NEUROPSYCHOLOGY OF AN

ADDICTED MIND

by

Dr Nader Korhani Ph.D.

 What IS addiction?
•opium addiction
•heroin addiction
•cocaine addiction
•alcohol addiction (“alcoholism(”
•marijuana addiction
•amphetamine addiction
•nicotine addiction
 What IS addiction?
• gambling addiction??
• food addiction??
• sex addiction??
• shopping addiction????
• internet addiction????
• cell phone addiction????
• chocolate addiction???
• exercise addiction???
• television addiction???
 How do we define addiction?

• I contend that “addiction” not a useful

scientific term
• Is heroin addiction similar to exercise
addiction? (Probably not..)
• Has this dichotomy caused a problem in
getting support for treatment, research,
& education?
 In Fact, It’s Even Worse!
• •Stigma (against the disease(
• •Prejudice (against the addict(
• •Anger (toward the addict(
• •Misunderstanding (about what to do(

• SPAM leads to myths: widely-held

inaccurate beliefs, as compared to
research-generated facts(
 DSM 5 :
•Substance use disorder (SUD :)
•a behavioral pattern of continual psychoactive
substance use that can be diagnosed as either
substance abuse or substance dependence

•Co-occurring disorders (COD :)

•the simultaneous existence of “one or more disorders
relating to the use of alcohol and/or other drugs of abuse as
well as one or more mental [health] disorders.”18
 The Facts……
• •DSM and ICD: two drug problems
• •abuse: caused by rebellion, money,
boredom, experimentation, thrill-seeking,
desperation, self-medication
• •dependence: caused by genetics, brain
chemistry sensitivity, with input from the
environment
• •we have medical and social criteria.…
 What is Addiction?
Addiction is A Brain Disease

• Characterized by:
– Compulsive Behavior
– Continued abuse of drugs despite negative consequences
– Persistent changes in the brain’s structure and function
 Addiction is Like Other Diseases…
 It is preventable
 It is treatable
 It changes biology
 If untreated, it can last a lifetime
Decreased Brain Metabolism Decreased Heart Metabolism
in Drug Abuser in Heart Disease Patient
High

Low
Healthy Brain Diseased Brain/ Healthy Diseased Heart
Cocaine Abuser Heart

Research supported by NIDA addresses all of these

components of addiction.
Relapse Rates Are Similar for Drug
Addiction & Other Chronic Illnesses
100
Percent of Patients Who Relapse

90
80
70
60
50
40

50 to 70%

50 to 70%
40 to 60%

30 to 50%
30
20
10
0
Drug Type I Hypertension Asthma
Addiction Diabetes

McLellan et al., JAMA,

Addiction Involves Multiple Factors
 Addiction Is A Developmental Disease
that starts in adolescence and childhood
1.8%
1.8%
TOBACCO
develop first-time dependence

1.6%
1.6% CANNABIS
% in each age group who

1.4%
1.4% ALCOHOL
1.2%
1.2%
1.0%
1.0%
0.8%
0.8%
0.6%
0.6%
0.4%
0.4%
0.2%
0.2%
0.0%
0.0%
55 10
10 15
15 21
21 25
25 30
30 35
35 40
40 45
45 50
50 55
55 60
60 65
65
Age

Age at tobacco, alcohol, and cannabis dependence per DSM IV

National Epidemiologic Survey on Alcohol and Related Conditions, 2003.

 Why Do People Take Drugs in The
First Place?

To Feel Good To Feel Better

To have novel: To lessen:
feelings anxiety
sensations worries
experiences fears
AND depression
to share them hopelessness
 Why Do People
Abuse Drugs?

Drugs of Abuse
Engage Motivation and
Pleasure Pathways
of the Brain
Drugs can be “Imposters” of
Brain Messages
 Drugs Associated wth
Neurotransmitters
Why do people have “drugs of choice?”
• Dopamine - amphets, cocaine, ETOH
• Serotonin - LSD, ETOH
• Endorphins - opioids, ETOH
• GABA - benzos, ETOH
• Glutamate -ETOH
• Acetylcholine - nicotine, ETOH
(Marijuana )?
 Movement

Motivation

Dopamine

Addiction Reward & well-

Dopamine Spells REWARD

Release
Recycle

Activate
 Effects of Drugs on Dopamine Release
Amphetamine Cocaine
1100 Accumbens 400 Accumbens
1000

% of Basal Release
900
% of Basal Release

DA
300 DOPAC
800 DA HVA
700 DOPAC
600 HVA 200
500
400
300 100
200
100
0 0
0 1 2 3 4 5 hr 0 1 2 3 4 5 hr

250 Nicotine Morphine

250 Accumbens
Dose
200

% of Basal Release
Accumbens 0.5 mg/kg
% of Basal Release

Caudate 200
1.0 mg/kg
150 2.5 mg/kg
150 10 mg/kg

100
100

0
0 1 2 3 hr 0
0 1 2 3 4 5 hr
Time After Drug Time After Drug
Di Chiara and Imperato, PNAS, 1988
 Science Has Generated Much
Evidence Showing That…

Prolonged Drug Use Changes

the Brain In Fundamental
and Long-Lasting Ways
 AND…

We Have Evidence That

These Changes Can Be Both
Structural and Functional
Structurally…
Neuronal Dendrites in the
Nucleus Accumbens

Saline Amph
Robinson & Kolb, Journal of Neuroscience, Volume: 1997
Functionally…
Dopamine D2 Receptors are Decreased by Addiction

Cocaine

Meth

Alcohol

Heroin
Control Addicted
Cognitive Deficits and D&A
• Memory problems – short-term loss
• Impaired abstraction
• Perseveration using failed problem-
solving strategies
• Loss of impulse control
These deficits are similar to
those with brain damage
 Common Characteristics of
People Who are Addicted
• Unemployed or employed
• Multiple or no criminal justice contacts
• Difficulty coping with stress or anger
• Highly influenced by social peer group or a
loner
• Difficulty handling high-risk relapse
situations or craves excitement
 More Common
Characteristics…
• Emotional and psychological
immaturity
• Difficulty relating to family
• Difficulty sustaining long-term
relationships
• Educational and vocational deficits
 Why do Mental Illnesses and
Substance Abuse Co-occur?
• Self-medication
– substance abuse begins as a
means to alleviate symptoms of
mental illness
• Causal effects
– Substance abuse may increase
vulnerability to mental illness
• Common or correlated causes
– the risk factors that give rise to
mental illness and substance
abuse may be related or overlap
 What Environmental
Factors Contribute to Addiction?

Stress
Early physical or sexual abuse
Witnessing violence
Peers who use drugs
Drug availability
Stress impairs our executive function,
which dampens our ability to resist
impulses. Chronic stress can increase
the reward responsiveness of our
brains. So if we are at all prone to
addiction, it's going to make us crave
palatable food or drugs even more. It
drives us to choose comfort foods,
whether unconsciously or with a strong
intention.

Elissa Epel PhD UCSF Professor

 Negative feedback loop of stress

Recent studies pointing out the mind and body feedback loop when early
childhood stress and developmental disturbance may in turn lead to activation of
genes that cause oversensitivity to later stressful stimulus which sequentially leads
to greater susceptibility to physical health problems resulting in more stress that
may eventually develop into a more permanent pattern of chronic stress, mental
health problems, and/or long term physical health problems as result. They
explained the early life experience of the excessive and cumulative stress will lead
to compromised immune system and over the years, it will eventually manifest
itself in form of long term physical health problems and disease in adulthood such
as Diabetes and Cushing disease.

Honkoff, Boyce, and McEwen (2009)

How early in life do the negative effects of stress begin?

MATERNAL stress, toxin exposure,

EXPERIENCES nutritional status

oocyte transcription/translation

prenatal placental function,

environment physiology

postnatal
sensory stimulation,
maternal frequency & stability of care
behavior
Parental Experience
OFFSPRING Influences Offspring
DEVELOPMENT Development
 Programming of Fetal Stress
Response
maternal fetal
risk of prematurity
lower birth weight
Stress
increased stress response
risk of depression & anxiety
 Epigenetics
Early Brain
Environmental Physiology
Experiences Behavior
Our experiences or “nurture” can have long-
term effects on our brain and behavior

Genes can be turned “on” or turned “off”

through epigenetic changes

HOW DOES THIS OCCUR?

 Epigenetic Epigenetics
Control of Gene Activity

Early Brain
Environmental Physiology
Experiences Behavior
Our experiences or “nurture” can have long-
term effects on our brain and behavior

Genes can be turned “on” or turned “off”

through epigenetic changes
 Functions of Pre-Frontal Cortex
• Regulate body and nervous system
• Quell fear response of amygdala
• Manage emotions
• Attunement – felt sense of feelings
• Empathy – making sense of expereince
• Insight and self-knowing
• Response flexibility
• Planning, decision making
 The Neurobiology of Child Abuse
- Martin Teicher
The Scientific American
March 2002

• Patients with physical and sexual abuse reported symptoms of temporal lobe damage
(specifically hippocampus and amygdala related) at a rate 113% higher than the control
group.

• Hypothesis is that exposure to high levels of stress hormones (cortisol) in development

can alter or kill neurons in the hippocampus and other limbic structures.

• Limbic electrical irritability can produce symptoms of aggression, exasperation,

anxiety, self-destructive behavior and increased risk for suicide.
•Reduced integration of right and left hemispheres and a smaller corpus
collosum may predispose the emergence of borderline personality disorder.

• Maltreatment before the age of 18 had greater impact than later abuse.

• Antisocial behavior resulting from child abuse appears to be caused by

overexcitation of the limbic system, the primitive midbrain region that regulates
memory and emotion.
 Neurobiology of Trauma
Dr Daniel Siegel

Impaired integration and self-regulation in the prefrontal regions

can be seen within the brains of those individuals with unresolved
trauma or grief.

Lower mode states ensue when the functioning of the integrating

prefrontal regions become temporarily impaired.

Behavior is then driven by emotional states and impulses of the

lower regions of the brain.

This creates a lack of experience integration and response

flexibility, which is mediated by the orbito-frontal region of the
prefrontal cortex.
Neurobiology of Trauma

Secondary Responses to Trauma

• Depression
• Aggression
• Low Self-Esteem
• Identity Confusion
• Difficulties in Interpersonal
Relationships
• Guilt
•Psychiatric Disorders in Addiction Treatment
•Two studies of Prevalence rates in addiction treatment settings had similar findings. Persons with
substance use disorders are also like to have mood and anxiety disorders.

Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988

 Addiction Risk Factors
• Genetics
• Earlier Age of Onset
• Childhood Trauma (violent, sexual)
• Learning Disorders & ADD/ADHD
• Mental Illness Predating Use
– Depression
– Bipolar Disorder
– Psychosis
– ADHD
 Neurotoxicity
AIDS, Cancer
Mental illness

Homelessness Health care

Crime Productivity
Violence Accidents
Treating a Biobehavioral Disorder Must Go Beyond Just
Fixing the Chemistry
We Need to Treat the
Whole Person!
Pharmacological Behavioral Therapies
Treatments
(Medications)

Medical Services Social Services

In Social Context