The Neuroscience of Addiction - with Marc Lewis

I can adapt and go straight in. I used to have a slide that said, you know,

addiction

can be defined in all these different ways like a disease, a choice, a self-medication, a social definition, etc., but now I'm going to cut to the chase and say That the predominant definition of

addiction

these days is that it is a disease and that is a definition that has been evolving over the last more than half a century. In a way, I come from a confluence between the 12-step movement, the AAA movement of the '30s and psychiatric medicine, particularly in the '50s and '60s, these two strange bedfellows came together and since then, the world of addiction treatment and the psychiatric view of addiction has been a chronic illness, you know. a a defines it as a permanent and essential characteristic of people and that is why they have to be very careful forever for the rest of their lives and that evolved into the current definition through the recent advancement in

neuroscience

and

neuroscience

technology and findings which, of course, have been huge and now people talk about addiction as a brain disease, okay, so it's defined as a brain disease and here are the main components of the definition from NIDA, the National Institute on Drug Abuse.

Drugs. Oh, this is, I'm sure there's a parallel organization here, but it's part of the NIH, the US National Institutes of Health that actually funds 90% of the addiction research in the world, it's a lot. and the National Institutes of Health, although they are obviously medically oriented, so this is the definition they come up with. I might need my glasses for this, yes I might. Please identify yourself with another stiff neck, here we go, addiction is defined as a chronic relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences, this is emphasized by imaging studies brain of people addicted to drugs. physical changes in the areas of the brain that are critical for judgment, decision making, memory learning and behavioral control, all good things and again, physical changes in the brain.

This is usually a website and is in all their literary publications, talks and articles. and finally the last important point is that in vulnerable individuals the disease of addiction is produced by the chronic administration of the drugs themselves, in other words, the drugs cause the addiction that has been part of the hegemony that the dominant view for a long time Alright. here's the model um and yeah I'm just going to give you the simplified version of the VAL model and it's not a model that I don't agree with because of the way it's pretty well researched and well defended and there have been many studies that converge in this type of addiction model there are three regions to think about first: the prefrontal cortex in particular, the dorsal lateral prefrontal cortex is the most sophisticated region here and is responsible for judgment, decision making and decision making. perspective. self-regulation, all that good stuff and you can think of that as the bridge of the ship, that's where we direct our behavior that tells where we're headed from, so there's that region and then there's the striatum, which the ventral striatum sometimes It is called core. accumbens you'll see that a lot in the addiction literature and we can call it the motivational engine, so the striatum evolved as part of the motor system and it actually makes us mammals act and basically pursue goals because that's what we do when In the act, we pursue goals, the goal could be to get away from something, but in this case let's focus on getting to something and it also generates the motivation to do it, so mammals, unlike frogs, need a push to achieve that goal. do something and with a motive or an emotional impulse, you know, we don't just look at the tongue when a fly passes by and we have to feel some type of attraction and that is generated by the striatum, so you can see that that is an important region of the brain when it comes to addiction and then this part of the midbrain, the ventral tegmental area, is called the dopamine pump, it makes dopamine, which is a neural network, it partly energizes the striatum, turns on all the cells in the striatum and gets the striatum. focus on the goal so that it narrows the beam of attention and drives the behavior towards the goal and yes, that is what does, it focuses and drives the behavior and allows it to follow a sequence of steps that leads to the goal that is After The particular thing, what happens in addiction is that you get a lot of dopamine that goes up from the midbrain to the striatum in the presence of drugs, alcohol, gambling, sex, pornography or pizza, whatever it is that you're into. you are addicted, etc. the striatum activates and focuses on the goal and that happens over and over again and it happens in response to cues or stimuli that are connected to the activity of choice, what you want is fine, so the other problem is that there is naturally, a balance between the activation of the striatum and the activation of the prefrontal cortex because these impulses need to be controlled and we know this all the time, in every moment of our waking life, there is practically some kind of balance between the impulse and the control of self-regulation that modifies behavior in favor.

Some of you know better long term consequences and also what happens is that this bundle of fibers that connects these two regions becomes less crosstalk, so there is a reduction in communication between the striatum and the prefrontal cortex and what happens. Over time, these two systems become less connected and you may even think that they are somewhat disconnected from each other when, in the presence of drugs, cues or other associated stimuli, it does not mean that this disconnection is always there because you can live a very normal life and doing very normal, well-planned things that require judgment and logic, but when those signs are present when you're driving, walking around the pub or the liquor store or you know you're using your dealer. calls, that's when this disconnection happens over and over again, so that's the problem, right, it's a big problem.

We all agree that it is a big problem. Okay, so this is what this is a graph that shows what happens when people use drugs like cocaine. alcohol and heroin, yes, over a period of time and over time, what you get in certain regions, according to several different labs, you get a real reduction in gray matter volume in some of these regions of the prefrontal cortex, dorsal prefrontal cortex and that's a very close relationship. related region called anterior cingulate cortex server connected and what this shows is that gray matter volume decreases with the year and duration of addiction.

Well, this dotted line is a baseline of the normal population of people who have never been addicted. This line shows What happens with addicts and the loss of gray matter volume means that they are losing synaptic densities, they are losing synapses, they are not brain cells, they are not dying, they are not cells, they are not dying, but the connections, you are losing density. of connections decreases over time, well, that's a pretty important finding and well, it sounds like a disease or it seems like something is really going wrong with the brain, so why not call it a disease?

Why not call it a disease? Because that's the rest of the talk is because here and this is my book, which is available in the lobby only here in the UK, the cover is white, that's a big difference and it's also in paperback, okay, so what I want to do is not question the neural data, but reinterpret it and try to find out what is wrong in the interpretation. The data is pretty solid, so the first point is that I'm a developmental bicycle psychologist and I've thought about changing brains throughout the entire process. most of my career, if you study child development, of course, it's obvious that brains change radically from infancy, through lessons to adulthood.

I mean, that's how we learn language and communication and everything else we learn, the brain is obviously changing, that's what it's for. A flexible Oregon is not designed to stay the same like a liver, a heart or a kidney, but the question would be that if brains change with learning and development, then brain change alone does not necessarily mean brain disease, so So the next question is, and by the way, brains don't stop changing at the age of 20, but they probably change less after that age, after things solidify, so the question is how do brains change over time? development and this cute little movie shows an average of MRIs of different children of different ages, from four to 20 years old, and what we're looking at is the density, the thickness of the cortex, the actual thickness, the density synaptic in the cortex.

I want to see how it works. It changes from four years old to 20 years old, so it's an eight second movie, so you have to pay close attention, but I'm going to show it again, so check it out first to get an idea, yeah, it's nice, huh? So, you see, what happens is the brain turns blue. Development is lost. Well, I was hoping that would go over well with a British audience because I thought it's a bit of a Monty Python type question, so I'm glad it worked well. it doesn't really change blue here when it turns blue, here's the scale and it's a scale that shows the amount of gray matter or the density of gray matter and if we come back here, the light colors yellow and green etc. show Fichter the thicker cortex and the The colors blue and purple show a thinner cortex, so as the brain becomes more blue and purple, it becomes sinful, the cortex becomes sinful and this is contradictory to some people, it is You might expect the opposite, so here we go, starting in infancy and synapses are being lost, twenty are being lost. to fifty percent of their synapses because there's a huge overabundance of synapses in infancy, that's why babies are so confused and you know they're, I mean, well, they're just off because they have too many synapses and so what? ?

What happens with development is you get this this change and what's happening we call it synaptic pruning and what's happening is different regions at different times okay, here it's like I can't stop this, stare, stop, No, I won't stop, oh me. I know I should click on that and try again, okay, so here's four six eight ten, let's capture the brain right there, so now the sensory motor strip is pruned and mature, the orbital frontal cortex, the lower part of the prefrontal cortex is mature because that is really important for processing emotional information, but this part and this part are association cortex, they are more sophisticated and advanced regions of the cortex and they have not finished pruning yet and I want you to see that this is the last part to disappear, this is the dorsal lateral prefrontal cortex. in charge of judgment and perspective taking, okay, just look at him and you'll see he's the last one to prune, okay, and finally he does, that means when you're 20 you'll be able to think clearly, but not before, okay . that's the brain changing with development just to give you an idea of ​​what pruning looks like in the big picture and development, but the developments in learning are actually very similar, they're almost almost synonymous and they just involve two processes. two mechanisms, one is synaptic growth and the other is synaptic pruning, you get a proliferation of synapses or synaptogenesis and then you get the pruning of synapses that I just showed and the balance of those two mechanisms is the development in the brain in the cortex, that is development, there is nothing. more and I think of it as kind of like the ivy on the garden wall that starts out quite chaotic and disorganized and then that would parallel synaptic growth and you get novelty and new associations and increase knowledge and skills and you learn. playing new keys on the piano and you know you learn to be whatever, you learn all these new skills and then with development you get more and more pruning for consolidation, more efficiency and habit formation, that's what pruning is for, It is to make the brain. more efficient for it to concentrate, so that several of the really important pathways take hold, myelinate, become, yes, become, become and signal much more quickly and the unimportant synapses just fade away and disappear, so that if you think about addiction in terms of there is the last stage, if you think about addiction in terms of synaptic pruning, then this decrease in the density of synapses in certain prefrontal areas, this decrease in synapses can be considered as part of a larger picture and then We should not be surprised if this is a developmental progression.

We shouldn't be surprised at greater synaptic changes if people stop doing it, and in fact, that's whatfound this particular study: with Cote students you get alcohol and heroin, you get an increase in The volume of gray matter in very similar areas are not exactly the same, the brain never goes backwards and development simply does not occur, but moves forward and there is increasing growth and increasing synapses and new regions that are closely related and We are probably very involved in self-regulatory impulse control because that is what people need to learn when they stop taking drugs and notice that within a year or so the curve crosses the average baseline of non-addicts and so you actually get to increase synaptic density above the general population in those regions that seem to be responsible for self-control, that's what happens when people stop smoking.

By the way, I just have to point out that people who are addicted usually quit smoking, not everyone knows this, but most addicts to any type of substance and even heroin end up quitting. and the period of time varies and the proportion varies with the substance with cocaine the average duration of an addiction is four years with marijuana if you smoke it compulsively it is six years with alcohol it is fifteen years and with tobacco it is 25 years so that is the really bad one on average, if you start smoking today on average you will stop smoking in 25 years, it's not really a good thing, okay, so many more changes occur when people's habits change, when their behavior changes, when they stop drinking whatever they are taking, so I would do it.

They say that addiction is a kind of skill that the addict's brain learns to identify and efficiently target the behavior. There is less prefrontal activation because it is the same behavioral routine that is repeated day after day, hour after hour. There are very consolidated forms of behavior. Habitual eyes. drooling eyes instead of having to wonder and think and judge and consider and compare and all those things that most of us do most of the time, it's a strange way to think about addiction, but I think that's really how it is, it's a kind of skill. It's very unpleasant, obviously, but still, um, and so we should, we should recognize that new skills or profound habit formation always changes the brain, it's not just addiction, so what are some examples?

Well, driving a taxi in London is one of the classics. You've probably heard that London taxi drivers have a hippocampus which is part of the brain in charge of memory, certain types of memory that are 20% denser or heavier than normal people, because they have to learn the location of thousands of tens of thousands of streets or probably not anymore since there is no GPS, but this finding came about a few years ago and has been replicated many times, so it's cool and we know other things about the hippocampus that has actually decreased in volume since the post-traumatic stress period, etc., but let's get out of the hippocampus and talk about falling in love, when you fall in love, there are all kinds of changes in the brain, there is an increase in dopamine in the striatum, there is more activation of the ventral striatum, There are more synaptic patterns and, of course, those patterns represent the loved one.

This is like an addiction in the sense that you have a behavior repeated day after day in which the emotional attractiveness of that other person is highlighted. The only thing you can think of is his good points at the beginning, yes. like with heroin and there's a lot of research showing that not only humans but even rodents, prairie voles increase napping, so dopamine flows into the ventral striatum when they're mating when they're in the process. of prairie voles. studied because they are monogamous and one of the few monogamous mammals, so their romantic habits have been studied in some depth because they are supposed to be like humans, but it is up for debate, okay, so falling in love and the practice of meditation consciously change the brain, a lot of research has been done on this in the last 10 years.

If you're a brain nerd, you might be interested in the default mode network, which is a network that processes information that has to do with self-reflective thinking. about your past thinking about your future and rehearsing patterns that have to do with your own activity in your own self and your mindfulness meditation reduces activation in the default mode Red is fine, it becomes muted that activation because you are simply not as ego involved and you know, this is like a fascinating area of ​​research, um, all these other behavioral addictions change the brain, I'll get to that in a minute, binge eating, binge drinking, whatever, having been shopping, changing the brain and psychotherapy changes the brain, just me I just wanted to I started watching this recently.

I thought, well, I'm talking about a brain change and I'm saying that everything changes the brain, anything that's important and that's what really changes the way you function in the world. the brain in a more recognizable and measurable way, so psychotherapy should do it and in fact I found a lot of literature on that, his studies with CBT, his studies with other forms of psychotherapy that show brain changes and then I thought, wait a minute, I used to study that. I guess when you were a former academic, I used to study, I used to do research with kids who had anxiety and aggression problems and we looked at their brains with what's called dense matrix EEG, do you know what an EEG is?

A dense matrix means there are like 128 channels, so you can get a pretty good picture of the spatial, anatomical, and temporal history of brain activation, so we put networks in these kids before and after these three months, um, a period of treatment and I believe that those who improve should show brain changes and in fact they do. I don't even bother trying to interpret that it's too difficult. That's what the average erp EEG looks like. It seems like an event potential, event-related potentials, but here's the gist. from the story um, this graph shows pretreatment and posttreatment, this is the average activation in the ventral region, this is the reduction of the rhythm and the ventral part of the prefrontal cortex and nearby areas and probably the amygdala with which not you can be just as good with EEG even with source analysis, but what we see here is that those who did not improve behaviorally and who had the same regression and anxiety scores after treatment showed no change, those who did improve showed a fairly significant drop and the activation of these areas was good.

What does that mean? It means they're not using this part of their brain as much as they used to and that's a good thing because when you use this part of your brain to modulate your interactions with other people, then they're colored. with anxiety and defensiveness and then you can get angry if provoked, so a lot of things change the brain. These are other slides with other images that we obtained from that study. It gives you an idea that it's a topographic EEG map for younger children and older children and the loss of activation reduction with age looks quite similar to the loss of activation with successful treatment.

It's a complicated story. I just wanted to give you an idea. Well, the other interesting thing is that not only substance addictions but also behavioral addictions change the brain in almost exactly the same way that substance addictions do. I have attended conferences of which there have been a few in the world. In recent years, the International Behavioral Addiction Society has held a conference every two years and it's surprising, but all of the brain changes that people associate with substance abuse are found in gambling, sex addiction, binge eating disorder and obesity, plus fat Nora Volkow. director of NIDA, who is actually one of the most powerful spokespersons for the disease model.

She has written several articles showing the incredible parallels between brain change due to drug use and brain-altered obesity and binge eating. There are many parallels, so what is that? Well, here are some examples of other things I just mentioned. These are the things that people are studying. Internet or gaming addiction. The Internet gaming psychiatrist doesn't know what to do about it, but now he's entered the DSM. There is now a category for conditions that. are under discussion and people are starting to call this an addiction and you know what I mean if you have a teenager or if you ever know if anyone has a teenager, right? and people can spend a lot of time on the Internet.

It becomes much more serious when they are adults, well if parents do not control the limit, they can also be quite serious in childhood, but they root that people can spend up to 18 hours a day on the Internet and that really is a disaster. his life so I thought I wanted to find I wanted to find an example of brain change an Internet addiction the first article I looked at there's another one the first article I looked at showed something quite remarkable um see if I could read these gray matter anomalies and Internet addiction a voxel-based morphometry Morpho I don't even know how to say that word morphometry study ah, it basically means fMRI, so this study aims to investigate the density of the gray matter of the brain, yes, changes in the density of gray matter in adolescence with Internet addiction using yes the rest of that, again the density of the gray matter, that is because it seems that the most serious thing is this loss of gray matter, there is a loss of synaptic density in the prefrontal cortex, so we're talking about the Internet, we're not talking about heroin.

Here, well, this is what it looks like. I found your graph and it looks like this: That little yellow spot is the region of the brain that shows a reduction in synaptic density for people who spend more time on the Internet and back to the brain. Image that I showed you before for addicts to heroin, coke and alcohol. It's exactly the same place. Look, it's great. Like I said, it's so cool. I was convinced I was right when I found this place. That place isn't actually the prefrontal cortex, it's the dorsal anterior cingulate. but it is a part that is very closely linked to the dorsal lateral prefrontal cortex, it is like a convergent zone for decision making and conflict resolution, so it is quite connected and there are these behaviors, in other words, the proposition that drugs cause addiction has to be completely wrong drugs don't cause addiction, they don't, um, internet games cause addiction, falling in love causes addiction, but you know, being a sports fan, being a jihadist, being what That is, all these things have the same type.

Same kind of fundamental properties, okay, so I'm going to go ahead and say that given everything we have, we still have to understand what addiction is and especially we have to understand why it's so hard to stop, it's not enough with saying that it is not an addiction. disease, what it is and that's what I'm going to spend the rest of this talk talking about what it is, why it's so difficult to stop it and there are three points that I want to highlight. The first is that addiction is based on a strong attraction to something, a substance or a behavior that is repeated many times and that leads to deep learning or accelerated learning.

That is the first point. The second point is this mechanism now called appeal or delayed discounting II which I'll talk about and then the last one is something called ego fatigue or ego depletion, which is basically the loss of self-control, if you try too hard to control things, you actually lose the ability to do it efficiently. Okay, so I'm going to go over those three points. The first is this. The basic picture I see addiction as a feedback loop, it's a self-reinforcing and self-perpetuating feedback loop and we could think of it simplistically as craving leads to more drug images and more drug images.

Drugs lead to madness and it goes around and around and builds. on itself and that can happen in five minutes or half an hour or half a day or whatever and finally when it gets intense enough you go and drink a little or do something or drink a little or whatever smoke a little, OK? So that's the feedback loop, ah, now let's try to think about that in terms of what happens to the brain. There's a simplistic cartoon here, but we'll start here with the trigger phase and there's always some kind of perceptual trigger, it might be, you know, looking. in paraphernalia or alcohol ads or whatever, but it could be finding half a pill on the bathroom floor or it could be that you have an intense dream about getting high or whatever, all of these things are triggers or signals, so what? they are input into any perception through the back of the brain through the posterior regions of the brain and then you have all these associations that are mediated by the temporal lobes here, the part that is associated with memory and all of these images. arise, and as they do, the midbrain sends dopamine to the striatum andThe striatum generates a desire that addicts call craving for good reason because this desire for something is not immediately available.

We call that desire the same thing in love and then the striatum. It sends messages to the midbrain and says more dopamine please, and there's a little feedback loop right there between those two parts of the brain and you crave spikes and you imagine spikes and of course the prefrontal cortex kicks in and you're planning where am I. I'm going to get it. How am I going to pay for it? Am I really going to do it? I was going to wait until Tuesday. I was going to wait until the weekend. I was going to wait until I could share it with you.

You know, friend? but no, I guess you know I could probably borrow some money from my aunt and you know then I could and all of that is the strategy that is happening in the PFC and that connects, of course, with the image making in the association . areas and those parts grow on each other and finally, of course, during this process you are sending commands to the motor cortex and the motor cortex does what you tell it to do and you go and get the things or you get higher, you get sex or you get porn or your Gamal and then you feel better and then that's it, it's over.

I'm not really crying, I just have something in my eye, but it's sad that you had such a good time and now it's over and that's really it. the point and this addictive in this addictive spiral of this feedback loop is that when it ends there is always loss, there is often depression, there is often shame, self-loathing, regret, all those things that of course make you feel I want to do it again, so it's a feedback loop on another scale, the day-to-day scale. day by day, day by day, I was doing cocaine, it could be hour by hour, so what's really happening here is I want to trace this feedback loop and show you how it plays out throughout development, there's the trigger, the signal leads to craving, craving leads to imagining imagining leads back to, I just said, more insight into the intended activity and that's a cycle of intensification and it goes on for a while and eventually when it gets intense enough you're going to get a little bit and you do something, that's the use part and now you get high or whatever get drunk and what does that do it has three effects the first effect is relief relief or pleasure and you know in learning theory that's just positive reinforcement that It's positive reinforcement so it's also reinforces the behavior and entrenches it even more, so that's you learn and then the loss comes, okay, and then the cycle repeats like I just said, then you get yes, then you get relief, you learn. and you lose and then you do it again.

Now think about every time this cycle goes through, every time you go through this cycle. In your mind and in your brain, what you are doing is activating particular synapses in a particular synaptic configuration that you have been building on occasion, maybe weeks, months or years, whatever, and you are strengthening the synaptic connections each time. you are strengthening synaptic connections think of the ivy, the ivy you are strengthening, which means that you are developing some synapses and you are pruning the synapses that are not involved, so you are actually sculpting and consolidating the synaptic configuration that makes you a addicted, then you do it over and over again, day after day, week after week, month after month, and that is development, that is development, it is the development of a very intense habit, you have it as an emotional habit, a strong habit and strongly compelling, but it's still a habit, it's a learned habit and again think about the IV, think while this is happening, you are pruning synapses, you are losing some synaptic connections in the prefrontal cortex and you are consolidating the addictive pattern, okay, that's the first point that is a The second general learning model of the development of addiction is this phenomenon that I now call attractiveness and that psychologists called delay discounting.

You may be familiar with this from the famous marshmallow test where they took this from. Where he came from? Was it Michela? Yes, they get three or four year olds in a room and a nice lady comes in and says would you like to have a marshmallow in ours or would you like to wait a few minutes? I'll be back in three minutes and then you could have two. marshmallows and three year olds sit there when the woman leaves the room and they twitch, they agonize because the marshmallow is sitting right in front of them, they really want that marshmallow and some caress it, others kiss it, there is a there. a movie of this on youtube which is just fantastic just look up marshmallow task it's the first thing that comes up on youtube by the way there's one for adults too and I'm sure you can imagine it so yeah that's right how to do it Dopamine works by focusing attention on the immediate goal and that produces craving and the problem is immediacy, which is why all mammals have delayed discounting and tend to overvalue immediate available rewards over more distal rewards, benefits at a higher price. long term are to their detriment, because if they were, if they waited a little bit, they would make a bigger net profit and all novels do it, even pigeons do it, and the point is that you know that we mammals know that, but we do it anyway because it's built into the striatum.

Built into the dopamine system, you look for the low hanging fruit, it's a very fundamental mechanism and here's an example. Why are they called discount curves and this on the x axis we have time and on the y axis we have the perceived value of the reward, well here is the reward, it is a piece of cake, it is a reward that is immediately available and , but if you didn't have that piece of cake, in a month you could lose five pounds, you could have a slimmer, nicer body or something, so the question is why is that man going after the cake and what these curves of discount show is that the increase in the perceived value of the prize increases suddenly, it is not just an exponential curve, it is a hyperbolic curve.

It's a sudden curve, when you get closer to the immediate reward, the perceived value suddenly increases and when that, these things are graphed mathematically by people in behavioral economics, if you're buying models based on these mathematical curves, there's a whole There are a lot of people working on this stuff right now and when the blue curve rises above the yellow curve that's when the guy is when you know you're done chasing that pie, whether you get fat or not, so He goes after it. cake because it seems to be worth more than imagining future happiness right now, here and there, and that's because the dopamine system is tuned to the cake, tune it to the immediate reward, so the consequences are, I think, quite Obviously, there is an immediate goal that seems worth much more than the long-term goal, so you waste it if you are going to run out of money if your girlfriend is going to leave you if you are going to get in trouble with the police if you are going to losing your job, those are future events and the only thing you can really think about is whether I'm going to get high tonight or today.

You never hear people say "let's get high next week", you're just not going to listen. let's get high next Tuesday No, so let's get high now tonight, so yeah, the immediate goal weighs the imagined future and that's how it works. Here's a study that I think is great because it recreates, simulates this in the lab. Tests where the participant looks at a screen and is offered small immediate rewards, so smaller rewards before they can click that button or larger rewards afterwards, meaning they can let you know that you know like a child of a year today compared to five euros. next week or should I say pounds or I don't know what currency you guys are going to use, thank you, but that's the task and you sit there and you all have the kind of relationship, a built-in relationship between the smaller immediate before and long term benefits. we have a part of our personality and the thing is that when you put this machine on the participants' head, it is TMS transcranial magnetic stimulation and what it does is it decombines the anterior front, the area of ​​the cortex that is correct.

On top of that it just disorganizes it, so it loses its yes, its function and this is over the left drawer, so the lateral prefrontal cortex, which is my favorite area of ​​the brain, so when you turn on the machine, guess what happens to the discounting curve, relationship between shorter before and longer after reward changes, you are less able to hold on to later rewards and are more impulsive and seek more immediate things than yes, less delays, sorry, yes, less yes, now You see what I'm saying right. you become more impulsive, more compulsive, etc., and that's really parallel to what we see when we see the loss of a connection between the striatum and the interdiction of the prefrontal cortex, that's exactly what we're saying, that loss of connection and here we can produce in a laboratory, fortunately, it is only temporary, so now it is attractive.

The next phenomenon is this phenomenon of ego depletion or ego fatigue, and this is also a completely normal psychological mechanism. I think one of the first experiments best expresses what it is. It's Baumeister's job and what they would do is take the participants into the lab and tell them that you can't have eaten in the last 8 hours, so they come in hungry and you have a plate of freshly baked chocolate chip cookies and a plate . of radishes and you know, psychologists love these types of studies because they are perfectly balanced and control that half of the sample says that you can eat all the radishes you want but no cookies and the other half says that you get all the cookies you want. you want but not radishes, this perfect experiment is deeply satisfying for the psychologists in all of us and what happens is that after 10 or 15 minutes of this situation, the people who have to suppress the urge to eat the cookies or they don't do it . well at a number of cognitive tasks, so they are given a bunch of cognitive tasks and they just don't do that well.

These tasks require cognitive control or executive control and somehow you've lost some of that, you've become fatigued. Worn down a bit, this is the phenomenon and it's very difficult to try to figure out exactly why. It's been examined for many years and recently questioned in some ways, but the point is that you can't keep trying not to do it. do something that's the point you can't keep trying to suppress an immediate impulse it's like extending your arm to the side you can do it for five minutes try doing it for an hour the machinery isn't made for that it's fine, it's not made That's why addicts They have a very hard time with that, an extremely difficult time because they have to repress control, inhibit their impulses for hours at a time, days at a time, weeks at a time, they are told in their group that they will never be able to drink again. and they are told that their addiction is doing push-ups in the parking lot and that they have to be under surveillance all the time and that is really very difficult, it is so difficult that most of them fail and the success rate in AAA is 5 to 8%.

So of course one of the problems is that they accuse them everywhere, this is my home country for now and especially with alcohol it is particularly difficult because also smoking, the accusers are all around us, so it continues to trigger the dopamine system. about the early reward and then you have to say no, I'm not going to do that, so the response to this recommended by the executive cortex of the United States of America was to simply say no, I'm Nancy Regan, I don't have it. If you remember, Nancy Reagan was the wife, husband and wife of Ronald Reagan and she was one of the spokespersons for the war on drugs, one of many that continues and she, yes, they were advising and, you know, urging young people to just say no to drugs just say no to drugs well here's an example of what happens when you just say no, in this study the participants watched a terribly sad movie clip so it's like you know a little boy with his father and the father dies and the children are alone and it is very sad and half the group is told to suppress their emotions and their expressions don't feel it, don't show it and the other half of the group is told Let him think about the movie, let him think about what the movie is trying to portray. intellectualizing it, in other words, reevaluating it is a very different way of approaching it and in this particular study what we see is that this is the suppression group this is the reevaluation this is the reevaluation so these guys are told not to show or express any emotion these guys are told to think about what the movie is trying to convey and this is a control group and this point here this ERP is called error related negativity is what it shows is a small point erp, for example, dot that represents cognitive control, the attempt to control also to overcome an error, okay and that dot is smaller for the suppression group, those who are told not to show any emotion show reduced activity in that region of the cortex that produces this response, that's howWe control our impulses, so that's pretty significant, we're seeing now that actually just trying to say no to yourself for a short period of time is already enough to change the functioning of the cognitive control part of the brain and if that happens on occasion You can imagine what happens occasion after occasion after occasion when the established circuits change and begin to become less effective over time and that is really serious for addicts, so simply saying no is not the right answer. , suppress those impulses, say no, that's not what works, what works.

It's reassessing the situation, thinking carefully if you take this as a parallel, thinking about what your addiction is about, thinking about why I do therapy with addicts over Skype and I never tried to tell them that you have to stop doing it. I know better, I'm not saying you have to stop taking drugs or drinking, I'm saying you know, let's talk about how you feel, let's talk about what you want to do and if you're going to get high, okay, okay. talk about it and just take all that pressure off to not make that kind of demand on the system and rather start thinking about what's going on in your life and what's going on in your past and what's going on and what this drug or substance does it for you and that is the way to start changing the way the system works well so in some brain change with addiction just a summary of what I said before here is the PFC in charge of the trial here is the striatum in charge of attraction desire craving um and here is the dopamine system and the dopamine goes to the striatum and sets up that little feedback loop so that you get more and more and then the striatum becomes hyperactive in the presence of cues and then you get that appeal mechanism now that's the narrow attraction to immediate reward and the loss of everything else, the other things go off the radar, okay, and then the connection between the PFC and the striatum starts to get compromised, it occurs. ego fatigue and the prefrontal cortex simply becomes less efficient. effective in control, well that's the model now in the book, by the way, it's not full of neuroscience in the book.

I tell the story of five addicts, one is addicted to heroin, one is addicted to methamphetamine, one was addicted to pharmaceutical opiates, the fourth was a British man who was a very serious alcoholic alcoholic and the fifth had an eating disorder and Each of these people I interviewed for many hours over Skype are from all over the world and I chose people who could talk about their addictions. because they were eloquent and honest and had been able to think about it and remember it clearly, he was not picking them and all their stories had a very similar profile to theirs, the addiction would progress and become more and it was more difficult to control and it would reach a point where the one that was really ruining their lives in a very serious way and then the attempt to stop it would begin and there would be a series of failures.

This was my case when I was an addict, it is a very typical profile and finally things get serious enough for people to decide to stop doing it and that determination begins to change the image of the guy who was an alcoholic, he was very, very close to death, actually it was. very close to death by alcohol or suicide, whichever came first, and he had them, since on these four-hour days he would get up, wake up, go straight to the refrigerator, pour a load of rum into his coke and start. drinking it before getting to the bathroom, he would actually finish the first one when you finished urinating and then you would go back to the second one and he would keep doing this and well, he would get more and more drunk and finally after three or four hours. he would go into a coma, he would fall on the floor and he couldn't walk or crawl to his bed, get into his bed and then wake up and start the cycle again, so he didn't have normal days, he had four hour days and this.

He continued for some time until he managed to get the help he needed and quit. Now I'm going to talk about recovery and how this happens because for each of the people in my book they actually found a way out of addiction, as people in general do, it takes time, it takes effort, but people find a way. exit, most people, not all, some people it is a dead end, but the percentage is small. Well, what I mean is that the disease model is not. helping these people the disease addiction model is not only incorrect, it is also harmful and one way to come to this conclusion is simply by looking at the statistics of conventional rehab programs.

Conventional rehab programs have very low success rates, typically people relapse anywhere from two to ten times. You know the revolving door phenomenon. I'm sure you've heard it. They go from program to program. They expel them. They send them to court to enter other programs. They get a waiting list for the state. funded programs that are universally bad, in the US they spent all their money and all their family's money on this process and these are rehab centers that have a main model, the banner is the disease, you have a disease and you let's help, this is a really very important calling card for addicts and many addicts, a kind of welcome that says, well, okay, I have a disease, that's why I do these things and I can't help it, and that's what That really explains it.

I have a disease, okay, but that's not necessarily beneficial. What proponents of the illness model say is that this reduces stigma and shame, and you know, you can feel smug and guilty and all that, because if you have an illness that you shouldn't be blamed for, that's supposed to be it will make you feel better, but I don't know if someone told you that you have a chronic brain disease that makes you do horrible things, that would make you feel better and I just think that logic is really flawed and the many addicts that I talked to, of course , not all addicts spoke.

For me and some people probably don't want to talk to me, but the people I talked to say I never felt like I had a disease. I never felt like I had an illness, but when I was in AAA they kept telling me that. I have this disease for life and I have to protect myself against it with all my might and it never felt right and it never made sense to me and blah blah blah and finally they left or they went somewhere else so they did something else and finally they stopped smoking, so many addicts do not feel good about the disease model.

It's not useful to them, but the results statistics themselves are pretty bad. The other problem is that these rehab centers, these addiction treatment centers, they get stuck, 85% of them in the US are based on the disease model, eighty-five percent and 85 percent almost overlapping uses 12 step methods as its main primary intervention method, well you know, that's hard to understand because medicine is this and twelve steps have very little to do with medicine, they are based on a religious orientation, it arose from the notion that you know that you are powerless and that you have to give your power to God and that is the only way you will achieve it. improve and this is a really strange confluence between that model and the medical model, but what they have in common is the idea that addiction is forever, that it is a fundamental defect, it is an essential characteristic of the person and it is not .

It's going to go away, it's chronic, so you have to keep doing what we tell you and that's the real common point: you have to do what we tell you, not what you think you should do because that doesn't work, you have to do what what we tell you. The big problem is that I would say that the disease model fails addicts because, well, the disease model requires medical treatment as the primary intervention, even though 12-step methods are deeply conflated with it and medicalization, the whole thing. system turns addicts into patients and patients surrender. control the professionals that is what you do in your patient you do what they tell you which causes a greater belief that you are chronic that is believing in chronicity there is a loss of empowerment the first of the 12 steps I am powerless to admit that they are helplessness and this sense of fatalism and surrender that for many addicts is actually a ticket to higher relapse rates.

I can't help it, I can't stop it and that's why I keep doing it. In fact, there are a number of studies that show that they know two and three of them one on alcohol one on methamphetamine showing that belief in the disease model itself is a predictor of relapse those who believe in the model relapse. more often and longer and sooner than those who don't, so that in itself is quite revealing. I know I sound a bit like a fanatic on this, well, and every time I calm down and think about you, you know there is and there is, there is room for overlap, there is a gray area, there are disease-like aspects. of addiction if that part is true and I should also say that I am not saying that doctors should be completely out of the picture, there are not at all some addictions for which medical intervention is really helpful, the main one being opiate addiction. heroin and other opiates because when you stop heroin you have these unpleasant withdrawal symptoms and for two or three weeks you are very vulnerable to relapse because you feel like you really want if you get methadone or buprenorphine, which is sometimes called suboxone these are substitutes for opioids, will reduce the number of students who quit opioids or eliminate them completely and then you may be able to know a more gradual trajectory to quitting, of course, sometimes that doesn't happen if people often continue to take opioid substitutes. opioids for long periods. sometimes for life, so that's considered problematic, but it's not as problematic as dying on the streets due to a heroin overdose, so I'm certainly not saying that these types of interventions shouldn't be available, they should be available, But that's not helpful for meth addicts or coke addicts or a lot of other things.

All behavioral addictions. There's no drug that's going to help you get over gambling or sex addiction or porn addiction or eating disorders except you know it's amphetamine, you know, that's how it is The reason it was prescribed years ago is for people who ate too much, took a lot of speed and stopped eating, so yeah, but for all those other addictions, there really are no appropriate medications for alcohol, there are some medications that help to some extent. things like antabuse that make you sick when you drink so they can be very effective because they tend to make you not drink until you stop taking antabuse because you really want to drink so you stop taking antabuse and then you drink so it's really a bit It's a flawed treatment strategy, but it works for some people and today we're talking about baclofen.

I have never heard of baclofen. It is a benzodiazepine that appears to help reduce alcohol and opiate cravings. If it works very well, let's use it. NO I'm not in any way adverse to that, but none of these things touch the psychological mechanisms that lead people to addiction and that make them so incredibly resilient and those psychological mechanisms have to be treated because doctors don't have the tools for that, they simply don't have them. They don't have the tools they're not trained in, so it's generally okay, so I'll end by saying: How do we help addicts well?

I'm going to go back to the two things I've emphasized: First, how can we help? helping addicts feel empowered rather than disempowered, which is a powerful antidote to ego fatigue to feeling empowered. I can do it well and I think we should help them have other goals. It's really important to replace the addictive meth with something else that they can't. just spend all your time not doing something you have to do something there has to be an attraction to something for me when I stopped around 30 I was doing meditation and Tai Chi I was doing Tai Chi in the park every night for an hour it was great and I had something else to do that really helped me and that's usually the case, helping them have other goals, but when I say go ahead I mean they have to be your goals, you have to formulate those goals that can't be handed to them. you by a group or by a doctor you know or by a sponsor and I think it's like what happens when you give the wheel of the car to your teenager until then they don't care how much gas is in the tank or how many mistakes in the tires or if there are some scratches, they don't care much about the car once they get behind the wheel, it's a completely different thing, so they care and that's what you have to do, that's what you have to catch yourself.

We have to capture that motivation, that sense of ownership, okay, that really empowers Minh, that comes in part from the striatum, so that's the first thing and the second thing is we have to help addicts imagine a future because now the appeal actually, you know, cuts the extremes of the short temporal dimensionthe past and cut out the future you can only think about today you can only think about getting high now you're stuck in this kind of eternal present tense that's really serious because you can't even imagine a future you don't want to think about next week you can't think about tomorrow next week you don't want to think about the past everything is too horrible and disgusting and how I got into this situation and how I met my marriage I broke up when I lost contact with my children and it's not pleasant to think about it, so you're stuck in this eternal present, for what you need to help addicts think about the past and the future and get that back into their mindset, so I think one way to think about that is to see life as a narrative, to see your life as a story that moves forward. .

I come from there. This is what happened to me. I myself went to a shitty boarding school for two years. I got very depressed. I went to Berkeley. I took a lot of drugs. I became addicted to certain things, whether it was or not. Now I'm here and now I'm going to do this and become a psychologist and have a good life, so I was able to put the threads come together and addicts can't do that, sometimes they need help and I think that's what professionals, family, friends, lovers, and many other people can do to help them think about where they come from and where they are going.

Put those two things together and that is the magic formula. I think okay, it's not that simple, it's not a simple thing, but it's certainly part of it, so what you're basically doing is reconnecting the striatum, which is the empowerment, with the prefrontal cortex. We are reconnecting the motivational engine with a bridge of the ship and that is happening in the brain and it has to happen in the mind of course, so I think this is my last slide, okay, so the treatment works by connecting or reconnecting the empowerment with the sense of a future self in time, which is like connecting the striatum back to the prefrontal cortex, which is like connecting the self to the social world, these are all overlapping things, like you know, linking parts of the brain and you're putting parts back together. of the mind and the way to do it, well, you know, there is the option of rehabilitation of conventional disease models, which is pharmaceuticals plus the good book, and that is one option and the other, I think it's all these psychological tools , psychological interventions that exist.available that need to be funded cognitive behavioral therapy explored and extended dialectical behavioral therapy motivational interviewing psychoanalytic therapy works for some people mindfulness meditation many really good results now with the use of mindfulness meditation to help addicts, which I think is very exciting contingency management other psychological approach and compassion approach therapy social support scaffolding all of those things can be very helpful and in particular should be determined according to the individual and their needs and remember that the brain It never stops changing, that's all, thank you.