Stress and Its Impact on Addiction.

1. Stress and Its Impact on Addiction. • By Frank Staggers, Jr, MD. • For Alameda County Behavioral Health Care Services, Alcohol and Drug Treatment Providers. • June 4, 2008.

2. Overview of the Impact of Stress on Addiction. • Stress alters an individual both physically and mentally. • The physical alterations and mental alterations brought on by stress are Pansytemic. • The physical alterations and mental alterations brought on by stress can be dramatic and even life-threatening.

3. Overview of the Impact of Stress on Addiction. • The physical changes and mental changes caused by stress can: (1) Lead to an Addiction. (2) Exacerbate an Existing Addiction. (3) Hamper Recovery. (4) Trigger a Relapse. (5) Exacerbate Comorbidities.

4. Overview of the Impact on Stress on Addiction. • Stress Reduction should be a component of any: (1) Addiction Education Strategy. (2) Addiction Prevention Strategy. (3) Addiction Treatment Strategy. (4) Relapse Prevention Strategy. (5) Harm Reduction Strategy.

5. The Stress Complex. • Stress = Stressor x Stress Response. (Simplest Workable Model of Stress.)

6. The Stress Complex. • Stress = Stressor x Personal Interpretation of Stressor x Stress Response. (This is an elaboration of the basic stress complex model, which helps isolate the role of cognitive processes.)

7. Stressor Characteristics. • Firsthand Stressor is some threatening object or event that you experience directly. • Secondhand Stressor is some threatening object or event that you experience through vivid descriptions, photographs, or movies.

8. Stressor Characteristics. • Stressor may be present here and now. • Stressor may be a powerful memory as in Post-Traumatic Stress Disorder (i.e., PTSD). • PTSD Symptoms can erupt even after a being dormant for over 60-years, as in some World War II Veterans.

9. Stressor Characteristics. • Secondhand PTSD (or Compassion Fatigue) can occur in mental healthcare providers who treat patients with PTSD. The constant descriptions of traumatic events by patients suffering from PTSD can ware down the healthcare provider, traumatize the healthcare provider, and lead to Secondhand PTSD Symptoms.

10. Stress Response General Characteristics. • Stress Response = Fight-or-Flight Response. • Stress Response = Adrenalin Rush. • Stress Response is a rapid response designed to get you out of an emergency situation.

11. Stress Response General Characteristics. • Over 40 major biochemical reactions are significantly affected by the stress response. • Biochemical reactions involving neurohormones, neurotransmitters, neuropeptides, and metabolic compounds closely associated with acute activation of the Sympathetic Nervous System are particularly affected by the stress response.

12. Stress Response General Characteristics. • Three Major Neuroendocrine Circuits are activated: (1) Sympathetic Nervous System--Adrenal Medulla Circuit-----> Elevates Serum Catecholamines. (2) Anterior Pituitary--Adrenal Cortex Circuit-----> Elevates Serum Cortisol and Elevates the Ratio of Cortisol to DHEA. (3) Renal--Adrenal Cortex Circuit-----> Elevates Serum Renin, Angiotensin, and Aldosterone.

13. Stress Response General Characteristics. • There can be either compensatory or complementary bursts of GABA, Serotonin, and Endorphin activity. • In general, stress tends to over-activate and eventually deplete most major neurotransmitter stores.

14. Physiological Changes seen with the Stress Response. • Major release of catecholamines. • Major release of cortisol. • Major release of renin. • Blood shunted from skin and gut to major muscles. • Brain is placed on high-alertness mode. • Brain waves are often rapid Beta type. • Blood pressure, pulse, oxygen consumption, blood glucose, all become elevated. • Immune System usually erupts and then shuts down.

15. Mental Changes seen with the Stress Response. • The brain is placed on high alertness mode. • Reflexes are sharpened and reaction time is quickened. • Rapid Beta brain waves predominate. • Survival instincts are activated and higher thinking is subdued as activation of the Prefrontal Cortex is diminished.

16. If the Stress Response is kept on, all Diseases get worse. • Anxiety and Depression get worse. • Insomnia is exacerbated. • Addictions are exacerbated. • High Blood Pressure, Heart Disease, Diabetes, Asthma, Arthritis, Infections, and Cancers are all exacerbated. • Brain cells may be damaged. • Heart cells may be damaged. • Immune System is depressed.

17. Physical Disorders Closely Associated with Chronic Stress. • Cardiovascular Disease. • Hypertension. • Diabetes. • Infections. • Cancers. • Asthma. • Dementia. • Arthritis.

18. Mental Disorders Closely Associated with Chronic Stress. • Addiction. • Depression Disorders (including Dysthymia, Major Depression, Bipolar Disorder). • Anxiety Disorders (including Phobias, Obsessive-Compulsive Disorders, General Anxiety Disorder, and Panic Disorders). • Nonspecific Organic Brain Syndromes. • Insomnia.

19. Stress-Induced Physical States that can lead to Addiction. • Physical Pain. • Chronic Fatigue. • Visceral Dysfunction/ Discomfort. • Insomnia.

20. Stress-Induced Mental States that can lead to Addiction. • Anxiety. • Depression. • Fear. • Stress Intolerance / Copying Inability. • Anhedonia / Reward Deficiency Syndromes. • Cognitive Deficiencies.

21. Stress-Induced Biochemistry States that can Lead to Addiction. • In general, the biochemistry states associated with severe persistent stress resemble the biochemistry states associated with persistent cocaine abuse, methamphetamine abuse, or other stimulant drug abuse.

22. Stress-Induced Biochemistry States that can Lead to Addiction. • Initial and Middle Stages of Persistent Stress are associated with high cortisol and high catecholamine levels. This is associated with anxiety, insomnia, and hyperactive states.

23. Stress-Induced Biochemistry States that can lead to Addiction. • Late Stages of Persistent Stress may be associated with Adrenal Gland Burnout. Thus, cortisol and catecholamines will be depleted when adrenal burnout occurs. This is associated with anhedonia, hypoactive syndromes, and chronic fatigue.

24. Models on How Stress Affects Addiction. • Chronic Stress Over-Activates and eventually depletes most major classes of neurotransmitters---> Multiple psychiatric and medical disorders are exacerbated---> Person is predisposed to addiction. (Major Neurotransmitters affected by stress include Serotonin, Norepinephrine, Epinephrine, Dopamine, GABA, and Endorphins.)

25. Models on How Stress Affects Addiction. • Chronic Stress---> Emotional Distress and Mood Changes---> Impaired Coping Skills and Self-Medication. (1) See Anxiety and Restlessness early, due to elevated Catecholamine levels. (2) Late stages may involve Depression, Lethargy, Anhedonia, and Reward Deficiency Syndromes due to Adrenal Burnout. (3) Cortisol may cause General or Specific Cravings. (4) Elevated Catecholamines can cause Sleep Disturbances which further exacerbate Emotional Distress. (5) Stressed out people often reach for “comfort foods” and “comfort drugs”.

26. Models on How Stress Affects Addiction. • Chronic Stress---> Cognitive Impairment---> Impaired Coping Skills and Self-Medication. (1) Blood is chronically diverted away from Prefrontal Cortex, thereby diminishing Executive functions such as Judgment, Planning, Decision-Making, and Impulse Control. (2) Elevated Cortisol is harmful to brain cells, especially those in the hippocampus. Dementia Syndromes may occur. (3) Elevated Catecholamines may result in Sleep Disturbances which further exacerbate Cognitive Impairments.

27. Models on How Stress Affects Addiction. • Chronic Stress---> Exacerbation of Pain Syndromes ---> Impaired Coping Skills and Self-Medication. (1) Elevated Cortisol Dramatically Hampers Tissue Repair and Wound Healing and may precipitate the accelerated utilization of Endorphins and other Internal Opioids. (2) Exacerbated Pain Syndromes also impair mental clarity and impair emotional stability, thereby further diminishing coping skills and leading to Self-Medication.

28. Models on How Stress Affects Addiction. • Chronic Stress---> Can alter Epigenome Patterns---> May Predispose someone to Addiction or Addictive Behaviors. (The role that Epigenomes play in Addiction is still largely under investigation. However, stress, diet, exposure to toxins, and other environmental factors can alter Epigenomic Patterns, thereby influencing Genetic Expression in regards to diseases.)

29. Models on How Stress Affects Addiction. • Stress---> Compounds and exacerbates organ damage done by drug abuse or diseases associated with drug abuse, such as Hepatitis C, AIDS, and endocarditis. (Stress is Pansystemic; so Multiple Organs including Brain, Heart, Liver, Kidneys, Skin, and Immune System can be effected.)

30. Vicious Cycle of Stress and Substance Abuse. Stressor---> Stressful Feelings---> Alcohol, Tobacco, and Drugs taken to dampen Stressful Feelings---> Alcohol, Tobacco, and Drugs themselves become Stressors. (The above Stress-Relievers can become a Person’s Killers.)

31. Summation on How Stress Impacts Addiction. • Stress can cause physical symptoms that lead to self-medication and other maladaptive coping mechanisms. • Stress can cause psychological symptoms that lead to self-medication and other maladaptive coping mechanisms. • Stress can alter epigenomic patterns and thereby alter genetic predisposition to diseases. • Alcohol and drugs taken to dampen stress can themselves become physiological stressors.

32. Summation on How Stress Impacts Addiction. • Stress can lead to an exaggerated release of critical neurotransmitters and neurohormones. • Stress can lead to depletion of critical neurotransmitters and neurohormones. • Stress can directly impair mental clarity (including memory, rational thinking, and judgment), thereby hampering recovery. • Stress can compound the damage done by alcohol abuse and drug abuse. • Stress exacerbates both physical and mental comorbidities.

33. Epidemiological Evidence of the close relationship between Stress and Addiction. • Since the Sept 11, 2001 World Trade Center terrorist attack, multiple surveys have confirmed the close relationship between exposure to major stressors, stress disorders, depression, and drug abuse. • During times of heightened fighting between the British Army and the Irish Republican Army, there was often a marked increase in the use of benzodiazepines by the residents of the war-torn areas. • The stress of the Viet Nam War propelled many US soldiers into heavy opiate abuse. A significant number of these soldiers suffered from PTSD after returning from the war.

34. Strategy for Countering Stress. • “MEDS AT HS” (This is a good mnemonic for an overall strategy for countering stress.)

35. Strategy for Countering Stress. • M = Meditation/ Deep Relaxation. • E = Exercise. • D = Diet. • S = Sleep. • A = Avoidance. • T = Talk Therapy. • H = Humor/ Attitude Adjustment. • S = Social Support.

36. Meditation/ Deep Relaxation. • Restful Alertness or the Relaxation Response relaxes the Mind and Body, while enhancing Mental Clarity and maintaining Physiological Flexibility. • Restful Alertness gives Alpha Brain Waves along with Lower Body Catechols, Cortisol, BP, Pulse, Oxygen Demand, etc. • Restful Alertness is different Neurophysiologically than Sleep.

37. Meditation/ Deep Relaxation. • Popular Deep Relaxation Techniques include Transcendental Meditation, Zen Quiet Sitting, Biofeedback, Neurofeedback, Progressive Muscle Relaxation, Restful Visualization, Basic Deep Breathing, Mindfulness Meditation, Listening to Soothing Sounds like Ocean Waves, & Listening to Soft Music.

38. Meditation/ Deep Relaxation. • By simply placing a stethoscope over your own heart and listening to your heartbeat, you can create a makeshift biofeedback system that can help you relax.

39. Meditation/ Deep Relaxation. • Suggest 20 Minutes of Deep Relaxation BID. • Can Reverse Biological Age Markers 6-12 Yrs. • Can be used as a Complementary Treatment Modality for multiple diseases including asthma, chronic pain, hypertension, diabetes, and anxiety. • Deep Relaxation Techniques are now taught in many Medical Centers and Clinics.

40. Deep Relaxation is known as the Relaxation Response. • The Relaxation Response is physiologically the exact opposite of the Stress Response. • The Relaxation Response is associated with lowered Blood Pressure, Pulse, Oxygen Demand, Cortisol Levels, Catechol Levels, etc. • Blood returns to the skin, gut, and immune system. • The mind is placed in a relaxed state.

41. Deep Relaxation is Not Leisure Activities or Sleep. • Leisure activities like sewing and reading keep the brain active, thereby limiting true relaxation. • Dreaming is necessary for mental health, but keeps the brain active. • Deep Sleep is necessary for health, but still does not give the deepest states of relaxation.

42. The Relaxation Response is an Awake Response. • The Relaxation Response is associated with a state called RESTFUL ALERTNESS. • During Restful Alertness, the mind remains alert, but minimally active. • During Restful Alertness, the mind has a chance to settle down.

43. Relax and Stay Fit. • Do Deep Alert Relaxation 20 minutes twice a day. • Alert Relaxation is the 4th Major State of Consciousness. • All 4 Major States of Consciousness are necessary for complete health: i.e., Awake Activity, Awake Relaxation, Dreaming, Deep Sleep.

44. EEG Demonstration

45. Location of Sensors • Frontal Lobe Two sensors placed on the prefrontal cortex, one on the rights side and one on the left side. This is the area of brain responsible for higher level thought and planning. • Occipital Lobe Two sensors placed over visual cortex, one on left side and one on right side. = EEG sensor

46. Key • Blue & purple – prefrontal cortex • Green & red – occipital lobe Eyes Open

47. Eyes Closed Rest

48. Transcendental Meditation

49. Notes on EEG & Summary • Frequency: In EEG, the frequency provides information on one’s general state of mind: active, asleep, or restful. • Delta – 0 to 3 Hz: sleep • Theta – 4 to 7 Hz: transition, dreamlike, floating mental state (associated with meditation) • Alpha – 8 to 12 Hz: no action, relaxed, tranquil, alert (associated with meditation) • Beta – 12 to 25 Hz: active thinking, active processing • Faster signals seen in slide 3 are predominantly beta: 12 to 30 Hz • Slower signals seen in green & red in slide 2, and in all signals in slide 3, are predominantly in the 7 – 10 Hz range, which high theta, low alpha (theta is 4 – 7 Hz; alpha is 8 – 12 Hz). This frequency is associated with deep relaxation, low metabolism, and restful alertness. • Highly uniform frequency in all signals in slide 3 indicates right left and front back brain coherence. • Amplitude: In EEG, the amplitude tells us about local ‘coherence’: if amplitude is high, then the neurons in that region of the brain are working together in a coordinated manner, communicating to each other. • Coherence generally indicates coordinated functioning of neurons. Exposure to increase in communication and coordinated functioning of neurons cultures a healthier brain and reduces functional holes associated with stress, violence, etc. • As a result regular practice of TM is correlated with healthier brain functioning, improve cognitive (memory, focus, creativity, intelligence) and psychological well being (reduced anxiety, reduced depression, increased self concept, increased happiness).

50. Exercise. • Want muscles to have “SAFE” qualities. • S = Strength • A = Agility • F = Flexibility • E = Endurance