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London iCAAD 2019 - Dr Tena Moyer - BEYOND DUAL DIAGNOSIS: THE HOLOGRAPHIC PATIENT
- 1. THE HOLOGRAPHIC PATIENT BEYOND DUAL DIAGNOSIS Tena Moyer, MD Director of Liaison Psychiatry
- 2. Six blind men wandering in the forest came across an elephant. They had all heard the term “elephant” but had never known one and so they each set upon the elephant to discover what, indeed, an elephant was.
- 3. The first one grabbed the elephant’s tail and, after pulling and tugging and squeezing it, announced “an elephant is like a thick, strong rope!”
- 4. The blind man who had grabbed the trunk vociferously disagreed and countered “No! An elephant is not like a rope, it is like a strong, writhing serpent!”
- 5. A third man, who had grabbed a leg, objected even more adamantly “Both of you are misguided! An elephant is like a broad and towering tree!”
- 6. And so went the various analyses and opinions with the other blind men declaring, having variously grasped an ear “A fan!”……………….
- 7. The side – “A wall!”…………………..
- 8. And a tusk, “A spear!”
- 9. Who’s Right & Who’s Wrong?
- 10. In the midst of all their arguing a sighted man walked by and, asking what the conflagration was all about, explained to them that an elephant was, in fact, nothing like what they described but a creature exactly and entirely like itself.
- 11. And it was at that moment the blind men realized, having previously been unaware of the fact, that they were actually blind!
- 12. DUAL DIAGNOSIS Co-Occurrence of both a mental health and a substance use disorder. Instead of being treated separately and sequentially, the disorders are treated simultaneously. This approach recognizes that each may be both cause and effect of the other and that neither can be successfully treated without addressing both with equal vigor.
- 13. ADDICTION ADDICTION Drugs of Choice Dependence/Withdrawal Medication? Length of Use Consequences Medical Complications
- 16. BIOLOGICAL
- 17. ▪ Born with 100B neurons ▪ Rapid increase in synapse production and density ▪ Synapse pruning deletes synapses not used ▪ Affects brain plasticity ▪ Influenced environmental factors ▪ Occurs in different regions at different times Human Brain Development
- 19. ▪ Myelination ▪ Increases rate of communication between neurons ▪ Region dependent Human Brain Development
- 20. ▪ Mirror Neurons ▪ Activated when seeing motor activity in others ▪ Understanding intentions and actions of others ▪ Activated when seeing emotions of others (pain, fear, disgust, anger) ▪ Basis of empathy? ▪ Present at birth? ▪ Newborns mimic facial expressions ▪ Infants attend to faces Human Brain Development
- 21. ▪ Two Types of Memory ▪ IMPLICIT – non-conscious, emotional, somatic ▪ EXPLICIT – conscious, narrative, semantic MEMORY
- 22. ▪ Present at birth (before?) ▪ Right brain process ▪ Somatic and emotional memory ▪ Unconscious understanding of how to do something ▪ Neural circuits fire without specific recall ▪ Non-verbal ▪ Pre-verbal IMPLICIT MEMORY
- 23. ▪ Hippocampus encodes conscious memory ▪ Immature at birth ▪ Contains stem cells ▪ Respond to stimuli to create memory ▪ Verbalization of episodic/biographical/narrative memory ▪ Semantic memory – acquired skills and knowledge ▪ Starts to come on line around 24 months ▪ Consistent at around 5 y/o EXPLICIT MEMORY
- 24. Brain Development Timeline 1st 2nd 3rd 7 weeks Neurons Synapses Auditory System 18-20 weeks BIRTH Sulci & gyri form Myelination Thickness of cerebral cortex 8-9 mo. Visual Cortex On-line 1 y/o Mirror Neurons – present at birth Facial Mimicry 15 mo 3 y/o Prefrontal Cortex Pruning Consolidation Of language areas Broca’s Wernicke’s 2 y/o Hippocampus Maximum synaptic density 200% of adult
- 25. ▪ Adopted at birth by “good enough” parents ▪ In NICU for 1 month ▪ Twin sister ▪ 1 week in NICU ▪ Anorexia, alcohol, borderline ▪ Multiple in- and outpatient treatments ▪ Highly motivated to get and stay clean and sober ▪ Failed suboxone, naltrexone, methadone ▪ Co-occurring severe GAD, h/o Bulimia - resolved ▪ Bio-mom - addiction, intermittent use during pregnancy ▪ Adopted younger brother - no mood, behavior problems Case study: 22 y/o female with heroin addiction
- 26. ATTACHMENT
- 29. Social Engagement System ▪ Neuroception ▪ Facilitates social behaviors by distinguishing safe from unsafe ▪ Limbic reactivity modulated by temporal lobe responses to intention indicated by: ▪ Facial expression ▪ Quality of voice ▪ Movements (especially hands) ▪ Familiarity Attachment
- 30. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis
- 31. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis OXYTOCIN PhysiologicalEffects Attachment Uterine Contractions Lactation Orgasm Prosocial Behavior Wound Healing Feeding and Satiation Psychological Effects Increased Trust Decreased Fear, Anxiety Decreased Depression?
- 32. Parasympathetic Homeostasis REST AND DIGEST/FEED AND BREED ▪ Decreased HR, RR, BP ▪ Increased absorption from gut ▪ Changes in blood flow ▪ Increase to GI tract ▪ Decreased to skin and muscles Social Engagement System
- 33. Secure ▪ Easy to be emotionally close ▪ Comfortable depending on others ▪ Warm relationship with others ▪ Positive view of self and others ▪ Comfortable with both intimacy and independence Attachment
- 34. POLYVAGAL
- 35. ▪ Divided into two components: ▪ Dorsal Vagal ▪ Ventral Vagal ▪ Each supports different evolutionary survival strategies Vagus Nerve (Cranial Nerve X)
- 36. ▪ Most primitive – occurs in all tertrapods ▪ Unmyelinated – slow transmission ▪ Primarily enervates viscera below the diaphragm ▪ Enervates pacemaker of heart ▪ Slows metabolism in stressful environments ▪ Survival Strategy: FREEZE Dorsal Vagal
- 37. ▪ All tetrapods ▪ Catecholamines (Dopamine, Norepinephrine) ▪ Cortisol ▪ Enervates pacemaker of heart ▪ Amygdala/Limbic System (present at birth) ▪ Survival Strategy: FIGHT or FLIGHT Sympathetic Nervous System
- 38. ▪ Encodes emotional memory and interpretation ▪ Unconscious processor ▪ Not connected to conscious system ▪ Neural circuits ready to fire without specific recall ▪ Sensory input (pain, visual, sound, smell) ▪ Prefrontal Cortex input (planning, complex behaviors, personality) Amygdala/Limbic System
- 39. ▪ Mammalian adaptation ▪ Myelinated – rapid transmission ▪ Enervates organs and structures above diaphragm ▪ Vagal Brake on heart rate (pacemaker) ▪ “FEED and BREED” or “REST and DIGEST” Ventral Vagal
- 40. ▪ Input from the sensory system ▪ Auditory, visual, olfactory ▪ Direct connections to Cranial Nerves controlling: ▪ Speech, Vocalizing ▪ Swallowing, chewing ▪ Facial Expressions ▪ Coordinates breathing, vocalizing, and swallowing ▪ Survival Strategy: FRIENDS & FAMILY Ventral Vagal
- 41. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis
- 42. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis NOREPINEPHRINE Increased HR Increased RR Increased BF Skin Muscles Decreased BF (GI track) Decreased GI activity Increased BP Increased blood glucose Memory formation Increased fat breakdown
- 43. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis NOREPINEPHRINE Increased HR Increased RR Increased BF (skin, muscles) Decreased BF (GI track) Decreased GI activity Increased BP Increased blood glucose Memory formation Increased fat breakdown DOPAMINE Seeking Behaviors Motivation/Desire Reinforcement/Reward Pleasure, Learning, Approach Motor Control Arousal
- 44. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis NOREPINEPHRINE Increased HR Increased RR Increased BF (skin, muscles) Decreased BF (GI track) Decreased GI activity Increased BP Increased blood glucose Memory formation Increased fat breakdown DOPAMINE Seeking Behaviors Motivation/Desire Reinforcement/Reward Pleasure, Learning, Approach Motor Control Arousal CORTISOL Memory Effects Increased emotional short term Inhibits memory retrieval Decreased learning Hippocampal damage Increased blood glucose Counteracts insulin Decreased peripheral uptake Gluconeogenesis Immunosupression Impaired wound healing Disruption of sleep cycle Metabolic/electrolytes
- 45. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Dorsal Vagal FREEZE Hypo arousal Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis *Predator = frightening or failure to soothe Parent as predator*
- 46. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols IED, ODD, CD Antisocial PD Anxiety Disorders GAD, SP, OCD, PTSD, AX NOS Dorsal Vagal FREEZE Hypo arousal Dissociation Depression Numbing Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis *Predator = frightening or failure to soothe Parent as predator*
- 47. ▪ 54 y/o female ▪ h/o childhood abuse – physical, sexual, emotional ▪ Dx’d PTSD, MDD, AX ▪ Inpatient and outpatient treatments – stable for years ▪ Successful marriage, healthy relationships, adult children, successful career ▪ 4-5 years PTA massive increase in anxiety, returned to therapy ▪ Last three years progressive anxiety, confusion, agitation, mood swings, disorientation, cognitive decline, memory loss, episodes of unresponsiveness, blackouts ▪ Marked and sometimes dangerous autonomic instability ▪ Multiple neurological workups – nothing definitive ▪ R/O Lewy Body, Pick’s Dx, early onset Alzheimer’s Case study: Polyvagal
- 48. Trauma
- 49. ▪ Anything that can kill/harm you is potentially traumatic ▪ Lions and tigers and bears ▪ Violence ▪ Illness/injury ▪ If I’m an infant and can’t take care of myself ▪ Hunger ▪ Cold ▪ Abandonment - no one to protect/feed me ▪ Loneliness - I need to feel loved, safe and seen What is trauma?
- 50. ▪ Observed or experienced personally ▪ Military, first responder, MVA, illness/medical, violence, abuse ▪ Explicit memory – narrative recall of experience ▪ May or may not be remembered based on age of experience and ego defenses ▪ Generally presents with classic symptoms of PTSD What is trauma? “Capital T Trauma”
- 51. ▪ Implicit and Explicit memory ▪ Often lacks classic PTSD criteria ▪ Dysregulation, impulsivity, compulsivity, lability ▪ Attachment trauma – implicit memory (up to 2-3 y/o) ▪ Developmental trauma ▪ Children rely on the competence and willingness of adults to keep them safe and meet their needs. If adults are not reliable and safe then it is life threatening. ▪ Depends on age at which events/experiences occur ▪ Mitigated or exacerbated by concurrent events What is trauma? “Little ‘t’ Trauma”
- 52. ▪ h/o alcohol use – 40 years sobriety ▪ h/o DP, AX including several hospitalizations ▪ h/o rheumatoid arthritis, hypothyroidism ▪ 18 mo PTA new onset dizziness, multiple falls, increased pain, DP, AX fogginess, confusion ▪ Medical workup negative ▪ “American Aristocracy” – high SES elegant, gracious Case study: 68 y/o woman c/o chronic pain
- 53. DEVELOPMENTAL
- 54. ▪ Admitted to Comprehensive Assessment Program ▪ Diagnostic clarification ▪ Family Dynamics ▪ Dad: “Get a job or I’m cutting you off” ▪ Wife: “There’s something wrong with his brain” ▪ Mom: “I’m really proud of your commitment to sobriety” Case study: Developmental 54 y/o white male
- 55. ▪ High SES ▪ Parents divorced at 5 y/o ▪ Mother had an affair with neighbor and married him ▪ “I hated my mother after she left my father” ▪ Patient & neighbor’s son saw them “kissing” through the window ▪ Stepfather was abusive ▪ Mother divorced SF but dated “a lot of men when I was in high school” ▪ Patient started smoking MJ 12 y/o with older SB and same age SB – “I felt better immediately”. Early regular use of alcohol ▪ Sobriety since 23 y/o – no relapse since initial treatment ▪ Very active in 12-step community Case study: Developmental
- 56. ▪ No psych history until 3 years ago (51 years old) ▪ No legal history ▪ Major complaints: ▪ “Racing and ruminating thoughts” ▪ “People say I talk fast” ▪ More isolative but still does meetings/sponsoring ▪ “Didn’t feel like getting out of bed” but still went surfing, to meetings, other activities ▪ Diagnosed prior to admission ▪ Bipolar vs MDD ▪ R/O ADHD/ADD ▪ OCD Case study: Developmental
- 57. ▪ Loves music “Especially the Dead. Music makes me feel better.” ▪ Had successful t-shirt company but no regular job ▪ “I’m here because I don’t want my dad to stop supporting me.” ▪ Surfs almost daily, lives in t-shirts and shorts ▪ Bathes 1-2x/wk (“I’m in water every day, why should I have to bathe?”) ▪ Really values social experiences – friends, family, sponsees ▪ Likes sports/physicality “but I was a skinny, scrawny kid and I hated playing team sports” ▪ “I don’t believe in monogamy” Case study: Developmental
- 58. ▪ Testing ▪ Secure attachment style ▪ Lots of “brain chatter” ▪ ADHD ▪ Minimal support of mood disorder ▪ Some histrionic traits Case study: Developmental
- 59. NOTABLE FINDINGS Speech - staccato, short sentences, decreased prosody Substance Use - sober for 31 years. No relapses/slips Legal - none Psychiatric - none until recently Worries - especially about parents’ well-being Ruminates - becomes fixated on contradictions, problem solving Feels relief when soothed Forgetful, disorganized - lots of sticky notes but individual entries, not lists No ordering, counting, checking, rituals, superstitions Difficulty understanding verbal exchanges - discussions, assignments and directions Cooperative, compliant - “I like it when people tell me what to do” Difficulty with attention Diagnostic Considerations
- 60. AUDITORY PROCESSING DISORDER▪ Difficulty with Auditory Discrimination ▪ Difficulty distinguishing different sounds (pat, bat) ▪ Mis-hear words so difficulty understanding ▪ Mis-understands or misses information ▪ Difficulty distinguishing important sounds from background noise ▪ What do I need to attend to? ▪ What do I need to figure out ▪ Impaired auditory memory - short and long term ▪ Difficulty with auditory sequencing ▪ Difficulty recalling lists ▪ Difficulty following instructions in sequence Developmental
- 61. Developmental THEORY AGE STAGE TASKS OUTCOMES/NOTES MAHLER Individuation-Separation 0-3 years old 1) Normal autistic 0-4 weeks 2) Normal Symbiotic 1-5 months 3) Separation- Individuation (5-24 months) 1) Infant only aware of own needs 2) Infant doesn’t recognize mother as separate 3) Exploration and independence competes with dependence on mother 2) Physical needs intertwined with psychological desires 3) Rapprochement Proximity vs Exploration Independence vs Abandonment Object Constancy (24+ months) Internalized mental model of mother Degree of ambivalence reflected in self-concept and confidence FREUD Psychosexual Development 3 - 5-6 years old Phallic Genitals as primary source of pleasure Oedipal conflict with father over mother must be resolved Identification with the father by imitation, emulation and joining with father in behaviors FREUD 5-6 - puberty Latency Sexual impulses are dormant (repressed) Sexual energy is sublimated in school, work, friendships, hobbies and (mostly same gender) play
- 62. Developmental THEORY AGE STAGE TASKS NOTES/OUTCOMES ERICKSON Stages of Psychosocial Development 18 months -3 years old 3-5 years old 5-11 years old AUTONOMY vs SHAME INITIATIVE vs GUILT INDUSTRY vs INFERIORITY Motor, toileting, language Is it ok to be me? Exploration, art, tool making Is it ok for me to move, act, do? Parental encouragement vs intolerance Can I make it in the world? What am I capable of? What do I like/dislike? PARENTS Willpower and Self Control Maladaptation - impulsivity Malignancy - compulsivity FAMILY Purpose and Direction Malignancy - Inhibition Maladaptation - Ruthlessness FRIENDS, TEACHERS, NEIGHBORS Competency, self- direction Malignancy - inertia Maladaptaion - virtuosity PIAGET Stages of Cognitive Development 0-2years old 2-7 years old 7-11 years old SENSORIMOTOR PREOPERATIONAL CONCRETE OPERATIONAL Learn about world through sensations and movement Object permanence Language for demands and cataloguing Symbolic thinking, proper grammar and syntax, imagination and intuition Magical Thinking - events caused by own thoughts Logical thinking Undoing, Conservation
- 63. FAMILY OF ORIGIN FAMILY OF ORIGIN Family Tree Family Dynamics Birth Order Parents’ Family of Origin Family Medical History Family Psychiatric History Eating Disorders Substance Abuse Abuse Extended Family Transgenerational Trauma
- 64. ▪ Admitted because parents concerned about SUDs, EDO ▪ Junior at well-regarded large state university, doing well ▪ Mother with h/o eating disorder ▪ Father with h/o multiple admissions for SUDs ▪ Very high SES (Texas oil money) ▪ Mild-moderate depression and anxiety ▪ Longstanding h/o psychosis since childhood ▪ No Delusions, other psychotic features ▪ Multiple neurological workups – all negative Case study: 21 y/o female college student
- 65. ▪ Oldest of three ▪ Morbidly obese ▪ Maternal grandfather – disordered eating (anorexia?) ▪ Mother – exercise bulimia, disordered eating ▪ Sister – anorexia ▪ Brother – wife with anorexia Listen to Family Stories 30 y/o female with EDO, SUDS, AX, DP
- 67. 45 year old white, Jewish woman ▪ Incapacitating depression and anxiety ▪ Lives with mother ▪ In bed all day, not working since early 30s ▪ Remote history of single suicide attempt ▪ Remote history of cutting as teen ▪ Diagnosed Bipolar, GAD ▪ Every medication and every cocktail known to psychiatry without lasting benefit ▪ Multiple inpatient treatments in different facilities ▪ ECT 5 different times over years with some memory impairment PSYCHODYNAMIC
- 68. FAMILY OF ORIGIN ▪ FATHER ▪ Psychiatrist and psychoanalyst, medical school faculty ▪ Very difficult, narcissistic, demanding mother ▪ Narcissistic - self-absorbed, needed lots of attention but otherwise benign ▪ Poor skills at tolerating affective states of important others - frustration, anger, dismissal ▪ MOTHER ▪ Psychologist ▪ Lost both parents at an early age, lived with various relatives ▪ Narcissistic - splitting, dependent, enmeshed, retaliatory, anxious ▪ Poor skills at tolerating affective states of important others - anger, severe anxiety, self-critical, abandoning ▪ BROTHER ▪ Very rebellious as teen ▪ Psychologist, professor, specializes in marriage counseling
- 69. Timeline ▪ 5 y/o - angry marriage and acrimonious divorce, lived with mother and brother ▪ 5-6 y/o - social/school anxiety: mother went to school with her for a year ▪ 13-14 y/o - developed anorexia ▪ 15 y/o - became orthodox Jewish ▪ Eating disorder resolved ▪ Mother became orthodox shortly afterwards ▪ 18 y/o - went to Israel, first of multiple hospitalizations ▪ Mid-20s - graduated from Princeton, started Columbia graduate school. Lived away from home ▪ Late 20s - teaching at Jewish girls school. ▪ Lived independently with roommate ▪ Dating per Orthodox guidelines ▪ Early 30s - started teaching middle schoolers ▪ Incapacitated by anxiety and perfectionism ▪ Moved back in with mother Psychodynamic
- 70. PSYCHODYNAMIC - FREUD DRIVE THEORY Primitive, instinctual urges are enacted emotionally and behaviorally Libidinal (sexual) Aggressive TRIPARTITE PSYCHE ID Primitive, impulsive, unconscious Pleasure Principle: “I want what I want when I want it” EGO Interface between ID and the world Mediates between ID and SUPEREGO Conscious and unconscious Rational, logical, realistic Reality Principle:”I want what I want but I have to get it in a socially acceptable way” SUPEREGO Morality, social norms Conscious and unconscious Consists of conscience and ideal self Punitive (guilt, shame) and rewarding (pride) Perfectionistic
- 71. Automatic Survival strategies THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols Dorsal Vagal FREEZE Hypo arousal Seek Safety, Soothing Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parasympathetic Homeostasis Parent as predator* ID TO CONSIDER Is the dynamic of depression like a Conversion Disorder? Does dissociation disguised as depression function as an ego defense? Is depression a reaction formation? EGO Regression Retreat to an infantile state Reaction Formation Conversion of unacceptable feelings to opposite Projection Misattributing unacceptable feelings to an other Splitting Good object, bad object Acting out Extreme behavior to express unacceptable feeling Denial Dismissing or avoiding painful or unacceptable feelings Sublimation Channeling unacceptable feelings into productive pursuits SUPEREGO *Punitive Guilt, shame Requesting ECT *Perfectionistic *Convinced others angry *Self-deprecation *Self-critical *Apologetic *Deprived of an adult life FREUD Anger turned inward is depression
- 72. CHARACTEROLOGICAL CHARACTEROLOGICAL Temperament Personality Traits/Features/Disorder Resilience Resourcefulness Relationships Adaptive/Maladaptive Patterns Talents/Skills/Interests Successes/Failures Affect Management/Tolerance
- 73. ▪ Oldest of three ▪ Morbidly obese ▪ Maternal grandfather – disordered eating (anorexia?) ▪ Mother – exercise bulimia, disordered eating ▪ Sister – anorexia ▪ Brother – wife with anorexia Listen to Family Stories 30 y/o female with EDO, SUDS, AX, DP
- 75. ▪ Admitted for severe cocaine abuse ▪ Severe GAD ▪ Stimulant Use Disorder ▪ Benzodiazepine Abuse (prescribed) ▪ Sexual Compulsivity (prostitutes) ▪ Social Anxiety Disorder, by history ▪ Very successful commodities trader ▪ No professional, legal, social, medical fall-out Case study: 35 y/o married male
- 76. ▪ In treatment because wife threatening divorce ▪ Addiction track with sexual compulsivity ancillaries ▪ Extremely anxious and seeking reassurance ▪ Perseveration on wife leaving him ▪ Very compliant with treatment program ▪ Liked by treatment team Case study: 35 y/o married male
- 77. NOTABLE FINDINGS ▪ Highly activating DOC (stimulants) ▪ Highly activating profession ▪ No other negative consequences than possible divorce ▪ Anxious about abandonment: “good boy” ▪ Sexual acting out with prostitutes: “bad boy” Behavior
- 79. AUTONOMIC SURVIVAL STRATEGIES THREAT SNS*FIGHT (Anger) FLIGHT (Fear) Norepinephrine Dopamine Cortisols IED, ODD, CD Antisocial PD Anxiety Disorders GAD, SP, OCD, PTSD, AX NOS Seek Safety, Soothing *Sympathetic Nervous System Ventral Vagal Social Engagement System Oxytocin FRIENDS & FAMILY Parent as predator* Dorsal Vagal FREEZE Hypo arousal Dissociation Depression Numbing Parasympathetic Homeostasis Sexual Compulsivity Represents conflict between desire and anger? Soothing via oxytocin? Acting out anger?
- 80. BUILDING A BETTER ELEPHANT
- 81. SPIRITUALITY
- 82. THANK YOU Tena Moyer, MD tenamoyer@gmail.com
- 83. ▪ Speech Centers in the Brain ▪ WERNICKE’S AREA ▪ 95% in left temporal region ▪ Receptive – comprehension of written and spoken language ▪ Speech processing Human Brain Development
- 84. ▪ Speech Centers in the Brain ▪ BROCA’S AREA ▪ Frontal lobe of dominant hemisphere (usually left) ▪ Motor center for speech production (expressive) ▪ Semantics (meaning) and phonology (sounds) ▪ Contains mirror neurons ▪ Interprets body language and gestures ▪ Ability of infants/children vocally mirror non-word pronunciation Human Brain Development
- 85. SELF PSYCHOLOGY Heinz Kohut ▪ Self ▪ A process or system of organizing subjective experience ▪ Sensations, feelings, thoughts, attitudes towards oneself, others and the world ▪ Maintain consistent patterns of self-regulation, self soothing throughout life ▪ Selfobject ▪ Children rely on others for care, meeting needs ▪ External vs internal meeting of needs ▪ Healthy adult internalizes selfobjects because can meet own needs ▪ Unhealthy self never internalizes selfobjects so reliant on others to meet needs Psychodynamic
- 86. Sympathetic Neurotransmitters/Hormones Chronic Sympathetic Activation Cortisol Memory Effects Increases emotional short term Inhibits memory retrieval Decreases learning (hippocampal damage) Increased blood glucose Counteracts insulin Decreased peripheral uptake Gluconeogenesis Immunosupression* Impaired wound healing Disruption of sleep cycle Metabolic/electrolytes Dopamine Seeking Behaviors Motivation/Desire Reinforcement/Reward Pleasure, Learning, Approach Motor Control Arousal Norepinephrine Increased HR Increased RR Increased BF (skin, muscles) Decreased BF (GI track) Decreased GI activity Increased BP Increased blood glucose Memory formation Increased fat breakdown SOMATAFORM DISORDERS FIBROMYALGIA NON-SPECIFIC INFLAMMATORY SX DIABETES? HYPERTENSION? AUTOIMMUNE DISORDERS?