Saturday, June 13, 2009

More Moronic "Mental"


Chris Vance as the unorthodox psychiatrist, Dr. Jack Gallagher and Annabella Sciorra1as his boss (and ex), Dr. Nora Skoff.

The late David Carradine made a surprise guest appearance Tuesday night on Fox's much maligned new show Mental, playing the main mental patient. His character, Gideon Graham, was a professor ["a national treasure"]2 and author of the books Anti-wisdom and the [heavy-handed plot device] Book of Judges. His diagnosis: treatment-refractory catatonia of neuropsychiatric origin following a traumatic injury (being struck by lightning).

According to DSM-IV-TR, catatonia is marked by “motoric immobility, excessive motor activity (that is apparently purposeless and not influenced by external stimuli), extreme negativism or mutism, peculiarities of voluntary movements, or echolalia or echopraxia.” Fink and Taylor (2006) suggest that:

Catatonia, a psychomotor syndrome, is defined in DSM classifications mainly as a subtype of schizophrenia. This identification does not recognize the syndrome’s ubiquitous nature, discourages its recognition in other psychiatric illnesses, and limits treatment to protocols that focus on antipsychotic drugs. We suggest that catatonia be reclassified as an individual abnormal behavior, akin to delirium and dementia.
Professor Graham did not respond to any treatment, including drugs and electroconvulsive therapy (ECT), so the perpetually smirking and supposedly brilliant Dr. Gallagher decides to try transcranial magnetic stimulation (TMS) to awaken him from his stupor. This is not unheard of in catatonic patients, as there are two case studies in the literature that did report some success (Grisaru et al., 1998; Saba et al., 2002). TMS involves the delivery of magnetic pulses to the brain through a specially-designed coil.


BioMag Laboratory, Helsinki University

Depending on the frequency of the pulses, TMS is thought to induce either excitation or inhibition of the brain tissue below. In the case reports of catatonia, the two patients improved following TMS, then their schizophenia was treated with antipsychotic drugs.


The late David Carradine in Mental, being fitted with earplugs prior to receiving TMS. The magnetic coil does indeed make a loud clicking sound, and ear protection is necessary to prevent hearing loss.

The caps being modeled in the two photos above contain electrodes that record brain waves, or EEG activity, in response to the TMS. This is technically difficult because the magnetic pulses produce a strong electrical field which can saturate the amplifiers. Once these methodological hurdles are overcome, Miniussi and Thut (2009) describe the benefits of combining the two in a research setting:
The TMS-EEG integration provides real-time information on cortical reactivity and connectivity through the analysis of TMS-evoked potentials (TEPs), and how functional activity links to behavior through the study of TMS-induced modulations thereof. It reveals how these effects vary as a function of neuronal state, differing between individuals and patient groups but also changing rapidly over time during task performance.
In a clinical setting, TMS has been most commonly used to treat major depression, when administered in a repetitive fashion (rTMS) over the prefrontal cortex (Padberg & George, 2009).3 TMS differs from ECT in that treatment is administered while the patient is awake, and the occurence of seizures (very rare in those without neurological disorders)4 is a bad side effect, not the desired outcome.


Mental patient Gideon Graham having violent seizures in response to single-pulse TMS.

But Mental gets it all wrong... very wrong. First, Dr. Gallagher announces that he has conducted some self-experiments on the sly. So when Gideon's daughter, who is a [unconvincing] supermodel, asks "will it hurt?" Gallagher answers from experience that some will feel "a small tapping sensation." Then Gideon is sedated for the procedure, which isn't normally done. Furthermore, the treatment produces violent seizures, convulsions, and writhing. TMS is not supposed to induce seizures; that would be considered an untoward side effect.5 And finally they keep turning up the field strength beyond recommended levels. At no point did supermodel daughter sign a consent form for such an experimental procedure. "It looks like an execution," she said... "I hope you people know what you're doing."

But this is TV, right, and other shows with medical themes depict ethical violations all the time, right? [Over-the-top plastic surgery show, Nip/Tuck, I'm thinking of you.] Unfortunately, it's not clear what type of show Mental is supposed to be. Is it supposed to be realistic that the brazen Dr. Gallagher literally pushes the evil drug rep out the door? Funny? Cliched, I would say, and that's one of the major problems. Everyone is a walking stereotype, and some of the plot devices are so painfully concrete and literal-minded that you can see them coming a mile away.

For instance, Gideon Graham was struck by lightning while hiking in the Sierras with his wife during a thunderstorm. He survived, she did not. He was trying to teach his wife a lesson in overcoming her fears, because of course going to the edge of cliff in the middle of a fierce thunderstorm is the best type of exposure therapy. And he hates people who are weak.

Here's Dr. Gallagher's brilliantly insightful theory of Prof. Graham's catatonia:
  • Lightning killed the supermodel's mother but not her father - does she blame her father for this fatality? [who wouldn't?]
  • TMS treatment is "like an electromagnetic pulse".
  • "Did you say TMS made him relive the lightning pulse?" asked his colleague.
  • Gideon was working on The Book of Judges...
  • Gallagher met with Gideon's tweedy academic colleague, who revealed that the book was dedicated not to his wife but to Vivian, a woman with whom he was having an affair.
  • This "brought guilt into his life" - his wife threatened to leave - so Gideon found a way to judge himself.
  • In the Old Testament of the bible, Gideon:
is a judge appearing in the Book of Judges... The name Gideon means "Destroyer", "Mighty warrior" or "Feller (of trees)".
Thanks, writers, what subtle and complex points you made here! Gideon feels guilty! He judges the world for taking his wife, and himself for his role in her death! In the end, Dr. Gallagher used the "scared straight" approach, yelling at Gideon, removing all reminders of his life, and accusing him of abandoning his daughter. He sets up one final TMS session, which was rigged to be a sham (unbeknowst to everyone but himself). An angry Gideon has supposed "seizures" (with no external stimulation), wakes up, and reaches out to strangle Gallagher, who says "Where's your lightning now?"

Footnotes

1 Emmy-nominated for her work in The Sopranos, Annabella Sciorra is by far the best actor in the entire cast.

2 This was a clumsily dubbed posthumous tribute to David Carradine.

3 However, Dr Shock isn’t impressed of the efficacy of rTMS in depression and has posted recently on the placebo response of TMS.

4 Koo et al. (2008) noted 12 published cases in their review of the literature.

5 However, there is an even newer procedure in limited clinical trials called magnetic seizure therapy (MST), which uses TMS to induce seizures (@vaughanbell). It's being tested as a possible alternative to ECT in treating refractory major depression. The show was not depicting MST, though.

References

Grisaru N, Chudakov B, Yaroslavsky Y, Belmaker RH. (1998). Catatonia treated with transcranial magnetic stimulation. Am J Psychiatry, 155:1626.

Miniussi C, Thut G. (2009). Combining TMS and EEG Offers New Prospects in Cognitive Neuroscience. Brain Topogr. Feb 25. [Epub ahead of print].

Padberg F, George MS. (2009). Repetitive transcranial magnetic stimulation of the prefrontal cortex in depression. Exp Neurol. May 3. [Epub ahead of print].

Saba G, Rocamora JF, Kalalou K, Benadhira R, Plaze M, Aubriot-Delmas B, Januel D. (2002). Catatonia and transcranial magnetic stimulation. Am J Psychiatry, 159:1794.

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