iPad...iBrain. What's The Difference?

Well, I finally ordered my iPad. It should arrive in about 4 weeks, hopefully in time for an upcoming trip to California, since it would be easier to take than my laptop. I can't leave home anymore without my iPhone and it’s hard to travel anywhere without my laptop. 

We’ve all become dependent on our computers--in all of their various forms. Microchips are everywhere. They’re in our washing machines, our ovens, and our cars--not to mention our Blackberry’s and iPhones. In fact, the average cell phone today is one million times smaller, one million times cheaper, and one thousand times more powerful than the most advanced computer at MIT 40 years ago.

In many ways, computers are extensions of our brains. They allow us to transcend the limits of our memory in much the same way that automobiles and airplanes allow us to transcend our ability to get from place to place. They allow us to transcend our ability to gather information about the world around us and share that information with other people. 

The same can be said about the telephone and television but there is one crucial difference: using a computer to gather information, store information, retrieve information, and communicate information, actually re-wires the brain.

Functional MRI studies, for example, have demonstrated stable and long-lasting changes in circuits of the frontal cortex as a result of performing Google searches or playing video games. In fact, virtual reality video games are used by the military to help soldiers sharpen their focus, shorten reaction time, and improve hand-eye coordination in order to improve their combat ability. These changes in behavior are the result of changes in brain functioning and these changes in brain functioning are the result of changes in brain circuitry which may become permanent.

UCLA neuroscience professor, Dr. Gary Small, explores these and other issues in his book iBrain. He points out the many ways in which text messaging and other social media alter not only the way in which information is exchanged, but also the way in which basic elements of communication, such as posture, gesture, voice tone, and facial expression are eliminated or fundamentally altered in some way.


When I talked with my 20 year old son about this a couple of weeks ago, he knew exactly what I meant and said, “Yeah, there’s no question about it. My generation has a totally different way of communicating and interacting.”


This phenomenon, in which human interaction with computers causes stable and long-lasting changes in brain circuitry, has profound implications. This kind of human-computer interaction is already the norm for a whole generation and is rapidly changing  not only the way in which individuals think and interact with one another, but also the way in which large groups or entire societies think and interact with one another. 

On a small scale, we can see how online dating has changed the whole pattern and ritual of courtship, something that took millennia to evolve and which seemed, at least until now, to be “hard wired” into our brains. On a larger scale, there is the wave of social unrest currently spreading through the Middle East, partly as a result of Internet based social media. 

David Fincher’s new film, The Social Network, chronicles how Mark Zuckerberg, a lonely and disillusioned Harvard undergraduate student, accidentally started a communication revolution  and global social network that has grown to more than half a billion people in a little over 7 years. 

This is not an incremental change in the way we communicate with one another. It’s not like going from mimeographs to photocopies or from courier carried documents to faxes. This is a transformational change. It’s like going from hand written manuscripts to the printing press or from hand written “slow mail”  to instantaneous email. 

This kind of transformational change, is occurring at an exponential rate. 

With the world’s computing capability doubling every two years, many scientists predict that, within 30 years, we will have the means to create superhuman intelligence. 

The point at which this occurs is known as the Singularity. 

When this happens, human civilization will be completely and irreversibly transformed. According to most experts, the Singularity--and the end of human civilization as we know it--is about 35 years away...

Your Brain Says, "Buy This!" What Is Neuromarketing?

Have you heard of the concept of neuromarketing?

Well, have you ever watched the AMC television show Mad Men, which follows the lives of 1960s Madison Avenue advertising executives? In one of the episodes, the lead character, Don Draper, says “Advertising is based on one thing: happiness.” He goes on to tell us that “Happiness is the smell of a new car. It’s freedom from fear. It’s a billboard on the side of a road that screams that whatever you’re doing is okay. You are okay.”

If Don Draper lived now, instead of the 1960s, he would love neuromarketing.

Everybody buys stuff. Sometimes it’s necessary stuff, like razor blades or a new pair of sneakers. Sometimes it’s not, like a 6 speed remote controlled back massager from one of those high-tech gadget catalogs. Sometimes we buy on impulse, such as when go to the supermarket while hungry. Sometimes we buy only after much thought, as when purchasing a new car. 

But why do we want a particular brand of sneakers or a particular make of car? And why would anyone want--let alone think they need--a remote controlled back massager? 

The answer lies in advertising--and its more sophisticated partner--marketing. What’s the difference? 

Advertising is simpler. A Coca-Cola sign on a building is advertising. It reminds you of the product but it doesn’t tell you why you should drink Coke instead of “that other cola beverage”. The “Pepsi Challenge”, on the other hand, is marketing. The goal is to convince you that, since most other people seem to prefer Pepsi, so should you. 

Notice the emphasis on the word “you”. The word “you” is one of the most powerful words in the English language--or any other language--because it activates the deep emotional centers in the brain. If someone says, “Oh, that’s a beautiful sunset!”, you may or may not agree. But if someone says, “Oh, you are so beautiful!”, whether or not you agree, your nucleus accumbens and other regions of your brain’s pleasure centers will be activated and “blush” with excitement at receiving the compliment.

That is something that we now know as a result of brain imaging experiments and this new understanding of how the brain works has given rise to a whole new approach to advertising known as “neuromarketing”. When I first heard the term, I thought it was just more “neurohype”. After all, we hear about all sorts of “neuro” things now, like neuroeconomics, neurolaw, and neuropolitics. But the more I’ve learned about neuromarketing, the more I’m convinced that it’s real and that we can all learn some useful things about ourselves by better understanding how we respond to the constant stream of marketing messages that bombard us every day.

For example, I use a computer in my daily work, not because I want to, but because I need to. That’s just how the practice of medicine has evolved. My patients’ medical records are electronic, so I can access them even if I’m not in the office. All of their prescriptions are sent electronically, right to their pharmacy. I could use a Dell or a Compaq or any other computer, but I use a Macbook Pro, not because I need to, but because I want to.

I use Apple products because of their high quality and ease of use. But I love Apple products because of their elegant design and cutting edge qualities. I don’t want to be the nerd in those “Hi, I’m a Mac-Hi, I’m a PC” commercials. I want to be the cool guy in the black turtleneck who’s super hip and so up-to-date. Even the packaging of Apple products is so cool--like some sort of origami puzzle--that I still have the box from my original iPhone.

But I do not have an iPad, at least not yet. I tell myself that it would make some things easier and it would certainly be lighter to travel with than my Macbook Pro. But do I really need one? I can’t decide. When I do decide, I hope it will be because of a rational decision, not because Apple says “You need an iPad”.

Everybody buys stuff. We should at least know why we’re buying. 

I don’t know if Apple is purposefully using neuromarketing techniques. What I do know is that their marketing is so successful that they cannot keep up with demand. Even if I ordered an iPad 2 online right now, it would take 4-5 weeks to get it. I might as well wait for the iPad 3. That’s how fast personal computers are evolving. And that’s how fast our iBrains are evolving. 

Have you heard of the concept of “iBrain”? Well, I’ll tell you about it in my next blog post.

When will winter (or depression) end?

The “official” start of spring is only two weeks away, but here in northern New England, it’s still winter. Parts of Vermont got almost 30 inches of snow yesterday and, here in New Hampshire, the mountainous snow banks in shopping mall parking lots will probably take another month to melt. The long winter and late spring of northern New England were hard to get used to when I moved here from the mid-Atlantic 22 years ago.

I was used to a long, slow, gradual spring. Here nothing much happens until the snow finally melts in late April. Then, all of sudden, everything seems to blossom at once. 

During a discussion with one of my TMS patients today, what struck me is how most people with depression expect their recovery to be like the New England springtime--overnight and all at once. In fact, it’s a lot more like springtime in the mid-Atlantic. 

In the same way that daffodils are followed by forsythia, which are followed by dogwood, sleep often improves before appetite, which may improve before energy level, motivation, or sex drive. 

All of these basic physical symptoms of depression usually improve before there is any subjective improvement in mood. 

This is why it’s not uncommon for someone else, rather than the patient, to notice the first signs of improvement--a brief smile perhaps--like the first crocuses--or a slight change in posture--like the first cherry blossoms. 

Different types of plants, animals, and insects emerge from hibernation at different times, each according to its own schedule. In much the same way, different symptoms of depression improve at different rates. And some people do get better more quickly than others.

It’s important to remember that, no matter how brutal or how long, winter always ends and snow always melts. And no matter how brutal or how long, depression can always be treated. 

The Changing Field of Psychiatry

A front page article in today’s New York Times (3/6/11) was all about the changes that psychiatry has undergone over the past couple of decades. The article profiled Dr. Donald Levin of Doylestown, PA and focused on the fact that, like many of the 48,000 psychiatrists in this country, Dr. Levin no longer performs “talk therapy” or psychotherapy. Instead, largely because of how much insurance will pay, he prescribes medication. Psychotherapy, when it is part of the patient’s treatment plan at all, is provided by some other mental health professional, such as a psychologist, social worker, or other trained mental health counselor. 

I could relate to much in Dr. Levin’s story. Like him, I trained at a time when psychotherapy was still the mainstay of treatment for most patients, especially those with depression and anxiety. Medications were often viewed as a “short cut” or a “crutch”. Then, only a year after I finished my residency, Prozac came out and changed everything.

It’s not that Prozac was any more effective than the antidepressants we already had. No studies have ever shown Prozac (or it many cousins) to work any better than the older antidepressants. It’s just that the newer drugs are a lot safer and easier to take. Eventually, primary care doctors learned how to recognize depression earlier, and because the newer drugs were so much safer and easier to prescribe, they began treating patients who would previously have been referred to a psychiatrist. 

Thus began a transformation of the practice of psychiatry. Primary care doctors began to prescribe medications for most “garden variety” depressed patients, leaving the more seriously ill patients for the psychiatric specialists. When managed care arrived and insurance companies started paying less and less for psychotherapy, psychiatrists began focusing more and more on the medication part of treatment.

In the mid 1980s, I would typically see a patient for 50 minutes at each visit. Most of that time was devoted to exploring the patient’s thoughts and feelings while trying to understand the root cause of their problem. I would try to reserve enough time at the end of the session to review their medications and make sure they were working and not causing too many side effects. Two decades later, it was very different. After the initial diagnostic evaluation, I would see most of my patients for brief, 15 minute check-ups every couple of months. Like Dr. Levin, I would often have to remind my patients that I was not their therapist when they would start to talk about their various relationship problems and other woes. “We need to stay focused on your medications”, I would say.

I missed the psychotherapy part of my practice. After all, I had spent years trying to develop my skills as a therapist. Medications are certainly important. Without them, many patients would not even be able to benefit from psychotherapy. But when it reached the point where I was seeing as many as 30 patients a day for brief medication check-ups, it began to feel shallow and unrewarding. That’s when TMS began to usher in another transformation of the practice of psychiatry. 

When I became one of the first TMS providers in late 2008, my practice of TMS was not too different than the rest of my practice. I would perform the first couple of treatments but would then hand things over to a trained nurse technician. It soon became clear, however, that when someone comes for a treatment every day for several weeks, something special starts to happen. As the magnet clicks away, patients start to talk about their thoughts and feelings. It was then that I realized that TMS offers a unique opportunity to combine the time honored practice of psychotherapy with the most advanced, cutting edge treatment. 

So when I opened my own TMS practice, I decided to make the most of this opportunity. By doing most, if not all, of the treatments myself, I now have the opportunity to know my patients in a way I haven’t done for many years. Rather than just focusing on medications and their side effects, I now have the opportunity to know my patients as people, to understand their life stories, and once again use the psychotherapeutic skills that I had set aside for so many years. 

This is just one example of how TMS is transforming the practice of psychiatry. TMS is the most advanced form of treatment for depression, yet for me it has brought things full circle.

http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&ref=health

Dealing With The Winter Blues

This has turned out to be quite a tough winter. Many parts of the country are having to deal with colder than average temperatures and higher than average snowfall amounts. I was supposed to fly to Washington, DC yesterday to deliver a lecture on TMS but it was cancelled when the capital region was buried under 8 inches of snow. 

Winter can be tough even if you’re used to it, like we are here in New Hampshire. And even if you don’t have Seasonal Affective Disorder, winter can make you feel pretty discouraged after a while. So here are a few tips for dealing with these dark and frigid days.

Get outside

On days when the sun is shining, bundle up and go for a walk. The sunshine, walking and being out with nature will lift up your spirits.

Exercise

Exercise releases endorphins, which help boost your mood. Exercise improves your health, energy, self esteem and sleep, and reduces stress levels. 

Do something that makes you happy

Think about what makes you happy and do it. If you love making jewelry or love to paint, take a class. If you enjoy poetry, join a poetry group. If you like to dance, take dance lessons. Go to the gym, go bowling, or go ice skating.

Do something productive

Finish a project you've already started. Organize something that you've meant to organize. Sort through your wardrobe and give away things you no longer need. Whatever the project, you'll feel better, more organized and more in control after you've finished it.

Do something rewarding

Volunteer at a local soup kitchen or social service agency. Visit an elderly neighbor. 

Socialize with people you enjoy

Being with other people allows you to look outside yourself and realize that there's more to life than your own concerns or what's happening in the news.

Talk with someone

If you're feeling down, tell a trusted family member or friend who is a good listener.

Get help

If you're still down, you may need professional help. Talk with your doctor or a professional counselor.

Remember too, that snow always melts and winter always ends.

TMS: Neurocircuitry-Part 2

Considering how important it is, the dorsolateral prefrontal is surprisingly small. And because everybody's brain is a little different, its precise location can vary slightly from one person to the next. But in TMS, precise location of the stimulus is essential along with intensity, frequency, and duration. By altering these parameters in different ways, TMS can be used for different purposes.


For example, fast, excitatory TMS applied to the left dorsolateral prefrontal cortex has been approved by the FDA as a treatment for depression, but slow, inhibitory TMS applied to the same region has no effect on mood. On the other hand, recent studies have shown that fast, excitatory TMS applied to the right dorsolateral prefrontal cortex is an effective treatment for depression and slow, inhibitory TMS once again appears to be an effective treatment for depression.


TMS has been used experimentally to treat refractory epilepsy. In this situation, slow, inhibitory TMS is applied directly to the epileptogenic focus, the site in the brain where the seizure originates. When this is done repeatedly, over time, it has the effect of quieting down the focus.


TMS has also been used experimentally to aid in recovery from stroke, but here a different approach is used. Fast, excitatory TMS can be applied directly to the site of the lesion in an effort to stimulate damaged brain cells to function more effectively. But better results come from stimulating the corresponding site of the opposite, undamaged hemisphere. When this is done repeatedly, over time, it has the effect of stimulating neuroplasticity and regeneration at the site of the lesion.


And this is really the essence of how TMS works--by stimulating neuroplasticity.


www.tmsnewengland.com

TMS: Neurocircuitry-Part 1

TMS was developed at the same time functional brain imaging was being perfected. Functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have allowed us to map cortical function with unprecedented detail and accuracy. For example, in the right cerebral cortex, we have separate circuits that allow us to tell the difference between pitch, rhythm, and harmony whenever we hear music. And in the left cortex, we have separate circuits which allow us to recognize a word if we see it written and the same word if we happen to hear it spoken or sung.


TMS can be combined with various forms of brain imaging. Studies like this have not only allowed us to map brain function but also brain circuitry--and not only in the cortex--but deep inside the brain as well. 


The part of the brain responsible for the antidepressant effects of TMS is the left dorsolateral prefrontal cortex. This is a small but important area concerned with executive function.

This part of the cortex is involved with high level organization and planning. You're using this part of your cortex right now to focus your attention and to hold new information in your working memory while you process it and incorporate it into what you already know. This is the same part of your brain that allows you to watch what you're doing so you don't make a fool of yourself in public.

The dorsolateral prefrontal cortex has extensive connections throughout the cortex as well as with deep, sub-cortical nuclei. And by modulating the circuits connecting them, TMS alleviates the symptoms of major depression.

One way to think about it is like this: antidepressants work their way up the ladder of the central nervous system. By altering neurotransmitter levels at the synaptic cleft, they alter communication between individual neurons, which changes the firing pattern in larger circuits, which, in turn, modulates the activity of entire networks.

In TMS, the therapeutic sequence moves in the opposite direction--from network...to circuit...to neuron...to synapse.