A DevelopmentalNeurobiological Model for
Treatment of Substance
Abuse in Emerging Adults
Presentation Title
DATEThe
HERE
Neuro-biological Wisdom
of the 12 Step Model
Jesse Viner, MD
Founder & Executive Medical
Director, Yellowbrick
Asst. Professor Psychiatry,
Northwestern Feinberg School of
Medicine
Faculty, Chicago Institute for
Psychoanalysis
Yellowbrick
Find Your Way Home
Disclosures
-
As a matter of policy, Yellowbrick and its
employees are prohibited from accepting gifts
from any corporations, including pharmaceutical
companies
-
The three psychiatrists at Yellowbrick, Drs. Viner,
Hamilton and Baron , have never accepted gifts,
grants, or any other funds from the Pharmaceutical
Industry, at any point in their careers.
-
In short, there are no disclosures to make!
2
Minding the Brain
• Emerging Adulthood as a phase of
development
• Mind, Self, Brain
• Brain maturation in emerging adulthood
• Risk factors for substance abuse
• Substance abuse and brain maturation
• Psycho-neurobiology & intervention
Emerging Adulthood
• Arnett & Tanner: “Emerging Adulthood: Coming
of Age in the 21st Century”
• Ages 18 – 29
• 5 Primary Features
Emerging Adulthood: Primary Features
Arnett & Tanner
• Identity exploration
• Generalized instability and change:
Education, Location, Jobs, Relationships
• Age of “in between”; $, responsibility, brain
• Autonomy> Community> Spirituality
• Age of possibilities as well as risks
The Developing Mind
Daniel Siegel, M.D.
• Research on the purpose of the brain.
• Evolve the Self as a brain representation for
survival and adaptation.
• Emerging adulthood is pivotal in the
maturation of attachment patterns which
affect self integration & emotional regulation.
• “Human connections shape neural
connections.”
Emerging Adult Brain Maturation
Prefrontal-Thalamic-Cerebellar Cortex
• Necessary for higher order cognitive functions
including: set shifting, behavioral inhibition,
decision-making, cognitive inhibition, and
working memory (Braver et al., 2002).
• Prefrontal cortex is the “convergence zone”
between the cortex and subcortex. It is the
“hierarchical apex” of the limbic system and is
responsible for the mechanisms of rewardexcitation and aversion-inhibition in emotion
regulation (Schore, 2003).
Emerging Adult Brain Maturation
Orbital Pre-frontal Cortex
• Social and emotional processing
(e.g., facial cues)
• Self-regulation
(e.g., tension and vitalization states)
• Homeostatic regulation of the body
(sympathetic and parasympathetic ANS)
• Behavior (e.g., reward gratification)
• Attachment patterns (SAO); Secure, Anxious –
Avoidant, Ambivalent, Disorganized (e.g.,
Steklis & Kling, 1985).
Emerging Adult Brain Maturation
(Giedd, 2008;Steinberg 2009):
• Sprouting and pruning of synapses;
information processing & logic (Keating 2004)
• Proliferation in reward system networks;
limbic-PFC (Chambers 2003)
• Myelination- Structural and functional
increases in connectivity, efficiency of
integrative processing & executive functioning
(Lenroot 2007)
• Subcortical – Cortical projections & corpus
collosum; Socio-emotional processing and
emotional regulation (Eluvathingal et al, 2007)
Normal Brain Maturation :
The Frontal Lobes mature later into emerging
adulthood
Gogtay, N., et al (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proc Natl Acad Sci U S A,
101(21):8174–8179.
Factors Affecting Emerging Adult
Brain Development (Giedd, 2008):
• Maturational timetable for networking of
information processing, motivation & risk-reward
centers, executive functioning, emotional
regulation.
• Cross-species maturation of risk taking and
exploration in service of separation. Risk and
identity formation (Baumrind 1987)
• Maturation affected by genetics, hyper-hypo
arousal, substances, socio-emotional context.
• 75% of psychiatric illnesses manifest ages15-30
Yellowbrick
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Imaging The Depressed Brain
12
Socio-emotional Context:
Developmental Risk Factors
• Loss of secure, structuring contexts: family, friends,
school, community.
• Search for motivation and direction; brain correlation
• Provocative triggering factors increase personal
vulnerability and associated neural activation.
• Increasingly responsible for life competence; threats
to self worth.
• Neuroplastic substrate of attachment patterns in
exploring mode, in search of peer community and
love partner; anxiety, aloneness, identification.
Predisposing Neurobiological
Factors for Substance Abuse
• Genetic (Kendler 1997, Kendler & Prescott 1998,
Tsuang 1996).Ex: Bingeing > Serotonin Transport
(Herman 2003); < Asians ALDH (Wall 2001)
• Temperament (Anxious; Stimulus Seeking).
• Disorders of attachment and self-regulation (trauma,
abuse, loss, neglect).
• Chronic pain & medical illness
• Chronic effects of substance dependence
(withdrawal; cravings).
• Pre-existing Psychiatric or Processing Disorder
(Khantzian & Albanese 2008).
Earlier Onset of Substance Abuse in ADHD :
1.0
ADHD
*
Probability
0.8
*p<.05 vs control
0.6
0.4
Control
0.2
0.0
0
10
20
30
Age of Onset
Wilens TE, et al. J Nerv Ment Dis. 1997;185(8):475-482.
40
50
60
Prevalence of Substance Abuse
(NSDUH 2008, CDC, National College Study)
• Total US: 95 million (38%) Illicit, Binge/Heavy ETOH
• Use by age 18
ETOH Past month 45%; Lifetime 73%
SA Past month 22%; Lifetime 48%
• By age 20
23% meet criteria for ETOH/SA abuse or dependence
• College students
45% have met criteria for binge drinking
1825 alcohol related deaths annually
600,000 injuries, 700,000 assaults
97,000 rapes
Causes of Death-College Students
(Turner & Kelter 2011; CDC)
(per 100,000)
•
•
•
•
•
•
•
•
•
Prescription Drug OD 8.4
Suicide 6.18
Non alcohol vehicular 3.51
Alcohol related vehicular 3.37
Non alcohol, non traffic injury 2.39
Cancer 1.94
Alcohol related non-traffic 1.49
Homicide 1.53
Total MH+SA: 19.44/ 9.37
Prevalence of Substance Abuse
(NSDUH 2008)
Prevalence of Substance Abuse
DUI - (NSDUH 2008)
Prevalence of Substance Abuse
(NSDUH 2008)
Substance Abuse Derails
Brain Development
• Limits brain growth (Volkow, Ma & Zhu et al., 2008) and
differentiation (De Bellis, 2005). Decreased PF(Debellis
(2005) & hippocampal volume-ETOH; reduced grey
matter-MJ (Nagel, 2005)
• Disrupts development of executive functions: attention,
decision-making, planning, conceptualization (Thorberg &
Lyvers, 2006; Crean et al 2011).
• Distorts Reward-Risk Decision-Making (Hanson, Luciana &
Sullwold, 2006). Motivational systems become organized
around danger of withdrawal, cravings, distress avoidance.
• Dysregulates HPA axis(Sher 2007)biorhythms, emotional
engagement and feedback networks, judgment and
resultant behavior.
Derailed Brain Development (cont’d)
• Substance becomes primary attachment
relationship.
• Heavy use (MJ) or binging (ETOH) before 17
worsens effects; earlier is worse
• Earlier (2.7+ yrs) onset of psychosis in heavy
marijuana use (Gonzalez, Pinto-Vega &
Ibanez, 2008; Large 2010).
• Higher Rate (4x) of depression with heavy
marijuana use (Bovasso, 2003). 7-12x rate of
relapse if use.
SPECT Scan –
brain function
in an 18 y.o.
woman with
ADHD, Conduct
Disorder and
Polysubstance
Dependence 
IMPULSE
DYSCONTROL
Sx
Note the hypofunction
= “hole” in left inferior
cortex (OFC)
Psycho-Neurobiology of Intervention:
Guiding Models
• Quieting the limbic system
Safety, Attachment, Self-Regulation,
• Re-network meso-limbic motivation
Competence(van der Kolk2005)self-efficacy
• Self-in-relation; Psycho-neurobiology of self
cohesion and regulation (Schore, Siegel)
• Neuro-cognitive Model of Decision Making
(Noel, 2006); Reaction-Reflection-Relation
(Viner et al)
Psycho-Neurobiology of Intervention:
Components of the Models
•
•
•
•
•
Abstinence/12 Step Recovery Commty
Psychiatry
In-depth Psychotherapy
Executive Function & Role Competence
Role of the Body & Physical Self
Psycho-Neurobiology of Intervention:
Resistance to Recovery
•Brain wired for exploration, novelty, stimulation
•Autonomy-self empowered-invulnerable-denial vs
Powerlessness, limits, support, risk assessment
•SA provides actual/illusory relief/control/separateness
Smith (2010) Quitting ETOH in EA & “loss of control”
Anxiety & affect/anger management; trauma
EF impairment, shame, avoidance
Secrets/separateness(authority)/ peer membership
•Narcissism vs affecting others, low transcendence
•Belonging & being normal within SA peer culture
Psycho-Neurobiology of
Intervention: Abstinence
• Abstinence opens neural pathways for
emotional and cognitive processing.
• Abstinence resets the reward motivational
systems via self-efficacy; highest correlation
with recovery.
• Abstinence interferes with the primary
attachment to substances.
• Supportive treatment of withdrawal and
cravings (medical and interpersonal)
facilitates abstinence, resets reward system.
Psycho-Neurobiology of Intervention:
The 12-Step Recovery Model
• Reassures danger systems by providing
ever-present safe places.
• Relieves distressing emotions of aloneness
and shame through group membership.
• Sponsor and members provide organizing
relationships to replace substances at times
of distress.
Psycho-Neurobiology of Intervention
The 12-Step Recovery Model
• Confronts denial and rationalization while
providing acknowledgment of the difficulties
maintaining sobriety.
• Supports self worth, hope and motivation through
acceptance and praise for realizable actions
supporting sobriety in self/ others.
• 12 Steps provide a guide towards self-efficacy,
empowerment and governance in connection to
others.
Psycho-Neurobiology of Intervention:
Psychiatry
• Effective treatment of psychiatric diagnosis
reduces distress and supports abstinence.
• Reduction of cravings and resetting reward
systems.
• Supervised withdrawal from prescribed
medications that promote relapse.
• Reframing of substance abuse as disease to
reduce self-criticism, shame and sense of
failure.
Psycho-Neurobiology of Intervention:
Psychotherapy
•Attuned Attachment; safety & self regulation
Mirroring, validation, mentalization
•Motivational Interviewing;
Collaboration, autonomy, efficacy
•Arousal-Affect immersion interferes with
dissociation;
“Limbic dialogue”(Schore,2001)
Here-and-now issue of the moment, in and
outside the Rx relationship; self disclosure
Psycho-Neurobiology of Intervention:
Psychotherapy
Targeting maturing brain systems linked with
researched protective factors:
• Emotional regulation & motivational systems
(trauma, abuse, neglect)
• Identity integration and coherence; neg risk
correlation (Schwartz 2010)
• Attachment patterns; peer & family
• Executive function/competence-rehabilitation
Shame-self-judgment-avoidance patterns
verbal-social mask
Psycho-Neurobiology of Intervention:
Support for Executive Functioning
• EF Predicts relapse on fMRI (Paulus 2005)
• Brief Action Planning; interest, next steps,
confidence, commitment
• Action analysis,problem solving,strategic plan
• Risk-reward recognition and consequences
• Relapse prevention and harm reduction
• Resistance to negative peer influence
• Sober community
Psycho-Neurobiology of Intervention:
The Body & Physical Self
•
•
•
•
•
•
•
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Action & experience; mode of learning
Emotional pathways to the body self
Distress tolerance (DBT).
Exercise
Yoga
Meditation & mindful practices
Heartmath, neuro-feedback
Gratitude, compassion & forgiveness
Psycho-Neurobiology of Intervention:
• High relapse rates
• Harm reduction: abstinence in EA
• “Though none among us may complete the
task, none among us is exempt from
contributing our unique part” (Talmud)
Minding the Brain
• Emerging Adulthood as a phase of
development
• Mind, Self, Brain
• Brain maturation in emerging adulthood
• Risk factors for substance abuse
• Substance abuse and brain maturation
• Psycho-Neurobiology of intervention
•The Residence
•Life Strategies
Presentation
ProgramTitle
DATE HERE
•Center for Clinical
Neuroscience
•Addictions Service
•Eating Disorder
Service
•Trauma Recovery
Program
•CareerDevelopment