Thursday, June 30, 2011

Habit and the Stages of Change


I have been writing for several weeks now about this mass of electrical activity inside our brains, dendrites and nerve endings, meeting at synapses, passing their spark from one neuron to the next, creating -- what?  A wink, a whisper, a sensation, the next big brainstorm.

Most of these connections could be called, in the widest sense, habits.  By habits, I mean that pathways get used over and over, form patterns, become familiar, channel us to certain outcomes.  Most bypass the cortex, requiring no decision.  Like breathing, smelling, salivating at the cinnamon.
 
Most of the remainder are still automatic.  But with effort, they can be brought to consciousness where the cortex could interfere, and a decision made.  Like blinking.  Or picking up the cookie.

What if you don't want to pick up the cookie?  Okay, you really do want to pick up the cookie.  What if you want to not pick up the cookie anyway? 

How Do You Change A Habit?


You're gonna take more than one step.

Last week, I put some numbers out there, the Wahls diet.  Nine cups a day of vegetables and fruits.  I broke it down for you: 3 cups leafy greens, 3 cups cruciferous veggies, 3 cups intensely colored.

This food plan helped Dr. Terry Wahls reverse her secondary progressive MS and get up out of her wheelchair.  It could help you reduce your symptoms of heart disease, lung disease, asthma, hypertension, depression, obesity, bipolar disorder, diabetes, Alzheimer's or Parkinson's.

If you have, or are tending toward any of these chronic diseases, you have already heard your doctor/mother/spouse tell you that you need to improve your diet.  Dr. Wahl's book, Minding My Mitochondria tells you just how much and why. 

Nine cups a day of vegetables and fruits:

3 cups leafy greens
3 cups cruciferous veggies
3 cups intensely colored

Stages Of Change 

So there is your canyon.  Here are the steps, more than one.  Several, in fact.  The steps are known as the Stages of Change.



The Stages of Change model appears all over the place lately.  This article from the journal American Family Physician uses the Stages to help physicians help their patients, something more effective than Just do it.  A Youtube search yields results for addiction recovery counselors, life coach trainers, weight loss clinics.


Different sites number the stages differently.  Some say Precontemplation is Stage 0.  Some give Relapse its own number.  Some add Transcendence, whatever that is -- said the priest who gets cynical when quasi-religious language gets used for the purposes of self-improvement.  Whatever we are supposed to transcend, evidently it is not our desire to improve ourselves. -- But I digress.


I like this site, which is the source of the graphic above, even if the author does use that word Transcendence that made me twitchy there for a minute before I got back on track.  It works through the stages from the perspective of the person who is making the change, not the person who wants somebody else to change. 


Crossing Canyons/Building Bridges In My Brain 


Dr. Wahls calls it a diet.  I don't diet.  Who wants to DIE-t?   Each chocolate chip cookie left on the plate represents a little death.  A diet is a temporary interruption.  When it ends, you go back to your life.  But there is nothing temporary about the nutritional needs of my mitochondria, without whom there would be no life.


I'm into changing my brain.  In that mass of electrical wiring, some potentially healthy pathways are blocked by the detritus of dead dendrites.  Other destructive pathways are carved into canyons of well-worn automatic responses. 


Changing my brain will take time.  It is taking decades.  It will take at least another blogpost. 


And The Word Became Flesh 


Question: What do the Stages of Change have to do with Prozac Monologues? 


Answer: Words.  The Stages of Change use language to shape the brain.


Language is one kind of pathway from neuron to neuron.  It connects electrical impulses from the autonomic systems, the olfactory nerve, the amygdala, through the hippocampus (memory and emotion) and the anterior cingulate cortex (pattern seeking) and into the frontal cortex (conscious thought).

Language is how all this electrical activity gets turned into meaning.  It is where the brain and the mind become one. 

The Stages of Change include a process of changing our patterned thinking about food.  And thinking is how we move from one stage to the next. 

Dr. Wahls' writes about synergy, how exercise and diet work together to heal her myelin and reduce the symptoms of her MS.  I'm thinking the same process works for changing habits, particularly food habits.  Each new behavior reinforces the preceding thought that moved you to the new stage.  That repeated behavior patterns the thought that will move you to the next stage. 

Meanwhile, what you are eating while you are trying to make any change matters.  Your mitochondria need the right materials to build the dendrites that form the new pathways.  Like lunch for the road crew.

So don't try to skip stages.  And don't skip broccoli.

One of these days I will write my own food autobiography, my trip through these stages.

photo of Women Working at a Bell Telephone Switchboard from the National Archives and Records Administration and in the public domain
photos of Hatherton Canal in Staffordshire by Roger Kidd, Coal Creek Falls by Walter Siegmund, Glen Canyon by Sascha BrückJeff Kubina used under the Creative Commons Attribution-Share Alike 3.0 Unported license.
Stages of Change graphic was created by Todd Atkins, who placed it in the public domain

Friday, June 24, 2011

Minding My Mitochondria -- A Review

Dr. Terry Wahls practices internal medicine and treats psychiatric patients at the VA in Iowa City Iowa.  In the year 2000, she was diagnosed with relapsing-remitting Multiple Schlerosis.

MS is an autoimmune inflammatory disease that damages the myelin (think, skin) of neurons, causing breaks in communication between the brain cells, neurotransmitter imbalances and cell death, with resulting physical and cognitive disabilities, including blindness, dizziness and pain.  In its earlier relapsing-remitting stage, MS is treated with chemo and immune system suppressants.  Dr. Wahls pursued the best and most aggressive treatment available.

Nevertheless, in 2003 her MS had developed into the secondary progressive variety.  At that stage, the treatment strategy is to slow the inexorable loss of function.  She used canes to walk.  Soon she was in a wheelchair almost all the time.

Wahls is a doctor.  She researched her condition.  But there are no treatments to reverse the loss of function, not even any clinical trials available for her to join.

So she went back to school, staying up at night after the rest of the family was in bed.  She studied the basic science of her condition and similar ones, Parkinson's, Alzheimer's Huntington's.

Then she designed her own treatment based on the basic science about why brain cells die.  She experimented on herself, developed a diet regime, tested potential food sensitivities.  She maintained.

This is Dr. Wahls in June, 2007.

She started working with a physical therapist to use neuro-muscular electrical stimulation, continued the diet modifications.  And then she got out of her wheelchair.

Over the course of that year, Wahls went from moving around on a scooter to walking with canes to riding a bicycle eighteen miles without assistance.

This is Dr. Wahls in October, 2008.

Today, Dr. Wahls is the one woman recovery movement for MS.  She is doing what people with secondary progressive MS don't do.  She is recovering.

I don't have MS.  I have another brain disease that began as remitting-recurring.  I tried what treatments were available.  My disease progressed to a chronic disabling condition.  Boy, do I wish I had gone to medical school.  It would be a lot easier to understand the research, figure out the basic science and develop a treatment plan that might make a difference for me.

Is it any wonder I find Dr. Wahls' story riveting?

I am glad I am not a one woman recovery movement for bipolar.  There are lots of us who are not satisfied with the limited life that our meds give us.  There are lots of us experimenting with our own treatment regimes, staying up nights reading the research, and learning from each other.

It turns out Dr. Wahls has learned some things that may aid our recovery, too.

Meet Your Mitochondria

All living things, including our bodies have tiny little maintenance workers inside our cells called mitochondria, which are busy supporting our cells doing the repair of the the wear-and-tear damage that naturally occurs each day.  Our DNA provides the blueprint for all the proteins and other biological components that need to be replaced on a regular basis.

If those little maintenance workers don't have all the proper nutrients, like amino acids, the correct minerals, and fatty acids, then they can't build according to the DNA blueprints.  Those nutrients are the building blocks that mitochondria in our cells need to keep our bodies healthy.  If those replacement molecules and structures get made incorrectly or not at all, our bodies begin to deteriorate.


Okay, this may come as a surprise to you.  But a long time ago these little critters (scientists call them organelles) swam inside the cells of living things.  Mitochondria live in our cells, like we live on the earth.  Except they are generally more useful to us than we are to the earth.

Minding My Mitochondria tells the story of how Terry Wahls overcame secondary progressive multiple sclerosis (MS) and got out of [her] wheelchair.  It is the story of what these little mitochondria critters do and what they need to do it well. 

The Essential Point

Mitochondria are the power plants inside our cells.  They take glucose molecules and convert them into adenosine tri-phosphate (ATP) -- think energy.

Many other diseases like asthma, chronic obstructive lung disease, hypertension, coronary artery disease, depression, obesity, bipolar disorder, and diabetes have all been shown to become worse as a result of mitochondrial stress and eventual failure.  Mitochondrial failure drives the development of diabetes, heart disease, lung disease, heartburn from stomach acidity, Alzheimer's, Parkinson's, many psychiatric disorders, and multiple schlerosis... Healthy cells are necessary to have healthy organs; healthy organs lead to healthier bodies and restored vitality.

The cells with the greatest concentration of mitochondria are in the brain, because the brain uses enormous amounts of energy -- unless you're sitting on the sofa, in which case your brain powers down.  So any of you readers who are concerned about the health of your brains, pay attention!

Our mitochondria need co-factors to facilitate the reactions that turn glucose into energy.  What are the co-factors?  The micronutrients in our food.  The Standard American Diet (SAD) is sorely missing in these micronutrients, making for sick mitochondria and resulting in a whole host of your favorite chronic diseases and mine. 

But you get these micronutrients simply by eating well.  Dr. Wahls applied the science of cell biology to an eating plan that helped her and can help others ensure adequate nutrition for these little critters on whom our lives depend.

Feeding Your Mitochondria/Healing Your Brain

So that is the basic message repeated over and over in each chapter of Minding My Mitochondria.  (For readers with cognitive deficits and/or fatigue issues, the repetition is helpful.)  You can eat your way to better health.


The early chapters teach the basic biology of brain cells, how brain cells are wired to each other, the role of myelin (insulation of neurons -- the issue of MS), how neurons communicate with each other.

Next Wahls describes how the chemical factory in our cells work, how cells get energy, and how mitochondria signal cells when to die or whether instead to become cancers.

Wahls includes a chart of the micronutrients needed for cell health, good food sources of each, and 100 recipes using some of the foods that are not part of the SAD -- Standard American Diet.

Cut To The Chase -- What To Eat

The typical message you hear is about what not to eat: salt, refined sugar, saturated fat.  Yeah, yeah, we all know that.   But it's only part of the problem.  Remember, if you are eating the SAD, you are not only overweight.  You are starving your mitochondria and yourself at the same time.

It's all about those micronutrients.  Wahls gets her lecture audiences to chant along with her: 

9 cups fruits and vegetables:

3 cups leafy greens
3 cups cruciferous vegetables
3 cups intensely colored.

That is the daily goal.

Okay, if you are the average consumer, you eat three cups of fruits and veggies per day max.  And you probably count peas.  Let me break it to you -- peas are not a vegetable for the purposes of nutrition.  Neither is the State of New York's state vegetable, corn.  Corn, for God's sake.  Peas and corn do not have the antioxidants or minerals you get from broccoli or spinach.  Nutritionally, they are starch.

But back to the goal.  Note that word, goal.  Work up to it, one cup at a time.

Here it is again:

Increase your daily fruit and vegetable intake, with the goal of 9 cups a day.

3 cups dark green leaves, such as spinach, Swiss chard, mustard greens... Count iceberg lettuce as water.  (60 grams = 1 cup)

3 cups cruciferous vegetables, such as cabbage, kale, collards, broccoli, the onion family.

3 cups intensely colored fruits and vegetables, such as beets, berries, oranges, your reds, your oranges, blues and purples.

There is more.  But that's a start.  Just do it.  Just start.  Today, eat a cup of cantalope for breakfast, a spinach salad for lunch, a cup of broccoli for supper, total of three.  Tomorrow, total of four.  Work up to two in each category.  Get to three later.  Just start.

What Else You Can Do For A Healthy Brain

Wahls' dietary recommendations include mushrooms, nutritional yeast, and nuts or seeds every day if possible, seaweed, dried kelp, and/or brewer's yeast, and more foods rich in omega-3 fatty acids: green leaves and the animals that eat them (less of grain-fed beef), wild fish, eggs from chickens that eat flax or bugs, flax oil, plus organ meats once a week.

The key balances addressed by the diet are GABA/glutamate and Omega 3/Omega 6 fatty acids.  We're looking to decrease inflammation and reel in those nasty free radicals.  You will learn lots about these balances in Minding My Mitochondria.  Big Pharma is pursuing exactly these issues in search of the next new wonder drug.  See my post from May 13, 2011, The Future is Bright -- For Whom?  I will come back to this topic, comparing Wahls and Big Pharma, at a later date.

Wahls includes in her program other self care recommendations that you have heard before, thirty minutes daily aerobic exercise to enhance serotonin and nerve growth factors, and thirty minutes brain exercises, puzzles, developing new cognitve and new physical skills to promote brain-derived neurotrophic factor production.

Supplements do not play a major role in the Wahls program.  While there is a mountain of evidence supporting her claims about the benefits of nutrients derived from food, it is not so clear that the body can use the nutrients in supplement form so well.  One exception is Vitamin D.  Vitamin D is free for the taking from sunshine.  But now that we all use sunscreen, Vitamin D deficiency is the newest health crisis in America.  Go figure.

Neuro-Muscular Electrical Stimulation

Parts of Minding My Mitochondria apply specifically to people with MS.  Wahls' most dramatic recovery happened when she started using electrical stimulation.  NMES is not a proven treatment for MS.  Remember, there are no proven treatments for secondary progressive MS.  However, it is recommended to treat symptoms that people who have MS have.  Wahls reviews the research behind it that led her to try her own experiment.  Now she is recruiting subjects for her efforts to replicate her results in others, by combining NMES with the diet. 

Synergy

So get real.  If NMES reverses damage to nerve cells, why bother with the heretofore fruitless exercise of trying to get grownups to eat their veggies?  It's easier to keep a drunk on the wagon than to change the food culture of the ever more obese Mc-Nited States of America.  Besides, you can bill for NMES.

One word.  Synergy.  Give the woman some credit.  She tried it.  When Wahls skips the electrical stimulation, she declines in function.  When she travels and can't eat the way she recommends, her symptoms return.  The different pieces of this program work together.

Which makes sense when you look at it from the perspective of the cell.

Our brain cells connect to each other through little arms called dendrites and axons.  It is likely, given what the literature says about exercise and the brain, that my additional exercise and/or NMES caused my brain to make more neuro-trophins, or brain cell growth factors, and the brain cells then received signals to grow more dendrites and axons.  That requires energy in the form of ATP and omega-3 fatty acids to build the myelin insulation around the new connections.  It makes sense that improving how the mitochondria generate ATP molecules (energy) is synergistic with exercise.  It is like adding an extra engine to your car.  You have more energy and more stamina.

The rate by which the brain cells respond to these messengers is likely therefore to be dependent, at least in part, on the availability of ATP generated in the mitochondria.  A diet containing more B vitamins (particularly riboflavin and niacinamide) coupled with more ubiquinone, or co-enzyme Q, should make it easier for mitochondria to make ATP and get rid of toxins generated in the cells.  That decreases the oxidative stress and makes for healthier mitochondria.  If the mitochondria are healthier, the brain cells are healthier, and healthier brains are better able to respond to brain-growth factors formed in response to the higher level of physical activity.

In other words, exercise (think of electrical stimulation as extreme exercise) makes the body produce more brain cell growth factors.  The body is designed to repair itself.  But to do the repair work, it needs the right material.  The wrong material actually increases the damage.  By contrast, good nutrition means that the mitochondria can do its job to produce energy, which can be used for repairing damaged brain cells.

It's road repair season in Iowa.  So here is synergy in road repair:  We want the roads fixed fast.  But there is no point in hiring more workers, unless you supply more asphalt.  There is no point in bringing more asphalt to the site unless you have the workers to lay it down.

What Else Is In The Book

The first sixty pages tell the story and provide the science behind it.  Wahls repeats concepts that may be new to the reader and uses real life analogies.  So don't worry about the science if you are not a science type.  She makes it understandable.

Also included: menus and recipes; charts that list nutrients, their appropriate doses, good food sources, and their function in brain (including symptoms of variety of chronic conditions caused by an insufficient supply); a list of abbreviations used; daily log sheets to help you track your food consumption and other self help practices; graphics of detoxification pathways, with the nutrients and foods that support detox; the riff on conventional and functional medicine that inspired my last week's blogpost; a glossary of terms; and references for the research studies that support Wahls' ideas.

Wahls needs more research subjects who have MS.  If she can replicate her own results in others, she hopes to get funding for more work that will move forward the science about MS.  The book includes her contact information.

Some versions of the 2nd edition were published without an index.  The one sold by Amazon does have the index, which is helpful if you want to look up something like aspartame, cognitive improvement, or cranberry chutney.

The font used in Minding My Mitochondria is APHont, developed by the American Printing House for the blind, to enhance reading speed, comprehension and comfort.  This accommodation for those who have MS and its vision difficulties makes the book easier to read and comprehend for people without vision difficulties, too.

But I Don't Have MS

Mitochondria don't have MS, either.  If they are malnourished, then their host (you, me) may have or be developing MS, or heart disease, lung disease, asthma, hypertension, depression, obesity, bipolar disorder, diabetes, Alzheimer's or Parkinson's instead -- all diseases in which sick mitochondria are implicated, all diseases for which your doctor has been telling you to eat better.  The market is bullish on chronic health issues these days.

We already know this stuff, that the way we eat is making us sick.  We read about this stuff in every magazine at every grocery checkout counter, where everybody is selling this week's magic berry or bean.

What I didn't know before I heard Dr. Wahls lecture was how all these magazine articles fit together, how exercise and nutrition play off each other at the cellular level, and how I really can help my brain heal with a long term, systematic change in how I feed my brain cells.

I will continue this ambling series on getting my brain back by exploring the realities of changing habits.

Meanwhile Remember, That's:

9 cups fruits and vegetables:

3 cups leafy greens
3 cups cruciferous vegetables
3 cups intensely colored.


To your health!



photos of Dr. Wahls used by permission
photo of mitochondria by NIH and in the public domain
graphic of neuron in public domain
photo of fruits and vegetables at Pike Place by Eric Hunt and photo of tablets by Pöllö, both used under the Creative CommonsAttribution-Share Alike 3.0 Unported license
flair from facebook
photo of road construction in Afghanistan taken by an Air Force employee and in the public domain
photo of french fries by Corpse Reviver and under the terms of the GNU Free Documentation License

Thursday, June 16, 2011

Conventional Medicine/Functional Medicine

I've had it.  I have just had it.  Go ahead, diagnose me, nod your heads, make a note in my chart.  Call it noncompliance or transference, depending on the initials behind your name.  Shake your head this time, make another note.  But I have had it.

An Emergency Room Story

We took a friend to the ER.  She takes a complicated med regime with risk of stroke and had the kind of vague warning signs that begin those if only... stories.  She felt *dreadful!!*, an 8 out of 10, and knew that something was desperately wrong.

It turns out her BP was elevated, but evidently not ER worthy.  And *dreadful!!* is not a symptom on a diagnostic protocol.  So the doc (resident?) focused on the headache.  Never mind that it was a 3 out of 10, and she insisted her headache was not her complaint.  He knew what questions he was supposed to ask, which didn't include questions on a 1 to 10 scale about just how **full systems dreadful!!** she felt.  In any case, he hadn't got to the part of the book where they teach you to listen to the answers.

So he gave her a med for the headache, then immediately a med for the side effects that the first med always causes.  Forty-five minutes later, the headache was down from 3 to 2, but the second med was not adequate, and she needed a third med for the jerking legs caused by the first med.

Eventually the doctor/resident's supervisor came in.  This doctor did know how to listen.  She listened even to what was not being said, the rising anxieties and suppressed rage of everybody in the room.  So she asked some more questions, and decided maybe there was a reason for the headache.  They did a CAT scan, which revealed nothing.  So she recommended my friend discontinue the BP med she had started last week, because that med could account for all the vague stroke warning signs that brought us there.  And they were on a roll in ER, having seen three people that day with side effects from this particular BP med.

On the other hand, it could be, and this is what my sick friend really believes, and I am sure she is right, it was a genuine hypertensive incident caused by the interaction of yet another med she takes and some processed chicken she ate for lunch, immediately before she started to feel dreadful.

Modern Medicine Sucks

Yes, I know.  The ER is best reserved for heart attack and stab wound.  But that is where Urgent Care sends people with stroke symptoms.  And you know very well, in any doctor's office, prescribing medicine for the side effects caused by the medicine prescribed for the side effects caused by something else again is standard clinical practice.

It's not just the health care delivery system that is failing.  "Modern" medicine itself has failed me, failed you, failed a whole lot of us, with a whole lot of different diagnoses, including a whole lot of people who even get paid to practice it.

You all know this.  It's just that it's impolite to say it, hypomanic if the person who says it has a mood disorder, paranoid if the person who says it has a psychotic disorder, impolite if the person who says it has thus far dodged the DSM, impolitic if it's your job.  But there it is.  The paradigm is screwed up.

Paradigm: A worldview underlying the theories and methodology of a particular scientific subject.

Here is the short version:

Conventional medicine = Your [fill in the body part] is sick.  Take your medicine.

Functional medicine = Your body heals itself.  Live, so as to be healthy.

Applying The Paradigms

Now let's look at the longer version.  Here is your body:


Lovely.  Of course it's lovely.  And God saw everything that he had made, and behold, it was very good.

Next, here is not your body, but rather a diagnostic tree.  When you don't feel so well, the doctor uses this tree to locate your problem:


This is how a diagnostic tree works:

Conventional Medicine:

You feel dreadful.  So you go to the doctor, during regular office hours, if at all possible.  You tell the doctor how you feel.  The doctor wonders, What system inside this body is causing these symptoms?

So he/she elicits more information about symptoms, takes some measurements, runs some tests to determine which limb up there in the tree is out of order.  Is it the metabolic limb?  Endocrine limb?  Cardiovascular?  Pulmonary?

Next, the doctor sends you to the specialist in that limb, otherwise known as a system.  Doesn't matter which system, same paradigm.  Let's say the symptoms and the tests lead to the conclusion, it's psychiatric.  (We could do this same exercise with the cardiovascular system.  But this is Prozac Monologues...)  Is it mood disorder, psychotic disorder, anxiety disorder?

Then, which twig?  And finally, which treatment is purported to work best to make the symptoms go away on the particular twig your doctor has identified?

God help you if the doctor gets the twig wrong.  Because if you take the medicine that works well (or is purported to work well) for the next twig over, then another limb might pick up a hatchet and chop the sick twig or branch or limb or even the whole trunk right down. 

The thing is, the meds are dumb.  They don't know they are supposed to fix just that one little twig.  It is the rule, not the exception, that the med will also do  something to a different system, maybe several.  Let's just hope it's not something too dreadful.

Functional Medicine:

You feel dreadful.  So you go to the doctor.  You tell the doctor how you feel.  The doctor wonders, What has caused the body, which is designed to balance itself, to malfunction?

In functional medicine, the doctor pays as much attention to the roots as to the limbs.  The tree takes in nutrients, water, air, energy, experiences, toxins from the ground and the air.  It processes the environment through its cells and structures.  It is designed to absorb input, produce energy, rid itself of waste, grow, differentiate, reproduce -- function.  If the body is not thriving, functional medicine looks both to the environmental input and to the individual processing for the source of the disruption. 

Functional medicine is anchored by an examination of the core clinical imbalances that underlie various disease conditions. Those imbalances arise as environmental inputs such as diet, nutrients (including air and water), exercise, and trauma are processed by one’s body, mind, and spirit through a unique set of genetic predispositions, attitudes, and beliefs.

The fundamental physiological processes include communication, both outside and inside the cell; bioenergetics, or the transformation of food into energy; replication, repair, and maintenance of structural integrity, from the cellular to the whole body level; elimination of waste; protection and defense; and transport and circulation.

The core clinical imbalances that arise from malfunctions within this complex system include:
  • Hormonal and neurotransmitter imbalances
  • Oxidation-reduction imbalances and mitochondropathy
  • Detoxification and biotransformational imbalances
  • Immune imbalances
  • Inflammatory imbalances
  • Digestive, absorptive, and microbiological imbalances
  • Structural imbalances from cellular membrane function to the musculoskeletal system

Different Questions Lead To Different Treatment

The italics above are quoted from The Institute for Functional Medicine.  Here is the next paragraph, on the difference between how conventional and functional medicine solve problems:

Imbalances such as these are the precursors to the signs and symptoms by which we detect and label (diagnose) organ system disease. Improving balance – in the patient’s environmental inputs and in the body’s fundamental physiological processes – is the precursor to restoring health and it involves much more than treating the symptoms. Functional medicine is dedicated to improving the management of complex, chronic disease by intervening at multiple levels to address these core clinical imbalances and to restore each patient’s functionality and health.

Functional medicine is about the relationship between parts, relationships between macro/big and micro/little (systems and cells), the relationships between the systems themselves (cardiovascular, neurological...) and the relationships between the whole body and what is acting upon it.

There is nothing weird about functional medicine, nothing foreign to what anybody learns in medical school.  It's just that it notices what people forgot from that one hour in med school on nutrition, one hour on circadian rhythms, one hour on the connection between one system and another.  They forgot because after that one hour, conventional medicine never expected them to ask a question or listen to an answer about it again.

To become a functional medicine doctor, you learn conventional medicine and then learn to notice how it all connects.

Do-It-Yourself Functional Medicine

People in recovery are figuring this stuff out on our own.

Back To BDNF, Serotonin and Cognitive Remediation

So once upon a time, some brain scientists noticed that people with depression generally have lower serotonin levels than people without depression.  The conventional medicine solution: squirt some more serotonin into those synapses.

It didn't work near so well as we all were taught to believe.  Okay, so it worked very well for the pharmaceutical companies.  One out of every ten people in the United States of America is taking an antidepressant right now.  Ca-ching.  It's just, it didn't work so well for the people with depression.

Now the tune has changed.  Serotonin increases BDNF.  BDNF is the real hero.  Since SSRIs cause so many side effects, and they don't really work so well, and the patents have expired anyway, let's skip the serotonin squirting and find a different pill to stimulate more BDNF.

The National Institute on Mental Health (NIMH) has figured out there is something wrong with this approach, and won't fund it anymore.

Meanwhile, while you are waiting for the next miracle drug, which will be a long time coming, because the pharmaceutical companies have lost interest in antidepressants, you should know there are lots and lots and lots of things that improve BDNF production and at the same time improve the functioning of every other system.

Try aerobic exercise like walking, swimming, bike riding, mental exercise like sudoku and computer brain games, learning a new skill like a musical instrument or language or drawing, losing weight, eliminating refined sugar and diet soft drinks, eating leafy greens, fruits and fish, falling in love.  These things do not come in pill form and don't make anybody any money.  It's just that they make us healthy. 

Notice that these interventions replace toxins with healthy input.  That is functional medicine.

Here Comes An Opinion About Government Spending

Go back and reread that of ways to stimulate production of BDNF, absolutely essential for learning.  Then think about the cuts in your local school board budget.  Were they by chance funded by cutting physical education, sports, music, languages, and by placing snack machines in the schools?


The doctor's office is not the only place where our brains go bad.  Schools themselves are making us stupid.

More To Come On Cognition and Functional Medicine

Lots of topics web out from Getting My Brain Back.  Next up, mitochondria...


photo of emergency room by Thierry Geoffroy and used under the Creative CommonsAttribution-Share Alike 3.0 Unported license
photo of tablets, medical waste by Pöllö and used under the Creative Commons Attribution 3.0 Unported license
L'arbre de Vie by Raphaël Toussaint is used under the GNU Free Documentation License
graphic of tree with roots created by Vectorink and used under the Creative Commons Attribution 3.0 Unported license
flair from facebook
graphic of Brunnian link in public domain
photo of fruits and vegetables from Pike Place Market by Eric Hunt and used under the terms of the GNU Free Documentation License
photo of Bb school trumpet by Roy Benson and used under the terms of the GNU Free Documentation License

Thursday, June 9, 2011

Getting My Brain Back -- In Praise of BDNF


Here is the star of Getting My Brain Back, the Neuron.  I've got lots of neurons.  So do you.  They are our friends and we need to take care of them, so they take care of us.  BDNF, brain-derived neurotrophic factor will help us do that.  How BDNF is giving me my brain back is our story for the day.  But first...

Preface

Did you notice?  I wrote a book report in April.  If you are a regular reader, I guess that is obvious.  Let me try again.

I read a book.  Not just the one by Agatha Christie.  Maybe you still don't get it.  Never mind.  Here is the story.


Introducing Neuron, The Brain Cell
 
To the right we have a line drawing of the neuron with its major parts.  Neurons are essentially communication devices.  Each one receives messages from another neuron and passes them on to the next.  Dendrites are like the receivers.  Yes, they look like kinky hair.  Today let's call them ears, one ear at the end of each little spine growing out of each branch.  Axons are senders.  They carry the messages to the next neuron.  Yes, the nerve endings look like feet.  Today let's call them mouths.

Now imagine each of these dendrites pressing its ear against the mouth of another neuron's ending, and each of these nerve endings pressing its mouth against the ear of the next neuron's dendrite.  A lot of action going on here!  A lot being communicated.  The dendrites/ears and nerve endings/mouths connect at synapses, where a chemical exchange occurs, which passes the information from one neuron to the other.  But the chemistry is a subplot, not to be detailed in this post. Maybe in a sequel, if this story goes well.

We Need Lots And Lots Of Dendrites And Axons

So the story begins.  Baby brain is born, with a cast of a million neurons, more or less, like the one above.  I like that line drawing.  I'm thinking of my neurons all lined up, dendrites and nerve endings touching, grooving on each other, a regular reggae party, Don't worry 'bout a thing.  'Cuz every little thing gonna be alright...

Just how many of these connections are there?  Notice lots of dendrites on the one cell body in this line drawing, with spines coming off branches, a dendrite at the end of each spine.  Some cells have just one dendrite.  In the cerebellum, the purkinje cells have about 100 branches and 60,000 spines on each branch, more or less.  That's 6,000,000 dendrites/ears/potential connections per cell.  Not all of baby's 1,000,000 brain cells are quite so crowded as the ones in the cerebellum.  But if we do the math, that adds up to a gajillion dendrites, give or take a few, a gajillion potential connections.

Pruning Dendrites -- Sometimes Less Is More

Okay, a gajillion connections is a lot of noise, even for a baby.  Baby's brain has work to do.  What tastes good when I bite it?  What hurts?  What doesn't hurt?  What gets mad and goes away?  Focus, kid!  That mad reggae party in there is great, but we need some focus!

So right off the bat, some of these connections get used a lot, and some start disconnecting.  At birth, baby will pay attention to anything.  Within a year, baby pays attention to people speaking the language (or languages) spoken in the house and gets bored by people speaking something else.  The rule of the house regarding dendrites is Use it or lose it.  The connections for all the other languages of the world die off, and the connections for baby's own language get reinforced.

This pruning of connections is how we develop habits, as the messages go down the same channels over and over, like chopping a path through the kudzu.  The next time we go that way, the chopping is already done.  We can get there faster, and have energy for whatever we want to do once we reach our destination.

Brain-Derived Neurotrophic Factor

But wait!  While you were standing there with the tape recorder, coaxing baby to coordinate lips and tongue and breath and come out with -- will it be mama or papa? -- BDNF was already on the scene.


Here is the co-star of Getting My Brain Back -- Brain-Derived Neurotrophic Factor.  BDNF is a protein, one of the neurotransmitters.  It is found in greatest concentrations in the hippocampus (memory, emotions, learning), cortex (thinking) and basal forebrain (which produces acetylcholine, another neurotransmitter used in learning).  Its job is to help cells grow, survive and differentiate.  It supports the dendrites, to strengthen existing connections and make new ones.

So Which Is It We Need, More Connections Or Less?

Both, of course.

I lost all my Spanish speaking dendrites when I was a baby, and painfully replaced them in high school, with the help of the protein designed to do just that, BDNF.  Then they fell into disrepair again for several years, until my spouse and I visited her high school foster family in Ciudad Obregon, Mexico.  Sra. Ramirez was teaching me some card game.  Only the rules seemed to change every turn.  I needed to repair those Spanish-speaking channels fast!  BDNF works, but not that fast.  That little old lady robbed me blind.

Stress Makes Things Happen

So we have our stars, Neuron and BDNF.  Now we need some plot.  Otherwise known as Stress.

Poor stigmatized and misunderstood stress.  How about for now, we rename it stimulation.  Here is what I mean.

Shiny new bicycle.  The five-year-old begs, Oh, please, please, please take the training wheels off!  It took a lot of begging.  It was made clear to me that once the wheels came off, they were not going back on.

Meanwhile, in the previous five years, the dendrite/axon connections in charge of balance were developing, as I learned to walk and even skip -- no mean feat!  But this was a new wrinkle on the task.  One step up onto those pedals, the other foot lifts off the ground.  Houston, we have lift-off.  And suddenly -- STIMULATION!!

The inner ear is going crazy, sending out urgent messages to the basal ganglia which is supposed to remember this stuff, like skipping.  And falling.  Remember falling?!  That sets amygdala, hypothalamus and pituitary into action.  Remember panic?!  Now the hippocampus gets the SOS.  This is a job for BDNF!

So inside hippocampus cells, the endoplasmic reticulum goes into BDNF production, and the dense-core vesicles start pumping the stuff out.  Time for some dendrite growth and support!

Nature/Nurture

What happens next is an interplay between the existing brain and its wider environment.

Nature: A normal hippocampus (here in red) looks like a sea horse or a curled up green bean, 1 1/2-2 3/4 inches long if stretched out. Depending on the genetic role of the dice and/or the stress experienced by the pregnant mother, and hence by the fetus who is along for the ride, some brains have smaller hippocampi right from birth, along with a diminished capacity to produce BDNF.

That is not necessarily a problem.  Little people can do big things, same with little hippocampi.  It depends on whether the demands for BDNF are matched by the capacity of the hippocampus to produce it.

Nurture: There is this perception out in parentland that shouting helps children to learn.  Actually, sometimes it does.  When the task is simple and the learner lacks motivation, like, how to take the dishes from in front of the television set and place them in the kitchen sink, an occasionally-used loud voice can be just the trick to stimulate the neurotransmitters needed for memory consolidation.  Downside -- this method loses effectiveness with frequent use.

Riding a bicycle, however, is not a simple task.  There is a lot of communication already going on inside the brain of the person who is trying with all her might not to hit the pavement.  That BDNF is pumping out just as fast as it can.  In this case, shouting adds more cortisol load to the hippocampus than is helpful.  It overwhelms the learning process and turns it into a survival process.

When stimulation crosses over to stress and from stress to terror, the brain has to get more efficient.  Learning is a luxury.  The over-stressed person falls back into what is familiar.  Like falling. 

Well, into every child's life, an occasional full adult meltdownage will fall.  Nobody will learn to ride a bike today.  But the brain is built with its own repair system.  BDNF will clean up the mess, and we will go back to bike-riding another day.

Overstimulation

Then there are those parents who think that nature is bad and that hitting is part of nurture.  Hitting is even less helpful than shouting for learning complex skills.  Hitting really overstimulates the brain.

Especially random hitting.  Unpredictable and random shouting and hitting disrupt the feedback circuits in the HPA (hypothalamus/pituitary/adrenal) axis.  Over time the HPA axis loses its ability to shut down when not needed.  Because it has learned that it never knows when it will be needed.  So it just pumps out that cortisol 24/7.  The hippocampus keeps getting the message and pumping out that BDNF, until it is depleted.  Learning stops.  The dendrites in the hippocampus itself atrophy and die.  Literally, the hippocampus shrivels.

Then that already-from-birth-little hippocampus gets smaller still, with even less capacity to produce BDNF to repair the damage.  Or learn to ride a bike.

As far as cycles go, this one is not good.

Getting My Brain Back Anyway

But.  Take away the shouting and hitting.  Take away the random and unpredictable.  Give the poor pitiful hippocampus a rest.  The brain comes equipped with its own repair system.  Give it a couple years.

Build some more implicit memory in the basal ganglia, more balance, more skipping.  How about some roller skating?  Stronger legs?

Then one day, go to some safe and sane spot.  Little bit at a time.  Push off.  Put a foot down.  Push off.  Put a foot down.  Over and over.  Nobody else knows how often the foot touches the ground.  Nobody gets bored or angry at this repetition that stimulates a new channel of communication from inner ear to hips and knees and shoulders.  Learn.  This is what the brain is designed to do.


I can ride a bike.

I Wrote A Book Report

In one long run-on sentence I will now slide by subsequent shouting, hitting and random adult meltdownage, resulting in hippocampal damage and over-sensitized HPA axis, followed by untreated episodes, inappropriately treated episodes, SSRI poisoning, countless chemistry experiments setting up insomnia, hypomania and hysteria, exacerbated by continual harassment and activation of HPA madness by the short-term disability carrier, terminating in brain damage and long-term disability.

Only, of course, that is not where it terminates.  The brain has its own built-in repair system, BDNF.

Take away the shouting  and hitting.  Take away the random and unpredictable.  Give that poor pitiful hippocampus a rest.  Give it a couple years.

I used to write books.  In 2005 I wrote most of the book Prozac Monologues in one week, and finished it in two more.  Well, maybe that was more a symptom than an accomplishment.  But still, it was written well.

Last year, on the other hand, I could not read a book.  The year before, I would pick up a magazine, like an airline magazine, read a sentence at random, read the sentence that came before it, remember you are supposed to read from the beginning, find the beginning, get halfway through the first sentence and lose interest.

But even that little pea pod hippocampus of mine can still produce BDNF.  Go to some safe and sane spot.  Push off.  Write a sentence.  Put a foot down.  Go empty (half) the dishwasher.  Push off.  Delete a prepositional phrase.  Collapse into an hour of BeJeweled Blitz on Facebook.  Write a paragraph.

Next day, rearrange the sentences of the paragraph.  Google something.  Half an hour later, try to remember what I wanted to know.  Delete the whole paragraph.  Quit for the day.

Over and over.  Nobody else knows how the writer wobbles, how often the foot touches the ground.  Nobody else gets bored or angry at this painful process that stimulates a new channel of communication from one part of the brain to the next, hippocampus, amygdala, facebook, frontal cortex, Pub Med, anterior cingulate cortex.

This is what the brain is designed to do, grow new dendrites to replace the ones that burned up in that fire, in all those fires of all those years.

I wrote a book report in April.  I am getting my brain back.

Afterword

If you have read the original (How the Brain Works), or God help me, wrote it, you may be disappointed to find major characters missing from this adaptation of the book to the blog post.  Given the name of the blog itself, Eli Lilly might marvel that serotonin did not get a mention.  Some other lab, ready to role out a new psych med, will protest that BDNF would be nothing without glutamate.  Me, I miss cousins Val and Met, who did get written, but whose paragraphs got left on the cutting room floor.  You dopamine channel fans, write your own story.

Gimme a break.  It's a blog post.


Golgi-stained Neuron with cell body, axon, and dendrites from Robert Huber and used under the Creative Commons Attribution-Share Alike 3.0 Unported license
Scott Foresman, the elementary education publisher released the line drawing of the neuron and parts into the public domain
photo of babies talking by P Pogo and used under the Creative Commons Attribution 2.0 Generic license 
Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute created the cartoon of BDNF and placed it in the public domain 
photo of child on bicycle by Jacob and Marlies and used under the Creative CommonsAttribution 2.0 Generic license
Wahington Irving created the image of the hippocampi based on an MRI, and placed it in the public domain 
photo of drill sergeant screaming taken by Corporal Shawn M. Toussaint and in the public domain
flair from facebook
photo of cyclist Giusto Cerutti from the Dutch Nationaal Archief and in the public domain
photo of woman on bicyle by pedrosimoes7 and used under the Creative Commons Attribution 2.0 Generic license

Thursday, June 2, 2011

Cognitive Deficits -- on the way to Getting My Brain Back

The speaker at our monthly NAMI meeting was tall, mid-60's, military bearing, a former ER doc who did a couple tours of duty in Iraq.  You know the type.  Only, a little less of that ER doc -- I'll call it self-assurance.

He showed us slides of the work he used to do, the before shots (which we really did not want to see) and the after shots of young people, kids he patched together at the medic stations.  He told us about the sticky dark trail running from the helicopter pad to the table, and what made it sticky dark.

His passion for his work lit the room.  We listened to stories of kids for whom he had after shots.  There weren't always after shots.

He told us about TBI's, traumatic brain injuries and PTSD and how war does damage to brains.

He was taking a break after two tours of duty, back in an ER state-side when he had the stroke.

Now it became a different story.

Stroke -- The Brain Is Part Of The Body

They told him it would be a long recovery.  Two months later, he was astounded at how long it was taking.  They told him again, it would be a long recovery.  Six months later, the frustration overwhelmed him.  His body was back, the use of his limbs, his balance, more or less.  But his brain wasn't.  And the rehab people said, This is good.  Rehab has begun.

See, we know a stroke is a physical event, something that happens inside the body.  But still we have trouble thinking of the brain as the body.  We have trouble thinking of the functions of the brain, like thinking, as physical functions.  The injured body has to rehabilitate.  We know that.  Doesn't the brain just come along for the ride?

But thinking is done by a body, the part of the body called the brain.  Thinking is a physical process, electrical charges tracing a pathway from one cell to the next, within an organ of the body called the brain.  And when the brain is injured, it has trouble performing its physical functions, like thinking.

Cognitive Deficits

This emergency medicine doctor with battle front experience can't work anymore.  He used the phrase cognitive deficits.

To illustrate, he told us about the work of an emergency room doctor.  When somebody comes into ER with a potential heart attack, there is a protocol.  There are 17 steps to this protocol.  [It might be 23 -- I wasn't taking notes.]  He told us the first step.  Check.  Then he told us the second.  The second step requires a certain mathematical calculation.  He told us what needs to be calculated, the ratio between two measurements.  [I didn't write them down.]  He knows how to do the calculation.  He can do it in 18 minutes.  The whole process is still in there, inside his brain.

The thing is, this entire 17 step protocol has to be done in 93 seconds.

So he can't work as an ER doc anymore.  His job is to do rehab for his cognitive deficits.  In rehab he is learning how to connect all the bits that are still in there.  His brain is finding new pathways around damaged areas to turn all those bits into coherent and accessible thoughts.

And I thought -- That's it!  That's my swiss cheese brain!

My Swiss Cheese Brain

I am told, now that I have lost half of my cognitive functioning, I am still smarter than 80% of the people in the room.  Well okay, between 10 and 11:30 on alternate Wednesday mornings.

All the bits are in there.  If only I could connect the dots.  I wander inside this brain like the hallways of Hogwarts, wondering what's behind those locked doors, getting caught on moving staircases that take me to places I shouldn't be, sitting cross-legged on the floor in front of the Room of Requirement, desperately requiring entrance, but not a clue how to get in.

Sometimes all the bits taunt me.  They light up like little Christmas tree lights, blink off and on.  But if I grab one, the whole chain goes out.  Other times, all of a sudden, it's back, my brain.  I can get it to take me exactly where I want to go.

You don't notice.  You don't see the day spent on a paragraph, the week that is lost when the wall will not yield.  It hurts to write.  But I don't know who else to be, if not a writer.

Brain Damage

I have been writing about this stuff for years now.  Listening to somebody recovering from stroke, it finally hit me, brain damage.  I have brain damage.  The source is not the same.  A stroke kills brain cells through oxygen deprivation.  Trauma kills brain cells through chemistry, a surge of catecholamines, depression of thyroid function and hypoxia... an outpouring of other neurotransmitters, neuropeptides, and hormones... heightened catecholamine endorphin secretion with eventual depletion... the secretion of corticotrophin releasing hormone (CRH), adrenocorticotrophic hormone (ACTH) and cortisol... always more cortisol...

All of which really screws your hippocampus, seat of memory.  Here is the source of my cognitive deficits.  They say that, unlike cancer or a broken bone, there is no picture of depression.  Actually, that is not true.  MRI's show that anxiety and mood disorders damage and shrink the hippocampus.  They do have the pictures.  It is real.  It is brain damage.



Traumatic Brain Injuries, Post Traumatic Stress Disorder and severe depression all do the same brain damage.  They look the same.  By that, I mean the same MRI's.  They act the same.  By that I mean the same dysfunctions.  And, what do you know, they respond to the same treatments.  [I wrote about this in more detail back on March 28, 2010, one of my most frequently viewed posts.]

You can rehabilitate brains damaged by TBI's, PTSD and depression, just as you can rehabilitate brains damaged by stroke.  Just like stroke, some damage is reversible, some is not.  And just like stroke, expect it to take a long time.

A Long Recovery

A friend who has been my mentor through this life transition of mine told me, Yes, your brain will come back.  Give it five years.

So then my brain did its half-full/half-empty thing.

Five years -- that takes the pressure off.  I can give myself a break, and give myself time.  I can have hope.  Maybe my brain will be brilliant like my friend's brain again.

Five years -- my career really is over.  I will be too old to go back.  There is no reclaiming what I lost.  The presenter will never work in the ER again, and I will never be Diocesan Ministry Developer again.

Both.

I do tend to focus on the half empty part.

But my brain stretches out to as healthy as I can imagine, if only for a moment --

So I will do something else, instead.

to be continued...

photo of army doctor during training in Baghdad in public domain, (not the speaker referred to in this post)
flair by facebook
reproduction of hippocampus from Gray's Anatomy in public domain
fresco of The Visitation from the 14th century, Museo Matris Domini in Bergamo Italy