Sunday, December 6, 2009

Coming out of a horse sized K-hole: Ketamine's antagonist action at NMDA receptors and impacts of D1 upregulation in dlPFC

One class of addictive drugs called dissociatives include such drugs as dextromethorphan (DXM), phencyclidine (PCP), and ketamine (K). Ketamine, commonly used in both veterinary and human medicine (high dose) as an anesthetic, is also used recreationally (typically in lower, subanesthetic doses), bringing on feelings of derealization, euphoria, dissociation, depersonalization, hallucinations, spiritual mind trips, etc., and is often used at dance events and parties. More specifically, “[k]etamine is a noncompetitive antagonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor” usually administered by intramuscular injection (IM) (Narendran, R., Frankle, W., Keefe, R., Gil, R., et al., 2005, p. 2352; action at the NMDA receptor as an indirect antagonist - Carlson, 2010, p. 615). Loose translation of the previous is that ketamine interferes with glutamate transmission at the NMDA receptor (not unlike alcohol, that also acts on GABA(A) receptors – Carlson, 2010, p. 631).

Perhaps not surprisingly, ketamine is linked to memory impairments, as the NMDA receptors are involved in long-term potentiation, implicit in learning (Carlson, 2010, p. 447). However, the long term effects of chronic ketamine use remain largely unknown (Narendran, 2005, p. 2352), while commonly thought to include K-pains – due to deterioration of the bladder, cognitive impairments – including memory, and neural network dysfunctions of various sorts (dearborization, etc. – see also common encyclopedic entries, ketamine was first synthesized in 1962 and is easily researched; see also RxList.com or Wikipedia.com).

Interestingly, the study I reviewed attempted to substantiate effects of chronic NMDA antagonist users (of ketamine) on the dorsolateral prefrontal cortex (dlPFC) because of earlier findings from “animal data indicated that the dorsolateral prefrontal cortex dopamine projections were especially vulnerable to repeated NMDA antagonist administration” (Narendran, et al., 2005, p. 2357). The study found that “D1 (dopaminergic) receptor availability was significantly up-regulated [“a compensatory increase in the sensitivity of receptors” (Carlson, 2010, p. 631); here, in correlation with the number of vials used per week] in chronic ketamine users… relative to comparison subjects … [and that] [n]o significant differences were noted in other cortical, limbic, or striatal regions” (Narendran, et al., 2005, p. 2357). While the authors did not, much to their surprise, find any cognitive deficits in users, it was made explicit that the typical user (who was not admitted to the study due to various psychiatric comorbidities, including polysubstance abuse), “even in the absence of cognitive deficits… repeated ketamine exposure… [is] associated with signs of disruptions of a critical component of cognition, the prefrontal dopamine system” (p. 2357).

In sum, the authors found that more research was needed, despite the evidence of neurotoxicity in animal models, as to the toxicity in humans (2005). They clearly stated, however that “the repeated use of ketamine for recreational purposes affects prefrontal dopaminergic transmission, a system critically involved in working memory and executive function [and might damage brain neurotransmission generally]” (p. 2358).

This study is a good one because of the link between exogenous substances, the dlPFC and receptor sites, with such illnesses as schizophrenia. Schizophrenia is characterized by an imbalance in dopamine transmission, especially at the D1 receptors (DA deficit; cognitive impairment) and the D2 receptors (DA excess; psychosis) (p. 2358). The authors provided the following link: “[t]he fact that chronic ketamine users and patients with schizophrenia exhibit the same endophenotypic trait (up-regulated D1 receptor expression in the dorsolateral prefrontal cortex) supports the hypothesis that in schizophrenia, this alteration might be secondary to NMDA dysfunction” (p. 2358). In fact, many researchers have long since established the link between DA agonists like cocaine and amphetamine, that also cause positive symptoms of schizophrenia (hallucinations, delusions, etc.), as well as PCP (angel dust) and ketamine (Special K or Vitamin K), as capable of causing positive, negative (poverty of speech, anhedonia, etc.), and cognitive symptoms (attentional problems, deficits in learning and memory, poor problem solving, etc.) of schizophrenia and therefore study the effects of these drugs with the hope of curing schizophrenia (Carlson, 2010, pp. 557, 567)

While not formally addressed in the article reviewed, is withdrawal from ketamine. I looked up information from a drug treatment center that described both the physiological and psychological processes involved. Since ketamine involves both psychological and physical effects, withdrawal is both a physical and mental process. The person undergoing the process should be kept under close supervision, due to the strength of the psychological addiction. While displacement away from the sources of drugs are a good tactic for the person in withdrawal, along with psychotherapy and behavior modification, another aspect of ketamine withdrawal, which is best addressed in a professional setting, is the physical side of ketamine withdrawal. The user more often than not has neglected their own physical well-being and often needs the help of nutritionists and physicians. (see also http://www.ketamine-effects.com/ketamine-withdrawal.htm)

Prolonged use has been associated with physical and psychological addiction. In the majority of individuals who frequently use ketamine, tolerance does develop to these effects, thus requiring the addicts to consume higher doses.

Although ketamine does not give rise to physical dependence like that seen with morphine, heroin or alcohol, it is associated with a powerful psychological addiction - like that seen with cocaine. Because of its ability to produce intense, vivid psychedelic effects it is frequently abused. The psychedelic effects and out of body experiences have been primary reasons why the drug is abused.

In conclusion, ketamine addiction, like all addiction begins with the acceptance of a problem by the individual. Many drug rehabilitation and treatment facilities are available for ketamine treatment. There are no antidotes to ketamine and the majority of therapy is psychotherapeutic. (see also http://www.addictionsearch.com/treatment_articles/article/ketamine-addiction-abuse-and-withdrawal_23.html)

References

Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Narendran, R., Frankle, W., Keefe, R., Gil, R., et al. (2005). Altered Prefrontal Dopaminergic Function in Chronic Recreational Ketamine Users. The American Journal of Psychiatry, 162(12), 2352-9. doi: 942933491.

Biopsychologically Informed Treatment of Trauma

Biopsychologically Informed Treatment of Trauma
by
Peter A. Brown, MA


California Institute of Integral Studies
Clinical Psychology
School of Professional Psychology


Biopsychologically Informed Treatment of Trauma

In much of the literature there are ongoing debates surrounding etiology of subcortical abnormalities in Post Traumatic Stress Disorder (PTSD)/trauma, with two prominent hypotheses: the predisposition hypothesis, and the so-called neurotoxicity hypothesis. In my recent paper, I reviewed these two hypotheses and some of the literature in this subfield of biopsychotraumatology and found that both are likely operative (reminiscent of the nature-nurture debate) (Brown, 2009). That said, and with a long-term goal of specialization in neuropsychotraumatology in mind, this paper covers the biopsychologically informed treatment of trauma used in the field today.

The person suffering from PTSD is likely to have a dysfunctional hippocampus that does not distinguish a safe context from a dangerous one, thereby triggering amygdalic-emotional response (see also Carlson, 2010, p. 607). This subcortical process follows the ‘low road’ in amygdalic connectivity parlance, bypassing the (ventro-)medial prefrontal cortex ((v-)mPFC – especially the Anterior Cingulate Cortex – ACC) which is unable to inhibit these triggers (or is itself impaired); the amygdala is highly connected, both ascending to cortical structures like the vmPFC or ACC and descending to other (sub-)pontine structures (including the spinal cord) (Zillmer, Spiers, & Culbertson, 2008, p. 150). Treatment, therefore, would need to address the subcortical, bottom-up processing ‘road’ and not only the top-down, cortical, cognitive ‘road’.

Interestingly enough, the sine qua non of the psychotraumatology specialty is cognitive-behavioral therapy, a high road therapy. Certainly, other treatments, such as pharmacotherapies are viable options, alongside integrative high and low road therapies. In this paper, I review a brief sampling from literatures related to pharmacotherapies and integrative methods, leaving those that focus on cognitive methods to future articles. I think that both pharmacotherapies and integrative therapies are vital to effective treatment, and maintain that biopsychologically informed treatments can help (even if simply to help researchers ask the right questions) to ameliorate efforts in the biopsychotherapeutically oriented treatment programs and research streams currently active today.


Literal wounds to the brain

One current article I reviewed argued for the re-medicalization of the PTSD construct in order to help fight against pathologization and stigmatization of PTSD and victims of trauma Nash, Silva, & Litz, 2009). In fact, the authors pointed out the deliberate decision to stigmatize ‘shell shock’ so as to prevent desertion during the world wars: “stigma was attached to mental health labels intentionally as a deterrent to stress-casualty epidemics” (p. 794). This re-neurologization of the modern research paradigm is revitalizing the work of Pierre Janet, a contemporary of Freud, who dealt with dissociation’s (theoretical) effects on brain function at the beginning of the 20th century (p. 792). In fact, the most recent studies indicate that severe stress can literally injure the brain and calls for this paradigm shift in thinking about traumatic stress (p. 792). While much of the rhetoric of the writing in the field, and of the article reviewed, (discussing etiological mechanisms) dovetails with the CBT literature, interesting conclusions merit attention, especially in the
extinction of fear-based conditioning… mediated by the medial prefrontal cortex, and social cue recognition… mediated by the orbitofrontal cortex, in addition to the hippocampus and amygdala…[and the ACC, a] brain center essential for the inhibition of situationally inappropriate or irrelevant thoughts and emotions, as well as for the situation specific regulation of autonomic arousal, including pulse and blood pressure. (p. 792)

What the authors fail to mention are the treatment modalities toward which they allude: behavioral modification (‘extinction’ etc., along the lines of classical conditioning), socially based therapies (milieu, systems, etc.), and biofeedback oriented psychoeducation (relaxation, mindfulness, guided imagery, hypnosis, etc.). They call for treatments that include remedying “deficits in memory…extinction of fear-based learning, [gaining] authority over one’s own emotions and thoughts, and the regulation of autonomic arousal” (p. 792).

The most valuable contribution of the article was articulation of the position that the suffering and impairment of those who suffer from PTSD, (especially soldiers, sailors, airmen, and marines),
are not due to their own failure or weakness, any more than any other physical wound would be. …this conception can provide a framework for more effective primary and secondary prevention programs in the military and other community settings, as have been adopted recently by the Navy and Marine Corps. By lessening the barriers to early recognition, the stress injury model may also promote more effective and targeted early interventions, such as those based on cognitive-behavioral therapy. (pp. 793-4)


Pharmacotherapeutic Treatment of Trauma

In light of what researchers know of the excitotoxicity of glutamatergic cascades, (as seen in Traumatic Brain Injury, depression, etc.) and along the lines of the excitotoxic hypothesis of PTSD (see also Brown, 2009), combined with the typical high-road focus of CBT oriented research and therapies, the field needs and fortunately uses medications as a growing, primary treatment modality. For example, phenytoin/Dilantin is an anticonvulsant used in epilepsy treatment that seems to modulate glutamatergic transmission, and was recently studied as to the cognitive and neurophysiologic impacts in PTSD patients (Bremner, et al., 2005, p. 159). The authors found that “[p]henytoin treatment resulted in a significant 6% increase in right brain volume … [and] [i]ncreased hippocampal volume was correlated with reductions in symptom severity” (p. 159). The mechanistic postulate is phenytoin antagonizes glutamate excitation and blocks the effect at the NMDA receptor (p. 163). Noting that the right side was ameliorated over the left, the authors called attention to the well-known contribution of the right brain to emotion and non-verbal cognitive processes, over and above that of the left side (p. 163).

The most important aspect of this study was the demonstration that medications used in neuropsychiatric treatments actually had effects on the very physiology of the brain itself (p. 163). This line of research, and that of other pharmacotherapies, such as propranolol (see also Pitman, et al., 2004, pp. 241-2) and paroxetine (one year SSRI treatment yielding a 5% increase in hippocampal volume and a 35% improvement in verbal declarative memory function in PTSD patients; Vermetten as cited in Bremner, et al., 2005, p. 160) are some of the most promising research that I reviewed, considering the biopsychological focus in the treatment of trauma.


Biopsychologically Focused Psychopharmacological Treatment

Another area of vital importance to the traumatology specialty is memory. It is commonly known that the amygdala influences the aroused encoding and consolidation of memory and that the extreme arousal of trauma leads to persistent memory traces (McCleery & Harvey, 2004, p. 487). While traumatically consolidated memories are stubbornly resistant to treatment, “the strength of memory for a learned task can be modified (either weakened or enhanced) by treatments, including drugs and hormones (adrenaline, glucocorticoids, …[though] the longer the gap… [before] treatment, the less effective the modification (McGaugh as cited in McCleery & Harvey, 2004, p. 488). This line of research suggests the modification by hormonal means can act on the activation of adrenergic and muscarinic cholinergic receptors in the basolateral nucleus of the amygdala (BLA), thereby leading to alternative interventions on those areas of the brain involved in traumatic memory (McCleery & Harvey, 2004, p. 488).

Another interesting approach is in the use of centrally acting noradrenergic beta-(receptor antagonists)blockers in order to inhibit the emotional enhancement of memory (p. 488); I think of prazosin/Minipress, a similar drug, though it acts on alpha-1-receptors and is typically used off-label for PTSD related nightmares in both veterans and civilians (Singh, personal communication, 2008; see also Friedman, Davidson, & Stein, 2009, who suggest the aforementioned, as well as alpha-2-receptor agonists like clonidine and guanfacine, p. 564). Contrariwise, yohimbine stimulates noradrenergic enhancement of memory (McCleery & Harvey, 2004, p. 488). Both these are interesting in examining the best course of treatment (considering a conservative approach) matched to the individual and the context – naturally fraught with problems. The undergirding is that when a memory is invoked and made labile, it may be acted upon and before reconsolidation, alteration can occur. In fact, “there is preliminary evidence … that a beta blocker administered soon after a traumatic event may reduce the strength of fear conditioning” (Pitman as cited in McCleery & Harvey, 2004, p. 488). Other methods under investigation include disruption of the conditioned fear response in rats by inhibiting protein synthesis after reactivating the memory (McCleery & Harvey, 2004, p. 489). However, the authors also point out that “[t]here is still little direct evidence for the reconsolidation hypothesis in humans” (p. 489), which naturally limit externalization of these findings.

I find it very interesting that the field seems to contradict itself in many areas, for example, that of the role of arousal in trauma and in trauma treatment:
in a positive psychosocial context … [arousal in response to traumatic events] forms an essential part of the mechanism of adaptation. Initial memories of a traumatic event will inevitably be distressing and, as described above, successful psychological adjustment seems to involve the incorporation of both increased factual detail and more positive interpretations … into declarative memory. This therapeutic processing… will also be promoted by arousal…[and] the success of exposure treatment is greater when there is a higher degree of arousal during treatment …with the possible exception of extremely high levels. The addition to exposure treatment of interventions specifically designed to reduce anxiety/arousal… has not been found to improve outcome. (p. 492)

Many studies note that using a more neurobiological consideration of the role of arousal and how pharmacotherapies might be helpful, for example in drastically reducing arousal states and promoting amnesia after trauma: psychotherapy plus beta blockers to reduce the strength of memories, beta blockers plus exposure therapy, and even administering beta blockers as soon as possible post-trauma (p. 492), similar to the proposed use of propranolol (Pitman, et al., 2004). However, the authors warn that while these drugs may be helpful in preventing overconsolidation of traumatic memory traces, they could also prevent incorporation of safety information, thus preventing timely recovery (McCleery & Harvey, 2004, p. 487). So for people who might even recover well (which it is still very difficult to completely determine propensity for PTSD development, “drug treatments are likely to be of benefit only if targeted very carefully at high risk individuals, whom it may not be possible to identify accurately in the acute phase” (p. 493) might be harmed by hasty use of beta blockers (or propranolol, or benzodiazepines - BZs - that induce anterograde amnesia in the BLA) (p. 488; see also Friedman, Davidson, & Stein, 2009, who maintain that BZs are contraindicated for PTSD monotherapy, p. 566).

In conclusion to the section on pharmacotherapies, due to the fact that trauma survivors need a robust cortisol response in order to contain sympathetic arousal, and that those with highest risk for development of PTSD typically do not show one, it is promising to consider that the use of “stress-level hydrocortisone treatment… was associated with a reduction in PTSD symptoms” (McCleery & Harvey, 2004, p. 493). However, this
preventative strategy…given the continuing uncertainty about the status of the HPA axis in PTSD patients and the fact that acute cortisol administration has been found to enhance emotional memory, this strategy too cannot be regarded as being without risk of harm. (p. 493)

Note that the brain might be damaged due to psychological distress by action of “stress-induced disturbance of the hypothalamic-pituitary-adrenal axis” (Sapolsky as cited in Schmahl, et al., 2009, p. 294), glucocorticoids, and glutamate active in the limbic system (see also Carlson, 2010; Zillmer, et al., 2008), but the exactness of the predispositional versus the neurotoxic etiologies of chronic PTSD is still debated (see also Brown, 2009).


Integrative Treatment Approach: EMDR

So, because of the difficulties in targeting those at risk for development of PTSD in the acute phase (and even the risk of harming them) with pharmacologic intervention, and that “[t]op-down approaches… do not process the episodic memories or resolve physiological hyperarousal” (Solomon & Heide, 2005, p. 56), what is the best treatment approach?

It is clear that people will, even after years of therapy, come into contact with events that ‘trigger’ them physiologically, and that their response is not of a logical, top-down, high-road, cortical nature, especially of the sort that therapies like CBT target (p. 56). In contrast,
[b]iologically informed therapy focuses on processing …[e]pisodic memories [that] are … transferred from the limbic system to the neocortex and filed away along with other narrative memories. Biologically informed therapy includes bottom-up processing, which focuses on what is going on in the body. This approach helps clients connect with their bodies and with their feelings. It facilitates their learning to tolerate intense feelings and to release emotion appropriately. Survivors learn to calm their physiology. (p. 57)

Eye Movement Desensitization and Reprocessing (EMDR) therapy involves visual, tactile, and auditory (even proprioceptive) stimuli that alternately stimulate the left and right hemispheres (p. 58). Some say “repetitive redirecting of attention [especially through eye movement] in EMDR induces a REM sleep-like state… that facilitates the activation of episodic memories…[which] are processed and integrated into neural networks in the neocortex as semantic (narrative) memory” (p. 58). This therapy is proving to increase
bilateral activity in the…[ACC, a] part of the brain that modulates the limbic system and helps us distinguish real from perceived (but not real) threat. The increase …[in ACC] activity suggests a decrease in hypervigilance… [there was also an] increase in prefrontal lobe metabolism, suggesting greater ability to make sense of incoming sensory stimulation. (p. 58)


Conclusions

It is clear that both high road and low road therapies must work together, alongside those underpinning hypotheses (neurotoxic v. predisposition) in order to develop innovative applications in prevention and treatment of PTSD and base them on biopsychological bases. Perhaps in a foreshadowing of what is still yet to come, Sapolsky (2002) suggests that, should the neurotoxicity hypothesis stand, the field needs to develop a kind of post-traumatic golden hour of response along with antidote to the cascade of glucocorticoids and glutamate in the brain (p. 1113; not unlike the propranolol preventative treatments - Pitman, et al., 2004, pp. 241-2).

As I mentioned elsewhere, single case findings from researchers treating PTSD patients with EMDR for 90 minutes per week for 8 weeks, show that this therapy increased total baseline hippocampal volume by some 11% (Letizia, 2007, pp. 475-6). I imagine that through ongoing studies such as these, in combination with various other methods of treatment, will give the field more questions to consider to the age-old human problem of suffering and its alleviation. The integrative application of biopsychology is indeed a powerful force in this change.


References

Bremner, J., Mletzko, T., Welter, S., Quinn, S., Williams, C., Brummer, M., … Nemeroff, C. (2005). Effects of phenytoin on memory, cognition and brain structure in post-traumatic stress disorder: A pilot study. Journal of Psychopharmacology, 19(2), 159-165. doi:10.1177/0269881105048996

Brown, P. (2009, November 14). Traumatic predisposition or neurotoxicity: Examining hippocampal volume and PTSD. [Web log post]. Retrieved from http://peterallenbrown.blogspot.com/2009/11/traumatic-predisposition-or.html

Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Friedman, M., Davidson, J., & Stein, D. (2009). Psychopharmacotherapy for adults. In E. Foa, T. Keane, M. Friedman & J. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (2nd ed.). (pp. 269-278). New York, NY, US: Guilford Press.

Letizia, B., Andrea, F., & Paolo, C. (2007). Neuroanatomical changes after eye movement desensitization and reprocessing (EMDR) treatment in posttraumatic stress disorder. The Journal of Neuropsychiatry and Clinical Neurosciences, 19(4), 475-476. doi:10.1176/appi.neuropsych.19.4.475

McCleery, J., & Harvey, A. (2004). Integration of psychological and biological approaches to trauma memory: Implications for pharmacological prevention of PTSD. Journal of Traumatic Stress, 17(6), 485-496. doi:10.1007/s10960-004-5797-5

Nash, W., Silva, C., & Litz, B. (2009). The historic origins of military and veteran mental health stigma and the stress injury model as a means to reduce it. Psychiatric Annals, 39(8), 789-794. doi:10.3928/00485713-20090728-05

Pitman, R., Sanders, K., Zusman, R., Healy, A., Cheema, F., Lasko, N. … Orr, S. (2004). Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Curr Psychiatry Rep., 6(4), 241-2.

Sapolsky, R. (2002). Chicken, eggs and hippocampal atrophy. Nature Neuroscience, 5(11), 1111-1113. doi:10.1038/nn1102-1111

Schmahl, C., Berne, K., Krause, A., Kleindienst, N., Valerius, G., Vermetten, E., & Bohus, M. (2009). Hippocampus and amygdala volumes in patients with borderline personality disorder with or without posttraumatic stress disorder. Journal of Psychiatry & Neuroscience, 34(4), 289-295.

Solomon, E., & Heide, K. (2005). The biology of trauma: Implications for treatment. Journal of Interpersonal Violence. Special 20th Anniversary Issue, 20(1), 51-60. doi:10.1177/0886260504268119

Zillmer, E., Spiers, M., & Culbertson, W. (2008). Principles of neuropsychology, (2nd ed.). Belmont, CA: Thomson Wadsworth.

Wednesday, December 2, 2009

The Synaptic Button and Drug Action

The synapse of the terminal button, both pre- and post-synaptically (that is, from transmitting to receiving button) are also effected by a mechanism called hyperpolarization of the dendritic autoreceptors where they are activated by neurotransmitter or antagonist drug action (that binds to and blocks the receptors) thereby reducing the rate of firing of the neuron, effectively acting as an antagonist (Carlson, 2010, p. 113). Certainly, drugs that block the autoreceptors antagonistically, reduce the effect of hyperpolarization (which is regulatory by nature) and thereby work as agonists (reducing this regulatory effect) (p. 113).

Drugs can affect synaptic transmission in a variety of ways. Carlson (2010) mentions at least 11 ways, ranging from drugs serving as precursor agonists (like L-Dopa on dopamine), inhibits synthesis of neurotransmitter antagonist (like PCPA on serotonin), prevents storage of neurotransmitter in vesicles as antagonist (reserpine on monoamines), stimulates release of neurotransmitter as agonist (spider venom on acetylcholine-ACh), inhibits release of neurotransmitter as antagonist (toxin on ACh), stimulates postsynaptic receptors as agonists (nicotine and muscarine on ACh), and naturally several others like blocks as antagonists, blocks or stimulates autoreceptors, blocks reuptake as agonists, or inactivates as agonists that which is transmitted synaptically. Certainly, the two basic forms of these are agonists and antagonists (drugs that are facilitating versus inhibiting postsynaptic effects) (p. 111).

Drug reactivity in tolerance and sensitization are both similar and different (compensatory mechanisms v. direction of effect). Drug reactions are similar in these two phenomena because drugs follow a dose-response curve that reciprocates larger drug effects with increase doses, up to a maximum effect, where dose increases no longer produce drug reactivity, and increase prevalence of side effects and risk (p. 107). Drug effects that diminish with repeated dosage are called tolerance; and effects that increase are called sensitization (p. 108). Drug tolerance effects are the bane of illicit drug users (think heroine), in that the brain works to maintain optimal levels of functioning at all times and with repeated (and increasing) doses of exogenous substances, the brain produces opposite reactions to compensate (hence the opposite withdrawal symptoms upon substance stop) (p. 109). Further, the sites where the substances bind become less sensitive to the drug as it is used more frequently and the receptors actually decrease in number, also knows as a compensatory mechanism (similar to the decrease in effectiveness of coupling, another compensatory mechanism) (p. 109). In contrast to tolerance mechanisms, sensitization is more rare (p. 109). Because sensitization causes ever-larger drug effects, compensatory mechanisms direct regulatory efforts away from physiologic processes, as in respiratory depressive effects of barbiturates or opiates that show sensitization (especially in combination) versus their euphoric and/or analgesic properties that show tolerance effects (p. 109).


References
Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Saturday, November 28, 2009

Social psychology tangent - Anomie or Cradle to Flag-Draped Grave: Social Constructivism and War

Running head: SOCIAL CONSTRUCTIVISM AND WAR









Anomie or Cradle to Flag-Draped Grave: Social Constructivism and War





Peter A. Brown








Professor Dr. Benjamin Tong
Social Psychology, Fall 2009










Author Note

Peter A. Brown, MA; California Institute of Integral Studies, School of Professional Psychology, Clinical Psychology Doctoral Program; 1453 Mission St., San Francisco, CA 94103; telephone: (415) 575-6100 x 6453.






















Anomie or Cradle to Flag-Draped Grave: Social Constructivism and War


The innocent American is the violent American –
which is usually how other nations perceive us.
-- James Hillman, (2004, p. 133)

Abstract
Background: Social psychologists have long studied violence, war, groups, hate and anger, power, and rules that people live by and how people can both decry war in all its forms and devastate whole societies when self-serving views are threatened.

Aims: This paper endeavors to present contemporary and historical evidence on the nature of the relationship between war and social constructivism and offer an integrative synthesis of findings.

Method: This synthesis follows what Torraco (2005) called an “integrative literature review.” In this sense, each article is integrated in order to generate innovations in this area of research and practice.

Results: The results are clear that war is both amenable to social constructivism and impervious to it, while always embedded in a biosocial matrix that uses its self-construction in order to raise consciousness of itself.

Conclusions: A conclusion of this study is the implication for evidence-based practice in healing the wounds of war – that is, an applied understanding of social constructivism as vital in therapeutic settings.

Keywords: social constructivism, war, social psychology


Table of Contents

Social Constructivism & War, Defined 3
Personal Perspective and Positioning Epoche 4
Living Questions and Method: An Exploration 5
From Rush to Mao: “Turn it 20,000 degrees and let’s start over.” 6
Integrated discussion of research: Will the dualists please approach 9
War as embedded in the social matrix: Co-constructed, burned-in – embodied violence 10
War’s Construction-of-Society-through-Destructive-Means Prize 17
Herr Dr. Mengele please report to the lab, the gentlemen from the thought police are here to see you: Constructing warring societies 20
Conclusion 24
References 27


O Lord our God,
help us
to tear their soldiers
to bloody shreds
with our shells;
help us
to cover their smiling fields
with the pale forms
of their patriotic dead;
help us
to drown the thunder
of the guns
with the shrieks
of their wounded
writhing in pain;
help us
to lay waste
their humble homes
with a hurricane of fire;

-- Mark Twain, from The War Prayer, 1923 (Hillman, 2004, p. 201)



Anomie or Cradle to Flag-Draped Grave: Social Constructivism and War


“Why did millions of people begin to kill one another? Who told them to do it? It would seem that it was clear to each of them that this could not benefit any of them, but would be worse for them all…the causes were innumerable and…not one of them deserves to be called the cause.” For Tolstoy war was governed by something like a collective force beyond individual human will.

The task, then, is to imagine the nature of this collective force. War’s terrifying prospect brings us to a crucial moment in the history of the mind, a moment when imagination becomes the method of choice, and the sympathetic psychologizing learned in a century of consulting rooms takes precedence over the outdated privileging of scientific objectivity. (Hillman, 2004, p. 7)


The above quotation from Tolstoy with commentary by James Hillman illustrates a commonly held fact: alongside a failure of imagination, culture and the society’s attitudes toward violence are primary factors in its spread (Elbert, Rockstroh, Kolassa, Schauer, & Neuner, 2006, p. 342). At the individual-as-embedded-in-culture level, one study found that between “34% to 45% of the interstate…serial killer activity could be accounted for by dimensions of local culture, with higher rates of violence being found in states supporting game hunting, military training, and a local culture supporting punitive violence” (DeFronzo & Prochnow as cited in Elbert, 2006, et al., p. 342). In any society, these are crimes and are outlawed; with war, at least of the traditional and historical variety, with thousands if not millions of combatants, wars and armed conflicts seem to have slipped through institutionalized ‘loop-holes’ (Elchenroth, 2006, pp. 907-8). After the bloodbaths in Rwanda and Yugoslavia, and
[a]s a reaction to the threat for the respect of fundamental rights caused by periods of armed conflict and by the breakdown of national institutions, there have been repeated efforts from the international community resulting in the growing institutionalization of international humanitarian law, which is supposed to compensate for the legal loophole generated by armed conflicts, by defining the principles of a minimal and irreducible law. (pp. 907-8)

However, does this push cover the seeming escalation of the “new wars” of organized violence? These new wars are state sponsored - harassment, torture, terrorism – and over 90% of these are intra-state conflicts, civil wars, and actions by rebel armies (using irregular forces, affiliations to different groups – ethnic, religious, etc., targeting civilians – over 80% of the casualties of new wars are civilians, and due to economic factors, including use of foreign resources to fund them) (Elbert, et al., 2006, pp. 343-4).

Naturally, there are consequences of these wars at both the individual and collective levels. Prevalence rates for trauma spectrum disorders – that is, disorders that incapacitate - range from 20% to as much as 60% (p. 344). These figures effectively wipe out communities and their abilities to recover from war, and produce secondary effects on the population such as domestic violence, intimate partner violence, transmission of trauma, further warring, and fosters a cycle of violence in whole regions and continents (most poignant in Africa) (pp. 344-5). These devastating effects have been referred to as “societal trauma” (p. 345).


Social Constructivism & War, Defined

This paper examines the relationship between war and social constructivism. Social constructivism is a critical theory that emphasizes a socially constructed view of reality by those involved; either emically – as insiders – within a context of time and place and supplanting a more positivist search for universal truth, or a more etically oriented – that is, ‘objective’ and outsider - perspective (Miller, Kulkarni, & Kushner, 2006, pp. 412-3). Emically, this paper eschews a positivist stance - despite the flavor and structure of an ‘integrative literature review’ as a legitimate, scientific method – in favor of a more pluralistic and constructive, postmodern view.

The late Dr. Sue Mansfield, Professor Emerita at Claremont McKenna College (Claremont, CA), who died in 2002, defines war as:

a particular type of institutionalized aggression in which social pressure is used to force individuals to kill other people they may not even hate or fear [or know]…[and] through which a group of individuals attempts to satisfy its needs by destructuring and imposing its will on another group. (Mansfield & Keen, 1982, p. 382)


Naturally, war might also be considered a state of anomie, where lawlessness prevails. On the other hand, war can also be constructed and used by societies. War is socially constructed in that it is fought over a differing construal of reality, truth, or belief. It is also far beyond that which a society can collectively understand, as it typically destroys societies. There are rules of war, war propaganda, war crimes, illegal wars, ethical wars, and total wars. There are honors in war, war hawks, societies or brotherhoods of war, war trophies, winning over hearts and minds, ethnic cleansings, truth and reconciliations committees, war crimes tribunals, holocausts, genocides, fratricides, and any number of destructive and counter-destructive acts of war and reactions to war. War confuses, enrages, and changes everything in its path.


Personal Perspective and Positioning Epoche

As a former Regular Army Captain, combat veteran, military academy graduate (USMA-West Point, Class of 1996, graduate [Cullum] number 53,003), I have some firsthand knowledge of rules of war, if captured was to be held to Category III of the Geneva Conventions (that is, a ranking system that also provides for pay to prisoners of war; Cat., III is for warrant officers and those commissioned officers below the rank of Major, who holds Cat. IV), the conduct of war, and the feel of war – that unmistakable pungency, the electricity and fear in the air; the sweat and the heat, the roar. I have shipped youth home in metal boxes and have helped put them in the ground; both close colleagues and strangers. I have luckily survived and can report that my hands are clean, though I fear much has rubbed off on me. I have had the opportunity to study the great wars, the strategists and generals, the participants, and battlefields. Despite this, in the wake of what is being called “The Fort Hood Massacre,” I am left shaking my head. Perhaps at the aggrandized and glorious end of the war-spectrum, “[a] wartime perception of reality has a "mythic" quality,” (Social construction of war, 2003). War has a particular salience in my work; that about sums it up.


Living Questions and Method: An Exploration

Social psychology has long sought to understand the problem of human suffering, especially with regards to Aronsonian categorization of the field: conformity, mass communication/propaganda/persuasion, cognition, self-justification, aggression, prejudice, loving/sensitivity, and science – perhaps boiling down to social influence that people have over others (Aronson, 2009, pp. v and 6). Perhaps then, this study is best suited to asking further questions in lieu of providing quasi-positivist ‘reality-as-it-really-is’ answers, exploring instead: “what are factors at play in influencing people’s relationship to war?” or “how does social constructivism relate to war and thereby influence people?” or “does social constructivism capture the manifold valences of war?” With these questions in mind, I aim to explore some of the relevant literature, while integrating material from authors in the fields of social psychology, neuropsychology and neuroscience, philosophy, anthropology, traumatology, and even some practitioners of psychotherapy. While this may seem like a vast area of research, the exploration serves as performatively oriented social construction of war, by way of dialogical argument.

Perhaps, too, it is important to mention that this study is by no means an exhaustive review of the literature, nor does it attempt to solve the dilemma of war, offer a groundbreaking theory, or cover every angle. Rather, my curiosity in the area of intersection between social constructivism and war piqued my interest sufficiently to design the present study according to a hybridization of what Torracco (2005) calls an integrative review of the literature, compellingly relevant to the study of social constructivism.

The method of literature review was to search using a common database. Some interesting studies turn up in the research and peer-reviewed literature, albeit largely in philosophic, qualitative, or case study format. In a search of one database (PsychInfo), I found 13 articles, 2 of which were brief reviews of much larger works, and 7 of which were suitable for inclusion in this paper based on keyword criteria, availability, and dated after 9/11(/2001) (keywords: social constructivism, war, violence, combat, trauma, construction, constructionism, constructivism and variants by thesaurus and combined search options).


From Rush to Mao: “Turn it 20,000 degrees and let’s start over.”

The rationale for this review of social constructivism and war, especially in terms of social psychological methods and their application, is my ongoing research into the nature of epistemic concerns in the research and treatment of combat veterans. These epistemic concerns, really a critique of whole, socially constructed, dogmatic paradigms of scientific hegemony, are not unlike religious belief systems where the diversity of others’ views are largely neglected, dismissed, and sometime, outright destroyed through violent means. This is not to say that scientific domination is the responsible culprit for wars in the world today, rather, that it is in the very beliefs themselves that power brokers use to maintain an intolerance of diversity.
Take for example, James Hillman’s book A Terrible Love of War, where he cogently argues that the Judeo-Christian ethic, as purveyor of monotheistic, patriarchal belief systems, is, at its root, a violent system that elicits warmaking (2004). Hillman wasn’t alone in his condemnation of the Judeo-Christian monistic and violent belief system, either. Perhaps Dr. Hillman knew Sue Mansfield who said: “Christian culture is at once more pacifistic in its intent and more violent in its action than any other culture that has existed” (Mansfield & Keen, 1982, p. 385). Hillman notes that

[w]ar presents theological dilemmas about the nature and intention of a one and only almighty God whose goodness and mercy are exalted by the three great monotheistic religions. By definition this God has the greatest power; there is nothing he cannot do – that is what omnipotence means. So why does he not put a stop to war? … Either he can’t stop war or he doesn’t want to. The first rebuts his claim to almightiness and the second implies that he likes war, or at least by not stopping it, he sustains it” (Hillman, 2004, p. 187).

It is perhaps clear that Hillman, a post-Jungian, founder of archetypal psychology, and a veteran of World War II himself (he was a corpsman in a hospital treating some of the more grisly injuries of the war), sees tolerance and belief as core splits that precipitate war:

[b]ecause a monotheistic psychology must be dedicated to unity, its psychopathology is intolerance of difference. Hence the issue of toleration has plagued theological thinkers for ages, leading to schisms and more schisms. As long as you hold that your god is the perfect supreme deity, all other gods will be lesser. There are no several truths, no other roads to the Kingdom. …Moreover, as long as the others, the lesser, continue to practice their precepts and believe in a different god (or a slight variation in the nature of your god), they exhibit in their very existence a denial of the complete truth of your god. It is a necessity of your truth and your faith to war against them, because no matter how quietly they live or how far away their territories, their existence places in essential doubt the foundations of your belief in your god [or politics, or money, or epistemological ground, or philosophy…and provides ample opportunity to fight ever more strongly for the cause of defending the faith, nation, etc.]. (Hillman, 2004, p. 183)

Social psychologists aren’t only complaining; they are also involved in researching the attempted control of war, through social justice efforts. One article I reviewed presented evidence to substantiate four major research programs in thinking about justice and war: 1) social justice is constructed and embedded in the same frame as the viewer – that is, people see it in their own terms (especially involving the fundamental attribution error (Jones & Nisbett as cited in Hatfield & Rapson, 2005, p. 173), 2) people define social justice to serve themselves (especially in primatology and in entitlement, neurobiology, etc.) 3) authority, power, and peer pressure have tremendous influence on how people treat each other, (Milgram, Zimbardo, et al.) and 4) emotions determine social justice views and how people treat each other (emotional contagion, basic biopsychology and neurophysiology, and research showing that people, when angry and frustrated will take it out on scapegoats – witness the holocaust, Stalin’s and Mao-Tse-Tung’s purges) (Hatfield & Rapson, 2005, pp. 172-4). Perhaps the best example of these is an excerpt from the infamous Rush Limbaugh, commenting on “his angry and nationalistic reaction to hearing of the American’s torture of the Abu Ghraib Prison prisoners in Baghdad, Iraq, and the subsequent killing of an American hostage [by beheading]” (p. 174) quoted here at length:

They’re the ones who are sick..[.] They’re the ones who are perverted. They’re the ones who are dangerous. They’re the ones who are subhuman. They’re the ones who are human debris, not the United States of America and not our soldiers and not our prison guards… [On Nick Berg’s beheading:] I thought I saw a couple smiles through the mouth holes in the mask, and at that instant I wanted to call George Bush and say, “Level the place. Turn it 20,000 degrees and let’s start over. …They don’t deserve to live. They don’t deserve sympathy. They don’t deserve understanding. They don’t deserve compassion. They don’t deserve traditional justice… To hell with rights and all this stuff. I wanted to be in the charge leading into that room to wipe ‘em out. (p. 174)


Integrated discussion of research: Will the dualists please approach

Several articles provide good material for the present study and raise several issues for consideration. For simplicity of presentation, the following indicate several positions in what I consider to be a debate for a positive correlation between social constructivism and war, and its counterpoints and alternatives. I will discuss each in turn, and synopsize with a brief conclusion.


War as embedded in the social matrix: Co-constructed, burned-in – embodied violence

In an attempt to understand war, look up the social construction of war in a Google search, and find striking headlines such as: “Females seem to find war to be an aphrodisiac…War makes people feel so alive… War: Comprehending Its Mystique and Its Madness…Letting out the (war) dogs…War is a force that gives us meaning…” and others. Indeed,

during wartime, notions of good and evil become black and white--it's us vs. them; the future of history hangs in the balance … the enemy acts out of a will-to-power, whereas we act out of self-defense, benevolence and a commitment to the fight; since the enemy is evil and untruthful, communication is impossible--only force will settle the conflict; the same actions are good when we do them, evil when the enemy does them; we are concerned only about outcomes, not causes of the conflict; and citizens who take umbrage with these perceptions of reality are considered traitors. (Utne as cited in Social construction of war, 2003)


In familial terms, Schore (2003) cites “why interpersonal deprivations and failures in the earliest stages of human development serve as a primordial matrix for a personality that is at high risk for violence” (Schore, 2003, p. 107) and that “experiences in infancy which result in the child’s inability to regulate strong emotions are too often the overlooked source of violence in children and adults” (Brazelton as cited in Schore, 2003, p. 107).

Even from the very beginnings, paternal abuse and neglect, indeed, any disruption in so-called natural biorhythms of man and infant or woman and infant, results in early imprinting of corticolimbic (especially right hemisphere) structures that are in a developmentally vital phase (first 2 years of life) (Schore, 2003, p. 130). Especially in cases of repetitive early abuse or neglect, it is in

this spatiotemporal imprinting of terror, rage, and dissociation [as the caregiver is also abuser, therefore the infant has no where to go for comfort except dissociative mechanisms which become ever more sophisticated and organized] is a primary mechanism for the intergenerational transmission of violence. (p. 130)


Clearly, then, violence begets violence, and very often this happens in the man-infant relationship, where little boys first learn modulation of fear and aggression (p. 130). Witness, too, the presence of seemingly innocuous exemplar of violence in movies and on TV, providing “all kinds of evidence to the effect that violent solutions to conflict and frustrations are not only predominant but also valued” (Aronson, 2008, p. 296). These formative experiences and reinforcements affect our neurophysiology, as we shall see.

Indeed, in postnatal development of the frontal lobes, especially the ventro-medial prefrontal cortex (vmPFC, and its role in limbic modulation of affectual triggers, ‘high-road’ inhibition) (see also Carlson, 2010; Zillmer, Spiers, & Culbertson, 2008) and orbitofrontal cortex (OFC) where traumatic or neglectful early attachment relationships lead to the aforementioned imprinting and ‘in-burning’, the amygdalic response to environmental stimuli is not regulated by the frontal brain structures, thereby leaving the person vulnerable to aggressive dysregulation and attacks of rage (pp. 134-6).

This begs the question, are biopsychological correlates of behavior not also embedded in a socially constructed reality? In a sense, the body is embedded, insofar as the cycle of transmission of aggression and violence has biological correlates to behavior, and certainly in that ‘parenting’ practices are socialized. Further, “the body may symbolize a society, and the dangers that threaten a society can be compared with the dangers threatening the body…rituals [therefore] work upon the body politic through the symbolic medium of the physical body (Douglas as cited in Sigurdson, 2007, p. 246).

Okay, but how does the biopsychological undermine or support the idea that war is socially constructed? Another way at approaching this question is through co-constructive (the confluence of genetic-biological and external, sociocultural systems) approaches (Elbert, et al., 2006, p. 327). So, is war a culturally determined expression of gene-potentiality (p. 327) and thereby an imposed, institutionalized “structure and function resulting from a history of genetic expression” (p. 327)? It certainly sounds plausible, though I might caveat this with allusion to the larger debate in the field of biopsychology and neuroscience, that of the post-traumatic neurotoxicity hypothesis versus the genetic predisposition hypothesis and refer the reader to an article I wrote available at: http://peterallenbrown.blogspot.com/2009/11/traumatic-predisposition-or.html . This gives ground for co-constructivist examination of how wars of terror and violence influence the brain, which individuals subsequently distribute to the society at large; the literature notes a

qualitative change in the way wars are waged and organized violence is exerted; in other words, a transformation in the culture of violence… [is at hand]. Moreover, scientific methods are available to study how traumatic stressors change individuals and communities so we can expect increasing knowledge about how social stressors and related learning conditions shape the structure and function of both the brain and the “societal mind,” including individual behavior and interactions on the community level. (p. 327)


Taking a bit of an implicit and inductive tact, Schore (2003) puts forth both the idea that biological correlates of neurological damage and relational trauma (abuse and neglect) contribute to “neurologically acquired sociopathy” (p. 137) (reminiscent of the legendary case of Phineas Gage – see also Zillmer, et al., 2008). The ideas of “hostile attributional biases” contribute to this line of thinking, in that it is believed that early onset antisocial boys (7-11) have these biases acutely activated as threats to the self, integrated in their “hostile world schema” (Dodge & Somberg as cited in Schore, 2003, p. 140). These are mechanisms of the cycle of violence, where the individual, embedded in community relationships, internalizes and structures himself or herself around and within the social matrix. It is clear from much of the research that people inculcate traumatic memories (amygdalic emotional learning) and that the collective memory trace (read: intergenerational transmission of trauma) precipitates violence through the aforementioned relational mechanism (see also Elchenroth, p. 910).

Therefore, it is my contention, and that of others - including Dr. Mansfield, that war as social construct starts in the arms of mother and father, really with the whole lineage of war and aggression. Even in pre-history, the institutionalization and reification of war follows distinct patterns of influence, literally, from cradle to grave (see also Mansfield & Keen, 1982, pp. 381 & 383). Even the reinforcement paradigms evolved from kings and rulers into the (patriarchal) family, supporting a feudal system of greed and materialist reward, using aggression and war as institutional purveyors of rage, discipline, and guilt (p. 383). This system eventually, and in terms of which Skinner might approve, became conditioned to equate goods with love, thereby awarding/reinforcing aggression with goods/booty, and finally making the extension (or stretch) that war is love (hence the elites diversified desires for goods – read: love - used aggression and war to satiate those desires) (see also Mansfield as cited in Keen, 1982, p. 384). Indeed, this reinforced (especially in the US) social matrix provides role models of violence as early as possible. Here, I feel moved to include a passage of some of the thoughts of Ron Roberts on this theme, as particularly salient and quoted here at length:

[c]onsiderable evidence exists that both the US and UK have nurtured the growth of extremist movements [even individual people] in areas of strategic interest (Ahmed as cited in Roberts, 2007, p. xi)…this ‘alternative’ narrative involves a profound reframing of the psychology that accompanies acculturation into Western society – in particular how and why people internalize the motives of Western governing elites [especially in regards to the obviously – at least as easily seen by those outside of the ‘West’ – aggressive, vindictive, and single-minded pursuit of energy, wealth and power]. … What does this tell us about our own psychology? … [Is the US actually preparing] citizens (children and adults alike) to not only accept the state’s actions but to assume benevolence in its intentions[?] … [Is this] a new postmodern variant of totalitarian rule fashioned by the security state [and propagated, executed, and controlled by complicit fields such as psychology] to safeguard elite interests at home and abroad, as well as the idea, unspeakable in our own media, that ‘we’, i.e. the… alliance of Britain, the US and Israel, do not want peace in the Middle East. Implanted deep in the American and British psyche is the product of a grand deception – the notion that we are continually exploring all means to bring peace, stability, justice, human rights and democracy to the world. The opposite fact appears more likely to be true: that all available avenues are followed to avoid peace, to wage war, to solicit evidence from torture and to antagonize people around the world toward position of hatred and violence…. This reality somehow survives outside of any critical scrutiny, even in the face of widespread skepticism about the motives of individual politicians. As the window on this hypocrisy opens ever wider, people in the West face the loss of the moral legitimacy of their culture in the wider world. … A common theme in this analysis is the power of social representations: of warfare, terrorism, and political action to shape our culture (a culture that has been engaged in military action abroad) and the actions of individuals within it. The theory of social representations makes possible a different kind of critique than that afforded by the experimental social psychology of the 1960s and 70s. It is not that the world of Stanley Milgram or Philip Zimbardo is no longer relevant to any understanding of the events unfolding in Iraq – particularly with respect to the commission of war crimes and torture at Abu Ghraib... but in the 2000s there is a need to look beyond these situationist accounts and direct our gaze at the wider culture within which the meaning of these actions are to be found – for actors and interpreters alike. (2007, pp. xi-xiii)


Foucault would approve and remind us that the roots are quite antique; the seekers of a perfect society (18th century) also sought a perfect militaire, with fundamental reference to “permanent coercions, not to fundamental rights, but to indefinitely progressive forms of training, not to the general will but to automatic docility (1979, p. 169).

Perhaps as a response to Roberts’ condemnation, albeit years prior and arguably a particularly insidious and backwardly subtle part of the rhetoric against which Roberts writes, an organization called the Psychologists for Social Responsibility (PSR), issued a statement that belies support of the very language that the PSR claims to decry. For example, the statement uses language such as in the urging of the UN to “thwart claims that the US has imperialist intentions in the Middle East…reverse the images of the US as a country that is unable to cooperate with other countries, threatens force when it doesn’t get its way, and breaks its word in international agreements,” (Washington, DC, US., 2003, p. 160) (perhaps this image is an honest account of US policy?). I might translate this statement as ‘help us help you move back into denial about our stance, give us peace as an to help us forget and repress’ about which Hillman also writes (peace as anesthetic of war and arguable cause of future wars; 2004). The tone of the PSR statement did not seem to help a struggling psychological field, in time of war, to frame its social responsibility as helping the populace to forget – ironic perhaps that it was published in a journal called Constructivism in the Human Sciences; how apropos.


War’s Construction-of-Society-through-Destructive-Means Prize


All I know is what they told me at command school. There are certain rules about a war.
Rule number one is ‘young men die.’ Rule number two is that ‘doctors can’t change rule number one.’

-- Colonel Blake, Commander, M*A*S*H (to Hawkeye, after his patient dies) (Humphreys, 2009, p. 716)


In setting up this debate, I earlier referenced so-called power brokers, promulgators of beliefs that maintain an intolerance of diversity. These power brokers might even be whole fields of study, like psychology where:

[i]t would be an act of supreme folly should we [psychologists] choose to ignore these global developments [referring to globalization, increasing economic disparities, induced climate changes, destruction of the biosphere, and the coming energy crisis consequent on the depletion of the planet’s natural resources…lead(ing) to further major conflict…(like) Iraq, Afghanistan and the ‘War on Terror’ (as)…manifestations of the end of the petroleum age, and the beginning of the battle for control of the world’s remaining energy reserves], hanging on desperately instead to an intellectually and morally bankrupt position which asserts the irrelevance of these things to psychology and psychologists. (Harper, Roberts, & Sloboda, 2007, pp. 222-3)


In fact, social psychologists of many camps, both the realistic-conflict- theorists and international-relations-thinkers (who generally favor power asymmetry hypotheses) in contrast to social-constructivists and social-identity-theorists (who favor shared identity-modulated threat perception) all have salient and important contributions in thinking about how people are likely to view powerful, threatening ‘others’ (Rousseau & Garcia-Retamero, 2007, p. 744). In one sense, this too is a construction of meaning used to understand warmaking. However, what these thinkers are finding, in their ‘hard-data’ experiments is that both power asymmetry and shared identity influence perception of threat in a systematic manner (p. 744). In fact, the authors of the study found, perhaps counterintuitively, that shared identity moderates the perception of power balance (high identity similarity equates to lower threat perception, which increases cooperation); naturally, as “shared identity decreases, the material balance of power becomes a more powerful predictor of threat perception” (p. 766). (The authors demonstrated these findings experimentally using a 2 x 2, between participant, design, including manipulation checks and an N=169.) This is important because the authors provide evidence for the systematic effect of ideas on threat perception – if a state needs an enemy, it may be easier to find one that is most dissimilar to blame – and history bristles with examples (any fascist dictatorship or hawkish state). Therefore, in shaping a (warring) society, there are factors both within (ideas and perceptions) and without (overt acts, etc.) – all taking place within ever-larger nested layers of a social matrix.

Are there any limits? Indeed, and it is perhaps vital to consider the confines of the social matrix, the ‘biosphere’, and how this ultimately shapes the construction of a social reality. These global challenges seem to demand the people of the world to regulate its population, with evolutionary forces and the survival of the fittest leading to wars of scarcity and competition for ever-dwindling resources.

Interestingly perhaps, is an article in the November “Awards Issue” of The American Psychologist – the flagship journal of the American Psychological Association – also recently presented at the APA’s annual conference in Toronto, Ontario, Canada, and for which the author, Dr. Keith Humphrey’s of the Palo Alto VA Health Care System, was awarded the “Award for Distinguished Early Career Contributions to Psychology in the Public Interest.” Dr. Humphreys’ article (2009) discusses the role of psychology in mental health provision of services to those affected by war, with special attention to “social problem definition,” (p. 713) which is how the psychology profession ‘reframes’ problems in such a way as to ensure ‘successful’ application of resources. This very interesting point is perhaps, on the surface - at least for Dr. Humphreys - simple, requisite, and obvious, though he states that

[t]he problem of problem definition often involves intense political struggle… because stakeholders appreciate that once a social problem is defined in a particular way certain policy responses seem more logical than others… In addition, a faulty problem definition can lead to the pursuit of a path that will never resolve the problem given infinite resources. (p. 714)


Curiously, this statement begs the question, that Dr. Humphreys cursorily addresses earlier in the article, that, ‘if a problem is really a problem, doesn’t that mean that by nature it is something about which is unknown, over which people struggle, for which resources allocated, and for whom there is some special interest?’ Interestingly, Dr. Humphreys’ earlier, brief reference was that one of his mentors referred to unsolvable problems as ‘facts’ and that was the rationale for altering the conceptualization of the problem. I might conjecture that the manipulation of problem definition is a means of social constructivism by power brokers who have the ability to alter reality such that their power remains dominant. This is a dark-side of post-modern thinking in that the shifting sands of thought, knowledge, and power, are easily changeable for those with resources to change social structures, laws, rules, and even language. This might be an appropriate time to introduce a historical view, from perhaps the most notoriously able reality-warping machines of all time, the Nazi Third Reich.


Herr Dr. Mengele please report to the lab, the gentlemen from the thought police are here to see you: Constructing warring societies

With regards to human experimentation and altered construction of reality of a particularly evil variety, a very interesting article I reviewed was on the neurosciences during Hitler’s Third Reich. According to Karenberg’s synopsis of the Nazi health policy, where “euthanasia, eugenics, and therapy were the three pillars…many researchers set ethical norms aside” (2006, p. 169). In a particularly poignant example of the brutality of man again man at war, and the power-broker’s ability to construct reality to support their own ends, these neuroscientists and psychiatrists in 1930s and ‘40s Nazi Germany began to find “interesting cases” in those who were treatment refractory/resistant or otherwise incurable and who also been first clinically observed and then murdered; who readily offered up – so to speak – their brains for histological examination (p. 169).

These diabolical social actors used science as social constructivist mechanism in time of war to further their scientific agendas. Parenthetically, and perhaps in acknowledgement and reparation of these horrors, many burials have taken place in recent years, complete with a German presidential apology in 2001 for “the suffering caused to the victims of these crimes in the name of science” (Markl as cited in Karenberg, 2006, p. 170). This reconstruction of the chaotic is revisited at the end of this section.

So, why examine a work such the Nazi example? The outrage and the imagery are atrocious and revelatory of the depths of human evil and the deliberate use of these depths to alter whole worldviews. I bring this work to illuminate the dangerousness of

state control from above instead of need-driven planning; the intertwining of science, the military and industry; dissolution of science and enlightenment; human experiments, some of them resulting in death…[s]hall we selectively define only a few of the historical periods…[?]…[or is society merely doomed to repeat history…shall I compare the NIH or NIMH to the Third Reich?]” (p. 170).


Perhaps these are far fetched, but Karenberg anticipated such a response. Quoting Shevell and Pfeiffer, Karenberg mentions that it is not adequate to simply state that the Nazi regime is a good example of what not to do (p. 171). Rather, he mentions several reasons why this is inadequate: 1) pure science in search of truth no longer exists and it is clear from examples such as these that there are political, financial, and social pressures that exert tremendous influence, 2) the Nazi example shows the medical fields the enduring conflict with ethical values (perhaps as a method of social control and constructivism in and out of war; see also the writings of Ken Pope against the APA for its lack of action against torture, www.kenpope.com) – “where and whenever the desire for scientific progress dominates and is made superior to all other moral values, that is where and when the ‘dark side’ of medicine will be found…” and 3) memory and history are fallible and prone to distortion (and/or manipulation or deliberate social construction (pp. 171-2). The images of the holocaust reverberate around Karenberg’s article, apropos to this present study.

While psychological research is perhaps different than the biological, for reasons more obviously owing to the physiology of the human body (which is also subject to the effects of social construction), there is, alas, ever a wound, psychic or bodily. These differences, between psychological and the biological, are perhaps encompassed in the fact that researchers seek out “subjects” (even the word choice, subject v. research participant, is revelatory) who do not always understand what is going on, data collection is self-serving in order to complete studies (itself a social construction), and there are “intense motivation[s] to gather data and other personal needs and agendas” (Koocher & Keith-Spiegel, 1998, p. 415). Certainly, the psychological and societal wound of the holocaust endures, even after the last brain specimen collected by euthanizing, self-serving, warped-constructivist, Nazi eugenicists, (and of the Nazi’s themselves,) have long since decomposed.

Before wrapping up this debate, I need to return to the point on reconstruction out of chaos and the German presidential apology. This last position is that of the very influential and institutionalized (read: constructed) upholders of the collective vulnerability worldview: the International Committee of the Red Cross (ICRC) and a long arm of international humanitarian law: the Geneva Conventions (GC). The GC turned 50 years old in 1999, and celebrated with a large survey of some 12000+ people of war torn lands on their thoughts about war (Elchenroth, 2006, p. 914). These people provided a surprising perspective, especially as masses of individuals who experienced tremendous vulnerability and a common fate whilst living in war zones (2006). From this study, and Elchenroth’s (2006) reanalysis of the data across cultures, it is clear that war causes people to experience great ambiguity especially with regards to their social norms and principles (pp. 911-2). In the context of uncertainty, the demand characteristics are for the community to modulate the tension (that is inherent in uncertain situations) of war, in order to reconstruct what has been de-constructed, made irrelevant, and that which has been destroyed (p. 912) – much as the German president attempted to do by apologizing these many years after the holocaust. That said, after whole communities, not just individual sufferers of war trauma, suffer systematic violence, they become objectified and their impacts are felt even beyond group boundaries and enter into every facet of life in the society, rendering all its populace vulnerable, which leads to a reshaping of belief systems, values, and meanings (p. 925), not to mention further propagation of violence, both interpersonally and societally – and here I return to the opening section of this paper and the data on both serial killers and intergenerational transmission of trauma. Even the humanitarian law itself is objectified as it is created contextually, in times of war, to protect those vulnerable to objectification (p. 925). The findings from this study, perhaps paradoxically, spell out that

within post-war societies, [individual] victims of war are less likely than their community fellows to adopt a legal perspective when judging war behavior…[which calls] into question claims that trials have some kind of therapeutic value and can provide a sense of closure to those most traumatized by war and mass atrocity…[alongside the finding that, at the collective level, it is] an important desire for seeing formal justice being held within those communities that have been the most strongly affected by collective war trauma, as a reaction to common experience of generalized vulnerability. (p. 926)


Conclusion

Interestingly, I find that as I reflect on this study, I notice that there seems to be an ever-expanding spider’s web of information and linkages to other fields, ideas, and approaches – in fact, I am starting to feel a kind of uncertainty about the material – a kind of desperation in the literature, now that I am moving toward conclusion. Foucault might have said, ‘bravo’ and echoed that

[t]he positivity of a [historical a priori] discourse…characterizes its unity throughout time, and well beyond individual œuvres, books, and texts. … Different œuvres, dispersed books, that whole mass of texts that belong to a single discursive formation – and so many authors who know or do not know one another, criticize one another, invalidate one another, pillage one another, meet without knowing it and obstinately intersect their unique discourses in a web of which they are not the masters, of which they cannot see the whole and of whose breadth they have a very inadequate idea… . (Foucault, 1972, p. 126)


Perhaps this entangled web of the de-construction of constructivism is what Kaisa Puhakka (2008) meant by the ‘post-modern malaise’. Perhaps it is that the field of psychology, with ever-greater range of methods and theory to choose from, loss of coherence and the accompanying uncertainty, and a new openness to alternative views – that the malaise sets in. Fortunately for us, Dr. Puhakka gives us an antidote in the form of transpersonal psychology (p. 6) – likely not without its own set of wars and issues. Perhaps the problematic is succinctly surmised by

a certain indeterminacy and inability to be fully captured by any theory or set of paradigmatic assumptions [which is] intrinsic to transpersonal psychology... This is because it is an inquiry that aspires to expand human consciousness beyond the ken of conceptual thought within which paradigms and their assumptions are forged… [It is within]…this postmodern predicament…[that the] isolation of people and fragmentation of the social fabric, in the ease with which ‘‘truth’’ has come to be equated with ‘‘opinion’’ or ‘‘feeling’’ and is used as a tool for manipulation by the media and in politics and advertising. (pp. 8-10)


While it is now clear that war is both embedded in the social matrix, and beyond it as well – especially in its destructive capacity – war is here to stay – part of humanity (one author reviewed suggested we adopt the homo hostilis moniker). Even how humanity goes about limiting war is yet another, ongoing war. Perhaps the splinter groups and anti-hawks will begin The War on ‘The War on Terror’. How will society construct this?






There is community in dying, and if your death belongs to others,
we are essentially not alone –
that is one of the great teachings of war.

-- James Hillman (2004, p. 153)





Ho ka he!
-- Lakota Native battle cry – translated it means, “Today is a good day to die.”



References


Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Elbert, T., Rockstroh, B., Kolassa, I.-T., Schauer, M., Neuner, F. (2006). The Influence of organized violence and terror on brain and mind: A Co-constructivist perspective. in P. Baltes (Ed.), Lifespan development and the brain: The Perspective of biocultural co-constructivism, pp. 326-349. New York: Cambridge University Press.

Foucault, M. (1972). The Archeology of knowledge and the discourse on language. A. M. S. Smith (Trans.). New York: Pantheon Books.

Foucault, M. (1979). Discipline and punish: The Birth of the prison. A. Sheridan (Trans.). New York: Vintage Books.

Hatfield, E., & Rapson, R. L. (2005). Social justice and the clash of cultures. Psychological Inquiry, 16(4), 172-175. doi:10.1207/s15327965pli1604_06

Hillman, J. (2004). A Terrible love of war. New York: The Penguin Press.

Humphreys, K. (2009). Responding to the psychological impact of war on the Iraqi people and U.S. veterans: Mixing icing, praying for cake. The American Psychologist, 64(8), 712-23.

Karenberg, A. (2006). Neurosciences and the Third Reich: Introduction. Journal of the History of the Neurosciences, 15(3), 168-172. doi:10.1080/09647040600717181

Koocher, G. & Keith-Spiegel, P. (1998). Ethics in psychology: Professional standards and cases, 2nd ed. New York: Oxford University Press.

Mansfield, S., & Keen, S. (1982, June). War as ultimate therapy. Psychology Today. 380-387.

Miller, K., Kulkarni, M., Kushner, H. (2006). Beyond trauma-focused psychiatric epidemiology: Bridging research and practice with war-affected populations. American Journal of Orthopsychiatry, 76(4), 409-22. doi:10.1037/0002-9432.76.4.409

Psychologists for Social Responsibility, Washington, DC, US. (2003). Statement on the Iraq war. Constructivism in the Human Sciences, 8(1), 159-160.

Puhakka, K. (2008). Transpersonal perspective: An Antidote to the postmodern malaise. The Journal of Transpersonal Psychology, 40(1), 6-19.

Roberts, R. (2007). Introduction. in R. Roberts (Ed.), Just war: Psychology and terrorism. Ross-on-Wye, UK: PCCS Books.

Rousseau, D. L., & Garcia-Retamero, R. (2007). Identity, power, and threat perception: A cross-national experimental study. Journal of Conflict Resolution, 51(5), 744-771. doi:10.1177/0022002707304813

Sigurdson, O. (2007). The Christian body as a grotesque body. in J. Krois, M. Rosengren, A. Steidele, & D. Westerkamp (Eds.), Embodiment in cognition and culture. Amsterdam: John Benjamins Publishing.

Social construction of war. (2003, January 25). Book review: The Psychology of War by Lawrence LeShan. The Christian Century. Retrieved from http://findarticles.com/p/articles/mi_m1058/is_2_120/ai_97173987/

Toracco, R. (2005, September). Writing integrative literature reviews: Guidelines and examples. Human resource development review, 4(3), 356-367.

Zillmer, E., Spiers, M., & Culbertson, W. (2008). Principles of neuropsychology, (2nd ed.). Belmont, CA: Thomson Wadsworth.

Monday, November 23, 2009

Polymodality in hemispheric lateralization: Auditory, language, and music processing

For this post, I will focus on verbal behavior and brain lateralization and link these to the latest research on music and hemispheric specialization. The auditory and language systems are inextricably linked because humans gained language via hearing, evolutionarily and developmentally (Zillmer, Spiers, & Culbertson, 2008, p. 215). In fact, it is in the study of people who have lost ability to speak or comprehend speech (aphasia), that researchers are able to discover such "neuropsychological… [anomalies such as] preserved singing capabilities in aphasic patients…[thus demonstrating] predominant involvement of the right hemisphere" (Sparing, Meister, Wienemann, Buelte, Staedtgen, & Boroojerdi, 2007, p. 322).

It is generally assumed that language functionality is located in the left hemisphere. The major language areas (and their functions) are Broca’s area (frontal operculum - speech production), Wernicke’s area (secondary auditory processing area - word recognition), arcuate fasiculus (connecting bundle allowing for thoughts to be translated into words) (Carlson, 2010, p. 499). These major speech areas, along with other brain regions, such as various cortical meaning-storage areas, as well as the “supramarginal and angular gyri of the inferior parietal lobes [which] are contiguous to Wernicke’s area,” and integrate highly (p. 217), along with visual, spatial, motor, memory, and even subcortical, suprapontine structures such as the basal ganglia and thalamus (within the cortico-striato-pallido-thalamo-cortical loop – language regulating and initiating) areas are all involved in auditory and language processing (pp. 216-7).

To further complicate matters, functional areas follow lateralization of the brain, that is, with the aforementioned auditory and language areas in the left hemisphere, the right hemisphere plays a vital role in helping people process information related to speech, emotion, and music (pp. 217-8; Carlson, 2010; Sparing, et al., 2007). For example, prosody is the intonation, dynamism, and rhythm of speech that, like music, can contribute to the communication of emotion. These functionalities are typically right hemisphere correlated, though some people (more women than men) have considerable bilaterality of speech (Zillmer, et al., 2008, pp 218-9). It goes, perhaps, without saying that language and perception of higher order thought processes, learning, and regulation also involve cognitive processing, further implicating highly integrated, polymodal cortical structures.

The authors of the study I reviewed, (Sparing, et al., 2007), cited research that explains both the traditional view of distinct/discrete hemispheric independence and the refutation of the classical view of “reciprocal cerebral hemispheric dominance” that modern neuroimaging shows a sharing of resources by speech/language and music processing centers (Perry; Riecker; Jeffries; Patel; Brown as cited in Sparing, et al., 2007, p. 319). While these very specialized brain areas are all interconnected and indeed ostensibly share resources, there is continued debate in the field as to the lateralization of cognitive abilities underlying music perception (Sparing, et al., 2007, p. 319). These authors investigated this by observing excitability of the brain during musical and linguistic tasks and the relation to left and right hand motor cortexes using Transcranial Magnetic Stimulation (TMS) while the participants sang, hummed, or talked (p. 319). Their findings that “production as well as reception of language predominantly increase the cortical excitability of the hand representation in the language-dominant (i.e. left) hemisphere [which] may suggest a closer relationship between the cortical networks mediating language processing, planning and execution of hand movements (Tokimura; Seya; Meister; Floel as cited in Sparing, et al., 2007, p. 319). These findings are of further interest because they demonstrate contrary evidence to the pre-study, extant literature that: “the relative increase of excitability of the left motor cortex during speaking aloud was less than the increase of excitability on the right hemisphere produced by both singing and humming” (p. 322), indicating that there is potentially greater lateralization with musicality and that we still have much to learn about brain polymodality/association.

“[T]he neural mechanisms required for musical perception must obviously be complex” (Carlson, 2010, p. 230). Certainly, many areas of the brain are involved: (beginning in the) subcortical auditory pathways, primary auditory cortexes, auditory association cortex (complexities, like pitch, etc.), superior temporal gyrus (pitch discrimination), inferior frontal cortex (harmony) right auditory cortex (beat, not unlike prosody), left auditory cortex (rhythmic patterns, in contradistinction to assumed, right-sided lateralization of prosodic content), cerebellum and basal ganglia (timing of rhythms and movements), even the brain stem shows more response to music than language (Carlson, 2010, pp. 230-1). While each adult individual has a specific hard-wiring and experience-driven, physiological correlation, musical ability appears to be primarily genetic and MRI studies show that those with amusia (severe and persistent deficit in musical ability, but without aphasia - speech deficits in either production/expressive or reception), have thicker auditory cortexes (right superior and inferior temporal gyri – STG and IFG), but thinner white matter of the IFG (p. 232). All this aside, it is clear that both the speech/language and musical processing abilities in the brain are highly specialized, interconnected/lateralized, and polymodal in nature, perhaps more so that we previously thought, and to ever-wider brain regions, previously held out to be quasi-uni-functional (remnants of one-to-one fallacy).

Paradoxically, the authors go on to discuss that their research shows that despite all the modern evidence, there is a preponderance of right hemisphere dominance in music processing (p. 321). They found that by using TMS, “the corticospinal projection of the left (i.e. dominant) hemisphere to the right hand during overt speech was facilitated. There was no effect on the right hemisphere during or after speaking. Moreover … excitability of the nondominant (i.e. right) motor cortex increases during both overt singing and humming, whereas no effect could be found on the left hemisphere” (p. 321). While this may seem obvious or cryptic, or both, the authors clarify with several calls for future studies and suggestion of use of TMS as “a complementary tool to investigate hemispheric lateralization of language-and music-related cortical networks…[and] to assess hemispheric lateralization by TMS ... to evaluate the effect of cognitive functions on motor cortex excitability as expressed in changes of the size of the TMS-induced motor evoked potentials (MEPs)” (p. 322).

In conclusion, by the end of this rather complex study, the authors concede what my other references also maintain, that the music and language functions of the brain are lateralized oppositely, in the right and left hemispheres, respectively. While there are theorists, including Darwin, who postulated that music was a proto-language that evolved, along with our brains, into the common speech of today, there has been no evidence to support this from modern imaging studies (p. 322). The conclusion is that further study is needed; I concur, and as in many of my posts, find it necessary to state that the brain and its functions do not follow a one-to-one correspondence and that polymodality and association, along with plastic and neurogenerative phenomena guarantee future opportunities for the contributions of bio-neuro-psychologists.




References


Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Sparing, R., Meister, I. G., Wienemann, M., Buelte, D., Staedtgen, M.,
& Boroojerdi, B. (2007). Task-dependent modulation of functional connectivity between hand motor cortices and neuronal networks underlying language and music: A transcranial magnetic stimulation study in humans. European Journal of Neuroscience, 25(1), 319-323. doi:10.1111/j.1460-9568.2006.05252.x

Zillmer, E., Spiers, M., & Culbertson, W. (2008). Principles of neuropsychology, (2nd ed.). Belmont, CA: Thomson Wadsworth.

Friday, November 20, 2009

Change up: Painting, Dementia, and FTLD

There are over 50 causes of dementia that affect either cortical or subcortical (or as in Alzheimer’s Disease - AD, traditionally considered a cortical dementia) and mixed types (see also Zillmer, Spiers, & Culbertson, 2008, pp. 406-7). The most common causes are vascular, infectious, and toxic. Generally, dementias are also divided into three types: progressive (cortical dementias like AD, Picks, Wilson’s; subcortical: Huntington’s Disease - HD, Parkinson’s Disease - PD, AIDS dementia, and Creutzfeldt-Jakob Disease - CJD), static (toxic: Alcoholic dementia, heavy metal poisoning; infectious: herpes encephalitis; and others like trauma, tumor, etc.), and reversible dementias (like systemic: anemia and uremia; B12 deficiency as in Korsakov’s Syndrome; endocrine as in Addison’s Disorder and thyroid disorders; and drug toxicity: from antipsychotics and anticholinergics) (p. 406).

Frontotemporal lobar degeneration (FTLD) is a cluster of diseases that have characteristics of primary dementia, warranting a DSM-IV TR diagnosis as a behavioral syndrome, that shows prominent and disproportionate atrophy of the anterior frontal and temporal lobes (Midorikawa, Fukutake, Kawamura, 2008, p. 224). By the DSM-IV TR, required for a dementia diagnosis are: memory impairment and in an additional area of cognition (language, praxis, executive function, etc.), impaired/decline in social/occupational functioning, clouded consciousness, and an organic contributor to etiology or absence of other conditions except an organic mental syndrome (see also American Psychiatric Association, 2000; Zillmer, et al., 2008, p. 407).

Primary dementia is significant for a loss of cognitive ability – memory, perception, verbal, and judgment – often seen in stroke patients and those suffering from AD (Carlson, 2010, p. 543). Additionally, aphasia is present in FTLD, with 2 subtypes, nonfluent aphasia and semantic aphasia. The 2 patients in the study I reviewed had semantic aphasia. Most interesting, however, was that these Japanese patients had no education in painting, did not paint prior to FTLD onset, and painted realistically. While the 2 patients studied did not show creativity in their paintings (that is, they were strictly painting what they saw) creativity does occurs with patients suffering from the nonfluent aphasia subtype (Midorikawa, et al., 2008, p. 228).


People with FTLD and primary dementia suffer from various problems in their day-to-day lives: difficulty recalling the names of certain objects (verbal deficit that worsens over time); difficulty recalling the meanings of words; abnormal behaviors such as intrusiveness and repetitive actions (that worsens); deficits in general verbal functioning (i.e., WAIS VIQ, etc.); frontal lobe function deterioration; preserved speech and comprehension ability, but with severe naming deficits; reading disturbances; other naming deteriorations (i.e. Western Aphasia Battery); sometimes apraxia (trouble following directions due to semantic deficit, with intact imitation and use) (p. 226); possible global deficits in visualizing and understanding objects (p. 228); visual semantic ability described as ‘a central semantic impairment’ (p. 229); marked atrophy in the left temporal lobe; and enlargement of the ventricle with possibilities for lacunar infarctions in the white matter. [important to note that these signs and symptoms are taken quasi-anecdotally, as the N=2] (p. 226). Additional symptoms not unlike those found in PD (including the typical muscular rigidity, slowness, resting tremor, and instability) are also possible in this kind of frontotemporal dementia (Carlson, 2010, pp. 537 & 546).

Interestingly, the patients in the study helped to show that “the assumption that the appearance of painting skills during FTLD does not reflect learning or cultural background, but rather is the expression of innate functions of the brain. In addition, our patients’ paintings were realistic in style, which might be an inherent phenomenon in humans, and not an advanced skill” (Midorikawa, 2008, p. 228).

The authors presented a couple of different theories for this finding: paradoxical functional facilitation (PFF) effects initiated by a disruption of inhibitory mechanisms and/or compensatory plasticity alongside a “decreased inhibition of ‘the right-sided and posteriorly located visual and musical systems’” (p. 228). The authors drew parallels to similar results by studies on children with autism in that “impoverished conceptual representation of the world may actually help rendering what we see’, and may arise from a common functional deficit. With these parallels, they concluded that it was perhaps more parsimoniously accounted for by a regression to childlike, quasi-autistic states. (2008).

Finally, while there are not any FDA approved treatments for FTLD, there are off-label treatments, garnered from experience treating AD, which can be used in addition to behavioral management (Caselli, & Yaari, 2008, p. 489). Currently, there are “six areas of pharmacotherapeutic consideration [which] are prevention (primary and secondary), intellectual decline, behavioral disorders (such as depression, anxiety, and psychosis), sleep disorders, frequently associated disorders (including motor neuron disease), and abrupt decline (pp. 489 & 497). While there are no curative treatments for this disorder, maintenance treatments and even treatments based on traditional Japanese medicine (Kampo - called Yokukansan), show promising results in symptom management (Kimura, Hayashida, Furukawa, Miyauchi, & Takamatsu, 2009, p. 38). Further important non-medical interventions concerning behavior are necessary: care for the care giver, maintenance of quality of life, containing weapons access, and limiting or eliminating driving privileges (Caselli & Yaari, 2008). Additionally, there are things that can be done behaviorally and for the caregivers to ensure that remaining/intact functions are used to a) slow degeneration (use it or lose it), b) increase agency and thereby quality of life (especially for caregivers who may be more reality oriented than patients), and c) treat co-morbid diseases and disorders and d) to take advantage of what intact functioning remains in order to provide reassurance, (acceptance stance) and emotional support to both the patients and those with whom they interact) (see also Midorikawa, et al., 2008, p. 229; Caselli & Yaari, 2008).



References

Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Caselli, R. & Yaari, R. (2008). Medical management of frontotemporal dementia. American Journal of Alzheimer's Disease and Other Dementias, 22(6), 489-498. doi:10.1177/1533317507306654

Kimura, T., Hayashida, H., Furukawa, H., Miyauchi, D., & Takamatsu, J. (2009). Five cases of frontotemporal dementia with behavioral symptoms improved by yokukansan. Psychogeriatrics, 9(1), 38-43. doi:10.1111/j.1479-8301.2008.00261.x

Midorikawa, A., Fukutake, T., & Kawamura, M. (2008). Dementia and painting in patients from different cultural backgrounds. European Neurology, 60, 224-9. doi:10.1159/000151697

Zillmer, E., Spiers, M., & Culbertson, W. (2008). Principles of neuropsychology, (2nd ed.). Belmont, CA: Thomson Wadsworth.

Monday, November 16, 2009

Forget the excitotoxic tiger: Memory, traumatic stress, and the amygdalae

Stress in both humans and animals has various effects, biopsychologically. One important effect (along with behavioral anxiety, hyperarousal, gastrointestinal motility, food intake changes, increased defecation, sleep disturbances, attentional deficits, and avoidance of novel stimuli, etc.) includes memory deficit (Vermetten, & Bremner, 2002, p. 127). Some of the physiological components of memory include the prefrontal cortex (PFC – especially in working memory), hippocampus (involved in declarative memory formation and sends efferent information to various areas for consolidation; even spatial memory in the right-posterior hippocampus; place/topographic, etc. – see also Carlson, 2010, pp. 471 & 483-4), the neocortex (damage to which causes semantic dementia – loss of facts), and the structure upon which I focus this post, the amygdala – involved in the emotional encoding of memory, and of course the hippocampi – which will not be discussed here in depth, the curious reader might consult any of the sources listed in the references section.

Stress has massive effects on memory processes involving “neurohormonal modulation of the laying down of memory traces” even thought to influence the strength of neuronal connections that influences consolidation (Vermetten, & Bremner, 2002, p. 138). In fact, “[i]ncreased level[s] of norepinephrine released during stress can modulate memory formation through action on the brain. … norepinephrine modulates [the following] aspects of memory: acquisition of new information… attentional component[s] of memory storage … and working memory” (pp. 138-9).

Norepinephrine isn’t the only neurochemical to influence the stressed brain, the glucocorticoids and glutamate also potentiate (especially in long term potentiation, LTP) severe damage to the structures and functions of the brain (Carlson, 2010, pp. 444-5). When stressed (damaged or diseased), synaptic vesicles are triggered to release glutamate that transporters do not remove, rather accumulate, in excess, extracellularly, allowing Ca+ ions to enter NMDA receptors leading to excitotoxicity and cell death (also happens in ischemic cascade in traumatic brain injury [TBI], stroke [cerebral vascular accident, CVA], autism, and Alzheimer’s Disease [AD]) (Carlson, 2010, pp. 446-8; Zillmer, Spiers, & Culbertson, 2008). Two other chemicals, dopamine (DA - especially in the PFC with working memory system, downregulated during stress) and epinephrine are endogenous memory modulators – and are especially active during arousal and stress (upregulated during stress) (see also Vermetten, & Bremner, 2002, p. 139).

The amygdala is involved in emotional memory and in the conditioned fear response (learning) mechanism (Carlson, 2010, pp. 369-71; Vermetten, & Bremner, 2002, p. 139). In fact, studies show that “the degree of activation of the amygdala during the encoding of emotionally arousing material (positive or negative) correlates significantly with subsequent recall of the material (declarative retention increase through enhanced hippocampal consolidation, though, with an upper limit – chronic over-arousal leads to impaired memory due to adrenalcortical upregulation – Zillmer, et al., 2008, p. 260). Lastly, the authors reviewed for this post (Vermetten & Bremner, 2002), provide an excellent (and very technical) synopsis of the major amygdalic connectivities (studied via lesion/damage) involved in stress, quoted here at length:

“Lesions of the central nucleus of the amygdala have been shown to completely block fear conditioning, while electrical stimulation of the central nucleus increases acoustic startle… The central nucleus of the amygdala projects to a variety of brain structures via the stria terminalis and the ventral amygdalofugal pathway. One pathway is from the central nucleus to the brainstem startle reflex circuit (nucleus reticularis pontis caudalis). … Pathways from the amygdala to the lateral hypothalamus effect peripheral sympathetic responses to stress. … Electrical stimulation of the amygdala in human subjects resulted in signs and symptoms of fear and anxiety including an increase in heart rate and blood pressure, increased muscle tension, subjective sensations of fear or anxiety … and increases in peripheral catecholamines. … There are also important connections between cortical association areas, thalamus and amygdala that are important in shaping the emotional valence of the cognitive response to stressful stimuli. In addition to thalamo-cortico-amygdala connections, there are direct pathways from thalamus to amygdala, which could account for fear responses below the level of conscious awareness” (pp. 139-40).

Maybe the most likely candidate for discussion of memory system damage is the boundary-ignoring, progressive dementia (traditionally thought of as a cortical dementia) known as Alzheimer’s Dementia [AD] (Zillmer, et al., 2008, p. 411). AD is a fatal illness, marked by both cortical and subcortical atrophy/degeneration; with postmortem autopsy (the only way the diagnosis is confirmed) revealing most damage to the cortical temporoparietal association areas (as well as the frontal – including subcorticofrontal nucleaus basalis of Meynert and olfactory areas – temporal, and parietal areas generally) and the subcortical limbic cortexes (where the amygdalae and hippocampi live) (p. 411).

In sum, the memory system is a very complex and interconnected one, impacted by experience and genetics, trauma and disease. I hope to incorporate this learning into my specialization with the work of those suffering the sequelae of trauma. Memory is a vast area, perhaps even a subspecialty in traumatology, and comprises many different areas of inquiry ranging from false memory, recovered memory, repression of memory, anterograde amnesia, retrograde amnesia, dissociative disorders, and, really, the entire foundation of traumatology. Were it not for memory, no one would have a problem with trauma, after the bodily reactions had passed – the sympathetic nervous reactions, the shaking, and the discharging. I recall the work of Peter Levine (Waking the Tiger) and his storying of the process an animal in the wild might go through after a brush with death, an attack. The animal might rest, shake and discharge, then get up and rejoin the heard. If only if it were that simple with humans.

Certainly, understanding the biopsychological underpinnings of memory and trauma are vital to my work. It is helpful to gain familiarity with the scientific thinking behind some of the interventions recommended by literature, and begin to see ripples and echoes of dovetailing work fitting nicely together, rounding out the toolkit to best help those who suffer their memories.


References


Carlson, N. (2010). Physiology of behavior, (10th ed.). Boston: Allyn & Bacon.

Vermetten, E., & Bremner, J. (2002). Circuits and systems in stress. I. Preclinical studies. Depression and Anxiety, 15(3), 126-147. doi:10. 1002/da.10016

Zillmer, E., Spiers, M., & Culbertson, W. (2008). Principles of neuropsychology, (2nd ed.). Belmont, CA: Thomson Wadsworth.