Stress and HPA Axis

 

The stress response releases glucose to energize us to “fight or flight” from a perceived danger. Too much stress can shut down our systems and cause Chronic Fatigue Syndrome. Early stress can impair the HPA axis and cause us to feel charged up even though we cannot identify a trigger. These are the concepts that I want to convey to my students. The problem is that we know so little. There is a developing system which is programmed to help us cope with perceived danger, however, when this system is injured in early childhood, our sense of perceived danger and/or our reaction to it may be seriously impaired, resulting in either an unnecessary hypervigilence or an overwhelming sense of collapse. Perhaps medication can press the re-set button, but we are a long way from knowing that, except to say certain patients have that experience. The below cited New York Times article speaks to the complexity of this circuit. We know a little, allowing us to once again have more questions than answers.

 

 

 

 

https://en.wikipedia.org/wiki/Hypothalamic%E2%80%93pituitary%E2%80%93adrenal_axis

The Violent Brain

www.latimes.com/…/la-na-prisoner-brains-20130715,0,5130358.story‎

The anterior cingulate cortex(ACC)  fires, giving the person a feeling for what others experience, otherwise known as empathy. It stands to reason that those who have an ACC which fires with more intensity are going to have a greater sense for what others experience. So, the researchers from Kent Kiehl’s laboratory found that when scanning violent inmates, those with low ACC firing are more likely to be repeat offenders. As Michael Haederle reported in today’s LA Times…

 

“The trove of data they have gathered has revealed telltale abnormalities in the structure and functioning of psychopaths’ brains. On the whole, they have

less gray matter in the paralimbic system — believed to help regulate emotion — which may help account for their characteristic glibness, pathological lying,

lack of empathy and tendency to act impulsively.”

The nature/nurture argument returns. Empathy and impulsivity seem to be largely innate qualities, such that if we can measure brain activity in convicted criminals, we would get a better sense of a person’s predisposition towards further heinous crimes. Yes, this is not perfect, and so biological data can be used to convict criminals who should be given a second chance. However, this does not mean that further exploration about how brain activity predicts behavior should not be done. In other words, this report is an exciting development in understanding how brain function influences judgment.

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.

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.

Brain Stimulation: Literally Speaking

 

Deep Brain Stimulation (DBS), Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT), and Vagus Nerve Stimulation (VNS) are all FDA approved treatments for neuropsychiatric disorders, heralding the new modality of treatment for psychiatric diagnoses. Darin Dougherty MD from the Division of Neurotherapeutics at a Harvard-affiliated hospital, presented his studies, demonstrating that when subjects were given active treatment, versus sham treatments, there was a high placebo response. To date, he has not been able to show the effectiveness of Deep Brain Stimulation, but he believes, that is because he has not determined where to place the electrode in the brain. Nevertheless, whereas drug companies used to sponsor most of the psychiatric research, now there is a lot of research sponsored by those who make these machines, such as Medtronics. Procedure-based psychiatry is the frontier, with hope of targeting a more specific area of the brain, moving us forward from ECT in which the entire brain has to seize in order to achieve the desired results. If we could localize the emotional brain, we could tickle it, and make folks feel better, or so the hope goes, for our future. In this way, this is an exciting time to be a psychiatrist, with the hope that like our medical colleagues, we hope to be able to offer our patients both pharmaceuticals and medical procedures which “fix” the underlying problem. Do I think this will put psychotherapists out of business? On the one hand, I would welcome the immediate relief that these procedures promise. On the other hand, I cannot imagine a substitute for working through difficult life decisions in a way in which one approaches junctures with thought and deep appreciation for the gravity of the decision. As always, I imagine these procedures could enhance psychotherapy by giving folks who are paralyzed by life’s traumas a way to move forward in psychotherapy so that they can navigate their world in a deeply conscious way. My work dovetails the work of those like Dr. Dougherty and so I welcome his neurotherapeutic  innovations.

Neuroscience Comes Alive!

 

http://www.latimes.com/news/science/la-sci-transparent-brain-20130411,0,313957.story

Space Sharing: Herd Animals-Confirmed!

So, now we have technology which places an office in a pocket. The calendar, the phone, the email and the fax are all being filtered through a hand-held device. Now, I know I am late in the game, but I am coming to understand portability. I could be anywhere in the world and return phone calls, have a phone session, renew prescriptions and stay in touch with the day to day struggles in my local news. So, I think to myself, this brings a new-found freedom of not being tethered to an office. Duh, my readers are saying. Yes, I am slowly coming to understand that, but at the same time, I also understand that young creative types are searching out work spaces which they can share, and yet work independently. The water cooler returns. How do I understand the need for freedom, while there also seems to be a need to gather and work with the energy of other working folks. As with most things that I right about, this is another push/pull experience. There is both a need to break out of the mold and lie on a beach while getting work done, and at the same time, there seems to be a need to be around others, in order to work in parallel. I attribute the latter to the social nature of the human condition. We are the people we surround ourselves with. We compete, we strive, we grow, based on the bar that our friends set for themselves. We are comparative beings. We measure success against others whom we care about. Positive growth stems from surrounding yourself with others who are striving for what you want for yourself. Intuitively, those seeking out a shared work space know that. They will be more creative if they can find the right energy, the right environment, the right people to work alongside. New technology does not change human nature, although it might change some aspects of the human brain. The part of human nature that needs others for growth and development does not change with the smart phone. We are herd animals, after all.

Brain Plasticity

Schizophrenia is a problem with brain mapping, so says Sophia Vinogradov MD, a psychiatrist from UC San Francisco. As such, cognitive enhancing programs might, and she said might at least twenty times during this one hour Grand Rounds, improve the outcome of this dreaded disease. She reminded the audience, filled with psychiatrists, that it was only twenty years ago that we were all taught that the brain stopped changing somewhere around age fifteen. Now, we know that the brain changes throughout one’s lifetime, albeit at different rates of change as we age. Learning, she reminded us takes place with repetition. I think we all know that! More specifically, she taught us that the first time we learn a new skill, we are tentative, but with intensive repetition, that skill, like playing scales on a piano, becomes automatic. I think we all know that too. This automatic quality to a new skill is evidence that we have created a new “brain map”. As such, we can train our brain, if we apply intense repetition, to form new neural connections, and hence new skill sets. Little children, it seems to me, need less repetition to develop new brain maps, and hence their brains are more plastic. Aging, in other words, demands from us that we have to work harder to acquire new ways of thinking, but the good news, is that we can expand our brain, literally. Phew!

 

http://www.psychiatrygrandrounds.com/namedlectures/may.html

Genes and Politics: We Knew That

http://www.latimes.com/news/science/sciencenow/la-sci-sn-politics-genes-republicans-tampa-20120827,0,6578432.story

 

The nature/nurture argument never ends, but as we come upon a presidential election, there is support for the notion that our poltics are genetic. Interesting that the article mentions that children tend to think like their parents until they leave the nest. Of course, as with all nature/nurture arguments, most kids are biological children, so one would assume they share genes which make them think in similar ways. The most interesting part of the article is the following:

“‘Modern questions about immigration are similar to the primal need to recognize and deal with out-groups,’ they wrote. Attitudes about welfare reflect age-old questions about               sharing  resources, while views on foreign policy are the modern-day equivalent of concerns about protecting one’s tribe.”

Once again, aspects of personality, generosity versus frugality, for instance, are largely genetically determined. Does this mean we can’t get mad at our spouse for genetic differences? Hmmm…

White Matter, Matters

http://www.latimes.com/news/science/la-sci-orphan-brains-20120724,0,1723553.story

“What they found was striking: Brains of children who had remained in institutions had less white matter — the type of tissue that connects different regions of the brain — than orphans who were placed in foster care or children living with their own families.

Reductions in white matter have been found in numerous neurological and psychiatric conditions, including autism, schizophrenia and attention deficit hyperactivity disorder, or ADHD.”

Children need families. This is news, seriously. The LA Times reported today of a randomized studies in which orphans were either sent to foster care or institutions. Those sent to institutions had less white matter in their brains, thanks to imaging studies. Now, we finally have proof that nurture, the factor that I struggle with in some of my posts, is critical to the developing brain. Brains need stimulation. To paraphrase Winnicott,  a baby is nothing without a mother.  Now, we can say with more certainty that intimate connections help a baby develop security by helping the brain develop white matter. The more white matter that develops, the less likely the child will suffer from numerous mental disorders including childhood anxiety. The attachment theorists are having a good day. This study supports the notion that a primary attachment is critical for development. This small window of time, infancy, is key to having the brain grow properly. Now, does this mean that if one misses out on a good attachment, and hence has less white matter, that he/she is bound to have psychiatric disorders? Maybe. Is it harder to compensate for this deficiency as one ages? Always. Still, understanding is still critical to our personal enhancement and empowerment. We now know that as a society, we should try to strengthen families, and not provide alternative ways of raising children. We also know that given an inadequate early childhood experience, mental disorders are more likely, and hence there might be a role for medication to attempt to compensate, however slightly, for these deficits. As a Child Psychiatrist, I feel excited to have data to support what children need from the moment they leave the womb until they are able to enter school. Now, we can have a public relations campaign……White Matter, Matters! You heard it here first!