Recovering executive function

red-pencilI was listening to the podcast of this On Being episode this morning and get to wondering about its application to addiction treatment and recovery. (The first 15 minutes or so cover the really relevant concepts.)

The interviewee is Adele Diamond,  an educator, researcher and scientist who focuses on early childhood and the role of executive function in academic and life success.

She broke executive function down into three areas:

  1. inhibitory control
  2. working memory-the ability to hold on to a concept and explore. examine or play with it
  3. cognitive flexibility

She has an early childhood curriculum that is focused on fostering/supporting the development of executive function. In the interview, she discussed some activities and tricks designed to develop or engage executive function. For example, her curriculum uses particular kinds of play and drama. She also gave an example of helping kids who mirror write by asking them to write problem characters in red pencil. (Just stopping writing and picking up the red pencil was enough of an intervention for most kids.)

This got me thinking about addiction as, in part, a disorder of the brain’s executive function. If one of the tasks of early recovery is to restore or re-develop executive function, what strategies and activities could help accomplish that? What strategies do we already use, or do mutual aid groups use, to achieve this?

What are our red pencils and how can we find more of them?

 

Cognitive performance of opioid maintenance vs. abstinence

brains!
brains! (Photo credit: cloois)

 

A new study finds lower cognitive functioning in maintenance patients compared with abstinent former users. It also found no difference between methadone patients and buprenorphine patients.

 

Background

To compare the cognitive performances of maintenance patients (MAIN), abstinent ex-users (ABST) and healthy non-heroin using controls (CON).

Methods

Case control study of 125 MAIN (94 subjects maintained on methadone, 31 on buprenorphine), 50 ABST and 50 CON. Neuropsychological tests measuring executive function, working memory, information processing speed, verbal learning and non-verbal learning were administered.

Results

There were no differences between the cognitive profiles of those maintained on methadone or buprenorphine on any administered test. After controlling for confounders, the MAIN group had poorer performance than controls in six of the 13 administered tests, and were poorer than the ABST group in five. The MAIN group exhibited poorer performance in the Haylings Sentence Completion, Matrix Reasoning, Digit Symbol, Logical Memory (immediate and delayed recall), and the Complex Figure Test (immediate recall). There were no differences between the ABST and CON groups on any of the administered tests.

Conclusions

Poorer cognitive performance, across a range of test and domains, was seen amongst maintenance patients, regardless of their maintenance drug. This is a group that is likely might benefit from approaches for managing individuals with cognitive and behavioural difficulties arising from brain dysfunction.

 

 

 

a thousand pasts and no future

“Choose [your memories] carefully. Memories are all we end up with … You’ll have a thousand pasts and no future.” –The Secret Behind Their Eyes (film)

forget about the sunshine by whatmegsaid

A friend shared this On Point episode with me and made a connection between it and resentments.

This matter of appropriate, helpful, deliberate forgetting is very fascinating.

We’ve talked before about role of the brain’s memory circuits. I’ve also been very interested in the similarities between PTSD and addiction. Both are characterized by intrusive, powerful, multi-sensory, involuntary memories.

The On Point episode discusses that the capacity this helpful forgetting relies on executive function which we’ve discussed is impaired AND depleted.

So…addicts may have limited capacity for this kind of helpful forgetting. Maybe this explains and supports 12 step recovery’s emphasis on letting go of resentments.

Further, the idea in the quote above may help explain the emphasis on gratitude and the power of gratitude lists. Aren’t gratitude lists really an attempt to choose what to remember?

Top Posts of 2011 #12 – Addiction redefined

The American Society of Addiction Medicine has issue a new definition of addiction. The short version good, but the long version is REALLY good.

Here are some of the new elements, some of them are followed by my responses:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.

Nothing new or exciting here, but any definition more than 15 years old probably needs to have this added.

The neurobiology of addiction encompasses more than the neurochemistry of reward.

This is important. Even people who have some basic literacy about the neurobiology of addiction often reduce addiction to being about pleasure. This is only part of the story, though it’s probably the easiest part of the story to explain, and reducing addiction to this has the potential to reinforce stereotypes of addicts as unrestrained pleasure seekers.

Genetic factors account for about half of the likelihood that an individual will develop addiction.

Good to include this, as it seems to have gotten less attention in coverage in recent years.

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:

  1. The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
  2. The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
  3. Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
  4. Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
  5. Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
  6. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
  7. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
  8. The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

This is decidedly and surprisingly old school, and by that I mean holistic. This is good news, particularly in light of some of the efforts to further medicalize treatment. I believe that addiction has profound direct and indirect impact on the addict’s social, emotional and spiritual life. Some of this may self-resolve with abstinence, but much of it won’t and will require the addict to develop new ways to address those problems and meet those social emotional and spiritual needs. In some cases, this needs to be done in the context of professionally directed treatment, in most cases it requires some form of sustained recovery support.

More highlights:

Addiction is characterized by2:

  1. Inability to consistently Abstain;
  2. Impairment in Behavioral control;
  3. Craving; or increased “hunger” for drugs or rewarding experiences;
  4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
  5. A dysfunctional Emotional response.

The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.

Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Cognitive changes in addiction can include…The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

The also address emotional changes that can easily be mistaken for a co-occurring psychiatric disorder:

Emotional changes in addiction can include:

  1. Increased anxiety, dysphoria and emotional pain;
  2. Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
  3. Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Finally, they embrace recovery. (This is surprisingly controversial. I’ve recently been involved in a discussion group where members rejected the notion of recovery.)

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.

Of course, not everyone is a fan. And, while I believe it’s appropriate to acknowledge the spiritual dimensions (life purpose and meaning), I think I agree with her that, pragmatically, they probably should have left it out.

For the record, the reason I believe it’s appropriate is that I believe the spiritual dimensions of addiction are uniquely profound.  Every person with a serious illness, particularly serious chronic illnesses, needs to wrestle with questions about how it happened, what it means, why me, what does it say about me, who was I before, who am I now, what does it say about my place in the world, etc. These are particularly difficult in an illness whose primary and secondary symptoms do so much to destroy social connections, hijack priorities, erode values, consume personal identity and diminish volitional control.

Willpower

Willpower by David Robert Wright

Steven Pinker reviews a new book titled Willpower:

What is this mysterious thing called self-control? When we fight an urge, it feels like a strenuous effort, as if there were a homunculus in the head that physically impinged on a persistent antagonist. We speak of exerting will power, of forcing ourselves to go to work, of restraining ourselves and of controlling our temper, as if it were an unruly dog.

First, let me say that I don’t believe addiction is a problem of willpower, I believe the problem lies on the other side—urge. Still, I wonder if this kind of research has the potential to be very helpful to recovering people. More in a minute.

In experiments first reported in 1998, Baumeister and his collaborators discovered that the will, like a muscle, can be fatigued. Immediately after students engage in a task that requires them to control their impulses — resisting cookies while hungry, tracking a boring display while ignoring a comedy video, writing down their thoughts without thinking about a polar bear or suppressing their emotions while watching the scene in “Terms of Endearment” in which a dying Debra Winger says goodbye to her children — they show lapses in a subsequent task that also requires an exercise of willpower, like solving difficult puzzles, squeezing a handgrip, stifling sexual or violent thoughts and keeping their payment for participating in the study rather than immediately blowing it on Doritos. Baumeister tagged the effect “ego depletion,” using Freud’s sense of “ego” as the mental entity that controls the passions.

If willpower can be depleted and addicts deal with urges that are particularly chronic and particularly powerful, are addicts living in a state of chronic depletion of willpower? Might functioning in this state for extended periods of time have long term consequences? The development of “bad” habits that are difficult to break from having lived with diminished willpower? Could this this chronic willpower depletion extend into recovery? Could this make it more difficult to engage in the behaviors associated with stable recovery?

Good news though. Willpower can be cultivated:

Baumeister then pushed the muscle metaphor even further by showing that a depleted ego can be invigorated by a sugary pick-me-up (though not an indistinguishable beverage containing diet sweetener). And he showed that self-control, though almost certainly heritable in part, can be toned up by exercising it. He enrolled students in regimens that required them to keep track of their eating, exercise regularly, use a mouse with their weaker hand or (one that really gave them a workout) speak in complete sentences and without swearing. After several weeks, the students were more resistant to ego depletion in the lab and showed greater self-control in their lives. They smoked, drank and snacked less, watched less television, studied more and washed more dishes.

Build up its strength, the authors suggest, with small but regular exercises, like tidiness and good posture. Don’t try to tame every bad habit at once. Watch for symptoms of ego fatigue, because in that recovery period you are especially likely to blow your stack, your budget and your diet. For that matter, don’t diet in the first place, since it starves the very system that implements self-control. Learn from Ulysses and tie yourself to the mast or fill your ears with wax so temptations are blocked out or you are unable to act on them. The authors also recommend Web sites and software that can audit, broadcast, punish or pre-empt lapses of will — a godsend, in particular, to Internet junkies and other infomaniacs.

Finally, to drive home the importance of this quality, the authors argue that

Together with intelligence, self-control turns out to be the best predictor of a successful and satisfying life.

The same point has been made about executive function, which is clearly plays an important role in addiction.

Related post:

Addiction redefined

The American Society of Addiction Medicine has issue a new definition of addiction. The short version good, but the long version is REALLY good.

Here are some of the new elements, some of them are followed by my responses:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.

Nothing new or exciting here, but any definition more than 15 years old probably needs to have this added.

The neurobiology of addiction encompasses more than the neurochemistry of reward.

This is important. Even people who have some basic literacy about the neurobiology of addiction often reduce addiction to being about pleasure. This is only part of the story, though it’s probably the easiest part of the story to explain, and reducing addiction to this has the potential to reinforce stereotypes of addicts as unrestrained pleasure seekers.

Genetic factors account for about half of the likelihood that an individual will develop addiction.

Good to include this, as it seems to have gotten less attention in coverage in recent years.

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include:

  1. The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers;
  2. The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors;
  3. Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;
  4. Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies;
  5. Exposure to trauma or stressors that overwhelm an individual’s coping abilities;
  6. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
  7. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and
  8. The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

This is decidedly and surprisingly old school, and by that I mean holistic. This is good news, particularly in light of some of the efforts to further medicalize treatment. I believe that addiction has profound direct and indirect impact on the addict’s social, emotional and spiritual life. Some of this may self-resolve with abstinence, but much of it won’t and will require the addict to develop new ways to address those problems and meet those social emotional and spiritual needs. In some cases, this needs to be done in the context of professionally directed treatment, in most cases it requires some form of sustained recovery support.

More highlights:

Addiction is characterized by2:

  1. Inability to consistently Abstain;
  2. Impairment in Behavioral control;
  3. Craving; or increased “hunger” for drugs or rewarding experiences;
  4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
  5. A dysfunctional Emotional response.

The power of external cues to trigger craving and drug use, as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.

Addiction is more than a behavioral disorder. Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Cognitive changes in addiction can include…The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

The also address emotional changes that can easily be mistaken for a co-occurring psychiatric disorder:

Emotional changes in addiction can include:

  1. Increased anxiety, dysphoria and emotional pain;
  2. Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and
  3. Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Finally, they embrace recovery. (This is surprisingly controversial. I’ve recently been involved in a discussion group where members rejected the notion of recovery.)

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction. As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery.

Of course, not everyone is a fan. And, while I believe it’s appropriate to acknowledge the spiritual dimensions (life purpose and meaning), I think I agree with her that, pragmatically, they probably should have left it out.

For the record, the reason I believe it’s appropriate is that I believe the spiritual dimensions of addiction are uniquely profound.  Every person with a serious illness, particularly serious chronic illnesses, needs to wrestle with questions about how it happened, what it means, why me, what does it say about me, who was I before, who am I now, what does it say about my place in the world, etc. These are particularly difficult in an illness whose primary and secondary symptoms do so much to destroy social connections, hijack priorities, erode values, consume personal identity and diminish volitional control.

Cultivating executive function

1 jour, 1 photo 27/01/11
by BlondieISfuckinCrazy

A few months ago I was listening to this episode of Being on an education researcher who believes that the development of executive function should be a central focus in classroom education. The conversation was fascinating and I kept thinking that this could represent an important developmental task in early recovery and treatment. (We know that one aspect of the neurobiology of addiction is that the frontal cortex, the part of the brain responsible for executive function, is impaired.) She talked about a multidimensional approach to this that includes strategies as diverse as play, rote memorization and teaching strategies that encourage students to pause before acting and train students to pay sustained attention to a subject.

Over the last day, one of our staff, Matt, shared this link with me.

They found that this type of training improved working memory and also reduced their discounting of delayed rewards.

“The legal punishments and medical damages associated with the consumption of drugs of abuse may be meaningless to the addict in the moment when they have to choose whether or not to take their drug. Their mind is filled with the imagination of the pleasure to follow,” commented Dr. John Krystal, Editor of Biological Psychiatry. “We now see evidence that this myopic view of immediate pleasures and delayed punishments is not a fixed feature of addiction. Perhaps cognitive training is one tool that clinicians may employ to end the hijacking of imagination by drugs of abuse.”

Dr. Bickel agrees, adding that “although this research will need to be replicated and extended, we hope that it will provide a new target for treatment and a new method to intervene on the problem of addiction.”

He also shared this story on recent findings from neurological studies of meditation:

…scientists say that meditators like my husband may be benefiting from changes in their brains. The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

Could strategies focused one developing executive function become important in addiction treatment?

Addiction and free will

This one slipped by me late last year. It offers a great description of the neurobiological processes involved in addiction. It also tries to tackle frequently neglected questions about free will and addiction. All of this is great, but the description of the client with a “secondary” addiction and their intervention (rather, the absence of any intervention) leaves me wanting.

In the early stages of addiction, the free will of someone like Jack is relatively intact. I say relatively because emerging research suggests that Jack probably had a decreased number of D2 dopamine receptors, and this state of hypodopaminergic function increased his risk to excessively respond to the suprathreshold dopamine stimulation of drugs of abuse.4 As the addiction progresses, the main brain engines of free will are damaged and begin to malfunction, including the attentional and self-control mechanism of the anterior cingulate gyrus; the crucial orbital prefrontal cortex that associates emotional and motivational valence with environmental stimuli and cues; and the dorsolateral prefrontal cortex, the seat of executive function and as such, the true decision maker.

In the later stages of addiction, Volkow cautions, free will may be virtually devastated: “We have come to see addiction as a disease that involves the destruction of multiple systems in the brain that more or less are able to compensate for one another. When the pathology erodes the various systems, you disrupt the ability to compensate, and the addictive disease erodes and destroys the life of the individual.”5

In the new conceptualization, addiction is not so much a matter of dysregulation of the pleasure systems but of a distortion of goal direction expressed by the term “salience.” Evolution has wired the brain to seek out and respond to environmental factors, such as sex, food, money, and affection, that improve the chance of the survival and even thriving of the species. All of these natural incentives release dopamine, not so much to satisfy desire as once thought but as a way of neurochemically cementing the salience of these stimuli (ie, potentiating learning).

Tragically, drugs and alcohol have a massively more potent dopaminergic action than even the best gourmet meal, a good run on a beautiful fall morning, or the devotion of a wife and children. These new neurobiological explanations of addiction give molecular weight to the phenomenological DSM-IV-TR criteria for “continued [substance] use despite adverse consequence” by a dependent person.6 Given the extreme biological response to drugs of abuse compared with daily life and work, it is no wonder that “time spent in obtaining the substance replaces social, occupational or recreational activity.”6 Jack had a family who loved him, and he was resourceful enough to have been successful had he only employed the immense energy he spent on substance use in the service of more productive aims.

So complete is drugs’ usurpation of human priorities that what were once semivoluntary actions and reactions become conditioned responses. In an elegant experiment, Volkow and colleagues7 measured dopamine metabolism in 18 cocaine-dependent patients while they watched a nature video and a video of persons using cocaine. Not only was there a substantial dopaminergic surge in the addicted patients when watching the cocaine film, but even more alarming, it corresponded to their subjective experience of craving, which itself is a measure of the compulsive quality of addiction.

These results obviously underscore the challenge of relapse prevention when even otherwise neutral cues can elicit the intensity of intoxication. But more ominously for free will, what Volkow calls the plastic changes in brain structure and function suggest the entire apparatus of self-determination may have been commandeered.8



 

Pediatric Ritalin Use May Affect Developing Brain, New Study Suggests

A new study identifies neurochemical changes from ritalin use:

Use of the attention deficit/hyperactivity disorder (ADHD) drug Ritalin by young children may cause long-term changes in the developing brain, suggests a new study of very young rats by a research team at Weill Cornell Medical College in New York City.

The study is among the first to probe the effects of Ritalin (methylphenidate) on the neurochemistry of the developing brain. Between 2 to18 percent of American children are thought to be affected by ADHD, and Ritalin, a stimulant similar to amphetamine and cocaine, remains one of the most prescribed drugs for the behavioral disorder.

“The changes we saw in the brains of treated rats occurred in areas strongly linked to higher executive functioning, addiction and appetite, social relationships and stress. These alterations gradually disappeared over time once the rats no longer received the drug,” notes the study’s senior author Dr. Teresa Milner, professor of neuroscience at Weill Cornell Medical College.

It will be interesting to see more research on the subject, particularly as we learn more about brain plasticity in adolescents.

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