Upload
sarahstonge
View
224
Download
0
Embed Size (px)
Citation preview
8/2/2019 St.onge Paper
1/23
Neurocognitive underpinnings of denial and decision making 1
Neurocognitive underpinnings of denial and decision making
in treatment choice for drug addiction
Sarah St. Onge
Cognition
James Nelson, PhD, Professor
Derner Institute for Advanced Psychological Studies
8/2/2019 St.onge Paper
2/23
Neurocognitive underpinnings of denial and decision making 2
Neurocognitive underpinnings of denial and decision making
in treatment choice for drug addiction
Drug addiction is conceived as a cognitive disorder that shares similarities with
neuropsychiatric and psychiatric disorders (such as schizophrenia). One notable
similarity is impaired awareness. This impairment affects failure to recognize an
illness, denial of illness, compromised control of action, and unawareness of social
incompetence (p. 372). In addition, impaired self-awareness affects such basic daily
functions as decision making. According to the results of a 2006 national survey on
drug use and health (SAMHSA, 2007, as cited in Goldstein et al., 2009), 80% of
addicted individuals failed to seek treatment because they were unaware of the severity
of their illness. Added to these 21.1 million persons, are individuals who are aware of
their illness, in treatment or remission. This results in an astronomical percentage of
people in our nation suffering from substance abuse or struggling not to relapse. This
reason alone behooves us to study the neurocognitive underpinnings of this disorder so
that practitioners from related fields can work together to determine the most effective
way to support and aid such individuals.
NEUROCOGNITIVE FINDINGS
8/2/2019 St.onge Paper
3/23
Neurocognitive underpinnings of denial and decision making 3
Three neuro-scientific studies offer significant and overlapping findings about the
effect and interaction of denial among the affected brain regions of addiction.
Goldstein and her colleagues (2009) place emphasis on the insula, anterior cingulate,
and dorsal striatum regions found to be most related to interoception, insight and self-
awareness. Bechara (2005) considers the conflicting impact of the dual systems of the
amygdala and prefrontal cortex in affecting the cognitive resources needed to exercise
willpower and impulse control in decision making. Verdejo-Garcia and Perez-Garcia
suggest alterations in the frontostriatal systems, which play a critical role in self-
awareness and denial.
Goldstein et al. (2009)
Among the affected brain regions in addiction, the insula, anterior cingulate, and
dorsal striatum regions are most related to interoception, insight and self-awareness.
These concepts are needed to help us recognize and describe our own (and others)
behaviors, cognitions and mental states (p. 372). Damage to any of these neural
circuits affects other, related neural structures, resulting in dissociated, or dysfunctional
behavior. As such, drug addiction can be viewed as a compromised ability to
recognize external and internal drug-related cues (p. 373), resulting in excessive use,
dysregulated control of use, and compromised self-awareness, often mislabeled
denial.
Clinical psychologists looking to the DSM-IV to guide decisions about a diagnosis
of drug dependency, note that altered awareness is a major criterion. However, with
denial in question as a valid marker of altered awareness, neuroimaging offers another
8/2/2019 St.onge Paper
4/23
Neurocognitive underpinnings of denial and decision making 4
example of what such a state looks like. Also, given the importance of self-awareness
and interoception in understanding drug addiction and its treatment, practitioners need
to have a better grounding in the abnormalities in the insula and medial regions of the
prefrontal cortex (including the anterior cingulate and mesial orbitofrontal cortices) that
underscore interoception and behavioral control.
The insula
The posteria insula in all primates contains interoceptive representation of the
physiological condition of the body. The anterior insula in humans integrates emotional
activity from other forebrain regions for a re-representation of interoceptive responses,
and is also related to emotional awareness, empathic feelings, and to cooperative social
behavior.
In determining the role that the insula plays in drug addiction, an interesting study
on cigarette smoking was conducted by one of the authors (Bechara in Naqvi et al.,
2007, cited in Goldstein et al., 2009). 19 smokers with sustained damage in the insula
were compared with 50 smokers who sustained damage in other areas of the brain.
Consistent with other research findings on the crucial role of the middle insula in
cravings for food, cocaine and cigarettes, the insula-damaged smokers experienced a
disruption in nicotine addiction as indicated in neuroimaging studies.
The anterior cingulate cortex
Similarly, reduced activity in the anterior cingulate cortex was associated with
selective attention and inhibitory control for cocaine, heroin, alcohol, cannabis and other
drug users. For example, in a study that compared cannabis users and non-users on a
task of determining error awareness, imaging reported blunted rostral and dorsal
8/2/2019 St.onge Paper
5/23
Neurocognitive underpinnings of denial and decision making 5
anterior cingulate (and insula) response along with significant diminished awareness of
errors in cannabis users. These studies predict, It is most likely that abnormalities in
the insula contribute to intense drug cravings and compromised insight and awareness
of disease severity, whereas abnormalities in the cingulate cortices contribute to the
disadvantageous decision-making that precipitate relapse (p. 377).
Additionally, the anterior cingulate cortex is implicated in conscious and
subjective experiences (such as pain and pleasure). The anterior cingulate and bilateral
anterior insula work together for perceptual awareness of visual or auditory stimuli.
Damage in these regions correlate with decreased emotional self-awareness and self-
conscious behaviors, and affect decision-making abilities. Distinctive roles for the
anterior insula and anterior cingulate cortices affect control over ones behavior.
Together, the anterior insula and anterior cingulate cortices are conjointly activated in all
human emotions and behaviors.
The dorsal striatum
Neural imaging results indicate that there is a switch that occurs from voluntary to
automatic drug use involving movement from the prefrontal cortex to the dorsal striatum
region of the brain, the site of dopaminergic reactions. This affects both drug-seeking
and drug-taking behavior. In a study with rats (Miller & Cohen, 2001, cited in Goldstein
et al., 2009), it was found that disconnecting the ventral-dorsal striatal loop greatly and
selectively decreases habitual cocaine seeking (p. 377). This switch to an automatic
and habitual system adds to an already compromised insight into the severity of ones
addiction.
8/2/2019 St.onge Paper
6/23
Neurocognitive underpinnings of denial and decision making 6
Drug cues have been found to stimulate drug craving in the limbic reward
circuitry of the brain. Imaging results indicate that, both cocaine and sexual unseen
cues activated the ventral striatum/pallidum, amygdala, anterior insula, and caudo-
lateral orbitofrontal cortex, paralleling prior studies of reward circuitry in humans and
animals (Childress et al., 1999, cited in Goldstein et al., 2009). These findings suggest
that drug-related stimuli outside of awareness affect brain motivational circuits but also
point to possible treatment modalities that may rely on systematic desensitization
efforts.
Bechara (2005)
Bechara noted that there are similarities between substances abusers and
patients with damaged ventromedial prefrontal cortex (VMPC) areas of the brain. Both
have a tendency to deny, or are not aware that they have a problem. Specifically, it was
noted that when faced with a choice that could result in an immediate pleasure
response versus negative future consequences, the majority of both drug addicts and
VMPC patents chose the more immediate, pleasure-seeking reward. This finding was
substantiated in a study in which patients and addicts were taught the rules to a
gambling game: the Iowa Gambling Task. Subjects were asked to choose between four
decks of cards, each with a different potential payoff, to maximize their monetary gain.
63% of drug addicts performed within the range of patients with VMPC in choosing
cards with immediate financial rewards despite increasing losses associated with those
choices. Based on this finding, Bechara became interested in understanding the link
between substance abuse, denial and decision making.
8/2/2019 St.onge Paper
7/23
Neurocognitive underpinnings of denial and decision making 7
Bechara proposes that multiple brain mechanisms work together in addiction. He
believes that addiction is a condition in which the neural mechanisms that enable one
to choose according to long-term outcomes are weakened, thus leading to loss of
willpower to resist drugs (p. 1). In fact,
Bechara suggests that while we may see reduced decision-making as a result of
addiction, it may well be that a weakened decision-making ability underlies the initial
use and escalation of substance use leading to addiction.
Somatic marker theory
Bachara bases his research on a somatic marker hypothesis. Somatic markers
are emotion-related signals, both body- and brain-related, that assist cognitive
processes in implementing decisions. The somatic marker hypothesis is a systems-
level neuroanatomical and cognitive framework for choosing according to long-term,
rather than short-term, outcomes (p. 1). The amygdala and VMPC are critical for
triggering somatic states: The amygdala responds to events that occur in the
environment; whereas the VMPC responds to events in memory, knowledge and
cognition. Bacharas research indicates that willpower emerges from an interaction
between the two neural systems in which the amygdala and VMPC reside: the impulsive
system and the reflective system.
The impulsive system
The somatic marker theory links the features of the stimulus to its
affective/emotional response. Physiological evidence suggests that powerful, short-
lived affective responses occur in the amygdala, such as viewing or encountering an
object of fear (e.g., a snake) or pleasure (e.g., money). Although money is not initially
8/2/2019 St.onge Paper
8/23
Neurocognitive underpinnings of denial and decision making 8
associated with affective properties, when its image is linked with drug use, it can
become a powerful reward trigger in the impulsive system. Research has been
conducted that suggests that drug cues, such as pictures of a needle, can also produce
strong, affective triggers in the amygdala-ventral striatum system. Like the Goldstein et
al. study, this ascribes a functional role to the striatum in the motivational and
behavioral aspects of drug seeking and addiction.
The reflective system
The VMPC is a critical substrate in the neural system necessary for triggering
affective states from recall or from imagination (Bechara, 2004, cited in Bechara, 2005).
In the reflective system, affective reactions can also be generated from recall of
personal or imagined affective/emotional events. One would think that recall of negative
consequences of drug use (i.e. trouble with the law, bodily damage, loss of finances,
family,job) would affect ones decision making process in future drug use; however,
dysfunction in the VMPC causes a state of obliviousness that may lead to escalating
use, and vulnerability to addiction.
Other systems within the VMPC are also linked to critical processes in decision
making. The dorsolateral sector of the prefrontal cortex and the hippocampus are
linked to memory. Maintaining an active representation of memory over a delay of time
involves the dorsolateral sector of the prefrontal cortex, and patients with damage to this
structure show compromised decision making. Thus, decision making depends on
memory as well as for emotion and affect.
8/2/2019 St.onge Paper
9/23
Neurocognitive underpinnings of denial and decision making 9
Cross-over effects
Bechara claims that addiction is the product of an imbalance between these two
separate, but interacting, neural systems that control decision-making. The control
between the two is not absolute; but evidence suggests that hyperactivity within the
impulsive system can override the reflective system. Drugs and drug cues can trigger
bottom-up, involuntary signals originating from the amygdala to take over the goal-
driven cognitive resources that are needed for the normal operation of the reflective
system and for exercising the willpower to resist drugs. However, there are also top-
down effects that mediate this finding.
Decision making deficits in addicts, and also in some of the normal controls in the
study, are not uniform across all individuals. As opposed to the 63% of addicts who
performed similarly to the VMPC patients, 27% did not. Bechara believes that there
may be more than one mechanism by which the reflective system exerts control over
the impulsive system. Besides decision making, there are other mechanisms of
inhibitory control to be examined, such as the ability to inhibit the intrusion of unwanted
information (such as thinking about drugs). Also, other neural regions of the prefrontal
cortex still need to be examined to determine the saliency of their effects on addiction.
Verdejo-Garcia & Perez-Garcia (2005)
In a study examining self-awareness of cognitive deficits in drug addicts,
Verdejo-Garcia & PerezGarcia state, Recent neuro-scientific evidence suggests that
denial of problems related to drug use can be associated with alterations in the
frontostriatal systems, which play a crucial role in executive functions and self-
awareness (p. 172). This area also affects emotional regulation and motivation.
8/2/2019 St.onge Paper
10/23
Neurocognitive underpinnings of denial and decision making 10
Specifically, poor awareness of cognitive deficits during rehabilitation can be
associated with reduced motivation towards reaching treatment goals, failure to use
recommended compensatory strategies, and a greater feeling of control over risky
behaviors, including those involving an actual encounter with the drug in the
environment. (Rinn, 2002, cited in Verdejo-Garcia et al., 2004, p. 174).
Study participants included a sample of 38 abstinent poly-substance abusers and
their self-appointed informants in Granada, Spain. Informants were required to know
the substance abusers well enough to report on their daily behavior patterns. All
abusers were abstinent for a minimum of 15 days and had ended rehabilitation at the
same time. No participant was taking any substance-related medication. Substance
abusers and their informants were asked to complete the Frontal Systems Behavior
Scale (FrSBe), a 46-item rating scale with 3 independent subscales for: apathy (poor
initiation, loss of energy and interest, blunted affective expression), disinhibition
(problems with inhibitory control, socially inappropriate behaviors, unmodulated or
excessive emotional expression), and executive function (deficits in planning, working
memory, mental flexibility). The FrSBe has high internal consistency and reliability,
especially in detection of frontostriatal deficits in substance abusers. The standard
version of the scale is intended to quantify behavioral change due to frontal lobe
lesions.
Abusers were assessed during drug use (they were asked to retrospectively
rate their behavior during lifetime drug use) and during abstinence. Results indicated
that informants scores were significantly higher than substance abusers scores on
apathy and executive function during drug use, indicating poor awareness of deficits.
8/2/2019 St.onge Paper
11/23
Neurocognitive underpinnings of denial and decision making 11
No significant discrepancies between abusersand informants scores were noted
during abstinence. Severity of alcohol and cocaine abuse significantly predicted poorer
self-awareness during drug abuse, but not during abstinence.
Based on the findings of this small study, researchers concluded that the
frontostriatal systems play a critical role in supervisory and self-awareness processes
in drug addiction. This is supported by previous observations about the similarities
between substance abusers and patients with lesions in the orbitofrontal cortex, who
also tend to present with poor awareness of their cognitive deficits. These results are
also consistent with the previous studies of Goldstein et al. and Bechara whot have
reported incidental and direct evidence of the relationship between cognitive deficits and
denial or poor awareness in drug addicts.
Although substance abusers reported relatively high levels of behavioral
symptoms (especially of executive dysfunction) during drug use, discrepancy with
informants scores may have relevant clinical implications. For example, reduced
awareness about the actual degree of deficits might be closely associated with poor
judgment and a variety of ill-considered choices during drug abuse, including sharing
needles, risky sexual behavior, driving under the influence of drugs, and higher
incidence of antisocial behavior. Furthermore, neurocognitive skills seem to modulate
the response of high-risk populations to prevention materials. Thus, the findings could
have important implications for prevention strategies, which should highlight the impact
of drug abuse on self-awareness. These findings may also have important implications
for motivational attitudes towards treatment, since substance abusers presenting poor
8/2/2019 St.onge Paper
12/23
Neurocognitive underpinnings of denial and decision making 12
awareness may be reluctant to acknowledge their addiction and to seek treatment (Rinn
et al., 2002, cited in Verdejo-Garcia & Perez-Garcia, 2005).
TREATMENT
The particular construct of denial is one that has various meanings within the
field of psychology. Understanding its function with substance abusers and determining
answers to essential questions is vital in determining effective treatment plans. For
example, given that there is impairment in substance abusers self-awareness, to what
extent can insight-oriented therapies be effective? With drug addiction seen as a
cognitive disorder, which cognitive therapies may be most effective? Similarly, with our
greater understanding of the neurological circuitry in addiction, how can
psychopharmacological interventions best improve neuropsychological functioning?
Also, if improved self-awareness is the goal, how can treatments be devised without
running the risk of incurring greater negative affect leading to greater substance use?
Some research offers hope and direction in designing effective treatment. For
example, studies involving activation of the anterior cingulate cortex (Grusser et al.,
2004; Paulus et al., 2005; Garavan et al., 2008, cited in Goldstein et al., 2009), indicate
positive outcome in alcoholics, methamphetamine and cocaine users. The well-
established role of the orbitofrontal cortex (Rolls, 2000, as cited in Goldstein et al.,
2009) in reversing stimulus-reinforcement associations also suggests a positive role in
insight and awareness. However, most current treatment for drug addiction falls within
more traditional approaches, ignoring the wisdom of neuroscience.
8/2/2019 St.onge Paper
13/23
Neurocognitive underpinnings of denial and decision making 13
The treatment-as-usual for alcohol or other substance abuse in the United States
is based almost exclusively on the 12-step, Hazelden, or Minnesota model. This
treatment modality is based on the premise that addiction is a disease, most likely
genetic, and not controllable unless one is completely abstinent. Furthermore, addiction
is considered incurable and irreversible. Unfortunately, there have been a number of
research studies that indicate that the disease model is not very effective in treating
addiction. Empirical evidence now points to the fact that substance use is a
continuously distributed phenomenon, ranging from problem use to dependence, and
not a discrete entity in which one diagnosis fits all. Thus, people who may be problem
drinkers but are not alcoholics, for instance, are not getting the help they need. Also,
the fear of labeling and stigma (i.e., I am an alcoholic), and the negatively-tinged moral
stance directed towards abusers is a major barrier to treatment entry. Empirically-
based treatments, on the other hand, have personalized, non-judgmental approaches
that lower resistance and increase awareness of ones abuse and engagement in
treatment.
Evidence-based treatments
In determining what constitutes as evidence-based treatment, Miller et al. (2005),
examined the conclusions of 10 reviews of evidence-based treatments from seven
research groups. The studies more than a thousand controlled clinical trials in the
literature for alcohol, tobacco, and illicit drugs - ranged from randomized clinical trials,
the gold-standard research design of the U.S. Food and Drug Administration (FDA) for
approving pharmacotherapies, to quasi-experimental and correlational studies. In
addition, anecdotal case reports, professional opinion and best practice guidelines
8/2/2019 St.onge Paper
14/23
Neurocognitive underpinnings of denial and decision making 14
developed by clinician consensus, such as was used to develop the Treatment
Improvement Protocols published by the U.S. Center for Substance Abuse Treatment,
were considered. Among the meta-analysis, 12-step programs fared 13th from a list of
29 treatment modalities. Topping the chart were motivational interviewing, cognitive-
behavioral treatments, and community reinforcement approaches. Thus, these are the
treatments that I will now discuss.
Motivational interviewing
For addicts, the notion of hitting bottom was often thought to be necessary for a
person to admit he or she had a problem and to accept help. Those who did not reach
that stage were thought not to be sufficiently motivated, Over the past three decades,
however, there has been a gradual yet dramatic shift in thinking about motivation for
change (Miller, 2005). With theoretical underpinning from self-determination theory, a
transtheoretical model for change emerged, in which people are thought to pass
through four discrete stages: precontemplation, contemplation, preparation, and
action/maintenance. The transition between each stage is dependent upon various
motivational tasks. Also, there was new thinking about the addictive personality. After
considerable numbers of research studies on alcoholism, it was evident that people with
alcoholism appeared to be as variable in personality as the general population.
Motivation was seen as a result of an interaction between the drinker and those around
him or her. Motivation was no longer something one has, but rather something that
one does. It involves the recognizing of a problem, searching for a way to change, and
then beginning and sticking with that change strategy (p. 134).
8/2/2019 St.onge Paper
15/23
Neurocognitive underpinnings of denial and decision making 15
Motivational interviewing consists of four strategies: expressing empathy for the
patients problems, developing discrepancy between how the patient is acting and how
that behavior interferes with other life goals, rolling with the patients resistance, and
supporting self-efficacy. Within the developing discrepancy strategy there is room for
the therapist to assist the substance user with feedback on areas in which the lack of
self awareness and denial is playing into repeated patterns of use and abuse. The
FRAMES model is currently seen as a major form of motivational enhancement which
includes these strategic elements. The six key elements upon which the FRAMES
acronym is based: offering non-jugmental Feedback on risks; stressing personal
Responsibility for changing; offering Advice to change when appropriate; providing a
Menu of alternative strategies for change; communicating Empathy for the patient; and
facilitating a sense of Self-efficacy. Organizations, such as The Center for Motivation
and Change in Manhattan, utilizing motivational interviewing techniques among other
cognitive-behavioral and psychodynamic approaches, are reporting excellent results
(from personal training at the Center, summer 2009).
Cognitive-behavioral approaches
Behavioral theories view psychoactive substance use disorders (PSUDs) as
resulting from a combination of factors presumed to interact in different ways to produce
PSUDs depending on each individuals unique characteristics and environment. Basic
assumptions of cognitive-behavioral treatments (CBT) include the following: behavior is
largely learned, rather than determined by genetic factors; the same learning process
that creates problem behaviors can be used to change them; behavior is largely
determined by contextual and environmental factors; and covert behaviors (thoughts,
8/2/2019 St.onge Paper
16/23
Neurocognitive underpinnings of denial and decision making 16
feelings) can change with the application of learning principles (Rotgers, 1996).
Additionally, actually engaging in new behaviors in the contexts in which they are to be
performed is a critical part of change. Like motivational interviewing, a critical task of
CBT is to foster motivation, but it also teaches or re-teaches important coping skills,
such as craving management and works to enhance interpersonal functioning,
communication skills and social support. These goals that can target many of the
cognitive deficits that remain out of awareness in the denying user. Amongst the many
forms of CBT, The Community Reinforcement Approach (CRA) is seen as most
effective, but other approaches include behavioral marital therapy, contingency
management, and dialectical behavior therapy. Systematic desensitization and cue
exposure therapy are two especially useful CBT strategies that can aid in relapse
prevention by bringing into awareness the stimulating effect of drug cues on the
amygdala system.
CRA and Community Reinforcement Approach and Family Training (CRAFT)
The CRA is a comprehensive behavioral intervention for substance-abuse
problems that focuses on multiple problem areas in an individuals life. It utilizes social,
recreational, familial, and vocational reinforcers to aid in the recovery process. The
reinforcing community includes family, friends, work/school, church, and social
activities. This operant program attempts to rearrange environmental contingencies
such that sober behavior is more rewarding than drinking or drugging, and
accomplishes this through positive reinforcement and specifically avoids the use of
confrontation (Smith et al., 2003). The CRA was the first of two treatments developed.
However, since it is common for individuals with substance use disorders to be
8/2/2019 St.onge Paper
17/23
Neurocognitive underpinnings of denial and decision making 17
uninterested in (due to lack of self-awareness and denial) and even opposed to
treatment, CRA was modified so that it could work through concerned family members
and friends of the addict as part of a programmatic effort to get the individual to seek
treatment. Central clinical components include sobriety sampling, developing a
treatment plan that may include optional use of disulfiram or antabuse, behavioral skills
training (such as improving impulse control and decision making skills), social and
recreational counseling, CRA marital therapy, CRA relapse prevention, and other
strategies (such as job counseling).
Psychopharmacological interventions
Abusable substances affect the limbic system of the brain. When dopamine is
released, neurotransmitters attach to specific receptors in the brain which cause a
pleasure response or high. Repeated stimulation of these receptors creates tolerance,
as well as withdrawal. In addiction, there is a decrease in the dopamine receptors
which reduces sensitivity to anything rewarding; the high is decreased, while the craving
is increased. Substance abuse treatment programs refer to the repeated attempts to
replicate the first high as chasing the dragon. The purpose of most
pharmacotherapies is to target the brain receptors or
neurotransmitters/neuromodulators that are dysregulated in addiction to a particular
drug of abuse (Miller & Carroll, 2006, p. 241).
Psychopharmacological interventions for substance abuse tend to fall within four
categories: agonists, indirect agonists, partial agonists, and antagonists. Robust
principles from drug-based research suggest that agonist replacement therapies have
the most efficacy for some drugs, such as methadone for heroin. Agonist therapies
8/2/2019 St.onge Paper
18/23
Neurocognitive underpinnings of denial and decision making 18
have advantages in that they do not require detoxification, they can prevent withdrawal,
and at adequate doses, they can reduce the reinforcing effects of the abused drug by
blocking the involved brain receptor. Partial agonists, such as buprenorphine for
opiates, which have milder agonist properties, less abuse liability, and greater safety,
can be very useful for office-based practice. Antagonists of specific receptors have
generally been found to be ineffective due to problems with adherence, the need for
detoxification, and side effects. Antagonists may be more beneficial with alcohol abuse,
because the antagonist blocks only a subset of the drugs actions and are less likely to
precipitate a withdrawal syndrome or result in discontinuation of the medication.
Indirect methods of inhibiting a drugs reinforcing potential (either positive or negative
reinforcement) that appear promising include medications that enhance the function of
the GABA (a major inhibitory neurotransmitter) system (e.g., topiramate for alcoholism)
or increase tonic levels of dopamine (e.g., disulfiram for cocaine)(from a lecture by Rita
Goldstein at the Stony Brook University Counseling Center where I work as an Extern).
Drugs that primarily make the drug of choice aversive (e.g., disulfiram for alcoholism),
are likely to be associated with compliance problems.
Pharmacotherapy can play a role at different stages of the recovery cycle
including initial abstinence and relapse prevention. The type of pharmacotherapy
needed at each stage may vary. All studies of pharmacological treatments have
incorporated some kind of counseling, from basic education about how to use the
medication to comprehensive behavioral approaches. The intensity and nature of the
behavioral treatment component can influence the overall outcome of treatment for an
individual patient. Combining therapies, such as cognitive-behavioral approaches with
8/2/2019 St.onge Paper
19/23
Neurocognitive underpinnings of denial and decision making 19
psychopharmacological interventions, offers the greatest support in adhering to
treatment.
Psychodynamic approaches
Although psychodynamic therapy is considered one of the less effective
treatments for addiction, I believe it should be considered, at least as an adjunctive
therapy. The one-on-one nature of the therapeutic setting is conducive to
understanding the nature, prognosis and possible treatment of addiction for the
individual person. Winnicott (1960) wrote, Changes come in an analysis when
traumatic factors enter the psychoanalytic material in the patients own way, and within
the patients omnipotence. (p. 37).
Lisa Director, a psychoanalyst who has worked successfully in the field of
substance abuse for many years, claims, Psychoanalysis has much to offer the chronic
substance user: while most drug treatment seeks to end substance-abusing behavior,
the psychoanalytic effort would encompass this goal and extend beyond it to explore
the omnipotent state that finds fruition in drug use and in other patterns of behavior in
his or her life. In effect, the analytic tack would be to treat the patients drug use but
seek to disengage such a symptomatic outbreak from the underlying self-state, which
has needed to be preserved for its history and meaning to the person, and for that
reason, warrants understanding (p. 569).
Director believes that the reason many users devotion to their habit outlasts its
delivery of pleasure is suggestive of unresolved relational dynamics. Drugs, drug
paraphernalia and the various effects on varying mood states and methods of
administration service a wide a range of relational needs. From this perspective, the
8/2/2019 St.onge Paper
20/23
Neurocognitive underpinnings of denial and decision making 20
therapeutic aim is to find the relational bind partly embedded in a persons drug use,
formulate it as conflict in symbolic terms, and revisit it in the transference, alongside
new connections. Meaning though by no means always or solely effective works to
dismantle addiction, by serving to transpose dynamics into terms of expression and
forms of object relationship that are more accessible to exploration and change (p.
571). Director adds: . . .one more reason why psychoanalysts trained in treating
addiction are uniquely suited to be of help to substance users, as compared with other
treatment professionals: We promote the choice of sobriety, of health overall, but
recognize the complexity of the choice, which lends essential pathos to the human
struggle (p. 582)
Regina Pally (2007) offers a technique that helps to bridge neuroscience and
psychotherapy. In her own therapeutic work, she explains neuroscience concepts to
patients to help them understand the link between past relational issues and the
repeated attempts to replicate those patterns in current behavior. She writes,
Unfortunately, some children receive far less than is optimal [in childhood] and must
erect defenses against powerful negative affect states early in life. These defenses
lead to repetitions, which tenaciously resist conscious awareness and change. What
neuroscience adds is that, in addition to defenses, repetition resists awareness and
change because of deeply encoded non-consciously operating predictions (p. 863).
Helping patients to recognize these patterns brings self-awareness to the surface so
that it can be used to inform change.
8/2/2019 St.onge Paper
21/23
Neurocognitive underpinnings of denial and decision making 21
Conclusion
Although I had hoped to learn more about the intersection between the
neurocognitive underpinnings of drug addiction and treatment, what has become
apparent, is that traditional treatment has been slow to integrate or even interface with
findings from the neuroscientific field. Pharmacotherapies address some of the neural
dysfunction and symptomatology of addiction, motivational strategies and CBT
treatments address behavioral issues in drug abuse, and psychotherapy addresses
underlying emotional issues, but much more needs to be done in this area. With
greater understanding of the neuro-structures that most deeply relate to the processes
of decision-making and self-awareness throughout the addiction cycle, including
relapse, treatments need to be devised to support the substance users ability to affect
change. While there may be no exclusively correct answer to which treatment may be
best suited to addiction for substance users, new links combining neuroscience and
psychotherapy should highlight the future direction. In addition, having a neural basis of
insight and self-awareness will enable everyone in the field to work with addicted
individuals with increased understanding, empathy and effectiveness.
8/2/2019 St.onge Paper
22/23
Neurocognitive underpinnings of denial and decision making 22
References
Bechara, A. (2005). Decision-making, impulse control and loss of willpower to resist
drugs: A
neurocognitive perspective. Natural Neuroscience, 8, 1458-1463.
Director, L. (2005). Encounters with omnipotence in the psychoanalysis of substance
users.
Psychoanalytic Dialogues, 15, 567-586.
Goldstein, R. Z., Craig, A. D., Bechara, A, Garavan, H., Childress, A. R., Paulus, M. P.,
and
Volkow, N. D. (2009). The neurocircuitry of impaired insight in drug addiction.
Trends in Cognitive Science, 13, 372-380.
Kosten, T. R,. and OMalley, S. S. (1996). Pharmacotherapy of addictive disorders. In
Miller, W.
R., & Carroll, K.M. (Eds.), Rethinking substance abuse: What the science shows,
and what we should do about it(pp. 240-256). New York: Guilford Press.
Miller, W. R., Zweben, J. & Johnson, W. R. (2005). Evidence-based treatment: Why,
what, where,
when, and how? Journal of Substance Abuse Treatment, 29, 267-276.
Pally, R., (2007). The predicting brain: Unconscious repetition, conscious reflection and
8/2/2019 St.onge Paper
23/23
Neurocognitive underpinnings of denial and decision making 23
therapeutic change. International Journal of Psycho-analysis, 88, 861-882.
Rotgers, F. (1996). Behavioral theory of substance abuse treatment: bringing science
to bear on
practice. In Keller, D. S., Morgenstern, J. and Rotgers, F. (Eds.), Treating
substance abuse: Theory and technique(202-240). New York: Guilford Press.
Smith, J. E., Meyers, R. J., and Milford, J. L. (2003). Community reinforcement
approach and
community reinforcement and family training. In Hester, R. K. & Miller, W. R.
(Eds.) 2003. Handbook of alcoholism treatmentapproaches (pp. 237-258).
Boston: A & B.
Verdejo-Garcia, A., & Perez-Garcia, M. (2008). Substance abusers self-awareness of
the
neurobehavioral consequences of addiction, Psychiatry Research, 158, 172-180.
Winnicott, D. W. (1960). The theory of the parent-infant relationship. In: The
Maturational
Processes and the Facilitating Environment. New York: International University
Press.