Wednesday, February 27, 2013

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


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

In 2011, O'Connor had surgery to remove a large brain tumor:
The tumor was in an area of the brain that involves "logic, reasoning and judgment," said O'Connor's attorney, Eugene Iredale.

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

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


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


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

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

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

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


O'Connor's Plea Bargain

In court, Ms. O'Connor pleaded not guilty to money laundering under the terms of a deferred prosecution, according to U-T San Diego. As part of the deal, she has two years to pay back funds "borrowed" from the nonprofit foundation, and she must attend treatment for gambling addiction:
The resolution of the case takes into account her poor health but also requires O’Connor to acknowledge she misappropriated the money and obligates her to pay it back and any tax penalties, [Assistant U.S Attorney Philip Halpern] said.

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

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

ABC 10 News reported:
If she does not obey all laws, she could face 10 years in prison.

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

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

CBS News aired an interview with the former mayor. O'Connor said that video poker was "...like electronic heroin. You know, the more you did, the more you needed and the more it wasn't satisfied."
As mayor she was always in control. Her gambling was out of control.

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

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

How slow-growing?

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

But as we've seen, meningiomas can be very slow-growing. Neurosurgeon Dr. Katrina Firlik presented the case of a giant olfactory groove meningioma on her website (the MRIs alone are worth checking out):
This patient presented with a several year history of depression, which was, in retrospect, most likely related to this benign tumor. This type of tumor typically grows slowly, over years or even decades.

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

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

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


Footnotes

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

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


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

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


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


References

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

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

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

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

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

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

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

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1 Comments:

At August 30, 2013 4:55 AM, Anonymous Anonymous said...

I think any changes in our brain may cause to many problems and thinking change

 

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