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.

MOOCs: Parallel Process To Health Care

 

This last week’s New Yorker got me thinking about MOOCs. This Massive Open Online Course, which sounds, like healthcare, a way in which technology, to huge benefits of many folks, is taking away the teacher/student relationship in the same way that advanced electronics is taking away the doctor/patient relationship. Clearly, I can see huge advantages. The internet opens up education to people throughout the world who would never have access to high quality professors. Similarly, more efficient medical systems will open healthcare to many people who could only see a physician in an emergency. Yet, I am also thinking of the cost of this change in delivery: be it healthcare or education. Many students learn by developing a personal relationship with his teacher. Similarly, many people are inspired to take care of themselves because of their relationship with their physician. Technology, in these two settings,  seems to pretend that the relationship is not a critical factor in personal growth. This is the problem I wrestle with. I suppose that these relationships are only going to be available to the privileged and in that way, the huge wealth gap in the world will persist. The issue will no longer be access to education or access to healthcare, but the issue will be access to individual mentors who can monitor and encourage progress. This latter relationship will be costly and prohibitive for most folks. That makes me sad.

 

The Aging Perspective

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.

My New Yorker Entry

 

“I said we need to know your weight, not to levitate.”

Moral Injury

 

Moral injury, a concept implying that one’s behavior goes against one’s morals, both individually and collectively. Behavior in one setting. like murder, is considered evil, but in the context of war, taking a life, is understood in a different way, and yet, it brings up the possibility of profound guilt, which, in my mind, is almost identical to moral injury. The idea that one can feel good about a behavior in the moment, but upon reflection, can have crippling regret, is the power of the human psyche to re-evaluate one’s actions with superego ideals, leading to despair, with the challenge of subsequent forgiveness. Suicides are high in our post Iraq and Afghanistan veterans, and so it is possible, but not proven, that this high rate of self-destruction, is due, at least in part, to a particular crisis in moral injury. Perhaps the behaviors of our returning soldiers, in retrospect, is too painful for words, too outside the concept of forgiveness. So, the question is whether the term “moral injury” furthers our understanding of these veterans, or whether it is redundant, given our established diagnosis of PTSD. I think “moral injury” focuses on guilt, whereas PTSD focuses on hyperarousal. Both are key components to the disabling psychological trauma which many of these veterans experience. “Moral injury” adds on to the multifaceted way in which those who have gone through an experience, so outside of mundane human activity, are left with a mind filled with confusion and anxiety. Understanding this suffering, perhaps by crystallizing a part of it under the term “moral injury” is one step further to helping those who suffer alone, join a community of empathic souls.

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…https://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.