Personality Disorder

28 03 2011

Al Pacino - Scarface

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

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

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

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

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

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

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

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

31 01 2010

Off Limits: Stop or Go?

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

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

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

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

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

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

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

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

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

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

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

Kids with ODD:

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

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

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

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

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

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

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

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

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

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

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

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

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