Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment

Impulsivity, Attention Deficits and Addiction: Perspectives on Concepts,

Diagnoses, and Treatment

Christian G. Schütz MD PhD MPH Associate Professor Institute of Mental Health, Dep. of Psychiatry Email: [email protected] Medical Manager The Burnaby Centre for Mental Health & Addiction

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Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summary

The Four Quadrant Framework for Co-Occurring Disorders

Less severe mental disorder/

less severe substance

abuse disorder

More severe mental disorder/

less severe substance

abuse disorder

More severe mental disorder/

more severe substance

abuse disorder

Less severe mental disorder/

more severe substance

abuse disorder

High severity

Mood disorders

Psychosis

Addiction

Anxiety disorders

Adult ADHD Self-Report Scale

ADHD screener >50%

18 questions Adler et al.

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genes environment

CGS www.thelancet.com Published online February 28, 2013

CGS www.thelancet.com Published online February 28, 2013

Consistent with a pleiotropic role of CACNA1C variants , neuro-imaging studies have documented effects of voltage gated calcium channels on a range of structural and functional brain phenotypes, including circuitry involved in: •  emotion processing, •  executive function, •  attention, and •  memory.

genes environment

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Childhood predictors of adult ADHD: Results from the WHO World Mental Health (WMH) Survey Initiative Lara et al. An average of 50% of children with ADHD continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to: •  attentional plus hyperactive type, •  symptom severity, •  comorbid major depressive disorder, •  high comorbidity, •  paternal anxiety-mood disorder •  parental antisocial personality disorder. Childhood adversity predicted ADHD, but not persistence into adulthood

Lifetime trauma experience

Stahl Essential Psychopharmacology

*

*

*

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Stahl Essential Psychopharmacology

ADHD Addiction Bipolar Schizophrenia

SJ Lupien, BS McEwen, MR. Gunnar and C Heim. Nature Reviews Neuroscience 10, 434-‐445 (2009) adapted

BL Thompson, P Levitt & GD Stanwood Nature Reviews Neuroscience 10, 303-‐312 (April 2009)

SJ Lupien, BS McEwen, MR. Gunnar and C Heim. Nature Reviews Neuroscience 10, 434-‐445 (2009) adapted

•  The prefrontal cortex subserves conscious decision making (thoughtful reflective response).

•  PFC is the brain region most sensitive to detrimental effects of stress exposure.

•  Even mild acute uncontrollable stress can cause a dramatic loss of cognitive abilities

•  Prolonged stress exposure causes architectural changes in prefrontal dendrites

AFT Arnstein Nature Reviews Neuroscience 10, 410-‐422 (June 2009)

genes

Multi-causality and Pleiotropy is the standard

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Overview •  introduction and context •  etiological considerations •  impulsivity and attention deficits •  interventions considerations •  summary

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Questionnaire Behavioral Tests

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Barratt Impulsivity Scale-11 (BIS) Patton et al., 1995 •  motor impulsivity •  non-planning •  attentional impulsivity 30 items, likert scale

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UPPS-P Impulsive Behavior Scale Perales et al. 2009 •  lack of premeditation •  lack of perseverance •  “negative” urgency •  "positive” urgency •  sensation-seeking

59-item likert scale

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REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)

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fronto-parietal–pre-motor circuits

prefrontal–striatal

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Latent Discounting

Peters 2011

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UPPS+P

BIS

Total

Neg Urgency

(lack of) Premed

(lack of) Preserve

Sens Seeking

Pos Urgency

Total

A>en?on

Motor

Non-‐Planning

DERS Total

Acceptance Goals

Impulse Awareness

Strategy Clarity

.57* .11 .58* .54* .69** .37 .44

.66** .27 .63** .69** .47 .53* .47

.53* .28 .42 .17 .73*** .30 .48*

.52* .21 .36 .13 .70** .46 .64*

-.33 -.54* -.11 .15 -.01 -.52* -.41

.55* .23 .59* .55* .36 .45 .38

.15 .15 -.21 .01 .22 .09 .43

.12 .04 -.09 .13 .09 .06 .34

-.09 -.01 -.30 -.03 -.06 -.13 .08

.27 .28 - .41 -.02 .35 .23 .58*

DDT $100 $1000

.47 -.09

.24 -.22

.24 .08

.13 -.14

.37 -.10

.41 .03

-.33 -.17

-.30 -.17

-.28 -.07

-.35 -.21

SST -.34 -.06 -.21 -.26 -.32 -.20 .67** .48* .62** .65**

SWM -.64**

-.44

-.38

-.41

-.35

-.42

-.17 -.19 -.04

-.18

UPPS+P

BIS

Total

Neg Urgency

(lack of) Premed

(lack of) Preserve

Sens Seeking

Pos Urgency

Total

A>en?on

Motor

Non-‐Planning

DERS Total

Acceptance Goals

Impulse Awareness

Strategy Clarity

.57* .11 .58* .54* .69** .37 .44

.66** .27 .63** .69** .47 .53* .47

.53* .28 .42 .17 .73*** .30 .48*

.52* .21 .36 .13 .70** .46 .64*

-.33 -.54* -.11 .15 -.01 -.52* -.41

.55* .23 .59* .55* .36 .45 .38

.15 .15 -.21 .01 .22 .09 .43

.12 .04 -.09 .13 .09 .06 .34

-.09 -.01 -.30 -.03 -.06 -.13 .08

.27 .28 - .41 -.02 .35 .23 .58*

DDT $100 $1000

.47 -.09

.24 -.22

.24 .08

.13 -.14

.37 -.10

.41 .03

-.33 -.17

-.30 -.17

-.28 -.07

-.35 -.21

SST -.34 -.06 -.21 -.26 -.32 -.20 .67** .48* .62** .65**

SWM -.64**

-.44

-.38

-.41

-.35

-.42

-.17 -.19 -.04

-.18

Chao 2013 DERS: Difficulties in emotional regulaton scale DDT: Delayed Disounting SST Stop Signal Task SWM: Spatial working memory UPPS+P

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Subcomponents attention: Top down: Prefrontal Cortex: sustain, switch

divide inhibit distraction

Inferior temporal cortex: focus Posterior parietal association cortex: orienting

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Mood stabilizers have been used extensively to treat impulsive disorders. Moderate efficacy in at least half of patients studied have been reported. Results differ across specific mood stabilizers. Positive data have been published for Valproate, Phenytoin, Carbamazepine, Topiramate and Lithium. (not for Gabapentin and Levotireacetam). Some positive results for atypical neuroleptics (Olanzapine, Aripiprazole, Quetiapine) and antidepressant (Bupropion) have been reported. Based on ADHD treatment Stimulants (Modafinil, Methylphenidate, Amphetamine) Atomoxetine, have lead to positive results in some patients. Cognitive Behavior Therapies, Dialectical Behavior Therapy and Contingency Management seem to be more promising psychotherapeutic approaches.

Symptom-targeted strategies appear to provide the best likelihood of success when using medications to improve the care of patients with personality disorders. Impulsivity appears to be the most consistent fundamentally disturbed behavior linking the spectrum of bipolar conditions, including those that present more as personality disorders or aberrations of temperament. Mood stabilizers have been used extensively to treat impulsive and aggressive disorders. Although most studies have limitations in design, moderate efficacy in at least half of patients studied has been reported. Results differ across drugs. More positive data have been published for valproate, although most are from open-label trials. The role of impulsive drug seeking is a major component of persistent drug abuse. Currently, therapies are at best of modest utility. More systematic studies of drugs and of psychological strategies are needed to address cues that trigger impulsive drug seeking. Naturalistic long-term studies indicate high rates of prescriptions of mood stabilizers for patients with borderline personality disorders. Cognitive therapies to enhance adherence to medication treatments are promising, but surprisingly poorly studied in systematic trials



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Glutamate GABA

Dopamine

Serotonin

Executive Control Reward/Motivation Emotional regulation

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Relapse Addiction Mood episode

Medication

Psychosocial setting Psychotherapy

Env

ironm

ent Abstract

Information

Incentives

Trust/threat signals

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ECT, TMS, DBS..

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DLPC OFPC Striatum VMPC Amygdala Insula


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Relapse Addiction Mood episode

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ADHD Addiction Mood episode

Mindfulness, Grounding

CM SCT, GNG

CBT, DBT, ME

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SCT: Several researchers tried to improve trait self-control. Successful training generalized to other tasks. To this end, participants were asked to brush their teeth or use the computer mouse with the non-dominant hand, keep a good posture, avoid slang words, perform Stroop tasks, keep a financial diary, or adhere to study or exercise plans (Azor Hui et al., 2009; Gailliot, Plant, Butz, & Baumeister, 2007; Muraven, Baumeister, & Tice, 1999; Oaten & Cheng, 2006a, 2006b, 2007).

GNG: One program aimed at fostering response inhibition. In this study, participants completed an adapted Go/No-Go task. (Houben, Nederkoorn, Wiers, & Jansen, 2010)

•  The prefrontal cortex subserves conscious decision making (thoughtful reflective response).

•  PFC is the brain region most sensitive to detrimental effects of stress exposure.

•  Even mild acute uncontrollable stress can cause a dramatic loss of cognitive abilities

•  Prolonged stress exposure causes architectural changes in prefrontal dendrites

AFT Arnstein Nature Reviews Neuroscience 10, 410-‐422 (June 2009)

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engagement in meaningful activities and relationships

self organization, structuring, healthy living

TREATMENT: diagnosis versus syndrome (domain-specific) informed

PSYCHO- SOCIAL SETTING



Contingency

Management

Cognitive

Behaviour

Avoidance

Training


SPECIFIC INTERVENTION

TREATMENT: diagnosis versus syndrome (domain-specific) informed



Contingency

Management

Cognitive

Behaviour

Avoidance

Training

Evidence based:


SPECIFIC INTERVENTION

Medication

Regular systematic off-label

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Thank you for your attention

Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment

Health & Medicine

Transcript of Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment