The Institute for the Research and Treatment of Addictive Disorders

1. The Institute for the Research and Treatment of Addictive Disorders Presents:

2. Anhedonia and Sexual Compulsivity How Trauma and Over-Stimulation lead to a shutdown in the pleasure system By: Dr. A. Todd Freestone, Psy.D., LCSW

3. The Addiction Process How the brain changes to form an addiction

5. The Body’s #1 Priority • The body’s number one priority is that of survival. • The most important priority in our body next to survival itself, is that of Homeostasis. • Homeostasis is the body’s priority to maintain the “status quo” or to keep everything the same. • This is such an important priority that when any change occurs, the body immediately begins to work on countering that change.

6. The Body’s #1 Priority • For example, if we put a stimulant into our body, it will immediately begin producing a depressant drug to counter the arousal produced from the stimulant.

8. The Body’s #1 Priority • The problem is that this race to produce equilibrium also causes a lot of fluxuation and so the body begins to learn.

9. The Body’s #1 Priority • The body (in an effort to minimize the impact of the drug to the body’s equilibrium), begins to recognize the surroundings, people and situations that drugs are used in, and then begins to introduce the “anti-drug” before we actually introduce the drug to get high. This insures that the drug does not get us as “high” and produces “tolerance.”

11. The Body’s #1 Priority • With this we see that the body actually begins to drive the cravings and addictive process. • The same process goes for what is called “process addictions” as well. • Process addictions are those compulsive behaviors that are not dealing with externally introduced drugs or alcohol, they are internal chemicals that are triggered by certain behaviors (compulsive sex, compulsive gambling, compulsive over/under eating, cutting, extreme relationships, over-exercise, etc.).

12. The Body’s #1 Priority • The process for these process addictions is basically the same as drug use, except it is that we are becoming addicted to our body’s own “drugs.” • Every substance that allows us to get “high” has a counterpart that our body produces naturally. These chemicals either directly connect to Neuron receptor sites or cause the body to release neural chemicals that produce the “high” or euphoric feelings.

13. The Body’s #1 Priority • These are the same chemicals that are over-produced in the body by either substance use or compulsive behaviors. • The body gets used to having intense amounts of these chemicals and resets the body’s equilibrium.

14. The Body’s #1 Priority • This is one of the main reasons that it is so difficult for a person dealing with addictions to stop the addictive or compulsive behaviors. Literally, to eliminate those behaviors, we are fighting our body’s #2 priority

15. Trauma and Compulsivity • So now we know how addictions are formed with the body learning from operand conditioning. Now if we add trauma to the picture, we can have the Classical Conditioning component coming into play. • In our DAPSA Model, we talk about one way that two simultaneous events can combine together to form sexually compulsive behaviors.

17. Negative emotional learning leads to anhedonia • Intense experiences leads to a breakdown in the pleasure receptors in our brain. The more over-stimulated they are, the more our brain lessens the opportunity for these receptors to be triggered.

18. Have you ever felt like this?

19. What is Anhedonia? • “Anhedonia: Loss of the capacity to experience pleasure. The inability to gain pleasure from normally pleasurable experiences. Anhedonia is a core clinical feature of depression, schizophrenia, and some other mental illnesses. • An anhedonic mother finds no joy from playing with her baby. An anhedonic football fan is not excited when his team wins. An anhedonic teenager feels no pleasure from passing the driving test. (Mednet.com)

20. What is Anhedonia • Severe forms are a diagnostic criteria, but like every other illness or disorder, there are gradations of anhedonia and this is what this presentation will focus on. • How do we damage our body’s pleasure system? • What can we do to control or restore this system?

21. Anhedonia Scale • Enter a score for each question based on the following: 0 = Never or rarely 1 = Occasionally (I seem to be able to control it) 2 = Often (several times per week) 3 = Always (every day or a lot of the time)

22. Anhedonia Scale • I used to enjoy good food but no longer do. • My emotions feel numb and I cannot respond to happy events. • Feelings of Sadness can easily overwhelm me. • Other people now seem to be much happier than I am. • I have great difficulty trying to get going in the morning.

23. Anhedonia Scale 6. I have lost interest in activities that used to give me pleasure. 7. I cannot think of anything that can make me feel happy. • I cannot give or receive affection as well as I used to. • I feel that God (Higher Power) is very far away and not interested in me.

24. Anhedonia Scale 10. I no longer want to socialize with people. • I avoid going to social activities. • I used to derive a lot of pleasure in hobbies or creative activities but no longer do. • Even when I accomplish something significant, I cannot enjoy it. • Most of what is happening in my life bores me and only big things can excite me. • The worst time of the day for me is in the morning or after I have taken a nap.

25. Anhedonia Scale • Scoring and Interpretation: 0-7 Little to no anhedonia 8-15 Mild temporary anhedonia 16-20 Moderate anhedonia 21-25 High signs of anhedonia not temporary 26-30 High in need of professional help 31-35 Severe in need of professional help. 36 –up Severe and needs immediate professional attention. (Hart, A.D., 2007, pp 35-37).

26. Case Study • The client was a 38 year old married man with 4 children, who came into treatment for pornography addiction. • He came to treatment after losing a very specialized job due to his pornography use at work in the middle of the worst of the unemployment crisis. • He grew up in a home where he found his father’s pornography stash at about age 9 and sexually inappropriate comments and gestures were common, from his father to his older sister . • His father was verbally and physically abusive to the client, and his mother made excuses for his father after each abusive episode. • The client reports being scared in his home often and accidentally finding masturbation while vacuuming and pressing his genitals on the handle to push it forward at age 10. His pornography use took a huge leap forward when he was introduced to the Internet at age 18. • He claims that he lost interest in all else at that time. He married and stopped his pornography use for about 6 months, but then resumed. He got a job that paid for his specialized training and became a maintenance mechanic on large machines and began to make a good living while still using pornography secretly. • The client’s mother died 2 years prior to his entering treatment. His pornography use moved to several times per day, and at work. He states “I felt like the worst person I could be. I was living two lives. I was living a lie. “ • Anhedonia was definitely present.

27. Our Addictive Society • It is our supposition that as society becomes more extreme, faster and more driven, we become less and less able to experience pleasure for the everyday pleasures in life. • Only high arousal activities give us enough of a dopamine boost to experience pleasure. These typically are those activities that have a large addictive potential.

29. Our Addictive Society • "A recent Logitech study revealed that people, on average, have six applications open on their computer at any one time, and the active window switches or a new window opens every 50 seconds. To navigate the vast content at their disposal, people spin their mouse's scroll wheel approximately 26 feet in an eight-hour day."

30. Our Addictive Society • “Technology and the Internet have prompted a new phenomenon referred to as “CPA” -continuous partial attention - where children and adults devote less-concentrated attention to two or more tasks that are attempted simultaneously without one’s full attention committed to any single one of those endeavors.As an expected outcome, the quality of execution in each task frequently suffers significant performance erosion. For example, a five-year-old can talk and he can also tie his shoe, but talking while tying his shoes concurrently can even lead to “performance paralysis.” One of the two tasks must reach the performance threshold of “automaticity” (where one task can be performed without actively and consciously thinking about each step in the process of execution) before we can successfully engage in the second task with some degree of expected proficiency.” http://sciencemaster77.blogspot.com/2011/01/attention-spans-revisited.html

31. Our Addictive Society • A study of U.S. workers by Pew Internet & American life found that 88 percent checked their inbox at least once a day. Of those 70 percent checked several times a day. Around 73 percent spend an hour or less per day on dealing with email. Of these, 23 percent spend under 15 minutes dealing with email. Http://www.e-gateway.net/infoarea/news/news.cfm?nid=2809 • Average attention span for internet users is 9 seconds. Http://news.bbc.co.uk/1/hi/sci/tech/1834682.stm • According to AMR Research you have 3 to 5 seconds to get someone’s attention with email. Http://www.zdnet.com.au/newstech/ebusiness/story/0,2000048590,20216598,00.htm

32. Our Addictive Society • Jeremy Waite advertising columnist for Entrepreneur magazine stated: “In 1960 the average person’s attention span was 42 seconds. Today it is less than 5 seconds for political messages until we switch off. What will YOU say in 5 seconds that will give people a reason to buy from you?” • Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 and an average of 5.5% per year from 2003 to 2007. (CDC Website)

33. Our Addictive Society • Recent TEMPO research also revealed some interesting demographic and diagnostic trends surrounding the use of Portable MP3 Players: • Younger Americans are driving recent growth, with over half of teens now owning a Portable MP3 Player (54%), and one third of 18-34 year olds (30%). Older Americans are less likely to own these devices overall, but still represent a sizable and consistent presence in the market (13% of 35 – 54 year olds report owning a Portable MP3 Player). • Males continue to lead females in Portable MP3 Player ownership, with nearly one quarter (24%) of U.S. males aged 12 and older owning a device, compared to 16% of females. • Nearly half of music downloaders own a portable MP3 player (48%), and these owners use their devices an average of 12 hours per week. Younger downloaders use their MP3 Players more often (average of over 16 hours per week among teens), but have less digital content stored on their devices. Overall, there is an average of 700 songs or files stored on a U.S. music downloader’s MP3 player.

34. Our Addictive Society • Why are we talking about anhedonia related to compulsive behaviors? • Anhedonia is the malfunction of the body’s pleasure system. • Pleasure is an essential function of the body. • Necessary to survival. • It rewards life-sustaining behaviors (food, water, sex, etc.) • It gives us a reason to live (happiness) • Our body is set up so that it habituates to even extreme circumstances over time. • Trains , airports, dairy farms, Mary Poppins

36. Our Addictive Society • BUT….. • Even when we habituate, it causes stress • What is stress? • Stress is the body’s response to any change in the environment. • It is a series of events that happens when “the sensory and reasoning centers in the cortex perceive –or think they perceive- a threat…”

37. Stress Response and Compulsivity • “The Journal of Science described experiments in which chronically stressed rats lost their elastic rat cunning and instead fell back on familiar routines and rote responses, like compulsively pressing a bar for food pellets they had no intention of eating. Moreover the rats’ behavioral perturbations were reflected by a pair of complimentary changes in their underlying neural circuitry. On the one hand, regions of the brain associated with executive decision-making and goal-oriented behaviors had shriveled, while conversely, brain sectors linked to habit formation had bloomed.”

38. Stress Response and CompulsivityContinued • “In other words, the rodents were now cognitively predisposed to keep doing the same things over and over, to run laps in the same dead-ended rat race rather than seek a pipeline to greener sewers. Behaviors become habitual faster than in the controls, and worse, the stressed animals can’t shift back to goal directed behaviors when that would be the better approach… We’re lousy at recognizing when our normal coping mechanisms aren’t working. Our response is usually to do it five times more, instead of thinking, maybe it is time to try something new. (New York Times, 8/18/2009)”

39. Anhedonia and Compulsive Behaviors • In particular, we focus our attention on the relationships occurring between anhedonia and substance use disorders, as highlighted by many studies. Several authors suggested that anhedonia is an important factor involved in relapse as well as in the transition from recreational use to excessive drug intake.

40. Anhedonia and Compulsive Behaviors • Furthermore, in subjects with a substance dependence disorder, there is a significant correlation between anhedonia, craving, intensity of withdrawal symptoms, and psychosocial and personality characteristics. Therefore treating anhedonia in detoxified alcohol-dependent subjects could be critical in terms of relapse prevention strategies, given its strong relationship with craving.

41. Anhedonia and Compulsive Behaviors • In addition to dopamine, primarily involved in hedonic experience are endogenous opioids, like endorphins, enkephalins, dynorphins, and orphanin FG as well as their various receptor subtypes (μ, δ, κ, and ORL1; Cooper et al., 2003), which are widely expressed in the ventral striatum (particularly the shell of the NAcc). Stimulation of these receptors is believed to underlie hedonic responses to food, and other natural rewards (Pecina et al., 2006).

42. Anhedonia and Compulsive Behaviors • Anhedonia is also present in other disorders and dysfunctional behaviors such as Parkinson’s disease (Isella et al., 2003), over-eating (Davis and Woodside, 2002), and risky behaviors in general (Franken et al., 2006b).

43. Anhedonia and Compulsive Behaviors • As should be clear enough by now, all of these things combined together, leads us to escapism and a break-down in our body’s pleasure system (anhedonia). If we do not address this in our treatment, we will ultimately fail in our desire to help our client’s reach sobriety.

44. Happiness meets Anhedonia • In order to help our clients deal with anhedonia, we must help them to repair their pleasure system and become happy. • Time magazine in its 2005 edition on mind and body stated this: A prominent brain researcher had discovered that “happiness, an essential emotion in pleasure, Isn’t just a vague, ineffable feeling, but a physical state of the brain. Furthermore, it is possible to deliberately induce such a state of happiness. In every sense of the idea, therefore, happiness is a choice.”

45. Case Study Pt. 2 • The client and his wife entered treatment. Techniques were used as outlined in CJ Sorenson’s presentation yesterday, and as will be talked about shortly. Anhedonia was reversed. The pleasure center that was broken in this client’s life, was repaired by his own brain. He states “Through the weekly visits with Dr. Freestone and group meetings with peers, I learned I was not a lost soul. I learned new ways to cope with life and a new way to live with my family. I stopped living in the moment, and found a greater perspective. Since then, I have been happier than I thought possible. Words truly cannot express how this treatment has changed my life for the better. I can find myself in a situation that would trigger me before, and instead of acting out, I can step back and step away. I thought I was weak, but I just needed the right tools.”

46. In order to be happy…….. • We must teach how to reduce/manage stress • We must teach and practice mindfulness • We must teach and practice physical exercise • We must make them successful (Hope) • We must teach them to have/recognize small simple pleasures • We must give them knowledge on neuro-science, and the addictive processes (knowledge is power)

47. Stress Reduction • Stress is necessary for motivation and learning, but continuous stress is counterproductive and destructive to the body. • Relaxation, yoga, stretching, guided imagery • Calming relaxing music and environment • Bio/Neuro-feedback • Meditation • Organization skills, financial management

48. Mindfulness • Mindfulness is the process of focusing on the moment and being in the here and now. • Smell the roses • Enjoy the beauty of a sunrise/sunset • Experience all things the first time with all your senses. • “Do not be overwhelmed by the future or anchored by the past, focus on the now and live.”

49. Physical Exercise • When the stress response is triggered, glucocorticoids are produced and if not burned up by aerobic exercise (or fight/flight) they become toxic to the body. • Neurogenesis and neuroplasticity are enhanced and increased by exercise.

50. Make them Successful • Use principles of accountability • Tracking form • Individual and group accountability • Soothers • Principals of learning • Consistency, Duration, Frequency • Positive Affirmations (Treatment pillars) • Support system involvement • Family, SO, friends, clubs/hobbies, 12-step programs • What price are you willing to pay?