Emotional Dysregulation and ABI. LN Matheson, PhD Epicrehab Goaling Institute

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1 Emotional Dysregulation and ABI LN Matheson, PhD Epicrehab Goaling Institute

2 Emotional Dysregulation 2 After a brain injury or stroke involving the prefrontal cortex, emotional dysregulation should be expected. Right orbitofrontal lesions result in anxiety and apathetic depression. Left dorsal frontal lesions result in anger and hostility. Ventromedial prefrontal cortex lesions result in difficulty with future consequences and values-based decision-making.

3 Ventromedial Prefrontal Cortex 3 VMPFC is associated with decision-making and emotion regulation impairments. Rapidly develops during adolescence and young adulthood to regulate the amygdala. Right VMPFC regulates cognition x affect > empathic responses, and gender-specific responses.

4 Damásio s Somatic Marker Hypothesis 4 VMPFC patients have difficulty experiencing and expressing appropriate emotions. VMPFC damage causes inability to use emotions to guide behavior based on implicit memories. VMPFC has a central role in developing somatic markers. Emotional associations between memories/ideas and visceral response in decision making. Decisions because it feels right.

5 Orbitofrontal Cortex (OFC) 5 Regulates interpersonal behavior based on values. Gradually-acquired moral development is dependent on intact and complete OFC development. Inhibition of impulsive behavior begins in OFC, integrating explicit values to regulate emotions. Decisions because it s the right thing to do. Lee D et al. J. Neurosci. 2007;27:

6 ABI Emotional Dysregulation 6 Impulsive Aggression with Remorse Premeditated Aggression without Remorse Impulsive Sexual Acquiescence with Remorse Financial Acquiescence with Remorse

7 Aggressive Behavior 7 Medial orbitofrontal cortex and amygdala communication is mediated by testosterone. Men and women with increased testosterone have diminished OFC control of the amygdala. Anterior cingulate cortex development is important, with diminished size and linkages of the ACC of men in prison who have been identified as psychopaths.

8 Aggressive Behavior Control 8 Phenytoin (Dliantin) is an anti-seizure medication that is also useful in some types of neuropathic pain and has been reported to be useful for depression. It works by decreasing the electrical activity in the brain by stabilizing the sodium channel. At low dosages, it is also helpful to diminish impulsive aggressive behavior when used in combination with cognitive behavior therapy.

9 Sexual Behavior 9 Right OFC links with the limbic system. Males & females demonstrate increased activity in the anterior cingulate cortex, medial prefrontal, orbitofrontal, insula, and occipital temporal cortex as well as the amygdala and ventral striatum. Men more activated in thalamus and hypothalamus, with stronger physiologic arousal and sexual behavior. Extent of hypothalamic activation is directly related to sexual arousal.

10 Right OFC Impairment Case Study 10 Burns and Swerdlow (2003) 40-year-old married male, father of two developed a strong interest in pornography and inability to control sexual behavior, including pedophilia. In spite of remorse, could not participate in a12-step rehab for sex addiction. Tumor in the right orbital frontal cortex. When the tumor was removed, behavior normalized. When the tumor recurred, his inability to control his sexual behavior resumed.

11 Addictive Behavior & OFC 11 Orbitofrontal cortex, insula, striatum, and the anterior cingulate cortex are activated in addicted subjects during craving, intoxication, and binging. Deactivated during withdrawal. Driven by dopamine. Diminished ability to maintain top-down limbic inhibition is due to drug-induced brain damage. Brain tissue is lost in the frontal lobes with long-term use of cocaine, alcohol, and heroin.

12 Brain Dopamine 12 Most stimulants cause an increase in brain dopamine in the limbic system, which results in implicit reinforcement of behavior. Cocaine Methamphetamine Nicotine Caffeine Heroin

13 Values, Goals and Addiction 13 Decision-making ability to inject rational decisionmaking is coordinated in the OFC. Linkages of OFC <> ACC balance competing goals, overvaluing drugs and undervaluing alternatives. Loss of healthy goal-directed behavior to automatic sensory driven behavior is a characteristic of loss of prefrontal volume and dynamic capacity. Goal-seeking behavior is a weak alternative to drugseeking behavior, although this can be enhanced.

14 Handling Dysregulation 14 The usual strategies to guide neuroplasticity must be adapted to emotional dysfunction, which is much more difficult to manage and achieve than changes in motor or cognitive function. Structured goal-directed behavior with frequent attention and reinforcement is helpful, but hard to do. How can we practice developing your impulse control?

15 Tim and Financial Acquiescence year-old married father of three. Banking executive with ABI two years ago. Returned to well-structured job one year post-injury. Problems with spending on ebay and in "charity" causes. Easily manipulated by mature females (oxytocin?). Remorseful about lack of financial control Wants to work with his wife to avoid problems.

16 Tim and Doris 16 On an errand at the post office, he was asked if he could provide a ride to Doris, a middle-aged female whose car had run out of gas six blocks away. He acquiesced and she praised his generosity and thoughtfulness. Underway, she asked if he could lend her $5 for gas so that she could get home to her sick child. She promised to pay it back the next day.

17 Tim and Doris in his Car 17 He stopped at the gas station, bought 1 gallon of gas to get it started. She asked if he could fill her tank and offered to pay him back. He returned to the gas station to fill her tank. She was vociferously grateful and asked if he could share a soda at the McDonald's restaurant nearby.

18 Tim and Doris at McDonald s 18 He accepted and paid for their sodas. She told him about her sick daughter, whose birthday was the next day, the same age as his daughter. She expressed sadness about lack of gifts and asked if he could help out, pointing to the Toys "R" Us store across the parking lot. He said that he did not have any more cash. She pointed out the ATM and asked if he could withdraw cash for a few small gifts. He withdrew $200.

19 Tim and Doris and Toys 19 They went shopping, gradually spending $185. She asked if he could meet her daughter, to which he acquiesced. On arriving at the apartment, she was not at home. As he was carrying the gifts, Doris grabbed his crotch, asking him if he could stay and get comfortable. "That set off a warning bell in my brain and I ran down the stairs. I was so embarrassed and humiliated and I told my wife about it and she was very angry."

20 Tim and Goaling 20 Tim previously had been involved with Goaling. Review Tim 1 and Tim 2. He and his wife spontaneously added a new goal that was focused on controlling this type of behavior. They also set up a system to monitor his progress throughout the day and on a day-to-day basis. After-dinner daily review and scoring. Seven weeks into this strategy, he has been under much better control and has regained his wife s confidence.

21 Thank you! Discussion and follow-up questions.

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