Trauma and Addictive Disease

5/16/2021

By Becky Georgi, MS, LCAS, LCMHC, CCS Adjunct Faculty, Dept. of Psychiatry Jeff Georgi, M.Div., CCAS, LCMHC, CGP Consulting Associate Dept. Psychiatry and School of Nursing Division of Addiction Research and Translation Duke University Medical Center Georgi Educational & Counseling Services Durham, NC

Trauma

 A major physical or emotional stressor.  These stressors may include childhood sexual or physical abuse, assault, robbery, witnessing crime, natural or man-made disasters, life threatening illness – pandemics, COVID-19, in short, any event that stresses the person beyond “normal” limits.

Other stress-induced disorders: s adjustment disorders, disinhibited social engagement disorder, reactive attachment t disorder, acute stress disorder P r T e S s D s

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The Exercise and the Brain the inverse “U”

sustained intense moderate exercise excellent not good exercise

repeated sustained some exercise better bad intense exercise

excessive no exercise very bad very bad exercise

The Stress and the Brain the inverse “U” stress and learning

sustained intense stress moderate stress excellent not good

repeated sustained some stress better bad intense stress

no stress very bad very bad excessive stress

Adverse Childhood Experiences

 Did an adult in the household ever... insult, humiliate threaten slap, grab, hit sexually abuse make you feel unloved, unworthy?

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Adverse Childhood Experiences

 In your household, did you ever... go without food, clothing, shelter witness abuse experience family separation or divorce experience substance use disorders, other forms of mental illness have anyone go to prison?

Resiliency study: center for Child resiliency Harvard University  Growing up, I was loved by my mother, father, and other people in the neighborhood.  Growing up, my parents and other relatives and friends like me and paid attention to how I felt.  Growing up, my family, teachers, coaches, neighbors and youth leaders cared about me going to school and supported my family to make life better.

Resiliency study: center for Child resiliency Harvard University

 Growing up we had rules in my house and I was expected to keep them.  If I needed help, there was always someone at home or in my neighborhood to support me.  I was supported to be an independent "go- getter" and was taught that life is what you make it.

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Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

Violence in America

3.1 million in 2017 12 or older who had been victims of violent crimes

15% of domestic violence inflicted on men 20% of women will be victims of rape during their lifetime © Georgi Educational & Counseling Services 11

Sexual Assault and Trauma Dean G. Kilpatrick, Ph.D. 2018 National Sexual Violence Resource Center

 One in five women and one in 71 men will be raped at some point in their lives.  One in three women and one in six men experienced some form of sexual violence in their lifetime.  51.1% of female victims of rape reported being raped by an intimate partner and 40.8% by an acquaintance.

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Sexual Assault and Trauma Dean G. Kilpatrick, Ph.D. National Violence Against Women Prevention Research Center

 Almost one-third (31%) of all rape victims develop PTSD at some point during their lifetime vs 10% who develop PTSD as victims of other violent crimes;  683,000 women are raped each year, approximately 211,000 will develop PTSD annually;  3.8 million adult American women have had rape-related PTSD.

Gun Violence: an American epidemic Centers for Disease Control and Prevention, 2020

There were 39,707 deaths from firearms in the U.S. in 2019.

There are approximately 115,000 non-fatal firearm injuries in the U.S. each year.

Glucocorticoid Storm generated by trauma

 Memory is impaired (excito-toxicity in cells of the hippocampus)  Prefrontal cortex slows  Amygdala takes over  Sub cortical structures increased activity  Global decrease in Serotonin  Evidence that these biological vulnerabilities can be transmitted to the next generation

EPIGENETICS (Sapolsky, 2008)

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Corpus callosum Anterior cingulate cortex

Nucleus accumbens Hypothalamus Olfactory bulbPre-frontal cortex Amygdala Hippocampus

Neurons that fire together wire together

Neurochemistry of PTSD a hypothesis

 van der Kolk’s most recent work indicates that traumatic memories are “stored” in the right hemisphere and right amygdala.  Miller and Gold’s model suggests that the increased concentration of dopamine in the ventral tegmental area and the pathways to the nucleus accumbens caused by drugs of abuse may temporarily “override” this sense of emotional numbness.

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Neurochemistry of Trauma a hypothesis

 Psychic numbing may be adaptive.  May be overridden by cocaine.  van der Kolk’s most recent work indicates that traumatic memories are “stored” in the right hemisphere and right amygdala. Any feeling can be experienced as danger.

PTSD Brain

Top down From back

amygdala Stanford Study

olfactory bulb

amygdala

hippocampus

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Neocortex

Thalamus Amygdala Amygdala Hypothalamus Hypothalamus

Timing is everything

 Trauma in early childhood, before the age of two, memories are recorded and held in the amygdala but not the neocortex.  Trauma before puberty can interfere with normal physical and emotional development.  Trauma during early adolescence will have profound social and psychological implications.

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Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

Limbic System React

emotional

survivalsurvival

amygdala

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N. Volkow Brookhaven National Laboratory

Anhedonia

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Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

Shame: the psychological piston that drives addiction

 Children have three basic psychological needs provided by "good enough parenting": Narcissistic – to be mirrored Exhibitionistic – to be seen Grandiose – to be seen as unequivocally wonderful  If these needs are not met, the child grows into an adult who sees themselves as: "less than", unworthy, empty, a fraud, not good enough.

Psychology of Addiction

Narcissistic exhibitionistic grandiose needs Ego

super ego id

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Psychology of Addiction Shame energy

Narcissistic exhibitionistic grandiose needs Ego

super ego id

Psychology of Addiction

Ego

super ego id

Psychology of Addiction

 Drugs of addiction, for the addicted, solve a fundamental structural problem within their psyche and they temporarily feel whole.  The problem is that this fix is temporary and the behaviors, the lies, and broken promises give greater energy to the shame which then requires more “medication” just to survive.

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Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

Social Isolation  We are thrust into our culture and defined by it.  We can not separate ourselves or our identity from our social context.  When we think we are “speaking” for ourselves, our personal truth is but an extension of social context.  We live in a shame-based culture.  Eventually, the shamed shame themselves.

Social Isolation

 The addiction patient may be surrounded by people, but they are relationally isolated.  The mechanisms in the brain that connect us to other people are impaired.  Over time, their drug of addiction becomes their primary relationship and love object.  People in their world become a means to use or an excuse to use.  They are alone, hidden from others by their emotional pain and shame.

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We are pack animals.

We are herd animals.

Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

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™

Spirituality

 The choosing is more important than the of the choice.  The risking is more growth producing than the “outcome” of risk.  The relating is more connecting than the relationship.  The wondering is more expansive than the object of awe.

Spirituality

 Spirituality is not defined by the content of our lives but by the experience of life’s process as we live it.  Activates the right hemisphere.

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Addiction differentially activates the right hemisphere

Biological + Psychological + Social + Spirituality Vulnerability Liability Isolation Bankruptcy Resiliency Flexibility Connection Presence

plus Trauma equals Addiction Recovery

If are patients are going to heal The neo-cortex is important, BUT

We better help them use what they “do” rather than just what they think.

We better help them be who and what they are rather than just what they know.

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Traumatic Stress and Addictive Disease : Treatment basics

 Use an integrated approach.  Support abstinence. Make it safe. Treat the symptoms.

Traumatic Stress and Addictive Disease : Treatment basics  You cannot out talk the limbic system.  Behavior changes the brain more effectively than words.  Pain is too potent a motivator for words to undo.  Medications are often necessary.  Harm reduction is an appropriate strategy.

Traumatic Stress and Addictive Disease : Treatment basics

 Traditional intervention?  Stabilize emotions often using cognitive behavioral interventions along with medications.  De-conditioning of traumatic memories.  Re-construct personal schema.  Re-connect socially and intra-personally.

 Expand emotional experiences slowly .

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High Road

 Will respond to RBT intervention.  Connected to thoughts.  Not necessarily craving related.  Has specific content.  Has physical behavior/emotional behavior/cognitive behavior aspects.  Find the self talk.

Low Road is a problem for more traditional interventions  The “feeling” comes before the thought.  Your body is ahead of your thoughts.  Pay attention to your body and learn from it.  Learn your physical cues for a craving, panic attack, rage attack or PTSD response.  Be clear that your “self talk” is not critical, cravings etc. are normal.

Traumatic Stress and Addictive

Disease : Treatment basics less traditional

 May need to move to a "somatic model.”  Use craving management techniques.  For chronic trauma the pain is too powerful for words to undo.  “The Body Keeps Score” (van der Kolk, 2014)  EMDR  Mindfulness and breathing

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Trauma and Addictive Disorders :

Treatment basics less traditional

 Yoga - movement  The importance of knowing your body  Therapeutic massage  Neuro-feedback  Psychodrama

Trauma and Addictive Disorders :

Treatment basics provide coping skills

 Wise mind - Mindfulness

Reasonable Mind Wise Emotional Mind Mind

(Linehan, 1993) 56

Trauma and Addictive Disorders :

Treatment basics provide coping skills

 Mindfulness Skills – WHAT Observe Describe Participate

Linehan, 1993

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Trauma and Addictive Disorders :

Treatment basics provide coping skills

 Mindfulness Skills – How Non-judgmentally One-mindfully Effectively

Linehan, 1993

Symptom Management measured breathing

 Select a number based on your lung capacity (usually between six and 10)  Inhale slowly to that number  Hold your breath to the same number  Exhale slowly to your number through the coffee straw or against another form of resistance  With the last number, exhale all your remaining air – the emphasis is on the exhale.

Other Breathing Exercises  Blow up a balloon until it bursts.  Blow bubbles and try and catch one bubble with another, now try three.  Breathe in normally and then breathe out to the count of one, then two, then three, etc.  Breathe into the words “slow down” and breathe out to the words “let it go” and if you can’t let it go “let it be.”

 The “funkie” Chicken (Holly Rogers)

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Taste and Smell Distractions

 Hot peppers  Candied ginger  Coffee straws dipped in cinnamon extract and dried  Cinnamon or peppermint Altoids  Wasabi Peas

Sources and further reading: Andreasen, Nancy C., Brave New Brain : Conquering Mental Illness in the Era of the Genome, Oxford Press, New York, 2003. Behrens, Alan and Satterfield, Kristin: “Report of Findings from a Multi-Center Study of Youth Outcomes in Private Residential Treatment”, presented At the 114th Annual Convention of the American Psychological Association, New Orleans, Louisiana, August 12, 2006. Brizendine, Louunn, The Female Brain, Random House, Inc., New York, New York, 2006. Damasio, Antonio, Descartes’ Error: Emotion, Reason, and the Human Brain, Penguin Books, London, 2004. Goleman, Daniel, Emotional Intelligence, why it can matter more than IQ, Bantam Books, New York, NY, 1998. Goleman, Daniel, Social Intelligence: the revolutionary new science of human relationships, Bantam Books 2006. Kohut, Heinz, The Analysis of the Self, International Universities Press, New York, New York, 1971. Kohut, Heinz, The Restoration of the Self, International Universities Press, New York, New York 1977. Kou, Francis E., and Taylor, Andrea Faber, “A Potential Natural Treatment for Attention Deficit/Hyperactivity Disorder: Evidence from a National Study”, American Journal Of Public Health, September 2004; 94: 1580 – 1586. LeDoux, Joseph, The Synaptic Self: How Our Brains Become Who We Are, Viking Penguin, New York, NY, 2002. LeDoux, Joseph, The Emotional Brain: the Mysterious Underpinnings of Emotional Life, Viking Penguin, New York, NY, 1999. Lewis, Thomas, A General Theory of Love, Vintage Press, New York, NY 2001 Pert, Candice B., Molecules of Emotions: the Science behind Mind-Body Medicine, Scribner, New York, NY, 1997. Porges, Stephen, The Polyvagal Theory, Neurophysiological Foundations of Emotions, Attachment, Communication and Self-regualtion, WW Norton, YN, NY 2011 Nathanson, Donald L., Shame and Pride: affect, sex, and the birth of the self, WW Norton & Co., New York, New York, 1992. Van der Kolk, Bessel, The Body Keeps Score: Brain, Mind and Body in the Healing of Trauma, Viking, New York, New York, 2014 White, Aaron, Keeping Adolescence Healthy, BookSurge Publishing, Charleston, SC, 2008