Anorexia, Insomnia, and Paranoia

The Machinist, a 2004 film directed by Brad Anderson, features the emaciated skeleton of Christian Bale as a haunted character named Trevor Reznik. He suffers from chronic insomnia ("haven't slept in a year" [which is impossible]), a cleanliness obsession that compels him to scrub his hands and bathroom floor with bleach, and a massively unhealthy case of anorexia complete with regular weigh-ins.


Reznik was involved in a horrible tragedy, is an outcast at work (even before causing an accident that amputates a co-worker's arm), and begins interacting with elusive individuals. You wonder how he has the energy to do anything, let alone work in a machine shop. He can only find solace in the arms of the proverbial hooker with a heart of gold, with Jennifer Jason Leigh in the typecast role. While they're in bed together, it seems the petite Jason Leigh might crush him.

I recently watched the film for the first time, and Bale's anorexic body obviously played the starring role. The 6 foot (1.83 m) tall actor lost 60 pounds (27 kg) for the part, reaching a low weight of 119 (54 kg). This put his body mass index (BMI) at 16.1, clearly in the range that should not have been allowed by the film crew.



He supposedly starved himself for 4 months, consuming only coffee, apples, and tuna. Was that really necessary? No. 140 pounds would have been sufficient. Usually anorexia is viewed as a disorder that only occurs in girls, but it can affect boys (and men) as well (Woodside et al., 2001; Scagliusi et al., 2009).

But Christian Bale is definitely not one who goes in for moderation, either in his personal life or his acting choices. For a nice analysis of Bale's performance and the spectacle (and specter) of his body in The Machinist, see Weight Watching: Method Acting as a Label and Subtext in The Machinist.

References

Scagliusi FB, Nakagawa KA, Campos RM, Kotait M, Fabbri A, Sato P, Cordás TA. (2009). Nutritional knowledge, eating attitudes and chronic dietary restraint among men with eating disorders. Appetite. Sep 3. [Epub ahead of print]

Woodside DB, Garfinkel PE, Lin E, Goering P, Kaplan AS, Goldbloom DS et al., (2001). Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. American Journal of Psychiatry 158:570–574.

Bleed It Out

I've opened up these scars
I'll make you face this
I pulled myself so far
I'll make you, face, this, now!
---Linkin Park

Deliberate self-harm, or self-injury, is becoming increasingly recognized as a problem affecting adolescents and young adults. Rates are difficult to determine, as the behaviors are often concealed. One recent study tracked a group of 1400 Midwestern US high school students over a 5 year period (Muehlenkamp et al., 2009). Rates of non-suicidal self-injury (NSSI) over 2001-205 were as follows:


Besides being associated with depression and eating disorders (especially among girls), the current psychiatric bible (DSM-IV-TR) includes self-injury as one of nine diagnostic criteria for Borderline Personality Disorder:

Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself.

Other criteria of BPD include:

• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving).
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).

Although it's considered a very serious personality disorder, the diagnostic label is a controversial one, coming under fire from feminists (Shaw & Proctor, 2005) and from some psychiatrists, like Dinah at Shrink Rap (see Over The Border Line).

Why Do Cutters Have Reduced Pain Perception?

An earlier study by Schmahl et al. (2006) examined the Neural correlates of antinociception in borderline personality disorder during the administration of heat pain. Do borderline patients injure themselves to "feel" (or "feel more normal") OR to down-regulate the emotional components of pain? The results didn't really answer this question, but the authors gave two options:

Limbic deactivation has been found to correlate with the degree of coping in aversive situations in general. . . . Thus, in view of these findings, self-inflicted pain may function to normalize neural activity in specific brain regions involved in emotional and cognitive processing. Alternatively, repeated self-injury could lead to an adaptation of pain thresholds and pain processing reflected in the current findings of elevated pain thresholds and disturbed prefrontal and limbic pain processing.

A new fMRI study by Kraus et al. (2009) took a different approach and compared BPD patients and controls who listened to standardized scripts of self-injurious behavior while in the scanner. The procedure was as follows:


Script-driven imagery was utilized to deliberately evoke emotional distress. The segments were Neutral (a woman on a shopping trip), Trigger (the woman watching a dispute between a mother and her child), Cognitive and Emotional Reactions (think about similar situations with your own mother), Self-Injurious Behavior (a typical act is described, from preparation to cutting itself), and Relaxation (presumably including the SI-induced decrease in aversive inner tension in BPD).

For the between-group comparisons, the imaging data weren't particularly strong at revealing robust differences. The primary finding was reduced activity in left orbitofrontal cortex in the BPD patients during the Cognitive and Emotional Reaction phase, possibly reflecting dysregulation of emotional control. However, the most intriguing finding in my view was deactivation in mid-cingulate cortex during the Self-Injury script. Although the authors didn't plot this result, the coordinates for the deactivation overlap with regions of the anterior cingulate involved in the affective components of pain (Rainville et al., 1997).

What's plotted below is the result of a coordinate-based meta-analysis of the neuroimaging literature on pain perception using the activation likelihood estimation (ALE) method. Articles on physical pain were identified in the BrainMap database (see Hypnosis and Pain Control for details). Of relevance for our current purposes is this midsaggital slice showing strong activation across studies of pain perception in a region of the anterior cingulate cortex that showed deactivation in the BPD patients during the self-injury script (the precise focus is indicated by the blue crosshairs). Although very preliminary, this finding may suggest that imagining an act of self-injury may downregulate the affective component of pain in individuals with borderline personality disorder.



As always, there are limitations with such a pilot study. The authors even list them at the outset:

• Fixed-effects analyses limit the ability to generalize from the study sample to the larger population of patients with borderline personality disorder (BPD).
• Due to the study design, a single section of the script could not be repeatedly presented, thus possibly diminishing the effect size of our results.
• As no control script was used, it cannot be determined whether our findings are related to self-injurious behavior (SIB) per se or to BPD features in general.

Nonetheless, Kraus et al. are continuing to expand on this work with fMRI studies that more closely mimic SIB than the present script design.

References

Kraus, A., Valerius, G., Seifritz, E., Ruf, M., Bremner, J., Bohus, M., & Schmahl, C. (2009). Script-driven imagery of self-injurious behavior in patients with borderline personality disorder: a pilot FMRI study. Acta Psychiatrica Scandinavica DOI: 10.1111/j.1600-0447.2009.01417.x

Muehlenkamp JJ, Williams KL, Gutierrez PM, Claes L. (2009). Rates of non-suicidal self-injury in high school students across five years. Arch Suicide Res. 13:317-29.

Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC. (1997). Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science 277:968-71.

Schmahl C, Bohus M, Esposito F, Treede RD, Di Salle F, Greffrath W, Ludaescher P, Jochims A, Lieb K, Scheffler K, Hennig J, Seifritz E. (2006). Neural correlates of antinociception in borderline personality disorder. Arch Gen Psychiatry. 2006 Jun;63(6):659-66.

Shaw C, Proctor G. (2005). Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder. Feminism and Psychology 15:483-490.

I bleed it out digging deeper
Just to throw it away
I bleed it out digging deeper
Just to throw it away
I bleed it out digging deeper
Just to throw it away

Just to throw it away
Just to throw it away
I bleed it out

Bleed It Out
---Linkin Park

Good News/Bad News Update on Nucleus Accumbens DBS for Treatment-Resistant Depression

Taken from Fig. 1 (Bewernick et al., 2009). Hamilton Depression Rating Scale (PDF) over time.

Two and a half years ago, The Neurocritic wrote about the very early results of deep brain stimulation (DBS) in the nucleus accumbens for severe, refractory depression. You can read about the details of the procedure and its scientific motivation here:

More About the Nucleus Accumbens

NAcc Localization for DBS

Briefly, the nucleus accumbens (NAcc) is considered one of the brain's PLEASURE CENTRES:

When the cortex has received and processed a sensory stimulus indicating a reward, it sends a signal announcing this reward to a particular part of the midbrain–the ventral tegmental area (VTA)–whose activity then increases. The VTA then releases dopamine not only into the nucleus accumbens, but also into the septum, the amygdala, and the prefrontal cortex.

The nucleus accumbens then activates the individual’s motor functions, while the prefrontal cortex focuses his or her attention.

It makes sense as a DBS target region from the standpoint of anhedonia (inability to experience pleasure from normally pleasurable life events) in major depression. Why not stimulate the "pleasure center" when you're feeling blue? Extensive research in animals and humans has demonstrated "hedonic hot spots" in the NAcc.

The current paper by Bewernick et al., 2009 reports on the results from 10 patients who received NAcc-DBS for at least 12 months. These patients were severely ill and completely non-responsive to any other treatment. On average, they had been continuously depressed for 10 years, were completely unable to work, had been hospitalized numerous times, had failed over 20 medication treatment courses, were currently on 4 different drugs, had received over 20 electroconvulsive therapy (ECT) treatments, and 316 hours of therapy, all to no avail.

The primary results are illustrated in Fig. 1 above. Half the patients (n=5) were considered "treatment responders" who experienced a 50% reduction of depressive symptom severity as assessed by the HDRS, and half did not respond. Anxiety scores also declined in the responders, and engagement in pleasant activities increased.

There were some adverse events related to the surgical procedure (swollen eye in 6 patients, pain and dysphasia in 3), as well as transient adverse events related to stimulation parameter changes e.g., anxiety (n=3), hypomania, paresthesia, and agitation (all n=2). Nonetheless, the authors concluded on a positive note:

DBS to the nucleus accumbens had clinically relevant antidepressant and antianhedonic effects in a patient population that was at least as treatment-resistant as those reported on in other studies of DBS in major depression (Lozano et al., 2008; Malone et al. 2009). The efficacy to adverse event ratio in this small group was favorable. Site-specific antianxiety effects also could be demonstrated.

By targeting one site in a network of brain regions implicated in processing of affective stimuli, it was possible to manipulate anhedonia in particular. Additional studies with larger sample sizes and rigid selection criteria are needed to analyze effects of stimulation to different targets on specific symptoms and clinical phenotypes of depression. In the future, symptom-based DBS therapy, adapted to the individual needs of the patients, could be a plausible treatment option for severe TRD.

References

Bewernick, B., Hurlemann, R., Matusch, A., Kayser, S., Grubert, C., Hadrysiewicz, B., Axmacher, N., Lemke, M., Cooper-Mahkorn, D., & Cohen, M. (2009). Nucleus Accumbens Deep Brain Stimulation Decreases Ratings of Depression and Anxiety in Treatment-Resistant Depression. Biological Psychiatry DOI: 10.1016/j.biopsych.2009.09.013

Lozano AM, Mayberg HS, Giacobbe P, Hamani C, Craddock RC, Kennedy SH. (2008). Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression. Biol Psychiatry 64:461-7.

Malone DA Jr, Dougherty DD, Rezai AR, Carpenter LL, Friehs GM, Eskandar EN, Rauch SL, Rasmussen SA, Machado AG, Kubu CS, Tyrka AR, Price LH, Stypulkowski PH, Giftakis JE, Rise MT, Malloy PF, Salloway SP, Greenberg BD. (2009). Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry 65:267-75.

I Feel Your Pain, I REALLY Do: Synaesthesia for Another's Pain

"I feel your pain"

Empathy for another person's pain is a hot topic of study in the glamorous field of social cognitive neuroscience. The capacity for empathy supposedly involves mirror neurons, those media darlings of The Young, [The Not-So-Young], and The Neuro:

A mirror neuron is a neuron that fires both when an animal acts and when the animal observes the same action performed by another. Thus, the neuron "mirrors" the behavior of the other, as though the observer were itself acting.

These magical cells have even inspired famous neuroscientists to utter ridiculous hyperbole:

The mirror neurons, it would seem, dissolve the barrier between self and others. I call them "empathy neurons" or "Dalai Llama neurons".

-- MIRROR EURONS AND THE BRAIN IN THE VAT
by V.S. Ramachandran

Synesthesia for pain, a newly described syndrome, goes one step further (Fitzgibbon et al., 2009):

In synaesthesia for pain a person not only empathises with another's pain but experiences the observed or imagined pain as if it was their own. Neural mechanisms potentially involved in synaesthesia for pain include “mirror systems”: neural systems active both when observing an action, or experiencing an emotion or sensation and when executing the same action, or personally experiencing the same emotion or sensation. For example, we may know that someone is in pain in part because observation activates similar neural networks as if we were experiencing that pain ourselves. We propose that synaesthesia for pain may be the result of painful and/or traumatic experiences causing disinhibition in the mirror system underlying empathy for pain.

And what is synesthesia, exactly? According to Edward M. Hubbard's website, SYNESTHESIA can be defined as

...an unusual conscious experience, in which stimulation of one sensory modality leads to a sensory experience in a second, unstimulated sensory modality. For example, seeing letters might lead some people to see colors. Others report that the days of the week or months of the year are arranged like a map in space. Still others report that hearing voices or music cause them to see colors, or that hearing words makes them taste foods...in fact, almost any sensory modality can be involved in synesthesia.

One of the more common forms of synesthesia (illustrated above) is grapheme-color synesthesia, where numbers and letters are consistently associated with specific colors (Ward et al., 2005). A more unusual form is lexical-gustatory synesthesia, in which spoken and written words elicit specific taste sensations that remain constant (Ward & Simner, 2003). For instance, Tony Blair tastes like desiccated coconut.

According to the recent review of the literature by Fitzgibbon et al. (2009), amputees with phantom limb pain comprise the vast majority of those with synaesthesia for pain:

Known Characteristics of Synaesthesia for Pain in a Sample of Amputees with Phantom Pain

Brought on by viewing others in pain and/or observing pain on the television and in movies.

Brought on both when observed pain matches that of the amputated site and/or any general pain

Brought on regardless of the identity of the observed person in pain, i.e. can be a loved one or a stranger.

The experience is similar to the experiences of phantom pain, for example, described as a short sudden ‘electric shock’.

Experienced in the phantom limb and/or stump.

The researchers propose that:

pain experiences may cause disinhibition of mechanisms underlying empathy for pain, resulting in synaesthesia for pain. This proposal is supported by studies that have found mirror activity to be involved in the pain matrix (e.g. Ochsner et al., 2008 and Singer et al., 2004); however, the specific processes that weaken these inhibitory mechanisms are unclear...

Ultimately, in synaesthesia for pain, "there is no self–other distinction in the observation of pain in another person."

References

Fitzgibbon, B., Giummarra, M., Georgiou-Karistianis, N., Enticott, P., & Bradshaw, J. (2009). Shared pain: From empathy to synaesthesia. Neuroscience & Biobehavioral Reviews DOI: 10.1016/j.neubiorev.2009.10.007

Ward J, Simner J. (2003). Lexical-gustatory synaesthesia: linguistic and conceptual factors. Cognition 89:237-61.

Ward J, Simner J, Auyeung V. (2005). A comparison of lexical-gustatory and grapheme-colour synaesthesia. Cognitive Neuropsychology 22:28-41.

Genomarketing!

You've heard of Neuromarketing, which measures the neural activity of consumers (via fMRI or EEG) in response to various products or advertisements. Now, get ready for Genomarketing! The Neuroethics & Law Blog has alerted us to a recent paper by De Neve and Fowler (2009) reporting that people with a specific low efficiency variant of the gene for monoamine oxidase A are significantly more likely to have credit card debt. Monoamine oxidase A (MAO-A) is an enzyme that breaks down the monoamine neurotransmitters (dopamine, norepinephrine, epinephrine, and serotonin). Using data from the National Longitudinal Study of Adolescent Health, the authors found in that sample of 18-26 year olds,

Having one or both MAOA alleles of the low efficiency type raises the average likelihood of having credit card debt by 7.8% and 15.9% respectively. About half of [the U.S.] population has one or both MAOA alleles of the low type. Prior research has linked this genetic variation to lack of conscientiousness, impulsivity, and addictive behavior.

Is this the foreshadowing of a highly unethical marketing practice? Marketing based on MAO-A genotype, as determined from mailed-in credit card applications and payments? Credit card companies will have in-house labs to extract DNA from stamps and envelope flaps (Sinclair & McKechnie, 2000; Ng et al., 2007).¹ Taking it one step further, entire marketing campaigns will be tailored to specific markers in an individual’s genome.²

Is this what it’s coming to? Not so fast. Are there any limitations in the findings of De Neve and Fowler (2009)? There are many!! The paper reported:

Allele frequency for the low grouping is 41% and high grouping is 59% in our sample. In Wave III, subjects were asked “Do you have any credit card debt?" About 41% answered in the affirmative.

However, the ONLY question asked was “Do you have credit card debt?” – not how much debt or anything else. And of course, the interactions between genes and environment are immense, despite what simplistic popular media notions might lead you to believe (see Neuroanthropology for a critique). Without getting into details (which are better left to other blogs), De Neve and Fowler also note that:

Model 2 includes a number of socio-economic factors that influence financial decision-making. Income and education may in fact mediate the relationship between the genes we have identified and credit card usage.

Finally, another recent paper (Beaver & Holtfreter, 2009) found that possessing the high efficiency MAO-A allele (opposite of the one discussed here) predicts involvement in fraudulent behaviors. But only if you hang around with the wrong crowd. Specifically,

Analysis of male participants from the National Longitudinal Study of Adolescent Health (J. R. Udry, 2003) revealed a statistically significant Gene × Environment interaction in which the high-MAOA activity allele increased the odds of fraudulent behaviors, but only among male participants with a high number of delinquent peers.

Fraudulent behavior was determined by two questions. Can you guess them?

(1) How many times during the past 12 months have you used someone else’s credit card or bank card without their permission or knowledge?

(2) How many times during the past 12 months have you deliberately written a bad check?

Ha! Beaver and Holtfreter discuss the contrast of careful and deliberate planning [high-activity alleles] vs. impulsive violence³ [which also has a link to low-activity alleles]:

Genetic imaging research examines whether different alleles of a particular polymorphism are associated with differences in brain structure and functioning. Results have revealed that respondents possessing the low-MAOA activity alleles have limbic volume reductions, decreased cingulate activation, and hyperactivity in the amygdala and hippocampus—differences that may begin to explain the link between MAOA and violence. However, the etiologies of serious violence and fraudulent behaviors may be dissimilar. For example, engaging in fraudulent behaviors may take more time and more planning than is typical of most other antisocial behaviors, which are relatively unplanned and impulsive.

Bernie Madoff vs. Phil Spector? Sort of.




Footnotes

¹ This would only work, of course, for those who still conduct such business the old fashioned way. And please note that the cited references use these techniques for legitimate purposes!!

² See also Please Complete a Genome Scan with Your Mortgage Application. EDIT: and this, too: Overspending: Blame It On Your ‘Debt Gene’?

³ Just stating the obvious here, but having credit card debt in no way, shape, or form implies that one is violent.

References

Beaver, K., & Holtfreter, K. (2009). Biosocial Influences on Fraudulent Behaviors. The Journal of Genetic Psychology, 170 (2), 101-114. DOI: 10.3200/GNTP.170.2.101-114

De Neve, Jan-Emmanuel and Fowler, James H. The MAOA Gene Predicts Credit Card Debt (August, 18 2009). Available at SSRN: http://ssrn.com/abstract=1457224

Ng LK, Ng A, Cholette F, Davis C. (2007). Optimization of recovery of human DNA from envelope flaps using DNA IQ System for STR genotyping. Forensic Sci Int Genet. 1(3-4):283-6.

Sinclair K, McKechnie VM. (2000). DNA extraction from stamps and envelope flaps using QIAamp and QIAshredder. J Forensic Sci. 45(1):229-30.

A New Outlook

"A New Outlook" is a multimedia installation by Bree Yenalavitch at...

...Project Room G3, an artist run project space found by Sojung Kwon started April 2009, that focuses on work which has a performative, temporal, and non-classical aesthetic. It is located at Angels Gate Cultural Center in San Pedro [in Southern California].

Bree Yenalavitch is a Los Angeles area artist working in multimedia. She received her BA from the University of California Santa Barbara in 2002 and MFA from Otis College of Art and Design in 2006. Her recent online project can be viewed at www.thebree.tv, where she presents the laboratory of Dr. Specialist - a great woman of science. Bree can also be seen in the Inauguration Show at Project Room G3, where viewers interacting with her participatory project will find their perspective has been rendered askew.

Everything in its Right Place

Sarah Sze
Things Fall Apart
2001
"010101: Art in Technological Times"

Sarah Sze is a contemporary visual artist (and winner of a MacArthur Fellowship in 2003) who creates unique, site-specific sculptures and installations which make use of ordinary technological and scientific objects.

Sarah Sze
Everything in its Right Place

Even the details in Sarah Sze’s sculptures have details. All her installations are extraordinarily ambitious and are constructed with fastidious precision, consequently, her output is relatively small compared with many other artists. Everything in its Right Place, 2002–03, is one of her most important and most ambitious works.

...

The multitude of small parts in Sze’s Everything in its Right Place shifts us away from a panoramic spectatorship to inspection mode. The site-specificity of Sarah Sze’s work is best understood through the idea of environments created by overarching structures of collection and models, where narratives and nostalgias intersect as property and space, affecting us through the flickering effect of their soaring elegance and beauty.

And then we have the ever-optimistic Thom York of Radiohead, who has a different idea of the concept...

Everything, everything, everything, everything..
In its right place
In its right place
In its right place
In its right place

What, what is that you try to say?
What, what was that you tried to say?
Tried to say.. tried to say..
Tried to say.. tried to say.. tried to say...

Everything In Its Right Place
------Radiohead

Beating Heart - Scott Becker Multimedia