Firehole Falls,
Yellowstone National Park
Topics That
Give Perspective
on Psychiatric Issues
The links below are to websites that I think give interesting perspective and information for all of us. Some of the sites are especially interesting in the context of specific illnesses and some are generally interesting for all.
Here are the topics covered:
Daniel Amen's Atlas of Brain Activity
Daniel Amen has been using SPECT scans to examine the brains of patients for many years now and has accumulated a large database of interesting cases. His atlas of cases graphically shows how even minor brain trauma can have a dramatic effect on how the brain is functioning. Seeing how trauma and drug use can change the brain adds a remarkable perspective to what I see clinically. I suggest looking first at his atlas of the normal brain to get oriented to how his scans show brain activity. Then check out the scans of minor brain trauma (head injury) correlated with behavior. The images of drug abuse should be seen by anyone even thinking about using or abusing drugs!
His imaging studies have lead him to observe different subtypes of Attention Deficit Disorder. Although his observations are not fully validated by double blind studies at this time, I think they give a very useful perspective that deepens my evaluations of patients and give broader ideas for treatment.
His site is called brainplace.com. To BrainPlace.com/bp
The Auto-Immune Connection
I am always looking for new ways of looking at psychiatric illnesses. Occasionally I come across data that forces me to change my underlying and organizing ideas. That happened when I first heard about how a Strep infection can set off the immune system to damage the brain and cause a psychiatric problem. Narcolepsy is also caused by an autoimmune destruction of a small nucleus of the brain, although we don't yet know what sets off the immune process that causes it. Recent data on how SLE (Lupus), another autoimmune illness, affects the brain to cause depression and thinking problems expands the complexity of this mechanism. The brain is protected by a barrier that keeps large chemicals (like antibodies) out of the brain. Some of the Lupus data indicates that the part of the brain damaged by antibodies can be determined by the particular stress that causes a failure in the barrier that protects the brain.
Here are some of the specifics for those who are interested:
PANDAS: An autoimmune caused psychiatric disorder
The National Institute of Mental Health (your tax dollars at work!) has pioneered the research in this area called Pediatric Autoimmune Neuropsychiatric Disorder of Adolescents Syndrome (PANDAS, for short). Their website describes the research into how Strep infections are linked to Obsessive Compulsive Disorder and Tic Disorder. It probably happens by activating the immune system to damage brain cells, an example of an autoimmune process. There is some data to indicate that Anorexia Nervosa may sometimes be caused by the same mechanism.
This data is most interesting because it combines infection, genetic predisposition, and autoimmune causes for a psychiatric illness. First the Strep infection like Strep Throat activates the immune system to make large amounts of antibodies to the Streptococcal bacteria. When the antibodies find the particular chemicals on the surface of the bacteria that identify it as an invader they attach and raise a flag for other immune system chemicals and white blood cells to come and kill the invader. It turns out that the chemicals on the surface of the Step bacteria resemble chemicals on some of our own cells. As a result, the antibodies start attacking our own cells, damaging them or killing them. We have known for some time that this happens to the cells that line the heart causing scarring. We call that Rheumatic Fever and the resultant scars cause heart valve problems later in life. When the antibodies attack the brain it can cause a movement disorder (Sydenham's Chorea). They also cause a version of Obsessive Compulsive Disorder and Tic or Tourette's Syndrome.
Note that this is all from an infection that sets off the immune system to attack our own cells (what we call an autoimmune disorder). But only those people with the particular genes to make certain specific chemicals on their cell surface can get it. That means only some people are genetically predisposed. Others who don't have that gene won't have this problem. This is a combined infectious, genetic and autoimmune cause of a psychiatric illness!
Here is the link to the National Institute of Mental Health's website on PANDAS: http://intramural.nimh.nih.gov/pdn/web.htm
SLE (Systemic Lupus Erythematosus)
Lupus is an illness with joint pain, muscle pain, fever and rashes. The immune system that normally combats foreign invaders like bacteria and viruses starts attacking parts of the body by mistake. Patients with Lupus have antibodies that attack DNA and some proteins that resemble DNA. Recent data indicate that certain parts of the brain have those proteins and are vulnerable to attack. Some of the areas of the brain that are vulnerable to attack include the NMDA receptor in brain areas that mediate fear (the amygdala) and memory (the hippocampus).
When the NMDA receptor is attacked by the antibodies it causes the cell to kill itself, a normal process called apoptosis. The areas where this NMDA receptor can be activated by this mechanism are in the hippocampus, amygdala, and hypothalamus. Usually protected by the blood brain barrier (BBB), these areas are damaged when the BBB is breached. BBB breach is caused by mucopolysaccarides from a bacterial infection, adrenalin and other causes. Mucopolysaccaride breach causes damage in the hippocampus that results in a memory deficit in mice. Adrenalin causes damage in the lateral amygdala that results in a deficit in learned fear in mice. In humans there is association between high levels of Lupus antibodies that attack the NMDA receptor and depression (Beck Depression Scale) but not with intellectual deficits. I wonder if the reason they didn't see a change in intellectual functioning is that not many of the patients had had a recent bacterial infection.
Now when I look at a patient with an possible autoimmune process I include the idea that the autoimmune process may cause different psychiatric problems depending on the different stressors affecting the patient. For instance if adrenalin has been activated by a frightening or angering event, it may cause emotional symptoms due to damage to the amygdala. On the other hand, if they have had a bacterial infection they may suffer increased memory problems.
Narcolepsy
Patients with narcolepsy can fall asleep suddenly during the day. They also have sudden drops in muscle tone when they experience strong emotions. Although this is not strictly speaking a psychiatric illness, I find this data provocative because it involves a brain illness caused by an autoimmune process that kills off a large percentage of a small group of specific cells. It indicates how carefully targeted these autoimmune processes can be. Here is the link to the National Sleep Foundation regarding Narcolepsy and other Sleep Topics (such as sleep apnea): www.sleepfoundation.org/
Sleep Apnea
Sleep apnea happens when breathing is blocked usually due to relaxation of muscles in the throat and tongue during sleep. If the air is completely blocked and air cannot get to the lungs for a period of seconds, the oxygen supply to the brain can be reduced causing sleep disturbance, daytime drowsiness and the mind not functioning well during the day. Severe sleep apnea can lead to cardiovascular problems.
The most obvious symptom of sleep apnea is snoring with an irregular pattern of breathing that may stop for several seconds and then start again with a snort. The sleeper may have no awareness of this at all, except for the complaints of their sleep partner.
Everyone should ask their sleep partner: Do I snore? If the answer is yes, consult with your doctor about sleep apnea.
The usual first line treatment is to have a gentle flow of air blown through a mask that keeps the airway open. Although most people I have known have some trouble getting used to the mask, the improvement in their functioning and feeling of well being turns out to be well worth the effort. For some people surgery to open the airways is possible.
Here is the link to the National Sleep Foundation regarding sleep topics (sleep apnea, narcolepsy etc.): www.sleepfoundation.org/