la neurobiologia del ”confine” nei … true important questions 1: is there an underlying common...

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LA NEUROBIOLOGIA DEL ”CONFINE” NEI

CONSUMATORI DI SOSTANZE IN COMORBIDITA’ CON I

DISTURBI PSICHIATRICI GRAVI: LA CLINICA DELLA

MODERNITA’Reggio Emilia, 27 Settembre 2017

Felice Nava, MD, PhDDirettore U.O. Sanità penitenziaria,

Azienda ULSS 6 Euganea, Padova

Direttore Comitato Scientifico Nazionale

FeDerSerD

COMORBIDITY OF SUBSTANCE USE AND MENTAL

DISORDERS: THEORETICAL BACKGROUND AND

RELEVANCE

Comorbidity:

“Temporal coexistence of two or more psychiatric disorders as definied

by ICD-10 (EMVDDA, 2004)

Dual diagnosis:

“The co-occurrence in the same individual of a psychoactive substance

use disorder and another psychiatric disorder (WHO)

THE TRUE IMPORTANT QUESTIONS

1: Is there an underlying common aetiological pathway?

2: What is the impact of this coexistence of clinical condition on clinical

care?

PATHWAYS TO COMORBIDITY (1)

Chance: this refers to comorbidity that occurs without causal linkage.

Recognising comorbidity that occurs by chance is important to avoid

false assumptions about causality

Selection bias: this refers to the selection of individuals, groups or daa

that are not representative of the target population. It is sometimes

referred to as the selection effets. The term was coined by Berkson

(1946), who observed tht disease clusters appeared more frequently in

patients seking care than in general population

PATHWAYS TO COMORBIDITY (2)

Causal association: this can be described using four models of

aetiological association that are not necessarily mutually exclusive

(Rhee et al., 2004) and have yet to be applied extensively to the study of

comorbidity

Direct causation model: the presence of one disease is directly responsible for another

Associated risk factor model: the risk factors for one disease are correlated with the risk

factor for another disease, making the simultaneous occurrence of the diseases mire likely

Heterogeneity model: diseases risk factors are not correlated, but each is capable of

causing diseases associated with other risk factors

Independence (distinct disease) model: the simultaneous presence of the diagnostic

features of the co-occurring diseases actually corresponds to a third distinct disease

EVOLUTION OF THE DIAGNOSTIC CONCEPTS (1)

“Primary” and “secondary”: on the basis of age at onset of each

disorder, with the disorder diagnosed at the eariest age being considered

“primary” (Feighner et al., 1972)

Organic versus non organic: subbjects in whom organic factors may

play a significant part in the development pf the psychiatric disturbance

were considered not to have an indipendent psychiatric disorder

(Research Diagnostic Criteria – Spitzer et al., 1978; DSM-III – APA,

1980; DSM-III-R – APA, 1987)


A primary disorder is diagnosed if symptoms are not due to the direct

physiological effects of a substance. There are four conditions under

which an episode that co-occurs with substance intoxication or

withdrawal can be considered primary (DSM-IV, APA, 1994; DSM-IV-TR.

2000; DSM-5, APA, 2013; ICD-10, WHO, 1992)

1: when symtoms are substantially in excess of what would be expected given in the type

or amount of substance used or the duration of use:

2: there is a history of non-substance-related episodes;

3: the onset of symptoms precedes the onset of substance use; and

4: symptoms persist for a substantial period of time (i.e. at least one month) after the

cessation of intoxication or acute withdrawal


A “substance-induced” disorder is diagnosed when the symptom

criteria for the disorder are fulfilled; a primary classification must be first

ruled out, the episode must occur entirely during a period of heavy

substance use or within the first four weeks after cessation of use; the

substance used must be “relevant” to the disorder (i.e. its effects can use

symptoms mimicking the disorder being assesed); and the symptmos

must be greater than the expected effects of intoxication or withdrawal

(DSM-IV, APA, 1994; DSM-IV-TR. 2000; DSM-5, APA, 2013; ICD-10,

WHO, 1992)


The “expected effects”: are the predicted physiological effects of

substance abuse and dependence. They are reflected in the substance-

specific symptoms of intoxication and withdrawal for each main category

of substances. The expected effects can appear identical to the

symptoms of primary mental disorder (e.g. insomnia, hallucinations)

(DSM-IV, APA, 1994; DSM-IV-TR. 2000; DSM-5, APA, 2013; ICD-10,

WHO, 1992)

MECHANISMS OF THE COMORBIDITY OF SUBSTANCE

USE AND MENTAL DISORDERS (1)

The first hypothesis (pre-existent factors - vulnerability) is that the

combination of a substance use and another mental disorder may

represent two or more independent condtions. Substance use disorders

and other psychiatric disorders would represent symptomatic

expressions of similar pre-exisisting neurobiological abnormalities (Brady

and Sinha, 2005)

Key factors:

Biological, genetic or epigenetic factors: Genes, neural bases and environment are

intimately interconnected. All psychoactive substances have a counterpart in, or

correspond to, some endogenous system – such as opioid, endocannabinoid system ect.

An inherited or acquired deficiency in these neurobiological systems and circuits may

explain addictive behaviour and other psychiatric symptoms

Psychobiological traits or states (development disorders): there are disorders that

begin very early in development, possibly through the interaction of neurobiological and

environmental factors, and may present with different phenothypes, such as addiction-

related or other psychiatric symptoms, at different stages of the lifespan (addiction is a

behaviour disorder)



The second hypothesis (self-medication) is that the psychiatric

disorder other than the substance use disorder is a risk factor for drug

use and the development of a comorbid substance use disorder

(Khantzian, 1985; Bizzarri et al., 2009; Leeies et al., 2010; Smith and

Randall, 2012).

Key factors:

Self medication hypothesis: The substance use disorder develops as a results of

attempts by the patients to deal with problems associated with the mental disorder (e.g.

social phobia, post-traumatic stress-disorder, psychosis).

MECHANISMS IF THE COMORBIDITY OF SUBSTANCE USE

AND MENTAL DISORDERS (3)

The third hypothesis (trigger) is that a substance use disorder could

trigger the development of another psychiatric disorder in such a way

that the psychiatric disorder then runs an independent course. Drug use

can function as a trigger for an underlying long-term disorder.

Key factors:

Cannabis and adolescents: It is well known that cannabis use in vulnerable adolescents

can facilitate the development of a psychosis that run as an independent illness

(Radhakrishnan et al., 2014).

Neuroadaptation model: Repaeted drug use leads, through neuroadaptation, to biological

changes that have common elements with abnormalities that mediate certain psychiatric

disorders (Bernacer et al., 2013)



The fouth hypothesis (temporary condition or “substance-induced

disorder”) is that a temporary psychiatric disorder is produced as a

consequence of intoxication with, or withdrawal from, a specific type of

substance. Temporary psychiatric conditions (e.g. psychosis with

features resembling schizophrenia) may be produced as a consequence

of intoxication with specific types of substances (e.g. stimulants, such as

amphetamines and cocaine) or withdrawal contitions (e.g. depressive

syndromes associated with the cessation of stimulant use).

Key factors:

Sharing aetiological factors: Substance-induced disorders may be a transitory state prior

to an independent disorder (Blanco et all, 2012; Magidson et al., 2013; Martin-Santos et

al., 2010).

I Fattori di Vulnerabilità dell’Addiction1

1. Neurobiology of addictive behaviours and its relationship to methadone maintenance.Stimmel B., Kreek

M.J. Mt. Sinai J. Med. 2000 67:375-380.

NEUROBIOLOGY OF ADDICTION

Le Teorie Neurobiologiche dell’Addiction

Teoria Meccanismi Autori di Riferimento

1. Genetico Vulnerabilità Schuckitt

2. Del Piacere Sensitizzazione-

Incentiva

Robinson & Berridge

3. Della Memoria Condizionamento -

Compulsione

Everitt & Robbins

4. Stress Correlato Allostasi vs. Omestasi Koob & LeMoal

5. Della Motivazione e

della Scelta

Ipofrontalità Volkow

6. Attaccamento Relazione Caretti

L’addiction è un disordine…:

IL VALORE TRANCULTURALE DELLA NEUROBIOLOGIA

Marc Schuckit

LA GENETICA DELL’ADDICTION

LA GENETICA DELL’ADDICTION

LA GENETICA DELL’ADDICTION: CONCORDANZA NEI

GEMELLI

Kendler et al., 1998

LA GENETICA DELL’ADDICTION: AMBIENTE VS GENI

True et al., 1999

Virginia Kelley, was married five times, twice to the same man

Bill Clinton Roger Clinton

Terry E. Robinson Kent C. Berridge

2. PIACERE = SENSITIZZAZIONE-INCENTIVA

Gian Luigi Gessa Gaetano di Chiara

PIACERE = DOPAMINA

STIMONALI NATURALI = SOSTANZE D’ABUSO

USO CRONICO = DOPAMINA E SALIENZA INCENTIVA

26

1. Drug of abuse: biochemical surrogates of specific aspects of natural reward?. Di Chiara G., Acquas E.,

Tanda G., Cadoni C. Biochem. Soc. Symp. 1993; 59: 65-81

IL SISTEMA DEL “PIACERE”: LE SOSTANZE COME

STIMOLI NATURALI (1)

Barry Everitt Trevor Robbins

3. MEMORIA = CONDIZIONAMENTO - COMPULSIONE

Dopamina (DA) Glutammato (Glu)

• Le Sostanze d’Abuso e i comportmenti compulsivi incrementano il rilascio di DA

• Gratificazione

•“e’ importante!”

•“la voglio!”

• PFC < NA < VTA

• Le Sostanze d’Abuso e i comportamenti compulsivi influenzano il rilascio di Glu

• Memoria degli effetti (ricerca della sostanza)

•“ok, la ricorderò”

•“bene, la cercherò”

•PFC > NA

Tre condizioni favoriscono la ricaduta:

1. la sostanza (rilascio DA)

2. l’esposizione agli stimoli (rilascio GLU)

3. stress (rilascio CRF)

LA RICADUTA E’ UNA QUESTIONE DI MEMORIA…

Michel Le Moal George Koob

4. USO CRONICO = ASSE DELLO STRESS

(OMEOSTASI VS. ALLOSTASI)

• L’uso cronico di sostanze e l’astinenza induce una attivazione del sistema “anti-reward” in grado di bilanciare l’eccesso del rilascio di dopamina (con un aumento del rilascio dell’ormone dello stress CRF, noraepinefrina, vaopressina, orexina, dinorfina e una diminuzione del rilascio di neurpeptide Y e nocicettina)

• Il cervello non è più in grado di mantenere la normale “omeostasi” neurotrasmettioriale

• Il cervello reagisce attraverso un sistema “allostatico” in grado di alterare il “set point” della soglia edonica

IL RUOLO DELLO STRESS NEL CONSUMO DI SOSTANZE

Sex

Sex

Job

Promotion

Job

Promotion

Disdneyland

Disdneyland

ALLOSTASI INDOTTA DALL’USO CRONICO

Nora Volkow

5. ADDICTION: IPOFRONTALITA’

L’USO CRONICO DETERMINA UNA RIDUZIONE DEI

RECETTORI D2 DELLA DOPAMINA E UNA

IPOFRONTALITA’

• “myopia for the future,” cognitive impulsiveness:

- gratificazione immediata

- insensibilità alle conseguenze negative (e positive);

• craving

LE CONSEGUENZE DELL’USO CRONICO

La relazione di attaccamento è in

grado di condurre a cambiamenti delle

strutture neurobiologiche (Schore,

2001; 2002; Siegel, 2001)

6. LA NEUROBIOLOGIA DELL’ATTACCAMENTO

Strathearn et al., 2008

STIMOLO “SORRISO”: ATTACCAMENTO SICURO vs.

INSICURO

(DISTANZIANTE)


STIMOLO “PIANTO”: ATTACCAMENTO SICURO vs.

INSICURO

(DISTANZIANTE)


STIMOLO “MIO BIMBO” “ALTRO BIMBO””:

ATTACCAMENTO SICURO vs. INSICURO

(DISTANZIANTE)

TRAUMAATTACHMENT

ADDICTION

“Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and to train him to become any type of specialist I might select – doctor, lawyer, artist, merchant chief, and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors”

John Watson, 1930

• Attachment is a deep and enduring emotional bond that connects one person to another across time and space (Ainsworth, 1973; Bowlby, 1969)

• Attachment does not have to be reciprocal

WHAT IS ATTACHMENT

BASIS OF ATTACHMENT

SECURE ATTACHMENT

• Caregiver

- responds to child’s needs consistently, promptly and appropriately

• Child

- uses caregiver as secure base for exploration

- protest caregiver’s departure

- seeks proximity to caregiver

- comforted by caregiver’s return can return to exploration

• The world is a safe place

• Adults care and can be trusted

• I am good

• I am lived and lovable

• Other people are ok

• I can trust and be myself

SECURE ATTACHMENT WORLD-VIEW

AMBIVALENT ATTACHMENT

• Caregiver

- inconsistent response to child’s needs (appropriate/neglectful)

- increased responsiveness with increased agitation/demand

• Child

- unable to use caregiver as secure base

- seeks proximity before separation

- slow to warm on caregiver’s return

- slow to return to exploration upon caregiver’s return

- seek contact but angrily resists when provided

FEARFUL ATTACHMENT

• Caregiver

- Frightened/frightening behaviours

- Oscillation between intrusive and withdrawn engagement

- Parental role confusion (tking role of the hild, asking child to take role of caregiver)

- Emotional communication errors

• Child

- Freezing, rocking

- lack of coherent coping

- Disorganized behaviours (e.g. approaches caregiver but with back turned)

DISORDER ATTACHMENT

SECURE AVOIDANT

AMBIVALENT FEARFUL

LOW DISTRESS

SEEK

DISTANCE

HIGH DISTRESS

SEEK

CONTACT

• The world is a dangerous place

• Adults (authority) will hurt me and cannot be trusted!

• I am worthless, “dirty”, and no good

• I am unloved and unlovable

• I need to keep people at a distance through negative behaviours so they cannot hurt me again

• I must control everybody and everything through lies and manipulation to be safe

ATTACHMENT DISORDER WORLD-VIEW

Autonomous (Secure): positive view of self and partner; comfortable with intimacy and interdependence

• relationships serve as a protective factor from stress

ADULT ATTACHMENT STYLES

Preoccupied (Ambivalent): seek approval through responsiveness of partner; emotionally impulsive and expressive in relationship; ongoing preoccupation with past painful experiences with parents

• difficulty regulating emotions

• low frustration tolerance


Dismissing (Avoidant): value independence; uncomfortable with emotional intimacy

• loneliness

• few social supports

• low levels of positive affect


“If human beings do not have the abiity to experience pleasure from healthy relationship, they will seek that pleasure in artificail means and the seeds for substance abuse are planted”

Dan Hughes, PhD

• Makes the actions of ourselves and other understandable

• Occurs through narrative – feeling/behaviours get “clearer”

• Learning through social feedback, mirroring, and accurate empathy

- First we are mentalized by others

- Then we mentalize ourselves

- Later, we can mentalize others

• This helps us to contxtualize our experiences, particularly the trauma

MENTALIZING

“Repeated experiences of parents reducing uncomfortable emotions (fear, anxiety, sadness, anger), enablig the child to feel soothed and safe when upset, becomes ancoded in implicit memory as expectations and then as mental models or schemata of attachment, which services to help the child feel an internal sense of a secure base in the world”

Dan Siegel, MD

• Take an attachment history

• Adverse childhood experiences survey (ACES)

• Adult attachment interview (AIA)

• Review of past relapse experiences through the “attachment lens”

ASSESSMENT OF ATTACHMENT DISORDER IN ADULT

Gotay et al., 2004, PNAS, 101: 8174-8179

LO SVILUPPO CEREBRALE

NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

AgeAge at tobacco, at alcohol and at cannabis dependence as per DSM IV

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

5 10 15 21 25 30 35 40 45 50 55 60 65% in

eac

h a

ge g

rou

p w

ho

dev

elo

p

firs

t ti

me

de

pen

den

ce

THCALCOHOL

TOBACCO

L’ADOLESCENZA E L’ADDICTION

Emotional Reactivity

Cognitive

Regulation

Emotional responses are heightened Cognitive controls are immature

Double Jeopardy!

THE IMBALANCES ADOLESCENT BRAIN

• Each stage of development, from infancy to early adulthood, is associated with a certain expected range of:

- intellectual ability

- language development

- cognitive, emotional and psychological functioning

- social competency skills

• Each needs attention to prevent the onset of drug use and dependence!!!

DEVELOPMENTAL PHASES

• Protective traits, skill sets & experiences:

- responsiveness to the environment and caregivers’ interaction

- caregivers who are responsive

- surroundings that provide stimulation

- learning how to be effective in having needs met

- easy to soothe

- not temperamental

INFANCY

• Factors predictive of later social competence:

- language

- cooperation

- control of emotions

- collective conscience

- social and emotional skills (including perception of others’ emotion)

- problem solving

EARLY CHILDHOOD

• Emerging executive cognitive and emotional regulatory functions:

- maintaining attention

- controlling emotions

- social inclusivity

- effective communication

- receptivity to others

- accurate perception of emotion in self and others

MILESTONES IN MIDDLE CHILDHOOD

• Integral to self-regulation of emotion and behaviour to prepare for adulhood:

- social and emotional skills to estabilish stable relationships

- conflict resolution

- prosocial skills

- impulsive control

- decision making

- problem solving

ADOLESCENCE

• Behavioural problems underlying drug use all involve poor self.regulation

• Social and physical environmental risk factors impact on executive-cognitive functions and emotion regulation. This impact depends on:

- personal characteristics (e.g. depression, high activity levels, attention deficit disorders, etc.) which develop and evolve over time

- development period of exposure to risk factors

- not only adolescence!!!

• Development phase determines what program components and polices will be understandable and executable

SIGNIFICANCE OF DEVELOPMENT PHASES FOR

ADDICTION VULNERABILITIES

INTERACTION OF PERSONAL CHARACTERISTICS AND

THE MICRO- AND MACRO-LEVEL ENVIRONMENTS

PRIMARY DEVELOPMENT OUTCOMES AND THEIR

ENVIRONMENTAL AND PERSONAL INFLUENCES

TYPES OF INFLUENCES ON BEHAVIOUR

• Personal Characteristics• Neurological delays

• Stress reactivity

• Mental health and personality traits

• Micro-Level Factors• Family

• School

• Peer

• Macro-Level Factors• Income and resources

• Social environment

• Physical environment

NEUROLOGICAL DEFICITS AND DELAYS

• When the prefrontal cortex is slow to develop or not functioning properly:

• Inability to accurately interpret social cues

• Negative emotions dominate

• Impulsivity & low self control

• Insensitivity to consequence

• But…heightened sensitivity to rewards

• Sensation-seeking

• Poor stress reactivity

• Inattention

IMPLICATIONS OF DELAYS IN BRAIN DEVELOPMENT FOR

BEHAVIOR

• The signs of poor self-regulation due to deficits and delays vary as a function of developmental stage:

• In younger children: language delays, poor school readiness and academic achievement, conduct problems, negative affect, insensitivity to consequences, and impulsivity.

• In late childhood and early adolescence: aggression, sensation-seeking, delinquency, negative affect, and poor decision making and coping skills.

• Detrimental environmental conditions (stress, maltreatment, poor nutrition, and other adversities) further compromise brain development and increase risk for drug use and addiction.

STRESS EXPOSURES AND REACTIVITY

• Stress compromises development of brain systems that are at the basis of social, behavioral, cognitive, and emotional functioning

• Stress disrupts hormones that regulate these functions

STRESS, DRUG USE AND ADDICTION

• Stress activates the same brain [reward] systems responsible for the positive reinforcing effect of drugs

• It may damage and cause further delays to the brain & ECFs

• It increases physiological sensitivity to drugs

• It increases desire to improve mood with drugs after exposure to stress

• Stress more strongly predicts drug use when there is a psychiatric disorder, poor parenting, family dysfunction, and adverse neighborhood characteristics.

• Stress, lack of social supports, and poor coping skills predict early onset and escalation of drug use, relapse, and treatment resistance.

SEX DIFFERENCES IN STRESS RESPONSES

• Girls report more negative life events during adolescence than boys and are more adversely affected by them, especially interpersonal stressors.

• Depression and anxiety are more common in girls starting in early adolescence.

• Interestingly, Post-Traumatic Stress Disorder (PTSD) often precedes drug use in girls, but occurs more often after drug use in boys.

• Girls are at increased risk for substance abuse when exposed to the stressors of family violence and alcoholism.

• Preventive Implications: Sex differences should be taken into account in identifying factors that contribute to drug use and in the development of a prevention or treatment plan.

MENTAL HEALTH PROBLEMS (1/2)

• Mental Health Disorders are strongly linked to drug use and dependence.

• Internalizing Disorders (PTSD, Depression, Anxiety disorders, Bipolar disorder)

• Brain responses are heightened in response to stress.

• Tendency to self-medicate the anxiety & depression this process causes.

MENTAL HEALTH PROBLEMS (2/2)

• Externalizing Disorders (Conduct Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Antisocial Personality Disorder)

• Low level of arousal in these disorders is related to an insensitivity to consequences and a need for more stimulation.

• Heightens risk for continued drug use to relieve symptoms

• Tend to be resistant to substance abuse treatment

• Exacerbates stress reactivity problems

PERSONALITY & TEMPERAMENT

• A difficult temperament and certain personality characteristics are consistently related to heightened risk for drug use.

• Impulsivity

• Aggressiveness

• Sensation or novelty-seeking

• Negative affect

• Impaired judgment

• High activity level

• Risk taking tendencies

• Lack of regard for negative consequences

• Lack of pain avoidance responses

• Abnormal levels of arousal in response to stress.

IMPORTANCE OF PERSONALITY IN ADOLESCENCE

• Normal adolescence is characterized by greater reward anticipation, sensitivity, and sensation seeking—particularly social rewards (e.g., peer regard, gains in social status).

• It follows that adolescence is the period during which drug use onset is most common.

• And, therefore, that adolescents with especially high levels of any combination of these traits are at heightened risk.

• Preventive Implications: These traits can be redirected through psychosocial means to decrease risk for drug use. Prevention programs must be designed to specifically redirect this developmental track.






• School

• Peer




PARENTING STYLES THAT INTERFERE WITH HEALTHY

CHILD DEVELOPMENT

• Negative influences• Insecure attachment

• Lack of warmth & affection

• Lack of supervision & monitoring

• Poor disciplinary tactics

• Inconsistent

• Reinforcements for negative behaviors

• Severely negative influences

• Harsh

• Restrictive

• Domestic violence

• Abuse & neglect

• Hostile

• High in conflict

• Emotionally triggered

• Caregivers who are not responsive

LINKS TO AGGRESSIVE BEHAVIOR & DRUG USE

• Children exposed to stress and conflict in the home are more likely to:

• Become more behaviorally and emotionally maladjusted

• Have high levels of mental and physical health issues

• Manifest high levels of aggressive behavior, the strongest predictor of later drug use and other risk behaviors

• Characteristics of the family (e.g., cohesion, supportive, communicative) influence the ability to develop resiliency skills.

• Preventive Implications for Exposed Children: Training in parent skills, relieving the stressors and mental health problems of caregivers, and trauma prevention and treatment strategies.

MICRO-LEVEL INFLUENCES: SCHOOL AND EDUCATION

• Lack of education or poorly equipped schools and teachers:• Slows child development, particularly cognitive functioning

• Interferes with development of self-regulatory and social skills

• Increases levels of stress, perceptions of inadequacy and failure

• Related to lack of parental involvement in schooling

• Compromises attachment to school (a resiliency factor)

• Prevents us from availing ourselves of opportunities for early detection, intervention and treatment

• Compromises children’s ability to succeed in life

• Preventive Implications: Quality of schools, its teachers, curriculum, and students’ social networks in school are major socializing influences to be taken advantage of.

MICRO-LEVEL INFLUENCES: PEERS (1/2)

• Peer relationships are influential socializing experiences that affect attitudes, skills, and “normative” behaviors:

• Can supersede parent influences.

• Presence of peers undermines executive decision making.

• Time spent in unstructured settings (e.g., on street) heightens this effect.

MICRO-LEVEL INFLUENCES: PEERS (2/2)

• Social networking technology removes parents from interactions with the child, further reducing their influence

• Preventive Implications: Parents’ use of rules to monitor adolescents’ activities and encouraging healthy outside-the-home activities are critical to reducing negative peer influence.

SEX DIFFERENCES IN PEER INFLUENCES

• Girls are influenced by peers differently than boys:• More likely to use drugs if friends & partners are using or introduces

drugs to them.

• Concerns about peer approval, depression and body image – all interrelated – increase susceptibility to drug use in girls.

• Early onset of puberty increases risk for risky behaviors. • Tend to date at younger ages and be with older risk taking males

• More conflict with parents around issues like dating, selection of friends, and shifting behavioral expectations.

• Higher levels of conduct problems

• Living in a poor community exacerbates the effect of peers on drug use risk for both sexes.






• School

• Peer




MACRO-LEVEL INFLUENCES OF POVERTY (1/6):

SOCIETAL LEVEL

• Affects the quality of the environment

• Limits choices and opportunities for adults to help children

• Places a strain on social systems and supports

• Increases conflict

• Has adverse effects on parent and child health

• Breaks down cooperation among residents and between community organizations

• Consequences for children:• Difficult to teach children effective social skills they will need to

interact with peers and other adults• Poor children are much more likely to grow up to be poor adults and

raise children who suffer the same problems


HARMING INDIVIDUAL CHILD AND YOUTH DEVELOPMENT

• Increases stress in caregivers• Less able to attend to basic and emotional needs of the child

• Child maltreatment and neglect is more common

• Reduces ability to invest in learning & educational opportunities in school and day care

• Compromises ability to be involved, patient, responsive and nurturing parents to their children throughout development.

• The caregiving environment is more disorganized and lacking in appropriate stimulation and support

• Creates conditions that are stressful for children• Interferes with growth, ability to respond adaptively to stress,

development of psychological health and self-regulatory skills


THE SOCIAL ENVIRONMENT

• The social environment of the larger community influences drug use risk through:

• Shaping social norms

• Enforcing patterns of social control

• Influencing beliefs about the risks and consequences of using drugs

• Effecting stress responses

• Critical to maintain neighborhood viability and cohesiveness

• Peers during adolescence are especially influential


DISCRIMINATION

• Discrimination and social exclusion have profound negative effects:• Physical and mental health disorders, including drug use and dependence

• Poor educational attainment & lower levels of employment

• Restricted access to services and social supports

• Effects are compounded for immigrants.


POLITICAL INSTABILITY

• Disrupts basic services; housing, sanitation, water, & health care

• Orphaned, living alone on the street, or forced to be soldiers

• Violence, unhealthy conditions, traumatized, and victimized

• Deficits and delays in numerous functional domains

• Preventive solutions could be found in governments that:• Protect child welfare

• Prohibit them from entering war zones

• Meet rehabilitation needs

• Provide shelter, food and clean water

• Provide psychosocial support to overcome damage

MANY ASPECTS OF THE PHYSICAL ENVIRONMENT

HARM CHILD DEVELOPMENT

• Affects social relations, crime and drug use:

• Decayed and abandoned buildings

• Ready access to alcohol and drugs

• Neighborhood disorder: vandalism, graffiti, noise, and dirt

• Urbanization of the area

• Neighborhood deprivation

• Neurotoxins: lead, cadmium, mercury, arsenic, second-hand smoke

• Prenatal exposure to drugs, alcohol, toxins, and nicotine

• Negative [pro-drug] media messages

Attaccamento Trauma

Sistema Edonico/

Apprendimento e Memoria

Relazione

Neuroni a Specchio

Addiction

IL CAMBIO DELLA PROSPETTIVA


NEUROBIOLOGY OF ATTACHMENT

Trauma e asse dello

stress.

Rilascio di epinefrine

e cortisolo.

Stimolazione delle

aree limbiche

NEUROBIOLOGY OF TRAUMA

Ipertropia dell’amigdala:

Incapacità di spegnere il segnale di allarme da altre

aree cerebrali

Atrofia dell’ippocampo:

Difficoltà di apprendimento e di memoria

Ipofrontalità:

“Shut down” delle funzioni esecutive: controllo degli

impulsi, deficti di working memory e della flessibilità

cognitiva

CLINICAL CONSEQUENCES OF TRAUMA

Newlin, Renton, 2010

NEUROBIOLOGIA DEI NEURONI A SPECCHIO

Attaccamento - TraumaCore Dynamic

of Risk Factor

Reazione

Temperamentale

Autoregolazione del Sé

(Relazione)

Risonanza

Affettiva/Emozionale

Instabilità

Emozionale/Affettiva

(Autostima)

Consumo PatologicoBreak Down

Relazionale

IL CAMBIO DELLA PROSPETTIVA

"La Relazione è elemento necessario ma non sufficiente”

Ezio Sanavio

Tecnica Relazione Tecnica Relazione

IL RUOLO DELLA RELAZIONE NELL’ADDICTION

• Il primo passo:

- rendere la relazione “inclusiva”

- condurre la relazione “sul qui ed ora”

- il terapeuta deve dimostrare interesse alla storia e alla vita

del paziente (“ingaggiare”)

IL SIGNIFICATO TERAPEUTICO DELLA RELAZIONE

• Il secondo passo:

- individuare i blocchi

- riparare le “rotture”

- il terapeuta deve

trasmettere che “una

base sicura nei fatti è

sicura”


• Il terzo passo:

- “mentalizzare”

- il terapeuta deve

permettere al paziente di

“raggiungere una più

profonda riflessione di

tipo emozionale e

cognitivo”


• Il quarto passo:

- “coinvolgere e lottare contro le tendenze distruttive”

- il terapeuta deve trasmettere il limite dimostrando che è

presente, coinvolto, non disinteressato e capace di

supportare ed agire…


• Il quinto passo:

- “favorire l’uso degli strumenti per accrescere la

consapevolezza”

- il terapeuta e il paziente sono un noi ed il colloquio si

trasforma in una conversazione


Le terapie per l’addiction devono essere riabilitative:

- efficaci, appropriate e sicure

- individualizzate ed integrate dalla relazione

Le terapie per l'addiction devono essere “patogenetiche”

La “relazione” per essere terapeutica:

- capacità di ascolto

- cura del “paziente malato” a quella della “persona che vive la

malattia”

- migliorando la capacità terapeutica e di riorganizzazione delle cure

- scoprendo il senso della cura

- rendendo la cura più sostenibile

IL VALORE DELLA RELAZIONE COME DIMENSIONE

DELLA CURA

la neurobiologia del ”confine” nei … true important questions 1: is there an underlying common...

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