Personality Disorder

28 03 2011

Al Pacino - Scarface

I’ve seen a lot of drug dealers lately. I’ve never met one in my personal life, but I have met plenty as a doctor. I must be on some list somewhere, because in the last week, I’ve seen three of them. In the process of doing my assessments I have seen an interesting trend.

3 out of three were diagnosed with anti-social personality disorder with narcissistic traits.

I’ve always been a bit of a skeptic when it comes to personality disorders. It always seems to me like a bit of a diagnostic cop-out.

It just so happens that in psychiatric circles, it’s pretty much a known fact that there is no treatment for personality disorders. That’s very handy.  If we don’t like you, and there is no treatment, then we have no duty to care for you. It’s the perfect ‘out’. So, if we don’t know what is wrong with you and we don’t like you, and we’d just as soon wash our hands of you, guess what… You have a personality disorder.

That’s why it struck me as odd that three of the last three patients I saw last week who had been diagnosed with personality disorders had recently had a psychiatric assessment on their way out of jail.

I know, you’re probably thinking… ‘They are the scum of the earth, let’s be done with them’! OK, I get that. It’s hard to have empathy for someone who has no empathy.

But what struck me was that each of these fellows was actually relatively likeable. I don’t mean ‘take them home for dinner’, likeable, but not as bad as you would think. They have a number of things in common that might explain why they are often tagged with the diagnosis, “personality disorder”

  1. They all grew up with mother’s who were either not around, or were pre-occupied, or just didn’t ‘get’ them. They did not have strong attachment to their primary caregiver. In fact, many were bullied, neglected or abused as children, so they often have little attachment to anyone.
  2. They are reward deficient. Meaning they have a tendency to be easily bored, are risk takers, defiant, irritable and sensitive to criticism.
    The first trait, ‘attachment disorder’ means they do not feel the misfortune of others. This allows them to lie, cheat, steal, manipulate, defraud, assault or even kill people, without losing sleep. If no one ever cared about you, why should you care about anyone else.
The second trait, ‘reward deficiency’ means that earning a living the legal way is too boring. It means you don’t sweat it too much when you are on a ‘most wanted’ list, because risk is part of the allure. It means you are oppositional; you don’t bow down to authority (because that’s no fun). It also means that you are quick to anger and you’d just as soon kill someone who disrespects you, than look at them. Remember Pacino in Scarface or Brando in The Godfather?
    Reward deficiency also ties into narcissism. Narcissism is a moral not a biological construct. In the animal kingdom you don’t call the alpha male a narcissist. He’s just looking out for number one, that’s how he got to be the alpha male. In our society we consider that being selfish. When I get to know these guys, I don’t see selfish. I see self preservation. I see a person who feels so bad, that he can’t tolerate things getting any worse. That manifests as not liking: being told what to do; being criticized; or not having things your way.
    In other words, he’s reward deficient. That pretty much explains it. If your like that, and you have attachment disorder, people consider you a narcissistic asshole. But is it really their fault? It’s not their fault that they inherited genes that disrupted their dopaminergic reward circuit. And, it’s not their fault that their mother and other’s did not teach them the language of empathy. That’s why when you talk to them, even though they just got out of jail for some pretty nasty business, they seem a lot less horrible than you would think, relatively likeable actually.
    However, I’m not saying it’s OK to be a drug dealer. But if you hear the whole story, like I do, you are less likely to ascribe blame. As one of my psyche teachers said. It’s maybe not their fault, but it is there responsibility and as such, even though I get where they are coming from, I still think they should pay for their crimes. However, while they are in jail, paying for their crimes, maybe they can get some therapy to help them understand themselves, or maybe they might get some medication to increased the voltage in their dopamine circuits. Maybe that might help them turn around more than just being in jail and then being diagnosed with an untreatable personality disorder.
Anthony Ocana MD
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Caution: Do Not Enter

31 01 2010

Off Limits: Stop or Go?

It’s that time of the year again, in Western Canada, when people start dying because they have been skiing out of bounds. Whether it’s back country skiing, snowboarding, snowmobiling it’s often the same… people going where they should not, doing what they should not.

I was perusing the paper when I came across this article, Ski deaths at B.C. resort leave victims’ Ontario hometown reeling: Globe and Mail January 30, 2009. So, I thought it might be interesting to explore the neurobiology of  risk taking and defiance.

You might not immediately think that people who die in avalanches have a disorder and to be fair, I don’t know this for sure, but when I read things like this, “For reasons unexplained, they decided to go out of bounds – off the run and into a steep, wooded area with a hard-packed surface. They took off their skis and tried to ascend the icy chute. But they slid down 100 metres on the rough ground and then over a cliff.”

Risk taking is a phenomenon well described in the psychological literature. It is associated with addiction, substance use and all manner of impulse control disorders. Although not well documented, it also correlates with Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD), two disorders that I see in my practice every day at the NorthShore ADHD Clinic.

ODD is defined in the DSM- IV (the bible of psychiatric diagnosis) as an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with day to day functioning.  It is considered a pediatric diagnosis, but I think we all know or have seen on TV, adults who meet this criteria.

Symptoms of ODD may include: Frequent temper tantrums; excessive arguing with adults; often questioning rules; active defiance and refusal to comply with adult requests and rules; deliberate attempts to annoy or upset people; blaming others for mistakes or misbehaviour; often being touchy or easily annoyed by others; frequent anger and resentment; mean and hateful talking when upset; spiteful attitude and revenge seeking.

This is the kind of atheoretical grab-bag of symptoms that give the DSM-IV, and psychiatry in general, a bad name. As described, there is no unifying theory, no attempt to explain why this list of symptoms should hang together. So here is where I am going to go out on a limb and tell you what I think about this disorder, and how understanding the neurobiology of ODD explains the recurrent catastrophes associated with skiing out of bounds.

Skiing out of bounds is essentially a kind of risk-taking. Risk taking usually occurs in the presence of boredom, which we previously defined as an under-functioning of the reward circuit.

Specifically, when the dopaminergic circuit, aka the reward circuit, under-functions for whatever reason, the result is lack of stimulation, i.e. boredom. When a kid says he’s bored, he’s telling you that the amount of dopamine hitting the post-synaptic receptors in his reward circuit is low. That is why he/she has to look for something more risky to do. Because from the brain’s point of view, risk = dopamine = reward.

Studies have shown that youth with ODD have the same dysfunctioning dopamine circuits as compulsive gamblers, crack addicts and people who ski-out of bounds, i.e. compulsive risk takers.

So now when we look at the symptoms of ODD, we can see that many of these align with an under-functioning reward circuit.

Kids with ODD:

have frequent temper tantrums, because when your reward circuit is not firing like it should, and someone tells you you can’t have what you want, you already feel so bad that you can’t bear to feel any worse, so you go ballistic. This is partly because you have learned that it works and partly because you can’t help yourself, because you are impulsive. (impulse control is also on a dopamine circuit)

like to argue because they are bored and arguing is more fun than saying, “yes”. The same is true for – often questioning rules – active defiance – refusal to comply with adult requests and rules

deliberately annoy people, because when you annoy someone, it is exciting. It creates a little chaos and that helps alleviate your boredom.

blame others for mistakes or misbehaviour, because if your reward circuit is not being stimulated, and you already feel bad, you can’t bear to take responsibility for your misdeeds, so you say any thing and do anything to avoid feeling worse. So while the ODD kid seems so tough on the surface, they are often very fragile, touchy or easily annoyed by others.

are frequently angry… see poor impulse control above. If you are already irritable, and someone pushes your buttons, and you are impulsive, you are not going to be able to control your emotions.

– engage in mean and hateful talking when upset, have a spiteful attitude and seek revenge…. This in my opinion is not necessarily ODD, but starts to cross over into what we call conduct disorder. If you are bored you might bug someone to get a rise out of them, but to be deliberately mean, hateful and vicious starts to take on what we call anti-social qualities that I wouldn’t lump in with ODD.

So you can see that skiing out of bounds, risk taking, deliberately opposing and defying rules, undervaluing risk and over-valuing reward, all derive from the same neurobiology. That is why having a theoretical underpinning to your diagnosis is important. If you understand the theory, your treatments are more likely to work.

That is why, if you have a kid who has ADHD as well as ODD, and you treat the ADHD with some intervention that increases dopamine neurotransmission, the ODD gets better too (because it is also caused by under-functioning dopamine circuits).

And by the same logic, when you treat ADHD, in many cases, you decrease drug seeking. This is because once you stimulate your dopamine circuit whether with exercise, food, passion or meditation, you don’t need to do it with drugs. This may sound crazy, but I have patients who swear up and down that when they tried to do cocaine while on ADHD medication, they did not feel a thing, yet every one else who used it, said it was good coke.

One way of looking at it would be that ODD is the paediatric version of addiction (or addiction is the adult version of ODD). If you don’t have access to substances to raise your dopamine, you need to get your thrills somehow…  by arguing and being defiant.

So, if we diagnosed and treated ADHD more effectively, I predict we would have less addiction and fewer people skiing out of bounds, falling off cliffs, drowning, getting into car accidents, dying of hypothermia or triggering avalanches. I might be wrong about this, but imagine if I were right.

Dr. Anthony Ocana MSc, MD, CCFP, ABAM – Special interest in Mental Health and Addiction

You can follow my posts on Twitter at: http://twitter.com/DrAnthonyOcana





Homelessness can be beaten

22 12 2009

In a few weeks, hordes of world’s media will descend on Vancouver, British Columbia for the 2010 Winter Olympic Games. The most intrepid journalists will grab a camera man and head down to Vancouver’s Downtown Eastside (DTES) to get their money-shot: a homeless person sleeping on a heating vent, or a drug user shooting-up in Blood-Alley. Then they will roll out the sad-but-true statistics to contrast the majesty of the snow-capped North Shore mountains with the human misery of Canada’s worst slum. This will be broadcast around the globe for billions to see. There will be gnashing of teeth and wringing of hands, as Canadians are forced to explain the horrors lurking on their doorstep.

However, in the wake of this social catastrophe, there are rays of hope. The local, federal and provincial governments have poured hundreds of millions of dollars into the area over the past decade in an effort to keep this from being cast as a totally bad-news story.

Duncan Sallie, cleaning up

This weekend’s Globe and Mail ran a two page story on Duncan Sallie, an ex-squeegee kid, and his quest for employment on the DTES. Mr. Sallie is a 26 year old homeless man with a checkered past, few marketable skills, years lost to drug-addiction and a history of mental illness. Yet, he showed up to his first job interview wearing a clean shirt and big smile.

One of the stories within the story is the success of BOB (Building Opportunities with Business) a government funded agency which provides unconventional services to the city’s neediest and hardest to employ, resulting in real jobs for 137 inner-city residents, like Duncan Sallie, since October 2008.

Mr. Sallie is an ex-crack addict with a rebellious and violent past. As a child, before taking drugs, he was diagnosed with Attention Deficit Hyperactivity Disorder. Although the story does not specify the details, it is a story that I hear in my office, every day.

Young men like Mr. Sallie have a frighteningly common trajectory. The movie goes something like this…

As a child, he was a charming and energetic boy, who did not like to read and had difficulty sitting still. He was a daredevil, risk taker, good at sports, but bored in school. He may have been raised in a loving home, and may even have done well in school, initially. But his quirks get him rejected by the popular students and invariably he falls in with the wrong crowd. He starts smoking and drinking early. He quickly graduates from smoking to “blazing”, but he does not graduate from high school. Smoking pot starts off as a way to ease the boredom or to be cool, but eventually becomes a daily ritual. If smoking pot is as far as this young man’s drug taking ever goes, the story may be a downer, but it’s not a tragedy.

In order to have a truly tragic ending, he needs to move on to more adventurous experimentation with mushrooms, acid, speed, ecstacy and/or cocaine…. And, he does. Again, while snorting cocaine may leave you in debt, it does not usually leave you homeless. In order to win that distinction, you usually have to tangle with one of the three home-wreckers: crack, alcohol or heroin.

If you want to see homelessness, live and in colour, go down to the DTES. Stand on the corner of Main and Hastings and the sights will break your heart. Homelessness is not caused by lack of money. Every day more money changes hands in the DTES than on the Vancouver Stock Exchange. Homelessness is not caused by mental illness per se. It is caused by the executive dysfunction and impulsivity that is associated with certain types of mental illness including substance abuse and addiction. Can’t get a job; can’t hold a job; can’t pay the rent; go on disability, get housing assistance, but get kicked out for doing drugs or beaking off to the landlord.

Mr. Sallie is trying to change his lot in life. Currently, he is on methadone, prescribed by an addiction specialist in Vancouver. It keeps him away from the needle and allows him to focus on getting a job. But even though 10 doctors will have seen ADHD on his chart at various hospital or clinic admissions, no one will have taken it upon themselves to treat it.

There are some good and practical reasons to be wary of treating ADHD in a person with an active addiction, but the experts agree, it’s not a deal breaker. All the research shows that the risk of treating ADHD, even in the actively addicted, can be managed. The problem is, as in the case of Duncan Sallie, the diagnosis is made and an initial treatment is prescribed, but there are not enough skilled clinicians to provide patient education, follow-up or ongoing treatment for those who go on to manifest ADHD as adults.

There were 1000 adults on the waiting list at the only adult ADHD facility in British Columbia. The BC government wanted to shorten the waiting list, so they closed the program. They pay for the risky, short acting, addictive stimulants, but they do not cover the cost of the safer, non-addictive, slow release stimulants. Go figure. They think they are saving money.

The hallmarks of ADHD are executive dysfunction and impulsivity. A number of recent studies have documented how frequent ADHD is in homeless men. A few years ago, the Mayor of Vancouver, Sam Sullivan tried to start a program of treating cocaine and methamphetamine addiction with “replacement therapy”. It was not a bad idea. If stimulant abusers were addicted to fast-acting stimulants, maybe we could wean them off their drug of choice by using slow-acting stimulants. The same principle is used in replacing heroin addict’s fast-acting opioids with slow-acting opioids (methadone). Sullivan’s wish to get replacement treatment on the street before the Olympics was innovative and plausible with some adjustments, but it met with significant resistance from various stakeholders and the plan died on the vine.

A more rationale idea would have been to screen homeless stimulant abusers for ADHD and, within the risk management guidelines alluded to above, treat their impulsivity and executive dysfunction. Duncan Sallie would likely, in my opinion, have benefitted.

Mr. Sallie showed up to his job interview on time, but at the last minute, he realizes that he has forgotten to put together a resume. He sits down to write one, but he is so nervous and so fidgety, that he spills coffee on his new pants. We don’t know for sure why he does not get the job, but we’re not given any reason to be particularly optimistic.

Last May, I presented a paper at the 2nd International Congress on ADHD in Vienna, Austria. “Management of ADHD in patients with co-morbid cocaine addiction”. To make a long story short, the study which included 53 patients, showed that those cocaine users whose impulsivity was pre-treated with a mood-stabilizer (which inhibits glutamate, increases GABA. or both) before their executive function was treated with ADHD medications, had significantly better outcomes than those who received ADHD treatment without a mood stabilizer. It’s a preliminary study,not yet replicated, and as yet unpublished, but there is a signal there. It is an outcome that I see every day in my practice…

Treat the impulsivity first (by modulating Glutamate and GABA), then treat the executive dysfunction (by boosting Dopamine) and the patient’s function will improve. Here are a few quotes from one the patients in the study….

“I still have ups and downs, but I feel more on an even keel. I can deal with things better. I can listen. I can go to a meeting and actually follow. I can take care of children and really be attentive. It’s amazing”.

“I don’t feel as aggressive. I don’t want to throw stuff, kill people, or kill myself. I’m not as violent. I don’t fly into rages anymore. I don’t seem to have nearly as many cravings. I can concentrate better. I can actually read three chapters. That’s a big improvement.”

I don’t know whether this kind of intervention could have helped Mr. Sallie’s chances of  making a comeback. What is important is that his story has been told and that the people following the Olympics realize that with with the right resources and a little political will, homelessness can be be beaten.


Dr. Anthony Ocana  MSc, MD, CCFP, ABAM             Family Physician/ Addiction Medicine Specialist                 drocana@telus.net





The little voice in your head

8 12 2009

Last week, I finally listened to the little voice in my head. At the time, I was contemplating, “Should ride back down on the road, or should I ride down the trail.”

The trail would have been much more fun. There are roots, rocks, some really steep pitches, lots of fast curves, tricky corners and a series of hairpin turns right before the big drop that delivers you back to the road just above the highway. Usually, by that time my heart is pounding, my legs shaking and my arteries flush from the injection of adrenaline. Then it’s back to the office.

But just then I passed the sign on the road that says, “Are you prepared? If you get lost, does anyone know where you are going? This is not for nothing. Every year, in every season, people die on the North Shore mountains, because they get lost, it get’s dark and they fall of a cliff or succumb to hypothermia. So, just before I pointed the front tire of my new Trek Fuel mountain-bike down that gnarly path, I heard the little voice in my head.

The voice said, ” You know, that might not be such a good idea. It’s Friday at noon on December 4th; there is no one on the trail, nor will there be anytime soon; the trails are super-slick because it has been raining like crazy for the last month; no one knows where you are; you don’t have a cell phone;  and if you fall and need help, it will be dark and cold soon and basically, you’re toast!”

Usually, I would have argued with the voice. I would have said, “Oh, what do you know. It’s a beautiful day; you haven’t ridden this trail in months and you’ve got lots of time. Don’t be a wimp.”

But then I remembered all the near death experiences I have ever had. Three of them, three and a half if you include the time Simon Parker and I got lost in the dark on the back side of Bowen Island. Right before each of them, I had a similar exchange with the voice in my head. And… I remembered that after each of them I promised that I would be more diligent, more careful and I would not ignore the voice of caution.

So this time I listened.

I listened to that voice… no questions asked. I listened because I finally realized that if you get that little voice in your head telling you, “maybe this is not such a  good idea”, that you should bloody well listen, because it is not telling you, it’s not such a good idea, for nothing. It’s telling you, it’s not a good idea, because it is desperately trying to save your bacon. So, listen.

Most anthropologists are pretty clear in saying that humans are not completely rational beings. They point out that humans often act in ways that are contrary to their best interests, when we make emotional rather than rational decisions. Recent research suggests that, it’s not that we are not rational, but rather that we often act before any rational thought has had a chance to influence our behaviour. We are often flying down that proverbial trail and before we know it, we are ass-over-tea-kettle, looking right at the worst possible consequence that we could ever have anticipated, if only we had…anticipated. But we didn’t anticipate. We didn’t think it through. We acted without thinking, again.

Does this sound familiar?

To most of my patients with ADHD and addiction, this is the story of their life. Shoot first, ask questions later. Neuro-biologically, this can be explained as follows…

Normal people have about 4 milliseconds between impulse and action, giving them a brief but adequate window, during which the little voice in their head has just enough time to say, “Hmm, maybe that’s not such a good idea.” This is when normal people put on the brakes, look over the edge of cliff and say, “Phew, that was close.”

On the other hand, impulsive people have about 1 millisecond between impulse and action, which means, by the time their little voice has spoken, they are already at the bottom of the cliff, wheels up, engine billowing smoke, wondering, “What the heck just happened. Maybe I should have hit the brakes.”

For the record, Buddhist monks have about 8 milliseconds between impulse and action, during which they have enough time to have a national debate on whether or not to hit the brakes.

So, as you can see, being impulsive is quite the handicap. Take for example, the patient I saw the other day. Tough kid…  smoked dope at 11; doing lines of coke at 13, dropped out of school at 14; smoking crack and shooting heroin before his sixteenth birthday. So you might think he was stupid, or came from a bad family. That’s the current thinking. But he was an intelligent kid, raised by loving and intelligent parents. Unfortunately, he was also impulsive, a risk taker, a stimulus seeker who found school to be too boring. He was a skilled mountain-biker, dirt-biker, 4×4 truck driver, but what really turned him on was seeing the duffle bag full of $20 bills when he cashed in his first grow. 4000 marijuana plants make a lot of pot and at $2000 a pound, that’s a lot of green. Pretty soon he’s running two grow-ops and starting a third. Money is as addictive as the finest drug.

Long story short, our friend, we’ll call him Jake, is now up for 5 counts of possession with the intent to traffic. So he comes in today to have a little chat. He was diagnosed with ADHD as a child because he was hyperactive and could not focus in school. He was tried on medication, but it made him an introvert and he did not like it and so he stopped.

I explain to him that is a very common outcome, because the medicines in those days were too short-acting; few people knew how to use them and that his experience is caused not by the medicine, but by the medicine wearing off. He and his father both nod as if they understand, but I can see that they both wish there would be could be a way to make it all better.

I explain that right now there won’t be any medication; that we first need to finish our assessment and I remind his father of what he already knows. There will be no more bail-outs. It’s not that we don’t feel any empathy for Jake’s plight. It’s just that protecting Jake from the consequences of his actions is not doing him any favours. So he is  looking at 6 months in jail. He’s made his bed, now he has to sleep in it.

I tell Jake that I am happy to help him, but the first thing he needs to do is to make a commitment to stop using cocaine, because I can’t safely treat his ADHD until he is cocaine free for 4 months. There are a few things we can do in the meantime, so I am not blowing him off, but he has at least to give me his best effort. I say good bye and wish them both luck.

A few hours later, Jake’s dad calls back in a bit of a panic.

As we discussed, Jake’s dad made it clear that there would be no more hand-outs, bail-outs or redemptions. That Jake would have to stay in a shelter and get some kind of temporary job so that he could get back on top again. It so happens that Jake is a highly skilled carpenter who could easily earn $50,000 a year, legally, by applying the skills of his trade. Unfortunately, he sold all of his tools to buy drugs.

Jake, being the master manipulator that all drug addicts are, will have none of it. He wants Dad to take him back. If he doesn’t, Jake says he will commit a few B/Es to get the cash that he needs.

Jake’s dad wants to know what to do. I tell him my thoughts and he thanks me. He just needed to hear it from someone else.

So, do you think Jake will take the time to think through the consequences of his threatened actions? Do you think he will listen to the voice in his head? Do you think he can even hear the voice in his head?

Stay tuned...

Dr. Anthony Ocana

MSc, MD, CCFP, ABAM

Family Physician

Addiction Specialist

drocana@telus.net







Everybody makes mistakes.

23 11 2009

Sam Brown

Last week I watched a documentary, on CBC’s The Fifth Estate, on one Sam Brown, a thrill seeking, award-winning, mountain-biker from Nelson BC, who found the greatest thrill was hauling hockey bags full of pot across the border to the US. (http://www.cbc.ca/fifth/2009-2010/over_the_edge/)

Sam didn’t fancy himself a drug dealer and would be offended at the suggestion. In his mind, he was just having fun. The more dangerous the mission the better. He revelled in pushing the limits and fancied himself as quite the tactician. And as time went on, the rewards got bigger.

Sam surrounded himself with fancy bikes, fancy sleds and fancy girls.

But the risks got bigger too. Soon enough, Sam was not only dropping off pot, but hauling back coke on the return trip, hundreds of kilos worth.

Even his Dad figured something was up when Sam came home one night with a helicopter for his Dad to fix. You’d think Dad would say something like, ‘What the hell are you doing with a helicopter. Are you out of your frickin’ mind. Do you know what the American’s will with you if they catch you? But instead his attitude was, ‘Don’t ask, don’t tell’. “I’d rather aid and abet my son’s illegal activity, than watch him crash because of faulty equipment”.

As it happens, one of Sam’s associates found herself with faulty equipment caught in the wrong place at the wrong time by the Feds and doing time, awaiting trial in the US. With the heat on, Sam starts wondering whether maybe he should quit while he’s ahead. Plan B was to cash out and maybe find something a little more mainstream. But, of course, there would have to be one last run to raise money for his associates’ legal fees.

As it happens, the DEA was on his tail too… and on that fateful night, with darkness falling and wind and snow closing in on him, he flew right into the web that his captors had set for him. Long story short, when they stuck this young man in the local jail, his characteristic bravado nowhere to be found, he hung himself with a bed-sheet.

Lyndon Mackintyre who I have always found to be an excellent journalist ends the piece with a sob-story about how this is his handler’s fault, the American’s fault, the drug culture’s fault, his parent’s fault. Everyone is to blame, except Sam. I nearly threw up.

But then I though, maybe I’m being a little too judgmental. So, I’m exploring the topic today in QuestForFire because it brings up a number of issues that I think are at the heart of our societies current ambivalence towards addicts and addiction.

My sense is that people are drawn towards one side or the other based on their inherent empathy quotient.

On the one side, those who do not fell for Sam, see him as the master of his own fate and as awful as it may seem, shed no tears for the daredevil drug dealer. This is the side to which, I must say, I gravitate to, at least initially. It’s not so much that I have no empathy for him, but rather that I have more empathy for the drug users who end up homeless, psychotic or in a ditch somewhere, as a result of the crack, that Sam was able to supply them with. As an addiction specialist, I am only too familiar with the shattered lives that drugs (and alcohol) leave in their wake.

On the other side, are people with a high empathy quotient who feel sorry for Sam and his family. They see Sam the victim, the young man with poor judgement. “Everybody makes mistakes”, they say.

Sure, everybody makes mistakes. But this was not an act of impulse. This was a repeated and persistent pattern of willful anti-social behaviour.  Sam was happy to enjoy the fruits of his labour and even took umbrage at being labelled a trafficker. But that’s what he did without any thought of the consequences to himself or to others.

Some have said, he was just looking out for number one. And if he didn’t deliver those drugs, well someone else would. And that’s true. But it doesn’t change the fact that it was wrong, and he knew it.

But there is another way of looking at it… that was not raised in that very long list of viewer feedback on the CBC website. Sam Brown was a daredevil, a thrill seeker, an adrenaline junkie. He had to to push the limits, because doing what everyone else does, the way everyone else does it, is just too boring. I know the type. I work with them every day. As an addictionologist, understanding this, is my stock in trade. Maybe Sam Brown was just a different kind of addict.

There is quite a bit of science that says that Sam Brown was likely suffering from Attention Deficit Hyperactivity Disorder. He has all the hallmarks: He was smart, but did not do well in school. He was hyperactive, never could sit still. And he was impulsive, to the nth degree. About 50% of ADDers suffer from one or more addictions (if you include nicotine) and probably higher if you include behavioural addictions such as compulsive shopping, gambling, gaming, sex and eating.

Addiction and ADHD have a lot in common. They are both associated with dysfunctional dopamine circuits. (read more about it on my web-site, northshoreadhd.com. I won’t go into anymore detail on that, but suffice it to say, both addicts and ADDers have chemical imbalances that lead them to be easily bored, to be unlikely to learn from their mistakes, and to have difficulty saying, “no” to temptation. And that leads them to make exceptionally bad choices, and to have the kind of poor judgement that can kill you.

So, I guess, if I think about it, maybe I can find some empathy in my heart for Sam Brown. I certainly feel for those who lost a friend or a family-member.

As a physician, hearing a story like this I find myself wondering, “what if”. What if someone had seen the ADHD pattern and directed him to some treatment. Or what if he had been able to stick to a less dysfunctional addiction such as extreme mountainbiking.It would have been nice to have been able to help this young man before he felt so desperate that he ended up taking his own life. I now if he were my patient, I might be able to look past his poor judgement. As long as he/she were willing to take some ownership of their actions. Those with a higher empathy quotient might say, “Let he/she who has not made mistakes, cast the first stone”.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                   Family Physician, Addiction Specialist                                         drocana@telus.net





QuestForFire

17 11 2009

QuestForFire is my new blog. I am an addiction specialist and would like to share some thoughts with you…LIfe through the lens of neurobiology. My teachers are my patients. They are like snowflakes, no two are completely alike. I feel honoured to work with them and not a single day goes by that I don’t learn something new. I’m sure I learn more from them than they learn from me.

Addiction refers to those experiences that are so engaging that once we taste them, we become so enthralled that we quickly find ourselves planning our next visit to this wonderful place. If we are not careful and if we are vulnerable to addiction we soon find ourselves seeking to recreate that initial high, not withstanding the harm that this might cause us, or those around us.

Addicts continue to use their “drug of choice”, despite negative consequences.

Before there were drugs, there were likely other pinnacle experiences that our ancestors had, and sought to repeat. I imagine that one of these occured the first time they tasted glucose from a sweet overripe fruit, first time they mated, or the first time they were able to harness fire.

I imagine that after any of these experiences, they were probably so excited that nothing else mattered. In fact, they may very well have forgotten to eat or sleep for days when they were right down to it. That sort of engagement, while not dysfunctional per se, is the kind of intense focus that accompanies the first hit of any highly pleasurable substance/ behaviour. So that’s why I’m calling this blog about addiction, “QuestForFire“.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                   Family Physician, Addiction Specialist                                         drocana@telus.net