Month: January 2019

The New Epidemic: Doctors Gaslighting their Patients

I got in a bit of a comment war on facebook yesterday because I got fed up with the snarkiness of the anti-vaccinations-triggering-autism crowd (a.k.a., the anti-anti-vaxxers, although I’m not an anti-vaxxer). Yes, the studies show that there is no widespread association between vaccinations and autism. However, on an individual basis, there does seem to be a connection of some sort, or else why on earth would it have become a controversy in the first place? If even one child developed autism or autistic characteristics (and, thus, they were diagnosed with being on the autism spectrum) as a consequence of vaccination, then I think we have an obligation to understand that connection. The main problem of this controversy is the implication of a widespread association between vaccination and autism. The research has unequivocally demonstrated that vaccines to do not cause autism in any significant proportion above the overall incidence of autism. However, this does not mean that a very small population of people (likely with a genetic or epigenetic susceptibility) may be triggered to develop autistic characteristics as a consequence of vaccination (and the immune response that it causes). However, I don’t want to discuss the particulars of this debate. This blog post is not about the epidemic of people not vaccinating their children due to fears of autism. This blog post is about a different epidemic that I think is possibly just as concerning: the epidemic of medical doctors not listening to the patients and essentially “gaslighting” them.

The term, “gaslighting”, is relatively new to me. I honestly wish I had heard of it years ago because it would’ve made me feel more sane having an actual term for the phenomenon I was experiencing with certain friends and exes. “Gaslighting” refers to when someone essentially tells you that what you experienced did not actually happen; it basically undermines your reality. This is what the Encyclopedia Brittanica says about “gaslighting”:

“Gaslighting [is] an elaborate and insidious technique of deception and psychological manipulation, usually practiced by a single deceiver, or “gaslighter,” on a single victim over an extended period. Its effect is to gradually undermine the victim’s confidence in his own ability to distinguish truth from falsehood, right from wrong, or reality from appearance, thereby rendering him pathologically dependent on the gaslighter in his thinking or feelings.”

A still from the 1944 movie, Gaslight, starring Ingrid Bergman and Charles Boyer, from which the term “gaslight” is derived.

Interestingly, the term is actually derived from the 1944 movie, Gaslight, starring Ingrid Bergman and Charles Boyer (including Angela Lansbury’s screen debut). In the film, the main character, Paula (Bergman), is slowly driven insane by her newlywed husband, Gregory (Boyer), who manipulates her reality in order to drive her insane so he can steal her cache of hidden jewels.

In this post, I’m not suggesting that doctors are intentionally trying to drive their patients mad by ignoring their reality or second-guessing it or trying to re-write it into a reality they can more easily explain, but I think they do it unintentionally for very selfish reasons, such as not wanting to appear like they don’t have all the answers. I believe there is a widespread problem with medical doctors and many in the medical establishment either ignoring their patients or part of what the patient tells them or trying to manipulate their patients’ stories into a story that fits their explainable paradigms. I think this is a very dangerous problem that pushes people through the cracks of the healthcare system. In fact, people die from this type of behavior.

A 20-year-old rugby teammate of mine passed away from a brain aneurysm last month. She had been suffering from some medical issues – all of which I do not know because I was not close enough to her – and I gathered that she had been seeing many doctors about these issues. When I saw her last in October, she looked like she may have had a stroke because she seemed to only be able to speak out of half of her mouth – it reminded me of how my Grandma spoke due to paralysis in half of her face (due to a surgical accident when the surgeon accidentally severed her facial nerve on one side). The issue is that it was a change in degree, not a binary change (i.e., appearing after not being there at all). What I mean is that since I met her two years ago she had this side-mouth way of talking, but it was more severe in October than previous times I’d seen her. I honestly am pretty upset with myself for not pressing harder about my concerns, but I did ask her if she was doing alright, health-wise. She told me that she wasn’t and that she was seeing many doctors, so I was hopeful that somebody was dealing with this concern. Then two months later, she’s dead from a brain aneurysm. At the funeral, her mother hinted at a pending fight with the healthcare system, that there may be lawsuits coming, and that the doctors didn’t listen to their cries for help, didn’t give them the care or tests that they asked for. If she had an MRI, there is a pretty decent chance that they could’ve seen a growing aneurysm and done something about it like surgery. Part of the story is that my teammate was a person of color and working class, and she was on Oregon’s medicaid, OHP (Oregon Health Plan). In general, people of color (and other marginalized people) and working class people do not get the same level of care as white people from the middle and upper classes. It’s a very sad reality. It must change. Universal healthcare would help change this reality, although it wouldn’t be all that needs to happen to help change it – doctors need to be aware of their biases and to actively try to counter them.

I have another friend who is very large, technically considered “obese” according to her BMI, although she is also very muscular and strong, which is always missed if you use BMI as the sole measurement for obesity. She has a lot of chronic pain issues with incidences of syncope and other malfunctions in her autonomic nervous system. She has spinal and cranial MRIs showing all sorts of pathologies that could explain at least a large fraction of her symptoms, but the doctors have predominantly focused on her weight, as if that’s the primary reason for her problems. It has taken her over eight years for a medical doctor to take her seriously enough to finally look beyond her weight! I was helping her investigate her health issues last year and I even attended a couple of doctor’s appointments with her and witness firsthand how disrespectfully the doctors treated her. I even had a neuroscience textbook with me and had to correct the spinal surgeon when he said that the bladder has nothing to do with the spine. It turns out that the nerves that innervate and control the bladder travel down the spine and exit the spinal column around the same regions in which she was having pain and which show pathologies in the MRIs. He ignored me despite the fact that I just proved his statement wrong. I am not an M.D., so I do not get the same level of respect for my knowledge and intelligence from M.D.s as other M.D.s do, despite my expertise in molecular, cell, developmental, and biochemical biology (MCDB) and my ability to perform and comprehend medical science and research.

There is a growing contingent of medical doctors that are changing the way they interact with their patients, but in general I am not impressed – in fact, I’m pretty concerned about the general attitude of medical doctors towards their patients. “Bedside manner” can refer to many types of communication, but what I’m particularly concerned with is doctors listening to their clients, believing that their clients are telling you the truth as much as they can tell it, and having the self-esteem and curiosity to investigate further when they don’t have a ready-made answer to the patient’s problem. Scientists tend to have more curiosity about the unknown, whereas I think medical doctors tend to want to portray a sense of all-knowing and security about what they know, but this leaves little room for growth – of medical science, of knowledge, of character, etc.

We all need to work together to hold our medical doctors accountable for listening to our stories, for putting in the effort into our healthcare. If they do not listen and they are not curious about what ales you and invested in finding it out when it does not fit into one of the diseases or disorders they know, find a new doctor who does.

Protein Waste Management in Neurodegenerative Diseases and Sleep

When I was in graduate school for molecular biology, one of the labs in my department studied chaperones, which are protein enzymes that assist in the folding of proteins into their functional, three-dimensional shapes. That lab (Dr. Jeff Brodsky was the Principal Investigator/P.I.) used the simplest eukaryotic cell model system, Saccharomyces cerevisiae (a.k.a. baker’s yeast), to study chaperones. I secretly thought to myself, “who cares” and “why would anyone get excited about studying that?”

But now I feel a little silly that I thought those disparaging things about what the Brodsky lab studied/studies because, as it turns out, protein misfolding and aggregation is a common characteristic of neurodegenerative diseases. The problem is that these aggregates of proteins do not get degraded like most misfolded proteins, nor do they get cleaned up and washed away in the cerebral spinal fluid (CSF) through the glymphatic system during sleep. Thus, these aggregates end up causing the neurons and glial cells to kill themselves (called apoptosis).

Neurodegenerative Diseases and their Associated Misfolded and Aggregated Proteins

The Brodsky lab studied chaperones in yeast, but sometimes they’d also try to bring human health relevance to their research, and when they did that they would study the protein that is misfolded in cystic fibrosis – CFTR (Cystic Fibrosis Transmembrane conductance Regulator). The reason I bring up CFTR in a post about neurodegeneration is to contrast what happens in lung cells (ionocytes) that express the misfolded CFTR protein to what happens in brain cells expressing the proteins that are involved in neurodegenerative diseases. The bottom line is that the cystic fibrosis lung cells do not end up killing themselves like the neurodegenerative brain cells do, despite the unfolded protein response (UPR) being activated in both cell types/conditions, which typically initiates programmed cell death (apoptosis).

One thing to keep in mind when comparing lung and brain diseases is that there are many different types of lung diseases that have many different types of mechanisms, but nearly all brain-related diseases (with the exception of brain cancers, for the most part) appear to have the same type of mechanism: protein misfolding, aggregation, and lack of clearing the aggregates, which leads to cell death. What this means is that brain cells (neurons and glia) are particularly sensitive to protein aggregates – these aggregates must be cleaned up ASAP or else the cells will kill themselves, leaving extracellular aggregates (sometimes the aggregates are secreted by the cell instead of killing itself, too), which can also inhibit neuronal signaling.

So how do we get rid of these protein aggregates? Well, usually, they are washed out of the interstitium (the extracellular space between cells in the brain) with the cerebral spinal fluid (CSF) while we are asleep. In fact, researchers suggest that this “waste management” is the primary function of sleep – to get rid of unnecessary proteins that were made during the day through proteolysis and clearing via the CSF and the glymphatic system, the recently discovered macroscopic waste clearance system through parivascular tunnels in the brain (created by astrocytes/astroglia). Furthermore, these protein aggregates can also trigger inflammation, which causes multiple brain toxicities.

When we do not sleep very much or very deeply, the brain does not get enough time to wash away its waste products, thus causing their accumulation and degenerative effects. Thus, there is a higher risk of developing dementia in people who have poor sleep habits. Therefore, sleep is not just for your beauty or comfort – it’s important for your brain function which means it’s vital for life. Lack of sleep kills.

Where Consciousness Resides in the Brain

I have been interested in the nature of consciousness and how and where it resides in the brain for a long time. I’m interested from the neurobiological standpoint as well as the spiritual, metaphysical, or epiphenomenal standpoint(s). There must be a mechanism for how the information of consciousness can be transmitted in the body – or stored – and for how it controls the body, which is biological.

Although we still have a lot to understand about the nature of consciousness or how it is embedded or interacts with the brain, we do have a pretty good idea about where it resides in the brain. About a year ago, this article was published about a study locating what could be described as one definition of consciousness, two characteristics of which are arousal and awareness, in the rostral dorsolateral pontine tegmentum, which is a small nucleus of neurons in the brainstem, and it connects to the left ventral, anterior insula (AI) and the pregenual anterior cingular cortex (pACC), which are associated with arousal and awareness. The finding is supported by the fact that all of the fMRI scans of patients in a coma and vegetative state had disruptions in the network between these regions.

Location is a major finding in neurobiology, but it is still pretty rudimentary if you really want to understand the phenomenon of consciousness. Another idea is how consciousness is either created by this region or somehow is stored in it temporarily. Even so, we want to also know how it interacts with the biology of the brain to control it through free will, whatever the nature of that is, too. [I believe we have free will, but not all scientists (including neuroscientists) agree that we do. I also believe that free will is one of the few inherent properties of consciousness, in addition to awareness, arousal, and love.]

In any case, it is pretty cool to have a place to look at for the residence of consciousness (well, specifically the aspects responsible for arousal, awareness, and free will, at least) in the brain. An interesting note is that the  is a region of the brain that processes sensory information from our viscera and is involved in the autonomic nervous system, such as the sympathetic (responsible for fight-or-flight mode) or the parasympathetic (responsible for the calm and resting to recover the body after a fight or flight) nervous systems. The pACC is associated with conscious awareness and free will, since disrupting its connection with the premotor and motor cortices (which often happens in split-brain surgery) results in not being able to consciously control the hand – this is called “alien hand syndrome” – a condition when the hand seems to have a mind – and personality – of it’s own.

I could go on and on and on about my thoughts on the nature of consciousness, but I think I will just stop here with the peak into where it is likely anchored in the brain.

Neuromarkers for Mental Health!

The idea of neuromarkers of psychiatric disorders has arrived with the first FDA-approved neuromarker for ADHD, which is a ratio of the relative power between two different brainwaves, theta and beta, in the cerebral cortex as measured by electroencephalography (EEG). It is called the theta-beta ratio [TBR], and it is a useful tool in supplementing the diagnosis of ADHD in about 25-40% of ADHD patients. Although the TBR is the first to be approved by the FDA, there are many other potential neuromarkers like it that we can measure using quantitative EEG, which may be able to help clinicians and patients to better understand their psychiatric symptoms, and even may help determine the best treatment.

Controversy over the meaning and use of neuromarkers remains. These measures should change with treatment only if they are causative for the condition or symptom(s); if they are not causative but are correlative, they may or may not change with changes in symptoms. Another possibility is that they may represent an underlying risk for the condition or symptom, but may not be sufficient to cause the condition or symptom, which, again, would not necessarily result in changes to the measure when symptoms change. This is similar to the mechanism of genetics and how individual genetic variations may correlate with diseases or indicate increased risk of disease, but the genetic variation in and of itself is insufficient to cause the disease. The current data suggests that a similar mechanism is likely for at least some of these neuromarkers, which makes sense for the complex nature of mental health.

Despite the caveats, the emerging field of neuromarkers for mental health disorders is very exciting! For the first time, we may have objective measures for mental health that can support psychological diagnoses, prognoses, as well as the possibility for monitoring treatment efficacy. We will soon have the capability to measure and explore these potential neuromarkers at Rose City Therapeutics since we now have been trained and have purchased the equipment – it is on its way!

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