Mental Health and the Brain:
Our ninth session and resulting on-line forum discussion  started us on a discussion of particular instances of mental health issues in the context of our earlier discussions of the variety of available therapeutic procedures and of the brain. This week we move on from schizophrenia and depression to Tourette's syndrome and migraine.
Readings for this week
- I have Tourette's but Tourette's doesn't have me 
- The tics of Tourette's often go undiagnosed 
- A surgeon's life  (requires registration, also available here )
Relevant recent materials elsewhere
Where we've been ...
Depression is not an opportunity and it is not normal, it is not used to build character ... llamprou 
someone who has never even experienced depression can still sense its tremendous power, not only as a negative phenomenon, but in being able to yield something positive--like a new perspective on life ... dfeingold 
I certainly believe that life is about encouraging an element of possibility and agency -- but I don't agree that helping to lessen severe suffering discourages that ... ysilverman 
I see depression as an absolutely "normal" human occurence. And so, my next thought goes to...being with one's SELF and at the same time attached to another/ knowing how to be SELF without the other AND still attached ... merry2e 
I understand the feeling that the "bad" things that happen to us help us grow, but at the same I know that some events in my life that have helped me become a more compassionate person I would still give a lot for them not to have happened ... Paige Safyer 
This is a very sensitive topic and must be treated that way ... I think that saying that depression and schizophrenia (SZD) may have benefits implies that it's a worthwhile or valuable experience that everyone should have. Regardless of one's intention, I think this implication comes out (and I think this is why the conversation is so polarized) ... Paul B 
for some people the proper approach is to relieve their suffering asap if possible, for others the only option might be to help them learn to live with it. For others it might be to allow them to suffer even though we could stop it because they are doing something with that situation which is valuable ... MartinBayer 
"symptoms" whether a caffeine-induced headache, or a pervasive sense of sadness whose genesis is unknown can be a "signal" that there is something amiss... However, I don't know that the "symptoms" themselves are actually the problem, but rather a limited solution implemented by the storyteller that needs to be revisited. The symtoms, perhaps, are the "signal" that alerts us of the problem? ... Sophie F 
one direction might be to continue to flesh out a more outside view of what depression really is ... perhaps there is something wrong with the connections between the TK and the ST (similar to Capgras). One line of information is coming in telling the ST that someone just gave them a hug. However, the line that is supposed to tell the ST that this is a pleasant experience and the proper response would be to be happy or feel loved is malfunctioning somehow. Second, perhaps the malfunction is inside the ST. This seems like it would call for a compartmentalization of the ST. We usually talk about it as a black box. However, maybe there are pathways and connections within the ST that are vulnerable to malfunction. For example, maybe all the necessary ingredients have entered the ST via connections from the TK and the "assembler," or the part that organizes them into a cohesive story is malfunctioning. Or perhaps the "motivator," or the part that sparks our motivation to construct a story in the first place is broken ... ryan g 
I feel that this question of 'function' really deals with what we have been grappling with this semester and at the end of the day sums up how we could potentially change the mental health system. If we focus on the story teller then we are able to appreciate each individual experience for what it is and help every person reach a place where they can grow/learn/thrive to the best of their ability. If we focus on function, then we deal with external behaviours in order to make sure that individuals can experience a 'normative' reality ... How do we need to change to make that happen? ... akerle 
A cure would not be aimed at changing the person itself, thereby eliminating a particular talent, but, on the contrary, at helping him/her flourish in all fields of his/her social life ... vpizzini 
Therapy, drugs, just sitting around and thinking – all of these are ways to change brain chemistry, why are some more “natural” than others? ... kmanning 
Being stuck and feeling like one cannot emerge from the tangle of one’s mind seems a common experience to both [depression and schizophrenia] and one that is not trivial ... Sophie F not all psychologists believe in agency. Stunningly most don't. I emphatically do. .... I had a frontal lobe tumor and frontal lobe syndrome ... schizophenia is also a disorder of free will. .... "Someone is controlling my thoughts" That is a common delusion. In my considered clinical judgement restoring that agency is a prime objective. Without that, life is not much fun and the stories you tell tend to be kind either very dull or really terrifying. Both somatic and talk therapies ought to take that as a first target ... Sam Flesher 
Take off points - Tourette's
Diagnostic Criteria for 307.23 Tourette's Disorder;
- both multiple motor tics and one or more vocal tics must be present at the same time, although not necessarily concurrently;
- the tics must occur many times a day (usually in bouts) nearly every day or intermittently over more than 1 year, during which time there must not have been a tic-free period of more than 3 consecutive months;
- the age at onset must be less than 18 years;
- the disturbance must not be due to the direct physiological effects of a substance (e.g. stimulants) or a general medical condition (e.g. Huntington's disease or postviral encephalitis)
Oliver Sachs ...
"Then Bennett took the knife, made a bold clear incision-there was no hint of any ticcing or distraction-and moved straightaway into the rhythm of the operation. Twenty minutes passed, fifty, seventy, a hundred. The operation was often complex-vessels to be tied, nerves to be found-but the action was confident, smooth, moving forward at its own pace, with never the slightest hint of Tourette's...Here, then, was an entire operation without a trace of Tourette's. Not because it had been suppressed, or held in-there was never any sign of control or constraint-but because, simply, there was never any impulse to tic."
"What most of us call a startling or "abnormal" speed of movement appears perfectly normal to Touretters when they show it This was very clear in a recent experiment of target pointing with Shane F., an artist with Tourette's. Shane showed markedly reduced reaction times, reaching rates of almost six times normal, combined with great smoothness and accuracy of movement and aim. Such speeds were achieved quite effortlessly and naturally; normal subjects, by contrast, could achieve them, if at all, only by violent effort and with obvious compromise of accuracy and control."
"The real problems, the inner problems, are panic and rage-feelings so violent that they threaten to overwhelm him, and so sudden that he has virtually no warning of their onset...the strain of controlling himself is severe and exhausting"
Take off points - migraine
From David W. Dodick and J. Jay Gargus, “Why Migraines Strike” Scientific American, July 2008 
"In addition, the activity of these cells [three clusters of cells in the brain stem—the locus coerulus, raphe nucleus, and periaquedcutal gray] is modulated by the behavioral and emotional state of the individual—factors that can trigger migraines. These brain stem areas receive input from only two areas of the cortex, the limbic and paralimbic cortices, regions that regulate arousal, attention and mood. Through its connection with the brain stem, the limbic cortex affects the functioning of the rest of the cortex—a fact that might explain how emotional and psychological stress could catalyze migraines, why mood fluctuates during migraine, and why there is an association between migraine and depression and anxiety disorders, both of which occur more commonly in migraine sufferers than in others."
From Jeff Tweedy, “Boy Meets Pain” 
"When I was growing up I lived in a household with caring people — my parents were definitely nurturing and wanted me to be happy and healthy. But it was a different time. If a kid was suffering from a mood disorder in my parent’s generation, the typical response was likely to be, “What are you crying about? I’ll give you something to cry about.” That sounds really harsh but it’s a reality of my childhood. It was much more difficult for me to explain, “I just feel sad for no reason,” than for them to see I was in literal pain. So I think there’s some connection there. In other words, the psychological suffering of the mood disorder may have manifested itself in a very real pain of the migraine that was much easier to express. It’s obvious your kid is hurting when he can’t stop vomiting and he can hardly open his eyes. And with my mother having migraines herself, she could identify – she knew they were real. There’s a lot to explore there — there was for me — how much of it was an outward manifestation of a mood disorder.
I’ve noticed that the arc of a migraine is very similar to some of the traits of panic disorder.
One of the things that happens a lot with panic disorder is that you’ll have an actual panic attack and for weeks or months after that you’ll have a fear of a panic attack that can heighten your anxiety and heighten your stress levels to the point where you end up having another panic attack. To me those things mirror each other. Migraines would add stress to my life in a way that would contribute to the next headache and it would begin a cycle that would be hard to stop. So I would have periods where I would have a migraine very frequently — every other day or twice a week — for months.
The hospital I went to in 2004 to address my painkiller addiction (which happened in part due to the migraines) was a “dual-diagnosis” facility — they treated my panic disorder and depression simultaneously. And I found that once I was able to manage those two things, I’ve been able to be mostly migraine-free for the last four years. For me, that solidified my theory about the connection.
From “Less than you Think” by Jeff Tweedy, Wilco
Your mind's a machine
It's deadly and dull
It's never been still and its will
Has never been free
A high-pitched drum
As your spine starts to shine
You shiver at your soul
A fist so clear and climbing
Punches a hole
In the sky
So you can see
If you don't believe me
There's so much less
To this than you think
From “Arms at Rest” by Siri Hustvedt 
"As a child, life with my peers in school was always hard for me, and my yearly purges [associated with migraine] no doubt served a purpose. For two days a year, I suffered a cathartic dissolution, during which I was able to stay home and be close to my mother. But times of great happiness can also send me over the edge — the adventure in Thailand and falling in love and getting married. Both were followed by a collapse into pain, as if joy had strained my body to its breaking point. The migraine then became self-perpetuating. I am convinced that a state of fear, anxiety, and a continual readiness to do combat with the monster headache pushed my central nervous system into a state of continual alarm, which could only be stopped by a deep rest. I continue to cycle. Periods of obsessive and highly productive writing and reading that give me immense pleasure are often followed by a neurological crash — a headache. My swings from high to low resemble the rhythms of manic-depression or bipolar disorder, except that I fall into migraine, not depression, and my manias are less extreme than those of people who suffer from the psychiatric illness."
From “In Bed” by Joan Didion
"But not all perfectionists have migraine, and not all migrainous people have migraine personalities. We do not escape heredity. I have tried in most of the available ways to escape my own migrainous heredity (at one point I learned to give myself two daily injections of histamine with a hypodermic needle, even though the needles so frightened me that I had to close my eyes when I did it), but I still have migraine. And I have learned now to live with it, learned when to expect it, how to outwit it, even how to regard it, when it does come, as more friend than lodger. We have reached a certain understanding, my migraine and I. It never comes when I am in real trouble. Tell me that my house is burned down, my husband has left me, that there is gunfighting in the streets and panic in the banks, and I will not respond by getting a headache. It comes instead when I am fighting not an open but a guerilla war with my own life, during weeks of small household confusions, lost laundry, unhappy help, canceled appointments, on days when the telephone rings too much and I get not work done and the wind is coming up. On days like that my friend comes uninvited.
And once it does, now that I am wise in its ways, I no longer fight it. I lie down and let it happen. At first every small apprehension is magnified, every anxiety a pounding terror. Then the pain comes, and I concentrate only on that. Right there is the usefulness of migraine, there in that imposed yoga, the concentration on the pain. For when the pain recedes, ten or twelve hours later, everything goes with it, all the hidden resentments, all the vain anxieties. The migraine has acted as a circuit breaker, and the fuses have emerged intact. There is a pleasant convalescent euphoria. I open the windows and feel the air, eat gratefully, sleep well. I notice the particular nature of a flower in a glass on the stair landing. I count my blessings.
From Oliver Sacks, Migraine
Case 68: This 32-year-old man was an ambitious and creative mathematician whose life was geared to a weekly psychophysiological cycle. Towards the end of the working week, he would become fretful, irritable and distractible, “useless” at anything save the simplest routine tasks. He would have difficulty sleeping on Friday nights, and on Saturdays would be unbearable. On Sunday mornings he would awaken with a violent migraine, and would be forced to remain in bed for the greater part of the day. Towards evening he would break out in a gentle sweat and pass many pints of pale urine. The fury of his sufferings would melt away with the passage of these secretions. Following the attack he would feel a profound refreshment, a tranquility, and a surge of creative energy which would carry him to the middle of the following week. (page 68)
“’Economic” considerations were also forced on my attention by another patient, the migrainous mathematician, who was among the first I saw. With this patient, to continue the history, it was easy to find antimigraine drugs. Ergot worked, and worked very well; but when I cured him of his migraines, I cured him of his mathematics too—he seemed, however paradoxically, to need one for the other. At this point, he said, “I’ll keep my migraines—I think we better keep everything as it is.” This experience also served to reduce my own impatient need to “treat,” and disposed me to listen more carefully to the patients, to that whole pattern of “ever-changing features and factors which the migraine patient both suffers and creates.”
Such considerations do not arise, or arise less, when migraine is occasional—when attacks come, for example, once a month or less. But if migraine is severe, if it intrudes more into life, then complex interactions are bound to occur, and treatment should not be “purely physiological.” One would not, of course, deny physiological treatment—one would seek out whatever drugs, or other measures, to help the patient. But, at the same time, one should search more deeply, both patient and physician should search more deeply; for migraine, when frequent, is not just a disease, but a whole way of being, which forces the organism into special adaptations and identities. (page 268)
This 55-year old man had been a former inmate of Auschwitz. He had suffered about one attack of classical migraine a month from the age of 7 until his incarceration in Auschwitz. During his 6 years in the concentration camp—6 years during which his wife, parents, and all other close relatives were killed—he did not experience a single attack of migraine. He was “liberated” by the Allies in 1945, and the following year emigrated to the U.S.
Since that time, he has been chronically depressed, guilt-ridden, preoccupied with the deaths of all his relatives, whom he feels he might have saved, and intermittently psychotic. During this time he has also experienced 6 to 10 attacks of classical migraine each month, attacks which are refractory to treatment, an accompanied by the intensest suffering.
He is also considerably “accident prone,” and during the two years that I saw him managed to sustain a Coles fracture, a fracture-dislocation of one ankle, and a head-injury. Each of these injuries was followed by several weeks’ remission of his migraines. It is also fo interest that on the three occasions in which he has been hospitalized for psychotic depression during the past 20 years, he was free from migraines. (pg. 168-69)
From Freud: “…Although it may be said…that he has taken “flight into illness,” it must be admitted that in many cases the flight is fully justified, and the physician who has perceived this state will silently and considerably retire…Whenever…advantage through illness is at all pronounced, and no substitute for it can be found in reality, you need not look forward very hopefully to influencing the neurosis through your therapy.” (qtd. in Sacks, Migraine, page 237)
And a final word from Sacks: But a migraine patient is not just complaining of a recurrent dysfunction—he is telling us, if we will listen, the story of his life, or patterns of living, and patterns of reacting, and (perhaps) deep patterns of which he has no conscious awareness, any of all of which may be relevant to his migraines. We cannot know in advance, on first meeting him, what is relevant or irrelevant. It is crucial to enquire minutely into all the circumstances of attacks—when they are most common, when they are rarest, what are their patterns and provocative triggers. But at a deeper level, one needs to know the “economy” of a life, the psychological and physiological “needs” of an individual. And this is not something which can be ascertained in a quick or casual way—it requires a relations between patient and doctor, and an insight, on the sufferer’s part, not to be achieved in a moment, as to the connections between the patterns of his life and his migraines. It requires, to some extent, making the unconscious conscious or, in Freud’s words, replacing an “It” with an “I.” (page 267)