We will begin of course by acknowledging the traditional custodians of the land along with elders, paying respect to elders past and present. It’s my pleasure this morning to introduce Dr.
Frances Dark who works in Mental Health Services in Metro South. Frances is a
psychiatrist who has been working at the PA for last 34 years, she’s the director
of rehabilitation academic clinical unit in Metro South, Fran’s also the
director of the statewide deafness and hard hearing team and she’s the chair of
statewide early psychosis advisory group She has a particular interest in
psychosocial therapies and psychosis and training in cognitive remediation and cognotive behavioral therapies. But today she’s here to talk about neuroscience and
motivation in particular with in mental health and Alcohol and Drug and so without further ado I welcome Fran and thank you for coming along to present today. [Fran] Yes thank you for having me, I just skipped along the freeway from Woolloongabba which is
our new clinic at 228 Logan Road, Woolloongabba I don’t profess to be an addiction
specialist I’m coming to you though from an interest in motivation and I went to
a conference about four years ago now where the neuroscience of motivation was
presented and I stopped and thought goodness gracious um we’ve been doing
things wrong in rehab by not understanding the neuroscience
underpinning motivation and for a while there for the last four years I’ve
been giving talks in neuroscience of motivation without extending it to
addictions and Rod contacting me has led me to extend it to addictions and I hope
you see the relevance to really refining. Some of our
evidence-based interventions for the very difficult group of dual diagnosis of
schizophrenia plus substance use disorders. So motivation obviously affects a lot of
part of all of our lives it’s very relevant to public health as we try and
improve the health of the nation we’re improving longevity but a lot of people
are living in ill health it’s also important in preventative health but
today we’re going to focus on addictions and disorders of dopamine like
schizophrenia. Addictions often involve the dopamine system and its the similar
neurotransmitter systems that link schizophrenia and addictions and probably
mean that the dual diagnosis adds to some of the complexity we have in
managing those dual diagnosis. Now at a behavioural level motivation can be
described by how frequent we exhibit a behaviour, how we regulate it particularly
when there’s competing demands do we go to the gym or do we have that piece of
chocolate you know these day-to-day challenges in life the choices we make
the duration how we persevere with activities there’s a number of
psychological theories of motivation generally surrounding values goals and
pleasure but it’s the neural underpinning that more recently has been mapped to
some of these other behavioural and psychological theories that I’m
particularly interested in one because it does validate what we’ve already been
doing I think that’s kinda nice that what we’re doing has a science behind it
but also because it can mean that for some people with particular symptom
clusters we may have to change our interventions. One paper that’s
referenced that I’ll use in the slides is to look at motivation in terms of generation of motivation, maintenance of motivation and regulation. I’m going to go through this
quite quickly but the reference which is by Kim is quite good if you want to get it but in the interests of getting really down to the stuff that’s relevant
to us today I’ll go through it fairly quickly today so you get a bit of a gist of where I’m coming from. So the role of reward in generating motivation it tends
to induce positive emotions it encourages approach behavior so if
somebody at work says oh it’s great that you’re riding to work it really makes
you feel good and more likely to keep on doing it so it increases the frequency
of that target behavior and prevents extinction. Reward processing, we have to anticipate a reward we’ve got to associate that reward with the behaviour
that healthy eating exercise is going to lead to praise from people I think are
important to me and you can plan to obtain a reward, so at the moment we’ve
moved clinics are I’m very close to langlands pool so I’ve started going
swimming and a lot of us are into regular exercise and we all compare notes about
how we’re going you feel as if you owe it to the group to keep going and
you know you are giving praise to each other regularly and it’s important to
see rewards, science has found that social rewards are just as powerful as monetary
rewards or external motivators so the praise we give each other for things
we’re trying to do or people we’re trying to help achieve their goal is
just as important as any monetary reward. We have to update the relative value of
the reward so is still going swimming of value to me when it starts getting
colder when it’s you know more tempting to sleep in it’s darker so all of these
things we do the whole time. So dopamine is involved in the pathway
of rewards and I’m going to be speaking a lot about dopamine so bear with me I
know there are other neurotransmitters in the brain but because dopamine’s
remain transmitting the reward processing bear with me if I focus
predominantly on dopamine today so in particular the reward driven approach
that I was talking about is subcortical nucleus accumbens and involved particularly with pleasure the value based decision making you could
understand requires a bit of higher order processing so the orbital frontal
cortex, so our frontal cortex the last part of our brain to develop
part of the executive system does all that higher process thinking that we
expect as I executive directors and drug and we expect of our frontal lobes. And
then goal-directed control is the dorsal lateral prefrontal cortex how does this
also will talk about in relation to schizophrenia involves memory,
particularly working memory which is part of our frontal executive system and part of the reason that some of our therapies may not carry over
between sessions because of deficits in memory as well as benefits in motivation.
Now motivation you probably know yourself different things motivated you
when you were young and it might have been lots of things motivated with you
when you were young as you get older you’re more refined in your interest and
things that motivate you and this is part of the exploration exploitation dilemma. So when we’re young our brains, when we are born, our brains are really unformed, it’s like a tree that hasn’t had the topiary done on it and it’s really
through experience that our brains get specialised into specialised areas
relatively specialised areas and develop for optimal adaptation for
our environment. You may think that this is a rather dangerous way to go about
things cuz obviously when you’re dealing with young people with these brains that haven’t finished maturing the brains are more vulnerable, more
malleable so it’s a trade-off between both of those things it’s necessary for
kids, young kids, its developmentally appropriate it’s good for your brain to
have lots of experiences but unfortunately the higher-order centers
that control and say don’t go there you might be in danger haven’t developed to the same degree and so explorate we are learning is characteristic of
young adolescents, really important in terms of normal brain development but also exploitative learning that a lot of things we do are
just virtual and so the pre-program we’ve done them so much we revert back
to prior learning also very important in motivation, if I go swimming it’ll make
me feel good I’ll expect a reward from from swimming if I explore other
exercise behavior I might not know if I’m going to find it rewarding or not
but it might maintain my motivation for exercise because it’s a novel behaviour.
So just repeating in development the nucleus accumbens sensitive to reward
grows rapidly and adolescence so particularly our sensation seeking adolescents are really wanting the reward of our new activities they get rapid dopamine
spikes for just shared this with a guy on Skate Board you know that sort of
activity skateboarding, taking on new challenges on the skateboard but the Amygdala that tells us what’s dangerous or not, grows more slowly so you can
see the dilemma and then obviously the frontal cortex that says
control you know you break your arm you’re not going to be able to finish
your senior because your right arm will be broken grows more slowly so
we’ve got to take this on board when we’re dealing with adolescents that we
need to make them aware of of their choices because the choices are not going
to be spontaneously generated by their frontal lobe still leaving the choice
with them still encouraging that exploratory behavior but reminding them
of the dangers and the trade-off because that’s not going to come spontaneously
for them they haven’t got those templates laid down in their neuronal
development are for a while. The interesting thing in terms of
schizophrenia in particular is that unlike what we’ve often been taught the
hedonic or liking systems are pretty much intact so these are predominantly opioid
gather systems people with schizophrenia like the things you and I
like and then motivations for substances are pretty much the same as you and I to
relax to perhaps have a euphoric experience to improve mood, improve negative mood, similar to all of us using substances the reward prediction the dopaminergic
system so are impaired by the illness so in schizophrenia they have trouble with
those frontal lobe functions of updating values they have problems on
balancing out the cost-benefit analysis and so some things that the you and I
seem like a no-brainer like walking the steps and to get a bit of incidental
exercise rather than taking the lift would seem insurmountable barriers
so they get a odd cost-benefit analysis where the cost seem greater
than the benefits and so you can’t assume can’t say to somebody come on that’s easy why don’t you do it for them it appears differently in their
brain so we’ve got to be sensitive to that. And again constructing an action
plan particularly if they’ve associated motivational problems and working memory
problems are going to have trouble actually enacting a plan that will be
able to be carried over independently after the plans being from formulated
say in our interaction in it session so motivation maintance we’ve touched a
little bit on this but on sustained motivation requires learning and memory
and herein lies the problems for people like people with schizophrenia and some
people with other mental illnesses like borderline personality disorder who have
problems with working memory PTSD some cases of bipolar disorder we
can predict rewards because we’ve come to learn over time and associate an
action with a reward and so the actions become automatic and you automatically
expect the reward. The reward is associated with these dopamine boosts and usually you have to mix it up a bit to get those dopamine bursts I only swim
three days a week with a gap in between trying to maintain my motivation for
swimming I’m not comparing myself with other leisure athletes but you
know some swimmers where they mix it up the trainers have mixed it up so they’ve
tried to get Thorpey to do backstroke for a while when he was losing
motivation for swimming they tried to mix up the training – most swimmers, I’m
sorry alluding to swimming if that’s not your sport it is mine, but without do,
cross training in the gym a little bit a part of that is to maintain
their motivation for their sport so that is to keep that dopamine response
high. So the magnitude of the learning depends on that dopamine release and the
reward prediction area. So if you get more reward than you expect you’re going
to get a huge dopamine release if you get less then
it’s not going to be you’re not going to get the same dopamine release it’s not
going to be as motivating you’re probably going to be, we’ll talk about later how
that’s important in terms of substance use and withdrawal phenomena, where
they’ve mucked up their dopamine system and they get a lot of these negative
are RPE’s because their Dopamine doesen’t respond like it used to to natural
rewards. Okay so a lot of these things we find are rewarding and the outcome
evaluation can be Pavlovian depends on the salience of the stimulus you know
whether it’s Lindt chocolate or just Cadburys, again that habitual
learning that we were talking about and that goal direction where you associate
the action in the outcomes and evaluate the reward particularly assigned to
other outcomes or other things you could be doing. The action selection is often
the judgement between the probability of the desired outcome so for
example if I was doing a low-impact exercise that isn’t going to make me
lose weight or tone up which for vein women is the main goal of exercising you
know they might not persist in doing it. The prefrontal cortex is that higher
order computation and for most of us who have done a tertiary degree for example
were able to hold on to long-term rewards with keeping in mind you know if
I finish my degree I’ll get a better job or get a better pay, we can hold on to
that people who don’t have a well-developed frontal lobe system or have
got working memory impairment find it very hard to be driven by those
long-term goals because they can’t hold them online long enough they need
frequent reminders of their intermittent goals to maintain their motivation, not that they can’t do it but they’re different from other people
like you and I for most people who have had to delay and you know there might be
lots of things that you have to put off while doing your degree and you were
able to compute that trade off on the rewards based on a long-term
achieving a long-term goal. ok regulation immediate rewards the favoured over delayed rewards that’s for us all those of us with a well develop frontal lobe are
able to hold on to that goal of delayed reward, but often you might reflect be
reflecting now most of us have intermittent rewards to help us continue
the long-term goal i’m doing a late-life PhD I just had my med confirmation on
Friday I went a little shop a little intermittent reward for the long term
goal, I haven’t finished my PhD so it was under $200 but I did think that I deserved, thank you for endorsing that choice, that judgement
I made. There is temporal discounting so if I delayed I’m going for shop until
the sales on the reward wouldn’t be as strong. sub control, okay we won’t
use it personal example for that one, so that’s the ability, to what we were talking
about, forgo smaller rewards for a long-term reward and this is what a lot of people with substance use disorders lot a lot of people with schizophrenia find very hard they can’t keep those long-term goals in mind
sometimes it becomes part of the demoralization and about their future so
they really don’t see themselves, they see themselves as losers, they can’t keep a positive
sense of self let alone a positive sense of obtaining goal of sobriety or
whatever. And so the differences in self-control
depend on working memory capacity. ok so in schizophrenia lots of problems with
motivation not for everybody with schizophrenia and this is my sort of
Eureka moment was really we should be profiling particularly people with
negative symptoms because these the ones who are going to need lots of
reinforcements are lots of intermittent goals to help them maintain their goal
directed activity where some people positive symptoms don’t have the
motivational deficits a nearly as much and can be able to be given a goal given
a plan and enacted independently in fact doing too much for that group wouldn’t, well may undermine their self-confidence in their own self efficacy whereas people
with negative symptoms need a lot of those type reinforcement schedules to
make up to those deficits and in working memory and the motivational deficits.
Again hedonic syntax, but the reward prediction, that cost benefit analysis, is
affected by impaired dopamine system so in the basal ganglia systems we’ve got
reinforcement learning ability to predict ques that lead to rewarding
outcomes, frontal lobe effects generating, updating and maintaining
value representations and Aberrant effort valued computations in
schizophrenia lead to some of the motivational problems that we have and
then managing our patients and also compounded by working memory deficits
and the dorsal lateral prefrontal cortex in terms of generating that exploratory
behavior particularly looking at novel ways of coping. so when I just
didn’t venture into substance use and dual diagnosis I saw that we needed
to profile symptoms, because people with negative symptoms and working memory
problems needed a different type of intervention we needed to profile
personal goals and interests to really optimize on what is motivating
the person not setting what we think of good goals like stopping your substance
use because it makes you schizophrenia worse, but that might be a goal for us
but if it’s not the person’s goal but their personal goal might be maintaining
a stable accommodation we link the subordinate goals into that goal of
maintaining stable accommodation. there needs to be tight reinforcement
scheduling with high expectations of success, so really small steps lots
of rewards for each step but they have to be real achievements because you
don’t get the dopamine response if you just saying great job well done for any
old thing. but the incremental and frequent, more frequent than you and I
are comfortable with, we come from a society that to give praise for a
little bit, I don’t know as a manager I’m always thinking and I don’t know if it’s
how I was socialized in my generation but you don’t give praise as much as you
should and particularly if I want my team to be motivated and dynamic I
should be giving more praise, but people with negative symptoms of schizophrenia we can’t assume how much they need that praise it needs to be valid it needs to
be realized but sometimes you’re thinking oh isn’t that nice that they
open the door for me and you don’t actually say it you don’t just a simple
thank you for opening the door for me is extremely reinforcing but we don’t often
say and other sort of things very simple things that we can do that can help
goal-directed behavior and people with motivational deficits. Errorless learning
again, so you try and give people show them the strategy rather than to learn
by trial and error trial and error in generally is very demotivating it’s much
better and they do this in schools now they teach the kids the process to try
and maximize their chance of being able to do it rather than to learn
and from trial and error, particularly important in schizophrenia though. giving
people choice really encourages intrinsic motivation, and for people with
negative symptoms greater environmental supports. so for example when running
groups there’s a bit of a issue with the NGOs, now they don’t want to be seen as
taxi services, but many groups are short-term often only about 10 weeks, it
takes our consumers about 5 weeks to encode the value of the group before
they will come along so now I’m trying to say to the NGO if you can just help
people to come along we’re not using you as a taxi service we’re using you to
help them encode the value, rather than, so some of these things for me was
you know I’ve got this you-beaut cognitive remediation program you say
you’ve got memory problems why aren’t you turning up and I can sit there
whinging “they’ve got memory problems and they’re not coming to my you-beaut” “well you know trust me I’m a doctor, why should they come spend
$5 on their go card for something they don’t even know is
going to be rewarding” so again using this neuroscience of motivation I’ve
changed how I think about NGO support how I think about our assisting people
getting to groups, particularly for these people with negative symptoms,
helps them to learn the value, encode the value, to have a greater chance of
sustaining motivated behaviour. okay what about Comorbid substance use
one of those things that are so specialists rehabilitation person I
should feel more comfortable with then I actually do again this is a disclaimer
slide I know it’s complex but I’m going to direct you to the dopamine system and
motivation in particular so bear with me people have been very interested in dual
diagnosis because of the shared common pathways between addictive drugs and schizophrenia, so dopamine gather you know other neurotransmitters serotonin,
very similar in addictions and in schizophrenia so these are the main pathways in schizophrenia. what happens in drugs of abuse, you get this dopamine
exaggerated dopamine response that you learn to associate the drugs with this
huge dopamine out put, so you have sex you have dopamine, you have amphetamine and the dopamine, I think I’ve got slide of it, we’ll come to it later, so the
all these drugs of abuse that effect primarily the dopamine system leading to
exaggerated dopamine response and the communication is altered, often this exaggerated dopamine response starts being associates through Associated learning this is all watching know from your standard 101 substance abuse 101 they start associating their drug abuse with where they at, where they use, and they come
the triggers become ubiquitous you know it’s very hard to manage triggers
because they’ll often associated with a huge number of triggers in the
environment and that’s because of this huge dopamine response and really
very tight on immediate learning. so there’s drugs of abuse inhibit the
re uptake of dopamine some of them stimulate dopamine transporter others
modulated dopamine through GABA and glutamate systems. again you don’t
need to remember all of this except if you get an exaggerated dopamine response
from taking these drugs so you know the bottom line is the lindt
chocolate the top line is Amphetamine use Lindt can’t compete can it really.
and therein lies some of our problems with addiction like I was saying
before adolescents are particularly at risk because risk-taking is
a normal part of the developmental tasks now many adolescents get by with taking
considered risks and but other particularly novel seeking adolescents
get themselves into problems with drugs mainly because they’re so cheap and
accessible and they’re sold at school bus stops and things like that. with
little starter packs and it’s everywhere do you know every school has it they’ve
got this incomplete development of the frontal regions and amygdala, the
amygdala saying “wow stop very danger lies ahead” it’s not developed nearly as
much as that nucleus accumbens that say let’s approach let’s get a dopamine hit
and not that executive functioning to help them control and remember the
adverse outcomes from use. there’s decrease in response to normally
rewarding stimuli, so people will say you know I used to enjoy doing such and such
and you know you guys will probably hear this all the time and I don’t enjoy that
anymore that makes it so difficult to using substitute rewards when you’re
coming off drugs and there’s associated increase in the stress symptoms of
corticotropin system and then so withdrawal is associated with the
significant anxiety and dysphoria essentially we’ve got to be honest with
people this is just part of it we’ll walk with you through this but part of
our goal is to keep that long-term goal in the forefront of their mind keeping
on reminding them of this because they have messed up the the neurobiology
of their reward system to get it back they’ll have to go through pretty yucky
stuff now we’ve you’ve been talking this stuff for years on a behavioral and
psychological level sometimes going back to the science really useful for people
they really think okay this makes sense, it’s not just you know you
guys hitting me with the psycho-babble and stuff you know I know you try and be
non-judgemental and all the rest of it but sometimes they need to know that
what you’re saying is actually supported by really clear brain science giving a
few images of brains shrinking etc. can be quite useful it’s interesting the
things that will change people’s behavior. so these drugs of abuse you
don’t get the dopamine firing decaying overtime and so you get
this better than expected prediction error while using drugs for a while. the
drug ques as we said becomes ubiquitous and difficult to extinguish
using normal behavioural techniques and ques that predict drug availability
take on enormous incentive salience and that consolidates drug-seeking behaviour
again anything that you’ve known all along just supported by neuroscience. and
these cues become overweighted compared to other choices and these are tragic
situations you know you’ll hear stories of mothers preferring seeking drugs over
looking after their children you know that their normal rewarding behavior has been
altered significantly. so addictive behaviors it’s not just my shopping
behaviors part of our normal human behaviour part of our dopamine reward
system but the addictive drugs in particular modify our functioning reward
sectors circuits to overvalue drug,s the rewards of drugs, and reduce the
comparative value of other rewards. the intention to stop is not enough to
stay bleak with substance as you all know that even when people will often
say I don’t like it I don’t enjoy it in fact they have stuffed up the dopamine
system they don’t get the dopamine peaks because it’s no longer novel but
on the other hand so they’ve gone from positive reinforcement of the addiction
development, again I’m not telling you anything you don’t know, to
the avoidance of the negative reinforcement of the withdrawal so the
the whole maintenance the commencement of addiction and maintenance is driven
by totally different things and I think in the community people don’t understand
that people don’t like their addictions over time they give them sort of horrible
names or you probably have got a collection of names that people call it
but it feels like a burden for them but they can’t stop because the withdrawal
state is so unpleasant so it’s not an indication of liking. the implications then if we bring the two halves of this talk together in terms of dual diagnosis with
schizophrenia, they’re recommending high intensity integrated programs, and again
it is hard in the real world to deliver this, we probably approximated in
things like our residential rehab this is where you know in the Queensland drug
policy they look at where mental illness is the primary concern and then the
substance abuse is comorbid compared to the large substance abuse and mental illness is part of that which is you’ve got rehab facilities for that I know but whether
we in our residential rehab where its big in mental illness with comorbid substance
abuse, we can mimic some of that high intensity in integrated programs, but as
you know we’re borrowing from your resources a lot of our people come into
Biala and we try and then help with that reinforcing managing the plans that you’ve put in place with people. Modifying the
programs based on illness so again for us realizing that people with
motivational problems and negative symptoms are going to be particularly
vulnerable, when that looked at dividing up between people with schizophrenia with
negative symptoms and those with positive symptoms the positive people
tend to seek drugs for sensation seeking they’re more impulsive less inhibitory, the negative symptoms it’s more that avoidance of pain so in some ways a lot
of the different theories of dual diagnosis, and self medication ethic
regulation for dual diagnosis, can be combined in this dopamine reward
motivational theory of addiction so with people with positive symptoms are sensation seeking, the people with negative symptoms are avoiding some of
the adverse effects of their illness there have been some conflicting studies
alcohol wrecks your brain not good for your cognition but some other drugs have
been found to slightly increase improve cognition including nicotine so that’s
rather transient so it’s still not good at dealing with the self medication of
some of the side effects of our medication from the symptoms of
schizophrenia it’s important to focus on specific behaviors rather than those
long-term goals have very lots of short-term goals and frequent reminders of the cost benefits and their and their goals and we can do this
in the residential rehab and really what we aim to do is build up that habitual
learning so it becomes routine we have a very strict no-smoking no illicit drugs
on site and if people come back as long as they’re not dangerously
intoxicated they can use off sight it’s interesting some people in this in the
residential rehab units have been asked to leave because of substance abuse and
have come back saying I agree to the conditions after a period away and I
said to one how do you feel do you think we were too strict and he said no it
gave me an alternative it showed me an alternative this is the sort of
flexible thinking that particularly people with negative symptoms aren’t
very good as they’re not good at seeing an alternative way of being and so in
the residential rehab we provide through a strict no use on-site policy we try to
be reasonable and have a harm minimization approach and again although
it’s led to some people being discharged from the CCU’s on the whole people have
found it beneficial and but it’s very hard in the community to mimic that and
so some of the modest improvements despite a lot of attention on substance
abuse is probably due to us not being able to provide those frequent reinforcers as a community service. okay so how do we get by being a community
service so a lot of our teams like mobile in terms of rehab team some
people get seen twice a week some people get seen more frequently usually through
relapses of a mental illnesses due to the substance abuse but not necessary to
it as part of the substance abuse and management we’re very interested in the
role of technology. the technology has an ability to real time feedback so somebody texts into their case manager says I’m getting an urge to use
text back you know I remember when you use last time what was the consequence
what could you do that to different get yourself out of that environment you
might have worked out a few strategies they’ve used other mobile technologies
where they’ve created a social community so there’s reinforces a bit like I
suppose AA online social media, AA goes to social media and again using that
leverage of social motivation to keep people goal-directed so these are some
of the things that we’re going to be exploring in the future particularly i
was thinking of in terms of motivation for schizophrenia but i think also in
terms of dual diagnosis but the reality is over fifty percent of the people we
look after have dual diagnosis problems that profile you’ve got to watch the
literature few problems of the literature most substance abusers
uses an exclusion criteria so the literature isn’t great in terms of RCT’s etc, the other thing with schizophrenia it’s an umbrella diagnosis
a lot of heterogeneity so being too inflexible in your programs isn’t wise,
but on sometimes profiling people particularly those with the negative
symptoms, may need a bit more assistance in terms of memory and
intermittent goal setting to maintain their motivated behavior may be
necessary. I hope as a service and this talks got me into this area a bit more
bit like forensics it’s not something I’ve been too motivated to indulge in
too much have left up to others but I think through the Gateway motivation
particularly the neuroscience of motivation I find and technology I
think there might be an avenue that we can help our patients a bit more than we
have done to date. but thank you for being partners
in care because you know we’re not experts and you guys are we appreciate you looking after our consumers that we Co manage so thank you. [Rod] usually we have time for questions so if anyone from the floor, I’m offering to anyone that has any questions to ask. I formulated a question earlier on when you’re talking
about memory, but I have forgotten what it was. thank you for that was great, I have a
question about a technology because I’m quite interested in using technology as a rehab tool for people, what do you think would be a benefit say in technology perhaps
an app or something that people could as a positive reinforcer to help them
with motivation or detracting from poor habits that lead to bad choices. [Frances] David Cavanagh at QUT is particularly looking at this
particularly for young people with substance use disorders and so the
young person can actually choose their screen savers or visual images and so
when they’re feeling an urge they get a an image so I think this is a really
ripe area for development and we’re trying to, there was an app developed – a
program called Prime Developed in San Diego where they use this social media
so my guess is for a lot of people and a lot of young people it’s also developing
a community so a social community so using things like visual cues that you
can individualize so you get that personal meaning plus the motivating
effect of being in a social group I’m always mindful of the limitations of
us as clinicians getting messages across to people
as well a lot of our messages can be given by other peers obviously you need
to select the piers that they’re all motivated for the same goals and you
have a lot of group behavior and that’s why the site’s monitored, so you don’t
want to say “well there’s this new drug you know down at the valley or Manning
street South Brisbane go and ask Matt for some of it, its cheap” um you know
none of that sort of behavior it is monitored but I think it’s the only way
to address this neuroscience that if we’re going to get more effective programs, if
we don’t respect these sort of the frequency of the reinforcement they need
to maintain that goal directed behavior we’re always going to be unsuccessful
successful with people because they don’t have these deficits so we’re going
to exclude a significant number of people and particularly dual diagnosis
that is difficult and our young people are in first-episode psychosis
and I know in Metro North you have the same issue, it’s not
just a drug abuse, its the charges that come with it, I sort of joke that our EP
Clinicians are expert at writing 238 reports, we don’t have them anymore we
have something else now but you know forensic reports because the costs,
the social costs of this is so high but technology, kids lover it. There’s high, they will, most of our kids have got
smartphones, or the equivalent of it, you wonder how they afford it but they
do, and again that the cost benefit they’ve made to keep in touch with their
friends they’re willing to to have a smartphone. I know they do a
lot of their deals on smartphones I know it’s not all good but there was a
concern about this sort of technology because our consumers
often don’t have much money but they have chosen to buy smartphones so I think
it’s back in 2000 there was like 32% of people with mental
illness have a smartphone, I think it’s probably higher and probably higher and
the younger age group so that shouldn’t be a barrier. developing the programs is hard, I don’t think monitoring this site is necessarily a barrier because in
our clinics we all have DIO’s and so particularly in an EP team whoever’s on
duty intake could be the monitor for the day for the site and some of these
things we see as onerous and I don’t think necessarily need to be, in MED we
run a 7 day a week service so part of that role could be monitoring that
site on the weekend so it’s definitely an area we hope to take further and again
I was thinking mainly just with schizophrenia but you know um we could
be more encouraged to take it more broadly after being asked to give this
talk and delving into the literature a bit more. [questioner] just conscious of the wider context medicinal cannabis is coming on board classically we think of Cannabis
users of developing a motivational states of some sort, many of the patients
we see, some of the patients we see have schizophrenia and they like
their Cannabis, we’ve got a real paradox here we’re trying to get people to
motivate themselves to change is the agent which it’s arguable whether it’s
going to produce as much change we’re looking at perhaps the opposite effect
what’s your view on that, there’s a growing public temptation with medicinal cannabis. [Frances] thats a newby, I’m not a substance abuse expert but look I think these are areas that substance abuse specialists will some of the issues they have to deal with some people will
need substitute medication that medicinal
cannabis they try and take the good stuff out of it and so it’s not going to
be the be-all and end-all just while on that motivational thing is still looking at
people who are driven by that high so understanding that yes it’s a
replacement, its looking at a harm minimization technique but in terms of
actually that will only be part of a broader integrated approach because
we’re taking away something from them and the things that they used to find
enjoyable, even if it’s things like skateboarding, surfing things like that
they won’t find as enjoyable so I don’t think it’s going to
be an answer initially they’re not going to be licensed for that group are
they, so I mean I think we’re still going to be stuck with it maybe in addition to
methadone we’re going to have another replacement therapy but it’s not going
to be the answer to actually getting people to meaningful life it’s going to
be a harm reduction strategy if it’s always important you know smoking and
alcohol obviously are the big substance abuse problems, the drama of ice etc. can’t be minimized for a minority population they do a hell of a
lot of harm particularly in specialist groups like and you know
the public hospitals and things but addictions alcohol and Nicotine are still probably our biggest challenges. [Questioner] with adolescents and understanding in their neurobiology would you what are your suggestions you know
like it seems to me do we do we make things more exciting you know if the
don’t get off on on their skateboard anymore do you up it to make it something
more thrill seeking or we just gotta wait around until their brain mature? [Frances] yes, so these are kids are already have got substance use problems, you
know look I think partly it’s to mobilize a lot my guess is, as I said it’s not
so not my bread and butter, but my guess is to actually mobilize everything
that we know is motivating for the young, peer group, positive peer
group, lots of diverse experiences is where I think things like outward-bound
etc is you know you know things where they do high ropes and all that
stuff and the kids are experiencing something that’s novel, it’s probably
in fact novelty more than going back to things that they previously like
skateboarding that they did in the past they might need a new challenge with
that and so it’s getting variety because that variety is where you get the
dopamine things so it’s keeping it fun looking at multiple things that motivate
the young and then always keeping reminding them of their giving them
choice but reminding them of the consequences because other things that
they are brain doesn’t generate as easily or as well and so that’s my
guess and you know you start seeing it everywhere so the
young lad that came up with the skateboard and was greeted by a case worker who said “oh great you are here early” that’s really
motivating to somebody rather than somebody saying “ohhh you are here early” you know that’s really positively reinforcing for the young person and
so it’s all these little things that you can do as a whole service and you
probably do do already now will help but you need lots of those and so
it’s everybody from the receptionist knowing to do that too in the groups
knowing that giving people permission to give praise to each other and keeping
novelty high is really important here and so this is this is I don’t know how
we go to getting funding from a high ropes course etc but I think it actually bring forward the neuroscience of motivation to justify funding for
that high ropes course or whatever it is or do abseiling off kangaroo point. [attendee] or ask the window cleaners. [Frances] but I think, again, probably the only difference when you look at the neuroscience of adolescence
is of keeping reminding them of the cost benefit of their choices not dictating
to them but it’s that that they’re not going to generate and keeping reminding
them of their ultimate goal because they’re not going to hold that on board
very well i think that that’s the issue [Questioner] I just wanted to ask, how does
the duration of illness effect the target of treatment we’re performing and second you know are there any data regarding you know the difference of you know the risk
providing for you know any of the 2 sexes. [Frances] yes so there is some issue for the Gender but I decided not to read that because I thought maybe I could get away with not being asked about it, sorry I’m being very honestly, so there is some
data and I can get that to you and what you tend to get is the early
onset with the early psychosis tend to but by far because it’s mainly young males, young males brains don’t mature as quickly so it’s mainly the
young males, mainly sensation-seeking that have got into illicit substance
abuse. Theories of substance abuse and schizophrenia have to note that a lot of
them have got into it before their diagnosis and then others yes so that’s
what we predominantly see because particularly the current drugs of abuse
if its amphetamines are so dramatic they end up presenting to ED and so the chicken and the egg phenomenon that we get into all the time with particular
first onset people but they tend to be the more the sensation seeking and then
they’ll split off so for people a lot of EP about 25% won’t actually go on to have what we call process schizophrenia, they’ve got a you
know a transient substance abuse induced psychosis very problematic psychosocial
circumstances but not nasty schizophrenia so and then
they’ll break up into the positive and negative syndromes and again the
positive ones will tend to be sensation-seeking for most of their lives
and then the negative ones you’ve got the avoidance of the negative side
effects of the medication or negative social increasing sociability because of
a bit schizoid etc so that tends to be the developmental pathway and then
there’s the issue of late-life substance abuse as well which we can’t I’ve
actually written. I think you’re going to be invited Jeremy maybe
to be involved in this where we are looking at comorbidity in
schizophrenia not just substance abuse but we’re looking at early psychosis the
middle phase where the issue is on pregnancy and reproduction and that sort
of thing and then old age with somebody who’s 66 on clozapine abusing alcohol and so those sort of co morbidities do carry on and we shouldn’t neglect that
substance abuse in an older person when psychosis can be a problem. often it is
some more alcohol that easily obtained medications, occasionally you’ll get
people still smoke a bit of dope but is the alcohol that
tends to be so easily available thats a real problem for them.

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