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PTSD – a speculation

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“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.

Written by asterix98

February 18, 2013 at 1:49 am

Critical thinking.Anyone?

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“ . . . intelligence . . . is in plentiful supply . . . the scarce commodity is systematic training in critical thinking.” –Carl Sagan (requoted from How to become a Critical Thinker)

Recently, when browsing the Health pages of Google News, I was intrigued by the following headline in the sidebar – Couple Addicted to Coffee Enemas, Up to Four Times a Day! If you know anything about enemas, well, the obvious is easily imagined. It turns out this couple are participants in a reality show – My Strange Addiction on TLC. And it is in its fourth season!! Fourth !?! What’s on tap for this season? I quote from the article “….In its premiere of the first of eight new episodes on Feb. 13 at 10 p.m. ET, the show will also highlight Lisa, a middle-aged woman from Detroit who eats cat fur, grooming her pet with her own tongue. In subsequent episodes, a woman is addicted to bee stings and another one inhales more than 30 jars of vapor rub every week. In the season finale, a woman is addicted to drinking blood….”  Really!  The good news here is that there is not much collateral damage as these strange behaviors are restricted to the individuals or their families.

Which brings me to another topic – Preppers! Anybody watch Doomsday Preppers, the reality show on National Geographic channel, no less! A NYTimes article described the show thus “…is more or less a weekly invitation to laugh at lunatics tunneling into mountainsides to escape a Russian nuclear attack. ” Of course, there was a significant segment of the population obsessing over the ill-fated Mayan end-of-the world prediction. Now it gets a bit worrisome because we are talking about larger groups of people who could potentially influence others in their network to think like them and create panic. The potential for collateral damage is higher!

Which leads me to L.Ron Hubbard. I urge you to listen to this interview – Going Clear – on the Fresh Air Program hosted by NPRs Terri Gross. It gives you some great insights into the mind of Hubbard, Scientology, and its practitioners. Essentially, Hubbard’s fight with his own demons gave rise to this cult with no real basis for broad applicability of its tenets to create social good.

Which points to two modern day abusers of their reach and power, one peddles physical health and wellness, Dr.Mehmet Oz, and another peddles, spiritual health, Dr. Deepak Chopra. You can read about Oz’s shenanigans in the New Yorker article – The Operator – Is the most trusted doctor in America doing more harm than good?. From the article, it will be obvious that Oz is a cardiac surgeon with stellar credentials but also a man who gets carried away by his own success and succumbs to peddling advice (taking on a messianic persona) that is clearly outside of his expertise. Hence, the subtitle question. Clearly, lot of folks tune in to watch his show which means he ought to be more responsible. I came across Chopra’s book, back in the early 90s and kind of bought into his holistic medicine philosophy of curing patients, because it made sense. I sampled some of his writings over the years and quickly determined he was losing it. He has truly become, as one blog calls him, appropriately I might add, the King of Woo Woo. He is #72 on the Top 100 American Loons – a place well deserved. He was on KQED’s Forum program recently talking about his new book – SuperBrain . As usual with his gift of gab and condescending voice, he doles out a bunch of nonsense (which compelled me to write this). What is even more surprising, he has convinced academics from Harvard, CalTech, and other prestigious institutions to co-author books with him. This guy utters pure drivel. But then he has a huge following (I have watched him hold audiences in rapture and wondered why they cannot see through his blasphemy).

Which brings me to the main point of this note, the central importance and need for critical thinking in our lives. P.T.Barnum said there is a sucker born every minute. If you don’t want to be one of them, embrace critical thinking with earnest. Just in case someone needs it, there is a lovely primer on Critical Thinking (targeted for high school and college kids).

Written by asterix98

February 11, 2013 at 9:29 am

Harry, Dumbledore and talking Gods

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About two thirds into the movie, Harry Potter and The Deathly Hallows – Part 2, Voldemart uses the killing curse on Harry. In the next segment, Harry awakens in a brightly lit King’s Cross station. A powerful dialogue ensues between Harry and Dumbledore, as Harry is confronted with the choice of returning to finish the work he had started or move on. In the exchange, Dumbledore offers him some words of wisdom thus ….” Words are our most inexhaustible source of magic ….capable of both, inflicting injury and remedying it…….Do not pity the dead..Pity the living….Above all pity those living without love…” Towards the end of this interchange, Harry asks the question “Professor, is this all real? Or is it just happening inside my head?” Before disappearing into the brilliant white light,  Dumbledore responds, ” Of course, it is happening inside your head, Harry. Why should that mean it is not real?”

Harry’s questions highlight something interesting and unique about the human brain. The “real” part implies we perceive the external world through our senses. Perception here means we bring to bear some prior knowledge when interpreting the significance of the sensory input and translate it to an appropriate action (including do nothing). This is not the unique part. The “just happening inside my head” part is. We are probably the only life forms on the planet that can run “simulations” in the absence of sensory input from external stimuli. This extraordinary ability to simulate events (anticipate and plan a response) in our head confers enormous survival advantages – in my mind (no pun intended), a key ingredient that has led to our being at the apex of the food chain.  Neuroscientists would, generally, be very happy with Dumbledore’s response, but only with the first part because they do firmly believe mind is a product of physical processes. Harry’s questions then are trying to separate the real from the imagined. But the second part of Dumbledore’s response implies that they are really not distinct. Philosophers drool on this stuff and have orgies debating its ontological and epistemological aspects.

In the realm of the ordinary, real vs imagined is fairly well defined. Imagination is the engine of creativity and has benefitted society tremendously (from literature to technology). Wild imagination leads to fantasy , as in Indian films and Chinese martial art movies where the protagonists can violate all physical laws, including gravity, and perform astounding feats. Nevertheless,  it is still entertaining.  When the imagined becomes pathological, we label these excursions delusional, schizophrenic, paranoia and so on. These have an underlying neurological/psychological basis and are subject to treatment with therapy and medications .

In the realm of the Divine (notice I instinctively capitalized the D),  no such boundaries exist. Your beliefs can be fantastic defying any rational analysis, but they cannot be classified as symptomatic of something amiss. Let’s see how. Tanya Luhrmann, is an anthropologist at Stanford University. She was recently on the NPR program, Fresh Air. The topic was her book – When God Talks Back. She spent sometime with Evangelical Christians (Vineyard denomination) who believe in the notion of an intensely personal God. In fact, he talks back. To get a flavor of what the content of the interview was like, here are the opening remarks Luhrmann made

“.. I wanted to understand what people meant when they said that God spoke to them, that God had heard from them, and that they had heard what God wanted them to do. I was at – first became intrigued by this when I was doing a different project, and it was on religion and community, and I went over to the house of an evangelical woman. And she told me that if I wanted to understand, I should have a cup of coffee with God.

She had coffee with God all the time. She hung out with God. She chatted with God. She talked about God as if he were a person. And I was blown away. I was just so intrigued by what that meant and how she was able to do that.”

Please either listen to the interview or view the entire transcript by clicking on the links.

Here is another very interesting segment of the conversation..(reproduced verbatim from the transcript on NPR)

——————

GROSS: Will you talk about, in going to the services and in going to prayer groups at this Vineyard church, how you felt that people were training their minds to perceive God? And you attended prayer training classes. What are some of the things you learn to do in prayer training classes?

LUHRMANN: Prayer, in this context, is in an imagined conversation with God. That doesn’t mean that you’re treating God as imaginary. It means that you’re using your imagination to have a back-and-forth interaction with God. And what people are first invited to do is to experience what I would call a new theory of mind.

They learn to experience some of their thoughts as not being thoughts from them, but thoughts from God, as being external communications from God that they hear inside their mind.

The second thing they’re invited to do is to pretend that God is present. And I take that verb from C.S. Lewis. He has a chapter of “Mere Christianity” entitled “Let’s Pretend,” and his, you know, his perspective is let us pretend in order to experience as real. These folks were invited to put out a second cup of coffee for God while they prayed, to go for a walk with God, to go on a date with God, to snuggle with God, to imagine that they’re sitting on a bench in the park and God’s arm is around their shoulders, and they’re kind of talking about their respective days.

And so what’s happening is that people are using their imaginations to create this conversation, and they’re seeking to represent God the way that God is represented in church – you know, in this kind of church, unconditionally loving, always wise, always responsive, always there. And then they’re trying to experience that God as talking back to them and to experience what God says as being really real, and not the creation of their own imaginations.

GROSS: How were you supposed to tell the difference between God actually speaking to you and you using your imagination to manufacture a conversation with God?

LUHRMANN: Well, that was tough, and one of the things I was so impressed by was how thoughtful people were about the process. But basically, the church taught people what they would call a style of discernment. So what thoughts – you know, what thoughts are good candidates for God’s thoughts?

Well, they are thoughts that feel different in some way. They stand out. They seem more important. They’re different from what you were thinking about at the time. They are thoughts that are consonant with God’s character. They’re the kinds of things that God would say. They give you peace. You’re supposed to feel good when you recognize God’s voice.

And so, you know, what I was fascinated by was that as, you know, people would enter the church, they’d be – you know, I don’t know what people are talking about. God doesn’t talk to me. And then they would try praying in this interactive, free-form, imagination-rich kind of way.

And after, I don’t know, six months, they would start to say that they recognize God’s voice. Some people told me that they recognized God’s voice the way they recognize their mom’s voice on the phone.

GROSS: Because, I mean, so distinctly, like it had a different sound to it?

——————————-

Listening to this, would you say we could possibly continue this conversation in English? I hope you get my point about no boundaries existing in the realm of Gods. [I have to admit, I have nothing against the practitioners as long as there is no collateral damage from their beliefs].

Luhrmann found that the Vineyard practitioner’s needed about six months to “…start recognizing God’s voice.”  This is surprising. I thought God had a big booming voice like James Earl Jones, very distinct and instantly recognizable. So what gives? Actually, if we go back about fifty years, we may find an explanation.  Solomon Asch, a sociologist, demonstrated through experiments, that there is enormous pressure on individuals to conform. In Asch’s experiments, subjects could be manipulated into actually believing a line was longer or shorter than it actually was, through feedback from a peer group, even if their senses was providing contradictory information. Another example is Stanley Milgram’s famous role playing experiments, where the participants lost all sense of normal reality and made role playing their primary reality. The transformation of Vineyard initiates into recognizer’s of God voice must largely be due to this pressure to conform to beliefs and expectations of the VIneyard congregation. Clearly, the conversation with God is happening inside the head of the congregationers. It is imagined. In this case, conceding and answering Dumbledore’s rhetorical question in the affirmative, thankfully, has no serious societal consequences, at least for now.

(Disclaimer : Transcript contents belong to NPR/Fresh Air)

Written by asterix98

December 11, 2012 at 1:44 am

Elevatoring anyone?

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Almost all of us encounter traffic lights, not one but multiple times, during our daily commutes to work or the store. You may have also encountered, on an expressway, a series of traffic lights, that seem to be perfectly synchronized. Sometimes, it may feel like a shuttle bus where you hit red on every light.  When they do not interrupt your flow, you just cruise along else you cuss at them like they had an evil personality. Unless you are an engineering professional, you are unlikely to have stopped to think about how traffic lights actually work. In reality, traffic lights are a small part of an elaborate field of study called traffic engineering.  The video below offers a glimpse into that world.

If this piqued your interest, you can also read more about traffic light science here :  Science Daily- Traffic Lights.  For the formulation of traffic light design as a engineering logic problem, follow this link 

A few days ago, WSJ carried an article  – The Ups and Downs of Making Elevators Go– on elevators, something we may never have thought of as another mode of transportation. It profiles the life of Teresa Christy , an OTIS Fellow [OTIS is the famous elevator company and Fellow is usually the highest technical distinction in an organization].  She has spent the better part of a quarter century optimizing “elevator traffic and scheduling”. It is a great read (be sure to read the comments too, sometimes goofy but informative). The article also deals with cultural preferences in elevator design.  A short interview with Christy is also posted on NPRs marketplace.org site.

The fascinating interplay of science, technology, and culture, in something as  “mundane” as elevator design gave me my cognitive high for the day.

Written by asterix98

December 6, 2012 at 7:05 am

face recognition in the brain

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One of my heroes in the field of neuroscience is Wilder Penfield. He pioneered the use of electrical stimulation of the brain, prior to surgery for treating epilepsy. The goal was to identify brain functions in the areas surrounding the locus of epilepsy and spare as much tissue as possible, if critical functions had been identified. The most remarkable part of this exercise was that the patient was fully conscious (although under a local anesthetic) and could verbally report sensations and perceptions experienced by the electrical stimulation of the probes. This technique contributed enormously to deriving functional maps of the human brain.

Penfield’s legacy is alive and well.  A couple of days ago, ScienceNow website reported on a study published in the Journal of Neuroscience.  By using techniques similar to Penfield’s, scientists at Stanford Univ, were able to determine the precise locus of face recognition in humans. Huffington Post has also included a really remarkable video of the patient’s experience as he is being stimulated by electrical current.  You must watch it!

That our three pound universe is a constructed reality, is on ample display in the video. Soul theorists, go figure!

What lay people may not appreciate, in this story and the video, is that our ability to recognize faces is confined to a small piece of our cerebral cortex. Destroying this piece of brain tissue only knocks out face recognition. One can still recognize objects (in the video, the perception of the scientist’s suit and tie is not distorted.) In fact, back in graduate school, I had the privilege of meeting a person, who due to an accident in early childhood, lost the ability to recognize faces, even his own! His non-face object perception was intact. He used salient features like a mustache, glasses, or other unique feature to remember and identify people he met.

This study and the video gave me the cognitive high for the day.

Written by asterix98

October 25, 2012 at 6:24 am

lighter side of life

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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

Written by asterix98

October 14, 2012 at 4:04 pm

Posted in humor, life choice

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n of 1 medicine

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The history of modern medicine begins around late 18th century with Edward Jenner’s discovery of smallpox vaccine and Humphrey Davy’s discovery of nitrous oxide, whose anesthetic properties proved very useful for making surgeries painless. Since then medicine has made tremendous strides in eradicating major diseases like smallpox, polio, malaria, cholera, and tuberculosis, in most parts of the world. Indeed, the list is long and impressive. Because of these advances, mortality rates have gone down significantly across the globe with a concomitant increase in life expectancy.

Western or allopathic medicine,  as currently practiced, treats the average. This approach has been very effective in treating a wide range of conditions – from the common cold to heart attacks, provided the underlying medical condition or disease has a common physiological basis that is broadly applicable across the entire human population. But, over the years, the field of medicine has discovered there are numerous diseases that have a genetic basis – examples include cancer, diabetes, cardiovascular, and others such as Tay-Sachs disease, sickle cell anemia, which have an even more specific pedigree. These diseases have yet to be corralled and contained.  Recent advances in microbiology have spawned the -omics revolution: microbiomics, proteomics, genomics, metabolomics, to name a few. In an earlier post – the dawn of omics ,  I had tried to captured some of the excitement surrounding these emerging fields of study.

Numerous articles, on these topics, continue to be written in the popular press. Recently, microbes made the cover page of the Economist and the attendant articles can be found here- Microbes maketh the man ; Me,myself, us. The upshot is we have symbiotic partnerships with multiple strains of bacteria that make their home in different nook and crannies of the body.  Here are some specific examples (quoted from the article) on how these microbiomes help us “….The microbiome does many jobs in exchange for the raw materials and shelter its host provides. One is to feed people more than 10% of their daily calories. These are derived from plant carbohydrates that human enzymes are unable to break down. And not just plant carbohydrates. Mother’s milk contains carbohydrates called glycans which human enzymes cannot digest, but bacterial ones can….”

Disturbing this ecosystem results in a myriad of consequences. So,  “…these links are most visible when they go wrong. A disrupted microbiome has been associated with a lengthening list of problems: obesity and its opposite, malnutrition; diabetes (both type-1 and type-2); atherosclerosis and heart disease; multiple sclerosis; asthma and eczema; liver disease; numerous diseases of the intestines, including bowel cancer; and autism….” Probiotic foods then are supposedly targeted at restoring the balance…” If you missed it, yes, autism is on this list !!

The other branch of -omics that has gained a lot of currency in the media is genomics. The holy grail for these practitioners – $1000 genome (to sequence, that is). Matthew Herper of Forbes has put together a nice summary article( The Gene Machine) on the most recent developments in gene sequencing. One of the characters he mentions is Jonathan Rothberg, probably the reigning rockstar of this industry, for having invented among other things, the Personal Genome Machine (the article has more specifics). But the point here is gene sequencing has moved from the purview of giant labs to your desktop! Also, the turn around times for having a genome sequenced, for a panel of genes, have come down dramatically. Because of these advances, places like Baylor College of Medicine, MD Anderson and others are undertaking vigorous research efforts to understand and actively treat various cancers.

I was lucky enough to attend a few sessions over two days at the ION World 2012 conference where Rothberg and other luminaries gave keynote speeches. It was really exciting to hear these folks talk of the coming revolution in medicine. This is when I first heard the phrase “n of 1 medicine”.  N of 1 (or personalized medicine)  refers to the practice of medicine based on an individual’s “omic profile” as opposed to the traditional approach of medicine, which is based on the average profile (derived from large populations).

Clearly, we are witnessing medicine’s new frontier. For me, and I am sure for many others, the view from this frontier is breathtaking. Of course, there is a lot of hype surrounding all this. But discounting the hype, there is significant and steady progress being made through multidisciplinary collaborative efforts (cloud computing, bioinformatics, semiconductor technologies, and fundamental science). As of now, next generation sequencing (NGS) efforts are primarily focused on building the tools that allow us to ask the basic questions and get answers in the shortest possible time. Once past this, we will need to focus on translating the science into clinical practice. Because of its very nature, n of 1 medicine may require a throwback to the old fashioned pharmacies where your medication will be mixed in real time based on personalized omit profiling.

Opportunities, to participate in this revolution, abound.

Written by asterix98

September 30, 2012 at 2:49 am

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