Dementia Exits: Neurocognitive Disorder Enters

• Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. New separate criteria are now presented” for major or mild NCD due to various conditions.  Substance/medication-induced NCD and unspecified NCD are new diagnoses.  
• en.wikipedia.org/wiki/DSM–5‎

So, mental retardation is now intellectual disability and dementia is now a neurocognitive disorder. Old wine in new bottles. Mild Cognitive Impairment (MCI), has become mild NCD. Ditto. Why are we changing nomenclature? The cynic in me says, the ten years to produce DSM 5 had to yield change, whether it was good, bad or lateral. The more generous person in me says that it makes sense to broaden the notion that as one ages, one’s brain declines, sometimes at a slow rate, consistent with the aging process, and sometimes, tragically speaking, the brain has an accelerated decline, a phenomena we used to call dementia and now we call NCD. This accelerated decline has rumblings which perceptive patients and family members detect, and now we can label those rumblings as mild NCD. The theme of DSM 5 seems to be to create umbrellas and then deal with the details later. There is the autistic spectrum umbrella, the trauma and stressor related disorders umbrella, the obsessive compulsive umbrella and the neurocognitive decline  or disorder umbrella. It reminds me of cleaning up a messy room, the first step is to make piles. There is the pile you want to give away. There is the pile to keep and the pile you are not sure what to do with. Breaking things down into piles makes the process of change less overwhelming. As such, DSM 5 feels like a temporary clean-up of psychiatry, leading the way to a more sophisticated understanding of the brain, downstream. Now, I want to take issue with the word  neurocognitive. What is the difference between cognitive and neurocognitive? Is that not redundant? Sometimes cleaning up makes things messier.

Lost Years Stimulated By Turning 50

Tea, turned 50 in December, but she is still fixated on this number. “I finally figured it out,” she tells me with great enthusiasm. “Yes,” I say, nodding that she has built up suspense. “Well, as you know, my son died twenty years ago and for me, the world just stopped. I was in a grief period, of course I still am, but I was really in another world for so many years, that turning 50 does not seem real to me. Everyone looks at me with a sense of recognition about how hard it is to turn 50, but I know that I am experiencing something that they do not connect to. I feel the loss of so many years where all I could think about was my son. That distortion, if you will, made me lose the normal tracking of time, such that I cannot latch on to my age. Sure, I have the other issues of aging, both body and brain, but that is not what is getting to me.” Tea relates this to me, as if she has solved a challenging puzzle. She is enthusiastic and not sad about her disclosure. “You know, it makes me sad to hear you talk about your son and particularly sad to hear how you feel you have so many lost years because of it. I am a bit perplexed as to why you don’t sound sad as you talk about it. At the same time, I can understand that you had an itch, which was the mystery of the meaning of turning 50, and now you have scratched it.” I say, knowing that we have discussed on numerous occasions how talking about her son is sad for both of us, but that does not mean we should not talk about him. “Yes, I do feel like I scratched an itch. That nails it. Before, I just felt so uneasy about my age, but it did not make sense to me, because normally I am not sensitive in that way. Now, it makes sense to me, so I feel better.” Tea, has done self-analysis, in a way in which she is communicating to me that the tools from our work together have helped her dig into her mind and test out hypotheses, until she lands on a concept that feels satisfying to her. “It must be so hard to ‘lose’ so many years, and have the people in your world not appreciate your feelings. I mean, I can connect with what you are saying, but it still must feel lonely.” I say, highlighting an old discussion about how Tea feels so alone in her grief. “Maybe you lost many years, but now that you have turned 50, you will be starting to appreciate time in a different way.” I say, highlighting that maybe this self-discovery will yield a deeper presence for her. “I can only  hope,” Tea says, now looking sad, but appreciative of our discussion.

Indiana Jones: The Franchise

This blog is part of my series on the media.

Some stories live through the ages. Some characters become the center of a franchise. Indiana Jones, the fictional adventurer does both. Henry Walton “Indiana” Jones Jr. lacks a proper father figure because of his strained relationship with his father, Henry Senior. Because of Indiana’s strained relationship with his father Indiana spent much of his youth searching for the Holy Grail.

In his role as a college professor of archeology, Henry Jones Jr is scholarly and learned in a tweed suit, lecturing on ancient civilizations. At the opportunity to recover important artifacts, he transforms into “Indiana,” a near superhero image he has concocted for himself. Mr. Jones is a fallible character. He makes mistakes and he gets hurt. Steven Spielberg said that “Indiana Jones is not a perfect hero, and his imperfections, I think, make the audience feel that, with a little more exercise and a little more courage, they could be just like him.”

Alan Zients MD, wrote a paper entitled The Psychoanalytic Treatment of a Child with Deviational Development (1999) where he presents the treatment of a little boy he has named Peter. Peter was a nine year old boy who was very excited by “Indiana Jones and the Last Crusade.” At the same time, Peter’s father, having suffered the loss of his first child, dedicated himself to his work thereby having little face time with Peter. The search for the Holy Grail paralleled Peter’s search for his father. The hopeful obyssey in the Indiana Jones’ movies contributed to Peter’s hope in himself.

The Holy Grail is what I call the “if only,” meaning that so many people in pain come to the conclusion that if only one thing did or did not happen in their life, everything else would be better. A 55 year old man I saw last week, said if “only I did not get a diagnosis of prostate cancer” everything else would be fine. His prostate cancer was cured with surgery. His prognosis is excellent. He is likely to die from another problem. Yet, he believes that this one event in his life was pivotal. By his account, the diagnosis changed him from a happy person to a scared person.

The human brain tries to simplify a complicated life.  This effort at simplification leads to spurious conclusions. Yet, one often holds on to these summations as if they are facts. Psychologists call this a false attribution. Dr. Robert Stolorow called it an organizing principle. By that he means that people try to organize their lives around a center. For some, this center is religion. For others, it is a traumatic event in their lives. Peter’s organizing principle was around the wish that if he could just find the Holy Grail, his difficult life would transform into a contented life.

Many movies, comic books, graphic novels, cartoons and fiction allow us to escape to a world where an organizing principle is a superhero, an individual who can beat the odds. Peter had a difficult relationship with his father and he wanted to make that better. Indiana Jones gave him hope.

Indiana Jones became a franchise. George Lucas created the character in homage to the action heroes of the 1930s film serials. The character first appeared in the 1981 film Raiders of the Lost Ark, to be followed by Indiana Jones and the Temple of Doom in 1984, The Last Crusade in 1989, The Young Indiana Jones Chronicles from 1992 to 1996, and Kingdom of the Crystal Skull in 2008. Alongside the more widely known films and television programs, novels, comics, video games, and other media also feature the character.

Identification is a psychological process whereby the subject assimilates an aspect or attribute of the  other and is transformed, wholly or partially, after the model the other provides. Multiple identifications create personality. Superheroes, such as Indiana Jones provide an opportunity for identification and personal growth. If Peter can feel that he can be like Indiana Jones then Peter can feel hope in the face of a disappointing father who Peter feels does not protect him.  In this case, the media is a tool promoting development. If Indiana Jones can survive not having a proper father figure, so can Peter. The franchise works.

Have Yourself A Merry Little Curry

This blog is part of my series on the aging brain.

With aging, comes slowness, both physical and mental. Jeff Cummings MD, one of my thoughtful and inspiring professors at UCLA, suggests that there may be ways to slow the decline. Dr. Cummings works in the world of neurobehavior, the interface of brain and action. He has done high quality research which gives us some possible tools to change the curve of the aging brain.  Dr. Cummings is one of the authors in a study published in 2005 which says that there is a potential role for the curry spice curcumin (turmeric) in  the PREVENTION or TREATMENT of Alzheimer’s Disease.

Alzheimer’s disease is characterized by the buildup of amyloid protein “plaques” within the brain. His review of the literature states that in rat studies, curcumin not only reduces the amyloid, but also reduces the brain’s response to the amyloid.

Curcuma longa Linn is a plant, also known as turmeric, is a member of the Xingiberaceae or ginger family. It has yellow flowers and aromatic, somewhat fleshy rhizomes that, when dried, yield a bright yellow powder commonly used as a spice or coloring agent-sometimes both, as in certain yellow mustards. Turmeric  contains potent antioxidant chemicals whose action inhibits the oxidative degradation of foodstuffs. This plant is indigenous to South and Southeast Asia where it is grown for commercial use.

Southeast Asia is the fabled source of the spices that Marco Polo and those who followed him brought back to Europe to enliven the dull fare that had been eaten there for millennia. The wealthy people of Europe became enamored of spices, which were more highly prized than gold and jewels for as long as they remained rare. Eventually they flooded the market and were joyfully embraced by everyone. The spices also served the practical purpose to mask the odor and taste of rancid meat and they inhibited further spoilage. This was vital in light of the fact that this was the era before refrigeration.

Curry, the quintessential Asian spice, is a pungent seasoning prepared from cumin, coriander, turmeric and other spices native to that continent. The turmeric in curry has attracted the attention of scientists, in part because turmeric has a long history of medicinal use in India, particularly in the traditional medical philosophy known as Ayurvedic. Also, since turmeric can protect foodstuffs from oxidative degration, perhaps it can do the same for our bodies which are composed of former foodstuffs. It stands to reason that the oxidative chemical reaction that can protect a piece of beef from spoiling can also protect our tissues from spoiling. The chemical compounds in turmeric that are primarily responsible for its antioxidant action are curcumin and the related compounds called curcuminoids. The belong to a broad class of compounds called polyphenols.

A colleague of Dr. Cummings, Sally Frautschy at the Sepulveda VA  in Los Angeles fed rats curcumin. She reported that “curcurmin reduced the accumulation of beta-amyloid and the associated loss of proteins” in the synapses, or gaps, between individual brain cells. Rats fed curcumin performed better in memory-dependent maze tests. Curcurmin also appeared to reduce Alzheimer’s-related infammation in neurological tissues.

The daily dosage is not clear. Greg Cole PhD  of UCLA is involved with a pilot study of 2000 and 4000 mg of curcumin per day. The dose is high because curcumin is poorly soluble and poorly absorbed. It should be taken with a fatty meal. He suggests the people start at 500-1000 mg per day.

In summary, curcumin appears to be a natural neuroprotectant. Curcumin is a supplement and supplements are a crowded field full of hype and misinformation. However, with the aid of good research, including studies by Professor Cummings, help for the aging brain may be here. At the very least, it is something to think about. It is fun to think about thinking. Right now, I am focused on how to preserve it.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1702408/

http://www.ncbi.nlm.nih.gov/pubmed/15590663?dopt=Abstract