Tonmoy Sharma, CEO of Sovereign Health Group, reveals how we must view addiction, and how we can reverse serious cognitive deficits that often go undetected in addiction treatment. Sharma also reviews the need for measurement-based care, and outlines in great detail, how the addiction-treatment industry can evolve to better meet the needs of our patients.

1. Un-frying your Brain – Reversing the
Cognitive Deficits in Substance Abuse
Dr. Tonmoy Sharma
June 2016

2. ADDICTION: a primary, chronic disease of brain
reward, motivation, memory and related circuitry
Un-frying your Brain by Dr. Tonmoy Sharma

3. Un-frying your Brain by Dr. Tonmoy Sharma

4. A Cognitive Behavioral Model of
the Relapse Process
Marlatt and Gordon (1985)
Un-frying your Brain by Dr. Tonmoy Sharma

5. Franken’s Neuropsychopharmacological Model of
Craving and Relapse
• Drug stimuli conditioning
increases dopamine levels 
increases AB for drug stimuli 
‘hypervigilance’
• ‘Hypervigilance’ increases craving
and decreases attentional
resources for other mental
activities
Un-frying your Brain by Dr. Tonmoy Sharma

6. Moss & Albery’s (2009) Dual-Process Model of the Alcohol-Behaviour Link
Dyer, Moss & Albery’s Dual Systems Theory of Addiction
Un-frying your Brain by Dr. Tonmoy Sharma

7. The Cognitive Processing Model
Addictive behavior: more common in people who place excessive
reliance on external structures to maintain a balance between their
physical and psychological needs
• Repeated behaviors become automatic
• Addictive behaviors are regulated by automatic processing
• Impaired control over actions lead to addictive behavior
People can perfectly predict present and future consequences but
they mostly attach greater weight to the present
Immediate reward over future benefit = cognitive myopia
Un-frying your Brain by Dr. Tonmoy Sharma

8. Neuropsychological sequelae of drug misuse
Heavy long term use of alcohol, cannabis, inhalants, opiates & psychostimulants has been
linked to deficits in:
• Attention/executive function
• Learning and memory
• Visuospatial abilities
• Postural stability
(Everitt et al (2001) The neuropsychological basis of addictive behaviour. Brain Res. Rev. 36.129-138 nm’,
f.ryan@psychology.bbk.ac.uk
Working Memory <STM+Attentional control>
• Maintains representations of external stimuli
• Stores action plans
• Goal representations
• Task relevant information
Even when goal maintenance fails in WM, goal is still retrievable from LTM
Kane, MJ & Engle RW (2003) Working memory capacity and the control of attention: The contribution of goal neglect,
response competition, and task set to Stroop interference. J of Exp Psych:(Gen) 132. 47-70
Un-frying your Brain by Dr. Tonmoy Sharma

9. Three Executive Functions
1. Shifting (Switching from addition to subtraction-or from addiction to sobriety)
2. Updating (Monitoring progress, keeping track or goal maintenance- or “I am not going
to use today”)
3. Inhibition (suppressing pre-potent responses e.g. Stroop task or anti-saccade task or
“I will not dwell on my thoughts about drinking”)
Miyake et al (2000) The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A
latent variable analysis.
Cognitive Psychology 41. 49-100.
f.ryan@psychology.bbk.ac.uk
Impaired inhibition and learning in substance misusers
To go, or not to go: failure to suppress pre-potent responses
What is good or bad for me? – impaired learning from implicit or indirect feedback on Iowa
Gambling Task.
Review see Garavan, H. Stout, J.C. (2005) Neurocognitive insights into substance misuse. Trends in Cognitive Sciences 9.195-201
Un-frying your Brain by Dr. Tonmoy Sharma

10. PET/fMRI of Cocaine Craving
Childress et al., 1999; Am.J.Psychiat
Un-frying your Brain by Dr. Tonmoy Sharma

11. Processing biases (latent but increased during craving)
Impairments in executive/frontal processes (subtle and not generally apparent on
psychometric tests)
Implications for therapy
Context is translational or applied research
Cognition and Addiction
f.ryan@psychology.bbk.ac.uk
Basic Assumptions
Executive control is the basis for the regulation of human action.
Recovery from addiction is impeded by cognitive processing biases, impaired goal
maintenance & error detection and compromised decision making.
In combination, these cognitive processes can be latent vulnerability factors for
relapse.
These are potential targets for direct or indirect modification and can index
therapeutic gain.
( Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M.
& Albery, I. (Eds) OUP
Un-frying your Brain by Dr. Tonmoy Sharma

12. Cognitive biases are linked to craving
Cognitive biases are associated with increased craving
Increased craving  increased cognitive bias.
Bias tends towards maintenance rather than engagement: this has implications
for treatment.
(Field, Mogg & Bradley, 2006 Attention to drug-related cues in addiction: Component processes in Wiers, W.W., & Stacey, A.W Handbook
of implicit cognition and addiction.(Eds) Sage. London.
f.ryan@psychology.bbk.ac.uk
Wanting and Liking
Drugs stimulate dopamine neurotransmission in reward pathways
Stimuli associated with this process are invested in incentive properties, an
attributional learning process
In some individuals, repeated drug use produces incremental neuroadaptations
which “hypersensitize” the relevant neural system
This “pathological wanting” is sub-served by mechanisms distinct from those that
govern liking.
Robinson & Berridge,1993
Un-frying your Brain by Dr. Tonmoy Sharma

13. f.ryan@psychology.bbk.ac.uk
Attentional bias priorities cue detection and infiltration of working
memory. The contents of working memory in turn influence attentional
bias.
Result is preoccupation with salient cues.
The “Black and White” Model of Relapse
Un-frying your Brain by Dr. Tonmoy Sharma

14. Relapse Prevention: Specific Intervention Strategies
Un-frying your Brain by Dr. Tonmoy Sharma
Marlatt, Parks, & Witkiewitz, 2002

15. f.ryan@psychology.bbk.ac.uk
Therapeutic Strategies
• Stimulus Control: know the triggers
• Implementation intentions: be aware of and attempt to correct cognitive biases
• Identify alternative rewards/goals
• Self-monitoring
• Distance /de-center / mindfulness meditation
• Challenge expectancies and implicit cognitions via behavioral experiments
• Support self-efficacy
• Goal specificity
Reward radar is always on!
• Emphasis on remediation of cognitive deficits and reversal of cognitive biases.
• Focus on goal maintenance and working memory mechanisms
• Prioritize impulse control strategies
Un-frying your Brain by Dr. Tonmoy Sharma

16. f.ryan@psychology.bbk.ac.uk
Bridging the gap between laboratory and clinic
There are now 45 studies using diverse methods implicating attentional
biases in addiction (Franken, 2003)
• Consistent with the “attribution of incentive salience” to cues that signal
drug availability
• Suggests detection of drug cues is the result of relatively automatic and
involuntary processes that occur outside of awareness.
Biased attentional processes are influential in fostering the persistence or
resumption of drug taking.
This early preferential processing decisively influences subsequent mental
operations such as memory.
Un-frying your Brain by Dr. Tonmoy Sharma

17. f.ryan@psychology.bbk.ac.uk
Implicit Cognitive Processes Can Subvert Therapeutic Allegiance
General implications
Prevention: Deferring age of first use is desirable
Treatment: Needs to be more intensive, more focused on
impulse control including “brain re-training”
Addiction is enduring due to the mandatory role of cognitive
biases and the subversive action of subtle but pervasive
cognitive failure
Un-frying your Brain by Dr. Tonmoy Sharma

18. f.ryan@psychology.bbk.ac.uk
Basic Assumptions
1. Impairment of executive control due to cognitive processing biases,
poor goal maintenance, error detection and compromised decision
making.
2. These cognitive processes can be vulnerability factors for relapse.
3. These are also potential targets for direct or indirect modification and
can index therapeutic gain.
(Ryan, (2006)
Un-frying your Brain by Dr. Tonmoy Sharma

19. Motivational Enhancement
Ambivalence is seen as conflict between controlled and automatic processes
rather than a “balance sheet”
Focus on decision making and goal specification is consistent with recruiting
working memory processes and exerting a “top-down” regulation.
f.ryan@psychology.bbk.ac.uk
Paradigm Shift
Addiction is maintained by enduring changes in priorities and deficits in
information processing.
Therapies that infiltrate and modify this, mainly via working memory processes,
are more likely to be effective.
There is a potential role for cognitive rehabilitation using the prototypical
neurocognitive behavior therapy described.
Conversely, changes in attentional and mnemonic functioning, especially implicit
processes, will index and predict therapeutic gain.
Un-frying your Brain by Dr. Tonmoy Sharma

20. Skill-Training with Alcoholics: One-Year Follow-Up Results
p < .05
SD = 6.9
SD = 62.2
(Mean = 5.1) (Mean = 44.0)
Days of Continuous Drinking
p < .05
SD = 2218.4
SD = 507.8
(Mean = 399.8) (Mean = 1592.8)
Number of Drinks
Consumed
p < .05 SD = 17.8
SD = 17.8
(Mean = 11.1) (Mean = 64.0)
Days Drunk
Un-frying your Brain by Dr. Tonmoy Sharma

21. Skill-Training with Alcoholics:
One-Year Follow-Up Results
p < .05
SD = 17.8
SD = 17.8
(Mean = 11.1) (Mean = 64.0)
Days Drunk

22. Enhancing Outcome
Implicit cognitive processes are plausible
mechanisms to account for involuntary aspects
of addiction
These are potential targets for direct or indirect
modification but component processes (e.g. goal
maintenance) operate in existing treatments
Addressing these processes has the potential to
enhance outcomes
Un-frying your Brain by Dr. Tonmoy Sharma

23. Definitely! Maybe?
Should be doing (good evidence
both laboratory & clinic)
• Focus on addictive habits
• Contingency management
• Encouraging attendance at self-help
“recovery” groups
• Behavioral Couples Therapy
Could be doing (plausible in
laboratory & indicative trials)
• Cognitive bias reversal (attentional bias
reversal; targeting automatic approach
tendencies; implicit challenges or
behavioral experiments)
• Mindfulness practice
• Trans Cranial Brain Stimulation
Un-frying your Brain by Dr. Tonmoy Sharma

24. Therapeutic Strategies With Potential For Increasing
Cognitive Control
• Goal specificity
• Stimulus Control: know those triggers
• Implementation intentions
• Be aware of and attempt to correct cognitive biases
• Identify alternative rewards/goals
• Self-monitoring
• Distance /de- center / mindfulness meditation
• Challenge expectancies and implicit cognitions via behavioral experiments
• Support self-efficacy
Un-frying your Brain by Dr. Tonmoy Sharma

25. f.ryan@psychology.bbk.ac.uk
Summary
In the context of addiction, attentional bias prioritises cue detection and infiltration of
working memory in a reciprocal way.
This compromises executive control.
If therapeutic intervention can increase cognitive control it is likely to reduce
preoccupation with salient cues and attendant cue reactivity.
“The Road to recovery…is paved with good rehearsals.”
Enhanced outcome in addiction requires changes in both controlled and automatic
processing
Automatic processes, previously overlooked, can be reversed through practice and pre-
empted by a range of techniques relying on goal maintenance and cognitive control.
“Tried & tested” interventions need to delineate and accentuate the role of implicit
cognitive processes.
Emerging cognitive bias reversal technologies need to be evaluated and developed for
further use.
To maximise efficiency these need to be easily available.
Un-frying your Brain by Dr. Tonmoy Sharma

26. f.ryan@psychology.bbk.ac.uk
Selected References
Childress, A R et al (2008) Prelude to passion: Limbic activation by “unseen” drug and sexual cues.
Leventhal, A.M.et al (2008). Subliminal processing of smoking related and affective cues in tobacco addiction. Experimental and Clinical
Psychopharmacology. 4. 301-312
Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical
Psychopharmacology. 10. 67-76.
Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP
Soto, D. et al. (2008) Automatic Guidance of Attention by Working Memory. Trends in Cognitive Sciences 342-348
Wiers, W.W., & Stacy, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.
Irvin, J.E, Bowers, C.A, Dunn, M.E. & Wang, M.C.(1999) Efficacy of Relapse Prevention: A Meta-Analytic Review. J. of Consulting and Clinical Psychology.
67.563-570
Ryan, F. (2002) Detected, Selected and Sometimes Neglected: Cognitive processing of cues in addiction. Experimental and Clinical
Psychopharmacology. 10. 67-76.
Ryan, F. (2006) Appetite Lost and Found : Cognitive Psychology in the Addiction Clinic. In Cognition and Addiction. Munafo, M. & Albery, I. (Eds) OUP
Wiers, W.W., & Stacey, A.W. (2006) Handbook of implicit cognition and addiction.(Eds) Sage. London.
Selected Bibliography: Cognitive neuroscience and addiction
Franken, I.H.A. (2003) Drug craving and addiction: Integrating psychological and
neuropharmacological approaches. Progress in Neuro-Psychopharmacology and Biological
Psychiatry.27, 563-57
Garcia, A V, Torrecillas, F L, de Arcos, F A & Garcia, M P (2005) Effects of executive impairments on maladaptive explanatory styles in substance
abusers: Clinical implications.
Archives of Clinical Neuropsychology 20. 67-80
Rogers. R D, Everritt, B J, Baldichino, A. et al (1999) Dissociable deficits in the decision making cognition of chronic amphetamine abusers,opiate
abusers, patients with focal damage to prefrontal cortex, and tryptophan-depleted normal volunteers: Evidence for monoaminergic mechanisms
Neuropsychopharmacology 20. 4 322-339.
Robinson T E & Berridge, K C (1993) The neural basis of drug craving: An incentive sensitization theory of addiction. Brain Research Reviews 18 247-291

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