is stopped. 

Is the medicine necessary? By no means! It is probably better, from a behavioral therapy standpoint, not to use it; but it can be a temporary help to get things started.

It’s similar with depression. If a person were depressed and lethargic, staying in bed all day and sleeping long hours, withdrawing from all activities that require energy, he would be caught in a vicious cycle: the less he did, the less energy he would have, and the more he’d think he needs to stay in bed. The psychological treatment is called “behavioral activation,” which helps him to deliberately engage in activities despite feeling depleted (or even better, with the goal of feeling depleted!). This can be helped with using medications such as antidepressants, or stimulants, that make it easier to engage in activities. As he engages more, his energy increases, and gradually the vicious cycle is broken and a positive cycle of engagement produces increasing amounts of energy; the medication is then slowly tapered and discontinued.

The process can be similar with addictions. There are medicines that can help to interrupt tunnel vision, decrease impulsivity, and increase the speed of habituation.

We'll start by talking about naltrexone.

Naltrexone is an antagonist of mu and kappa opioid receptors in the brain, and binds to these receptors with very high affinity. This means that it blocks other opioids from being able to activate the opioid receptors, including the endogenous (native) opioids that form part of the brain's response to addictive pleasures. 

We do not exactly know how this relates to blocking the formation of tunnel vision and keeping automated pursuit of pleasure from turning on; but it makes sense that opioids would be involved in pleasure pathways, and that blocking them could impact the vicious cycles that pleasures can create. Stay tuned for more research on this topic.

Naltrexone should never be taken by people who are currently using opioid medications, and needs to be expertly administered in cases of opioid addiction (i.e., by an addiction psychiatrist).

Naltrexone comes in 50mg pills, and usually patients have to start on half a pill in order to avoid the feelings of nausea that it can produce at first. It can be taken as needed, and has a time-frame of action similar to using ibuprofen for headaches (around 6 hours of full effect). Patients that take a full pill daily often report that the effects seem to last all day.

This means that if a person can foresee that they will be vulnerable to cravings during a certain time period, he can take the naltrexone to “pre-treat” the tunnel vision and automation that gets triggered. If needed he can take it daily and experience a longer-lasting effect.

I usually continue the naltrexone until there has been at least a couple months (more typically, six to twelve months) of sobriety, at which point we can slowly decrease the dose. The dose decrease can give patients chances for “practice” — having cravings more present, and learning how to not reinforce them, so that eventually the cravings fade again; then decrease the dose again, go through another round of practice until the cravings fade, etc. The pill only comes in one size, so this means taking halves, quarters, or crumbs. 

In my experience, every patient that has taken naltrexone for sexual addictions has significantly improved, and perhaps more than 90% experience a total remission of the addiction. I have also found that, if one has done good behavioral therapy work in the meantime, the rate of relapse after slowly tapering naltrexone has been quite low. The remission rate seems unrelated to the severity of the addiction.

The other medications that I commonly prescribe are called SSRIs (e.g., Prozac, Zoloft, Lexapro, etc). These are typically used in cases where the patient has significant anxiety or depression, and is unable to participate in full-fledged behavioral therapy due to costs or their own unavailability. I have seen these medications make a significant impact on sexual addictions; at times, however, they also interfere with normal sexual functioning, since they can inhibit libido and delay orgasm.

I'd appreciate any feedback you have to offer about this module. Thanks!