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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Carrots and Sticks

24 01 2010

Our future human resources

I got up early yesterday to drive these two daredevils to their ski-race camp. And, it got me thinking about how we, both as parents and as a society, choose incentives and disincentives to manage our human resources, ie. carrots and sticks. In this case their parents, who are friends of mine, have found Franny (left) and Kristina are willing to lift weights, dry-land train, get up early in the morning and hurtle their growing bodies down icy slopes, in exchange for the rewards associated with competitive ski-racing. They do it, because they love it. That seems like a progressive way of steering kids into healthy pursuits.

In contrast, it occurred to me that we as a society are regressing.  A new Angus Reid public opinion survey found 62 per cent of respondents favour capital punishment for murderers. This is a significant increase since 2004, when 48 per cent favoured capital punishment. The survey, conducted last fall in Canada, the United Kingdom and the United States, reveals the shared belief by many that even though mandatory minimum sentences can be unfair, they are an indispensable tool, a good stick, that helps deter criminals from committing crimes.

Unfortunately despite the average Canadian’s experience with punishment as a way of deterring behaviour, experts in criminology have shown that neither mandatory sentences nor capital punishment have ever been shown to deter crime.

As a recent letter to the editor of the Globe and Mail by Jim Hackler, author, Canadian Criminology: Strategies and Perspectives, Victoria documented: both California and Texas offer case studies of how politicians used “get tough” policies to deceive voters who respond to simple-minded slogans about crime. For several decades, these states built prisons to accommodate an ever-increasing number of convictions. Funds for education and child care, which provide a positive return for society, were cut. Funds for prisons, which provide a negative return, were increased. Why not spend taxpayer money on things that actually reduce crime?

Negative consequences do deter crime, unfortunately not in most criminals. There are some good neurobiological reasons for this. Let’s take a moment to review the neurobiology of reward and punishment.

Humans have a reward circuit. It’s a dopamine circuit and it runs from the brainstem to a place called the nucleus accumbens, aka, the reward centre. But dopamine does not only communicate reward, it also is the neuro-chemical for at least four other circuits. The five main dopamine circuits are:

Reward Dysfunction here is manifested as being easily bored, feeling diminished pleasure, reward or satisfaction from normal stimuli.

Attention Dysfunction here is manifested as poor attention to detail, careless mistakes, difficulty listening, losing things.

Executive function Dysfunction here is manifested as difficulty with commitment, difficulty sticking to task, difficulty self monitoring, poor planning/ organization, poor problem solving.

Motor control Dysfunction here would manifest as fidgeting, inner restlessness, difficulty sitting through meals, meetings, movies.

Impulse control Dysfunction here would cause distractibility, impulsivity,  excessive talking, blurting things out, being impatient and interrupting others. One of the most obvious deficits associated with poor impulse control is the difficulty making choices between competing priorities.

You can see in the italicized text, that many common criminal traits are associated with dopamine circuit dysfunction. It’s no surprise then that the likelihood of finding ADHD and addiction, two disorders associated with dopamine dysfunction, is very high in criminals.

This is not my opinion or some excuse that bad people use to avoid responsibility for their bad behaviour. This can be shown on SPECT scans of criminals, gamblers, adulterers, liars, thieves, rapists, murderers, you name it. When they are in the heat of the moment, the part of the brain that usually lights up in normal people when they are weighing the consequences of a potential action, DOES NOT LIGHT UP. Simply put, in most cases they WERE NOT thinking through the consequences of their actions. Now before you jump down my throat and label me soft on crime, hear me out.

  • I am not saying criminals do not know wrong from right. They do.
  • I am not saying that criminals have not pre-meditated their crimes. Ususally they have.
  • I am not saying that criminals should not be responsible for the consequences of their actions. They should.

What I am saying, is that most criminals have poor impulse control and don’t show much foresight. They know the consequences, they just don’t weight them properly. They know logically that their actions will have negative consequences, they just don’t value those consequences at the point of performance. Like a kid who launches his skateboard down a steep hill without a helmet. He “knows” the danger. He just values the reward, higher than the risk.

And who do you think becomes a criminal in our society? People who are willing, on multiple occasions, to choose actions with huge potential negative consequences, because they undervalue the risk. Criminals are essentially compulsive gamblers. And all the research we have ever done on pathological gamblers show that they do not have a normal risk evaluation system. That is their illness. That is why mandatory sentences including capital punishment are excellent deterrents for normal people, they just don’t work on criminals, because there is such a thing as a criminal mind.

I could go on, but I think you get my point.

So why are we building bigger jails and spending more money on lawyers, judges and crown prosecutors? Every bit of data ever collected says this is not only the wrong approach, it is THE MOST EXPENSIVE APPROACH. On the contrary, the data shows that we save $7-10 dollars in the social costs of mental health, addiction and crime for every dollar we spend on youth centres, mental health services, child care, parenting programs, etc.

It is my considered opinion that if we paid more attention to parents and children, we would have to spend much less on crime and punishment. If we improved the use of carrots, we would need to spend less on sticks.

Which brings me back to Franny and Kristina. I’m not saying that were it not for ski-camp, these two would be headed for a life of crime. Ski-camp may not be for everyone. But organized, group-based, outdoor physical activity, whether it is soccer or sailing, provides kids with bevy of physical, emotional, cognitive and spiritual benefits that should be considered highly prized social outcomes. These kids will be fitter, their brains will be more flexible, they will learn to cope with failure and loss, they will learn social skills, they will be more accountable for their actions, they will learn to soothe their fears, they will be more confident and will probably spend less time obsessing about their clothes or possessions, THEY WILL SPEND MORE TIME IN NATURE and LESS TIME AT THE MALL. There is a good chance they will be better stewards of the environment. In short, while there is no guarantee they will fly straight, the chances are in their favour.

It would be simplistic to think that we don’t also need to have negative consequences when people break rules. We do. We need both carrots and sticks. And, we need to be progressive with both. While money invested in youth  does not guarantee good social outcomes, playing to our kid’s strengths and spending at least as much money on parents and kids as we do on jails is in my opinion a preferred human resources management.

Cheers, A

Dr. Anthony Ocana – MSc, MD, CCFP, ABAM – special interest in mental health and addiction – co-founder NorthShore ADHD Clinic

http://www.northshoreadhd.com





Sex, text and Tiger’s fall from grace.

15 12 2009

Tiger and Elin in happier days KAREN BLEIER / AFP/Getty Images

Much has been written recently about Tiger and his ‘transgressions’. The revelation of the escapades of this once untouchable hero provide a timely opportunity to discuss the science of sex addiction.

It’s not really acceptable in medical circles to diagnose someone you have never met, so let’s stick with the undisputed facts.

Tiger Woods is a distinguished athlete and a very wealthy man, who can afford to buy just about anything he wants. He is married with children. By his own admission, he has had affairs with multiple partners in the recent past. He has lied about these. And, only by the dogged perseverance of the press and the release of those sordid texts, has he come clean.

In my business, there is really no room for judgement. Good people do bad things. Tiger was not the first, nor will he be the last to cheat on his wife and children. It is easy to frame his behaviour in moral terms, but that is a bit tired and does not give us any new insights.

If we could have a better understanding of why people cheat, maybe we might have a better chance of doing something useful about it. Regardless of why, it is clear that Tiger’s transgressions caused a lot of negative consequences for a lot of people.

Let’s start with Tiger’s embattled wife Ellie. Despite what financial benefits she may gain from this fiasco, it can’t be pleasant having your husband’s dalliances smeared all over the front pages, ditto for the kids. Ellie’s mom has already been to the hospital with what is likely stress induced gastritis. Tiger’s friends and associates are likely suffering too and as for Tiger…yikes, put yourself in his shoes. It’s a lose/ lose for everybody.

Imagine what the rest of his life will be like, no matter how much he apologizes, no matter what he does to make up for this, at any time, some wise-guy can bring it up again. Ha-ha, just kidding. Except it’s not so funny. As I stood at the check-out counter today, I saw Tiger’s anguished face on the cover of one of those gossip magazines. “Tiger suicidal”, read the headline. Can you blame him? He is now, and forever will be the laughing-stock of 2009.  No matter what short-term benefits he got from being sexual with his bevy of busty blondes, the long term harm is immeasurable. Never mind the billions of dollars in potential income lost, that’s the least of his worries.

Some in the psychiatric field have thrown around the term, “sexual addiction” which by definition is compulsive sexual activity despite evidence of harm. Well you might say, there was not, until recently, any evidence of harm. I can’t say for sure, but that’s unlikely. More likely is that there was a progressive loss of intimacy between Tiger and Elin that lead to the loss of attachment that preceded his transgressions. Maybe his kids felt the distance when he slipped out to be with his mistress, rather than spend time with them. The early harm associated with his affairs may not have been as evident, or as catastrophic, but the warning signs probably were. Intuitive women can tell when their man has other things on his mind.

So, does Tiger’s fall from grace follow from his sexual addiction. That has a certain amount of validity, but to understand what that really means, let’s break addiction it into three parts.

Addiction starts with dysphoria. Dysphoria is the opposite of euphoria. Basically you feel uneasy in some way. Dysphoria can be secondary to all kinds of emotional triggers: sadness, loneliness, worry, distress, boredom, pain, fatigue, confusion, irritability, agitation, anger, racing thoughts; you name it.

It would of course be optimal if we could manage these emotions on our own. That is the goal of cognitive therapy. Learn to recognize your emotions; Learn to “be” with your emotions; or because most emotions are secondary to thoughts, learn to modulate your thoughts as a way of managing your emotions. That sounds easy enough, but it’s not. Many people are neither capable of recognizing, reading or managing their emotions. When emotions become unmanageable they experience dysphoria.

The next step in the addiction cycle is… using a substance or behaviour as a coping mechanism for dysphoria.

“Using” as a way of coping starts off innocuously enough. Some might say that addiction is a kind of resourcefulness on the part of the addict. “I feel usually bad… but when I do this, I feel good”. Research suggests that addiction is a pediatric disorder. The large majority of addiction starts in adolescence.  For the truly vulnerable, it starts in childhood. As we progress though our youth, we are exposed to various behaviours and substances, experimentation naturally follows. In time, by an unconscious process of trial and error, we stumble upon what makes us feel good. We find out what calms us; interests, energizes and/or rewards us. We experience our environment and find out what is important. The neurobiologists call it salience attribution. Our brain has a way of recognizing what’s important and what’s necessary for survival because these stimuli light up the brain’s dopamine circuits. It just so happens that all addictive substances and all addictive behaviours stimulate also dopamine neurotransmission. So, on some level, addiction is really a big fake-out.

Addictive substances and behaviours stimulate dopamine, and as such, trick the brain into thinking that they are necessary for survival. That’s quite the story, but it’s not the whole story.

The third step in the addiction cycle is the loss of control.

While dopamine and the associated “feel good” that it provides, triggers the “go” switch that drives us to preferentially choose these substances and behaviours over others, we also have brain circuits give us control over the dopamine circuit.

Glutamate stimulates/ GABA inhibits

The dopamine “go” circuit can either be potentiated (by Glutamate) or inhibited (by GABA).

Glutamate says, “Just do it”. GABA says, “Hmmm, maybe that’s not such a good idea.”

Glutamate pushes us down a corridor that quickly turns into a tunnel, leading to loss of control. GABA buys us time. Time to weigh the pros and cons of using. Time to think through the consequences of our actions. Time to envision the look on a loved-one’s face. Time to insert a more rational thought.

Finally, when poor choices lead to negative consequences, we return full circle to dysphoria…and so it goes around and around and where it stops, nobody knows. Where it stops is usually a cold hard place.

Tiger’s transgressions, then, can be seen as behaviour that he initially chose as a coping mechanism for some type of dysphoria, but over which he progressively lost control, despite evidence of negative consequences, eventually resulting in unimaginably more dysphoria.

That does not excuse the behaviour, nor does it absolve him of the responsibility for the harm that his actions caused. It just takes this out of the realm of morality and puts it under a less judgemental light.

I think I’ll stop there.

Stay tuned for more QuestForFire next week.

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