Michael Okun: Now, you might be wondering why a neurologist and a neurosurgeon are talking together. Most people that know the traditional roles of neurologists and neurosurgeons, they know that there’s not much chance we’re going to talk at all. But it turns out, what we’re going to tell you about today, it takes a “we”, it takes a team. And in fact, there is a whole bunch of people that have to stand behind us to do what makes this happen.
Kelly Foote: So, we are going to start a little bit by talking about the brain. Your brain is a living supercomputer. As we learned earlier, there are a hundred billion neurons in the brain. And each one of those neurons has the capacity to fire. That is to say, to send an on signal — we call it an action potential — to other neurons that it’s connected to.
Neurons have two states: on or off. Your brain speaks a binary language just like your computer. These neurons are interconnected with living wires called axons and dendrites, and at those connections, which are called synapses, it’s estimated that there are 100 trillion synapses in the human brain. So, we’re up to speed.
The neurons in the brain tend to be clustered in functional units called nuclei, and then those nuclei are wired together in functional circuits, and those functional circuits control everything you do and everything you are.
Michael Okun: Now, when those circuits, become dysfunctional, what happens?
Bad things happen. That’s when patients come to see us, Parkinson’s disease, Tourette syndrome, tremor… and there’s a lot of really smart people out there who’ve tried to figure out what happens to cause these diseases. Maybe there’s a piece of the DNA that gets left out, maybe there’s a chemical that’s out of whack, maybe there’s a protein that is accumulating in the brain. Whatever the reason, we actually can’t see the dysfunction in this set of diseases. We can point to an MRI scan but we can’t see a problem because it’s not structural.
So, what we need to do is we need to find that circuit that’s misfiring and we need to apply electricity in something that’s called Deep Brain Stimulation (DBS).
Kelly Foote: So, why on earth would we put an electrode in someone’s brain and try to control it? Are we mad scientists? Maybe, but we’ll come back to that question.
First, let me show you what we are talking about. This is a gentleman in our operating room, who has essential tremor. There are a group of neurons in his brain that control the movement of his hand and that are firing in synchrony in a pathologic way; and, this is what it produces. When we can identify those neurons in his brain, deliver electrical stimulation to that place and interrupt that malfunctioning circuit, this is what happens.
Michael Okun: Let me show you another example. The next woman that we’re going to show you, she has multiple sclerosis. She is trying to hold that arm still. She says that it’s useless to her. This is quite embarrassing, and in fact the neurons in the brain that are causing this, there’s so much dysfunction that we’ll actually have to put two of these DBS leads into the brain. We’ll insert two wires into the brain to get this. How cool is that?
Kelly Foote: So, how fun is our job! If you think that’s fun, let me tell you the story of another one of our patients that will blow your mind.
This young woman from Davenport, Iowa, who has the same disease as Howard Hughes died of, called Obsessive Compulsive Disorder or OCD. She is obsessed with fears of being contaminated, everything out there is dirty to her and she is paralyzed by these fears. She won’t touch anything. In fact, when she came to see us the first time, she refused to sit down in our psychiatrist’s office for her first interview.
Let me tell you about her life. She’s had Obsessive Compulsive Disorder for a long time. But when she got pregnant, her symptoms got a lot worse. And of course everybody said, you know, “It’s the hormones, I’m sure when you deliver the baby everything will be OK.” Well, it wasn’t. It got a lot worse.
And then, two years later, Child Protective Services is threatening to take her 2-year-old daughter away because she can’t stop washing her. Her baby is red and scaly and tender.
Now, here is the cruel thing about Obsessive Compulsive Disorder: these patients have insight. She knows that she is hurting her baby, she knows that her obsessions are irrational, she knows she is driving away the people that love her and she has no power to stop these behaviors.
If you can imagine, her husband is pretty tired of it. Let me tell you about his experience. He goes to work, he comes home from work, he pulls his car into the garage, closes the door behind him so that he can strip naked and launder his “contaminated clothes” in a special laundry facility that she’s set up outside the house. And then, he walks into the house and takes a “decontamination shower” with a special soap that she has deemed acceptable, so that he would be allowed to walk into his home naked and clean.
She can’t leave the house, so he does all the shopping. He comes home from the grocery store, and, of course, all the packages at the grocery store are “contaminated”. So there’s the ritual of opening every can of soup and every box of cereal and transferring the content of those packages into some clean container that she says is OK to bring into the house.
So, as you might imagine, this is a marriage that is strained.
So, she is desperate and she’s tried everything. She’s a smart lady. She’s taken all the medication, she’s been through in-patient behavioral therapy programs, nothing’s working. She heard about our research and she contacted us. And we implanted two deep brain stimulators in her brain in the area of the brain that we thought would be likely to help quiet these obsessive thoughts that are plaguing her.
And, to make a long story short, this is her today. It worked and it was pretty damned exciting to us.
Now, I have to say that at one point she did call me in a panic. She said, “Dr. Foote, something is terribly wrong, my DBS (deep brain stimulators) have stopped working because I was at the movie theater last night and I was walking across the floor and it was really sticky and I was completely grossed out.”
And I calmed her down and I said, “Woh, woh, wait a minute. Number one, you were at the movie theater last night, and number two, that really grosses me out too! I think you are going to be OK.”
So, to me, the most intriguing thing about this case is that we are moving beyond using deep brain stimulation to treat movement disorders like Parkinson’s disease and tremor, which now we know we can do, and it looks like we are going to be able to address malfunctioning other circuits in the brain like limbic circuitry that cause problems like depression and OCD.
Michael Okun: You know, Kelly, let me take that idea just maybe one step further. I’m going to tell you something that’s going to blow your mind.
There is a place in the brain called the nucleus accumbens, and a lot of scientists believe this is the final common pathway for where pleasure lives. It’s the reward center, it’s the motivation center. If you take a heroine addict and you put him in a functional MRI scanner, a fancy MRI scanner, you give him his drug of choice, this area lights up, the nucleus accumbens. If you take a graduate student and you put her in the scanner, and you give her chocolate or you tell her, “Why don’t you pretend like you’re having a sexual fantasy?” This area lights up, the nucleus accumbens.
So, it turns out in these patients that had OCD, we’re stimulating very close to that area. And what I’m going to show you next is a patient with OCD, where we’re going to tickle that area inside the operating room and see what happens.
[Video clip — Man: …next condition is now…
(Girl laughing) Oh, man!
Man: Describe what you’re feeling right now.
Girl: I feel happy.]
Michael Okun: I – feel – happy.
Now we’ve done it. Now we’ve crossed into that territory where some of you are beginning to feel uncomfortable in your seats. Is this something — is this a technology where we can actually disrupt your thoughts? Your emotions? We can control them?
Kelly Foote: Should we control the way you feel? Maybe we are mad scientists.
Well, obviously, this is powerful stuff and we’re excited about it. But hopefully just as obviously, we need some ethical guiding principle to guide us on this journey into the electric brain. And we’re going to propose one in a minute but first Mike has one more patient story.
Michael Okun: Let me introduce you to Chris. Chris is a young man who was normal two years before this video was shot. And now, his muscles have turned against him. He has a disease called Dystonia, where the muscles fight against each other, and often leave him to suffer in these abnormal and uncomfortable postures.
Now, if we take Chris and we try to find the region in the brain, that circuit we talked about that’s causing the disruption in his motor loop, in the motor area that’s causing his muscles to do this; if we take Chris and we put DBS electrodes into him, and we turn them on, nothing happens.
But, if we wait, if we wait, and we let the electrical stimulation set in, what we’re going to see is that very slowly, over time, over days, weeks, months…
Kelly Foote: Long, long time.
Michael Okun: Long time.
Kelly Foote: We may have to wait a long time.
Michael Okun: Centuries! What we’re going to see is, slowly, that electrical stimulation is going o begin to work on that circuit. His hands are going to become loose, he’s going to be able to tap his fingers. Suddenly he can move his arms with fluidity. His neck is starting to loosen up, his back is starting to loosen up, he is even looking at his hand saying, I’m not sure how my hand can do this. Very slowly the brain is reprogramming, it’s reorganizing this circuit in response to the electricity that’s coming out of that implantable electrode; it’s remodeling Chris’s brain.
Now, one day Chris is going to wake up. He’s going to tell his mum, “Mum, I think I can walk again.” And he will…
Kelly Foote: And he did.
Michael Okun: So, what’ve we learned?
Kelly Foote: Well, we’ve learned that the brain is a supercomputer, and that we can tweak it with Deep Brain Stimulation.
Michael Okun: You know, I think we can summarize this in three points: identify, intervene and personalize.
Identify the abnormal circuit in the brain, intervene with Deep Brain Stimulation, and personalize the approach, tailor the approach to the symptoms of the sufferer.
Kelly Foote: And we should point out also that I believe we’re just scratching the surface here. This is powerful technology and if you think about it, any malfunctioning circuit in the brain that’s causing a problem for a human being, if we can figure out where that malfunction is, there’s the potential for us to modulate that malfunctioning circuit to help that person.
So, let’s come back to that question that we posed earlier — not the mad scientist question, the question about an ethical principle, and the question about why on earth would we implant an electrode in someone’s brain to try to control it?
And the answer is, and should always be, to alleviate human suffering.
