Friday, November 27, 2009

Thanksgiving and the Anterior Cingulate Cortex

Did anybody decompensate at your Thanksgiving Day feast, when there were no pearl onions in cream sauce, notwithstanding the fact that nobody has ever eaten a single pearl onion in cream sauce, since Great grandma Libby died forty-five years ago?

Was it you?

I think I figured it out.  Unfortunately, this flash of brilliance came to me yesterday morning, in my hypomanic surge that prepared me for my speed pie-making.  Not in time for you to prevent the scene by preparing said onions.

Somebody's anterior cingulate cortex blew a fuse.

Of course, I don't know for sure.  It is one more hypothesis that I would like to test in that Million Dollar fMRI machine that I am not getting for Christmas.  But here is the hypothesis:

The bad economy, the fear-mongering health care debate, the single-payer stillbirth, the war in Afghanistan, global warning -- your anterior cinculate cortex (ACC) is doing all that it can to calm your amygdala.  That is one of its jobs, partnered with the prefrontal cortex, to exercise executive function over your amygdala, which is convinced that you are about to die and is sending out messages to your adrenal gland, telling it non-stop to keep pumping out those glucocorticoids that are destroying your hippocampus, not to mention your heart.  The amgdala must be brought under control!  So your ACC has plenty of work to do already, and needs for you to help out by deep breathing.  And yoga.  And crystals.

But it also has another job, which is to detect abnormalities in patterns.  You know those games where you are supposed to find five details that differ in two nearly identical pictures?  That's a job for the ACC.  But what with global warming and all that other stuff (and we still don't have any snow in Iowa the day after Thanksgiving, so my amygdala keeps telling my ACC, "I do so need to worry"), when somebody's ACC detected a variation in the Thanksgiving feast day table, i.e., the missing pearl onions, that was just one thing too many.  And it blew a fuse, releasing the amygdala from its cage.  And this time, the amygdala did not send out the message to freeze.  It came out fighting.

So now you know.  Or would know, if somebody who does own an fMRI machine would construct the experiment.  Any takers?

Tuesday, November 24, 2009

Holiday Shopping for Your Favorite Loony

The Day after Thanksgiving, traditional start of the Christmas, Hanukkah and Kwanzaa shopping season is just around the corner.  You Hanukkah people better start cracking!  It is Prozac Monologue's attempt to be ever helpful to my dear readers. As my therapist says, " Virgo -- your destiny is service.  Get used to it." (I have a therapist who says stuff like that. The following is a holiday shopping list to guide normals who want to please their loony loved ones.

[Note: I am going to start using "loony" as a generic term, in place of "consumer of mental health services," and "normal" as the term for the "not-yet-diagnosed."  You are welcome to discuss that if you wish.]

Anyway, next week, I will turn it around to guide my loony readers into appropriate gift-giving behavior toward the normals in their lives. 

Crazy Meds can be your one stop shopping for "Straight Jacket T-shirts, when you're crazy enough to let your medication do the talking," with a range of messages for any diagnosis, medication or level of "in your face."  The lettering is made by arranging capsules, for that homemade, from the heart touch.  You can even order custom messages, but it costs more, because Jerod has to pull out his pill bottles.  If you are shopping for me, medium size, long-sleeved, and black, of course.  My favorite message: Bat Shit Crazy.

There are other gifts targeted to differential diagnoses, as well.

For the person in your life who talks back to his/her voices, but is trying to "pass" as normal, what could be more thoughtful than a blue tooth telephone?

Purse or pocket-sized hand sanitizer makes a nice stocking stuffer for your loved one with OCD -- Obsessive Compulsive Disorder.

Don't ask somebody in the "Whale Shit at the Bottom of the Ocean" stage of depression, "How can I help?"  Simply tell your friend that you are going to arrive at his/her house at whatever o'clock on whatever day to clean the house.  Your friend doesn't even need to get out of bed.  You can use the hospital method of rolling the body from side to side to change the sheets.  For the frosting on the cake, leave a pot of soup in the kitchen when you go.  For that matter, leave the cake.  Important tip: this gift may not be welcomed by somebody with OCD.

Art supplies make a nice gift for any diagnosis.  Those in the manic stage of bipolar might especially like spray paint.  Or glitter.  Again, your OC friends have certain limitations -- no clay, no fingerpaints.

Almost anybody with a mental illness could use a toy carpenter's work bench, that thing with the pegs you pound through to the other side with a hammer, and then turn over to pound through again to the original side.  The old fashioned wooden ones are charming, but if self-harm is currently an issue, they do make them in plastic nowadays.

Recently, when I was invited to a large dinner party, my very thoughtful hosts designated a safe room to which I could (and did) withdraw when things got overwhelming.

If your loony is spending the holidays in confinement, loose change for the telephone, Nicorette patches or gum, and real French Roast coffee brought in at visiting hours (and labeled "decaf") will bring a little cheer to the stay.

Deep tissue massage is a great reliever of depressive symptoms.  Some people use it weekly in lieu of medication.  Ask the potential recipient first whether massage or even a whole day at the spa would be welcome, or if it would just stir up issues.

A health club membership is nice, if your loony has expressed a desire for one, but likely to ignite a scene if you have been nagging about exercise.

I saved the big ticket items for last.  We loonies are always bemoaning that ours is an "invisible" disease.  There are no x-rays, no blood tests to prove our suffering.  But there does happen to be physical evidence, not for the diagnosis, but for the propensity for it.  People with schizophrenia have larger than normal ventricles, the spaces inside the brain containing spinal fluid.  People with depression or post traumatic stress disorder have small hippocampuses (hippocampi?)  Getting the proof will take a bit of effort.  A full MRI scan, pictures of the brain from dorsal, saggital and coronal perspectives, will run you $400-3000, depending on who orders it and who pays for it.  If that's you, don't expect a discount.  But if you can get your loony into the right research study, he/she may be able to get a slide or two of the relevant features printed -- truly a one of a kind gift.

And then there is that fMRI machine I am always wishing I had.  It prices out somewhere between $1,000,000 and $2,300,000, depending on the power, with an additional $500,000 to build the lab.  Oh well.

You know, morning talk shows, magazines, even Science Friday on NPR all have their suggestions for holiday giving.  but I do believe that this one is a first for the mentally interesting.  DVD and book selections will follow, as well as suggestions for the normals who do so much for us the rest of the year.
clip art from microsoft

Sunday, November 15, 2009

OMGThat'sWhatTheySaid! -- Language

The following post contains material that could be considered uppity, outlaw, provocative, offensive and paranoid. 

This month's OMGThat'sWhatTheySaid Award considers the nature of the vocabulary that we all use for mental illness, in particular, the language that norms the relationship between those who receive a diagnosis and those who make it.

Once upon a time, I wrote a senior thesis for Reed College on this topic.  I was a religion major, and it was 1975, when the Episcopal Church was considering the ordination of women.  My topic was what priests are called.  My thesis was that the language we use establishes the normative relationship between priest and parishioner.  I am discouraged thirty-four years later, that new, freshly graduated priests in Iowa still permit and even encourage little old ladies to call these twenty-somethings "Father."  Oh well.

In the mental health field, this kind of paternalism is out of favor, perhaps the influence of so many women in the field.  But the language has not escaped from reinforcing the power relationship, one up and one down.

I am taking a Peer to Peer (P2P) course, sponsored by NAMI, where we scratch the surface of this topic.  The course text notes that every stigmatized group that has resisted oppression has done so by claiming the language, deciding for themselves what they will be called.  Invariably, these claims are disputed, whether ladies/women, Negroes/blacks/African Americans, homosexuals/gay men and lesbians.  Sometimes the self-chosen word is turned into a form of ridicule.  Women became "women's libbers."  "Gay" is a high school put down.

Typically, those in power deny the power of their language, or do not take responsibility for it.  They cite ancient derivations and precedents, and accuse those uppity people of being over-sensitive, "It's just a word."  People with mental illness can expect no less, or even more.  Those who have power to diagnose us define us to a public that is nervous about us anyway.  They have power to mess with our medications, our disability payments, even our liberty.  For example, that sentence itself could be diagnosed as paranoia.  Has my depression progressed into psychotic features?  Consider, many who are involuntarily committed receive their sentence for something they said.

However, the mentally ill are everywhere, to appropriate another group's phrase.  We include among our ranks those who have been through the previous struggles.  For me, it was when my employer wanted to know how to phrase the announcement of my disability leave (originally called a "retirement") that I realized, I know the map.  So do a number of my peers.

So let's dive into it.  Doctor/patient -- See, that could be power neutral, but for the deep layers and long tradition of one up/one down behaviors and the language that supports the existing relationship.  Sticking with language, one gives doctor's orders; the other either complies or is called noncompliant.  When they do clinical trials of medications, they measure the rate of noncompliance.  Who came up with that?  Not the person with the diagnosis, who does not take the medication as directed if the reasons are not explained well enough, if the medication is not effective or is too expensive, or if the side effects are intolerable. For all the latter day talk of how doctor and patient are partners in this relationship, if the patient had the power to name his/her own experience, the word would not be noncompliant.  It would be dissatisfied.

Moving on to therapist/clientClient isn't so bad, and this one might stick around, if therapists were called by the parallel term, mental health consultants.  That would suggest that the client has certain expectations.  Imagine an intake interview in which the expectations of both parties were discussed.  The consultant has policies about cancellation of appointments and payment of co-pays.  Would it not be balanced, therapeutic even, for the client to name his/her expectations, for respect, for discussion of the diagnosis, for disclosure of what the consultant reports to the insurance company and the consultant's peer review or supervision, how confidentiality is handled in such settings, for the consultant's knowledge of side effects, so that problems with medication could be identified as such, and not misinterpreted?  How about a regular review of whether each other's expectations are being met? What expectations would you have?

Here is a big one for me: provider/consumer.  I suspect the intent of this couplet was to soften stigma and normalize the experience of therapy.  But it misses the mark.  No consumer invented the word.  It is the word that degrades the entire population.  We are a consumer society, defined by our usefulness to business.  It has become our duty to shop when terrorists threaten shopping malls, spend when business is hurting, and thereby relieve the anxieties of stock holders.  They say that the economy is improving when the owners of the economy are making money, not when there are fewer people who live in the streets or beg at street corners, not when all receive adequate health care that they can afford, not when each of us can make a meaningful contribution to the quality of life on the planet.

In the language of mental health providers, our health has become a commodity.  Mental health providers deliver mental health services, as mother and father birds drop food into the open mouths of their chicks, the consumers.

Well, there is no turning back the forces of the economy in health care until the whole system collapses.  Its voracious appetite consumes us all.  So how do we who have a mental illness claim power within the economic paradigm?  What language do we use?

This examination of language is a collaborative process which NAMI has begun, inviting peers to participate.  Already, NAMI reshapes the language, when it calls people who have schizophrenia, people who have major depression, people who have bipolar, people who have obsessive compulsive disorder, people who have been labeled with a borderline personality disorder, all of us peers.  Peers consult with one another, learn from and support one another, and come together to name and meet their own needs.  There is power in numbers, power in cohesion.  If we can recognize that there is more that unites us (our experience) than what divides us (our differential diagnoses), then together we can act.

And how to name the relationship with psychiatrists?  I propose that we are "customers."  We purchase the services and pay the salaries of psychiatrists/sales reps.  They get their commissions from the pharmaceutical companies.  Their commissions are not as big as they used to be, no Hawaiian vacations for those who prescribe/sell great quantities, unless they become the middle men, the doctors who sell the product to other doctors as speakers at conferences.  Although ethical issues have been raised about these practices, pharmaceutical companies still supply commissions in the form of research grants and pay for almost all of psychiatrists' continuing education.  Really.  We pay the salaries.  They pay the commissions.

Now let me make my own disclosure .  AstraZeneka, the producers of Seroquel, used to treat schizophrenia and bipolar, is the sponsor and funding source for Peer to Peer.  At each meeting we sign in, so that the program can report back to AstraZeneka.  If attendance falls below ten, then AstraZeneka pulls the funding.  I drive sixty miles each Thursday evening to attend this class in the next county, because NAMI hasn't gathered a full class size in my county.  Last week we did an exercise.  Each person who could state something positive about their medication finished this statement, "Without my medication, I would..."  The exercise had its desired effect, as I gave thanks for my medication.  So NAMI is part of the sales force as well.  And I receive these services gratis.

Back to psychiatrists -- If we are customers, then efforts at compliance become concerns about customer satisfaction.  Now the power balance begins to shift.

Do you have other words to suggest?  Feedback?

 Permission is granted to copy this document 
under the terms of the GNU Free Documentation License

Saturday, November 7, 2009

Nonsense and the Anterior Cingulate Cortex

John McNamany put the thought into my head, the New York Times tickled my fancy and a blog new to me gave me the illustration.

Finally, it's Anterior Cingulate Cortex Week!  This lovely portion of the brain is found in the limbic system, located just above the center, about where Iowa would be, if you flipped the image so that it faced right, as I did here.  Like a true Midwesterner, the ACC modulates emotional response.  A hard-working manager, the ACC handles motivation to solve problems and anticipation of tasks and rewards.  It also monitors for conflict, things that don't make sense.  The brain is unhappy when it cannot detect the pattern.  Confronted with anomaly, the ACC goes to work.

"Researchers have long known that people cling to personal biases when confronted with death... In a series of new papers, Dr. Travis Proulx of University of California Santa Barbara and Steven J. Heine, a professor of psychology at the University of British Columbia, argue that these findings are variations on the same process: maintaining meaning, or coherence. The brain evolved to predict, and it does so by identifying patterns.  When those patterns break down — as when a hiker stumbles across an easy chair sitting deep in the woods, as if dropped from the sky — the brain gropes for something, anything that makes sense. It may retreat to a familiar ritual, like checking equipment. But it may also turn its attention outward, the researchers argue, and notice, say, a pattern in animal tracks that was previously hidden. The urge to find a coherent pattern makes it more likely that the brain will find one." [Benedict Carey, New York Times, October 5, 2009]

To test whether confronting the absurd leads to pattern-searching behavior, they had twenty college students read Kafka, "The Country Doctor," a story that is urgent, vivid and nonsensical.  Does anybody who is not in college ever read Kafka?  Anyway, after reading the story, they were given a task, to study strings of letters that did not form words.  They were then shown a longer list, and asked to find the strings they had seen before.  The letters did have patterns, very subtle patterns.  And the students who had read Kafka did better at this task than another twenty who had not been exposed to the absurd, 30% better.  With a Kafka-stimulated ACC, they were primed to find the patterns.

I wonder if that explains the college student's propensity to read Kafka, in the first place.  Not to mention all those posters by Salvador Dali on dorm room walls.  The college student is at a crossroads, and has to puzzle through the animal tracks of his/her life, to discern the pattern, the call, the next direction.  These representations of the absurd stimulate the part of the brain needed at this developmental moment, just as caffeine stimulates the system before the exam.

I graduated from college at loose ends, with the Episcopal Church still discerning the patterns that would allow for the ordination of women.  That was a few years off, and I wasn't ready to commit to a vocation that might not be received.  But I didn't read Kafka.  Instead, I decided to read everything that Kurt Vonnegut had written up to that point, a modern day Kafka, Kafka-lite, if you will.  Today, as I am filling out disability applications, I am again at a crossroads, and again, instinctively, I am drawn to Vonnegut, whose body of work has grown since 1975.  Evidently I am stimulating my ACC and boosting my pattern/meaning/coherence finding abilities, priming myself to discern my next direction.

Oh boy, I found another fMRI experiment!  There is a study in the Journal of Pain (what a title!) that discovered, when people were prompted by pain-related words to remember painful autobiographical episodes, the fMRI machines showed that it was -- you guessed it?! -- the anterior cingulate cortex that lit up.

"This person loved me; this same person abused me" -- two memories in conflict.  Put them together, they cause pain. They call it dialectical thinking if you can hold two seemingly contradictory ideas in the same head at the same time.  But dialectical thinking is a highly developed skill.  Before anybody ever suggested to me that I could employ it to reduce my pain, I spent (and still do spend) enormous amounts of energy trying to make sense of events that were absurd.

Some of us had Kafka-esque childhoods.  I wonder, does the ACC becomes quiet if we engage in dialectical thinking?  I wonder. Does it can blow a fuse, if we don't?

If you are searching for Christmas gift ideas for the Prozac Monologues blogger, an fMRI machine would certainly be well received. 
image of brain from NIMH 
artwork found at Glocal Christianity