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Clinical Applications/Implications

Posted by Dr_Anna_Pecoraro on 13 Feb 2008 at 16:23 GMT

This is a very important article. Demonstrating that the brain reward circuitry responds to drug and sexual cues outside of awareness for the first time is a breakthrough. However, there are important clinical implications that the authors did not fully explore. They stated:

"Clinical implications
The brain’s rapid response to ‘‘unseen’’ reward cues may have clinical implications. The brain can strike up a prelude to passion in an instant, outside awareness, and without heavy policing from frontal regulatory regions. By the time the motivational state is experienced and labeled as conscious desire, the ancient limbic reward circuitry already has a running start. This dilemma may be reflected not only our daily human struggle to manage the pull of natural rewards such as food and sex, but also in the chronic,
treatment resistant disorders for which poorly controlled desire is a cardinal feature (e.g., the addictions). Encouragingly, neuroimaging paradigms with ‘‘unseen’’ cues may be used to develop treatments that address problematic motivation at its earliest beginnings, i.e., outside awareness."

I would like the authors to address the following questions in relation to the clinical implications of their findings:

1. How do these findings impact our clinical conceptualization of addictive disorders in general and craving in particular?

2. Ideally, what would the neuroimaging treatment paradigms that you briefly mentioned look like? (I assume that they have a feedback component and would therefore be a ‘biofeedback’ approach).

3. Could less expensive technologies (e.g., EEG neurofeedback) be used to pilot these treatments?

4. Are there any general counseling and/or psychotherapeutic implications/applications? Given these findings, would maximally effective psychotherapeutic approaches (excluding all biofeedback) be predominantly behavioral, cognitive-behavioral, or psychodynamic, or some combination thereof?

RE: Clinical Applications/Implications

childress_a replied to Dr_Anna_Pecoraro on 13 Feb 2008 at 18:17 GMT

Thanks so very much for these thoughtful comments -- as the clinical issue of addiction has driven the research, I am very glad for the clinical implications to have a little more space!

I will keep my own responses brief -- hopefully a stimulus for others to comment, as well...

"1. How do these findings impact our clinical conceptualization of addictive disorders in general and craving in particular?"

For me, the results suggest that drug motivation beginning outside awareness is likely to be a core feature of the addictive disorders, a prelude to the conscious craving states that currently draw most of our clinical attention.

Drug motivation beginning outside awareness is rapid, primitive and wordless -- and may therefore be difficult to impact with our usual clinical tools that depend on the patient consciously recognizing that they are in a state that could lead to relapse. We may need to adapt these tools, and find others, to help us target the great "unseen".

"2. Ideally, what would the neuroimaging treatment paradigms that you briefly mentioned look like? (I assume that they have a feedback component and would therefore be a ‘biofeedback’ approach). "

The "unseen" brain probes could be used in a number of very different ways -- they could be used to screen medications that might provide ongoing modulation of this ancient circuit, essentially "resetting" the threshold for its activation, calming it down a bit. We have some promising work ongoing in this arena; stay tuned!

And , yes, using feedback of the"unseen" brain signal to the individual, training better control over the problematic target regions, has become a real possibility with the advent of "real-time fMRI feedback". We have hopes to apply this approach.

"3. Could less expensive technologies (e.g., EEG neurofeedback) be used to pilot these treatments?"

EEG technologies have been used in a few "outside awareness" paradigms, showing event-related potentials (ERP) to an "unexpected" stimulus in a long sequence, even though ALL of the stimuli are "unseen". However, EEG works best for cortical (near the surface) signals...and unfortunately wouldn't be very useful for detecting/feeding back the signal from the subcortical limbic targets (e.g., amygdala and ventral striatum; insula). For this purpose real-time fMRI or magnetoencephalography (MEG) would be needed. Not cheap...but much cheaper than relapse!

"4.Are there any general counseling and/or psychotherapeutic implications/applications? Given these findings, would maximally effective psychotherapeutic approaches (excluding all biofeedback) be predominantly behavioral, cognitive-behavioral, or psychodynamic, or some combination thereof?"

Ah, wonderful question -- I think the findings do imply that therapies (of whatever sort) directed ONLY at conscious drug desire may run into some constraints, potentially explaining their modest benefits in the addictions.

Interestingly, though psychodynamic approaches have long appreciated the pesky problem of motivation occurring outside awareness -- the problem is (unfortunately) easier to recognize than it is to fix.

Fixing/modulating/re-setting/managing these ancient brain circuits -- whether for desire (as in the substance and non-substance addictions), or for fear (as in PTSD) -- will require our best science. We fortunately have many new and powerful tools (e.g., circuit-modulating medications, real-time brain feeback, and eventually, gene-based therapies) that can be expected to impact the "unseen" motivational substrates.

I have great hopes that characterizing the previously "unseen" brain targets, as we have done in this paper, will speed application of these new tools, with great clinical benefit.

Again, thanks for the helpful comments!
Anna Rose Childress