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Saturday, June 20, 2009

The Death of the Frontal Lobes

Our frontal lobes are dying.

Well, maybe not really. But they may be suffering. The old quote "rumors of my demise are greatly exaggerated" comes to mind here. But if our frontal lobes have not died they are perhaps in peril.

The prefrontal lobes of our brains contain much, if not most, of what makes us human. Our ability to plan and solve problems. Our ability to initiate a course of action and persevere. Our ability to hold back our emotions when necessary. Our ability to do the hard thing rather than the easy thing. Our ability to notice when we are missing the mark and need to change our course of action to be more effective.

But these are not the types of abilities which are now reinforced in our everyday lives. We often do not read books so much as skim across web pages. We do not make conscious decisions about what will enter our brains so much as clicking the most interesting web page link in front of us.

I know of what I speak, for I too seem to at times become one of the emerging prefrontal lobe brain dead. I can sit down at the computer and encounter lines of email "famspam" (my term for the unending funny pictures, interesting Youtube videos, patriotic Powerpoints, and so on, sent by well meaning family members and friends). Once I have sat in front of the computer, my clicking on links sometimes leads me to forget what I originally intended to do at the computer.

This is a passive approach to the world and to information, and, I am afraid it is leading to a passive approach to life in general. We do not do the hard thing. We seek the easy or the most interesting thing to do with the click of a button. Check our email. Check Twitter. Respond to email. Respond to Twitter. Watch TV, surf the channels.

It is the adult version of what happens when children play video games. We become passive responders. We are responding, but without clear intent, planning, or moral effort. (There is effort in playing a video game, but only of a type.)

Human life needs to be more than passive responding, whether it is to a video game or to Twitter. But it is not just a matter of whether we will seek to do the hard thing. It is also a matter of whether we will be able to do it. Will our prefrontal lobes be there for us and have the necessary complexity and ability to do what does not come easily?

I believe that the proper functioning of the frontal lobes depends on the building up of the neural substrate, that branching of nerve endings which is so marvelously complex in our brains. And I believe that the branching of the nerve cells ("dendrite arbors") can only occur when we use our prefrontal lobes.

Why are we in this position? Were our forebears morally superior "Giant Brains" and we are only "Tiny Brains?" (I am alluding here to the movie "Defending Your Life." If you haven't seen it yet, put it on your list to see.) I don't think that our forebears had better brains. They made many stupid mistakes, of which racial prejudice was just one. But we have so many interesting things to look at. We do not need to invent anything of interest because 10 things of interest have already been shoved at us in one way or another, constantly vying for our attention.

What happens when we don't exercise our frontal lobes? When writing a term paper becomes a simple exercise in cutting and pasting on the computer? My speculation is that we are not developing our frontal lobes and that as a result we will lose some of our self-directedness. We may also lose some our ability to do the hard things in life.

The most important "hard thing" is to set our own goals and then to pursue them. It is so much easier to fall in line behind people who will show us what to do, tempt us with something to do, and so on.

Time, as an empty, cavernous structure yawning before us does not comfort us. It seems to create anxiety in many. Visit a casino with the banks of slot machines. These slot machines can help us to "pass the time," "kill time," and "fill" our time. (I am not being a prude here; I like a little slot machine action once in a great while.) Killing time may also be a way of letting our frontal lobes atrophy.

What the world needs are people who can do that most difficult of all things, set meaningful goals, plan to complete those goals, and then make meaningful efforts to reach them.

Wednesday, May 06, 2009

The Triple Layer Cake

There is nothing like cake to get my attention. So maybe I have your attention, too.

This is the way I explain depression to my clients. It's like a triple layer cake.

Layer one is the original depression. Let's call it biological depression. Something has happened in the brain in response to stress. As a result, mild to moderate depression has set in. The person is having difficulty concentrating, less enthusiasm for doing things (anhedonia), and some fatigue. As a result, they aren't getting as much done. Their grades are going down in school. They are snapping at their children.

Now here is the kicker. Now they start to criticize themselves: "I am lazy." Or, they may think or say, "I am stupid." And so on. They are not able to deal with their decreased efficiency. They think that they "should" be totally in control of themselves, their symptoms, their behaviors, their lives, and if they are not, then they are defective. Now we have the second layer of the cake--being depressed about being depressed. This drives the person down deeper into depression--perhaps from being mildly to moderatly depressed all the way down to severely depressed.

Now for the third layer. The person stops doing the positive behaviors they used to do. They quit socializing. They quit doing their hobbies. They start developing the habit of thinking negatively. Old, good habits start to extinguish. New, bad habits are taking their place.

If the person is treated with an antidepressant, they may recover their appetite, their energy, their sex drive, etc. And this may well help layer two--their self blame, since they have less to blame themselves for.

However, the habits of negative thinking, avoidance, and withdrawal may remain even though many of their depressive symptoms are in remission. This is one of the tasks of psychotherapy--to make sure that the person fully returns back to their normal self.

Many of my clients find that this simple little model helps them understand how their depression became severe in the first place and also focuses them on what they need to be doing to recover. Namely, they need to quit blaming themselves for any remaining depression. They need to overcome their acquired habit of negative thinking (e.g., as in cognitive therapy), and they need to get back to their old positive habits of socializing and having pleasurable experiences.

Sunday, May 03, 2009

The Therapeutic Alliance

In my testing and therapy, I am constantly struck by how much we don't know. How different is Bipolar II from Bipolar I? How different is Aspergers from Autism? Does depression permanently damage the brain, or are brain cells regenerated (as they are sometimes in the hippocampus)? And on and on. We know so much and so little. There is so much depression research appearing that a person could spend all of their time just reading it. But the big questions often elude us. And our patients must patiently suffer through our lack of awareness. It is as if we are always in the dark ages. Future generations will look back and marvel at how little we know, just as we look back and marvel at the treatments used in Freud's Vienna (and those were better than what was being used in the rest of the world!). It is my goal to use the best of current knowledge. What isn't known has to be imagined. We have to connect the dots and extrapolate in between for the benefit of our patients. And we have to learn from our patients. They teach us. The most exciting situation is when the partnership (AKA "therapeutic alliance") actually forms, and the patient and I go on a voyage of discovery together. We put together what we know, and something very important happens. It is an exciting experience.