Art and Humanity in Behavioral Neurology with Dr. Michael P.H. Stanley

Episode Transcript
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Dr. Michael Kentris (00:01):
Hello and welcome back to The
Neurotransmitters.
Once again I am very pleased tointroduce a new guest, but
first I should probablyintroduce myself.
I'm Dr Michael Kentris,Neurologist in Ohio, and we are
here to talk about everythingrelated to clinical neurology,
and perhaps beyond, today.
So I want to thank andintroduce Dr Michael P.

(00:23):
H.
Stanley.

Dr. Michael P.H. Stanley (00:24):
Thank you very much for coming on talk
today.
It's a sort of Mike and Mikerecording.
It sounds like.

Right, like those old radio shows, Mike and
Mike in the morning, right,exactly.
So tell us a little bit aboutyourself, your background and
your role in the greaterneurology sphere.

Sure, absolutely so.
Currently I am a behavioralneurology fellow at the Brigham
and Women's Hospital.
And how did I get there?
From there, I guess, ratherthan there from here?
So I started out in Maine.
I went to school in Maine, thenwent to Harvard for my

(01:03):
undergrad and then went backactually to Maine.
I split the difference.
I was at medical school atTufts in what was called the
Maine Track Program, so my twopreclinical years were in Boston
and Chinatown and my twoclinical years were up in the
great state of Maine.
And then I came back to Bostonto do the National Brigham

(01:27):
Neurology Adult NeurologyResidency.
And that is the kind of theimmediate, or I should say the
goalposts.
And then you tell me where youwant to talk about something
else.

Now you know you're our first kind of
cognitive, behavioralneurologist that we've had on.
So neurology, brain, nerves,everything in between.
But this particular emphasis isprobably more of the more, as
it says, on the tin, behavioralaspect.
So how does one wind up being,let's say, attracted to that and

(02:02):
then pursuing that as asubspecialty within the field
that's?

a great question, very, very good
question.
So firstly, one way to look atit is that you're always
speaking to the organ inquestion, right, I mean, it's
the only field that allows thator asks that.
Right, you get a kidney problem.
You're talking to Mike and tofind out if it was kidney, but
you got a brain problem talkingto the organ in question.

(02:28):
So that alone is very seductivefor many people.
They think, wow, this is kindof a complicated situation to
begin with and that's intriguing.
And then, furthermore, becausethe nature of the questions in
cognitive neurology are depth ofconsciousness, content of

(02:48):
consciousness and theexpressions of those which are
largely behavioral, personality,language, the things that come
together to make us us, that is,it's a humanistic discipline by
its very nature.
So I think that's the other wayto be kind of seduced into the

(03:10):
subspecialty.
It's also an area of incredibleresearch opportunities.
We've just seen in the past fewyears the first real disease
modifying treatments for some ofthe diseases of cognition, like
Alzheimer's.
So it's available or amenableto people that are actually

(03:31):
still kind of bench researchersor clinical trial researchers,
where it is the cutting edge ofneuroscience.
There's still enough whitewhales that are out there, as
opposed to just putting yetanother drug out there.
I don't know, this is the firstone, so that's the other way to
be kind of attracted to thefield.

(03:51):
And then, of course, from therethere's a lot of ways to define
oneself within it.
So, unlike subspecialties,where they are disease specific
and that's what you study,that's what you learn, or that
are diseases of a particularpart of the neuro access, by
definition One could consideroneself a behavioral neurologist

(04:17):
or a cognitive neurologist or aneurocognitive specialist.
If you come to this fieldthrough psychiatry, it's
neuropsychiatry, and each one ofthose labels, splitting the
semantics, actually does placeemphasis on how you view this
relationship between the beingand the brain, and so that's

(04:40):
another way.
Once you're even there,training aside, there comes the
how do you view yourself andwhat kinds of what are you
treating?
And that has a lot to do withwhat label you decide to use.

Yeah, that's an excellent point and
this is something I don't thinkwe kind of mentioned in our
pre-show talk, but I'm curiousfor your take on it.
There's been a lot of pushbackin recent years in the concept
of dualism and I see your eyeslight enough there, and it's one
of these things.
That so my background.

(05:16):
I'm an epileptologist, althoughI'm doing mostly general
neurology these days, and so wesee a lot of these functional
neurologic disorders which I'msure show up on your radar not
infrequently, and this pushbacklike the mind versus the brain.
Is there really any substantivedifference?
What's your kind of take?

on that.
That is, there's a long answerand there's a short answer.
The long answer is probably forits own, not just podcast or
episode, but probably series orlife's work.
The short answer to that is tothink about situations in which

(06:03):
because you've wrapped up thefunctional question and so those
are two separate functionalneurological disorder or
functional symptoms are oftenexplained to patients by using
this concept of hardware andsoftware that's often kind of
employed.
You say well, if this was ahardware problem, you'd see a

(06:24):
stroke or you'd see multiplesclerosis lesion or you'd see
something like that.
But this is not a problem withthe hardware.
It is often how it's explainedto patients.
You say, well, this is aproblem with the software.
But if you actually press thoseneurologists or the
psychiatrists about theirunderstanding fundamentally
about what is hardware and whatis software, it becomes very
clear that this is a veneer of ametaphor.

(06:47):
It's not a well thought outmodel and because it gets
immediately back to thequestions that you're asking
about, it's like what do youthink?
Is it all in one?
Are there kind of separatesituations?
And this of course leads tomany examples where neurology is
in this in-between zone andshould have more to say.

(07:08):
Neurologists could have more tosay about it, but usually don't
.
A good example of this is inlanguage.
When we think about either aconnectionist or a connectionism
approach to language, which Ithink in the most recent
continuum issue for behavioralneurology, the section on
language, the introduction doeskind of state as a matter of

(07:32):
fact from on high, as if it's arevealed truth, that
connectionism is the way itworks.
Now, if you ask a number ofprominent linguists and
neurolinguists about that thereare severe issues with accepting
that to the degree that it'saccepted in that continuum
article.
So these questions are open.

(07:58):
The best way that I would liketo think about it is a nice line
by Hugh who goes tell me that alover's touch is more than
nature-changing genes.
So on the one hand we arebiologically constrained, on the

(08:23):
other hand we are kind ofculturally liberated as
creatures, as species, and ifyou begin to think about what
that means in terms of whatcognition does for us, even
something like language is, itallows us to really escape
fundamentals of a purely sensory, motor, concrete world.
I can come up with things likethe concept of or either or

(08:47):
Either.
Or has no representation in thereal world.
It's purely a product oflanguage.
Another would be thinking aboutAustin, the philosopher, who has
this notion of performativeverbs, verbs where they take a
word like promise to.
I promise to be on the show.
It doesn't exist anywhere elseother than in the language.

(09:10):
You could say well, michael, Icould write it on a piece of
paper.
It's a promissory note.
That's different, right?
The sense of it is evendifferent.
So what's very intriguing aboutcognitive neurology is that
these problems and theirdifficulties and these dogmas
that are kind of well theschools of thought that people

(09:31):
die on hills from, they all fallapart when you're in your
clinic.
That's my point, to slowly butsurely work my way around not
answering this question.

Right, and I think that's kind of the other
thing right.
We're in the process of tryingto find a lot of these answers.
Still To your earlier point.
It is that research element ofit where a lot of people talk
about the Star Trek fans outthere, the Final Frontier being
out there, but I think you couldjust as easily make the
argument that you can turn thatsame microscope inwards, because

(10:08):
there's still so much we don'tknow about how our own cell is
functioned.

As far as we know, for our species
there is no access to mindwithout a brain.
So that's one statement thatyou could make.
That's pretty good, stable anda very weak statement actually.
But that's about as far as wecan actually go.
As far as I know, in ourspecies there is no access to
mind without a brain.
The next thing, which of courseimmediately troubles that and

(10:34):
then pulls the rug right out ofit right from under you is to
say, but what about a book?
Now I've got information forthe first time where, yeah, I've
got evidence of mind.
Right, there it is.
It has language, it has ideas,a figure that's drawn, a symbol
that indicates stop or danger,same sort of thing.

(10:54):
There's evidence outside of thebrain, but it took a brain to
make it right.
So you get into thosesituations.
I think Fran Liebwood says thatline closest thing to a person
is a book.
Right, it's got mind, it's gotlanguage, it's got these
features.
It looks terrifying to her tosee a book in a trash.
Can I think she has this line?

(11:15):
It's like seeing a severed head.
It's an awful thing to do thatto a book.
What she's getting at comically,but it is a serious point is
how extraordinary this thingcalled cognition, the processing
of information, external andinternal within the brain is,

(11:35):
what a profound faculty that, aswe were saying in our prequel
to the recording, there arefundamentals like the brain.
Then there are thesefirmamentals, the thing that
it's drawn to, or VictorFrankel's lines about being
pushed by drives, pulled bygoals.
In many ways you could say well, the metaphor of that is

(11:59):
between your brainstem and yourbasal ganglia, up into your
limbic system on the one handright, and then these like
incredibly noble properties thatcome abstractly from the
neocortex.
Just to make that kind ofmetaphor is something you get to
do when you're in neurologythat you don't get to do in

(12:20):
other fields.
That's to me kind ofinteresting.
To your point about externalintro, there are astronauts, but
I think we should think aboutourselves as neuronauts.
What do we do in our clinics ascognitive neurologists?

exploring stuff, yes, no, that's a very
interesting take and I'm goingto bring us back down to earth
for a moment.
I know I took us off the railsquite quickly, but for those who
might be, let's say, newer tothe neurosciences or the
practice of clinical neurology aword that you see thrown around

(12:54):
very often in communicationpieces, like you were saying
about these drugs that came outin the last few years dementia
right, dementia is a word that'sthrown around very often in the
public discourse and a lot ofpeople I'm sure you encountered
this as well last, like you knowwhat we say dementia.
What do we actually mean whenwe say that?

Oh yes .
So dementia here again, thistheme will keep coming back and
forth of avoiding questions of,you know, being identity,
personhood on the one end, anddriving it into things that feel
more familiar to us or feelmore comfortable to us, which

(13:35):
are the biology.
So one way to look at this iswith this term, dementia.
So dementia has a history and acontext all on its own right.
Which is to say, we've heardAlzheimer's dementia, frontal
temporal lobe dementia, dementiawith lewy bodies, those sorts
of things on the one hand, andthen on the other hand is well,

(13:59):
but what is dementia?
Okay, if we use Alzheimer's asthe adjective or frontal
temporal lobe as the adjective,then okay, thank you.
But what is dementia?
And if you look at the currentdefinitions for it, it's
actually, it's a functionaldefinition.
By then I mean it has to dowith how well a person is doing

(14:20):
right, but it's actuallyagnostic to what is the origin
or the source, so how itprobably makes the most sense to
explain it in the context ofthe progression.
So if a person has a memoryproblem and they say I have a
memory problem but it doesn'tinterfere with any of my
instrumental activities of dailyliving, then I call it

(14:43):
subjective cognitive impairment.
If I say, well, I do have amemory problem and it is, I
catch it on my testing.
I go ahead and get a mocha or amental status or a slums or any
number of these things, nowit's mild cognitive impairment.
And if I experience a memoryproblem and your doctor finds
evidence of the memory problemon testing and you lose one

(15:08):
instrumental activity of dailyliving, now you qualify as
having dementia.
It's not a mild stage ofdementia but it's a dementia in
the less.
Now that is purely a definitionbased on function, right, how
well somebody is doing.
It doesn't actually give anyinsight into what the underlying
disease is, right, whether itis the origin from Alzheimer's,

(15:29):
from Sorrento Temporal Loan,from Louis Vaudev, you name it.
That being said, the kind oftradition or the underlying
current or the theme is to sayif I am using that spectrum to
begin with, if your doctor isalready saying subjective
cognitive impairment or mildcognitive impairment or dementia

(15:51):
slash, major neurocognitivedisorder, that doctor is already
thinking about a degenerativedisease.
That in some ways applying itto a stroke or applying it to a
traumatic brain injury on itsown almost feels like a
nozological incompatibility tomany people.

(16:12):
They go well, you should beusing a different term.
But if you are going to use SCIor MCI or dementia, you are
kind of token that the originand question is going to be
degenerative.
Now, that's not an absolutetruth, but the way that it is
thought, the way that it is usedand the way that it is
researched is usually with thatin mind.

There is a certain connotation to it.

At least a connotation.
I think it is a denotation thatis little thought of, as
opposed to a.
It is more than implied and itis certainly more than inferred.

Got you.
No, that's a great point.
That is certainly one of thechallenging parts that we see
like a deficit To your pointwhere we are talking about these
declines in abilities of dailylife.
Everyone starts from adifferent functional level.

(17:14):
We are saying that this isdifferent than normal.
We wind up well, what is normalfor a certain person?
Everyone has differentintellectual capacity, that they
start with different levels ofeducation.
I know that is something thatthey try to account for in some
of the more in-depth batteriesof neuropsychologic testing.

(17:34):
But in your experience, howmuch of a role does that
starting point play in making adiagnosis or a delay of
diagnosis?

It's a huge issue If you think about
it.
Take something very basic likeorientation With the medical
students, when I do differentlittle lectures or little chalk
talks about cognitive domains orcognitive elements, I usually
ask them what does it mean?
We could take this, for examplewhat does orientation mean?

(18:14):
What does it mean to beoriented?
Usually the answer that you getand you get this answer from
cognitive neurologists orbehavioral neurologists as well
it's about knowing the date orit's about knowing where you are
in space.
That's orientation.
That's not orientationexplicitly.
If you're looking at a mocha ora mini-mental status or a slums

(18:36):
they all have as an element ofit very specifically, with
points assigned to it, does heknow the day of the week?
Does he know the year?
Does he know the month?
Does he know the specificlocation?
Does he know the county?
Counties are a very interestingthing to look about for
orientation.
There are some regions of thecountries where counties are
extraordinarily important.

(18:58):
They have salience where themini-mental status was developed
.
Counties did have a lot to say,whereas parishes in some parts
of Louisiana might have more tosay, or awards in certain parts
of Massachusetts.
So you get my idea thatactually what orientation is is

(19:21):
not very discreet things likedoes he know the date or does he
know the location?
What does he have command of?
The whereabouts and whenaboutsthat are sufficient for him to
act as an actor in a world ofmeaningful decisions?
So, if you are so now to grindthis back down into earthly

(19:44):
matters, if a guy is retired andhe spends most of his time
fishing, what need has he forthe month or the day of the week
, right, correct?

Before.
I feel that same way Right.

And how many of us have looked to
double check.
When we say, oh, what's the dayof the month?
And they say it's the 27th andyou're looking like, hold on,
let me look and see if it is Now, what makes it?
Why should we take a point offof them?
But not a point off for us,right, because it goes to this
fundamental question is thisbeyond what we would consider

(20:27):
normal?
So now we're in a world ofjudgements, value exeology,
value judgments.
Is this what is sufficient forthis patient in front of me to
go about the world in whichthey've told me they go about it
?
That's actually much moreuseful than finding out if they
know if it's the 21st ofNovember.
So what do you do if the guydoesn't know what month it is?

(20:51):
But he can tell you aboutwhat's going on in the news and
he can right.
So those are the things thatdon't get captured on basic
screens and might even not getcaptured in terms of formal
batteries on more intensivescreens, but they do involve an
interpretation and a synthesisand an analysis in the context

(21:15):
of.
I think that's actually anotherfeature of what cognitive
neurology provides.
That is interesting is that weare very context dependent in a
way that other fields aren't,because other fields it's either
there or it's not there.
Again, going back to your sortof troublesome dualistic thing
that you decided to knock me offmy perch with as an intro

(21:36):
question, right, which is sortof just to say, well.
I don't know, I don't reallywant to say.

Yeah, and I remember one of my instructions
and I think that's like, as wekeep saying, a very fundamental
aspect of neurologic assessment,just in general, is the context
.
I always remember one of myinstructors would always tell me
what is the company that itkeeps in terms of the symptoms
or, in her case, different EEGfindings?

(22:04):
Is it in the setting of anotherwise abnormal background or
a normal background?
Are we seeing, like if we seeone isolated abnormal reflex but
everything else is fine?
How hard do we go into thatworkup?
And it really is one of thosethings where it's like what's
the sensitivity and specificityof what I'm doing?

What makes a seizure a seizure Right?
Oh my goodness.
Well, I mean, but that's mypoint is there are what seem
like obvious infirmities in mysubspecialty, because of the
sort of squishy nature of someof the questions that are asked

(22:48):
are present in pretty much everyother part of the neuro axis as
well, or the other soespecially.
It's just much more cleverlyconceived, right, because you'd
say, well, it's a seizure, butit's not a convulsive seizure.
Okay, so it's a nonconvulsiveseizure?
Okay, well, but it doesn't havean epileptic correlate.

(23:09):
Okay, what do you mean by anepileptic correlate?
Well, it has this particular.
And then all of a sudden youstart to realize that what
you're dealing with is just ashard now as it was for
Hippocrates, right, you know.

Right, yeah , some of those writings, some
of the descriptions are very,very similar to what we elicit
in our histories like 2000 yearslater, and it is uncanny how
unchanged in general the humanis over what we would consider
in our brief lives, right.

Well, you make an extraordinary
spanner, a very astute point,which is that there are only so
many ways it can go wrong interms of output, right, so there
are many, many inputs that arefaulty.
There are enormous amounts ofgenetic reasons why somebody
could end up with thisparticular tremor, or there are

(24:07):
enormous number of structurallesions a person would have that
would lead to this particulartremor.
But isn't it a funny thing thatthere are only so many
frequencies we see of tremor.
There are only so many kinds ofmovements.
There are many, many.
We have a hard time binningcertain movements, like God, is
that Korea?
Or is that?
You know what is it?
But there's only so many.

(24:28):
In other words, there areload-bearing walls of
phenomenology that become useful.
And the same can be said as wejust talked about for movement,
or as one might think about forhow something might propagate as
an epileptic potential or aspreading depression in a
migrant phenomenon.
But there are only so many ways.

(24:50):
It doesn't.
And that's actually a veryuseful anchor for an astute
scientific clinician, supposedto a clinician scientist, that
they look at the world aroundthem.
And so I see this cognitivelyin my clinic where, if you take
a disease like you know, what iscalled Alzheimer's disease,

(25:13):
which has all of these differentsubtypes as defined you know,
you can have a posteriorcortical variant where they lose
vision in the back.
There's a dis-executive variant, right, but that's also.
It's defined by its amyloid.

No, I think that's a great point and I
think we've seen numerousstudies in different
subspecialties within neurology,like epilepsy or movement or
dementia, where if you look atthe clinical diagnosis that was
made and then in those whounderwent autopsy down the road,
there's very often a lot ofdisparity between the phenotype

(25:55):
and the underlyingpathophysiology.

that we ultimately developed.
So again circling back to yourinitial question, your profound
one, which I still don't wish toanswer right, is to say, okay,
there are a billion differentgenetic reasons, and
pathologically, is it aproteomic reasons?
And et cetera, et cetera, etcetera.
That could look like this onething you know, an amnestic

(26:20):
syndrome.
So that's one direction.
You could also say that thisprotein, same protein, could
look like many other things, soyou could have.
So you have amyloid diseasesthat can be amnestic, or
anything else you have.
And then you have the reverse.
So you either get to say I'monly going to believe in

(26:41):
proteins and I'm going to ignorethe phenomenology, or you could
say, well, I'm going to keeplooking at the phenomenology,
which is what, for example, likeMarcel Messelon did, where he
took a thing like aphasia, aprogressive aphasia, and they
said wait a second.
If we actually dope out the waysin which their language is
impaired, if we take a trulyphenomenological, semiological

(27:05):
approach to the languageimpairments themselves, we
actually see subcategories and,lo and behold, some of those
subcategories are very specificin terms of which proteins go
wrong, which diseases relate tothat subtype.
So all of a sudden, we salvagethis idea, which is what
neurology came out of right,which is that if I localize

(27:26):
really well, it tells me notjust where but what.
And as we've gotten to sort ofdrill down deeper into biology
and biochemistry, we start toquestion that, oh, maybe it
doesn't really matter at all.
And you go, no lo and behold,still works.
Still good, you know, but ittook.
What it took was a veryprofound and thoughtful approach
to what is a phenomenon, whatis a semiology, and then the

(27:51):
right kind of research apparatusto then uncover the
relationship between these kindof protein etiologies and the
cognitive domain.
That's effective, the way thatit's effective.

Yeah, I think no, those are.
Those are all great thoughtsand I find when I'm working with
trainees whether they're, youknow, residents from other
specialties who are rotatingthrough, or medical students, as
you said earlier, with ourdifferent like mochas and MMSC,
is our different kind ofcognitive batteries that we do
at the bedside, that you knowthey'll come back and like, oh,

(28:27):
the patient got a, you know a 25out of 30 or what have you, and
I'm just like, okay, well, inwhat domains or what were their
deficits within that?
Like, how does that translateinto, like, what they're
presenting with?
You know, very often, you know,I'll get a call from the
emergency department.
Let's say, the patient'saphasic and very often maybe

(28:50):
they're just really disart rightor an arthric, even to the
point where they cannot producespeech, or you know.
So I find a lot of it istranslating Like I've observed
this phenomenon but I don'trecognize what I'm observing.

Oh, yeah, or your point about.
So let us take a screening test, you know, like a mocha or an
MMSC or a slump, and I mean Iwould bless it.
I mean there are many, many,many, and the only reason I'm
bringing these up is becausethey're common.
This applies to most, all ofthem.
But you know, when most ofthese tests were done, they were
normed on less than 200 people,and they were normed I mean.

(29:27):
Now we've got many more decadesand they've been applied to
different things.
If you think about it, many ofthese were normed on, like less
than 200 people.
They were usually as a whole,right.
So let's take the mocha, forexample.
Early on and initially, as itwas produced, the fact that you
got all of the points wrong onmemory as the result of getting

(29:47):
you below the threshold of whatwould be considered abnormal did
not have statistical power tosay that you had a memory
problem any greater than youknow.
Pick three random words, right.
So its statistical power wasthat you had less than you know
26 or less than 25, less thanthat.
That's the cutoff where there'ssome statistical power, not on

(30:11):
the subset of the sections ofthe mocha, right?
That's similar to many of theother screening tests.
So it's funny though, becausewe've got numbers, because we do
like numbers, we love numbers,you know.
I mean people forget what's theline for that Neil Young song
numbers add up to nothing.
This is true.

(30:31):
You have to know what you'readding, you know.
So here's a good example whereyou're looking at that mocha and
you're asking your student theright question, which is well,
where are the deficits, what arethe deficits?
But you're not askingintriguingly and I don't think
you've ever asked this, forexample well, how much deficit

(30:52):
based on that mocha?
Right, and has that those wordsever left your mouth?
Where you look to the trainingon how much, how much, how bad
is it based on that mocha?

Well, I do tend to be a little flicked, so
I might have said something thatI effect, but not expecting an
answer.

But you do ask where and what, and
that's which means that'sactually where the, where the
doctoring comes in right and inthe, the thinking the thoughtful
nature is is to look at thespread of the deficits, except
from right.
Right, at that moment I am nowgoing off of empirical, I've
left the empirical world.
You know, I am no lie, I am inthe data free zone as soon as I

(31:29):
start to say, well, yeah, butthe, that first top section was
all wrong and they don't,statistically speaking, they
have no, not statisticallyspeaking.
You are now making qualitativeassessments.
You know, I mean, I've got thisbag, this toolbox, filled with
all sorts of things that have nonorms whatsoever to them, right
, but a lot of things don't havenorms to them but are

(31:52):
nevertheless entirely use, veryuseful.
They just don't have a number.
I think we get very caught upwith numbers.
We like numbers.
But if you start to push andpull and you say, well, is this
really a phenomenon that can bequantitative?
And if so, is it on a discreet?
Is it discreet, is it adiscreet?
And you start to ask thosequestions of people, and again,
you, you, you find out prettyquickly how shallow those

(32:14):
principles are, and it's anotherreason why cognitive neurology
is fascinating, because you getto, you get to sort of, you
figure out quickly where areyour weak spots, like you were
where you decided that youthought this was, this was
stable ground, and your eyes itis not stable ground, and so
it's very much like you and yourpatient out on the moors, you

(32:34):
know, trying to figure out howdo I not step in something and
sink.
You know the goal is to try tomap out for them what's what's
real about their disease,because they want to know not
just what's happening now butwhat's happening later.
You know, if you have a, let'ssay, your mocha has no
orientation, the guy has nohistory of a driving problem, do

(32:56):
you say, well, I'm going totake your license, like those,
those kinds of fundamentalquestions we don't have great
answers to, and so a lot of itis this judgment where you go.
Well, I can see visual spatialdistortion, I don't have a
number of effects to it andwe're starting to get numbers.
I mean, there's some, there'ssome, there's some good
neuropsych testing that showsessentially a correlation

(33:18):
between a trails be of longerthan three minutes or more than
three errors, seems to be, seemsto be a naughty point.
People do well.
People do well driving perhaps.
But things get really bad whenyou look at more than three
minutes for a trails be or morethan three, three errors.
So like that's a useful test.
But you'd have to, as acognitive neurologist, know that

(33:39):
, know that's what you're afterand stick to those guns and sort
of say I'm going to use thiseven if they look great.
So again, you figure out whichprinciples you let go and which
principles you hold on to forthem home.
And you know in this field,yeah, that's.

That's a really challenging thing,
because every every person'sconstellation of symptoms can be
very varied and it will changeover time.
Right, that's a great point,right.
A lot of these dementias areare progressive, you know,
neurodegenerative conditions,and so from one year to the next
, it is a moving target in termsof counseling and safety and

(34:19):
all that.
So how do you tend to grapplewith that with with your
patients who are, let's say, inthe earlier stages and maybe
have more insight into thecondition?

I?
I always start asking you knowwhy?
Why have you come?
How can I be helpful?
What are your concerns?
You know what.
What are the what?
What do you need to know to goabout your business?
Because then, in the course ofdoing the, the work up, you
start to figure out okay, I knownow what this is, or I think I

(34:49):
know what it is.
I'm going to tell you what.
If you want, what the name ofit is, I can tell you, based on
what I think it is, how this isgoing to go in terms of months,
years or or so, and what onemight see or expect to see
sooner rather than later.
So you can sort of limb out arough cartography of, of the

(35:12):
clinical progression, but youhave no idea if that's going to
actually match that person ornot, and so a lot of it requires
close communication, askingquestions that you think they
may have but feel tooembarrassed to talk about, and
or ask questions that really tryto discern.

(35:35):
Is that in the same with aneuromuscular doctor?
It doesn't take it for grantedthat the person says they're
numb right, they go well, numbor tingly or weak, and they get
examples.
Neurologists are so in thatzone of questioning and
qualifying everything.
And imagine doing that in afield that's mostly subjective,

(36:00):
right, like, is it a memoryproblem?
Well, actually it's anattention problem.
Well, what do you mean?
It's an attention problem.
I can't remember something.
Well, if the flashlight's off,you can't see anything.
To begin with, right, if yourattention's off, you got nothing
to look at you.
Or, and it's a lot of it ismetaphor making, because you're
you're trying to give the personin front of you a model to

(36:26):
understand what's going on,because, again, you're asking
them the brain to questionitself.
So you know, a lot of it issaying, well, memory is like a
well, and I'm going through thereasons of like, why that could
be, and like which parts of thewell are busted, and and then
seeing if that works andlistening.
If that doesn't work, picking adifferent one.
You know, because a lot of whatI do which cannot change

(36:51):
fundamentally the, the origin,you know the ideology, is a lot
of tuning up.
It's a lot of tuning up andlike asking about sleep and why
the CPAP might be importantReally, and then you know having
to try to come up with ametaphor that will make sense,
like, oh, you got to rechargeyour battery.
I mean, have you ever had alaptop?
You know those kinds of things.
So it's, it's always a movingtarget, not just in terms of the

(37:17):
disease but the person'sunderstanding of the advice that
you're giving.
You know, the metaphor ischange, even if the, as the
disease changes, in order to getsomething that makes sense to
them, because the, the apparatusthat is the sense maker, is
what's going bad over time.
And then there's always thetoggling between what makes

(37:38):
sense to the patient, as bestyou can, and what makes sense to
the, the other people in theroom, the other people at home.
You know, oftentimes it's, it'sthey're much more distressed or
bothered by than the patient,depending on what the, the
impairment is.
So you have to negotiate thatsituation where, well, even if

(38:00):
the patient isn't bothered bythis, if the loved one is, it's
going to lead to an agitatedmilieu.
So in some ways I have to alsotreat that patient's loved one,
because whatever bad vibes thatloved one's going to give off is
going to make that milieuuncomfortable for the patient.
And so, which I think is afairer way or a more honest way

(38:24):
than saying like, and I treatthe family too.
I think, I think I think I getyou get to do that if you're in
family medicine.
That's the glory of familymedicine, I think.
I think it's a it's it's unfairannexation for a neurologist to
say and I treat the family too,because we don't have that
training.
I think it's fair to say.

(38:46):
But I can look at what theimpact of this relationship is
going to be on the, on thepatient, and therefore try to
treat or alleviate the, theenvironment that that patient's
in.

Right, yeah , we know no caregiver.
Burnout is especially in those,those long term conditions,
yeah, very huge impact.

And, and there's a lot of internal
turmoil, there's a lot of selfblame.
Unfortunately, a lot of time isspent not on himming and
harming over this or that pill,but in trying to reconcile a
loved one's experience to thepatient and what these behaviors

(39:31):
are, what they mean, what theloved one's responses to those
behaviors, which is often a verynatural response or even
correct response, butnevertheless feels bad, carries,
guilt, and so then you have tosort of do this thing of
reconciling.
Going back to your initialquestion, uncomfortable as it is

(39:52):
, how does me relate to my brain, right, and all those
troublesome philosophicalprinciples of agency and
volition and insight, and those,those are the, those, those
linchpins start to get separated, and it's really that's where
the bulk of that's where theheavy lifting is for, for I

(40:14):
think a clinician in this fieldis is is reconciling those
features of you know the who andwhen the who goes awry.

No, that's.
That's a well put Anecdotallyin your your own clinical
experience.
What do you find are the mostdisruptive symptoms to to a
stable home life and someoneremaining in a home as opposed
to moving more towards kind ofan institutional setting?

Lack of insight is the thing that
leads more than anything else,because lack of insight or poor
judgment is what precedes unsafebehaviors.
Right.
So so, although early on, formany, many people the short term
memory problems or some troublein coding or registering

(41:06):
information is distressing.
Right, because you go.
I should have remembered thator I should have written those
things are very distressing.
Ultimately, you can build a lotinto your schedule and routine
and regiment and you know, withvery little memory, go about a
lot of activities and still dothings and enjoy and you know,

(41:27):
be functional.
Right.
But but when the executivecomponents or those kind of
higher level executivecomponents of insight and
judgment, when they start to gowrong, that's where unsafe
behaviors set in or that's wherethere's risk to self or others
and that's where this questionof independence really starts to

(41:49):
go to rear its ugly head.
So a lot of it is is a lot ofit is spent on trying to
understand not just where thereare holes in a person's
cognition, but but actuallyfigure out like do they notice
it, do they recognize it, how dothey feel about it, what do
they do around it?

(42:09):
One of the earliest signs yousee in memory problems, of
course, a patient comes in withhis wife and you know they sit
down and you're having aconversation and you say, so,
well, you got any pets, you know, mr Smith.
And Mr Smith says, yeah, I gota dog, you know.
And you say, well, what's thedog's name?
He looks to his wife right Now.

(42:30):
The first order clinical is yougo, aha, I'm every problem
because he's looked to his wife,he's has an amnestic problem.
A second order clinical pointis to go, but what strategy he
has employed?
He knows that his wife is asource of information and he
turns and defers to her.

(42:51):
Okay, right, that's verydifferent than somebody who
gives an answer that isincorrect and you see the wife
correct and say no, that's notthe dog's name, you know,
confabulation or things likethat or can be troublesome or
can be dangerous, whereas thatkind of turning and learning is
good and they learned that.
I mean, you think of this as adisease.

(43:13):
That is all regression, butthere's, you know, learning and
development go hand in hand.
So if there's a sign oflearning or accommodation, that
is to some extent a sign,cognitively, of development and
so that's a good sign.
I take that as a bad memory,but good sign right.
Bad memory, but good insight.
They learn that.

Right?
No, that's a great point, and Iknow agitation as the disease
progresses is often frequently atroublesome thing for keeping
people at home as well.
What role?
Obviously counseling is a hugeelement of this, in terms of you
know whether people are havinghallucinations or delusions or

(43:55):
things of that nature.
I've heard different schools ofthought on how much family
should engage with thesethoughts.
What's your perspective on that?

Dr. Michael P.H. Stanl (44:06):
Embedded in that question are two things
.
So one of the words that youuse is agitation, and then kind
of beneath or within that yousort of already were talking
about.
Well, that might be a source ofagitation, which I think is
what you're if I dope this outright is like hallucinations and
delusions.

Yes, Well, but they might be treated
differently, yeah, right.

So, for example, the most common
form of agitation, right, whichwe don't necessarily think about
as agitation outright, but itis is the frustration one gets
with the failure as a result ofthe cognitive issue.
So, memory, right, and then youknow it starts as, just, you
know, shocks, right, and then itbecomes losing your cool,

(44:56):
sweating the small stuff, andthen you know, then it's a full
blown tantrum.
That's that progression, right?
Well, that, if you think aboutit, is nothing more than not
being able to put a lid or aregulator on what is a very
reasonable response, right, it's.
It's so.
The way that one deals with thatcould either be with the person

(45:19):
themselves and thinking well,what is, do they have enough
wherewithal to count and talk tofive?
You know, count, stop and talkto five.
Count to five Is it the abilityto say, step away from the
problem, think about it and comeback.
Then you get to a point wherethose aren't, those are not
abilities one has, and then youcan say, well, can I use a

(45:41):
medicine to regulate theautonomic system, to put a
governor on that?
So you know, there may becertain kinds of blood pressure
medicine, pills, but actuallyactually, rather than the
antisecotic and putting agovernor on it, or am I using
antidepressant or anti anxietymedicine to kind of get put a
regulator on those reactivities?

(46:01):
That's one approach.
Now you raise a separate issue,which is the question of what
does one do about a delusion ora hallucination, and a lot of
that again has to deal with whatis the interaction that the
patient has with said delusionor interaction.
Have you seen?
There's a nice little meme outthere.

(46:23):
The person says something likeI just heard a rumor the other
day that the Loch Ness monstermight just be a ghost of a
dinosaur and then as a dot dotdot and says as this idea causes
no harm to anyone, I'm going tobelieve it as a little treat to
myself.

Right, Well , I like that yeah.

Dr. Michael P.H. Stan (46:48):
Delusions for some are fantasies, for
others, the question is aboutharm in many ways.
So you could look and you couldsay is the delusion that the
person has harmful?
They just talk about it a lotand so it's annoying.
And then again, how you'reasking am I treating the, who am

(47:08):
I treating and how my verseversus?
Is there a quality to thedelusion, right, is it?
Is it an ego dystonic thing,something paranoid, something
hurtful, something scary?
Well, that needs to beaddressed in a way that you know
an idea that the neighbors havea lot of parties, okay, well,

(47:29):
is that?
Is it bothering you?
Is it just a thing that youknow, or an idea that you have?
And so that could be thedifference between an
antisecotic and minding it orplaying around with it or, you
know, ignoring it.
Where are the challenges?
Again, now I'm getting kind ofairy, so I'll ground it.

(47:52):
Think about think about a LewyBody Disease, where they have a
lot of visual phenomenon right,visual hallucinations and or
posterior cortical atrophies ingeneral, which are at a greater
risk of a thing called CapgrassSyndrome right, where you look
at a familiar person but findthem to be an imposter.
So I have a number of patientswhich are in this, in this

(48:14):
situation, and what we've beenable to do early on in some of
these diseases or some of thesesyndromes rather, is use a
different sensory modality toprovide the positive feedback
they need to check themselves,right.
So that could be something likehaving the person presumed an
imposter, leave the room andstart talking or singing or some

(48:36):
sense that oh yeah, that'stheir voice.
It could only be MichaelKentress' voice.
I know that voice anywhere.
It could only be Michael'svoice and have them continue to
talk as they reenter the room,right, so that's one option.
Another is to say well, I knowwhat his hand feels like, right,
so closing me, or I know whathis cologne smells like, or
those sorts of things, andtrying to get around what

(48:57):
otherwise is a, at that point intime, just one modality that's
screwed up as opposed to later.
So that's one way to do it.
So that's one way.
Another is, again, bymanipulating or trying to give a
little bit of cognitive powerthrough, like a colonesteroids

(49:19):
inhibitor.
There is some evidence tosuggest that capgrass and
certain peridolic phenomenon getbetter with a little bit of a
cortical tone.
You know what you get with acolonesteroids inhibitor.
Or again, some of these thingshappen because a person is
subtly anxious.
And so, therefore, the errorchecking that we have, like you
know, when you're in the storeand you're like three aisles

(49:41):
over from somebody and you say,oh yeah, that's Jeff, right.
So you wave and then, as Jeffapproaches, you realize it's not
Jeff, In fact it's Jane.
You know.
Well, that's because we do havean error checker and we have a
maker or a matcher function.
You know that's going on, andwe had enough information to
feel pretty good about what wethought this was.

(50:02):
Similarly, they've got enoughinformation to feel pretty good
about what it is.
They're wrong, right as far aswe're concerned.
But so the question is oh well,are they pretty sure, because
the anxiety or fear isheightened enough that they've
chosen the wrong, they've madethe wrong match, you know.
And so if I give them a lexapro, if I give them an anti anxiety

(50:26):
medicine, it'll calm it down,it'll give them a larger
repertoire of options to choosefrom.
And maybe it's not an angrything or a scary thing or you
know paranoid thing.
So that's another option.
And then there are people thathave had figured out some very
clever things to do with Frankhallucinations.
There's somebody, for example,that the hallucinations are

(50:50):
annoying, but they don't reallyinteract with them, they don't
name call, they don't do badthings, they're just annoying.
And what's very annoying isjust that initial sense of is
this real or not Right?
Because if this is a realstranger in my house I got a
problem Right, whereas if it'snot a real stranger, I can

(51:10):
ignore it.
So they've got like a what doyou call it?
Infrared thermometer.
You know the long distancethermometers and it's like you
know it's on their TV dinnertray and basically when they're
watching TV and they look in thecorner and they see there's
something they're like I don'tknow.
It looks like a person Wonderif they're real.
They just put the you know,turn, turn the infrared
thermometer on them.
They look and they go nope,temperature of the wall, not

(51:34):
real Right.
Now, why does that work?
Well, the reason it works isbecause they still have insight.
You lose insight Right, and nowthere's no explaining away.
Right Now it's a delusion,fixed idea, right, as opposed to
a perceptual experience withoutan extra, extra personal

(51:58):
stimulus.
You know, it's a hallucination,as currently defined.
And so those are the kinds oftricks that are patients figure
out on their own, and then itbecause you ask about them, they
tell you, and then you, thenyou have the ability to say to
somebody who is going throughsomething well, I thought what
about this?
You know, and when they look atyou, like you're crazy, but I

(52:19):
have a patient who this worksfor, and now they believe it,
right, because it's been triedout there in the world, and so
so those, those are the kinds ofways that you're, you know, you
, you're working around these,these, these issues, so the
person can remain functional,can remain themselves, can keep
that sense of identity.
And it's only when you start torealize that what they've, what

(52:41):
they're thinking or whatthey're seeing, is tipping into
unsafe, or you know that's whereor could or could start to be
unsafe is is where you start tosay, okay, now how do I him in
the perimeter of their abilityto act on said thing?
And maybe that's, maybe that'swhat I meant.
Maybe it's with supervision,maybe you know who knows it

(53:04):
depends.
It depends on the person.

No, that's.
That's a great point, and Ilove the integration of like
those, those intact sensorymodalities, especially like the
very outside the box kind ofstrategies that you're.

Well, it came to me from.
I had a.
Well, she wasn't a patient, shewas.
She was somebody I wasintroduced to.
I've written about her and oneof she had.
She had a synucleinopathy, shehad a sort of Parkinson's and
then did all Parkinson's diseasewith dementia, and but one of
her heralding signs was she hadcome back home and she had

(53:42):
opened the closet door, like youknow, coats and that kind of
stuff and there was a manhanging in there, you know,
which is terrifying.
So she fled.
And then again something whichtells you, she told, she told us
all something was up.
She went back, yeah, she, likeyou know, looks at it again and

(54:03):
yeah, it looks like a guyhanging in the closet.
But then she reached out totouch him, which already tells
you that something, something inthe analyzer, lets you know
that it probably wasn't legit,you know.
In other words, she quiteliterally was testing reality,

(54:23):
Right, and she was right,because when she touched it and
felt it, this thing, this man,the image of this man in the
closet, it no longer looked likea man hanging in the closet,
you know.
And you'd ask, you'd say, well,what does it look like, what did
it look like?
A coach is well felt like acoat.
You know, I could feel the coat, I could feel it was on a

(54:45):
hanger and it looked different.
Now, it didn't look like a man,but it also didn't look like a
coat either, you know.
But it but it felt like a coaton a hanger and that was what
gave me the idea of saying Iwonder if I can bust up some of
these, these perceptual errors,by providing some alternative.
You know feedback, eitherhaptically through your

(55:06):
fingertips, or automatic, withsmell, or you know you name it,
and that's been relativelysuccessful for a number of cases
.
But that's because a patienttold me something which which
you then sat and thought about,you know.

That's very interesting.
Now that makes me curious aboutif you have any thoughts about
like pseudo hallucinations orsomething like Charles Benet
syndrome or both, you know,acquired hearing loss.
You might hear snatches ofmusic or things like that.
How do you think that that kindof like sensory release
phenomenon relates to kind ofthese perceptual changes in

(55:43):
dementia, or do you think it'stotally different mechanisms?

I like to, I like to believe in
lumping rather than splitting,you know.
So I like to think about how,you know, I did very early, very
early apparatus, very earlyapparatus get kind of exapted
into higher and higher corticalor cultural needs.

(56:09):
And so, you know, one thing tolook about is to say, in the
same way that you would take anumber and you would factor it
out to figure out, you know, ifthe number is 24, okay, the
factors are somewhere betweenone and 24, can't be less than,
can't be more than right.
So, similarly, on the one hand,we have a thing that's called a

(56:29):
hallucination, which, again,that current definition is like
there's not a stimulus out therein the world, but I have a
perception on the inside.
And then you brought up thispoint about sort of Charles
Bernay, which we which isdescribed, as you know, quote
unquote a release phenomenon,you know.
And then we have these thingsthat are paradox, cloud gate.
We all do this as cloud gazing,right, you look at something

(56:52):
and you make meaning, that of anotherwise meaningless pattern,
right, and so you can see it.
And patients with a weak bodydisease have a lot of will, have
a lot of pareidolia.
They'll see faces and things,or writings and things, and so I
like to think about it likefactoring that number.
So now let me take thesephenomena and let me organize
them.
On the one hand, I have a thingcalled hallucination.

(57:13):
That's maybe 24, right, that'sthe thing.
That's just we.
We, we allege that there is noexternal stimulus and that it's
all internal perception.
And then, on the side of thelowest side.
The number one is there'sabsolutely stimulus out there,
but I'm misperceiving it and I'mmaking a.
You know, I'm parsing in thelocal and global features in a
way that make you see a face andsomething that isn't a face,

(57:36):
and then you'd say, well, maybeCharles Bernay sits right in
between.
So now you get to ask yourself,well, does that really mean
that there's nothing out therein space that those people with
hallucinations aren't respondingto, that it's totally
internally derived.
Then what makes that anydifferent than a Charles Bernay
hallucination?
Right, which is quote unquote arelease, because in theory,

(57:58):
what do we say?
What is release phenomenon?
So what releases?
It's in there, right, if youstart to get poking fraud people
on this as well, it's in there,but it comes out as if you know
, your skull is like a littlePandora's box and there's stuff
in there, right, it just comesout, right.
So that doesn't make sense.
I mean, when you, right, whenyou start to really peel it away
, you go.
This doesn't make any sense atall.
This is a complete fabrication.
This is, this is a metaphor of,this is a myth, right, and it's

(58:22):
a myth that helps us explaincertain phenomenon that where we
don't really know, but weapprehend them, but we don't
comprehend them right.
So what I would say is probablygoing back to like big art
historians, like Ernst Gombrich,who said that the how aesthetic
movements, moments work as we.

(58:43):
You know, we make a thing inour head and we match it.
You know what am I looking at?
Well, it could be this, itcould be that, and then I look
and I try to fit some featureson that and get some insight and
draw some conclusions.
I do it very fast, right, itdoesn't take long to make this,
but I do that.
And so you would say, all right, so if that's kind of exactly
what's happening in aparatheolic phenomenon, who's to

(59:06):
say that?
What the hallucination is,whether it's an auditory
hallucination or a visualhallucination is there's
something out there in theenvironment, however small, that
is leading to conclusion,jumping, making and matching
erently.
And then you know the brain isamplifying that that would.
And then the question is okay,if that's a true construct,

(59:28):
michael Stanley, what does itmean to amplify?
And then you'd have to say,okay, well, how would that work
in the brain?
But now I have somethingtestable, I have something I can
look out in space, as opposedto saying it gets released.
You know, we get into the wholen-gram problem when we start to
talk about release.
You know like well, okay, well,where is there just a little
librarian card thing that I pullout and I find that work.

(59:52):
What that doesn't make thatstarting to not make any sense.
Right Now, that starts to feellike we've left the world of
hardware and software and we'reyou know so, or in fact we're
exactly in that point.
My point is, I think, what theactual examples that patients
have given me of working aroundtheir hallucinations or their

(01:00:15):
delusions or their opticalillusions, mirages, mr Magooisms
would tell me that it'sprobably a continuum rather than
that they're separate things.
And that's where my head is interms of thinking about this as
a construct, which puts me inthe camp of a smaller group of

(01:00:38):
people.
But it's still a camp.
I'm not the only one out therein space who thinks that.

Dr. Michael Kentris (01:00:43):
Yeah, and I've only in the last couple of
years, started reading a littlebit more about the neuroscience
of some of these things, likeyou said, like ideational
construction, linguisticconstruction, all these kinds of
phenomenon that you know whenwe're in medical school we're
trying to like oh, you know,your expressive language is in

(01:01:03):
focus.

Dr. Michael P.H. Stanley (01:01:05):
Well, like, take Charles Bernay, for
example, because you broughtthat up as like okay, charles
Bernay suggests that this is ahallucination.
It's a form to hallucination,usually sometimes abstract, but
mostly form to hallucinations,and that the person has, a
person knows that they're notreal, right?
Well, do they?
Do they know it right from theget go, or is it after like a

(01:01:25):
second or two?
They go, wait a second.
This person is too small andthey're floating in space and
that doesn't make sense, rightas opposed to well, the exact
same I mean, I've heard this toothe exact same hallucination in
one patient we call CharlesBernay, because they recognize
it to not be real when they tellit to you, versus a different
patient has the exact samehallucination and we say, oh no,

(01:01:49):
it's an organic hallucinationand it's a hallucination out of
Charles Bernay and it's not realwhen, because they don't
recognize it's real.
Now, what that would suggest isthat the difference is really
not of a visual perceptive, butof the insight into it, and
therefore it raises a funny ruleof thumb that many old timers
will tell you but again troublesthe, the gravitational field of

(01:02:11):
the academic world.
When you go it's kind of afunny thing you don't see
Charles Bernay in the very youngRight and a surrogate right.
We don't know.
It's true, I take it to be thatit's true, but I am not sure
that it's true, Right, I've notseen, I've not seen to the and

(01:02:32):
therefore you could say, well,it's probably nothing about
being young.
I mean, there's a lot of goodpoints about being young, but
that's probably not one.
It's probably that what we meanis there's some degree of
cognitive impairment already atwork in those with Charles
Bernay, right, there's alreadysomething at work, it's just

(01:02:54):
that it's not bad enough thatthey've lost the insight into it
.
And it's very interesting thatif you do a literature search on
this, the Charles Bernay, theyeither haven't lived long enough
to develop dementia, right, orit's a funny thing that they

(01:03:17):
usually transform into somethinglike Parkinson's, or they
transform, you know, it'sprobably in the way it's on the
way to getting somewhere.
So, so that's really cool.
Because now it goes back tothinking about a sort of tried
and true in medicine of like thetwo hit phenomenon.
And so we say, well, what arethe two hits?
One of Charles Bernay is, asyou mentioned, always something

(01:03:39):
in the periphery I've gothearing loss, or I've got some
optic, I've got some retinalstuff or I've got, you know,
glaucoma.
That's the peripheral, and thenthere's something central, and
the thing that's central is whatleads to that Charles Bernay
phenomenon.
So it's not released.
In other words, now that you'veteed it up that way, now you go

(01:04:00):
well, it isn't necessarilyreleased, right, because that
would suggest that there'salways some little grotesque man
in my head that just isconstantly being repressed.
And then you go what does thatmean?
What would?
What would right, right?
If you say release phenomenon,what's repressed phenomenon,

(01:04:21):
right, nobody wants to right.
So either.
If you say, well, there's nosuch thing, then I go well,
there's probably no such thingas release phenomenon, right?

So yeah, and I do wonder, sometimes, you
know, we kind of think like, for, say, someone who has, you know
, like developed complexregional pain syndrome after a
peripheral limb injury of somesort, right, we get this
centralization of pain over time.
You know, very likely, if we'retalking about like a peripheral
hit to the eyes and we losethat sensory input, you know, is

(01:04:53):
this the centralization of thatlack of input.

And now what you're doing is exactly
what we should be doing asneurologists, right, which is,
you know we're, which you'restarting to think about as you?
Well, hmm, I, I, I have a welltrod metaphor and model for one
kind of phenomenon out there,and then I say, well, wait a
second, there's a peripheral anda central thing.

(01:05:17):
And what if I applied that to adifferent modality and a
different one?
You go, well, this one checksout this one checks out this one
.
And now you actually be able tothen really boost, now you get
to really actually abstract fromthose separate metaphors, a
true kind of, you know,syn-topic analysis, where you
get to say, wait a second, maybewhat's going on is just a step

(01:05:42):
before we get into the, the, themodal, right, it's actually,
maybe this is an A modal prop,this is an A modal phenomenon,
it's, it's, it's independent.
In other words, it doesn'tmatter that the thing that's
going on, the actual mechanismthat's going on, doesn't matter
if it is haptic, nociceptive,visual, you know, gustatory.

(01:06:06):
So the mechanism thereforecan't be in the, in the very
specific modality, right, it'snot buried there, it's something
one above right.
It just happens to be that, youknow, the downstream effect is
that, you know, on the Plinkogame of of sensorium, it's, it's
ending up in the visual ratherthan but that's.
And then now you've got a coolmodel.

(01:06:26):
Now you've got something toreally think about, not not what
are the functions of the brain,but again, now you're what you
were doing by building thatmodel, michael, was you were
talking about what is thebrain's function?
What does the very fact ofhaving a brain do for us as an
organism?
And then once you and thiswould be one of those things

(01:06:48):
would you say hmm, I have aperipheral portion of my
apparatus, a central portion ofmy apparatus, and this is the.
This is what the central doesfor the peripheral.
And you've noticed that whenthe central goes wrong and it's
nearby this modality, I getchronic pain when it goes wrong
on this one.
So, so now you get to, now youget to test this out, which is
you go.

(01:07:08):
Isn't it a funny thing that Ican use certain anti ASMs?
Now, right, anti-seizuremedicines for central pain, and
I could use.
And so then you say, well, howwell could I use it for another
thing?
So well could I use that for?
Could I use that for theseCharles Benet phenomenon?

(01:07:31):
Is that a thing?
Well, now you have a reason fortrying it out, as opposed to
just blindly trying it out.
You're trying to fit a model.
Another way to look at this isthat there was a thing that was
called olfactory referencesyndrome.
It's a, it's a psych.
Technically speaking, it livesin the psychiatric world,
although to me it just feelslike like a chronic pain

(01:07:52):
disorder of the nose, likeyou've got horrible, horrible
smells that have no particularsource or origin.
You know, you, you, they gettheir sinuses worked up and
everything and it's empty and,and importantly, they get EEGs,
right to note that they're nothaving, like you know,
metatemporal of seizures andthey go.
Nope, as far as we know,they're not seizing.
But if you put these people incarbamazepine, it goes away.

(01:08:15):
You know, just like withchronic pain stuff, you know, or
or or deserene, you put them onASMs and sometimes it helps and
go.
What's that about?
You go because I'm probablymodulating something centrally,
in the same way that I'mmodulating those, and you go low
and behold, as we justmentioned earlier in our in your
podcast, that there are only somany ways the thing goes wrong.

(01:08:36):
Right, cause it's only causethere's only so many ways to
have built it in the first place, there's certain load bearing
walls, of how these structureswork.
Surely, then I can probably usethe same solution over and over
and it'll probably work, aslong as I'm correct about the
load bearing wall.
You know, and that's exactlywhat you're pointing out, and so

(01:08:56):
now we're again.
We're now we're beingscientific clinicians about it.
You know, which is cool.
That's what's great aboutneurology we get to do that, you
know it is.

I always tell students that that's it's
both one of the most interestingbut also potentially, depending
on your temperament the mostfrustrating things about
neurology is we don't have theserobust, high number of studies
but you get to play around witha lot of abstractions, like,
like you said, if this principleis true and this treatment is
working, works in this situation, maybe it'll work in this

(01:09:34):
situation as well, and wecertainly see that exact thing
done for a lot of, like you know, in rare situations, like using
levatoracetam for differentkinds of tremors and things like
this right, things for which itwas definitely not ever
developed, but someone tried itbased on some example, and found
that it works sometimes, and sowe wind up with another

(01:09:55):
potential branch in thetreatment.
Yeah, thinking about well, whyis?

that Is it?
Because the receptor that istickling is also in a different
place?
That's one way of looking at it.
That would tell you that it's.
It's a drug specific phenomenon, you know, or a receptor, but
it goes through.
Or you say, wait a second,these two phenomenon have a have
a shared mechanism.
That's another way to look atit.
You know, a little higher up,you as the neurologist who

(01:10:20):
hopefully has a good sense ofneuroanatomy, gets to sit down
and go well, wait, no, I can'tpossibly be.
You just cannot possibly be ashared mechanism.
It's got to be.
The receptors are in twodifferent places, you know.
But that's what's great, as you,you know, you sit down and you
think about I, I, I likecognitive and you know neurology
in general and cognitiveneurology specifically, because
it really is a lot of it'stesting out your principles.

(01:10:46):
You know, against the practice.
You know your, your philosophyagainst the reality.
You know just as much as mypatients are often attempting to
test their realities.
I'm testing their realitiesright along with it, but we're
just doing it in a with slightlydifferent lenses, that you know
.
They're doing it for their ownfunctional independence and I'm

(01:11:07):
doing it to understand not justthem but the diseases that are,
you know, uh, uh, beleagueringthem, um so, uh, but.
But yeah, it's a great fieldfor starting to think about.
Well, how does it work that way?
Why does it work that way?

Um, yeah, I find a lot of physicians do
fall down a little bit on thewhy uh, which is, you know, sad,
because I think that's a lot ofthe the most fascinating parts
of practice Absolutely.

Um, you, you.
I think the other element of itis um, a lot of what and this
is true for for for cognitiveneurology, I'm sure it's true
for for the other um subspecialties as well which is, we
ask these extraordinarily goodquestions and we see some
incredible instances and casesin our clinic and because of the

(01:12:03):
nature of the practice ofmedicine.
Now, the literature that weread and the information that we
read, how vast it is, how muchit is, it's all we can do just
to stay on top of the, the, thetrade, uh papers, if you will,
um, but actually the really goodthings come from connections
outside of our field, you knowso, where you get to use that

(01:12:27):
skill set somewhere else.
So what do I mean by that?
I mean, um, there are a numberof very good insights that were
made by Luria and made byJonathan Miller and made by
Oliver Sacks, because they tookand brought to bear their
neurological andneuropsychological tools and
applied them to people's livesoutside of the clinic, you know,

(01:12:50):
back in their environments,back in their ecosystems, back
in their functions.
Or, similarly, you know, if youare going along reading in, you
know, harper's Weekly or somesome other magazine that has no
relevance in theory to to ourown.
And you hear a story and you goI have a neurological answer to

(01:13:11):
that story or I have aneurological question in that
story.
That's, I think, where a lot ofreally good um insights come
from.
You know, if you, if you keeppressing out into um other
fields, either because they giftyou with different um analogies
that you get to work with,different models you get to work
with, or they provide um youknow, they provide to you data

(01:13:36):
you otherwise weren't going toget in your clinic.
You know, I've had a couplearticles which have been like
that, where I was readingsomething in you know Washington
Post or is reading something inthe Atlantic or whatever, and I
I went oh, this person hasprovided me what happens before
they come into my clinic.
Let me write a letter to theeditor explaining what happens

(01:13:56):
after their article.
You know, but I never wouldhave the idea, never would have
occurred to me, if I hadn't haveread their article.
You know which means I wouldhave had, which means I had to
be reading something that wasnon neurological.
You know, in order to have thisneurological epiphany, I had to
be reading somethingnon-neurological.

(01:14:16):
And so, again, it's a clarioncall to say that you do have to
square away.
You know, as Osler said, 30minutes a day to consult the
saints of humanity, you know, inorder to get those insights
into medicine.
Because, you know, medicineultimately is a normative

(01:14:37):
science, it's a moral science,and so it requires you to be
reading that literature as well.

I think that's well said and of course I
would be remiss as people mayhave gathered from your passion
about the humanities that youare yourself quite prolific in
the neuro-humanities.
If you will, but tell me alittle bit about how you found
yourself in that arena.
Did that come after thefellowship training or was it

(01:15:09):
kind of on route?

I came in response.
Well, the neuro-humanitiesthing is a or that term or
whatever.
That's a later development.
But the general concept of thesort of vialondongra, this okay,
he's doing the medical thingand he does this thing as
non-medical.
Where does that come from?
That's largely responsive orreactive.

(01:15:32):
So, as you recall and I'm surepeople listening who either are
experiencing it or shortly willor medicine is a very jealous
mistress, takes all of your time.
You know all of it, and so youget to choose which things you

(01:15:53):
let go.
And you know I had let go inthe pursuit of medicine a lot of
things that were reallyimportant to me, which was a bad
idea.
And it wasn't until I had goneto Maine, actually my third year
of medical school, when inRockport, maine, at Penn Bay

(01:16:15):
Hospital, which is where I didmy training, richie Kahn Dr
Richie Kahn, who was aninternist and an incredible
medical historian, sort of tookme under his wing and sort of
pointed out he says well, if youlike history or you like
literature or you like thosesorts of things, you may just
have to tweak the subject matterright so that it gets counted

(01:16:40):
and it gets considered asrelevant to whatever medical
academic overlord you happen tobe working for, right, like, if
I do this incredible thing about, if I want to write about Keats
, people go, okay, you do thaton your own time.
I don't see how that's relevant.
Don't even put that on your CV.
If you write about, well,actually I'm going to write

(01:17:02):
about how Keats' medicaltraining influences poetry, and
they go, oh, you can probablyput that on the CV, right?
So what Richie taught me wastwo things A, there's nothing
wrong about being a doctor whowants to learn about and read
about and write about and teachabout humanities topics.

(01:17:25):
That's actually probably theright thing to be doing, and it
was a thing that we were doingfor many, many years.
And then two, with a little bitof augmentation or twisting,
you can do it.
Then you aren't necessarilyhaving to live two totally
separate lives.
I mean, I pretty much do livetwo totally separate lives, but
there's a little at least.
There's a doorway or a windowin between, more like an

(01:17:48):
elevator maybe, but that's onething.
And then what happened, ofcourse, was neurology is the
place for that, becauseneurology is where I mean it's a
quote, steve Hyman, it's athree-pound universe, like right
.
Or going back to Fran Leibowitzwith the book, right?

(01:18:10):
I mean what doesn't passthrough the brain for great
literature, for great art, forgreat photography, for great,
you name it.
And so there is something to besaid about a neurologist.
It's like philosophers thinkabout thinking and a neurologist

(01:18:32):
thinks about how a philosopherthinks about thinking, right.
So there's this interestinglayer that we can provide, not
necessarily with explanatoryvalue, some augmented value
maybe.
And so that's where it started.
Basically, that was the start ofit, and then what happened was

(01:18:54):
I had a really interestingpatient that I thought was just
a phenomenally important story,as every intern thinks that
anything that they do isphenomenally important, right.
So they become an M1 and theyrealize, no, no, no, actually
that's not true.
But I thought it was a verygood story and I couldn't get it

(01:19:14):
published in any of theacademic papers.
But I would go around talkingabout the story over and over
and over and people go, god,it's a great story, you should
get that published.
Nobody would publish it.
Nobody in the academic journalswould publish it, and I got
very frustrated as to, fine,I'll put it in the lay press.
And I sent it out to a two-plusin the lay press and the Wall
Street Journal wrote me back.
They said, yeah, we'll take it,these are the edits.

(01:19:35):
You make those edits orwhatever, and then locked out.
Like four months later anotherincredible thing happened and
you go I wonder so okay, I sendthat around to the academic
journals?
And again, nobody wasinterested.
Nobody was interested at all inthis, didn't even give you the
courtesy of running back and Isaid, well, I'll try the lay

(01:19:58):
press again.
I sent it out again.
Sure thing, it took it.
And so it started this situationof being a conduit to a lay
audience about things that arethat might be we only see in our

(01:20:20):
world, but we know are outthere in the world and we know
have some relevance to theeveryday person.
We just see extreme examples ofit, or we see really
exacerbated phenomenon, butsomething that everybody really
has.
And so that's how it startedwas.
I just kept writing.
And then other topics.
Then people write to you, othertopics present themselves and

(01:20:44):
they say, hey, could you writeus about this?
What are your thoughts on this?
I don't know if I should betalking about this.
I don't know, I have nothoughts on the matter.
And they say, yeah, but youexplain things in a way that we
don't get explained to otherwise.
And so you say, oh, okay, Iguess that's a reasonable role
to take up, and so that's what Istarted doing with more

(01:21:05):
frequency.
And then it isn't until reallythe last three years that the
work that I had done insocieties, academic societies,
finally being allowed in to someextent as sort of a tolerated,
informed tourist, you know, intothese academic societies for

(01:21:27):
this thing that I do, and inthat role I've been able to kind
of advocate more strongly forthis question of what are the,
what are the?
This thing called theneurohumanities or this thing
called romantic science, whichis what Luria and Sacks said
their writings were.

(01:21:48):
And that's really been adistinct pleasure and privilege
is to try to support as aplatform, through whatever kind
of blogs or writings orconferences, other people that
are really doing some seriouswork in this but are they're not
getting the credit they deservein their local institutions or

(01:22:11):
their societies.
But because I have amassed thistiny little lens you know it's
got a high luminescence but it'sa tiny little dot, you know on
the wall but it's enough to kindof like push that little
spotlight on somebody else andgo, oh my God, look at this
thing they just did, you know,this wonderful seminar series
they're doing or this incredible, you know, form of journalism

(01:22:32):
that they're doing, and that'sbeen.
That's kind of the mode thatI'm in now is trying to promote
enough of a critical mass ofpeople that want to think about
the medical humanities and,specifically, in our world, the
neurohumanities, not as a toolof pedagogy, you know, and not

(01:22:56):
as a solve for, you know,wellness, but as a true
scholarly discipline, you know,as a field of inquiry and
research.
And that's where I'm reallypushing hard to do, because that
, I think, is, I think that'swhat's called for now.

No, I think that's excellent and it, you
know, I would say delving,dipping my toes into more of the
classic philosophy side ofthings, more so than the modern.
But it gives me, when we talkabout, like you know,
epistemology and ways of knowingso many of us these days,
especially with many of ushaving kind of more of a STEM

(01:23:38):
background, you kind of right,we focus so much on the reason
but if you think back to like,kind of like, like ancient
spirituality, like things likethe noose, if you're familiar,
like the spiritual way ofknowing things right, very much
ties into this, this way, thisqualitative aspect of knowing
right.
So these, not to be too touchy,feely, hand wavy about it, but

(01:24:02):
different ways of knowing things, like these stories, are very
much that right, there's nostudy, there's no data, but we
know from talking with thisperson, from the language they
use, from the way that they holdthemselves and communicate
right, these things that wecan't necessarily even
communicate to ourselves, thatthere is something there that we
are perceiving that they arecommunicating to us.

(01:24:25):
That is somewhat inevitable.

Yeah, what would you?
How do you?
Where do you want to go?
It's such a broad topic.
What I would, what I would say,is neurologists are in a really
good position to ask questions.

(01:24:50):
That, and I mean really askquestions.
Ask questions from a positionof humility about knowing.
Again going back to this,because it's a, it's a, it's a,
it's a sore spot to me the, thenotion that we have some very

(01:25:16):
important institutions that haveallowed it to be printed as if
it is a truth, as if it is agospel truth about connectionism
and language, when it couldn'tbe further from proven

(01:25:37):
linguistically or neurological,let alone neuro linguistically.
The reason that that's allowed,I think, is because, no, there
isn't enough people in theneurological community to
question that fundamentallyright.
The metaphor is offered, or themyth is offered and you go well
, that makes sense, and sothat's actually where I think

(01:26:00):
you are absolutely right to takethis sort of Richard Onion's
view.
You know, the origin of originof thought, I think is his, his
book, richard Onion's classicbook, talking about how do you
get from?
You know Suke, and what does itmean for Suke, which can become
psyche for us.
You know, versus Numa, right,and where were those localized

(01:26:23):
and what did they meanseparately?
Or Fumos, right, the thymus, soyou think of it, so think about
that.
We just take psychiatric, thatworld itself,
neuropsychiatrically, let's,let's put it in that balance
that I don't mention psychiatry,because I have nothing to speak
about in psychiatry.
I'm speaking at a turn.
I'm talking about psychiatry,but neuropsychiatry I can maybe
talk a little bit about.
So there we have it.

(01:26:44):
So I've got, I've got neuro andwhat it countenses, I've got
psychiatry, psychase, so psyche,so Suke, and what did that mean
over time?
And then?
So how does the Suke differfrom Fumos, which is where we
get dysthymia and euthymia,right, and what's really being,

(01:27:04):
what's the connotations of thoseor what?
And then, and then you getsomething like you know, numa
Numa.
And so those are three differentways of looking at the soul,
looking at the mind, looking atthe spirit, looking at the, and
if you start to take thatneurologist view on it, who,
luckily for us, have decided tosay I will only look at this

(01:27:29):
three pound bit of integratedhamburger, and now I will try to
fit these, these costumes right, these metaphors, over that,
and see which ones fit, whichones don't, and if they don't
fit, not necessarily discardthem, but ask wait, why doesn't
that fit?
Does that not fit?

(01:27:50):
Because there's a.
It's a, it's a cultural costume, and I am outside of the
history and I am outside of thecultural context for that to
work.
And just as well, if I took thecultural costume off my three
pound hamburger and I put itback, then it wouldn't fit right
.
In other words, is it a, is itthat kind of thing, or is there

(01:28:11):
something fundamentally flawedabout it, you know.
So those are the.
Those questions start to come inwhen you go.
Well, wait a second.
What does that metaphor mean tome?
What does that model mean?
What does that myth mean to me?
Why is it that certain, you know, myths might be more or less
universal, you know, I mean,there's a lot of Joseph
Campbell's, you know, mythologyis after forge, which bears

(01:28:34):
fruit, even clinically, if youtake the hero's journey and you
apply it to certainneuropsychiatric situations and
they understand it and they gooh my god, this makes sense and
it relieves a lot of tension forthem and you go.
Well, that's funny.
Why should that thing thatdoesn't have any randomized,
controlled trial to it, you know, have bears such fruit?

(01:28:58):
Why should it be such a helpfultechnique and you go.
Well, I don't know, it's beenaround a long time.
Not that tenacity is proof ofefficacy.
I want to point that out.
Right, there are a number ofvery tenacious ideas in medicine
that I'm sure are completelyflawed, and you know, either we
don't know it now or we do andwe don't want to talk about it.

(01:29:22):
But I think that's what makescognitive neurology so cool.
Is that again an Elliot-likeway?
You know, coming back where westarted, seeing it for the first
time, we are dealing with thissituation where I am studying
the brain and patients see mebecause they have a brain
problem but their symptom is not.

(01:29:43):
They don't go, my brain hurts,they do say.
They do say brain fog.
The closest that you ever cometo directly implicating the
brain when somebody comes intoit in terms of complaint, in
terms of, like the hard, harshrelationship between symptom,
right, and it's origin.
Somebody breaks their arm, theirarm is flopping, and they point

(01:30:06):
to it and you're like, aha,they say their arm hurts, I see
the thing flopping, it's abroken thing, right.
But it's much more like being aremote viewer in cognitive
neurology, where you'relistening to these symptoms and
you're thinking in your headlike we're somehow on some other
plane, cognitive plane.
I'm trying to isolate thesymptom or the phenomenology,

(01:30:27):
and then I then have to groundit into some part of the brain
or some network or some nodalstructure, or you name it, and
so that's what becomes kind ofcool is you're starting to look
at this and you're going, oh God, this either does work or it
doesn't work, you know.
And when it doesn't work,you're looking at your patient
and going well, you've got as itbegan.

(01:30:47):
You say, you've got dementia.
And they go oh, thank God, Iwas worried, I had Alzheimer's
Right, see what I?
mean yes, yeah, that's a hardstarting point for a
conversation that is exactly theproblem, right, you would say

(01:31:08):
to me oh my God, this is just amatter of semantics and this has
become one of the most boringthings I've ever had to listen
to.
But it's not boring at all, infact.
This is you know what somethingmeans, right?
And then the question is whatis the something?
And neurologist asked the nextquestion, which is what does it
mean?
What does it mean?
And I feel that right now,we've lived in a world where

(01:31:32):
we've been relatively lucky thatall the low hanging fruits
since you know, charcot and nowhas been in the something part,
and now we're getting into themeans, you know, of the what
something means, and the problemis I don't think we've got the
tool set, or we have yet toreach back to some tools that

(01:31:53):
have been left on the shelfright when it was very hard to
figure out how any of this mighthave even remotely worked.
You know, because we're almosta wash in a world of
technologies and things thatsort of give us an answer or a
seeming answer.
It's like every Wednesday, I amforced to do the images for our

(01:32:16):
, like our, morning report kindof thing.
I'm forced to do that and and Ialways start, or almost always
start, with you know, this is animage or this is a picture of
the brain.
You know this is an MRI of thebrain, but it isn't the brain,
right?
You know it's a, it's a, it'sthe treachery of images.
This is not a pipe, right, andthis is not a brain.

(01:32:39):
And again you would look atthis and say, oh, that's very
cheeky and kind of Don Eschumer,michael Stanley, and you know
this is really not to be this,not to be tolerated in a medical
environment.
But actually when you listen to, like Alan Roper give a talk
about broad neurology I rememberAlan was the first one to
mention this and I heard it Iwas like, yep, that sounds true.

(01:33:00):
He goes.
It's funny, when you guys thinkabout a stroke in your heads,
you see an image, you see a DWI.
When I think of a stroke, say,alan Roper, because I see
pathology, I see tissue, becausewe had a whole year of
neuropath, and so you go, ok,you know, again the going back
to this, like what's the layerwith the deeper layer, the

(01:33:22):
initial layers, you go, fine,things change.
And you know, now we look at itas an image, as it was looking
as a pathology slide, and itcan't make that much difference.
And you go?
Oh, contrary, because when youare faced with a three
dimensional object like thebrain, and you're looking at the
lesion, seeing how that lesionlike works its way through, you

(01:33:42):
get really good, like you weretalking about it at
neighborhoods, you realize youreally feel what's connected to
what and what becomesanatomically and therefore
clinical, anatomicallyimpossible, in a way that we
just don't with images, becauseimages are always too big and so
we're always kind of thinkingabout it, kind of looking at us,

(01:34:04):
a two dimensional image, and weit's harder to grasp.
Again, going to apprehensionand comprehension, it's harder
to apprehend those neighborhoodsand those connections when
you're looking at a 2D, in theway that Alan didn't have that
difficulty because he's he's gotthe brain in his hands, you
know, and then when he slices itinto a 2D thing, he's still

(01:34:25):
putting it in a in his head inthis 3D model.
So there again, I think we're.
We're right now in that placewith cognitive neurology where
for many years we've beenblessed with luck that most of
the syndromes seem to line upwith most of the pathology that

(01:34:45):
we had stains for.
And then new stains on newproteins and new genetic markers
and new genetic things and werealize, oh, wait, a second.
This syndrome can be explainedby a huge array of pathologies,
and while the instinct therefore, in a very reductive way, is to

(01:35:06):
say well, then, the semiologieshave no utility, the actual
answers to say well, thesemiologies are providing the
semiologies are providinganswers that are categorically
different to what makes adisease a disease than the, than
the, than the genetic screening, or then, you know, the protein

(01:35:26):
screening or whatever those are.
Those are actuallycategorically different answers
to the questions.
Useful question.
So, for example, if a patienthas posterior cortical atrophy,
they have a visual spatialdistortion, they have trouble
navigating things, and it reallydoesn't matter to them at all

(01:35:47):
if I determine that it is fromblue bodies or from Emily's
right, because the actualbehaviors that result from these
cognitive deficits are at thelevel of functionalism, right,
at the level of cognition tobehavior, and not pathologically
.
And so this, then again, tryingto ground this because I could,

(01:36:10):
I do, we've been up high andlet's make this useful.
So if we, if we look at themost cutting edge thing in my
field right now, it's aboutthese new antibody treatments
for right, amyloid basedantibody treatments.
For all times the trials weredesigned, though, specifically
around amnestic presentations.

(01:36:32):
But the but.
The mechanism of action isabout the protein, so it
shouldn't matter if thepresentation of the patient with
Alzheimer's is a posteriorcortical atrophy or a logopenic
variant, primary progressiveaphasia.
The drug's mechanism is amyloiddependent and if I believe, and

(01:36:56):
I say that the disease iscaused by amyloid, and I approve
that you've got amyloid in yourhead, it should work the same
right.
And so this.
What's interesting is to watchthe field do that, where the,
where the field did say, yeah,that's true, we developed this,
we developed a study whichactually excluded all these
people phenomenologically, but Iwill include these people now

(01:37:22):
in a way that we don't do thatwith almost any.
I mean, think of the diseasekinds, or we would do things in
your world and seizure where youwould ever have done that.
We've never happened, right.
And so again, what you're, whatyou're doping out, is huh,
there's a little bit of a thisis an unspoken or unacknowledged
or an ideological unconsciousbetween what do we mean by the

(01:37:44):
disease pathologically and whatdo we mean by the disease
syndromically, how they'rerelated, how treatment is
related.
You know how the know how thenozology is related and the the
area for something like romanticscience or the area for
something like the neurohumanities is to actually get
right into that spot and callthat, call that out and call it
into question so that ourscience is better.

(01:38:07):
You know, and that's where Ithink it gets misconstrued is, I
think there's a lot of timeswhere people look at it and they
go well, but either I don'tthink this is going to be
applicable or a better.
I think this is just a soundingyour barbaric yop on principles
, as opposed to saying what'sthe practical value?

(01:38:27):
And you go, well, the practicalvalues right there, which is I
just watched you do somethingwith ideological unconsciousness
.
I watched you make a decisionabout that the diseases of
diseases, of disease by itsphenomenology, and that was
inclusion criteria and exclusioncriteria.
And then, after its approval, Igo well, actually, diseases

(01:38:48):
really based solely on theprotein, the protein alone, and
so then I will allow them tocome back in even though I
technically don't have any datawhatsoever to support that it
would be helpful into thosecognitive domains.
Right, that is a.
That's an extrapolation.
Now, again, it's not an unfairextrapolation, because we do
that in medicine all the time.
Actually, medical science worksin a way and we bootstrap it

(01:39:09):
into into clinical practice inthat way, but to be thoughtful
and explicit about it.
Through these kinds ofapproaches, like the neuro
humanities approach or romanticscience approach, can be looked
at as kind of hostile youngturkism.
You know, to some, especiallysome who you know do gain a lot

(01:39:31):
of grant money, and so I thinkthat's the first right, as
opposed to me who, if they say,well, how do I fund you?
You go, well, I need to, I needa notebook and a pencil, and
they go great, here, you know,here's 10 bucks, and you go, oh,
no, wait a second, maybe Ishould have asked for more.
I have space, you know, I justlounge space, language, that

(01:39:54):
kind of thing.
So but what actually becomesvery vital?
Because if you start to put inthe, it's the, it's the
complement to what you know messalong did by looking at a vague
thing like primary, and thenyou go to Asia and realizing,
wait, if I take a strong neurolinguistic approach, I actually
find out that there aredifferent diseases within it.

(01:40:14):
This is the exact same thingwhere you're looking and saying
wait a second.
I'm pointing out that there isthere's an inconsistency here in
the pattern of thought onbehalf of clinical science, and
not that it's created any harm.
It's not done any harm.
That's not at all.
We're saying right, we'resaying actually.
Here's an incredibleopportunity, therefore, to

(01:40:35):
clarify what do we mean as afield, which then immediately
helps inform our patients aboutwhat we believe a disease is a
disease, so that we don't havethat woman that came up to me
and said, oh my God, thank God,I have to mention I don't have
Alzheimer's.

Right, yeah , and I think that it brings up
this whole idea of, like youknow, convergent versus
divergent, phenomenology of thesame pathophysiologic process
versus disparate, like, say,genetic abnormalities or
prognopathies leading to thesame clinical manifestation, and

(01:41:12):
I think that both are important.
But, yeah, it does make it very, very difficult on the ground
sometimes.

Yeah, and I think that's why there is
this, this unmet need which isstarting to be met around,
literally just health literacyfor these, not provided by by
doctors in the clinic to theirpatients, but sort of around it.
And you see this in somethinglike the platform room, which

(01:41:45):
I've done some work for right,where you know they've taken a
few diseases which are, you know, complex and they've asked
patients, experts, occupationaltherapists, you name it, the
same question just to see themany different answers that they
have, which either complimentor contradict.

(01:42:05):
But it gives the patient twothings either some useful
information or be some veryuseful sense of wait a second.
There's a lot of answers tothis question.
Maybe there isn't either onetruth or we don't know anything
about it, and that's useful to.
So, again, going back to peoplewho say well, you know, dr

(01:42:25):
Stanley, I can't, I don't havethe bandwidth to write a whole
bunch of articles about a wholebunch of disparate topics, or I
don't have a bandwidth to createa seminar series you know what
you do or any of those things.
What can I do to flex orscratch that itch?
In something like the neurohumanities or romantic science,
you say, well, actually there'sthe, there's a strong tradition

(01:42:48):
of physicians being involved inpublic education, and I would
say that's a strong tradition.
If you go one step further,academics have a moral
obligation, if not certainly aprofessional one I would go so
far as to moral obligation todisseminate the findings in a
way that makes sense to thelicense, paying public, you know

(01:43:10):
.
And that's one way to say toyourself oh God, I've got so
many competing interests, how doI ever spend, you know, 20
minutes to do this thing, whichmight be writing a nice little
one pager about a subject andmaking it available at your
local library or whatever, you'dsay?
Oh well, the reason I have todo this is that I'm obliged to

(01:43:33):
Like.
My hospital doesn't pay me todo it right and my medical
school doesn't pay me to do it,but technically speaking, I have
a professional obligation to dothis and there is a sense of
not just being right but doingright.
That comes from that.
And I would say that I startedto realize that after, at the

(01:43:54):
start of and through thepandemic, when a lot of my
writing shifted to reallypointing out parallels between,
like, for example, I had writtena piece in Portland Press
Herald about the first COVIDwave and it had been described

(01:44:15):
in terms like World War Two.
And I actually point and I hadbeen reading a lot of Paul
Fussell War and Modern Memoryand I was actually doesn't have
anything to do with World WarTwo.
This is much cleaner and closerto paradigms in World War One
and the before and after of that.
You know I wrote this piecewhich again you would have
thought would have been tooweedy and too inside baseball to

(01:44:36):
have had any relevance to thelay public and that would have
been much more relevant toacademic medicine.
But academicism wasn'tinterested in it, didn't want to
look at itself in that way.
But the lay public looked atthat and went oh my God, when
you put it that way, this makessense, this is useful for us, we
can kind of orient.

(01:44:57):
Going back to this concept oforientation, we now know the
whenabouts and whereaboutshistorically, we know the
whenabouts and whereaboutsmetaphorically and based on
those two things, our responseto this pandemic might be
different than what it was if Ihadn't read the piece, because
it wasn't.
This medical paradigm had notbeen structured appropriately in

(01:45:20):
a way that was useful to thepublic, which is ultimately what
we want to be.
It's just useful in our clinicsand without our clinics.
So, yeah, that would be a waythat you could say well, why
should I write a piece or pickup a pen or go on a local
podcast or somebody you know?
Because of this reason, becauseit's important to do that, I

(01:45:42):
mean, what you do is in thatconcert.
Your podcast is a part of thatapproach.
I don't know, you don't have tothink so, I know.
So that's exactly what it'sdesigned to do and the role that
it plays, which is a veryimportant one, because, as as
the profession of medicine makesthis change into the industry

(01:46:08):
of health care, the ability forphysicians, who sort of go from
professionals to laborers, youknow, from from independent
practitioners to employees,actually does restrict the
ability of the platform and theforum that they can do this

(01:46:28):
thing that they areprofessionally obliged to do,
and so having these kinds offorums like yours to explore for
the, for everybody, what is thekind of doc, what is this kind
of doctor, how do they thinkabout their world, how do I use
this doctor's services versushow do I use this doctor's
approach, and how is it relevantto my life?

(01:46:50):
It's actually through throughthis kind of world.
Again, in many ways we're goingback to, or we're making use of
, the sort of Lyceum tour thatused to be ongoing, you know, in
America, where guys would justgo and lecture right, because
they weren't book guys, theywere writing guys.
Or the notion of having theseradio shows and always having

(01:47:11):
interviews and always talking topeople, or for a public that
doesn't read long form anymore,this is the equivalent of
reading, you know, instead ofthe 18th century gentlemen's
magazine where you'd be readingabout, like what is
procrastination and what do I doabout it?
Is it a moral failing?
This is the equivalent of thattoday.
So the medium has changed, butnot the message.

Although you know some people would say
the medium is the message.
I suppose right.

Well, yeah, some people would, Some
people would.
You could name them if you like.
There's a theory of that injournalism.
What I would say and maybe thisis a fair way to kind of button
this whole conversation andanswer more directly your
initial question, which I didnot wish and still do not wish

(01:48:04):
to directly engage with is thereis a line which I think comes
from Penfield I check my tangles, it's not working.
My temporal lobes aren'tworking like they should, and
it's.
The brain is messenger.

(01:48:24):
It is not the message, and Ithink that, in the way that we
think of, is it cognitiveneurology, is it behavioral
neurology or is it?
You know, neurocognitivism is a, is the way to explore what,
what, what a behavioralneurologist or cognitive
neurologist or aneurocognitivist would say about

(01:48:45):
that paradigm that Penfieldlays down, which I think is also
a paraphrasing of Hippocratesthe brain is a message, a
messenger, but it's not themessage.
That's actually how you sortout whether you're a behavioral
neurologist, whether you're aneurocognitivist or whether
you're a cognitive neurologist,and I think that's kind of where

(01:49:06):
that's the gauntlet.
That should be the researchprogram.
That's what we should beworking for is trying to figure
out valid, invalid, correct,incorrect and wrong, correct,
incorrect, disprovable, you know, is it a, is it?
Does this lay in the world ofmystery or is this a problem?
Neurology is cool becauseneurology both walk into your

(01:49:27):
clinic.
We get both mysteries and weget both problems, and it's not
many fields that get to do that.

No, I think .
I think this was this was agreat conversation.
I I have a lot of thoughtsbubbling under the surface right
now.
Certainly, I do tend toindulgence on some of these more
rare fried topics as well,especially when we start verging
on the near metaphysicalaspects of what it means to be a

(01:49:54):
person, and I think thesethat's the really very
interesting part of neurology.
And how, like you said, thesethree pounds of meat in our
skulls, why, why, how?
You know all these kinds offascinating things that we're
still learning about, and I'mvery grateful that we have
someone like you working on someof these, fusion, fusing these

(01:50:17):
questions together into a waythat brings it to the wider
public.
So you know, you sent me a lotof your work that you've been
doing online and, in particular,with the Boston neuroscience
site.
I apologize, I keep getting thename wrong.

It's a long name.
It's a very long name.

But in one in particular.
I mean, many of them were veryexcellent, but I really enjoyed
the analysis from the lastHalloween issue.
I'm not much of a horror personby nature, but I thought the
the analysis of kind of the theunderlying psychology, if you
will was very interesting.

Oh yeah, so kind of the position
that I've been in and reallyenjoying now is the management
of a number of blogs ornewsletters or just taking a
supporting role in otherorganizations that are neuro
humanities driven or bound andhelping to support them.
And the pure sighting, the oneon body horror for the Halloween

(01:51:15):
edition, that had come fromMatia Rosso and Charlie Palmer,
who are two neurology residentsat Medical University of South
Carolina and they have reallybuilt up a critical mass of
seminars that are around theneuro humanities and they keep
finding more and which is reallyincredible, and every once in a

(01:51:39):
while when I go to one of theseI think, wow, this is really
good.
You think you could write thatup for me, you know, and so so
Matia and and Charlie have havekind of knocked off a few of
these, and the one on bodyhorror was really cool because a
, what is it mean to behorrified Like?

(01:51:59):
What does, where does that live, what, what, what is the
cognitive processes of that?
What is the autonomic input?
What is the?
You know, those are the kindsof things that you know Matia
and Charlie took a seriousapproach to, and so those are
what a thing like what Matia andCharlie have done is show that

(01:52:20):
there are a wealth of questionsor topics that could be
questioned with a neurologist'sobservation or neurologist lens,
and that that role I thinkthey've been able to assume
really well and and make thataccessible to other neurologists
, other psychiatrists, othereven the lay public.

(01:52:42):
They had, they just did aseminar on Chuck Close, who's an
artist who has visualperceptual difficulties, and I
had invited to the seminar acouple photographers that I know
that also have visualperceptive difficulties, and

(01:53:03):
they loved it, you know, andthese were not neurologists or
medical people, but they wereartists and they, what they got
out of that and what they putinto that seminar was really
incredible.
So it shows that this is not afield that lives all alone on
some astral plane although we'vespent most of our time today on

(01:53:26):
the astral plane, but but it isan everyday, lived and embodied
experience and can be reflectedupon in that, and that the
neurological lens does havesomething to say, not
necessarily something to explain, but something to explore.
So yeah, the body horror one isa good example that even if
you're kind of creeped out aboutthe creepies and crawlies, if

(01:53:49):
you bear with it, somethingbeautiful can be found there.

I love that phrasing not necessarily.
Not necessarily to explain, butto explore.
Hopefully someday to explain,but the exploration is the first
step, right?

Well, all depends on the question, you
know.
I mean science accumulatesknowledge, but that's different
than understanding, and so thereare hard points as far as
neurology can go for some of thequestions in the accumulation
of its knowledge.

(01:54:19):
But the real thing to be borneout in this proposition of the
neurohumanities is A if we dohave that idea correct, this
sort of program, this method ofinquiry, interdisciplinary,

(01:54:41):
multidisciplinary way ofinquiring, will that allow us to
go from the role of knowledgeaccumulation, which is really
the province of science, intounderstanding, which is the
province of the humanities.
Humanities are forunderstanding, and so that's

(01:55:01):
kind of.
The interesting question is tosay, does the addition of
neurologists in the conversationallow, through the dialogue,
the kind of analysis and thenlater the kind of synthesis from
a humanities perspective?
Because neuro is the prefix onthis right, it's not the noun to

(01:55:22):
actually get us to some pointsof understanding about the human
condition that would have beenlacking if the neurologist had
not been present?
That's kind of the point.
Interesting so how does horror?
And so if you go back to theBoston Society of Neuro-Surgical
, neurosurgery and Psychiatryblog and you read the piece on
body horror, one of the thingsthat I think does come out of

(01:55:45):
that is I do feel that there isa bit more understanding on my
part about what horror is andhow horror might work and what
horror's role is, from havingread that piece.
So I do think that that is awork of neuro humanities as
opposed to a work of romanticscience or just some

(01:56:08):
neurologists sounding a barbaricyop and sort of.
Here's my essay, here's mythoughts.
Right, just because you havethoughts.
I mean, that's the great dangerof doctors in general and I
certainly am guilty of this leftand right.
I mean first degree of having athought on something because I
know something about somethingelse and so therefore, my
opinion must matter, and it'sreally good to have that checked

(01:56:31):
publicly from time to time.
You know where somebody goes.
You have absolutely no ideawhat you're talking about and
you go.
Oh, my God, you're right, Idon't, you know.
I'm very sorry.
So that's what this impressivenew or I should say return to a

(01:56:51):
field has been about is tryingto figure out who is part of
this program.
Who's at the table?
Who's inquiring?
What's the language of theinquiry?
What are the tools of thisenterprise?

And yeah it does.
The whole endeavor does giveskind of those echoes of that
classic, you know, physician,kind of echoing back to like
Sharco's education programswhere he would is very much
about the patient, you know, atthe at the center of the entire
story, and I really doappreciate the work that you've
been doing in terms ofreintroducing that and bringing

(01:57:31):
us back to you, some might saykind of again that foundation
that we keep echoing around.

Yeah, and I think the what, what
ultimately crippled the use ofthe single case study.
You know, the single patientstudy was the very fact that
when there is an ascendance ofstatistics which is very useful

(01:57:55):
to answer certain questions, Imean is it is the most powerful
way of answering a number ofquestions generating generating
answers that can be verifiableor at least can be found to not
be disproved.
That's great.

(01:58:15):
But that that's not the onlystatistics, not the only way of
answering many of the questionsthat are that are actually still
within the purview of neurology.
And there are many, manyquestions that we can supply
knowledge to that the numbersadd up to nothing.
You know, to quote Neil Young,that that it's actually

(01:58:38):
unhelpful.
They get in your way.
You know they're meaningless,they are comforting because we
like to have a thing that seemsobjective, but objective how you
know.
So that's actually where thesingle case study comes back and
you start to look at the roleof, like romantic science, with
what you know Luria did with themind of an M Anest or a man

(01:59:00):
with a shattered world.
Or you know what SACs did in anumber of his papers not just
his essays to the lay public,but I mean his papers is a long,
long form articles that weresingle case studies.
And you realize that the kindsof knowledge generation that can
only be brought about throughromantic science is because the

(01:59:22):
numbers have nothing to say.
It's an application of thewrong tool, you know, to a
particular special field.
And so now the compliment iswhat's kind of being tried,
where we say, okay, well, we'vegone only so far for our
knowledge generation inneurology and for understanding,
we need the humanities, we haveto have the humanities, we need

(01:59:45):
humanists, scholars of thehumanities to help us with this.
And what we can supply on theneurology side is the knowledge
of the neurological to helpdirect that humanities inquiry.
And then so that's kind ofwhere we're at right now, and I
think guys like Charlie andMatia are really pioneering that

(02:00:08):
kind of second generation ofthis enterprise.
So it's a really good thing,yeah, those so.
So if you're, if you're,interested in these kinds of
subjects, the places to look are, you know, at the on the BSNNP
blog, because we've got a lot ofthem and that is that's the
place for it.
And then, more broadly, in themedical humanities, the American

(02:00:29):
Osler Society has a very goodblog which engages to some
extent on the medical humanities, although it does have a
stronger history focus,particularly.
And then you know the, theinstitutions in the country that
are really leading on this,like Duke has a, has a, has a
neuro humanities center, gabbyStarr, who's the president of

(02:00:52):
Pomona out in California.
I mean she's an incredibleleader in the in the neuro
humanities.
Her book Feeling Beauty isextraordinary.
I think that should be a Biblefor a lot of people interested
in this subject.
And she's got a new one comingout on on the neuro aesthetics
of time, how time is appreciated.
So you know she's, she's got aprogram, she's running that

(02:01:13):
program.
It's beautiful.
David Friedberg at Columbia.
David, david is sort of thecontinuation in the art history
world of what guys like Mattiaor Charlie or you know to some
extent me, is on theneuroscience side, where David,
really David is a human, youknow human.
He really is a humanitiesscholar.
But David, because of hisinfluence, both positively and

(02:01:37):
his approach away from peoplelike Ernst Gombrich, for example
, or Ernst Christ who areinterested in this from the art
history side, what neurology andwhat psychiatry says, sorry,
what neurology and whatpsychology has to say about art
history David has, through hisresearch program at Columbia and
his fellowship program atColumbia have been able to

(02:01:58):
expand that and really makemeaning for work.
And of course, his books Powerof Images the first one and the
recent one on iconoclasm driveshome, going again from the
astral plane and back down toconcrete examples.
Like, his book on iconoclasmshows how this method of inquiry

(02:02:18):
and the results of it haveexplanatory power, not yes, but
also explanatory power for theway that we do certain things,
the way that we destroy certainimages and not other images.
And so you know it is a workthat is not just meaningful but

(02:02:39):
also useful.
So I think David's program atColumbia is again, along with
Gabby Starr's work over her end,you know, probably the biggest
and the most productive.
And then, as I mentioned,vanderbilt and Duke have good
medical humanities andneuro-humanities programs.
They're everywhere.

(02:02:59):
I mean, there are, whether itis a course, one off or, you
know, a real institution or acenter there.
And depending on which focus isit visual arts, is it music, is
it whatnot?
You don't have to go to a bigplace, and in fact oftentimes
going to a very big place iswhat's going to limit you,

(02:03:19):
because it's extremely siloed.
You are in many ways better offin a smaller place where it's
easier to have a friend in theEnglish department and a friend
in the neuroscience departmentand say let's start something,
than it is to be in a placewhere which neuroscience
department do you want to talkwith?
Which English department do youwant to talk with?

(02:03:40):
That's when it becomesdifficult.
So yeah, I think there is a wayfor any neurologist to get
involved with theneuro-humanities in some way if
they want to.
And then the question is youknow whether that's productive
for them and productive field.
But you can do this.

Excellent and I know we could and have
talked at length, but you'vehinted at some of your work.
If people want to find more,where should they look online
for the projects you're working?

on?
They probably shouldn't.
I think they should be lookingat other things.
A lot of my stuff is one-offs,so like you'll find commentary
in things like the Wall StreetJournal or Boston Globe or
National Review or ChristianScience Monitor.
So it's a lot of one-offs.

(02:04:33):
There's no consistent home.
So I guess if you want to checkin and kind of see what's
happening lately what troublehave I gotten myself into this
time the best way to do thatwould either to be to follow me
on LinkedIn or follow me onTwitter.
Mphstanley is the handle.

(02:04:54):
Everyone says I should have awebsite and I know I should, but
I would have to have time to dothat and I'm not about to yet.
So one day I will get time.
So that's the way to.
If I've written something andI've posted it, it'll be there.
So that's where you find me.
But really a lot of my effortsright now are either in talking
and promoting this field, thisdiscipline, with folks like

(02:05:17):
yourself, or in one-off lectures.
I mean, I've been doing my ownlittle like Lyceum tour of
lecturing to different places,so that's probably the best way
is if you want to know what Ithink, come invite me.

And I'll tell you what I think.
A dangerous offer, to be sure.
Well, I really appreciate youtaking the time to come and talk
with me, to talk with ourlisteners, and I'm sure I'll be
asking you back on later andassuming that you have the time
and bandwidth for it.
So, thank you Once again.
I really do appreciate it.

Oh, thank you so very much for
having me Presuming.
Your listeners are satisfiedwith this and this was a good
thing for them.
Then, yes, I'll look forward toyour email in my inbox, and if
I never hear from you again,well, I'll understand.

All right, well, hopefully it doesn't come
to that.

We'll see you.
Thank you, bye.

Thank you again to Dr Michael PH Stanley
and thank you, listener, formaking it through this entire
conversation.
I hope it was interesting toyou.
It certainly was to me.
If you want to find more of ourwork, you can find us online at
theneurotransmitterscom.
You can find me on twitter,slash X, at drkentris
D-R-K-E-N-T-R-I-S.
And please, if you like this,share it with your friends.

(02:06:33):
Help get the word out, and ifyou have any ideas or you want
to perhaps have somethinginteresting to say for our
audience, drop us a line on thewebsite.

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