Affect Regulation Therapy ART for the treatment of

Affect Regulation Therapy (ART) for the treatment of cognitive and health disorders Mitchell R. Slutzky, Ph. D. CHE Senior Services March 27, 2011 Alzheimer’s Disease International, Toronto

Conflict of Interest Disclosure Mitchell Slutzky, Ph. D. Has no real or apparent conflicts of interest to report.

Key Concepts Ø Affect Regulation Therapy (ART) can improve cognitive functioning and physical health of persons with dementia Ø Catastrophic affect upsets the balance of the immune system and creates or exacerbates memory disturbances Ø Positive emotions benefit cognitive, emotional and physical health by reregulating the immune system Ø Many people with dementia can improve positive emotions with practice, even if cognitive memory is impaired (as long as emotional circuitry is better preserved)

What is Affect Regulation Therapy? Ø Built upon work of Allan Schore Ø Empathy and secure attachment reduces catastrophic affect extremes Ø Hyperactivation: Fight-Flight Ø Hypoactivation: Dissociation Ø Teaches one to recognize extreme affect states Ø Re-evocation of traumatic event recalled in context of safety leads to a more positively-valenced affective response Ø Positive affect state strengthened with each reinforcement in context of safety Ø Improves brain neuroplasticity Ø Improves endocrine and immune system Ø Has direct application to improve functioning Ø Even with cognitive impairment or health disorders

Allan Schore: Affect Regulation Theory Ø Early social environment, mediated by primary caregiver, influences developing brain structures Ø Maturation of the right orbitofrontal cortex is dependent upon dyadic interactions of the attachment relationship Ø Predicts the child’s future capacity to: ü self-regulate emotions ü appraise others’ emotional states

Polyvagal Theory: Evolution of Three Survival Strategies (Stephen Porges) Ø Dorsal Vagus Nerve/Primitive Parasympathetic NS Ø In response to threat perceived as life threatening Ø Primitive, not myelinated Ø Role: Shuts down to conserve metabolic functions Ø Sympathetic Nervous System ØIn response to perceived danger (escape possible) Ø Role: Activates fight-flight Ø Ventral Vagus Nerve/Evolved Parasympathetic NS Ø Arises only in the context of secure attachment Safety Ø Only in mammals Ø Myelinated Ø Role: can calm in face of danger by inhibiting fight-flight Ø Allows for attachments, well-being, balanced health

Safety: Balanced well-being Stilling and Stimulating both in balance Ø Occurs only when feeling safe Ømaximizes brain health and function Ømemory and other cognitive functions Ømaintains capacity for positive emotions Ømaximizes capacity for Øcompassion Øsocial connection Øindividuality Øimproves immune system functioning Øregulates appetite and sleep Whole is greater than sum of the parts

How ART reduces cognitive impairment Ø Cognitive and emotional systems develop parallel to each other Ø Emotional memory remains relatively preserved in the amygdala after cognitive memory fades with damage to the hippocampus Ø Build up amygdala’s emotional memory systems when hippocampal cognitive memory erodes

Key Memory Areas Lay Under the Neocortex In the Limbic System

Two ways emotional trauma leads to dementia Ø Step 1: Response to perceived danger is Fight Flight Ø Amygdala initially becomes hyper-activated Ø Plaques and tangles accelerate Ø Too much cortisol erodes the hippocampus Ø Hippocampal deterioration accelerates memory loss Ø Step 2: If perceived as life threatening leads to Dissociation Ø Amygdala becomes underactive Ø Metabolic preservation of hippocampus Ø β-endorphin numbs and enhances reality distortions Ø Functional deficit: memory loss but hippocampus is preserved Either way: Ø When faced with cues that re-evoke earlier trauma, the original affect state is triggered accelerating injury Ø Amygdala continues to record memories and the emotional significance of related events Explicit Memory deteriorates but Implicit Memory remains intact longer

Cycles of dysregulated affect Hyper-activation to danger Fight-Flight Reflex: Anger/fear (Over-stimulating sympathetic NS) Cortisol dysregulation Safe/Connected Normal emotional range Ventral Vagus nerve Right frontal orbital lobe both optimized Regulated alpha-msh Hypo-activation when life threatening Slutzky’s theory, 2010 adapted from Fosha and Schore, 2009 Dissociation/withdrawal/detachment (Over-stilling Dorsal Vagus Nerve) Beta-endorphin dysregulation

Acute Hyper-activation In Response to Stress Ø Increased Sympathetic NS (Fight/Flight) Ø Hyper-recording of memory Ø“light bulb burning too bright” Ø Increased cortisol secretion and burn Ø Decreased inflammation Ø Suppressed immune response Do not appear sick even if have a germ Get sicker when immune system finally kicks in

Chronic Hyper-activation Ø Chronic high cortisol levels: ØDamages hippocampus memory (Alzheimer's and other dementias) ØUnderactive immune system ØIncreased risk of cancer or immunodeficiency or: Ø Depleted supply of cortisol from chronic hyperactivtion ØIncreased inflammatory response ØImmune system overactive ØIncreased risk of autoimmune disorders Osteoarthritis Multiple Sclerosis Crohn’s Disease Parkinson’s Disease

Acute Hypo-activation In Response to Stress Ø Fewer memory frames per second Ø“light bulb not burning bright enough” Ø Increased Parasympathetic NS decreases ØHeart rate ØRespiration/O 2 requirements ØBlood pressure Ø Other Effects: ØIncreased Endorphins/Enkaphalins ØDecreased sensation of pain

Chronic Hypo-activation Ø Chronic flooding of beta-endorphin: ØDissociative disorders ØDID, somatoform disorders, emotional numbing, fugues Or: Ø Depleted supply of endorphins while hypoactivated: ØDepression ØChronic pain ØSubstance abuse ØSocial isolation Memory impairment either way

Neuroplasticity through A. R. T. Positive stimulation through A. R. T. improves ØThinking ØLearning ØActing Changes Brain: ØPhysical Structure ØFunctional Organization From Top to Bottom Dr. Michael Merzenich Major Researcher in Neuroplasticity ØNeuroplasticity continues to occur at any age

All you need is LOVE Look empathically: contain fight-flight & prevent dissociation (Auxiliary Amygdala) Organize emotional and cognitive memory (Auxiliary Hippocampus) Validate feelings to re-integrate affective and cognitive memory and to enhance reasoning (Auxiliary Right Prefrontal Cortex) Evaluate effectiveness of intervention (R)epeat (modify if necessary) to reduce catastrophic affect, consolidate memory and establish a polysemantic context that enhances encoding and retreival © Mitchell Slutzky, 2011

Affect Regulation and Brain Exercises Ø Progressively challenging Ø Use the Goldilocks principle: “just right” Ø Strengthen: ØAttention ØSpeed of processing ØRecent memory ØPlanning skills

Affect Regulation through Aromatherapy: essential oils Ø Lavender: Stilling Ø Calms anxiety, fear or anger Ø Sandalwood: Connecting Ø Maintains positive emotions Ø Ylang-Ylang: Stimulating Ø Brightens mood Ø Increases energy Ø Myrrh: Motivating Ø Reduces apathy Aromatherapy appears to trigger changes in neurochemistry especially in the emotional brain Never use full strength: Put a few drops in a “carrier oil” or buy it in dilution “ready to use”

Conclusions: Ø Affect Regulation Therapy reduces intensity of negative emotions Ø Negative emotions harm all aspects of life Ø Positive emotions heal the whole person: ØCognitively ØEmotionally ØPhysically Ø Positive emotions can be cultivated through a balance of stilling and stimulating Ø Even in persons with dementia

All you need is LOVE Look empathically: contain fight-flight & prevent dissociation (Auxiliary Amygdala) Organize emotional and cognitive memory (Auxiliary Hippocampus) Validate feelings to re-integrate affective and cognitive memory and to enhance reasoning (Auxiliary Right Prefrontal Cortex) Evaluate effectiveness of intervention (R)epeat (modify if necessary) to reduce catastrophic affect, consolidate memory and establish a polysemantic context that enhances encoding and retreival © Mitchell Slutzky, 2011

Thank you Mitchell R. Slutzky, Ph. D. CHE Senior Services mslutzky@gmail. com