A faulty risk/reward area of your brain can get you into trouble, but it can also free you to think outside the box. Cognitive neuroscientist Heather Berlin explains how the prefrontal cortex develops – or doesn’t – and how cognitive behavioral therapy can help you harness the power of neuroplasticity.
Dr. Stieg: I'm with Dr. Heather Berlin, who is a cognitive neuroscientist and Assistant Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. Today we're going to talk about what happens in our brains when we control or lose control of our unconscious impulses and how we can turn off our inner critics to find more joy in our lives. Heather, thank you so much for being with me. Thanks for having me. Maybe you can explain for us what is going on in our brain when we experience impulsivity.
Dr. Berlin: Well, there's a lot. There's not just one thing happening in the brain. There's a whole circuit and system that's involved, but in general, if you think of the prefrontal cortex or parts of the prefrontal cortex as kind of a brake system in the brain, then you have these sub-cortical evolutionarily older parts of the brain, like the reptilian brain that are kind of driving us forward for immediate pleasure or avoidance of pain and the prefrontal cortex kind of thinks about the future consequences of your actions so that you can behave adaptively. But if the prefrontal cortex is either not functioning properly or there's a brain lesion there, then you're not able to control those basic drives.
Dr. Stieg: As I understand it, there are different regions in the prefrontal cortex is not just this whole big glob on both sides, and we'll get into that in a little bit, but what is really going on when you have an impulse disorder?
Dr. Berlin: Well, symptomatically, usually what happens is first you get the urge to engage in a particular behavior and then it leads to sort of this anxiety and a buildup of tension until finally you just can't resist. You have to engage in the behavior. And then usually just after that, the person will feel guilty and they'll feel sort of bad about themselves, which can restart the whole cycle again, because then you want to do something that makes you feel good, and then you go back to that reward seeking behavior. So they're sort of locked in a, in a cycle of dysfunctional behavior. There's no one sort of line that distinguishes, okay, now it's a disorder, but it's really about sort of quality of life because when we think about impulsive behavior, it's about either getting immediate pleasure, right? Immediate pleasure, and not sort of discounting the punishment that can occur after the fact, right? But in this case, no matter what the punishment is, they'll just keep going for the pleasure for the reward despite the consequences. And that's really what we started to see, an impulse control disorders.
Dr. Stieg: Let's talk a little bit about what specific impulse disorders exist. First one, I think where a gray line is the impulsive gambler, versus the compulsive gambler, versus the professional gambler. Where's that line?
Dr. Berlin: Yeah. Well, so, so gambling or pathological gambling used to be defined as an impulse control disorder, or actually it was called impulsive compulsive gambling disorder. Now in the latest, um, it's called the diagnostic statistical manual. What we use to classify psychiatric illness, in the latest version, version five, it's now classified as an addiction. So the same neurocircuitry is involved with being addicted to gambling or say the internet as is involved in being addicted to it, a drug. And, and again, there is no sort of cutoff point, but we look at how severe their symptoms is. So, so for example, can they resist gambling? Can they resist it, do they stay there until 5:00 AM gambling at all costs? And so there's no distinct line between what's pathological or not, but usually it's kind of like pornography — when you know what you see, you, you see it, you know?
Dr. Stieg: How do we distinguish then between, I presume there's a compulsive disorder versus an impulsive disorder. Can you please make that distinction for me?
Dr. Berlin: Yeah, now something that, it's sort of two sides of the spectrum in general. Think of impulsive behavior as going for a reward despite the consequences, whereas compulsive behavior is engaging in a behavior to avoid something negative.
Dr. Stieg: You've referred a couple of times to brain circuitry and neural chemistry. Other specific neuro receptors and transmitters that are either depressed or elevated in impulsive compulsive disorders.
Dr. Berlin:Yeah, we find that in a healthy person or person without an impulse control disorder, when they're ab out to, they're anticipating getting a reward, they get increased activation, increased dopamine in striatal areas. However, people with pathological gambling did not have that increase. They had less activation. So the idea is that they actually might need more stimulation just to get the same feeling of reward that a person without impulse control disorder gets. So in a sense, they're not necessarily seeking out a high, they're just seeking out to feel normal and they need more for that.
Dr. Stieg: Can you tell us which groups are particularly prone to impulsive disorders or can it strike at any age? Could I be normal for 50 years and all of a sudden at 55 I've become an impulsive gambler?
Dr. Berlin: No, I mean it tends to be lifelong. So it tends to be you're born with a certain kind of temperament. I mean, we can see something like antisocial personality disorder, you know, you can see it early on and actually in order to get diagnosed as that as an adult, you had to have had some sort of conduct disorder as a child. So there are different than other kinds of psychiatric disorders. For example, like schizophrenia where you're more likely to have the psychotic break, you know, in your late teens, early twenties or some types of depression. This really is a lifelong, so even in babies you can see their temperament and you'll see them being impulsive. And that's why the marshmallow test, although it's controversial—
Dr. Stieg: What's a marshmallow test?
Dr. Berlin: That basically is, they give these kids ages three to six — you can either have one marshmallow now or two later and then they just leave the room and leave them with the one marshmallow and like see what happens.
Dr. Berlin: Right. And they gave these, it was Walter Michel, who's at Columbia, gave these kids a whole array of different measures and tests and they found that all the measures, this one test was the greatest predictor of all these future outcomes in life. Like job attainment, marital status, you know, body mass index. And you know what? I see it as, it's the measure of prefrontal cortex function. You know, if you're able at that age to withhold responding for an immediate pleasure, that means you're having a more evolved prefrontal cortex. And that's gonna lead to, for example, staying home and studying instead of going to the party and getting a better job later. So impulse control. It's not that if you don't have it, you're doomed. Maybe you just have to work harder to—.
Dr. Stieg: So what can you do about it?
Dr. Berlin: So I think a few things, I mean, cognitive behavioral therapy is really helpful. This is what I often say to people.
Dr. Stieg: Can you describe what that is?
Dr. Berlin: So for example, if you get people to stop and think — so often when they're engaging in impulsive behavior, say it's that marshmallow right there and they just can't stand it. It's, they have to have it. First of all, I also looked at time perception and they have a faster perception of time. So they feel like the waiting is even feels longer to them. But if you can get them to stop and wait and actually engage their prefrontal cortex doing certain exercises or just becoming more self aware, even some sort of mindfulness, it can engage the prefrontal cortex. So maybe they can get past that moment of the urge and then not engage in the behavior. But it's about getting them to kind of stop and think and take a moment. And it's, it's a hard process. You know, you have to really be conscious of it. Whereas for others it comes naturally. They really need to work at it.
Dr. Stieg: How effective is that? Is that 80% 70% 50?
Dr. Berlin: It's hard to put a percentage on it. I think it depends on the person. You know, I often see like our genetics, um, gives us kind of the boundaries with which our behavior can be in. So you can work towards being at the higher or you can be at the lower end within that boundary. So, for example, if you're an anxious generally you know, anxious person, we can get you to be a little bit less anxious, but you're never going to be the most relaxed person in the room cause that's just not part of your makeup or the way your brain is wired. So I think that it really varies between people. If some people have a really extreme impulse control disorder, you know, they're, they, they probably will need some sorts of medication
Dr. Stieg: With cognitive behavioral therapy, is there, you mentioned it — is there a rewiring? Is there neuro-plasticity that's occurring?
Dr. Berlin: There is, I mean we do see changes in the brain based on these cognitive behavioral therapies. Cause anything learning is a change in the brain. Right? Um, so you can to a certain extent, that's why I think intervening at a younger age is really important because the brain is still developing. Think it's less effective when you're first start treating somebody who's, who's older and they've already have fully formed their neural network. So if you see a kid who is acting sort of more impulsive than the average kid, again, it's all relative. Intervening early on can actually help with the way the brain is being wired up.
Dr. Stieg: Let's talk a little bit about flow state. Can you tell me what flow state means?
Dr. Berlin: Yeah, so like, well I got interested in flow states because I was so working so much with patients to try to get them to turn on their prefrontal cortex to try to control these, these basic urges and desires. And you can only go so far with that. And then, I started getting interested in what happens if we can, if they can turn down certain parts of the prefrontal cortex in a controlled way and actually almost like release their, the desire itself. And these flow states that people get into, we've all had them, right? It's sort of where you lose your sense of time and self in place, whether you're engrossed in a really good book or you're doing something physical like, like rock climbing. And a lot of artists talk about this flow state when they're in their creative flow and they lose sense of time. They feel like the information is coming through them. And what we find is that parts of the prefrontal cortex in particular, the dorsolateral prefrontal cortex is turned down in these flow states. So you actually do lose your sense of self that cause our sense of agency is part of the function of the dorsolateral prefrontal cortex. And you lose your sense of time.
Dr. Stieg: By sense of agency you're referring to basically judgment. You don't do something because you understand the consequences of something are bad.
Dr. Berlin: Right, right. You know, like just like, so children's prefrontal cortex isn't fully developed until about the age of 25, let's say.
Dr. Stieg: I thought that was boys, I thought girls are earlier.
Dr. Berlin: Girls are a little younger. That's correct. Girls are a little bit younger obviously, but so you can think about a child, you know, they want to do things, they want things right away and they don't really think about or they're not able to control their behavior or think about the consequences of their actions. And so you take on a fully formed adult brain and turn down that part of the brain. And again, it's similar where you can't really—
Dr. Stieg: So that means the middle part of your frontal lobes becomes accentuated.
Dr. Berlin: Yes.
Dr. Stieg: Which can lead to impulsivity or compulsivity.
Dr. Berlin: Right, but the thing is, why when you get in these flow states, you can actually be more creative. Cause normally, I mean, think about children as well. They're, they don't have a filter. So it can be bad in that they're more impulsive but good in that they're more creative because they can make, um, divergent association between ideas, right? They don't have that filter like, Oh no, that's not the right way to think. Or you shouldn't be, you know? So when you remove the constraints in an adult, you can actually get to these places where you can be more creative. You can think outside the box. And when you turn up the medial prefrontal cortex, it actually has to do with the internal generation of new ideas. And then it's unfiltered because the dorsolateral is turned down.
Dr. Stieg: Aside from potential for drug addictions in people that have impulse control issues, don't they also experience a fair level of anxiety or possibly depression related to this activity?
Dr. Berlin: Well, ironically, when they're actually in those flow states, it's associated with really positive emotions; people strive to get there. So it could be that in their normal state when they're not in these states that I mean anxiety has to do with turning on the prefrontal cortex and rumination and you sort of can't get outside of yourself and being self aware and when you can remove that and get into the flow states, it actually is associated with a decrease of anxiety and self-awareness. The moment you become too self-aware, you're actually out of that state.
Dr. Stieg: I understand you've made this a little bit personal in the sense that your husband is a rapper and you've studied him. So tell me what, tell me what that's about and what you found.
Dr. Berlin: Again, I started getting interested in trying to access these, the unconscious and the ways we can turn down the prefrontal cortex in order to actually access the unconscious to help treat psychiatric patients. And then I saw what my husband was doing in terms of his freestyle rap and—
Dr. Stieg: Which is a flow state.
Dr. Berlin: It is a flow state and it really reminded me a lot of Freud's like free association, right? You don't have time to think. It has to rhyme. It has to come. And the things that would come out of his mouth were rather interesting and you know, I would gain some access into his unconscious. And so I thought, wow, maybe we should put them in the scanner and actually look at what's happening in his brain. So I had him go and do, a memorized rap versus an improvised a rat and using fMRI, looking at blood flow to different parts of the brain in real time.
Dr. Stieg: So fMRI is a functional MRI scan looking at brain activity and brain segments.
Dr. Berlin: Right, looking at blood flow, which is a proxy to neurons firing. And so what I found was that, and this was based on also some preliminary work that was done by um, Charles Limb, um, who did it with jazz provisors. Um, and then more recently there was a rap study as well, looking at a group of rappers. But basically you find this distinct pattern of activation in these flow states where you have decreased dorsolateral prefrontal cortex activation and increased medial prefrontal. And you see it in the jazz improvisers. You see it in the rappers, you saw it in my husband. And so one idea is like, is there a neural signature of creativity and improvisation and can we get people into these flow states more easily and get them to maintain them longer as maybe a form of therapy. Now that being said, when people with impulse control disorders can't get out of that state, right? If you permanently have dorsolateral prefrontal cortex turned down, that's maladaptive. But the idea is if you can take someone with the sort of healthy brain and turn it down in a controlled way, it could be very therapeutic.
Dr. Stieg: What I also find interesting, however, is how do you separate out the star performer and that balance that must go on between the middle part of your frontal lobe and the lateral parts. So when you're performing, you're looking at your audience and going, "Oh, this ain't working. And so all of a sudden, so it's a delicate balance between all segments of your brain working together.
Dr. Berlin: Yeah, and that's actually something we wanted to look at. So it's a process of switching between, these two modes are kind of like general circuits that are more active in the brain. You have this default mode network, which is kind of the inward looking: I'm going to be creative and turning up the medial prefrontal cortex. Then you have this outward looking called the executive control network where you turn back on the dorsolateral prefrontal cortex and kind of check in with the environment, see what's happening, look at like, what feedback you're getting and then adjust your behavior accordingly. So it's not like you're completely out of it, you know, in some random flow state, you'd go in and out of these two modes to adopt your creative process in the moment.
Dr. Stieg: We've talked a lot about the flow state as it relates to being an artist for we mortals that don't have any, what we think is pure artistic talent. Are there other ways that one can achieve a flow state?
Dr. Berlin: Yeah, of course. I mean, not everybody is an artist. Um, but if you, even people who are really engrossed in, I mean as an academic, like when I'm involved in writing a paper and I really get into it, um, and I lose my sense of self and time and place, um, that's a flow state or you know, reading a book or gardening, um, running — people get into these flow states when they're running or rock climbing. So it doesn't have to be, it could be a mental act that you're engaged in. It doesn't have to be a creative art act, although people tend to be more creative in those states, and come up with ideas or solve problems when they're in those states.
Dr. Stieg: So essentially a flow state is a complete absorption into some activity, whether it's cognitive or physical that divorces you from a perspective on the sense of time.
Dr. Berlin: Yes. Yeah. We found that, I've looked, I've done studies on this, which is looking at our sense of time. And when you're in these states, you really do lose your sense of time. And again, you are able to think outside the box. There's a study where they gave people a riddle to solve and they couldn't solve it. And then they use TMS, transcranial magnetic stimulation, which kind of knocks out the dorsolateral prefrontal cortex temporarily. And they found, once they did that, they actually immediately could solve the puzzle so they could think outside the box. But the idea is that in impulsive people, this part of the brain is turned down and it's a negative thing. They can't control their behavior, but in certain controlled ways when we turn down the dorsolateral prefrontal cortex, it can actually be really positive and we could come up to solutions to problems or lose our sort of rumination that running around in our head.
Dr. Stieg: I want to thank you, Heather, for taking the time to really go through impulsive compulsive disorders. I think it's really important for people to understand the, the, the positive impact that cognitive behavioral therapy can have on patients with these disorders. And it, I'm finding that it's even applicable in other dysfunctions like chronic pain and in, in people that have experienced head trauma. So it's, it's really something that is positive. You don't have to use drugs, and the impact of cognitive behavioral therapy, I think is, is astounding for our patients. I agree. Thank you so much for being with me.
Dr. Berlin: Thank you, for having me.