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fMRI brain scans of a patient’s transition from pre-
treatment alcohol related craving activations to post-
treatment alcohol related aversion activations following
hypnotic covert sensitization plus emetic (chemical
aversion) counter conditioning for alcohol use disorder
Ralph Elkins, Ph.D., Kalyan Dandala, M.D., Richard Repass. M.D.
and Robert Nieson, A.S.T., from Schick Shadel Hospital
plus
Todd Richards, Ph.D. and Hunter Hoffman, Ph.D., from the
University of Washington
Introduction
Schick Shadel Hospitals’ (SSH’s) 10-day inpatient multimodal
treatments include 5 emetic counter conditioning sessions that pair
patients’ addictive substances with nausea and emesis that are
produced by oral ipecac. The treatment originated in 1935 as a clinical
application of Pavlovian conditioning. However, now it is known to rest
on the firm theoretical and empirical foundations of conditioned taste
aversions (CTAs) (Elkins, 1975; 1991). Nausea based CTAs are prevalent
among humans, where they can extend from taste to the sight, smell,
and even to the thought of a substance that has been appropriately
paired with gastrointestinal distress involving nausea (diSilva &
Rachman, 1987). Most SSH’s counter conditioning recipients previously
had acquired one or more naturally occurring CTAs during their
development; they therefore readily accept the counter conditioning
rationale. The treatments typically eliminate their cue- or memory-
induced alcohol cravings that are replaced by strong alcohol
aversions/revulsions. The treatments are well tolerated by patients and
have generated multiple treatment-outcome reports of one-year
abstinence rates of contacted patients in the range of 60% to 70%
(Elkins, 1991; Frawley & Howard, 2009; Revusky, 2009).
Background
Strong Conditioned aversions are readily observed and reported by
nausea based counter conditioned patients. The validity of these
aversions have been confirmed by psychophysiological studies from
several different settings (Elkins, 1980a; Canon et al., 1986; Howard,
2001). This report will extend these psychophysiological indices of
successful conditioning to fMRI brain scan recordings. The report will
present a patient’s pre- and post-treatment fMRI recordings that show
the changes in cue induced brain activations that underlie the transition
from alcohol cravings to alcohol aversions/revulsions. Other researchers
have reported brain scan evidence of addictive substance cravings
(Volkow et al., 2006). This is the first known report that includes a
transition from pre-treatment brain scan activations associated with
substance cravings to post-treatment activations associated with
aversions/revulsions.
fMRI RECORDINGS
This 46 year old female volunteer who was to receive SSH’s emetic
counter conditioning for alcohol use disorder reported that a habitual
drinking experience involved her standing on her back patio drinking
wine from a glass. She was transported from the Seattle SSH to the
University of Washington Neuroimaging Laboratory. She was briefed
concerning the imaging procedures and assured that she could
terminate the imaging session without prejudice at any time if she felt
uncomfortable. All fMRI scans were acquired using a standard protocol
on the research dedicated Philips 3.0 Tesla scanner. The patient was
positioned in the imaging apparatus and familiarized with a hand
signaling devise containing a left, right and middle button. She then is
instructed to read the following projected written directions.
Drinking Scene: I want you to imagine that you are on your back porch
holding a glass of red wine of your choosing. Imagine that you see the
wine and have some in your mouth that you can taste and perhaps
smell. You will signal your successful imagination with the middle
button and continue to focus on the wine. We will let you know when to
open your eyes.
After 45 seconds pass from the beginning of the drinking scene the
subject is signaled to open her eyes. She then is directed to
Press the right button if you liked the experience, the middle button if it
was neutral and the left button if you disliked it.
About 60 seconds have passed since the start of the Drinking Scene
Instructions. The patient then views the following instructions.
Beach Scene: I want you to imagine that you are visiting Newport
Beach and are enjoying seeing the sun, sand and water. You will signal
your successful imagination of that scene with the middle button. Close
your eyes and begin to imagine that scene. We will let you know when
to open your eyes.
After 45 seconds pass from the beginning of the drinking scene the
subject is signaled to open her eyes. She then is directed to
Press the right button if you liked the experience, the middle button if it
was neutral and the left button if you disliked it.
About 15 seconds after the eyes open instruction will complete the
Drinking Scene and Beach Scene imagery for a total time of about two
minutes. The Drinking Scene and Beach Scene imagery exercises with
ongoing fMRI recording are repeated four more times for a ten minute
total session.
Immediately following this 10-minute imagery and fMRI recording
session the subject participated in a second fMRI recording session
involving drinking scene and neutral scene print media advertisements
and in a subsequent structural fMRI recording. Those data will not be
reported in this presentation. The patient completed a written
questionnaire that recorded some of her positive or negative reactions
to the drinking scene imagery before leaving the Imaging Laboratory.
SSH TREATMENT AS USUAL
The patient was returned to SSH where she participated in all routine
treatments including four emetic counter conditioning treatments for
alcohol use disorder that were administered on alternating days. She
also received two hypnotic covert sensitization aversion enhancement
treatments. The aversion enhancement treatment are based on Elkins
(1980) covert sensitization research and are a standard SSH treatment
for patients who experience any difficulty with respect to normal
aversion formation. The combination of the four emetic and two
hypnotic counterconditioning treatments resulted in the patients
reporting a maximum + 5 aversion to alcohol at the end of her fourth
counter conditioning session as recorded on a bipolar
DESIRE/AVERSION SCALE (DAS) that is administered by a SSH treatment
nurse at the beginning and end of every treatment session. The
patient’s DAS results will be included on the poster.
fMRI AVERSION ASSOCIATED RECORDINGS
The patient was returned to the University of Washington
Neuroimaging Laboratory and completed her second brain scan session
on the day following her fourth emetic counter conditioning treatment.
All procedures and instructions including those to produce the Drinking
Scene and Beach Scene imagery duplicated those of the first imaging
session. However, as will be seen below, the patient’s fMRI brain
activations were markedly different from those that were generated
during the pre-treatment recording session.
RESULTS
The Pre-treatment fMRI with alcohol-craving related activation appears
in Fig. 1.
The Post-treatment fMRI with alcohol-aversion related activation
appears in Fig. 2.
The results of the post-scan questionnaires confirmed that imagination
of the alcohol scenes during the first scan session before any counter
conditioning treatments produced substance attraction and cravings.
However, the same instructions during the second scanning session
generated alcohol imagery that was rated as being unattractive.
Figure 1
Figure 2
DISCUSSION
The widespread pre-treatment cravings activations indicated by
yellow/red of Fig. 1 are no longer apparent in post-treatment Fig. 2.
(i.e., there is a large post-treatment reduction in craving-related brain
activity). Instead, they are replaced by widespread post-treatment
brain activations shown in blue that include brain areas previously
associated with aversion/revulsion (e.g., the amygdala).
The evidence of post treatment aversion localization in the amygdala
was predicted on the basis of Elkins (1980b) study of taste aversion
learning in rats. That animal model research reported that, unlike intact
rats, rats that had received bilateral lesions of the amygdala displayed
impaired learning of a conditioned taste aversion to a saccharin
flavored solution.
This preliminary report does not include any precise activation
localizations or the quantification of the magnitude of those
activations, and case studies are scientifically inconclusive in nature.
The study is ongoing and that work is in progress. The final report of at
least 15 subjects will feature a three dimensional localization and
magnitude quantification of all significant activations. However, it now
is clear that the fMRI findings will provide an important new brain
activation aversion dimension. It is predicted that the fMRI results will
augment prior behavioral and psychophysiological evidence that
nausea based counter conditioning replaces relapse promoting
substance cravings with abstinence facilitating aversions.
References
Cannon DS, Baker TB, Gino A, Nathan PE (1986). Alcohol-aversion therapy:
Relationship between strength of aversion and abstinence. Journal of Consulting
and Clinical Psychology, 49, 360-368.
Elkins RL (1980a). Covert sensitization treatment of alcoholism: Contributions of
successful conditioning to subsequent abstinence maintenance. Addictive
Behaviors, 5, 67-89.
Elkins RL (1980b). Attenuation of x-ray-induced taste aversions by olfactory-bulb
or amygdaloidal lesions. Physiology and Behavior, 04/1980.
Elkins RL (1991). An appraisal of chemical aversion (Emetic Therapy) approaches
to alcoholism treatment. Behaviour Research and Therapy, 29, 387-413.
Frawley JP, Howard MO. (2009). Aversion Therapies. Principles of Addiction
Medicine 4th edition. Published by The American Society of Addiction Medicine,
61, 843-855.
Howard MO (2001). Pharmacological Aversion Treatments of Alcohol
Dependence 1. Pproduction and Prediction of Conditioned Alcohol Aversion, Am.
J. of Drug and Alcohol Dependence, 561-585.
Revusky S (2009). Chemical Aversion Treatment for Alcoholism, Conditioned
Taste Aversion, Chapter 21. Published by Oxford University Press, Oxford, New
York.
Volkow ND, Wang GJ, Telang F, Fowler JS, Logan J, Childress AR, Jayne M, Ma Y,
Wong C (2006). Cocaine cues and dopamine in dorsal striatum: Mechanism of
Craving in Cocaine Addiction. The Journal of Neuroscience, 26, 6583-6588.
This research has been approved by the institutional review board of
the University of Washington.
