What Does the Brain Have to Do With Recovery??easa.pdx.edu/PDF/conference-2019/Slides_Brain-and-Recovery_Moller.pdfBasal Ganglia: ‘The Bee Gee’s’ • Located at the base of each

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What Does the Brain Have to Do With

Recovery??

Mary D. Moller DNP, APRN, PMHCNS-BC, CPRP, FAAN

Early Assessment and Support AllianceAnnual Conference, 11/04/2019

Sun River, Oregon

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Conflict of Interest

• Mary D Moller is on the Speaker’s Bureau for Alkermes and Otsuka Pharmaceuticals.

• There will be no off-label discussions.

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Purpose of This WorkshopThrough the introduction of unique way to label significant parts of the brain, participants will learn a fun, new approach to understanding the key structures and functions of the brain. By viewing and discussing brain scans that depict the neurobiological differences in the brains of individuals living with schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, major depression, and PTSD, participants will gain a deeper appreciation of the daily struggles facing the clients we serve.

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Learning Outcomes

• At the completion of this workshop the participant will:

1. Describe the key brain structures significant in the recovery process

2. Discuss the relationship of brain function to overall recovery


Cortex

Corpus Collosum

Thalamus

Pons

Cerebellum

Brain stem

MRIMRI2019- Mary D. Moller_EASA Conference 5

Information Processing Systems

2. The middle roada. Hippocampusb. Hypothalamusc. Cingulate

3. The high roada. Frontalb. Pre-frontalc. Temporald. Parietale. Occipital

1. The low roada. Brainstemb. Thalamusc. Basal gangliad. Amygdala


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Bee Gees

Hal

Amy

Library

Little Hal

Harry Hormone

Traffic Cop

The Low Road To Information Processing

The Low Road To Information Processing


Amygdala: “Uh-Oh!! Amy is our safety monitor” Amygdala: “Uh-Oh!! Amy is our safety monitor”

Basal Ganglia: “Get us outta here”Basal Ganglia: “Get us outta here”

Thalamus: Hal the Computer

Thalamus: Hal the Computer

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The Low Road--The Brain Stem ‘The Traffic Cop’

• Stop-Look-Listen• Responsible for eye movement• Coordinates visual and auditory reflexes• Source of dopamine, norepinephrine and serotonin• Orienting response


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Effects of Psychosis on the Brain Stem

• Over-development of midbrain functions result inAnxietyImpulsivityPoor affect regulation Motor hyperactivity


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Thalamus:‘Hal the Computer’

• Processes and distributes almost all sensory and motor information going to the cerebral cortex.

• Regulates and integrates levels of awareness and emotional aspects of sensory experiences through a wide variety of effects on the cortex—initiates the autonomic and endorphin cascades.


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Thalamus:‘Hal the Computer’

• Enables us to have impressions of the agreeableness or disagreeableness of a sensation—is it safe? If so, stimulus moves through the brain.

• Monitors sensory input and acts as relay station for nearly all sensory and motor information by connecting cerebral cortex, basal ganglia, hypothalamus, and brain stem.


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Thalamus

• Responsible for generating different kinds of ‘brain rhythms’ that correspond with different cognitive states such as wakefulness and sleep.


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Thalamus Effects of

• Difficulty integrating the emotional aspects of sensory stimuli

• Hyper/hyposensitivity to pain• Unable to differentiate if something is pleasurable or not• Difficulty staying present


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Amygdala:‘The Safety Monitor’

• Involved in all emotions, especially anxiety and fear. The core emotions of happy, sad, mad, and afraid are unmodulated and occur without consciousness

• Coordinates actions of the autonomic and endocrine systems

• Functions as a ‘safety monitor’.

• Involved in all emotions, especially anxiety and fear. The core emotions of happy, sad, mad, and afraid are unmodulated and occur without consciousness

• Coordinates actions of the autonomic and endocrine systems

• Functions as a ‘safety monitor’.


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Heart rateBlood pressure Muscle

LeDoux 1996: 166

Over a dozen regions quickly activate a myriad

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Amygdala: Effects of

• Over/under response to anxiety• Unable to learn from mistakes of the past—unconscious

memories are stored here as raw data prior to myelination• Everyday events that cause anxiety seems like they are brand

new—results in impulsiveness due to transmitting an immediate experience of pain if not modulated by reflective function of forebrain


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Amygdala: Effects of

• Unable to discern what to do with incoming sensory stimuli—body is unreliable in giving cues and clues

• Due to feedback loop, affects memory of declarative nature—Yogi Berra—I wouldn’t have seen it if I hadn’t believed it!


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Basal Ganglia:‘The Bee Gee’s’

• Located at the base of each hemisphere.• Receive input from all four lobes of the cortex, thalamus, and

substantia nigra but only have output (efferent projections) to the frontal cortex via the thalamus.

• Major activities include the planning of movement and all cognitive functions.


Basal Ganglia


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Basal Ganglia: Effects of

• Disorders of affect• Disorders of cognition• Inability to complete information processing circuits

with thalamus and cortex• Obsessive-compulsive behaviors


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Hypothalamus: Effects of

• Decreases response of glucocorticoid receptors—atrophy of dendritic tree

• Eating disorders• Disorders of pituitary hormone secretions• Disorders of emotional expression• Abnormal sleep/wake cycle• Disorders of sexual function/behavior


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Hypothalamus Dysfunction: Treatment

• Teach conscious regulation of survival functions• Teach to self monitor survival functions• Avoid pressure to perform


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Cingulate:‘Mood Manager’

• Sometimes called the limbic lobe• Located just under the frontal lobe cortex• Plays a major role in working memory• Serves as a bridge between the cortex,

thalamus, hypothalamus, and hippocampus, this secondarily affects the amygdala

• Reacts when people make mistakes or perform poorly

• Registers gains and losses2019- Mary D. Moller_EASA Conference

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The High Road to Information Processing

• Cortex: “Corporate Offices”• Parietal lobes: “Secretary”• Frontal lobes: “Boss/CEO”• Pre-frontal lobes: “Board of Directors”• Temporal lobes: “Intercom system”• Occipital lobes: “Surveillance system• Insula ‘lobes’: “Identity, salience,

prosody”


Occipital lobe

Parietal lobe

Prefrontal lobe

Supplemental Motor Area

Premotor cortex


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Corpus Collosum ‘Holes’

• Difficulty with transferring information between right and left hemispheres

• Disconnect between emotions and logical thinking• Behavior either emotional or logical without emotion• Threat to safety triggers emotional response• Alexithymia


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Reductions in Size of Middle Portions of Corpus Collosum

Documented in:

• Borderline personality disorder• Depression• Panic disorder• Post-traumatic stress disorder• Dissociative symptoms• Memory impairments• Alexithymia


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Alexithymia

• Describe feelings with facts rather than emotions• Difficulty differentiating emotions from bodily sensations• Inability to differentiate between emotions or express

feelings• Act impulsively rather than thinking• Inappropriate relations with others


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Disorders With Co-existing Alexithymia

• Eating Disorders• Borderline Personality

Disorder• Abuse/trauma• Substance abuse

• AIDS• Panic Attacks• Marked Depression• PTSD• Fibromyalgia


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Cortex:‘Corporate Offices’

• Interpreting sensory and motor stimuli• Processing sensory and motor stimuli• Integrating sensory and motor functions.• Controlling sensory, motor, and motivational systems• Modulates emotions coming from thalamus, amygdala,

hippocampus


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Frontal Lobes:‘The CEO’

• Responsible for judgment, decision making, and problem solving

• Right frontal lobe is associated more with nonverbal communication and functions

• Left frontal lobe is associated with verbal functions and controls motor aspects of speech.


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Frontal Lobes: Effects of

• Inappropriate or uninhibited behavior• Impulsiveness: inability to evaluate and

control emotions, judgment, and conduct• Emotional impoverishment• Irritability; lability• Lack of motivation• Difficulty with all cognitive functions• Difficulty with abstract thinking


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Prefrontal Lobes:‘Board of Directors’

• Referred to as the association zone—it remembers where everything is stored!

• Integral in the ability to have cause and effect reasoning (cognitive behavior)

• Primarily concerned with motor skills--particularly in the planning of movements—it decides whether you are going to stay or leave when you are afraid.


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Prefrontal Lobes: Effects of

• Difficulty with recognition of facial expressions • Great difficulty in the ability to inhibit impulsive behaviors• Concrete thinking• Poor cause and effect reasoning


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Parietal Lobes:‘Secretary’

• Receive and organize sensory information from external and internal sources related to pain, temperature, pressure, and touch.

• Proprioception: knowing the relationship of the body to the environment

• Prioritizes and screens out what is extraneous


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Parietal Lobes: Effects of

• Body image disturbance• Inability to recognize body parts• DENIAL OF ILLNESS: ANOSOGNOSIA• Impaired right/left orientation• Loss of memory association• Impaired spatial abilities• Loss of the ability to visualize three

dimensions2019- Mary D. Moller_EASA Conference

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Temporal Lobes:‘Intercom system’

• Concerned with hearing, learning, complex memory, emotion, and reception of speech (usually the left temporal lobe).

• Sensory memory--the brief retention of sensory input while something is scanned, evaluated, and acted on or ignored.

• Musical ability. • Control of sexual and aggressive drives.


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• Alexithymia: lack of words to express emotions verbally• Difficulty in using language to express self• Difficulty understanding intended message • Sexual inhibition affected• Facial recognition decreased


Temporal Lobes:‘Effects of ’

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Occipital Lobes:‘Surveillance System’

• Serve as both the primary and secondary sites for vision. • Separate important visual information (foreground)from

unimportant (background) information.


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Occipital Lobes: Effects of

• Disturbed spatial orientation: difficulty with physical and environmental boundaries

• Visual illusions/hallucinations• Simulated hysteria• Loss of visual memory and object constancy• Loss of visual speech (ability to understand the meanings

of written words


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The Salience NetworkSignificant News Network: SNN

Central Executive Network: CENEX

SNN=Right Anterior Insula: RAI

Dorsal Anterior Cingulate: DACK

CENEX=Dorsal Lateral Orbital PFC: DORLA

Lateral Parietal: LAPIERRE

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Salience Network (SNN-”Significant News Network”)

(CENEX-”Central Executive Network”)

Palaniyappan L, et al. Neuron. 2013 Aug 21; 79(4): 814–828.

CENEXLOPFC + Parietal

Default Mode NetworkPosterior cingulate, precuneus, medial PFC, ACC, Lateral parietal, PFC Temporal

Salience-Preps the Brain for Action

Interoceptive pathway(emotional appraisal)

SNN:Insula and

ACCStimuli

Prefrontal System(a priori models,

goals, plans

CEN

DMN

Proximal Salience

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SalieNce NetworkSNN = Significant News Network

RAIRight Anterior Insula

Palaniyappan, et al. Neuron. 2013;79(4):814-828

Lies deep in folds of cortex Anterior portion of limbic system Involved in conscious desires Decodes bodily states-capability to

translate a bad odor into feeling of disgust/touch into feeling of delight Connects to several other areas Involved in assessment of whether

or not to trust Integrates external stimuli with

internal homeostatic contextMarks objects that require further

processing

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Focus on the Insula

Palaniyappan, et al. Neuron. 2013; Ducharme, S, et al. 2016Sherman, L et al. D2014 Behrmann, M. et al. Curr Opin Neurobiol. 2004;

Facial affect processing (temporal gyrus relays higher order visual information/ Prosody-emotional aspects of speech Variations in rhythm, stress, intonation Occurs in the insula and the process is nonverbal

(you can hear an argument behind doors and know it’s an argument without understanding words) Correlates with level of negative symptoms

Pain processing Self vs Non-self Cholinergic dysfunction (increased smoking)

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Effects of Schizophrenia on Insula

Failure of Bottom-Up (Magnificent 7) Processes

Loss of Function with Medial Temporal Lobe

Anhedonia Doesn’t ‘switch off’ during cognitive tasks

Apathy Default mode network (self-referential activities) impaired

Negative symptoms Related to frontal insufficiency results in maladaptive paralimbic gating of executive system

Cognitive dysfunction

Wylie K P, Tregellas JR. Schizophr Res. 2010;123(2-3):93–104.

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SalieNce NetworkSNN = Significant News Network

DACKDorsal Anterior cingulate

Palaniyappan, et al. Neuron. 2013;79(4):814-828

Sometimes called limbic lobe• Located under frontal lobe• Major role in working memory Bridges cortex, thalamus, hypothalamus,

hippocampus Secondarily affects amygdala Reacts when people make mistakes or

perform poorly Governs executive function/ generates

motor programs Planning-maintain attention- problem

solve-learn-retrieve remote memories-sequence temporal order of events-shift cognitive/behavioral sets

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Cenex: Central Executive NetworkDorsal Lateral PFC (DORLA)

Lateral Parietal Lobe (LAPIERRE)

Ducharme, S, et al. In Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2nd Ed. Elsevier. 2016. Sherman, L et al. Dev Cog Neurosci. 2014;10(2014):148-159. Behrmann, M. et al. Curr Opin Neurobiol. 2004;14(2), 212-217

•Governs executive function and generates motor programs•Planning, maintain attention, problem solving, learning, retrieve remote memories, sequence temporal order of events, shift cognitive and behavioral sets

•Manipulation of information in working memory

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Cenex: Central Executive NetworkDorsal Lateral PFC (DORLA)

Lateral Parietal Lobe (LAPIERRE)

Palaniyappan L, et a;.2013

•Anatomically interposed between anterior PFC, dorsolateral PFC, anterior cingulate, anterior insula, anterior inferior parietal cortex

•Mediates dorsal attention and hippocampal-cortical memory circuits

•Working memory•Sustained attention•Response selection/response inhibition

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Cognitive Feedback Loop

• Sensory input through thalamus to amygdala • Amygdala to pre-frontal lobe to hippocampus• Hippocampus to cortex • Cortex back to amygdala• Amygdala gives signals of safety or danger


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Cognitive Feedback Loop Disrupted by

• Sensory input through thalamus to amygdala• Amygdala gives inaccurate signals of danger or safety• Flight/fight response is triggered even when there is no

danger (kindling effect)


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Effects ofon the Cortex

• Under-development of limbic/cortical functions result in: Problems with empathyPoor problem-solving skillsMemory disturbances


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AREAS OF CORTEX NEEDED TO PROCESS LANGUAGE

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NORMAL HYPERVENTILATION

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Normal MRI

Anterior View

Patient with Schizophrenia

Anterior View


Normal Schizophrenia

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Normal Patient A

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Normal Patient B

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Normal Patient C

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NORMAL SCHIZOPHRENIA

PATIENT WITH SCHIZOPHRENIA ON HALOPERIDOL

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Normal Blood Flow Blood Flow in Schizophrenia

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NORMAL

SCHIZOPHRENIA

PTSDPTSD


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Normal Major Depression


662017- Mary D. Moller_APNA New Mexico 66BenzoPanic

Alpha (red)Alpha (red)

Normal

Beta (blue)Beta (blue)

Theta (yellow)Theta (yellow)

Delta (green)Delta (green)

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Normal Benzodiazepine

Receptors

Blocked Benzodiazepine

Receptors

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delta theta alpha beta

Major Depression

692003- Mary D. Moller MSN, ARNP, CS, CPRP 69Mania

delta betaalphatheta

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70First week of alcohol detox

betatheta alphadelta

71Schizophrenia


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Alzheimer’s


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HIV DementiaHIV Dementia


What Does the Brain Have to Do With Recovery??easa.pdx.edu/PDF/conference-2019/Slides_Brain-and-Recovery_Moller.pdfBasal Ganglia: ‘The Bee Gee’s’ • Located at the base of each

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