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Craving to quit: insights from studies of mindfulness training for alcohol, cocaine and nicotine dependence
Judson Brewer MD PhD Medical Director Yale Therapeutic Neuroscience Clinic Assistant Professor Department of Psychiatry Yale University School of Medicine www.ytnc.yale.edu
Stress
Consequences of the failure to respond appropriately to emotional or physical threats to the organism, whether actual or imagined. (Selye 1956) [Ven. Sariputta:] Sariputta:] "Now what, friends, is the noble truth of stress? not getting what is wanted is stressful... (MN 141)
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Stress induces drug craving (Sinha 2005) and consumption (De wit 2003) Stressful life events are associated with nicotine dependence (Balk 2009) Negative affect drives continuation of smoking
(Markou 1998)
Sensory Information
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Sensory Information
Sensory Information
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PositiveCue
(haveagoodmealor sex)
NeutralCue
(getinyourcar)
NegativeCue
(getyelledatbyyour boss)
AVOIDANCE OFCUES
PositiveAffect (happyorrelaxed)
re
NegativeAffect (stressedout)
CRAVING
Automated
in
SMOKE
MaintainorIncrease PositiveAffect/Decrease NegativeAffect Reinforcementof AssociativeMemory/Habit (smokingmakesyoufeel better)
SUBSTITUTE BEHAVIORS
Zinser 1992, Piasecki 1997, Carter 1999, Lazev 1999, Cox 2001, Robinson 2003, Bevins 2004, Baker 2004, Cook 2004, Olausson 2004, Shiffman 2004, Carter 2008, Perkins 2010
I can't get no satisfaction I can't get no satisfaction 'Cause I try and I try and I try and I try get no, , I can't get g no I can't g
-Mick Jaggar
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fronto fronto-striatal striatal-limbic loop, including the orbitofrontal cortex, ventromedial prefrontal cortex (vmPFC), posterior cingulate cortex (PCC) (PCC), and ventral striatum (McClure 2004; Hare 2009; Kober
2010)
Deliberative/ Deliberative/cold cold processing effortful, influences behavior through rules of logic and involved in inhibitory control (Weber 2004; McClure 2004;
Ochsner 2005, Knoch 2007; Hare 2009)
dorsolateral prefrontal cortex (dlPFC), and posterior parietal cortex etc (McClure 2004; Hare 2009; Kober 2010; Steinbeis
2012)
HOT
COLD
There is no end of craving. Hence contentment alone is the best way to happiness.
-Sivananda Saraswati
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Overview of Mindfulness
Two Component Definition: 1) SelfSelf-regulation of attention so that it is maintained on immediate experience, thereby allowing ll i for f increased i d recognition i i of f mental l events in the present moment. 2) Adopting a particular orientation toward ones experiences in the present moment, characterized by curiosity, openness, and acceptance. acceptance .
Bishop 2004
Sensory Information
Trigger
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Brewer et al 2009
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Randomized (n=88)
Allocated to FFS (n=47) Started Treatment (n=39) Randomized but did not complete baseline assessments or start treatment (n=8) Completed Treatment (n=32)* Completed 6 week followfollow-up interview (n=33) (87%) Completed 12 week followfollow-up interview (n= 32) (84%) Completed 17 week followfollow-up interview (n= 33) (87%) Included in Analysis (n=46) Excluded from analysis (**incarcerated, n=1) Allocated to MT (n=41) Started Treatment (n=33) Randomized but did not complete baseline assessments or start treatment (n=8) Completed Treatment (n=29)* Completed 6 week followfollow-up interview (n= 27) (82%) Completed 12 week followfollow-up interview (n= 29) (88%) Completed 17 week followfollow-up interview (n= 29) (88%) Included in Analysis (n=41)
Brewer et al 2011
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FFS MTS
0 1
1 2
2 3
3 4
4 5
Brewer et al 2011
Treatment week
35
* **
MT
FFS
30
25
20
15
10
End of Treatment
17 week follow-up
Brewer et al 2011
For each 1 SD increase in craving score on target quit date, daily risk of lapsing rose 43% For each 1 SD increase in the average craving experienced during a given day, risk of lapsing the following day rose 65%
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Working hypothesis
Hypothesis: MT works by decoupling craving and behavior (e.g. smoking) Prediction: should see dissociation between craving and smoking BEFORE they both subside i.e. should still have some craving, but it is not coupled to smoking
For each 1 SD increase in craving score on target quit date, daily risk of lapsing rose 43% For each 1 SD increase in the average craving experienced during a given day, risk of lapsing the following day rose 65%
Working hypothesis
Hypothesis: MT works by decoupling craving and behavior (e.g. smoking) Prediction: should see dissociation between craving and smoking BEFORE they both subside i.e. should still have some craving, but it is not coupled to smoking
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p = .04
p
0.001 0.591 0.53 0.652 <0.0001 0.026
0.735 Overall Model Baseline Craving Baseline Cigarette Use End of Treatment Craving Informal practice (days/wk) Craving*Informal (days/wk)
r
0.582 0.126 0.561
r2
0.339 0.016 0.315
p
< 0.0001 0.491 0.004
df
1, 31 2, 31 2, 31 2, 31 2, 31 2, 31
b
3.41 0.41 0.47, -1.33 0.35, -0.99 0.33, -0.009 0.56, -0.03
b
(standardi zed)
p
< 0.0001 0.491 0.358, 0.001 0.516, 0.008 0.533, 0.008 0.273, 0.001
0.58 0.13 0.14, -0.55 0.11, -0.47 0.10, -0.47 0.17, -0.55
QSU+ Informal
(days/week)
0.484
0.234
0.021
QSU+ Formal
(total minutes)
0.482
0.232
0.022
QSU+ Informal
(total times)
0.566
0.320
0.004
A moderator (M) is a variable that alters the direction or strength of the relation between a predictor and Moderator Variable (M) outcome (Frazier 2004)
gender
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Does home practice moderate the relationship between craving and smoking?
Independent Variable (X) Craving Moderator Variable (M) Mindfulness home practice Dependent Variable (Y) Daily number of cigarettes smoked
p = .04
r
0.735
R2
0.540
p
0.001 0.591 0.53 0.652 <0.0001 0.026
Abstainers Non-Abstainers
*
p = 0.03
6-Week f/u 3-Month f/u 4-Month f/u
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PositiveCue
(haveagoodmealor sex)
NeutralCue
(getinyourcar)
NegativeCue
(getyelledatbyyour boss)
AVOIDANCE OFCUES
PositiveAffect (happyorrelaxed)
re
NegativeAffect (stressedout)
CRAVING SMOKE
MaintainorIncrease PositiveAffect/Decrease NegativeAffect Reinforcementof AssociativeMemory/Habit (smokingmakesyoufeel better)
Zinser 1992, Piasecki 1997, Carter 1999, Lazev 1999, Cox 2001, Robinson 2003, Bevins 2004, Baker 2004, Cook 2004, Olausson 2004, Shiffman 2004, Carter 2008, Perkins 2010
in
SUBSTITUTE BEHAVIORS
-Dhammapada (354)
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Mechanisms of Mindfulness?
Improved attentional focus (Jha 2007; Lutz 2009) Improved cognitive flexibility (Moore 2009) Reduced affective reactivity y (Frewen 2008; Farb
2010; Goldin 2010)
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Loving Lovingkindness
Please think of a time when you genuinely wished someone well (pause). Using this feeling as a focus silently wish all beings focus, well, by repeating a few short phrases of your choosing over and over (for example: May all beings be happy, may all beings be healthy, may all beings be safe from harm.)
Choiceless Awareness
In the next period please pay attention to whatever comes into your awareness, whether it is a thought thought, emotion emotion, or body sensation. Just follow it until something else comes into your awareness, not trying to hold onto it or change it in any way. When something else comes into your awareness, just pay attention to it until the next thing comes along.
Task of MT?
The task common to all of these meditation techniques is the training of attention away from selfself-reference and mind mind-wandering and toward ones immediate experience.
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Brewer et al 2011
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x = -6
z = 21
Brewer et al 2011
x = -6
BOLD signal change (%)
0.3 0.3
z = 21
0.1
0.1
-0.1
-0.1
-0.3
-0.3
-0.5
Meditators
Controls
-0.5
Meditators
Controls
Science is a way of trying not to fool yourself. The first principle is that you must not fool y yourself, , and you y are the easiest person to fool. fool.
-Richard Feynman
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1 min
Expert
Run 4
Run 1
Run 4
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"Practice does not make perfect. Only perfect practice makes perfect. perfect .
-Vince Lombardi
Pay attention
NOVICE MEDITATOR
felt a lot more relaxed, like it was less of a struggle to prevent my mind from wandering
RUN 1
RUN 2
RUN 3
RUN 4
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NOVICE MEDITATOR
Thinking about the breath focused more on the physical sensation instead of thinking in and out
RUN 1
RUN 2
RUN 3
RUN 4
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HOT
COLD
Summary
Stress leads to craving and unhealthy coping (e.g. addictions) MT may be helpful with alcohol and cocaine dependence Changes psychological and physiological responses to stress MT may help people quit smoking More practice = better outcome MT seems to decouple craving and smoking Practice may moderate this Neural mechanisms of MT may involve DMN Less selfishness = happier and healthier?
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www.ytnc.yale.edu
FUNDING: NIDA (R (R03 03 DA DA029163 029163-01 01A A1, K12 DA DA00167 00167, , P50 DA DA09241 09241), ), Mind and Life Institute, Yale Center for Clinical Investigation (UL1 (UL1 RR RR024139 024139),Yale ),Yale Stress Center (UL1 (UL1 DE DE019586 019586-02 02), ), VAMC MIRECC
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