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Sunday, June 19, 2011

Consciousness, Empathy, Self and Wisom - 3

More recently the term Self has also come under scrutiny. The idea of self is both physical and philosophical. William James is credited with showing that the so-called “self” (he called it the me self) has three components: the material self, the physical self dealing with one’s care of one’s own body with clothing etc, the social self that is recognized as a consistently predictable individual and the spiritual self which determines one’s internal philosophical values.

I will leave out for the present, the “self” as defined by philosophers and religious scholars who suggest that there is a non-material entity called self or atma or spirit which activates the functions of the human body, including that of the brain and independent of the body. I am also leaving out the study of “self” by neuroscientists such as Antonio Damasio who suggests that there is a proto-self, core self and autobiographical self.

Based on the suggestions of William James, one group of neurologists defined self as “temporally stable, trans-situational consistencies in behavior, dress, or political or religious ideologies”. Since patients with dysfunction in frontal lobe functions have been shown to exhibit dramatic changes in their beliefs and self-care, these neurologists studied 72 patients with fronto-temporal dementia. The studies included documentation of change in the core aspects of “self” as defined above, such as changes in style of dress, social presentation, political and religious ideologies and self-concept related to their work.Imaging studies (MRI and SPECT) were also completed on these patients.

Seven patients showed dramatic changes in “self” as defined above. Six of those with change in their “self” showed clear structural abnormalities on fMRI with asymmetric loss of function in the non-dominant frontal lobe.
In other words, some of the components of what we call “self” in our daily, practical usage are represented in specific areas of the brain.That is not surprising at all.It is surprising that it took so long to figure that out.

The reason I am summarizing all of this is because with an increase in aging population, we see many patients with loss of mental functions including awareness, a personal self and judgment. In addition, patients with several types of neurological diseases based on organ pathology manifest behavioral problems and mental illness in which they have lost or have exaggerated mental functions. I believe neuroscience can help our patients based on solid evidence. It is obvious that these studies are important in understanding mental illness with objective data and are essential to developing reliable treatment modalities.

In addition, compassion, empathy, altruism, wisdom are important in the making of a physician. If we understand what wisdom is and what empthy is, we may be able to train our future physicians better.

Further reading:

Singer T, Lamm C. Social neuroscience of empathy in The Year in Cognitive Neuroscience 2009: Ann. N.Y. Acad. Sci. 2009; 1156: 81–96.

Budson AE, Price BH. Memory dysfunction. New Eng J Med 2005; 352: 692-699.

T R Insel . Faulty circuits. Scientific American April 2010 pages 44-51.

J W Buckholtz et al. Dopaminergic network differences in human impulsivity. Science 2010; 329: 532-534.

Mohammadreza Hojat, PhD, Michael J. Vergare, MD, Kaye Maxwell, George Brainard, PhD, Steven K. Herrine, MD, Gerald A. Isenberg, MD, Jon Veloski, MS, and Joseph S. Gonnella, MD.The Devil is in the Third Year:A Longitudinal Study of Erosion of Empathy in MedicalSchool. Academic Medicine 2009;84(9):1182-1191.

Steve Twomey. Phineas Gage: Neuroscience's Most Famous Patient - An accident with a tamping iron made Phineas Gage history's most famous brain-injury survivor., Smithsonian Magazine, January 2010.

Damasio A. The Feeling of what happens. Harcourt Brace. 1999

Sunday, June 12, 2011

Consciousness, Empathy, Self and Wisom - 2

Empathy is an essential requirement for any physician. Also note that empathy and altruism are characteristics of a “wise physician”. At a time when patients think that physicians value technology more and do not truly understand their suffering, it is important to re-establish the value of empathy in patient-physician relationship. (DeWitt Stetten, a brilliant physician- scientist said that his ophthalmologists were interested in “vision”, not in his blindness). Patients are more likely to comply with treatment regimes when they feel that their physician is empathic. They are more likely to feel comforted and supported by an empathic physician.

However, empathy is a double edged sword. Too much empathy may cause earlier burn-out among physicians. In an interesting study from the Thomas Jefferson University School of Medicine, 400 medical students were studied for their level of empathy during the entire four year period of medical school. The researchers used a well-tested questionnaire to study empathy and noted that medical students show decline in their level of empathy during the third year of medical school. It is also interesting to note that women in general show more empathy. In a separate study senior physicians were noted to learn and modulate their level of empathy so they do not burn out.

We also know that it is possible to learn empathy. Meditation studies on Buddhist monks have shown that areas of brain which are active when one experiences compassion is more active in an experienced monk practicing compassion-meditation than in a novice. In other words, it is possible to improve the neural correlates of empathy and hopefully empathy. If we can teach skills in developing appropriate empathic connection with their patients, it may help prevent emotional stress and burn-out among our young physicians. It may also enhance professionalism and patient-physician relationship.

Is it possible to study the neural circuitry involved in what we call wisdom? Some may say that it is a quality that cannot be studied and quantified. But, it is possible to list qualities that are present in someone whom we call “wise”. Indeed all cultures have an idea of what wisdom consists of.

In an article summarizing neurophysiology of wisdom, Meeks and Jeste show that many of the elements which are listed as component of wisdom are common in different cultures. They are “rational decision making based on general knowledge of life, pro-social behavior including empathy, compassion and altruism, emotional stability, insight and self-reflection, decisiveness in face of uncertainty and tolerance of divergent values systems”. Interestingly, neuro-imaging studies show that prefrontal cortex and the limbic striatum are the two regions of the brain connected with several of these mental functions, when studied separately.

The limbic system is involved with emotions. Prefrontal cortex is essential for what are called the executive functions of the brain. Executive functions control and regulate other behaviors and include the ability to form concepts, think in abstract, adapt to new situations and change behaviors as needed and plan future actions based on observation, experience and insight. Wisdom involves balancing one’s emotional and rational aspects. Therefore it is not surprising that when you define wisdom by its component parts, it is possible to find out what its neuroanatomy is.