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 cingulate 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 amygdala 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?

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.

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.

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

Weighing the Risks and Benefits - Will My Life Be Better?


"You have to weigh the risks and benefits."  That is what the doctor says.  It's your body, your decision, your responsibility.

But how do you weigh them?  There is that list of side effects.  They sound pretty scary, but the doctor assures you they are usually manageable.  Then there is the potential benefit of feeling better.  Well, that would be the gold ring, now wouldn't it?  Being able to get back to your family, your job, your life?

It's not a hard sell.  Reach out your hand and the pharmaceutical company will place in it that most precious of all commodities, hope.

Perverse little smarty pants that I am, after my hopes had been dashed six times, I started to read.  For four years I read journal articles about clinical studies.  The basic format begins with a measurement of depressive symptoms, usually the Hamilton Rating Scale for Depression, HAMD, depressed mood, suicidal ideation, sleeplessness, loss of appetite, etc.  You get points for severity.  Unlike your junior high math exam, the higher the score, the worse off you are.  In fact, if you ace this test, they will administer electric shocks to your brain (yes, I know, you will be unconscious at the time and won't feel a thing) until you forget how bad you feel and get a lower score.

So there are two groups, as alike as possible, Group A averages a HAMD score of 21.6, Group B's average is 22.1.  That's the mid range for moderately depressed, and the typical test subject score.  They don't include you in medical trials if you keep getting a high score, because now it's the medication that is being tested, and they want an audience that is easier to please.  Group A gets the medication being tried, Group B gets the placebo.  After 8 weeks, Group A's HAMD score is 8.2, Group B's score is 10.9, both in the mildly depressed range, but the difference is "statistically significant."  [That would depend on how big the sample is, and I am not doing the math.]  More people in Group A than Group B reached remission, a HAMD score of 6 or less.  A certain number dropped out because of side effects, so they don't count.  And there we have it.  The medication improves depressive symptoms by a statistically significant amount and is well tolerated, and you should get yours today.

But you know what?  That study with all its statistics did not answer your question.  Will you feel better?  Will you get your life back?  It told you what the odds are that your depressive symptoms would be reduced.  But that is not the same thing.  Not at all.

For example,the truck driver who is sad, not sleeping well, has no appetite, worries a lot and feels guilty is given Zoloft by his family practitioner.  Now he's eating better and is learning to put past sins behind him.  But he is too dizzy to drive, gets in fights with his friends and can no longer satisfy his wife, or even himself in bed.  So he decides to quit his meds.  The doctor is focused on his HAMD score and is very concerned, convinces him to try another med, then another.  But each time he gets the same side effects, and meanwhile has lost his job.

The truck driver has weighed the risks and benefits, asking is my life better? No, it isn't.  Let's hope his doctor knows that Cognitive Behavioral Therapy is often as effective as antidepressants for mild and moderately depressed people.  Ditto aerobic exercise, which could help his lose those extra pounds, improve how he feels about himself, and change the nature of what happens when they turn out the lights.

It turns out there are lots of psychological tests.  Many try to do what the HAMD does, and their inventors think that their tests do it better -- measure depressive symptoms.  But there is also a test that asks the real question: Are the lives of the people who take this medication better?  The Sheehan Disability Scale is a three question test, answered by the patient.  On a scale of 1-10, how much have the symptoms disrupted your work/school, your social life, your family/home responsibilities this past week?  It's simple.  It's easy.  It's what the people who are taking the meds want to know, will my life be better.  The people doing the research are focused on symptoms, not on the patient's life.  So that is how I read journal articles for four years and had never heard of the Sheehan Disability Scale (SDS).

For some reason, the clinical trials for Abilify decided to ask the patient's question, using the SDS.  Actually, they used seven different tests.  When the journal articles came out, they reported only one, the Montgomery-Asberg Depression Rating Scale (MADRS), a substitute for HAMD.  My September 4 post, OMG!! That's What They Said! Significant, reported its not particularly impressive, but FDA passable,  "statistically significant reduction in depressive symptoms."  The other test results disappeared.

But somebody noticed, and called them on it.  That is when I learned that the SDS even existed.  Why would they go to all the trouble of doing seven different tests, and then publish the results of only one?  Turns out that while Abilify.com says that "Clinical studies of adults with depression showed that adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms compared to adults treated with an antidepressant alone," as far as the people who actually swallowed the stuff were concerned, it was a wash.  When you weigh symptoms and side effects, they reported that there was no improvement in their work/school life, a little improvement in family life.  But overall, it was a wash.

What was the author's response?  "Robert Berman from Bristol-Myers Squibb wrote... "this may be due to the lower sensitivity" of the measure."  I got that from "Abilify, Depression and the Memory Hole" at clinpsyc.blogspot.com.  Robert Berman, chief author of the research report, is not only an employee of Bristol-Myers Squibb, his compensation also includes stock options -- a little side note on how medical research is conducted in a for-profit health care system.

Okay, so the Sheehan Disability Scale is not sensitive enough to pick up what were pretty small decreases in depressive symptoms anyway.  That isn't its purpose.  What it will do is weigh your risks and benefits. Will Abilify improve my life, at work, at home, at play?  Nope.  Not if you are taking it for depression.  It won't.

What Prozac Monologues wants to know is what the Sheehan Disability Scale would tell me about Lamictal, the medication I have just added to my antidepressant instead of Abilify.  But as far as I know, nobody asked.

photo by Hans Anderson, This file is licensed under the Creative Commons Attribution ShareAlike 3.0

Taking a Break


Into the life of every over-medicated lab rat, a little downtime must fall.  Prozac Monologues is taking a bit of a break, with apologies to regular readers.  I hope to tinker with the sidebars to add some resources, while not being able to maintain my own writing standards.

Meanwhile, let me once more recommend Knowledge is Necessity for information about the Pharma/Medico/Therapeutic Industrial Complex, and occasional good clean fun. 

Photo credit: Copyleft Attitude http://artlibre.org/licence/lal/en/

To our Families

To that end, I am going to live with this disease the way Don lived with his. Openly -- I have a mental illness. Actively -- I will answer ignorance with education. Politically-- I will meet discrimination with change. And in community -- I will support and be supported by others who share this illness with me, so that we can survive it together.

I did get to say those words on Sunday night.  

This morning I made a list of all the things you would be reading about at prozacmonologues if only I were able to read more than three paragraphs at a time.  I am tempted to feel badly, especially for all my older readers, who come here expecting to find out about the relationship between nonsense and the anterior cingulate cortex, or Wyeth's research techniques in its effort to get Abilify approved for augmentation in the treatment of major depressive disorder, or "Akathisia: Stop it or Die," or my discourse on the concept of a failed suicide attempt. 

But down, damn ant! [automatic negative thought] You, dear reader, are not reading about all those things because sedation and supervision in lieu of hospitalization is working just fine.  ["Plan?  What's a plan?  Do I have to stand up?"] So I was able to speak my piece on Sunday night, the candlelight vigil that began Mental Illness Awareness Week.

Everybody thinks I am a wonderful speaker, and they told me so and the local paper quoted me, and that was very nice.  But somebody also needs to say that it was possible, not only because God was willing, but because my spouse has turned her life upside down to take care of me right now.  She is negotiating with her workplace, she is working from home, she is attending Family to Family meetings, she represents my interests, she fights my battles, she keeps my meds, she does the dishes, she walks the dog.  She is exhausted.  And she comes home from Family to Family meetings and tells me that there are other families, too.

Mental illness is a family disease.  And when I say that we survive it together, well, family is a very big word.  Some of us become family, because we choose to be.  I am so grateful for four friends who attended that sexuality talk that didn't turn out to be quite what we thought it would be, but instead has become the germ for the Loony Review, by the Not Ready for Discharge Players!  [A potential addition to next year's program?]  We are family because we choose to be, because to not choose to be wouldn't be insane, it would simply be stupid.

But some of us are family because that's how we started out, when we didn't know what it would cost.  The members who do not have the diagnosis, boy, do they still get to have the disease!  And pay the cost.

Some of us who have the diagnosis don't have the capacity or the wit to say it.  I do.  So today I will say what they would if they could.  Thank you.  We owe you our lives. We wish it didn't have to cost you so much.  Sometimes we lie to you, or are mean to you, or even desert you.  And you aren't always right.  And sometimes you DO make it worse.  But mostly we know that we owe you our lives.  Not all of us survive.  But those of us who do, we survive it together.  Thank you.





Thank you, Helen. 



photos in public domain 

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