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![Page 1: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/1.jpg)
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Impaired Decision Making In Substance Use Disorders
Claire Wilcox MD
UNM Dept of Psychiatry
Alcohol Medical Scholars Program
© AMSP
![Page 2: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/2.jpg)
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Case 55 y.o. male Physician High intelligence Methamphetamine dependent Multiple prior treatments Negative consequences: unemployed Repeated relapses Wants to quit
© AMSP
![Page 3: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/3.jpg)
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This Lecture Will Cover
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
© AMSP
![Page 4: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/4.jpg)
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How Are Decisions Made?
Mental process Neurocognitive
Involves 3 stages
• Interconnected
• Experience-driven© AMSP
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Stage 1: Stimulus Assessment
Preference
Valence
Salience
Context
© AMSP
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Stage 1:Assessment
Stage 2:Execution
Action selection
Action performance
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Stage 3: EFFECT!!
Evaluation/feedback: pros and cons of choice© AMSP
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Stage 1:Assessment
Stage 2:Execution
Stage 3:Effect
Stage 3: Learning
© AMSP
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Stages in the Case
Stage 2 (Execution)• Became obsessed• Unable to fight impulse
Stage 3 (Effect & Learning)• Use pleasure, relief drug use reinforced
Stage 1 (Assessment)• Saw friend use• Frustrated/stressed
© AMSP
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Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
![Page 11: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/11.jpg)
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Dopamine
Salience Cost benefit analysis
Action Inhibitory control
‘High’ Learning
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Stage 1: Assessment
Stage 2: Execution
Stage 3: Effect & Learning
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Glutamate
Learning
Stimulus Preference
© AMSP
Stage 1: Assessment
Stage 2: Execution
Stage 3: Learning
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Noradrenaline Stress response
• Sympathetic NS• CRF release
Focus on task Exploration
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Stage 1:Assessment
Stage 2: Execution
Stage 3: Learning
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Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
![Page 15: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/15.jpg)
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Decision Making In SUDs
Failure at any of 3 stages Biological root Possible pre-morbid deficits Worsened by drug use
• DA release to reward• DA receptor density • NA and CRF to stress
© AMSP
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Assessment Deficits
Response to cue
Preference,short-term reward/”high”
Stress, cue salience
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Execution Deficits
Habitual actions favored
• Can’t see other options
Inhibitory control
• Can’t hold back
© AMSP
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Effect/Learning Deficits
Imbalanced reward encoding• First drug use, reward • Once dependent
o Drug rewardo Further drug consumption
Learning from negative © AMSP
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Case
Assessment: preference for drug
Execution: inhibitory control
Effect: / response to drug
Learning: response neg consequence
© AMSP
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Lecture
Neurocognitive aspects
Neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications© AMSP
![Page 21: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/21.jpg)
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Prevention
Exposure
Target high-risk
• Adolescents
• Genetically vulnerable
• Cognitive probs (schizophrenia, brain injury)
• Stress reactive (depressed/anxious)© AMSP
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Medications
Drug cue effect
Naltrexone (AUDs), opioid blocker
DA release
Craving
Relapse
© AMSP
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Medications
Negative emotional states drug craving
Methadone (opioid use disorder)
Withdrawal/craving
Brain stress response/ anxiety
Treat co-occurring disorders© AMSP
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Medications
Cognitive functioninhibitory control
Experimental
• Varenicline (Nicotine Use Disorders)
• Memantine (Alzheimer’s Disease)© AMSP
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Medications
Drug reward
Under development
Cocaine & nicotine vaccines
Abs block drug entry into brain © AMSP
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Psychotherapies
Contingency Management Therapy
• Reward changes behaviors
• Learn abstinence earn $$$
Relapse Prevention Therapy
• Identify triggers
• Learn avoidance
© AMSP
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This lecture covered
Neurocognitive aspects of decision making
Neurochemical systems
How systems can malfunction in SUD
Treatment implications © AMSP
![Page 28: 1 Impaired Decision Making In Substance Use Disorders Claire Wilcox MD UNM Dept of Psychiatry Alcohol Medical Scholars Program © AMSP.](https://reader035.fdocuments.us/reader035/viewer/2022062714/56649d195503460f949ee4b9/html5/thumbnails/28.jpg)
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Thanks to:
Dr. Ann Manzardo (a power point genius)
Dr. Marc Schuckit (for an excellent learning
experience, and all of his help and time)
Alcohol Medical Scholars Program (for the yummy
food and spectacular hotels)© AMSP