Cognitive Behavioral Therapy as taught by Professor Jason M. Satterfield Part I

This is the second course I’ve been taking from The Great Courses. It is Cognitive Behavioral Therapy: Techniques for Retraining Your Brain by Professor Jason M. Satterfield. Since CBT principles are what SMART Recovery is based on I thought it would behoove me to take the course. This first entry will have 4 out of the 24 lectures in the course. It gives the basics of CBT including the “Third-Wave” of CBT. The next several lectures deal with  specific diagnosis and how CBT deals with them. For a list of the lectures click here.

I found the topic as presented difficult to understand. Professor Satterfield shifted between didactic teaching and case presentations. Although, with effort, by the end of the fourth lecture I had a clear understanding of what CBT is and how it differs from traditional psychotherapy. I hope this summery is helpful.

Cognitive Behavioral Therapy: Techniques for Retraining Your Brain

Course by Professor Jason M. Satterfield

University of California, San Francisco

Course in 24 lectures

Lecture 1: Cognitive Behavioral Foundations

The Professor introduces the course with stating the goals. The goal of the course is to present the science of how we change. If there are things we can’t change we can learn things to lessen suffering and improve the quality of your life. Another goal is to give the student a toolbox of evidence based strategies you can use whenever you need them.

He also introduces us to three people who will be his case study subjects in the lectures.

1) Carol, 30 year old woman who has anxiety, especially in social situations. This impacts her personal and work life in a negative manner.

2) Michael, 50 year old male, normally kind but prone to angry outbursts.

3) Maria, 70 year old woman. Under a lot of stress due to taking care of a husband with dementia. The stress has led to depression and anxiety.

The lecture goes on talking about change. What can and cannot be changed. For instance, our degree of introversion versus extroversion may be difficult or impossible to change but we can all be taught to improve our social skills. He mentions a study that compared functional MRI (fMRI) of the brain for treating depression. One treatment used Cognitive Behavioral Therapy (CBT) and another used Paxil psychopharmacology. Both groups had improvement in their depression but the CBT group showed changes in their hippocampus and the Paxil group showed changes in their prefrontal cortex. Why they had different responses is unclear but the main point is that CBT can change your brain.

So we can say that therapy can change your brain in positive ways. There are some non specific factors such as empathy from the therapist and the therapeutic alliance. Social support from groups can help also. Even SMART Recovery groups can help!

Introduction to Cognitive Behavioral Therapy

Cognition – All our mental activity.

CBT Triangle

Top of triangle – Thoughts

Other 2 corners are Behavior and Emotions

The 3 corners of the triangle all influence each other. The emotion anxiety will influence thoughts, like I’m afraid of social situations and your behavior such as I’m staying home instead of going to a party. If you accept some discomfort and get out of your comfort zone and go to the party your behavior may eventually effect your emotions by getting less anxious in social situations.

Special Features of the Cognitive Behavioral Therapy process

1) CBT is collaborative and transparent. Collaborative in that the patient and therapist work together in a partnership. They collect data on what their problems are. They agree on a formulation of the problems and develop a treatment plan. Transparent in that it’s all done above board. No hidden agendas.

2) CBT is empirical. A hypothesis is developed about why you may be anxious or depressed but that can change as therapy progresses and new things are learned.

3) CBT is time limited. Depending on individual but usually 12 to 24 sessions.

4) Skills focused. Teach behaviors that address the problems.

5) Symptom focused. Monitor how changing your behavior impacts your original symptoms.

6) Focused on the present. Delving into the past generally not done extensively.

Since this is recorded and a Q and A session at the end of the lecture isn’t available Dr Satterfield offers the FAQs. Questions that he’s frequently asked when presenting this material.

FAQ 1 – It sounds like you are asking us to not go with our gut, or to downplay our emotions.

Answer 1 – CBT asks you to have more of a balance. We need our passions and emotions but when things get out of balance and our lives are getting out of control we may need to appeal to our rational mind to get us back in control. An out of control life can result in great emotional suffering.

FAQ 2 – Why did you become a CBT therapist?

Answer 2 – I started in the neurosciences at MIT. I later got hooked on how the neurosciences impacted people and decided to go the psychology route.

FAQ 3 – The CBT triangle seems too simple.

Answer 3 – The triangle is simplistic but it is just scratching the surface of psychological behaviors.

Lecture 2: Quantified Self-Assessment for Therapy

Lecture starts with a little history. Aaron T. Beck is the father of CBT. In the 1960s he became frustrated with psychoanalysis in a group of depressed patients he was treating.

There were some roots of CBT in ancient philosophy. Socratic questioning, in which the person is not told the answer but asked a series of questions to arrive at the answer themselves. Epictetus postulated that “Men are disturbed, not by things, but by the principles and notions which they form concerning things.”

Albert Ellis was already writing about REBT, Rational Emotive Behavior Therapy. This was very influential to Beck. CBT formally started when Beck and others published Cognitive Therapy of Depression in 1979.

Theory of CBT.

How does CBT explain emotions, suffering, mental illness? How does CBT explain individual variations? Does the theory hold for everyone? To answer these questions remember we are looking at 3 key variables, the CBT triangle, cognition, behavior, emotions. We want to engage these 3 variables in 3 ways.

1) Detection, data gathering

2) Analysis and evaluation

3) Challenging or changing those cognitions, behaviors and emotions.

This is just the surface of the therapy. The job of the CBT therapist is to delve deeper into the reasons and motivations of the client. Classic psychotherapy starts at the bottom, looking at early development, unconscious motivations etc. and works it’s way up. Hopefully these insights will help the client improve their behavior. CBT is the opposite. It starts at the top, focusing on current problematic behaviors and setting behavioral goals to strive for. Eventually deeper insights are gained as therapy progresses.

CBT will start with a Case Formulation and Assessment. Data can be gathered by interview, questionnaires, diaries, social and medical histories etc.

The lecturer then goes into an example with Maria, the elderly woman caring for her husband. She filled out several questionnaires. He points out that repeating these questionnaires later in therapy can give us a measure to show progress. This assessment shows she is at the border between moderate and severe depression. She has physical symptoms like anorexia, insomnia fatigue, aches and pains. She is also on the lower end of the moderately anxious. He points out that treatment of depression and anxiety will be part of the goals set up for her.

For an alternate perspective on Case Formulation he turned to Michael as an example. Michael is prone to anger outbursts and for him self monitoring, diary keeping were more helpful. He is asked to keep a diary noting emotions throughout the day.

He now talks to Carol about setting some SMART goals. Carol has difficulty with sleep, shyness and relationships. SMART Goals are Specific, Measurable, Attainable, Relevant, Timely. Carol uses the example of poor sleeping.

Specific – Go from 5 hours of sleep a night to 7 hours.

Measurable – She’ll do a sleep diary

Attainable – She thinks this is possible

Relevant – Definitely a goal she want to achieve

Timely – Needed for her increase the quality of her life.

Lecture 3: Setting Therapeutic Goals

In lecture two we described how we get a case formulation based on the data we’ve collected. Case formulation is defined as an individualized theory that explains a particular patients symptoms and problems. It serves as a basis for an individuals treatment plan and guides the therapy process. A formulation is always a work in progress. It can change as new data is taken in and as therapy progresses. The formulation is always transparent between patient and therapist.

Key Elements of a Case Formulation

1) First we need a problem list or diagnosis.

2) Second we’ll develop a working hypothesis. Four elements needed for a working hypothesis.

  1. a) Cognition and deeper cognitive structures. (Beck’s cognitive model.)
  2. b) Behaviors with attendant punishments and rewards.
  3. c) Origins – Early learning, family issues.
  4. d) Lastly – Tie it all together and create a summary to tell a story.

3) Third key is to focus on the patient’s strengths and weaknesses.

4) Fourth is to create a treatment plan based on our hypothesis, strengths and weaknesses and goals.

Now lets look at our patients: Maria has a problem list that includes problems with relationships with her husband and daughters, emotional issues like depression, stress, anxiety and some physical symptoms like aches and pains. She has a working diagnosis of major depression. Michael has conflicts with his wife and son. Also conflicts with coworkers, some friends and neighbors. He also has hypertension and high cholesterol. Emotionally he has anger outbursts. No formal psychiatric diagnosis.

Next we are going to work on developing a working diagnosis. At this point we need to understand Beck’s cognitive model. Activating events can cause automatic thoughts. However, different people have different automatic thoughts for the same event. Beck believed people follow scripts or schemas based on our core beliefs. These scripts give rise to our automatic thoughts.

Interviewing Michael Dr Satterfield determines he has strong beliefs of fairness and personal responsibility. He’s a hard working perfectionist and wants to control situations around him. Next we will evaluate his behavior based on these beliefs. He is quick to anger when he perceives others are being unfair or irresponsible. We will also consider where he learned these beliefs from his past.

Lecture 4: Third-Wave Cognitive Behavioral Therapy

A little history: First wave is early Freudian psychology. Looking at the subconscious, dream interpretation etc. Therapists are always looking for deeper meanings in what is said and how we behave. Second wave is cognitive model or CBT as presented thus far in this course. We react to events or have automatic thoughts that are provoked.

Cognitive model assumes we are not very rational. We often misinterpret events. We minimize or awfulize. All or none thinking. Mind reading, assuming what other people are thinking. Fortune telling. Example, if you’re depressed you are probably assuming bad outcomes. Over-personalize “I know it’s about me.”

He then goes through an example of use of the ABCs to unpack an event with Marie, who went out to do errands and left her husband with a caretaker. The Activating event is going out to do errands. The Beliefs are she was dwelling on feeling guilty for not taking care of her husband. The caretaker doesn’t understand him. Something might happen to him while she’s gone. Consequences are guilt, depression and she skipped a trip to Starbucks where she wanted to get a treat. To Dispute the belief that something might happen to him he asks her to bring up an example of what would she tell a friend she was out with who was worried about a daughter. She reminds herself that he is with a caretaker.

Third-Wave CBT

Third-wave therapy distinguishes itself from the other two by focusing on the process of cognition rather than the content of cognition. Acceptance and Commitment Therapy, ACT, teaches people to accept their thoughts rather than trying to control them. He then throws out the acronym FEAR to highlight our negative reactions to events.

     Fusion with your thoughts. Our irrational thinking is our identity.

     Evaluation of experience in the negative filters of our irrational beliefs.

     Avoidance of experience. Our dysfunctional reaction to the experience.

     Reason or rationalization for your dysfunctional behavior.

The healthy alternative is to, you guessed it, another acronym, ACT.

     Accept your reactions.

     Choose a valued or appropriate direction.

     Take action to go towards your appropriate behavior.

 

ACT has six core principles.

1) Cognitive diffusion. Learning methods to reduce the tendency to think our thoughts are our identity.

2) Acceptance of our thoughts and letting them come and go without struggling with them.

3) Contact with the here and now. Don’t struggle with thoughts of the past and future. Mindfulness.

4) Accessing the transcendent self. The core of who you are despite surrounding events and the jumble of thoughts coming and going.

5) Values. Keeping aware of what values are important to you and your identity.

6) Committed action. Setting goals according to values and carrying them out responsibly.

The lecturer then makes a brief mention of MBCT. Mindfulness Based Cognitive Therapy. There are times to let the thought storm blow in and be accepted and then let it go without struggle. He discusses the problem with Michael who has anger outbursts. A useful strategy may be to let the anger thought storm come and go without acting on it.

The Addictive Brain as taught by Professor Thad A. Polk Part V

This is the final post of the review of The Addictive Brain. Please see part one dated 12/5/2016 and scroll upwards for the subsequent parts. The last two lectures covers the controversial subjects of behavioral addictions.

Lecture 11: The Gambler’s Brain

Gambling behavior often mimics drug addiction behavior. Obsession to gamble despite severe personal and social consequences. A very high percentage of people have experienced gambling but the vast majority don’t develop problems. 4 – 6 million americans experience problems due to gambling. About 2 million meet criteria for pathological gambling. The 5th edition of the Diagnostic and Statistical Manual, the bible of psychiatry, classified pathological gambling along with the behavioral addictions. Was classified as impulse control problem such as kleptomania in older editions.

Behavioral similarities to drug addictions:

1) Recurrent substance use, or gambling resulting in failure to perform major role responsibilities at work, school or home.

2) Jeopardized or lost a major relationship or job or career opportunity due to gambling.

3) Persistent desire or unsuccessful efforts to cut back, stop or control gambling behavior.

4) Continued gambling despite significant negative consequences.

In a sense tolerance develops to gambling. The problem gambler often needs to wager larger amounts or go for larger jackpots to get the same rush of excitement he used to get with gambling smaller amounts. They do have symptoms with withdrawal. 91% of problem gamblers experience craving upon withdrawal. 87% feel restless and irritable. 2/3 of people reported physical symptoms like headache, insomnia, shaking and sweating.

Brain changes in addiction to drugs are mirrored in gamblers brains:

1) Numbing in the Nucleus Accumbens so things besides gambling don’t give pleasure.

2) Large releases of dopamine in the reward circuits of the brain. Eventually leads to cravings and triggers.

3) Chronic use results in reduced self control in the prefrontal cortex.

Twin studies show that problem gambling are heritable. Problem gamblers often have alcoholism.

Some of the same approaches in drug addiction are helpful in gambling addiction. CBT and social support like 12 step groups help. Naltrexone effective in reducing gambling behavior.

Lecture 12: Junk Food, Porn, Video Games – Addictions?

Dr Polk starts by reminding us of the shared characteristics of addiction. Genetic susceptibility of some. Similar patterns of neural rewards and reinforcements. Continued addictive behavior despite significant negative consequences. In this lecture he wants to talk about 3 behaviors that people seem to pursue compulsively: Junk Food, Pornography and Video Games.

This is a grey area and scientists don’t all agree these behaviors constitute a true addiction. It is safe to say that many people do have trouble with these behaviors to the point of it adversely affecting their lives.

It’s important to understand the concept of supernormal stimuli. We are naturally attracted to sweet foods. In nature they are found in fruits. When you refine sugar and make “super sweet” desserts we naturally are attracted to the supernormal sweet. Intense sweet foods that don’t exist in nature. You can make the point that all three of the above are supernormal stimuli. Our reward circuits were evolved to give us pleasure in eating natural sweets so they are super stimulated by the supernormal sweets.

The same logic applies to sex. We are highly motivated to seek the pleasure of sex but sexually provocative stimuli in the natural environment is rare. Porn and sexually provocative stimuli are now common.

Video games have progressed a lot since Pong. We now have sophisticated graphics and gamers get immersed in elaborate fantasy worlds. It’s also big business. In the first 3 days the latest Grand Theft Auto made over a billion dollars. There is a scientific consensus that video gaming can become compulsive in some individuals. One study showed that about 8% of a study group had pathological gaming. Gaming that was causing problems and interfering with their life.

Michael Astolfi, a video game designer, wrote a thesis at NYU claiming video games have stimuli that are supernormal. Mainly that we may have evolved to be hunters and video games overstimulate our hunting instincts. Many of the popular games are first person shooter games. In real hunting you maybe take a shot once in a day or so. With video games you take shots every second or two or even more rapidly. Thus getting your reward system over stimulated.

Neuroscience studies for behavioral compulsions are in their infancy but the lecturer points out that some studies have shown that these behaviors increase dopamine in the brain reward circuits. Even the pattern of the reward centers getting numbed to chronic stimulation from these behaviors is present.

For treatment the individual has to recognize that they have a problem and want to improve their behavior. Cognitive behavioral strategies help along with social support networks.

Epilogue:

Dr Polk then did a couple of minutes of summary of some points.

1) Addiction is defined as the continuation of a behavior despite significant consequences. Characterized by abuse, physical dependance and a pathological craving.

2) Some people are genetically more susceptible to addiction. There is not a single addiction gene. There seems to be a large number of genes involved and just because someone is susceptible doesn’t mean they will become an addict.

3) The brains of an addict are different from the times before they started using or drinking. The reward system has been hijacked and rewired to produce pathological craving, numbing of the reward centers and weakening inhibitory self control.

Understanding the biological basis of addiction helps us understand the seemingly incomprehensible behavior of some addicts such as the alcoholic with cirrhosis continuing to drink. Also understanding this helps us approach the addict with compassion and understanding instead of judgement and criticism.

 

 

The Addictive Brain as taught by Professor Thad A. Polk Part IV

Fourth in my series of the review of The Addictive Brain. Please see part one dated 12/5/2016 then part two dated 12/20/2015 and yesterdays’s post if you haven’t read them yet. These 2 lectures cover the “hard” drugs, stimulants and opiates.

Lecture 9: Stimulants – From Cocaine to Ritalin

Cocaine was the first stimulant isolated from the coca plant. Originally used in Coca Cola.

Coca leaves have been chewed for the effect for hundreds of years. Isolated and used in high concentrations in the mid 1800s. Cocaine powder is a salt. More properly called cocaine hydrochloride. In the mid 1970s people began to separate the salt and started using free basing. Crack cocaine is also the free base. You can smoke the free base but not the hydrochloride salt form. This causes a very intense high with a high likelihood of abuse.

Amphetamine and methamphetamine are derived from the Ephedra plant. In the late 1800s chemists isolated and learned to synthesize amphetamine from the plant. Methamphetamine was synthesized a little later and found to me more effective as a psychostimulant. These meds were commonly used by the military in the 40s and later widely used as diet pills.

The most widely used psychostimulants now are Ritalin and Adderal. Both are used for treatment of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder. ADD and ADHD respectively, Low doses of these medication can help increase focus for these disorders. Doses are lower than those needed for a euphoric high. Methamphetamine is the most commonly abused illegal form of amphetamine.

Main positive effects of psychostimulants are increased alertness, decreased fatigue and euphoria. Adverse effects can be disastrous. Young people have had strokes and heart attacks and even sudden death from these drugs. Chronic stimulant use can lead to psychosis and paranoia. They can repeatedly pick or scratch at insects they imagine are crawling under their skin. “Meth Mouth” can occur with multiple cavities, loss of teeth and gum inflammation. Felt to be due to decreased salivation during meth use, stimulant effects leave to teeth grinding, also meth addicts often stop seeing dentists and have poor oral hygiene.

How do psychostimulants effect the brain? All psychostimulants directly increase the amounts of dopamine in the brain. Dopamine release is associated with all addictive drugs and the stimulants are very effective at this. Dopamine also stimulates the brain reward center. Stimulants also increase the levels of norepinephrine. This is what causes increased blood pressure and inability to sleep. The stimulants are some of the most addictive drugs known. Often these drugs are used in binging patterns. Unable to stop until the drugs are gone or you collapse from exhaustion. Addicted people can have intense cravings and associations with triggers.

Treatments are behavioral in nature. Cognitive behavioral therapy is helpful. Community based support programs or meetings are helpful. High relapse rates for stimulant addiction. No pharmacological treatments approved at this time.

Lecture 10: The Science of Poppies, Pleasure and Pain

The opiates are derived from the Poppy plant. Opium is derived from latex. In botanical terms a latex is a secretion produced from a plant that has an injury to it. The latex can cover the wound and protect against insects that try to eat the injured plant. Opium can be modified to form many different drugs called opioids. Opioids include morphine, codeine and heroin. There are many others. Opioids are characterized as being able to produce a dreamlike euphoria in their users.

Opium has been used since ancient times. Sumerians used it and called it Joy Plant. Ancient Egyptians used it. In the 17 and 1800s a mixture of opium and alcohol called laudanum was very popular. Used as a pain reliever and sleep aid. In 1804 morphine was isolated from opium. Named after Morpheus, the Greek god of dreams. Morphine became an invaluable tool in medicine for pain relief. It was used liberally in the Civil War and many Civil War veterans became addicted. It was called “Soldiers Disease”. In 1898 Bayer started marketing a drug they said was 2.5 times stronger than morphine. It was said to be non addictive and used for pain and cough suppression. The name of this drug – heroin.

Many opioids are marketed currently. Vicodin, Percocet, Methadone, Codeine, Oxycontin etc. Very effective for pain but also very addictive. They cause a dreamlike euphoria that rewards the user. Also can cause nausea and constipation. Opioids that don’t effect the brain are used as cough suppressants and anti diarrheal agents. Most dangerous side effect is suppression of breathing. Overdoses cause people to die because they stop treating.

The brain has several opioid receptors but the one that seems to cause the effects that lead to its uses and abuses are the mu receptors. Mu receptors are found in high concentration in areas of the brain associated with pain perception and with the reward circuits especially in the nucleus accumbens. The endogenous chemicals for the opioid receptors were eventually found. 3 types of chemicals were found, the dinorphins, enkephalins and endorphins. Endorphins are found in the brain. The name itself is a shortening of endogenous morphine. Endorphins are released in response to pain to help coping with the pain but can also be released with exercise – hence the term “runners high”.

How do opioids work? They mainly work by inhibiting the transmission of neural signals. The body has an elaborate system of pain receptors and nerve fibers to conduct those signals. Opioids work by inhibiting those transmissions. They work in the spinal cord and centrally. The placebo effect is also felt to be related to the release of endogenous opioids. Placebo effect can be blocked by naltrexone, an opioid antagonist. The high of opioids is from stimulation of the reward centers in the brain.

The health effects of opioid addiction are not due to the toxicity of the drug itself, like in alcohol. The health consequences are due to the behavioral changes associated with the addiction. Addicts often neglect personal hygiene and nutrition as their lives get consumed by pursuing the addiction. They use dirty needles to use the drugs. There is a narrow gap between a euphoric high and an overdose, so overdose is common.

Recent survey reports over 5 million americans have used, illegally, opioids in the past month. This includes prescription abuse of opioids. Over 92 thousand ER visits in a single year from opioid overdose. About 45 people a day die from prescription opioids. More than heroin and cocaine overdoses combined.

Opioids cause addiction much like other drugs. They overstimulate the reward centers and cause a large release of dopamine. Opioids inhibit the neurons that inhibit the VTA so they have a strong addiction potential.

Treatment for overdose is naloxone. A drug that has a high affinity for opioid receptors but doesn’t activate them. Thus other opioids don’t bind to the receptors and activate them.

To treat the addict first you must detox them. The withdrawal is very unpleasant. Methadone maintenance can be helpful. Naltrexone is an opioid antagonist that can be taken orally or in time release injection form. It blocks the opioid receptors so if someone in treatment relapses and takes an opioid it doesn’t result in getting high. Suboxone is a partial agonist, antagonist that can ameliorate withdrawal. Cognitive behavioral techniques and community meetings and support help.

The last 2 lectures in this series covers the behavioral addictions, food, gambling etc.

The Addictive Brain as taught by Professor Thad A. Polk Part III

Third in my series of the review of The Addictive Brain. Please see part one dated 12/5/2016 then part two dated 12/20/2015 if you haven’t read them yet. These 2 lectures cover alcohol and marijuana.

Lecture 7: Alcohol, Social Lubricant or Drug of Abuse?

The title makes the point that alcohol is regarded as a social lubricant. It’s legal, considered mandatory at most parties and many social functions and many people feel pressured to partake of alcohol in these social situations.

It turns out that alcohol behaves like many other drugs in that it binds to neurotransmitter sites and effects changes in their function. Alcohol binds to multiple sites to cause many different effects. One mentioned is that it binds to sites involved with learning and memory. This may explain why some people can “black out” drink and have no memory of what happened. There is also cross reactivity to the barbiturate class of drugs. People who have tolerance built up against barbiturates also have tolerance against alcohol. It takes them more drinks to get drunk. Another mechanism of tolerance is that alcohol induces your liver and GI tract to make more enzymes to break down the alcohol.

There are compensatory changes in the brain as a result of chronic alcohol exposure. Since alcohol is a depressant the brain compensates by becoming excitable. So with alcohol withdrawal you have excess excitability such as tremors and even seizures. Alcohol withdrawal is one of the most dangerous drug withdrawals. So alcohol behaves like a drug of abuse with respect to effecting neurotransmitters and in developing tolerance and withdrawal symptoms when withheld.

Now lets look at its addictiveness. Alcohol causes dopamine release in the Nucleus Accumbens so the reward center is stimulated. It also is associated with triggers that produce craving similar to drugs of abuse. Genetic factors also play a role in susceptibility to addiction to alcohol.

Treating alcohol addiction. First, detox. Sometimes substitutes such as valium are prescribed. Next comes psychosocial methods like rehab or group participation. Some medications can help. Such as disulfiram, (Antabuse). This makes it very unpleasant to drink. Naltrexone inhibits pleasure response of alcohol and can be useful. Acamprosate is a drug that seems to blunt the effect of alcohol. Said to be as effective as naltrexone in aiding abstaining from alcohol.

Lecture 8: The Science of Marijuana

The psychoactive chemicals in marijuana are called cannabinoids. The main psychoactive compound, isolated in 1964 is called Delta-9-Tetrahydrocannibinol (THC). In 1988 scientists found cannabinoid receptors in the brain. 2 main types of receptors were found, CB1 and CB2. The CB1 receptors in the brain are the receptors that result in it’s effects. After finding the receptors scientists looked for the natural neurotransmitters that bind to these receptors. In 1992 they found anandamide and later some others. These are called endogenous cannabinoids or endocannibinoids, meaning they are produced from within. THC would then be considered an exogenous cannabinoid or exocannibinoid, meaning produced externally.

Two important characteristics about endocannibinoids is that they are not stored in neurons but made as needed. Almost all neurotransmitters are made and stored in neurons and released when needed. They other important characteristic is that they seem to function as retrograde messengers. In other words, the cannabinoid receptors are on the neuron that is behind it in the chain of neuronal signals. This functions in regulating the functions of the presynaptic cell. It can prevent the presynaptic neuron from over firing.

There is evidence that this plays a role in forgetting things. For instance if you parked your car in a certain spot today you need to forget where you parked it yesterday so it won’t interfere with finding the car today. Genetically engineered mice that lack cannabinoid receptors can be trained to find food in a certain spot but they can’t unlearn it if you start placing the food in a new spot. Hence they will starve until you put food in the old spot. This can lead to some benefits in people with PTSD who have intense memories of past events that interfere with their present life. Also some people with PTSD seem to have less than average amounts of anandamide. This can also explain why heavy marijuana users often report memory problems and may interfere with learning.

Cannabinoid receptors are found in multiple areas of the brain including the reward centers. Users report multiple effects. Euphoria, exhilaration, inability to control laughter and laughing at things that aren’t funny. Increased appetite is common. Many report enhanced visual and auditory perception. May feel relaxed or calm. Time perception can be affected. Sometimes it can cause anxiety and paranoia. Also disorganized thoughts and impulsive behavior.

Some medical uses include reducing nausea and increasing appetite. Useful in patients on chemotherapy for cancer or who have AIDS. Can be helpful in pain management, especially when other medications have failed. May inhibit certain types of tumors.

Marijuana is the most widely used illegal drug in the world. 17 Million americans have used marijuana in the past month and 3 million are daily users. Most start in adolescence. 1/3 high school students have tried marijuana. About 9% of people who have tried marijuana become addicted. For alcohol that number is 15% and for cocaine it’s about 17% so you can say marijuana is less addicting than those drugs. The worst offender was nicotine at 32%. Marijuana stimulates the reward center in the brain and can result in addiction similar to other drugs.

People who are addicted do have withdrawal symptoms such as irritability, intense craving, anxiety, depression and reduced appetite. Evidence of tolerance is less clear. Most regular users report that they don’t need more drug to get the same high as they had in the past.

Effects of long term use are controversial. Regular marijuana use is correlated with poor academic achievement. It’s unclear if this is because there are social factors that correlate with poor academic achievement and these social factors lead to marijuana use. There also seems to be a correlation with what’s called an amotivational syndrome. People who are passive and have low motivation for accomplishment or productivity. Again correlation may not necessarily mean causation. It just might be people who are poorly motivated may be the ones more likely to choose marijuana. There is another correlation with people who later use hard drugs but most researchers do not consider marijuana a gateway drug. It’s just people who chose one drug are more likely to choose other drugs.

Long term health effects are insignificant. People who smoke marijuana generally smoke much less than the average cigarette smoker so the lung damaging effect are less over time.

Treatment is mainly behavioral. Cognitive behavioral therapy, support groups etc are the mainstay of treatment.

The next two lectures will cover the “hard drugs”. The stimulants and opiates.

Affinity Fraud

I learned a term the other day that got me to thinking about recovery meetings. Here’s an extensive quote about the term Affinity Fraud.

“Affinity fraud refers to investment scams that prey upon members of identifiable groups, such as religious or ethnic communities, the elderly or professional groups. The fraudsters who promote affinity scams frequently are – or pretend to be – members of the group. They often enlist respected community or religious leaders from within the group to spread the word about the scheme by convincing those people that a fraudulent investment is legitimate and worthwhile. Many times, those leaders become unwitting victims of the fraudster’s ruse.

These scams exploit the trust and friendship that exist in groups of people who have something in common. Because of the tight-knit structure of many groups, it can be difficult for regulators or law enforcement officials to detect an affinity scam. Victims often fail to notify authorities or pursue their legal remedies and instead try to work things out within the group. This is particularly true where the fraudsters have used respected community or religious leaders to convince others to join the investment.”

In my opinion recovery groups, be they SMART or 12 step, are groups that people perceive as being there for mutual help and support. As such they may be more fertile ground for sexual predators or con artists. Over the years I have seen people robbed by people who trusted other group members, often with no other experience with the person other than they met in a recovery group. The history of sexual predation in recovery groups is well known. Recovery rooms have more than their fair share of people with criminal history. Often people are there with no interest in recovery but are on a court card. Add to that that newcomers may be particularly vulnerable.

For the group I facilitate I occasionally mention that we are here for mutual support but to keep a normal level of skepticism for new relationships. Treat the group as you would if it were an adult education class. You’re there with a mixture of young and old with the purpose of learning a subject. You may benefit from outside relationships with classmates such as study groups etc, but you don’t give them your house keys until you have extensive experience with them.

The Addictive Brain as taught by Professor Thad A. Polk Part II

This is a continuation of the blog started on December 5th. Summaries of the 4th – 6th lectures are presented here. Please read the blog from the 5th first if you haven’t read them yet.

Lecture 4: Genetics—Born to Be an Addict?

In this lecture much detail in genetics and various scientific studies discussed. This much detail not needed to understand the basic points.

1.  Some people more at risk of addiction than others due to genetic susceptibility. Genetic susceptibility does not mean that they will become addicted. Nor does it mean if they do become addicted they can’t recover.

2.  Many genes are involved in inheriting the genetic susceptibility.

3.  Many of the genes contribute to the susceptibility of addiction to a variety of substances.

4.  Scientists are learning more about what the different genes are doing and may allow for tailoring of treatments. For instance, some people are more likely to be helped by naltrexone than others depending on their genetic makeup.

Lecture 5: Your Brain on Drugs

This lecture focuses on 3 questions, first is how can drugs cause pleasant sensations or change our mood. next is how are some drugs more potent than others and last, how do we get dependent on drugs.

To understand how drugs work the lecture starts out with a basic explanation of how neurons work. Neurons communicate by means of what is called neurotransmitters. Chemicals that activate neuronal signals. Serotonin and dopamine are examples. Neurons communicate by releasing neurotransmitters and nearby neurons have neurotransmitter receptor sites. An analogy is made that neurotransmitters and receptors have a lock and key arrangement. Certain receptors are only activated by certain neurotransmitters.

Question 1) How do psychoactive drugs produce psychological effects? Psychoactive drugs imitate natural neurotransmitters. They act as a key to activate neurons. The more drugs in the brain, the more stimulation of receptors.

Question 2) Why are some drugs stronger than others? Has to do with affinity. – How well the key fits in the lock. If the drug fits well in the receptor, the more neuronal stimulation will occur. He then defines two terms, agonist and antagonist. An agonist is a chemical that binds to a receptor and activates it. The key fits and activated the neuron. An antagonist is a chemical that binds to the receptor but doesn’t activate it. The key fits but doesn’t activate the neuron. Naltrexone is a drug that binds to receptors but doesn’t activate the neuron and also blocks the drug that normally activates the cell.

Question 3) How can someone get dependent of drugs? One mechanism is that as your brain is repeatedly exposed to drugs your brain will compensate by making less receptors available for stimulation. Hence you will need larger doses for the same effect.

Lecture 6: Coffee and Cigarettes

The next several lectures focuses on specific drugs and how they work and possible treatments. He starts with two common and legal drugs, caffeine and nicotine.

Caffeine – Works by being an antagonist of adenosine. Binds to adenosine receptors but doesn’t active the neurons. Adenosine is inhibitor of neural activity, therefore your brain is a little more alert. People do develop a tolerance and can have withdrawal symptoms such as headache. Little medical consequences. Not highly addictive.

Nicotine – Smoking is responsible for dopamine release in the VTA. (Ventral Tegmental Area as discussed in lecture 3.) Hence it is one of the most addictive substances known. Smoking causes mild psychological effects similar to caffeine but has unfortunate health consequences. There are some options for medically assisted therapy for quitting smoking. One is nicotine replacement like patches or gum. Behavioral therapy for avoiding triggers and coping with urges. Verinicline (Chantix) is a partial agonist of nicotine and can lessen withdrawal symptoms.

The 13th Step

The 13th Step

A Film by Monica Richardson

a Review by Steve Bergier

This documentary on the well established phenomenon of sexual predation in the rooms of AA was ultimately inspired by the murder of Karla Mendez Brada. She was killed in a domestic violence incident in Santa Clarita in 2011. Killed by a man she met in AA.

The filmmaker documents numerous anecdotes of rape and abuse in AA, including larceny and pedophilia. They make the point that many people are forced by the courts to attend AA. People with criminal records and some not even having alcohol problems. These people are mixed in with newcomers that may be desperate for help and acceptance and are vulnerable to predators. They also point out that many AA old-timers are 13th step predators. Another point that the filmmaker attests is that AA is very resistant to doing anything about it. She is literally kicked out of the world service office while trying to talk to officials there. The effect is to make you feel that the rooms of AA are very unsafe.

AA cooperates with the law and a valid point is that along with people with alcohol problems, other criminals, without alcohol problems are put on court cards. The courts seem to rely on AA for giving parolees a way to document compliance with conditions of parole. Many are not problem drinkers or if they are, are not interested in sobriety. The rooms of AA may just give them a fertile playground to ply their craft. Perhaps a more judicious use of court cards could help with this problem.

It would be daunting for AA to attempt to ban people from coming to meetings. It’s a program open to all and the groups function autonomously. Over a decade ago AA in the UK and Australia adapted a code of conduct with a moral imperative to call out inappropriate behavior. AA in America voted down a similar proposal in 2009. – Not a good move.(1)

The movie also spends a lot of time pointing out the ineffectiveness of 12 step recovery. Jim Christopher, who founded SOS, Tom Horvath, president of SMART Recovery and Stanton Peele, long time critic of 12 step, along with others make appearances in the film. The point being that people are being put in a program ostensibly to help them but it’s ineffective. Then members may be placed in harms way. Sexual predation and harassment could happen with any program and isn’t unique to AA. However, they point out that the AA philosophy of turning it over to a higher power and not resisting the counsel of others with more sobriety can play into newcomers vulnerability. Many people come to recovery broken and vulnerable and unfortunately many people have learned to exploit that.

I think this is a good film if you are an addiction counselor of other professional. Counseling people on the pitfalls that are possible in recovery meetings is important. It’s also useful to see if you are a participant in recovery meetings or are considering attending. Community involvement and support can be helpful in recovery. I think the film can help people who choose to participate in 12 step to at least go in with their eyes open.

References:

(1) Article in the Fix: “Is AA at Fault for the Murder of one of it’s Members” by Zachary Siegel https://www.thefix.com/content/aa-fault-murder-one-its-members

URLs

Movie site: http://www.the13thstepfilm.com

Karla’s Story: http://www.propublica.org/article/how-alcoholics-anonymous-can-be-a-playground-for-violence

SMART Recovery: http://www.smartrecovery.org

SOS: http://www.sossobriety.org

Jim Christopher’s webpage: http://www.sossobriety.org/james%20christopher.htm

Stanton Peele’s website: http://www.peele.net