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“Heroin is My Mother, and Booze is My Father:”Addiction as an Attachment Disorder

“Heroin is My Mother, and Booze is My Father:”Addiction as an Attachment DisorderMichael G BrickerMS, CADC-2, LPCBehavioral Health ClinicianLCS Drug Court Program

Learning Objectives:After today’s Workshop, you should look forward to Being able to identify at least 3 types of childhoodattachment deficits associated with adult SubstanceUse Disorders Understanding how successful SUD treatmentmodalities can effectively remediate dysfunctionalattachment by offering corrective developmentalexperiences Being more comfortable addressing attachmentissues in your own practice, with handoutsyou can use

“Mary, Mary quite contrary how do your neurons grow?”Image: www.brainconnection.com 1999 Scientific Learning Corporation

Brain architecture is built over time (“Epigenetic principle”)

Sequential neuronal developmentAt birth the brain is 25% ofadult size & reaches 90% ofadult size by age 5.The brain develops fromthe bottom up and fromthe back to the front.Impact of theenvironment on thestructure and functionof the brain is greatestduring the first 3 yearsof life.

Hierarchy of Brain DevelopmentFOREBRAINCortex“Executive Center”MIDBRAINLimbic“Emotional Center”HINDBRAINCerebellum &Brainstem“Alarm Center”Abstract ThoughtLogic & ReasoningMemory storageAttachmentContext MemorySexual BehaviorEmotion ReactivityAppetite/SatietyBlood PressureBody TemperatureMotor RegulationBalanceHeart RateBreathing

Neuronal pruning birth age 5 “use it or lose it!”Predominanceof od

Neuronal plasticity has its limits

“Mirror Neurons” seem to beimportant in this process Discovered in the mid-1990’s in monkeys Theoretically, they provide an internal“mirror” of other’s actions, intentions andemotions This becomes an internal representation ormap of interactions with important “others” Could they be the foundation of attachment?

Gene EnvironmentinteractionsEnvironmental interactionscan influence genes as theyare “expressed”. Theirintensity can either reduceor increase genetically basedrisks.

Interaction of nature and nurtureBiologyshapesability to:RecognizespeechDiscernsoundsLink meaningto wordsThe nedVocabularyDialect

Mirror Neurons areimportant in parenting:When you focus on your children's innerexperiences (feelings), something reallyimportant is happening. This focus helpsyou develop a balanced way of regulatingyour child’s emotional states. For example,when you interact using mirror neurons youcan both calm your child when he or she isupset, and you can teach your child to calmhim or herself.Jacque RistauMS, LPC, 2006

Implications First 2 years of life is“blooming” of the prefrontal cortex Experience-basedinteraction is essentialto the process Implicit vs explicitmemory Early experiences reinforced by interactions All children will attach ;what differs is thequality of attachment– To what or whom?– Secure or insecure– Malleable or not? Patterns are persistentbut can change Anger and aggressionare most stable

The child’s brain developmentis governed by 2 processes:Blooming: As the child’sbrain grows there is aninitial “sprouting” ofneurons and synapticjunctions.Pruning: Those neuronsthat are not encouragedto fire gradually atrophyin favor of neuronalconnections that areused.Due to the infant’s limited psychomotor capacity, the brainat this point is a passive recipient, waiting for anexperience. As experiences, interactions andenvironmental stimulation are provided these activatedneurons shape the actual structure of the brain.

And the result is:

Attachment is not just for babies anymore it becomes part of or survival system.(Have you ever had a “gut hunch”about somebody?)Lewis, et. al. (2000)

By the time a child is a year old, they havemade the three most important decisionsthey will ever make: The world is a safe place for me, orit’s not If I make my needs known, they will bemet, they’ll be frustrated or (worst ofall ) I can never tell Either the world is glad that I’m here,or it’s not

Michael G Bricker MS, CADC-2, LPC (2002)

The child’s answer to these three questionsbecomes a “life posture” that is preconscious and durable across the life spanChronic traumaresponseHypervigilenceTrust issuesAttachment D/O’sPersonality D/O’sSecurityMyNO worldis safeYESHealthyAttachmentStablerelationships

The child’s answer to these three questionsbecomes a “life posture” that is preconscious and durable across the life spanInsecurityAmbivalenceTrust issuesExtremes MyNO needs YESare metSense of worthHealthyAttachmentStablerelationships

The child’s answer to these three questionsbecomes a “life posture” that is preconscious and durable across the life spanInsecurityDepressionTrust alitySecurityWorldNO is glad YESI’mherePositiveself- worthHealthyAttachmentStablerelationships

The child’s answer to these three questionsbecomes a “life posture” that is preconscious and durable across the life spanWhen asked to evaluate kids because a parent or professional suspectsRAD, the child is usually exhibiting some combination of problematicbehaviors from the following list: Lack of conscience or empathy for others, manifesting in antisocialWorldbehaviorglad Severe aggression that (atistimes)may appear deliberate on the partof the childI’m Property destructionhere Pathological lying Stealing Removing and hiding food from the family’s kitchen or refrigerator Inappropriate sexual behavior Manipulative behavior

Origins of Attachment TheoryAnn W Smith MS, LPC, LMFT, NCC

Ann W Smith MS, LPC, LMFT, NCC

Mirrorneurons arethe basis ofattunement whichleads toattachmentAfter Bessel Van Der Kolk MD

Ann W Smith MS, LPC, LMFT, NCC

Ann W Smith MS, LPC, LMFT, NCC

Ann W Smith MS, LPC, LMFT, NCC

Ann W Smith MS, LPC, LMFT, NCC

Ann W Smith MS, LPC, LMFT, NCC

Attachment is influencedby trauma or neglect:CAPACITY FOR RELATIONSHIPSIntimacy ---------------------------- IsolationIDENTITYSecure sense of self -- Identity confusionSELF-EFFICACYSense of mastery -------- PowerlessnessSELF-REGULATIONSelf-control --------------------- ImpulsivityAfter Teresa Stroup, MSW

Dr Daniel Sonkin

Dr Daniel Siegel

Dr Daniel Siegel

Experiencecreatesexpectationwhich altersperceptionwhich shapesbehavior

Where does it go wrong? As biological beings, we are “hard-wired” atbirth for survival, attachment, pleasure andcomfort (homeostasis) Brainstem & limbic functions: increases in––––dopamine (motivation & pleasure)oxytocin (bonding & comfort)PEA (excitation & arousal)Vasopressin (social & sexual motivation) Trauma or neglect create highly reinforcedneural pathways in unconscious and preconscious “survival brain” systems

Where does it go wrong?Inconsistent attachment results in diffusememory formation (“fun-house mirror”neurons)Trauma “splintered” memory formationstress fragmented memory storage w/omarkers for conscious recall flashbacksNeglect mis-attribution of self Victimstance: “What’s WRONG with me?” vs“What’s happening to me?”

Where does addiction come in? We are “hard-wired” at birth for survival,attachment, pleasure and comfort. This is abiological imperative, and WILL be satisfied Brainstem & limbic functions––––dopamine (motivation & pleasure)oxytocin (bonding & comfort)phenylethylamine PEA (excitation & arousal)vasopressin (social & sexual motivation) For genetically vulnerable persons, drugintoxication fires the same parts of the brain,and feels like an acceptable substitute

Where does addiction come in? For genetically vulnerable persons, drugintoxication fires the same parts of the brain,and feels like an acceptable substitute “Loaded feels like love!”

The Benefits of OxytocinFear - CortisolCOMFORT - OxytocinAggressionAnti-stress hormoneCauses arousal, Anxiety, Feelingstressed-outActivates addictionsFeeling calm and connected,Increased curiositySuppresses libidoIncreases sexual receptivity –promotes orgasm in womenAssociated with depressionPositive feelingsCan be toxic to brain cellsFacilitates learningBreaks down muscles, bones andjointsWeakens immune systemRepairs, heals and restoresIncreases painDiminishes sense of painClogs arteries, Promotes heartdisease and high blood pressureLowers blood pressure, Protectsagainst heart diseaseObesity, Diabetes, OsteoporosisLessens cravings & addictionsFaster wound healingWhich way would you vote?

Dopamine otivatedAnxietyDepressionCompulsionsAnhedonia - no pleasure,world looks colorlessFeelings of well-being,satisfactionPleasure, reward inaccomplishing tasksSexual fetishesLack of ambition and driveHealthy libidoSexual addictionInability to "love”Low libidoGood feelings towardothersHealthy bondingGamblingErectile dysfunctionHealthy risk takingCompulsive activitiesNo remorse about personalbehaviorSound choicesAggressionADD/ADHDRealistic expectationsPsychosisSocial anxiety disorderMaternal/Paternal loveUnhealthy risk-takingSchizophreniaAntisocial behavior

Actions of PEA on Neurotransmitters Stimulates dopamine’s nerve terminals and activity forfeeling pleasure, libido and emotional wellbeing; Increases epinephrine and norepinephrinecatecholamine activity, for energy production andinhibition of their reuptake; Increases the action of acetylcholine for cognitivefunctions by stimulating the AMPA glutamatereceptors; Elevates mental alertness and mood by suppressingthe inhibitory effects of GABA-B receptors; Enhances serotonin release and its uplifting activity onmood, emotions and control.

Where does addiction come in? Brainstem & limbic functions are similar inpositive attachment and intoxication– dopamine – responds to pleasurable events thatare novel and significantly better than expected– oxytocin – may function to “bond” the user to thenew and pleasurable experience– PEA – triggers the “giddy” lovestruck feeling– vasopressin – may close the motivation loop For attachment-deprived persons, drugintoxication fires the same parts of the brain,and feels like an acceptable substitute So, in the absence of dependable attachment:LOADED WILL DO!

The goal of attachment is homeostasisin a “felt sense of security”3 main characteristics Safe haven – who youturn to when upset Proximity – who do youwant to be close to Secure base – who isalways there for you (Remember Maslow’sPyramid?)3 main functions Reduces stresshormones like cortisol Increase bondingneuropeptides like PEA,oxytocin & vasopressin Shift from sympathetic(activating) to parasympathetic (calming)Autonomic NS

DSM-5 Attachment Disorder revisions

DSM-5 Attachment Disorder revisions Moved out of “disorders Reactive Attachmentof Infancy and earlyDisorderchildhood” in DSM-IV– Minimal emotionalengagement DSM-IV Criteria A & B– Limited positive affectsplit and treated as– Unexpected fear/angerseparate disorders Disinhibited Social Redefined as a traumaEngagement D/Odisorder– Overly familiar verbal &physical behavior withstrangers

Implications for Recovery When we get sober, wenow have lost our“attachment surrogate” The biological imperative is still in force Lacking the developmental attachmentskills, secure sense ofself and self-soothingskills we look for somethingelse to fill the void, eg. cross-addiction “process” addictions and last, but not least the “13th Step” ! Wefind someone who feelslike they’re “the ONE ” so we still don’tdevelop the skills!

Implications for Recovery Now we’re faced withthree unpleasantalternatives:– Sequential engulfment(ultimately unsatisfying)– Isolation (violates thebiological imperative)– Grow up! Get to knowwho I am so that I canconnect in a healthy,meaningful way. So how do we do THAT?We need to find developmentally appropriateexperiences– Unconditional acceptance– Peer support groups Reciprocal positiverelationships– Counseling & therapy– Sponsorship & mentoring