The role of somatosensory feedback in Attention The role of somatosensory feedback in Attention Deficit Hyperactivity Disorder: three cases treated Deficit Hyperactivity Disorder: three cases treated

with Mindfulness–integrated CBTwith Mindfulness–integrated CBT

Bruno A. Cayoun, PsyDBruno A. Cayoun, PsyD

APS Conference 2008 - Hobart AustraliaAPS Conference 2008 - Hobart Australia

Attention Deficit Hyperactivity Attention Deficit Hyperactivity Disorder (ADHD): Definition & Disorder (ADHD): Definition &

Subtypes in DSM-IV Subtypes in DSM-IV

Attention Deficit Hyperactivity Attention Deficit Hyperactivity Disorder (ADHD): Definition & Disorder (ADHD): Definition &

Subtypes in DSM-IV Subtypes in DSM-IV • “…“…A major disorder of self control” (Barkley, 1999).A major disorder of self control” (Barkley, 1999).

1.1. Predominantly Inattentive (ADHD-PI)Predominantly Inattentive (ADHD-PI)- deficits in selective and sustained attention, speed of deficits in selective and sustained attention, speed of

information processing and memory retrievalinformation processing and memory retrieval

2.2. Predominantly Hyperactive-Impulsive (ADHD-HI)Predominantly Hyperactive-Impulsive (ADHD-HI)- persistent and maladaptive symptoms of hyperactivity and persistent and maladaptive symptoms of hyperactivity and

impulsivity impulsivity

3.3. Combined type (ADHD-C) Combined type (ADHD-C) - All symptoms are presentAll symptoms are present

ADHD – Causes and DeficitsADHD – Causes and DeficitsADHD – Causes and DeficitsADHD – Causes and Deficits

• Etiology is essentially unknown (NHMRC, 1997)Etiology is essentially unknown (NHMRC, 1997)- Genetic, neurophysiological, cognitive, familial and environmental Genetic, neurophysiological, cognitive, familial and environmental

factorsfactors

- Current views (Barkley, 1997; Sergeant, 2000)Current views (Barkley, 1997; Sergeant, 2000)- Inhibitory dysfunction as a primary deficitInhibitory dysfunction as a primary deficit- DDecreased ability to regulate motor output or inhibit a responseecreased ability to regulate motor output or inhibit a response

• Associated deficitsAssociated deficits- Deficit in sustainDeficit in sustaineded attention (Heaton et al., 2001) attention (Heaton et al., 2001) - Dysfunctional reinforcement (Zentall, 1985; Johansen et al., 2002)Dysfunctional reinforcement (Zentall, 1985; Johansen et al., 2002)- Slower general processing speed (Cayoun et al., 2008)Slower general processing speed (Cayoun et al., 2008)- Deficit in Cognitive Flexibility (Tannock et al., 1995; Cayoun et al., Deficit in Cognitive Flexibility (Tannock et al., 1995; Cayoun et al.,

2008)2008)

Three complementary definitionsThree complementary definitions

1.1. Sustained attentionSustained attention: : “…paying attention on purpose, from moment to “…paying attention on purpose, from moment to moment, and nonjudegmentally” (Kabat-Zinn, 1994).moment, and nonjudegmentally” (Kabat-Zinn, 1994).

2.2. Cognitive flexibilityCognitive flexibility: : “…a state of continuous category formation. A “…a state of continuous category formation. A mindful individual creates new approaches to events and situations. mindful individual creates new approaches to events and situations. He or she is not bound by previously formed rigid attitudes; rather, He or she is not bound by previously formed rigid attitudes; rather, the mindful person, situated in the present, explores a situation from the mindful person, situated in the present, explores a situation from several perspectives” (Margolis & Langer, 1990). several perspectives” (Margolis & Langer, 1990).

3.3. Inhibitory controlInhibitory control: : “…mindfulness is achieved through the “…mindfulness is achieved through the development of experiential awareness and equanimity, which is development of experiential awareness and equanimity, which is the the ability to remain unperturbed by an event experienced within the ability to remain unperturbed by an event experienced within the framework of one’s body and thoughts as a result of objective framework of one’s body and thoughts as a result of objective observation” (Cayoun, 2003).observation” (Cayoun, 2003).

MindfulnessMindfulness

Practice & OperationalisationPractice & Operationalisation: : 2 Main Aspects2 Main Aspects

1.1. Concentration on breathing (“shaping” attention)Concentration on breathing (“shaping” attention)– Training in sustained attention, meta-cognitive awareness, inhibitory Training in sustained attention, meta-cognitive awareness, inhibitory

control and attention switchingcontrol and attention switching– Benefits include decreased distractibility from irrelevant thoughts Benefits include decreased distractibility from irrelevant thoughts

and sensory stimuli and cognitive flexibilityand sensory stimuli and cognitive flexibility

2.2. Systematic body scanning to develop equanimitySystematic body scanning to develop equanimity– A generalised interoceptive exposure and response prevention A generalised interoceptive exposure and response prevention

procedure procedure – Requires inhibitory control to prevent learned responses and foster Requires inhibitory control to prevent learned responses and foster

acceptance acceptance

• General AimsGeneral Aims– Develop greater self-awareness, objectivity, acceptance and Develop greater self-awareness, objectivity, acceptance and

detachment with each experiences detachment with each experiences

Development of metacognitive awarenessDevelopment of metacognitive awareness Awareness and acceptance of one’s thoughts Awareness and acceptance of one’s thoughts

Maladaptive thoughts are reprocessed more neutrally Maladaptive thoughts are reprocessed more neutrally ((Teasdale, Segal, & Teasdale, Segal, &

WilliamsWilliams, 1995; Chambers, Chuen Yee Lo, & Allen, 2006), 1995; Chambers, Chuen Yee Lo, & Allen, 2006)

Development of experiential acceptance (i.e., awareness and Development of experiential acceptance (i.e., awareness and acceptance of thoughts and body sensations)acceptance of thoughts and body sensations)

Practice of systematic body scanning (two 30-min sessions per day)Practice of systematic body scanning (two 30-min sessions per day)

Unilateral, Bilateral and Sweeping methodsUnilateral, Bilateral and Sweeping methods

Facilitates skill transferFacilitates skill transfer Promotes neuroplasticity in prefrontal inhibitory networks and Promotes neuroplasticity in prefrontal inhibitory networks and

somatosensory pathways somatosensory pathways (Davidson et al., 2003; Carey, Bhatt & Nagpal, (Davidson et al., 2003; Carey, Bhatt & Nagpal, 2005; Lazar et al, 2005)2005; Lazar et al, 2005)

Increases internal locus of control Increases internal locus of control (see Witkiewitz, Marlatt, & Walker, 2004)(see Witkiewitz, Marlatt, & Walker, 2004)

General Benefits of Mindfulness General Benefits of Mindfulness Training Training

Main Associated Brain StructuresMain Associated Brain Structures

• Parietal Lobe (Interoceptive Awareness)Parietal Lobe (Interoceptive Awareness)– Plays a major role in Plays a major role in

• the overall allocation of attention the overall allocation of attention

• Monitoring of body sensationsMonitoring of body sensations

• Frontal Lobe (Metacognitive Awareness)Frontal Lobe (Metacognitive Awareness)– Plays a major role inPlays a major role in

• control of attention control of attention

• ““online” decision and execution of behaviour online” decision and execution of behaviour

• Inhibitory control of reactive behaviourInhibitory control of reactive behaviour

Neuroplasticity ResearchNeuroplasticity Research

• Lazar et al. (2005) Lazar et al. (2005) • Anatomical MRI measured cortical thickness in 20 long-term Anatomical MRI measured cortical thickness in 20 long-term

mindfulness meditators and 20 matched controls.mindfulness meditators and 20 matched controls.

• Cortical thickness was greater (P < 0.0001) in the prefrontal Cortical thickness was greater (P < 0.0001) in the prefrontal (BA 9/10) and somatosensory cortices of the meditators (BA 9/10) and somatosensory cortices of the meditators relative to controls. relative to controls.

– These areas correlated with Mf practice experience These areas correlated with Mf practice experience – Since behavioural inhibition lies particularly within the orbital-frontal regions Since behavioural inhibition lies particularly within the orbital-frontal regions

of the prefrontal cortex (Barkley, 1999) there may be of the prefrontal cortex (Barkley, 1999) there may be implications for ADHDimplications for ADHD

• Between-group differences in prefrontal areas were most Between-group differences in prefrontal areas were most pronounced in older adults, suggesting that “mindfulness pronounced in older adults, suggesting that “mindfulness might offset age-related cortical thinningmight offset age-related cortical thinning

– There may be implications for dementiaThere may be implications for dementia

Somatosensory NetworksSomatosensory NetworksAnd Body Scanning TechniquesAnd Body Scanning Techniques

Somatosensory NetworksSomatosensory NetworksAnd Body Scanning TechniquesAnd Body Scanning Techniques

Areas 1, 2, 3 are central to interoceptive awarenessAreas 1, 2, 3 are central to interoceptive awareness

1.1. Unilateral scanningUnilateral scanning

2.2. Bilateral scanningBilateral scanning

3.3. Partial sweepingPartial sweeping

4.4. Sweeping Sweeping en masseen masse

5.5. Transversal scanningTransversal scanning

6.6. Sweeping in depthSweeping in depth(From FitzGerald & Folan-Curran, 2002)(From FitzGerald & Folan-Curran, 2002)

(Adapted from Banich, 1997, p.30)

(Adapted from FitzGerald & Folan-Curran, 2002)(Adapted from FitzGerald & Folan-Curran, 2002)

Somatosensory Cortex Somatosensory Cortex and Body Scanning Techniquesand Body Scanning Techniques

WEEK 1 WEEK 2 WEEK 3 WEEK 4

Case Study Case Study (N = 4)(N = 4) Participant 1Participant 1

12 year-old boy12 year-old boy Referred by his GP for ADHD-HI leading to peer rejection, anxiety and Referred by his GP for ADHD-HI leading to peer rejection, anxiety and

depressiondepression Father diagnosed with ADHD-CFather diagnosed with ADHD-C

Participant 2Participant 2 38 year-old male38 year-old male Referred by her GP for severe depression and ADHD-CReferred by her GP for severe depression and ADHD-C

Participant 3Participant 3 31 year-old female 31 year-old female Referred by her GP for depression and ADHD_PIReferred by her GP for depression and ADHD_PI

Participant 4Participant 4 58 year-old female 58 year-old female Referred by her GP for depression, anxiety and ADHD_HIReferred by her GP for depression, anxiety and ADHD_HI

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Emotional Working Plan/ Org. ofInhibit Shift Control Initiate Memory OrganizeMaterials Monitor BRI MI GEC

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Behavior Rating Inventory of Executive Behavior Rating Inventory of Executive Functions (BRIEF)Functions (BRIEF)

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Self Initiate WorkingPlan Task Org. of BRI MI GEC Control Monitor Memory OrganizeMonitorMaterials

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Behavior Rating Inventory of Executive Behavior Rating Inventory of Executive Functions (BRIEF) – 2 Adult FemalesFunctions (BRIEF) – 2 Adult Females

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Relationship between Global EF and Relationship between Global EF and Somatosensory FeedbackSomatosensory Feedback

SummarySummary

• Mindfulness training was effective in addressing ADHD Mindfulness training was effective in addressing ADHD symptoms in half the clients despite high comorbiditysymptoms in half the clients despite high comorbidity

• Effectiveness of treatment was dependant on ability to feel Effectiveness of treatment was dependant on ability to feel body sensations and prevent reactivitybody sensations and prevent reactivity

• A gender effect?A gender effect?

• Need for researchNeed for research