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1 Presentation Title DATE HERE
A Developmental-Neurobiological Model for Treatment of Substance Abuse in Emerging Adults The 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 Presentation Title DATE HERE

2 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 2

3 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

4 Emerging Adulthood Arnett & Tanner: “Emerging Adulthood: Coming of Age in the 21st Century” Ages 18 – 29 5 Primary Features

5 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

6 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.”

7 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).

8 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).

9 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)

10 Normal Brain Maturation : The Frontal Lobes mature later into emerging adulthood
We know that executive functions continue to mature into early adulthood, up to age 25. I guess the car rental companies figured that out without needing brain scan evidence, but the important point to be made here is to stress the late maturity of the frontal lobes and I will stress how important that is in understanding the neurobiology of ADHD and even comorbid BD and SUDs. 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. 10

11 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

12 Yellowbrick Find Your Way Home
Imaging The Depressed Brain Maybe “Imaging the depressed brain” or something…? Just b/c there is a control there and the labels in the pic may or may not be visible to the audience 12 12

13 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.

14 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).

15 Earlier Onset of Substance Abuse in ADHD :
10 20 30 40 50 60 0.0 0.2 0.4 0.6 0.8 1.0 ADHD * *p<.05 vs control Probability Control 1: It happens EARLIER: The average age of ADHD patients at onset of substance abuse was found to be 19 years compared to non-ADHD controls (age 22). 2. The SUD becomes SEVERE MORE QUICKLY [abuse  dependence] (1.2 years in ADHD versus 3 years in non-ADHD controls) Age of Onset Wilens TE, et al. J Nerv Ment Dis. 1997;185(8): 15

16 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

17 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

18 Prevalence of Substance Abuse
(NSDUH 2008)

19 Prevalence of Substance Abuse
DUI - (NSDUH 2008)

20 Prevalence of Substance Abuse
(NSDUH 2008)

21 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.

22 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.

23 SPECT Scan – brain function in an 18 y. o
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) 23

24 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)

25 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

26 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

27 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.

28 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.

29 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.

30 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.

31 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

32 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

33 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

34 Psycho-Neurobiology of Intervention: The Body & Physical Self
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

35 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)

36 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

37 Presentation Title DATE HERE
“Minding the Brain” The Residence Life Strategies Program Center for Clinical Neuroscience Addictions Service Eating Disorder Service Trauma Recovery Program CareerDevelopment

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