What is Not Criminally Responsible?

You’re running, but they seem to be catching up. Guns. You think you saw them carrying guns.

red and white bus on road — Photo by edwin josé vega ramos on Pexels.com

“Excuse me,” you mutter as you push up the street. You look over your shoulder and see one of them speaking into a cell phone. You mutter under your breath and dive onto a close bus. He’s calling for reinforcements.

Salvation. You think you’ve escaped them. The bus doors shut close and the vehicle begins moving. That’s when you notice a man reaching into his pocket. He’s reaching for a gun.

You take out a knife you’ve been carrying to keep you safe, since these guys started chasing you a few months ago.

Stab him.

The voice is overpowering. You bring your arm forward and the blade sinks into the mans abdomen. The bus comes to a halt before people can even process what happens, and you make a bolt for it,

* * *

It’s a sunny day and you decide to head to the mall and meet some friends. You step out of your apartment and take a breath of fresh air. The bus soon pulls up and you step on. It’s a red light so the bus stays stopped for a little while with the doors open. You hear some commotion down the street and see a guy running.

“Oh great,” you mutter to yourself. These guys are never good company. And of course, he jumps onto the bus. You’re standing with your hands in your pocket and try and not make eye contact.

The guy gets off the bus. And your bleeding. You sink to the floor and everything goes black.

* * *

Psychosis is among the most debilitating of psychiatric illnesses. Psychosis sets in at an early age, and often rears its head in resistance to many of our best treatments.

But was is psychosis?

In broad strokes, psychosis can be defined as a severe abnormality in perception. These abnormalities can come in two forms. Delusions are fixed, false beliefs that are inappropriate in a given context. Hallucinations are sensory experiences unique to an individual not otherwise experienced by others. Psychosis is also accompanied by cognitive symptoms, which can include problems thinking, disorganization of thought, and disorganization of behaviour. Finally, negative symptoms may also occur, such as flattened emotional response, and troubles with motivation.

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It sounds nice on paper. In reality, individuals with psychosis experience a different subjective reality than most. And that’s OK. Usually. I don’t see much difference in believing you have microchips in your back than believing there are God’s in the sky. As a physician, it isn’t my job to tell you what to believe.

Many people with psychosis experience it pleasantly. They hear voices that others do not, which do not bother them. They see connections in the world that I can’t begin to compute and they love it. Sometimes, and not unusually, psychosis can be unpleasant. It can be depressing. It can be downright terrifying. It is at these points, that danger occurs.

As you can see in the scenario above, these are times we have to intervene.

Scared people act in self defense. This is true whether you have psychosis or not. When you have psychosis, you may suffer from a delusion of persecution. In other words, this would be the belief that people are after you. In the scenario above, the first person believes they’re being followed. They run up the street, they dive onto a bus and even have been carrying a knife. Finally, they commit an act of violence, and stab the person in the second scenario. Not out of malicious intent, but out of a true belief of self defense. To the second person, they were simply standing on the bus.

Even more worrisome can be command hallucinations. These are a form of auditory hallucination, or “voice,” that a person hears. These voices give orders or commands to a person, and often times, the person feels compelled to listen. This can be entirely “out of their control.” In the first scenario above, the person experiences a form of command hallucination, and this plays a role in causing them to stab the second person.

So is person one responsible for the murder?

Yes.

But this doesn’t mean they are criminally responsible.

Every few months, it appears. The latest headline and protest, lauding complaints that the most vile among us have been completely exonerated for their heinous crimes. “Not criminally responsible.” The uproar is usually dramatic. The disgust even more. From my seat, I simply try and waft away the stench of ignorance, and hope that some understanding will finally come from the news story of the day.

That time of the year has arrived again, as featured here, You can thank Joe Warmington

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for inspiring today’s blog post, so let’s set the record straight.

What is Not Criminally Responsible (NCR)?

The easiest way to explain NCR, is to explain what it isn’t. It is not a complete and total exoneration (sorry Donald Trump). It is not a get out of jail free card. And it is not a failure of the justice system.

When someone is found NCR, they are basically found to be guilty of their crimes, but because of their illness. Presumably, someone who commits a crime and who is found NCR would not commit a crime while well.

Why does it matter?

The NCR system is designed to get people well, so that they can exit the system, and begin reclaiming their life. From a sociological perspective, they begin, “contributing,” to society again. To achieve this, a finding of NCR allows the courts the compel you to take physician prescribed medications, and to comply with any drug safety monitoring required. You are typically detained in a high security psychiatric hospital, and given limited benefits, only titrated along with medication effect. Ideally, with the proper treatment, you achieve remission.

So how long does an NCR last? Well, that depends. And the system isn’t perfect. Unlike the traditional justice system, NCR findings typically do not carry sentences. To be released from an NCR, you need to have the approval of a board (here in Ontario, the Ontario Review Board), to be released. For them to be satisfied, your symptoms typically have to achieve remission. This can take a wildly different amount of time for different individuals, since everyone’s condition responds uniquely. The detention typically lasts years, followed by a step-down outpatient monitoring system. Eventually, you achieve an absolute discharge, and you have no more restrictions than your average citizen.

Like I said the system isn’t perfect. Vincent Li was infamously discharged after only nine years, following a gruesome bus beheading. Anecdotally, I’ve heard of NCR findings for robberies lasting decades longer than a regular robbery sentence. At the end of the day, the system usually works, and does a fairly good job at balancing victims rights, with human rights, and acknowledging the terrible impact these life changing illnesses may have on not only the ill individual, but all of us.

And it could use some tweaks.

Editor’s note: The focus of this post was NCR findings, therefore I focused on the risk of violence in cases of psychosis. Violence remains very rare in people with psychosis. Much more commonly, psychosis puts a person’s own safety at risk, through an overwhelming desire to complete suicide, and through personal neglect.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Are you a patient or a client?

Depending who you’re asking, you might not always get the same answer.

I had just begun working at a psychiatric hospital in Ontario when this quirky word suddenly became part of my vocabulary – client. I had met countless patients before but these clients, it would seem, represented a new hurdle. What is a client? What do they want? Do they like the Raptors? Do they drink water?

Well as I would come to learn, clients are not so different from patients. Clients breath air, live in cities, and walk among us. They suffer from depression, anxiety, mania, and psychosis. They have addictions.

So what makes a client? Themselves.

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Medicine is rooted in a millennia of traditions. Some of the principles of medicine still used today date back as far as the Ancient Greeks. Hippocrates, and the Hippocratic oath, remain a quasi-initiation at the front end of most medical schools. Leonardo DaVinci, and his drawings of the human body, can be considered to still have an impact on the field of medicine today.

With all history, we tend to focus on the highlights, and leave the dark corners undiscussed and ignored.

Paternalism is part of medicine’s darkest legacy. What is paternalism? Here’s a long, winded answer.

In broad strokes, medicine is super #$%&ing complicated. No doctor understands all of medicine perfectly, and we certainly don’t expect a patient/client to understand all, most, or even some, of medicine. As a physician, my job is to explain the relevant information to you, so that you can make your own decisions. I have the responsibility to give you the required information, and to ensure that whatever I do, is in your best interests. This results in something called a fiduciary relationship, meaning that if you need a test ordered, it is on me to order that test, even if it’s seven o’clock in the evening on a Friday and the Blue Jays are about to take their first swing. Fiduciary relationships are a great and essential part of medicine. I reiterate my comments on just how complex medicine is! However, there are also some unwanted side effects.

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As a doctor, if you are under my care, as we would say in the field, I am taking ownership of your care. This doesn’t mean I own you or your property, but basically that I am the captain steering the boat that is your health into harbour. Ownership in many ways is how things get done in medicine. If nobody feels responsible, than who would make sure your x-ray was ordered or that the proper consultations had been made, after all. Like all captains, we have a natural aversion to back seat drivers. “I know how to lay the anchor, so bug off!” kind of deal. We can even start feeling this way when the patient has different opinions from our own. Sometimes, we can even have a natural tendency to dismiss a patient’s thoughts when they conflict with our own. This would be paternalism, or in other words, a medical care model where the doctor’s wishes are given the highest priority, although presumably to save your life (whether or not you want your life saved – a whole other discussion there).

In another time, only decades ago, you might find that this is actually how medicine was practiced. What the doctor says goes. Forced sterilization and lobotomy being some more infamous examples. Today, we know better.

You are the captain, and I am the first mate. I help you navigate, but it’s up to you to steer. As a physician, it’s my job to listen to your concerns and give them thoughtful reflection, no matter how they may conflict with my own thoughts. This doesn’t mean ordering unsafe medications or needless tests, but giving an honest, thoughtful, patient-centred approach to care in all respects. This is the opposite of paternalistic medicine.

So what does this have to do with the whole patient/client conundrum?

Patient is a physician-born word. It’s language we have always used to describe those we care for and it’s comfortable. But some people take offense to that word, and that’s OK. This is particularly important in psychiatry. The reasons for this? They’re many and complex, the stigma associated with being a “mental health patient,” born out of 20th century mass media being the most surface-level example. In psychiatry, the word “client” carries particular meaning, and has more voluntary connotations than “patient” can sometimes imply, given the history of (at times necessary) coercive treatment in psychiatry. The point is not every “patient” likes the word, and they have a right to not be addressed that way. Mental illnesses are to many, after all, not considered illnesses, and people would prefer to describe their experiences as something akin to psychological distress.

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At the hospital I worked at in Ontario, the alternative term adopted by the institution was ultimately “client.” (As a side note, we borrowed this word from out psychologist colleagues!) They chose to institute an institution-wide movement to address every single patient as a client. As you can see from reading this blog, I obviously don’t do that. But I also do not call everyone a patient. The reality is, I am more comfortable with the word patient and it’s been what I’ve always used. But the moment my client or patient or glerblegerker let’s me know that they disagree with the idea of being a patient, I’m quick to change my language with them. It’s about them, after all.

So you tell me – are you a patient or a client?

Editor’s note: Mental illnesses are true illnesses from my perspective, but not because of any of the particular symptoms you have – hear and chat with the voices in the empty room all you want. To me, your experience is an illness when it begins to interfere with your functioning and safety.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Is electrocompulsive therapy inhumane?

“Open your mouth?”

“What’s that?”

“To keep you from biting your tongue.”

“No! No!”

It’s a Friday night in 1975. You decide to hit up the cinema and see the latest Jack Nicholson flick that’s been pegged as Absolutely Maddening! One Flew Over the Cuckoo’s Nest, based on the 1962 book written by Ken Kesey, went on to become one of the most popular and absolutely terrifying psychological thrillers of it’s time.

It’s also caused significant damage to the field of psychiatry that remains felt today.

ofc — Credit: One Flew Over the Cuckoo’s Nest

There are a number of disconcerting features of the movie, with inpatients being locked in straight jackets and handcuffs serving as just one example (this never actually happened except in certain cases of very dangerous, high-risk people, which I agree is still inhumane; it’s not practiced whatsoever any longer). One of the most significant and gruesome scenes featured in the movie is a scene featuring electrocompulsive therapy (ECT).

The main character Randle McMurphy is played by Jack Nicholson. In the scene, Nicholson is brought into a room by security, and is met by another twelve men, who proceed to man-handle him onto a stretcher. They paint him with “conductive,” and shove a mouth guard in his mouth. They proceed to shock him, featuring loud screams, huge convulsions, and best of all, all while he is still completely awake. Gruesome. But come on.

ECT remains a procedure of mystery in the public realm and sadly that has resulted in people disproportionately and incorrectly being informed on the nature of ECT by modern media. In the 1970’s, at a time when media was limited to movies, and television, productions like One Flew Over had a tremendous impact that still hurts the field of psychiatry, and most importantly, patients.

What am I talking about?

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“My recommendation is a short course of elctrocompulsive therapy, also known as ECT.”

“No, no way I want that. I don’t want to be electrocuted man.”

“In my experience, ECT is the treatment that would work best for your condition.”

“There’s no God damn way.”

ECT remains today one of the most under-utilized therapies in medicine. That’s because ECT actually has a tremendous amount of evidence for a number of different psychiatric disorders, and in many cases, works significantly better than medications. Yet due to patient and provider stigma, ECT is often left aside because people “don’t feel comfortable” with it. Movies like One Flew Over popularized what can only be described as torture in the movie, and called it ECT, which is actually an extremely safe and effective procedure.

What are some advantages of ECT?

Electrocompulsive therapy is unique in it’s ability to treat a number of different illnesses. I have routinely used ECT to treat depression, depression with psychosis, mania, and behavioural/psychiatric symptoms of dementia.
ECT is the most effective treatment for unipolar depression (also known as Major Depressive Disorder). Remission rates have been estimated as high as 90%.
ECT is the most effective treatment for bipolar depression and mania. Remission rates have been recorded as high as 80%.
ECT, in many cases, works more quickly than medications.
ECT is safe in pregnancy whereas many psychiatric medications for bipolar disorder are not.
No medication side effects.
ECT is performed under anaesthetic.
ECT is performed with muscle relaxants; usually, the only convulsion seen happens in the big toe.
ECT is one of the only treatments approved for suicidality.

What are some disadvantages of ECT?

ECT requires a hospital, an anaesthesiologist, and a psychiatrist to administer. This costs money and resources (arguably, the cost saved by the quick and larger effect mitigates this).
ECT does have some side effects, most notoriously memory and thinking problems on the day of the treatments (a typical course involves three treatments a week for a month, and then tapering that down).
ECT can require maintenance treatments once a month for a few years or longer after you complete the acute course.

The conclusion? ECT remains one of the most effective and safest treatments in medicine. It has the ability to help people, and I’ve seen it. What’s inhumane is how little access there is to this treatment around the country.

Editor’s note: Working in Toronto, ECT was a relatively accessible service. I’ve worked at three hospitals, at least, with the ability to do ECT. This is not the case everywhere. I’ve worked in centres acorss the country where there is no access to ECT, and sick, unwell people, who deserve to have this excellent treatment, are left to go and suffer without. Improving ECT access and education is part of ending the stigma!

Stay tuned for “How does ECT work?”

Dr. Travis Barron is a resident physician in Toronto, Canada.

Why does anxiety make me tense?

It’s mid-July, and that means vacation. You’ve been waiting for this all year. You can’t wait to have a few weeks to just sit, relax, maybe take in a few books. And don’t forget the wine.

You arrive home and see your husband. He’s beaming as he gets off the phone. You kiss him hello and for a moment, everything is still.

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“Guess what?” he says.

“I don’t know, you bought good steaks for the weekend?”

“Well also that, but something else… my mother is coming to stay with us for a week!”

The calm serenity melts out of your hands and you instantly feel tight. Your muscles start to ache and your teeth are grinding. You notice your heart rate is picking up as your husband asks, “are you OK honey?”

It’s an uncomfortable feeling.

I think we can see why our fictional character may be anxious in this case. A surprise visit by the in-laws on her vacation. Yikes! (If you’re reading this my in-laws, totally love you guys!)

So she’s anxious – but why does anxiety make us feel this way?

Like I’ve spoken about time and time again, anxiety is not a mental illness. It is a personality trait. Like all personality traits, anxiety can both serve us and hurt us. Anxiety makes us not forget our wives’ birthdays, and makes us turn off the stove. On the other end, anxiety can be the root of some mental illnesses, such as Generalized Anxiety Disorder.

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Anxiety originally involved in humans as part of the adrenaline nervous system, called the sympathetic nervous system. It’s function? To help us stay safe in the jungle, and to help us fight off a predator – but doesn’t help us do much about it. Fortunately for us, we have evolved a way around this. As I’ve discussed previously, the brain operates through it’s connections, and those connections exist in very complicated but specific ways. This means the brain likes patterns. Anxiety is no exception. The anxious nervous system directly connects to the adrenaline nervous system, and turns it on when we are feeling anxious. What does the adrenaline nervous system do? Well it’s also called the fight-or-flight nervous system. This nervous system prepares our bodies and allows us to either fight off a predator such as a boar, or flight/run like crazy from something like a tiger. To allow us to do these things, the adrenaline system dilates our pupils, to improve our vision in the dark. It raises our heart rate and blood pressure to get blood to our organs and muscles, and tightens our muscles, in anticipation of a great battle or a long sprint. It freezes our digestion to preserve resources. The benefits of this connection-based system are obvious when we examine someone like a caveman.

Not so much with anxiety.

The brain doesn’t always distinguish one situation entirely from another, a symptom of it’s pattern-based operation. These same connections are activated when anxiety is caused by a seemingly harmless threat, such as news your in-laws are visiting. Increased heart rate and blood pressure can feel overwhelming and make it impossible to sleep. Muscle tightness turns into uncomfortable chronic tension. Frozen digestion becomes abdominal pain.

But there’s an end. As these things go, the physical symptoms of anxiety typically burn out over the course of a few hours. There may always be more mild chronic symptoms in the background but in general, anxious people are not always in relative crisis. Funny enough, the duration of the average panic attack (about fifteen minutes) last about as long as our adrenaline stores last.

And we can retrain these connections. Through cognitive behaviour therapy (CBT) you and a therapist work together to identify the thinking patterns that lead to a number of mental illnesses, including anxiety. Once you identify those patterns you can begin to change them, and “train” your brain to not always turn on your fight-and-flight response, at least so intensely, when you feel anxious.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Blogging for mental health

Of all of the human accomplishments through the ages, none capture the beauty of our soul to the same degree as art. Art is an activity unique to humans, and is perhaps the most significant way we differ from our animal relatives. Art transcends the individual, the collective, time, and space. Art in many ways is eternal. The impact of one person’s art, if forever forgotten in it’s truest form, is reproduced again and again through the impressions of those that first drank it in.

Which brings me to the topic of today’s blog post – blogging for mental health.

multicolored abstract painting — Photo by Steve Johnson on Pexels.com

I started this blog just over three weeks ago, on what would become the tail end of my time in the Department of Psychiatry. During the spring months, I held many conflicted feelings on the field. I was not happy professionally and yet mental health remained, and remains, something very important to me. My self reflection led to a conclusion – that I needed an outlet. So I started the blog.

And it’s helped. I went into medicine for a reason, to be a support for those in need. I hope I’ve lent myself to you. But I cannot understate the support you’ve given me by helping my spirit be at peace!

I’m not alone in this. The catharsis of art is undeniable and the positive impacts of art on our mental health have been documented for decades. Our human languages are beautiful, and often fail to describe the emotions many of us are feeling. Art provides a medium for expression, unquestionable expression, because you know at the end of the day that you’ve done this for you.

On a clinical level, I often recommend art to patients when they are suffering. And even when they are not. I’m often met with a comments like, “I don’t know how to paint,” to which I usually respond, “neither do I!” Art can be as simple as rearranging your bookshelf. Taking in a movie. Or writing a blog.

Dr. Travis Barron is a resident physician in Toronto, Canada.

How being in crowds (may have) caused psychosis

It’s Canada Day, and boy are you hungry. You have a hankering for sticky meats and while the drool begins to pool in your mouth, you remember. The Mandarin Chinese Buffet is having a free Canada Day buffet!

You hop on the subway and go to your nearest Mandarin. When you arrive at your stop, you wonder, “what’s that noise?” You exit the station and then it hits you. The noise was the massive crowd of hundreds of people who had the exact same idea as you. Just a few hours earlier.

For me, those crowds were outside of my home, and man what a spectacle. Hundreds – maybe a thousand? – of people lined up to stuff their faces. This crowd is one thing at ten in the morning after a nice breakfast. It’s an entirely different beast at two in the afternoon with a rumbling stomach. Tensions start to build (indicated by the police presence that has slowly built up over time), and it’s easy to imagine how something could go wrong.

But it doesn’t. Against what seems tremendous odds, these events, as most do, go by without a major hitch or injury. It leads one to wonder, what exactly allows us to do accomplish this as humans?

If you’ve grown up in a rural community like myself, you’re probably familiar with ant hills. If, like me, you essentially lived in a forest, there might be a few different ant hills around. Inevitably, as kids do, you take an ant from two different colonies and leave them together.

Spoiler: they fight to the death.

macro photo of five orange ants — Photo by Poranimm Athithawatthee on Pexels.com

This obviously doesn’t happen with humans. In fact, you can take two humans who couldn’t be from more different walks of life, and often times, a relationship will form. Why have we evolved this way? Well, it helps us! Humans are social animals at their very core, and our human society is the only society (think meercats, honey bees, other social animals), that have built a civilization. Civilization has allowed us as a species to thrive and master the planet like none before us. What does it take to build a civilization?

Trust, for one. Humans have needed to evolve trust of one another so that we can take full advantage of the world’s resources. We need to trust that by doing our jobs (which often times have absolutely nothing to do with the basic necessities of life), we get paid, and we need to trust that by getting paid, we are able to buy food and resources to sustain ourselves. It would be difficult to wake up every morning and be an insurance broker if that didn’t translate into food, shelter, and security for your family.

Trust, however, can only go so far. There are inevitably people among us who would violate that trust, and who would harm us, were our defenses so low. This problem has been increasingly important as humans live in denser and denser cities. It has required us to develop suspicion, to complement our trust of each other. In big cities, a mild level of paranoia keeps us safe. It makes us lock our doors at night, avoid the dark alley, and be aware of people acting strangely or dangerously around us. To simplify things, you could say all of us have inherited a little suspicion from our parents.

Sometimes, people can inherit too much suspicion. We may call this paranoia, or psychosis. This might make you believe people want to harm you, or that you are being monitored. You might begin to take meaning from completely innocuous things, due to hyperviligance. Think of psychosis as our natural suspicion in overdrive, suspicious traits that have become too concentrated. This perhaps lends to the fact that living in an urban environment significantly increases your risk of developing psychosis.

This theory is one of many behind the question, why does psychosis exist? We may never know for sure. What I do know, is that the human mind is fascinating, and we can often under appreciate the profound significance behind something as apparently simple as being in a crowd.

Like more on psychosis? Try this out!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Mental illness exists for a reason (part 4)

Thanks for reading and keeping up with this series – Mental illness exists for a reason! In part 1, part 2, and part 3, we discussed the evidence for genetic control of behaviour in primates, and found that variability within a species’ genome allows that species to be adaptable. Humans are an example of a species with a variation in genes within their genome, allowing us to become one of the most successful species on the planet! We discussed that because of this variability, some of us succeed in cities, rural areas, at high elevations, or thrive working underground. It also means that not all of us will succeed – at least in every environment.

So how do we guide treatment and recovery, with this understanding of mental illness?

three toddler eating on white table — Photo by Naomi Shi on Pexels.com

When I was in grade school, as there tends to be, there was always the one problem child. Teachers would scorn this child, parents would be caught whispering about the kid in hushed after-dinner conversations as they dispersed the latest rumors coming from the school. This child had bad grades, would act out in class, and was the regular example of how not to act when your parents warned you about the repercussions not studying. “Do you want to end up like Johnny? No future?!” You could say that in the eyes of the masses, this child was struggling.

Johnny felt he was struggling too. He didn’t seem to jive with the classroom environment. He had a lot of pent-up energy he felt he had nothing to do with. He intended well, but ultimately was ambivalent regarding his grades. ‘What will I ever need that for, anyway?”

I eventually moved on from grade school, and high school, and university, and medical school. Years later, on a short trip home to Newfoundland, I saw Johnny in the supermarket, He was with his beautiful family, and had three kids. We got to talking and it turned out he entered trade school after high school, was at work a few years later, and now actually owned a home. The thing that stuck out the most was he was glowing. Absolutely glowing., I couldn’t help but feel, this guys got it all figured out.

But Johnny was struggling. So what happened?

Not everybody will thrive everywhere. I could think of lots of examples from my office, but I thought that this example was more down to earth and a great example of how things are not always as they seem.

Johnny was never meant to sit in a classroom, and was intended to use his hands. When given the wide open expanse of a work day and a welders hat, he found his niche, and owned it. The reality is, the filtration system this is our school system didn’t work for him, and he struggled.

The conclusion? Sometimes, a change in environment is the most important intervention when you are struggling with a mental illness. If you live away from your family and friends, and are struggling, my pill will have limited benefit. Until jobs can stop requiring people to work 50, 60 hours a week for next-to=nothing, people will suffer.

Editor’s note: As if it wasn’t complicated enough, I’ll add an asterisk! Often times, when you are in the throes of a mental illness, your judgement can be distorted. In general, I recommend people do not make life-altering decisions while severely unwell. A discussion with your doctor on how to best approach this scenario is my recommendation.

Not all mental illness is a result of person-environment incompatibility. There are true, organic mental illnesses out there. Often times, a combination of medication, therapy, and life changes, is required.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of parts 1-3 of this blog series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Can you develop ADHD?

low angle photography of basketball hoop — Photo by Ricardo Esquivel on Pexels.com

Andrew was always a high achiever. He got straight A’s in high school, was valedictorian, and assistant captain of the basketball team. Andrew would often spend long evenings on the weekdays and even some of the weekends studying. His parents reassured him he was developing good habits.

When Andrew was 17, he graduated high school, and started university. As in high school, he spent much of his time studying. He put considerable effort into his academics. Unfortunately, a few weeks into his first semester, Andrew forgets to hand in a major project. A few weeks later, he doesn’t do well on a test. Andrew begins to panic and decides to see his doctor.

“Doc, there’s something happening to me.”

“What makes you say that, Andrew?”

“I think my brain is… failing or something. I’m struggling so much at university and I never had any trouble in high school at all…”

Attention-deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects attention. You can read more about ADHD here. What does neurodevelopmental disorder mean? In general, this term refers to any problem which may arise during brain development. While brain development occurs to some extent throughout our lives, the major development of the brain happens while we are still a fetus! This means that our understanding of ADHD is that it develops before we are born, as a result of numerous genetic, environmental, intrauterine factors.

Andrew might have ADHD. So how does that make sense, given what we know about ADHD? If ADHD exists from birth (probably), how is he only having problems now?

What Andrew is describing may be what is known as adult ADHD. What is adult ADHD? Well, it’s the same as ADHD! And it’s also present from birth. The only difference between adult ADHD and ADHD is that adult ADHD has been, until adulthood, undiagnosed, for a variety of factors.

two girls doing school works — Photo by Pragyan Bezbaruah on Pexels.com

ADHD screening is usually initiated by primary grade school teachers. Sometimes I meet kids from lower serviced neighbourhoods and poorer schools that simply were not given the opportunity to be screened as a child. I meet kids who were recommended to be screened as a child by their teachers, who have parents which declined the screen for any number of reasons, including not believing in ADHD and religion. I often meet women (and some men) who have gone undiagnosed, despite having struggles with academics when they were younger, because they have the “less obvious” inattentive subtype (previously known as ADD). Other times, I meet children who have been able to compensate for their natural attention abilities in their brain, for example by excessive studying (4+ hours a day in some cases) and who have flown under the radar. These kids often run into problems as they move through the academic system and the demands of the program exceeds their ability to compensate.

Andrew is an example of one of these children. He was likely able to compensate for a naturally lower attention span/hyperactivity in high school, and these coping strategies were likely overwhelmed when moving to post-secondary. Features of ADHD in adults can include mood swings, impulsive anger, losing keys, forgetting appointments, trouble holding down a relationship, and trouble holding down a job. Fortunately for Andrew, medications for ADHD are 85% effective, among the most of any drug! Ever.

So did Andrew develop ADHD? No. ADHD is a neurodevelopmental disorder, and is (in all likelihood) present since birth.

Editor’s note: There are however other illnesses which can affect attention which can develop later in life. Depression and anxiety, for example. One thing that is not ADHD, which I often see college age kids asking about, is marijuana. Marijuana interferes profoundly with attention is my most likely suspect when a marijuana user presents with new symptoms of inattention.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The small things

“Thirty five!”

My heart begins to pound. Could it be? That’s three out of six numbers so far, I had never done this well.

“Seventeen!”

I’m out of the seat. I grasp the lottery ticket in my right hand tightly and stare at the TV. Images of yachts, parties, European vacations flash before me. The woman on the TV bends over and pulls the last number from the bin.

“Eleven!”

I’m screaming. Everyone’s screaming. We’re hugging, jumping crying in joy, when –

cup of coffee near croissant bread — Photo by julie aagaard on Pexels.com

BEEEEEEEEEEEEEEEEEEEEEEEEP

I role over as I bring myself from a foggy haze back to the planet Earth. I look to my side, expecting to see the brightness of the TV and the infinitely smiling lottery woman. Instead I’m met with a dark bedroom and the slightest hint of sunlight beginning to break through the bedroom window.

It was all a dream.

For a moment, I’m sad. I mourn my yacht. I mourn the Greek islands. I prepare to mourn for my would-have-been pet Tiger, when the hope begins to trickle into my mind.

It’s Saturday.

Oh, Saturday. The king of days, the glory of glory. We meet again. What have you brought me today? Is it a hike? An interesting play? The sweet nectar of shameless hedonism and laziness so that I may bathe myself in relaxation? Perhaps.

But first, there’s coffee.

Ah, coffee. I smell the sweet fumes, the pungency of the beans as they’re cracked over blade. I’m intoxicated with the idea. I climb out of bed and realize my mouth is watering. I sneak by my loved one and enter the kitchen, the regular opening scene to my Saturday-plays.

I grind the beans, turn on the machine, and wait patiently through the glug-glug. Soon, it’s ready. I sit on the step and drink from my chalice. I find myself wondering just how much of my blood is this very drink. For those moments, the world is still. As long as there’s blackness that sits in my cup, time is frozen, and it remains in good form until I take the final sip.

I find myself mourning the lottery once more. I look to my cup and smile to myself. What I really appreciate, are the small things.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Mental illness exists for a reason (part 3)

In part 1 of Mental illness exists for a reason, we discussed the evidence behind genetic control of temperament in two different primate species, Chimpanzees and Bonobos.

In part 2, we discussed how having a variation of behaviours within a species makes that species adaptable to a broad range of environments. Voles were a great case study on how polymorphic genes lead to a variety of behaviours within a species, allowing voles to thrive in a wide range of habitats on the planet.

In part 3, we will be discussing the role of the gene we have been examining, vasopressin 1a receptor, in human behaviour, and extrapolating from that why mental illness may exist.

adult biology chemical chemist — Photo by Pixabay on Pexels.com

Humans are not voles. Before we get started, I want to reiterate that there are thousands of genes which interact to have an effect on human behaviour. No one gene is responsible for the beauty that is the human mind. When we examine human behaviours in studies, like the one I will be discussing today, we are observing trends in behaviour, and not absolute rules. Remember, personality is thought to be at most 50% genetic, and each one of those thousand genes are in direct interaction with each other, and our ever changing environment, at any given moment, to produce the “climate” of traits that becomes our personality.

So what’s the deal with vasopressin 1a receptor? What is it anyway?

In the human body, brain function is dependent on something called neurotransmission. In a nut shell, neurotransmission is when two different nerve cells, called neurons, communicate with each other. Neurons are constantly communicating with each other at any given time to produce consciousness, vision, hearing, touch, and just about any neurological function you can imagine.

41592_2018_268_Figa_HTML — Credit: Nature

How does neurotransmission occur? Through chemicals called neurotransmitters. In a neuron “discussion,” the first neuron sends a neurotransmitter to the second neuron. There is a receptor on the second/receiving neuron that picks up the message. Vasopressin 1a is this kind of receptor. Depending on the shape or form of the receptor, different things will happen to the second/receiving neuron. This is how variation in the receptor produces variation in effects!

Why is this important? Vasopressin 1a receptor has been implicated in pair bonding behaviours, across a wide range of species, including humans, chimpanzees, bonobos, and voles. Consistently, a “longer” form of the gene has been associated with increased pair bonding and less aggressive behaviours. Think the lazy, horny Bonobo and the monogamous Prarie Vole’s. And some humans.

A group at John Hopkins set out in the mid-2000’s to investigate the role of vasopressin 1a receptor in humans. You can read their study here. To summarize, the group found that a number of variations of the vasopressin 1a receptor exist in humans. That makes this a polymorpic gene. As expected, certain forms of the gene correlated with certain behaviours in humans. Longer forms of the gene were associated with increased pair bonding, as determined by a questionnaire. Amazingly, not only did carriers of the longer gene tend to report happier marriages, their partners did as well. Carriers of the shorter gene were unhappier in their marriages on average and were considerably more likely to have had a threatened divorce within the last year.

So why can’t we all be married, well fed, and happy?

buildings near body of water at night — Photo by James Wheeler on Pexels.com

Like the Prarie Vole, humans live in a wide variety of environments. This is different than Chimpanzee’s and Bonobo’s, who are really good at living in the kinds of places they live, but not great at living elsewhere. Humans live in mountains, on swamps, the plains, the coasts. There’s hardly a terrestrial environment on this planet that we haven’t conquered. The point? Humans have had to be extremely adaptable to achieve this level of success across the wide range of environments we inhabit. This doesn’t only apply to geography. The massive differences between an urban metropolis and a rural village cannot be understated. The variation in cultures across the West and East is difficult to appreciate. These differences in the societies in which we lives requires a broad range of behaviours to be within our species to succeed. We need people who thrive in a big city, among thousands of their peers, in cramped, noisy, stimulating environments. Without them, the economic engines of our nations would collapse. We need people that can’t stand the city, who need wide, open expanses, and tranquility to survive. Without them we wouldn’t be able to feed the masses. The point is that variation in our personalities allows some of us to succeed, and to excel, so that society and the species may go on.

But that doesn’t mean we are all meant to succeed. Or rather, that we are all meant to succeed in every environment.

Variation means exactly that – variety. For every person that thrives in a city there’s another who suffers. Sometimes, there is a fundamental mismatch between our personality, and our environment. Try as you may, a monogamous Vole ain’t gonna do well at a polygamous Vole frat party. A Bonobo chimp would be dead meat caught in a Chimpanzee civil war.

These mismatches occur in humans as well; sometimes, we may call that mismatch, a mental illness.

Join me in part 4 for a discussion of how we can use our understanding of why mental illnesses may exist to help guide treatment and recovery!

Editor’s note: I do not want to diminish the role of, “nurture,” in the nature vs nurture argument. By no means in personality 100% genetic (most studies show it’s around 50%)! This blog simply looks at the genetic side of things.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

Dr. Travis Barron is a resident physician in Toronto, Canada.