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

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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





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