Aaron Alan, MFT, CSAT Executive Director Foundry Clinical Group Thuy Bui, LCSW, CSAT Clinical Director Foundry Clinical Group Mark Forman, PhD Clinical Director Life Design Centre The Neurobiology of Trauma, Sex Addiction, and Meditation: Current Research and Clinical Implications Today’s Talk Who We See and What We Treat Trauma and Adverse Childhood Experiences (ACEs) Trauma, Addiction, and SA/SC Neurobiology of Trauma Neurobiology of Addiction Today’s Talk cont. Theory and Types of Meditation Neurobiology of Meditation Clinical Applications Clinical Issues and Unknowns Q&A Foundry: Who We See and What We Treat… Trauma, Adverse Childhood Experiences, and Addiction Addictions and Adverse Childhood Experiences Kaiser Adverse Childhood Experiences (ACEs) Study (Felliti et al., 1998; Felliti, 2004) 17,000 middle-class American adults underwent comprehensive, biopsychosocial medical evaluation. Adverse Childhood Experiences Study Each participant received 1 pt. for: 1. recurrent and severe physical abuse (11%) 2. recurrent and severe emotional abuse (11%) 3. sexual abuse (22%) growing up in a household with: 4. an alcoholic or drug-user (25%) 5. a member being imprisoned (3%) 6. a mentally ill, chronically depressed, or institutionalized member (19%) 7. the mother being treated violently (12%) 8. both biological parents not being present (22%) Addictions and Adverse Childhood Experiences "Addiction highly correlates with characteristics intrinsic to that individual’s life experiences, particularly in childhood… Commonly understood examples of addiction are the compulsive use of nicotine, alcohol, methamphetamine, and heroin. More subtle examples are compulsive eating, sex, gambling, or shopping.” (Felliti, "Neuroscience of Addiction", 2004) Adverse Childhood Experiences and Alcoholism Adverse Childhood Experiences and Injected Drug Use Adverse Childhood Experiences, Addictions and Mortality What About Sexual Compulsivity? Adverse Childhood Experiences and Sexual Compulsivity Persons who had experienced 4 or more categories of childhood exposure, compared to those who had experienced none, had: 4- to 12-fold increased risks for alcoholism, drug abuse, depression, and suicide attempt; 2- to 4-fold increase in smoking, poor self-rated health, > 50 sexual intercourse partners, and at least 1 sexually transmitted disease and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity. Adverse Childhood Experiences and Sex Addiction? Hillis et al. (2001) found using this data set that ACEs were proportionately correlated in women with: Earlier sexual activity (under age 15) Higher number of sexual partners Odds of having 30+ sexual partners went from… 1.6 for those with one type of ACE 1.9 for those with two ACEs 8.2 among those with 6-7 ACEs Case Vignette •4 ACEs: recurrent physical abuse, recurrent emotional abuse, an alcoholic parent, chronically depressed parent overheard father call him stupid to sibling and overheard parents frequently fighting. Sexually compulsive bxs: online pornography, compulsive masturbation, anonymous sex with women, listening to ppl having sex. •Was able to stop anonymous sex early in tx, but intermittent pornography viewing and searching for audio content continued until underlying trauma/ACEs were addressed and treated. Clt currently has 2 yrs of sobriety and recently was married. What Does Trauma Do to the Brain? Trauma and the Brain Brain processes are not entirely “local” – they are both local and distributed/coordinated across different structures and regions of the brain. However, research in trauma has focused heavily on three local parts of the brain: Amygdala Hippocampus Prefrontal Cortex AMYGDALA Amygdala – Function develops immediately after birth. Allows rapid assessment of danger and experience of fear. Becomes activated upon cues or “triggers” that are reminiscent of early traumatic events. But it does so with poor accuracy. (van der Kolk, 2003) AMYGDALA Stevens et al. (2013) found… A study of 40 women… Participants with PTSD showed a significantly increased response to fearful stimuli in the right amygdala. The right amygdala is more responsive to pictorial or imagerelated material [the left to highly detailed and linguistic]. AMYGDALA Stevens et al. (2013) cont… Right amygdala activation correlated positively with the severity of hyperarousal symptoms in the PTSD group. Participants with PTSD showed decreased functional connectivity between the right amygdala and left prefrontal cortex. That is, the cortex can help regulate the amygdala, but this connection is deficient in PTSD patients. AMYGDALA HIPPOCAMPUS Hippocampus – Function develops gradually over first five years. Allows recognition and organization of nature of threat. Large role in memory. Can accurately pair cues or triggers with threat responses when hippocampus is developed enough at time of traumatic event. Specific and accurate, particularly later in life, but not so in childhood. (van der Kolk, 2003) HIPPOCAMPUS Gilberston et al. (2002) found… In a monozygotic twin study, severity of PTSD symptoms was negatively correlated with the hippocampal volume. Smaller hippocampal volume predicted vulnerability to psychological trauma. HIPPOCAMPUS Woons et al. (2010) found… In a meta-analysis of 39 studies… Hippocampal volume deficits associated with exposure to psychological trauma and posttraumatic stress disorder in adults. Additional hippocampal reduction was found in PTSD compared to the trauma-exposed group without PTSD. HIPPOCAMPUS Carrion et al. (2007) found… Stress predicts lower hippocampal volume in youth with PTSD symptoms. HIPPOCAMPUS Carrion et al. (2010) found… Youth with PTSD symptoms demonstrated reduced activation of the right hippocampus during a memory retrieval task. PREFRONTAL CORTEX Prefontal Cortex – Develops gradually over first 25 year (perhaps more) of life. Is primarily responsible for executive function, reasoning, and planning in stressful and nonstressful situations. Prefrontal cortex helps regulate amygdala responsiveness. PREFRONTAL CORTEX However, activation of limbic and stress responses are “faster” than activation of prefrontal cortex, thus an overactive amygdala creates challenges for prefrontal performance. (van der Kolk, 2003) PREFRONTAL CORTEX van Harmelen (2010) found… In a study of 84 unmedicated adults who reported emotional maltreatment prior to age 16. Found “profound” reductions in the volume of the medial prefrontal cortex, even in the absence of physical or sexual abuse. PREFRONTAL CORTEX Carrion et al. (2010) found… Youth (10-16) with PTSD symptoms had significantly decreased total brain tissue and total cerebral gray volumes in comparison with healthy control subjects. Significant negative correlation between prebedtime cortisol levels and left ventral prefrontal cortex volumes. PREFRONTAL CORTEX Shin et al. (2005) found… In a fMRI study of 13 men with PTSD and 13 men without PTSD. Studied the response to facial expression images. PREFRONTAL CORTEX Shin et al. (2005) found… The PTSD group exhibited exaggerated amygdala responses and diminished medial prefrontal cortex responses to fearful vs happy facial expressions. The stronger the amygdala activation, the lower the prefrontal cortex functioning. The two responses were inversely related. Summary of Neurobiology of Trauma Trauma and PTSD symptoms are strongly correlated with: over-activation of the amygdala a decrease-in-size and underfunctioning of the hippocampus, a decrease-in-size and underfunctioning of the prefrontal cortex, including decreased regulatory connectivity to the amygdala Neurobiology and Addiction “[A]ll addictions create, in addition to chemical changes in the brain, anatomical and pathological changes which result in various manifestations of cerebral dysfunction collectively labeled hypofrontal syndromes. In these syndromes, the underlying defect, reduced to its simplest description, is damage to the “braking system” of the brain.” (Hilton & Watts, 2011 – “Pornography Addiction: A Neuroscience Perspective”) Hypofrontal Syndromes May result from genetic predisposition or the cumulative impact of addictive behavior alone… But when trauma is present or underlying… It sets up the perfect conditions for addiction and compulsion to begin and take hold, since the “brakes” are already off. Underfunctioning Prefrontal Cortex Traumatized Brain Underfunctioning Hippocampus Overfunctioning Amygdala Why is meditation potentially important in regards to trauma and addiction? SHORT ANSWER: Meditation appears to directly counteract these specific neurobiological problems. Theory of Meditation From a psychological/subjective perspective… Let thoughts and emotions pass. Enter deep, calm concentration. Encourage “transpersonal” moments. Theory of Meditation From a neurobiological/physical perspective… Engage in a self-directed neuroplastic alteration of the brain. It is this neurobiological-neuroplastic process that current research has been investigating. Types of Meditation: Mindfulness Mindfullness – Nonjudgemental noticing of thoughts and feelings, letting them pass with attitude of calm. Cultivate specific insights about the nature of the self. Focus on present moment. Types Of Meditation: Concentrative Concentrative – Focus on an object, image, word or phrase (mantra) meant to absorb a person into various trance states. Types of Meditation: Imaginal Imaginal – Calling to mind specific positive emotional states (and their imaginal associations) in order to cultivate deeper positive emotion. e.g., Metta meditation (Loving-kindness or compassion meditation) Very often, meditative techniques borrow/overlap from all three categories Meditation Research: Some Important Studies Changes in cerebral blood flow during meditation (Newberg et al., 2001, 2003) Meditation Studies Lutz et al. (2004) found heightened gamma wave activity throughout cortex – the highest ever recorded in a nonpathological population – in a group of 8 highly trained Tibetan monks. Dose-response relationship Gamma activity remained heightened outside of meditation itself – apparently permanent neuroplastic change. Gamma highest in left prefrontal cortex, an area associated with positive, pro-social emotions. Meditation Studies Lazar et al. (2005)… MRI with 20 highly experienced meditators Meditation Studies Lazar et al. (2005) cont… Brain regions associated with attention and introspection were thicker in meditation participants than matched controls, including the prefrontal cortex and right anterior insula. Between-group differences in prefrontal cortical thickness were most pronounced in older participants, suggesting that meditation might offset age-related cortical thinning. Meditation Studies Luders et al. (2012) in a study of 50 advanced meditators and 50 controls (meditators represented all three types of meditation styles). Carefully matched for sex and age. Study focused on the gyrus (hills and valleys) of the cortex. Increases in gyrification means increased connectivity and growth in number of brain neurons. Decrease in gyrification means decreased connectivity and “pruning” of neurons; normal outcome of aging, worse in dementia. Meditation Studies Positive correlation found between the number of years of meditation and gyrification in a number of areas of the cortex. Also, positive correlations between number of meditation years and gyrification in the right anterior dorsal insula (volume increased most here). Meditation Studies Desbordes et al. (2012) study… Healthy adults with no prior meditation experience took part in 8 weeks of training in Mindful Attention Training (MAT; mindfulness), Cognitively Based Compassion Training (CABT; compassion), or control group. 2 hours spent in class per week (40 minutes meditating) plus 20 minutes per outside class. Meditation Studies Desbordes et al. (2012) cont… Study looked at activation of right amygdala using positive, negative, and neutral images using fMRI in nonmeditative state (outside of meditation) Meditation Studies Found a decrease in right amygdala activation in response to positive images, and in response to all images in MAT group. Similar changes in CBCT group except there was higher amygdala responses to negative images. Authors hypothesized this response in CBCT might be due to increased empathy, which is a result consistent with others studies of increased empathy. Meditation Studies Luders et al. 2012 found… Long-term meditators (30 persons) had significantly larger left hippocampal volumes “Larger hippocampal dimensions may similarly account for meditators’ habits and abilities to engage in mindfulness behavior, cultivate positive emotions, and retain emotional stability.” Sample Clinical Studies: Meditation and Trauma Direct evidence is showing up for PTSD and elements of other addictions, with some initial connections to SA/SC. Sample Clinical Studies: Meditation and Trauma Kearney et al. (2013) found that Loving-kindness (compassion) meditation in PTSD patients produced reduced symptoms and depression. King et al. (2013) did a pilot study mindfulness-based cognitive therapy (MBCT) for combat veterans and showed significant improvement in PTSD symptom severity on post-treatment assessment. Sample Clinical Studies: Meditation and Trauma Rosenthal et al. (2013) found that Transcendental Meditation (TM) was effective in small pilot study of U.S. war veterans in terms of reduced PTSD symptom severity and improved quality of life. Sample Clinical Studies: Meditation and Trauma Substance addiction issues… Bowen et al. (2009) found addicts who underwent Mindfulness Based Stress Reduction had significantly lower rates of substance use in those who received typical treatment protocols at 4-month post-intervention period. Also showed reduced cravings as compared to treatment controls. Clinical Studies: SA/SC and Meditation? Reid et al. (2013) found… In a study of 40 hypersexual patients vs. 30 controls, found an inverse relationship between hypersexuality and mindfulness, above and beyond meditating factors of emotional regulation, impulsivity, and stress proneness. This sounds very promisingand it is! but what are the clinical complexities? Clinical Issues and Concerns… Drawn from large body of existing literature – mostly case, phenomenological reports, and clinical summary judgments from meditators across traditions and clinicians who have incorporated meditation in practice for the past few decades (e.g., Forman, 2010; Walsh & Shapiro, 2006) Clinical Issues and Concerns… Having clients sit/practice during intense periods of PTSD symptoms? Sometimes meditation can be de-repressive Internalizing vs. externalizing attention Emotional dysregulation is expected at certain points in typical meditation practice… Meditation and dissociation? THE ISSUE OF STRUCTURAL DISSOCIATION Trauma Creates Structural Breaks in Mind Going on With Everyday Self Traumatized Part Long-term meditation Clinical Issues and Concerns… Final question… Very important for SA/SC treatment! Meditation and attachment? For all its positive impacts on self-regulation (in general), does meditation impact attachment style? Clinical Issues and Concerns… Probably not. Meditation is about containment, regulation, and generalized positive “spiritual experience.” Meditation is not in-and-of-itself a “corrective emotional experience.” Typical relationship issues exist in meditation communities, with some notable “exemplars.” Clinical Highlights Meditation is very, very promising as an adjunct intervention to therapy, particularly with traumatized and addicted clients. Neurobiological study is showing this. Hence, why we use it at Foundry. But like any potent intervention, it needs to be administered with oversight – watching for dysregulation or dissociation. Clinical Highlights It is not a substitute for warm, empathic supportive relationships with therapist or loved ones… Future research should explore the types of meditation that work best with trauma or subtypes of trauma. Knowledge and practice of meditation is highly useful on part of therapist when possible. References For references, please contact Dr. Mark Forman at firstname.lastname@example.org.