Authenticity, Psychiatry and Brunette River Walk

I’ve just had a lovely walk along the Brunette River with Gilbert, my blind Cockapoo.  I took my iPhone X and my Apple Air Pods to listen to the Podcast on Authenticity, July 4, 2016, from the University of Oxford, 8th Unconscious Memory seminar, “Trust in Experts.”
Authenticity is a critical factor in clinical medicine, especially psychiatry and even more important in Addiction Psychiatry and Addiction Medicine.  A number of the leading specialists in this field feel most strongly that if a practitioner is unwilling to self disclose their own struggle with addiction then they really don’t belong in the field.
It’s noted that in general medicine non compliance can range to 30% In psychiatry it’s not uncommonly 80% and it well can be argued that in Addiction Psychiatry it’s not uncommonly 100%. This gave rise to the development of motivational psychotherapy and a scale assessing willingness to change.
In contrast in general medicine where the patient is seeking help and has a particular complaint, this is increasingly less the case as clinicians are increasingly coopted by third parties to do their bidding rather than 'heal' which is what the doctor's original role was before the corruption. The 'voluntariness' of the patient, seeking help for a bio psycho social or physical or mental problems still exists.   In Forensic Psychiatry by contrast, the psychiatrist is backed by jail and guns, the patient not being 'free' and care potentially 'coerced'.   In addiction psychiatry there’s a peculiar dance in which the ‘therapeutic alliance’ is foundational and critical.
St. Paul,  was the first Addiction Psychiatrist and said , Romans 7.20  "I do not understand what I do. For what I want to do  I do not do, but what I hate I do."
Repeatedly studies of psychotherapeutic outcomes in psychotherapy and especially psychiatric psychotherapy and even more so Addiction Psychiatry/Medicine, has declared the critical importance of ‘authenticity’.  Note that, in contrast to studies which historically declared doctors the most trusted of experts and lawyers the least trusted and politicians.  Administrative medicine given it’s ’scripted’ association with the whims of politics and lack of scientific veracity, has yet no need for ‘authenticity’. Indeed 'in authentic doctors would likely be attracted to such an aloof in human field of scripts and obedience to the degree that Arendt described as 'banal'.   The closer to the ‘police’ the administrative function is the less it requires “authenticity’. It doesn't directly serve the patient but serves the institution. Relying as Forensic Psychiatry does on ‘position authority’ and ‘weapons’ versus ’tools’, it really doesn't know the importance of 'authenticity' or 'spontaneity' . It doesn't even grasp the concept of 'therapeutic alliance' because it's focus is 'walls' and 'boundaries' rather than the kind of 'cooperative' process which occurs in frontline clinical work where individuals are not hierarchically established despite the 'talking points' presentation of this relationship based on 'cultural communism.'
The significance of ‘authenticity’ is further important given the rise in ‘fake news’.  Ironically, a Harvard study found that some percentage akin to 75% of pro Hillary reporting and 75% of pro Republican reporting was ‘fake news’.  More significantly the ‘fake news’ was remembered and more ‘effective’ than the truth in deciding election outcome.
Churchill said, ‘a lie gets halfway around the world before the truth has a chance to get its pants on."  The great Nazi Marketting Guru, Goebels, said, "A lie told once remains a lie but a lie told a thousand times becomes the truth."  and "the bigger the lie the more it will be believed."
Prof. Andrew Parker, Physiology, Anatomy and Genetics at Oxford discussed his fascinating study of brain activity using modern brain scanning techniques.  They took Rembrant Paintings ones known to be authentic and ones known to be ‘fake’ and showed them to their subjects equally.   He said it was unfortunate but that their subjects brains didn’t differentiate authentic and fake.  What was most important was that when they were told that a copy was a fake the brain behaved differently.  Indeed the ‘fake’ was made more memorable because the subjects seemed to be more interested what made it ‘fake’  rather than the ‘original’.
In clinical work, a patient faced with an ‘inauthentic’ or outright ‘lying’ clinician tends to focus most on that and not hear or pay much attention to the message after. This is especially true in the addiction field where patients have experienced significant trauma and know intuitively all the subtleties of in authenticity, like ‘damning with faint praise’, “trust me I’m here to help you”, "I'm not concerned for myself or seeking revenge I'm just concerned for others that they won't have to experience the terrible things I have."
An interesting study of administrative medicine showed that administrators were incapable of recognizing sociopaths which were readily identified by a judge.  As a family physician I had difficulty understanding certain psychiatric patients referring several a year to psychiatrists. Now I have seen tens of thousands and spent 4 decades working with psychopaths, sociopaths, psychotics and addicted I'm very experienced in this process. I actually find alot of people rather 'loud' because they're literally shouting their psychopathology and neediness and showing all manner of verbal, non verbal behaviours usually without any insight whatsoever.  Bullies are especially transparent.  Lawyers and administration are often a bit amusing to a psychiatrist because they historically rely on the 19th century masculine idea of 'playing their cards close to their chest” when in fact they radiate 'tells' time and time again mostly because they are so often 'above the law' and lack the skills and fitnesse of those below them or the chameleon psychopaths who routinely use them. Sociopathic women, borderlines are very adept as playing to the sexual weaknesses of the older male authorities by suggestively implying that they find them sexually arousing and that if they're supportive they might well be rewarded. The whole 'victim' culture which has been described extensively as  'cultural marxism" and coopting feminism. (Fiamenco, Hoff Summers, Dana Davison etc).
The stigmatization of mentally ill and addicted  patients has long been associated with an equal stigmatization of those who directly care for such people.  Such care givers are used to the discrimination, the jokes, the demeaning and humiliation that their patients suffer.  There's an element of fear which those unfamiliar with insanity have while those who are insane and especially the dementing are as bad as the 'lady that protestest too much."
Dr. Hannah Drayson, “The Experience of Spontaneity” , Digital Art and Technology, Plymouth University, talked about hypnosis and gave special reference to psychotherapy.  Spontaneity is the antithesis of the Bureaucratic Administrative Process. Indeed the ‘spontaneity’ of President Trump has infuriated the entrenched methodical bureaucratic government awakening from the experience of 2 decades of Lawyer Presidents, Obama, the Clintons and the Bushs. The American populist reaction is simply a backlash against this  perceived elite back room dealing.
Spontaneity is threatening to those ’stuck’. Studies show that ‘learned helplessness’ and the return to the ‘fetal position’ is more common than the idea of renewed ‘escape’ and ‘progress’.  Apathy is the characterization of the Canadian population along with those in asylums and jails. It was the character of the ‘peasants’ both before and after the Revolution and Lenin’s symbolic and actual killing of the Czar , his wife and his children.  The godless state has been more cruel than any godly state before.  Yet Canada trends to this as did the European Union with it’s appalling layers upon layers of  Brussels Bureaurocy. Dr. Phillip Ney has recorded that the numbing of the killing of  abortion in a society has made the administration insensitive to the 'people'.
It’s sad really that Authenticity and Spontaneity, critical to psychiatric psychotherapy and especially Addiction Psychiatry have so little meaning to lawyers and administrators.

As I continued my walk along the Brunette River I was happy to see the green tinged Mallard male and his female mate. There’s a flock of these ducks that commonly make their home along this stretch.
I especially enjoyed seeing the Wood duck male, a very colourful fellow. It was my first sighting of him this spring. I’ve not seen the female. This is likely the couple that has nested the last two years in the little man made lagoon. I so enjoyed watching the couple with their ducklings. Tragically each year I’ve seen the ducklings go missing till none remained.  I suspect a very happy coyote made that lagoon it’s dinner stop.
The mallards don’t seem to have this problem so I was glad to see the Wood Duck further down the stream.  I do hope that the couple have learned that the lagoon is a bad neighbourhood.
I was  blessed to see the Kingfisher darting by above the fast rushing stream. A couple of Kingfishers have made this river home.  I’ve spent years trying to photograph them as the male seems always on the go.
The Great Blue Heron was there too.  He actually let me take his picture. Last year I found his nest high up in the near by woods.  I took a video of him lifting off and was so pleased with myself only to lose it when I didn’t back up my photos.

A number of us with dogs gathered and chatted about the day, dogs, plans, grand children, dogs, children, and dogs, WWIII unfolding, dogs, generally having a good chat. The dogs all licked genitals and sniffed asses. Rick was still wearing his pyjama bottoms.  I came home for my second cup of coffee.

It was a great walk made better by the podcast and delightful first sightings of returning birds. The flowers are all blossoming. The daffodils are truly a delight. We are making plans to visit the Tulips near Abbotsford.  Le Conner near Bellingham and now the Canadian Tulips are an annual wake up experience for the winter weary brain.

Spring is such a joy with all it’s authenticity and spontaneity.

Fentanyl Epidemic

“I’m a doctor just like you,” he said.  I knew him in passing.  A good fellow.  Well intentioned. Most of his life a drug addict.  Now he and a friend like two teen agers going fishing patrolled the Downtown Eastside with Narcan kits they got free from the pharmacy.  Instead of trout he caught life slipping away in the gutters. Occasionally, he brought it back with drama and flourish.
“I’ve saved a dozen lives,” he said.
It was good entertainment. He used himself. The suboxone helped him and only a few times a week did he ‘party’.
 “We like the fentanyl because it’s strong enough we can push through the suboxone.” he said.  The patients liked the oral methadone and suboxone because it stopped the withdrawal sickness.  They could have a life separate from the daily grind of finding the money and getting high.
Their faces linger in my memory.  Only weeks ago I saw them.  A couple of young Caucasian women, in their 20’s with boyfriends.  They came as couples to get their opiate replacement medication.
I talk up a storm about AA/NA/SMART, the non pharmacological treatment groups, Detox and Treatment Centres and Recovery Homes..  We really only get paid for the prescriptions. The doctors break into two groups. The rich ones who write a lot of prescriptions and the poorer ones like me who do counselling and try each time to push the patients closer to recovery.
Recovery isn’t Harm Reduction.  Recovery is a proactive program of wellness leading to abstinence from mood altering substances.  Harm reduction is supposed to be a step on the way. But now our Prime Minister is so vocal about smoking pot and all the tobacco company wealth is back in the business of smoke everyone in the DTES is either smoking marijuana or cigarettes or both.  The trouble with drug addiction is that it really dulls the senses and their addiction to smoke is seen as nothing compared to the heroin and crystal meth and crack cocaine.  Then there’s the sex addiction, gambling and pornography and crime.  It’s a smorgasbord of free choice in the DTES.
But mostly they tell me they don’t want God or any of that spiritual or religious stuff.  They want drugs.  Addicts are materialist hedonists.  They are sometimes even like the monkeys we studied back in school with the electrodes in their amygdala pleasure centre who would live to pull the lever of pleasure.
More and more they tell me they don't want any of the recovery options. "I just want that free heroin. Can you direct me to where I can get my injections for free.  I don't want to stop using. I just want to get the stuff free."
Each of the women was demure with whimsical smiles and street smart eyes. College drop out. They’d been into opiates only for a year or two at most. They’d started with pills they got at parties and then became hooked. With their boyfriends they now needed fentanyl pills every day, at least one or two, sometimes more. They ground up the pills and snorted them.  They smoked marijuana too.  A lot of the marijuana had been sprinkled with fentanyl so the herb was hurting folk bad.  Even the organic shops marijuana had been tested and come back positive for fentanyl. I imagined with the fentanyl so cheap dealers were going about sprinkling powder here and there to increase their clientele.
Drug dealers are lizards who want to be your friend.
The Fentanyl was coming from China.  It was sold on line and brought in over the border en mass.  My hypochondriac patients complain that it and crystal meth are in the air in the DTES.  The paranoids are afraid of the food outside in the markets. They’re crazy but no more so than the neighbourhood.
It’s just that their faces linger. The two women from last month. I've mostly forgotten the patients that died before them.
Sometimes I remember Gordon Lightfoots song, “Only a go go girl in love with someone who doesn’t care.”  I think of their mothers.
They’re dead now.
Their boyfriends each on different weeks came in and told me the same story.
“We got high together and overdosed.  I woke up but she didn’t”.
They were sad but it hadn’t changed their own drug habit.  If anything they did more.  Running from the demons. Burying the pain.
“Sometimes you see the shadows out of the corner of your eye,’ the older guys tell me.
I talk about higher power and participation.  I repeat till the cows come home that it’s a disease of relationship and that they have to find a way to associate with people that don’t use.  I hand out pamphlets and point them to all the different groups and services that we have.  The government pays for drug and alcohol counsellors but it’s like getting adolescent boys out of gangs, one on one care doesn’t work. They need a new group, a new club, a new association.  Their religion is addiction. They see their drug as god and their dealer as their priest.  It’s high ritual.  The language doesn't tell you that but it's there as bold as the body bags.
I ask him if he’s stopped using.
“Not yet. “ he says telling me about the great feeling saving a life gives him with his free narcan kits.  I think of it as band aids.  It’s like a lone medic in Afghanistan. Every life counts.  Don Quixote charges another wind mill.  There has to be a Dulcinea.
I expect the feminists would call me chauvinist because I remember those two women more than the half dozen more young men I’ve known who are just as dead in these last few months.  It’s wrong to even speak of gender. Freedom of speech is dying as quickly as youth.  It's only okay to speak of what we're told to speak.  Designated truth or fake news.  More illusion of choice. There are so many divisions today.  I worry I’ll offend someone even by asking them to live. The Prime Minister is proud of his new physician assisted suicide programs.  They’re opening more and more needle injection sites with dilaudid and some are even giving free heroin.
They once assisted the Tong, Euro Gangs and Hell’s Angels who brought in the Heroin profiting by the government taking care of providing drug clubs, keeping their business alive with safe injection sites  and carrying all the costs of bad drugs.  Now they’re actually going toe to toe with pharmaceutical grade product versus the ‘shit they call down’, the gangs provide.
“It’s not heroin anymore.  It’s not been for a long time. Synthetic shit. That’s why the fentanyl is attractive. Cheaper and it does the trick better.” he said.
The uppers go with the downers.  Jib, or crystal meth is everywhere as well. Not as much crack smoking as doing jib these days.  There’s a lot of doing jib then heroin to get to sleep and then getting onto straight heroin and maybe cigarettes or pot. After the drugs get happening big time the alcohol which may or may not have been there in the beginning becomes less important.  Some say drugs account for 80 or 90% of the material theft.  The insurance companies are not suffering.
Legalization which is what our Prime Minister was pushing means that a drug could be sold in a school candy machine. If it’s legal, it’s legal. Like mother’s milk.
Decriminalization is accepting the disease model and treating the whole matter not as a moral issue but rather as an epidemic.  Harm Reduction, really palliative care, a term with a marketing twist came out of the cancer treatment and then the Aids Epidemic.
Harm reduction may not be that good for the individual. Individuals do best if they get into AA or NA , treatment, recovery houses or join a church.  When they look at people 20 years abstinent individually they mostly work,  belong to spiritual organizations and have replaced their previous habit with community participation and love.  Love of God, love of family, love of fellow man and woman.  Drug addiction is at best mental masturbation.
The Harm Reduction is good public health and ultimately may be preventative as the profit in drug sales moves into the public purse. It’s hard to say if there’s any less gambling today but the government gets the money rather than the Mafia.  Now one then wonders what’s the difference between public sector crime and private sector crime.
But I’m a medic in D Day and the enemy in this case, the drug dealers, they don’t provide medics for their ‘side’.  I still think I'm on the good side. I just don't know some days if I'm doing righteous work or enabling.  There’s a whole lot of other types of medicine I could do.  But I’m down here in the DTES with more and more young people. When I began in the 80's working in a detox the clientele was mostly in their 50's.  Not a lot of really old people in this work.  Living past 60 not so common here as in the suburbs.
My patient is going off with his buddy to look for more bodies in back alleys in hope he can revive them.
I’m just doing what doctors do, pushing life, where the profit always seems to be more in pushing death.

Dr. Shaohua Lu - Addiction and Consultation Liason Psychiatry

It was a rainy dark night at the end of a long day of clinic.  While the Seasons is a very fine restaurant,   on such a night I'd gladly have been home.   Dr. Shaohua Lu, however. was the night's dinner speaker. His topic was Pain and Addiction, A Psychiatric Perspective.
Dr. Lu is extremely well educated in the field but more importantly he is one of the leading clinicians in hospital based psychiatry for the addicted and medically ill.  His contribution to psychiatry at Vancouver General Hospital is immense.  Personally I've always admired his knowledge and clinical acumen in the treatment of difficult and complex cases.
I've had the pleasure of treating people in the community who were seen by him in the hospital.  There had been no platitudes or stupidities, no missed diagnosis, or whacky medication regimens.  He'd given patients the straight goods and they'd returned to the community well aware of the seriousness of their illness and exactly what they needed to do to address it.
When the College of Physicians and Surgeons employed lesser qualified physicians in the field of addictions it was always a pleasure to listen to the greater experience, training and wisdom of Dr. Lu. Never a policeman, in the field of addiction where sometimes punitive controllers loved to act out their unresolved traumas of  potty training, Dr. Lu by contrast, was always a physician first, and always a gentleman.  He based his work on the latest in research and taught the basic foundations of medicine and psychiatry.
It was a packed room he spoke to that night. Two of my most seasoned addiction medicine colleagues had been at another talk sitting next to him.  Later they'd say they'd got more clinical 'pearls' from him than from the speaker. The people in this room were impressive.  Dr. Paul Sobey, a leader in the Canadian Society of Addiction Medicine, sat near Dr. Malomed from the excellent BC College of Physicians and Surgeons Methadone Committee.  Dr. Horvath and Dr. Tsung, well weathered clinicians from the DTES Docside Clinic. Dr. Durnin. with her vast clinical experience, from her practice at Pender and also in Surrey. Dr. Klajic, humorous and wise, spoke with the very bright Dr. Cohen who sat near a couple of the top East Indian clinicians whose long names I shamefully forget.  I actually asked one fellow twice and really should have written it down. There were several others too, a great turn out.  Mostly the over 40's crowd.  There might well have been another 60 year old but I fear my beard was whitest. The experience,  knowledge and collective wisdom was palpable.  The questions asked of Dr. Lu came from that depth of experience.
Dr. Lu spoke to the overlapping areas of Pain and Psychiatry, the appropriate use of antidepressant, anti anxiety, anti inflammatory medications and finally opiates. There's been much talk of abuse of prescription opiate medication.  Dr. Lu cited the appropriate use of opiates but distinguished his work with cancer patients and palliative care versus his work with 'chronic pain'.  There's clearly a different approach to dosage when a person's life expectancy is months not years.  Further he emphasized proper medical work up for pain and the importance of recognising co morbidity with psychiatric disorder.
"No chronic pain patient is without psychological consequences."
Nadine Sparks, the Senior Sales Representative for Eli Lilly Canada Inc had organized this meeting for the benefit of pain and addiction clinicians who were commonly prescribing a variety of medications to address the patients issues with complex pain.  Cymbalta, (duloxetine) is the new antidepressant the FDA has approved for pain treatment especially fibromyalgia.  No other antidepressant medication has received such approval to date though commonly the tricyclic antidepressant, elavil (amitriptylline) has been a mainstay of pain treatment.  My patients swear by Cymbalta,this breakthrough medication.
Dr. Lu never spoke to any drug or company by name, having no conflict of interest and clearly basing his discussion of the research data to date.  He discussed buprenorphine as well in the chronic pain patient and addressed the importance of exercise in the treatment of chronic pain.
Discussing the controversial topic of 'medical marijuana' in the treatment of chronic pain he cited the research that showed that the cannabinoids that help with pain are not the same that get people high. Essentially he said, "If a person is 'feeling' high on the marijuana the dosage is too high or its not the right cannabinoid medication."
He was especially helpful in his discussion of the early onset of hyperalgesia.  Most people think of opioid induced hyperalgesia as happening at high dosage whereas Dr. Lu cited low dose induction. He maintained that it was wise clinical course to be aware of this phenomena with all opioid usage but especially when the response is not what is anticipated.
It was a truly delightful presentation and I was thankful even driving home late in the rain that I'd made it out for the evening.  Yes the Season's was a very nice restaurant.  And yes, Nadine Sparks is extremely enthusiastic and convincing.  It was great too to see fellow front line workers, the clinicians who work with the patients who suffer from these ofttimes difficult but equally challenging illness.      

International Education and Training in Addiction Medicine - ISAM 2013 - Kuala Lumpur

(The following are my rough notes from the International Society of Addiction Medicine Conference Kuala Lumpur Symposium. I hope that it will give some idea of the depth and breadth of presentations but apologize if there are any errors and would ask that you go to the sources for the definitive information in the area of specialization-W.Hay)
Greg Bunt, President Elect of ISAM


Gabrielle Welle-Strand, Norway - hosted ISAM conference in Norway 2 years ago - coordinating project to assess training around the world

1) Addiction Psychiatry Training in the US - Merrill Herman

I began wanting to be an orthopedist but a psychiatrist working in addiction at Cornell served as my mentor.  There was a methadone clinic there…. Then at Einstein….I met Greg Bunt…..met Marc….he wanted me to come to NYU to be his first fellow …..somehow Dr. Bunt joined us and we became first two fellows in addiction psychiatry….2 years program….but a lot of the training was on a dual diagnosis unit at Bellevue……not a lot of addiction psychiatry with medicine…..mostly dual diagnosis and that was role of addiction psychiatrist….went to be medical director of adolescent dual diagnosis unit….I'm from the Bronx and got recruited to come back to do the Methadone program…..integrated primary care program….I became first psychiatrist in department of family medicine…..AIDS epidemic hitting full on in New York…worked with Peter Selwin, HIV researcher…I was working and teaching residents….department of psychiatry didn't want anything to do with addiction….all the addiction medicine was coming out of family medicine….then they asked me to become director of addiction psychiatry fellowship - we now have addiction consultation in general medicine service….expose students to HIV, hepatitis, methadone, we have classic methadone, ISAM is interesting because the Bronx is multi cultural and a lot of my fellows came from all over the world…..and they'd tell stories of alcoholism around the world…..one of my residents is a sik and there's a major problem with alcoholism in sik community - crossing cultures, where do they fit in….I went to temple and was honorary sik for day - they couldn't talk about alcoholism - talked about it through the other medical problems, hypertension, diabetes……department of psychiatry began to like us and then they took us over and theres this evolution, full circle back into psychiatry…..there are 46 addiction psychiatrist fellowships and 16 addiction medicine residents - theres now parity between medicine, psychiatry and addiction - there are people who leave our family medicine , psychiatry and go to addiction…we need way to find way - there's a big need - there's not going to be enough addiction psychiatrists or addiction medicine - where are we going to go - where in psychotherapy and psychopharmacology - we need to link our forces together, addiction psychiatry and addiction medicine.  ISAM is bringing the various expertise from around the world
2) Addiction Medicine Training in the US - Dr. Stuart Gitlow - president of American Society of Addiction Medicine


First question I want to ask is what per cent of public is addicted …you might think …somewhere between 10 and 15 % - we have 5000 doctors in states certified - not all active -I'm a young addiction - there are 3000 actively practicing - more than half have only 8 years before they retire.  There are 60 fellowships, about 100 doc produced per year - were losing numbers - at the very time when we passed the affordable care - that will increase demand for addiction docs in the socioeconomic area likely to use -where are they going to go
Who can treat addiction - we dx'ed it as a disease of the brain - the reward system of the brain - in a way different from the substance - we may in future be able to identify a person who will need treatment - what is the difference between sw, counsellor, nurse , peer, psychologist, non addiction doctor, addiction doctor, addiction psychiatrist - they're all important but what is the difference. ---Spectrum of training - we need to be able to readily what a nurse can do that a doctor can't and what a doctor can do and nurse can't - ny times ran series on buprenorphine treatment - many doctors are prescribing buprenorphine inappropriately - we looked at what percentage of prescribes were members of addiction therapy - only 20% were members - so what percentage of nurses, and others were doing wrong - we in ASAM decided to move away from being a guild and letting non doctors in to the organization - we could provide training for the people - if I gave you 20 hours or a 1 year course - would a person with nursing or psychologist would that person differ from the physician.
Not many people go into field of addiction ….we wanted to know what to do to maintain people in their interest - medical students year1 - if we ask them 80 to 90% say yes, but in year 4 - 80 to 90% say no - something we're doing in medical school is wrong - so we took willing students  and placed them in a rehab program for 1 month - they went through as if they were patients - these students wrote book chapters on their experience -thought they were just like them
I encourage that kind of experiential process
 We followed them and everyone who did that was involved in some type of addiction work years later

3) Training in Addiction Medicine Training around the world and ISAM's network of addiction.- Gabrielle Wells-Strand

ISAM -evidence baed education and adequate training
we have ISAM exams
established network of national contacts in as many countries as possible
developped questionnaire
Limitations - some of questions in questionnaire not clear enough, my interpretation may be wrong but it's a start

National contacts

Populations
greater than 100 million
50 to 100
10 to 50
less that 1o million

Organization of drug treatment
primary care - belgium denamark
Secondary care  hungary japan,
Mixed models - australia
Under which speciality is addiction medicine organized
psychiathry - canada, england, indian, japan, sweden
Medicine - australia new sealan
several - france
primary care - belgium

Present training and certification
-advance training and certification - austrailia , NZ
Systematic training and certification - Finland 2 years, Hungary 2 years
Master program - australia, NZ, nethenlands
 National training courses in addiction medicine - canada, denmakr
Part of psychiatry

Future Plans
-full specialty - norway
Subspecialty - sweden, thailand
master - indonesia

Where do we go from here
- ISAM products - feed back on ISAMS rol in promoting Addiction Medicine training in different countries and discussion
Put national contracts and survey on ISAM web page
mobilize more national contacts and evaluation

4) Barriers to Addiction Medicine Training in Australia and New Zealnd  -Dr. Mark Montebello - Chair Chapter of Addiction

Medicine Education Committee -
Population australia 23 million-156 ChAM Fellows
New Zealand 4.5 million - 21 ChAM trainees
There were 4 models and we now can't get people in because of the barriers.  The program is great but has a very high standard.
Problem with aging workforce and shortages
To get into the program you have to have done another specialist

Pre requisites
Registered medical practitioner
and fellow of one of the following
-anaethetics, emergency medicine, general practice, adult medicine, pain medicine, psychiatry, rehabilitation, Rural and remote Medicine, Pediatrics and Child health Division
or completion of RACP General Basic Training - 3 years
To develop a fellow who is competent to provide a specialist level, unsupervised comprehensive medical are in Addiction Medicine
18 months core training
- prescribing, pain meds, public health, psychiatry and co morbidity, general medicine
- non core - working in rural setting, isolated communities, indigenous, specialists in research,
-everyone has to do research program and quality improvement
- all under review - moving towards the canadian model - must demonstrate learning objectives learned in clinics

Clinical assessment, attitude, ethical issues, administration, teamwork, medico-legal, self-education, patient management, communication, cultural competency, clinical decision making, health advocacy

23 specialities in college - hard to get consensus
get stigmatized,
Study investing ChAM Training Program Barirs
Aims to examine Junior Medical Officers knowledge about cham
to identify barires.
said things like I don't know, it's okay
JMO's - in medical curriculum - get huge exposure to hematology - very little to addiction medicine - the addiction ward is very old wing, versus the hematology ward
We've become more flexible and offer 3 months
Looking at having a 'masters'  - it's already done in Public Health
Looking at it as another way of getting into the program
Also developing diploma for 6 months and this is already in other specialities

5) Improving Conversational Skills in Addiction Medicine -Cor de Jong - Netherlands

- Residents in Addiction Medicine - have 80 well trained
Master in Addiction Medicine
2 years full time cours, 20 residents per group, accredidtated by Royal Dutxh Society of Medicine
Competencies
Themes
Modules
Academic teaching at University and Clinical teaching
Evidence based medicine and professional medical communication
Relationship - rapper building and relationship management
Motivational interviewing
Shared decision making

General aspects of a conversation - welcome, introduction, agenda setting, time monitoring, involvement , empathy, word choice
Non verbal communication
Retreat, Motivational Interviewing, Bedside , role playing, Moral dilemans, family counselling, aggression management
Personal learning style, Interpersonal behaviour Feelings.
Measuring quality aspects of professional communication
Can we measure this, Instruments and video assessment, rate with 3 or 4 observers.  Cross correlation  - intra class - showed reliable instrument
Means scores given at the end of 2 years
Instrument - successful and then get others who get second chance
We developed focussed training course in professional conversation skills in addiction medicine

6) Norway II - shaping of a full speciality in addiction medicine - Garbrielle Well Strand

- first medical specialty in 15 years
 first medical specialty developed by norwegian directorate of health
at the same time - suggested change in the education across the board
first proposal turned down in 1999 - said existing specialities should take care of these patients
2003 - turned down  - better strategy to increase training in family practice and pscyhiatry
2012 - successful - drug reform of 2004 - specialized health care got the responsibility for drug treatemnt
documented increased and severity of health problems among drug users
increased research and knowledge based medciine

Ministry of Health has commissioned Norwegian Directorate of health to evaluate the present specialty training

Part 1 -18 months - 12 months in hospital(general medicine/surgery/psychiatry) and 6 months in municipal general practice
Part 2 - 0 to 3 years fro groups of specialties that naturally fit together
Part 3 Common platform for groups of speciality

Common compulsory cores

New speciality should take account of user involvement and interdisciplinary cooperation
Cooperation between specialists and municipalities

A specialist in Addiction medicine
should always involve the user
-group level
have non stigmatizing practice
 be competent in cooperating with different parts of health services
Developing plans for course work
Teaching goals
Assessment standard
Specification and accreditation = for teaching hospitals

Addiction medicine specialty - training and placement and course work laid out.

Pregnancy and Post Partum Addiction

Dr. Shimi Kang

-Faculty UBC Addiction Psychiatry

I'd heard from Dr. Shaila Misri, world renowned psychiatric authority on Pregnancy and Psychiatric Disorder, that Dr. Shimi Kang was a remarkable addiction psychiatrist who'd been doing incredibly fine work at the BC Women's Hospital.  I was thoroughly delighted to hear her presentation. It was extraordinary. She's an amazing speaker and communicator with tremendous academic and scientific knowledge coupled with obvious clinical experience and skill.  One of the finest presentations I've ever heard, reminiscent, really, of those great presentations I heard by Dr. Misri , beginning decades ago, when she was making the most telling breakthroughs in helping pregnant women. Now here was Dr. Shimi Kang going forward with addressing this 'taboo' subject of addiction and pregnancy with the same deep concern and marvellous clinical acumen. 

I apologize that my rough notes don't do justice to this superb presentation but hopefully they will help someone and should they need more I would most strongly recommend they contact Dr. Shimi Kang or the UBC Department of Addiction Psychiatry. 

Pregnancy and Post Partum Addiction 

Women who use substances have 70% chance of concurrent psychiatric diagnosis

• often trauma and chronic pain are complicating factors

Concern now with pregnancy that women who have alcohol abuse problems are switching to marijuana in pregnancy because they say it helps with nausea and eating.

Presented a case of a woman who drank heavily in pregnancy and gave birth to a child with Fetal Alcohol Syndrome - she was an internist and the issue of alcohol was never raised in her pregnancy.  Dr. Kang - “I want to bust the Stigma - I work with all kinds of women with addiction issues.

Used of mood altering substances has been an accepted feature of human society for thousands of years

Alcohol Use and Binge Drinking among pregnant women

7.6% of pregnant women reported drinking in the last 30 days - 10 % of these women are college graduates. they report starting drinking in college

1.4% of pregnant women reported binge drinking in the last 30 days

Showed slide of twins - mother drank 10 beer a day in pregnancy - one child appears normal, other appears obviously with fascies of Fetal Alcohol Syndrome.  - same womb, same mother, same amount of alcohol but one thoroughly affected and the other not

Younger population is at higher risk

If a woman is smoking in pregnancy - red flag - likely woman is using another substance

My concern stated, Dr. Kang, is not just addiction in pregnancy but ‘concurrent disorders’.  

Biopsychosocial risk factors for mental illness and addiction run in parallel

Concurrent disorders in Pregnancy - 35% to 60% of patients 

Mood disorder, Mania, Depression, Panic, Agaraphobia, Generalized anxiety,

Opioid prescriptions are going up and up in women - young people

Used to be stimulants

Women present in pain with oxycontin - often with having all kinds of prescriptions from having all kinds of procedures

Prescription use and chronic 

Concurrent Disorders - more relapse - outcomes far worse

Women are different from Men

• Global context -gender based violence, low income, unremitting responsibility for care of others, socioeconomic disadvantage, 
• over and over again I see women who can have services but cant take them because they are caring for a mother or children or someone

Women are more likely to use pharmaceutical drugs

May become dependent on some illicity substance faster

greater rates of concurrent mental health problems

More likely to have suffered sexual and/or physical abuse

May engage in more HIV risk behavior

Higher mortality and advances to AIDS from HIV

Poly-substance use is often present

Freeze, Flight or Fight - depression/addiction/acting out - I explain your brain grew up with adrenaline - when you grew up with trauma - cortisol is linked

I give this explanation so they know there is a biology as well as a psychology

It is normal to be anxious to being chased by axe murderer but not to go to buy milk

Women are more stigmatized and less likely to be acknowledged

More severe problems at start of treatment

More likely to be introduced to and carry on using with partner

Less resources (education,employment,income)

Care for dependent children

Women versus men

• more concurrent diagnosis
• more rates of violence
• more difficulty accessing treatment

75% of women in treatment for addiction report childhood sexual abuse

Severity of SUD related to trauma

Menstrual cycle, fertility and substance use

• substance disrupt menstrual cycle
• asking about pms and relapse and craving - looking for patterns 

-Fertility -substances can effect fertility, cocaine and opioids cause secondary amenorrhea and risk of unplanned pregnancy

-can have no period but still be ovulating

Risk factors for substance use in pregnancy and postpartum

-past history Substance Use Disorder

Pregnancy red flags

• missed or inadequate prenatal care
• recurrent somatic complaints
• psychiatric condition
• trauam
• nicotine and /or alcohol
• failure to gain adequate weight
• intra-uterine growth delay/retardation
• withdrawal signs (eg. delivery)

Window of Opportunity

-for many women first time in health care system

in prenatal period women more liekly to engage with care and abstain or reduce their substance use, without treatment will relapse

****90% of those who remain abstinent for 2 years will be substance free for at 10 years******NIDA 1995- Vaillant et al 1988

-requires integrated approach to treatment of mental health and substance use disorder

Perinatal consequences of Substance Use

In general - LBW (less than 2500 g), prematurity, small head circumference, poor nutritional status, infections, withdrawal issues

Substance specific

-Alcohol - fetal alcohol syndrome/effects

-Marijuana - behavioural problems - impaired decision making, memory and attentiveness, tremors and altered visual responsiveness

-Stimulants

Breast Feeing

Contradindicated

-active substance use - eg heroin, cocaine

-breast pump 

Child protection

-professional responsibility

• encourage self - referral
• physical harm, sexual abuse or exploitation, emotional harm, deprivation, parental refusal of needed treatment, death and abandonment, 

Female vs Mixed Gender Services

• treament engagement and adherences
• children are 5x less likely to be put in care if woman goes to gender specific service

Tools

Motivational Therapy

Importance Confidence Ruler

• smoking woman
• on scale 1-10 if you could wish on a star what would be number
• in general we get, 7-8 10
• in general women don’t want to be using in pregnancy

Next question

On same scale , how confident are you you can quit smoking today

-tends to be 2 or 3

I then say I don’t need to tell you the risk, you’re there - importance , and we can shift to building confidence 

‘Ask how do we build your confidence?”

if they say 3

Then ask why did you say 3 instead of 1

Then they will give you reasons to quit

• i quit before, ministry on my back
• we are evoking their reasons to quit

Questions

-Methadone Prescriber

dilemna prescribing SSRI’s and Antipsychotics

-half of doctors are saying don’t prescribe i npregnancy

Answer

-I say to women you don’t want to take anything in pregnancy - say this is tough - I don’t like prescribing to women - our principal is not prescribing and if we do we use lowest dose - then we said all associations, pediatricians, obstetricians, family physicians - got to gether and said - maternal health must be guiding principal - so we prescribe medication for asthma and diabetes despite those medications having risks in pregnancy

• I give them the risks and ‘motherrisk.com
• I tell them risks of treatment and the risks of not being treated
• I say what can happen to you - when you last quit smoking you relapsed to cocaine because of anxiety

If all else is equal we go with SERTRALINE for anxiety and depression

For schizoprhenia SEROQUEL

Sociopaths and their Communication

Another observation on sociopaths and their communications to add to their narcissism, narcissistic entitlement, compulsive lying, denial and chronic rationalization is their insistence that they are cool and calm whereas you are  'over reacting' or even 'hysterical'.

They like to appear 'rational' which can be a product of their lack of feeling or sensitivity or a consequence of anesthetization by drugs or alcohol.  The fact is they are emotionally 'shallow' and lacking depth are 'still' like 'stagnant' waters, definitely not deep by any stretch of the imagination.

They have a hurtful and insensitive behaviour which reflects their intense jealousy and envy of others especially the majority of individuals who are clearly more emotionally developed than them and often have true accomplishments that make these latter individuals admired.

Sociopaths lack essential boundaries usually because of an overly sexualized relationship with their mothers especially if they are male. Whether the mother has encouraged this perception is a separate issue. Females will have serious sexual issues either oversexualized or innappropriately asexual and will misperceive adult sexual behaviour because of their lack of truly adult sexual emotional development , The fact remains that male or female they are developmentally fixated at a point where they are unable to differentiate them selves truly with others. What is good for them they assume is good for everyone else. They do not feel themselves causing pain but really do experience pain when others reflect back to them what they 'dish out'.  They can 'give it' but they simply cannot 'take it'.  They 'feed' on people and graze through social networks using up families and friends often by excessive demand for attention, influence or loans of money.

Lacking a separation of self from the other and being truly ego centric they simply lack feelings for others and only feel for themselves.  Professionals collectively describe them as pathologically narcissistic.  They appear to love their children as long as their children 'mirror' them and will love their families as long as their families don't question their often bizarre and privately insane behaviour. The most disturbed  will threaten to kill their wives, will kill their children and commonly are the ones one reads about in newspapers as stalking and killing their families. These are the individuals also who kill a co worker over a minor 'slight' yet appeared quite normal to those who didn't really know them, were new to their social network, yet probably had seem them reacting apparently 'rational' and saying to someone else that 'they' were 'over reacting'.

Hence when they are hurting and uncaring of others they see others as 'over reacting' and 'being hysterical'. However, most commonly these boy men and girl women, hurt themselves are the worst squealers, whiners and drama queens. They inflict pain without concern but hurt  themselves they become big babies and scream and sometimes even pee. They rage and pout and were it not for their outward adult appearances would be recognised for exactly what they are.  In psychiatry wards they are given frequent 'time outs' and in jails they spend inordinate amount of time in solitary.  They lack the developmental capacity of understanding laws in an abstract sense and only respond to laws as 'threat' and 'potential hurt'.  Lacking any true sense of  family or community they can't comprehend really anything so sophisticated as the 'golden rule'.  They principally operate on the simple hedonistic rule of 'if it feels good do it' and 'if it hurts others, don't get caught'.

Threatened they lack all manner of adult behaviour and devolve into infantile gestures and sometimes even assume fetal positions. Considering their over sensitivity to any even minor insult to themselves in contrast to their own grossly insulting and damaging behaviour they try desperately to produce the greatest level of 'victimship' because they lack higher levels of inhibition. When they 'steal' and 'assault' others they try to cover up the damages with 'talk' and 'promises'.  Unfortunately they are all talk and talk is cheap, especially when it lacks any connection to reality but rather comes with the lies and magical thinking of their highly distorted inner fantasy world.

The borderline variants of sociopaths especially the male borderline sociopaths are this odd mix of outward manliness and sadistic or passive aggressive tough boy behaviour coupled with this truly unseemly girlish behaviour when ever they themselves aren't on top, winning or being seen positively. Homophobia often is their way of covering up their latent homosexuality.  Further they are commonly antisemetic or identify with neo nazi elements.   They imagine emotional abuse where none is and have a chronic almost paranoid flavour whenever they are not being adulated.

Splitting is essential to their undeveloped character so they see people in black and white terms, as either you're all for me or all against me. At times this becomes overt paranoia and they can rant for hours about someone who has harmed them when usually the person is someone who has not tolerated their abuse and attack.

 If they ran face first into a stationary brick wall they'd insist the wall was out to get them and coming at them. Given the depth of their infantile fixation the world is all about them and metaphorically bite the nipple with intense sadism then complain vociferously if their "victims"  and "prey" pull back or avoid them.






- Posted using BlogPress from my iPad

Lying and Health

Research by Anita Kelly of University of Notre Dame showed that the more people lied the more unhealthy they were. She did her study by coupling lie detection with a lie detector to periodic health surveys.
Linda Stroll strudied trust and health find that those who were least trustworthy had more stress due to increased conflict in their lives.
Outwardly sociopaths and psychopaths appear at least for awhile to have success but all the while their 'insides' are 'putrifying.  It was apparent that the relationships of liars lacked substance and depth. Possibly Fathers who lied couldn't 'love' their children with depth or their families as such  because lying is associated with an unhealthy environment.  Mothers who lie are prone to excessive conflict as well.
http://www.suntimes.com/news/metro/14285134-418/avoiding-lies-can-help-your-health-study-finds.html

Who do you defer to, Doctor?

I was asked the question, "Who do you defer to, Doctor?" by a lawyer in a court case.  It caused me to pause.  I was being asked about the care of my patient.  I was a generalist, a specialist and a sub specialist.  I knew that the lawyer seemed to consider some 'hierarchy' applied to doctors as it presumably does among lawyers and certainly is a matter in the military.
It probably pertained when I was an Assistant Professor at the University too.
But it wasn't relevant in that way to clinical medicine.
I said, "I don't defer to another doctor, unless he is willing to take responsibility for the patient and assume full accountability."
Indeed, that's what clinical practice is about. It's all in the relationship.
I thought about the question overnight.  Clearly I defer to God.  I defer to authority in a governmental sense but in regards to patient care, again it's different.
The lawyer asked specifically about someone who is high profile in the court system.  I found that interesting because again clinically the lawyer couldn't grasp that 'big guns' and 'little guns' weren't a matter of much substance in my clinical world.
I do have a constellation of characters who I admire and respect and would on specific questions seek their advice and probably accept this though in the end it would be a consultation. In a consultation I can disagree and go my own way with greater risk and responsibility once I'd asked for advise and chose not to follow it.
I have a host of doctors, though fewer as I've grown in years and experience, who I consider have more specific experience than I do in a particular area.
I am a psychiatrist in the general sense but am a subspecialist in the area of addiction with certification and extensive experience.  I routinely seek advise of colleagues who have more experience with a particular kind of patient. I have a half dozen doctors who are certified in addiction medicine, some of them psychiatrists even, but I don't think of them as 'superior' to me.  I think of their individual training as comparable in many instances as mine but think more about them in terms of numbers of cases diagnosed and treated.  I also think of their outcomes and most importantly the complexity of cases.
One fellow is particularly good with heroin addicts, but of two doctors I know one is more experienced with abstinence while another is more experienced with harm reduction therapies.  Another doctor has far more experience in sex addictions than me and there is one character locally and another in the next province who know more about gambling addiction than I can ever hope to know. Yet I don't think any of them know more about 'addiction' and the diagnosis and treatment of addiction than I do in my addiction psychiatry work.
In my psychotherapy practice I have subspecialised in trauma and especially with those in recovery, the 'dual diagnosis' group and don't really know another psychiatrist who shares my particular approach to this group, a mixture of 12 step facilitation, dynamic spiritual therapy focussing on the anxiety and isolation components.  I know others who work with a similiar population but their particular approaches to treatment are often different but I think they may get similiar results.
I have another niche where I am commonly sought for advise and that's where patients have major medical problems coupled with psychiatric disorders. The psychopharmacology of this subset of patients is particularly difficult.  Patients with head injury and an anxiety disorder or depression and a seizure disorder, kidney disease and psychosis.  These are a particular group of patients who I found that a colleague was also commonly seeing and I've benefitted from his specific insights.
I don't 'defer' to these colleagues in a 'deferential' sort of way except one lady doctor who has specialised in the treatment of pregnant patients with psychiatric disorder.  And come to think of it I would defer to her and do. It's an area of psychiatry that I really have limitted experience to hers.  There's definitely some areas in psychiatry in which I probably do 'defer' now that I think of it but they're areas like that.  Child psychiatry and Geriatric Psychiatry. The latter is a subspeciality area that requires more training certified geriatric psychiatrist would see far more patients over 75 years old than I do. Right now I only have a half dozen in my practice and may have seen less than a hundred in my lifetime.  In contrast my female colleague in geriatric psychiatry is not only a great clinician but she's my age and has being seeing old people as long as my other colleagues has been focussing solely on children.
So yes I do 'defer' in these cases and would surely and do surely defer to other specialists outside my own area of specialization. Hence I'm forever deferring to orthopods, surgeons, cardiologists, endocrinologists, rheumatologists, and urologists etc.  There are however some areas of overlap in neurology for instance. I do defer to neurologists commonly but there's some areas where my own experience and expertise cause me to feel that the area of overlap might be more in my peculiar bailiwick than that of a neurologist. This is true for pain specialists and occupational health specialists.  There are little overlapping territories where I acknowledge that the two of us might have equal expertise despite coming from wholly different backgrounds.
The matter of responsibility and accountability is always at play. There are commonly alot of 'adjunctive' players in the field but when the ball is dropped I'm very much aware of whether I'm going to be stuck holding the ball.  Alot of people who refuse to carry the ball really want to tell you how a ball should be carried. I'm more aware of these with age and experience.  Monday morning quarter backs and and arm chair philosophers.
The question was a good one. Lawyers are astute and I am thankful for the questions they raise and the opportunity their questions give me for self examination and further learning.  When personally I've need a lawyer I've been rather deferential to him or her though know that in the end I'm going to be the one who is ultimately accountable.

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."