Affect Regulation Therapy (ART) for the treatment of cognitive and health disorders

1. Affect Regulation Therapy (ART)for the treatment of cognitive and health disorders Mitchell R. Slutzky, Ph.D. CHE Senior Services March 27, 2011 Alzheimer’s Disease International, Toronto

2. Conflict of Interest DisclosureMitchell Slutzky, Ph.D. Has no real or apparent conflicts of interest to report.

3. Key Concepts • Affect Regulation Therapy (ART) can improve cognitive functioning and physical health of persons with dementia • Catastrophic affect upsets the balance of the immune system and creates or exacerbates memory disturbances • Positive emotions benefit cognitive, emotional and physical health by reregulating the immune system • Many people with dementia can improve positive emotions with practice, even if cognitive memory is impaired (as long as emotional circuitry is better preserved)

4. What is Affect Regulation Therapy? • Built upon work of Allan Schore • Empathy and secure attachment reduces catastrophic affect extremes • Hyperactivation: Fight-Flight • Hypoactivation: Dissociation • Teaches one to recognize extreme affect states • Re-evocation of traumatic event recalled in context of safety leads to a more positively-valencedaffective response • Positive affect state strengthened with each reinforcement in context of safety • Improves brain neuroplasticity • Improves endocrine and immune system • Has direct application to improve functioning • Even with cognitive impairment or health disorders

5. Allan Schore: Affect Regulation Theory • Early social environment, mediated by primary caregiver, influences developing brain structures • Maturation of the right orbitofrontal cortex is dependent upon dyadic interactions of the attachment relationship • Predicts the child’s future capacity to: • self-regulate emotions • appraise others’ emotional states

6. Polyvagal Theory: Evolution of Three Survival Strategies (Stephen Porges) • Dorsal Vagus Nerve/Primitive Parasympathetic NS • In response to threat perceived as life threatening • Primitive, not myelinated • Role: Shuts down to conserve metabolic functions • Sympathetic Nervous System • In response to perceived danger (escape possible) • Role: Activates fight-flight • Ventral Vagus Nerve/Evolved Parasympathetic NS • Arises only in the context of secure attachment Safety • Only in mammals • Myelinated • Role: can calm in face of danger by inhibiting fight-flight • Allows for attachments, well-being, balanced health

7. Safety: Balanced well-being Stilling and Stimulating both in balance • Occurs only when feeling safe • maximizes brain health and function • memory and other cognitive functions • maintains capacity for positive emotions • maximizes capacity for • compassion • social connection • individuality • improves immune system functioning • regulates appetite and sleep Whole is greater than sum of the parts

8. How ART reduces cognitive impairment • Cognitive and emotional systems develop parallel to each other • Emotional memory remains relatively preserved in the amygdala after cognitive memory fades with damage to the hippocampus • Build up amygdala’s emotional memory systems when hippocampal cognitive memory erodes

9. Key Memory Areas LayUnder the NeocortexIn the Limbic System

10. Two ways emotional trauma leads to dementia • Step 1: Response to perceived danger is Fight Flight • Amygdala initially becomes hyper-activated • Plaques and tangles accelerate • Too much cortisol erodes the hippocampus • Hippocampal deterioration accelerates memory loss • Step 2: If perceived as life threatening leads to Dissociation • Amygdala becomes underactive • Metabolic preservation of hippocampus • β-endorphin numbs and enhances reality distortions • Functional deficit: memory loss but hippocampus is preserved Either way: • When faced with cues that re-evoke earlier trauma, the original affect state is triggered accelerating injury • Amygdala continues to record memories and the emotional significance of related events Explicit Memory deteriorates but Implicit Memory remains intact longer

11. Cycles of dysregulated affect Hyper-activation to danger Fight-Flight Reflex: Anger/fear (Over-stimulating sympathetic NS) Cortisol dysregulation Safe/Connected Ventral Vagus nerve Right frontal orbital lobe both optimized Regulated alpha-msh Normal emotional range Hypo-activation when life threatening Dissociation/withdrawal/detachment (Over-stilling Dorsal Vagus Nerve) Beta-endorphin dysregulation Slutzky’s theory, 2010 adapted from Fosha and Schore, 2009

12. Acute Hyper-activationIn Response to Stress • Increased Sympathetic NS (Fight/Flight) • Hyper-recording of memory • “light bulb burning too bright” • Increased cortisol secretion and burn • Decreased inflammation • Suppressed immune response Do not appear sick even if have a germ Get sicker when immune system finally kicks in

13. Chronic Hyper-activation • Chronic high cortisol levels: • Damages hippocampus memory (Alzheimer's and other dementias) • Underactive immune system • Increased risk of cancer or immunodeficiency or: • Depleted supply of cortisol from chronic hyperactivtion • Increased inflammatory response • Immune system overactive • Increased risk of autoimmune disorders Osteoarthritis Crohn’sDisease Multiple Sclerosis Parkinson’s Disease

14. Acute Hypo-activationIn Response to Stress • Fewer memory frames per second • “light bulb not burning bright enough” • Increased Parasympathetic NS decreases • Heart rate • Respiration/O2 requirements • Blood pressure • Other Effects: • Increased Endorphins/Enkaphalins • Decreased sensation of pain

15. Chronic Hypo-activation • Chronic flooding of beta-endorphin: • Dissociative disorders • DID, somatoform disorders, emotional numbing, fugues Or: • Depleted supply of endorphins while hypoactivated: • Depression • Chronic pain • Substance abuse • Social isolation Memory impairment either way

16. Neuroplasticity through A.R.T. Positive stimulation through A.R.T.improves Thinking Learning Acting Changes Brain: Physical Structure Functional Organization From Top to Bottom Neuroplasticity continues to occur at any age Dr. Michael Merzenich Major Researcher in Neuroplasticity

17. All you need is LOVE © Mitchell Slutzky, 2011 Look empathically: contain fight-flight & prevent dissociation (Auxiliary Amygdala) Organize emotional and cognitive memory (Auxiliary Hippocampus) Validate feelings to re-integrate affective and cognitive memory and to enhance reasoning (Auxiliary Right Prefrontal Cortex) Evaluate effectiveness of intervention (R)epeat (modify if necessary) to reduce catastrophic affect, consolidate memory and establish a polysemantic context that enhances encoding and retreival

18. Affect Regulation and Brain Exercises • Progressively challenging • Use the Goldilocks principle: “just right” • Strengthen: • Attention • Speed of processing • Recent memory • Planning skills

19. Affect Regulation through Aromatherapy: essential oils • Lavender: Stilling • Calms anxiety, fear or anger • Sandalwood: Connecting • Maintains positive emotions • Ylang-Ylang: Stimulating • Brightens mood • Increases energy • Myrrh: Motivating • Reduces apathy Aromatherapy appears to trigger changes in neurochemistry especially in the emotional brain Never use full strength: Put a few drops in a “carrier oil” or buy it in dilution “ready to use”

20. Conclusions: • Affect Regulation Therapy reduces intensity of negative emotions • Negative emotions harm all aspects of life • Positive emotions heal the whole person: • Cognitively • Emotionally • Physically • Positive emotions can be cultivated through a balance of stilling and stimulating • Even in persons with dementia

21. All you need is LOVE © Mitchell Slutzky, 2011 Look empathically: contain fight-flight & prevent dissociation (Auxiliary Amygdala) Organize emotional and cognitive memory (Auxiliary Hippocampus) Validate feelings to re-integrate affective and cognitive memory and to enhance reasoning (Auxiliary Right Prefrontal Cortex) Evaluate effectiveness of intervention (R)epeat (modify if necessary) to reduce catastrophic affect, consolidate memory and establish a polysemantic context that enhances encoding and retreival

22. Thank you Mitchell R. Slutzky, Ph.D. CHE Senior Services mslutzky@gmail.com