AN RANCISCO EDICINE S F M VOL.82 NO.6 July/August 2009 $5.00
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Neuroscience and Perception
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In This Issue
SAN FRANCISCO MEDICINE July/August 2009 Volume 82, Number 6 Neuroscience and Perception
FEATURE ARTICLES
MONTHLY COLUMNS
10 The Brain that Changes Itself Norman Doidge, MD
4 Membership Matters
12 Neuroscience and Perception Catherine Madison, MD
7 President’s Message Charles Wibbelsman, MD
13 Twenty-First-Century Love Thomas Lewis, MD
15 The Alchemy of Consciousness Mike Denney, MD, PhD
8 Letters
9 Editorial Mike Denney, MD, PhD 29 Hospital News
17 Magic and Neuroscience Stephen L. Macknik, Mac King, James Randi, Apollo Robbins, Teller, John Thompson, and Susana Martinez-Conde 18 Understanding PTSD Mardi J. Horowitz, MD
20 Clarifying Autism Fernando Miranda, MD
21 Nuland on Neuroscience Steve Heilig, MPH
23 Proust Was a Neuroscientist Dennis Patrick Slattery, PhD
OF INTEREST
28 San Francisco Medical Society: Advocating for Physicians and Patients 32 Public Health Update: Influenza Robert Gross Spencer, MD
34 Health Care Policy Perspective: The Prognosis for Real Reform Steve Heilig, MPH
25 “What’s Love Got to Do With It?” Jeanne Achterberg, PhD 27 Before and After Nancy Griffiths, MBA, MS, NP Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Web: www.sfms.org Advertising information is available on our website, www.sfms.org, or can be sent upon request.
www.sfms.org
Welcome New Doctors! If this is your first issue of San Francisco Medicine, please enjoy the publication! In an effort to reach a broader audience with our information on health care in the city, we are now sending our publication to all practicing physicians in San Francisco. Please contact Therese Porter in the SFMS membership department if you have any questions about our organization, (415) 561-0850 extension 261 or tporter@sfms.org, or visit us online, www.sfms.org. July/August 2009 San Francisco Medicine
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Membership Matters July/August 2009 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 82, Number 6 Editor Mike Denney
Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney
Obituarist Nancy Thomson
Stephen Askin
Shieva Khayam-Bashi
Gordon Fung
Ricki Pollycove
Toni Brayer
Linda Hawes-Clever Erica Goode
Gretchen Gooding
Arthur Lyons
Terri Pickering
Stephen Walsh
SFMS Officers
President Charles J. Wibbelsman
President-Elect Michael Rokeach
Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney
Immediate Past President Steven H. Fugaro SFMS Executive Staff
Executive Director Mary Lou Licwinko
Director ofPublicHealth &Education Steve Heilig
Director of Administration Posi Lyon
Director of Membership Therese Porter
Director of Communications Amanda Denz
Board of Directors Term:
Jeffrey Newman
Andrew F. Calman
Michael H. Siu
Jan 2009-Dec 2010 Jeffery Beane
Lawrence Cheung Peter J. Curran
Thomas H. Lee
Richard A. Podolin Rodman S. Rogers Term:
Jan 2008-Dec 2010 Jennifer H. Do
Keith E. Loring
William A. Miller
Thomas J. Peitz
Daniel M. Raybin Term:
Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain
Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan
Shannon UdovicConstant
CMA Trustee Robert J. Margolin AMA Representatives
H. Hugh Vincent, Delegate
Robert J. Margolin, Alternate Delegate 4
San Francisco Medicine June 2009
Do We Have Your Correct Contact Information? Don’t run the risk of missing out on important information from SFMS and CMA because your contact information is not correct! Every year SFMS sends out a database update mailing in August. This gives you an opportunity to update your information so that we can keep you up to date. There is also a card in the most recent edition of the SFMS Membership Directory that you can use throughout the year. Additionally, you can update your records online, or by contacting the Membership Department at (415) 5610850 extension 268 or tporter@sfms.org. There has never been a more critical time for health care, and the San Francisco Medical Society wants to ensure that you have the information you need. Increasingly, we will be sending important information to you as quickly as possible through e-mail. If we don’t have your email address, please let us know (SFMS does not share its members’ e-mail addresses).
New Ways to Pay Your Dues!
The 2010 dues statements will go out in mid-September, and there will be a new option for paying dues—you will be able to elect to pay your dues via credit card in installments. Details and an authorization form will be on the dues statements. You may also use the online dues payment system on our website, or pay by check or credit card via fax or U.S. mail.
Help Grow the SFMS (AND Get a Break On Your Dues)!
Members of the San Francisco Medical Society/California Medical Association know that participation in organized medicine benefits both physicians and their patients. SFMS members have been helping to shape the future of medicine for nearly 150 years. If each member of the San Francisco Medical Society/California Medical Asso-
ciation encouraged just one new member from among their physician peers to join, SFMS/CMA would become a an even more powerful force in the legislature, the courts, the media, and on the local level. All it takes is one SFMS/CMA member recruiting just one new member to have a significant effect on membership. With the SFMS/CMA “Connect the Docs,” you can help grow membership in CMA and SFMS, and give yourself a break on your dues. Through the “Connect the Docs” program, CMA and SFMS reward peerto-peer recruitment. How it works—If you are a full-duespaying member of SFMS/CMA: Recruit three new full-dues-paying members and get a 50 percent discount on your 2010 CMA dues (SFMS dues remain due and payable). Recruit five or more new full-duespaying members and get a 100 percent discount on your 2010 CMA dues (SFMS dues remain due and payable). In addition, any SFMS member who refers four or more new members also gets free SFMS dues for the upcoming dues year in addition to the CMA discount For TPMG physicians, a TPMG physician who refers five or more members, he or she will receive two free tickets to the SFMS Annual Dinner. To receive dues rewards, you need to bring in three or more new members by the end of September 2009. Be sure that your referred peer completes the “referred by” information so that you receive appropriate credit. You could be paying reduced, or even no, CMA/SFMS dues for 2010! Joining has never been easier with the online application system. All a prospective member has to do is visit www. sfms.com and click on the “JOIN SFMS” button in the upper right-hand corner. If the new member has never been a member of CMA before, they may be eligible for a 50 percent discount on their first year dues. www.sfms.org
You—or the prospective member— can also contact Therese Porter in the Membership Department at (415) 5610850 extension 268 or tporter@sfms.org with questions, or to have a membership information packet sent.
T h e N e w 2 0 0 9 - 2 0 1 0 SFMS Membership Directory and Desk Reference
Active members should have received their 2009-2010 SFMS Membership Directory and Desk Reference. This trusted health care resource is now available for sale. Members—including retired members—will be able to order extra copies for $45 each (a significant discount from the nonmember cost of $75). To purchase more Directories, contact Carol Nolan at (415) 561-0850 extension O or cnolan@sfms.org. If you are an active member and have not received your Directory, or if you have any questions, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@ sfms.org.
Mark Your Calendars for the Return of the UCSF Student/SFMS Mixer
Thursday, September 24, at the UCSF campus, 6:00—7:30 p.m., location TBA. An opportunity for the students of UCSF and the physician members of the San Francisco Medical Society to meet in a fun and informal setting. It will be a wonderful chance for our physician members to meet and talk with the next generation of doctors, who are equally eager to meet those already established in the profession This event was one of our most successful events last year, and we hope for an even bigger turnout this time. Watch for more details.
Do You Work with Residents?
Give the residents of San Francisco a chance to participate in organized medicine. SFMS is making a special effort to reach out to San Francisco-based residents. If you are an attending physician, www.sfms.org
you have an opportunity to guide doctors about to embark on their careers. Getting them involved in organized medicine is just one of those ways that can have lasting effects both on their careers and the future of the practice of medicine. If you work with residents, tell them about SFMS and CMA, and encourage them to join. An arrangement between the California Medical Association and the San Francisco Medical Society has made resident dues complimentary for the duration of the physician’s residency. Additionally, the Membership Department will be visiting graduate medical education offices at the city’s hospitals as part of the Medical Society’s outreach project. If you know of a graduate medical education office contact or a suggestion for outreach opportunities, please contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.
SFMS Supports Ban on Tobacco Sales in Pharmacies
Along with a solid list of health advocacy groups, including the CMA, UCSF School of Pharmacy, and many more, the SFMS joined a group in legally defending San Francisco’s new policy to keep tobacco products out of pharmacies. The SFMS previously took this policy to the CMA, and it was adopted as statewide medical policy. The case is widely seen as a national test case for this issue. Joining the lawsuit does not involve the use of SFMS funds for legal or other fees. The SFMS recently received the following letter from the SF Department of Public Health in relation to the case: “Dear Dr. Wibbelsman, I wanted to personally thank you for your amicus brief in support of our ban on the sale of tobacco in pharmacies. It means a great deal to me to know that the California Medical Association and the San Francisco Medical Society support our efforts. Sincerely, Mitchell H. Katz, MD, Director of Health.”
SFMS Endorses Alcohol Tax Increase The SFMS Board of Directors has unanimously endorsed the proposal to increase alcohol taxes to help cover alcohol-related costs. In the recent round of California budgetary struggles, Governor Schwarzenegger asked for the equivalent of an alcohol excise tax increase of five cents per drink. Unfortunately, alcohol industry opposition killed the tax. The Marin Institute, a private nonprofit organization devoted to improving alcohol-related policy and reducing harms from drinking, released a 2008 report titled “The Annual Catastrophe of Alcohol in California.” The report found that the economic cost to California from alcohol-related causes is $38 billion per year. California alcohol taxes have not increased since 1992, and then by only a penny. State authorities around the nation are proposing such taxes and SFMS will take this proposal to the CMA and AMA this year to increase support.
SFMS Joins Legal Defense of Local “Universal Health” Program
The SFMS has joined an amicus or “friend of the court” brief in support of Healthy San Francisco, the “universal health” option developed by a Mayoral committee in 2006, with SFMS representation, and implemented in 2007. The program now has almost 40,000 enrollees. A restaurant association has sued to stop the mandated employer contribution to this program but has lost each step in this suit to date; it is now appealing to the Supreme Court. The SFMS joins the Mayor, San Francisco Department of Public Health, and others in seeking to defend this program. Joining as an amici in this case does not involve the use of SFMS funds for legal or other fees. For more information on Healthy San Francisco, see www. healthysanfrancisco.org.
July/August 2009 San Francisco Medicine
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President’s Message Charles J. Wibbelsman, MD
The Brain and the Practice of Medicine
I
n this issue of our journal, when our editor and contributors delve into the delicate subject of neuroscience, one at first may conjure up memories from neuroanatomy in medical school and the first serious encounter with dendrites, axons, and ganglia. When I attended medical school at the University of Cincinnati in the seventies, neuroanatomy was taught in the freshman year. The learning process was predicated on having every possible color pencil in order to learn all of the pathways and connections of the nervous system and to chart each system and color each new anatomic component. Once the course was in full gear, all of us busily tried to keep up with the anatomy professor, who sped through the topic as we frantically switched from color to color making our notes. The most memorable afternoon in this high-powered learning course was when one of our classmates, who was taking notes furiously, dropped his box of colored pencils, all of which rolled all over the floor of the classroom. For each of us in the practice of medicine, to take the neuroscience that we learned as medical students into our own clinical practices and professional lives is quite an adaptation. I now reflect on many of my practicing colleagues, whose personal and professional lives were severely changed as a result of a change in their neurological state and brain function. Several years ago one of my colleagues, while working at home in his
study, suffered a head injury from a falling bookcase. Although he returned to regular practice with minimal delay, the effects of this injury, from a phenomenon called postconcussion syndrome, were not well described at that time—and they lingered. Injuries to the delicate neurological system can be difficult to cope with in one’s personal and professional life. Another colleague of mine fared less well when he fell from a ladder while working in his yard. It was many months before he could return to his clinical practice; unfortunately, he was never able to return to his leadership position. So many of us cherish our free time at home and look forward to having some time around the house to relax and catch up on chores that we think any physician should be able to do, rather than hire a workman or painter to accomplish simple tasks. Unfortunately, the white coat of medicine does not provide a cloak of protection, nor does it offer anyone any greater immunity to the many accidents that can occur working in the home that, indeed, can affect the quality of our professional lives and can influence our decision making in the practice of medicine. Neuroscience is a very exacting science, as it affects our everyday personal and professional lives. We should be grateful to have all of our colored pencils neatly packaged in the box of life’s neurological assets.
ANNUAL GENERAL MEETING OF THE SAN FRANCISCO MEDICAL SOCIETY
Date: Monday, September 14, 2009 Time: 6:00 p.m. – 7:30 p.m. Where: Commodore Room, Golden Gate Yacht Club Dev GhanaDev, MD, the president of the California Medical Association, will provide an update on what CMA has accomplished in the last year, as well as touch on the major issues in health care today. The Nominations Committee report will also be presented. Dinner will be provided, RSVP is required. Please RSVP no later than noon on September 7. Attendees are welcome to stay for the regular meeting of the Board, which immediately follows the General Meeting. This is a good opportunity both to meet with SFMS leadership and to learn firsthand what SFMS and CMA are involved in on behalf of physicians in San Francisco and California. Please RSVP to Posi Lyon by phone at (415) 561-0850 extension 260 or e-mail plyon@sfms.org. Make sure to include your phone number and e-mail address, so we can provide directions to the event.
www.sfms.org
July/August 2009 San Francisco Medicine
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Letters
Dear SFMS, As a lifetime member of the AMA, as a member of the GLBT interest group of the AMA and of the Gay and Lesbian Medical Association (GLMA), as a primary care internist and member of the American College of Physicians, and as one of the first HIV/AIDS specialists in the country, I am deeply disappointed in the AMA’s rejection of a public health insurance plan alternative, as envisioned by Senator Ted Kennedy and President Barack Obama. We need a public plan as an alternative choice under universal health coverage, not only to assist those patients who are not eligible for large employer sponsored plans, but also to help private insurance become more competitive and keep costs under control and to assist small businesses where the high costs of health insurance have made it impossible to include health care as an employee benefit. A public plan can also set quality standards that must be matched by private insurers. Further, a public plan would offer the opportunity to redress the severe imbalance in payments for primary care providers that is already apparent as a shortage of PCPs in high-cost areas, like San Francisco, but will become critical across the entire U.S. as baby boomers enter their senior years. In the current economic downturn, I have had a significant hemorrhage of patients, both general internal medicine patients and those with HIV/AIDS, as they have lost their employer-sponsored insurance and have been unable to afford COBRA-sponsored extensions of their coverage. After years of providing high quality care to my patients, many are now having to transfer to Kaiser-Permanente or to public health clinics where the financial burden of their care will have to be supported by the citizens of San Francisco, a city where the municipal government is already strapped by a shortage of local revenues as well as by a dramatic decline in assistance from the State, due to California’s extreme financial crisis. I realize that the American Medical Association is comprised of both primary care physicians and surgical specialists. In this case, you have clearly sponsored the position of surgical specialists. In so doing, you have not only alienated primary care providers but have also betrayed the citizens of the U.S. who deserve a better health care system, based on the model of the medical home, with the primary care provider as the center of that model. I hope that the American Medical Association will reverse its current ill-considered position. The AMA must support a public insurance option, as envisioned by Senator Kennedy and President Obama, as a pillar of universal health care in the U.S. Sincerely, William F. Owen, Jr., MD San Francisco, CA 8
San Francisco Medicine June 2009
Dear Dr. Wibbelsman, I wanted to personally thank you for your amicus brief in support of our ban on the sale of tobacco in pharmacies. It means a great deal to me to know that the California Medical Association and the San Francisco Medical Society support our efforts. Sincerely, Mitchell H. Katz, MD Director of Health San Francisco Department of Public Health San Francisco, CA
Dear Editor, As an infectious diseases physician, I was intrigued by the cover of the June 2009 edition of San Francisco Medicine. I truly appreciated and enjoyed reading this issue on “Ritual in Medicine,” as I tried to find further reference to hand washing and ritual. Hand washing is not ritual. The benefit is evidencebased and the majority of nosocomial infections are transmitted primarily by the hands of health care workers. For those of us more visually oriented, I have included a link to a recent “Images in Clinical Medicine” from the New England Journal of Medicine documenting the benefit of alcohol foam on the hand carriage of methicillin-resistant Staphylococcus aureus. Unfortunately, we as health care personnel do not do enough to promote and model this behavior and have not been successful in finding the solution to better adherence to this important activity. I apologize if I missed the intent of the cover photograph showing an operating room person washing his hands with the title “Ritual in Medicine.” Let’s hope that we do not abandon hand washing as “ritual.” Sincerely, Stephen E. Follansbee, MD SFMS President, 2007 San Francisco, CA
Dr. Paul Tang to Speak on Healthcare IT and the Stimulus Funds The American Recovery and Reinvestment Act passed earlier this year provides funding for the wider use and dissemination of health information technology. SFMS will be hosting an educational session on health care IT for all members on October 6 from 6-7:30 p.m. at CPMC. Please RSVP to Posi Lyon at 415-561-0850 extension 260 or plyon@sfms.org for more information, including the exact location.
www.sfms.org
Editorial Mike Denney, MD, PhD
Strange Loops of Consciousness
H
uman consciousness is inescapably enmeshed in a profound recursive paradox. It is a paradox known since an ancient Greek philosopher, Eubulides of Miletus, said words to the effect, “I am lying.” The paradox was reiterated in 1947 when Harvard students William Burkhart and Theodore Kalin programmed a computer to tell the truth, then asked it to evaluate the statement, “This sentence is false.” The computer went crazy, processing paradoxical infinite loops of data through strange recurring patterns and making “a hell of a racket” until it was unplugged. A year later, a hint of this self-referential paradox was popularized by the country music group Lonzo and Oscar with their Winston County Pea Pickers, when they performed the hit song “I’m My Own Grandpa.” This liar’s paradox, sometimes called “strange loops,” reveals itself when a statement seems to have two opposite meanings at the same time—if Eubulides is lying, he is telling the truth; if he is telling the truth, he is lying; if the sentence given to the Harvard computer is false, it is true; if it is true, it is false; and if Lonzo, Oscar, and the Pea Pickers say they are telling the truth, then they are lying; and if they say they are lying, they are telling the truth. In his book Gödel, Escher, Bach: An Eternal Golden Braid, Douglas Hofstadter, professor of cognitive science at Indiana University, speaks of these strange loops as aspects of consciousness. He reveals the self-referential paradox in the never-ending chord structures in the canons and fugues of musical compositions by Johann Sebastian Bach. He points out the liar’s paradox in the drawings of M. C. Escher, with their spatial perspectives of waterfalls and stairways that always end on a level where they started, so as to repeat the up-and-down circuits ad infinitum. Hofstadter’s ideas are based upon the work of Kurt Gödel, who in 1931, at the University of Vienna, proved his “incompleteness theorem,” which demonstrated that logic itself, the very basis of human reasoning, is locked in the recursive self-reference of the liar’s paradox—certain groups of mathematical and logical entities both cannot and must belong to their own group. When philosophers and mathematicians try objectively to resolve this incompleteness in logic, they instead inevitably find themselves subjectively enmeshed in the paradox they are trying to solve. They cannot deny the self-referential paradox that www.sfms.org
the only way they can study consciousness is by using their own consciousness. As they experience it subjectively they are caught in objectivity, and as they study it objectively they are caught in subjectivity. As Hofstadter says, “There is a famous breach between two languages of discourse: the subjective language and the objective language. For instance, the ‘subjective’ sensation of redness, and the ‘objective’ wavelength of red light.” In recent years, these disparate ways of knowing have come to be understood by comparing the activities in the brain’s more subjective, intuitive, and metaphoric right hemisphere with those in the more linear and logical left hemisphere. Exciting new possibilities in the neuroscience of consciousness are now suggested by a book titled My Stroke of Insight: A Brain Scientist’s Personal Journey, by Jill Bolte Taylor, PhD. It is a heartwarming story of a brilliant neuroscientist who suffered a hemorrhagic stroke in her left cerebral hemisphere. During the advancement of the stroke, Taylor experienced with her right brain the subjective awareness of losing her speech and other neurological functions, but she also used her left brain to analyze exactly what tissue in her brain was being destroyed. During her illness and recovery, she struggled to keep her intuitive and blissful right brain from being overcome by her more assertive and logical left brain. This is the first recording of a neurological event simultaneously experienced both subjectively and objectively. Ever the neuroscientist, Taylor now says, “I have learned so much from this experience with stroke, that I actually feel fortunate . . . I have had the chance to witness firsthand a few things about my brain that otherwise I would never have imagined to be true.” In this regard, Douglas Hofstadter’s most recent book is titled I Am a Strange Loop, and in it he postulates that, paradoxically, human consciousness actually is itself a self-referring liar’s paradox within the tangled neurons and their synapses in the brain. Hofstadter says, “The strange-loop characterization of our essences gives us a deeper and subtler vision of what it is to be human.” Perhaps that is why Eubulides of Miletus finds wonderment in the sentence “I am lying,” why the Harvard truth-telling computer goes into a strange loops of craziness when confronted with a sentence that is paradoxical, and why Lonzo, Oscar, and the Pea Pickers think they are their own ancestors. July/August 2009 San Francisco Medicine
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Neuroscience and Perception
The Brain that Changes Itself Neuroplasticity Defined
Norman Doidge, MD
T
he Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science is about the revolutionary discovery that the human brain can change itself, as told through the stories of the scientists, doctors, and patients who have together brought about these astonishing transformations. Without operations or medications, they have made use of the brain’s hitherto unknown ability to change. Some were patients who had what were thought to be incurable brain problems; others were people without specific problems who simply wanted to improve the functioning of their brains or preserve them as they aged. For four hundred years this venture would have been inconceivable because mainstream medicine and science believed that brain anatomy was fixed. The common wisdom was that after childhood the brain changed only when it began the long process of decline; that when brain cells failed to develop properly, or were injured, or died, they could not be replaced. Nor could the brain ever alter its structure and find a new way to function if part of it was damaged. The theory of the unchanging brain decreed that people who were born with brain or mental limitations, or who sustained brain damage, would be limited or damaged for life. Scientists who wondered if the healthy brain might be improved or preserved through activity or mental exercise were told not to waste their time. A neurological nihilism—a sense that treatment for many brain problems was ineffective or even unwarranted—had taken hold, and it spread through our culture, even stunting our overall view of human nature. Since the brain could not change,
human nature, which emerges from it, seemed necessarily fixed and unalterable as well. The belief that the brain could not change had three major sources: the fact that brain-damaged patients could so rarely make full recoveries; our inability to observe the living brain’s microscopic activities; and the idea—dating back to the beginnings of modern science—that the brain is like a glorious machine. And while machines do many extraordinary things, they don’t change and grow. I became interested in the idea of a changing brain because of my work as a research psychiatrist and psychoanalyst. When patients did not progress psychologically as much as hoped, often the conventional medical wisdom was that their problems were deeply “hardwired” into an unchangeable brain. “Hardwiring” was another machine metaphor coming from the idea of the brain as computer hardware, with permanently connected circuits, each designed to perform a specific, unchangeable function. When I first heard news that the human brain might not be hardwired, I had to investigate and weigh the evidence for myself. These investigations took me far from my consulting room. I began a series of travels, and in the process I met a band of brilliant scientists, at the frontiers of brain science, who had, in the late 1960s or early 1970s, made a series of unexpected discoveries. They showed that the brain changed its very structure with each different activity it performed, perfecting its circuits so it was better suited to the task at hand. If certain “parts” failed, then other parts could sometimes take over. The machine metaphor, of the brain as an organ with specialized parts, could
11 San San Francisco Francisco Medicine Medicine June July/August 2009 10 2009
not fully account for changes the scientists were seeing. They began to call this fundamental brain property “neuroplasticity.” Neuro is for “neuron,” the nerve cells in our brains and nervous systems. Plastic is for “changeable, malleable, modifiable.” At first many of the scientists didn’t dare use the word “neuroplasticity” in their publications, and their peers belittled them for promoting a fanciful notion. Yet they persisted, slowly overturning the doctrine of the unchanging brain. They showed that children are not always stuck with the mental abilities they are born with; that the damaged brain can often reorganize itself so that when one part fails, another can substitute; that if brain cells die, they can at times be replaced; that many “circuits” and even basic reflexes that we think are hardwired are not. One of these scientists even showed that thinking, learning, and acting can turn our genes on or off, thus shaping our brain anatomy and our behavior—surely one of the most extraordinary discoveries of the twentieth century. In the course of my travels I met a scientist who enabled people who had been blind since birth to begin to see, another who enabled the deaf to hear; I spoke with people who had had strokes decades before and had been declared incurable, who were helped to recover with neuroplastic treatments; I met people whose learning disorders were cured and whose IQs were raised; I saw evidence that it is possible for eighty-yearolds to sharpen their memories to function the way they did when they were fifty-five. I saw people rewire their brains with their thoughts, to cure previously incurable obsessions and traumas. I spoke with Nobel laureates who were hotly debating how we must rethink our model of the brain now www.sfms.org www.sfms.org
that we know it is ever changing. The idea that the brain can change its own structure and function through thought and activity is, I believe, the most important alteration in our view of the brain since we first sketched out its basic anatomy and the workings of its basic component, the neuron. Like all revolutions, this one will have profound effects. The neuroplastic revolution has implications for, among other things, our understanding of how love, sex, grief, relationships, learning, addictions, culture, technology, and psychotherapies change our brains. All of the humanities, social sciences, and physical sciences, insofar as they deal with human nature, are affected, as are all forms of training. All of these disciplines will have to come to terms with the fact of the selfchanging brain and with the realization that the architecture of the brain differs from one person to the next and that it changes in the course of our individual lives. While the human brain has apparently underestimated itself, neuroplasticity isn’t all good news; it renders our brains not only more resourceful but also more vulnerable to outside influences. Neuroplasticity has the power to produce more flexible but also more rigid behaviors—a phenomenon I call “the plastic paradox.” Ironically, some of our most stubborn habits and disorders are products of our plasticity. Once a particular plastic change occurs in the brain and becomes well established, it can prevent other changes from occurring. It is by understanding both the positive and negative effects of plasticity that we can truly understand the extent of human possibilities. Norman Doidge, MD, is a psychiatrist, psychoanalyst, researcher, author, essayist, and poet. He is on the research faculty at the Columbia University Center for Psychoanalytic Training and Research, in New York, and is a professor in the University of Toronto’s Department of Psychiatry. To learn more, visit his website www.normandoidge.com. Reprinted by arrangement with Penguin Books, a member of Penguin Group (USA) Inc., from The Brain That Changes Itself, by Norman Doidge. Copyright © 2007 by Norman Doidge. www.sfms.org
Welcome New Members! The San Francisco Medical Society would like to welcome the following new members: Amy Berlin, MD, Solo/Small Group Todd A. May, MD, SFDPH: SF General Hospital Dawn Rosenberg, MD, CPMC, Referred by Lisa Dana, MD
From The Permanente Medical Group
Justin W. Genant, MD Joaquin A. Barahona, MD Charles E. Binkley, MD Rebekah Chang, MD (transferring from Solano County Medical Society) Emily Chen, MD (transferring from Santa Clara County Medical Society) Mark Chen, MD Jessica L. Matchett, MD, Referred by Chuck Wibblesman, MD Homero Mui, MD (transferring from Solano County Medical Society) Gabrielle B. Poindexter, MD Jennifer P. Schmitt, MD, Referred by Chuck Wibblesman, MD TJanet C. Shimotake, MD Pim Suwannarat, MD Alice Tso, MD, Referred by Chuck Wibblesman, MD
House Officers
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Neuroscience and Perception
Neuroscience and Perception Notes on Processing Information
Catherine Madison, MD
I
ncreased longevity over the last century has led to a larger number of individuals with neurodegenerative diseases. We can all remember the hurry to grow up that transitioned into a desire to reset the clock. But in working with dying patients, I look them in their eyes and say that death is the only certainty in life. So we need to make the most of the time we have, and optimize brain function. To achieve this goal for ourselves and our patients, we need to better understand how the system works. Now that our basics have been expanded from sodium/ potassium channels and individual neurons to inhibitory interneurons and glial cells, scientists are beginning to suspect how much awaits discovery. We are familiar with normal brain changes in aging, such as slowed processing speed and diminished ability to multitask. This latter is especially pertinent in a society with only more distracters. Notice the rapid-fire sequences presented in television commercials and how very slow our old classic movies seem to kids. At each moment, our brain is filled with past images, musical lines, and future plans while navigating incoming information. While the brain has been studied microscopically for more than 100 years, let’s consider the cellular processes whereby we consolidate these fragments into learning, language, and cognition. This involves neurons and supporting cells (glia), as well as the numerous chemical, hormonal, and neurotransmitter messenger systems acting between them. In the nervous system, thoughts and actions are encoded in patterns of activity within cellular networks. With 1,000
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San Francisco Medicine June 2009
to 10,000 synapses per each of the more than 100 billion neurons, much modeling and interaction is done at the cellular level. The individual cells then interact in larger systems between cortical regions forming working networks. But exactly how these connected circuits are integrated into ongoing brain activity remains unclear. Single-unit recordings from monkey neurons have demonstrated how firing frequency and pattern correlate with the presentation of information and its use later in behavior. For humans, functional magnetic resonance imaging (fMRI) allows mapping of brain regions associated with a specific task or task component. The area of activity observed with fMRI may be modified with sharpening, as a cell field focuses response to optimal stimuli while decreasing response to suboptimal inputs. Mathematical models to connect individual cellular activity to cortical fields and dynamic mechanisms are growing. Much emphasis has always been placed on neurons—we follow a neuroncentric approach to the brain. Some of us were taught in medical school that humans cannot grow new nerve cells. As that has changed in recent years, the supporting system of glial cells has received increasing attention, particularly as it relates to inflammation and recovery. The most abundant glial cell is the astrocyte. Interestingly, greater brain complexity phylogentically is accompanied by increasing astrocyte counts. For lower species such as Caenorhabditis elegans, neurons outnumber glia by a 6:1 ratio. This ratio reverses in the mouse cortex to 1:3, and in the human cortex there are 1.4 astrocytes for each neuron. The structural
complexity of astrocytes is also greatest in the human cortex, with heterogeneity between different brain regions. The fine distal processes of astrocytes are interposed between nerve cells, giving them an excellent opportunity to regulate the microenvironment in which neurons develop and function. For example, potassium needs to be tightly regulated in the extracellular space, given its role in membrane excitability. Astrocytes actively take up potassium in regions of higher concentration and release it to areas with lower concentration, providing an active buffering system. Similar work is done with sodium and neurotransmitters, such as glutamate and GABA. So how might the astrocyte influence processing and learning? Neurotransmitter receptors and ion channels allow them to sense neural activity and respond with elevations of cytosolic calcium. This calcium transient may alter gene expression and initiate morphological change. Various staining methods have been developed to measure the flow of calcium, as waves of this ion are associated with signal propagation and neurotransmitter release. Large-scale in vivo cell populations can be stained, giving an opportunity to study the functional architecture of neuronal and glial circuits in action. In addition to neurotransmitters, astrocytes also release cytokines and ATP. There is convincing evidence that astrocytes are highly dynamic elements in the CNS, contributing to remodeling and likely phenomena as complex as learning. Further refinement of imaging will soon allow identification of functionally linked subnetworks linked with specific stimuli Continued on page 19 . . . www.sfms.org
Neuroscience and Perception
Twenty-First Century Love The Neurological Underpinnings of Human Relationships
Thomas Lewis, MD Come to the orchard in Spring, There is light and wine, and sweethearts in the pomegranate flowers. If you do not come, these do not matter. If you do come, these do not matter.
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n the thirteenth century, the Persian poet Rumi penned these lines (translated by Coleman Barks) on the centrality of love, one of his favorite themes. Eight hundred years later, even Rumi might be surprised at the view of love that is emerging from current scientific investigations, where the various components of love are being traced to their respective sources in the brain. Modern neuroscience views love as no passing fancy but instead as a powerful neurophysiologic force to be reckoned with. Just as physics recognizes three fundamental forces that draw inanimate bits of matter to one another (gravity, strong nuclear force, and electro-weak force), modern investigators into the neuroscience of human relationships postulate a trio of powers that attract and hold human beings: sexual attraction or lust; “falling in love” or romantic infatuation; and a long-term affectional bond that, in the psychiatric world, goes by the name “attachment” (Fisher et al. 2006). We will consider briefly some of the recent findings in each of these domains below. Sexual attraction is unimaginably ancient. Sexual reproduction arose shortly after the appearance of life itself, some three billion years ago. Every living thing we see around us, from the trees in the distance to the grass underfoot (not to mention the birds and the bees) engages in sexual relations of one sort or another. www.sfms.org
Because the origin of sex predates so profoundly that of the self or even the nervous system, perhaps we should not be surprised at the unruliness of sexual motivations and their tendency to flow through human lives without regard for the demarcation of self and self-interest, marriage, family, and society. A recent study found that lovers, when compared to strangers with no history of sexual desire between them, were likelier to show differences in the parts of their DNA that encode for the major histocompatibility antigen (MHC) (Kurup et al. 2003). At the level of the gene, combining diverse versions of MHC genes may confer a survival advantage, but this system is disconcertingly alien when considered from the perspective of the self that we often assume is the center of our love lives. How many of us suspect that the thrill of our desire can have so little to do with me or him or her, and instead hangs upon a few chance base-pairs in an obscure coil of the genome? That is sexual chemistry indeed, of the most implacable kind. Falling in love, or romantic infatuation, is thought to be a distinct brain state whose purpose is to stabilize and cement an attraction long enough for successful impregnation to be reasonably likely. In human beings, a viable pregnancy may take months to achieve, but usually not years, accounting for the oft-lamented brevity of this romantic phase in most people. Neuroimaging studies of the recently infatuated document the dopaminergic burst in the brain’s primitive reward circuitry, the ventral tegmental area and the nucleus accumbens, the likely origin of love’s much-sought ecstatic period (Bartels and Zeki 2004). At
the same time, areas critical for the production of negative emotion (amygdala) and logical, evaluative judgment (dorsolateral prefrontal cortex) are actively suppressed in the romantically entranced, providing the neurophysiologic basis for the clinical observation that people in love exhibit astoundingly poor judgment with monotonous regularity. Love may not be literally blind, but it does seem to be literally incapable of reason and the levels of appropriate negativity necessary for realism. The dopaminergic basis of infatuation, moreover, suggests that inborn differences may exist in susceptibility to Cupid’s arrow: In one study, serum dopamine levels were significantly lower in adults who had never fallen in love when compared to those who had (Kurup et al. 2003). Lower dopaminergic tone (which the study of attention-deficit hyperactivity disorder, or ADHD, suggests is strongly heritable [Durston et al. 2009]), may make a lover less able to tumble over the affectional precipice into the free-fall of infatuation. A young reptile breaks from its egg a fully functional survivor, and so reptiles have no need of parents as such—genetic progenitors, yes, but not parents in the sense that we understand the concept, that of multipurpose nurturer and guardian. Where reptiles hatch independent, mammals are born to depend. Young mammals require elaborate care if they are to survive: They need supervision, food, water, warmth, and protection from a concerned adult or they will die. Attachment supplies these necessaries, and much more, through the provision of a long-term bond between a mamContinued on the following page . . .
July/August 2009 San Francisco Medicine
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Twenty-first Century Love Continued from the previous page . . .
malian mother and her young. Because human beings are so exceptionally helpless in their immaturity, the human infant requires not only a devoted mother but also a devoted father as well, and the deployment of a set of bonds that establish, out of the raw materials of adult female and adult male and offspring, a multiply interlinked, intraloyal group, the family. Long-term attachment bonds are mediated in important ways by the brain’s oxytocin and the opiate systems. Downregulation of the opiate system mediates the pain of social loss, an arrangement that almost certainly represents evolution’s improvisational extension of the opiate system’s established role in physical pain. The pituitary hormone oxytocin, long known to handle some of the mechanical tasks of childbearing (uterine contractions, milk letdown), appears to have been recruited by evolution to undergird some of the emotional ties of relationships as well. Administering oxytocin in several studies appears to foster affiliation: In one study, giving oxytocin to couples before an experimentally induced argument shifted their interaction in the direction of relationship-building behaviors such as listening and compromising, and away from time-honored habits such as criticism and defensiveness (Ditzen 2009). In another study, the number and length of gazes that dogs delivered correlated with oxytocin levels in their owners, suggesting that oxytocin may be a critical element in forging the relationship bond between human and canine companions (Nagasawa 2009). A wholly remarkable and largely unnoticed aspect of attachment is the extensive regulation of physiology that occurs within attachment relationships. Studies continue to accumulate documenting the ability of long-term relationships to modulate an ever-expanding list of physiologic functions: cardiovascular, immune, endocrine, sleep, gene regulation, neuronal excitability, and much more. For example, consider a recent study in which subjects were given subcutaneous injections of Japanese cedar pollen or human
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dust mites, both powerful antigens that intervention markedly reduced them. In often can (and did) produce impressive this case, the experimental condition to skin wheals (Kimata 2003). After thirty which infants were exposed was their minutes of sitting quietly in a room, the mother’s laughter, as the women listened wheals on the control group did not through headphones to a comedy prochange. For the group exposed to the gram that the infants themselves could study’s experimental condition, however, not hear. If the sound of maternal mirth can the outcome was quite different: Thirty minutes of exposure produced a marked significantly down-regulate a baby’s alreduction in the size of the wheals. In- lergic responsiveness, in what other ways stead of resting quietly, the intervention and through what other channels might group had engaged in a half-hour of kiss- relationship experiences modulate physiing their spouses or lovers, an activity that ologic parameters? We can only guess, produced a specific and significant de- and the elaboration of this entangled network of physiologic regulation awaits crease in circulating levels of IgE (Kimata San Fran Med Mag 2006). This study thus demonstrates a further similarly ingenious investigators physiologic link between kissing and01-29-09 the and studies. To the eye of the modern neuroscienregulation of allergic inflammation that few of us might suspect is hiding beneath tist, love in all of its three phases already the skin of our relationships. The same appears to be enormously powerful, and investigators performed a similar study, the investigations are just beginning. The this time injecting infants with the same next few decades of research should be allergens (Kimata 2004). Again, thirty revelatory and exciting, for scientists and minutes of resting produced no change in lovers both. A full list of references is available the size of the infants’ wheals, while thirty minutes of exposure to the experimental online at www.sfms.org/archives.
San Francisco Medicine July/August 2009
www.sfms.org
Neuroscience and Perception
The Alchemy of Consciousness Neuroscience and Metaphor
Mike Denney, MD, PhD
T
he ancient theory and practice of alchemy began in China before 1000 BC, then spread to India, the Middle East, and Egypt. Originally, the practice was purely spiritual, represented by the concepts, respectively, of the Tao, Ayurveda, al-kimiya, and the Egyptian god Toth. Long before the knowledge of the science of chemistry, these practices were based upon a metaphor of “as above, so below,” which symbolically reflected upon the cooking of metals like lead, mercury, and antimony with sulfur, salt, acids, and bases in boiling cauldrons to produce clouds of vapor, swirls of thick liquids, and various clumps of new matter. These seemingly miraculous, multicolored, and sometimes explosive reactions were viewed as metaphors for the union of matter and spirit, the highest of which was the theoretical formation of gold from more base metals. Mystically, the gold represented the highest consciousness of the spirit of the cosmos. Sometimes the metaphor of alchemy was desecrated when the practices were literalized into the more worldly quest of actually trying to create gold from base metals. Under the tutelage of wealthy royalty and venture capitalists of the day, this physical endeavor continued well into the Middle Ages and Renaissance and, although completely unsuccessful in producing gold, was finally developed more logically by Boyle, Lavoisier, Dalton, Priestly, and others during the seventeenth and eighteenth centuries into what became the science of chemistry. Beginning in the ancient world, this literalized view of alchemy was also applied to healing, using the living body as the melting pot. Heavy metals were mixed www.sfms.org
into elixirs to be ingested by human beings in an attempt to cure illness or bring health. Perhaps partly because of the resultant effects of heavy metal poisoning on the human body, Chinese alchemy returned to the concept of matter and spirit during the Tang Dynasty (600-900 AD). Alchemy was again practiced metaphorically by meditating upon the chemical transformations to achieve enlightenment and health. Thus, the relationship of alchemy to consciousness itself, with the propensity of sentient human beings to contemplate themselves in relationship to the cosmos, continued the principle of “as above, so below.” Alchemy became an expression of human consciousness. In 1928, this alchemy of consciousness entered modern culture when the empirical analytical psychologist Carl G. Jung received a manuscript, a German translation of an ancient Chinese alchemical treatise entitled The Secret of the Golden Flower. Jung’s psychology had always included the seemingly innate propensity of human beings to contemplate themselves in relationship to the cosmos, thus seeking a union of matter and spirit. Studying the Taoist manuscript and other alchemical Gnostic Latin texts, Jung found a new metaphorical language for the human psyche, stating, “I had very soon seen that analytical psychology coincided in a most curious way with alchemy. The experiences of the alchemists were, in a sense, my experiences, and their world was my world.” Thereafter, to Jung, a psychologist who was educated as a scientific physician, consciousness was clearly a function of the material matter of the human body and brain. Throughout history, philosophers
also contemplated the nature of human consciousness, using a more deductive logical approach. In a view of consciousness that lasted until the Renaissance, Plato included desire, emotions, and knowledge as equal components of human experience, and Aristotle considered the soul to be united with the material of the body. Then along came Descartes, the seventeenth century philosopher who in his treatise Discourse on Method stated that the only entity in the world that cannot be doubted is human consciousness. He firmly stated, “I think, therefore I am,” thereby inferring that the mind itself is a more reliable indicator of reality than any physical matter, including the human body. This elevation of consciousness to a place separate from the brain continues to the present day by philosophers who contemplate the relationship of spirit and matter. Examples can be found in the book Explaining Consciousness: The Hard Problem, in which David J. Chalmers, philosopher of consciousness studies at the Australian National University, describes the hard problem as “. . . explaining how any physical system, no matter how complex and well-organized can give rise to experience at all . . . this is the phenomenon that makes consciousness a real mystery.” Other authors in this anthology suggest a “panpsychism” system in which an all-pervading consciousness is more fundamental than the matter of the brain, while still others try to relate consciousness to the everyday reality through a vague notion of quantum nonlocality, by which the behavior of subatomic particles can be
Continued on the following page . . .
July/August 2009 San Francisco Medicine
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Alchemy of Consciousness Continued from the previous page . . .
said to supersede the usual concept of the material world. The latest contribution to this idealistic train of thought is offered by Alva Noë, professor of philosophy at the University of California at Berkeley. In his 2009 book, Out Of Our Heads: Why You Are Not Your Brain and Other Lessons from the Biology of Consciousness, Noë complains that it is erroneous for people to think that consciousness is something that happens “in the human brain, just as digestion must take place in the stomach.” He goes on to state the obvious, i.e. that one must be in relationship with the rest of the world in order to have learning experiences, but then again demeans the material matter of the brain, saying that it is impossible for even “a vast assembly of nerve cells and their associated molecules” to give rise to consciousness. Alchemists, however, would attribute a deeper and more spiritual quality to material matter, the substances whose actions and reactions in boiling vessels represent the highest levels of spirituality and consciousness—“as above, so below.” Similarly, neuroscientists would consider the generation of consciousness by the human brain to be much more complex, intricate, and mysterious than digestion of food in the stomach. To some, the conscious brain may be the ultimate in complexity, the culmination of all the events since the creation of the universe. After the Big Bang about 15 billion years ago, subatomic particles gradually formed stars, and then planets took form. About 4 billion years ago on earth, some carbon molecules spontaneously learned to replicate themselves, gradually evolving into multicelled organisms. About 350 million years ago, the first vertebrates appeared, and 200 million years ago dinosaurs ruled the planet. Homo sapiens appeared only 200,000 years ago, and with them the human brain, the most complex entity known in the universe, containing over 100 billion neurons, each of those neurons influencing 10,000 synapses. Indeed, in the frame of reference of complexity science, one
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can view the spontaneous emergence of consciousness as being too complex to be explained by the logic of philosophers. In this context, it seems not at all surprising that consciousness might arise from the material matter within the brain. It was in this same context of the brain as mediator of consciousness that neuroscience was born. In 1887 in Paris, Charles Richet, MD, hypothesized that the physiology of the brain and the psychology of human beings are aspects of the same science. Then in 1900, Santiago Ram�n y Cajal demonstrated the synapse, that discontinuous space between neurons where exchanges of neurochemicals in highly complex recursive feedback mechanisms can form an almost infinite number of networks. Neuroscience proceeded from microscopic anatomy to a more alchemical approach during the first half of the twentieth century when adrenalin, oxytocin, histamine, acetylcholine, and serotonin were identified. Yet there is neither a logical explanation of the complex chemical relationships within the brain nor a full knowledge of the impact of psychopharmaceuticals upon brain function concerning such disparate inner experiences as creative imagination, joy, sorrow, or an urge to commit suicide. Nowadays, researchers use SPECT and fMRI scans to map out areas of increased or decreased metabolic activity in response to such esoteric states of consciousness as spiritual transcendence, experiencing beauty, watching magical tricks, falling in love, and finding meaning in music. Again, there is no logical or scientific explanation of the objective physiology of the brain in relationship with these deep subjective experiences within consciousness. It may be that understanding the neuroscience of consciousness is currently in a state similar to the ancient alchemists when they provoked chemical reactions in boiling cauldrons to produce dramatic, multicolored, and sometimes explosive clouds of vapor, swirling liquids, and various clumps of new matter—and who chose metaphor as their initial path to knowledge. In that regard, studies at the De-
San Francisco Medicine July/August 2009
partment of Psychiatry at UCLA and the Psychology Department at the University of Madrid, using fMRI scans to study the paradox of metaphor, indicate that more right brain activation occurs when processing metaphor as compared to literal meanings of sentences. In addition, neuroscientists at the University of Haifa and at the University of Tuebingen, Germany, have shown that in addition to right brain excitation in response to metaphor there is increased activity in the left inferior frontal gyrus and bilaterally in the inferior temporal cortices. Paradoxically, all of this indicates that using the brain metaphorically to study the brain may offer a way to use consciousness to understand consciousness. Speaking on his blog about this immeasurable paradox and complexity, the theoretical neuroscientist Joshua Fost offers his own neuroscience metaphor: “The brain is like a world with 100 billion people, each one of whom has 10,000 friends. Each person talks to all of their friends all day every day. But when they talk, they put every single one of their friends on speakerphone simultaneously and say only the most boring things you can possibly imagine.” As in alchemy, our understanding may ultimately depend upon the inclusion of metaphor in our method to develop what someday will become a neuroscience of consciousness. As Carl G. Jung, the analytical psychologist who introduced a metaphor to psychology, said, “The experiences of the alchemists were, in a sense, my experiences, and their world was my world.” As above, so below.
www.sfms.org
Neuroscience and Perception
Magic and Neuroscience Turning Tricks into Research
Stephen L. Macknik, Mac King, James Randi, Apollo Robbins, Teller, John Thompson, and Susana Martinez-Conde
M
agic shows are a manifestation of accomplished magic performers’ deep intuition for and understanding of human attention and awareness. By studying magicians and their techniques, neuroscientists can learn powerful methods to manipulate attention and awareness in the laboratory. Such methods could be exploited to directly study the behavioral and neural basis of consciousness itself, for instance through the use of brain imaging and other neural recording techniques. Magic is one of the oldest and most widespread forms of performance art. It is also a discipline with a long legacy of informal experimentation. This informal research by magicians aims to determine what conditions allow for the maximum manipulation of human attention and perception. Much as early filmmakers experimented with editing techniques to determine which technique would communicate their intent most effectively, magicians have explored the techniques that most effectively divert attention or exploit the shortcomings of human vision and awareness. As such, magic is a rich and largely untapped source of insight into perception and awareness. Insofar as the understanding of behavior and perception goes, there are specific cases in which the magician’s intuitive knowledge is superior to that of the neuroscientist. Visual illusions—and other sensory illusions—are phenomena in which the subjective perception of a stimulus does not match the physical reality of the stimulus. Visual illusions occur because neural circuits in the brain amplify, suppress, converge, and diverge visual information in a fashion that ultimately leaves www.sfms.org
the observer with a subjective perception that is different from the reality. Visual illusions are often used by neuroscientists to dissociate the neural activity that matches the perception of a stimulus from the neuronal activity that matches the physical reality. Recording neural activity (by fMRI, electroencephalogram, magneto-encephalography, and so on) in someone who is watching magic tricks that are accompanied by humor might help researchers determine the potential interaction between the allocation of attention and the sensation of mirth. If neuroscience researchers succeed in adopting magical methods with the same alacrity as professional magicians, they too should be able to control sensory awareness precisely and in real time, while at the same time assessing the neural activation that is associated with it. This excerpt is from an article that
can be found in its entirety on the advance online publication Nature Reviews Neuroscience, July 30, 2008. Stephen L. Macknik is director of the Laboratory of Behavioral Neurophysiology at the Barrow Neurological Institute in Phoenix; Mac King is a premiere comedy magician performing on television and in Las Vegas; James Randi is a retired professional magician, author, lecturer, and amateur archaeologist and astronomer; Apollo Robbins is a unique combination of magic performer, speaker, and consultant who makes his living as an honest thief; Teller has been a professional magician, writer, actor, and director for thirty-three years; John Thompson is regarded in magic as the most versatile and knowledgeable performer and consultant/director; Susana Martinez-Conde is the director of the Laboratory of Visual Neuroscience in the Department of Neurobiology at the Barrow Neurological Institute in Phoenix.
The New Membership Directory Available Now! The 2009–2010 SFMS Membership Directory and Desk Reference went out in June. This year’s Directory features a beautifully redesigned look and revamped content, with an expanded and updated Health Organization and Services section as well as a tear-out card you can use to make updates to your contact information. This trusted health care resource will also be available for sale. Members can order extra copies for $45, a significant discount from the nonmember cost. If you know of nonmembers who wish to purchase the Directory, they are available for $75, s/h included. To order additional Directories, contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@sfms.org.
July/August 2009 San Francisco Medicine
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Neuroscience and Perception
Understanding PTSD Mind and Brain in Posttraumatic Stress Disorder
Mardi J. Horowitz, MD
U
CSF has recently opened a specialty clinic focused on the evaluation and treatment of Post Traumatic Stress Disorders. This clinic is concerned with mind/brain interactions and is studying the causal basis of symptoms so as to improve treatments. We are aiming to improve our theories about: • The relationship of PTSD to other manifestations of anxiety such as phobias, panic symptoms, and obsessions • The functions of suspected fear circuitries in the brain • The tendency for PTSD to lead into comorbid substance abuse and major depressive disorders In the current Diagnostic and Statistical Manual version IV, text revised (DSM-IV-TR), PTSD is diagnosed by the A, B, C, D, E, and F criteria. The A criterion is experiencing a terrifying event. The B criteria are intrusive thoughts and feelings; the C criteria are significant avoidances of ideas and emotions; the D criteria include hyper-arousal symptoms such as acute startle and alarm reactions. The E criterion is duration of more than one month and the F criterion is significant distress or impairment in functioning. In our PTSD clinic, we are reformulating the B, C, D criteria in terms of representing problems in lower to higher functions that may suggest alternative types of therapeutic interventions. Lower functions seem to involve the amygdala and other limbic modules. Primary symptoms such as startle reactions may occur when perceptual systems deliver stimuli to overly sensitive synaptic connections. Functionally, the result is hypervigilance, a cardinal PTSD symptom. Hypervigilance leads to fatigue, and so
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can evoke more complex symptoms. The overall result can increase disability by exacerbating other medical conditions. When primary symptoms are predominant, then optimum psychotherapeutic approaches may include efforts at calming, restoration of coping functions, and extinction of associations by guided desensitization to trauma-associated stimuli. Although beta blockers and antianxiety medications have been found to be useful in some individual cases, they are not typically helpful in most cases. Secondary symptoms involve intrusive, distressing recollections of the event. These memories can involve a feeling of loss, of personal remorse for inaction, or fantasies of being hurt or dismembered like other victims. These intrusive thoughts and memories can be experienced while awake as unbidden images, and while sleeping as nightmares. Loss of a retirement fund during an economic crisis can lead to repetitive worrying with an inability to think about productive strategies to deal with the financial downturn. Such secondary symptoms are often superimposed on primary symptoms and exacerbate the primary symptoms. Efforts to restore control of emotions can lead to excessive numbing of feelings about certain emotionally laden topics. That in turn may block the corrective cognitive processing that can lead toward resolution of PTSD symptoms. The psychotherapeutic techniques to help master such complex symptoms usually involve exploring with the patient the specific meanings of the stressor event and how these meanings relate to their feelings about themselves. Tertiary symptoms may include
San Francisco Medicine July/August 2009
feelings of lowered self-esteem, with a sense of oneself as bad, worthless, and ineffective. This may lead to feelings of vulnerability and hopelessness. The traumatic event and the person’s reaction to it become an irrationally exaggerated and negative part of how someone feels about oneself. These secondary and tertiary symptoms of PTSD probably involve complex neural nets, huge numbers of synaptic alterations, and interneurons in tracts between amygdala, hippocampus, paralimbic, frontotemporal, and prefrontal cortical projection areas. Complex memories and meanings about the traumatic events and oneself are stored and revised in these arrays of connectivity. The tertiary type symptoms probably involve the most complex neural nets in areas of the prefrontal cortex. Little is yet known of the neurotransmitters and protein changes that might be specific to such circuitry in the human brain. SSRIs, however, have been sometimes helpful in some cases where increased emotional self-governance may be reported. Tertiary symptoms involve repetitive interpersonal maladaptive patterns that can lead to undermodulated states with intense feelings of guilt, rage, and shame in addition to the fear reactions found when primary symptoms predominate. Having tertiary symptoms in addition to primary and secondary symptoms may indicate the treatment need for specialized psychotherapeutic techniques derived from psychodynamic case formulations and attention to unconscious as well as conscious mental processes. The PTSD program at Langley Porter Psychiatric Institute specializes in providing clinicians www.sfms.org
with valuable second opinions on these clinicians’ ongoing psychotherapies of individuals suffering from complex PTSD syndromes. When tertiary symptoms such as mistrust of others, rage at feeling rejection by others, or consistently feeling like a victim predominate in a symptom picture, then psychotherapy techniques should enhance identity coherence and reduce confusional states. The most common confusional states of mind involve difficulty in differentiating between one’s own feelings and the feelings of others and lack of the ability to differentiate between thoughts and actions. When these issues are addressed, the result is usually an improvement in self-governance of emotion, improved positive mental states, and symptom remissions. As researchers and clinicians in the area of PTSD, we envision that outcome assessments of the future will be able to use methods that are more sensitive than clinician and patient rating scales; the hope is to add the use of biomarkers yet to be validated or even discovered. For example, we may use repeated brain scans such as functional magnetic resonance imaging or position emission technologies. We have yet to fully understand how all this works. We think the brain circuits involved may be affected by prolonged exposure to stress hormones and that the circuits increase their sensitivity when exposed to the effects of brain injury and substance abuse. Loss of functionality can have a deleterious effect on attention deployment which can lead to concentration deficits and an increase in intrusive experiences. Inability to inhibit priming of a traumatic memory can then evoke the dreaded states of mind that lead to diagnoses of PTSD. PTSD is a valid, important, and problematically complex diagnostic issue. Research continues to improve our understanding of the interactions among biopsychosocial factors and amplify the effects of existing evidence-based treatments. Mardi J. Horowitz, MD, is a professor of psychiatry at the University of California, San Francisco. www.sfms.org
References Horowitz, M.J. Treatment of Stress Response Syndromes. Washington, D.C.: American Psychiatric Publishing Inc., 2002. Horowitz, M.J. Essential Papers on PTSD. New York: New York University Press. Neuroscience and Perception Continued from page 12 . . .
and responses. Investigation of learning has focused on the temporal lobes beginning with the well-studied patient HM. After complete surgical removal of both temporal lobes, including most of the hippocampus, to treat refractory seizures in 1953, he was found to be unable to learn new information. The hippocampus is structurally and functionally unique. Unlike cortical areas that contain mostly reciprocal connections, the hippocampus functions primarily as a unidirectional circuit. Different regions of the hippocampus are thought to contribute to diverse functions, such as episodic memory, spatial learning, and declarative memory. Neuronal changes underlying learning and memory involve long-term potentiation (LTP) and long-term depression (LTD) of activity. Evidence from mouse models supports the idea that this is achieved through modulation of AMPA and NMDA receptor subunits. Additional hormones influence dendritic morphology and synaptic plasticity with interaction at hippocampal receptors. Leptin and insulin both modulate LTD and LTP in the hippocampus through NMDA and AMPA receptors. Estrogen is more complicated, with numerous receptor systems and inherent differences related to brain age that modulate its effects on dendritic morphology and synaptic plasticity. Estradiol has been shown to increase dendritic spine density and performance on memory tasks in animal models. We will see more about dendritic spines, as they appear to be a primary source of excitatory activity at the synapse. Like astrocytes, their number and
diversity has increased in more complex nervous systems. The role of testosterone is more elusive but is also under study. Protein synthesis has long been identified as essential for the formation of long-term memories. Neuronal activity induces gene transcription by modulating transcriptional activators and repressors. Recent work has identified micro-RNA present at the synaptic junction to be involved in modulating protein synthesis. The expression and incorporation of new proteins at the synapse is essential to learning and synaptic plasticity. Numerous neurotransmitters are involved, allowing emotion to further influence our reactions. Much of this interaction in the CNS is based on inhibitory input to achieve a balance of activity. The serial flow of excitatory signals along chains of neurons is modulated by GABAergic interneurons. This cell group likely comprises 15 to 20 percent of cortical neurons, with different structures, firing patterns, and activity. Coordinated inhibition ensures that excitatory trajectories are properly routed and modified to an appropriate output. So with improved imaging and analysis of activity at the microscopic level, we have moved from the concept of single cells in discrete brain regions providing images or memory to the concept of integrated systems. With increasing understanding, we can better modulate input at the macroscopic level to affect change at the microscopic level. This takes us back to the routine office encounter, where we preach about the importance of physical and mental health to our patients in whatever circumstance they may be. It is wise to take a deep breath and heed our own advice. Perhaps we can reset the clock.
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Neuroscience and Perception
Clarifying Autism How One Brain Disorder Can Benefit from Better Neurological Understanding
Fernando Miranda, MD
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he disorder commonly referred to as autism is currently diagnosed almost entirely on the basis of observable behavioral symptoms. Autism comprises an entire spectrum of behavioral conditions of varying severity, characterized by a combination of stereotypical behavior, impaired social interaction, communication disturbances, and an inevitable mental retardation compared to normal. Hence, it is often referred to as “autism spectrum disorder.” Two statements about autism can be made unequivocally. First, autism is a disorder that is localized in the central nervous system—specifically, the brain. Second, the above-mentioned behavioral markers do not provide a clear indication of where in the brain the problem lies. Thus it is safe to say that being diagnosed with autism entirely on the basis of behavioral symptoms, and without looking at the brain, is analogous to an ophthalmologist observing symptoms of blurred vision and difficulty reading in an individual and diagnosing them as myopia or astigmatism, without directly examining the eye. Furthermore, being prescribed medications entirely on the basis of a diagnosis would be analogous to the ophthalmologist prescribing a generic pair of glasses labeled “myopia” or “astigmatism” to treat any and all symptoms of blurred vision or reading difficulties. Were such an ophthalmologist to exist, no one in their right mind would go to him for reliable, methodical treatment for blurred vision. In neurology, all observations are augmented with objective and quantifiable tests that examine the brain in much the same way that the ophthalmologist
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examines the eye before making any diagnosis or prescribing any treatment. In the case of autism, we use MRI imaging to examine the anatomy of the brain. Specifically, it is used to look for abnormalities in neuronal migration, deficits in connectivity of the corpus callosum across hemispheres, presence of cysts that may be impinging on the brain parenchyma, and/or asymmetries between the two cerebral hemispheres that manifests as abnormal ventricular sizes (indicating lack of growth) or hyperplasias (indicating excessive cell proliferation) of the temporal lobes, frontal lobes, and prefrontal regions. MRI scans have established the importance of the dominant hemisphere in language, as well as the dorsolateral, ventromedial, and orbitofrontal regions of the prefrontal cortex in frontal lobe syndrome. We also use MR spectroscopy to study the composition of the brain matter in the frontal regions, basal ganglia, temporal regions, parietal regions, and the cerebellum. Specifically, NAA (Nacetyl aspartate), creatinine, and choline indicate the presence or absence of cell abnormalities in the white matter. Other abnormal peaks may indicate other abnormalities. For example, we have found that glutamate levels that are lower than those expected for age may explain the hyperexcitability in some of our patients. In addition to the structure and chemical composition of the brain, it is crucial to look at brain function in patients with autism. The language hemisphere is significantly more complex than the visual cortex (Casanova,). However, both regions
have a similar multicolumnar, functionspecific arrangement of neurons. In children with autistic spectrum disorder (ASD), many of these columns become disarranged due to a destruction or injury of the afferent nerve fibers, resulting in an interruption or elimination of nerve impulses, a phenomenon known as “deaffernation.” It is now well established that nerves that do not receive appropriate innervation due to such deaffernation become hyperactive. Clinically, this is manifested as the presence of paroxysmal discharges. Using dense-array EEG, we have identified such paroxysmal discharges in at least 60 to 70 percent of children with ASD. Moreover, at least 30 to 40 percent of children with ASD will have, or have had, at least one or two generalized seizures during their lifetimes. Hence it is extremely important to identify the presence or absence of paroxysmal discharges in children diagnosed with ASD and to determine whether the antiseizure medication used to control such discharges will successfully improve the child’s cognitive and behavioral function. There are many antiseizure medications currently available, such as Lamotrigene, that produce very little, if any, cognitive side effects. Temporal lobe epilepsy (TLE) can often occur in the language hemisphere, producing retardation in language processing. Recent literature indicates clearly that children with Rolandic epilepsy, which was previously considered to be benign, suffer from a retardation of language progression and a series of other Continued on page 30 . . . www.sfms.org
Neuroscience and Perception
Nuland on Neuroscience Sherwin Nuland, MD, on the “Jangled Connections” of the Brain
Steve Heilig, MPH
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herwin Nuland, MD, is one of the most renowned medical authors of our time. A longtime Yale professor of surgery, he was already a noted historian of medicine when his book How We Die won the National Book Award in 1994. His dozen books and numerous articles range widely over his professional and personal interests, with his most recent book being The Soul of Medicine. SFM: From the perspective of medical history, what do you think about the explosion of recent knowledge and speculation about neuroscience?
Sherwin Newland: It’s actually pretty straightforward for me—the more we have understood the structure of the brain and its biomechanics, the more we have sought causes for behavior based on organic factors. And I’m very much afraid that this might be a wild-goose chase in the long run. We’ve now reached the point where we have found certain brain cells in other species, such as whales, that are similar to certain cells in the cortex of humans; and if those cells are thought to do with emotions and feelings, then we hear that those species have similar emotions and feelings. I can’t buy a lot of this, and I think we are going through a phase that we will have to step back from within the next fifteen to twenty years. But isn’t it natural tendency to try to ascribe behavior to biological factors?
Perhaps—it’s a recurring thread in the history of science. In the mideighteenth century, for example, doctors www.sfms.org
and others got the notion that if they understood the structure of the body well enough, they could understand all its function and diseases as well. This became anatomical pathology. Later we discovered that changes important to diseases were not just anatomical but physiological—which means biochemical, essentially. So science in this regard went from trying to explain everything mechanically to later realizing there’s a lot more to it than that. And I think that’s what’s happening with our notions of the brain—we’re now in this anatomical phase. What do you think the human motivation is toward that sort of reductionism? Well, we want to be able to explain everything! We don’t want to admit that we will need thirty or forty years to know brain chemistry better and then find specific genes. But even there, we will have to stop and remember that even genes are variable through the course of a lifetime. Do you see any dangers to the sort of neo-Darwinian speculations of Richard Dawkins and others who attempt to link everything to genes? It takes away from progress by focusing so much on anatomical factors that people tend to ignore physiological and other ones. And then there is this tendency, when we discover one genetic characteristic, to say this is fixed, that a child born with it will never change—that it is “hard-wired,” a term that sends shivers down my spine as I just don’t believe
it. Finally, from a more sociological or demographic point of view, if you begin to find a particular genetic trait in one group more than another, you begin to generalize that this trait will always be there. But genes are not really destiny. You’ve written about your own personal struggle with a neuroscientific malady, severe depression.
What’s interesting here is that diseases like depression and the major neuroses had been thought, thanks to Dr. Freud, to be emotional or psychodynamic and related wholly to early childhood experiences and so on. But as we’ve gotten more focused on anatomical changes in the brain and are beginning to understand physiology better, even the psychoanalysts are saying that behind many of the major neuroses and certainly the psychoses lies a biological invariance. And I have trouble with that, since I remember so well my own experiences with depression. And there is a lot more that is volitional than one might think by listening to the present-day descriptions of people, who are said to be fixed and determined to develop bipolar or other disorders.
You’ve described your own depression as being situational as well, triggered by events.
There is no question about that. And I’ve also noticed that in recovery there comes a point where one’s own basic decisiveness to get better is a major factor. So I can’t believe that if the biological factor is
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Nuland on Neuroscience Continued from the previous page . . .
so strong, the conscious decisiveness can be as important as I have found it to be. How do you think that works—do you think you’re actually changing your neurochemistry by decisive action?
There’s a good chance of that, yes. I think you can change your own neurochemistry. I do not believe that anything here is smoky and spiritual and shadowy, but that everything has a basis in neurophysiology—there are a lot of factors in brain anatomy we can change, so there must be many in physiology too. You have said that the electroshock treatments you underwent “got all the jangled connections cleaned out.” What did you mean by that?
That’s what it felt like! The brain is a vast system of communication, and even though it weighs only three pounds, it has 30 billion nerve cells and at least a million billion connections or synapses within every cell. So of course connections and messages can get scrambled in patients who are emotionally ill. And thus, for all sorts of reasons, you start making the wrong choices. But again, you can address that by changing neurochemistry. Many have observed that this is one of the functions of meditation, for example.
Oh, no question—when you’re meditating, you are essentially changing a whirlwind of stimuli into pathways that are less dangerous to one’s health. Do you have an opinion on what the priorities for ongoing neuroscientific research should be?
Well, you can’t get anywhere without starting with the anatomy and brain structure, as people are now doing. I think that one of the most important things that is being worked on, and it probably always will be important, is how genes
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may change in how they’re expressed. This tells scientists that this is not a fixed response; the mere fact that you have the same genetic pattern in two individuals does not mean that they’re going to be the same in other ways. So studying how individual genes express themselves differently in people is amazingly important, as is the ongoing research on the basic chemistry of the brain. And synaptic changes have not been touched on enough, as we do know that certain synapses change over a lifetime—there is plasticity among the synapses. A simple example of this is that it is well known that people who are intellectually active into their seventies and eighties and nineties are more likely to be capable of that intellectual activity. We even know that there are certain protein factors that can affect the synapses and the amount of blood supply that goes to a particular part of the brain, or that can prevent damage to the cells themselves, as in the case of brainderived neurotrophic factor, the name given to these substances produced in the brain that help determine the efficiency of neurotransmission.
The theme of this issue of the SFMS journal might have the term “mystery” in the title. What remains most mysterious about neuroscience to you? I’ve been fascinated for a very long time by the question of what is this thing we call the human spirit. Is there some spiritual thing we have that is extracorporeal and doesn’t arise from our internal chemicals? If we like symphonic music, for example, and we hear some piece that we love, we can feel things swell up in our chest. What is that? And as for music, I noticed some time ago that in the music that young people have loved so much since, say, the sixties, you can almost always hear the heartbeat in the background—there’s a beat to it that you can recognize as the “lub-dub, lub-dub” of our hearts. Why is that universal, as drumming is universal in the kind of cultures we call “primitive”? There is something going on there that I think is based on brain structure and function, but I would
love to see that structure and function correlated with the emotions we feel so strongly at times. Scientists are talking about “genes for emotions,” but I’m having trouble with that. I think that there are factors within us that that have been built up by experiences that may be even deeper than Freud’s unconscious. There may be something that we’re aware of on some level that arouses a sympathetic response.
In fact, the famed San Francisco band the Grateful Dead were among those who consciously tried to emulate the heartbeat at times, with their drummer even recording his unborn son’s fetal heartbeat; and they strove to evoke the Dionysian celebratory impulse in listeners.
The Greeks were constantly revisiting what they called kosmos versus chaos, and they felt there were forces in this world that want to destroy cosmos, to make things chaotic. But they also felt there were forces to keep things stable. And we know in our bodies there are also forces in every cell, and that for every destructive factor there are those that correct the damage that can be done. This is how we stay alive, by repairing the damage done by free radicals, making new cells, and so on. How did the Greeks come to this notion, which fits so well with our own physiology? I’d argue, with no support whatsoever, that within each of us there is some kind of awareness of this “chaos versus kosmos” battle, and, as with evolution, we seek out bonds and physiological changes that tend toward cosmos, or stability, or what is called homeostasis. One of the great miracles of life is the ability to correct the damage that is occurring in and around all of us.
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Neuroscience and Perception
Proust Was a Neuroscientist An Exploration of Creativity and Neuroscience
Dennis Patrick Slattery, PhD Proust Was a Neuroscientist Jonah Lehrer New York: Houghton Mifflin, 2008
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ike so many of you, I am an avid reader. Probably obsessive would be a closer marker. If I am not reading three to four books at a time, I feel the wasteland opening its maw to engulf me. But in my reading, most books hold my interest but few arrest me in fascination. Recently, one of those rarer texts, Proust Was a Neuroscientist, came across my path courtesy of two friends, Mike Denney and Jane Estelle. Both know me and thought it would be a good platform from which to reflect. When I finished, I had fifty-one pages of typed notes. Surely something was clocking in, helping me realize that reading can be revelatory in a way that takes one way beyond data processing, as well as far past one’s earlier level of awareness. Lehrer’s book trip-wired thoughts I have had as someone who teaches the classics of world literature and mythology from a depth-psychology perspective. One of those thoughts came to me after teaching Dante’s Divine Comedy for a number of years. I became fascinated with his rhyme scheme, which he called terza rima and which he invented for just this poem. Terza rima is a structure for the poem, not its content. It works in the Italian along three lines of poetry, where each of the letters below is assigned to the last word of each of the three lines: A—B—A B—C—B C—D—C You can see how the middle term of one set of three lines becomes the first www.sfms.org
and third rhyme of the next set of lines. Dante keeps this rhyme scheme going for more than 14,000 lines of poetry. I began to wonder, might this not be how the mind or imagination structures experience— always recursive, always folding back on itself, revisiting but not quite repeating itself in ever-recursive feedback loops that deepen understanding? Then I came to the end of Lehrer’s book, a chapter devoted to Virginia Woolf’s brilliant insights on the nature of the self and of consciousness through two of her novels, To the Lighthouse and Mrs. Dalloway (though her wisdom does not end with them). Lehrer points out in several reflections that Woolf came to an understanding that neuroscience has only recently acquired: “The brain is the universe’s largest knot. Each of the brain’s neurons is connected with up to a thousand other neurons. Consciousness derives its power from this recursive connectivity” (p. 187). Here, in other words, is Dante’s poetic structure as a pattern of consciousness itself. A second set of revelations came to me in my pleasant task of trying to read the bulk of Joseph Campbell’s works in preparation to teach a course on his thought. One of those that took hold of me was a series of conversations with Stanley Keleman, held over decades and published in a slim volume, Myth and the Body: A Colloquy with Joseph Campbell. There the two men speak at length and in depth about how myth arises from the organs, tissues, and even body type of our enfleshed being. In fact, in another of Campbell’s works, he labels one chapter “Bios and Mythos.” He was fascinated, as
he admits to Bill Moyers in The Power of Myth, by the idea that myths originate from the energies of the organs of the body in conflict with or in complement to one another. Lehrer’s superb study of figures such as Walt Whitman, George Eliot, the famous chef Auguste Escoffier, Marcel Proust, Paul Cézanne, Igor Stravinsky, Gertrude Stein, and Virginia Woolf shows that each—in their respective works that include poetry, writing, cooking, music, and painting—revealed a major insight or observation that intuited and predated a related major discovery in the relatively new field of neuroscience. I see this new poetic physiology as opening fascinating and profound ways of rethinking the body, self, consciousness, the nature of fiction, and our own fundamentally fictional nature. Indeed, we each have a strangely and mysteriously loopy, recursive fictional self that, in the process of repeatedly remembering our past, we tend to further fictionalize—and we recollect it less accurately with each iteration of memory. The paradoxical trade-off is that we grow closer to its felt meaning in exactly this creative process. The excitement I felt in reading Lehrer’s commentary and his factual data on the above characters is that we are in actuality such stuff of which fictions are composed. Other causes of neuron-firing excitement for me were the many implications Lehrer opened me to think about regarding the nature of myth and story. Through his study of the artists, he points out repeatedly that in our “self,” which neuroscience continues to attempt to find the source of (if only it could pinpoint
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the right fold of the neocortex in which the little critter may be hiding), we can designate the origin of what is loosely called self-consciousness. But even neuroscience is coming to recognize that the self and consciousness are part of a process of imagining or fictionalizing the self, and not a place or location. The self and consciousness are more akin to gerunds—verbal nouns—than they are to the nouns that name things. Like stories, consciousness is a fiction that moves us closer to the truth of our identity. Enter mythos. Lehrer’s book in many places allows me to realize that myth is deeper than story or narrative, deeper than its original meaning in muthos, or “word.” When we open our muthos, we speak our mythos, as the Greeks discovered in antiquity. But Lehrer’s study pushes myth back, earlier than story, to energy, electricity, and powerful firings in parts of the brain. Here I bring in the poetic text. I love to read key passages aloud in class, or ask students to read them aloud, so that we can work on them together and, in the process, rework ourselves. I call it “archetypal imaginal reading.” Lehrer has convinced me that I am on the right path. Literature and poetry are crafted artifacts—I almost wrote artifictions and will leave the error in. When we read a great classic, like Homer’s Odyssey, Melville’s Moby-Dick, or Toni Morrison’s Beloved, we enter imaginatively into that world by way of what the Greeks called mimesis. A tricky term, it points out that some deep action of the soul—and now I want to add the body—is generated, evoked, agitated through the plot, which we can enter because it carries so many analogies to our own life story. But the deeper action is, I now believe, neurologically mythic or mythically neurological, because the story’s action, deep in the folds of the brain of the narrative, kindles some similar structural awareness in us. So it is not just the story but its very structure that orders, reframes, realigns our own story through neural pathways that are at the same time poetic pathways, since the self,
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as Lehrer reveals through neuroscience, is an elaborate fiction. Mimesis is both imaginal and matter-aligned in the body. Not a lie, literature is a fiction by which we gain greater access to the intimacy of our lives by means of the energy patterning that the classic narrative holds for us. Mythos, as the deep structure of the story while it is also the deep structure of ourselves both physically and imaginatively, is tested and tests us by means of its mimetic veracity. To the extent that the story is true for us mythically, it is true for us neurologically. Furthermore, in the very exciting and complex act of not just reading but of rereading, neural pathways are cut more deeply into us. Literature, one of my best teachers of poetry would repeat to us, can transform one’s thinking and behavior. Lehrer reveals that such a statement is not a romantic fallacy but a physical probability. Rereading becomes so important because it is a richly elaborate way of remembering. Remembering, as Proust realized in his magnum opus, newly translated as In Search of Lost Time (p. 75), is not necessarily a remembrance of things as they were, “ . . .because memory obeys nothing but itself” (p. 95). From this observation Lehrer posits that “the past is never past. As long as we are alive, our memories remain wonderfully volatile” (p. 95). The power of myth, if I can end in a reframing of Joseph Campbell’s title to his most popular book on mythology, is that it (1) originates in the memory; (2) is physiological and psychological with no gap between the two; (3) is something we depend on in order to see or bring attention to something—no mythos, then no perception; (4) restructures the meaning of the past in continual ways throughout a lifetime, trying to get the story to be as true to our self as possible; (5) is indeed electric, energetic, a force field of power that courses through the lines of our neurology and our lifeline of meaning in a continuous recursive action of redefining, reinventing, and revitalizing this illusive fiction we loosely label as the self. All art, but especially poetry, in my slanted view, moves us closer to the events of the world as ordered, selected,
San Francisco Medicine June July/August 2009 2009
surmised, and interpreted than any objective events of our past. The mythic self is the mysterious inner fold of our being that engages events and prompts them into meaningful experiences; without this mythic self, as Lehrer intuits and as neuroscience confirms, nothing would matter because our life events would never reach the conscious level of experience, nor would they ever be able to pattern themselves into a meaningful whole. Such is the mystery of a self lying deep in the fissures of our neurological pathways, where body and brain collectively dismiss the language of split or separation. Neuroscience, mythology, and the elaborate fiction of memory and memorial fictions have entered a new galaxy of collaboration. Very exciting. Now on to Proust and the Squid: The Story and Science of the Reading Brain by Maryanne Wolf. Proust is indeed making the rounds. Dennis Patrick Slattery, PhD, is core faculty in the Mythological Studies program at Pacifica Graduate Institute. He is the author or coeditor of fourteen books. His most recent include, with Glen Slater, Varieties of Mythic Experience: Essays in Religion, Psyche, and Culture (2008); and, with Jennifer Selig, Reimagining Education: Essays on Reviving the Soul of Learning (2009). He is currently completing a book called A Daily Meditation in Dante’s Divine Comedy.
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Neuroscience and Perception
What’s Love Got to Do with It? fMRI Evidence for Distant Healing Connections
Jeanne Achterberg, PhD
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rom the beginnings of medical history, humans have had a belief that there is a spiritual or mind/body connection to others who are separated from them at a distance. These beliefs have been held as the basis for prayer, so-called energy healing, and the general ability to heal others at a distance (nonlocal or transpersonal healing). Despite the longevity of the concept and the fact that humans are empiricists (we continue activities that appear to be efficacious), these phenomena are largely dismissed by the advocates of the biomedical model because they do not align with the theoretical infrastructure of the current scientific paradigm. In 2001, Dr. Earl Bakken (developer of the pacemaker, founder of Medtronics, and a generous spirit) invited me to begin a six-year study of prayer and distant healing at North Hawaii Community Hospital, on the Big Island of Hawaii. The setting was ideal. It had been recognized as a healing island by native Hawaiians for many generations, the natural resources for health are abundant, and numerous types of healing arts are practiced. The small hospital is committed to a vision of combining ancient, allopathic, and integrative medicine and has received international attention for its architecture and mission. An imaging center houses state-of-the art technology, including an MRI scanner that has the software for performing functional MRI’s (i.e., fMRI), allowing for information on brain function and dynamics, as well as structure. The primary question for the first phase of the study was: “Does distant healing intentionality have an effect on the brain function of those who receive www.sfms.org
it?” Distant Healing Intentionality (DHI) is a relatively new term that includes any form of practice conducted while being physically separated and sensory isolated from the person or persons seeking healing. The healers who were recruited for the study represented a variety of specific DHI practices including Healing Touch, pule (a traditional Hawaiian practice that includes prayer, chant, song, and the breath), Reiki, Qigong, Peruvian shamanic healing, vibrational healing, and eclectic methods that combined several forms of distant healing. Initially, eleven pairs of healers and recipients were studied. The healers were eligible for inclusion if they practiced some form of DHI and were acknowledged by their communities as having received the appropriate training and apprenticeship for their work. Their abilities to heal could not be tested in a pilot study of this nature, but rather “proof of principle” was sought regarding interconnectedness. Each healer was asked to name a client/patient who would be willing to have a 35-to-40 minute MRI, and with whom they felt a special bond, or empathic connection. The researchers (a nurse and myself), the healer, and the radiology technician were in a control booth shielded from electromagnetic fields, and isolated from all known physical connections with the person in the scanner. The healers were asked to send DHI in a way prescribed by their own training and practice at two-minute off-and-on intervals signaled to them by a researcher. The design is considered blind because the individuals in the MRI did not know when the distant intentions were being sent—a very im-
portant feature of this research. The results of the study were highly significant. Nine of the eleven individuals receiving a scan had major and significant changes in brain function when they were sent DHI (as compared with the brain activity during the “off” or control time), even though they did not know when they were receiving it. Their brains lit up like Christmas trees during the DHI times. When the results of the eleven pairs were combined, the significance level was less than a probability of .000127 that the results could have happened by chance alone. The individual receivers of the DHI had slightly different areas of their brains activated, but, as a whole, the frontal lobes, the cingulate cortex, and the precuneus were activated. The study was expanded to a second phase, to address the questions (1) “Is there evidence for correlations between DHI and brain function in recipients of DHI who are unknown (and nonempathically bonded) to the healers?” And (2) “Are there significant differences in brain function between empathically bonded versus nonbonded healers and clients/patients?” In other words, “What does love have to do with it?” or, more apropos to the topic of this article, “What, if anything, does empathy contribute to a DHI connection?” A limitation of addressing the second question is that only three healers in the first group were willing to participate in a second study, primarily because they expressed a fear of being so close to the source of electromagnetic energy a second time, and that it might impair their healing abilities. This does not reflect my personal beliefs, but it is of vast
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What’s Love Got to Do With It? Continued from the previous page . . .
importance to honor the belief systems of research participants. Furthermore, only one healer (a Qigong master), and two participants receiving MRI’s in the first group were willing to have another scan. Nevertheless, there were significant results. The short answers were “No, there was no evidence for DHI and brain function when the nonbonded group as a whole was analyzed.” And, “Yes, there were significant differences in brain function during the DHI sessions when bonded versus nonbonded pairs were compared.” An empathic or bonded connection seemed to lend the DHI validity and potency. My work was underway when two large, randomized, carefully controlled studies failed to find any effect of prayer on the physical health of cardiac patients. In one instance, prayer had a negative effect on outcome. The studies, conducted at Harvard and Duke Medical Schools, were given extraordinary amounts of attention in the public press—one newspaper headlined, “Obituary for prayer!” Yet, when the studies are closely examined, it is obvious that they were designed to eliminate a personal, empathic relationship. The persons who prayed did not know the patient participants and had scant information about their circumstances. In one of the studies, only first name and last initial was provided to the prayer groups. Larry Dossey, MD, a well-known spokesperson in this field, observes that nowhere in the world is prayer conducted in this fashion (randomized, double-blind, controlled trials), and people generally pray for loved ones whom they know and care for, and in the context of ceremony and ritual. The current gold standard of scientific research therefore dooms the results of DHI to failure by systematically eliminating the active ingredients of the treatment. The positive findings from studies of DHI have been summarily dismissed by scientists, journal editors, reviewers, and mainstream health care professionals who state there is no known biological mechanism to account for the results,
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and therefore the phenomenon cannot exist. This argument used to discount novel findings is weak because scientific models change drastically over time. The introduction of quantum physics last century is a case in point. In the instance of DHI, Entanglement Theory, posed by quantum physicists (Einstein, Podolosky, and Rosen) provides a possible description for the connectedness results. This theory, which Einstein referred to as “spooky action at a distance,” asserts that once photons come into contact, their subsequent activities are inexplicably connected forever in nonlocal fashion. Entanglement Theory, like quantum physics generally, took the popular culture by storm, even though it was initially based on thought experiments only. Recently, though, evidence has been mounting that points to the possibility of entanglement in macrosystems, such as human neurons, or, perhaps, as the fMRI studies suggest, between whole human beings who know and care for one another. A current stance on the neuroscience forefront is the heralding of the mirror neurons in the brain as being as important to the study of consciousness as DNA was to biology. Some neuroscientists believe that the mirror neurons may provide a unifying framework to help explain mental abilities that have thus far eluded explanation, including precognitive recognition of the intentions of others and other parapsychological events. Not surprising, mirror neurons are thick in the areas of the brain associated with empathy, especially the anterior cingulate cortex, which in turn serves as a type of executive control, making decisions via networking with cortical and subcortical brain areas. The anterior cingulate cortex was highly activated during the present fMRI research on healing; thus a rich basis exists for the relationship between brain function of mirror neurons, distant or nonlocal healing, and empathy. Larry Dossey again offers his thoughtful insights here: “The psycho-constant in all remote healing studies is empathic bonding and compassion. Perhaps, as scientists get comfortable with mirror neurons, they may finally open up to a form of bonding
San Francisco Medicine July/August 2009
that occurs even when people are outside sensory contact—mirroring without the mirror.” In summary, care, compassion and empathy appear to have an effect on the physical matter of the recipient of DHI. The research is novel, and has the usual flaws of pilot efforts, but the implications of the research for training and clinical work in all forms of health care are monumental. If it is true that intentions create a physical effect in others, even when the recipients are unaware of these intentions, then we have a certain responsibility to consciously monitor our thoughts, not only as health care professionals but as members of the human family. Whether care, compassion, and empathy can be learned or taught effectively remains to be seen, but denying or ignoring the idea could rob health and healing of its most fundamental and vital ingredients. Jeanne Achterberg, PhD, is a professor at the Saybrook Graduate School and is the author of Imagery in Healing: Shamanism and Medicine (Shambhala), Rituals of Healing (Bantam), and Intentional Healing (Sounds True, Inc.).
www.sfms.org
Neuroscience and Perception
Before and After When a Cure is Not a Cure
Nancy Griffiths, MBA, MS, NP
I
t was with more than a little trepidation that I approached the door to the locked unit at the New York Psychiatric Institute’s Schizophrenic Research Center. I was beginning a new clinical rotation in my graduate training as a psychiatric nurse practitioner at Columbia University. Knowing the patients were voluntary commitments alleviated some of my anxiety. I rang the bell, identified myself, and a staff member buzzed me in. The nursing supervisor showed me around the floor, which was occupied by patients undergoing various research protocols for the treatment of their disease. I was there to assess Francisco over the next six weeks—both before and after his treatment. The unit was quiet and open. Some patients were in their rooms, while others were in communal areas, watching TV or sitting alone in their private worlds—accessible to no one but themselves. A few were in the arts and crafts room and two were huddled over a checkerboard. After the quick tour, the supervisor pointed to a small table where I sat down. Within minutes, she returned with a pleasant, well-dressed man. I stood up and smiled at Francisco and asked him to join me. “I’ll be coming to visit with you for the next six weeks,” I explained. He smiled and responded softly, “OK.” Francisco told me he had come to the U.S. from Puerto Rico with his mother when he was in his twenties. He was now thirty-four years old. He was very polite but shy, often looking down when responding to my questions. I understood how his easy smile and eagerto-please manner had made him a favorite with the staff. When I returned the following week, www.sfms.org
Francisco greeted me and sat down at what had become “our” table. Other patients would pass by and wave to him. He would quietly acknowledge them with a smile. “How was your week?” I asked. “My week was fine,” he responded. I asked Francisco to tell me how he had spent the time since I had seen him. “I watched TV with Harry (another patient) and did some art yesterday. My mother visited me and brought some good food.” I laughed, commenting that his mother’s cooking was probably better than the food he was served here. “Yes, my mother brought me some good food,” Francisco repeated. Knowing I needed to gather as much information as I could about Francisco and that he was not able to initiate conversation, I continued, “Do you know why you are here?” “Because my mother gets worried when I talk to my friends.” I probed further, “Can you tell me about your friends?” “They were my friends in Puerto Rico. The three of us did things together. They were very nice to me.” His expression conveyed the warmth he felt for these friends. As we continued our discussion about Francisco’s friends, I learned that none had moved to the States and that Francisco had had no actual contact with them since he had left Puerto Rico. He told me that he never saw his friends when he spoke with them. I ended our session, telling Francisco that I would like to hear more about his friends next time we met. The following week, he greeted me in his usual cordial manner. We picked up our conversation about his friends where we had left off the previous week. His re-
sponses continued to be very repetitive, always incorporating my questions in his answers. “How often do you and your friends talk?” I inquired. “My friends and I don’t talk that much—just sometimes,” he said. After a little more probing, Francisco told me he and his friends spoke several times a month. Knowing auditory hallucinations are quite common in schizophrenics, I delved further into the content of Francisco’s hallucinations to determine if they could be potentially dangerous. “Do your friends ever tell you to do bad things—like hurt someone or yourself?” “Oh no! They just want to know I’m OK,” he replied. When I inquired if Francisco had made any friends since he’d moved to the States, he told me his mother was his only friend. I then asked if he knew why his mother was worried about him talking to his friends. “Because she thinks it means I’m sick, and I need to come here to get better.” I knew that Francisco had been an elevator man but had lost his job because he was caught talking to his friends. His mother was his only relative and was getting older. She worried about her son’s future when she was no longer around to care for him. Consequently, she enrolled him in a research study which involved depleting the dopamine in his brain, using an AMPT protocol with SPECT imagining. Once the depletion was complete and his dopamine baseline quantified, Francisco would be given a new antipsychotic medication that would establish a therapeutic
Continued on the following page . . .
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Before and After Continued from the previous page . . .
level of dopamine and eliminate the hallucinations. I asked Francisco if he knew anything about the treatment he was to receive. He told me that the doctors would be giving him some medicine so they could look at his brain. The first procedure was scheduled for the next day. When I returned the following week, I noticed a dramatic change in Francisco. He looked tired and disheveled. In preparation for his new medication, his brain had been depleted of dopamine, which explained his change in mood and behavior—induced dysphoria. Seeing that he was tired and preferred not to talk, I kept our meeting brief. After I told him I would see him next week, he shuffled off toward the TV room. Upon my arrival for our final session, a more serious and tired-looking Francisco emerged. I asked him if he had been taking his new medication. “Yes,” he responded, “and I’ll be going home soon.” “Have you talked to your friends again?” I asked. “No. The doctor said that wouldn’t happen any more.” He told me his plan was to look for a job when he returned home. His responses to my questions were less repetitive now, and his speech and affect were more normal, from a clinical perspective. “Is there anything more you would like to discuss?” I asked. “No, I don’t want to talk about anything else.” I told Francisco that I would not see him again and wished him good luck. He said good-bye, stood up, turned, and walked away. Later that week, I met with my supervisor and colleagues to discuss my case. I reported that the medication seemed to be working and that Francisco would be discharged very soon. I knew it was critical for him to learn to function independently and be able to support himself, but my eyes welled up with tears as I concluded my presentation. The outcome was successful, but we had taken away his friends and he had lost his smile. 29 28
The San Francisco Medical Society Advocating for Physicians and Patients As San Francisco Medical Society members know, since its inception in 1868 SFMS has been an activist organization when it comes to the health of our community. Many projects and activities that have begun in San Francisco have gone on to have implications for the state and the nation. Here are some highlights from the current SFMS community health agenda.
Agenda for 2009 • Preserving the safety net and public health programs in times of severe budget cuts. Opposing Proposition 1D and 1E in special election. • Testifying in support of antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. With the California Medical Association, submitting amicus brief opposing lawsuit to overturn the ban. • Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in the lawsuit to preserve the program. • Providing physicians for medical consultation for the San Francisco Unified School District. • Working on legislation to allow minors to receive vaccines to prevent STIs without parental consent. • Participating in the Hep B Free program in San Francisco and educating physicians and patients on prevention and treatment of hepatitis B.
SFMS Community Health Activities
REBUILDING AND PRESERVING SAN FRANCISCO GENERAL HOSPITAL: SFMS spokespersons have taken a lead in advocacy for full funding of the necessary seismically sound rebuild and in acting on the Mayoral committee to advise where and how that would occur. Many of our members and leaders trained and have practiced at SFGH. UNIVERSAL ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and most recently our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS recently signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies. HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures. REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medicalindicated services.
San Francisco Medicine June July/August 2009 2009
www.sfms.org
Hospital News Saint Francis Wade Aubry, MD
Saint Francis has recently implemented some changes in the Radiology Department. On behalf of the medical staff, I would like to acknowledge and thank the Bay Area Radiologists (BAR) group for its many years of dedicated and excellent service to Saint Francis physicians since BAR first arrived at the hospital in 1971. The group includes Stephen Benzian, MD; Douglas Sheft, MD; Frank Mainzer, MD; Robert Clark, MD; Jon Shanser, and Michael Staloch, MD. In June, Saint Francis welcomed the Image Guided Therapeutics (IGT) Group, including Michael Taylor, MD; Daniel Lentz, MD; David Priest, MD; Douglas Bourgon, MD; John Didovic, MD; Flora Stepansky, MD; Michelle Nguyen, MD; Murali Ranjithan, MD; and Eric Wang, MD. IGT brings Saint Francis a full complement of radiology services, including PET, CT, MRI, musculoskeletal, and neuro- and interventional radiology. In keeping with this issue’s topic, Saint Francis welcomes the BrightMinds Institute to the hospital campus. Medical Director and Founder Fernando Miranda is considered a leading expert in treating children with learning and developmental delays. BrightMinds is a multidisciplinary diagnostic/treatment center for children with autism, ADD/ADHD, and learning and special needs disabilities. The Institute offers advanced diagnostic testing and medical management for all levels of learning deficits and language disabilities. A collaborative team of doctors, therapists, educators, and psychologists work together to develop a complete treatment plan and continuously monitor each child’s progress. In closing, let me say farewell to the Medical Society readership as the author of Saint Francis Memorial Hospital’s column. My term as chief of staff ended on June 30. I would like to congratulate and welcome my successor, Patricia Galamba, MD, as the new chief of staff and wish her well in her new position. www.sfms.org
CPMC
Kaiser
Damian Augustyn, MD
Robert Mithun, MD
The Stroke Program at CPMC is designed to ensure the delivery of the highest quality, most advanced, and most effective stroke care to our patients in a timely fashion with specialized medical and surgical care, specialized tests, and interventional therapies as outlined by the Brain Attack Coalition recommendations for Comprehensive Stroke Centers. The stroke program at CPMC has continuously achieved a 24-25 percent tPA (tissue plasminogen activator) administration rate annually, which was among the highest rates in the country, compared to the national average of less than 3 percent. The average time for treatment of patients with acute stroke requiring thrombolytic therapy was less than two hours from symptom onset. Over 50 percent of treated patients experienced no significant residual disability after treatment. CPMC is a Joint Commission-certified Primary Stroke Center and received the Gold Performance Achievement Award from the American Heart/Stroke Association in November 2008 for meeting the stroke performance standards at 85 percent or higher for twenty-four consecutive months. The program also has great expertise in the management of brain hemorrhage and other complex cerebrovascular disorders. Our stroke program is a resource for other health care facilities in the greater San Francisco Bay area. Through means of telemedicine or telephone consultation, CPMC stroke physicians provide expert recommendations in managing and triaging particular cases. Our program is also a valuable educational source for other hospitals and health care professionals. Congratulations to Dr. David Lowenberg, who was reappointed Chair of the Department of Orthopaedic Surgery for a five-year term. This is Dr. Lowenberg’s second term as Chair. Congratulations to Dr. Robert Osorio, who was reappointed Chair of the Department of Transplantation for a five-year term. This is Dr. Osorio’s second term as Chair.
Since the explosion of international space programs during the 1960s, mankind has viewed space travel as one of the ultimate feats of human ingenuity. Ongoing advancements in astrophysics and engineering have fermented optimism that one day humans would be able to explore the vastness of the enigmatic universe much as they do in the movies. While tremendous scientific progress toward this vision has been made, myriad roadblocks remain, and none are more glaring than the maladaptive effects of space flight and microgravity on nervous system physiology, especially the vestibular and neuromuscular systems. Exposure to microgravity leads to muscle atrophy, increased muscle fatigue, and reduced power. Return to a terrestrial environment is also commonly associated with profound muscle weakness and soreness. Like the neuromuscular system, the vestibular system poses its own unique challenges in space, as the brain relies on the presence of gravity to correctly negotiate changes in head and body position. The removal of gravitational influences on the vestibular system leads to postural and movement illusions, sensations of rotation, and deterioration of visual fixation. Again, with reintroduction of the Earth’s gravity, many astronauts experience ataxia and lack of coordination. The physiologic origin of these symptoms is not entirely clear but is thought to occur by way of compensatory molecular alterations in nerve and muscle cells, peripheral and central synaptic changes, and systemic hormonal and metabolic alterations. Effective countermeasures have yet to be precisely formulated but will likely be multimodal, including simulated gravity environments, prescribed exercise regimens, hormonal and nutritional modifications, and pharmacologic interventions. Given our limited command of space medicine and neurology, it does not seem that long-term space travel is a very safe option at present.
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Hospital News St. Mary’s
Richard Podolin, MD
St. Mary’s Medical Center has a long history of grappling with the complexities of neuroscience and recovery of brain function after injury. A flagship of St. Mary’s for over twenty-five years has been our inpatient rehabilitation unit, known for treating the most complex brain-injured patients with personalized care in an intimate setting and using innovative technology. Our inpatient rehabilitation Medical Director, Marc Wakasa, MD, continues his close collaboration with the UCSF neurosurgery and neurology departments to facilitate recovery after complex injuries to the brain. Our rehab unit is investigating brain injury outcomes, the relationships between type of injury, functional improvements, and quality of life. Our full-time neuropsychologist, Kevin Carroll, PhD, is beginning collaboration with our recently developed Clinical Research Department to connect the complex array of dots between neuroscience and real-life daily living. St. Mary’s was the first Bay Area facility to incorporate the Nintendo® Wii game console into our program to facilitate recovery, improve motivation, and decrease perceived pain. We are also developing systems of care to maximize the facilitation of recovery and reaching out to the community to meet the specific needs of the brain injured in San Francisco, a place which presents exceptional challenges to the disabled because of the hilly terrain and large public transportation system. Recognizing the complexities involved with neuroscience and brain-injury recovery, we recently developed a rehabilitation services director position. Amit Mohan, PT, will coordinate and lead the rapidly evolving course of neuroscientific knowledge as it relates to injury, hospitalization, intervention, rehabilitation, and reintegration into the community. St. Mary’s strives to offer personalized rehab services and uses technology to aid those who suffer neurological injury.
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Veterans
Diana Nicoll, MD, PhD, MPA
A researcher at the San Francisco V.A. Medical Center has developed a new tool that can help predict whether people age sixtyfive and older have a high risk of developing Alzheimer’s disease. “This new risk index could be very important both for research and for people at risk of developing dementia and their families,” said study author Deborah E. Barnes, PhD, MPH. “The tool could be used to identify people who have no signs of dementia but should be monitored closely, allowing them to begin treatment as soon as possible, and potentially helping them maintain their thinking and memory skills and quality of life longer.” The risk index is a fifteen-point scale. People who score eight or more points on the scale are at high risk of developing dementia in the next six years. Several of the items on the scale are well-known risk factors for Alzheimer’s disease, such as older age, low scores on tests of thinking skills, and having a gene that has been linked to the disease. Other factors predicting dementia risk were more surprising: People who are underweight, do not drink alcohol, have had coronary bypass surgery, or are slow at performing physical tasks such as buttoning a shirt are more likely to develop dementia than people who do not have these risk factors. To develop the index, researchers examined 3,375 people with an average age of seventy-six and no evidence of dementia and followed them for six years. During that time, 480 of the people, or 14 percent, developed dementia. The researchers then determined which factors best predicted who would develop dementia and created the point index. Barnes said the risk index will need to be validated with other studies, and she and her colleagues are evaluating whether a shorter, more simplified index could be as accurate as this index.
San Francisco Medicine June July/August 2009 2009
Clarifying Autism Continued from page 20 . . .
neuropsychogical deficits that impede learning. At BrightMinds Institute, we have documented numerous “mile markers” for children who have not developed language, as well as for children who have a communication disorder (verbal or nonverbal) but appear to have intact social interactions. In testing, it is also crucial to obtain a sleep EEG, since the majority (80 percent) of epileptogenic discharges will occur at nighttime, during sleep or in transitions between sleep and wakefulness. In addition, if the child is of age and able to communicate to some degree, careful neuropsychological testing is desirable not only to provide developmental landmarks for reference but also to pinpoint the child’s unique areas of excellence so as to foster the child’s learning. We have also observed that neuronal connections are created and reinforced through behavior modification and training. We have yet not invented a pill that will help us learn German, and it still has to be learned the conventional way— by understanding the vocabulary and grammar and then practicing. The same applies to children with developmental disorders such as ASD. Although we can repair some of the faulty substrate of the central nervous system, therapies that are tailored and designed to address the child’s specific deficits are still required to reinforce impaired neuronal connections and enable more effective learning. MRI scans and EEG recordings can then be used as objective biomarkers to measure the level of recovery from the injured brain, by comparing those taken during treatment to those taken before treatment commenced. We have observed surprisingly significant neuronal growth in areas of atrophy following targeted training.
www.sfms.org
Independent But Not Alone.
Richard Ward, M.D. Hill Physicians provider since 1994. Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.
Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.
Your health. It’s our mission.
Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.
www.sfms.org
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Public Health Update Robert Gross Spencer, MD
Influenza: Spanish, Swine, or Other
I
n early summer 1918, H1N1 influenza was circulating in the population in Haskell County, Kansas. A few community members were ill, but most were recovering at home. Soldiers at nearby military bases, preparing for their overseas deployment, were also ill. Many soldiers were traveling abroad to engage in World War I, as many are traveling to engage abroad now. Following that spring and summer, flu returned to communities in the U.S. during the fall and winter of 1919 in successive waves, and in a new, far more virulent form. Spread by soldiers, it made its way to the trenches of France and the Low Countries. Reports from neutral Spain’s free press gave this disease its name: the Spanish flu. This disease altered the war. It also altered history. Flu made its way throughout the planet from its probable origins in Kansas. Before the end of 1919, 600,000 Americans died. Tens of millions, some say 100 million, died worldwide. 1918 was the first of three influenza pandemics in the twentieth century. More soldiers succumbed to this so-called “Spanish” flu than died from combat. Pfeiffer’s bacillus (haemophilus influenzae), now known to be a secondary invader, was erroneously thought to be the etiologic agent. During the Spanish flu pandemic, the already highly developed discipline of public health would do its best to apply nonpharmaceutical countermeasures, such as school closures and the cancellation of other congregate events. This would prove to be the differentiating factor in comparative community mortalities. The health care system was nevertheless overwhelmed by the sheer magnitude of the event and was totally unprepared to deal with the number of critically ill, contagious patients. Influenza met the definition of pandemic twice more in the twentieth century. In 1957, the “Asian” flu pandemic resulted in 70 thousand lives lost in the U.S. In l968, the “Hong Kong” flu pandemic killed 35 thousand in the U.S. Today, we know much more about the influenza virus, which is about one-one hundredth the size of bacteria. The disease, a panzootic in migrating waterfowl, resides in birds, humans, and pigs and is able to cross species. There are three types of human influenza: A, B, and C. A and B account for seasonal outbreaks. Type C causes a disease similar to the cold virus and is of minor clinical consequence. Case definition usually identifies an influenza-like illness (ILI) and requires fever greater than 100 degrees F and either cough or sore throat. Type A is associated
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with pandemics and the ability to cross species. Virulent strains cause significant systemic illness, for the most part respiratory, but involvement of other systems such as GI is not uncommon, as is true with the current H1N1. Influenza uses an RNA template for replication. Unlike DNA viruses, which are “high fidelity” reproducers like measles and which make uniformly true copies of themselves (and for which we can produce predictably effective vaccines), influenza is a “low fidelity” RNA virus and is prone to mistakes and mutations that produce antigenic “shifting” and “drifting”. This characteristic, which it shares with other RNA viruses, such as HIV, makes production of vaccines dependent on the morphology of the virus at any given point in time. If the virus “shifts” to a highly pathogenic strain, such as the closely watched bird flu (H5N1 Avian HP), prior vaccines become relatively ineffective. In addition, with the pig as a “mixing vessel,” coinfection with swine, avian, and human viruses leads to reassortment with new genetic segments from various species. Influenza A virus is further classified by the surface hemagglutinin and neuraminidase antigens. Of the recent and now-current pandemics, 1918 was H1N1, 1957 H3N2, and l968 H2N2. The current pandemic culprit H1N1 Novel 2009 was first recognized in Mexico in April 2009. Its genome contains gene segments from bird, human, and pig viruses. The true origin of this strain is still being debated, as gene sequences are similar to Eurasian strains. The World Health Organization (WHO) monitors worldwide outbreaks of influenza and makes a scientific guess as to which of the two A and one B strains that are circulating in humans will compromise the trivalent flu shot for the coming season. Sometimes WHO guesses incorrectly, as in the case of the 2007–2008 mismatch. On June 11, 2009, Dr. Margaret Chan, director of the WHO, declared that the current influenza A outbreak now met the criteria for worldwide dissemination and declared a “Phase 6,” making this the first pandemic of the twenty-first century, and the fourth in the last 100 years. She stated that HINI was of “moderate” severity, infecting mostly the young under age twenty-five—with most deaths, however, occurring in the twenty- to fifty-year-old population. Those considered at especially high risk are pregnant women and people with various other medical comorbidities such as cardiorespiratory disease, www.sfms.org
immunosuppression, and membership in populations in the underdeveloped world. Atypically, older groups are currently proportionally underrepresented among the ill, which may be credited to some immunity from prior influenza exposures, or to social networks that differ from those of younger populations. Severe disease in young immune-competent patients suggests the ability of the virus to trigger an overcalibrated cytokine-mediated inflammatory response, resulting in Adult Respiratory Distress Syndrome (ARDS) and other manifestations of Systemic Inflammatory Response Syndrome (SIRS). The healthy young, such as military recruits, were the prime target population in the Spanish flu. As in 1918, there is now concern for this propensity as a complicating pneumonia with Group A streptococcus, pneumococcus (Streptococcus pneumoniae), or “staph” (Staphyloccus aureus). Tamiflu and Relenza, Class C drugs in pregnancy, can attenuate the severity of illness when given early, and clinicians should have a low threshold for use in the pregnant patient and others with risk conditions for influenza. The potential for very high case loads this coming fall will stress our institutional ability to deal with isolation, sanitization, and ventilatory support in our facilities. While at this time the virus appears susceptible to neuraminidase inhibitors, there is no assurance it will remain so. Vaccines to the existing seed strains from Mexico and the U.S. are making their way through the vaccine production line at this time and offer the best pharmaceutical medical countermeasure to blunt successive waves of H1N1 influenza, should they occur. The term surge has now made its way into the lexicon of medical health care operations as the metric for that event or series of events that has the potential to overwhelm the capability of the health care system. Not surprisingly, surge battlefield origins are shared by triage, another wartime mode of casualty management. It is tacitly accepted that we are at war with disease and trauma. In fact, many view the medical response to pandemic influenza, if not illness and injury in general, as a moral equivalent of war. Strategic health planners therefore are faced with a basic capacity issue. How does our health care system, already stressed at greater than 90 percent capacity, deal with the potential volumes of a large, slow-moving, or immediate surge event? For example, consider these statistics: H1N1 Spanish flu 1918, 100 million U.S. population at risk, 20 percent ill, 3 percent mortality, 600 thousand deaths. Consider these other extremely virulent emerging entities: SARS 2003 (corona virus), 300 deaths with 15 percent mortality and effective human-to-human transmission; and, finally, waiting in the wings (so to speak), Avian H5N1, 65 percent mortality, albeit with poor human-to-human transmission. The potential for existing scenarios to initiate patient surges, especially following our experiences with SARS, avian flu, and anthrax, has jump-started emergency preparedness planning and the development of emergency operation www.sfms.org
plans (EOP). The need for a common language and operational structure has led to mandates for a Hospital Incident Command System (HICS), the medical expression of the National Incident Management System (NIMS). Your hospital command structure will be supported by the four divisions of Planning, Operations, Logistics, and Finance. Operational managers (the “doers”) and Logistics (the “getters”) will deal with scarce resources and the ethics involved with rationing care and supplies. Will staff show up to work? Do we have enough Cipro for anthrax, enough ventilators for ARDS? Will we need to care for people at alternative care sites and practice with ethically guided “alternative standards of care?” Additionally, are we as individuals and families prepared to sustain our households so that we are free to care for the ill? What if there is interruption of the food and other supply chains? What if daycare centers and schools are closed for weeks or even months? Remember YOYO: You’re On Your Own. Remember what you learned in kindergarten: Wash your hands, cover your cough, and play well with others. Are you prepared? Are we prepared? Robert Gross Spencer MD, FACEP, FCCP, is the chair of the Emergency Preparedness Committee for the San Mateo County Health System. He can be contacted at robertspencer@cep.com. References Barry, JM. The Great Influenza. Penguin, 2005. Centers for Disease Control and Prevention. H1N1 flu (swine flu). www.cdc.gov/h1n1flu/. Communicable Disease Control and Prevention, San Francisco Department of Public Health. H1N1 (swine) influenza guidance for healthcare professionals. www.sfcdcp.org/swinefluforproviders.html. Flu.gov. Know what to do about the flu. www.pandemicflu. gov/. Fulghum R. All I Really Need to Know I Learned in Kindergarten. Ballantine Books, 1993. Hillyard DR. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. NEJM. 2009; 360:2605-2615. Kolata G. Flu. Simon and Shuster, 2001. National Institutes of Health. Dynasty: Influenza virus in 1918 and today. www.nih.gov/news/health/jun2009/niaid-29. htm. Wikipedia. Swine influenza. wikipedia.org/wiki/Swine_influenza. www.hicscenter.org/docs
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Health Care Policy Perspective Steve Heilig, MPH
The Prognosis for Real Reform
A
key element in the evolving national health reform effort is a “public option,” wherein Americans under sixty-five years of age could choose to enroll in a government plan analogous to Medicare. In mid-June, President Obama traveled to the AMA’s annual meeting in Chicago, just after a headline appeared in the New York Times reading “Doctors’ Group Opposes Public Insurance Plan.” That widespread report garnered very mixed reactions, including among physicians. When Obama spoke to the AMA delegates, he told the “receptive but wary” audience that “the public option is not your enemy. It is your friend, I believe.” He said it would “keep the insurance companies honest.” And he added, “I need your help, doctors. To most Americans, you are the health care system . . . will listen to you and work with you to pursue reform that works for you.” By then, the AMA had already backpedaled a bit, stating that “the AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of a public plan that are currently under discussion in Congress.” And soon enough, the AMA had in fact endorsed some elements—but not all—of the Obama proposals. But also by then, the politicking had begun in earnest, with virtual “gridlock” achieved in an “ugly, all-out scramble for dough,” noted David Brooks, a NYT columnist. The August deadline for a Congressional vote on the relevant legislation was soon postponed. But Obama was still holding that reform is “a moral imperative, and a financial imperative.” Thomas Bodenheimer, MD, professor of ambulatory and community medicine at UCSF, has authored many articles on health policy in leading journals and is coauthor with UCSF’s Kevin Grumbach, MD, of the book Understanding Health Policy: A Clinical Approach, now in its fourth Edition. He agreed to share his perspective on the current health care reform scenario. SFM: The prospect of substantial health care “reform” has frustrated many for years. What do you think the realistic prospects are this time? Dr. Bodenheimer: There is a very good chance for significant health care reform, but it won’t be as far-reaching as many would like due to the intense opposition of many elements of the health care industry. What do you see as most important to be included in any reform “package”? 34
San Francisco Medicine July/August 2009
First, cost inflation must be slowed. As costs go up, access goes down. Providing universal access without cost control will be a temporary victory. Universal access with cost control would be a major and sustainable achievement. Another key provision of a successful health care reform must be rescuing the dying primary care sector of the health care system. Primary care needs investment in more physicians and other caregivers, computerization, and assistance in improving the efficiency and patientcenteredness of primary care practices, and primary care needs to be paid for all the nonvisit work that takes up a substantial proportion of primary care physicians’ time. The “public” option to be included in Obama’s proposal is the subject of much controversy. How do you think such an option might work, and how might it fit in with the current system? A public option would need to improve on Medicare, which has many flaws; in particular in the area of cost containment, which has been a failure for Medicare. On the other hand, a wellrun public option could provide useful competition for private insurers and their HMO, PPO, and other products, particular in the area of cost containment. Any “single-payer” option is “off the table”. What’s your opinion on the prospect and desirability of such a system in the USA? Do you see Obama’s public option as an intermediate step toward single payer? A single payer has the great advantage of simplifying billing for physicians and reducing the large administrative cost burden shouldered by health care consumers, employers, and governments. However, if there is so much controversy about the relatively mild public option, there certainly is no prospect for a single payer solution at this time. Obama’s public option would become a single-payer only if private insurers are unable to attract customers, and it would be in their interest to make their products attractive. It is very doubtful that the public option would end up as a single payer.
As of press time, the prospects for reform remained very uncertain. As Arnold Relman, MD, editor emeritus of the New England Journal of Medicine, concluded in a recent article, “Sometime in the not-too-distant future, health expenditures will become intolerable and fundamental change will at last be accepted as the only way to avoid disaster. When that time arrives, the opportunity to enact real health reform will finally be at hand.” www.sfms.org
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When was the last time a doctor came to YOU?
At California Pacific Medical Center’s Atrial Fibrillation and Arrhythmia Center we are com-
mitted to a comprehensive team approach in treating your patient. Whether a patient is having debilitating palpitations, recurrent syncope or severe heart failure, sensitive and difficult challenges await – for them and their family. We are Andrea Natale, M.D., Steven Hao, M.D. and Richard Hongo, M.D., electrophysiologists who specialize in complex ablation procedures. In fact, we have the highest atrial fibrillation ablation volume on the West Coast; last year, we performed over 450 procedures. We would
like make an appointment to see you in your office. Why?
We’d like the opportunity to acquaint you with our facilities, staff and equipment – including California Pacific’s new Stereotaxis lab. We’d also like to help familiarize you with referral indicators for your patients with arrhythmias, particularly atrial fibrillation.
The Atrial Fibrillation and Arrhythmia Center offers: •
Board certified, fellowship trained cardiac electro- physiology specialists
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State of the art technology and facilities for the treatment of arrhythmias
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Nationally and internationally recognized expertise in complex ablations, providing care for patients and education for physicians throughout the world
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In 2008, HealthGrades® ranked California Pacific “Best in the San Francisco Area for Cardiology and Overall Cardiac Services”
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Dedicated arrhythmia nurse and nurse practitioner to provide continuity from the consultation through the procedure to follow ups
Let’s schedule an appointment for a visit to your office: 415-600-7459
www.cpmc.org/services/heart