1. Impaired Decision Making In Substance Use Disorders
Claire Wilcox MD
UNM Dept of Psychiatry
Alcohol Medical Scholars Program
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2. Case 55 y.o. male Physician High intelligence
Methamphetamine dependent
Multiple prior treatments
Negative consequences: unemployed
Repeated relapses
Wants to quit
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3. Decision Making Impairment
Not question of self-control/intelligence
Initial use of substances
Escalation of problems
Repeated relapses
Decision making impairment → relapse
Eg. of sugar for adaptive vs. maladaptive
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4. This Lecture Will Cover
Neurocognitive aspects
Neuroanatomical/neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
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5. How Are Decisions Made? Mental process Neurocognitive
Involves 3 stages
Interconnected
Experience-driven
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6. Stage 1: Stimulus Assessment
Preference
Valence
Salience
Context
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7. Stage 2: Execution Stage 1: Assessment Action selection
Action performance
Action completion
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8. Stage 3: EFFECT!!
Evaluation/feedback: pros and cons of choice
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9. Classical/ operant conditioning
Stage 1:
Assessment
Stage 2:
Execution
Stage 3:
Effect
Stage 3: Learning
Summarize again
Classical/ operant conditioning
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10. Stage 1 Modifiers Assessment State (hunger, mood, intox, withdrawal)
Psychological processes/traits
“Impulsivity”
Emotion regulation
Attention (stimulus)
Craving
Cost-benefit analysis
Assessment
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11. Stage 2 Modifiers Preference from stage 1
Moderating psychological processes/traits
Flexibility
Inhibitory control
Selective attention
Sustained attention
Execution
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12. Stage 3 Modifiers Action from Stage 2 Experience of outcome
Timing of effect
Moderating psychological processes/traits
Value/reward encoding
Ability to process pros/cons
Error calculation
Learning
Effect
Learning
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13. Stages In Case Stage 1 Stage 2 Stage 3 Saw friend use
Frustrated/stressed
Stage 2
Became obsessed
Unable to fight impulse
Drug decreased anxiety/ neg affect
when sees cue in future
b/c happen later in time
Stage 3
Use pleasure, relief  drug use reinforced
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14. Lecture Neurocognitive aspects Neuroanatomical/neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
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15. Dopamine Salience Cost benefit analysis Attention (stimulus)
Stage 1:Assessment
Attention (selective, sustained)
Action selection, execution
Stage 2:Execution
‘High’
Conditioned learning 
Stage 3: Effect & Learning
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16. Noradrenaline Stress response Sympathetic NS(fight/flight) CRF release
Stage 1:Assessment
Optimizing performance/focus
 exploration of options
Stage 2:Execution
Learning
Conditioning
Stage 3: Learning
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17. Glutamate Preference formation Cue-elicited behavior Action selection
Stage 1:Assessment
Action selection
Stage 2:Execution
Learning
Conditioning
Stage 3: Learning
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18. Prefrontal Cortex (PFC) Anterior Cingulate (ACC)
Stage1:
Assessment DS VS
PFC/ACC
Stage2:
Execution
Stage3:
Effect
Learning
Dorsal Striatum (DS)
Ventral Striatum (VS)
Prefrontal Cortex (PFC)
Anterior Cingulate (ACC)
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19. Brain areas activated by:
Alcohol cues
Cocaine cues
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20. Dopamine: From Ventral Tegmental Area (VTA) & Substantia Nigra (SN)
PFC/ACC
Dopamine:
From
Ventral
Tegmental
Area (VTA) &
Substantia
Nigra (SN)
Striatum
VTA/SN
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21. PFC/ACC
Noradrenaline
From
Locus
Coeruleus
(LC)
Amygdala LC
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22. Glutamate
PFC/ACC
Striatum
Amygdala
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23. Lecture Neurocognitive aspects Neuroanatomical/neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
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24. 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
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25. Stage 1 Deficits  Response to cue Preference,short-term reward/”high”
Stress,  cue salience
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26. Stage 2 Deficits Habitual actions favored Can’t see other options
 Inhibitory control
Can’t hold back
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27. Stage 3 Deficits Imbalanced reward encoding First drug use,  reward
Once dependent
 Drug reward
Further drug consumption
 Learning from negative
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28. Case Stage I:  preference for drug Stage II:  inhibitory control
Stage III: / response to drug
Stage III:  response neg consequence
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29. Lecture Neurocognitive aspects Neuroanatomical/neurochemical systems
Malfunction in substance use disorder (SUD)
Treatment implications
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30. Prevention  Exposure Target high-risk Adolescents
Genetically vulnerable
Cognitive probs (schizophrenia, brain injury)
 Stress reactive (depressed/anxious)
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31. Treatment of SUD  Adaptive decision making  relapse
Medications (target any of 3 stages)
Psychotherapy
Improve choices
Avoid triggers
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32. Medications  Drug cue effect Naltrexone (AUDs), opioid blocker
 DA release after ETOH
 craving
 relapse
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33. Medications  Negative emotional states drug craving
Methadone (opioid use disorder)
 Withdrawal/craving
 brain stress response/  anxiety
Treat co-occurring disorders
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34. Medications Cognitive functioninhibitory control Experimental
Varenicline (nicotine use disorders)
Memantine (Alzheimer’s Disease)
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35. Medications  Drug reward Under development
Cocaine & nicotine vaccines
Abs block drug entry into brain
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36. Psychotherapies Contingency Management Therapy
Reward changes behaviors
Learn abstinence  earn $$$
Relapse Prevention Therapy
Identify triggers
Learn avoidance
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37. This lecture covered Neurocognitive aspects of decision making
Neuroanatomical/neurochemical systems
How systems can malfunction in SUD
Treatment implications
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38. 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)
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