Mark Forman, PhD Clinical Director Life Design Centre

2. Aaron Alan, MFT, CSAT • Executive Director • Foundry Clinical Group Thuy Bui, LCSW, CSAT Clinical Director Foundry Clinical Group The Neurobiology of Trauma, Sex Addiction, and Meditation: Current Research and Clinical Implications Mark Forman, PhD Clinical Director Life Design Centre

3. Today’s Talk • Who We See and What We Treat • Trauma and Adverse Childhood Experiences (ACEs) • Trauma, Addiction, and SA/SC • Neurobiology of Trauma • Neurobiology of Addiction

4. Today’s Talk cont. • Theory and Types of Meditation • Neurobiology of Meditation • Clinical Applications • Clinical Issues and Unknowns • Q & A

5. Foundry: Who We See and What We Treat…

6. Trauma, Adverse Childhood Experiences, and Addiction

7. Addictions and Adverse Childhood Experiences • Kaiser Adverse Childhood Experiences (ACEs) Study (Felliti et al., 1998; Felliti, 2004) • 17,000 middle-class American adults underwent comprehensive, biopsychosocial medical evaluation.

8. Adverse Childhood Experiences Study Each participant received 1 pt. for: 1. recurrent and severe physical abuse (11%) 2. recurrent and severe emotional abuse (11%) 3. sexual abuse (22%) growing up in a household with: 4. an alcoholic or drug-user (25%) 5. a member being imprisoned (3%) 6. a mentally ill, chronically depressed, or institutionalized member (19%) 7. the mother being treated violently (12%) 8. both biological parents not being present (22%)

9. Addictions and Adverse Childhood Experiences • "Addiction highly correlates with characteristics intrinsic to that individual’s life experiences, particularly in childhood…Commonly understood examples of addiction are the compulsive use of nicotine, alcohol, methamphetamine, and heroin. More subtle examples are compulsive eating, sex, gambling, or shopping.” (Felliti, "Neuroscience of Addiction", 2004)

10. Adverse Childhood Experiences and Alcoholism

11. Adverse Childhood Experiences and Injected Drug Use

12. Adverse Childhood Experiences, Addictions and Mortality

13. What About Sexual Compulsivity?

14. Adverse Childhood Experiences and Sexual Compulsivity • Persons who had experienced 4 or more categories of childhood exposure, compared to those who had experienced none, had: • 4- to 12-fold increased risks for alcoholism, drug abuse, depression, and suicide attempt;  • 2- to 4-fold increase in smoking, poor self-rated health, > 50 sexual intercourse partners, and at least 1 sexually transmitted disease and a  • 1.4- to 1.6-fold increase in physical inactivity and severe obesity.

15. Adverse Childhood Experiences and Sex Addiction? • Hillis et al. (2001) found using this data set that ACEs were proportionately correlated in women with: • Earlier sexual activity (under age 15) • Higher number of sexual partners • Odds of having 30+ sexual partners went from… • 1.6 for those with one type of ACE • 1.9 for those with two ACEs • 8.2 among those with 6-7ACEs

16. Case Vignette • 4 ACEs: recurrent physical abuse, recurrent emotional abuse, an alcoholic parent, chronically depressed parentoverheard father call him stupid to sibling and overheard parents frequently fighting. Sexually compulsive bxs: online pornography, compulsive masturbation, anonymous sex with women, listening to ppl having sex. • Was able to stop anonymous sex early in tx, but intermittent pornography viewing and searching for audio content continued until underlying trauma/ACEs were addressed and treated. Clt currently has 2 yrs of sobriety and recently was married.

17. What Does Trauma Do to the Brain?

18. Trauma and the Brain • Brain processes are not entirely “local” – they are both local and distributed/coordinated across different structures and regions of the brain. • However, research in trauma has focused heavily on three local parts of the brain: • Amygdala • Hippocampus • Prefrontal Cortex

19. AMYGDALA • Amygdala– Function develops immediately after birth. Allows rapid assessment of danger and experience of fear. • Becomes activated upon cues or “triggers” that are reminiscent of early traumatic events. But it does so with poor accuracy.(van derKolk, 2003)

20. AMYGDALA • Stevens et al. (2013) found… • A study of 40 women… • Participants with PTSD showed a significantly increased response to fearful stimuli in the right amygdala. • The right amygdala is more responsive to pictorial or image-related material [the left to highly detailed and linguistic].

21. AMYGDALA • Stevens et al. (2013) cont… • Right amygdala activation correlated positively with the severity of hyperarousal symptoms in the PTSD group. • Participants with PTSD showed decreased functional connectivity between the right amygdala and left prefrontal cortex. • That is, the cortex can help regulate the amygdala, but this connection is deficient in PTSD patients.

22. AMYGDALA

23. HIPPOCAMPUS • Hippocampus– Function develops gradually over first five years. Allows recognition and organization of nature of threat. • Large role in memory. Can accurately pair cues or triggers with threat responses when hippocampus is developed enough at time of traumatic event. Specific and accurate, particularly later in life, but not so in childhood.(van derKolk, 2003)

24. HIPPOCAMPUS • Gilberston et al. (2002) found… • In a monozygotic twin study, severity of PTSD symptoms was negatively correlated with the hippocampal volume. • Smaller hippocampal volume predicted vulnerability to psychological trauma.

25. HIPPOCAMPUS • Woons et al. (2010) found… • In a meta-analysis of 39 studies… • Hippocampal volume deficits associated with exposure to psychological trauma and posttraumatic stress disorder in adults. • Additional hippocampal reduction was found in PTSD compared to the trauma-exposed group without PTSD.

26. HIPPOCAMPUS • Carrion et al. (2007) found… • Stress predicts lower hippocampal volume in youth with PTSD symptoms.

27. HIPPOCAMPUS • Carrion et al. (2010) found… • Youth with PTSD symptoms demonstrated reduced activation of the right hippocampus during a memory retrieval task.

28. PREFRONTAL CORTEX • Prefontal Cortex – Develops gradually over first 25 year (perhaps more) of life. Is primarily responsible for executive function, reasoning, and planning in stressful and nonstressful situations. • Prefrontal cortex helps regulate amygdala responsiveness.

29. PREFRONTAL CORTEX • However, activation of limbic and stress responses are “faster” than activation of prefrontal cortex, thus an overactive amygdala creates challenges for prefrontal performance. (van derKolk, 2003)

30. PREFRONTAL CORTEX • van Harmelen (2010) found… • In a study of 84 unmedicated adults who reported emotional maltreatment prior to age 16. • Found “profound” reductions in the volume of the medial prefrontal cortex, even in the absence of physical or sexual abuse.

31. PREFRONTAL CORTEX • Carrion et al. (2010) found… • Youth (10-16) with PTSD symptoms had significantly decreased total brain tissue and total cerebral gray volumes in comparison with healthy control subjects. • Significant negative correlation between prebedtimecortisol levels and left ventral prefrontal cortex volumes.

32. PREFRONTAL CORTEX • Shin et al. (2005) found… • In a fMRI study of 13 men with PTSD and 13 men without PTSD. • Studied the response to facial expression images.

33. PREFRONTAL CORTEX • Shin et al. (2005) found… • The PTSD group exhibited exaggerated amygdala responses and diminished medial prefrontal cortex responses to fearful vs happy facial expressions. • The stronger the amygdala activation, the lower the prefrontal cortex functioning. The two responses were inversely related.

34. Summary of Neurobiology of Trauma • Trauma and PTSD symptoms are strongly correlated with: • over-activation of the amygdala • a decrease-in-size and underfunctioning of the hippocampus, • a decrease-in-size and underfunctioning of the prefrontal cortex, including decreased regulatory connectivity to the amygdala

35. Neurobiology and Addiction • “[A]ll addictions create, in addition to chemical changes in the brain, anatomical and pathological changes which result in various manifestations of cerebral dysfunction collectively labeled hypofrontal syndromes. In these syndromes, the underlying defect, reduced to its simplest description, is damage to the “braking system” of the brain.” (Hilton & Watts, 2011 – “Pornography Addiction: A Neuroscience Perspective”)

36. Hypofrontal Syndromes • May result from genetic predisposition or the cumulative impact of addictive behavior alone… • But when trauma is present or underlying… • It sets up the perfect conditions for addiction and compulsion to begin and take hold, since the “brakes” are already off.

37. Traumatized Brain

38. Why is meditation potentially important in regards to trauma and addiction?

39. SHORT ANSWER: Meditation appears to directly counteract these specific neurobiological problems.

40. Theory of Meditation • From a psychological/subjective perspective… • Let thoughts and emotions pass. • Enter deep, calm concentration. • Encourage “transpersonal” moments.

41. Theory of Meditation • From a neurobiological/physical perspective… • Engage in a self-directedneuroplastic alteration of the brain. • It is this neurobiological-neuroplastic process that current research has been investigating.

42. Types of Meditation: Mindfulness • Mindfullness –Nonjudgemental noticing of thoughts and feelings, letting them pass with attitude of calm. • Cultivate specific insights about the nature of the self. • Focus on present moment.

43. Types Of Meditation: Concentrative • Concentrative – Focus on an object, image, word or phrase (mantra) meant to absorb a person into various trance states.

44. Types of Meditation: Imaginal • Imaginal– Calling to mind specific positive emotional states (and their imaginal associations) in order to cultivate deeper positive emotion. • e.g., Metta meditation (Loving-kindness or compassion meditation)

45. Very often, meditative techniques borrow/overlap from all three categories

46. Meditation Research: Some Important Studies

47. Changes in cerebral blood flow during meditation (Newberg et al., 2001, 2003)

49. Meditation Studies • Lutz et al. (2004) found heightened gamma wave activity throughout cortex – the highest ever recorded in a non-pathological population – in a group of 8 highly trained Tibetan monks. • Dose-response relationship • Gamma activity remained heightened outside of meditation itself – apparently permanent neuroplastic change. • Gamma highest in left prefrontal cortex, an area associated with positive, pro-social emotions.