Department of Psychiatry

1. Mount Sinai Medical Center Department of Psychiatry Kimberly Hoppes Psy.D Psychiatry

2. Mindfulness-Based Interventions for Treatment of Addictive and Co-morbid Affective Disorders Adapted from: Hoppes, K. “The Application of Mindfulness-Based Cognitive Interventions in the Treatment of Co-occurring Addictive and Mood Disorders.” CNS Spectrums, 11:11, 2006.

3. Evidence-Based AddictionTreatment Approaches: Cognitive Behavioral Treatment Motivational Enhancement Treatment

4. Efficacy and Cognitive Behavioral Treatment for Substance Dependence The modality which has accrued the most substantial body of supportive outcome research • Strength of methodological rigor of research • Strength of theoretical foundation • Absence of alternative compelling research findings

5. Classical conditioning Stimulus Control Operant conditioning Contingency of Reinforcement Expectancy Modeling Cognitive Behavioral Principles for Treating Addiction Disorders Functional analysis Decreasing stimulus control Urge management behaviors and cognitive skills Alternative behaviors which are incompatible with addictive behavior Psychological modeling and drug refusal skills Developing new contingencies of reinforcement for abstinent behavior Restructuring faulty and distorted expectations Self efficacy Proximal vs. distal skills Cognitive Behavioral Modelsof Addictive Disorders Principlesof Learning Theory

6. Cognitive Behavioral Principles for treating mood disorders • Negative mood states are primary among internal or proximal relapse prevention factors • Cognitive behavioral interventions focus on: 1) The cognition and behavior that influences affect and emotion 2) Restructuring negative and distorted thoughts 3) Increasing adaptive and rewarding behaviors 4) Increasing self-efficacy 5) Increasing social support

7. Evidence-Based Motivational Interviewing- Miller & Rollnick MET offers an evidence-based technique to facilitate enhanced motivation for changing addictive behavior by: • amplifying pro change talk • reducing resistance and resolving ambivalence within the therapeutic dialogue

8. Enhancing Motivation through Mindfulness Interventions MET research on the process of developing motivation to change identified three key dimensions: • Importance • Confidence • Readiness

9. Additional Factor of Motivation The perceived ability to tolerate distress and regulate mood changes associated with substance cessation may also be an additional dimension to predict readiness to change.

10. Theory and Objectives Treatment should help the addicted individual find alternatives ways to feel better and restore emotional wellness by integrating research, theory and intervention from: “Addiction is an accident that happens in the course of the human search for happiness.” Stephan Klein Ph.D • Neuroscience of Addiction and Emotion • Eastern Philosophy and Buddhist Psychology • Neuroscience of Mindfulness Meditation • Neurobiology of Mental Wellness/Resilience and • Recovery

11. Interfacing: Neurobiology of Emotion Buddhist Psychology The Recovering Mind

12. Mindfulness-Based Intervention: • Increases motivation and self efficacy to utilize non-addictive skills to deal with emotions • Introduces more adaptive states of mind • Applies knowledge from the neurobiology of emotional wellness to enhance restoration of neuronal functioning in recovery • Increases behavioral and subjective manifestations of neural plasticity and adaptive states of mind

13. Affective and Mood Challenges with Addictive Disorders • Life time co-morbidity rates as high as 38% to 44% • Depressive symptoms among 80% of individuals with alcohol dependence • Unique to the mood regulation challenges of the recovering individual : • Intensified negative affect, moods, due to the neurochemical changes • Diminished tolerance for negative moods and emotions • Negative emotions are heightened in response to the secondary negative consequences

14. The Effects of Addictive Substances on Dopaminergic Reward Pathways Nora D. Volkow M.D. , Director of the National Institute on Drug Abuse,Brookhaven National Laboratory Pet Scan imaging identified structural changes in the mesolimbic reward pathway mediating: reward motivation pleasure higher level executive functions

15. The effects of psychoactive substances on dopaminergic pathways • Stimulate the release of dopamine in greater amounts 2) Inhibit re-uptake of dopamine 3) Mimic and bind with the receptor cells

16. Dopamine Reward Pathway(National Institute on Drug Abuse)

17. Effects of Substance Abuse on the Mesolimbic Dopamine Pathway and Motivation • Intense surge of dopamine reinforces the behavior that proceeded it • Reduces the number of D2 receptors • Marks behavior associated with survival (Saliency) • Creates “Incentive Sensitization” ( Elevation of threshold) • Pre-existing lower levels of D2 receptors increase risk

18. Substance Abuse and Inhibitory Balance “Impaired response inhibition and salience attribution model” (Goldstein and Volkow) Frontal cortical region and anterior cingulate: inhibitory control within the reward circuitry Disrupts the communication between limbic system and frontal cortical inhibitory ( and decision making ) regulation Overvaluing drug induced stimuli and undervaluing natural stimuli

19. Adaptations in Multiple Neurotransmitters Prolonged substance abuse also leads to adaptations among other neurotransmitters: • glutamate • GABA • serotonin • naturally occurring opiates (endorphins and enkephalins) • and neuropeptides. • Dopamine: neurotransmitter of expectation and desire prepares the brain for the effects of these other neurotransmitters

20. Perfect Storm of Early Recovery Compromises in the neurobiological activity: • Reward • Affective Experience/ Emotion Regulation • Pleasure • Motivation • Desire or Goal- Directed Intention • Inhibitory Process • Balance of activation of desire and restraint • Pain Management • Judgment and decision making • Compromises can exist for months into the course of recovery.

21. Intervention for Enhancing the Plasticity of Brain "Neural plasticity" : New experience creates new pathways in the brain Volkow, Fowler, & Wangl: Identified the potential for neurons to regenerate and increase synaptic connections in recovery Recognizes the need to develop new cognitive-behavioral strategies to assist recovering individuals in developing new pathways

22. Mindfulness and Compensatory Skillsto Weather the Perfect Storm • Address affective and mood issues directly • Provide experiential alternatives to addictive behavior • Enhance hopefulness for improving affect • Increase attention and inhibitory control • Enhance responsiveness to adaptive rewards • Alter reactivity to addictive stimuli • Enhanced tolerance and perspective of emotional states

23. Continuum of Psychological Responses to Emotional Distress/Pain

24. Positive Effects of Mindfulness Meditation on Neural Plasticity Mediation of : • attention • arousal and • autonomic control • Increases in cortical thickness in prefrontal cortex and right anterior cortex • Regulates attention • sensory processing, • the integration of emotions

25. Davidson and Kabat-Zinn: Mindfulness Based Stress Reduction • Enhanced immune system functioning • Enduring increases in prefrontal left-sided anterior activation • Associated with positive emotional states • Correlated with improvements in measures of positive and negative affect • Promotes integration between prefrontal regulation and limbic emotion activation • Significant reductions in chronic pain and anxiety

26. Mindfulness in Cognitive Behavioral Applications Marsha Linehan: Dialectical Behavior Therapy • Reductions suicidal behaviors, admissions to inpatient treatment, treatment attrition, measures of anger Alan Marlatt • "Riding the wave" of addiction urges • Positive effects in reducing substance abuse in a preliminary study using Vipassana Meditation Kabat-Zinn • Introduced Mindfulness to Western Behavioral Medicine/Psychiatry • Reductions in Chronic Pain and Generalized Anxiety

27. Mindfulness and Relapse Prevention with Major DepressionSegal, Williams, and Teasdale : Combined Beck’s cognitive behavioral treatment for depression with Kabat-Zinn’s Mindfulness Based Stress Reduction training Instructed clients to use mindfulness skills : To recognize and interrupt ruminative thinking Assume a de-centered position to their negative thoughts Results: Risk of relapse reduced by almost 50%

28. Unique Elements of Mindfulness –Based Theory and Interventions 1) Changing one’s relationship to affective states and emotions 2) Balancing change strategies with acceptance philosophies 3) Embracing the value of equanimity 4) Meditative practice and skills utilizing the process 5) Meta-level approach to mental events: Observing De-centering Non-judgmental

29. Application of the Neuroscience of Addiction/Recovery • Becoming a Wiser and More Effective Neuroscientist • Understanding how substance use impairs the natural brain pathways and processes • De-pathologizing the pursuit of adaptive strategies to improve neural plasticity • Promotes increased empowerment in mood regulation

30. Emotion Regulation/Resilience What it is: • Capacity to recover from negative moods • Strengthening of the brain circuits that connect the sub-cortical limbic with the prefrontal cortex to modulate arousal What strengthens it: • Experience and training • Attentiveness and care • Non-judgmental awareness and self-nurturing

31. Emotion Regulation Skills • Differentiating emotions, feelings, moods, and mood disorders • Experiencing without judgment or secondary elaboration • Balancing distress tolerance skills with emotion regulation • Understanding the purpose and functions of emotions

32. Meta-level change in response to pain and disturbing feelings • Paradigm shift regarding painful feelings • Relevant when negative thoughts are based in reality • Learning from the emotion without elaboration or judgment • Validation of the reality of pain with support of more adaptive alternatives • De-centering from obsessive thoughts related to painful feelings: "Cars in the ever present flow of traffic; vehicles that you can observe from the roadside, while allowing them pass by without climbing inside.”

33. Addressing Avoidance-Based Problems • Potentially protective in early recovery • Prolonged avoidance behaviors increase the risk of relapse • Validating painful experience without reinforcing negative behaviors • Empowered to redefine pain as manageable and transient • Responding to discomfort as a cue to formulate change • Embracing the value of equanimity • Non-attachment to positive experience

34. Mindfully Correcting Imbalances in the Saliency of Adaptive vs. Addictive Reinforcing Stimuli • Correct the diminution of responsiveness to sources of naturally occurring reinforcement • Learning ways to enhance stimulation of non-psychoactive sources • Significance of novelty, new learning, stimulation of curiosity • Dealing with boredom and appreciation of nuance and "non-doing" • Seeking balance between desire/pleasure/and "quiet" present moment acceptance : "Non-doing"

35. Enhancing Emotional Experience and Mental Wellness to Enrich Recovery • Enhancing attention to the undervalued emotions: • Desire, curiosity, and anticipation • Enhancing attention to naturally rewarding stimuli through increased mindfulness • Understanding the benefit of novelty and new learning in enhancing motivation • Building adaptive passions • Meta ( Lovingkindness) • Embracing the value of "Equanimity"

36. Goals of Mindfulness-Based work in Recovery

37. Measures of Mindfulness Applied to Mindfulness Construct Research Baer : • Applied a complex method of statistical sorting of major surveys • Subjects completed four different mindfulness surveys • Compared scores with other measures of personality and emotional experience • Composed a hierarchical model of understanding mindfulness: 1) Describing experience 2) Acting with awareness 3) Non-reactivity to inner experience 4) Relating non-judgmentally to one's experience

38. Next Steps in Expanding Research • Comparing MB interventions combined with CBT to CBT alone to determine differential effects on measures of mood disorders and addiction • Comparing MET/CBT to MB/MET/CBT • Factor analysis of critical factors of Mindfulness associated with change in measures of addiction and co-occurring mood disorders • Examining anterior asymmetrical prefrontal cortical activity in the addicted brain over different stages of substance use and recovery • Examining the effects of MB interventions on anterior prefrontal activity in the recovering brain • Examining the effects of MB interventions on PET scan imaging studies of dopaminergic reward pathways and prefrontal activation in the recovering brain.

39. Mindfulness-based Interventions in Addiction Treatment Long term effects of psychoactive substance abuse on neural processes along with their behavioral and emotional effects present unique challenges for recovery. Mindfulness-based interventions can provide: • Alternative skills for dealing with emotion-regulation challenges • Enhance neural plasticity in the recovering brain and • Assist recovering individuals in developing more hopeful alternatives in their pursuit of mental wellness.