Presentation TitleDATE HERE

A Developmental-Neurobiological Model for Treatment of Substance

Abuse in Emerging Adults

The Neuro-biological Wisdom of the 12 Step Model

Jesse Viner, MDFounder & Executive Medical

Director, YellowbrickAsst. Professor Psychiatry,

Northwestern Feinberg School of Medicine

Faculty, Chicago Institute for Psychoanalysis

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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!

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 MindDaniel 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 reward-excitation 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

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Imaging The Depressed Brain

• 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.

Socio-emotional Context:Developmental Risk Factors

• 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).

Predisposing NeurobiologicalFactors for Substance Abuse

Earlier Onset of Substance Abuse in ADHD :

0 10 20 30 40 50 60

0.0

0.2

0.4

0.6

0.8

1.0

ADHD

Control

Age of Onset

Pro

babi

lity

Wilens TE, et al. J Nerv Ment Dis. 1997;185(8):475-482.

**p<.05 vs control

• 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

Prevalence of Substance Abuse(NSDUH 2008, CDC, National College Study)

(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

Causes of Death-College Students(Turner & Kelter 2011; CDC)

Prevalence of Substance Abuse(NSDUH 2008)

Prevalence of Substance AbuseDUI - (NSDUH 2008)

Prevalence of Substance Abuse(NSDUH 2008)

• 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.

Substance Abuse Derails Brain Development

• 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.

Derailed Brain Development (cont’d)

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)

• 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: Guiding Models

• Abstinence/12 Step Recovery Commty• Psychiatry• In-depth Psychotherapy• Executive Function & Role Competence• Role of the Body & Physical Self

Psycho-Neurobiology of Intervention:

Components of the Models

•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:

Resistance to Recovery

• 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: Abstinence

• 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 The 12-Step Recovery Model

•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: Psychiatry

•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: Psychotherapy

•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:Support for Executive Functioning

• 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: The Body & Physical Self

• 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)

Psycho-Neurobiology of Intervention:

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

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