Impulsivity, Attention Deficits and      Addiction: Perspectives on Concepts,           Diagnoses, and TreatmentChristian ...
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
The Four Quadrant Framework for     Co-Occurring Disorders Less severe        More severemental disorder/   mental disorde...
Mood disorders
Psychosis
Addiction
Anxiety disorders
Adult ADHD Self-Report ScaleADHD screener >50%                          18 questions Adler et al.
CGS
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
genes   environment
CGS      www.thelancet.com Published online February 28, 2013
CGS      www.thelancet.com Published online February 28, 2013
CGS
Consistent with a pleiotropic role of CACNA1C variants ,  neuro-imaging studies have documented effects of  voltage gated ...
genes   environment
Childhood predictors of adult ADHD: Results from theWHO World Mental Health (WMH) Survey InitiativeLara et al.An average o...
Lifetime trauma experience
Stahl	  Essential	  Psychopharmacology	  	  
*	  *	  *	  *	  
*	  *	  *	  *	  
*	  *	  *	  *	  
ADHD	                                Addiction	                                Bipolar	                                Sch...
SJ	  Lupien,	  BS	  McEwen,	  MR.	  Gunnar	  and	  C	  Heim.	  Nature	  Reviews	  Neuroscience	  10,	  434-­‐445	  (2009)	...
SJ	  Lupien,	  BS	  McEwen,	  MR.	  Gunnar	  and	  C	  Heim.	  Nature	  Reviews	  Neuroscience	  10,	  434-­‐445	  (2009)	...
BL	  Thompson,	  P	  Levitt	  &	  GD	  Stanwood	  Nature	  Reviews	  Neuroscience	  10,	  303-­‐312	  (April	  2009)	  	  
|                  |                  |                  |                  |Substance use disorder                  |    ...
SJ	  Lupien,	  BS	  McEwen,	  MR.	  Gunnar	  and	  C	  Heim.	  Nature	  Reviews	  Neuroscience	  10,	  434-­‐445	  (2009)	...
• 	  	  The	  prefrontal	  cortex	  subserves	  conscious	  decision	  making	  (thoughtful	  reflective	  resp• 	  	  PFC	...
Multi-causality and        Pleiotropy is the        standardgenes
Overview •  introduction and context •  etiological considerations •  impulsivity and attention deficits •  interventions ...
Questionnaire      Behavioral TestsCGS
Barratt Impulsivity Scale-11 (BIS)      Patton et al., 1995      •  motor impulsivity      •  non-planning      •  attenti...
UPPS-P Impulsive Behavior ScalePerales et al. 2009•  lack of premeditation•  lack of perseverance•  “negative” urgency•  "...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
fronto-parietal–pre-motor circuits                                           prefrontal–striatalCGS                       ...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
Latent DiscountingCGS                           Peters 2011
DERS: Difficulties in emotional regulaton scale DDT: Delayed Disounting  SST Stop Signal Task SWM: Spatial working memoryC...
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes      Harriet De Wit (20...
Subcomponents attention:      Top down:      Prefrontal Cortex:                        sustain, switch                    ...
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
CGS
Mood stabilizers have been used extensively to treat impulsive disorders.Moderate efficacy in at least half of patients st...
GlutamateBrain (cell)                            Executive                                         Behavior           GABA...
Psychosocial                           Psychotherapy       setting          AbstractEnvironment                           ...
DLPCBrain (anato.)                             Executive                                          Behavior             OFP...
ExecutivePsychotherapy                               Brain                                                    Behavior    ...
SCT: Several researchers tried to improve trait self-control.Successful training generalized to other tasks.To this end, p...
• 	  	  The	  prefrontal	  cortex	  subserves	  conscious	  decision	  making	  (thoughtful	  reflective	  resp• 	  	  PFC	...
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions ...
TREATMENT: diagnosis versus syndrome (domain-specific) informedPSYCHO-          engagement in meaningful activities and re...
TREATMENT: diagnosis versus syndrome (domain-specific) informed                 Cognitive        Contingency           Avo...
Evidence based:                                    Medication                   Regular                  systematic off-la...
Thank you      for your attentionCGS
Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment
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Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment

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This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference, that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada

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Impulsivity, Attention Deficits, and Addiction - Perspectives on Diagnoses and Treatment

  1. 1. Impulsivity, Attention Deficits and Addiction: Perspectives on Concepts, Diagnoses, and TreatmentChristian G. Schütz MD PhD MPHAssociate ProfessorInstitute of Mental Health, Dep. of PsychiatryEmail: christian.schutz@ubc.caMedical ManagerThe Burnaby Centre for Mental Health & Addiction
  2. 2. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  3. 3. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  4. 4. The Four Quadrant Framework for Co-Occurring Disorders Less severe More severemental disorder/ mental disorder/ more severe more severe substance substanceabuse disorder abuse disorder Less severe More severemental disorder/ mental disorder/ less severe less severe substance substanceabuse disorder abuse disorder High severity
  5. 5. Mood disorders
  6. 6. Psychosis
  7. 7. Addiction
  8. 8. Anxiety disorders
  9. 9. Adult ADHD Self-Report ScaleADHD screener >50% 18 questions Adler et al.
  10. 10. CGS
  11. 11. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  12. 12. genes environment
  13. 13. CGS www.thelancet.com Published online February 28, 2013
  14. 14. CGS www.thelancet.com Published online February 28, 2013
  15. 15. CGS
  16. 16. Consistent with a pleiotropic role of CACNA1C variants , neuro-imaging studies have documented effects of voltage gated calcium channels on a range of structural and functional brain phenotypes, including circuitry involved in: •  emotion processing, •  executive function, •  attention, and •  memory.CGS www.thelancet.com Published online February 28, 2013
  17. 17. genes environment
  18. 18. Childhood predictors of adult ADHD: Results from theWHO World Mental Health (WMH) Survey InitiativeLara et al.An average of 50% of children with ADHD continued to meetDSM-IV criteria for ADHD as adults.Persistence was strongly related to:•  attentional plus hyperactive type,•  symptom severity,•  comorbid major depressive disorder,•  high comorbidity,•  paternal anxiety-mood disorder•  parental antisocial personality disorder.Childhood adversity predicted ADHD, but not persistence into adulthoodCGS
  19. 19. Lifetime trauma experience
  20. 20. Stahl  Essential  Psychopharmacology    
  21. 21. *  *  *  *  
  22. 22. *  *  *  *  
  23. 23. *  *  *  *  
  24. 24. ADHD   Addiction   Bipolar   Schizophrenia  Stahl  Essential  Psychopharmacology    
  25. 25. SJ  Lupien,  BS  McEwen,  MR.  Gunnar  and  C  Heim.  Nature  Reviews  Neuroscience  10,  434-­‐445  (2009)  adapted  
  26. 26. SJ  Lupien,  BS  McEwen,  MR.  Gunnar  and  C  Heim.  Nature  Reviews  Neuroscience  10,  434-­‐445  (2009)  adapted  
  27. 27. BL  Thompson,  P  Levitt  &  GD  Stanwood  Nature  Reviews  Neuroscience  10,  303-­‐312  (April  2009)    
  28. 28. | | | | |Substance use disorder | | | | | | | | | | |
  29. 29. SJ  Lupien,  BS  McEwen,  MR.  Gunnar  and  C  Heim.  Nature  Reviews  Neuroscience  10,  434-­‐445  (2009)  adapted  
  30. 30. •     The  prefrontal  cortex  subserves  conscious  decision  making  (thoughtful  reflective  resp•     PFC  is  the  brain  region  most  sensitive  to  detrimental  effects  of  stress  exposure.  •     Even  mild  acute  uncontrollable  stress  can  cause  a  dramatic  loss  of  cognitive  abilities    •     Prolonged  stress  exposure  causes  architectural  changes  in  prefrontal  dendrites   AFT  Arnstein  Nature  Reviews  Neuroscience  10,  410-­‐422  (June  2009)  
  31. 31. Multi-causality and Pleiotropy is the standardgenes
  32. 32. Overview •  introduction and context •  etiological considerations •  impulsivity and attention deficits •  interventions considerations •  summaryCGS
  33. 33. Questionnaire Behavioral TestsCGS
  34. 34. Barratt Impulsivity Scale-11 (BIS) Patton et al., 1995 •  motor impulsivity •  non-planning •  attentional impulsivity 30 items, likert scaleCGS
  35. 35. UPPS-P Impulsive Behavior ScalePerales et al. 2009•  lack of premeditation•  lack of perseverance•  “negative” urgency•  "positive” urgency•  sensation-seeking59-item likert scaleCGS
  36. 36. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  37. 37. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  38. 38. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  39. 39. fronto-parietal–pre-motor circuits prefrontal–striatalCGS Tüscher et al 2012
  40. 40. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  41. 41. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  42. 42. Latent DiscountingCGS Peters 2011
  43. 43. DERS: Difficulties in emotional regulaton scale DDT: Delayed Disounting SST Stop Signal Task SWM: Spatial working memoryCGS UPPS+P Chao 2013
  44. 44. REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)CGS
  45. 45. Subcomponents attention: Top down: Prefrontal Cortex: sustain, switch divide inhibit distraction Inferior temporal cortex: focus Posterior parietal association cortex: orientingCGS
  46. 46. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  47. 47. CGS
  48. 48. Mood stabilizers have been used extensively to treat impulsive disorders.Moderate efficacy in at least half of patients studied have been reported.Results differ across specific mood stabilizers. Positive data have been publishedfor Valproate, Phenytoin, Carbamazepine, Topiramate and Lithium.(not for Gabapentin and Levotireacetam). Some positive results for atypicalneuroleptics (Olanzapine, Aripiprazole, Quetiapine) and antidepressant(Bupropion) have been reported.Based on ADHD treatment Stimulants (Modafinil, Methylphenidate,Amphetamine) Atomoxetine, have lead to positive results in some patients.Cognitive Behavior Therapies, Dialectical Behavior Therapy and ContingencyManagement seem to be more promising psychotherapeutic approaches.CGS
  49. 49. GlutamateBrain (cell) Executive Behavior GABA Relapse Control Dopamine Reward/ Motivation Addiction Serotonin Emotional Mood regulation episode Medication
  50. 50. Psychosocial Psychotherapy setting AbstractEnvironment Executive Behavior ADH Brain Information Control Reward/ Incentives Motivation Addiction Trust/threat Emotional signals regulation Mood episode
  51. 51. DLPCBrain (anato.) Executive Behavior OFPC Relapse Control Striatum Reward/ VMPC Addiction Motivation Amygdala Insula Emotional Mood regulation episode ECT, TMS, DBS..
  52. 52. ExecutivePsychotherapy Brain Behavior CBT, DBT, ME ADHD Control CM SCT, Reward/ GNG Addiction Motivation Mindfulness, Emotional Mood Grounding regulation episode
  53. 53. SCT: Several researchers tried to improve trait self-control.Successful training generalized to other tasks.To this end, participants were asked to brush their teeth or usethe computer mouse with the non-dominant hand, keep a goodposture, avoid slang words, perform Stroop tasks, keep afinancial diary, or adhere to study or exercise plans(Azor Hui et al., 2009; Gailliot, Plant, Butz, & Baumeister, 2007; Muraven, Baumeister, & Tice,1999; Oaten & Cheng, 2006a, 2006b, 2007).GNG: One program aimed at fostering response inhibition.In this study, participants completed an adapted Go/No-Gotask.(Houben, Nederkoorn, Wiers, & Jansen, 2010)CGS
  54. 54. •     The  prefrontal  cortex  subserves  conscious  decision  making  (thoughtful  reflective  resp•     PFC  is  the  brain  region  most  sensitive  to  detrimental  effects  of  stress  exposure.  •     Even  mild  acute  uncontrollable  stress  can  cause  a  dramatic  loss  of  cognitive  abilities    •     Prolonged  stress  exposure  causes  architectural  changes  in  prefrontal  dendrites   AFT  Arnstein  Nature  Reviews  Neuroscience  10,  410-­‐422  (June  2009)  
  55. 55. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  56. 56. Overview •  introduction and context •  etiological considerations •  attention deficits and impulsivity •  interventions considerations •  summaryCGS
  57. 57. TREATMENT: diagnosis versus syndrome (domain-specific) informedPSYCHO- engagement in meaningful activities and relationshipsSOCIALSETTING self organization, structuring, healthy living
  58. 58. TREATMENT: diagnosis versus syndrome (domain-specific) informed Cognitive Contingency AvoidanceSPECIFICINTERVENTION Behaviour Management Training PSYCHO- engagement in meaningful activities and relationships SOCIAL SETTING self organization, structuring, healthy living
  59. 59. Evidence based: Medication Regular systematic off-label Cognitive Contingency AvoidanceSPECIFICINTERVENTION Behaviour Management Training PSYCHO- engagement in meaningful activities and relationships SOCIAL SETTING self organization, structuring, healthy living
  60. 60. Thank you for your attentionCGS

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