Have you caught Olympic Fever?

22 02 2010

Olympic Fever

We all interpret events through the prism of our own “world view”. That means that given the same input, different people perceive things differently. A powerful natural experiment occurred on 911. Because every TV station in the world broadcast that event over and over for the next few days, it would be fair to say that it was a global experience. So, given that there were hundreds of thousand of people who were directly affected and billions more who experienced that trauma indirectly, you would think that the incidence of post-traumatic distress would be highest in those who were directly traumatized and would drop off the further away one was from the trauma. But that’s not what happened.

The incidence of post-traumatic distress was highest in anxious people, regardless of how close or how directly or indirectly they experienced the event.

So, let’s talk Olympics. Yesterday, I took my 6-year-old daughter to the Norway vs. Switzerland, men’s hockey game. And, over the last two weeks I have observed a huge range of people’s response to this global experience. There are people who rail against even the concept of the Olympics; people who are indifferent; and people who are completely committed to them. My premise is that your response to the Olympics has nothing to do with the Olympics per se. But it says a lot about your ‘world view’.

For the sake of argument, let’s say there is a gene for “party”. In which case, there are broadly-speaking three categories:

There are people who are homozygous (they have a copy of the party gene from their mother and a copy from their father. These people are hard-core party people. They put the fan in “fanatic”. They have caught the party bug to the point that you could call it “party-fever”. These are the people who paint their whole upper-body with the Canadian flag or come to Olympic events in full costume. These are the people who pay $1000 or more for a hockey ticket, no questions asked.

Then there are people who are heterozygous for party. They likely have one party-philic parent and one party-phobic parent. These people dreaded the Olympics in December and January. They may not have protested against them, but they strongly sympathized with the cause of the protesters. “Why should be take money away from healthcare and education so that we can indulge in a big wasteful party?” But, once mid February came along, and the Canadians started winning medals, and there was a spontaneous outpouring of National Pride, they caught the Olympic bug… and from then on they could be found downtown singing the national anthem, high-fiving complete strangers and waving the red Maple Leaf. They were glued to TV sets in bars, and hosting their own Olympic-themed parties at home.

Then, there are the party-phobes. They have not inherited any party genes. Or, you could say they have two copies of the “stick in the mud” gene. They focus on the negatives: They are upset that money spent on the Olympics could have been spent elsewhere; They are offended that Olympic sponsors have dominated the media-scape; They shamelessly criticize any athlete who did not live up to the public’s expectation. They say things like, we choked; we should have won. They trumpet Olympics gaffes, from the inconvenient to the fatal; They have a need to assign blame to all negative outcomes, even the weather. They see Olympic fever as ’empty nationalism’. Looking back, you may wonder, who do they represent?

Here is a quote from one such person.

“The Olympics long ceased to be interesting and long ago quit being an expression of the human spirit. Stronger, higher, faster, has been replaced by money, corruption, fraud, professionalism, drugs and mindless nationalism – not to mention the truly insidious notion of rewarding fascist states with this money producing extravaganza. The games are both expressions of mindless statism, and emotionally empty nationalism and little else. Time to end them.”

I guess the desired take-home point would be: None of these perspectives is either right or wrong.  They just are. They represent the spectrum of perceptions that people can legitimately have, regarding this global event. There is no ‘truth’, but rather a spectrum of perceptions. Everyone has a right to their perception, and there is certainly some truth to each point of view. But what occurred to me was that the media, at least initially, thought they were speaking for the masses. But I think the masses spoke and said, quite emphatically, the opposite. “This is what nationalism is all about. There is nothing empty about it!” and (to borrow a phrase from poker) we’re ‘all in’.

The media were taken by surprise. The big story of this totally controlled and overly scripted event was entirely uncontrolled and unscripted. The story was not about the Olympics or the athletes or the medals. It wasn’t about the weather or the Olympic flame or the Luge track. The story was the people. The boring, grumpy, self-absorbed, indifferent citizens of Vancouver had caught the party bug and it was spreading faster than the swine flu.

I am going to speculate, based on my experiences talking to people about the Olympics so far, that the breadth of world views is like the breadth of mental health. You can group the factors that affect your world view into three broad categories:

The first is “genetics”. If your parents were highly social, gregarious, out-going people, there is a good chance that you inherited some of those traits.

The second force is what I would call, “experiences”. We know that your environment can affect your world view quite powerfully. Experiences can actually turn genes on or off. This is what we call epi-genetics. It means that if you have a vulnerability to anxiety and you experience some traumatic or adverse events in your youth, there is a greater chance that you will express some anxious traits, compared to an equally genetically vulnerable person, who did not experience traumatic events. On the other hand, if you were raised in a family that experienced the joy and unity associated with social interaction, you are more likely to see a party as a necessary and useful event, rather than a waste of time and money.

The third force includes all the day-to-day factors that affect your world view: amount of sleep, diet, exercise, hormones, the weather, what is happening at work, at home, whether you recently fell in love or won the lottery, etc. So, physiology permitting you are more likely to: be motivated to party; be able to enjoy the party; be able to sustain the party; and be able to look back on the party with fond memories.

So, that suggest that:

  • every person’s party view is like a snow-flake, i.e., unique
  • everybody comes by their party view honestly
  • these views are subject to change without notice

It also supports the age old saying, ‘You should not judge someone’s world view or their party view, unless you know their whole story, i.e., you have walked a few hundred miles in their shoes.

The reason I bring this up, is that understanding the concept of ‘world view’ has been quite helpful to me as an addictions doctor…. And, it might help you too if you are struggling with what seems like and unsolvable problem. It is my considered opinion that you can’t solve a problem, help someone, or change something if you start with a judgement.

Sorry, it has taken me so long to finally finish this post, but I was too busy enjoying the Olympics. Since then, I have been nursing a bit of a post-Olympics social hangover, and then I had to catch up on all the work that I didn’t do as a result of the above. But it was a heck of a good time and I’m glad I was there to experience it. Go Canada Go. Nice work, Crosby.

Cheers,

Dr. Anthony Ocana MSc, MD, CCFP, ABAM               Special Interest in Mental Health and Addiction                NorthShore ADHD Clinic               http://www.northshoreadhd.com

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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