ECT: the blues and the electric avenue

Electroconvulsive therapy, ECT or electroshock therapy is the most controversial treatment in psychiatry, and it’s also the most misunderstood.

It’s impossible to discuss ECT without mentioning One Flew Over the Cuckoo’s Nest because the book, the play and the film have given us the most culturally salient image of the treatment.

Kesey depicts it as little more than tool of oppression to subjugate Randal P. McMurphy who is only in hospital because, as far as he can figure out, “I, uh, fight and fuck too much”.

This negative portrayal is almost standard in the film industry but captures little of the reality of the average ECT treatment, which is usually prescribed for depression of the most severe kind (it is sometimes used for psychosis and catatonia, but much less frequently).

ECT treatment involves passing about 800 milliamps of electricity through the brain. 800 milliamps is a bit more than your average mobile phone battery puts out, but is quite significant as far as the brain is concerned and is enough to cause a seizure.

The current can be applied to both sides of the brain (bilaterally, most common) or one side only (unilaterally, less common), and can take the form of a pulse (most common) or a sine-wave (less common). There is evidence to suggest that different versions have different benefits and side effects, but the choice may depend on national guidelines or clinic preference.

This effect on the brain is essentially the same as an epileptic seizure, but it looks quite different. This is because the patient is given a general anaesthetic, so they are unconscious, and a muscle relaxant, so there is barely any movement.

In terms of physical health risks, ECT is thought to be much safer than most drug treatments and is often prescribed to people in the most fragile state of health (e.g. pregnant women, the elderly) for exactly this reason.

The biggest risk to health is actually the anaesthetic and muscle relaxant drug, which is the main reason a heart and general medical check-up is given before treatment.

ECT is usually given in doses of 6-12 treatments over a similar number of weeks (psychiatrists seem to have a superstition about giving an odd number of treatments for some reason, and so it is usually given in ‘pairs’ of doses), although can be given as a ‘maintenance’ treatment, less frequently, over longer periods.

We still don’t know how ECT works, although effects on brain plasticity (physical change and adaptation) and neurochemistry are being investigated.

In terms of its effectiveness and impact, the whole business of ECT is a complicated issue, but here’s what the current evidence suggests.

At least in the short-term, it is one of the most rapid and effective treatments for severe depression.

It is associated with ongoing memory difficulties, even after the treatment has stopped.

Patients generally view it much less favourably than clinicians, and it is generally viewed negatively by the public and carries significant stigma.

Now here are the caveats: because ECT is typically given to the most severely depressed patients (who likely already have cognitive problems), it is difficult to do ideally balanced, gold standard randomised controlled trials that give a good matched measure of both benefit and side-effects. In fact, these sorts of studies have not been done.

This is why there is disagreement, even with the medical and scientific community, about its effects, both good and bad.

Furthermore, Dr Richard Abrams, one of the leaders in ECT research and author of the standard clinical textbook, has a financial interest in, and reportedly owns, Somatics, one the world’s biggest suppliers of ECT machines and equipment. This makes some people suspicious of his promotion of the treatment.

However, Dr Harold Sackheim, probably the other ‘big name’ in ECT research, has no financial interests in any ECT company and does not receive financial compensation for consultation with the ECT industry.

Importantly, there is considerable individual variation in how people respond to ECT, in terms of their symptoms, post-treatment cognitive impairment, their subjective experience, and their attitudes.

Some people find ECT ineffective and damaging, others feel their life has been saved and their illness properly treated for the first time.

There are many articulate and moving accounts of the treatment on the web. Journalist Liz Spikol found ECT largely unhelpful and suffered debilitating cognitive effects, while surgeon Sherwin Nuland found it was the only thing that helped him recover and return to work.

Perhaps the most controversial topic is involuntary or forced treatment.

The majority of ECT patients volunteer for the treatment (usually on the suggestion of their doctors) and sign a consent form for treatment.

In some countries, where law allows, a minority of patients are treated with ECT against their will, usually if they are deemed to be a danger to themselves or others, and where other treatments have failed.

In a nutshell, it seems to be the most effective treatment for severe depression, seems to impair memory, is disliked and stigmatised, and is difficult to research. Most notably, as a patient, your mileage may vary. Some people have no benefit, some have huge improvement; some have no side-effects, some have ongoing difficulties. Most have some of each.

It’s also really hard to have a sensible discussion about ECT because of the emotions it stirs up. Like any treatment that provokes such opposite reactions from both those that have had it, and those that haven’t, it’s worth learning more with a cool head and an open heart.

I’ve avoided giving my own opinions on the treatment, which, like the evidence are complex, but I hope you’ll learn more, decide for yourself and be able to consider both new scientific evidence and reaction from people you meet who have had, or are considering ECT.

Link to Wikipedia page on ECT.

Think Green and put your brain in a tree

Rebel online clothing shop Ban T-Shirts have a t-shirt extolling the virtues of thinking green, nicely illustrated with a brain-tree hybrid.

Whether a brain-tree hybrid would itself be considered environmentally friendly is anyone’s guess, but it makes for a good visual statement nonetheless.

But if paranoid resistance is more your thing, their ‘thought criminal’ shirt should serve to promote your illicit cognitions.

Of course, you might think you’ve got nothing to hide, but we know that’s exactly what they want you to think. I think.

Link to Think Green t-shirt.
Link to Thought Criminal t-shirt.

Sleep disorders in Disney characters

A study published in Sleep Medicine has found that several Disney films have surprisingly accurate depictions of clinical sleep problems, particularly a disorder called ‘REM sleep behavior disorder’.

Also known as RBD, REM sleep behavior disorder is where normal sleep paralysis doesn’t happen during REM sleep, so to varying degrees, a person might ‘act out’ what they’re dreaming.

Three additional dogs were found with presumed RBD in the classic films Lady and the Tramp (1955) and The Fox and the Hound (1981), and in the short Pluto’s Judgment Day (1935). These dogs were elderly males who would pant, whine, snuffle, howl, laugh, paddle, kick, and propel themselves while dreaming that they were chasing someone or running away. In Lady and the Tramp the dog was also losing both his sense of smell and his memory, two associated features of human RBD. These four films were released before RBD was first formally described in humans and dogs.

In addition, systematic viewing of the Disney films identified a broad range of sleep disorders, including nightmares, sleepwalking, sleep related seizures, disruptive snoring, excessive daytime sleepiness, insomnia and circadian rhythm sleep disorder. These sleep disorders were inserted as comic elements. The inclusion of a broad range of accurately depicted sleep disorders in these films indicates that the Disney screenwriters were astute observers of sleep and its disorders.

This is not the first time that Disney films have featured in the medical literature.

One 2004 study published in the Canadian Journal of Psychiatry looked at the representation of mental illness in Disney movies (and found, rather disappointingly, that mental illness was typically referred to when one character was denigrating another).

Link to abstract of study on Disney and sleep disorders.
Link to abstract of study on Disney and mental illness.

2008-01-04 Spike activity

Quick links from (roughly) the past week in mind and brain news:

San Francisco Science Cafe puts video online of a talk on the neuroscience of meditation.

AP News reports US Military apparently not recording suicides in Iraq and Afghanistan veterans.

Was the development of cooking a kickstart to the evolution of the modern human brain? SciAm investigates.

The New York Times has an interesting piece on the use of dissociation (‘splitting off’ areas of consciousness) in endurance sports people.

Glossy Autism magazine now available on newsagent shelves (also covers Aspergers, ADHD etc). Not sure how I feel about that.

Retrospectacle has neurosurgical tools of the 19th century! To only be used with a large bottle of brandy (by the patient, not the surgeon, although by the look of the tools, it probably didn’t make a huge amount of difference).

Hypothalmus activity may be crucial in migraines, reports BBC News.

The New York Times on a study where researchers stimulated a single dendritic spine in a neuron (wow).

The mighty Fortean Times discusses the Wellcome Collections’ new exhibition on sleep and dreaming.

More from the increasingly cognitive New York Times: an article on synaesthesia induced by a brain injury.

The Guardian covers a slightly tongue-in-cheek study that notes the similarities between images in Renaissance paintings and brain structures.

The mind is a control structure for an autonomous agent. The Science and Consciousness Review has a feature article on modelling unconscious perception in artificial intelligence.

Studying the anthropology of depression during motherhood. The New York Times looks at the work of Dr. Marian Radke-Yarrow.

The BPS Research Digest on a study that found that students who endorsed sex stereotypes showed more biased recall of their past exam performance (e.g. girls thought they did worse at maths, boys worse at art, than they actually did).

Cognitive Daily looks at research which attempts to answer the question ‘does test-taking help students learn?’

Psychologist Carol Dweck is interviewed about her work on praise, motivation and achievement in children.

Bad Science has an mp3 of Ben Goldacre giving the President’s Lecture at the British Pharmacology Society’s annual conference: More than molecules ‚Äì how pill pushers and the media medicalise social problems.

Certain brain injuries (that, unsurprisingly, affect parts of a key anxiety circuit) may prevent PTSD, reports Treatment Online.

Deric Bownds looks at the role of nature vs nurture in the visual cortex.

The Neurotech Industry Organisation both reviews 2007 and looks forward to 2008.

PsyBlog gets philosophical with articles on the relationship between happiness and the work of Schopenhauer and Epicurus.

Boredom, psychedelics and mind-bending images

The bi-monthly Scientific American Mind seem to be making more of their feature articles freely available online after the first month has gone (and bravo to that!), and they’ve just opened-up two new articles: one on the psychology of boredom and the other on the use of psychedelic drugs to treat mental illness.

But before we start on the articles, have a look at the beautiful image on the right. Click for a larger version because the small size doesn’t do it justice.

It’s the image that accompanies the psychedelics article and it’s by Phil Wheeler, who, as it turns out, seems to specialise in wonderful psychological illustrations.

They’re psychological in both senses of the word, as some contain images associated with psychology, but also often contain hidden images, visual illusions and distortions.

His online gallery of images is really quite striking, and many of them meander between a sort of organic cyberpunk and a visual stream of consciousness.

The psychedelics article discusses the neuroscience and current research trials and looks at some of the main research compounds: LSD, ketamine, MDMA, and ibogaine, and, although it barely touches on psilocybin, is remarkably comprehensive for a feature article of its size.

The article on boredom does a really good job of investigating this under-appreciated mental state, and looks at research showing that having nothing to do is only part of being bored – personality factors, emotions and current interpretations all play a part.

It also makes a distinction between transient, situational boredom, and a more profound existential boredom stemming from a dissatisfaction with life.

A little ironically, it turns out there’s a surprising amount of fascinating research on boredom.

Link to Phil Wheeler’s beautiful illustrations.
Link to Phil Wheeler website with more images.
Link to SciAmMind article ‘Bored?’.
Link to SciAmMind article ‘Psychedelic Healing?’.

The year in sex and psychology

Psychologist Dr Petra Boyton has just completed her yearly review of the past year in sex, revisits last year’s predictions and looks forward to possible developments in 2008.

One of her predictions is that the media will become obsessed with ‘future sex’. Indeed, the recently published book Love and Sex with Robots got a huge amount of media coverage, including a review in The New York Times, despite being big on speculation and short on current evidence.

My own personal barometer of the progress of sex research is the balance of how many papers have been published on the neuroscience of orgasm compared to the neuroscience of hiccups.

At the time of writing, PubMed lists 99 papers on the neuroscience of hiccups, whereas only 71 are listed as discussing the neuroscience of orgasm.

Let’s hope 2008 does a better job of redressing the balance than 2007.

Link to Dr Petra’s review of 2007.
Link to review of last year’s sex predictions.
Link to predictions for 2008.

Would you vaccinate your child against cocaine?

Treatment Online has an interesting piece on the development of a cocaine vaccine. Unlike other drugs that reduce the pleasurable effect of addictive drugs, this is genuinely a vaccine – it persuades the immune system to attack cocaine molecules.

There are various drugs that are sometimes described conveniently, but inaccurately, as ‘vaccines’ for addictive substances.

For example, disufiram (aka Antabuse) creates a severe hangover 10 minutes after taking any alcoholic drink by inhibiting certain enzymes in the liver which break down alcohol. The idea is that it acts as an instant form of aversion therapy.

A drug called naltrexone blocks opioids in the brain which all pleasurable drugs trigger, either directly (in the case of heroin), or indirectly (in the case of alcohol). Naltrexone simply aims to reduce how ‘fun’ the drug is, leading to extinction of the link between the drug and the ‘high’.

However, neither of these are actually ‘vaccines‘ in the proper sense of the word.

Vaccines are substances that stimulate the immune system. The immune system identifies and adapts to the key features of the potentially dangerous invader, and works to destroy it.

Of course, this happens when foreign pathogens (like diseases) enter the body, but the immune system can be triggered by safe or less dangerous substances that share the ‘key features’ with the more dangerous disease. This safe or less dangerous substance is the vaccine.

Edward Jenner invented the procedure after working out that giving people a tiny amount of the non-lethal cowpox virus vaccinated them against the deadly smallpox virus. In fact, this is where the word ‘vaccinate’ comes from as ‘vacca’ means cow in Latin.

The developers of the new cocaine vaccine, known as ‘TA-CD’, are doing essentially the same thing by cleverly combining a deactivated cocaine molecule with a deactivated cholera toxin molecule.

The deactivated cholera toxin is enough to trigger the immune system, which finds and adapts to the new invader.

Because the cholera toxin and the cocaine molecule are combined, the immune system also adapts to the key features of cocaine, so works out how to seek and destroy cocaine molecules.

This means they never reach the brain in sufficient quantities to cause an effect.

A key advantage is that unlike other anti-addiction drugs, which have to be in the body to have their effect, the cocaine vaccine permanently changes the immune system to neutralise cocaine.

Of course, it may not be completely effective, or it may not work in all people, but that’s the aim.

The drug is about to studied with a Phase III clinical trial to see if it useful in treating cocaine addiction, after which, if it is shown to be safe and effective, it could be approved for widespread use.

Unlike the current concerns about the supposed ‘new ethical challenges’ of medical therapies being used by healthy people (which, as we’ve noted, are actually as old as drugs themselves), this therapy may present a relatively new ethical dilemma.

If effective, you can see that some parents might want to vaccinate their non-addicted, perfectly healthy children, so they are ‘immune’ to cocaine.

The difference here, is that once given, the ‘immunity’ may be permanent. In other words, you would make the decision that your child will never be able to experience the effects of cocaine for the rest of their life.

One interesting effect might be an ‘arms race’ between illicit drug producers and vaccine makers. As children become ‘vaccinated’ against the common drugs of abuse, the market for street drugs would fragment and diversify into drugs that don’t have vaccines yet.

A Brave New World indeed.

Link to Treatment Online on cocaine vaccine.
Link to PubMed papers on cocaine vaccine.
Link to Toronto Globe and Mail article on the vaccine.

Are repressed memories a product of culture?

Harvard Magazine has an interesting article on whether it is possible to repress memories to force them into the unconscious.

As well as discussing the phenomenon, it also updates us on the challenge put forward by the McLean Hospital Psychiatry Lab: find a single account of repressed memory, fictional or not, before the year 1800 and win $1000.

It turns out, the $1000 dollars has just been awarded, although the account only sneaked past the post – it was from 1786.

The point of the challenge was because the McLean lab suspect that repressed memories, also called ‘dissociative amnesia’, are a ‘culture bound syndrome‘ – in other words, they’re so heavily influenced by cultural ideas that they are not a universal feature of the human mind and brain.

If they are a universal human feature you’d expect them to be reported throughout history, but it turns out that there are no clear reports of anyone repressing a memory, either in historical writing or in fiction, until the late 1700s.

Their paper [pdf] on culture, dissociative amnesia and their challenge, was published just before they awarded the prize, so doesn’t include the winning account, but discusses the cultural influences on this controversial concept.

As well as being enormously good fun, their challenge is an interesting way of gathering date to inform a hot topic in psychology.

Link to Harvard Magazine article on repressed memory and culture.
pdf of paper ‘Is dissociative amnesia a culture-bound syndrome?’.
Link to McClean Psychiatry Lab challenge page with entries.

Changing minds

Online chin-scratching club Edge have asked their annual question. This year’s it’s “What have you changed your mind about?” and the respondents include a number of cognitive scientists or people thinking about mind and brain issues.

Actually, all of them are a good read (although spot the few who don’t seem to have changed their mind very much!).

We’ve listed the psychology and neuroscience-related answers below if you want to cut to the chase (and fixed a few broken links from the original website along the way).

Enjoy!

Continue reading “Changing minds”

Challenging the banality of evil

The British Psychological Society’s magazine The Psychologist has just been redesigned and relaunched and its cover article on the psychology of evil has been made freely available online.

The phrase the ‘banality of evil’ was coined by philosopher Hannah Arendt after witnessing the trial of high-ranking Nazi Adolf Eichmann who seemed, at least to Arendt, to be the most mundane of individuals whose evil acts were driven by the requirements of the state and orders from above.

A number of social psychologists, most notably Philip Zimbardo – famous for his prison experiment, have argued for a similar view of evil, suggesting that evil occurs when ordinary individuals are put into corrupt situations that encourage their conformity.

The cover article in The Psychologist re-examines key historical studies and new experimental evidence to challenge the “clear consensus amongst social psychologists, historians and philosophers that everyone succumbs to the power of the group and hence no one can resist evil once in its midst”.

For example, some Nazis who later claimed to be ‘just following orders’ often exceeded their orders in their brutality, while others deliberately avoided capricious violence, suggesting a significant amount of personal choice was involved.

Interestingly, this seems to apply equally to Eichmann and Arendt’s famous phrase may have been a result of her leaving the trial at a crucial point:

On the historical side, a number of new studies ‚Äì notably David Cesarani’s (2004) meticulous examination of Eichmann‚Äôs life and crimes ‚Äì have suggested that Arendt‚Äôs analysis was, at best, naive. Not least, this was because she only attended the start of his trial. In this, Eichmann worked hard to undermine the charge that he was a dangerous fanatic by presenting himself as an inoffensive pen-pusher. Arendt then left.

Had she stayed, though, she (and we) would have discovered a very different Eichmann: a man who identified strongly with anti-semitism and Nazi ideology; a man who did not simply follow orders but who pioneered creative new policies; a man who was well aware of what he was doing and was proud of his murderous ‘achievements’.

The article also looks at famous psychology studies, such as the Stanford Prison Experiment and Milgram’s conformity studies, and argues that the people who were supposedly most likely to be led into brutality were actually psychologically quite different from the others, suggesting that they were not just ‘average people’.

It’s a refreshingly provocative look at the widely accepted idea that group pressure is the key driving force in the birth of ‘evil’.

Link to article ‘Questioning the banality of evil’ (with link to PDF version).

Full Disclosure: I’m an unpaid associate editor of The Psychologist.

Sampling risk and judging personal danger

We live in a dangerous world and we’ve learnt to judge risk as a way of avoiding loss or injury. How we make this appraisal is crucial to our survival and an innovative study published in December’s Risk and Analysis investigated what influences risk perception in everyday life and has shown that our retrospective estimations of risk are quite different from how we judge them at the time.

Many studies on the psychology of risk ask people to look back on past situations or judge risk for hypothetical or lab-based situations.

The trouble is, imaginary or lab-based situations may not be a good match to real-life (after all, what’s really the danger?) and our perceptions when looking back might be influenced by the outcome – perhaps we judge things as less risky if they turned out OK in the end.

One way of trying to get a handle on how people feel during the flow of everyday life is to use a method call ‘experience sampling’.

This usually involves giving participants a pager, an electronic diary or just sending them texts to their mobile phone.

Participants are alerted at random times during the day by whatever method is chosen and they’re asked to rate how they feel there and then, or as soon as safely possible (I discussed how this has been applied to psychotic experiences in a BPSRD article in 2006).

In this study, participants were asked to rate their mood, what activity they were doing, what is the worst consequence that could occur, how severe that consequence could be, how likely it is to happen and what would the risk be to their well-being.

Generally, risks were perceived to be short term in nature and involved “loss of time or materials” related to work and “physical damage”.

Interestingly, everyone rated the severity of risk as about the same, but women were more likely to think that the worst consequence was likely to occur.

Furthermore, the better the mood of the participants (both male and female), the less risky they thought their activity was.

As an additional part of the study, participants were asked to look back and re-assess some of the situations they rated on the spot. These ratings tended to be much lower, showing that people tend to judge things to be more risky ‘in the heat of the moment’.

Both of these findings demonstrate the importance of emotion in risk judgements, suggesting that it forms another source of information, along with more calculated rational estimates.

In fact, this is one of the key ideas behind understanding anxiety disorders.

Anxiety acts as an emotional risk warning, but it can get massively ‘out of synch’ with our rational judgements, so even when we ‘know’ that (for example) the risk of air travel is smaller than the risk of driving a car, ‘in the heat of the moment’, the information from our emotions overrides this in our judgement of risk in the form of anxiety.

Of course, risk perception in itself is an important topic to understand, particularly as risk judgements are the basis of safety decisions in many professions.

Link to PubMed abstract of paper.
pdf of full-text of paper.

The philosophy of wine

Two views on wine appreciation. The first from the introduction of an academic book edited by Prof Barry Smith called Questions of Taste: The Philosophy of Wine, a volume that collects perspectives from philosophy and cognitive science on how we understand the qualities of wine:

Do we directly perceive the quality of a wine, or do we assess its quality on the basis of what we first perceive? Tasting seems to involve both perception and judgement. But does the perceptual experience of tasting – which relies on the sensations of touch, taste and smell – already involve a judgement of quality? Is such judgement a matter of understanding and assessment, and does require wine knowledge to arrive at a correct verdict?

Some philosophers would claim that one cannot assess a wine’s quality on the basis of perceptual experience alone and evaluation goes beyond what one finds in a description of its objective characteristics. According to these thinkers something else is required to arrive at an assessment of a wine’s merits. This may be the pleasure the taster derives from the wine, the valuing of certain characteristics, or the individual preferences of the taster. Is there room among such views for non-subjective judgements of wine quality?

And the alternative view, from The New York Times review of the same book:

The rhetoric and rituals of wine appreciation are sometimes said to be the alimentary equivalent of lipstick on a pig: they are meant to give an attractive sheen to the ugly business of getting drunk.

Link to book details (thanks Kat!).
Link to NYT review.

When a Rose Is Not Red

There’s an interesting article in January’s Journal of Cognitive Neuroscience about a brain injured patient who has a curious form of simultanagnosia – the inability to perceive more than one object at once.

In this case, he also seemed unable to report more than one attribute, like colour or name, at a time, while looking at the object.

Simultanagnosia: When a Rose Is Not Red.

J Cogn Neurosci. 2008, 20 (1), 36-48

Coslett HB, Lie G.

Information regarding object identity (“what”) and spatial location (“where/how to”) is largely segregated in visual processing. Under most circumstances, however, object identity and location are linked. We report data from a simultanagnosic patient (K.E.) with bilateral posterior parietal infarcts who was unable to “see” more than one object in an array despite relatively preserved object processing and normal preattentive processing. K.E. also demonstrated a finding that has not, to our knowledge, been reported: He was unable to report more than one attribute of a single object. For example, he was unable to name the color of the ink in which words were written despite naming the word correctly. Several experiments demonstrated, however, that perceptual attributes that he was unable to report influenced his performance. We suggest that binding of object identity and location is a limited-capacity operation that is essential for conscious awareness for which the posterior parietal lobe is crucial.

This is particularly interesting because it relates to a key question in understanding consciousness, known as the ‘binding problem‘.

The brain deals with different parts of perception (for example movement, colour, light-dark differences) in different parts of the brain, yet when we perceive an object, it all seems to be integrated into one conscious experience.

For example, our experience of an object’s colour and movement never seem to be ‘out of synch’. How this happens is the essence of the binding problem.

This case report is of someone whose brain injury seems to prevent ‘binding’.

Looking at what brain injured patients can no longer do and matching this with the damaged areas can give us a clue to how the brain works because “you don’t know what you’ve got ’till it’s gone”.

Strictly speaking, this is called the transparency assumption in cognitive neuropsychology but I call it the Joni Mitchell principle as the quote is a song lyric of hers (I got this from a student essay I once marked so thank you insightful mystery student!).

In this case, the patient suffered damage to both sides of the back of the parietal lobes because of a stroke (“bilateral posterior parietal infarcts”), suggesting the parietal lobes might be key in binding perceptual elements for consciousness.

Unfortunately, I can’t get to the full-text of the paper yet, so I’m not sure what insights the authors themselves have offered. Still, a fascinating case.

Link to PubMed abstract.

Finding Alzheimer’s

The New York Times has a fantastic article on the neuroscience of Alzheimer’s disease, as well as the human impact of the disorder on individuals and their families.

The article is accompanied by two video reports that weave together personal stories with some of the latest developments in understanding the disorder.

Alzheimer’s is a form of dementia, which is where the mind and brain break down quicker than would be expected through normal ageing.

Like many forms of dementia, the first symptoms (such as memory, attention, language or movement problems) appear after a significant amount of brain damage has already been done.

One of the key aims of dementia research is to identify this process while it is still ‘silent’ to understand how it forms and try and prevent it developing further.

Genetics are one focus, but they are known to be complex. Certain genes (most famously ‘ApoE’) are known to alter the risk of developing the Alzheimer’s in older people, but they’re only one part of the puzzle.

However, there is one form of Alzheimer’s that is inherited in an autosomal dominant pattern, meaning that if one of your parents has it, you’ve got a fifty percent change of getting it too.

It means that if you’ve inherited the gene or genes (autosomal dominance implies a single gene, but several are currently candidates), you’re almost definitely going to develop the disorder.

Interestingly, this autosomal dominant version of Alzheimer’s tends to happen much earlier in life, in the early 60s, 50s or in some cases, even the 40s.

A similar thing happens with other similarly inherited dementias, like CADASIL, where a single gene has been fairly confidently identified.

It’s both terrifying and amazing to think that a difference in a single gene, expressing a single different protein, can cause such as massive break down in brain function.

The article also looks at a new type of dye which allows abnormal clumps of amyloid protein, a brain change characteristic of Alzheimer’s, to be seen on a PET brain scan done on living people.

At the moment, Alzheimer’s can only be diagnosed with 100% accuracy after death, but this new technique could allow brain changes to be tracked in people before they develop any symptoms.

However, it’s become clear that you can have protein clumps without having the disease.

Researchers are increasingly talking about ‘cognitive reserve‘, a measure of ‘wear and tear’ or ‘fitness’ of the brain, with the idea that the disease happens where various factors tip the brain ‘over the threshold’ into physical decline.

The ‘threshold’ is thought to be set by a combination of genetics, physical health, cognitive ability, education and level of activity.

The New York Times article is a wonderful guide to the scientific debates behind the quest to understand the disorder, and the videos really bring home the effect of it.

Link to NYT article ‘Finding Alzheimer‚Äôs Before a Mind Fails’ with videos.

Sex, prodrugs and rock and roll

BBC News has a report on the increasingly popularity of gamma-Butyrolactone or GBL as a recreational drug. Actually, it’s not a drug in itself, but once ingested it is metabolised into GHB, a drug often sold under the name ‘Liquid Ecstasy’.

Actually, the effects are much more like alcohol than ecstasy (the street name is just a marketing ploy) and the similarities to alcohol can be seen in its structure and effect on the brain, as both affect GABA receptors.

The increasing popularity of GBL is particularly interesting, however, as GBL is legal, but the body transforms it into the illegal UK Class C substance GHB.

Compounds that are weak or inactive until the body transforms them into an active drug are called prodrugs, and this is the first situation that I can think of where a legal prodrug has been found for an illegal drug.

Probably the most commonly used illicit prodrug is heroin, which is metabolised into morphine in the body, but both are Class A drugs in the UK so there’s no legal benefit to having one rather than the other.

GHB is usually described as a ‘date rape drug’ despite the fact that it is barely used in ‘date rapes’, unlike alcohol, which is used in the vast majority of cases and is a much better candidate for the ‘date rape drug’ label.

GBL is closely related to 1,4-Butanediol, which is also a GHB prodrug. 1,4-B recently caused a scare because a toy called ‘Aqua Dots’ was made using the compound and had to be withdrawn after several infants swallowed the plastic pellets and became dangerously intoxicated.

Needless to say, the news inspired some to swallow the plastic pellets for fun and the experience was, inevitably, reported online.

GHB is a nervous system depressant, and like all depressants, a major danger is unconsciousness, coma, and collapse of breathing and circulation.

Consequently, there have been a number of reports of these cases being admitted to hospital emergency rooms.

The long-term toxicity of these substances aren’t really known, but as both GBL and 1,4-B are used as industrial solvents and cleaning fluids, it’s likely that they give the body a fairly rough time.

Link to BBC News on the rise of GBL use.

A War of Nerves

I’ve just started reading Ben Shephard’s stunning book A War of Nerves: Soldiers and Psychiatrists that tracks the history of military psychiatry through the 20th century.

Even if you’re not interested in the military per se, the wars of the last 100 years have been incredibly important in shaping our whole understanding of mental breakdown, mind-body concepts and clinical treatment.

For example, the effects of trauma stemming from World War I were so shockingly obvious and happened in such large numbers that the medical establishment could no longer deny the role of the mind in both the theories and practice of treating ‘nervous disorders’.

In effect, it made psychology not only acceptable, but necessary, to a previously sceptical medical establishment that were largely focused on an ‘organs and nerves’ view of human life.

One of the big concerns during World War I was ‘shell shock’, a confusing and eventually abandoned label that was typically used to describe any number of physical problems (such as paralysis, blindness, uncontrollable shaking) that arose from combat stress.

The original name came from early theories that suggested these symptoms arose from the effect of ‘shock waves’ on the nervous system.

However, it became clear that only a small percentage of cases actually resulted from actual brain injury (interestingly, a recent article in the American Journal of Psychiatry notes parallels between ‘shell shock’ and concerns over the effects of Improvised Explosive Devices or IEDs in Iraq).

It turns out, many of the symptoms were triggered or exacerbated by unbearable stress and were shaped by beliefs and expectations.

This was clearly demonstrated when a ‘gas shock’ syndrome emerged during World War I when gas attacks became more frequent.

Like ‘shell shock’, it arose from a combination of extreme stress and was shaped by expectation and fear (the descriptions of death by mustard gas are truly horrifying) even when no gas injury could be detected.

An eye witness recalled that: “When men trained to believe that a light sniff of gas meant death, and with nerves highly strung by being shelled for long periods and with the presence of not a few who really had been gassed, it is no wonder that a gas alarm went beyond all bounds. It was remarked as a joke that if someone yelled ‘gas’, everyone in France would put on a mask. Two or three alarms a night was common. Gas shock was as common as shell shock.”

The military managed (and still manage) these forms of combat stress reactions by rest (stress and fatigue play a great part) but also by managing expectations.

Soldiers are typically treated briefly and near the front line, with the expectation they’ll rejoin their unit. In effect, instilling the belief that the effects are unfortunate but transient. As a result, they usually are.

Shephard’s book is full of fascinating facts, quotes and insights on every page as he’s used some incredibly in-depth historical research to bring not only the scientific and medical issues alive, but also the culture and attitudes of the time.

He’s interwoven military records and scientific research with press commentary and personal letters to make the book really quite moving in places.

I’m sure I’ll be posting more gems as I read more.

Link to book details.
Link to abstract of ‘Shell shock and mild traumatic brain injury: a historical review.’