Dorsolateral Prefrontal Cortex (DLPFC): Heart Of Life’s Success

According to Wikipedia…..

“DL-PFC serves as the highest cortical area responsible for motor planning, organization, and regulation. It plays an important role in the integration of sensory and mnemonic information and the regulation of intellectual function and action. It is also involved in working memory. However, DL-PFC is not exclusively responsible for the executive functions. All complex mental activity requires the additional cortical and subcortical circuits with which the DL-PFC is connected.^[2][3]

Damage to the DL-PFC can result in the dysexecutive syndrome,^[4] which leads to problems with affect, social judgement, executive memory, abstract thinking and intentionality.^[5]“

Academic Child Psychiatry, and Laura Tully PhD, in particular,  is trying to understand how social skills work on a neuroanatomical level, and in light of that, all roads point to the importance of a well-functioning dorsolateral prefrontal cortex (DLPFC). When this part of the brain works well, people can plan, anticipate, organize, empathize and thereby make good judgments, socially and otherwise. These findings deepen my appreciation for genetics, and how much of behavior, and positive outcomes, are based on DNA. Unempathic parents can disorganize a good brain, a good child, but empathic parents cannot replace a defective DLPFC. In other words, I think of the nature/nurture argument, as often supported by Steven Pinker PhD at Harvard, that growth is pre-determined, but malnutrition can change the outcome. A good diet cannot make someone taller, but a bad diet can make them shorter. So too with behavior. Good parenting does not always create “good” kids, but “bad” parenting can hurt “good” kids. The basic ingredient, a good DLPFC, is essential for life success. It is almost impossible to compensate for a defect in the DLPFC, as seen by people with head trauma resulting in damage to this area. Understanding the need for good brain functioning, helps parents of children with mental handicaps understand their limitations, as parents. Likewise, parents of children who do have good  brain functioning, need to understand that  their main job is “not to screw it up,” as I like to say. Nature and nurture go together, but understanding how this dynamic plays out, is essential to promoting the best development possible.

A Psychoanalytic Rant

1993-2001 were the years that I did psychoanalytic training at an institution then called Los Angeles Psychoanalytic Institute (LAPSI), and now called the New Center for Psychoanalysis (NCP). This training involved 200 hours of supervision to discuss 800 hours of patient care activities. Plus, I had four hours of seminars a week for four years, that came along with four hours of reading each week, to prepare. At the end, I had to pass an oral examination, write-up four cases, and go before a committee to qualify for graduation. This work, done in the midst of  my development of a psychiatric practice, was a questionable activity, according to those who followed me through my path. “Would it earn me more money?” Some folks would ask. “Nope” I replied proudly. This education was not intended to pad my income. Clearly it was a financial sacrifice, given the many hours of dedicated time to understanding psychoanalytic thought. Given the paradox of this educational activity, I was rather closed-mouth about it. Psychoanalysis, at the time, was thought to be “going out of business”. I understood that, but I maintained the conviction that deep understanding of the human mind is valuable to any kind of interpersonal activity, be if professional or personal. Over a decade after graduating, I am immensely proud of this accomplishment, and deeply connected to my work. I now teach at psychoanalytic institutes with the notion that the torch carries on, despite insurance pressures to the contrary.

My current rant centers around the notion that this eight year journey of mine is not always clear to those in educational institutions. More specifically, when volunteer teachers are sought, there is no targeted search for those with psychoanalytic training. This catches me by surprise, because although one could argue that the business of psychoanalysis might be fading, the need to teach in-depth psychotherapy skills is still a valuable entity. As such, the more depth one has as a clinician, the better the teaching could be. As a psychiatry resident in the 1980s, I made sure that all of my teachers/mentors were psychoanalytically trained, because this background enhanced their ability to articulate the ideas of the human mind. Without this training, I experienced teachers who, although bright, were often at a loss as to how to explain human motivation. One needs to cite  the literature, a skill developed over years of instruction, not given in psychiatry residencies that do not have a psychoanalytic bent.

The internet, however, gives me some hope.   This post, along with others, allows people from all over the world to chime in about their psychoanalytic journey, thereby reassuring all of us, that psychoanalysis is alive, making the need to teach deep thinking, alive as well. Perhaps this teaching will not go on at universities, but rather in free-standing institutions of psychoanalytic thought. This thought, likely to be true, gives me pause. Without the backing of a university, psychoanalytic thought will lose its intellectual rigor. A university needs to ponder the many ways of thinking about human behavior. Likewise, psychoanalysis needs the university to fertilize the thoughts that are in parallel with our explosion in understanding the mapping of the human brain. This divorce of in-depth psychology from universities is the basis of this rant. Some might say that the humanities keeps psychoanalytic thought alive, as many people who study literature and anthropology are concerned with human motivation. Although that may be true, it is still sad to me that psychoanalytic thought is being divorced from neuroscience. These two disciplines can learn from one another.

Am I Bad And/Or Did I Have Bad Parents?

 

“Outer security is thus purchased at the price of inner security,” so says Ronald Fairbairn about a child who protects his parents, defends them, at the expense of his self-esteem and intuition. In other words, when one senses that one’s parents are malicious, then one can protect them, and discard one’s sense of right and wrong, outer security, and thereby dismissing one’s internal sense of ethics, inner security. “It is better to be a sinner in a world ruled by G-d, than to live in a world ruled by the Devil,” Fairbairn continues. To be in a world ruled by the devil, “he can have no sense of security and no hope of redemption,” he elaborates. Fairbairn is famous for his example of the boy faced with poisonous chocolate pudding, as a symbol of difficult parents. He can either eat the poison and die, or starve and die. Inevitably, the boy will eat the poison, as this wins over starvation. This example is meant to illustrate how paranoid thinking can come into existence, if one grows up needing to trust people, who ultimately betray them. In essence, unwinding  from bad parenting is a long journey of self-reflection, requiring a separation from parental figures which is both agonizing and destabilizing.

 

 

 

 

See also…http://shirahvollmermd.wordpress.com/2012/08/06/relationships-heal-fairbairn-comes-alive/

Why Psychotherapy?

http://www.apsa.org/

Check out the animated video on the home page of APSA (link above), which I think is a great explanation of why psychotherapy is so important to build quality of life, in ways that medication management is severely limited. With the movement of psychiatry away from psychotherapy, we are limiting ourselves to a limited treatment, and hence we are leaving to non-MDs the treatment of very complicated mental states with means other than medication. I hope, with some technical assistance to be able to embed that video into my post, but for now, this will be a two step process. I think Dr. Norman Kohn did an excellent job illustrating why the narrative is critical to healing. In the second video, the one that I could embed in my post, there is a tutorial on Freud’s model of the mind. The illustration that we have behaviors which we are ashamed of, or not proud of, or that make us feel guilt, helps us to understand that guilt is the point of inquiry into the recesses of our minds. Understanding this guilt, in addition to minimizing the anxiety which arouses around the guilt, is key to promoting mature and sophisticated human beings. Psychopharmacology, although useful, does not take away guilt and it is this guilt, which is often the key to understanding inconsistent, or neurotic, behavior. More than any other reason, promoting this cause, psychiatrists doing psychotherapy along with psychopharmacology, is a major motivation for this blog. For reasons that seem to be unconscious, at the moment, I felt like I  just had to write this today.

Hedda Bolgar PhD: A Life Well Lived!

Hedda Bolgar 1909-2013 (via http://psychoanalyticpost.com)

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My colleague, Hedda Bolgar PhD, practicing psychoanalyst for 80 years, passed away yesterday at age 103. Her mind was vibrant. Her compassion was enormous. Her vision for the future was spot on. She taught, she saw patients, she started a free-standing psychology graduate school and a psychoanalytic institute. Los Angeles Institute for Psychoanalytic Studies (LAISPS), an institute that I am on faculty, came to life because Hedda recognized that psychologists, social workers and MFTs, needed a place to explore psychoanalysis. This was at a time when the American Psychoanalytic did not admit non-MDs (other than academics) into their training programs. LAISPS carries Hedda’s tradition of understanding that although the world is changing rapidly, what does not change is an individual’s need to share their stories, to be listened to, to be understood. No medication, no neuromodulation device, no psychosurgery, will ever change this. She was a wise woman because she realized man’s evil, as she lived through and protested against the Nazis, yet at the same time, she loved life and she loved people. Her home was a constant place for get-togethers to share stories, do book signings, and plan conferences. She was warm, intelligent and caring. She often voiced how she understood that working into her sunset years meant that she would inevitably abandon those who depended on her. She was open and honest about her impending departure from this material world. Her strength of character came through with this brutal honesty and integrity. She was both ambitious and nurturing, a combination that is rarely seen. She wanted to make a mark on the world, while at the same time, helping her colleagues and her patients strive to be the best that they could envision for themselves. She was a visionary, both for herself, and for psychoanalysis, but for those who came in her path. I was fortunate to be in her path, although in a small way, allowing me to feel her goodness, her reliability and her strength. Her loss is huge, but so is her legacy.

See also….http://www.latimes.com/news/obituaries/la-me-hedda-bolgar-20130519,0,2504238.story

Psychiatrists Don’t Care About DSM 5?

 

http://www.nytimes.com/2013/05/12/opinion/sunday/why-the-fuss-over-the-dsm-5.html?emc=eta1

 

Sally Satel MD, writes her opinion about the upcoming release of DSM 5. Apparently former President Bill Clinton will announce the release this coming weekend in San Francisco. The book has been fourteen years in the making, and with all due respect to Dr. Satel, I think psychiatrists care a lot about this new publication, attempting to pronounce who has a mental illness. I am not sure how one can care about the mentally ill and not care about the labels which shape patient’s identity. As one of my commenters said recently, in response to my post about distinguishing ADHD from Asperger’s Disorder (now called Autism Spectrum Disorder), she did not understand herself because she was told that she had issues which made no sense to her. This confusion, brought on by clinicians, not meticulous about diagnostic classification, causes harm to patients and their families. DSM 5 is likely to cause more patients to believe they have a mental illness, when, in fact, they are struggling with issues of powerful family dynamics, causing symptoms which potentially disable them. This uptick of diagnosis brings more business to psychiatric facilities, mental health practitioners and disability offices, but it also changes the patient’s understanding of what ails them. Likewise, the promise of quick treatment, can lead patients to feel very discouraged that they are not obtaining symptom relief. It would be as if yoga promised patients flexibility, instead of promising them the journey towards deep breathing. The depth of the problem is often not captured in our diagnostic manual, and as such, patients with means, are left to seek treatment from practitioners willing to take the time and the thoughtfulness to tolerate the messiness and uncertainty of exploring an interior landscape which is varied and constantly changing. DSM 5, like DSM IV, encourages a hastiness which is destructive to training new psychiatrists, and hence destructive to patients understanding the complexity of their experience. Dr. Satel is wrong, in my opinion, that DSM 5 is a non-event to clinicians. DSM 5 dashes our hopes for a field which promotes depth and breath, rather than checklists which look at static experiences. DSM 5 is an outrage. That is the fuss.

Parenting Frustration: New Yorker Caption Contest

 

“I take futility to a new level.”

UCLA: Game Changer!

 

http://www.latimes.com/health/la-me-0510-usc-ucla-brain-research-20130510,0,6976660.story

 

Coping with change, particularly at UCLA, is an issue dear to my heart. UCLA changed my life, time and time again. College at UCLA was a straight shot. It was not tough to get in; not like today. I did not need high grades or SAT scores to enter this prestigious institution, yet I knew that UCLA opened doors for me, and for many of my high school friends, which would have been out of reach, had the tuition or the threshold for admission been elevated. Over the years, both of those dimensions have limited access, making me frightened for the lack of opportunity to those who do not bloom in high school and/or do not have the resources, or the vision, to sacrifice time for the value of education. Then, there was the UCLA medical school, now called the David Geffen School of Medicine. Again, the opportunity was enormous. The financial price was low, but the time demand were excessive. Now, it is the reverse. Then, there was the UCLA Psychiatry Residency, one of the best in the country. That has remained the same, although the definition of “best” has changed away from multimodal treatment, to a large tilt towards psychopharmacology and neuromodulation treatments. And then, the UCLA Child Psychiatry fellowship, presented another outstanding opportunity. Again, the reputation maintains, but like in adult psychiatry, the tilt leans strongly towards neurobiology, away from the value of the doctor/patient relationship. Now, with this news in the LA Times today, that two prominent UCLA neurobiology researchers are being poached to go to USC, there seems to be another sea change. Private universities are blooming with more money and more ease in administration. The loss to UCLA feels enormous, and yet, I know that the scope of UCLA’s neuroscience is so large, that even with  this major hit, UCLA remains a strong neuroscience powerhouse. Still, I can’t help but feel sad for the institution that trained me, and that , in turn, train others,  is changing, once again. Like the famous football rivalry, the strong team rises and falls, and so, I imagine, that will happen with research, as well.

The Suicide Question Continues

 

“A new report from the Centers for Disease Control and Prevention shows a nearly 30% increase in the suicide rate among adults 35 to 64, with the most significant increase in those 50 and older. Why the suicide rate is climbing in this age group is a question without a simple answer.”

 

http://www.cnn.com/2013/05/08/opinion/gebbia-suicide-rate/index.html?eref=mrss_igoogle_cnn

 

Stuck. That is how I feel when I ponder these statistics. What is this change about? I am not satisfied with the stress factors of unemployment, recession, or the floating ideas about access to prescription drugs, or the stress of growing up in the baby boom generation. None of these hypotheses hold together, since every generation has had major environmental stressors, and yet this statistic is a drastic change. Yes, in the United States, there is a tremendous favoritism to youth. Historical perspective is hardly valued. Yes, life can be painfully disappointing, with little vision about how to pivot to make things better. Yes, mental illness can lead to suicide, but none of these suggestions explain the drastic change. I am going to continue to post about this, as the explanation, it seems to me, will shed a large light, on the issues we face in our society.

 

 

Did Medicine Lose The Narrative?

Gene Beresin MD, Harvard Medical School faculty, wants to bring back the narrative to medical education. He made the point yesterday that coherent narratives help both patients understand themselves, and medical trainees understand their field. Narratives, he argued, creates attachment, and attachment creates security and comfort-crucial elements of a healing process. I am sorry, Dr. Beresin, as much as I fully support your mission, I am afraid that despite all of the advantages of electronic medical records, the major downside is the loss of the narrative. The stories are becoming much less important, replaced by symptom checklists and automated responses. I am not saying that medical care will get worse without the narrative, but I am saying that without the narrative, the practice of medicine changes its lure. Some folks,  like myself, are drawn to narratives. We love stories, be that in our patients, in books, in film or in theatre. The stories create a richness of life’s experiences which deepen one’s sense of oneself, as one begins to see a wider perspective of the world. So, maybe if I were coming of age today, I would be drawn to Eastern medicine, where the narrative still matters. Dr. Beresin, a man, I would guess, in his sixties, holds the old torch, making me nostalgic. He volunteered that he is also a musician, a man of the arts. That’s cool. Yet, despite his Ivy League credentials, I am afraid no mover or shaker in our health care system is going to listen. The value of the narrative is slipping away from the health sciences. It is too bad, but it is our future.