The science and philosophy of deep brain stimulation.
It is a good question, but I was a little surprised to see it as the title of a research paper in a medical journal: “How Happy Is Too Happy?”
Yet there it was in a publication from 2012. The article was written by two Germans and an American, and they were grappling with the issue of how we should deal with the possibility of manipulating people’s moods and feeling of happiness through brain stimulation. If you have direct access to the reward system and can turn the feeling of euphoria up or down, who decides what the level should be? The doctors or the person whose brain is on the line?
The authors were asking this question because of a patient who wanted to decide the matter for himself: a 33-year-old German man who had been suffering for many years from severe obsessive-compulsive disorder and generalized anxiety syndrome. A few years earlier, the doctors had implanted electrodes in a central part of his reward system—namely, the nucleus accumbens. The stimulation had worked rather well on his symptoms, but now it was time to change the stimulator battery. This demanded a small surgical procedure since the stimulator was nestled under the skin just below the clavicle. The bulge in the shape of a small rounded Zippo lighter with the top off had to be opened. The patient went to the emergency room at a hospital in Tübingen to get everything fixed. There, they called in a neurologist named Matthis Synofzik to set the stimulator in a way that optimized its parameters. The two worked keenly on the task, and Synofzik experimented with settings from 1 to 5 volts. At each setting, he asked the patient to describe his feeling of well-being, his anxiety level, and his feeling of inner tension. The patient replied on a scale from 1 to 10.
The two began with a single volt. Not much happened. The patient’s well-being or “happiness level” was around 2, while his anxiety was up at 8. With a single volt more, the happiness level crawled up to 3, and his anxiety fell to 6. That was better but still nothing to write home about. At 4 volts, on the other hand, the picture was entirely different. The patient now described a feeling of happiness all the way up to the maximum of 10 and a total absence of anxiety.
“It’s like being high on drugs,” he told Synofzik, and a huge smile suddenly spread across his face, where before there had been a hangdog look. The neurologist turned up the voltage one more notch for the sake of the experiment, but at 5 volts the patient said that the feeling was “fantastic but a bit too much.” He had a feeling of ecstasy that was almost out of control, which made his sense of anxiety shoot up to 7.
The two agreed to set the stimulator at 3 volts. This seemed to be an acceptable compromise in which the patient was pretty much at the “normal” level with respect to both happiness and anxiety. At the same time, it was a voltage that would not exhaust the $5,000 battery too quickly. All well and good.
But the next day when the patient was to be discharged, he went to Synofzik and asked whether they might not turn the voltage up anyway before he went home. He felt fine, but he also felt that he needed to be a “little happier” in the weeks to come.
The neurologist refused. He gave the patient a little lecture on why it might not be healthy to walk around in a state of permanent rapture. There were indications that a person should leave room for natural mood swings both ways. The positive events you encounter should be able to be experienced as such. The patient finally gave in and went home in his median state with an agreement to return for regular checkups.
“It is clear that doctors are not obligated to set parameters beyond established therapeutic levels just because the patient wants it,” Synofzik and his two colleagues wrote in their article. After all, patients “don’t decide how to calibrate a heart pacemaker.”
That’s true, but there is a difference. Few laymen understand how to regulate heartbeat, but everyone is an expert on his or her own disposition. Why not allow patients to set their own moods to suit their own circumstances and desires?
Yeah, well, the three researchers reflected, it may well come to that—sometime in the future, that is—people will demand deep brain stimulation purely as a means for mental improvement. (...)
Questions of pleasure and desire go right to the core of what being a human in the world is all about. The ability to stimulate selected functional circuits in the brain purposefully and precisely raises some fundamental questions for us.
What is happiness? What is a good life?
Hedonia. There is something about this word. It rolls across the tongue like walking on a red carpet and leaves a pleasant sensation behind. Hedonia might well have been the name of the Garden of Eden before the serpent made its malicious offer of wisdom and insight. And more than anything else, hedonism has become the watchword for how we should live.
The absence of joy and pleasure—anhedonia—has, in its way, become a popular issue in the wake of the disease depression. A quarter of us are affected by it over the course of a lifetime, various studies suggest, and its frequency is increasing in the industrialized world. The treatment of depression has become both a window display and a battleground for deep brain stimulation.
It was with the American neurologist Helen Mayberg and the Canadian surgeon Andres Lozano that the method got its breakthrough in psychiatry. It struck a sweet spot in the media when, in 2005, the two published the first study of deep brain stimulation for the treatment of severe chronic depression—the kind of depression, mind you, that does not respond to anything—not medicine, not combinations of medicine and psychotherapy, not electric shock. Yet suddenly, there were six patients on whom everyone had given up who got better.
At once, Helen Mayberg became a star and was introduced at conferences as “the woman who revived psychosurgery.” Later, others jumped on the bandwagon, and now they are fighting about exactly where in the brain depressed patients should be stimulated. It is not just a skirmish between large egos but a feud about what depression really is. Is it at its core a psychic pain or, rather, an inability to feel pleasure? (...)
Mayberg focused on a little area of the cerebral cortex with a gnarly name, the area subgenualis or Brodmann area 25. It is the size of the outermost joint of an index finger, located near the base of the brain almost exactly behind the eye sockets. Here, it is connected to not only other parts of the cortex but to areas all over the brain—specifically, parts of the reward system and of the limbic system. That system is a collection of structures surrounding the thalamus encompassing such major players as the amygdala and the hippocampus and often referred to as the “emotional brain.” All in all they are brain regions involved with our motivation, our experience of fear, our learning abilities and memory, libido, regulation of sleep, appetite—everything that is a affected when you are clinically depressed.
“Area twenty-five proved to be smaller in depressed patients,” Mayberg relates, adding that it also looked as though it were hyperactive. “At any rate, we could see that a treatment that worked for the depression also diminishes activity in area twenty-five.”
At the same time, it was an area of the brain that we all activated when we thought of something sad, and the feeling that area 25 was a sort of “depression central” grew and grew as the studies multiplied. Mayberg was convinced that this must be the key—not just for understanding depression but also for treating those for whom nothing else worked. This small, tough core of patients who had not only fallen into a deep, black pit but were incapable of getting out again. These were the chronically ill for whom nothing helped, the kind of depressive patients who often wound up taking their own lives; it was this type of patient that, 50 years ago, were warehoused in state hospitals.
If only Mayberg could reach into their area 25!
It is a good question, but I was a little surprised to see it as the title of a research paper in a medical journal: “How Happy Is Too Happy?”
Yet there it was in a publication from 2012. The article was written by two Germans and an American, and they were grappling with the issue of how we should deal with the possibility of manipulating people’s moods and feeling of happiness through brain stimulation. If you have direct access to the reward system and can turn the feeling of euphoria up or down, who decides what the level should be? The doctors or the person whose brain is on the line?
The authors were asking this question because of a patient who wanted to decide the matter for himself: a 33-year-old German man who had been suffering for many years from severe obsessive-compulsive disorder and generalized anxiety syndrome. A few years earlier, the doctors had implanted electrodes in a central part of his reward system—namely, the nucleus accumbens. The stimulation had worked rather well on his symptoms, but now it was time to change the stimulator battery. This demanded a small surgical procedure since the stimulator was nestled under the skin just below the clavicle. The bulge in the shape of a small rounded Zippo lighter with the top off had to be opened. The patient went to the emergency room at a hospital in Tübingen to get everything fixed. There, they called in a neurologist named Matthis Synofzik to set the stimulator in a way that optimized its parameters. The two worked keenly on the task, and Synofzik experimented with settings from 1 to 5 volts. At each setting, he asked the patient to describe his feeling of well-being, his anxiety level, and his feeling of inner tension. The patient replied on a scale from 1 to 10.The two began with a single volt. Not much happened. The patient’s well-being or “happiness level” was around 2, while his anxiety was up at 8. With a single volt more, the happiness level crawled up to 3, and his anxiety fell to 6. That was better but still nothing to write home about. At 4 volts, on the other hand, the picture was entirely different. The patient now described a feeling of happiness all the way up to the maximum of 10 and a total absence of anxiety.
“It’s like being high on drugs,” he told Synofzik, and a huge smile suddenly spread across his face, where before there had been a hangdog look. The neurologist turned up the voltage one more notch for the sake of the experiment, but at 5 volts the patient said that the feeling was “fantastic but a bit too much.” He had a feeling of ecstasy that was almost out of control, which made his sense of anxiety shoot up to 7.
The two agreed to set the stimulator at 3 volts. This seemed to be an acceptable compromise in which the patient was pretty much at the “normal” level with respect to both happiness and anxiety. At the same time, it was a voltage that would not exhaust the $5,000 battery too quickly. All well and good.
But the next day when the patient was to be discharged, he went to Synofzik and asked whether they might not turn the voltage up anyway before he went home. He felt fine, but he also felt that he needed to be a “little happier” in the weeks to come.
The neurologist refused. He gave the patient a little lecture on why it might not be healthy to walk around in a state of permanent rapture. There were indications that a person should leave room for natural mood swings both ways. The positive events you encounter should be able to be experienced as such. The patient finally gave in and went home in his median state with an agreement to return for regular checkups.
“It is clear that doctors are not obligated to set parameters beyond established therapeutic levels just because the patient wants it,” Synofzik and his two colleagues wrote in their article. After all, patients “don’t decide how to calibrate a heart pacemaker.”
That’s true, but there is a difference. Few laymen understand how to regulate heartbeat, but everyone is an expert on his or her own disposition. Why not allow patients to set their own moods to suit their own circumstances and desires?
Yeah, well, the three researchers reflected, it may well come to that—sometime in the future, that is—people will demand deep brain stimulation purely as a means for mental improvement. (...)
Questions of pleasure and desire go right to the core of what being a human in the world is all about. The ability to stimulate selected functional circuits in the brain purposefully and precisely raises some fundamental questions for us.
What is happiness? What is a good life?
Hedonia. There is something about this word. It rolls across the tongue like walking on a red carpet and leaves a pleasant sensation behind. Hedonia might well have been the name of the Garden of Eden before the serpent made its malicious offer of wisdom and insight. And more than anything else, hedonism has become the watchword for how we should live.
The absence of joy and pleasure—anhedonia—has, in its way, become a popular issue in the wake of the disease depression. A quarter of us are affected by it over the course of a lifetime, various studies suggest, and its frequency is increasing in the industrialized world. The treatment of depression has become both a window display and a battleground for deep brain stimulation.
It was with the American neurologist Helen Mayberg and the Canadian surgeon Andres Lozano that the method got its breakthrough in psychiatry. It struck a sweet spot in the media when, in 2005, the two published the first study of deep brain stimulation for the treatment of severe chronic depression—the kind of depression, mind you, that does not respond to anything—not medicine, not combinations of medicine and psychotherapy, not electric shock. Yet suddenly, there were six patients on whom everyone had given up who got better.
At once, Helen Mayberg became a star and was introduced at conferences as “the woman who revived psychosurgery.” Later, others jumped on the bandwagon, and now they are fighting about exactly where in the brain depressed patients should be stimulated. It is not just a skirmish between large egos but a feud about what depression really is. Is it at its core a psychic pain or, rather, an inability to feel pleasure? (...)
Mayberg focused on a little area of the cerebral cortex with a gnarly name, the area subgenualis or Brodmann area 25. It is the size of the outermost joint of an index finger, located near the base of the brain almost exactly behind the eye sockets. Here, it is connected to not only other parts of the cortex but to areas all over the brain—specifically, parts of the reward system and of the limbic system. That system is a collection of structures surrounding the thalamus encompassing such major players as the amygdala and the hippocampus and often referred to as the “emotional brain.” All in all they are brain regions involved with our motivation, our experience of fear, our learning abilities and memory, libido, regulation of sleep, appetite—everything that is a affected when you are clinically depressed.
“Area twenty-five proved to be smaller in depressed patients,” Mayberg relates, adding that it also looked as though it were hyperactive. “At any rate, we could see that a treatment that worked for the depression also diminishes activity in area twenty-five.”
At the same time, it was an area of the brain that we all activated when we thought of something sad, and the feeling that area 25 was a sort of “depression central” grew and grew as the studies multiplied. Mayberg was convinced that this must be the key—not just for understanding depression but also for treating those for whom nothing else worked. This small, tough core of patients who had not only fallen into a deep, black pit but were incapable of getting out again. These were the chronically ill for whom nothing helped, the kind of depressive patients who often wound up taking their own lives; it was this type of patient that, 50 years ago, were warehoused in state hospitals.
If only Mayberg could reach into their area 25!
by Lone Frank, Nautilus | Read more:
Image: Pasieka / Getty Images
