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1. 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 TitleDATE HERE

2. YellowbrickFind 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

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 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.”

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 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.

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. YellowbrickFind Your Way Home Imaging The Depressed Brain 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 NeurobiologicalFactors 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 : 1.0 0.8 0.6 0.4 0.2 0.0 0 10 20 30 40 50 60 ADHD * *p<.05 vs control Probability Control Age of Onset Wilens TE, et al. J NervMent Dis. 1997;185(8):475-482.

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. woman with ADHD, Conduct Disorder and Polysubstance Dependence  IMPULSE DYSCONTROL SxNote the hypofunction = “hole” in left inferior cortex (OFC)

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,problemsolving,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. “Minding the Brain” • The Residence • Life Strategies Program • Center for Clinical Neuroscience • Addictions Service • Eating Disorder Service • Trauma Recovery Program • CareerDevelopment Presentation TitleDATE HERE