Showing posts with label Dopamine. Show all posts
Showing posts with label Dopamine. Show all posts

Monday, February 9, 2015

Journal, Feb. 9, 2015

Thank you God for a wonderful sleep.  I’m on my boat and enjoy the rocking motion in this harbour.  I would have liked to have headed out for the weekend but it’s been raining so much and chilly, cloudy grey too. I’ve not tested my heater. The dock is so crowded I’ll not be able to moor again without some one on the dock.  It all seemed overwhelming. Instead I read. I’ve been a major slouch.  Enjoying it only for it’s novelty.
Gilbert has kept me busy throwing the ball about the boat. I heard him snacking. He’s resting now.  We had a late night walk so I’m sure his bladder is fine. He barks at the door if he needs to go out. I took him up yesterday morning this time and he turned around after facing the rain and returned to bed.  My little dog of comfort. Without his heavy fur coat I think the heavy rain is uncomfortable. He doesn’t mind the drizzle.
I’m not particularly joyous and free today but that usually follows sloth and illness:
There’s work I could be doing on the boat.  I might just measure one piece of wood that needs replacing or get a real latch to remove my several year old jury rig with bungee chord.  Bungee chords are marvellous but they weren’t meant to be permanent solutions.  I could clean up the loose cables and even run the new cable from the tv to the radio so I could have better speaker accompaniment.  There’s a lot of tidying that needs to be done in this boat but it’s likely to wait till I decide to go on some expedition where the boat needs to be lean and mean.  That’s the ultimate spring cleaning time for a boat.  It’s really close to offshore ready right now.  If I didn’t have work I’d begin various projects knowing I had an open ended schedule to finish them.  It’s so easy to put off today knowing if I ran into a snag I’d not get the time for possibly weeks to complete the thing.  Better to hire someone so I can work while this work gets done.  I love working on my boat but not when I’ve got a full time job.
I thought of driving down to the US yesterday and could today especially with the nexus to ensure no lengthy delay at the border. Yet driving is it’s own kind of work these days.  I’m really entrenching my sloth here.  Swimming was a consideration and a meeting too but then there’s Gilbert and I don’t like leaving him in the car with all the dog thieves about. I do leave him at times but figure the least number the better. (I just saw my older neighbour going by in his Harley Davidson jacket.  He’s now one of the dock old guys. There are several.  We’re a loose community.  The couples are here too, coming and going and seeming more ‘normal’.  Some of the other guys have kids that come and visit but not ex wives. Then there are the girlfriends.  Weird world this boat world.  When I was in the RV I felt more like suburbia. This is definitely a different space.
I could paint my chain again on a sunny day.  The depth markings wore off years ago.  I’ve siliconing to do.  The roof just dribbled down onto the table.  It’s so little I just put a paper towel down and remember to keep electronics away from that place.  (There, I just tightened a hatch screw and think I’ve stopped it.)
I keep thinking of getting another stainless steel rifle.  I’ve the new membership to the rifle club and thought of driving out there and shooting some targets.  It’s covered over so even in the rain it would be a thing to do.  I don’t know if the rifle store is open.  I even thought that going to the states I could stop at the big new Cabelas store across the border and look at rifles.
I like my 223.  It’s really rated for deer and rabbits and such.  Too small a load for hunting bigger game.  I have the 22 but it’s really only rated for rabbits and birds.  So when I’m out in he woods during hunting season and see ruffed grouse but am really hunting deer if I had this caliber I could shoot the grouse as well as the deer or shoot a rabbit as well. I had the 30:30 which was overkill for grouse but good enough for bear and deer.  My 30:06 is good for everything and my 300 win mag is ultimately for moose and big game.  The 223 I have is the ultimate target rifle.  I got it on sale, a Chinese rifle.  I actually planned to give it away when I got it, knowing if I liked it I’d want the stainless steel model because I hunt mainly in the wet. Further if I sail up north I’d take it with me and only stainless does okay in the sea air.
Bear hunting season starts in a couple of month.  Goose hunting season opens next week. I have the perfect double barrel 12 gauge goose gun but don’t know if I’ll be able to make the time.
I really should have been fishing this weekend. Or writing the great canadian novel.  Or doing sit ups.  I’m fat and ornery as a result. I could be socializing too.  There’s a lot of ‘shoulds’ in my internal world which I rather happily ignore as left overs from a more focussed past.  I lack he discipline I once had but have something else in stead. I think it’s called ‘surrender’. I also have more balance and some self care.  I read more schlock and watch more movies when in the past I really was intent on learning.  Now I tend to study in an applied way.
I ve a book launch for my book Psychiatry and Addiction, Personal Perspectives on March 1st , 6 to 9 pm at the Alano Club Granville and 7th.  I think how much better I could have written that.  But I’d have needed more stretches of time. I laughed learning my academic friends who write a book a year have 5 mornings a week for study and writing.  Here I’m seeing patients 12 hours a day, preparing countless med legal reports, studying what I need to know for the patients I see,  living a weekend life of boating and motorcycling and doing a number of activities and yet somehow with the help for friends get a book done.  It’s the first one, not counting poetry books.  I’m excited by it because I can see how I can write more with more time and focus and less distractions.
I look forward to retirement one day where I could ‘book’ my mornings to write to a specific purpose.  Then I think also of taking a few weeks to write a book. I could do that as well.
I’ve just reviewed the notes I’ve done on Sexuality and don’t really think I have enough to say but under the topic of spirituality I’ve more material so it seems like I’m going forward with that as the next project.
I am tempted to write a volume II to Psychiatry and Addiction - with all the latest brain chemistry and genetics and MRI data. To do that I’d need some weeks of study and writing time.  I know now I could do a good job.  Writing this book was like writing my first paper. Once I got the first one done the rest followed easily.  I feel I’ve definitely gone over a hurdle.
I like thinking about God more than dopamine.  I know about salience and up and down regulations and all that but I really prefer to think and write about God.  My relationship with the unknowable is much more interesting to me than the mechanics of pathways and glucose utilization.  The God thought is a love story.  I’m happier when I’m considering that more than when I’m thinking about neuroanatomy. That’s very functional whereas there’s art and beauty in the infinite.  I like looking for words to describe the relationship I have with this mystery.
I even enjoy somewhat arguing with those who insist they know God more than I do.  I’m suspect of those who hear God’s message as a call to arms.  To me it’s a wee small voice but at times it has been more. I’ve actually had the sense that God has put me on the ice and I’ve been chosen to play though mostly I feel I’m on the bench.  Right now I’m on the bench.  I’m sitting here knowing God is all and everywhere but that doesn’t answer my question what I’m to do today.  Certainly I know I’m not meant to chop someone’s head off.  I’m muddling along. Muddling is the best description of my journey right now.
That’s okay with God though personally I’d like a little more inspiration.  I”m older. That’s a telling factor.  Older I recall all the dashing about.  I recall all the promises too. I also think it’s good just to sit here and maybe get back to reading.
People think I should make more money but I was just reflecting how in Canada when I make a lot of money by working a lot harder than the herd, the parasites take the excess.  There’s  no longer a sense that there’s any protection in our community. Right now I’m waiting to hear if the banks lost or took my savings.  Every day a new lawsuit afflicts my fellows and the easiest way to make money is to attack someone on false accusations.  The politically correct are stealing by the minute.  But that’s all fear based thinking.  It does sap my will to get up and do something useful. The people who I employ take advantage of my extra work and generosity too so it’s always a question of why work harder.
In Canada the welfare state is so strong that everyone gets by coasting.  And there’s little benefit in running ahead carrying extra loads. It’s not like communist countries where those who do that are punished but the reward for extra work is punished here by higher taxes and more and more condemnation.  It makes spending a day reading and watching tv seem reasonable.  If I'm truthful I'm really hiding out.  I'm isolating.I'm hibernating. I'm social phobic.
I remember that week I sat in a bar for the first time in my life.  I’d been in bars and worked in bars but never hung out in one for a week.  We were waiting out storm and there was little else to do in the port so it seemed like the thing to do, hang out at the bar.  We chatted and drank and time passed.  It was the most useless I’ve ever been in my life but it felt good as a ‘change’ from the disciplined focused responsible way of being that is my norm. Now so many of my superiors are the folk who sat in bars and 'networked'.  They get huge grants and keep the money to themselves.  Lots of vague down time and lots of committee and even new names for phoney research.  I'm never invited because I'm not seen by the 'government sort' as a 'team player'. I've been a 'whistleblower'. I've been the one to stop killing and expose graft and corruption so I'm not 'welcome'.  Live and let live is my motto today.  No good deed goes unpunished. Yet I can say I've stopped directly personally a half dozen killing machines in the system and survived the back lash by those who were supposed to protect people and didn't.
The other such time of extended sloth was when I watched the NHL play offs.  We were working on an old car and watching the play offs.  A group of guys. None of us working.  I was waiting to start a new position while the guys I was with were all on disability or comp.  It was an amazingly laid back existence.  Upward mobility is really costly compared to downward drifting.
It’s like today.  I’ve no real demands. There’s lots I could do.  Even things I should do but I’m just thinking of reading this old Robert Ludlum book and the new William Gibson book. The Ludlum I picked up in a book bin, a paper back so enjoyable to read. The William Gibson latest, "The Peripherals' is a kindle. I've been reading it on my iPhone.  It's typical William Gibson genius, incredible writing and genius ideas. It's just that I can only read my iPhone for a time before my eyes bother me.  That's still the advantage of real books.  If I had my kindle reader in the larger format it might be easier. I still enjoy real books more for long stretches of reading. Digital is great for research and short reads but nothing like a paper back for hours of reading.
I think another cup of coffee is in order.  Gilbert and I walked over for a burger on the saturday that was like this too.  Rainy day.  I might get out the guitar.  If I had more of these days I ‘d start sketching for sure. I really wanted to sketch better. It’s practice. I could be studying a language too.  I remember last year I made my way through a major theology textbook and read a neuroanatomy text along with a new physiology text. I also tried to learn another language.  All heavy reading. Today it's light reading. Great past times.
Today I’m not even motivated to get off the couch and go look at another rifle.  Walking around stores is fun. When I was with Laura last week I got some shirts and underwear to get me through the week. I love the new Calvin Klein underwear material. It doesn't bunch up in the ass when sitting at the office. I could drop my laundry off.  I’ve got clothes for a few days. The freezer needs  cleaning. I could change the sheets on the bed.  There’s more tidying to do.
This weekend I’ve been recovering from the flu.  Each day I’ve been better with less sore throat and less cough. My sinuses are no longer constantly stuffed. I only had a little fever yesterday.  Sunday was a great day especially with Kevin and AJ and the god kids.
When I got home though I’d thought of taking the boat out but my fever was back ,I was exhausted and after a nap it was too late to go out. I don’t know what time the fuel barge is open to and didn’t want to compound setting out with the variable of darkness.  I’m so much more cautious with age.  More laid back too.  After the nap I felt well again but didn’t like the cold rain and wind so thought my recovering ‘cold’ would benefit from more rest. Yet maybe if I’d gone skiing at Whistler or taken the boat out it wouldn’t have made any difference to the outcome of the cold.  We say rest but I’ve been taking it easy for a couple of weekends because elf this silly flu and don’t know really if it speeded up the healing. The fact is I’m getting better steadily so shouldn’t pull up the plant to look at the roots to see how well it’s growing. I think illness,especially my own, is such a lousy excuse for sloth and gluttony.
Sloth is so politically correct too.  No one counts the ‘sins of omission’. The ‘system’ kills daily with delays, negligence and incompetence yet any ‘sin of commission’ is attacked furiously.  While some of the government and courts slide further into the past the sciences are flying ahead spectacularly with mars expedition, anti vitals, robotics, new probe planned to Saturn, organic computers. It's amazing. I loved the personal helicopter being developed.  Stem cell research is exciting too.
It’s not like I haven’t ‘identified’ the things that need doing. A whole lot of people like to get ‘administrative’ jobs because they think they’re good at ‘identifying’ problems. They’re ‘critics’ and ‘critics’ are a dime a dozen.  I’m a great consultant.  The trouble is that there’s a real excess of chiefs and not enough Indians.  Even here the administrator in my mind has identified the ugly task of cleaning the freezer and my Indian hands would rather type the doggerel or hold a book.
Cleanliness is next to godliness. I thought having a wife or girlfriend who was obsessive compulsive this way would be a great thing but I always hooked up with girls are kind of dirty and happy to leave things to gather dust or  who like to order me to do these things for them.  I remember one marriage particularly tainted by her bossiness.  In retrospect I really never was that good of a mate.  I made a great wife at times.  No child reward. My cohort live for their children and grand children. It gives them their motivation.  So many are trying to make their places attractive so their kids will visit.  I've got Gilbert. He's happy if I keep him well supplied in tennis balls. He'll go anywhere I go.  Any hour now he'll want me to take him for a walk.  Children come and go but dogs stay.
There’s that bitterness that creeps into my thoughts.  Self pity and bitterness are easily identifiable. I have to forgive and let the past compost.  It was never one sided either. It was ‘us’ and always ‘us’ and not the paranoid ‘he did, she did’ that makes the courts such a money game.  Pseudo war. I’d rather go over to fight the IS but my back hurts.  War is a young man’s sport.  I figure all I could be today is a sniper because it’s a lying down job.  The kids are all lining up for the office jobs of flying drones.  It’s just like video games.
Brad Pitt in Fury was a great movie. I could drive a tank but really expect if a war happened I’d be immediately on a ship like this one and somehow expected to heal people rather than kill folk. My training and skills are all in healing. Yet now the Supreme Court with the typical lawyer ignorance of medicine wants us to ‘assist suicide’.  Lawyers don’t have a hippocratic oath so their fundamental ignorance about our profession is destroying it.  I’m a dinosaur.
Oops that’s another thing that’s upset me.  Work gets under my skin. The mixed messages and the ‘new medicine’.  Doctors can lose their licenses for hugging patients but not for killing them. The abortionists are the richest most protected doctors.  I feel like I alone am the only one who sees the blasphemy of the supreme court deciding doctors can assist suicide.  Fundamentally shouldn’t that be a decision made by the Canadian Medical Association. but the law has no respect for doctors and over rode us pushing marijuana and now death. What’s become of this country?
Oops, there I go again. Not being ‘accepting’. God’s in charge. All is well.  It’s the Charge of the Light Brigade. It’s Gallipoli.  It’s all those lemming charges into the ocean. It’s basically fear and I have to live in hope. Someone is sane.  The media always confuse the issue to sell passion but still it seems thanatos is trumping eros these days. Again negative thinking.
Be positive. Be hopeful.  Trust.  Cognitive Behavioural Therapy is a bitch when the errant one is your own ego.
Back to the book.  Thank you God for this time of ‘waiting’.
Some recent pictures: George Laura's new cat is big on hiding. He's probably still under the bed.  There's a lot to be said for this hiding out. It's okay. If I'd taken the boat out and anchored somewhere I'd be doing about the same thing but feeling more 'accomplished'.  George is just thankful for another day under the bed probably.  We both have water and food and litter boxes or their equivalent.  Gilbert's napping. Maybe a nap would be the thing. No I think I'll read some more.  I showered last night.  I've avoided getting dressed too. Still in t shirt and shorts.  Thank you God for 'time out'.
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Friday, November 22, 2013

Roles of Neurobiology in Redefining Treatment for Addiction - Eliot Lawrence Gardner PHD - ISAM 2013 - Kuala Lumper

Dr. Gardner has written more than 400 papers. Harvard University. Albert Einstein. Head of Neuroscience NIDA, Distinguished Science Scholar
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Addiction - primary chronic disease of brain , reward, motivation, memory and related circuitry
What do we know of brain circuitry and is this knowledge helping in the treatment of addiction
Of 30 million chemicals known, only 100 are addictive,  humans and animals self administer
Pleasure reward system of brain - nucleus accumbens Medial Forebrain Bundle, VTA - reward; amygdalll - emotions; frontal and prefrontal - planning judgements
Know this by electrical brain stimulation reward in laboratory animals and in human patients
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Animals will self administer - ecstatically euphorically pleasurable - electrical stimulation
Planting electrodes into reward circuitry of brain, surgically.  Electrodes inserted into various parts of the brain pleasure circuitry and studied doing tasks, can be done with monkeys and rats
Canula can be inserted in the animals so that lever presses can increase dosage
Stimulation frequency - stimulation response curves -- lever presses/30 sec
Shows left shift of dose response curve showing THC is very pleasurable, same in animal that clinic patient, 'high dose - good trip, low dose - bad trip'
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Crucial reward circuitry is dopamine - know this by virtually all addictive drugs are DA agaonists, one common feature
Animal set up with IV cocaine and also a micro dialysis tubing to sample neurochemistry from brain during the self administry
eg Heroin - Dopamine in the extracellular space by pleasure centre of the brain - animals pattern can be seen with hit of cocaine and elevation of dopamine then as dopamine falls animal voluntarily self administers. They are self administering to titrate the dopamine and their pleasure
Catecholamine Synthesis Pathway - Blockade - stops electrical stimulation reward -
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IMG 1876We have known since 1969 dopamine the reward
Proponent and Opponent -  giving morphine and tolerance increases - move the giving of morphine slightly and the effects are dysphoric
-patients tell us , after a while that they don't use heroin to get high, use to get straight, they enter a chronic dopamine deficiency state
Drug withdrawal processes  - shown with thc as example
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"Reward deficiency is the driving force of addiction"
There is atrophy of the pleasure centres in those genetically bred for addiction potential and those who
have used drugs for a while

DA D3 receptor antagonists
Feeling good and well being are associated with dopamine
Social and dominant monkeys are high in dopamine whereas those who are subordinate and especially those alone have low dopamine.
Relationship of social rank to cocaine self administration - subordinate monkeys will use more cocaine, more at risk for drug abuse
227 days of abstinence the monkey is still at greater risk of using drugs with low dopamine
Reduced D2/D3 and impulsive animals
Cocaine self administered more in the impulsive aniamls

Medications that reverse drug seeking for pleasure to habit forming

Relapse - reuse trigger of drug, cues and stress

Stress trigger relapse circuits 2 in brain -
- leads to possibility of using CRF antagonists and Functional Noradrenaline Antagonists
presynaptic eg - clonidine

Increase relapse vulnerability over time - incubation of craving -
BDNF mediatied synaptic remodelling
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What about Memory?
Maladaptive drug associated memories
disorder of aberrant learning
strong instrumental memories as persistent stimulus-response habits
interation between pavlovian and instrument learning
Memories related to addiction - hippocampus and amygdalla

IMG 1886Future of Addiction Th

IMG 1887erapy
-neurobiology driven
social therapies work but we need more
-predicting vulnerability to addiction by neuro-imaging - pre teens to get them in treatment before they
take the drug

Question and Answer
- what about spontaneous recovery and recovery in general, and those who grow out of it
Noted this true and can show in animals with PET scan , so question is to explain and identify those who can with research
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(This was a truly gifted presentation of basic science and research in the field by one of the most experienced and insightful leaders. These are my rough notes with a few of the slides. I apologize for any errors and would suggest going to the source for clarity. I offer this here only to show the depth and breadth of material in the field - W.Hay)

Thursday, August 2, 2012

Neurobiology of Addiction - Dr. Steven Jurd

Neurobiology of Addiction

Dr. Steven Jurd, Clinical Associate Professor, University of Sidney, Australia (http://sydney.edu.au/medicine/addiction/staff/academics/profiles/sjurd.php) presented  Aug. 2, 2012, IDAA, Orlando

(These are my rough notes from Dr.Jurd's Continuing Medical Education lecture at the IDAA conference. In contrast to the 'dryness' of this material Dr. Jurd's presentation was most engaging, peppered with clinical anecdotes and some very humorous slides that had the hundreds in attendance LOL)

Dr. Jurd hypothesized that as Addiction is a Brain Disease there would be a  neurobiological basis which could be defined, the neurological systems involved could be identified, and the underlying molecular pathology would show. 

He made a strong statement that Addiction was ‘not simply withdrawal’.  He expressed the concern that he still encountered physicians who identified ‘addiction’ with the simple state of ‘withdrawal’.  

In contrast to this outdated idea, he quoted the Diagnostic and Statistical Manual of the American Psychiatric Association which said ‘early remission’ occured up to 12 months after withdrawal.  Addiction persists therefore long after use has stopped.

It is a common problem, with serious social and medical impact and many psychiatric complications.

Thirty six years ago “Alcohol Dependence Syndrome” was reported in the medical literature as involving tolerance,repeated withdrawal symptons, relief of withdrawal by drinking, salience of Drink seeking behaviour, subjective awareness of compulsion  to drink, narrowing of drinking repertoire, and reinstatement after abstinence.

These points were later included in the more extant Substance Dependence used in the DSMIV.

Substance Dependence - DSM IV describing well and succinctly the maladaptive pattern of substance use.

The brain was obviously the site of addiction given the subtle interplay between various brain functions.

Dr. Jurd described  Griffith Edwards  term “salience” which encompassed ‘drink seeking behaviour’ and the tendency of the substance to assume greater importance.

There is a reward  system , hard wired into mammalian brains, which is a good thing but unfortunately it is ‘high jacked’ in addiction. 

All attempts to track this reward system down have identified dopamine as the central neurotransmitter.  Once noted for his significance to the development of psychosis and parkinson’s disorder it’s now understood to be central in the addiction as well.

The “new” dopamine hypothesis states that DA is not merely a vector for production of psychosis. DA is crucial for all reinforcement. DA in the nucleus accumbens causes reward = attention, memory, learning. Addiction subsumes this basic mechanism.

Dr. Jurd showed the complex slides indicating all the effects of the different drugs of abuse and how they have been shown by research to act on dopamine. Then he offered  this simplification. 

“All drugs increase dopamine in the nucleus accumbens
Uppers put pressure on the accelerator
Downers damage the brakes”

Then he said, 
 but “remember that it is tonic not a phasic system’. There is always some dopamine in the process.

Having said this Dr. Jurd went on to discuss what causes relapse stating that three things have now been identified in ‘animal’ models: Stress, Cues and Priming dose.

It was found that 10% of rats like alcohol but this was only the rats that liked pure alcohol.  All rats liked beer and can  over time  be conditioned to drink  the equivalent of 24 cans of beer per day.Once hooked get them to press lever to obtain the alcohol. 
When the spigot is turned off, they eventually go back to other rats. It is then that ‘relapse behaviour’ can be induced with ‘foot shocks’, and example of stress, and also cuing and priming by added a little alcohol to the water. This will result in the rats returning to the lever and spigots even though they’d left them for some time previous. 

Neural Circuitry mediates drug seeking.
The final common pathway goes from the Pre frontal cortex to nucleus accumbens to ventral pallidum.
Cue and stress pathways have also been identified.

Childress in 2008 showed in  Prelude to Passion with functional MRI studies of 22 male cocaine patients that  limbic activation  occurred to ‘unseen’ cocaine and sexual images of 33 milliseconds.
Brain reward circuitry responds to drugs and sexual cues presented outside of awareness.
48 hours later, however, the addicted ‘liked’ visible versions of the same cues.
This study displayed the  unconscious vulnerability in addiction.
(Reward circuitry fired up even though their conscious brain didn’t see)

In addition to this there is ample evidence from Genetics studies of the disease basis of addictions.  Dr. Jurd listed some of the primary studies in his slides showing how even early work had been replicated confirming the reliability of the data.  Some of this research included the following: 



Twin studies (Kaij 1961, Prescott 1999)
Adoptee studies (Goodwin 1972, Cloninger 1979, Sigvaardson 1996, Cadoret 1995)
Longer term follow up (Vaillant 1983, 1995, 2003)

Dr. Jurd then presented the Nano Evidence for brain disease indicated in the genetic research showing :
GABA a2 receptor subtypes associated with alcoholic dependencdence Soyka 2008
A1 allele of D2

Finally he presented studies that showed that both pharmacology had an impact on the disease, with solid research showing Naltrexone and Acamprosate could alter relapse rates. 

Acamprosate works by decreasing the negative reinforcement
Naltrexone blocks the positive reinforcement

There was some discrepancy in the findings of European studies and American which could be attributed to the daily patterns of European drinking versus the more episodic pattern of alcohol consumption in American.  German studies showed that combined the drugs had even greater benefit that either alone.

Animal studies for acamprosate done with technique called alkalinization, putting the rat in vapor chamber and misting alcohol into the chamber , confirmed the effects of the medication on use. 



The fact that pharmacological treatments work certainly supports the disease hypothesis.

In summary: 

Addiction is a disease
Craving is a phenomena
Addicts reward themselves chemically

Several neurotransmitters are relevant
Combination drug treatment may be appropriate
There may be pharmacological subtypes of the disease

Dr. Jurd then went on to quote the research on successful treatments which showed that approximately 80% success rate could be achieved for 5 years. 

Brewster, Kaufman et al (2008) showed in Ontario Physician Health Program , a 5 year follow up of 100 physicians
AA/NA a required component
 71% no relapse while 85% response rate

McLellan, Skipper showed a 75% similiarly good outcome in their studies. 

This roughly 80% recovery rate was seen to be a product of the following key components: 
-contingency management
-frequent random drug testing
-tight links with AA/NA = abstinence
-Intensified treatment and monitoring follows relapse
-continuing care approach
-lifelong recovery focus

Explaining “recovery” Dr. Jurd turned to our present day understanding of “Brain Plasticity”

Synaptic structures are highly dynamic. Synapse count per cell body changes from 2,5000 in infants to 15, 000 in adolescents to 7,500 in adults  
Mature brains can generate new neurons. Exercise increases neural production.
Cells actually move within the CNS.

The Brain is active. It changes, and adapts to circumstances.
Dr. Jurd warned us that during this lecture we were all growing new synapses.

The brain is not a hard wired black box


Recovery is a consequence of new behaviour,new thoughts, new feelings
In new cells, new synapses and pathways are developing. Ultimately, a new microscopic neural architecture develops.

Dr. Jurd concluded by saying, 

Addiction lives in the brain. We can agree on a definition of addiction.  Mainstream medical profession agrees on this.  The relevance of the reward pathway,  it’s biochemistry and pathology have all been demonstrated. Further. we manipulate it with pharmacology and recognise the relevance of  neuroplasticity to recovery

In Sidney we noted that when there was a drought on heroin the uses switched to cocaine and ampetamine so there’s a cross over capability.

At the end of his talk he put in a plug for the Australian Doctors in Recovery annual conference. www.ausdocsinrecovery.org 
The Hotel Windsor , Melbourne
March 22 to 24 to 2013
One week after grand prix




Thursday, April 19, 2012

Paranoia

Wikipedia defines Paranoid as a "thought proces believed to be heavily influenced by anxiety or fear, often to the point of irrationality."
It's as good a definition as any.  Freud stated though that a "man who does not lose his reason over certain things can have no reason to lose" (Freud 1895).
Paranoia is therefore considered a useful developmental 'defence' or 'stage'.  Fear of alieness is self protective. Discrimination is healthy and beneficial to individuals and the species.  Immunology is essentially the biological science of the 'same' and the 'other'.
In psychoanalytic psychiatry Rycroft 1968 describes paranoia as " a functional psychosis characterized by delusions of grandeur and persecution, but without intellectual deterioration. In classic cases of paranoia, the delusions are organized into a coherent internally consistent delusional system on which the patient is prepared to act."
Paranoia is seen in several modern DSMIV-tr diagnosis.
Paranoid Disorder is a specific persecutory delusional state that is relatively fixed.  Patients will say that they believe they are being followed.  They believe people are talking about them. They believe that people are watching them.  What's significant in the grandiosity involved.  A standard question is 'why would they be watching you."  Tied into the paranoia is an inferiority complex with egomania for sure. I remember a cleaning lady who believed the RCMP had invested millions of dollars in watching her, surveillance being a very costly affair.  Addressing this she expressed a sense of wonder but wasn't rational about the obvious discrepancy about her mundane life and the belief that it warranted dozens of men in uniform following her every day.
Paranoid disorders aren't usually associated with hallucinations.  If these are present we consider the diagnosis of Paranoid Schizophrenia instead.
In Paranoid Disorder there's a often a believable thead despite the over the top character of the concern.  A person might have a specific conspiracy theory. In one case a man believed his boss was persecuting him despite his leaving the firm a year before.  Another woman believed her ex husand was spying on her in the bathroom.  A tragic man who had been in a concentration camp believed the nazis were still watching him.
Mostly these people are highly functional and capable unless their paranoid delusional state was addressed. The son of the man who'd survived the concentration camp said his father was fine so long as no one mentioned Nazi's or the news didn't focus on Germany.  If something triggered his delusional state he was convinced the neighbours were spying otherwise he was able to go about work and care of family without much evidence of this very disturbed 'corner' or 'compartment' of his mind.
Paranoid Schizophrenia is more commonly more dispersed and often coupled with hallucinations. Whereas paranoid disorders often remain constant with often poor response to medication, paranoid schizophrenia can respond well to antipsychotics such that the patient will realize and have insight into their previous pre medication insaniety.  With paranoid disorders medications have modified the level of concern but mostly the patients have felt their ideas were true but that perhaps they'd 'reacted poorly'.  'Still it's true what I said.'
Paranoid Personality Disorders are persons who don't have frank delusions or hallucinations but persist in maintaining the idea that they are the subject of persecution.  They see the world in black and white, us against them.  They do well in oppositional parties, cults and marginal church organizations.  These institutions can give them a place to 'associate'. Any group association can generally help to modify these people.  Alone they tend to maximize their bizarre ideas.   More often than not they are loners. These people insist that Jews are controlling the world. If not the Jews it's the Conservative Government of Canada, the Democrats, or the Republcians in the States. Sometimes the identified enemy is anyone that will help maintain the person's paranoid position of one downmanship. The secondary gain in paranoid personality disorders is evidenced in the power that individuals and groups who function as paranoid can bring to their cause.  Indeed media these days is often seen as promoting paranoid personality disorders.  Once drug dealers ravaged America with marijuana smokers and jazz muscians seeking the daughters of the wealthy today it's just terrorists in general.  There's always an element of truth in paranoia and the more discrete the more alluring.
One interesting paranoid disorder is 'pathological jealousy'.  This is the situation where a person will believe everyone is out to get their mate and that their mate is out to betray them with everyone else.   Again there's a combination of inferiority complex and egomania.  There's narcissism and entitlement and often some reason for the concern.
Medications are highly beneficial with paranoid schizophrenia. The original meds for this condition were Chlorpromazine and haldol.  While these medications are still used especially in institutions newer major tranquillizers have been developed with less side effects and greater specificity for the neurochemical deficit.  Dopamine channels are thought to have been overworked, defficient or imparied and the medications restore the brain chemistry to the appropriate balance. Modern research shows that different areas of the brain are 'overfiring' and the inhibitory channels aren't working appropriately.  Untreated modern scans show that the brains of paranoid schizophrenics increasingly lose matter with late stage subjects showing enlarged ventricles and decreased frontal lobe functioning.  Early psychosis units are now the mainstay of treatment with recommendations for early intervention.
A brief psychotic episode lasts weeks to months.  Schizophrenia is definitely diagnosed when a person has a year of delusional thinking especially if this persists despite medication and therapy.
Paranoid disorder is ameliorated with medication.  The newer medications for treatment of paranoia in general are much better tolerated with little or no side effects in the low dosages which are usually most beneficial.  These medications include rispiridone,olanzepine,  seroquel (quitiapine), abilify (aripiprazole) and ziprasidone.  Sometimes patients will need just the least amount of medication whereas others need a much higher dosage. Medication is titrated against an identifiable sympton.  A person who won't go out of the house because they're sure that the devil is going to get them this day may well return to work and activities and church without the extremely persecution on any of the above medications. It's as amazing to see the restoration of function of people tragically brought down by mental illness.  Medications in this sense are like insulin and digitalis in terms of the break throughs and advances they have provided individuals.
Interestingly there is a depressive disorder which is associated with paranoia.  In the above cases paranoid disorders and paranoid schizophrenia and delusional jealousy don't respond to traditional antidepressant medications.  Paranoia as noted is neurochemically seen as related to dopamine receptors whereas depression is most associated with serotonin and noradrenaline receptors.  However in psychotic depression, the particular form of depression associated with paranoia a person can indeed have essentially two overlapping disorders. The treatment is first to treat the depression but to modify depression treatment with the combination of the medications already noted. Abilify works well in this regard but if insomnia is a problem seroquel commonly is coupled with the antidepressant medications for benefit.
Paranoid personality disorders don't respond to medications generally. If they do it's usually the lowest dose of one of the atypical antipsychotics.
I've mentioned medications first because paranoia, even more severe intransigent monosymptomatic delusional disorder where the paranoia is highly specific and highly resistant to change, can respond to medication.  Medications in these group of patients often are the first step in treatment and can often allow a person to overcome their paranoia to enter into some form of therapeutic alliance.
Sadly today given the litiginous society we live in , paranoids are often the prey of unethical lawyers.  Police often have a 'frequent flyer' list of paranoids in the community who commonly call the police for help when they experience delusions.  One of my patients, well known to the police. often wakes in the night convinced that some famous actor has raped her.  She herself is very beautiful and it was a concern initially because she falsely accused a star who indeed was in town making a movie. There was no association and no consequence, the star being a mensch of the first order despite the threat and potential damage.  Shortly thereafter it was recognised that the patient was being raped by men who were clearly not in town and often not on the continet. A classic paranoid disorder medication had a limitted benefit but if she was under stress for any other reason this delusion might resurface despite the medication.  I was thankful that my treatment years back reduced her phone calls to the police from weekly to only a couple of times a year.  As a truly lovely and sophisticated lady she was deeply perplexed by these decreasing episodes and definitely remorseful about her causing trouble.  As a result she was highly compliant with medication and had a very good result last I heard.
Psychotherapies have not been particularly beneficial for paranoid disorders.  I've treated a few with one on one psychoanalytic therapy or cognitive behaviour therapy with the principle concern being, not allowing one to get caught up in the person's delusional system.  Normally the junior doctors do just this.  With paranoids you're the greatest friend as long as you thoroughly agree with them that the Conservative Party of Canada or the CIA or Catholics are malevolent and likely to be out to get this poor persecuted individual.  However once you challenge this premise you are rejected and seen to be part of the conspiracy and in fact more confirm the diagnosis.  Given this many psychopharmacologists limit therapy to focus on the brain disease with far greater benefit than inexperienced therapists who think that by exploring the person's past they will 'solve' the paranoia.  There is often 'trauma' but just addressing the trauma doesn't necessarily resolve paranoid disorders as it might resolve a ptsd or depressive disorder.  R.D. Laing who worked with schizophrenia wrote a book called 'knots'.  It was mostly poetry but the metaphor as it applied to paranoia and for him paranoid schizophrenia is that the knot is very good and very tight.
There is an attempt today with dialectic therapy, a new form of psychotherapy based broadly on the philosophical ideas of Marxism and showing some benefit in the treatment of paranoia. I confess I find this not a bit ironic since Marxism - Lennonism has been seen to be one of the greatest paranoid structures wholly reliant on the evil 'capitalist' . McCarthyism was a similar competing paranoid system.
Group therapy has been beneficial but only in the traditional low level 'supportive' way.  There is alot of 'rage hidden in the paranoia and commonly it is a a person with a quiet form of paranoid disorder that one day goes 'postal'.
My own exposure to an excessive amount of paranoid spectrum disorders is because I work in addictions.  All of the chemical addictions increase paranoid tendencies. The alcoholics are forever persecuted by usually the wife, boyfriend, government or boss or parents.  "If you were married to my wife, you'd drink like me."  There's tremendous self pity and grandiosity as every alcoholic is described as a 'legend in their mind', their depression being the greatest, their suffering monumental.  Alcoholism results in regression of defensive and coping mechanisms to an adolesecent stage with clear cut splitting of 'good guys - those who let me drink, and 'bad guys; , those who interfere with my drinking. All the pathological jealousy I've seen has been associated with alcoholism.  This might well explain the success of soap operas given the plops so often reflect the behaviour of alcoholics.  This indeed made Two and a Half Men a tremendous parody until Charlie Sheen's had his Purple Rose of Cairo meltdown.
Drug abuse is an even more associated with paranoia.  Most often this is directed at authority and specifically the police. A quote attributed to Keith Richards was "I don't have a drug problem, I have a police problem".  So again there's those who are for me and those who are agin me the early adolescent dilemna when the child is first leaving home, rejected parents for friends and struggling to resolve in group and out group association.  Marijuana smokers are especially prone to conspiracy theories.  Ask any marijuana smoker about 9-11 and it's sure to be an adventure in some mix of fantasy and reality.
Cocaine seems more specifically paranoia associated with money.  The 'harder' the drug the more of the frontal lobe or humanity of an indivdual is lost. Cocaine addiction and psychopathy go hand in hand with sex and  money the 'pac man' pursuit of the addict.
In all these cases treating the addiction is the answer.  For most people removing the substance for a year or two allows the persons brain to restore especially if there is a process of mental "decontamination' removing them from the cult paranoid thinking that helps to perpetuate addiction. 12 step communities and religious and ethnic communities and families can counteract the paranoid gang like thinking that goes hand in had with the addiciton.  Dr. Rabbi Twerki's book Addictive Thinking is a marvellous treatise on the negative effects of addiction on thought.  Insight therapies have traditionally proved very unsuccessful with addicts and the development of group therapy and motivational therapy and 12 step faciltation therapies often coupled with spiritual psychiatry approaches is now considered the treatment of choice psychotherapeutically.
Given that addictions are anxiety avoidance techniques and addicts collectively have by nature an underlying anxiety disorder most of the insight therapies and essentially therapies that result in eureka and dynamic realization and change as a consequence of new learning don't work with addicts because change causes anxiety and promotes relapse.  Supportive therapies usually are beneficail in the first three months of therapy when a patient abstinent is detoxing. Anxiety provoking therapies, psychoanalytic, relationship etc are used carefully because of the learning impairment implicit with addiction.  Addicts have rarely been able to grasp quantum changes but can learn more of the same old same old in a clever way.  Historically they were once using therapists consciously or unconsciously like psychopaths do, to improve their game with no real intention of changing.  Therapists who aren't trained in addiction more commonly are 'enablers' and on the street are called the 'addict's bitch'.   Meanwhile the therapist is either feeling warm and fuzzy or thinking of how much money they are making.
Antipsychotic medications are beneficial in the first year of treatment of addicts.
Commonly therapeutically I may agree in part but not in whole with a paranoid so that I don't so easily become caught in their black and white reality.  For example I might say 'The CIA can be concerning" in response to the patient telling me he believes the CIA have planted a chip in his tooth. I certainly wouldn't disagree with him without proof.  I watch NCIS and Insecurity on television so I know what spy agencies are capable. I will focus my attention however on 'why you'.  And what can you do to effectively not be overwhelmed by this fear.
Finally I like to remember, especially when I have my own paranoid moments, that Jesus said, "Do not be afraid."  My minister psychiatrist friend and colleague likes to say, "That wasn't a suggestion. That's a command."