Can a Slow-Growing Brain Tumor Cause a Gambling Problem?

Maureen O’Connor, former mayor of San Diego and heir to her late husband Robert O. Peterson’s Jack-in-the-Box fortune, won over $1 billion playing video poker over the course of 9 years (2000-2009), according to U-T San Diego. However, she lost an even greater amount during that time, resulting in a net gambling debt of $13 million. To cover some of these losses, she transferred $2 million from her husband's nonprofit foundation to her personal bank account. She was recently charged with misappropriation of funds in federal court.

In 2011, O'Connor had surgery to remove a large brain tumor:

The tumor was in an area of the brain that involves "logic, reasoning and judgment," said O'Connor's attorney, Eugene Iredale.

Is It Possible That Maureen O’Connor’s Gambling Problem Was Caused by the Brain Tumor?

Can a tumor cause irrational economic decision-making (Koenigs & Tranel, 2007) and insensitivity to future consequences (Bechara et al., 1994)? In cases of orbitofrontal meningiomas, the answer is yes.

T1 + contrast MRI scan shows a large olfactory groove meningioma affecting the medial orbitofrontal cortex.  Image source:  Radiopedia.


While I cannot speak to Ms. O'Connor's specific case, there are a number of reports in the neurological literature of patients who do incur large gambling debts during the time a slow-growing, non-fatal tumor impinges upon the frontal lobes. Specifically, a meningioma (a relatively common and “benign” non-infiltrating tumor in the meninges, or membranes that cover the brain) in the region of the orbitofrontal cortex (OFC) can grow to be the size of an orange over decades before it is discovered (Tomasello et al., 2011).¹

Eslinger and Damasio (1985) reported the case study of patient EVR, who had surgery to remove a large meningioma affecting medial OFC bilaterally. Although EVR showed intact cognitive function through standardized neuropsychological testing, he made a series of unwise decisions that led to very negative consequences in his life. His business went bankrupt after he took on an unsavory business partner. He drifted from job to job, often being fired for his unreliability. He got divorced, remarried against the advice of others, and then divorced again shortly thereafter.

Bechara et al. (1994) developed what came to be known as the Iowa Gambling Task (IGT) to assess the decision-making capacity of patients like EVR. In the task, participants are shown 4 decks of cards (real or virtual) from which they are allowed to draw in a series of gambles. They are told they can win money, but might also win and lose money, and will be informed of the consequences of their choice only after picking a card from one of the decks. Unbenownst to the subjects initially, Decks A and B pay out $100 but also incur larger penalties on an unpredictable schedule ("disadvantageous decks" resulting in a net loss) while Decks C and D only pay $50 but result in smaller penalties ("advantageous decks" resulting in a net gain). In the long run, patients with lesions in medial OFC (aka ventromedial prefrontal cortex, or VMPFC) preferred the higher immediate payoff than the safer decks, while controls showed the opposite pattern.

In other words, EVR (and 6 other patients like him) chose from the disadvantageous decks significantly more often than control participants, who appeared to better learn the good and bad nature of the decks. Although the IGT is not without its critics in terms of the cognitive and affective processes necessary for optimal task performance, other studies suggest that VMPFC is indeed important for future-oriented thinking (Fellows & Farah, 2005).²


O'Connor's Plea Bargain

In court, Ms. O'Connor pleaded not guilty to money laundering under the terms of a deferred prosecution, according to U-T San Diego. As part of the deal, she has two years to pay back funds "borrowed" from the nonprofit foundation, and she must attend treatment for gambling addiction:

The resolution of the case takes into account her poor health but also requires O’Connor to acknowledge she misappropriated the money and obligates her to pay it back and any tax penalties, [Assistant U.S Attorney Philip Halpern] said.

She also has to get psychiatric treatment for gambling addiction. [Defense attorney] Iredale said that O’Connor’s doctors have said it’s possible her brain tumor pressed on centers of the brain that affect judgment and reasoning, and could explain in part her gambling addiction.

Prosecutors dispute that. “We believe the gambling preceded her medical condition,” Halpern said.

ABC 10 News reported:

If she does not obey all laws, she could face 10 years in prison.

All parties agreed that O'Connor's medical condition render it highly improbable -- if not impossible -- that she could be brought to trial.

"We think largely as a result of the brain tumor, she had engaged in a period of compulsive gambling in which she systematically gambled away an inheritance that was left to her of several million dollars," said Iredale.

CBS News aired an interview with the former mayor. O'Connor said that video poker was "...like electronic heroin. You know, the more you did, the more you needed and the more it wasn't satisfied."

As mayor she was always in control. Her gambling was out of control.

"I thought I could beat that machine," she said. "And when it got worse, I didn't know I had the silent grenade in my head that could go off at any time."

The "silent grenade" was a golf ball-sized tumor doctors removed from her brain. They discovered it two years ago when she started hallucinating. She says she believes the slow-growing tumor contributed to her gambling addiction. "It's not an excuse for my gambling, but I think that was, yes, a part of it. You lose your sense of control," she said.

How slow-growing?

Prosecuting attorney Halpern was skeptical of the tumor explanation, saying "she began her gambling run in 2001 -- a decade earlier. It would have to be a pretty slow-growing tumor."

But as we've seen, meningiomas can be very slow-growing. Neurosurgeon Dr. Katrina Firlik presented the case of a giant olfactory groove meningioma on her website (the MRIs alone are worth checking out):

This patient presented with a several year history of depression, which was, in retrospect, most likely related to this benign tumor. This type of tumor typically grows slowly, over years or even decades.

Now,  it bears repeating that I do not know whether Ms. O'Connor had this type of tumor. However, her symptoms could be seen as consistent with an olfactory groove meningioma affecting the OFC, including the visual hallucinations (perhaps due to pressure on the optic nerve). Visual disturbances can also be seen in medial sphenoid wing meningiomas, but these are not generally associated with such extreme behavioral changes (Sughrue et al., 2013).

O'Connor also had a stroke at some point and shows signs of memory loss, difficulty reading, and occasional language comprehension problems, according to her doctor. The latter symptoms are not consistent with an OFC tumor but could be due to the stroke. ³

Finally, it's important to note that O'Connor no longer feels compelled to gamble now that the tumor has been removed: "After the tumor was taken out and I started healing, I have no desire to gamble."


Footnotes

¹ Olfactory groove meningiomas that exceed 6 cm in diameter are known as "giant olfactory meningiomas" (d'Avella et al., 1999). The largest one in this case series was 9 cm in diameter, the size of an orange (shown below).

Left: preoperative and Right: early postoperative T1-weighted MRI.

² In this study (Fellows & Farah, 2005), patients with VMPFC lesions demonstrated a dissociation between future time perspective (which was impaired relative to controls) and temporal discounting, or "the subjective devaluation of reward as a function of delay" (which was intact). Thus, VMFPC damage did not result in unusual discounting of rewards given in the future, relative to those given in the present.

³ An infarction of the left posterior cerebral artery, for example, could result in damage to the left hippocampus (memory loss) and left ventral temporal and/or occipital cortices (reading difficulties).


Additional coverage: Can a Brain Tumor Turn You Into a Gambler?


References

Bechara A, Damasio AR, Damasio H, & Anderson SW (1994). Insensitivity to future consequences following damage to human prefrontal cortex. Cognition, 50 (1-3), 7-15 PMID: 8039375

d'Avella D, Salpietro FM, Alafaci C, Tomasello F. (1999). Giant olfactory meningiomas: the pterional approach and its relevance for minimizing surgical morbidity. Skull Base Surg. 9:23-31.

Eslinger PJ, & Damasio AR (1985). Severe disturbance of higher cognition after bilateral frontal lobe ablation: patient EVR. Neurology, 35 (12), 1731-41. PMID: 4069365

Fellows LK, Farah MJ. (2005). Dissociable elements of human foresight: a role for the ventromedial frontal lobes in framing the future, but not in discounting future rewards. Neuropsychologia 43:1214-21.

Koenigs, M., & Tranel, D. (2007). Irrational Economic Decision-Making after Ventromedial Prefrontal Damage: Evidence from the Ultimatum Game. Journal of Neuroscience 27 (4), 951-956.

Sughrue ME, Rutkowski MJ, Chen CJ, Shangari G, Kane AJ, Parsa AT, Berger MS, McDermott MW. (2013). Modern surgical outcomes following surgery for sphenoid wing meningiomas. J Neurosurg. Feb 22. [Epub ahead of print]

Tomasello, F., Angileri, F., Grasso, G., Granata, F., De Ponte, F., & Alafaci, C. (2011). Giant Olfactory Groove Meningiomas: Extent of Frontal Lobes Damage and Long-Term Outcome After the Pterional Approach. World Neurosurgery, 76 (3-4), 311-317 DOI: 10.1016/j.wneu.2011.03.021

The Neuroanatomical Correlates of Self-Sabotage

Self-Sabotage, by jesse.millan

I should be preparing for a Very Important Presentation at an upcoming meeting. But I'm not. I'm sitting at home on a Saturday night, blogging about self-sabotage.

"Self Sabotage is when we say we want something and then go about making sure it doesn't happen."
-Alyce

I do have a lot of clever ideas and useful data that are relevant for the meeting in question, I just haven't been able to start preparing my presentation yet. Am I afraid of failing? Angry at the complete lack of incentive structures at my workplace (which is organized and run in such a laughably inept manner as to be totally demotivating)?


Psychology of Self-Handicapping

What is behind the act of setting yourself up for failure, for unconsciously compiling a list of excuses for why you didn't perform at your best? What motivates this behavior?

It's an act of self-preservation, actually, to have external reasons for why you didn't achieve what you set out to accomplish. That way, you're not a complete and total failure as a person. It protects your fragile self-esteem, but this comes at a price.

Zuckerman and Tsai (2005) found the long-term costs of this strategy include a loss of perceived self-competence, negative mood, increased substance use, and a decline in motivation. Self-handicapping can be an effective strategy in the short-term, but eventually you'll suffer the consequences and end up a failure anyway.


Anatomy of Self-Handicapping

A group of Japanese researchers (Takeuchi et al., 2013) wanted to determine the neuroanatomical correlates of self-handicapping behavior, to see what sets this population apart from others. They used voxel-based morphometry (VBM) to quantify individual differences in brain anatomy across a large group of healthy students (94 men and 91 women). The participants were administered a Japanese version of the self-handicapping scale, along with assessments of self-esteem and depressive mood. The scale included questions like these (PDF):

• When I do something wrong, my first impulse is to blame circumstances.
• I always try to do my best, no matter what.
• I tend to put things off until the last moment.
• I would do a lot better if I tried harder.

Regional gray matter volumes (rGMV) were quantified in a whole-brain analysis and related to scores on the self-handicapping scale with age, sex, total brain volume, intelligence, self-esteem, and depression as covariates.

The major finding is that self-handicapping was positively correlated with rGMV in a portion of the subgenual cingulate gyrus (sgCG), or Brodmann area 25. This general area has been dubbed the "sad cingulate" by some, because it's the region targeted by deep brain stimulation for severe intractible depression by Helen Mayberg, Andres Lozano and colleagues (e.g., Riva-Posse et al. 2012).¹

Fig. 1a (adapted Takeuchi et al., 2013). Anatomical correlates of self-handicapping tendency. The region of correlation is overlaid on a single subject T1 image rGMV in sgCG was correlated with individual self-handicapping tendency. Results are shown with P < 0.05 after correction for multiple comparisons at voxel-level FWE at the whole brain level.


The extent of this correlation did not differ between males and females (see fig below). No other regions showed positive or negative correlations with self-handicapping scores. It might seem a little implausible that the size of such a circumscribed area is the only one that correlated with the tendency for self-sabotage, but there you go.

Fig. 1b (adapted Takeuchi et al., 2013). Scatter plot of the relationship between the self-handicapping scale score and rGMV values at the peak voxel (x, y, z = −5, 11, −16). The blue line represents the regression line for males, while the red line represents that for females.


A counterintuitive aspect of this result stands in contrast with previous studies of depressed individuals, who show smaller rGMV in sgCG (Drevets et al., 2008). In the present study, higher self-handicapping was correlated positively with depression symptoms and negatively with self-esteem. But remember, this was a non-clinical population of 21 yr old students, not treatment-resistant patients with severe depression. In fact, it would be interesting to follow this population longitudinally, to see if continued use of self-handicapping tactics eventually wears down mood and sgCG volumes to pathologically low levels.

After a lifetime of self-sabotage, the fill-in-the-blank answer to...

"When I do something wrong, my first impulse is to _____"

...might change from "blame circumstances" to "blame myself for being such a miserable failure." When there's no self-esteem left, why try harder? What's the point?


Footnote

¹ However, the sgCG region in the present study seems inferior and posterior to the DBS target (Riva-Posse et al. 2012).

References

Drevets WC, Savitz J, Trimble M. (2008). The subgenual anterior cingulate cortex in mood disorders. CNS Spectr. 13:663-81.

Riva-Posse P, Holtzheimer PE, Garlow SJ, Mayberg HS. Practical Considerations in the Development and Refinement of Subcallosal Cingulate White Matter Deep Brain Stimulation for Treatment Resistant Depression. World Neurosurg. 2012 Dec 12. [Epub ahead of print]

Hikaru Takeuchi, Yasuyuki Taki, Rui Nouchi, Hiroshi Hashizume, Atsushi Sekiguchi, Yuka Kotozaki, Seishu Nakagawa, Carlos Makoto Miyauchi, Yuko Sassa, Ryuta Kawashima (2013). Anatomical correlates of self-handicapping tendency. Cortex doi: 10.1016/j.cortex.2013.01.014

Zuckerman M, Tsai FF. (2005). Costs of self-handicapping. J Pers. 73:411-42.

Save Me... from myself, by tankgirlrs

The 'evil patch' in the brain's central lobe

In a stunning new finding, a German neurologist has discovered the locus of evil in the brain, indicated by red arrows in the figure above. It shows up as a dark mass on the MRI of every single evil person in the universe.

Dr Gerhard Roth told The Daily Mail:

'We showed these people short films and measured their brain waves,' he said.

'Whenever there were brutal and squalid scenes the subjects showed no emotions. In the areas of the brain where we create compassion and sorrow, nothing happened.'

The dark mass at the front of the brain, he says, appears in all scans of people with records for criminal violence.

It's truly remarkable that brain waves (EEG activity) show up in the shape of a Hitler moustache on an MRI scan. Let's take a closer look at the original story:

Where evil lurks: Neurologist discovers 'dark patch' inside the brains of killers and rapists

• Scans reveal a patch at the front of the brain can be seen in people with records for criminal violence 

• German scientist who made the discovery classifies evil in three groups

By Allan Hall In Berlin
PUBLISHED: 10:32 EST, 5 February 2013 | UPDATED: 18:29 EST, 5 February 2013

A German neurologist claims to have found the area of the brain where evil lurks in killers, rapists and robbers.

Bremen scientist Dr Gerhard Roth says the 'evil patch' lies in the brain's central lobe and shows up as a dark mass on X-rays.

. . .
He added: 'When you look at the brain scans of hardened criminals, there are almost always severe shortcomings in the lower forehead part of the brain.

. . .
'Or there are physiological deficits, because certain substances such as serotonin in the forebrain are not working effectively.

'But this is definitely the region of the brain where evil is formed and where it lurks.

The Reality

OK, I superimposed the Hitler moustache on the scan above. But in reality, this is one of the most ridiculous news stories about the brain to come along in quite a while. Clearly, The Daily Mail did not get the memo on the backlash against Brain Porn and Neurobollocks in the popular press.

There is no such thing as the 'central lobe', and 'the lower forehead part of the brain' is not a descriptive anatomical term. The 'dark patch' is clearly some sort of artifact, along with the black diagonal bar coming out of the skull. This is truly a laughable attempt at science journalism, and rather damaging to Dr. Roth's reputation (although that's his own fault). EDIT 2/11/13 - Dr. Roth was misunderstood, see below.

As Vaughan Bell said in his post on The dark patch of death:

"...it’s not satire if written while high on cleaning products."

Link via @Keith_Laws

ADDENDUM (Feb 8, 2013): An indignant anonymous German commenter alerted me to a press release from Universität Bremen saying that the "central lobe" does not exist at all, and the terminology was "due to a deep misunderstanding of statements in an interview." My reply to this comment suggested there were other problems with the ideas expressed in the tabloid articles and noted that Dr. Roth's ideas have been criticized previously.

ADDENDUM #2 (Feb 11, 2013): An article in Yahoo! News / LiveScience (Brain Area 'Where Evil Lurks' Doesn't Exist: Neurologist) quotes Dr. Roth: 

Roth, however, denies finding such an evil spot. "The report initially released by the German ... newspaper BILD was based on deep misunderstandings of what I had said in an interview," Roth told LiveScience in an email.

I apologize for the deep misunderstandings, although I doubt The Daily Mail and BILD will apologize...