1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry...
-
Upload
lester-curtis -
Category
Documents
-
view
216 -
download
1
Transcript of 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry...
1
Impaired Decision Making In Substance Use Disorders
Claire Wilcox MD
UNM Dept of Psychiatry
Alcohol Medical Scholars Program
© AMSP
2
Case 55 y.o. male Physician High intelligence Methamphetamine dependent Multiple prior treatments Negative consequences: unemployed Repeated relapses Wants to quit
© AMSP
3
This Lecture Will Cover
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
© AMSP
4
How Are Decisions Made?
Mental process Neurocognitive
Involves 3 stages
• Interconnected
• Experience-driven© AMSP
5
Stage 1: Stimulus Assessment
Preference
Valence
Salience
Context
© AMSP
6
Stage 1:Assessment
Stage 2:Execution
Action selection
Action performance
© AMSP
7
Stage 3: EFFECT!!
Evaluation/feedback: pros and cons of choice© AMSP
8
Stage 1:Assessment
Stage 2:Execution
Stage 3:Effect
Stage 3: Learning
© AMSP
9
Stages in the Case
Stage 2 (Execution)• Became obsessed• Unable to fight impulse
Stage 3 (Effect & Learning)• Use pleasure, relief drug use reinforced
Stage 1 (Assessment)• Saw friend use• Frustrated/stressed
© AMSP
10
Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
11
Dopamine
Salience Cost benefit analysis
Action Inhibitory control
‘High’ Learning
© AMSP
Stage 1: Assessment
Stage 2: Execution
Stage 3: Effect & Learning
12
Glutamate
Learning
Stimulus Preference
© AMSP
Stage 1: Assessment
Stage 2: Execution
Stage 3: Learning
13
Noradrenaline Stress response
• Sympathetic NS• CRF release
Focus on task Exploration
© AMSP
Stage 1:Assessment
Stage 2: Execution
Stage 3: Learning
14
Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
15
Decision Making In SUDs
Failure at any of 3 stages Biological root Possible pre-morbid deficits Worsened by drug use
• DA release to reward• DA receptor density • NA and CRF to stress
© AMSP
16
Assessment Deficits
Response to cue
Preference,short-term reward/”high”
Stress, cue salience
© AMSP
17
Execution Deficits
Habitual actions favored
• Can’t see other options
Inhibitory control
• Can’t hold back
© AMSP
18
Effect/Learning Deficits
Imbalanced reward encoding• First drug use, reward • Once dependent
o Drug rewardo Further drug consumption
Learning from negative © AMSP
19
Case
Assessment: preference for drug
Execution: inhibitory control
Effect: / response to drug
Learning: response neg consequence
© AMSP
20
Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
21
Prevention
Exposure
Target high-risk
• Adolescents
• Genetically vulnerable
• Cognitive probs (schizophrenia, brain injury)
• Stress reactive (depressed/anxious)© AMSP
22
Medications
Drug cue effect
Naltrexone (AUDs), opioid blocker
DA release
Craving
Relapse
© AMSP
23
Medications
Negative emotional states drug craving
Methadone (opioid use disorder)
Withdrawal/craving
Brain stress response/ anxiety
Treat co-occurring disorders© AMSP
24
Medications
Cognitive functioninhibitory control
Experimental
• Varenicline (Nicotine Use Disorders)
• Memantine (Alzheimer’s Disease)© AMSP
25
Medications
Drug reward
Under development
Cocaine & nicotine vaccines
Abs block drug entry into brain © AMSP
26
Psychotherapies
Contingency Management Therapy
• Reward changes behaviors
• Learn abstinence earn $$$
Relapse Prevention Therapy
• Identify triggers
• Learn avoidance
© AMSP
27
This lecture covered
Neurocognitive aspects of decision making
Neurochemical systems
How systems can malfunction in SUD
Treatment implications © AMSP
28
Thanks to:
Dr. Ann Manzardo (a power point genius)
Dr. Marc Schuckit (for an excellent learning
experience, and all of his help and time)
Alcohol Medical Scholars Program (for the yummy
food and spectacular hotels)© AMSP