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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

Making relatedness a treatment goal

Brian Johnson M.D.

Assoc Prof Psychiatry and Anesthesia

SUNY Upstate Medical University

Member – Boston Psychoanalytic Society

disclosures
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)
neuropsychoanalysis
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”
what are depression and addiction
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

national epidemiologic survey on alcoholism and related conditions
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?
gender issues in addiction and depression
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?
anxiety depression watt and panksepp 2009
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?
watt panksepp 2009
Watt & Panksepp 2009

SEPARATION

ANXIETY DEPRESSION

anaclitic depression freud 1905
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
childhood adversity leads to adult depression harness monroe 2002
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%
nemeroff reanalysis 2003
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)
addiction and unrelatedness
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
slide22
Deterioration of drug response to mood or pain as a result of the “b” process of allostatic compensation (Koob 2001)
will allostatic adaptations reverse with abstinence
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?
destructive brain effects gradually make recovery less likely
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)
diagnosis of depression in addicted patients
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
use of hamilton rating scale for depression
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
diversion college garnier 2010
Diversion-College (Garnier 2010)
  • ADHD – 62%
  • Amphetamines – 71%
  • Methylphenidate – 37%
  • Methylphenidate ER – 39%
  • Opioids – 35%
  • Bupropion - 0
rickels 1993
Rickels – 1993

Triangle – placebo,

what about sex
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
risk of suicide benzodiazepines
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)

month year cost of medications
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
bipolar
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
pain relief 6 hours
PAIN RELIEF – 6 HOURS
  • Which is codeine 60 + acetaminophen 600?

A

C

B

D

E

F

szasz psychoanalytic concept pain
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
hyperalgesia
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
human hyperalgesia
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
uh psychiatric pain consultation cold pressor test n 34 seconds
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

treatments for chronic pain
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”)
prescribe according to side effects
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
treatment of comorbid anxiety
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
medications for anxiety
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
conflict with a drug is a drug
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
pharmacology of relatedness
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
summary
Summary
  • Best understanding of depression and addiction: symptoms of disruption of relatedness
  • Addiction causes repeated harm (TV, exercise)
  • Treatments focus on promotion of relatedness: psychotherapy, 12 Step programs
  • Many depressed patients respond to relatedness alone
  • If prescribing medications, think about using them to restore relatedness