Brain mysteries exposed

Welcome to the mysterious and perplexing world of a neurological condition known as conversion disorder. It has been written about for centuries but is only now being unlocked by psychiatrists including the co-head of the Florey Institute’s Biological Psychiatry and Mental Health division, Professor Richard Kanaan.

Originally from Scotland, and having spent 11 years working at the Institute of Psychiatry in London, Professor Kanaan has been in Australia for four years. Treating patients with conversion disorder is his passion, as he seeks to determine the causes of this misunderstood and under-diagnosed ailment. Until recently there were no patient support groups or official acknowledgement. In fact, a major study in Scotland found it to be the most common condition referred to psychiatrists by doctors in that country, more than headaches, strokes or epilepsy. In his first two years at Austin Health, Richard has seen about 100 cases of conversion disorder and says referrals are increasing.

In some parts of the world, conversion disorder has been blamed on witchcraft, or deemed to be some kind of possession by evil spirits. Western general practitioners may not even think of it as a possible diagnosis. Among the many presentations, patients may have symptoms of epilepsy, stroke or paraplegia.

“A lot of the symptoms can appear to be voluntary,” Richard says. “This has puzzled people. Are the patients doing it on purpose? Is there some other reason? Is it an evil spirit? Can they control it?

“It’s hard for doctors and patients alike. Lots of people stray off the path to saying things people find difficult to accept. ‘Your problems are not real; there’s nothing wrong with you’. People may be suffering paralysis or fits yet doctors are repeatedly saying: ‘I can’t find anything wrong on the scans. Everything is normal’.”

Conversion disorder was originally brought into the light by the famous Austrian neurologist Sigmund Freud, who believed it was the result of trauma, but then his theories faded from view as his work lost favour within academia. But in the last two decades, psychiatrists like Richard have started to use a variety of tools and modern scanning to research the disorder, even by a process of elimination, through MRI scans or, for example, by clearing a patient of epilepsy through an EEG scan. “Scanning is not a clinical tool,” he says. “It’s for research.”

“But for the first time, we can say we understand what’s going on and we know why a patient can’t walk,” Richard says. “Lots of people recover and not every person is paralysed. All patients could be cured, we think.”

The research is so new that Richard says published papers by him and other leaders in the field have not yet been formally replicated and confirmed, to be accepted scientifically. “We haven’t had one particular breakthrough but the incremental breakthroughs are happening,” he says. “The next 10 years will be significant in our understanding of this, I believe.”

However, patients are starting to see the benefits.

“We are evaluating treatments that are working very well. With fits or seizures, due to conversion disorder, we would expect most people to recover. Evidence also tells us that most people will improve with a short course of physiotherapy.”

Another question still being considered is the role anxiety plays in the disease. While high levels of anxiety are naturally present in most sufferers, Richard believes researchers are still trying to unravel whether anxiety is embedded in the cause of the disease, or is an understandable by-product of it. There’s a lot of work still to be done, but the mystery is beginning to unravel.

Its size, the folds and troughs on the brain’s surface, and sometimes what is noticeably missing from its surface, mean she can make astute judgments about this individual’s health — and their ultimate demise — long before she picks up a knife.

Conducted behind a locked cage door in the bowels of the Florey, this is detective work like no other.

As leader of Victoria’s Brain Bank, the busiest and one of the largest in the country, Catriona and her collection of 1500 brains are helping researchers around the world unlock the secrets of head trauma and degenerative brain diseases.

The 60-70 annual donations provide crucial pieces to the puzzle of brain diseases that cannot be adequately and ethically studied until after death. Catriona and her small team are helping researchers wanting to improve diagnosis and treatments to prevent progressive brain diseases.

Under the microscope the brain, when removed from its bony helmet, reveals its secrets.

An Alzheimer’s brain, for example, is much smaller than a healthy brain.

For more than 25 years, the bank has existed for two main reasons: to provide a diagnosis for the family, who may also be at risk of developing the disease; and to provide samples of brain tissue and spinal cord for research purposes.

While it conjures images of something out of a sci-fi movie — with rows of illuminated brains in vats — the bank is a compact filing system that houses neatly packed rows of plastic containers.

Each shelf is labelled: trauma, Parkinson’s disease and Alzheimer’s sit alongside motor neurone disease, bipolar and schizophrenia. Some are healthy “controls”.

Inside each container is half a brain, sliced into pieces, wrapped and topped with formaldehyde. This half is used for a diagnosis — to confirm if the condition is hereditary, and, if the person was receiving treatment in a clinical trial, to confirm that they actually had the condition the trial was testing.

The other half of the brain is sliced and then frozen in the freezers of the upstairs laboratory, ready to be shipped to researchers around the world.

Last year about 3500 samples were sent to researchers in Melbourne, New South Wales, Korea, Germany and Sweden.

The youngest brain is from a 22-year-old with an early onset dementia.

The oldest are samples taken from the Papua New Guinea cannibal tribe that ate their dead as a funeral rite, leading to kuru, the first human-transmitted form of the rare and deadly brain disease transmissible spongiform encephalopathy.

“The tissue is invaluable for research work into neurodegenerative diseases, otherwise you’re studying a mouse model or cells,” Catriona says.

“To me, if you’ve got the tissue, that’s the real disease you’re studying. You’ve got the end point, you can study that disease process.”

It is in this upstairs laboratory that McLean and her colleagues lay the brain on a plastic kitchen chopping board and use a knife — with no serrated teeth but as big as a breadknife — to strategically cut each brain into more than 100 slices.

A brain is soft like jelly to cut through, except when you reach an area affected by a neurodegenerative condition, and then it’s softer, like butter.

Catriona is keen to expand the service to allow analysis of new neurological diseases and head traumas such as football-related concussion. She also wants to train the next cohort of neuropathologists to continue this highly specialised detective work.

“There is an ongoing need for this work,” says Catriona, who is part of an international project studying a degenerative brain disease that has never been described before.

“We still don’t understand the process of disease.

“Research is about trying to find out exactly what’s happening, so in diseases like Alzheimer’s we can flick the right switch to stop it happening or delay it.

“When we understand what’s happening in motor neurone disease, Parkinson’s and Alzheimer’s, and with all the new diseases still coming on board in 2016; when we can diagnose them all in life, correctly every time, there will be no need for us. But we’re not there yet. The brain still has some mysteries.”

With thanks to Brigid O’Connell and News Limited.