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Making relatedness a treatment goal

Making relatedness a treatment goal. Brian Johnson M.D. Assoc Prof Psychiatry and Anesthesia SUNY Upstate Medical University Member – Boston Psychoanalytic Society. Disclosures.

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Making relatedness a treatment goal

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  1. Making relatedness a treatment goal Brian Johnson M.D. Assoc Prof Psychiatry and Anesthesia SUNY Upstate Medical University Member – Boston Psychoanalytic Society

  2. Disclosures • I have never taken a pen or drank a soda at a drug-sponsored event. I have not benefitted personally from sponsorship by a drug company; except- • Research on shifts in the hypothalamic-pituitary-adrenal system and depression during and after alcohol withdrawal sponsored by the Distilled Spirits Council of the United States (Johnson 1986)

  3. Neuropsychoanalysis • Takes advantage of advances in both neuroscience and psychoanalysis to formulate testable hypotheses. • Like Freud’s original models of mental functioning, neurology is the material base. • Contrast with cognitive-behavioral psychology where the brain is a black box, outcomes are counted. • Example – “Reward” versus “SEEKING”

  4. THE BRAIN HAS DRIVE SYSTEMS (Pfaff 2006 )

  5. ACETYLCHOLINE

  6. SEROTONIN

  7. NOREPINEPHRINE

  8. DOPAMINE

  9. SEEKING/dreaming system (Solms 1999)

  10. Neural Circuit Mediating Goal-Directed Behavior (Volkow 2005)

  11. BRAIN ADDICTION PATHS

  12. Diffusion Tensor Imaging-SEEKING and PANIC systems (Panksepp 2011)

  13. What are Depression and Addiction? • If depression is so disabling, why is it so prevalent? • It must have some functional use. • What is an addiction? • Heroin • Where is the line on drinking? • What could the brain mechanism be in gambling? • Internet? Exercise? TV watching? Repeated harm from X

  14. National Epidemiologic Survey on Alcoholism and Related Conditions • Lifetime incidence of MDD – 13% • 12 month prevalence – 5% • Lifetime MDD – Alcoholism 40% (8.5%) Nicotine addiction 30%(20%) Drug addiction 17% (2%) • Why?

  15. Gender issues in Addiction and Depression • Women more MDD than men – 2/1 • Men more addiction – 2/1 • 12,500 Amish, no addiction – 1/1 (Egeland & Hostetter 1983) • Women tolerate emotional distress better without resorting to drugs (Khantzian) • Could we be observing symptom constellations with similar underpinning?

  16. Anxiety, Depression (Watt and Panksepp 2009) • PANIC (GRIEF) system-Insures contact • Babies cry when they are separated • In primitive conditions, crying babies starve or are eaten • Is depression a protest shutoff?

  17. Watt & Panksepp 2009 SEPARATION ANXIETY DEPRESSION

  18. Anaclitic Depression (Freud 1905) • Maternal deprivation a major risk factor for both depression and addiction (Heim…Nemeroff 2008) • Heim/Nemeroff depression model in rats • Separation for 15 minutes on days 2 – 14 leads to more licking • Separation for 3 hours leads to ignoring, biting, high CRF • Reversed by paroxetine and recurs off paroxetine

  19. Childhood adversity leads to adult depression (Harness, Monroe 2002) • Obvious answer, give antidepressants? (restore brain health) • Keller et al. study NEJM 2000 • Response rate nefazodone 50%, CBT 50%, combination 80% • Remission rate nefazodone 20%, CBT 20%, combination 40%

  20. Nemeroff reanalysis (2003) • Childhood trauma subset: No added benefit of nefazodone • Is there a subset of depressive illness (anaclitic) that responds to psychotherapy and not antidepressants? • (Lack of efficacy of antidepressants except for severe depression)

  21. Addiction and Unrelatedness • Addictive behavior has a transitional object quality for teenagers leaving home • Wurmser’s “Addictive Search” (1974) • Idealization used as a defense against terror • Addictive splitting • Wonderfully related/unrelated • Omnipotent power/helplessness • Independence/dependence • Rebellious separateness/not autonomous

  22. Deterioration of drug response to mood or pain as a result of the “b” process of allostatic compensation (Koob 2001)

  23. Will allostatic adaptations reverse with abstinence? • Changes in sleep induced by cocaine only became worse over 17 days (Morgan 2006) • Hyperalgesia induced by opioid exposure persisted for months in abstinent subjects (Prosser 2008) • Drug dreams persisted for 5 years of abstinence (Johnson 2001) • Anecdotal drug dreams for alcohol – 32 years, nicotine – 50 years • Permanent changes – mood, sleep, pain-tolerance, desire?

  24. Destructive brain effects gradually make recovery less likely • Alcohol, cocaine/methamphetamine, opioids – each impair cortical functioning • Drug seeking becomes an automatic, compulsive action mediated by NAC • Cognitively impaired patients most likely to leave psychotherapy • Cognitive evaluation of patients central to any evaluation (word-finding)

  25. Diagnosis of Depression in Addicted Patients • Patients in alcohol WD: HRSD bifurcated after one week (Johnson, Perry 1986) • 110 patients followed for 1 year: dep equally likely – independent or subst. induced depression (Nunes…Hasin 2007) • “Depressed” patients started at McLean (Greenfield 1998): 20% sober if on antidepressants, none stayed sober 4 months off antidepressants

  26. Use of Hamilton Rating Scale for Depression • Repeat during early abstinence for diagnosis • Helps patients see what you are treating • Helps with lack of mood-altering effects • Helps patients see constellation of anxiety, somatic and vegetative sxs

  27. Choice of Pharmacologic Agents

  28. Diversion-College (Garnier 2010) • ADHD – 62% • Amphetamines – 71% • Methylphenidate – 37% • Methylphenidate ER – 39% • Opioids – 35% • Bupropion - 0

  29. Rickels – 1993 Triangle – placebo,

  30. What About Sex? • SSRIs and SNRIs inhibit at least one phase of sexual functioning in 96% of women and 98% of men; interest, erection/lubrication, orgasm (Clayton 2006, 3114 subjects) • Mechanism of decreased libido – decreased testosterone: dopamine/serotonin balance • Bupropion increases libido as side effect, average patient loses 5 pounds • Trazodone is weight and sex neutral

  31. Risk of Suicide-Benzodiazepines Risk factors for completed suicide • History of self harm • Prior psychiatric treatment • Current psychiatric treatment • Benzo (Cooper 2006) Risk factor for subjects over 65 (Voaklander 2008)

  32. Month/year Cost of Medications • Duloxetine 60 220 2640 • Imipramine 150 33 396 • Trazodone 150 3 40 • Propranolol 10 3 40 • Paliperidone 900 10800 • Haloperidol 2 3 40

  33. Bipolar • Only 1/3 “bipolar” by psychiatrist admitted to Dual Diagnosis Addiction Service met DSM-IV criteria (Goldberg 2008) • Lithium #1 • Lamotrigine #2 • Avoid antidepressants – work, then provoke rapid cycling

  34. PAIN RELIEF – 6 HOURS • Which is codeine 60 + acetaminophen 600? A C B D E F

  35. Forbes, 1990

  36. DeAndrade 1996, S/P ORTHOPEDIC SURGERY

  37. Szasz Psychoanalytic Concept - Pain • Outside A -----Ego-----Inside B • Sensation – Felt by all • Perception – Felt by some. Can be pointed out. Requires input from memory • Affect – Specific to each person. Includes relationship • Experience of patient – sensation (outside) • Understanding of physician - complex

  38. HYPERALGESIA • WHITE (2004) ADD. BEH. 29:1311-24 • RATS IMPLANTED WITH MORPHINE PELLET • INITIAL RESPONSE TO RADIANT HEAT; ANALGESIA • BY DAY 4, CLEAR HYPERALGESIA (ON MORPHINE!) • BIPHASIC RESPONSE TO OPIATES; RELIEF FOLLOWED BY MORE PAIN; REPEATEDLY

  39. HUMAN HYPERALGESIA • HAY-WHITE 2009 – CPT 31 CONTROL, 18-20 ON MORPHINE, METHADONE • METHADONE; 30 HOUR HALF LIFE; PEAK AND TROUGH • COLD PRESSOR TEST: 65 SEC. CONTROLS, 15 SECONDS ON METHADONE • DURATION LESS THAN HALF AT PEAK METHADONE LEVELS

  40. ROSENBLUM ET AL. JAMA 2003

  41. UH Psychiatric Pain ConsultationCold Pressor Test (N>34 seconds) Age Gender Seconds Pain Medication 1 30 female 3 80 hydrocodone 2 26 female 10 80 oxyc 240/day 3 40 female 14 10 illicit painkiller 4 42 male 5 8 oxyco 60/day 5 17 female 3 minutes 10 oxycodone 6 27 male 10 70 hydrocodone, then methadone Repeated after detox 3 minutes 20 1 week later

  42. Treatments for Chronic Pain • Countertransference: Responsibility is patient’s, not physician’s • Look for a specific cause with a specific intervention • Don’t try to fix emotional or social problems with medications – accept helplessness and model it for the patient (“You have to live with pain”)

  43. Nonaddictive Interventions

  44. Prescribe According to Side Effects • Trazodone 200 – 600/day • Triad of ADHD, nicotine, depression makes bupropion excellent • Avoid SSRIs because of sexual side effects • Tricyclics for refractory depressions • Include cost as a side effect • Addiction included as a side effect

  45. Treatment of comorbid anxiety • “For every problem there is a pill” mentality • “Racing thoughts” and “Constant worrying” often have to do with living life on life’s terms • Usually anxiety does not require medication, but difficult behavior may require meds to allow treatment

  46. Medications for Anxiety • Antidepressants best, but have latency of onset of action • Propranolol, clonidine - cut norepinephrine • Anticonvulsants: valproate, gabapentin • Antipsychotics: No reason to pay for second generation

  47. Conflict with “A drug is a drug”? • “The AA Member and Medication” – AA public policy • Go to doctors who understand addiction • Tell your doctor that you have an addiction

  48. Pharmacology of Relatedness Sexuality is a central aspect of relatedness – don’t disrupt it • Medications can be categorized as dulling or promoting relatedness • Dull relatedness: Benzos, opioids, SSRI/SNRIs? • Enhance relatedness: Antidepressants, ADHD meds, antipsychotics – if psychotic

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