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

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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

Are we having fun yet?

11 01 2010

Happy Hank

I’m not the most dedicated hockey fan, but recently I have been following the Vancouver Canucks as they move up the NorthWest Division. In the process, we have seen two hat-tricks by Alex Burrows, two fights by Rick Rypien, a slew of goals by Samuelsson and the Sedins and a pair of shoot-outs. I thought it might be interesting to explore “winning” through the lens of neurobiology.

When I was in high school. I was cajoled into being the stats guy for the senior basketball team and then the trainer for the senior football team. In the process, I spent a lot of time on the side-lines and I can tell you, it’s uncanny how closely the ‘fun quotient’ parallels performance on the field.

Well, of course, you say. Winning is fun. No. I’m saying, I could predict when we would start scoring, before the fact, based on how much the guys were smiling! And, I think you could see the same thing with the Vancouver Canucks and their opponents this past few weeks. Let me give you a few examples…

If you watched the players warm up, skate or talk on the bench, you can tell when they are having fun. Regardless of the intensity of the game, when the mood was up, the players seemed looser.You could see this even if they were getting outshot, even if they were getting penalties, even if they made dumb turnovers and even when pucks were bouncing off goalposts and crossbars left and right,  When they relaxed they, stick-handled more adeptly, were quicker on their feet, made sharper passes, checked harder and always seemed to have their sticks in the right place at the right time. There is a reason for that.

In the low stress state, the body is in what we call parasympathetic mode. That is the nervous system’s nurturing mode. That suggests looser muscles, slower heart rate more blood to the brain allowing increased rational and more flexible thinking and … a sense of humour.

Having fun releases endorphins which increases pain tolerance, dopamine which improves focus, and satisfaction, adrenaline which increases motivation and energy and serotonin which improves mood and confidence. All in all, an almost unbeatable cocktail of feel good chemicals.

The high stress state is also known as the  sympathetic mode. That is the nervous system’s fight or flight state. That is accompanied by tighter muscles, faster heart rate and less blood to the brain, facilitating rapid reflexes, but not much nuance. Sympathetic mode may increase performance if you are a sprinter or a weight-lifter, which require lightning fast, but very predictable effort. Sympathetic mode may not be so helpful if you have to think on your feet.

If you want to wheel and deal, it’s better to be strong, but flexible, able to adjust your attack based on a number of scenarios, rather than just an on-or off switch. It’s better to be having fun. Take the Burrows and the Sedins. When they are having fun, it’s like watching the ballet: Burrows looks up ice, finds Henrik who carries across the line, streaks right, drops left to Daniel who slams it home, GOAL! Wow. That was fun.

On the other hand, if you’re angry at the ref, or trying to get revenge for a late hit or scared you might lose in a shoot-out…there’s too much negative vibe and that spells trouble. Take Rypien for example. In the first fight on Saturday night he threw a few jack-hammers and had a slight upper hand.  Then Prust landed that uppercut and Ripien kind of faded, but later in the penalty box, you could see he was upset, which he then carried with him through the rest of the game, drawing Prust into another fight, but also sucking a certain amount of energy out of the team as they watched his already bruised and bloody face take a few more gut wrenching hits.

Seeing a team-mate get hurt triggers the release of a massive amount of the neurotransmitter GABA. It has an inhibitory effect on motor function and drops blood pressure. That tiny bit of reservation, that tiny bit of hesitation, that tiny decrease in motivation… is the difference between a successful poke check and watching your man skate around you. Hockey is a game of micro-seconds. Whoever wants it more, wins.

Finally, in overtime, watching Iginla laughing on the bench, joshing with the ref, I thought…OhOh. When the opposing team is laughing in over-time, that’s a bad sign (for us). And sure enough they were the more relaxed team, especially in the shootout when they scored 3/3. Did you see that little move that Lundmark pulled at the last second. He weaves right on the forehand, kicks his foot out to the left to distract Luongo, then flips the puck to his backhand and taps it in the corner. The guy looks like he’s back in the school-yard, dipsy-doodling. You can’t do that when you’re stressed.

Flames move to the top of the division. Ouch. Are we having fun yet?

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

What is evil?

29 12 2009

Umar Farouk Abdulmutallab

Looking through the paper today, I could not miss the article about the Nigerian guy who tried to blow up the Northwest flight from Amsterdam to Detroit on Christmas morning.

According to an article in the Globe and Mail, December 28, 2009. This baby-faced 23 year old was the quiet and studious son of a wealthy Nigerian banker, who resembles, at first glance any other young man from the northern Nigerian city of Kaduna. He wore designer clothes, sunglasses and fashionable suits. However, there was something  different about him.  His neighbour noticed that he stayed at the mosque far longer than anyone else after prayers. He rarely talked, and when he did it was mainly about Islam. According to the neighbour, “There is a serious and growing problem of Islamic fundamentalism in this part of Nigeria. He is a product of this type of hatred and intolerance.”

His father, a prominent banker, was so worried by the radicalization he saw in his son that he contacted the U.S. embassy in Nigeria to report his concerns.

According to the current world-view, this young man is the epitome of evil. But what is evil?

If we look at Mr. Abdulmutallab through the lens of mental health, there are a couple of things that we can say: He is angry, intolerant, obsessed. He lacks empathy for others, remorse for his actions. He may have even been psychotic at the time. What we can say for sure is that he meets the criteria for what we call anti-social personality disorder. This does not mean that he did not like to socialize, although that may be true. It means he is capable to committing acts that are against the most basic social norms.

Again, the Western media is happy to moralize these traits as “bad”. But it might be more appropriate to view these traits under the umbrella of “sick”. In fact whenever the veneer is stripped back on people who commit these types of acts, they often come across more as “troubled” rather than evil. In many other aspects of their lives they seem either very normal, or often, subject to real or perceived trauma.

Take the young men at the centre of the Columbine massacre. They were the victims of relentless bullying….

We don’t know why Mr. Abdulmutallab saw fit to try to blow up an airplane full of people, but it seems to me this is more the domain of forensic psychiatry than morality.

This is neither to condone, nor to justify, terrorism. The taking of innocent lives for any reason is always a tragedy. It is an act for which we must hold people accountable. However, if we can understand why people commit acts of terrorism, maybe we might be more successful at fighting it. On the face of it, we have spent billions of dollars and sacrificed thousand of lives and we seem no further ahead in the fight against terrorism. A terrorist can be anybody. A suicide bomber will be effective in any small crowd. It seems to me, this is not the sort of thing you can fight using conventional warfare.

The person who commits terrorism, especially through suicide, obviously feels deeply wronged on some level. Real or perceived, that sense of injustice is so great, that the person feels it is worth dying for. We ignore these underlying causes at our peril.

That’s what bullies do. They are neither attentive to, nor do they take responsibility for the wrongs that they perpetrate on their weak or innocent victims; Then they are surprised that their victims lash out using what seem like cowardly methods; Finally, they retaliate with the fury of righteousness on their feeble attackers.

Again, this is not to blame the US, nor any other country or target of terrorism, it is merely an attempt to make sense of this seemingly senseless act and perhaps to cast it in less moralistic terms in the hopes that we might avert some of the negative consequences.

A healthy person who is wronged and then invalidated might feel helpless. An angry, intolerant, anti-social person is more likely, in a final act of defiance, to lash out in the most extreme way possible, by sacrificing his/her life to harm his tormentor .

In the mental health business, we have a name for the disorder that allows someone to harm others with no remorse. We call it “attachment disorder”.

It is often the case that bullies have at one time been traumatized themselves. As mentioned earlier, this may may be real or perceived. It doesn’t really matter. People who suffer from attachment disorder, feel no attachment to others and are therefore insensitive to the hurt that they may cause. As opposed to a psychopath who chops off someone’s head in a mad impulse, the person with attachment disorder has pre-meditated the consequences of his/her actions in gruesome detail, but without a whiff of remorse.

The theory goes like this: The person with attachment disorder was never properly nurtured by his/her primary caregiver. On the contrary, he/she was likely verbally, emotionally, physically and/or sexually abused, neglected, shamed and/ or abandoned. Often this type of abuse is repeated, ritualized and/ or relentless. For the record, this is not rare.

There are millions of people in our society who have endured tis kind of trauma, somewhere in their lives. According to the theory, if the people who are supposed to care for you, don’t, then why would/should you care about anybody else. And when you don’t care about anybody and you are or feel wronged and invalidated you become the kind of person that can blow up an airplane full of innocent people Christmas Day.

Now, I don’t know Mr. Abdulmutallab, nor is there any suggestion that he had this kind of background, so for the moment this is purely speculation, but anyone who is capable of such an act, despite their outward appearance, is usually someone who is acting from a place of extreme hurt. So, if this is the case, what is evil and how should we best deal with it?

Dr. Anthony Ocana

Addiction Specialist
Co-founder NorthShore ADHD Clinic

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       

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       

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


Family Physician

Addiction Specialist