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Un-frying your Brain – Reversing the Cognitive Deficits in Substance Abuse Dr. Tonmoy Sharma June 2016
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Un-frying your Brain – Reversing the Cognitive Deficits in Substance
Abuse
Dr. Tonmoy SharmaJune 2016
ADDICTION: a primary, chronic disease of brain reward, motivation, memory and
related circuitry
Un-frying your Brain by Dr. Tonmoy Sharma
Un-frying your Brain by Dr. Tonmoy Sharma
A Cognitive Behavioral Model of the Relapse Process
Marlatt and Gordon (1985)Un-frying your Brain by Dr. Tonmoy Sharma
Franken’s Neuropsychopharmacological Model of Craving and Relapse • Drug stimuli conditioning
increases dopamine levels increases AB for drug stimuli ‘hypervigilance’
• ‘Hypervigilance’ increases craving and decreases attentional resources for other mental activities
Un-frying your Brain by Dr. Tonmoy Sharma
Moss & Albery’s (2009) Dual-Process Model of the Alcohol-Behaviour Link
Dyer, Moss & Albery’s Dual Systems Theory of Addiction
Un-frying your Brain by Dr. Tonmoy Sharma
The Cognitive Processing ModelAddictive behavior: more common in people who place excessive reliance on external structures to maintain a balance between their physical and psychological needs• Repeated behaviors become automatic• Addictive behaviors are regulated by automatic processing• Impaired control over actions lead to addictive behavior
People can perfectly predict present and future consequences but they mostly attach greater weight to the present
Immediate reward over future benefit = cognitive myopiaUn-frying your Brain by Dr. Tonmoy
Sharma
Neuropsychological sequelae of drug misuseHeavy long term use of alcohol, cannabis, inhalants, opiates & psychostimulants has been linked to deficits in:• Attention/executive function• Learning and memory• Visuospatial abilities• Postural stability(Everitt et al (2001) The neuropsychological basis of addictive behaviour. Brain Res. Rev. 36.129-138 nm’,
Working Memory <STM+Attentional control>• Maintains representations of external stimuli• Stores action plans• Goal representations• Task relevant informationEven when goal maintenance fails in WM, goal is still retrievable from LTM Kane, MJ & Engle RW (2003) Working memory capacity and the control of attention: The contribution of goal neglect, response competition, and task set to Stroop interference. J of Exp Psych:(Gen) 132. 47-70
Un-frying your Brain by Dr. Tonmoy Sharma
Three Executive Functions1. Shifting (Switching from addition to subtraction-or from addiction to
sobriety)2. Updating (Monitoring progress, keeping track or goal maintenance- or “I am
not going to use today”)3. Inhibition (suppressing pre-potent responses e.g. Stroop task or anti-
saccade task or “I will not dwell on my thoughts about drinking”)Miyake et al (2000) The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis.
Cognitive Psychology 41. 49-100.
Impaired inhibition and learning in substance misusers
To go, or not to go: failure to suppress pre-potent responsesWhat is good or bad for me? – impaired learning from implicit or indirect feedback on Iowa Gambling Task.Review see Garavan, H. Stout, J.C. (2005) Neurocognitive insights into substance misuse. Trends in Cognitive Sciences 9.195-201
Un-frying your Brain by Dr. Tonmoy Sharma
PET/fMRI of Cocaine CravingChildress et al., 1999; Am.J.Psychiat
Un-frying your Brain by Dr. Tonmoy Sharma
Processing biases (latent but increased during craving) Impairments in executive/frontal processes (subtle and not generally apparent on psychometric tests)Implications for therapyContext is translational or applied research
Cognition and [email protected]
Basic AssumptionsExecutive control is the basis for the regulation of human action.Recovery from addiction is impeded by cognitive processing biases, impaired goal maintenance & error detection and compromised decision making. In combination, these cognitive processes can be latent vulnerability factors for relapse.These are potential targets for direct or indirect modification and can index therapeutic gain.( Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUPUn-frying your Brain by Dr. Tonmoy
Sharma
Cognitive biases are linked to cravingCognitive biases are associated with increased cravingIncreased craving increased cognitive bias.Bias tends towards maintenance rather than engagement: this has implications for treatment.(Field, Mogg & Bradley, 2006 Attention to drug-related cues in addiction: Component processes in Wiers, W.W., & Stacey, A.W Handbook of implicit cognition and addiction.(Eds) Sage. London.
Wanting and Liking Drugs stimulate dopamine neurotransmission in reward pathwaysStimuli associated with this process are invested in incentive properties, an attributional learning processIn some individuals, repeated drug use produces incremental neuroadaptations which “hypersensitize” the relevant neural system This “pathological wanting” is sub-served by mechanisms distinct from those that govern liking.Robinson & Berridge,1993 Un-frying your Brain by Dr. Tonmoy
Sharma
Attentional bias priorities cue detection and infiltration of working memory. The contents of working memory in turn influence attentional bias.
Result is preoccupation with salient cues.The “Black and White” Model of
Relapse
Un-frying your Brain by Dr. Tonmoy Sharma
Relapse Prevention: Specific Intervention Strategies
Un-frying your Brain by Dr. Tonmoy Sharma
Marlatt, Parks, & Witkiewitz, 2002
Therapeutic Strategies• Stimulus Control: know the triggers• Implementation intentions: be aware of and attempt to correct
cognitive biases• Identify alternative rewards/goals • Self-monitoring• Distance /de-center / mindfulness meditation• Challenge expectancies and implicit cognitions via behavioral
experiments • Support self-efficacy• Goal specificityReward radar is always on!
• Emphasis on remediation of cognitive deficits and reversal of cognitive biases.
• Focus on goal maintenance and working memory mechanisms• Prioritize impulse control strategies Un-frying your Brain by Dr. Tonmoy
Sharma
Bridging the gap between laboratory and clinicThere are now 45 studies using diverse methods implicating attentional biases in addiction (Franken, 2003)• Consistent with the “attribution of incentive salience” to cues
that signal drug availability• Suggests detection of drug cues is the result of relatively
automatic and involuntary processes that occur outside of awareness.
Biased attentional processes are influential in fostering the persistence or resumption of drug taking.This early preferential processing decisively influences subsequent mental operations such as memory.
Un-frying your Brain by Dr. Tonmoy Sharma
Implicit Cognitive Processes Can Subvert Therapeutic Allegiance
General implicationsPrevention: Deferring age of first use is desirable
Treatment: Needs to be more intensive, more focused on impulse control including “brain re-training”
Addiction is enduring due to the mandatory role of cognitive biases and the subversive action of subtle but pervasive cognitive failure
Un-frying your Brain by Dr. Tonmoy Sharma
Basic Assumptions1. Impairment of executive control due to cognitive processing
biases, poor goal maintenance, error detection and compromised decision making.
2. These cognitive processes can be vulnerability factors for relapse.
3. These are also potential targets for direct or indirect modification and can index therapeutic gain.
(Ryan, (2006)
Un-frying your Brain by Dr. Tonmoy Sharma
Motivational EnhancementAmbivalence is seen as conflict between controlled and automatic processes rather than a “balance sheet”Focus on decision making and goal specification is consistent with recruiting working memory processes and exerting a “top-down” regulation.
Paradigm ShiftAddiction is maintained by enduring changes in priorities and deficits in information processing.Therapies that infiltrate and modify this, mainly via working memory processes, are more likely to be effective.There is a potential role for cognitive rehabilitation using the prototypical neurocognitive behavior therapy described.Conversely, changes in attentional and mnemonic functioning, especially implicit processes, will index and predict therapeutic gain.
Un-frying your Brain by Dr. Tonmoy Sharma
Skill-Training with Alcoholics: One-Year Follow-Up Results
p < .05
SD = 6.9
SD = 62.2
(Mean = 5.1) (Mean = 44.0)
Days of Continuous Drinking
p < .05SD = 2218.4
SD = 507.8
(Mean = 399.8) (Mean = 1592.8)
Number of Drinks Consumed
p < .05 SD = 17.8
SD = 17.8
(Mean = 11.1) (Mean = 64.0)
Days Drunk
Un-frying your Brain by Dr. Tonmoy Sharma
Skill-Training with Alcoholics: One-Year Follow-Up Results
p < .05
SD = 17.8
SD = 17.8
(Mean = 11.1) (Mean = 64.0)
Days Drunk
Enhancing Outcome
Implicit cognitive processes are plausible mechanisms to account for involuntary aspects of addiction
These are potential targets for direct or indirect modification but component processes (e.g. goal maintenance) operate in existing treatments
Addressing these processes has the potential to enhance outcomes Un-frying your Brain by Dr. Tonmoy
Sharma
Definitely! Maybe?Should be doing (good evidence
both laboratory & clinic)
• Focus on addictive habits• Contingency management • Encouraging attendance at self-help
“recovery” groups• Behavioral Couples Therapy
Could be doing (plausible in laboratory & indicative trials)
• Cognitive bias reversal (attentional bias reversal; targeting automatic approach tendencies; implicit challenges or behavioral experiments)
• Mindfulness practice• Trans Cranial Brain Stimulation
Un-frying your Brain by Dr. Tonmoy Sharma
Therapeutic Strategies With Potential For Increasing Cognitive Control
• Goal specificity• Stimulus Control: know those triggers• Implementation intentions• Be aware of and attempt to correct cognitive biases• Identify alternative rewards/goals • Self-monitoring• Distance /de- center / mindfulness meditation• Challenge expectancies and implicit cognitions via behavioral experiments • Support self-efficacy
Un-frying your Brain by Dr. Tonmoy Sharma
In the context of addiction, attentional bias prioritises cue detection and infiltration of working memory in a reciprocal way. This compromises executive control. If therapeutic intervention can increase cognitive control it is likely to reduce preoccupation with salient cues and attendant cue reactivity.
“The Road to recovery…is paved with good rehearsals.” Enhanced outcome in addiction requires changes in both controlled and automatic processingAutomatic processes, previously overlooked, can be reversed through practice and pre-empted by a range of techniques relying on goal maintenance and cognitive control. “Tried & tested” interventions need to delineate and accentuate the role of implicit cognitive processes.Emerging cognitive bias reversal technologies need to be evaluated and developed for further use.To maximise efficiency these need to be easily available.
Un-frying your Brain by Dr. Tonmoy Sharma
[email protected] ReferencesChildress, A R et al (2008) Prelude to passion: Limbic activation by “unseen” drug and sexual cues. Leventhal, A.M.et al (2008). Subliminal processing of smoking related and affective cues in tobacco addiction. Experimental and Clinical Psychopharmacology. 4. 301-312Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical Psychopharmacology. 10. 67-76.Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUPSoto, D. et al. (2008) Automatic Guidance of Attention by Working Memory. Trends in Cognitive Sciences 342-348Wiers, W.W., & Stacy, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.Irvin, J.E, Bowers, C.A, Dunn, M.E. & Wang, M.C.(1999) Efficacy of Relapse Prevention: A Meta-Analytic Review. J. of Consulting and Clinical Psychology. 67.563-570Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical Psychopharmacology. 10. 67-76.Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUPWiers, W.W., & Stacey, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.Selected Bibliography: Cognitive neuroscience and addictionFranken, I.H.A. (2003) Drug craving and addiction: Integrating psychological and
neuropharmacological approaches. Progress in Neuro-Psychopharmacology and Biological Psychiatry.27, 563-57
Garcia, A V, Torrecillas, F L, de Arcos, F A & Garcia, M P (2005) Effects of executive impairments on maladaptive explanatory styles in substance abusers: Clinical implications. Archives of Clinical Neuropsychology 20. 67-80
Rogers. R D, Everritt, B J, Baldichino, A. et al (1999) Dissociable deficits in the decision making cognition of chronic amphetamine abusers,opiate abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: Evidence for monoaminergic mechanisms
Neuropsychopharmacology 20. 4 322-339. Robinson T E & Berridge, K C (1993) The neural basis of drug craving: An incentive sensitization theory of addiction. Brain Research
Reviews 18 247-291
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