Brain2Brain: Using Neuroscience to Facilitate Meaningful Change

Presented by

John Arden, Ph.D.

Disclosure Neither Dr. John Arden, the presenting speaker, nor the activity planners of this program are aware of any actual, potential or perceived conflict of interest

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IBP is a nonprofit scientific and educational organization dedicated to promoting advances in behavioral medicine. IBP is entirely supported by the tuition it charges for its seminars and the sale of educational materials. Neither IBP, its planning committee, nor any of its instructors has a material or financial interest with any entity, product, or service mentioned in the seminar unless such relationship is disclosed at the beginning of the program. The information presented is of a general nature. For specific advice, please consult a specialist in your area. Brain2Brain: Using Neuroscience to Facilitate Meaningful Change Agenda: Institute for Brain Potential • Practical Neuroscience •Autostress Disorders •GAD •panic •PTSD •OCD Depression Promoting Brain Health John B. Arden, PhD

The Time is Changing Theme Colors “We must recollect that all of our provisional ideas in psychology will presumably one day be based Purple color family and teal—Main on an organic substructure.” presentation ‐‐ “The act of will activates Green—Client information neural circuits” Yellow—Neuroscience ‐‐William James Then 1890 Red—Anxiety and stress “ works by producing changes in gene expression that alter the strength of Blue—Depression synaptic connections…” Eric Kandel Now

The Cartesian Blizzard The Cartesian Past

Abreaction Cognitive analytic response prevention Integral psychotherapy therapy Psychotherapy ACT therapy Expressive therapy psychotherapy Provocative therapy Sensorimotor Adlerian therapy CBT Family Integrative Psychedelic therapy psychotherapy Adventure therapy Coherence therapy Constellations psychotherapy Nonviolent Sexual Identity Immunology Attachment Analytical Collaborative Intensive short-term Communication Therapy psychology therapy dynamic Nude Psychodynamic Sex therapy Neuropsychology CFT psychotherapy psychotherapy psychotherapy Social Therapy Attack therapy Concentrative Freudian Internal Family Object relations Psychosynthesis Solution focused Modeling Attachment-based movement therapy psychotherapy Systems Model psychotherapy Pulsing brief therapy psychotherapy Contemplative FAP Interpersonal Ontological RET Somatic Epigenetics Attachment-based psychotherapy Future-oriented psychoanalysis hermeneutics RLT Experiencing therapy (children) Conversational therapy Interpersonal Orthodox Somatic psychology Empathy Attachment therapy model psychotherapy psychotherapy Rebirthing- Status dynamic Neurology Conversion therapy Gestalt theoretical Jungian Parent–child breathwork psychotherapy Client-Centered Behavior Core process psychotherapy psychotherapy interaction therapy Recovered-memory Supportive Psychopharm Alliance modification psychotherapy Group analysis Parent management therapy psychotherapy Behavior therapy Group therapy Marriage counseling training Re-evaluation Systematic Biodynamic Depth psychology Guided affective Pastoral counseling Counseling desensitization Diagnosis psychotherapy Daseinsanalysis imagery -based Person-centered Reichian Systemic Psychotherapy Bioenergetic DNMS Hakomi therapy psychotherapy Constellations CBT Research analysis DBT Holotropic Mindfulness-based Relationship Systemic therapy EBP-- Drama therapy Breathwork stress reduction Positive psychology counseling T-groups DSM 5 Body psychotherapyDreamwork Holding therapy Mentalization-based Positive Relational-cultural Therapeutic Panic Mindfulness EBP-- DDP Humanistic treatment psychotherapy therapy community ACT, DBT EBP-- Classical Adlerian Ecological psychology MOL Postural Integration Remote therapy Thought Field GAD psychotherapy counseling Human Givens MDT Primal therapy Reprogramming Therapy Narrative OCD Chess therapy EFT Morita therapy Primal Integration Rogerian Transactional Child psychotherapyEFT Inner Relationship Motivational Process oriented psychotherapy analysis Psychodynamics MI, Harm Reduction Client-centered EMDR Focusing interviewing psychology Sandplay Therapy Transference psychotherapy Integrative body Process psychology Schema Therapy focused EBP-- IPT Developmental Co-counselling Exposure and psychotherapy Multitheoretical Prolonged exposure Self-relations psychotherapy Depression

1 Biopsychosocial Synthesis The BASE of BBT

NEUROSCIENCE EVIDENCE-BASED Brain PRACTICE Alliance

PSYCHOLOGICAL THERAPEUTIC Evidence-Based THEORIES ALLIANCE Systems Practice

Psychotherapy and the Brain Brain Change: Two Perspectives

Direct, observable links between successful CBT/IPT and brain changes – Reduced amygdalar activity in:

– phobics ( Straube, et al., 2006),

– panickers (Prasko et al., 2004),

– social phobics (Furmark et.al, 2002) – Increased ACC activation in PTSD clients (Felmingham et al., 2007) – Increased hippocampal activity in

depressives (Goldapple et al., 2004)

– Decreased caudate activity in OCD (Baxter, et al., 1992)

Mind/Brain Causality Brain-Based Therapy

• Discriminates between what is therapeutic and what’s not • Includes techniques consistent with how the brain works • Relies on the therapist’s alliance with the client • Employs common denominator methods of psychodynamic therapy, CBT, DBT, ACT, IPT, mindfulness, etc.

2 BBT: The BASE Brain-Based Therapy

• B is for Brain • BBT changes how we think about the relationship and • A is for Alliance change: • S is for Systems –Need a “Safe emergency.” of psychological –Experience creates brain biology theories and intervention –Brain biology effects • E is for Evidenced-based Practice experience (e.g. depression)

DLPFC and the OFC

Dorsolateral Prefrontal Cortex

Client Education

• The more advanced part of your brain

can neutralize irrational anxiety generated

by the primitive parts of your brain.

• And that is what you will learn from

therapy.

3 Practical Neuroscience

• Neuroplasticity ● Neurogenesis ● asymmetry ● Default mode network • Social Brain networks • Nutritional Neuroscience ● Psychoneuroimmunology

20

Left PFC:

Suppressing

Activating Positive

Client Education Left PFC:

• When you are overwhelmed with Activation anxiety or depression it is best to shift & from the big picture to the small, and do Approach something that approaches a goal in a Behaviors (curiosity; assertion) piecemeal, incremental manner.

4 Right PFC: Activity in the default mode network Activating Behavioral Inhibition

Associated With negative Emotions

Sheline Y I et al. (2009)

DMN Variations Client Education • Increases when DLPFC is not engaged: • It’s natural and normal to fade – Stressed, bored, no novelty, or tired off and reflect every once in • Social and self-referential –needed for awhile. sense of self • Malfunctions in the DMN: • Try to make these periods – Schizophrenia—impaired self useful by reflecting on ideas reflection—not sure where thoughts and impressions about what come from just occurred or positive and – Depression—negative ruminations creative thoughts.

5 Neuroplasticity DENDRITE SPINES & SYNAPSES

Client Education

• Your brain is not hardwired but soft-wired. • Our job together is to rewire your brain so that you no longer suffer from anxiety and depression.

Spine Growth one-half hour • Optimally–repetition of a stimulus ↓ the amount of glutamate necessary to make the next transmission •i.e. lowers the threshold & strengthens the connection (LTP) via a glutamate receptor called n-methyl-D- asparate (NMDA)

6 Client Education

• Though you feel like you’re not ready to take the first step, actually it is not feeling ready that provides the brain chemistry necessary to rewire your brain. Don’t wait to feel ready!

Examples of Neuroplasticity Examples of Neuroplasticity

Neuroplasticity Examples Client Education

• Bilingual people have a larger • To learn a new skill you must do what you don’t feel like angular gyrus (Green, et. al. 2007) • Professional musicians have a doing so that eventually you Heschl’s gyrus -2xs larger than feel like doing it. non-musicians • The more you practice the new skill, the more your brain rewires to make that skill come easily.

7 Client Education BBT Strives to: • Rewiring your brain to change •Induce repeated states (weak bad habits into good habits attractors) requires that you endure the confusing experience of feeling •(i.e. positive moods) worse before you feel better. •Repeat often enough so they • To feel better on a regular basis become traits – (or strong you must ride through the brief attractors) period of feeling worse.

Repeated Firing Patterns A Mnemonic “Recipe” for Rewiring the Brain

Focus: Turn on you PFC

Effort: Establish a habit

Effortlessness: It will eventually become easier but not permanent

Determination: Stay in practice to keep it going

Brain Derived Neurotropic Factor Neurogenesis •BDNF plays a crucial role in reinforcing neuroplasticity and neurogenesis. It helps: –Consolidate the connections between neurons. –Promotes the growth of myelin to make neurons fire more efficiently –Act on stem cells in the hippocampus and PFC to grow into new neurons

8 BDNF: Impact on Factors that Decrease Dendrite growth: 24 hours Neurogenesis Aging Chronically high cortisol Chronic stress Recurrent depression Poor diet and no exercise Obesity

Factors that Increase Client Education Neurogenesis Exercise You can grow new neurons in the area Fasting of your brain that gives you the capacity Fewer calories consumed for memory. The first steps include Food content --(Omega—3) Antidepressants? maintaining a healthy diet, aerobic and

cognitive exercise.

The ACE Score and the Prevalence of The ACE Study Severe Obesity (BMI>35) • Examined the health effects of ACE’s throughout the lifespan among 17, 421 members of Kaiser Permanente in San Diego county • What are Adverse Childhood Experience?

– Childhood abuse and neglect obese (%) Percent – Growing up with domestic violence, substance abuse, parental discord, ACE Score crime, or mental illness in the home

9 The ACE Score and the Prevalence of The ACE Score and a History of Attempted Suicide Lifetime Depression Percent attempted (%) attempted Percent Percent depressed (%) Percent

ACE Score ACE Score

The ACE Score and Drug ACE’s Smoking and Lung Disease Addiction

The ACE Score and the Risk of ACE Score and HIV Risks Coronary Heart Disease Increase in RiskinIncrease (%)

ACE Score

10 Inflammation

Death

Early Death

Disease, Disability and Social Problems Adoption of Health-risk Behaviors

Social, Emotional, & Cognitive Impairment

Adverse Childhood Experiences

The Epidemic Belly fat

Belly fat generates inflammation by releasing proinflammatory cytokines • Lowers BDNF • ↑ risk of dementia • If you’re going to gain weight go for the pear not the apple shape

Obesity-Associated Adipose Tissue Client Education Inflammation If you have extra weight, hope for the pear not the apple shape. Better yet, lose the body fat for the sake of your brain. Fat cells leak out toxins that go to the brain causing inflammation, clouding thinking, and increasing depression.

11 Obesity, Inflammation, and Diabetes Metabolic Syndrome

• Prediabetes occurs when blood glucose levels • Fat cells secrete IL-6 are higher than normal but not high enough • IL-6 can induce insulin resistance for dx of diabetes Higher IL-6 may predict diabetes type 2 • US Dept. of Health estimates 1 in 4 adults—57 million had diabetes in 2007 • Most of them develop type 2 diabetes in 10 years unless: – Lose 5 to 7% of body weight – Make major changes to diet – Increase exercise

• Bad Diet • Simple carbs Gut Bacteria • Transfatty acids Di • 90% of bacteria in the colon F/B ratio: • Saturated fats • Food • Firmicutes allergies • Bad oils – Fat loving—increases fat absorption • High dairy • High gluten – Efficient at extracting calories from carbs •No exercise •Chronic illnesses – Turns on genes that increase the risk for • Autoimmune obesity, diabetes, and CVD disorders •Chronic pain • Bacteroidetes • Chronic stress • Being – More dominant in lean people overweight • Apple shape • Leaky gut

Allostasis

• Allostatic adjustments are adaptive over the short term with moderate and fluctuating levels of cortisol to help orchestrate adjustments by: Allostasis – enhancing or inhibiting gene transcription – regulation of BDNF & – up regulates activity Allostatic Load – targets prefrontal systems involved in stress and the (Sullivan & Gratton, 2002).

– maintaining stability through a change (McEwen, 1998). • Allostatic load --When demands exceed the balance of energy and regulatory gains from rest and recuperation. (McEwen and Wingfield, 2003).

12 Client Education Sympathetic ANS and Neuroendricine Systems

• Just as your car needs shock absorbers for bumpy roads, so too can you develop the durability to adapt to daily challenges.

Locus Coeruleus (LC) source of NE which has extensive projections throughout the brain and can trigger the HPA axis (Aston-Jones, et al., 1994).

AMYGDALA HIPPOCAMPUS Implicit Memory System Explicit Memory System • Many Cortisol • Conditioning Receptors •Emotional Valance • Context Specific •Generalized •Cortisol Heightened • Heightened Cortisol •Sensitivity leads to atrophy • (Hypervigilence) • Matures Later AMYGDALA •Matures Early • Vs. Infantile Amnesia •“Little Albert” • “H.M.” HIPPOCAMPUS •“LSMFT”

Henry Molaison Henry’s Brain

Dr. Brenda Milner

13 Threat Appraisal: EXPLICIT DECLARATIVE KNOWLEDGE Amygdala Level

IMPLICIT PROCEDURAL KNOWLEDGE

The Fast Circuit to the Amygdala The Fast Track to Survival

• Sensory info goes to the Thalamus then directly to the Amygdala: • Fight or Flight: SNS and HPA activation • Emotional Learning • Fear Conditioning • PTSD, panic, etc. • Flashbacks • Rapid, crude, adaptive, and immediate • “Bottom up” • Cannot reality test • Prone to false alarms

The Slow Circuit to the Amygdala Threat Appraisal • Sensory info goes to the Cortical Level Thalamus through the Cortex and Hippocampus to the Amygdala • Limitations: – Worries and GAD – and • Benefits: – Tames the Amygdala – With exposure, New Thinking (cortex) • “Top down”

14 Client Education The Dynamics of Fear

• When you are immediately • Amygdala memories are hard to frightened then find out that forget (“Stone tablet”) there is no danger, that’s a clue that you need to teach your slow track to catch up with your fast track. • Hippocampal circuits tell us what to fear and in what context (“Etch-a-Sketch”)

Cortical-level Appraisal Applications Autostress Disorders – Generalized Prefrontal Cortex –Panic Reality –PTSD testing –OCD • Depression

Medical and Drug Related Factors Anxiety that Mimic Anxiety • Neurological: complex partial seizures, head injuries • Pulmonary: Asthma, hyperventilation, COPD, lung cancer • Various meds, drugs, and ETOH • Endocrinological: Hyperthyroidism etc. • Cardio: MVP, high blood pressure, • Toxins such s hydrocarbons, mercury, and carbon dioxide • Deficiencies in magnesium, Vitamin B-12, potassium, and calcium

15 Physiology of GAD Balancing the ANS • Less parasympathetic more sympathetic-- reduced vagal tone

• Bed nucleus of the stria terminalis (BNST) –Free-floating anxiety • Amygdala—an intolerance for ambiguity – Anxious individuals select more threatening interpretations of

ambiguous stimuli (e.g., Mathews & Mackintosh, 2000) •

Activating the PNS Breathing and Over-Breathing

• Most people breathe 9 to 16 breaths per minute. Panic • Diaphragmatic attacks - 27 breaths Breathing: • Over-breathing pulls in too much oxygen forces down the Stretch carbon dioxide level in the blood • Yoga stream. • Meditation • Carbon dioxide helps maintain • Cuddling the critical acid base (pH) level in blood. Lower pH level causes • Orgasm nerve cells become more • Pulling the Kegel excitable and people associate the feelings with a panic attack.

Client Education Hypocapnic Alkalosis • Your breathing speed and your heart – The excessive dissipation of carbon dioxide leads to hypocapnic alkalosis, making blood more alkaline and rate are interconnected. less acidic. This leads to the following: » Vascular constriction, resulting in less blood and less • As you learn to breathe more slowly and oxygen released to the tissues and the extremities. deeply your heart rate will slow, allowing » The paradox is that though too much oxygen is you to enjoy a calm and clear frame of inhaled, less is available to the tissues. mind. – Symptoms: – cerebral vasoconstriction, which leads to dizziness, • Deep diaphragmatic breathing allows light-headedness, racing thoughts, feelings of your lungs to fill to capacity. Emphasize unreality, the exhale. – peripheral vasoconstriction, which leads to tingling in the extremities. •

16 Client Education Jane’s Song

To interrupt hyperventilation: B—Breathing, sympathetic • Exercising vigorously increases your arousal metabolism, use up excessive oxygen thus A—Anxious attachment to producing more calm energy. anxious mother, father • Hold your breath for 10 to 15 seconds. This codependent temporarily prevents the less of carbon S—GAD, need for dioxide. parasympathetic activation • Breath in and out of a paper bag. This will E—Breathing exercises with song help restore the balance of oxygen and Silent Night, REAL mnemonic carbon dioxide.

Worry Loop attempts dampen GAD -- Cognitive features autonomic arousal only to crank it back – Meta cognitions -- beliefs about worry up • “Worrying helps me cope.” • “If I worry I can prevent bad things from happening.” –or • “My worries are uncontrollable.” Thalamus • “Worrying is harmful.” Orbital –or Frontal Amygdala • “I feel anxious, so there must be a reason why.”

CBT vs. Metacognitive Models Interrupting the Worry Loop (ACT, DBT, MBCBT, etc.)

CBT MC Models Rationale=control Rationale=relinquish control Thought Diffusion Breathing retraining Observe & accept Interoceptive exposure to Interoceptive exposure with lessen fear & avoidance acceptance of internal cues Situational Situational exposure to lessen fear exposure to achieve fear and avoidance life values and goals

17 Client Education REAL not GAD “R” is for relaxation, including deep breathing, stretching, self , mediation, and prayer to activate your • The next time a well-meaning parasympathetic nervous system and increase vagal tone. person tries to reassure you “E” is for exposure such as in scheduling an hour of worry time, allowing focused exposure to all your worries, and giving your that there is certainty in life, higher brain a chance to work on developing the capability of say: dealing with the ambiguities inherent to life. “A” is for acceptance. Since there is no ultimate certainty with • "Thanks, but I'm learning how much of life, acceptance of uncertainties allows worries to fade into the texture of normal living. to appreciate uncertainty and “L” is for labeling. When you have an anxious thought you can the shades of grey." label it as just “an anxious thought,” thereby detaching from the feeling of anxiety.

Deborah’s Worry Loop Neurodynamics of Anxiety

B—OFC hijacked by amygdala • Two routes to the amygdala, the fast and slow A—Critical gambling father, worrying mother • Right frontal bias in general for anxiety disorders S—GAD, need for ambiguity • Under-activation of the left acceptance frontal lobes and in Broca’s area explains why some E—Exposure to ambiguity people feel “speechless”

especially to boring part of one when they’re scared (Rauch et al., 1997). hour worry time, until there is no energy anymore, REAL mnemonic

Client Education Slow Track—Allostasis • Getting your memory –Automatic thoughts—fast track systems in sync will help you impulse—interrupt with curiosity and time to feel more comfortable in – Assumptions—from pessimism to non-threatening situations incremental optimism • “I’m working on it and can tolerate that previously you found distress” threatening. – Core beliefs—existential self descriptor • You can get your thinking • “I’m a survivor.” • Global/Passive (R-PFC) vs. and feeling in synch. Detail/Action (L-PFC)

18 Shifting Perspective to Speed Up the Slow Track Avoidance: the Polarizer • Labeling thoughts—”That is an anxiety •Over-Sensitizing the provoking thought” vs. “This makes me Amygdala anxious!”—R-vlPFC –Forms of Avoidance • Externalizing—”What would another person in this situation say and how is s/he right?” »Escape behaviors • Temporal Distance—”How will I sensibly view this situation in six months?” »Avoidant behaviors • Humor—”What is funny about this?” »Procrastinating • Wisdom—”How can I grow from this?” »Safety behaviors

Deceptively Simple Why avoidance is hard to resist but so Complex –It works to reduce fear over the short term Exposure –The more you avoid the harder it is to resist repeating --they become habits Techniques –There is a superficial logic to avoidance, --- and the Will “Why wouldn’t I avoid something that makes me anxious?” to face fears –You get some secondary gain from it like extra care because people around you feel sympathy

Client Education • Sensations from your own body should not be the cause for alarm. • Don’t let your body be the boy who cried wolf.

19 Interoceptive Exposure + Interoceptive Exposure +

• There are a variety of interoceptive exercises including: –Swallowing quickly--- to cause a lump in the throat –Running in place--- to increase heart rate and hyperventilation –Tensing the body--- leading to chest constriction –Holding your breath--- to simulate sensations of suffocation –Standing up quickly from lying on the floor---to cause dizziness. –Spinning--- leading to dizziness –Staring at one spot---to increase the –Hyperventilation or breathing feeling of being trapped through a straw---leading to light- headedness

Client Education Exercise and Anxiety • Since fight/flight is meant for action exercise • Do you have shortness of breath, provides the method to feelings – take action. rapid heartbeat, sweating, headaches, or nausea? • Exercise: –Reduces muscle tension • Each one of these are normal –Builds brain resources (neuroplasticity and body sensations. It’s when you neurogenesis) overreact to them you may tumble into a panic attack. –Increases GABA and serotonin –Interoceptive exposure • Befriend your own body sensations. –Improves resilience – self-mastery

BBT and Panic Disorder BEAT Panic

“B” is for body. When you feel your heart race or breathe too fast just ride it out. Say, “I can befriend my own body! • Desensitizing the Amygdala— “E” is for exposure. Through interceptive exposure exercises Avoiding avoidance you can regain tolerance to body sensations. Say, “this is not a heart attack but just my own body sensations that I’ve • Interceptive exposure exercises— felt many times before.” Embracing body sensations “A” is for the amygdala. With its fast and slow tracks. “I can learn to slow down my fast track and speed up my slow • Speeding up the slow track—Getting track.” “T” is for thinking. To speed up your slow track, remind the pre-frontal cortex involved yourself that what you think is happening has a dramatic effect on what you feel is happening.

20 Post Traumatic Stress Chronic, severe, inescapable Disorder • War Zones • Rape • Child abuse • Elder abuse • Domestic violence • POWs and refugees

Time Sequence Phylogenetic Responses to Stress

• 1) Trigger the social engagement system— the myelinated vagus • 2) Fight or flight—SNS and HPA axis arousal • 3) Immobilization—freeze, collapse, and feigned death: – 2 stages • Freezing in terror • Paralyzed—shut down—total submission, trancelike, dissociation

PTSD Neurodynamic Aspects Window of Tolerance

• ↑ amygdala—general false positives for threat • ↓ mPFC especially the ACC (reduced

neurointegration and cortical volumes) (De Bellis, et.

al., 2000) (inadequate top down inhibition of the amygdala) • ↓ hippocampus (cortisol, excitotoxity, blocking of neurogenesis)

21 Trauma Responses are Autonomically Driven Client Education

Hyperarousal-Related Symptoms: High activation resulting in impulsivity, risk-taking, poor judgment • Since the trauma, your brain Chronic hypervigilance, post-traumatic paranoia, chronic dread Intrusive emotions and images, flashbacks, nightmares, racing thoughts Obsessive thoughts and behavior, cognitive schemas focused on chemistry has shifted to worthlessness and dread maintain super alertness to danger.

“Window of Tolerance”* • A bad diet can make it even Optimal Arousal Zone more likely to trigger false alarm. Hypoarousal-Related Symptoms: Flat affect, numb, feels dead or Hypoarousal empty, “not there” Cognitively dissociated, slowed thinking process Cognitive schemas focused on hopelessness

Cortisol Cascade Model Hippocampal atrophy

• Stress causes over-production of cortisol • Excessive cortisol causes dendrites in the

hippocampus to shrivel up (Sapolsky, 1996) • PTSD patients with smaller hippocampi (Bremner, 1999) • This feedforward loop leads to heightened reactivity of amygdala • The hippocampus is essential for turning off HPA axis and damage to it leads to even more cortisol release as time passes

PTSD Vulnerability Client Education • Monozygotic twin brothers, one with combat related PTSD and the other who • Though your memory may never went to war. Both had smaller be temporarily impaired, hippocampal volumes. – Thus, the you can revitalize these vulnerability hypothesis may be viable as a possible partial explanation for risk. areas of your brain by aerobic exercise followed • It appears that both smaller hippocampus by learning and goal increases vulnerability and the cortisol- oriented behaviors. cascade shrinks hippocampi. (Gilbertson, et al, 2002)

22 Possible Neurochemical Client Education Vulnerability of PTSD

• ↑ NE post trauma may predict PTSD (Yehuda, et. al., • It’s common to feel like being alone 1998) after a traumatic event. But, • ↑ cortisol in the evening not in the morning isolating now will make you worse • ↑ proinflammatory cytokines post trauma and feel even more alone. – The secretion of IL-6 inflammatory cytokines can be triggered by B-adrenergic receptors • Parts of your brain activate when with ↑ NE you are with people which helps you – Inflammation can occur post trauma via buffer anxiety and lift depression. CRH/substance P-histamine axis with ↑

cortisol and IL-6 (Elenkov, et. al., 2005)

Research on PTSD Treatments Exposure

• Institute of Medicine (IOM) 2007 Review • Imaginal exposure (trauma memory) – Exposes client to memory of the trauma in structured, controlled way – Thorough review of psychotherapy – Trauma exposure helps client in two ways: • Helps reduce anxiety associated with trauma memory (via extinction of research for PTSD (requested by the VA) conditioned fear) • Helps client organize memory into coherent narrative (calms overactive • Treatments not found to have clear empirical amygdala) support: – Generally need minimum of 12 sessions (CBT, PE, CPT) • CBT approach starts with psychoeducation, anxiety management, and – EMDR, group therapy, hypnotherapy, coping skills • Minimum 4-6 imaginal exposure sessions (temp. increase of anxiety and re- eclectic, CBT alone…. experiencing symptoms) • Cognitive processing of trauma memory & associated meaning (beliefs) • Exceptions: review found strong efficacy of • Situational exposure (CBT & PE) exposure: – targets avoidance of trauma-related situations (and agoraphobic avoidance) – Prolonged Exposure (PE) • Interoceptive exposure – Cognitive Processing Therapy (CPT) – Targets “fear of fear” or somatic (treatment for panic disorder)

Window of Tolerance PTSD and Memory • People with PTSD typically remember that the traumatic event occurred • But describe blank periods, gaps, between vague details • Recollection for details are often

unclear, and disorganized (Harvey & Byant, 1999)

23 Dual Processing Theory The Explicit system

• Limitations of the “fear network” • Verbally accessible memory (VAM) system—the theory – doesn’t account for implicit narrative—autobiographic

memory: – Can be deliberately retrieved (Brewin, 2005) –Verbally accessible memories – Cortex and hippocampus (VAMs) on the conscious memory – Past, present, and future level. VAMs can be accessed in – Available to verbally communicate therapy through deliberate recall. – Restricted by attention and arousal • Traumatized people use the VAM system to evaluate –Situationally accessible memories the trauma (SAMs) non-conscious. SAMs are only accessible through exposure – They ask themselves “could it have been cues that activate the non- prevented?” – “What are the consequences….the meaning?” conscious network (Brewin, Dalgleish, and Joseph, 1996).

The Explicit system The Implicit System

• VAM system memories are accompanied by • Lower level perceptual processing—too “secondary emotions” (not experienced at the time of the trauma) briefly apprehended to be bounded together in consciousness memory – Directed at the past—i.e. regret or about the risks taken required for VAMs – Often involves guilt or shame over – Sights perceived failure or not preventing the – Sounds event – Physiological sensations including – Thoughts about the future—i.e. sadness at changes in heart rates, temp, or pain the loss of cherished plans or hopeless at the thought of not finding fulfillment

The Implicit System Explicit and Implicit interactions • Primary emotions—fear, horror, helplessness • SAM—implicit memory—amygdala • Accounts for flashbacks that can be triggered related to the intensity of emotions involuntary by cues related to the trauma • VAM—explicit memory—hippocampus (sight/sounds etc.) related to context and time • Not structured by verbally coded memories— • SAM flashbacks occur via the fast track therefore more extensive to the amygdala and override the VAM • The more drawn out the trauma, the greater system the tendency to experience a range of • ↑ cortisol and catecholamines impair the sensations and emotion VAM system and kindle the SAM • Difficult to access in therapy

24 Therapeutic Client Education Explicit and Implicit Integration • Deliberately maintaining attention on the • Every time you go through this content of flashbacks w/o avoidance-- exposure exercise it will get SAM memories can be encoded in the easier. VAM system. • The timeless qualities of the SAM • The higher parts of your brain, images and sensations get linked with will rewire to put the brakes on spatial and temporal context—within the the alarm button in the lower safety of the therapeutic relationship part of your brain. • “I’m safe now—those things that that happened to me in the past”

Converting traumatic memories into meaning Client Education • Traumatic memories are fragmented • Step-by-step. I am going to and disorganized into “hotspots” which help you expose yourself to the can spur flashbacks cues that trigger the flashbacks • Hotspots occur where there is maximal functioning separation between SAMs so that you can bring them

and VAMs (i.e. less integration) (Brewin, 2005) under control. • They need to be integrated and converted into a coherent and an organized form to reduce the risk

intrusions into flashbacks (Ehlers & Clark, 2000; Conway & Playdell- Pearch, 2000)

Converting traumatic memories Explicit and Implicit Integration into narrative memories

• The process needs to be repeated • Raw sensory information needs to be for: interpreted and anchored with personal –Neuroplasticity—the inverted “U” narrative organization and meaning. –To neutralize the traumatizing • Reactivated through exposure and reconsolidated. quality of the SAM system – Not “correct” (i.e.. CBT) but a coherent and –So that VAMs can compete with acceptable meaning (Constructivist) SAMs and integrate them • Newly constructed memories compete with • The new VAM system puts the original traumatic memory for attention SAM system in perspective

25 Orienting Response, REM, and Client Education Memory • By getting your memory • Somatic stimulation of the orienting response (i.e. via EMDR, EFT, acupressure etc.) involve: systems in sync, what had – Shto takoe? (Что такое? or What is it?) triggered flashbacks will fade – Reorienting of attention -- triggered automatically when a sudden movement grabs attention or away. intentionally when you chose to look at an object – The reorienting of attention requires you to release • Those flashbacks will lose their your focus on one location so that it can shift to a new ever presence and be placed location where they belong, in the past • The shift in attention involves: – The orienting response (Sokolov, 1990) as you develop a meaningful – Induces REM like state

future. • Both facilitate cortical integration of memories (Stickgold, 2002)

Shifts in attention and asymmetry Client Education • Why activate the RH when it is already • I’m going to ask you to direct overactive? How about tapping the right your attention to the specific hand and/or foot? movement while at the same • The right limb tapping method still includes: time you describe the traumatic – reorientation response event. – attentional shift • This will help you reset your – grounding brain so that it will no longer be • This method is portable—the client can stuck in the past and you can practice on his own (neuroplasticity) move ahead to a positive future.

Growth After Trauma Client Education • Some assumptions buffer us from initial distress of the trauma but • Many people who have reduce the possibilities for schema been horribly traumatized change and growth. have gone ahead to gain a • Yet, growth occurs when schemas deep sense of meaning, are changed by traumatic events. Old schemas are destroyed and and wisdom. replaced by new schemas with questions: “I almost died! Why?”

26 BBT and PTSD SAFE from PTSD

• Phase 1: Psychological first aid—stabilizing ASD and “S” is for stabilizing. To establish a healthy preventing PTSD foundation for recovery. • Phase 2: Integration of implicit and explicit memory systems: – Explicit memories (VAMs) –The conscious memory “A” is for acceptance of what happened. No level, which can be accessed in therapy through victimization on one extreme or on the deliberate recall. other of event(s) that occurred in the past. – Implicit memories (SAMs) –The nonconscious, which are only accessible through cues that activate the “F” is for future. To visualize a hopeful network. – Aided by somatic reorienting method posttraumatic growth. – Phase 3: Posttraumatic growth—developing meaning and “E” is for exposure. To confront the feelings direction (Constructivism) and sensations that trigger flashbacks.

Bret’s BASE OCD B--Increased amygdala and dampened hippocampus— Substance abuse A--Buddy connection S--Numbing, re-experiencing (barbecue) and avoidance E--New Narratives—Exposure at McJack Jr’s—Posttraumatic Growth

Structures The Habit Brain and OCD with Roles in OCD • Anterior Cingulate Cortex– error detection Cues: e.g. an –“I feel bad!” emotional state, • Orbital frontal cortex-- gets flooded with information stress, fatigue, and generates error messages: addictive cue – “Something is wrong!” Ignites a Behavioral • Striatum-- gate is left open for habit routine: previously associated with reward –caudate serves as a gate for thoughts and or relief (e.g. counting, emotions food, sorting, bite –putamen serves as the gate movement finger nails, hair pulling, tics…) »Do it!

27 Flooded OFC in OCD OCD: failure of top down control

• OFC flooded with nuisance info and tries to make sense of it Caudate • Given its inhibitory role pts try to use it to Thalamus “stop that thinking!” Orbital But that results in a Amygdala Frontal . paradox—“try not to think about pink elephants”

Strengthened Pathways and Pulling Out of the OCD Circuit Improved Gating

• Prefrontal Cortex (DLPFC and OFC) – DLPFC—Breaks out of auto pilot and decides “time to do something new” – With help the OFC can now learn to inhibit the amygdala and the fear network Anterior Caudate • Anterior Cingulate Cortex—error correction Cingulate • Hippocampus-- provides context and what is DLPFC worthy of fear –Remembers that you engaged in a compulsive behavior that never seems to solve the problem.

ORDER ORDER • O—Observe--the OCD • R—Remind--By reminding that thoughts and behaviors. obsessing itself is the problem, not what is being obsessed about: –DLPFC activation. – call it a symptom of the brain's OCD habit and nothing more to be –Attention key first step for concerned about. learning something new. – “This is just OCD. –Break out of autopilot

28 ORDER ORDER

• D—Doing--By doing something E—Exposure--to the situation or place that different than the usual OCD had been intolerable. Exposure allows compulsive behaviors establishes a habituation. new practical habit. The new behavior –Taming of the amygdala draws attention and interest to expand upon: –The new habit builds a system of practical and enjoyable behaviors through neuroplasticity.

ORDER ORDER for OCD R—Response Prevention--Refraining from O is for observing the obsessive thoughts and compulsive behaviors that contribute only to behaviors. The shifts you out of autopilot. momentarily “feeling better.” R is for reminding that yourself that the obsessive This step strengthens the inhibitory circuits thoughts are mere symptoms of OCD. D is for doing something practical and enjoyable rather than the usual compulsive behaviors. E is for exposure to the situation, objects, or place that is intolerable which eventually makes it tolerable. R is for response prevention which strengthens all your ability to shut off OCD.

Penelope’s BASE

B—Straitum's open gate for the OCD habit – OFC gets flooded (DLPFC activation to break out of autopilot)

A—Forming an alliance based on the marital Depression inequity

S—Conceptualizing the need to address the OCD with the felt need to clean up the disorder in her marriage.

E—Exposure Response Prevention methods with EBP and the ORDER system

29 Illness and Depression Bottom Up

• Anemia • Mono • Asthma • Diabetes • Hepatitis • Congestive Heart Failure • Hypothyroidism • MS • Obesity • inflammation • Medications, drugs, and alcohol

Top Down

X

Cytokines Pro-inflammatory Cytokines

• Protein molecules that act as cellular • Stress can increase PICs levels messengers • High PICs can lower the • Healthy people optimally regulate and concentration of serotonin and DA balance pro-inflammatory (PIC) and anti- inflammatory cytokines. –Cognitive dysfunction, anxiety, • Too little PIC activity -- fearfulness, depression, immunodeficiency, severe infection, and thoughts about suicide even death. • “Sickness behavior”---fatigue, • Hyper arousal of PICs can cause death, social withdrawal, and immobility-- or in illness, tissue damage, or shock (Granger, et al, 2006). depression (Hickie and Lloyd 1995).

30 Bidirectional Systems of Client Education Depression

• Mood changes (dysphoria, hopelessness, suicidality, anhedonia, • Feeling ill makes you act ill anxiety) and if you do, the feelings of • Circadian dysregulations (low drive, depression will increase. energy, appetite, sleep, libido) • Motor deficits (slow movement, restlessness, agitation) • Cognitive impairments (poor attention, working memory, executive functions, ruminations)

Gender Differences and Stress Induced Depression Depression • 2:1 women > men-- Only Post pubescence • ↓ DA, NE, and 5-HT as much as

• Male symptoms –anger, irritability, 90 minutes post stress (Irwin, 2000) recklessness • ↓ DA is associated with • Female symptoms—sadness psychomotor retardation • 4:1—men from suicide • Psychomotor retardation is associated with ↓ blood flow to “Women seek help, men die” the PFC • L-PFC can inhibit negative affect

↓ amygdala activation (Davidson & Sutton, 1995)

Re-balancing Hemispheric Asymmetry • Instead of putting details into context, depressed patients are overwhelmed by a global negative perspective. • Creating a constructive and goal oriented narrative generates positive, optimistic emotions which are all products of robust left hemispheric functioning • Behavioral activation (left PFC) is one of the principal EBPs for depression

31 Balancing R-PFC and L-PFC Client Education • The forest and trees together—not one • To balance the two sides of or the other your brain and rev up • A symphony—all pieces in synch circuits to lift yourself out of • Not passivity—not mindless action but depression you’ll need to moving with purpose with time initially do some things you • Mindful action—Zen is not like chopping wood. Zen is chopping wood. don’t feel like doing. • We will talk about it as you get underway.

Effort-Driven Reward Circuit (Lambert, 2008) Client Education

• Nucleus accumbens-striatal PFC • When depressed, if you do network what you feel like doing, – ↓ accumbens—loss of pleasure which is not much, you will – ↓ striatum—sluggishness and slow become more depressed. motor responses • Inactivity will fuel your – ↓ PFC—poor concentration depression.

Effort-Driven Reward Circuit (Lambert, 2008) Effort-Driven Reward Circuit (Lambert, 2008)

• PFC activates when you plan an • Kindling this circuit by activities activity (Behavioral Activation) • Striatum activates as you do it –↑ DA and 5-HT • Accumbens activates when you feel –↑ positive feelings the pleasure of doing it –Reap rewards of problem • All the above increases the sense of solving self control

32 Therapist vs Psychiatrists in Dx Loneliness

• In Portugal 1000 people 65> assessed: – Loneliness was the single most important predictor of depression (Paul, et al, 2006) • In London 2600 people 65> Therapists were three Psychiatrists dxed times as likely as MDs depression and made • More than 15% were at risk for social isolation and scant mention of to see the issue as a depression (Illife et al., 2007) relationship problem relationships

Client Education Exercise and Depression

• Alameda County study of 8,023 tracked for 26 years • Though you may feel like – Those that didn't exercise were 1.5 times more withdrawing from family and likely to be depressed friends, it will only make you • Finnish study of 3.403 – those that exercised 2 to 3 times per week were more depressed. less depressed, angry, stressed and cynical • Dutch study of 19,288 twins and their families – • Activating your social brain – those that exercised were less anxious, depressed, neurotic and more socially outgoing networks are key to your • Columbia University study of 8,098 physical and mental health. –inverse relationship between exercise and depression (reviewed inRatey, 2008)

Exercise and Depression Client Education

• Ohio State study---45 minutes of walking per day/ 5 days per week (heart rate at 60% to 70% of their maximum) lowered BDI • Exercise is the best mean scores from 14.81 to 3.27 compared to no change for controls (depressed non-walkers) antidepressant that we have to • Univ. of Wisconsin – exercise (jogging) as effective as psychotherapy for moderate depression offer you. – After one year 90% of exercise group were no longer depressed. 50% of psychotherapy group • Better than medications, better • Duke Univ. – found that exercise was as effective as Zoloft – At 6 month follow-up exercise was 50% more effective in than psychotherapy, and preventing relapse better than both combined. – Combining exercise and Zoloft added no benefit re: relapse

(Babyak, et. al. 2000) • NIMH panel concluded that long-term exercise reduces • And it is cheap and there are moderate depression. good side effects!

33 DMN (in blue). All of the other colors are overactive in people with depression. Client Education • When depressed you will more likely ruminate over things that are depressing. This does not mean that there weren’t things that happened in the past that were positive. • This tendency is called “state-based” memory. When in a depressed state you tend to ruminate about things that occurred when in that state.

DMN and Depression Client Education • The DMN increases when DLPFC is • When you find yourself not engaged: drifting into ruminations – Stressed, bored, no novelty, or tired bring yourself back to the – Obsessive ruminations over negative experiences present moment. Ruminations fade with: • Goal directed behaviors • Pulling out of the rumination • Exercise stew and into the now will • Social activities help you climb out of the • mindfulness black hole of depression.

Mindfulness and Depression Client Education Targets depression by neutralizing: • When you have a –Monotony: via attention to novelty and cultivation of depressing thought, call it curiosity just that, a depressing –Ruminations: via wide spectrum thought. observation and detachment –Thinking errors: via affective • This will help you put labeling –Fixations on imperfections: via distance between the acceptance thought and the feeling.

34 Meta-awareness: Principles of Therapy - Depression General Concepts Decentering – thoughts and • Alliance feelings are events—not realities Intentionality – breaking out of • Perspective shifting automatic thoughts and – New narratives behaviors Reducing Avoidance -- facing – Behavioral activation difficulties – Affect regulation Anti-ruminative – here and now focus not the past or future – Social brain networks—shared compassion – Present focus

Brain-Based Therapy Brain-Based Therapy

Up regulate Down regulate • The Social Brain Networks withdrawal tendency by: – Individual psychotherapy • Right hemi – Social engagement – Groups – Active behavior – Expanding social supports – Challenging negative generalizations • Activity Reward Circuit – Humor – Behavioral activation – Labeling moods • Hippocampus • The amygdala and the HPA axis by: –Exercise – Exposure – Rebuilding a positive explicit memory system –Exercise • Prefrontal Cortex – Goal directed behavior – Mindfulness • The ACC by: – Goal planning and follow-through – Challenging self-criticism – Meta-awareness

Brain-Based Therapy Client Education

Interventions that bolster under-active areas of the brain • Physiology • Because many factors can – Exercise contribute to your depression – Sleep hygiene – Diet , including Omega 3 you’ll need to do all the things • Hippocampus we talk about doing – Counter mood-congruent bias with inquiry • Rebalance left PFC simultaneously to climb out of – Details depression. – Active – Goal directed behavior • Activity Reward Circuit • Mindfulness – Quieting ruminations and monotony

35 TEAM for Depression The Five Healthy Brain Factors T is for thinking to defuse negativistic thinking • Social associated with depression. • Exercise E is for effort, to activate the approach circuits of the L-PFC and the effort driven reward circuit. • Education A is for accepting that the world is not perfect • Diet and the things that happen are not always good. • Sleep M is for mindfulness to focus on the present • moment and novelty of each experience, gratitude, and forgiveness

The Effects of Social Medicine Client Education

• Cardiovascular reactivity (Lepore, et al, 1993)

• Blood pressure (Spitzer, et al, 1992) • Your brain has been • Cortisol levels (Kiecolt-Glaser, et al, 1984) endowed with circuits • Serum cholesterol (Thomes, et al, 1985) that thrive on positive • Vulnerability to catching a cold (Cohen, et al, 2003)

• Anxiety (Cohen, 2004) social interactions.

• Natural killer cells (Kiecolt-Glaser, et al, 1984)

• Slows cognitive decline (Bassuk, et al 1999) • When they are not • Improves sleep (Cohen, 2004) activated your health

• Improves depression (Russell & Cutrona, 1991) suffers.

Systems of the Social Brain Social Brain and the PSN

• Brain Structures • Neurochemistry includes: – Orbital Frontal Cortex (OFC) –Oxytocin – Amygdala • Turns down cortisol – Insula – Cingulate • Central Parasympathetic Nerves – Mirror Neurons –“Smart” Vagus Nerve – Spindle Cells – Facial expression modules

36 On the market The Vagus Nerve System

• Tenth Cranial Nerve --a complex of sensory and motor nerve fibers.

• Vagal tone- the ability to modulate target organs without sympathetic arousal

• allows attachment and sustained relationships.

Vagal Brake(Porges) • Higher vagal tone correlates with: – Self-Soothing capacity – Quality of caretaking and attachment – More reliable autonomic responses – The range and control of emotional states • Lower vagal tone correlates with: -- Anxiety – Impulse Control problems – Hyperactivity, Attention deficit and distractibility – Avoidant & Disorganized Attachment – Irritability

Mirror Neurons • Gives us the ability to anticipate others’ intentions • Helps us respond sympathetically and empathically to others • Mirror systems are found in circuits for: – Motor – Affect – Social contagion (e.g., yawning) 222

37 Contralateral Facial Muscles and Nerves Facial Expressions

Left Hemisphere Right Hemisphere Controls expression Controls on the lower right expression on the side of face lower left side of face • Is NOT adept at reading facial • Is adept at emotion expression reading facial (e.g. alexithymics) emotion expression

Facial Expressions D Smiles • We view objects and faces with different • Guillaume Duchenne (1806-1875) systems identified the orbicularis oculi • Facial-reading systems --amygdala, muscles around the eyes fusiform gyrus, and supertemporal gyrus (Gauthier, et al, 2000) • Non-D smiles, possibly masking • Reading of faces when faces are right-side negative states and are more likely to

up, but not when faces are upside-down (Kilts, be asymmetrical et al, 2003) • When we view faces upside-down, we • D smiles -- L-PFC activation view them as objects, unable to read their emotional content • Non-D smiles -- R-PFC activation (Ekman, et al, 1996) • ASD patients read faces as if they were viewing objects

Feedforward Expressions • Therapists can model and influence the patient’s facial expressions and mood via feedforward and feedback: – Contracting muscles on the right side activates LH and positive emotions – Contracting muscles on the left side activates RH and negative

bias--e.g., a “smirk” (Schiff, et al, 1992)

38 Facial Action Coding System--FACS Microexpressions

229 230

The Therapeutic Brain The Therapeutic Brain

• Successful psychotherapy requires • Polyvagal System—Social engagement neuroplasticity system—the parasympathetic NS – States to traits • Mirror neurons and spindle cells— • Keep brain bias toward PFC and increasing empathy and emotional hippocampal vs. amygdala learning states intuition – Affect regulation -- “self”-organization • Theory of Mind—Intersubjectivity • Bumping the set point • Facial Expressions—enhancing mood • Making the DMN useful • Outcome Management—monitoring the relationship

Exercise Summary •Evolutionary imperative •Not exercising is worst than “Smokadiabesity” •Exercise boosts mood •Exercise boost cognition •Miracle grow—neurogenesis

39 Break a Fast Skipping Breakfast contributes to: ↓ problem solving ↓ working memory ↓ attention ↓ concentration ↓ energy

↑ Mood swings ↑ depression ↑ stress reactivity ↑ anxiety

Client Education Hydration Dehydration contributes to: • A bad diet will deplete your brain Brain cells shrivel up, enlarging chemistry, making your alarm ventricles system unnecessarily overactive. Brains work harder with poor results • Just skipping breakfast will cause Impaired mood you to be depressed and have less Anxiety and depression energy and ability to deal with Impaired cognition stress and anxiety. Attention Forgetfulness

Deficiencies of B Vitamins Omega 3

Low B-1 Low B-2 Low B-6 Low B-12 Folic Acid 20% of the brain is made up of essential fatty *Decreased *Trembling *Nervousness *Mental *Memory acids (EFAs) Alertness *Sluggish *Irritable slowness problems *fatigue *Tension *Depression *Confusion *Irritable One third of myelin is EFAs *Emotional *Depression *Muscle *Psychosis *Mental Instability *Eye weakness *Stammering sluggishness International Recommendations: 650 mg *Decreased problems *Headaches *Limb reaction *Stress *Muscle weakness Current American average consumption: 130 mg time Tingling The imbalanced ratio between Omega-6 and Omega-3. Increased triglycerides (vegetable oil and animal

fat) is correlated with depression (Glueck, 1998)

40 Vitamin D Amino Acids • Vitamin D receptors are located in the

cortex, hippocampus, and cerebellum: Amino Acid Neurotransmitter Effects L-Trytophan Serotonin Improves sleep and – deficiency common in older adults calmness and mood implicated in neurologic disorders. L-Glutamine GABA Decreases tension and – deficiency associated with irritability depression. L-Phenylalanine Dopamine Reduces anger and increases feelings of Associated with: pleasure • Glial cell-derived neurotrophic factor L-Phenylalanine Noreprinephrine Increases energy, feelings of pleasure, and • Nerve Growth Factor memory • Brain-Derived Neurotrophic Factor

The OFC and Serotonin Blood Sugar

• Large numbers of 5-HT receptors in the •When blood sugar (glucose) drops below 50 OFC milligrams per milliliter symptoms include: • ↓ 5-HT in OFC ↓ inhibition of the Free-floating anxiety amygdala Shakiness • Tryptophan depletion impairs reverse Lightheadedness learning tasks (Robbins & Everitt, 1995) Irritability – Ability to evaluate, integrate, and act on environmental cues Rapid heartbeat – To stop responding to something when it Difficulty concentrating becomes unhealthy and shift back to something healthier Memory problems

Glycemic load (GL) – a measure Glycation (excess glucose) of rise in blood sugar • The body’s membranes become “gunked The higher the GL of a food: up”--slowing down neural communication the greater the adverse insulin • Blocks protein from moving freely effects • Interferes with synaptic transmission Long-term consumption of foods • Causes structural damage to the with a high GL leads to a greater mitochondria (the cells’ energy factories) risk of: • Lead to free radicals Obesity • Causes inflammation. Diabetes Inflammation.

41 Advanced glycation end products trans-fatty acids can: (AGEs) • Acts as chemical glue that 1. Be absorbed directly by the nerve attaches molecules to one another membranes 2. Block the body’s ability to make its • Causes cross-linking, (like own essential fatty acids overcooked meat) 3. Alter the synthesis of • Associated with the formation of neurotransmitters such as dopamine plaque, inflammation, 4. Negatively effect the brain’s blood atherosclerosis, particularly in supply diabetes 5. Increase bad (LDL) cholesterol while decreasing good (HDL) cholesterol

trans-fatty acids

6. Increase plaque in the blood vessels 7. Increase blood clots 8. Increase triglycerides, which cause the blood to be sluggish and reduces the amount of oxygen to the brain 9. Cause excess body fat, which can have a destructive effective on the brain i.e. proimflammatory cytokines

7 Principles Common to prayer, meditation, Mindfulness and the Brain relaxation exercises, and hypnosis.

• Long-term meditators show increased thickness of the medial prefrontal cortex – 1) Breathing Rhythmically—deep, and also enlargement of the right insula deliberate, and focused breathing allows (Lazar, et al, 2005). you to slow your heart beat. • The process of verbal labeling of affective states reduces anxiety and negative affect – 2) Focused attention—to the present (Leiberman, et al, 2004) moment can transform each experience into a rich and calm experience by turning • The middle prefrontal cortex has been associated with self observation and on your brain’s brain.

mindfulness meditation (Cahn and Polich, 2006). • A shift to the left PFC which puts a

positive spin on the experience (Davidson, et al., 2003).

42 7 Principles of Relaxation 7 Principles of Relaxation

– 3) An accepting and a nonjudgmental – 5) Labeling what you experience can calm attitude shift away from rigid expectations your amygdala. that helps you appreciate reality as it is, rather than what you fear it could be. – 6) A quiet environment—This will give you an opportunity to learn how quiet your – 4) Observation—This allows you to detach mind without distractions. from bad feelings by not denying their existence. – 7) A relaxed posture—This can reduce tension include sitting in a relaxed posture or stretching (e.g. hybrid yoga)

Transcendent Awareness [email protected] www.drjohnarden.com • Mindfulness • Acceptance • Forgiveness • Gratitude • Compassion

Abbreviation Glossary Abbreviation Glossary

• 5-HT—Serotonin • IPT—Interpersonal Therapy • AAI—Adult Attachment Inventory • ISS—Infant Strange Situation • ACTH—Adrenocorticotropin Hormone • lvPFC—Lateral ventral Prefrontal Cortex • ACC—Anterior Cingulate Cortex • OFC—Orbital Frontal Cortex • BDNF—Brain Derived Neurotrophic Factor • PE—Prolonged Exposure • CPT—Cognitive Processing Therapy • NE—Norepinphrine • CRH—Corticotropin Releasing Hormone • NMDA—n-methyl-D-asparate receptors • DA—dopamine • PICs--Proinflammatory Cytokines • DLPFC—Dorsolateral Prefrontal Cortex • SAM—Situationally accessible memory • DMN—Default Mode Network • TPJ—Temporal parietal junction • EFCs—Essential Fatty Acids • VAM—Verbally accessible memory • GABA-- gamma-Aminobutyric acid • VTA—Ventral tegmental area

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IBP programs are designed to be based on the best available evidence from current scientific research. However, the interpretation of evidence-based research may vary among researchers. The views and opinions expressed in this program are those of the presenter and do not necessarily reflect the views and opinions of IBP.

Self-Test Questions Brain2Brain

1. The concept of allotasis suggests that stress: a) is bad for you. b) Represents an effective response to stressful demands c) Should be avoided d) Genes determine the limits to stress resiliency

2. The concept allostatic load describes how: a) Stress can be avoided by medication b) Stressful demands can exceed the capacities to meet those demands and begin to wear down the physiological system. c) People can shrug off stress with a stiff upper lip d) any stress can wear down the body

3. The Institute of Medicine (IOM) study on PTSD found that what therapeutic approaches are efficacious? a) Prolonged Exposure and Cognitive Processing Therapy b) Long term analysis and c) EMDR and DBT d) Gestalt Therapy and Psychodrama

4. Immediately after a traumatic event it is best to: a) Help the hippocampus code in all the memories b) Medicate heavily c) Explore the symbolic significance of the trauma d) Provide supportive therapy, education about the details of the event(s) so that the excessive traumatic memories do not get coded.

5. The memory dynamics important to integrate with clients with PTSD are: a) Implicit memory and explicit memory b) Procedural memory and declarative memory c) Flashbulb memory and procedural memory d) Flashbulb memory and autobiographical memory

6. People with panic disorder are often helped with: a) deep analysis b ) dream work c) age regression d) Interceptive exposure

7. Generalized anxiety is characterized by: a) a generally over active left prefrontal cortex b) a cool body temperature c) a craving for vanilla yogurt d) intolerance for ambiguity

8. The three neural structures involved in the OCD loop includes: a) The hypothalamus, thalamus, and fusiform gyrus b) The striatum, the orbital frontal context, and the amygdala c) The parietal lobes, temporal lobes, and the occipital lobes d) The brain stem, cerebellum, and thalamus

9. A Brain-Based Therapy approach to OCD represented by the mnemonic ORDER emphasizes: a) Overcoming, Rehearsing, Describing, Erase, and Return b) Ongoing, Repeating, Dito, Erase, and Return c) Observation, Remind, Doing something different, Exposure, and Relapse Prevention. d) Doomed, Rocked, Done, Exhausted, Ridiculous

10. What is the “workhorse” activating neurotransmitter in the brain which needs a moderate degree of activation to produce neuroplasticity? a) Oxytocin b) Serotonin c) Glutamate d) Dopamine