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P00: frame around

P01: olicognography

P02: addictions

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OLICOGNOGRAPHY on ADDICTIONS

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Working Hypothesis on Minesota's Method for AA

Basic Olicognograph: Art of Judgment

Integrated Health Care

A of difficulty of Adapted Twelve Step's program management is related to personnality. Where what could be important is less the benefit of people involved in ATS program. Even psychiatric comorbidity can have a positive benefit with the program but more the limit of resources like of trained human resources able to managed such sort of personality and the group management wchich need not too complicated heterogeneity of group.

In ATS program there are both counsellors (recovered addicts) that need not to be too exposedto personalities disorders difficult management and; groups that need not too contradictory conflicting dynamics so the sequence of the program could be applied insistingly but smoothly. Meanwhile personalities disorders are quite common in addicts. Example of prevalence of screen-positive for personality disorder features in drugs abusers: Paranoid (66%); Schizoid (13%); Schizotypal (32%); Antisocial (57%); Borderline (70%); Histrionic (22%); Narcissistic (30%); Avoidant (59%); Dependent (40%); Obsessive-compulsive (30%); At least one of those trait in 92% and; more than one these in 78%.

lso as in any group optimum size of management a group classroom of 12 to 18 persons in "pressuring program" is often better and; not all structure has ressources like for caring simultaneously 3 to 5 groups that could each be somehow homogeneous (as flows in and out).

Another issue is with health systems. In an ambiguous way there is a trend to integrated management of health care, but integration may or may not care specific registers, especially when required anonymity, transversal (crossing levels) groups out forced framing of free societies captured by excess of "specialized professional knowledge" where pluridisciplinarity turn too soon, not more than a battlefield of privileged influences instead of closely informed autonomous networks of cooperative commited concerned.

Level of community health will integrated ressources, apprently in the integrated oversight of health and people but ambiguously to promote as much as economic savings at level of primrary health care. This integration may compete with other sorts of register integration, like in the health care of addictions. Quite often the burocratic bias will prevail in selective management over the "democratic way" of AA (NA, etc.).

Collaborative care involves providers from different specialties, disciplines or sectors working together to offer complementary services and mutual support, to ensure that individuals receive the most appropriate service from the most appropriate provider in the most suitable location, as quickly as necessary, and with a minimum of obstacles. Collaboration can involve better communication, closer personal contacts, sharing of clinical care, joint educational programs and/or joint program and system planning. But increasingly literature is reporting collaborative interventions targeted at specific patient populations (eg serious and persistent mental illness, depression, the depressed elderly, substance abusers, high users of medical care), involving professionals with different skill sets, different resource requirements and a range of implementation methods.

In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.

Byside of difficulties there are also positive aspect. Development of methods and advances of science can have the effect to validate complex results, programs not based on lone dogmatism, better discrimination in kind of psychological and neurological pathologies if a openmind epistemological position is taken respect to scientific details. This makes working guidelines more suggestive, more detailed in tautologies, better assessed: good things especially if this can prevent brutality overdeterminism and common sense.

Brain's Fuctionnal Studies

Drug addiction has aspects of both impulse control disorders and compulsive disorders (1). Impulse control disorders are characterized by an increasing sense of tension or arousal before the commission of an impulsive act; pleasure, gratification, or relief at the time of commission of the act; and following the act, there may or may not be regret, self-reproach, or guilt (2). In contrast, compulsive disorders are characterized by anxiety and stress before the commission of a compulsive repetitive behavior and relief from the stress by performing the compulsive behavior.

In the incentive sensitization model an exaggerated motivation for drugs of abuse results when factors associated with casual drug use sensitize the mesolimbic reward system of neuromediators.The mesocorticolimbic dopamine system originates in the ventral tegmental area (VTA), which projects most notably to the nucleus accumbens (NAc) and the prefrontal cortex (PFC). It is a defining commonality of all addictive drugs that they increase dopamine concentrations in target structures of the mesocorticolimbic projections.

It is also to mention the involvement of serotonin (5-HT) and 5-HT receptors in the regulation of the gene expression of hypothalamic hormones and in the secretion of the pituitary gland hormones prolactin (PRL), adrenocorticotropic hormone (ACTH), vasopressin (AVP) and oxytocin in basal and stress conditions.

It has been argued that homeostasis was not adequate to explain brain-body interactions. Allostasis was defined as the process of achieving stability through change. Originally it was formulated as a hypothesis to explain the physiological basis for changes in patterns of human morbidity and mortality associated with modern life. There are many stress regulatory systems in the brain that may also contribute to the allostatic changes hypothesized to be critical to the development and maintenance of motivational homeostasis : 1) Corticotropin releasing factor activating the hypothalamic-pituitary-adrenal axis, 2) Norepinephrine, 3) Neuropeptide Y, 4) Nociceptin, 5) Orexin, 6) Vasopressin.

Modern imaging techniques like: 1)Structural magnetic resonance imaging (MRI) 2) Magnetic resonance spectroscopy (MRS), 3) Positron emission tomography (PET), 4) Single photon emission computed tomography (SPECT), 5) Functional magnetic resonance imaging (fMRI) - have enable researchers to observe drug actions and consequences as they occur and persist in the brains of abusing and addicted individuals. Pratically it isto observe that provide much more complex knowledge even if with rightfull hypothesis the effects suggest complex networking of brain (so more knowledge does not mean simplifications reductions and easy determinism). They tend to qualified more integrated approaches of such sort of problems, pointing at "wholist" approach of people suffering from these problems and more appropriated than limited diversity of psychotropic pharmacolgy. No miraculous simple curing drug(s) from addiction (to drugs). Qualifying also the ressource of Minnesota's model as a good evidenced mean, for many and ... between others, or a wholistic platform between patients, ethical advocates of crossed concern and "scientific gains".

Pragmatically

Modern day methods have made brain's overview possibly more flexible than thought before and psychologists-like less confronting theorists. So complexity, cautiousness with contain of mental processes can be more pragmatically cognitive.

  • brain is quite plastic: by amount and diversity of synapses, complexity of membranes (on synapse) receptors and of neuromediators (some half a dozen core and others dozens - hard to track),including the supportive effect of glia),
  • capability of renewal of some neurons (selective by area - may be from paleo to neo - and not unlimited) and local and displaced (relative mobilization of new neuros),
  • networks processes variations, plasticity of networks if some defect, relative compensations between brain's areas (if not all a functional fully destroyed and having survived to trauma) , redundancy of functional networks of sensibility, imperative need of functions and so on,

As a result if we add the non specific diversified and helps of common life there are some reasons to qualify:

  • cognitive therapies "as primary and as unsophisticated" they can be;
  • qualify other integrated approaches including self-supporting groups, life's changes, solidarity, self-analytic training, validity for many of life without psychotropes and plenty for short treatments, high suffisient doses only by short period then minimum if not none, only with other cognitive support intercurrent;
  • or for very few ones able to manage their addiction (do not bet on that) free from any traffic; policy to make a difference between psychological taxonomies, complexity of treatments and people; limits of psychopharmacology (needed sometimes more according social constraints than always happily supported by patients; common life requirements not all perfect or not so necessarilly to stressfully top perform, long periods evolving patterns of life; importance of ways of life in the variety of moods and reasonable tolerance to mad people.

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