tag:theconversation.com,2011:/africa/topics/neuropsychiatry-10916/articlesNeuropsychiatry – The Conversation2023-09-20T15:04:57Ztag:theconversation.com,2011:article/2136472023-09-20T15:04:57Z2023-09-20T15:04:57ZDepression recovery can be hard to measure − new research on deep brain stimulation shows how objective biomarkers could help make treatment more precise<figure><img src="https://images.theconversation.com/files/548890/original/file-20230918-23-pisigx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2190%2C1369&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deep brain stimulation can alleviate treatment-resistant depression for some patients.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/brain-connection-royalty-free-image/1272275035">PM Images/Digital Vision via Getty Images</a></span></figcaption></figure><p>It can be challenging to create a treatment plan for depression. This is especially true for patients who <a href="https://doi.org/10.2147%2FNDT.S198774">aren’t responding to conventional treatments</a> and are undergoing experimental therapies such as deep brain stimulation. For most medical conditions, doctors can directly measure the part of the body that is being treated, such as blood pressure for cardiovascular disease. These measurable changes serve as an objective biomarker of recovery that provides valuable information about how to care for these patients. </p>
<p>On the other hand, for depression and other psychiatric disorders, clinicians rely on <a href="https://doi.org/10.1371/journal.pone.0203574">subjective and nonspecific surveys</a> that ask patients about their symptoms. When a patient tells their doctor they are experiencing negative emotions, is that because they are relapsing in their depression or because they had a bad day like everyone does sometimes? Are they anxious because their depression symptoms have lessened enough that they are experiencing new feelings, or do they have some other medical problem independent of their depression? Each reason may indicate a different course of action, such as altering a medication, addressing an issue in psychotherapy or increasing the intensity of <a href="https://theconversation.com/brain-stimulation-can-rewire-and-heal-damaged-neural-connections-but-it-isnt-clear-how-research-suggests-personalization-may-be-key-to-more-effective-therapies-182491">brain stimulation</a> treatment.</p>
<p><a href="https://scholar.google.com/citations?user=JHuo2D0AAAAJ&hl=en">We are</a> <a href="https://scholar.google.com/citations?user=K0dED3QAAAAJ&hl=en">neuroengineers</a>. In our study, newly published in Nature, we identified <a href="https://www.nature.com/articles/s41586-023-06541-3">potential biomarkers</a> for deep brain stimulation that could one day help guide clinicians and patients when making treatment decisions for those using this approach to alleviate treatment-resistant depression.</p>
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<figcaption><span class="caption">Deep brain stimulation involves surgically implanting electrodes in the brain.</span></figcaption>
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<h2>Biomarker for depression</h2>
<p>Clinical depression does not respond to available therapies in a significant number of patients. Researchers have been working to find alternative options for those with <a href="https://doi.org/10.2147%2FNDT.S198774">treatment-resistant depression</a>, and many decades of experiments have identified specific brain networks with abnormal electrical activity in those with depression.</p>
<p>This notion of depression as abnormal brain activity rather than a chemical imbalance led to the development of <a href="https://doi.org/10.1016/j.neuron.2005.02.014">deep brain stimulation</a> as a depression treatment: a surgically implanted, pacemaker-like device that delivers electrical impulses to certain areas of the brain. Studies testing this technique have found that it can <a href="https://doi.org/10.1016/s2215-0366(17)30371-1">decrease depression severity</a> over time in most patients.</p>
<p>Our research team wanted to find specific changes in brain activity that could serve as a biomarker that objectively measures how well deep brain stimulation is helping patients with depression. So we <a href="https://www.nature.com/articles/s41586-023-06541-3">monitored the brain activity</a> of 10 patients receiving deep brain stimulation for severe treatment-resistant depression over six months.</p>
<p>At the end of six months, 90% of the patients responded to the therapy – defined by a reduction of symptoms by at least a half – and 70% were in remission, meaning they no longer met the criteria for clinical depression.</p>
<p>To identify a potential biomarker, we developed an algorithm that looked for patterns in brain activity changes as patients recovered. The algorithm was based on data from six out of the original 10 patients who had usable data from the experiment. We found that there are <a href="https://www.nature.com/articles/s41586-023-06541-3">coordinated changes in different frequencies</a> present in the electrical activity within the area of the brain being stimulated. Using these patterns, the algorithm was able to predict whether someone was in a stable recovery with 90% accuracy each week.</p>
<p>Interestingly, we observed some parts of this pattern <a href="https://doi.org/10.1038/s41398-021-01669-0">moved in the</a> <a href="https://doi.org/10.3389/fncom.2018.00043">opposite direction</a> later in stimulation therapy compared with the patterns at the start of therapy. This finding provides evidence that the long-term recovery is due to the brain adapting to the stimulation in a process <a href="https://theconversation.com/medication-can-help-you-make-the-most-of-therapy-a-psychologist-and-neuroscientist-explains-how-209200">called plasticity</a> rather than as a direct effect of the stimulation itself.</p>
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<a href="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person lying in bed, light speckled over their face." src="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548887/original/file-20230918-23-pyx5bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Depression is a debilitating disease.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/depressed-woman-lying-on-the-bed-at-home-royalty-free-image/1433295949?adppopup=true">Guido Mieth/Moment via Getty Images</a></span>
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<p>We also saw other potential biomarkers worth investigating further. </p>
<p>For example, abnormalities in brain imaging taken before implanting the electrodes in specific parts of the brain correlated with how sick each patient was. This could provide clues about what’s causing depression in some people, or help develop imaging methods to determine who might be a good candidate for deep brain stimulation. </p>
<p>For another example, we found that the facial expressions of patients changed as their brains changed over the course of their treatment. While physicians often report this anecdotally, quantifying these changes may provide a way to develop objective markers of recovery that incorporate a patient’s behavior with their brain signals. </p>
<p>Because the results of our study are based on a small sample of patients, it’s important to further investigate how broadly they can be applied to other patients and newer deep brain stimulation devices.</p>
<h2>Improving decision-making for depression</h2>
<p>Clinical depression is a debilitating condition that causes significant personal and <a href="https://doi.org/10.1007/s40273-021-01019-4">societal suffering</a>. It is one of the largest contributors to the <a href="https://apps.who.int/iris/handle/10665/254610">overall disease burden</a> of many countries. Despite the many approved treatments available, <a href="https://doi.org/10.4088/jcp.20m13699">nearly 30% of the 8.9 million U.S. adults</a> taking medications for clinical depression continue to have symptoms.</p>
<p>Deep brain stimulation is one of the alternative therapies for treatment-resistant depression that researchers are investigating. Studies have shown that deep brain stimulation can offer effective and <a href="https://doi.org/10.1176/appi.ajp.2019.18121427">long-term relief</a> for some patients. </p>
<p>Although deep brain stimulation is an approved treatment for other conditions like <a href="https://www.ninds.nih.gov/about-ninds/impact/ninds-contributions-approved-therapies/deep-brain-stimulation-dbs-treatment-parkinsons-disease-and-other-movement-disorders">Parkinson’s disease</a>, it remains an experimental therapy for treatment-resistant depression. While the results from small experimental studies have been positive, they have not been successfully replicated in <a href="https://doi.org/10.4088/jcp.21m13973">large-scale, randomized clinical trials</a> necessary for approval from the U.S. Food and Drug Administration.</p>
<p>Finding an objective biomarker that measures recovery in depression has the potential to improve treatment decisions. For example, one patient in our study had a relapse after several months of remission. Were a biomarker available at the time, the clinical team would have had warning that the patient was relapsing weeks before standard symptom surveys showed that anything was wrong. Such a tool could help clinicians intervene before a relapse becomes an emergency.</p><img src="https://counter.theconversation.com/content/213647/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Rozell serves on the scientific advisory board and owns shares in Motif Neurotech, Inc. and is a listed inventor on intellectual property related to this work. He receives funding from NIH, NSF and the James. S. McDonnell Foundation. Hs is affiliated with the Georgia Institute of Technology, serves on the board of directors at Neuromatch, Inc., and serves on the advisory council of the Institute of Neuroethics. </span></em></p><p class="fine-print"><em><span>Sankaraleengam Alagapan receives funding from the National Institute of Health. He is affiliated with the Georgia Institute of Technology. He is a listed inventor on intellectual property related to this work.</span></em></p>Deep brain stimulation can help some people with treatment-resistant depression feel better, but it can be unclear whether a bout of low mood is a relapse or a bad day.Christopher Rozell, Professor of Electrical and Computer Engineering, Georgia Institute of TechnologySankaraleengam Alagapan, Research Scientist in Electrical and Computer Engineering, Georgia Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1861092022-09-28T12:32:58Z2022-09-28T12:32:58ZDeep brain stimulation can be life-altering for OCD sufferers when other treatment options fall short<figure><img src="https://images.theconversation.com/files/486344/original/file-20220923-8064-5j7otz.jpg?ixlib=rb-1.1.0&rect=1161%2C23%2C6826%2C4467&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deep brain stimulation relies on thin electrodes implanted deep in the brain that deliver electrical currents. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/artificial-intelligence-digital-concept-royalty-free-image/1283240410">Olemedia/E+ via Getty Images</a></span></figcaption></figure><p>Imagine growing up tormented by fears and life-consuming rituals that make no sense to you or those around you. Then imagine the shame of being told by mental health providers that, because you understand that your behaviors are illogical but keep doing them anyway, you must want to stay sick. </p>
<p>One of my patients, Moksha Patel, who is a doctor himself, endured this from childhood until his early 30s. In September 2021, Patel underwent deep brain stimulation surgery, a rare neurosurgical procedure that can be used for severe obsessive-compulsive disorder, or OCD, when it has been resistant to less invasive treatments. </p>
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<p>Patel has consented to this publication of his medical information. He <a href="https://news.cuanschutz.edu/news-stories/ocd-ruled-moksha-patels-life-until-a-rare-surgical-procedure-changed-everything">shares his story publicly</a> to combat stigma and to provide hope for other sufferers that relief is possible. </p>
<p>The term OCD is thrown around casually, often by someone joking about how organized they are: “I’m so OCD.” But true <a href="https://doi.org/10.1176/ajp.153.6.783">obsessive-compulsive disorder is debilitating</a> and leads to <a href="https://doi.org/10.1007/s40263-013-0056-z">significant suffering</a>. </p>
<p>I <a href="https://som.ucdenver.edu/Profiles/Faculty/Profile/13845">lead a team</a> that treats people with OCD using <a href="https://medschool.cuanschutz.edu/psychiatry/PatientCare/obsessive-compulsive-disorder-program">evidence-based approaches</a>. I am also co-director of the <a href="https://medschool.cuanschutz.edu/psychiatry/PatientCare/obsessive-compulsive-disorder-program/reclaim-deep-brain-stimulation-therapy-for-ocd">OCD surgical program</a> at the University of Colorado, Anschutz campus, and UC Health, a nonprofit health care system in Colorado. </p>
<p>Our surgical program is one of the few academic centers in the U.S. that offer deep brain stimulation for the treatment of OCD. My experience and research have given me insight into how a rare procedure can be used in <a href="https://doi.org/10.3389/fpsyt.2021.568932">real-world settings</a> to provide relief to those who suffer from OCD when other less invasive treatments have not been successful.</p>
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<figcaption><span class="caption">Dr. Sabine Wilhelm of Mass General Hospital answers the most commonly searched questions about obsessive-compulsive disorder.</span></figcaption>
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<h2>What does OCD feel like for a sufferer?</h2>
<p>A brain with OCD is primed to detect any signs of potential danger. Many people with OCD <a href="https://iocdf.org/blog/2019/04/22/what-it-feels-like-to-live-with-ocd/">wake up every day with a sense of dread</a> and an expectation of bad things happening. Daily life is overshadowed by ever-present guilt, shame, fear and doubt. As a result, they carry out compulsive and repetitive activities to attempt to forestall disaster and manage the painful emotions. </p>
<p>OCD fears most often involve the things and people that matter the most to the sufferer, such as their values, loved ones or purpose in life. For example, someone who values kindness and compassion might fear that they will offend, betray or somehow hurt the people they care about.</p>
<p>Sometimes what is hardest for someone who suffers with OCD is a recognition that the fears and behaviors are illogical – insight that provides no relief. </p>
<p>And because other people usually don’t understand, those with OCD do their best to hide their illness so they won’t be judged as ridiculous or “crazy,” which often leads to long delays in diagnosis and treatment. This is a painful and lonely life for the approximately <a href="https://www.psychiatrist.com/jcp/ocd/ocd-prevalence-and-gender/">1%-2% of the world population with OCD</a>. </p>
<h2>Current OCD treatment options</h2>
<p>The best initial treatment for OCD is a type of mental health therapy called <a href="https://www.erp4ocd.com/">exposure and response prevention</a>. During these sessions, OCD sufferers are supported in gradually confronting their fears while also limiting the behaviors they have come to associate with providing safety. </p>
<p>For instance, someone with a fear of harming others might start by sitting near a butter knife and work their way up to holding a sharper knife to their therapist’s throat. They either learn that their fear does not play out, or – in the case of fears that cannot be disproved – that they can tolerate their anxiety or distress and move forward even in the absence of certainty. </p>
<p>The primary <a href="https://iocdf.org/about-ocd/ocd-treatment/meds/">medications used to treat OCD</a> are <a href="https://www.fda.gov/drugs/information-drug-class/selective-serotonin-reuptake-inhibitors-ssris-information">serotonin reuptake inhibitors, or SRIs/SSRIs</a>, which are commonly prescribed for treatment of depression and anxiety. But when used for OCD, these medications are typically prescribed at much higher dosages.</p>
<p>Unfortunately, <a href="https://doi.org/10.4088/jcp.v67n0214">OCD is a chronic condition</a> for most; studies show that only 65% of people with OCD respond to standard treatment, which is a combination of therapy and medication, and only about 35% recover completely. About 10% of individuals with OCD <a href="https://doi.org/10.1186/s12888-014-0214-y">remain severely impaired</a>, regardless of how intensively they are treated.</p>
<h2>The potential of deep brain stimulation</h2>
<p>For this small group of individuals with severe and persistent OCD, deep brain stimulation – a procedure that <a href="http://dx.doi.org/10.5498/wjp.v11.i9.659">fewer than 400 people</a> with OCD have undergone worldwide – provides hope. </p>
<p>Patel, an internal medicine doctor, first came to my office in 2019. He is one of 13 patients I’ve worked with to provide deep brain stimulation for OCD and other psychiatric illnesses.</p>
<p>He has suffered with OCD since the age of 4 or 5, with obsessive fears about germs, contamination and social interactions, among other things. He learned to function and succeed by shaping his life around his rituals – for example, by not consuming water or food at work so that he would not need to use public restrooms. </p>
<p>Patel, like many others with OCD, is conscientious, thorough and compassionate, traits that contribute to his success as a physician. However, before deep brain stimulation, most of his life outside of work was occupied by painful, consuming rituals. These included scrubbing himself with harsh chemicals for hours. </p>
<p>He had explored every treatment he could find, seeing 13 mental health providers since high school and participating in years of exposure therapy. He had tried at least 15 different medications, all with little benefit. Then he learned that deep brain stimulation was available at the hospital where we both work. </p>
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<a href="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A neurosurgeon prepares his patient, who is lying down, for deep brain stimulation surgery." src="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486645/original/file-20220926-8644-62d70o.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Dr. Steven Ojemann, a CU Anschutz/UCHealth neurosurgeon, preparing Dr. Moksha Patel for deep brain stimulation surgery on Sept. 15, 2021.</span>
<span class="attribution"><span class="source">Radhika Patel</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<h2>How deep brain stimulation works</h2>
<p>Deep brain stimulation requires a neurosurgical procedure to place thin electrodes into deep structures of the brain, specifically a region known as the <a href="https://doi.org/10.1016/j.wneu.2019.01.254">ventral capsule/ventral striatum</a>. These <a href="https://www.youtube.com/watch?v=wYLJGuUt4iI">electrodes deliver electrical currents to the brain</a>. The current is produced by pulse generators in the chest that look much like cardiac pacemakers. They are connected to the electrodes in the brain by wires tunneled beneath the skin.</p>
<p>We researchers do not yet have a precise understanding of exactly how deep brain stimulation works, but we do know that it <a href="https://doi.org/10.1038/nn.3344">normalizes the communication</a> between parts of the brain responsible for taking in information and those responsible for acting on this information. These areas are hyperconnected in people with OCD, leading to a reduced ability to make thoughtful, value-driven decisions and an over-reliance on <a href="https://doi.org/10.1038/s41380-020-01007-8">reflexive or habitual behaviors</a>. And the changes induced by deep brain stimulation correlate with a reduction in OCD symptoms.</p>
<p>This type of neurostimulation is most commonly used to manage symptoms of <a href="https://www.nia.nih.gov/health/parkinsons-disease">Parkinson’s disease</a>, a movement disorder that leads to tremors and body rigidity. OCD is the only psychiatric disorder that currently has approval from the Food and Drug Administration for deep brain stimulation treatment. But deep brain stimulation <a href="https://doi.org/10.3171/2015.3.FOCUS1546">has been investigated</a> in <a href="https://doi.org/10.1016/j.neuroimage.2020.117515">other conditions, including major depression</a>, Tourette syndrome, schizophrenia, substance use disorders, post-traumatic stress disorder and eating disorders. </p>
<p>Deep brain stimulation is a procedure of last resort for patients with OCD. Because of the invasive nature of brain surgery and the potential for <a href="https://doi.org/10.1016/j.neubiorev.2020.01.007">serious adverse effects</a> such as infection or hemorrhage, individuals need to try standard, less invasive treatments first and meet the <a href="https://doi.org/10.3389/fpsyt.2021.706181">criteria for severe and persistent OCD</a>, which have been established based on OCD and brain stimulation research. </p>
<p>But for those who do undergo the procedure for OCD treatment and receive ongoing stimulation, <a href="https://doi.org/10.1038/mp.2008.55">up to 70%</a> have a <a href="http://dx.doi.org/10.5498/wjp.v11.i9.659">good long-term response</a>. “Good” is considered to be a 35% reduction in OCD symptoms based on a <a href="https://doi.org/10.1001/archpsyc.1989.01810110048007">standardized scale for obsessive-compulsive behavior</a> that experts in our field rely on. </p>
<p>This, for example, could mean that someone goes from spending more than eight hours per day on OCD behaviors and not leaving the house at all to spending four hours per day and being able to go to school with significant support. Such progress is remarkable, given how ill these individuals are.</p>
<h2>Barriers and stigma</h2>
<p>There aren’t very many treatment centers anywhere in the world, so patients who need this procedure may have trouble getting to one. Additionally, as our team has described in published research, getting insurance coverage for the procedure is <a href="https://doi.org/10.1038/s41591-022-01879-z">often time-consuming</a> and <a href="https://doi.org/10.3389/fsurg.2021.642503">sometimes prohibitive</a>. </p>
<p>Another barrier is the stigma associated with brain surgery for psychiatric illness. The reasons behind this stigma are complicated, and some factors have historical roots. In the early to mid-1900s, destructive, dangerous and <a href="https://nihrecord.nih.gov/2019/11/01/when-faces-made-case-lobotomy">not very effective brain surgeries such as lobotomies</a> were performed routinely for mental illness without regulation, ethical guidelines or regulatory oversight.</p>
<h2>A way forward</h2>
<p>After I worked with Patel for about a year, including trials of six additional medications and ongoing exposure and response prevention therapy, his symptoms remained severe. I recommended he begin the extensive evaluation process for deep brain stimulation surgery.</p>
<p>Three weeks after his surgery, I turned on electrical stimulation, and we began the intensive programming procedure to determine the optimal settings. This process takes several hours a day over the course of several days, with fine-tuning in the following weeks and months. </p>
<p>Patel recalls that early on, during programming, he experienced a roller coaster of feelings, shifting between “giddiness and sadness.” Most individuals experience gradual improvement over the course of six to 12 months. At first, they feel happier and less anxious, and weeks to months later they experience a decrease in OCD symptoms. </p>
<p>Most commonly, stimulation is constant, 24 hours a day. But the treating psychiatrist may give the patient the ability to turn it off, such as at night if the stimulation causes problems with sleep.</p>
<p>Since surgery, Patel has continued weekly therapy sessions. Research shows that <a href="https://doi.org/10.1017/s0033291714000956">deep brain stimulation is most effective</a> when people continue to engage in exposure and response prevention therapy. Electricity alone will not break years of hard-wired habits, but it can be the catalyst that allows for new neural pathways to be established and new behaviors to be learned. Likewise, most individuals need to continue medication. Though the effects of deep brain stimulation can be remarkable, it is not a cure. </p>
<p>Patel has experienced a 54% reduction in his OCD, according to the <a href="https://doi.org/10.1001/archpsyc.1989.01810110048007">standardized scale</a>. This means that his symptoms decreased from the “extreme OCD” to the “moderate” range. </p>
<p>He can now eat and drink at work and use public restrooms. He has more social connections, seeks less reassurance and spends less time decontaminating himself and his belongings. While sleep was previously his only respite, Patel is now intentional about finding meaningful activities to fill the hours that are no longer occupied by rituals. </p>
<p>Most importantly, he is beginning to feel hopeful that it just might be possible to build a life driven by purpose and intention, rather than by fear.</p><img src="https://counter.theconversation.com/content/186109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Davis consults for Medtronic, Inc. She receives funding from the NIH . </span></em></p>This rare procedure is offered by only a handful of centers in the US and around the world and should be used only when less invasive treatment options for OCD have been tried.Rachel A. Davis, Associate Professor of Psychiatry and Neurosurgery, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1900392022-09-09T09:47:35Z2022-09-09T09:47:35ZMonkeypox may cause neurological damage, including inflammation of the brain – new study<p>Monkeypox’s effect on the skin – the disfiguring rashes – and the flu-like symptoms have been well described, but few have investigated the neurological and psychiatric problems the virus might cause. </p>
<p>There are historic reports of neurological complications in <a href="https://www.nejm.org/doi/full/10.1056/nejmra020025">people infected with the related smallpox virus</a> and in <a href="https://jamanetwork.com/journals/jama/fullarticle/201968">people vaccinated against smallpox</a>, which contains the related <a href="https://theconversation.com/monkeypox-some-countries-are-protecting-contacts-with-the-smallpox-vaccine-which-uses-humanitys-only-domesticated-virus-183551">vaccinia virus</a>. So my colleagues and I wanted to know whether monkeypox causes similar problems.</p>
<p>We looked at all the evidence from before the current monkeypox pandemic of neurological or psychiatric problems in people with a monkeypox infection. The results are <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00374-1/fulltext">published in the journal eClinicalMedicine</a>.</p>
<p>A small but noticeable proportion of people (2% to 3%) with monkeypox became very unwell and developed serious neurological problems, including seizure and encephalitis (inflammation of the brain that can cause long-term disability). We also found that confusion occurred in a similar number of people. It’s important to note, though, that these figures are based on a few studies with few participants.</p>
<p>Besides the severe and rare brain problems, we found evidence of a broader group of people with monkeypox who had more common neurological symptoms including headache, muscle ache and fatigue. From looking at the studies, it was unclear how severe these symptoms were and how long they lasted. It was also unclear how many people with monkeypox had psychiatric problems - such as anxiety and depression - as few studies looked into it. Of those that did, low mood was frequently reported. </p>
<p>We don’t know what factors are driving these neuropsychiatric problems in people with monkeypox. We would want to know whether the strain of monkeypox virus and the severity of infection affects these problems. However, we were unable to look into this properly because it was not consistently reported in studies. </p>
<p>Although we found that people with monkeypox infection can have neuropsychiatric symptoms, the studies in our paper cannot say with any certainty that it’s the virus causing these problems. Future research exploring this will need to follow up people with no neuropsychiatric conditions before becoming infected with monkeypox. </p>
<p>If it is the virus that is causing these problems, the biological processes underlying it are unclear and could involve the virus directly entering the nervous system, a reaction by the immune system or something else entirely. It’s also possible that the stigma people experience from monkeypox infection and the effect of disfiguring skin rashes could contribute to psychological distress such as low mood. </p>
<p>Our research focused on the evidence before the current monkeypox pandemic. Most of the data was from west Africa and in people hospitalised with an infection, whereas the current pandemic has predominantly affected North America and western Europe. It is unclear to what degree the symptoms of previous outbreaks will mirror what we are seeing now. </p>
<h2>Backed by other recent studies</h2>
<p>Important research has come out since we finished our paper. A study in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">New England Journal of Medicine</a> included over 500 people with monkeypox from 16 countries in the current outbreak. Although no cases of encephalitis or seizure were reported, headache and fatigue were found in more than a quarter of people infected with monkeypox and low mood in up to one in ten people. </p>
<p>However, there have been <a href="https://cdn.who.int/media/docs/default-source/blue-print/isabel-jado_case-control-studies_who-monkeypox-vaccine-research_2aug2022.pdf?sfvrsn=d81df2d0_3">two recently reported cases</a> of monkeypox-confirmed encephalitis in Spain. Further surveillance is needed to determine the true extent of more serious problems like encephalitis and seizure. </p>
<p>The monkeypox outbreak <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">remains a global concern</a> and ongoing public health measures, including improving access to vaccination, are needed. </p>
<p>Although monkeypox mainly causes flu-like symptoms and skin problems, our latest study – and subsequent studies – show that neuropsychiatric symptoms are not uncommon. We are not expecting a tide of serious brain problems, but complications such as encephalitis and seizure may occur in a small proportion of people. We need more research to find out if these symptoms persist over time and whether they’re caused by monkeypox.</p><img src="https://counter.theconversation.com/content/190039/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Brunton Badenoch does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As with COVID, monkeypox may do more damage than initially thought. A new study looks at the evidence for neurological damage.James Brunton Badenoch, Academic Foundation Doctor, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1772442022-03-13T12:28:41Z2022-03-13T12:28:41ZWhen you eat matters: How your eating rhythms impact your mental health<figure><img src="https://images.theconversation.com/files/450784/original/file-20220308-3342-10y3ywk.jpg?ixlib=rb-1.1.0&rect=1146%2C204%2C5333%2C3390&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When the main circadian clock in the brain is out of sync with eating rhythms, it impacts the brain's ability to function fully.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Eating is an essential part of human life and it turns out that not only what we eat but when we eat can impact our brains. Irregular eating times have been shown to contribute to poor mental health, including depression and anxiety, as well as to <a href="https://dx.doi.org/10.3390%2Fnu13082775">cardio-metabolic diseases and weight gain</a>. </p>
<p>Fortunately, it is possible to <a href="https://dx.doi.org/10.1038%2Fs41398-020-0694-0">leverage our eating rhythms</a> to limit negative mood and increase mental health. As a doctoral student in the field of neuropsychiatry and a psychiatrist studying nutrition and mood disorders, our research focuses on investigating how eating rhythms impact the brain. </p>
<p>Here’s how it all works: The circadian clock system is responsible for aligning our internal processes at optimal times of day based on cues from the environment such as light or food. Humans have evolved this wiring to meet energy needs that change a lot throughout the day and night, creating a rhythmic pattern to our eating habits that follows the schedule of the sun. </p>
<p>Although the main clock manages metabolic function over the day-night cycle, our eating rhythms also impact the main clock. Digestive tissues have their own clocks and show regular oscillations in functioning over the 24-hour cycle. For example, the small intestine and liver <a href="https://dx.doi.org/10.3389%2Ffnut.2020.00018">vary throughout the day and night in terms of digestive, absorptive and metabolic capacity</a>.</p>
<p>When the main circadian clock in the brain is out of sync with eating rhythms, it impacts the brain’s ability to function fully. Even though the brain is only two per cent of our total body mass, it consumes up to 25 per cent of our energy and is particularly <a href="https://dx.doi.org/10.1016%2Fj.tins.2013.07.001">affected by changes in calorie intake</a>. This means that abnormal meal times are bound to have negative health outcomes. </p>
<h2>Food and mood</h2>
<p>Although the underlying mechanisms are still unknown, there is overlap between neural circuits governing eating and mood. Also, digestive hormones exert effects on dopamine, a neurotransmitter that plays a large role in mood, energy and pleasure. Individuals with <a href="https://dx.doi.org/10.1073%2Fpnas.1500877112">depression and bipolar disorder have abnormal dopamine levels</a>. Altered eating rhythms are thought to contribute to the poor maintenance of mood. </p>
<figure class="align-center ">
<img alt="A chalk drawing of a brain on a blackboard, with the right half of the brain filled in with healthy foods" src="https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=278&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=278&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=278&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=349&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=349&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450786/original/file-20220308-23-10zpba4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=349&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is overlap between the neural circuits governing eating and mood.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Irregular eating may even play a role in the complex underlying causes of mood disorders. For example, individuals with depression or bipolar disorder <a href="https://doi.org/10.1016/j.jpsychires.2009.08.003">exhibit disturbed internal rhythms and irregular meal times</a>, which significantly worsen mood symptoms. In addition, shift workers — who tend to have irregular eating schedules — <a href="https://dx.doi.org/10.2105%2FAJPH.2019.305278">demonstrate increased rates of depression and anxiety</a> when compared to the general population. Despite this evidence, assessing eating rhythms is not currently part of standard clinical care in most psychiatric settings. </p>
<h2>Optimizing eating rhythms</h2>
<p>So, what can be done to optimize our eating rhythms? One promising method we have encountered in our research is time-restricted eating (TRE), also known as intermittent fasting. </p>
<p>TRE involves restricting the eating window to a certain amount of time during the day, <a href="https://doi.org/10.1016/j.cmet.2016.06.001">typically four to 12 hours</a>. For example, choosing to eat all meals and snacks in a 10-hour window from 9:00 a.m. to 7:00 p.m. reflects an overnight fasting period. Evidence suggests that this method optimizes brain function, energy metabolism and the healthy signalling of metabolic hormones. </p>
<p>TRE has already been shown to <a href="https://doi.org/10.1002/jnr.24741">prevent depressive and anxiety symptoms in animal studies designed to model shift work</a>. The antidepressant effects of TRE <a href="https://dx.doi.org/10.2174%2F1570159X13666150326003852">have also been shown in humans</a>. Eating on a regular schedule is also beneficial to reduce the <a href="https://dx.doi.org/10.1038%2Fnm.3010">risk of health issues such as obesity, diabetes and cardiovascular disease</a>.</p>
<h2>Circadian rhythms in a 24-hour world</h2>
<p>We live in a 24-hour world filled with artificial light and round-the-clock access to food. That makes the effects of disturbed eating rhythms on mental health an important topic for modern life. As more research provides data assessing eating rhythms in individuals with mood disorders, incorporating eating rhythm treatment into clinical care could significantly improve patient quality of life. </p>
<p>For the general population, it is important to increase public knowledge on accessible and affordable ways to maintain healthy eating. This includes paying attention not only to the content of meals but also to eating rhythms. Aligning eating rhythms with the schedule of the sun will have lasting benefits for general well-being and may have a protective effect against mental illness.</p><img src="https://counter.theconversation.com/content/177244/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elisa Brietzke receives funding from Faculty of Health Sciences, Department of Psychiatry and Centre for Neuroscience Studies (CNS), Queen's University.</span></em></p><p class="fine-print"><em><span>Elena Koning does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Healthy eating is not just what you eat, but when you eat. Eating rhythms that are in sync with the circadian clock can benefit general well-being and may have a protective effect against mental illness.Elena Koning, PhD Student, Centre for Neuroscience Studies, Queen's University, OntarioElisa Brietzke, Professor, Department of Psychiatry, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1708632021-12-08T18:46:43Z2021-12-08T18:46:43ZJunk food and the brain: How modern diets lacking in micronutrients may contribute to angry rhetoric<figure><img src="https://images.theconversation.com/files/431386/original/file-20211110-25-1wi438n.jpg?ixlib=rb-1.1.0&rect=0%2C268%2C5190%2C3718&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research reveals links between the irritability, explosive rage and unstable moods that have grown more common in recent years, and a lack of micronutrients that are important for brain function.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Emotional, non-rational, even explosive remarks in public discourse have escalated in recent years. Politicians endure insults during <a href="https://calgaryherald.com/news/politics/braid-jansen-stuns-legislature-by-reading-out-explicit-anti-female-slurs">legislative discussions</a>; scientists receive emails and tweets containing <a href="https://doi.org/10.1126/science.acx9488">verbal abuse and threats</a>.</p>
<p>What’s going on? This escalation in angry rhetoric is <a href="https://www.sciencefocus.com/the-human-body/why-social-media-makes-us-so-angry-and-what-you-can-do-about-it/">sometimes attributed to social media</a>. But are there other influences altering communication styles?</p>
<p>As researchers in the field of nutrition and mental health, and authors of <a href="https://thebetterbrainbook.com"><em>The Better Brain</em></a>, we recognize that many in our society experience brain hunger, impairing their cognitive function and emotion regulation. </p>
<h2>Ultra-processed products</h2>
<p>Obviously, we are not deficient in macronutrients: North Americans tend to get sufficient protein, fats (though usually not the best fats) and carbohydrates (usually not the good complex carbs). But we are being cheated of micronutrients (minerals and vitamins), particularly in those whose food choices are dominated by ultra-processed products. </p>
<p>Ultra-processed products include things like soft drinks, packaged snacks, sweetened breakfast cereal and chicken nuggets. They generally contain only trivial amounts of a few micronutrients unless they are fortified, but even then, only a few at higher amounts. </p>
<figure class="align-center ">
<img alt="A plate of chicken nuggets and fries" src="https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431460/original/file-20211111-17-7h2spi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ultra-processed products contain only trivial amounts of vitamins and minerals.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Three published analyses from the 2004 Canadian Community Health Survey and the 2018 U.S. National Health and Nutrition Examination Survey revealed these sobering statistics: in Canada, in 2004, <a href="https://doi.org/10.1016/j.appet.2016.11.006">48 per cent of the caloric intake across all ages</a> came from ultra-processed products; in the United States <a href="https://doi.org/10.1001/jama.2021.10238">67 per cent of what children aged two to 19 years</a> consumed and <a href="https://doi.org/10.1093/ajcn/nqab305">57 per cent of what adults consumed</a> in 2018 were ultra-processed products.</p>
<p>Most of us are aware that dietary intake is a huge issue in physical health because diet quality is associated with chronic health conditions such as <a href="https://doi.org/10.1111/obr.13349">obesity, diabetes and cardiovascular disease</a>. The public is less aware of the impact of nutrition on brain health. </p>
<h2>Micronutrients and mental health symptoms</h2>
<p>Given that our society’s food choices have moved so strongly toward ultra-processed products, we need to learn about the substantial scientific evidence proving that micronutrient intake influences mental health symptoms, especially irritability, explosive rage and unstable mood.</p>
<p>The scientific evidence base for this statement is now vast, though it is so rarely mentioned in the media that few in the public are familiar with it. A dozen studies from countries <a href="https://doi.org/10.17269/cjph.104.3845">like Canada</a>, <a href="https://doi.org/10.1017/s1368980011001856">Spain</a>, <a href="https://doi.org/10.1017/s1368980020001548">Japan</a> <a href="https://doi.org/10.1176/appi.ajp.2009.09060881">and Australia</a> have shown that people who eat a healthy, whole foods diet have fewer symptoms of depression and anxiety than people who eat a poor diet (mostly ultra-processed products).</p>
<p>Correlational studies cannot prove that nutritional choices are the cause of mental health problems: for that we turn to some compelling prospective longitudinal studies in which people with no apparent mental health problems enter the study, are evaluated for their health and dietary patterns, and are then followed over time. Some of the results have been astonishing. </p>
<p>In a study of about <a href="https://doi.org/10.1192/bjp.bp.112.114793">89,000 people in Japan</a> with 10-15 years of followup, the suicide rate in those consuming a whole foods diet was half that of those eating less healthy diets, highlighting an important new direction not yet covered in current suicide prevention programs. </p>
<p><a href="https://doi.org/10.1542/peds.2018-3307">Here in Canada</a>, similarly powerful findings show how children’s dietary patterns, as well as following other health guidelines on exercise and screen time, predicted which children aged 10 to 11 years would be referred for diagnosis of a mental disorder in the subsequent two years. It follows that nutrition education ought to be one of the first lines of treatment for children in this situation.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Foods typical of Mediterranean style diet, including fish, grains, fruits, vegetables and beans" src="https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=770&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=770&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=770&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=968&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=968&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431461/original/file-20211111-6783-wkr3qx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=968&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A Mediterranean-style diet is typically high in whole grains, fruits, vegetables, nuts, legumes, seafood and unsaturated fats such as olive oil.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Irritability and unstable mood often characterize depression, so it’s relevant that multiple independent studies have found that teaching people with depression, who were consuming relatively poor diets, how to change to a whole foods Mediterranean-style diet resulted in significant improvements. A <a href="https://theconversation.com/what-is-the-mediterranean-diet-and-why-is-it-good-for-you-12656">Mediterranean-style diet</a> is typically high in whole grains, fruits, vegetables, nuts, legumes, seafood and unsaturated fats such as olive oil. </p>
<p>In <a href="https://doi.org/10.1186/s12916-017-0791-y">one such study</a>, about one-third of the people who changed to a whole foods diet in addition to their regular treatment found their depression to be in remission after 12 weeks. </p>
<p>The remission rate in the control group using regular treatment but no diet changes was fewer than one in 10. The whole foods diet group also reported a cost savings of about 20 per cent in their weekly food budget. This final point helps to dispel the myth that eating a diet of ultra-processed products is a way to save money. </p>
<p>Important evidence that irritability, explosive rage and unstable mood can be resolved with improved micronutrient intake comes from studies evaluating micronutrient supplements to treat <a href="https://doi.org/10.3390/nu12113394">mental health problems</a>. Most public awareness is restricted to the ill-fated search for magic bullets: <a href="https://doi.org/10.1037/0033-2909.133.5.747">studies of a single nutrient at a time</a>. That is a common way to think about causality (for problem X, you need medication Y), but that is not how our brains work. </p>
<p>To support brain metabolism, <a href="https://www.helpguide.org/harvard/vitamins-and-minerals.htm">our brains require at least 30 micronutrients</a> to ensure the production of neurotransmitters such as serotonin and dopamine, as well as breaking down and removing metabolic byproducts. Many studies of multi-nutrient treatments have found improved mood regulation and reduced irritability and explosive rage, including in placebo-controlled randomized trials of children with <a href="https://doi.org/10.1111/jcpp.12817">attention deficit hyperactivity disorder</a> and <a href="https://doi.org/10.1016/j.jaac.2021.07.005">mood dysregulation</a>.</p>
<p>The evidence is clear: a well-nourished population is better able to withstand stress. Hidden brain hunger is one modifiable factor contributing to emotional outbursts, aggression and even the loss of civility in public discourse.</p><img src="https://counter.theconversation.com/content/170863/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bonnie Kaplan receives funding from no organization currently, because she is retired. But during her career she received many grants from private foundations (donor funds) and from provincial funding competitions. Her only current affiliation is as a member of the Scientific Advisory Board of the John W. Brick Foundation.</span></em></p><p class="fine-print"><em><span>Julia J Rucklidge receives or has received research funding from Health Research Council (NZ), Waterloo Foundation, Vic Davis Memorial Trust, University of Canterbury Foundation, Canterbury Medical Research Foundation, GAMA Foundation, and the Foundation for Excellence in Mental Health Care.</span></em></p>Ultra-processed foods high in sugar, fat and empty carbs are bad for the mind as well as the body. Lack of micronutrients affects brain function and influences mood and mental health symptoms.Bonnie Kaplan, Professor Emerita, Cumming School of Medicine, University of CalgaryJulia J Rucklidge, Professor of Psychology, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/724692017-03-02T01:39:16Z2017-03-02T01:39:16Z‘Alternative facts’: A psychiatrist’s guide to twisted relationships to truth<figure><img src="https://images.theconversation.com/files/158963/original/image-20170301-5494-ru9aai.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2038%2C1512&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Does your nose grow if it's a falsehood, not a lie?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/5477733246">Thomas Hawk</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>The phrase “<a href="http://www.cnn.com/2017/01/22/politics/kellyanne-conway-alternative-facts/">alternative facts</a>” has recently made the news in a political context, but psychiatrists like me are already intimately acquainted with the concept – indeed, we hear various forms of alternate reality expressed almost every day. </p>
<p>All of us need to parse perceived from actual reality every day, in nearly every aspect of our lives. So how can we sort out claims and beliefs that strike most people as odd, unfounded, fantastical or just plain delusional?</p>
<h2>Untruths aren’t always lies</h2>
<p>First, we need to make a distinction often emphasized by ethicists and philosophers: that between a lie and a falsehood. Thus, someone who <a href="https://plato.stanford.edu/entries/lying-definition/#TraDefLyi">deliberately misrepresents what he or she knows to be true</a> is lying – typically, to secure some personal advantage. In contrast, someone who voices a mistaken claim without any intent to deceive is not lying. That person may simply be unaware of the facts, or may refuse to believe the best available evidence. Rather than lying, he’s stating a falsehood. </p>
<p>Some people who voice falsehoods appear incapable of distinguishing real from unreal, or truth from fiction, yet are sincerely convinced their worldview is absolutely correct. And this is our entree into the psychiatric literature.</p>
<p>In clinical psychiatry, we see patients with a broad spectrum of ideas that many people would find eccentric, exaggerated or blatantly at odds with reality. The clinician’s job is, first, to listen empathically and try to understand these beliefs from the patient’s point of view, carefully taking into account the person’s cultural, ethnic and religious background.</p>
<p>Sometimes, clinicians can be wildly mistaken in their first impressions. A colleague of mine once described a severely agitated patient who was hospitalized because he insisted he was being stalked and harassed by the FBI. A few days into his hospitalization, FBI agents showed up on the unit to arrest the patient. As the old joke goes, just because you’re paranoid doesn’t mean they aren’t after you!</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159026/original/image-20170301-5540-1ka8qw3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As strongly as she believes, it doesn’t make it true.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-telling-her-friends-story-207125380">Talking image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>When what you believe is wrong</h2>
<p>We can think of distortions of reality as falling along a continuum, ranging from mild to severe, based on how rigidly the belief is held and how impervious it is to factual information. On the milder end, we have <a href="http://professionaltrainingresourcesinc.com/wp-content/uploads/Paranoid-Delusions-vs-Paranoid-Ideas-vs-Overvalued-Ideas.pdf">what psychiatrists call over-valued ideas</a>. These are very strongly held convictions that are at odds with what most people in the person’s culture believe, but which are not bizarre, incomprehensible or patently impossible. A passionately held belief that vaccinations cause autism might qualify as an over-valued idea: it’s not scientifically correct, but it’s not utterly beyond the realm of possibility.</p>
<p>On the <a href="http://doi.org/10.4103/0972-6748.57851">severe end of the continuum are delusions</a>. These are strongly held, completely inflexible beliefs that are not altered at all by factual information, and which are clearly false or impossible. Importantly, delusions are not explained by the person’s culture, religious beliefs or ethnicity. A patient who inflexibly believes that Vladimir Putin has personally implanted an electrode in his brain in order to control his thoughts would qualify as delusional. When the patient expresses this belief, he or she is not lying or trying to deceive the listener. It is a sincerely held belief, but still a falsehood.</p>
<p>Falsehoods of various kinds can be voiced by people with various neuropsychiatric disorders, but also by those who are perfectly “normal.” Within the range of normal falsehood are so-called <a href="http://doi.org/10.1080/09658211.2015.1010709">false memories</a>, which many of us experience quite often. For example, you are absolutely certain you sent that check to the power company, but in fact, you never did.</p>
<p>As social scientist Julia Shaw observes, false memories “<a href="https://blogs.scientificamerican.com/mind-guest-blog/how-false-memory-changes-what-happened-yesterday/">have the same properties as any other memories</a>, and are indistinguishable from memories of events that actually happened.” So when you insist to your spouse, “Of course I paid that electric bill!” you’re not lying – you are merely deceived by your own brain.</p>
<p>A much more serious type of false memory involves a <a href="http://www.memorylossonline.com/glossary/confabulation.html">process called confabulation</a>: the spontaneous production of false memories, often of a very detailed nature. Some confabulated memories are mundane; others, quite bizarre. For example, the person may insist – and sincerely believe – that he had eggs Benedict at the Ritz for breakfast, even though this clearly wasn’t the case. Or, the person may insist she was abducted by terrorists and present a fairly elaborate account of the (fictional) ordeal. <a href="http://www.psychiatrictimes.com/cognitive-disorders/confabulation-bridge-between-neurology-and-psychiatry">Confabulation</a> is usually seen in the context of severe brain damage, such as may follow a stroke or the rupture of a blood vessel in the brain.</p>
<h2>Lying as a default</h2>
<p>Finally, there is falsification that many people would call pathological lying, and which goes by the extravagant scientific name of pseudologia fantastica (PF). Writing in the Psychiatric Annals, Drs. Rama Rao Gogeneni and Thomas Newmark <a href="http://doi.org/10.3928/00485713-20141003-02">list the following features of PF</a>:</p>
<ul>
<li>A marked tendency to lie, often as a defensive attempt to avoid consequences. The person may experience a “high” from this imaginative story-telling.</li>
<li>The lies are quite dazzling or fantastical, though they may contain truthful elements. Often, the lies may capture considerable public attention.</li>
<li>The lies tend to present the person in a positive light, and may be an expression of an underlying character trait, such as pathological narcissism. However, the lies in PF usually go beyond the more “believable” stories of persons with narcissistic traits.</li>
</ul>
<p>Although the precise cause or causes of PF are not known, some data suggest <a href="http://doi.org/10.1192/bjp.bp.106.025056">abnormalities in the white matter of the brain</a> – bundles of nerve fibers surrounded by an insulating sheath called myelin. On the other hand, the psychoanalyst Helene Deutsch argued that <a href="http://search.proquest.com/openview/8c8791514f5a1ecfa6e4a5c1013372c9/1?pq-origsite=gscholar&cbl=1820984">PF stems from psychological factors</a>, such as the need to enhance one’s self-esteem, secure the admiration of others or to portray oneself as either a hero or a victim.</p>
<h2>Who cares about facts anyway?</h2>
<p>Of course, all of this presumes something like a consensus on what constitutes “reality” and “facts” and that most people have an interest in establishing the truth. But this presumption is looking increasingly doubtful, in the midst of what has come to be known as the “<a href="https://theconversation.com/in-a-post-truth-election-clicks-trump-facts-67274">post-truth era</a>.” Charles Lewis, the founder of the Center for Public Integrity, described ours as a period in which “up is down and down is up and everything is in question and <a href="https://www.nytimes.com/2017/01/28/us/politics/donald-trump-truth.html?_r=0">nothing is real</a>.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/158976/original/image-20170301-5507-ug5g29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Are lies becoming our rose-colored glasses?</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/yamagatacamille/4124052288">Christian Bucad</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Even more worrisome, the general public seems to have an appetite for falsehood. As writer Adam Kirsch recently argued, “<a href="https://www.nytimes.com/2017/01/15/books/lie-to-me-fiction-in-the-post-truth-era.html?_r=0">more and more, people seem to want to be lied to</a>.” The lie, Kirsch argues, is seductive: “It allows the liar and his audience to cooperate in changing the nature of reality itself, in a way that can appear almost magical.”</p>
<p>And when this magical transformation of reality occurs, whether in a political or scientific context, it becomes <a href="https://theconversation.com/unbelievable-news-read-it-again-and-you-might-think-its-true-69602">very difficult to reverse</a>. As the writer Jonathan Swift put it, “<a href="http://quoteinvestigator.com/2014/07/13/truth/">Falsehood flies, and the Truth comes limping after it</a>.”</p>
<p>Psychiatrists are not in a position to comment on the mental health of public figures they have not personally evaluated or on the nature of falsehoods sometimes voiced by our political leaders. Indeed, the “<a href="http://www.psychiatrictimes.com/blogs/deconstructing-and-reconstructing-goldwater-rule">Goldwater Rule</a>” prohibits us from doing so. Nevertheless, psychiatrists are keenly aware of the all-too-human need to avoid or distort unpleasant truths. Many would likely nod in agreement with an observation often attributed to the psychoanalyst Carl Jung: “<a href="http://www.azquotes.com/quote/675269">People cannot stand too much reality</a>.”</p><img src="https://counter.theconversation.com/content/72469/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald W. Pies does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Alternate realities don’t just exist in politics – and not all falsehoods are lies. Distortions of the truth can range from a normal part of human nature to pathological.Ronald W. Pies, Professor of Psychiatry, Lecturer on Bioethics & Humanities at SUNY Upstate Medical University; and Clinical Professor of Psychiatry, Tufts University School of Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/275912014-06-10T20:28:53Z2014-06-10T20:28:53ZLooking for psychopaths in all the wrong places: fMRI in court<figure><img src="https://images.theconversation.com/files/50677/original/sw9jzpdw-1402381846.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People are becoming more likely to believe that high-tech visualising techniques might allow us to see psychopathy in the actual physiology of the brain.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jetheriot/6186786217/in/photolist-aqGTZT-niwG-sUk8Y-5kpAF6-6SCgyS-2ZKyJ-88vUCB-7A2f5q-96kggg-5DFXnV-4J6pL9-5uFETL-7qPG4L-kjAshW-5vuQhg-3MYT-5U2AQc-e4CcRp-3MZj-8v8DYZ-7zQwgc-aXr9yn-7iG2pk-4PTLMq-5Rjfht-5TMrYz-5Mchw8-5G4EHt-5MxeE7-5GsB5B-36fL9x-5yxm2W-5Nz4pi-4rdZ9E-7si8jt-ShC9j-7N5Pot-61DQLB-4wVAX1-kWfuq-4KH9B2-dLSKTQ-7x6RJG-fzT9Xx-9Xsr6X-6oi5aB-bPbME2-4wjQDd-tmJ6c-5yiug4">JE Theriot/Flickr (resized)</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>In the latest instalment of our series <strong><a href="https://theconversation.com/topics/biology-and-blame">Biology and Blame</a></strong> Micol Seigel poses some important questions about the assumptions behind the legal use of fMRI.</em></p>
<hr>
<p>Of the current uses of psychiatry in legal settings, the claim that psychopaths can be identified through <a href="https://theconversation.com/the-science-of-medical-imaging-magnetic-resonance-imaging-mri-15030">functional magnetic resonance imaging</a> (fMRI) is among the most worrisome. </p>
<p>Psychiatrists who make this claim present their polychrome powerpoints, which, to the rest of us, look like Jackson Pollock in a sunshiney mood, and point to this or <a href="https://theconversation.com/adventures-in-blobology-20-years-of-fmri-brain-scanning-4095">that stripe or blip as proof</a> of a physiological predisposition to carry out dastardly deeds.</p>
<p>No matter that psychopathy is only glancingly referred to in the American Psychiatric Association’s <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual of Mental Disorders</a>. (Rumours that the fifth edition, which came out earlier this year, would embrace the terminology explicitly, turn out to have been exaggerated.) </p>
<p>And no matter that the interpretation of such images are in a stage we might generously term “developmental.”</p>
<h2>Two broken tools equal?</h2>
<p>The scientists offering fMRI images admit their data is unconvincing on its own. Their solution is to cross the scans with results from a diagnostic tool based on personal interviews using the <a href="http://en.wikipedia.org/wiki/Hare_Psychopathy_Checklist">Psychopathy Check List-Revised</a>.</p>
<p>As an analytic instrument, the <a href="http://www.jonronson.com/psycho.html">Check List is not much better</a> than the brain scan. It suffers from a lack of specificity, tabulating a series of rather common characteristics – egocentricity, lack of realistic long-term goals, manipulation, dishonesty, impulsivity, grandiose self-righteousness, narcissism, dependence, irresponsibility, bullying, boredom, and promiscuity. </p>
<p>The blurriness of these profiling points can reveal them everywhere or nowhere.</p>
<p>So, take one inconclusive diagnostic test, cross it with another inconclusive diagnostic test, and … honest science would agree you have nothing at all. </p>
<p>As <a href="http://www.jstor.org/discover/10.2307/25619824?uid=3737536&uid=2&uid=4&sid=21104133560837">one group of researchers puts it</a>:</p>
<blockquote>
<p>the medical and psychological understanding of psychopathy itself is an empty vessel, a characterization of behaviors without stable symptoms, a disease without a cause.</p>
</blockquote>
<p>Yet the champions of fMRI diagnosis continue to forge ahead, and in an era in which neuroscientific explanations are offered <a href="http://www.nytimes.com/2012/11/25/opinion/sunday/neuroscience-under-attack.html">for every arena of human experience</a> (success in business, for instance, political leanings, and sexuality), their arguments are gaining ground. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Psychopathy researchers assume people in prison did heinous things and that most heinous things land their agents in prison.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/10490113913">Thomas Hawk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>People are more and more likely to believe that psychopathy is a disorder inscribed upon the body. And that high-tech visualising techniques might allow us to see psychopathy in the actual physiology of the brain.</p>
<h2>An alarming similarity</h2>
<p>To a historian such as myself, this claim sends off little alarm bells, recalling 19th-century criminal anthropologists such as Italian legal scholar <a href="http://en.wikipedia.org/wiki/Cesare_Lombroso">Cesare Lombroso</a>, who conducted research in prisons and mental asylums to determine the physical characteristics of criminal types. Mapping cranial shapes and sizes, he claimed to find congenital, hereditary, and unavoidable evidence of criminality.</p>
<p>Lombroso has long been in ill-repute thanks to the overly-biological focus of his assumptions and the circularity of his research design: he studied prisoners to draw conclusions about crime. </p>
<p>So even if there had been clear patterns of bumps and bones of the skull, his science could not determine whether they were evidence of criminal types, or traits of the poor and working people in the district of the jail — or even qualities acquired inside, as adaptations to imprisonment itself.</p>
<p>Interestingly, the problem of research location is something modern psychopathy research shares with its 19th-century precedents: proponents of psychopathy as a coherent diagnosis have all researched in prisons or focus on incarcerated subjects. </p>
<p>This is a methodological misstep, to put it mildly. Researchers assume psychopaths are concentrated in prisons, run experiments in prisons, and then conclude that psychopaths are concentrated in prisons. </p>
<h2>A tautological definition</h2>
<p>Indeed, <a href="http://www.newyorker.com/reporting/2008/11/10/081110fa_fact_seabrook?currentPage=all">one of the most-cited definitions</a> of psychopathy is actually:</p>
<blockquote>
<p>the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population… </p>
</blockquote>
<p>This is what logicians call a tautology – a circular proof, a statement that substitutes premise for conclusion.</p>
<p>Again, some scientists recognise this problem. <a href="http://www.hare.org/scales/pclr.html">Robert Hare</a>, the author of the famous checklist, for example, wrote a book called <a href="http://www.snakesinsuits.com/">Snakes in Suits</a> about psychopaths in corporate boardrooms. But many researchers continue merrily to scan those ever-available brains behind bars.</p>
<p>Using the prison as site for research, psychopathy researchers embrace and ignore one overwhelmingly distracting, toxic assumption: that the criminal justice system works. </p>
<p>Their research assumes people in prison did heinous things (that they are guilty) and that most heinous things land their agents in prison (that the balance of miscreants are caught). </p>
<p>What if prisons actually mainly house the poor, the mentally ill, the addicted, and over-policed black and brown youth? What if the majority of prisoners is in for crimes of poverty or as casualties of the drug war – or both? </p>
<p>If the truly evil are not in prison, why is neuropsychiatry looking for them there? And can we trust its conclusions in a court of law?</p>
<p><br></p>
<p><em>This is the fourth article in our series <strong><a href="https://theconversation.com/topics/biology-and-blame">Biology and Blame</a></strong>. Click on the links below to read other pieces:</em></p>
<p><strong>Part one – <a href="https://theconversation.com/genes-made-me-do-it-genetics-responsibility-and-criminal-law-27395">Genes made me do it: genetics, responsibility and criminal law</a></strong></p>
<p><strong>Part two – <a href="https://theconversation.com/irresponsible-brains-the-role-of-consciousness-in-guilt-27432">Irresponsible brains? The role of consciousness in guilt</a></strong></p>
<p><strong>Part three - <a href="https://theconversation.com/psychiatrys-fight-for-a-place-in-defining-criminal-responsibility-27514">Psychiatry’s fight for a place in defining criminal responsibility</a></strong></p>
<p><strong>Part five - <a href="https://theconversation.com/why-shouldnt-addiction-be-a-defence-to-low-level-crime-27520">Why shouldn’t addiction be a defence to low-level crime?</a></strong></p>
<p><strong>Part six – <a href="https://theconversation.com/natural-born-killers-brain-shape-behaviour-and-the-history-of-phrenology-27518">Natural born killers: brain shape, behaviour and the history of phrenology</a></strong></p>
<p><strong>Part seven - <a href="https://theconversation.com/put-down-the-smart-drugs-cognitive-enhancement-is-ethically-risky-business-27463">Put down the smart drugs – cognitive enhancement is ethically risky business</a></strong></p><img src="https://counter.theconversation.com/content/27591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Micol is a member of Decarcerate Monroe County, a local prison activist group, and the national grassroots abolitionist organization Critical Resistance.</span></em></p>In the latest instalment of our series Biology and Blame Micol Seigel poses some important questions about the assumptions behind the legal use of fMRI. Of the current uses of psychiatry in legal settings…Micol Seigel, Associate Professor in American Studies & History, IUPUILicensed as Creative Commons – attribution, no derivatives.