Caspar’s Cases #9 “The Brain is the Brain and Movement is Movement”
Opportunities of Movement Diseases and University Students?
To Plan B or not Plan B [1]
As I mentioned previously[2] I had little success building up a pool of potential cases for my PhD research on ‘apraxia’. AND all the time my Commonwealth Scholarship was running out. So my Psychology Department Supervisor (Dr Geoff Winter) and my Psychiatry Department Supervisor (Dr David Dennison) have independently suggested I return to the laboratory to extend my experimental research on movement planning and control in normal brains (i.e. University student volunteers).
Doing what comes naturally
The Supervisors were not the only ones opting for plan B. My friend and occasional student, Marie-Anne Lawson (MAL)[3] was anxious about my continual frustrations over my lack of sufficient apraxia cases for my PhD research.
“Caspar – a PhD is a PhD! The brain is the brain and movement is movement! Yes you are an aspiring clinician with good intentions – but you can’t keep torturing yourself with the difficulty of differentially diagnosing damaged brains….” MAL kept nagging me.
Surprisingly my clinical Supervisor, Dr Dennison, was more persuasive:
“Caspar – you can be on the ground-floor of clinical testing with your RT – MT technique[4] across a range of movement disorders, which is the stuff that PhDs and academic careers are made of.” Dennison advised.
He suggested in addition to re-running variations of my Reaction Time (RT) and Movement Time (MT) research in the lab with normal (student) subjects, as Dr Winter advised, I could switch my PhD research and try out some motor skills testing on patients with movement disorders with his access to: Parkinson’s Disease, Korsakoff’s disease, Huntington’s Chorea, Dystonias, and even Psychiatric cases of extreme anxiety, such as writer’s cramp. Indeed it seemed a compromise too good to be true.
Levodopa vs Levodopa + Carbidopa – my first Parkinsonian experiment
Dr Dennison was well placed to help me extend my research into clinical use of RT-MT. He happened to have done some research for his PhD on the cognitive functioning of Parkinsonian patients. Typically these patients are identified by movement disorders, or bradykinesia, resting tremor, shaking palsy or paralysis agitans (ie. they have a distinctive ‘pin-rolling’ motion of the fingers when they are not deliberately moving their hands, but sadly they eventually turn into a complete rigidity) rather than cognitivedysfunction. But Dennison found some slight mental impairment[5] in advanced stages of the disease. So when his Neurology colleagues at the neighbouring Kew Hospital got involved with the drug company which produced the Levodopa used to treat the Parkinsonian tremors, he had an opening for my research.
As it happens Levodopa (L-Dopa) works by stimulating the brain’s supply of dopamine, which is deficient in Parkinsonian neurone transmission involved with muscle control. However, L-dopa causes side-effects of gasto-intestinal (GI) discomfort because of the high doses needed to transfer across the blood-brain barrier when ingested orally. Consequently, the use of Carbidopa in combination with L-Dopa was the new treatment regime being tested to allay the GI complications. Dr Dennison suggested a test of RT-MT pre- vs post- treatment of L-Dopa+Carbidopa. This seemed to be an interesting enough prospect to warrant involving a lowly Psychology PhD student.
Dr Winter was getting excited about expanding his range of research and publications. He even helped get the Psych Department’s Lab-techs to design a portable version of my RT-MT research equipment, so we could transport the gear out to the suburban Kew Hospital, where the research was funded. Geoff was nervous because he’d not been into Hospitals to work with top medicos before.
When the big day came to meet the Neurologists at the Kew Hospital, he was uncharacteristically chatty and giggly. As I travelled with him, and the trailer of our RT-MT gear, I was the first to introduce him to Dr Desmond Brain5 Chief Neuro-surgeon of the Kew Hospital. Desmond was that rare top professional who came across as a warm person and he pleasantly subjugated his obsessive inquiring mind. He was somewhat of a celebrity around the Neurology and Neuro-surgery circles as the first to try brain stimulation with Parkinson’s patients in their final stages of unresponsive rigidity.
But we all had to defer to the Chief of Neurology and Neurosurgery at Kew Hospital, Associate Professor Nigel Nugent. He was not only the rival to Prof Guy Gibson[6], in terms of ego and power over his domain, but sufficiently sub-ordinate in the University pecking order for Nugent to want to out-shine Gibson with the great prestige of enormous research funds for innovative treatments of Parkinsonian patients. Needless to say, they saw an advantage of using movement measurements such as I could offer.
Results speak louder than drug company’s prospectus
Adapting the RT-MT study to patients in a Hospital was not much of an issue. The problem was that Parkinson’s patients were also mostly quite old people whose visual acuity and auditory attentiveness were less than the reliable Uni students. Also their ‘static tremor’ meant that the RT key was frequently lifted and so the RT clock was set off before the RT trial began. So we got the Lab- tech guy to adjust the spring base force of the RT key to make the pressure needed to hold down the key harder. This seemed to work for the younger string patients, but made the older more disabled patients more likely to have premature RT key movements. So we had very slow average RTs with high standard deviations7 even to the basic 1-light condition and attention difficulties meant significant number of trials had to be repeated because of the ‘outliers’ of the oldies.
Once we had trialled 20 patients we were able to get a sufficient power of our statistical test to suggest a slightly statistically significant difference between pre- Carbidopa & L-Dopo vs post- treatment. This was sufficient to appear as an improvement due to the treatment to make the drug company happy. This of course made the senior medical members happy. Far be it from me, a lowly Psychology student, to bring up Prof Paul Meehl’s (1954) famous comments about the importance of ‘clinical significance’.
Another Distracting opportunity : HYPNOSIS.
Another distraction from my research emerged with MAL’s Uncle, the famous Psychoanalyst and Hypnotherapist Prof Archie Lawson (my ultimate boss in the Psychiatry Department). Being there as the tame Psych Tutor & PhD student in the Psychiatry Department facilitated my introduction to many side benefits, including attending Prof Lawson’s Hypnosis classes and drinks with the Psychiatry students and staff on Friday nights. One of the obligations which emerged was that I was being groomed to be a Hypnosis Tutor for the final year Psychiatry students who wanted a special elective course be given by Prof Lawson to add to their curriculum. So apart from observing for months, eventually Dr Dennison said I had to step up, and be hypnotised first, before I could Tutor others. Indeed I should have known because all the Psychiatry students had to undergo all the treatment regimes they intend to practice. This gave each student a partner to try their techniques on and gave them some insight into the impact of the treatments on their patients.
MAL & the dreaded Big Safety-Pin
As I had to practice and needed a partner I asked MAL if she’d mind. She was excited to be asked to find out about hypnosis and was especially curious as to what goes on in the ‘big league’ (her joke about her Uncle’s reputation for being the “top of the top” medical profession). I realised that trying hypnosis with MAL could be seen as unethical and suspiciously like ‘grooming’ her for inappropriate relations. So I checked with her Uncle and the Warden. The fact that I asked permission from her and them impressed them and made me feel a bit easier about it. Of course they said I wasn’t allowed to conduct these sessions in my rooms or her room at college, the hypnosis had to be at the Psychiatry Department where someone could observe us.
MAL was eager to try some hypnotic tricks. But no I said let’s think about what bothers her about studying and try to help her relax a bit. I tried the usual tests that I’d seen Prof Lawson use in his classes, to see if she was hypnotisable8.
1. Hypnotic Induction Profile test – yes she could roll her eyes back into the top of her head;
2. Visual imagery – yes she can picture in her mind an image when requested both with her eyes shut and open;
3. 12 questions – yes she answered them all positively indicating a strong control of her attention and imagination.
So then we started with relaxation and deep breathing. I used this as an opportunity to try the “Quieting Reflex” (QR) developed by Dr Charles Stroebel (a visiting Psychiatrist, stress management9 expert and director of research at the Institute of Learning in Hartford, Conn. USA). The QR must be practiced until it becomes a ‘reflex’, and it goes like this:
Step 1: Recognise when you are stressed;
Step 2: Tense up your hands and biceps;
Step 3: Breathe in deeply as you pull your tense arms in toward your chest;
Step 4: Hold your breathe for 5 seconds and as you feel the tension say to yourself “Alert amused mind” or some similar short positive thought;
Step 5: Breathe out forcefully and as you feel the tension leaving say to yourself “calm. body” or some similar short positive thought;
Step 6: as you breathe out release the tension in your hands and arms
Step 7: Smile
This technique really appealed to me as it could be done easily anytime anywhere. Sure enough MAL was almost drowsy with relaxation after doing the 7 steps twice.
Next we talked about what stressed her when she was studying.
“Ugh swotting for exams!” she expelled an abrupt exhale to try to relieve the stress of thinking of exams.
‘OK let’s think of what you do to get yourself ready for swotting for exams – when do you feel that tension coming on?”
“NOW!” she laughed louder than usual.
‘OK let’s close your eyes now and use that great imagination of yours. Put yourself at your desk in your room and textbook in front of you with your highlighter pen thinking of what the lecturer said would be important to revise.’
“Oh yeah – I GET IT” I could see her hand turning the imaginary pages of the book & holding the imaginary pen.
‘Now remember the Quieting reflex exercise we just did with the 7 steps – this is the time you should apply them – when you recognise you are starting to feel tense.’ – Then straight away I could see her lips move silently through the steps with the commensurate hands, arms and chest breathing and then smiling.
Wow – I thought how easy is this!
MAL did her usual diligence in rigid routines and practiced the QR and her imaginary exam preparation till the real situation arose. AND yes she rushed up to my room after the first exam all smiles and jumping enthusiasm.
“I think that was the best exam I’ve every done”
“So now what?” We both simultaneously gasped, then laughed at the synchronicity.
Unfortunately what came next was a bit too scary to fully recall -even at this distance in time!
As part of the education about Hypnosis Prof Lawson had all the students come back after a week of practice to share their stories and get feedback from him about their technique and how to improve. Needless to say Prof Lawson was impressed with my account of the sessions MAL and I had and the apparent success with her exam nerves.
When it came to end of the class he approached his niece MAL saying (to the class rather than to her per se):
“Now do you want to go to the ultimate level – to show the clinical benefits of hypnosis?”
MAL found herself surrounded by 20 Psychiatry Students in their stern business suits eagerly poised note pads and pens at the ready, all staring at her awaiting the revelation which they knew that Prof Lawson would spring on them.
“Dear Niece Marie-Ann – you know I would never hurt you, and I know you’re here to learn and share about the clinical benefits of hypnosis.” <she nodded somewhat apprehensively>
“SO seeing as how you are so good at hypnosis, can I get you to help me with a little demonstration please?” <she nodded more apprehensively>.
“OK – I know you have been working with Caspar on your relaxation technique – yes?”
“yes” <she said less apprehensively>
“Can you please lie down on this couch <Prof Lawson gestured to the far side of the room> and show us how deeply relaxed you can get?” <she moved to the wall couch & lay down somewhat apprehensively>.
“Remember your 7 steps or relaxation….” <he said gesticulating with his arm tensing up towards his chest as he held a beep breathe then loudly expelled and dropped his arm strongly down>
As if by automatic mimicry of his actions her arms and chest began the motions of deep breathing and arm tensing as she had been taught.
“You are getting deeper and deeper into a relaxed state where nothing will bother you and you are perfectly safe and deeply drawing into your Quieting Reflex ….so relaxed you don’t need to keep tensing and releasing your arms and hands”. As he lowered his voice volume and tone – we could see her arms getting tense then released with her breathing getting deeper and face softening, eyes closed and apparently now quite deeply relaxed without moving her arms and hands.
“Now let me show you how deeply relaxed and safe you are my dear Niece, Marie -Ann let me lift your right arm and show you how nothing can harm you and nothing will interrupt your relaxation” < he was gently lifting her right arm and gradually moving her shirt sleeve a few inches up her wrist exposing her flexor carpi radialis muscle area>.
“Marie-Ann are you ok with that as I touch your arm please?” < she nodded slowly with one of the regularly occurring smiles as she continued her QR routine>. Then Prof Lawson looked at the class and raised his index finger to his lips indicating they must be quiet as he then produced from his pocket a very big safety pin and proceeded to open it up widely so it was shaped to use as a pointed needle. Then he turned back to MAL on the couch:
“Marie-Ann are you ok with me giving you a little pinch on your arm to show how relaxed you are please?” < again she nodded slowly with one of the regularly occurring smiles as she continued her QR routine>. Now he steadied her arm with his left hand and with his right hand he made a pinch of her skin lifting the skin a bit above the muscles in her forearm.
“Dear Marie-Ann are you ok with me pinching your arm a bit harder to show how relaxed you are please?” < again she nodded slowly with the steady tempo of one of the regularly occurring smiles as she continued her QR routine>.
This time he used the safety pin as a syringe pressing the point of the pin through her upheld skin at about the flexor carpi radialis muscle area. There was a slight hush of a collective deep breathe from the class (I was getting angry and could barely control myself). But MAL showed no sign of pain or even a flinch at the suddenness of the prick of her skin. There was no blood and no obvious discomfort in MAL’s demeanour.
“Dear Marie-Ann <Prof Lawson continued to support her arm while he clipped the safety pin into the locked position> you are so relaxed that nothing will bother you” < again she nodded slowly with one of the regularly occurring smiles as she continued her QR routine>.
“Dear Marie-Ann are you ok to talk with me and the class about how good you feel please?” < again she nodded slowly with one of the regularly occurring smiles as she continued her QR routine>.
“OK Marie-Ann while you stay in your nice deep state of relaxation, would open your eyes and look at me please?” MAL gradually opened her eyes while still reclining on the couch <Prof Lawson continued to support her arm> as she made eye contact with her Uncle she smiled, and then he quietly asked:
“Dear Marie-Ann are you ok to talk with me and the class about how good you feel please?” < again she nodded slowly with the tempo of one of the regularly occurring smiles as she continued her QR routine>. “Now while you are still deeply relaxed - look at your arm please <she looked down at her arm with the big safety pin stuck through its skin – but didn’t seem bothered>
“ Do think that pin would hurt you?” Prof Lawson asked quietly while still gently supporting her arm so all the class & she could see the big safety pin protruding.
“Oh… <she flinched & blushed a little and a few blood drops exuded from her skin for the first time>.
“No worries dearest Marie-Ann you are still relaxed as you know I would never do anything to hurt you” he said reassuringly. Sure enough the blood stopped and her face returned to the passive smile and relaxed demeanour.
“There you see you are totally relaxed and it’s ok that I remove that silly big safety pin so you can go back to your deep breathing safe in the feeling of calm and carefree painlessness” he said while her eyes closed and he gently removed the big safety pin.
“So my dearest Marie-Ann you’ve had a lovely restful relaxation session and it’s time we come back to discussion in the class, so in a few deep breathes you can bring yourself to sit up and stay quite relaxed and awake, with eyes wide open now slowly so we can talk with the class please.”
But as she awoke and sat upright her arm began to bleed again in the two holes where the pin had been.
“Oh shit! – what’s this?” MAL looked surprised – but Prof Lawson had a bandage and sterile wipe applied in a few seconds to stop the small blood stream while MAL looked stunned.
Meanwhile the class exhaled its long collectively held breathe and spontaneously broke in cheers and applause. Even I was amazed and let go of my anger in sheer appreciation of the enormity of the lesson we all participated in. Nevertheless I rushed over the MAL’s side and helped her up off the couch which she needed as she was still somewhat dazed.
“How do you think that relaxation session went Marie-Ann?” He quietly lowered his hands to signal silence of the class.
“Hell I didn’t know you were going to stick a big safety pin in my arm!” she laughed loudly and blushed nervously. “But somehow I felt it was all ok and safe and didn’t hurt … until I woke up at the end.”
“Thank you my dear Niece you will go far in your life with your ability to relax and stay hypnotised” Prof Lawson said giving her a big hug. Again the class cheered and applauded loudly. I still remained disturbed about the ethics of what happened and felt for MAL as she was now clutching her arm in discomfort. As I escorted her back to the College I asked would she want me to complain to Prof Lawson about how he treated her:
‘Certainly I was shocked at his presumption of taking advantage of you like that…’ I said worriedly.
“Not worry – it’s all good – just goes to show how well you trained me to use the QR and to get into a deep state of relaxation.” She said tiredly as I shepherded her up to her room.
“I guess I learned more about Hypnosis than I had expected….” She yawned as she slumped on her bed and straight away began to fall asleep.
The next afternoon we bumped into each other on the way to the Dinner at the College Hall.
We both were glad it was over and that MAL’s arm was healing quickly. Nevertheless we were both concerned about the way we were treated by the Psychiatry elite. MAL never looked at her Uncle in the high degree of admiration she had always felt. We continued to practice relaxation and hypnosis on our own terms, dealing with real anxieties about our studies and building the trust of our strong platonic relationship.
Moral of the story
As I got more deeply involved with the Psychiatry Department and the Medical system I gradually realised this was a mixed blessing:
· Yes - I had increasing opportunities and avenues for achieving my PhD despite the frustrations of the clinical realities of dealing with the precarious clinical neurological patients;
· Yes – I made interesting contacts who seemed to be supporting my career;
· Yes - I was now relying on methodology I knew well (especially the RT- MT technique);
· But – what of the ethical concerns, conflicts of interests and disturbing exploitation which lurked below the surface?
· Also I was only a mere Psychology PhD student who would only ever be seen as an academic/ Psychologist not a true member of the medical tribe; only a supporting role not a principal.
Unfortunately I did not have the moral fortitude to revolt against the system which was increasingly encompassing me and my career.
REFERENCES
Meehl, P. E. 1954 Clinical Versus Statistical prediction: A theoretical analysis and a review of the evidence. Minneapolis: University of Minnesota Press.
NOTES:
[1] I write these notes so that others may learn from my experience and reflect on my lessons learned from these cases from a burgeoning practice of psychology. I share these events and analyses of the people and psychology – recounted as best I can, given the efflux of time and the constraints of confidentiality. So the names and places which appear herein have been changed to cover for the concerns of clients and institutions.
NOTE: Unless stated images are from Substak.com photo gallery or of my own camera.[2] Caspar’s cases #6: Apraxia or not Apraxia and the Impairment of the patient see https://casparalexanderpearson.substack.com/p/caspars-cases-6-apraxia-or-not-apraxia
[3] See Caspar’s Case #2 “The NeuroPsychology of forsaken sex”
[4] See Caspar’s Cases #8 Figure 1
5 Remember in Caspar’s Cases #5 he stuck up for me at my first Grand Round presentation and supported my attempt at the diagnosis of apraxia.
[6] Remember (see Caspar’s Cases #5) Prof Gibson was Chief Neurologist at the Roal Hospital & Convenor of the Neurology ‘Grand Round’.
7 As with most of these early studies I can’t now easily access the original publications long-lost from my collection, so my detailed recollection is somewhat vague or incomplete. But I think I can give a reasonable approximation where needed.
8 NOTE – I failed all these tests – indicating I’m not likely to be able to be hypnotised.
9 Dr Stroebel was one of the series of experts on stress management and biofeedback who Dr Dennison had met when studying in the USA and he invited them to the Psychiatry Department Monthly seminars.