Chapter

Seeking relief: the activation of motivational and reward circuits

Fabrizio Benedetti

in The Patient's Brain

Published on behalf of Oxford University Press

Published in print October 2010 | ISBN: 9780199579518
Published online February 2013 | e-ISBN: 9780191754661 | DOI: http://dx.doi.org/10.1093/med/9780199579518.003.0004
Seeking relief: the activation of motivational and reward circuits

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1) This chapter is aimed at analysing why and how the patient starts seeking relief. By asking this apparently simple question, the act of seeking relief is analysed in terms of motivated behaviour, whereby motivation mechanisms are at work in order to trigger the appropriate behavioural repertoire, whose final step is the suppression of discomfort. 2) Basic motivations, like hunger, thirst, and thermoregulation lead to the appropriate behaviours in order to placate the discomfort deriving from a lack of food and water as well as from excessive cold and hot temperatures. The behavioural repertoires that are activated in these conditions are basically characterized by the search of a means to get food or water, or to find a cold/warm place. Different specific biological mechanisms do exist for each of these motivated behaviours. 3) Although sex can be considered a motivated behaviour in all respects, it is quite different compared to hunger, thirst, and thermoregulation. In fact, whereas a lack of food/water intake may be harmful to health and critical for survival, the lack of sexual activity does not lead to any harm to health. Therefore, in the case of sex, motivation can be better conceptualized as aimed at getting a pleasant reward. There are motivated behaviours other than sex that aim to seek pleasure, like self-administration of drugs of abuse and gamble. 4) The distinction between suppressing discomfort and getting a reward is not always straightforward. When one wants to suppress his own discomfort from hunger, he is actually seeking the reward of food, which is itself the means leading to hunger suppression. The mesolimbic dopaminergic system is at the very heart of this seeking behaviour, and can be identified as a motivation/reward system. The main regions of this system are the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex. The mesolimbic dopaminergic system is involved in many forms of reward, from alimentary stimuli and food intake to sexual arousal and sexual activity, and from drugs of abuse and euphoria-inducing drugs to monetary incentives and gamble. 5) Seeking relief from sickness is a motivated behaviour in all respects. When a patient feels sick, he starts seeking relief, in the same way as when he is hungry or thirsty. Cultural differences play a crucial role when adopting a given behavioural repertoire. What the sick does first is to rely on the healer who, he believes, is capable of suppressing the pathological process. It is important to realize that, for the sake of this chapter, the ability, competence, and skills of the healer do not matter. What counts is the patient's behaviour, regardless of the healer whom he refers to. 6) Seeking relief from sickness is more similar to hunger and thirst than to sexual behaviour. In fact, like hunger and thirst, a lack of search of relief may be harmful to health and critical for survival. In this sense, seeking relief from sickness can be conceptualized as a powerful mechanism of survival. 7) There is compelling experimental evidence that the mesolimbic dopaminergic system may be activated when a subject expects clinical amelioration. Most, if not all, of this evidence comes from the placebo literature, whereby an inert medical treatment is administered along with verbal suggestions of improvement. In at least three medical conditions, Parkinson's disease, depression, and pain, the activation of the mesolimbic dopaminergic system has been found to be activated when expecting clinical improvement. 8) By considering the sickness-suppressing-motivated behaviour and the involvement of the motivation/reward neural network, the clinician must consider himself as a powerful reward, thus any effort should be directed to enhance the reward mechanisms. It will become clear in Chapter 6 that a therapy can, at least in some circumstances, be conceptualized as a reward.

Chapter.  8575 words.  Illustrated.

Subjects: Psychiatry

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