The Tomorrow River

 

The Tomorrow River is a small Wisconsin stream that crosses US Highway 10 three or four times between Fremont and Waupaca.  It eventually runs into a creek and becomes the Waupaca River.  I crossed all those tributaries twice on a trip last weekend. It gave me the usual opportunity to free associate to my past life. Two memories came immediately to mind – both from about 1977.  I was freshly out of the Peace Corps and trying to establish myself in a job as a research assistant cloning trees at an Institute in the area. That involved a lot of travel down Highway 51 to Highway 10 and I did not have a car.

One day I was travelling on a Greyhound bus heading to my apartment.  That was the first time I caught the Tomorrow River sign, as I looked up from a letter I was writing to my friend Glenn. I had a good experience in the Peace Corps entirely due to the Americans I met in my group.  They were bright, excitable, and energetic. We had gatherings where we listened to music, ate pizza, and played basketball.  We had long discussions into the night about what was important, what art meant, literature, music, math, science, and the meaning our work as high school teachers in the Peace Corps. We read the hipster literature of our time – Kerouac, Pirsig, Kesey, Brautigan, Wolfe, and others.  There were animated discussions and arguments.  All of that probably influenced the letter I was writing and then I saw the sign. The letter took on a surrealistic quality that Glenn appreciated in a letter he sent back to me.  As I visualized that decades old experience – it was a good feeling. I still feel a connection to my Peace Corps friends even though it has been decades and we rarely see one another or communicate.  I know that when I do – we will pick things up the way they have always been.

Between the second or third Tomorrow River sign there is an uphill curve in the road that bends to the left when you are traveling east. It is a long half mile bend. Later that same year just after Thanksgiving – I was getting a ride to my apartment from my friend Walt.  We went to the same high school and college. He was two years younger than me. Walt’s personality was completely the opposite of me. He was spontaneous, outgoing, and engaging. He could joke about anything.  I was the lab assistant in his organic chemistry section and one day his condenser hose broke loose and started spraying water just over the top of a freshly cut pile of sodium metal. I was able to grab the hose and redirect it.  Luckily there was no contact with the sodium, but after that point he started referring to himself and his lab partner as Captain Sodium.  On that day he was dropping me off and heading to his graduate program in endocrinology in Chicago.  The weather was not cooperating.  On that bend – the traffic that was usually travelling at 65-70 mph was at a dead stop in an ice storm and backed up for miles.  We both got out for a better view and realized it was impossible to stand on the road. Even  maintaining your balance, you eventually slid from the highest to the lowest part of the road and were forced to crawl back across the lane of oncoming traffic. We got back in the car and spent a long time joking about his bright reddish orange Dodge sports car and all of the trash talk he got from people in our home town about that car.  When he walked into a local bar he would hear: "Here comes the Fire Chief!"  We eventually completed the trip and I would see him from time to time over the next decades as he completed his PhD, then medical school, then residency in anesthesiology.  He became one of the top anesthesiologists in the country. And then several years ago, I got the news that he had died suddenly after a brief illness.  He was at the top of his game at the time – a department head and national expert in neurosurgical anesthesia.  I felt badly about not seeing him and not congratulating him on all of his success. I always feel badly when people don’t make it to retirement and a lot worse if I know them.  

Even before I went into the Peace Corps, I spent a lot of time navigating these roads with my friend Al.  We did that mostly in a 20-year-old Volkswagen beetle with a defective gasoline heater. When you tried to turn the heater on it might blow the hood open. Al was a mathematical genius and had accumulated almost enough math credits for a major when he was in high school - all self-taught by reading the texts. He decided to go to medical school and that led him to spend an additional 2 years as an undergrad taking the prerequisite courses.  Somewhere along the line driven by my insomnia and his sense of adventure, we ended up driving long distances to other towns at night to see movies or bands that we knew would never come farther north to our college town.  When you drive on roads in Wisconsin, Minnesota, and Michigan unusual things can happen.  When the pitch-black night is underlit by the snow cover – anything can happen. One night at about 2 AM we were on a road running parallel to Hwy 51 north when suddenly – an old model Chevrolet was airborne about 50 feet in front of us.  By airborne I mean it crashed over the top of a 5- or 6-foot snowbank at a high rate of speed and crossed our highway in a perpendicular path.   It landed on the other side of the road clipping the top of that snowbank first.  Turning around it was obvious that this was a planned attempt to launch the car from a parking lot outside of a bar to the other side of the road.  A few seconds later would have resulted in our Volkswagen being T-boned. That night we were able to turn up the radio and keep going.

These are the kinds of associations I have when I am driving these roads.  The paragraphs seem flat compared to the images in my head. I can envision my friends, our youth, images of what happened, the associated emotions, and the thoughts I have stacked on these events over the past 40-50 years. People I knew then often in a casual way.  People who I wanted to know better. People who – if I had interacted with them differently – would have drastically altered the course of my life and the people who did alter the course of my life. People who I wish would call me or send me an email.  People who I regularly think about and dream about.  But then I tell myself – “This is your own weird perspective on life – most people don’t think like this.”  Generally, that is good to know but at the same time – people do reach out from the past. They seem to realize that we are not the same people we used to be – but the common experience means something.  In many cases, it means a lot.  At my 50^th high school reunion, I was sitting outside of the main room when a classmate approached me and asked if she could sit down. I have known her for over 50 years and yet, that conversation was the longest I had ever spoken with her. It was longer than all of the conversations I ever had with her combined.  It was probably the best experience of the reunion.

I should probably clarify that I have no regrets and consider myself to be very fortunate.  All of these thoughts about the past don't cause regret - but there is often that feeling that you get when you go back to your home town for the first time. You see things in a different light.  You realize that you can't go back to the way things used to be. These thoughts have continuity with the present and the future.

At some point in the drive, I do a memory check.  I use the autobiographical memory test format and think of famous movie stars, visualize their image, and try to match names.  So far – so good.

I fantasize - primarily generative fantasies. I first encountered that term in the writings of the late Ethel Persons, MD.  She was an American psychoanalyst I found when I started to research fantasies in the 1990s.  She seemed to be one of the few psychiatrists writing about it. Generative fantasies are primarily problem solving fantasies that are more stimulating than coming up with lists in your head or your software. As I type that I am reminded of another road trip (east of Duluth on Hwy 2) when my wife asked me: "Do you ever have fantasies?' I told her I was fantasizing right at that time and she was very interested in the content. "I was thinking about what it would be like to win the men's 500M in the Olympics." She knew immediately that I was thinking about speedskating. I took up speedskating during residency and got quite good at it in my 40s. I was never an elite speedskater by any means, but I had the movements down, could endure the pain, and skated a lot of laps.  Part of learning the movement had to do with fantasies and thinking about the skaters I was seeing in the Olympics and racing against and remembering any advice I had received. I always have plenty of these thought patterns that seem focused on a hypothetical future.

 As a student of consciousness, I always wonder about how all of these thoughts are generated and (as a psychiatrist) what they might mean. Twenty years ago, I did a presentation on what I called the bus theory of the human brain. In computers, a bus is any system that connects components and allows data transfer between those components.  I decided that there was not enough emphasis on white matter and studied those tracts, their fiber content, and tried to calculate the bandwidth of those fiber tracts. At about the same time, I was wrapping up a course that I taught for many years on dementia diagnosis and cortical localization that was more of a behavioral neurology approach to the problem.  I tried to think of all of the recent papers I had pulled on hippocampal connectivity and recent papers on the neurochemistry of the hippocampus.  I thought about a paper I recently read on entropy and consciousness and whether thermodynamics could be a granular explanation for conscious states.  I am still a skeptic.

My wife wakes up.  We are driving home from her high school class reunion. There is a significant celebrity in her class and he sent a video when he could not make the reunion. The audio-visual equipment did not work, but we could see his projected image. We start to talk about the events of the night and what some of them might mean.  We talk about the A-V problems and the celebrity who clearly has become a projective test for everyone in her class. We talk about how good it will be to get back home and what we will need to do to reestablish the routine.

Thinking is a big part of life for me and life is very good…..

 

George Dawson, MD, DFAPA  

 

Photo credit for this one goes to my wife.  That is a Tomorrow River sign shot alongside Highway 10 last weekend.

References:

1:  Osanai H, Nair IR, Kitamura T. Dissecting cell-type-specific pathways in medial entorhinal cortical-hippocampal network for episodic memory. J Neurochem. 2023 May 30. doi: 10.1111/jnc.15850. Epub ahead of print. PMID: 37248771.

Brain Fog

 

“Brain fog” or “brain-fog” is a popular term that has penetrated the medical literature fairly recently.  In talking with hundreds of patients who have used the term in my evaluations most of them mean an actual fogginess to their mentation.  That typically occurs in two ways. The first is an underwater feeling and noticing that both the speed and content of thought is not quite up to par.  The second is more of a problem in concentration and focus where it takes a noticeable effort to sustain both.  I have personally had these experiences during illness and probably on a developmental basis.  In the case of the illness, I was running my usual team meeting at about 8AM, and suddenly realized my thoughts were clouded. I developed chills and knew that there was a mini-epidemic of influenza in my staff. I told my team members that I had to stop due to illness and went home.  It took about 48 hours for that to clear.  Since that time, I have been very interested in how infectious diseases and diseases in general have that effect on the brain.

The closest term that I could think of that might approximate brain fog is “clouding of consciousness”.  This term from descriptive psychiatry and psychopathology is commonly associated with neurocognitive disorders. It is typically a criterion for delirium but in most texts, it is also associated with other anatomical and functional brain disorders.  The best review of the psychopathology and phenomenology of clouding of consciousness is from Lipowki’s text (1).  Lipowski reviews the 2500 year history of delirium and how confusion and clouding of consciousness became critical concepts in advancing research in this area.

A lot of the current psychopathology texts have very little to say about clouding of consciousness and symptoms of delirium.  There are a few exceptions.  Sims discusses it in a chapter “Consciousness and Disturbed Consciousness”.  He starts with defining consciousness by three components an inner awareness of experience, intentional reaction to objects, and knowledge of the conscious self.  He also has an excellent diagram (Fig 3.1 p. 40) that ties together the medical use of the term, clinical context, and changes that can occur in that context.  Since I cannot get permission to post the diagram I will describe it.  Normal consciousness is the central component and it is transitioned to reduced wakefulness, sleep, and stages of sleep and deep sleep.  There is another transition to the unconscious mind (via preconsciousness).  The final transition is to clouding of consciousness, drowsiness, stupor, and coma. The latter transition is obviously the only pathological one, but in terns of psychopathology there is obvious overlap between reduced wakefulness transitioning to normal sleep and drowsiness that may be a prelude to neurocognitive disorders.  That is also a critical decision point in thinking about brain fog.  Is the underlying mechanism one of reduced wakefulness or a focal or global decrease in brain metabolism seen in neurocognitive disorders?  Sims also defines clouding of consciousness as: “most intellectual functions are impaired including attention and concentration, comprehension and recognition, understanding, forming associations, logical judgement, communication by speech and purposeful action”. (p. 41).  Sims definition is most consistent with an early delirious state but not “brain fog” described by a person who is going to work every day and subjectively feels that their work performance could be better.

I have followed the evolution of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) across the last 3 versions of Lahita’s text on SLE.  There are generally 2 chapters dedicated to this topic in each text.   Over the years, there has been much more specificity in terms of the biological mechanisms involved in NPSLE.  There are 19 separate neuropsychiatric syndromes involving neurocognitive symptoms and constellations of more pure psychiatric symptoms like anxiety and depression.  From a purely cognitive standpoint, an interesting concept is that many of the mechanisms that are thought to moderate cognitive function like long term potentiation (LTP), synaptic plasticity, and neurogenesis are immune cells and inflammatory molecules.  The diagram below illustrates some upstream perturbations in the cytokine system that can result in impaired learning and memory.  There are additional immune systems affecting neurogenesis.

     

In the review that I constructed this diagram from, the author states: “‘‘Lupus brain fog’’ is an extremely common patient complaint that refers to periods of forgetfulness and confusion that are related to impaired cognition.”  She cites the range of 21-80% of SLE patients having some degree of cognitive impairment leading to some degree of disability or impaired quality of life.  NPSLE and the associated studies of how inflammation and immune function impair learning and memory is an excellent example of how various disease processes can have effects on cognition. It is also a good example of how the term “brain fog” has developed recently in this clinical population with clear CNS pathology.  It also suggests a lack of specificity for the term given the range of impairment.

At this point – a few clinical vignettes of “brain fog” can be considered as additional examples:

Vignette 1:  60-year-old man referred for assessment and treatment of mania and possible bipolar disorder.  He gives a history of drinking 750 ml/day of alcohol and appears intoxicated at the time of the evaluation.  As part of the initial evaluation, he is given a standard cognitive exam and scores a perfect 30/30 points indicating no deficits in orientation, attention span, short term memory or language skills (comprehension, repetition, or naming).  He has no subjective cognitive symptoms.  He returns a week later for reassessment and does not recall meeting the same physician or doing any cognitive testing. He does not believe he was ever at the clinic in the past.

This patient essentially blacked out or was amnestic for the initial interview with the psychiatrist.  Like many heavy drinkers he has a sustained mood disturbance at times that resembles manic episodes, but these symptoms resolve after detoxification and abstinence from alcohol. Patient with these problems are likely to described brain fog during episodes of intoxication, withdrawal, detoxification, sleep deprivation from the effects of alcohol, decreased attention span and concentration that is probably multifactorial and during mood changes that are alcohol induced.  Heavy alcohol consumption can lead to profound and persistent cognitive changes, most notable from untreated Wernicke encephalopathy the result of Vitamin B1 deficiency that can accompany persistent alcohol use.

Vignette 2: 40 yr old woman referred for assessment of severe anxiety and panic. She attributes both symptoms to “chronic Lyme disease” despite extended course of antibiotic treatment by experts and extended treatment by non-medical personnel using more atypical types of treatment.  She was previously very vigorous and physically active but that is no longer the case.  She describes fatigue, hypersomnia, and “brain fog” that puts her job at risk because of decreasing productivity and performance. She is being treated with benzodiazepines for anxiety and z-drugs for sleep.

This is a familiar scenario for psychiatrists. In this case the patient is diagnosed with a controversial illness and has not recovered despite very aggressive treatment.  She is anxious because of the decrease in her level of functioning and describes fatigue, hypersomnia, and brain fog.  It is often difficult to determine the progression of symptoms without detailed records – depending only on the patient’s recollection of what happened over a number of years.  In these cases I have found that it is best to track all of these symptoms and see how they fluctuate with logical changes based on the patients current clinical status. In these cases I would typically proceed with tapering and discontinuing the benzodiazepines and z-drugs and monitoring the fatigue, hypersomnia, and brain fog while simultaneously providing psychotherapy that I thought would be most effective for the target symptoms.

Vignette 3: 50 yr old man being seen for severe alcohol use disorder, persistent depression disorder, major depression, chronic insomnia, and possible attention- deficit/hyperactivity disorder. He has had lifelong insomnia, onset of chronic depression at age 18, and heavy daily drinking for the past 15 years. He describes inattentiveness, distractibility, procrastination, and “brain fog”.  He is requesting that treatment for the “brain fog” be prioritized since it is currently his most significant problem.

Very common scenario in treatment settings.  The ADHD diagnosis is more controversial lately based on the idea that some people may develop it as an adult.  I always ask adults about childhood sleep problems and it is a very common finding.  Childhood sleep disturbance also results in erroneous diagnoses of ADHD, but it is often difficult to establish that diagnosis in generations where it was not emphasized on school.  The diagnosis of alcohol use disorder is a complicating factor. In the case of heavy drinkers, they are often drinking all day long, in a state of intoxication or withdrawal, and typically wake up in the middle of the night and need to decide whether to drink in order to fall back asleep or tolerate withdrawal until the morning and then drink to reduce more severe withdrawal symptoms.  Clearly, every one of those transitional states is associated with some cognitive impairment and some have described it as “brain fog”.  An additional patient-based bias is wish that a medication can correct all of this cognitive impairment.  That wish is complicated by the fact that many heavy drinkers have used cocaine or amphetamines to drink more and improve their concentration and attention.  They have also used benzodiazepines as a way to treat insomnia and withdrawal symptoms, especially withdrawal symptoms in the morning that could otherwise lead driving to work with high blood alcohol levels and risking legal problems.  In all of these cases, the patient needs to be followed and serially reassessed up to the 60-day mark.  In my experience, the transient cognitive symptoms should be clear at that point and the baseline symptoms and their severity can be determined.

If brain fog exists can it be phenomenologically separated from other psychiatric diagnostic terms?  Sedation or excess somnolence is a common form of clouding of consciousness.  There is a temporal aspect to both related to a combination of both alerting mechanisms and circadian rhythms and the biological basis of both has been grossly determined (6).  I would anticipate that sedation or somnolence would fluctuate over the course of the day, with the exception excessive sleep deprivation or external sources of sedation like a sleeping agent.  Most people tend to describe brain fog as unrelenting.

In the final analysis, is brain fog a useful term?  Is it a colloquialism rather than a technical term that should be used in medicine? My argument suggests that it may be a useful descriptor of a sub delirious state or very early clouding of consciousness.  There are multiple associated etiologies and conditions including some that are just a temporary disruption in normal physiology.  Based on my clinical experience it is clearly a word that patients frequently use. From the PubMed search, it is also being used more frequently in the medical literature, just over the past 20 years. 

 

A word of caution is needed before it is adopted on any widespread basis. Lipowski points out how 19^th century psychopathologists advanced the field by specifying a class of disorders based on clouding of consciousness and confusion arising in the context of acute brain dysfunction.  What followed was a proliferation of terms that set back further research for decades (p. 27).  Time will tell if the term becomes more widely adapted or it is fitted into existing nomenclature.  Based on the recent tightening of the nomenclature for delirium (7) it is not likely.  Since most people seem to be using it to cover both mild and moderate subjective cognitive impairment - it does not add much precision. On the other hand psychiatrists are focused on the patient’s subjective state and use of language so it is undoubtedly useful for beginning the early exploration of the problem that led to the consultation.

 

George Dawson, MD, DFAPA

 

References:

1:  Lipowski ZJ.  Delirium: Acute Confusional States.  New York: Oxford University Press, Inc; 1990.

2:  Sims A.  Symptoms in the Mind: An Introduction to Descriptive Psychopathology. 3^rd ed. Amsterdam: Elsevier Limited; 2003.

3:  Mackay M, Ulug AM, Volpe BT.  Neuropsychiatric Systemic Lupus Erythematosus: Mechanisms of Injury.   In:  Lahita RG, Tsokos G, Buyon J, Kolke T.  Systemic Lupus Erythematosus. 5^th ed. London: Academic Press; 2011. p. 491- 512.

4:  Hanley J.  The Nervous System and Lupus. In:  Lahita RG, Tsokos G, Buyon J, Kolke T.  Systemic Lupus Erythematosus. 5^th ed. London: Academic Press; 2011. p. 727-746.

5:  Mackay M. Lupus brain fog: a biologic perspective on cognitive impairment, depression, and fatigue in systemic lupus erythematosus. Immunol Res. 2015 Dec;63(1-3):26-37. doi: 10.1007/s12026-015-8716-3. PMID: 26481913.

-Reference 5 is an excellent open access review of the relationship between inflammation, immune systems, and cognition (especially memory and learning).

6:  Valentino RJ, Volkow ND. Drugs, sleep, and the addicted brain. Neuropsychopharmacology. 2020 Jan;45(1):3-5. doi: 10.1038/s41386-019-0465-x. Epub 2019 Jul 16. PMID: 31311031; PMCID: PMC6879727.

7:  Slooter AJC, Otte WM, Devlin JW, Arora RC, Bleck TP, Claassen J, Duprey MS, Ely EW, Kaplan PW, Latronico N, Morandi A, Neufeld KJ, Sharshar T, MacLullich AMJ, Stevens RD. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med. 2020 May;46(5):1020-1022. doi: 10.1007/s00134-019-05907-4. Epub 2020 Feb 13. PMID: 32055887; PMCID: PMC7210231.

8:  Servick K. COVID-19 ‘brain fog’ inspires search for causes and treatments.  Science. 2021 Apr 27;372(6540):329. doi:10.1126/science.abj2105. 

Graphic Credit:

Graphic was downloaded from Shutterstock per their standard agreement.  The artist in this case had many similar brain fog graphics and these depictions are probably an indication of how common this term has become.

Here is an additional graphic that I complied as I did the literature search for this post:

 

Computational Aspects of the Human Brain

As part of my lectures on the neurobiology of addiction - I digress briefly to discuss the computational aspects of the brain.  A lot of that discussion is focused on on the above graphic showing that overlaps in capacity with a list of the world's ten fastest supercomputers.  At least that is the estimate of the AI Impacts group.  It is basically a computation based on edges and nodes. I include power estimates for a brain from existing hardware to the actual power estimate of the human brain that I would guess every physical chemistry student from my era had to contemplate at one time.  And then I try to stimulate some discussion of supercomputers versus the human brain and it generally falls flat.  My Socratic process goes something like this:

"OK so we know that humans can't really beat computers on straightforward calculations so what advantages do we have?"

"I will give you a hint - why do we all go thorough residency training? Why can't you learn your specialty by reading about it in a book?"

The first lesson is pattern matching.  The human brain is designed not only to match patterns but to be trained to match a lot of them.  Some research article suggest about 88,000, but when  you consider what has to be matched that has be very a very low estimate.  I quote references from 15-20 years ago and a course I used to teach on diagnostics and diagnostic decision making.  Ophthalmologists correctly diagnosing diabetic retinopathy at a much higher rate than nonspecialists.  Dermatologists diagnosing rashes faster and correctly classifying ambiguous rashes with greater precision than nonspecialists. If I am really on a roll I might digress to talk about Infection Disease rounds at the Milwaukee VA sometime during 1982.  I was the medical student on a team of residents and fellows doing a consult for possible subacute bacterial peritonitis.  As the attending listening to the presentation he was also looking at a rash on the patient's shin.  By the time we were done he had also diagnosed a strep infection in addition to the peritonitis.  When you have significant pattern matching capacity, and you have been exposed to relevant patterns you can recognize them quickly and improve the speed and accuracy of the diagnosis.

I move on at that point to illustrate that the computers are catching up.  The simple captcha is less robust in discriminating machines from humans.  Opening an account may take more that checking the "I am not a computer" box. Now you might have to look at 8 pictures and check the one that contains an automobile or a stop sign.  Some of these photos are often difficult for humans to decipher.

At that point I touch on human consciousness - both the unique aspects and computational power it takes to generate.   About a decade ago I started saying that if there are 8 billion people on the planet - there are 8 billion unique conscious states. It makes sense at a number of levels especially when I put up hard numbers on cell types, protein types, the genetic information represented, and the typical stream of consciousness that every person experiences every day.  What is the content and flow of that activity? How does it get biased in psychiatric disorders and addictions?  How much computational power does it take to generate all of this information?

My latest step is what I like to consider The Matrix observation.  If I am standing in front of a room of 15-20 residents - what does it take to generate the physical representation of all of the people and all of the objects in that room? What does it take to make all of those representations unique? There can be a general consensus about what is happening - but just looking around it is clear that there are obvious different experiences.  One person looks very interested and one semi-interested.  One person is more focused on her Smartphone and is indifferent to my presentation.  Some people look sleepy.  Others look irritated.    They also appear to be indifferent to the context.  I know that my job is to try to get this information across and make is semi-interesting.  There is no real expectation on the residents.  It is clear from the questions I ask that they really don't know too much about the brain.  There are parallel streams of information processing that allow us all to evaluate what is occurring on the fly both the information content and emotion.  In some case there are pre-existing heuristics and in other cases associative memories and biases.  All of this represents a tremendous amount of information or computational power depending on how you may want to discuss it.

I have been preoccupied myself with the computational power and estimating it accurately. I used to try to model it in terms of electrical buses and neuronal firing rates - but the numbers I got were far too low.  There really are no good equivalents in the physical world with the possible exception of the Transversed Edges per Second (TEPS) metric used by the AI Impacts group for the above graphic.  You can't really use estimates of typical audio or visual information and concluding that is what is being processed by the brain.  I have never really seen an accurate estimate of all of the sensory information that the brain is handling in real time.

I went to bed last night and waited for sleep reverie or that period of time where you stream of thinking is jumbled and illogical just before you fall asleep.  As a chronic insomniac it is one of the few reliable cues that I am probably getting some sleep.  It happened when I had a sudden image of a baby high up on a brick wall, followed immediately by a person who seemed to be me sitting in a single seat futuristic car.  The salesperson was describing it to me and suddenly the car and everything else was being swept down what appeared to be a very sophisticated hydraulic roadway. The roadway was bright orange and the salesman shifted his pitch to tell me the advantages of this kind of a roadway with this car.  The roadway was moving at about 20 miles per hour.

I shifted briefly and remembered it was 2018 and I was in my bedroom in Minnesota.

And for a minute I thought about being able to estimate the information necessary to generate that brief full color science fiction scene and the three or four more I would encounter that night.


George Dawson, MD, DFAPA


Some additional examples as they happened:


1. Dream of 11/22/2018:  I am back on my old inpatient unit.  The layout is exactly the way it was 20 years ago (the building has since been razed).  I am working with the same staff.  I walk into the examination room to look at the templates for the day.  In those pre-EHR days I had designed a template with all of the relevant features necessary for the billing and coding requirements.  At the time we were all threatened with legal action if we did not comply with these regulations even though they were totally subjective.  In those days I worked with a physicians assistant who prepared the templates ahead of time before we started interviewing patients and completing the subjective aspects of the evaluation and documenting the progress.

The templates were all stacked in two circular patterns - ten templates in each circle.  They appeared to be the exact temples that we used right down to the blurred fonts from being photocopied too many times.  The precise handwriting of my physicians assistant in the diagnostic section was exactly the way he wrote things down.  The placement of the exam table and crash cart were exactly where they were in reality.  The table we used was circular and about 6 feet in diameter with a laminated blonde wood finish and it was also exactly the way it was in that now 20 year old reality.

I looked at the templates and asked myself: "Why are they all face down?  I can't see the patient's name or identifying data.  I will have to go through them all to find the correct template when I start interviewing patients."

I felt somewhat irritated.

And then I woke up. 

2. Dream of 11/23/2018: I am in a large modern, multi-floor medical facility. It is not one that I specifically recognize, but it seem like there are elements of many that I have been in.  I am rushing around on the ground floor. The impression I have is that I am late for a lecture. It doesn't seem to be an explicit CME lecture but everyone else there (including myself) is too old to be a medical student or resident. I run into the elevator just beating the door as it closes.

I make to to the lecture.  It is basically a large room - maybe 50' x 50' and for some reason I burst through the door running at full speed.  Just before the crash into the back wall, a guy standing on the side wall grabs my arm to slow me down and stop me.

I ask myself if that was really necessary because my plan was just to stop myself by reaching out and planting my hand on the back wall.  I notice that there are several people who I assume are physicians that are standing and sitting near the back wall and they seem a little alarmed about something.

Then I am back in the elevator and headed to the ground floor.  I am walking out of the building and realize that I am chewing something metallic.  I realize that is is a collection of machine screws, nuts, and ball bearings. I realize that is purchased them on the ground floor of this building and that they are sold for that purpose.  I also know that I cannot really chew them or I will break my teeth.  I have to cautiously move them around in my mouth.  They remind me of a chap stick product that is applied with a ball bearing device at the end of the dispenser.

I wake up with a metallic taste in my mouth.

3.  Dream of 11/24/2018:  I am back in my home town. The streets and buildings are identical to the way they look in reality.  I am with a friend of mine and we are looking at a 1960s vintage Buick.  It is large and chalky white.  He tells me that his sister recently bought it and she wants to take everyone for a ride.  He thinks I should come along, but just then I remember something that his sister said to me in the last 15 years that would make me not want to go with them. He is talking about the car as though it is a great buy, but as I walk past the tail end of the vehicle, I notice that it has a new paint job and that whoever did it just painted over the decals of the previous dealers.  You can see them faintly through the paint.

I tell my friend that I can't stay around because I have to go grocery shopping. Just then one of his friends comes out and tells me that he has a lot of groceries he can just give me so that I will not have to go to the store.  I decline but he continues to insist. I reluctantly accept free groceries and sling them over my shoulder in a large garbage bag and start to walk home.

The real path home is just 6 blocks - 4 blocks south and 2 blocks east. It is all residential. But in the dream I encounter a large modern baseball park right next to the street. The game is just completed and they are interviewing the winning pitcher. She is in her mid 20s and short and compactly built.  Her uniform and short brown hair are drenched with sweat.  Just then I notice that it is hot. The announcer asks her if the heat was a factor in the game and she says:

"The hot was so hot that when my hot fingers touched the hot ball - I could barely feel it." 

The ballpark looks real.  There are thousands of cheering fans and the announcer and the pitchers statements are amplified over the PA system.  Everything is in color.

I wake up and feel hot and flushed.

Koch's Book On Consciousness

I was pleasantly surprised to find this book.  I have been following the work of Guilio Tononi for some time and that involves reading articles co-authored by Christof Koch as one his main collaborators.  There also have several excellent videos available on YouTube where they discuss consciousness and Integrated Information Theory (IIT) of consciousness.  In this book we learn about Koch's personal and professional trajectory in the field and several of his influences.  He is currently the President and Chief Scientific Officer of the Allen Institute for Brain Science and a Professor of Biology and Engineering at Caltech.  His academic credentials are available at the link to his web page and they are reviewed in this book as a backdrop to how he came to the field of consciousness studies.     

The layout of the book is 10 chapters over 166 pages.  It is well written in that it contains technical terms but they are well explained for the novice.  On the other hand there are also higher level concepts pertaining to consciousness that will probably not be obvious to many readers that are well explained and worthwhile reading for anyone who is not an expert in the field.  The text reminds me of a slim guide to neuropathology that one of my med school professors claimed was the only book he studied to pass his subspecialty boards exams.  In other words, the more you bring to a book like this, the more you may take away.  At the same time it is interesting reading for a novice.   

A typical chapter is organized around clinical and scientific observations, associated philosophy and the personal experience and meaning to the author.  I thought about characterizing the writing as a very good blog, but this writing by one of the top neuroscientists of our time is several levels above that.  Koch writes from the perspective of admiration of some of the best scientists in the world when it is clear that he is among them.  He adds a unique perspective referencing his training, his family and social life, and the relationships he has with colleagues and mentors.  In the final chapter he describes how his career and experience has impacted on his belief system and personal philosophy.

I will touch on a couple of examples of what he covers and the relevance to consciousness.  Chapter 5: Consciousness in the Clinic is a chapter that is most accessible to clinicians specializing in the brain.  He briefly summarizes achromatopsia and prosopagnosia or face-blindness.  He discusses prosopagnosia from the perspective of clinical findings and associated disability, but also consciousness.  For example, patients with this lesion do not recognize faces but they do have autonomic responses (galvanic skin resistance) when viewing faces that they know (family or famous people) relative to unknown people.  This is evidence of processing that occurs at an unconscious level that he develops in a subsequent chapter.  He describes the Capgras delusion - as the "flip-side" of prosopagnosia in that they face is recognized but the patient believes the original person has been replaced by an impostor.  In this case the expected increase in galvanic skin resistant is lacking because there is no autonomic response to unconscious processing.

In the same chapter he details the problem of patients in a coma,  persistent vegetative state (PVS) and minimally conscious state (MCS) and how some new developments in consciousness theory and testing may be useful. From a consciousness perspective coma represent and absence of consciousness - no arousals and no sleep transitions.  Persistent vegetative state result in some arousals and sleep-awake transitions.  In the minimally conscious state there are awakenings and purposeful movements. The minimally conscious person may be able to communicate during the brief arousals.  At the clinical level being able to distinguish between the persistent vegetative state and the minimally conscious state is important from both a clinical and medico-legal perspective. He discusses the use of fMRI in the case of apparently unresponsive patients who are able to follow direction to think about very specific tasks and produce the same brain pattern of activation seen in controls.  In a subsequent chapter Tononi and Massimini use transcranial magnetic stimulation (TMS) and electroencephalography (EEG) for the same purpose.  This technique is considered proof of IIT as well as a clinical test to differentiate PVS from a minimally conscious state.  In normal awake volunteers the TMS impulse results in brief but clear pattern of reverberating activation that spreads from the original stimulation site to surrounding frontal and parietal cortex.  The pattern can be viewed in this online paper (see figure 1).  In the patient who is in non-REM sleep there is no cortical spread from this impulse and the total impulse duration is less, illustrating a lack of cortical integration required for a conscious state.  When applied to PVS versus MCS patients, the MCS patients show the expected TMS/EEG response that would be seen in conscious patients.  The PVS patients do not.  He describes the TMS/EEG method as a "crude consciousness meter" but obviously one that probably has a lot more potential than traditional clinical methods.

There are many other clinical, philosophical and scientific issues relevant to consciousness that are discussed in this book that I won't go into.  I will touch on a recurring theme in the book that gets back to the title and that is science and reductionism.  Philosophical perspectives are covered as well as the idea that the origin of consciousness may not be knowable by scientific methods. Koch's opinion is that most everything is knowable by science and that science generally has a better track record of determining what is knowable.  That is certainly my bias and I am on record as being an unapologetic reductionist rather than a romantic one.                           

This is a book that should be read by psychiatrists and residents.  These concepts will hopefully be some of the the mainstays of 21st century psychiatry.  It can be read at several levels.  I was interested in the development of Koch's ideas about consciousness.  I wanted to learn about his relationship with collaborators.  I was pleasantly surprised to learn that we had similar thoughts about popular media, philosophy, and and psychodynamic psychiatry.  I have had career long involvement in neuropsychiatry and behavioral neurology so the description of cortical localization and clinical syndromes was second nature to me.  But even against that background, he makes it very clear where consciousness comes in to play.  One of my concerns about psychiatric training is that there is not enough emphasis on neuroscience and consciousness.  Condensed into this small book there are number of jumping off points.  Each chapter has a collection of annotations and there is a list of about 100 scientific references at the end.  It may take some work, but this book is a brief syllabus on how to get up to speed in this important area and greatly extend your knowledge of how the brain works.


George Dawson, MD, DFAPA


Reference:

Christof Koch.  Consciousness: Confessions of a Romantic Reductionist.  First MIT Press Paperback.  Cambridge, Massachusetts, 2017.  Copyright 2012.   

Attribution:

Figure 1 above used with permission of the publisher.  The complete reference is:

1:  Massimini M, Ferrarelli F, Sarasso S, Tononi G. Cortical mechanisms of loss of consciousness: insight from TMS/EEG studies. Arch Ital Biol. 2012 Jun-Sep;150(2-3):44-55. doi: 10.4449/aib.v150i2.1361. Review. PubMed PMID: 23165870.  Open Access Free Text.

Blade Runner 2049

In keeping with the previous two posts - I did get out to see Blade Runner 2049 last Saturday.  It was clearly a first rate science fiction film and I guess some viewers not used to the genre might also call it a thriller.  Visually I thought it was less stunning that the first due to the lack of street level scenes and the hectic activity on the street.  It has critical acclaim but because of the high cost is being described by some critics as a "box office bomb".  In this film replicants (bioengineered androids) have become Blade Runners.  In some reviews of the film they are referred to as bioengineered humans and that is not a trivial difference since the main plot theme is whether or not the androids can reproduce.  The focus is on K (Ryan Gosling) who is the main protagonist.   We seem him interacting with and dispatching another replicant in the initial scene.  That replicant asks for mercy on the basis that they "are the same kind" and that there is a higher calling based on the miracle that he has witnessed.  When K returns to the station (LAPD) he undergoes a rapid debriefing protocol, test questions with monitoring of various anthropometric and physiological parameters.  The meaning of the test questions is not clear but the implication is that it determines if he has stayed at his baseline or his status had been perturbed in some way.   The test is also being administered for a very different reason than the Voight-Kampff protocol since the test subject is a known replicant.

There are three generations of replicants in the film starting with K - a Nexus 9 series, to the Nexus 8 replicant he retires in the original scene, the the Nexus 7 series that dates back to Rachael in the original Blade Runner film.  Over the course of that time frame the replicant population has become less subservient and more interested in equality or autonomy.  There is a rebellious faction.  We learn later in the film based on a series of events that the common "miracle" that the replicant population refers to is the birth of a child by Rachael in the original film.  In that film in the final scene she was leaving with Deckard (Harrison Ford).  There were implications that Rachael was a specially modified replicant and in retrospect the question is whether she was modified to reproduce.   

The competing forces in the film were threefold.  First, the LAPD is invoked as the police force determined to suppress any replicant rebellion.  K is a detective for the LAPD and after discovering Rachael's remains buried at the site where he encounters the initial replicant and there is evidence that she gave birth to a child..  Second, Tyrell corporation has been replaced by the potentially more evil Wallace Corporation header by Niander Wallace.  Wallace is very explicit about the need for replicant reproduction since he does not believe that manufacturing capacity can ever meet the need for replicants in service of his corporation and its off world needs.  And finally there is the role of K as a free agent in all of this.  Does he do the bidding of his boss at LAPD or not?  His boss emphasizes the importance of killing any story that replicants have reproduced - she sees it as a game changer for civilization as they know it.  She assigns him to find and kill the child.  He is later assigned to kill Deckard for the same reason.

I will leave the plot specifics to the various reviews and descriptions already out there and concentrate on the main issues that have to do with consciousness in the film.  At one point K is asked about childhood memories and recalls being bullied by a group of boys who wanted a small hand carved horse that he was carrying.  We see him escaping the boys and burying the toy in a pile of ashes in the bottom of an old furnace.  Later he consults with an expert to determine if the memory is real or not.  She confirms that it is a real memory and that leads him to believe he may be the child of Deckard and Rachael.  I asked myself at that point if K's interest in the memory was even possible if he was a replicant.  By definition in Tononi Koch theory, this experience requires consciousness and even perfectly engineered system mimicking the human brain could not generate the human experience associated with the memory much less the integrated emotions associated with this scene.  When K finally finds Deckard he is in a state of emotional turmoil related to information that Deckard provides him about his origins.  In a shootout Deckard is captured by Wallace Corp and is in the process of being tortured to find out information about the location of his and Rachael's child.  He is both rescued by K and united with his child by K.  In both Blade Runner movies Deckard is rescued in the end by a replicant.

My summary may not match up well with other reviews about specifics.  I did not view the protocol being given to K as the Voight-Kampff protocol, since it did not seem like it was an updated version.  Keeping Tononi Koch theory in mind it would be totally unnecessary even if he was really a highly sophisticated bioengineered replicant.  It would only be necessary to place a transcranial magnetic stimulation (TMS) coil close to his brain and observe the high density electroencephalogram (EEG) pattern.  If consciousness exists the theory predicts a pattern of widespread activation and deactivation.  It should also be possible to observe the characteristic sleep EEG pattern of transitioning from consciousness to unconscious dreamless sleep and back.  Of course these androids would need to be flawlessly engineered to protect circuitry from magnetic and electrical fields that occur with these measurements. 

In summary, I thought that Blade Runner 2049 was an excellent film just based on the plot and artistry.  I can always see the distinction between real science and science fiction.  If Tononi Koch theory is accurate, it is hard to imagine that a replicant would not be obvious to conscious humans.  I guess we will need to either wait until that day comes or until the theory has more widespread acceptance and proof.  The other parallel aspect of this film is bioengineered human reproduction.  It is difficult to see how that could ever be done, especially through human sexual contact with machines.  Sexual contact with bioengineered androids is a more frequent science fiction theme these days than in the past.  It is probably easier to see how that might happen from the human side.

There is currently not enough information about human sexual consciousness to imagine how it could be built or programmed into an android.     


George Dawson, MD, DFAPA               

Tononi Koch Test for Machine Consciousness

In follow up to my previous post and before I saw Blade Runner 2049, I wanted to post a more modern take on the Turing Test based on a coherent theory of consciousness  by Tononi and Koch - both experts in the neuroscience of consciousness.  Their theory is the Integrated information Theory (IIT) of consciousness.  I have included the reference (1) and a graphic from their public access paper on the theory and there are also several very useful videos available to listen to the verbal descriptions of the theory.  I have been following consciousness research for at least the past 20 years including the two main listservs on this topic until they shut them down.  When a topic is so specialized, barring any breakthroughs the arguments become repetitive and a lot of time is spent bringing novices up to speed.  The videos fill a useful gap that these listservs previously addressed although I must admit  that I am always biased toward the written rather than the spoken word because it is a much more efficient information transfer for me.  The videos listed at the bottom of this page also serve another useful purpose.  The viewer is able to see how researchers in this area define consciousness and describe their theories.  I think that it is possible to notice that some of the definitions and descriptions are so vague as to have limited utility.

That is one of the reasons that I like the approach by Koch and Tonini.  I will also also say from the outset that I am not sure whether they view the theory as a joint venture or not.  As an example of what I mean looking at this specific search on consciousness finds that Tononi has been working in this area for at least 20 years.  A similar search on Koch goes back even 8 years earlier.  I don't know either of the authors but based on reading this paper it seems like a joint effort and that seems to come across in  the available videos of their presentations. (see addendum).

In the paper, that authors outline phenomenological definitions that are more exacting than any that I have seen in the past from other authors.  They are also neuroscience based and that makes a difference to me.  In various venues people often faintly praise but then lament psychiatry's emphasis on biology.  That is obviously not true or at least without reason and it also illustrates the lack of research that people do when it comes to critiquing psychiatry.  Psychiatrists have actively researched practically all forms of social, psychological, and biological etiologies of mental illness since the specialty was founded.  Any cursory review of a general psychiatric text illustrates that point.  So if a psychiatrist is focused on brain biology, it is certainly not without reason.  I previously posted a breakfast that I had with a mentor and after a long career as a psychiatrist he summed it up the way a lot of psychiatrists do: "It is all about the biology."  Critics take that to mean some kind of medical intervention.  They are certainly studied, but every other non-medical intervention has been studied as well.  It is common to read about non-medical interventions (psychotherapy, meditation, etc) altering the brain in some way.  In psychiatry that has been known within the field for at least 70 years.

There are two levels to study the work of Tononi and Koch.  The first is at the purely descriptive level.  That is the level that you will find in the first reference.  The second level is at the level of neuroscience and mathematical theory.  The authors have produced this work as well and reference it in this paper, but for the purpose of this post I am going to stay at the descriptive level and possibly post a more technical article on the advanced theory at a later date.  I will add that there are several competing theories of consciousness that I am not going to mention here.  I have studied several of them and think that they have less to offer than the Integrated information Theory (IIT) of consciousness.  I am admittedly a reductionist seeking to close the explanatory gap between brain biology and how conscious states are generated.  In some of the videos available online where there are panel discussions it is clear that the proponents of the other theories think that their own theories are correct and IIT is wrong. I have been down the rabbit hole with a few of those theories and don't want to take time to criticize them.  Feel free to look them up and form your own opinion.  For now I will focus on IIT.   

If you have never heard of Tononi, Koch, or IIT the first task is to read the paper.  I found it to be very clear in terms of definitions, postulates, and a clearly stated theory.  They point out that every experience will have an associate neural correlate of consciousness (NCC). There is currently an explanatory gap at the level of how conscious experiences are actually produced by the NCC.  They discuss the axioms necessary for a coherent phenomenology of consciousness.  From there they move on to the postulates.  Eventually they discuss how a conceptual structure that is maximally irreducible conceptual structure occurs in the brain.  These states are also known as quale.

They give a couple of examples about how conscious states occur within their theory.  They provide and example of how to calculate the quality and consciousness given a particular state containing elements (Figure 4).  They provide a clear example of the physical substrate of experience (complex), and a set of maximally irreducible cause-effect repertoires (concept), and a maximally irreducible "cause -effect structure in cause-effect space made of concepts..." or conceptual structure (quale)(p. 12).  The quantity of experience or consciousness is specified as Φ^max.  The quality of experience is the form or shape of the conceptual structure. Distinct shapes occur with different experiences.

A more accessible example is discussed on page 9 and that is seeing Jennifer Aniston in a movie.  In that case, the complexes at the neuronal level affects the probability of past and future states. Consistent with neuroanatomy many specialized neurons are firing or not firing in the visual system that are associated with Jennifer Aniston as an invariant concept.  Other neurons are associated with other invariant concepts that allow for a fuller description in terms of appearance, age, etc.  All of the elements of the complex are intrinsic information and do not depend on visual inputs for example if dreaming or imagining the actress.

The authors also briefly review some of the experimental evidence that is consistent with the theory. They find that the theory is predictive in number of experimental paradigms. Transcranial magnetic stimulation (TMS) can be applied to to conscious individuals and unconscious (dreamless sleep, general anesthesia) individuals. In the conscious state there is a widespread pattern of activation and deactivation noted with high density EEG.  In the unconscious state cortical response is local or global and stereotypical - integration and information are lost.  A metric called the perturbation complexity index (PCI) a measure of the EEG compressibility from TMS stimulation can be used consciousness and it decreases in states that lack it.   

Tonini has been very explicit about the issue of machine consciousness - it doesn't exist no matter how sophisticated the machine is.  Any machine recognizing inputs that the human nervous system would recognize and producing identical outputs, even if that machine duplicates the structure and function of the human brain - is not conscious.  Tononi uses the consciousness science term zombie to characterize such machines.  By definition a zombie system is one that lacks consciousness and they are described as being subsystems in humans (2) when they are active outside the sphere of conscious recognition.

That brings us back to the ability to detect machines from humans.  If a machine is a perfect human zombie in terms of its input and output, we would not expect an empathy or Turing test to throw it off.   IIT theory acknowledges that what appears to be human input and output can be perfectly simulated.  The original Blade Runner protocol seems more than an empathy test. Specific questions about past memories illustrate an attempt determine if there is continuity between any current and past experiences, even though in the case of Rachael - the memories are false and implanted.

That being said IIT states there there is no Turing test for consciousness.  By now it does seem that fairly basic programs (like self learning neural nets) can replicate a narrowly defined human skill. In that case many people speculate that there is an intelligence or even human consciousness behind it.  On the other hand the perturbation complexity index (PCI) seems like a potentially useful test based on current results.



George Dawson, MD, DFAPA


References:

1: Tononi G, Koch C. Consciousness: here, there and everywhere?  Philos Trans R Soc Lond B Biol Sci. 2015 May 19;370(1668). pii: 20140167. doi: 10.1098/rstb.2014.0167. Review. PubMed PMID: 25823865; PubMed Central PMCID: PMC4387509.

2:  Koch C, Crick F. The zombie within. Nature. 2001 Jun 21;411(6840):893. PubMed
PMID: 11418835.

Addendum:

I read Christof Koch's book Consciousness - Confessions of a Romantic Reductionist a couple of months after this post.  In it he credits Tononi for Integrated Information Theory:

..."The theory of integrated information, developed by the neuroscientist and psychiatrist Giulio Tononi, starts with two basic axioms and proceeds to account for the phenomenal in the world." (p. 6)


     

A New Perspective on Dreaming

From: Reference 1 with permission.

A friend of mine insists on telling me his dream.  He knows I am interested:

"So I am in this old house.  I have the feeling it is my Grandmother's house, but it is really a house I have never been in before.  There is a gathering on the main floor and there are two people there.  I know that one of them is supposed to be my grandmother but it doesn't look at all like her.  There is a guy there who is apparently dating my grandmother.  I know that he is supposed to be a handyman that my brother introduced to my Grandmother but I have never seen him either.  They look like they are in their 70s.  But in reality as you know - my grandmother has been dead for over 20 years."

"Suddenly I am no longer at the party.  I am in the house and I am in an upstairs bedroom.  For some reason, I think it is my grandmother's bedroom.  I don't know why I'm there but all of a sudden this guy comes down the hallway.  He is one of the commentators from TMZ that Hollywood gossip show (let's call him Bob).  I look to the floor next to the wall to my right and there are two small bowls of M&Ms - a bowl of green M&Ms closer to him and a bowl of red M&Ms closer to me.  They are in those Anchor Hocking glass bowls without the blue plastic lids.  Anyway - I grab a small handful and start eating them.  They are dark chocolate M&Ms.  I look at Bob and say: "That's what they're there for" and he starts eating a few."  He asks why I am there and I say: "I heard there was a mouse in here and I need to kill it."

"A mouse runs between me and Bob and I tell him to kill it.  He misses it and it runs at me and I kick at it and knock it into the corner.  Bob is still reluctant to kill it.  The mouse runs at me again but this time it is as big as a rat.  I kick it into the corner of the room again.  This time it runs back out at me and it not longer looks like a rat - it is as big as an otter.  I kick it again - but this time I am shaken awake by my wife.  She asks me if I was having a bad dream.  She said I was kicking my legs like I was running and punching my arms in the air for a few seconds.  My heart was pounding like I was really in a fight with this thing.  What was all of that?  What  does it mean?"

There are a few things about this dream that are striking.  The first is the amount of detail recalled right down to what appear to be the product placements.  Most people telling me about their dreams rarely recall this level of detail.  Often they recall only the emotional tone of the dream and the vague idea that something happened.  The second is the overall content of the dream.  By the dreamer's report it is illogical - none of the events really happened or are likely to happen.  With the exception of the TV celebrity, none of the people in the dream were really who they were supposed to be.  Strangers were supposed to be his grandmother and his grandmother's boyfriend but in reality - there was no such relationship.  There is the movement.  The dreamer is thrashing about the bed until his wife wakes him up.  A final consideration that I like to think about is the processing power necessary to create this experience either de novo or from existing elements.

Dream interpretation is still alive and well in psychiatry - at least the way I practice it.  It is not quite the detailed analysis of all of the elements that Freud thought were important but a combination of a look at the predominate affects and what might be called a synthesis of what is supposed to happen in dreams.  It is also not quite where we need it to be from a neuroscientific perspective.  For example, for the most part we are still operating on a model that suggests more dream activity occurs in REM (rapid eye movement) sleep and that NREM (non-rapid eye movement) sleep contains very little.  We know from dream studies that is not completely correct because both REM and NREM sleep have EEG correlates and we can wake research subjects up during dreams and determine if they are dreaming or not.  Based on those studies there is a rough correlation - but there are still dreams occurring during NREM sleep and REM sleepers without dreams.  Various theories have been advanced about why that occurs, but there is no comprehensive theory.  The other issue is that dream content needs a better explanation.  The simplified explanation is that illogical impossible dreams like the one described here are REM dreams and that NREM dreams are more like plausible events.  Finally - movement during REM dreams is not possible suggesting that the dreamer in the above example was not in REM sleep or he has a neurological problem to account for the dissociation between his motor activity and the fact that he should be paralyzed in REM sleep.  These thoughts about REM and NREM sleep are so pervasive in our society that I routinely interview patients who tell me why they think they are (or are not) getting enough "REM sleep".

I was lucky to have found a recent paper (1) on the subject that if correct may prove to be a landmark study about the neural basis of dreaming and possibly consciousness.  One of the advantages of this paper is that is it written from the perspective of consciousness researchers with an interest in the neural correlates of consciousness.  In this study the authors ran three experiments looking at the question of dream reports and high density (256 channel) EEG.  They used a serial wakening model in which subjects were awakened and asked to report if they were dreaming and could recall some of it (DE = dreaming experience) or if they experienced something but could not recall (DEWR=dreaming without recall of content).  A third option was no experience of dreaming (NE = no experience).  They were asked to characterize any content further according to protocol.  There were two groups of research subjects.  The first was a group of 32 subjects who underwent few awakenings - 233 total.  The second was a smaller group of 7 subjects who had many (815) awakenings.  In a third experiment 7 subjects were studied with 84 awakenings to see if the results of the first two experiments could be predicted.

The initial section of the paper reports on the results of DE versus NE experience in the low frequency (1-4 Hz) power spectrum.  The authors were able to identify what they describe as a posterior cortical hot zone (bilateral parieto-occipital area including the occipital lobe extending to the precuneus and posterior cingulate gyrus superiorly p. 873).  DE occurred when there was decreased low frequency power in this region.  That condition occurred in  both REM and non-REM states.  This finding across distinct sleep stages appears to be highly significant.

The next section of the paper reports on DE versus NE in the high frequency power spectrum (20-50 Hz) that corresponds with high rates of neuronal firing.  Some of the results are summarized in Figure 3 at the top of this post.  In the DE experience condition increased high frequency power was noted in the same parieto-occipital regions that were associated with decreased low frequency power but it was more extensive. DE with recall of content was associated with more widespread extension of the high frequency map than DEWR (no recall of content).  Additional observations were made of the high frequency maps with regard to specific recalled dream content.  The results here are extremely interesting in terms of the specifics of content.  The authors comment on the "perception versus thought" content of dreams.  Some recalled content is an isolated thought or emotion and other content is very vivid imagery including full conversations like the example at the top of this post.  In their experiments, the authors note that there appears to be an anterior -> posterior gradient for high frequency activity with thought content mapping out over frontal cortex and perceptual content mapping out over posterior cortical regions.  They looked at dream content involving facial recognition and noted an increase in high frequency activity over the right fusiform gyrus - a structure noted to be involved in facial recognition during wakefulness.  Dream content that involved spatial imagery was correlated with increased high-frequency activity in the right posterior parietal cortex and area with that expected function during wakefulness.  Additional correlations were noted with movement and speech.

In the final phase of the experiments, the authors sought to find out if the markers identified in the initial sections of the paper could be used to predict where or not a person was dreaming just based on their EEG data.  They were able to accurately predict dreams 80.7 to 91.6% of the time (87% accurate across all states).  

I consider this to be a potentially critical paper to any psychiatrist interested in sleep or dreaming.  If replicated it illustrates that there is a posterior cortical hot zone that correlates with dreaming across REM and NREM sleep stages.  That in itself explains the lack of tight correlation of dreams with REM and NREM sleep.  From a theoretical standpoint they point out the the low delta activity (1-4 Hz) that correlates with dreaming also corresponds to alternations in neuronal depolarization and hyperpolarization that causes a breakdown in cortical communication.  High delta activity  corresponds to states of diminished consciousness including some forms of delirium and loss of consciousness.  They suggest that posterior cortical activation should be studied in patients with disorders of consciousness to see if there may be consciousness without responsiveness based on activity in this area. They also discuss the broader implications of dreaming as a model for the study of consciousness.

That is a good point to end this post.  I will continue to monitor the work of these authors and have been following some of them for some time.  Dr. Tonini for example is probably one of the top experts (and theorists) on consciousness and the only psychiatrist who I am aware of who is doing this work.        


George Dawson, MD, DFAPA


References:

1:  Siclari F, Baird B, Perogamvros L, Bernardi G, LaRocque JJ, Riedner B, Boly M,Postle BR, Tononi G. The neural correlates of dreaming. Nat Neurosci. 2017 Jun;20(6):872-878. doi: 10.1038/nn.4545. Epub 2017 Apr 10. PubMed PMID: 28394322; PubMed Central PMCID: PMC5462120



Attribution:

Figure 3 at the top used with permission from Nature Publishing Group - License Number 4154981341951.  The figure is from reference 1.



Supplementary:

As I have previously posted - I have experience with standard array quantitative EEG (QEEG) and its limitations.  I am a little skeptical of being able to determine the EEG spectrum in the fusiform gyrus by standard surface electrodes in what I imagine is a cap array.  But time will tell.

Being Suicidal - The Conscious State

The assessment of potential for suicide is a large part of a psychiatrist's work.  Within the past decade these footnotes have popped up even in algorithms that are designed to guide decisions about psychopharmacology.  They have always been present in treatment guidelines for most major psychiatric disorders.  They are a major cause of anxiety for practitioners, because we all know that our predictive capacity is low, but more importantly we know that unlike Internists and Surgeons we have limited access to the resources necessary to address the problem.

Considering for a moment a typical outpatient crisis, for a person known in the practice with depression who is now clinically changed in an office assessment with suicidal thoughts, the options are very limited.  In the case of an assessment of extreme risk, inpatient treatment may be offered.  If the patient has any inpatient experience at all, he or she knows that inpatient units are generally miserable places where very little active care happens and where they are enclosed with a number of very ill patients.  They may also know that there are an arbitrary number of hoops that must be jumped through in order to be discharged and that as a result they may be in that environment much longer than they need to be.  They may also have had a typical experience of the inpatient psychiatrist not talking with their outpatient psychiatrist and making a number of abrupt medication changes that are neither necessary or indicated based on their brief familiarity with the case.  For those reasons and also because most people are averse to sitting in hospitals - people will balk at the suggestion of inpatient care.

The suggestion of inpatient care also assumes there is the availability of that option in the community.  Most hospitals in any given state do not offer inpatient psychiatric care.  That level of care has been discriminated against at a political and financial level for 30 years and as a result hospital services and inpatient psychiatric beds have contracted in an expected manner.  Patients are often transferred hundreds of miles within states to reach these beds.  A related issue is the availability of electroconvulsive therapy (ECT) for severe depressions.  In the case of high risk depression it may be the only effective option.  Many states have no availability of this option for patients who need it.

The suggestion of emergency department (ED) care is an even bigger dead end.  The vast majority of ED care is provided by mental health professionals who are not psychiatrists and who are making triage decisions that ED physicians can sign off on.  The wait is hours and if a high risk determination is made it might be days in the ED before any disposition can be made.  Patients are often discharged on the basis of whether their suicidal ideation is chronic or not and whether they are saying that they have a suicidal thought and an intent to harm themselves right at the time of the assessment.

All of the above factors generally place the burden of care back on the original treating psychiatrist, even when the risk is higher that he or she would want.  Most psychiatrists recognize that if they are treating very ill patients, there needs to be an element of acceptable risk in order to provide treatment and the hope of recovery.  Psychiatrists realize that resources are severely rationed, that their patient needs acute treatment, that the patient will only accept certain treatment, and that there is a societal expectation of medical paternalism if the patient in not able to remain safe.   The psychiatrist and the patient are frequently operating in this zone of acceptable risk that is perceived very differently by others.  Family members are the clearest case in point.  Like society in general, many family members have their biases when it comes to psychiatry.  Many have been instrumental in discouraging their family member from getting treatment.  In some cases they have interfered with treatment and suggested that the family member discontinue treatment or throw away any medications that they have been taking.  At the same time, family members generally favor a zero risk treatment environment.  They would prefer that the patient's suicidal thinking resolve completely so that there is no risk that they will attempt suicide.  They see suicidal thoughts as controllable and the product of a series of correctable decisions.  They don't understand why the thoughts just can't be turned off by the patient, their psychiatrist, or in some cases - the medication the patient is taking.  In extreme cases, they may threaten litigation if the patient suicides or makes a suicide attempt implying a volitional and controllable basis for suicidal thinking.

An understanding of human consciousness provides a way to analyze this situation and the misperceptions about suicidal thinking and behavior.  The predominant model of risk assessment for both suicidal ideation and aggressive potential is risk factor analysis.  It generally proceeds from an elaboration of the specific thoughts to past history of attempts, availability of lethal means, diagnostic risk factors, past history and analysis of attempts, and specific demographic risk factors associated with suicide attempts.  Many texts like the Harvard Medical School Guide To Suicide Assessment and Intervention have detailed approaches to the problem and further conceptualizations like proximate and distal risk factors.  In an earlier post, I discovered a checklist of risk factors that looked at the issue of Increased Reasons or Decreased Barriers to suicide called the Convergent Functional Information for Suicide Scale (CFI-S).   Many institutions these days prefer the Columbia Suicide Severity Rating Scale (C-SSRS).  All of these methods are essentially based on risk factor analysis.  Some are more elaborate than others.  There all estimate risk to one degree or another and in some cases factors that mitigate risk.  I won't debate the merits of these methods here.  All that I want to say about them is that after the risk has been estimated, the psychiatrist may still be working with a high risk patient who is unpredictable in both an inpatient and an outpatient setting.  Interventions can be initiated to reduce the risk, but there is no assurance that they will be effective fast enough to prevent a suicide attempt.  In many clinics where a standardized approach like this is used with an electronic health record and a cutoff score is used to determine risk, a psychiatrist may find the patient visits being flagged for months or longer based on these numbers.

Is there another model that might supplement or improve upon the risk factor analysis models?  For about 15 years now, I have been looking at a model that considers the basic question of what happens when a human conscious state shifts from one that would never contemplate suicide to one that does or in the extreme state proceeds rapidly to suicide.  The usual psychiatric model considers the development of an illness state like depression, bipolar disorder, borderline personality disorder, or alcoholism as a precursor state.  The cognitive changes, like depressogenic thinking seen in the precursor states are seen as the basis for suicidal thinking.  The intervention is generally directed at reversing the precursor state, acutely structuring the environment as necessary for safety, and direct verbal interventions to address the suicidal thinking.

It is possible to explore with people the transition of their conscious state from a person without suicidal thinking to a person who develops suicidal thinking and consider a broad array of associated factors.  Just being able to recognize that this transition has occurred is an important part of any evaluation and intervention.  Some people are so severely depressed that it seems like the suicidal thinking has been there forever.  They can barely recognize a time when they felt better or were not suicidal.  In many cases they are preoccupied with existential factors such as meaningfulness of their life, personal freedom, and of course life and death - factors that they were only peripherally focused on during their daily life.  In some cases they are important psychodynamic factors such as the death of a family member or friend from suicide.  I speculate that many psychiatrists have heard of or been involved in situations like this.  These events are also described in some of the psychoanalytic literature but not necessarily the risk factor analysis literature.  John Bowlby described some examples in his book Loss:

"From many examples from Cain and Fast we select two: one eighteen year old girl who drowned herself alone at night in much the same fashion as had her mother many years earlier;  the other a thirty-two-year old man who drove his car over the same cliff that his father had driven over twenty-one years earlier.  Some of these individuals, it seems, had lived for many years with a deep belief, amounting to a conviction, that they will one day die by suicide.  Some quietly resign themselves to their fate.  Others seek help." (p. 389)

Of course the complexity of this situation is much greater than Bowlby can capture in his brief explanation.  Just at the psychodynamic level there is the issue of identification with the parent and their suicidal actions.  Do they believe that they have a deeper understanding of the parent's action and consider them to be logical?  Have they incorporated this into their worldview and consider it to be their fate?  At the neurobiological end of the spectrum, is it a case of straight genetic vulnerability to suicide or were there epigenetic factors related to a severe disruption of the home environment that the suicide of a parent can cause?  Do they remember an event or series of events during childhood when the affected parent seemed to transmit a tendency to anxiety or depression directly to them?  All of these are relevant considerations when examining what is going one at the conscious level in an individual who has become suicidal.

Elementary risk factor analysis also benefits from the broader perspective of considering other conscious factors.  It allows for an exploration of additional degrees of freedom.  For example, the issue of firearms possession and the elaboration of risk often depends on possession and risky behavior with that gun.  But what constitutes risky behavior and what needs to be asked?  Have you had the gun in your hand when you were thinking about suicide?  Was the gun loaded?  Did you actually point the loaded gun at yourself? What were you thinking about at that time?  The questions and responses cannot be anticipated in a linear risk factor analysis or algorithm.

A nonlinear consciousness approach can also incorporate an informed consent approach to provide active feedback to the patient on the current risk and the limitations of treatment.   This often opens a window into the dynamics of how the patient conceptualizes risk and their ability to work with the psychiatrist in minimizing it.  A more linear assessment often takes on the structure of the psychiatrist trying to guess whether or not the patient is going to kill themselves and leaves the patient as a relatively passive participant.  A consciousness based approach recognizes that the patient has entered at least partially into a conscious state that is foreign to them, less predictable, and represents some degree of risk to them.  They need to hear very clearly that they and the psychiatrist need to work together to restore their baseline conscious state and reduce risk in the meantime.  The process encourages them to not leave the interview leaving something that is potentially important - unsaid.  


George Dawson, MD, DFAPA      


References:

1:  John Bowlby.  Attachment and Loss - Volume III: Loss - Sadness and Depression.  Basic Books. New York.  Copyright by the Tavistock Institute of Human Relations.  1980, p 389.

2:  Douglas G. Jacobs (ed).  The Harvard Medical School Guide to Suicide Assessment and Intervention.  Jossey-Bass Publishers; San Francisco.  Copyright by the President and Fellows of Harvard College. 1999.