Examining depression through the lens of the brain | Dr. Helen Mayberg | TEDxEmory

so I'd like everyone to do is it's just closed their eyes because I think this morning inspired by all the other speakers I'd like to actually put us all in a first-person perspective on the topic that I'm going to be discussing which is depression and I want to start by having you just listen to depression I was pretty convinced that I was going to die that there was nothing left for me I had completely my life had completely closed and I had no other choices really clinically my own psychiatrist did basically there was nothing what to do so just imagine that that's the sound of a malignant depression if you've ever been depressed you might think that well that doesn't sound any different from the state that any depressed person gets in except you usually come out of it that's the sound of a 37 year old man a son a partner a valuable employee a cyclist a competitive cyclist who actually become depressed not the first not the second episode he'd ever had but he got stuck and he couldn't get out he'd stopped responding to multiple medications psychotherapy was essentially worthless he'd even failed multiple courses of electroconvulsive shock therapy so the question is is what happens when you are so low so stuck so unable to get out of the hole that basically nothing is left for you think about it and the question is is what is a neurologist standing here in front of you telling you about it what's what's the point of a neurologist in this story well what you heard is when the brain fails to be able to adapt to circumstance to the situation when it breaks and the question is that's what neurologists study that's what I've been trying to figure out and I'm going to tell you the story of how we look at depression through the lens of the brain but thumb and listening to the first-person perspective of those patients to understand what goes wrong and how do we fix it so I need to put you back a number of years where actually this story is about imaging and the mapping of circuits in the brain and these are extremely old pictures probably older than many of you in the audience but at the very beginning it was simply a matter of can you map depression in the brain if you're measuring the brain in action does it have a signature and it turned out if you studied patients with stroke or Parkinson's or Huntington's or unipolar or bipolar depression when people were ill there was a pattern there was a signature and it wasn't one area of the brain that wasn't functioning normally it was a whole constellation of brain areas which turned out to be a circuit and the question was how could we map that circuit the approach was to do what neurologists always do deconstruct compartmentalize different areas of the brain serve different functions in the old days we were very simplistic lesion deficit and area does a particular function it turns out it's a orchestration a symphony with different regions across the brain working together to choreograph complex function but in depression a big issue is that it's always about negative mood but it's also about change in drive whether it's appetite libido sleep but in the setting of your thinking is off you're slow you're inattentive you're guilty you can't feel pleasure and your movements get slow your will to act becomes impoverished and it's the combination of these various symptoms is what we map and through a series of experiments we tried to understand what regions what combination of regions did what we treated people we we took advantage of every treatment known whether it was therapy or drug or shock or magnets to actually understand how do you change the brain what symptoms change and actually what's the state of going from sick to well to understand what in the brain isn't working and we had a very classical view because we followed what psychiatry told us when you're sick you're in state a when you're well you and state B there's a linear transfer of going from a low state to a high state we have rules that apply these linear principles I'm trying to pretend like I'm talking math here but in fact we we have a threshold where we say when you're 50% less bad we call it a win any combination of those symptoms if you're 50% better it's a win and that was all fine and good except there was something that started to really not me about again as a neurologist thinking about depression it's easy to look at the cognition easy to measure motor speed easy to measure immune or inflammatory markers the issue was where's that sad part there's something about the pain of a major depression that's unlike anything I've never been ill but even to take the third-person perspective to be empathetic compassionate with a patient who is ill is to experience a true black hole even in third person and what is that state to suffer yourself that must be like that to me has always been the part that's hardest to explain hardest to localize and at the end of the day the only thing that's really most important to try to understand as a starting point because in many ways everything else is a derivative of what happens you have that negative experience so if you think about this is something that has been known for a very long time William James described his own depression not by I can't think straight I can't go to class and I don't feel pleasure but by them mental pain something that is so indescribable that a person who has an experience can't know what it is and our patients if one listens actually describe the same thing annoying agony how can pain cause you to be self-loathing what an amazingly cool state a twisted state to be in that not only do you feel bad but you actually think it's somehow your fault if ever there was a state where you said there was a loose wire in the brain a miscommunication of what something should be functional was not I think it'd be hard to argue that this is it I particularly like this because it really shows how the negative state starts to invade every part of everyday life every action every thought to do anything that one wants to do gets hung up on that loop of hesitation and it ends up feeling like you can't move at all but actually most critically and again thinking about why does sadness why does pain why does and why do we use empathy and compassion to deal with both our own pain and pain of others even in the non pathological state what happens when you can't get outside of yourself and literally can't connect to anybody else around you that also might be able to help so the question is is where is that where is that and really in the early experiments we could model that with a really kind of poor approximation of the clinical state but to ask even if a healthy person experiences an intense recollection of a personal loss what happens in the brain and in real time you can map that areas of the brain change some areas go up some areas go down and it turns out that that pattern is incredibly important the pattern helped us to identify that limbic areas core drive state areas and dominated by a region called the sub colossal cingulate or broad area 25 led the charge when it activated it shut down the cortex areas that drive thinking planning moving or offline when these emotional centers are activated but importantly if when mapped how patients respond in clinically as they got well there was a flip of the pattern that area 25 down regulated his activity and in concert cortical areas came back online it's what we all know there's a natural toggle between our emotion and our action when we really get on side ourselves because something happens we actually turn our our attention to other things away from outside to inside so the question becomes what happens if that natural toggling can no longer happen and I think that that is the point that we reached now more than 10 years ago and again we were mapping all in third person what happens if you treat with X or Y what happens when you get better when you don't even to actually start to discriminate that people before you actually offer them a treatment might be in different states where you could actually treat people to match a brain type so that people who need therapy should have therapy and should never see a drug or alternatively if you need a drug you get a drug and therapy or rehabilitation can always help you but again in science and in medicine the question is is what do you do when you don't have an alternative how do you use where you are at present point in time to appreciate or to test out what some people might think is a radical idea or where in fact the data is telling you this is actually the next step and this is really the switch where from the problem of people who are in a depressed state and can't get out who really are off the grid to actually just think about their brain and realize that maybe we can we can change the balance by directly intervening if we know the map that we can go directly to what we think might be the source and you might say a tagged audacious perhaps but not so much because back in 2001 2002 we were in the heyday of deep brain stimulation the implantation of small leads that can electrically tune specific neural circuits to treat Parkinson's disease they had taken the strategy of map the motor system understand the nodes in the circuit and target a node in patients who no longer respond where the science itself informed where in the network one should go and we took that same strategy knowing that area 25 seemed to be very important it was a node in a much more distributed network and maybe we should implant and see if it can have effect in patients who have no other options this is a point where you go from mapping and third person to actually listening to the patient and what we did is you can see the electrodes - one on each side implanted deep in the brain through small burr hole in the skull patients are implanted they're awake in the operating room they're available to talk to us and let us know what's happening our goal was to maybe we would change negative mood but we were going to move that whole system these people weren't sleeping their appetite was bad they they had really little movement little thought and this intense vasive negative empty state that they were in that we could apply a small amount of current just like they did in Parkinson's and see what happened our first concern was let's just see if we can do this safely depression obviously takes a long time to get well why should this be any different and so what we did is we turned it on and what we found is that we have as we applied the stimulation first patient as we crossed our fingers that nothing went wrong first sight of stimulation nothing second state of stimulation nothing in third sight of stimulation suddenly the woman expressing that she suddenly felt calm and as she tried to explore and find the words to describe it which he was really describing is a lifting a clearing of this void of this intense negativity that had just been part of her life incessantly for the last five years we turned it off and suddenly all she could say was well maybe I was just imagining it so these first effects in the operating room totally unexpected and it wasn't even clear if it was even important and so we proceeded to implant tests use chronic stimulation to actually see if the depression syndrome would go away but what we found in patient after patient not always predictably but that is you had hit the switch that patients would say things like this the tension is gone the vortex is gone you can ask yourself what is a vortex every patient had some odd idiosyncratic way in which they characterized this state that they were no longer drowning they were out of a hole they felt lighter less heavy less resistance the fact that they felt that they could breathe people even started describe the room being brighter feeling more connected to suddenly feel more optimistic to feel more connected to us in the room and even wanting to do stuff we all started cracking up when one guy on the table bolted into the to the operating device said well I know I'm kind of locked in right now but if I was holding right now I'd really like to clean my garage so suddenly we were seeing that there was a consistent although kind of not the routine pattern that you'd expect from a neurology examination so personal that's Oprah found and so the question went back to not the g-wiz oh this is this interesting but what did we do to move from the amazement back to the dissing passioned passionate approach to the science to just figure out what it was and it was actually to the neurological process to say what are we actually doing when we stimulate in that location we're actually affecting an entire circuit in the brain to map what exactly we can use our models of connection area 25 and we can actually plan our surgery now to precisely predict where we can get that effect and when we can lift that acute change in mood patients get well so we have two phases now of recovery this early rapid change the lifting the the reset but then we have a delayed process where actually patients have to relearn how to have a bad day you don't get better overnight all your new habits need to be reshaped and we actually have to totally revise our linear way of thinking about depression to a nonlinear way of recovery regular depression is off to the left you can go up and down along a continuum less or more we don't understand what happens when you fall into that pit but what we're learning is that something about stimulating in this location can help you to jump out and it's then that the chronic stimulation which is still required combined with therapy psychiatric care and all of the other things that go one to recovery and rehabilitation can go on so I just want to end with a last quote because what's happened now is an appreciation as scientists is that it's no longer about third person as a medical researcher it's about using the first-person perspective to use the patient's story to let a patient tell us what's happening to them because in fact they know better what we're doing to them than we think we know what we're doing to them and I think that we what we've learned and what I'd like to help you to understand as I finish my talk and I'm overtime is the fact that it's about listening to the patient but then dissing passionately moving in a direction to test the new hypothesis we do it with the team but the patient is our collaborator not our guinea pig and that it's only through this process that I think that will really understand the nature of how emotion and reason interacts in our brain and will understand how to actually provide alleviation from suffering from patients um in this situation thank you

Channel: TEDx Talks

Views: 115,615

Rating: 4.8364997 out of 5

Keywords: TEDxTalks, English, United States, Health, Brain, Depression, Neurology

Id: KwHFHV9Jfd8

Length: 19min 18sec (1158 seconds)

Published: Wed May 27 2015