the pain of pleasure

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The Pain of Pleasure: Trauma and Addiction

Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D Clinical Associate Professor University of Georgia College of Pharmacy Athens,Georgia Email: [email protected]

“If all you have is a hammer then all your problems are nails”

-Abraham Maslow

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Definitions of Trauma and Addiction

!   “Because the stress response disrupts general information processing, survivors of trauma live in a somatic world rather than a world of language.”"" " " " " ""

Alexander McFarlane"

“I have absolutely no pleasure in the stimulants in which I sometimes so madly indulge. It has not been in the pursuit of pleasure that I have periled life and reputation and reason. It has been the desperate attempt to escape from torturing memories, from a sense of insupportable loneliness and a dread of some strange impending doom.” ― Edgar Allan Poe!

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Does Trauma Cause Addiction or Does Addiction Cause Trauma? !   Both Trauma and Addiction cause changes in the brain’s

functionality and neurochemistry;

!   Both Trauma and Addiction activate the Anti-Reward Brain System ( operates by using primarily the Glutamate and GABA pathways);

!   Both Trauma and Addiction depleted and shut down the Reward Brain System( operates by using primarily the Dopamine, Endorphin, and Serotonin pathways);

!   Both Trauma and Addiction are activated by the Stress Response;

!   Primarily difference is that Trauma can change the brain in seconds; Addiction may take months or years;

!   Recovery from Trauma and Addiction takes a lifetime of effort.

THE WAY WE USED TO LOOK AT SUBSTANCE ABUSE AND TRAUMA

MENTAL ILLNESS

SUBSTANCE ABUSE

TRAUMA

THE RELATIONSHIP BETWEEN TRAUMA & SUBSTANCE ABUSE

TRAUMA

SUBSTANCE ABUSE

MENTAL ILLNESS

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THE RELATIONSHIP BETWEEN TRAUMA &

SUBSTANCE ABUSE

•  There is a true cause and effect relationship between trauma and substance abuse.

•  Those who have been traumatized are at risk for substance abuse; and those who use substances are at risk for experiencing trauma.

“For those who suffer from addiction and trauma, there is great difficulty sustaining abstinence because of trauma-based physiological responses, emotions, thoughts, and relationship patterns. Trauma-related distress continuously stimulates the addiction compulsion.”

Dusty Miller (2002)

TRAUMA AND ADDICTION CYCLE

TRAUMA

EMOTIONAL UPHEAVEL

USE OF SUBSTANCES

DECREASED ABILITY TO LEARN NEW SKILLS AND

PROCESS TRAUMATIC MATERIAL

CONTINUED USE WHICH

CAN LEAD TO DEPENDENCE

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Addiction is a Complex Illness

…with biological, sociological and

psychological components

11/18/13 Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

Biology/genes

Environment

Biology/ Environment Interactions


Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D

Factors Contribu.ng to Vulnerability to Develop a Specific Addic.on

use of the drug of abuse essential (100%)!

Genetic (25-50%)"• DNA"• SNPs"• other " polymorphisms"

Drug-Induced Effects (very high)!

Environmental(very high)"• prenatal"• postnatal"• contemporary"• cues"• comorbidity"

Kreek et al., 2000"

• mRNA levels"• peptides"• proteomics"

• neurochemistry"• behaviors"

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11/18/13" 13"Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D"

We know that despite!their many differences,

most abused substances enhance the dopamine and

serotonin pathways!


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“The Necessary Nine” •  Norepinephrine/Epinephrine-

stimulant,anger,fear,anxiety,fight,flight •  Serotonin-depressant,sleep,calm,pleasure •  GABA-relaxant,stress reduction,seizure threshold •  Endorphins-pain relief,pleasure •  Acetylcholine-involutary actions,memory,motivation •  Anandamide-memory,new learning,calmness •  Glutamate-organization of brain signaling,memory,pain •  Dopamine-perception,movement,pleasure •  PIP- loving of one’s self,others,GOD


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Neurotransmitters of Dependence

PIP Dopamine Glutamate

Acetylcholine Anandamide

Endorphins / Enkelphins GABA

Serotonin Epinephrine / Norepinephrine

Addiction/Trauma Recovery

Depletion may take less than 12 months-

Trauma may take just seconds to shut down these neurochemical

systems

Replenishment may take 5 to 7 years ?????

“Human Doing” “Human Being”



17 Koob.G 2008


18 Koob,G 2008

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Koob,G 2008


20 Koob, G 2008


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LeDoux, Scientific American, 1994

The Hiker and the Rattlesnake

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AMYGDALA

Medial Prefrontal Cortex Anterior Cingulate Cortex

Hippocampus

Thalamus

Sights Sounds

Smells Coordinated Response

+

+

+

_

_

Battlemind: Dys-coordination of Threat Response & Dissociation

dissociation

PFC bypass

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Schick Shadel Hospital, 2009 11/18/13 25

Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

The An.-‐Reward Brain •  1. A key element of addic.on is the

development of a nega.ve emo.onal state during drug abs.nence.

•  2. The neurobiological basis of the nega.ve emo.onal state derives from two sources: decreased reward circuitry func.on and increased an.-‐reward circuitry func.on.

•  3. The an.-‐reward circuitry func.on recruited during the addic.on process can be localized to connec.ons of the extended amygdala in the basal forebrain.

•  4. Neurochemical elements in the an.reward system of the extended amygdala have as a focal point the extrahypothalamic cor.cotropin-‐releasing factor system.

•  5. Other neurotransmiOer systems implicated in the an.-‐reward response include norepinephrine, dynorphin, neuropep.de Y, and nocicep.n.

•  6. Vulnerability to addic.on involves mul.ple targets in both the reward and an.-‐reward system, but a common element is sensi.za.on of brain stress systems.

•  7. Dysregula.on of the brain reward system and recruitment of the brain an.-‐reward system are hypothesized to produce an allosta.c emo.onal change that can lead to pathology.

•  8. Nondrug addic.ons may be hypothesized to ac.vate similar allosta.c mechanisms.

Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 26

Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 27

ANTI-‐REWARD The concept of an an.-‐reward system was developed to explain one component of .me-‐dependent neuroadapta.ons in response to excessive u.liza.on of the brain reward system. The brain reward system is defined as ac.va.on of circuits involved in posi.ve reinforcement with an overlay of posi.ve hedonic valence. The neuroadapta.on simply could involve state-‐shiXs on a single axis of the reward system (within-‐ system change; dopamine func.on decreases). However, there is compelling evidence that brain stress/emo.onal systems are recruited as a result of excessive ac.va.on of the reward system and provide an addi.onal source of nega.ve hedonic valence that are defined here as the an.-‐reward system (between-‐system change; cor.cotropin-‐releasing factor func.on increases). The combina.on of both a deficit in the reward system (nega.ve hedonic valence) and recruitment of the brain stress systems (nega.ve hedonic valence) provides a powerful mo.va.onal state mediated in part by the an.-‐reward system. (Koob & Le Moal 2005).

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+ Desire Corresponds with Drug Use

Liking • Non-problematic Use

Wanting • Abuse

Craving • Addiction

+ Desire Corresponds with Drug Use

Liking • Non-problematic Use

Wanting • Use

Craving • Addiction

50%

89%

11%

50% 0f US population DOES NOT USE any alcohol/drugs

+ Cravings

  Craving: memory of rewarding aspects of drug use superimposed on a negative emotional state   Compels drug-seeking in dependent individuals

  3 Types of Cravings   Withdrawal induced

  Cue-induced

  Drug-induced

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Stages of the Addiction Cycle

Neurobiology of Addiction

Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238

Binge/Intoxication Stage


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Withdrawal/Negative Affect Stage


Preoccupation/Anticipation “Craving” Stage


Positive Reinforcement

Negative Reinforcement

Non-dependent

Negative Reinforcement

Positive Reinforcement

Dependent

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Brain Arousal-Stress System Modulation in the Extended Amygdala

From: Koob, G.F. 2008 Neuron 59:11-34

Merrill Norton D.Ph.,NCAC II,CCS 38

Merrill Norton D.Ph.,NCAC II,CCS 39

Allostasis - Definition

“The ability to achieve stability through change”

“To obtain stability, an organism must vary all of the parameters of its internal milieu and match them appropriately to environmental demands.”

From: Sterling P and Eyer J, Allostasis: a new paradigm to explain arousal pathology. In Fisher S and Reason J (eds), Handbook of Life Stress, Cognition and Health, John Wiley, New York, 1988, pp. 629-647.

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Brain Reward Pathways"


Activation of Reward"


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Drug-induced Craving

High

Craving

Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

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Basolateral Amygdala"

Prefrontal Cortex"

Mediodorsal Thalamus"

Motor Nuclei"

Ventral Pallidum"

Nucleus Accumbens"

Ventral Tegmental Area"

GABA and Glutamate Role in Motivation"

Adapted from Kalivas and Nakamura, Curr. Opin. Neurobiol., 1999.!

Dopamine"

Glutamate"GABA ""

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What is Trauma?

“Trauma is experiencing too much, too fast, too soon.”

Or

“The body remembers what the mind forgets”

-Jacob Moreno

Movement from Chaos to Connection

“The deep digging in therapy is to make conscious these early wounds and convert them into words so that they can be felt and understood—to use the skills of emotional literacy.

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We help them place the trauma in proper perspective.

Help give them a context (where, when and how).

Help integrate them back into themselves with understanding as to what happened and what meaning they made out of it.

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Movement from Chaos to Connection Our Tasks

Modulating Emotional Responses

Intense Fear Rage Disassociation or Shutdown

Addiction offers relief

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Trauma Impacts relationships by creating

1. Enmeshment-part of trauma bonding. 2. Disengagement-avoiding skill building. 3. Chaos through impulsivity.

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How do we help them?

4 Steps to Emotional Expertise

Our clients need to know: •  All emotions serve a function. •  Trauma and Addiction blunt our range of emotions. •  Self Efficacy comes as consciousness of emotions

grows.

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What is Trauma

Trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood, and untreated cause of human suffering. Although it is the source of tremendous distress and dysfunction, it is not an ailment or a disease, but the by-product of an instinctively instigated, altered state of consciousness.

We enter this state - let us call it survival mode - when we perceive that our lives are being threatened. If we are overwhelmed by the threat and are unable to successfully defend ourselves, we can become stuck in survival mode. This highly aroused state is designed solely to enable short-term defensive actions; but left untreated over time, it begins to form the symptoms of trauma.

Peter Levine

Effects of Trauma (Dayton,2000)

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• Long term fear of intimacy.!• Relational Commitment-Simultaneous fears of ! abandonment and being overwhelmed.!• Poor Communications-as the internal dictionary, listening, ! and seeking feedback are distorted. !• Boundaries are enmeshed.!• Deregulated emotions-high frequency, intensity and !•  duration to complete shutdown.!• Distrust, unable to receive and lack of faith in others.!• Blunted play –inability to move freely in a space.!• Unconscious patterns of disconnecting, reenacting, ! transference, splitting, hyper-vigilance and perfectionism.!

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“The imprint of the trauma is in the limbic system and in the brainstem: in our animal brains, not our thinking brains”

Survival responses based on the following criteria: 1. Severity of trauma. 2. Genetic Predisposition. 3. Developmental Phase when trauma occurs. 4. A Social Support System. 5. Prior traumas. 6.Preexisting phobias and maladaptive behavior

Bessel van der Kolk

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Trauma and the Brain

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The Triune Brain

x

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“Bottom-up, The Hi-Jacked Brain”

Janina Fisher, 2007

Everyday experiences connected to the trauma will trigger instinctive survival responses: fight, flight, freeze, collapse and numbing, dissociation, re-enactment behavior. The client’s animal brain takes over, the ability to think goes “off line,” & acting out behavior takes place without conscious intention or judgment, even without awareness!

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Normal Response

Trauma Response

Amygdala

Fight, Flight or Freeze Response

Visual Cortex

Trauma vs. Intimacy

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“Trauma originates as a response in the nervous system, and does not originate in an event. Trauma is in the nervous system, not in the event.”

Peter Levine

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•  The Polyvagal Theory

•  by

•  Stephen Porges, PhD

•  www.stephenporges.com

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The Parasympathetic Nervous System The Sympathetic Nervous System

Originates in the brain stem and lower part of the spinal cord; opposes physiological effects of the sympathetic nervous system: stimulates digestive secretions; slows the heart; constricts pupils; dilates blood vessels. Trauma may result in the PNS staying “on”, which causes it to superimpose shutdown over the hyperarousal of the SNS, rather than discharging its energy.

The SNS gets our whole body ready for action. It regulates arousal. It increases activity during times of stress and arousal – whether positive or negative. It is active when we’re alert, excited, or engaged in physical activity. It prepares us to meet emergencies and threat.

The Parasympathetic branch acts like the brake pedal for our nervous system. It helps us to relax, unwind and ultimately discharge the arousal of sympathetic activation.

The Sympathetic branch is like the gas pedal of our nervous system. It gives us energy for any action we plan, and it helps us prepare for threat.

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The Polyvagal Theory By Stephen Porges

The Vagus Nerve in three parts, all working simultaneously:

Ventral Vagal System: Is part of the Parasympathetic Nervous System (Social Engagement/frontal cortex)

Sympathetic Nervous System: (Fight/Flight, Freeze - Limbic Brain)

Dorsal Vagal System: Is part of the Parasympathetic Nervous System (Freeze/Immobility/Brainstem)

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Social Engagement

Fight, Flight, Freeze

Immobility

Safe

Danger

Life Threatening

Ventral Vagal

Sympathetic Nervous System

Dorsal Vagal System

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Sympathetic Hyperarousal

Parasympathetic Hypoarousal

Autonomic Arousal is Designed to Adapt to Environmental Demands

Window of Tolerance feelings can be tolerated, able to think and feel

easy charge"

easy discharge"

sympathetic"

parasympathetic"

Foundation of Human Enrichment"Ogden and Minton (2000)"

AROUSAL

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Stuck on “ON”

Stuck on “OFF”

•  Hyperactivity •  Panic •  Rage •  Hypervigilance •  Elation/Mania

•  Depression •  Disconnection •  Deadness •  Exhaustion

Foundation of Human Enrichment"Fisher, 2006"

Window of Tolerance

Optimal Arousal Zone

Autonomic Adaptation to a Threatening World

A R O U S A L


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Foundation of Human Enrichment"Fisher, 2006"

Window of Tolerance

Optimal Arousal Zone

How Chemical Addiction Modulates and “Medicate” Complex PTSD to attempt Self-Regulation

Acting out

Acting in

A R O U S A L


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Treatment must address the relationship between: A.  the trauma and the addictive behavior B.  the role of the addictive behavior in “medicating” traumatic activation C. the origins of both in the traumatic past D. the reality that recovering from either requires recovering from both.

The Challenge of Trauma and Chemical Addiction

Fisher, 2007

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Modes of Inventions

Cognitive Behavioral Therapy"

EMDR"

Somatic Experiencing"

Hypnotherapy"

Transactional Analysis"67

Provider Tasks

•  Screening & Assessing!

•  See trauma as a defining and organizing experience that can shape a survivor’s sense of self and others. (understanding ability to cope).!

•  Psycho-educational information on how intertwined SUDS and Trauma are during and after an event. !

•  Establish and maintain consumer support and developing coping skills. (Ex: Learning communication and problem

solving strategies such as healthy fighting. (cont.)"68

Addiction Labeling

•  The goals associated with any problem are at least partially determined by the way the problem is assessed. !

•  What you do about something is influenced by what you call it.!

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Our Lens •  We tend to call ourselves objective but

we interpret situations from their own particular theoretical, philosophical or ideological perspective.!

•  Do we need to transcend it?!

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Our Lens (cont.)

We know clients don’t see themselves as addicts but often seek to negotiate an alternative explanation to negate acting out behaviors or minimize having to change.!

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Provider Tasks

•  Helping consumer understand the range of parallel connections between SUDS and trauma.!

•  Minimizing re-occurance of trauma!

•  Ensuring consumers’ physical and emotional safety where possible and avoiding shame inducing confrontations triggering trauma related responses.!

•  Helping with referrals for ancillary services such as legal, financial, vocational, housing and health care.!

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Resiliency

•  Recognizing and Reinforcing Resiliency !

•  Definition-The process of “bouncing back.”!

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The Post Traumatic Stress Inventory

The Inventory consists of 144 questions designed by David Delmonico, M.Ed. and Patrick Carnes, PhD. Questions fall into 1 of 8 categories providing when tallied a strategic map on how the client can once again gain internal locus of control.!

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The Post Traumatic Stress Inventory

8 Specific Therapy Strategies"

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1.Trauma Reacting

Write amend letters to those you know you have harmed.!

•  Decide with therapist what information is appropriate to disclose and send.!

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Trauma Reacting- Experiencing current reactions to trauma events in the past.!

Study ways client is still reacting. EX: projected anger out on others. !

Write letters to perpetrator telling them of the long-term impact you are experiencing.!

2. Trauma Repetition •  Trauma Repetition – Repeating behaviors or situations which

parallel early trauma experiences. !

•  Understand how history repeats itself in your life experiences.!

•  Develop habits which center yourself- Ex. Breathing or journaling so you are doing what you intend –not the cycles once used.!

•  Work on setting boundaries-using effective communication.!

•  Boundary failure is key to repetition compulsion.!77

3. Trauma Bonding

•  Trauma Bonding- Being connected (loyal, helpful, supportive, enmeshed) to people who are dangerous shaming, or exploitive. !

•  Learn to recognize trauma bond by identifying those in your life. !

•  Look for patterns.!

•  Use “detachment” strategies for difficult people.!

•  Use a First-Step if necessary.!

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4. Trauma Shame

•  Trauma Shame - Feeling unworthy and having self-hate because of the trauma experience. !

•  An acutely self-conscious state in which the self is “split” imagining the self in the eyes of the, other; by contrast, in guilt the self is unified. (Gilliland, et al. 2011).!

•  Judgment of self by another whether real or imagined. !

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4. Trauma Shame (cont)

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Goal: Shame Reduction and resolution.!

Understand shame dynamics of family and family of origin.!

Who was important to that you should feel shameful?!

Do a list of problems, excuses and secrets.!

Complete an inventory of affirmations. !

5. Trauma Pleasure

•  Trauma Pleasure – Finding pleasure in the presence of danger, violence, risk or shame.!

•  Do a history of how excitement/ shame are hooked to the past traumatic event (s).!

•  Note the costs and dangers to you over time.!

•  Do a First Step and relapse prevention plan about how powerful this is in your life.!

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6. Trauma Blocking

•  Trauma Blocking- A pattern exists to numb, block out, or overwhelm feelings that stem from trauma in your life. !

•  Work to identify experience which caused pain or diminished you.!

•  Re-experience feelings and make sense of them with help.!

•  This will reduce the power they have had. !

•  Do a First Step if appropriate.!

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7. Trauma Splitting

•  Trauma Splitting- Ignoring traumatic realities by disassociating or “splitting off” experience of parts of self. !

•  Learn that disassociating is a “normal” response to trauma.!

•  Identify ways you split reality and the triggers that cause that to happen. !

•  Cultivate a “caring” adult who stays present so you can stay whole.!

•  Notice any powerlessness you feel. !83

8.Trauma Abstinence

•  Trauma Abstinence- Depriving yourself of things you need or deserve because of traumatic acts. !

•  Understand how deprivation is a way to continue serving perpetrators. !

•  Write a letter to the victim(s) that was you learning to tolerate pain and deprivation.!

•  Work on strategies to self –nurture including inner child visualizations.!

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WHAT NEXT- 30 Performables

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1. Break through Denial ! 2. Understand Addiction ! 3. Surrender! 4. Limit change! 5. Establish Sobriety! 6. Physical Integrity! 7. Culture of support!

16. Lifestyle Balance!17.  Building Support!18.  Exercise and nutrition!19. Spiritual Life !20. Resolve Conflicts!21. Restore Healthy Sexuality!22. Family Therapy!

8. Multiple addictions! 9. Cycle of Abuse! 10. Reduce Shame! 11. Grieve losses! 12. Closure to shame! 13. Relationship with self.! 14. Financial Viability! 15. Meaningful work !

23. Family Relationships!24. Recovery commitment!25.  Issues with children!26. Extended Family!27. Differentiation!28. Primary Relationship!29. Coupleship!30. Primary Intimacy! Carnes,2011!

Questions??????????

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Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

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the pain of pleasure

Documents

trauma cause addiction

addiction cause trauma

survivors of trauma

definitions of trauma

traumarelated distress

seconds addiction

addiction compulsion

addiction cause changes