The Addicted Brain

1. The Addicted Brain Joseph Vollaro, Ph.D Assistant Professor of Psychology, Suffolk County Community College Executive Director, RES Company, Inc.

2. DSM –IV Criteria for Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 

3. (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) (2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights) 

4. B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

5. DSM-IV Criteria for Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 

6. (1) Tolerance , as defined by either of the following:  • (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect  • (b) markedly diminished effect with continued use of the same amount of the substance 

7. (2) Withdrawal as manifested by either of the following:  (a) the characteristic withdrawal syndrome or the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)  (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

8. (3) the substance is often taken in larger amounts or over a longer period than was intended  • (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use  • (5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects  • (6) important social, occupational, or recreational activities are given up or reduced because of substance use  • (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) 

9. Specify if:  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)  If drinking is interfering with your work, you're probably a heavy drinker. If work is interfering with your drinking, you’re probably an alcoholic. ~Author Unknown

10. Addiction continues to be a growing problem in our society!! • 8% of the population are believed to be users of illegal drugs (Substance Abuse and Mental Health Services Administration, 2003), despite numerous “Wars on Drugs” Did you know America ranks the lowest in education but the highest in drug use? It’s nice to be number one, but we can fix that. All we need to do is start the war on education. If it’s anywhere near as successful as our war on drugs, in no time we’ll all be hooked on phonics. ~Leighann Lord • Even legal drugs and their devastating effects • Obesity • 25% of Americans are Obese (Mokdad, et, al, 2003) • American Obsessions: Caffeine, Television, Internet, Sex, McMansions

11. Even legal drugs and their devastating effects • Obesity • 25% of Americans are Obese (Mokdad, et, al, 2003) • American Obsessions: Caffeine, Television, Internet, Sex, McMansions

12. If addiction is judged by how long a dumb animal will sit pressing a lever to get a ‘fix’ of something, to its own detriment, then I would conclude that Netnews is far addictive than cocaine. ~Rob Stampfli

13. To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times….~Mark Twain

14. Addiction is nothing new..it has been with part of the human condition from the beginning of time.. researchers continue to ask that age-old question…….Why? Thou hast the keys of Paradise, oh, just, subtle, and mighty opium! ~Thomas De Quincey, Confessions of an English Opium-Eater, Part II

15. In 1990, George Bush declared the 90’s the decade of the brain……leading to an explosion in the field of Neuroscience

16. This has lead to an explosion of knowledge related to how our brain affects all aspects of our life and functioning….including in the field of Addiction • As our knowledge has progressed, it has become clear that substances that have the power to make us feel good seem to share some remarkable similarities once they hit the brain

17. It is important to note, that the best explanation of addiction is the Biopsychosocial Model. As Lyvers (2000) states: “ The identification of underlying biological mechanisms in addiction does not render psychosocial factors irrelevant, but rather implies that such factors may interact in important ways with biology, as it is widely acknowledged in the currently popular biopsychosocial perspective.”

18. As providers of services to individuals with Traumatic Brain Injury (T.B.I.), it is not uncommon toreceive areferral for CIC/IBP services, or more because:-Consumer has begun to use a drug compulsively-The consumer has lost control of their behavior-Use of the substance begins to affect their decisions, health, finances, and presonal relationships

19. Which addiction is a problem for our society, it is of particular concern in people with disabilities…. OASAS (1997)- 22.4% of the clients served had a coexisting physical/mental disability Many people believe that this number reflects a great underreporting! Why are people with disabilities more likely to experience Substance use Disorders? -Unemployment -Lack of recreational activities -Social isolation -Homelessness -Victimization (i.e. physical, psychological abuse)

20. THE ADDICTED BRAIN: the Disease Model of the Alcoholism:

21. Addiction is not a character flaw, or a sign of weakness, but a disease, similar to other psychiatric diseases, whose etiology can be better understood by understanding brain functioning in the addiction process

22. At the very center of this model is the idea of the Pleasure Center (Olds & Milner, 1954 ) Using the brain stimulation paradigm, they came to the following conclusions: • Electrical Stimulation of the brain could be experienced as pleasurable or rewarding • An area known as the Nucleus Accumbens played a major role in this response

23. Subsequent experiments have demonstrated animals will take drugs or choose electrical stimulation of the brain at the expense of normal activities (i.e. eating, sleeping) and that they come to prefer an environment that they associate with the drugLed to the formulation of the idea of a brain “Pleasure Center” which gives new meaning to the word “To Die for”

24. Much work subsequent to this has established that a class of neurotransmitters, known as the catecholamines, which includes Norepinephrine, Epinephrine, and Dopamine, seemed to be involvedOf particular interest, is the neurotransmitter, Dopamine, whose activation in the area of the brain known as the Nucleus Accumbens, appears to be a common denominator in many drugs of abuse

25. Newer theories of addiction suggest that overtime, humans have either discovered or manufactured substances that hijack this system, creating addiction

26. A common question that evolves from this idea is Why would we have such a place in our brain to begin with? The answer to this question comes from the theory of evolution!! • According to Darwin, our ultimate goal is survival of the species • Thus, it is believed this “reward system” has evolved as a mechanism to reinforce behaviors that facilitate the survival of the species (i.e. eating, drinking, sex)

27. Studies have begun to compare how different activities affect the level of stimulation in this system with some very interesting results!!!!! Level of Intensity: (from greatest to least): • Addictive Drugs • Sexual Activity • Eating • Exercise • Mediation, Spirituality, Deep thought, Art, Music, Nature, Socialization

28. The Addicted Brain: A macro view

29. The Major brain areas included in Addiction include: Nucleus Accumbens Ventral Tegmental Area (VTA) Prefrontal lobe Limbic System

30. Nucleus Accumbens: release of Dopamine in this area seems to be related to the experience of intense pleasure

31. Ventral tegmental area: • When stimulated, sends a signal (release of Dopamine) to the Nucleus Accumbens, and then, through the process of reuptake, ends this signal • Also is involved in what has become known, as an Anticipatory signal • If this anticipation can’t be fulfilled, it might be replaced with another behavior • It is believed many forms of addiction begin here!

32. Prefrontal lobe: • Willed actions are associated with this area, in contrast to “routine” or “automatic” tasks • Mediate or inhibit these relatively automatic or “fixed action patterns”, giving these behaviors certain flexibility and relative independence from the environment • Damage to this area can lead to • Disinhibited behavior • Perseveration • Failure to assess consequences of ones actions • Apathy • Poor self-monitoring

33. Limbic system:

34. Amygdala; primitive emotional responses (i.e. anger, surprise, fear, novelty) • We recall how well we feel when we satisfy the addiction (i.e. good feelings around Xmas, birthday, Hanukah, many years later) • This at times overwhelms our logic! • This explains why stimuli associated with addiction (i.e. a bar, friends, neighborhood, drug paraphernalia) • Hippocampus • Long term potentiation (LTP): physical process in which memories are formed- relies on the neurotransmitter Glutamate

35. THE ADDICTED BRAIN: THE MICRO VIEW

36. Plasticity of brain function: the fact that the brain changes permanently in regards to both internal and external stimulationPsychopharmacology and Plasticity are beginning to provide an explanation of two characteristics associated with addiction: Tolerance and Withdrawal

37. The mechanisms of how these drugs exert their effects in the brain are well worked out. There are two main ways this occur: • Increases the activity of these systems by mimicking the activity of the drug:

38. 2. Inhibiting re-uptake of the drug, causes a longer, stronger signal

39. More recent evidence has begun to help us understand other aspects of addiction • Tolerance and withdrawal occur, because, in the initial stages of addiction, frequent drug use can initially suppress parts of the brain’s reward system by activating a substance called dynorphin, whose function it is to loop back and inhibit (“turn off”) the VTA • This makes the same dose of the drug less rewarding • Also contributes to a growing depression, as the person begins to experience Anhedonia, failure to take pleasure in previously enjoyable activities

40. The next stage: Sensitization • Recent work has identified a substance, Delta Fos B, whose concentration rises in the Nucleus Accumbens and other brain regions in response to chronic drug use • This protein is extraordinarily stable, thus, remains active in the neurons for weeks and even months after drug administration • It is believed that prolonged induction of this molecule causes animals to become hypersensitive to drugs

41. The next step is highly speculative at this point: • Prolonged exposure to drugs in animals has led to additional “sprouting” on the dendrites of the Nucleus Accumbens- Delta Fos B may lead to these changes, thus, when its’ levels return to normal it has left a lasting “impression’ on the brain

42. ADDICTION AND THE FRONTAL LOBES

43. Some theorists have begun to look at addiction in a behavioral sense as a loss of self-control • Self control, or inhibition, is considered to be one of the aspects of functioning known as the Executive Functions: • Self-control, delay of gratification, drive inhibition, and anticipation of future consequences • Environmental dependency syndrome (Lhermitte, 1986): With those who have frontal lobe damage, behavior becomes largely a function of external stimuli

44. Evidence now suggests frontal lobe dysfunction is associated with a host of disorders including Autism, ADHD, OCD, and Schizophrenia • There have been a number of studies examining the effects of Chronic Alcohol use on the brain • Volkow (1994): Chronic alcoholism is associated with abnormally low frontal cortical metabolism, more specifically orbitofrontal areas, which gradually improved with month of abstinence • Studies have also indicated that these decreases tend to outlast the withdrawal phase, despite the initial improvement • Excessive Dopamine release and overstimulation of Dopamine receptors in the prefrontal cortex have been shown to impair prefrontal-cortex dependent cognitive functions in laboratory animals (Arnsten & Goldman-Rakic, 1998) • Similar short-term and long-term effects have been found with other substances, such as, Cocaine and the Opioids

45. Putting it all together:In addition to causing the experience of pleasure, the Dopamine system by virtue of its’ connections with the frontal lobe, can help explain some of the behavioral results of long-term substance abuse It has been suggested that the Mesocortical Dopamine System serves to take the prefrontal cortex “off line” during stressful events so that faster, more automatic or instinctive processes mediated by the limbic system

46. Acute depression of prefrontal lobe activity due to excessive inhibitory mesocortical dopaminergic neurotransmission evoked by drugs is increasingly accompanied over time by sensitization of dopaminergic transmission and perhaps chronic neurotoxic drug or dopamine actions on the frontal lobes, should significantly reduce the inhibitory control exerted by prefrontal cortical areas over posterior cortical and subcortical systems mediating reinforcement and automatization of behavior (Tiffany, 1990). Leads to impaired control over drug use and behavior in general