PTSD – a speculation

“Are you abandoning me? Have you given up on me?”. These were the questions my wife was asking me in my dreams, a week or two, prior to my planned recent travel abroad. No, my wife and I were not engaged in a bitter marital discord or about to break up. Rather, as I have catalogued elsewhere on this blog, my wife endured and fought a very painful battle with cancer before finally succumbing to it. That was almost three years ago. This dream highlights something important about our minds. It draws attention to the fact that although I have never felt it overtly, there is a lingering feeling of guilt that I could and should have done a lot more for her.  Then, of course, there are always undercurrents of hopelessness, and thoughts contemplating the fleeting nature of our existence not to mention inexplicable feelings of sadness, the onset of which could be triggered by a piece of music or a story in the news.  In short, existential angst amplified by looking at life through the lens of a departed individual who is of deep emotional significance to you. Left unchecked, these thoughts and feelings could create a positive feedback loop leading to a full blown depression, and complete withdrawal from society. The checking comes from a grieving process involving intense rationalization or cognitive effort and a constant readjustment of our worldview (could be rational or irrational) to accommodate these life shocks. In fact, most people are able to regain their bearings, given adequate time (note: the recovery period is not the same for everybody).  [ Fortunately for me, this experience has translated into a passion :  to help transform the practice of medicine and delivery of healthcare through innovative use of technology. That is now my singular focus.]

The Wall Street Journal published an article – Last Marine Standing : A Life Tormented by Survival.  It chronicles the life of Marine Lance Cpl. Williams post-Iraq. It is a very poignant article. It has been seven years since 11 members of his team were blown up in a roadside bomb. Cpl.Williams remains tormented by guilt, hopelessness, and other debilitating symptoms that  make it difficult for him to lead a “normal” life. The article offers some clues on how the Army psychiatrists are approaching the treatment of these individuals, as in the following excerpt:

“….The VA’s Dr. Maguen hasn’t met Lance Cpl. Williams. But she says his symptoms are typical of these more-complicated cases “where there are many different elements of moral injury and loss acting together, making it challenging for [the patient] to recover.”

Researchers are just beginning to study the prevalence of these  types of psychological injury among combat veterans and seek treatments to supplement PTSD therapies. In small-scale studies, researchers have found that about 30% of Marines and soldiers seeking treatment reported that moral-injury experiences were the incidents that most haunted them on their return from war.

In a pilot program with the Marines, clinicians used “adaptive disclosure” therapy to treat traumatic loss and moral injury. Patients held mock conversations with dead friends and imagined aloud how their buddies would respond.

The Pentagon has agreed to fund a larger-scale trial among Marines, according to psychologist Brett Litz of the Boston VA, who along with Dr. Maguen is a pioneer in the field. Dr. Maguen, meanwhile, is recruiting candidates for a VA study of treatment for troops troubled by having taken the lives of others…..”

Pioneers they may be, but I don’t think techniques like “adaptive closure” go far enough. Neither do the standard assortment of available drugs in the psychiatrist’s toolkit. As an alternative, I want to propose a cognitive neuroscience framework that may help illuminate the underlying mechanism and motivate approaches to treatments that may prove more effective.

Ever heard of Theory of Mind (ToM). If you have not, don’t worry. From Wikipedia,

“Theory of mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires, and intentions that are different from one’s own…”

We tap into this ability for everything, from buying a gift for our beloved to anticipating the reactions of our bosses when asking for a raise. In short, we have the ability to running simulations of imagined events and predict behaviors of the other actors in the scene. Wearing my scientific hat, I have always wondered whether grief intensely engages the ToM system (because emotional centers are also included)  in our brains. More specifically, I view a large portion of grieving as involving simulations in the brain taking the departed person’s point of view or reliving moments of joint interactions and anticipating how they may have  reacted emotionally (happy, angry, etc.,). “Moving on” is then an disengagement from the simulation behavior (or, at a minimum, significant blunting of the emotional components) specific to the departed individual(s). Disengagement is a function of intense rationalization, which I alluded to earlier.

I believe this can be extended to, at least, certain flavors of PTSD experienced by the veterans returning from war. In these individuals, it is the exaggerated response of the ToM system. In some sense, the systems engaged in “theory of mind” have gone awry. In the link below, is a very interesting conversation with the commander of a bomb diffusion unit.

http://www.npr.org/2012/07/09/156454241/the-life-that-follows-disarming-ieds-in-iraq

He mentions that in crowded places like airports, he is constantly looking at “who he needs to kill” to get to an exit, an example of “theory of mind” misfiring.

My prediction is Transcranial Magnetic Simulation knockout of  selective parts of the ToM system (particularly regions involved in emotions) would help provide relief (at least temporarily) for such individuals or those trapped in the local minima of “overuse of simulations”. The neural correlates of the ToM system are being actively studied by experts in the field and I am pretty sure what I noted above can be mapped onto actual brain sites for targeted therapies.

One of the hallmarks of PTSD is “stress”. Robert Sapolsky wrote a book called “Why Zebras Don’t Have Ulcers?”. The simple answer is, their stress levels are highest only when the predator is in sight. When this happens, they literally run for their life. If they survive, they go back to grazing. No more thinking about who is going to attack me next or what other danger should I worry about now. Out of sight, out of mind. But we on the other hand, have the brilliant twin abilities : running simulations and making predictions. One massive side-effect : grief and its really ugly cousin PTSD, witness Marine Lance Cpl. Williams.

lighter side of life

I heard of Tig Notaro, a couple of weeks ago, on KQED 88.1 FM.  She was diagnosed with breast cancer, in late July, this year. She, by now famously, went on stage (the next day) to perform a stand up routine at Largo in Los Angeles. It is really funny (and an amazing attitude to tragedy). Check out the excerpt here

Tig Notaro on this American Life

Also, I liked this cartoon that appeared in today’s San Jose Mercury News

The Word – On the Straight and the Narrow-Minded

The title is taken from a brilliant political satire segment called the “Word” from the 07/17 episode of the Colbert Report. Watch the first eight or so minutes. Enjoy!

The Colbert Report
Get More: Colbert Report Full Episodes,Political Humor & Satire Blog,Video Archive

On a lighter note

Religion or atleast its purveyors have thrived on logic like this!

Is this a promotion for a Stephen King novel??

Just in time for the Olympics

Men are from Mars, Women from Venus

Favoritism

It’s all about perpsective!

Natural Instincts!!

Disclaimer: All of these images are copyright their respective owners.

an inspiring and entertaining talk

A couple of nights ago I had the opportunity to listen to Dr.Michael Phelps from UCLA. He is the inventor of an imaging technique popularly known as PET (Positron Emission Tomography). Since its invention, it has been used 37 million times worldwide to help  detect tumors in vivo!

His early years were steeped in tragedy. He lost his two young siblings in a fire. His mother had 50% burns on her body. Due to the circumstances, he was given up for adoption to a neighbor. He was a boxer and a welterweight champion, till a coma suffered in a car accident put paid to his dreams of a boxing career. A friend coaxed him into attending college (“with the promise of women, sex, and booze….”).  Eventually, he obtained a PhD in Chemistry and started out a as faculty somewhere in Washington State. From here, he went on to describe the journey that lead to the invention (a key ingredient was passion …. with a little help from friends along the way). All this culminated in tremendous monetary success (he sold his company to Siemens for, I think, a couple of billion dollars).

He is a great speaker, peppering his talk with lots of well placed humor . He was speaking to an audience of wannabe entrepreneurs as well as seasoned entrepreneurs. His messaging was near perfect. In the space of 45 minutes, he told a beautiful story of tragedy, resilience, serendipity, entrepreneurship, innovation, success, humor, goodwill, passion, and friendships. This is a talk that will stay with me for a long time.

He ended the talk with this joke (not original) – I have reproduced it from this site

This Middle aged man was going through his mid-life crisis so he went out and bought him a new bright red Porsche. So he decided to take his new Porsche on a test drive down the interstate one day.He got up to about 85 mph and all of a sudden he saw this highway patrolman with his blue lights and siren blaring coming toward him. He decided he and his new Porsche would outrun the officer. So the man sped up to 95 mph,and then to 105 mph, but the patrolman was still coming.The man finally came to his senses and said to himself, “This is crazy, I could go to jail for this,” so he pulled over. The patrolman came to the car and told the man, “It has been a long week , it’s Friday and I am ready to go home.. If you can give me one excuse that I have never heard before , I will let you go.” So the man told the officer, “Last night my wife ran off with a cop and when I seen you chasing me I thought you were trying to bring her back.” The officer looked at the man and said, “Have a great weekend pal !”

wireless, street smarts, and strategy

I retrieved the above image from the web. Image copyright of the originator.

Downloaded this from the New Yorker (Feb 6th). Street smarts but no book smarts?

Also from the New Yorker (Feb 6th). I would love to use this to introduce the concept of strategy in business!

More on taxing the rich – Scott Adams

This weekend there was another brilliant piece in the WSJ by Scott Adams – Driving the Rich into the Sea .

Here are some excerpts

“….This was a pivotal moment in life’s long march from amorphous sea snot into the highest form of mammalian beings—hedge-fund managers. ”

“….It will start innocently with a modest tax increase on the rich, the same way you might pluck a chicken to give it fair warning before you barbecue it. The final phase will involve a tax rate on the top 1% of earners that is so high it can’t be described without the Viking word for pillage.”

Social commentary combined with humor at its best.

In lighter vein…..

I heard this one while at lunch today

“The leading cause of Death is LIFE !!”

Brilliantly beautiful isn’t it? When I heard this, the experience was similar to popping a lump of horseradish into one’s mouth.

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On someone’s office wall

“Even the calendar says Monday and Tuesday are followed by WTF!!”

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