Lifestyle changes for better brain health

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Dr. Gary Small knows all about brain health. As professor and chair of psychiatry at Hackensack University Medical Center, he oversees all professional and administrative activities within the behavioral health care transformation service at Hackensack Meridian Health. Prior to this gig, Dr. Small was a professor of psychiatry and biobehavioral sciences and a Parlow-Solomon professor on aging at the David Geffen School of Medicine at UCLA, director of the Division of Geriatric Psychiatry at the Semel Institute for Neuroscience and Human Behavior, and director of the UCLA Longevity Center. Now 72, Dr. Small is known for his public work in promoting the practice of psychiatry and innovative research on brain health, aging, and Alzheimer’s disease. He is a co-inventor of the first positron emission tomography (PET) scanning method that provides images in living people with Alzheimer’s disease with abnormal brain proteins, amyloid plaques, and tau tangles. Dr. Small has authored more than 500 scientific works and received numerous honors, including the American Psychiatric Association Weinberg Award in Geriatric Psychiatry. What’s more, Scientific American magazine named him one of the world’s top 50 innovators in science and technology. He is the author of 14 popular books, including a bestseller titled, The Memory Bible. (Dr. Small also recently spoke at a NAN workshop; to access the archived event, click here.) Earlier this year, BrainWise Managing Editor Matt Villano sat down with Dr. Small to discuss the most important aspects of brain health, and how aging adults can take better care of themselves for the future. What follows is an edited transcript of their conversation.

BrainWise: If we had to categorize lifestyle activities, what are some of the top things people can do to improve their brain health?

Dr. Gary Small: I would say number one is physical exercise. Mental exercise and challenging the brain is very important, but the scientific evidence is even more compelling that regular aerobic or cardiovascular conditioning protects your brain too. You don’t have to become a triathlete to achieve that. Some studies show that just a half hour of brisk walking each day will lower a person’s risk for Alzheimer’s disease. And it’s not just cardiovascular conditioning, which improves circulation to the brain, it increases levels of endorphins which lift a person’s mood and improves issues with pain. Physical exercise also increases levels of brain-derived neurotrophic factor, which is a protein that helps our brain cells communicate more effectively. Strength training appears to provide additional benefits. It may be that when you’re lifting weights or using resistance bands, it provides an additional cognitive challenge to get your form correct, or it may be that other factors are involved. We know that as people age, they are at risk for developing a condition called sarcopenia, which is loss of lean muscle mass, which is a predictor of shorter life expectancy. So that’s another area that strength training helps us in. A third component of physical exercise would be balance training. Older people are at risk for falls, and if you fall, you can hit your head and head trauma is not good for your brain health. [Literature such as this article, this article, and this article suggest that] people who hit their heads and lose consciousness for an hour or more [may have] greater risk for developing dementia or cognitive decline that interferes with their ability to care for themselves.

Brainwise: How can PET scanning help patients become better acquainted with and better in control of their own health?

Dr. Small: It’s a complicated issue because any test or technology that you’re going to use, you have to ask the questions, ‘How is it going to be helpful? What is the potential harm? What is the potential benefit?’ I have worked in this area for a number of years. In 2004, [PET scans were] used to differentiate Alzheimer’s disease from Frontotemporal Dementia (FTD). Today, PET scans are used for all sorts of other things. A PET scanner is essentially like a Geiger counter, it measures radioactivity. When a patient gets one, we inject the patient with a radioactive chemical marker that is taken up by the brain. The marker enables us to see how the brain cells are using sugar, which gives you a measure of cellular function. Of course, there is the risk that if you get these scans, it’s going to cause anxiety in [some] patients. I’m not really a big fan of telling people to go out and get a scan or get genetic testing [unless it’s medically necessary], because it could have negative effects. I am a big fan of encouraging everyone to live a healthy lifestyle, to see their doctor if they have cognitive concerns and get tested and find out where they are and whether these scans are [necessary] or not.

BrainWise: You mentioned genetic risk. What role do genetics play in all of this?

Dr. Small: I always want to encourage people to not be discouraged by their family history. One thing to keep in mind is that the age at onset of a cognitive decline tends to be consistent within families. So if you have a grandparent who developed dementia at 95, the chances are that’s more age-related, and whatever forgetfulness you’re experiencing in your forties is likely unrelated. Another factor, and we’ve done these studies, others have done these studies, is you find that even if somebody has a genetic risk, even if you’re an identical twin to someone who has dementia, that doesn’t necessarily mean you’re going to develop it, that if you live a healthy lifestyle, you can do better. We’ve done studies of people with that genetic risk for Alzheimer’s disease, and we find that if they exercise more, if they don’t have too much overweight or obesity in midlife, that they have less Alzheimer’s disease in their brain when we do brain PET scans.

BrainWise: Can someone be too cautious about protecting their brain?

Dr. Small: It’s never too early and it’s never too late to start protecting your brain. We see very good results in older adults, and one of the advantages of starting early is that you don’t have to change habits so much. It’s one thing to educate people about what’s good for their brain health, it’s another to get them to change. And we’re not just talking about becoming a weekend warrior and playing basketball once a month on Sundays; we’re talking about daily habits that have an impact. And we know from other research [such as Dr. Wendy Wood’s work; see this and this] that to convert a behavior into a habit takes a bit of time and takes some motivation and some consistency. It’s also important to develop a program that is not overwhelming. Not long ago, my wife (Gigi Vorgan) and I wrote a book called, Two Weeks to a Younger Brain. If we called it, ‘Two Years to a Younger Brain,’ I doubt anyone would read it, but the point was, two weeks is enough time to take baby steps to begin to change your life habits, your lifestyle habits, so that it becomes easy to protect your brain every day.

BrainWise: So how can someone jump-start momentum to make a change?

Dr. Small: It’s incremental. It starts with what we’re doing right now, educating people. If you let people know that ordering broccoli as your side dish rather than French fries is going to be better for your brain, you’re more inclined to do that. And part of that education is not just about physical exercise and mental exercise and healthy diet, but it’s also about how to get enough sleep, how to manage stress better, how to avoid experiences like head trauma that will worsen your brain health. If you have high blood pressure or high cholesterol, just taking the medicines for those illnesses can extend your life expectancy and lower your risk for dementia. Many of the books I’ve written outline these programs in some detail. There are many ways to get there. Sometimes it’s reading a book, sometimes it’s checking out a website. Other times it’s meeting with a [trained] professional [such as a psychologist or a neuropsychologist, a dietician, or a nutritionist, as the case may be]. Also, there are apps. I remember reading an article several years ago, it’s much easier to break into training with an app than with a person who will kind of give you a hard time if you don’t show up.

BrainWise: How much exercise is too much?

Dr. Small: When I see patients, I not only go through the standard medical interview and assessment and find out about their history, medications, illnesses, etc., but I ask about their lifestyle. I specifically ask, ‘How much exercise are you getting? How are you doing it? What holds you back?’ And I work with them to try to design something that makes sense for them. Let’s say somebody’s a very busy executive and they don’t have time to go to the gym. Well, what about parking your car a little bit further from the building and walking briskly to the office? Maybe take a few flights of stairs. We always think of it in terms of starting low and going slow. You don’t want people to injure themselves, but you want them to be able to build up in a gradual way. And if you can get the program going so that they get these endorphin rushes, the so-called endorphin high that elevates your mood, that’s very helpful in solidifying those exercise habits because people look forward to it. They know they feel better after they exercise. They have less pain after they exercise. I had a trainer who would always say, ‘Motion is the lotion,’ because it lowers inflammation. Exercise is really something that’s individualized and tailored to the person’s lifestyle. If you make it too daunting, they’re not going to do it.

In the aerobic area, exercise could be almost anything that gets your heart to pump oxygen nutrients to your brain. It could be swimming, jogging, or walking. Part of what determines a specific type of exercise is what’s convenient for you, what you enjoy, what kind of injuries you’ve experienced. For example, if you have a bad ankle, jogging may not be good for you, but you could probably swim. If you have a bad shoulder, maybe a treadmill might be better for you. I think that those kinds of considerations will come into play as someone tries to evaluate what form of exercise is best.

BrainWise: What about social activity? How can that impact the brain, and how much of that should people be emphasizing?

Dr. Small: It really needs to be individualized. My wife and I wrote a book about that called, Snap! Change Your Personality in 30 Days, and it brings up a couple issues. First, despite the clinical lore, it is possible to change your personality traits in a positive way to improve your health and improve your life. Personality is also important when it comes to brain health. If somebody is an introvert, they are not so keen on being so social. They come home at the end of the day, and they like to wind down by curling up next to a fire and reading a good book. An extrovert wants to talk about their day and kind of deprogram all experiences in that way. And so, an introvert wouldn’t necessarily want to spend so much time or need to spend so much social time. But a certain amount of social interaction, I think, is important for everyone, whether they’re an extrovert or an introvert, and it has several aspects that will affect brain health. If you’re having conversations, that’s a form of mental exercise and mental challenge, and that’s going to be good for your neural circuits. If you have conversations with friends who are supportive, that will lower your stress levels and that’s going to help your brain health. Loners don’t do well as they age. We saw this really impact people during the pandemic, among people of all ages. Isolation can lead to depression, and depression is a risk factor for cognitive decline.

BrainWise: Finally, what about diet? Can that really affect brain health?

Dr. Small: Diet is significant. Watching your calories, particularly in midlife, is key. The fat around the abdomen is inflammatory. Many of us think that heightened inflammation drives brain disease as we age, so watching out for that is important. The average western diet includes too much Omega 6 fat compared to Omega 3, and we want the Omega 3. Consuming at least seven servings of fresh fruits and vegetables, which lower oxidative stress in the brain and the heart, is wise. Processed foods and refined sugars, which can increase the risk for diabetes, [also may increase] your risk for dementia [as outlined in this CNN article about a recent study on this point]. I was just reflecting about diet this morning when I woke up. I got a reasonable night’s sleep and I felt pretty good getting up. And I thought, ‘Well, what did I eat for dinner last night?’ I had Mediterranean food. We hear a lot about the Mediterranean diet, and I felt a lot better than I did the day before. On that day, I had just returned from a business trip to Chicago where a lot of the airplane food, all that salt and more of a Western diet didn’t help me sleep so well and didn’t make me feel so great. People can experience subjective differences depending on diet. And you can talk to a lot of people who have changed their diet and notice subjectively they feel better. I think that’s one of the things I’d like to emphasize about taking these baby steps to improve your lifestyle. If you do it, you’re going to notice it’s not just the long-term effects on your brain health, but you’re going to start feeling better right away, which reinforces the habits.

BrainWise: Five years from now, what do you think we’ll be talking about when we talk about everyday ways that we can improve brain health?

Dr. Small: Well, I’m hoping that we’ll have more incentives for people to live healthier, because I know how hard it is to get people to change. We don’t want to force them to change, but we need carrots, not sticks, to motivate them.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

When age is really just a number

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We all age. Some of us age better than others. This is an area of expertise for Dr. Emily Rogalski, professor of neurology at the University of Chicago. Dr. Rogalski heads the school’s brand-new Healthy Aging & Alzheimer’s Research Care (HAARC) Center, which will focus on building deep multidisciplinary expertise and bridging the gap between scientific disciplines to accelerate breakthroughs in cognitive resilience. This focus is increasingly important as the world’s population continues to age—the World Health Organization estimates that one in six people will be aged 60 years or older by 2030. Early in her career, while at Northwestern University, Rogalski operationalized the term “SuperAger” to describe people over the age of 80 whose memory still functions as well as that of someone in their 50s or 60s. That project has received considerable attention, including this piece from CNN. The project also received a $20 million from the National Institute on Aging and the McKnight Brain Research Foundation to establish an international multi-center SuperAging Consortium. BrainWise Managing Editor Matt Villano caught up with Dr. Rogalski before a talk at the recent NAN Conference in Philadelphia to discuss her work, its implications, and where SuperAger research goes from here. What follows is an edited transcript of their chat.

BrainWise: How did you get into this area of neuropsychology?

Dr. Emily Rogalski: I grew up the daughter of a schoolteacher who taught kids with learning challenges. From a very early age I was surrounded by brilliant kids that learned a little bit differently. That’s really where my interest in the brain came from. As a young kid, I had a very naive question: ‘If these kids are so brilliant but they can’t learn in the traditional way that our schools are set up, I wonder if there’s something different about their brains.’ I think I’ve been always attracted by things that are on the outskirts rather than in the main lane, and how those elements can inform both the mainstream, but also help those on the outside. When I was in graduate school, I learned about a really rare dementia called Primary Progressive Aphasia (PPA), where instead of losing memory like we lose in Alzheimer’s dementia, individuals lose language. And not only that, but they lose it at a really young age. They can be in their 50s and 60s, even [in their] 40s sometimes. When this is happening, nobody is thinking it’s dementia. It can take years to get a diagnosis. I was really struck by the lack of research that was going on 20 years ago in this space and thought, ‘This is a real opportunity to explore and help.’ This dementia can be caused by Alzheimer’s disease about 40 percent of the time. And so I found myself in an aging and Alzheimer’s center for my dissertation work.

In the trajectory of aging, you’re constantly told there’s nowhere to go but down. Normally, the first thing that’ll come out of the mouth of anyone who’s giving an aging talk is something like, ‘As we get older, we lose our memory.’ [We’re taught to know] that when you get older, your eyesight changes, your hair gets gray, your skin gets wrinkled, and your memory declines. And while that makes sense in general, I think if we all stop to think about that, it’s not in practice all of the time. We all know the Betty Whites of the world. We know these people who really stick out as being something different. We know them as our neighbors, we know them as our aunts and uncles in our daily lives. And so this thing that we talk about with aging and it being nothing but bad news doesn’t really fit with people’s lived experience of they know at least somebody in this other sphere.

The challenge was that 15 years ago, there were people already studying successful aging. I think that was a great change in something that really [John] Rowe and [Robert Louis] Kahn did a great job of getting that concept out there, that there could be another trajectory called successful aging. But that definition and that concept was general. There was a great review done by [Colin] Depp and [Dilip] Jeste [in 2006] and they looked at definitions of successful aging. What they found was that in 28 studies, there were 29 different definitions. In and of itself, that’s not a problem. They also found that in those studies, the percentage of people who met the criteria for successful aging ranged from 0.9 percent to something like 97 percent. So virtually nobody to virtually everybody. That proved the definitions for successful aging were all over the place. One was you’re over the age of 65, dementia free, and you have good physical health. Another definition was that if you’ve lived to age 90, you’re a successful ager. There also were definitions in between—sometimes requiring good cognition, sometimes requiring good physical health. I started looking into aging and what makes for ‘successful’ aging. That’s when I [coined the phrase], SuperAgers.

BrainWise: What characterizes a SuperAger?

Dr. Rogalski: I operationalized this term SuperAger so it would be very specific. [The paper that established the definition is here.] While it fits under the larger umbrella of a type of successful aging, the goal was really to say we wanted to have both a specific neuropsychological definition and an age criteria. SuperAgers are individuals who are over age 80 who have memory performance at least as good as individuals in their 50s and 60s. Why age 80? Again, kind of back to this idea is everything gets worse when you’re older. And it turns out that merely getting older is the biggest risk factor for Alzheimer’s dementia. It wins. It wins over all other factors right now. By age 80, you’ve reached a point where you’re at great risk for typical or average cognitive decline. You’re at greater risk for Alzheimer’s dementia. If you’ve reached this age and then you have memory performance that’s youthful, that’s unique. If you’ve gone through all of those lived experiences, all that wear and tear, and you’re able to really look like a 50- to 60-year-old, that is, neuropsychologically speaking, quite different.

BrainWise: So, neuropsychologically speaking, what do all SuperAgers have in common?

Dr. Rogalski: We require them to have this memory performance that’s at least as good as 50- to 60-year-olds. Then we say other cognitive domains have to be at least average, but we’re going to explore it and then we’re going to look at those as variables to say, well, how much does attention and executive function contribute? When Dr. Amanda Cook Mayer was a graduate student at Northwestern working with me (now she’s faculty at the University of Michigan), we did a study on that to say, what are their other strengths in cognitive function? What we found is there’s not one path to get there, but [SuperAgers] tend to have strengths in attention and executive function, and that there’s some variability that helps to explain some of their memory performance. Some SuperAgers, no matter which cognitive tests you give them, knock it out of the park. They perform like 50- to 60-year-olds or better across all the cognitive domains. In other instances, there’s people where memory is really their strength and other cognitive domains are average. There’s a third trajectory where people of course have great memory, and the other cognitive domains oscillate a little bit. I think this is important because it’s not that the SuperAgers had to get there all the same way. There can be different paths or trajectories that got them here. As we move more toward personalized medicine and precision health, we have an opportunity to understand the contributors to each of those pathways.

BrainWise: How does this translate to your current study?

Dr. Rogalski: Our goal in this study is not to just look at one domain. So some studies are like, ‘I’m a study of sleep.’ That’s very important, but that’s not what we are going for. We really wanted to cover as many domains as possible, do them well, and then look for that integration across the things. So we’re going to look at structural function, but how does that relate to cognitive function? We’re going to look at genetic factors. What’s the interplay between cognition, genetics, neuropathology, and brain structure? What can we detect during life, knowing that in a living person, we can only see with a certain resolution? I liken this to when we first got digital cameras and we were all excited, we didn’t need film anymore, and we could take a bunch of pictures and that seemed great and they looked great on the back of our cameras. And then we printed them out in our home printers, and everybody’s faces looked like little squares. They were pixelated. Well, that’s about the resolution we can see during life. And so this is where someone donating their brain at the time of death gives us that better resolution where we’re at with our iPhones now or better so that we can really look at contributors of cellular and molecular factors.

BrainWise: Can you give us specifics about one of your SuperAgers?

Dr. Rogalski: Our oldest SuperAger is 109. And I was at her house a couple of weeks before her birthday to bring her a present, and we did a little video shoot with her. The day before, she made us strawberry rhubarb jam. She’d never made strawberry rhubarb jam before. She’s still trying new recipes at age 109, and it was delicious. She enrolled [in the SuperAger study] when she was in her early 100s. At that time, she was driving, and I would’ve ridden in the car with her. She only stopped driving because she got gout, and the medicine she was taking messed with her grip strength. She’s sharp as a tack. We ended up doing a three-hour interview [with her]. Her best quotes were at the end of the interview. I mean, everybody was in tears as she was sharing aspects of her life. She was the first Black woman to graduate from Grinnell College in Iowa. She talked about the first time there was a radio in her house, the first time there was a phone. Think about what she’s lived through: two pandemics, World War I, [World War II]. That’s pretty remarkable. She’s seen a lot.

BrainWise: How many people over 100 are participating in the study?

Dr. Rogalski: Fewer than 10, out of about 300 total.

BrainWise: How do I know if I’m a SuperAger, and what can I do to increase my chances to become one?

Dr. Rogalski: We know that diet and exercise are important from [epidemiologic] studies and from other cohort studies. When we look at SuperAgers specifically, we see they have variable diet and exercise. The good news [there] is [that] it’s a good idea to pay attention to your diet and exercise, but all may not be lost if you’ve not paid the closest attention.

We know that SuperAgers range in education from 12 to 20 years. So it’s not just doctors and lawyers that we’ve enrolled. And every time we make a comparison in our study, the IQ of the control group is always in the same range. So that means it’s not just general intelligence or a measure of intelligence that’s differentiating the groups. I’ve worked with cohorts in South America where they have focused on enrolling or identifying SuperAgers that have little to no education, and they’ve been able to find them. We [too] are starting to enroll more diverse samples. It is possible to find SuperAgers who have lower education. We’re not just picking up on extreme levels of education that allow you to maintain good cognition over age 80.

I think one practical thing that we’ve seen, and now we’re trying to quantify it more objectively, is that SuperAgers report having stronger social relationships with others. We don’t know much about those relationships. We don’t know whether they have one best friend that’s a trusted partner, or if they are the social butterflies of their community. I know anecdotally many of them are the social butterflies of their communities.

Until recently all the data we collected on SuperAgers was self-reported. Then in 2020 we had this opportunity to write a grant that expanded the program to make it multi-site and to change the depth and breadth of science that we do. And one of the ways that we changed the depth and breadth of science was to add in wearable sensors. Now we ask the SuperAgers to wear these in their daily lives for about 14 days so we can get measurements of activity and social engagement. Objectively we can get measures of sleep and autonomic function. For all the survey data and the anecdotes that we have collected over the first 15 years, we’re now collecting those data objectively and quantitatively moving forward across five cities in the U.S. and Canada.

BrainWise: To what extent could a SuperAger potentially have issues with eyesight or have some physical disability, and where does that come into play with your research?

Dr. Rogalski: I was very intentional in not requiring super agers to have good physical health. We know from the larger body of research that good physical health tends to be associated with good cognitive health. And this makes sense for a lot of reasons. However, if you make that an entry barrier, now you’re kind of penalizing people who were able to maintain great cognitive health, but they might need a wheelchair or a walker. Their physical aging or their physical brain age may outpace their cognitive brain age, and I didn’t want to have that penalty. Instead, I wanted to be able to look and say, ‘How many people do we find that are using wheelchairs or walkers?’ So our SuperAgers vary. Some of them are riding their bikes hundreds of miles a week or in the pool doing exercises and weightlifting in the pool. Others are leading a chair stretching class. There also are several who are like, ‘I don’t exercise and I don’t plan to start exercising.’

What we do see in our super agers is that their brain integrity and brain structure looks different. They tend to look more like 50- to 60-year-olds in brain structure than they look like 80-year-olds. In this instance, we’re talking about cortical thickness. That’s the outer layer of your brain where your brain cells live—we can measure that thickness and it gives us a proxy measure of the health of the brain. Generally speaking, thinner is worse and thicker is better. When we compare our average 50-year olds to our average 80-year olds, we see that same thing that others have shown: cortical thinning across the cortex of the brain. When we compare our super agers to the average 50-year olds, we don’t see any significant cortical thinning. In fact, we see a region in the anterior cingulate cortex that’s thicker in super agers than it is in the 50-year olds. This has spurred some of our investigations pathologically to make sure we’re paying close attention to this anterior cingulate region.

BrainWise: Where do biomarkers fit into this research? At what point do you hope we can begin to apply some of these lessons you’ve learned to say 40- and 50-year-olds to maybe help them get a sense of whether or not they will become a SuperAger?

Dr. Rogalski: The larger body of research tells us social isolation and loneliness are bad. There are studies that have shown those who are socially engaged and have Alzheimer’s dementia tend to have slower trajectories of decline and tend to fare better cognitively. Our data fit with that. The practical implication is that if you’re going to go home today and on your commute home, you’re thinking about calling your best friend, call them, talk to them, stay socially engaged. Why might that be important from a brain health standpoint? Conversation is hard. I don’t know exactly what you’re going to say next, but you’re going to ask me a question. And then I have to think really quickly on my feet to say, ‘Okay, how am I going to answer that?’ Our brain likes new and challenging things, and social engagement creates that newness all the time to keep you on your toes, so to speak.

Finding the thicker anterior cingulate, that was serendipitous and it led us to other research questions. Under the microscope, it turns out we see a greater density of a special type of neuron called Von Economo neurons. These are neurons that have only been described in two regions of the brain, the anterior cingulate [cortex] and the frontal insular cortex. They seem to have something to do with social behaviors and social function, and they tend to be abnormal in Alzheimer’s dementia, frontotemporal dementia, autism, schizophrenia, bipolar disorder. They also tend to only be present in higher order species like [humans and] whales and elephants. We can now look cellularly, molecularly, genetically at these neurons to say, what role are they playing? This [part of our research] isn’t going to have an actionable endpoint tomorrow, but we need to be looking at all of these different levels. And so that’s kind of the beauty of the design that we have, is that some things kind of glean more actionable things to think about today, where others might lead to whole new directions and protective factors that might take a little bit longer to get there.

[To speak to the issue of biomarkers], we are looking at blood-based biomarkers. Some of the SuperAgers have been getting amyloid PET and tau PET scans so that we can measure aspects of Alzheimer’s disease during life, and then also measure it at the time of death when they pass away. As I’ve mentioned, one thing about SuperAgers is that they tend to be healthier, so I always joke that I do better in my side of the study that’s on the living side than my colleagues who have to wait until they pass away because they keep living.

BrainWise: Which questions will you be asking in your research next?

Dr. Rogalski: I lead what’s called the SuperAging Research Initiative, which now has five sites across the U.S. and Canada. My particular expertise is in the cognitive aspects, the neuroimaging aspects, and in some of the social function and other survey data that we give. My partners in this are geneticists, neuropathologists, neuroanatomists, [and others]. I’m kind of fluent in many of these things, but they’re the primary leaders, and that’s the goal, to bring together these scientists with these different expertise so that we can really dig a little bit deeper. And so now we’ve got these partners across the U.S. and Canada, and we’ve got the SuperAgers.

Another goal is to diversify our sample, make sure we’re identifying SuperAgers in different communities, both regionally across the U.S. and Canada, but also racially and ethnically. We’re working hard to make sure we’ve got strong community partnerships and trusted relationships, and we’re not just coming in and saying, ‘Sign up for research!’ We want to make sure we’re intentionally there and building partnerships because these folks are with us for life. When they sign up, they’re coming back year after year after year. It’s a relationship we’re starting with them. It’s not a study where they come in for one blood draw, and we never see them again. This is longer term.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

What brain imaging can tell us about brain conditions

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Attendees at the annual NAN Conference in Philadelphia last month were treated to a keynote speech from Marek Marsel Mesulam, MD, the Ruth Dunbar Davee Professor of Neuroscience and Founding Director Emeritus of the Mesulam Center for Cognitive Neurology and Alzheimer’s Disease at Northwestern University. Dr. Mesulam’s talk spotlighted what happens in the temporal pole, the very tip of the temporal lobe. Dr. Mesulam is a neurologist, and his textbook, Principles of Behavioral and Cognitive Neurology, has been part of training programs in neurology, psychiatry, neuropsychology and cognitive neuroscience. Dr. Mesulam’s current research focuses on the functional imaging of neurocognitive networks, the factors that promote memory preservation in advanced age, and treatment of dementia. After Dr. Mesulam’s talk at the NAN Conference, BrainWise Managing Editor Matt Villano caught up with him to ask him about the intersection between brain imaging and neuropsychology, and how 50 years of experience in the field has informed his perspectives today. Their chat was the latest in a series of interviews Dr. Mesulam has given on this subject (for another good one, click here). What follows is an edited transcript of the conversation.

BrainWise: You’ve been researching brains for more than 50 years. How has brain imaging evolved in that time?

Dr. Marek Marsel Mesulam: Until the 1970s, all we had were traditional X-Ray films of the skull. At that time, it was difficult to localize regions of the brain. If you had a patient and they showed certain deficits and you wanted to find out what part of the brain was causing that deficit, it was almost impossible. There were a few instances where arteriograms were done and that helped to find out which vessel was impacted. That might provide information about where a lesion might be, but that was it. It is important to realize that for the first 100 years of neuropsychology, the brain lesion correlation has been central to understanding brain function. Logic says that if you lose certain function and there’s a lesion in the brain, that was the part of the brain critical for that function.

There was revolution in imaging in the 1970s. We had the first CAT scan. Then we had the MRI, which was far more powerful. These are structural methods. They show you where a stroke is or where you have loss of substance. They helped establish an important distinction between stroke and the sudden death of a whole bunch of neurons in a specific part of brain, like where there is atrophy that could be the result of degenerative disease. Then we had another revolution in the structural/functional relationship. This first came in the form of PET scans where blood flow was scanned. Later we had single-photon emission computerized tomography (SPECT) scans. This allowed us to see where function was lost in the brain physiologically. For instance, when a part of the brain doesn’t work it doesn’t draw blood.

The last layer in the revolution has been to use PET scan and MRI to do something called functional imaging. In the initial paradigm, when you lose function, you look at part of brain that’s injured either by stroke or atrophy and you correlate the two. With functional imaging—with PET and MRI—we have the ability to ask the converse question or complimentary question: If you do a function, which part of the brain shows activation? That is a different paradigm.

By the time the 90s were over, we had all these tools in place. That means the past 20 years they have kept getting refined. Temporal resolution got better. Spatial resolution got better. Computational methods for analyzing data became better. Right now, we’re still reaping the benefits of these various technologies. The downside is that this is not something you just take off the shelf. You have to be pretty sophisticated in order to make sense of this. What I’m saying here is that images don’t come with labels. Interpretations can vary because the methods are so noisy. There is sometimes a lot of fantasy in interpreting results. By and large, compared to the 70s, where it was just a desert in terms of imaging, right now it’s really like being in a toy store. I think there will be continuous improvement.

BrainWise: From a research and clinical perspective, what do these new techniques offer?

Dr. Mesulam: They enable us to address impairment, for one. Where is the structural change in the brain? That gives you clues to identify the disease that is causing the problem. There are certain regenerative diseases that impair primarily the hippocampus. One other advantage, in addition to the scientific question of where in the brain is such-and-such a function, is to be able to understand what the underlying disease might be.

There are now dozens of different techniques. You can search for structural imaging of volume. Or structural imaging according to thickness. You can look at fibers. You can look at a resting state connectivity analysis. With PET scans alone, the options are multiplying. There are now metabolic PET scans, scans that show the number of synapses. We can also go in and look at amyloid distribution, tau distribution. Like I said earlier, there’s no such thing as ordering an image and getting an answer. The data provides information for a continuous hypothesis. As a doctor you start and try to make do with the least possible disruption and expense to the patient. If your initial imaging doesn’t give you an answer, then you keep getting deeper and deeper.

BrainWise: How does cognitive measurement assist imaging in getting a full picture of someone’s brain functioning?

Dr. Mesulam: People don’t come to you and say, ‘Doctor, I have atrophy in my frontal lobe.’ They come and say, ‘I have difficulty with x, y, and z.’ What people say and what really is there are two different things. People are not neuropsychologists. Many times, when we have patients coming in and saying, ‘My memory is not the way it should be,’ you have a have big differential. What do they mean by memory? Do they mean they can’t find words? Do they mean they can’t see faces from the past? Does it mean they can’t remember things from childhood? From yesterday? Does it mean they can’t hold someone’s phone number. Each one of these is a different kind of memory and each one of them has a different relationship to the brain. The job of neuropsychologist is to translate the lay language of patient into a language that can be correlated into what imaging shows. [For a systematic review of work on this subject, read this peer-reviewed article from the Archives of Clinical Neuropsychology.]

BrainWise: Looking forward, based on the decades of experience you have, how do you think artificial intelligence can help impact the way we read brain images?

Dr. Mesulam: Artificial intelligence (AI) is one of these totally ambiguous terms to me. Of course, we’re using artificial intelligence in interpreting images. We have powerful computers that are chewing out the data and comparing it to controls and giving us incredible and sophisticated information based on whatever thresholds we want. If one wants to call this artificial intelligence, they can suit themselves. To me the word is meaningless. We like to play with toys, and that’s what this is. If AI can find out the handedness of a patient, the developmental history, whether they had dyslexia in the past, that would be significant. If you assume that all the data in the world someday will be in some kind of computers, I suppose there eventually will be something slightly better, but right now it’s not as if we’re screaming out for some artificial thing doing something we can’t do.

BrainWise: So what does the future hold, Dr. Mesulam? How will better brain imaging make for better and more efficient neuropsychology?

Dr. Mesulam: We’ll get better inventions and statistics, better special resolution. We’ll invent new things that will show different chemicals in the brain. By 2028, I don’t think there will be much conceptual change. In 200 years, I don’t know. If we had a chance to introduce an electrode into each of the 40 billion neurons in the head, what questions would we ask? We don’t have a theory of brain function yet. Could we develop one? Data is a dime a dozen, and you need to interpret it to the best of your ability. We do our best and still even for the most seasoned clinicians there are surprises. Ultimately a clinician must believe the results of a clinical exam over imaging. That’s what the patient is experiencing. For people who take care of patients, at least as of now, that remains the primary source of data and therefore the primary part of the experience.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

From neuropsychologist to young adult novelist

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Northern California resident Katie Keridan spent the first 12 years of her professional career as a neuropsychologist. Following her schooling, she served as a predoctoral intern at the Kennedy Krieger Institute at Johns Hopkins University School of Medicine in Baltimore, then moved on to become a postdoctoral research fellow and licensed clinical psychologist at Children’s National Health System in Washington, D.C. In 2017, she moved to California and started a private practice. She also was a member of the National Academy of Neuropsychology (NAN); the first annual conference she attended was in Vancouver, B.C., in 2010. During the Covid-19 pandemic, Keridan made a major life change, setting aside psychology and psychometric analysis for a new career as a young adult novelist. Since the switch, Keridan has published two full-length fantasy books for young adult readers, and she has already finished her third book in the series. The books and characters in them benefit from Keridan’s knowledge of psychology and neuropsychology. BrainWise Managing Editor Matt Villano recently caught up with her to talk about her journey and what’s next. What follows is an edited transcript of their interview.

BrainWise: Making the leap from neuropsychology to YA fiction is not a very traditional path. What prompted this transition?

Katie Keridan: Yeah. Who would go from being a doctor to a young adult fantasy author? Oh wait, that would be me. I have always loved to write, always. I mean, some of my earliest memories are of me taking paper and folding it and stapling it and making little books. And I’d go through and I’d write about these wild adventures I had as a child growing up on a ranch in Texas. And then I would illustrate my own little written books. However, I was the first person in my family to go to college and thinking about a career that is going to be sustainable, writing was not really up there at the top of what my parents hoped to see me do. Since my parents were paying for me to go to college, they had a real vested interest in what I was going to major in and what I was going to do. Probably because I love creating characters and I love figuring out how people think, psychology was a natural fit for me. I loved figuring out what’s going on for someone and how I can meet them where they’re at and help them. Neuropsychology is even a further branch off that, figuring out what’s going on in this child’s brain so that we can meet them where they’re at and help them and connect them with the resources that they need to be as successful as they possibly can. I loved the career that I developed, it was fantastic. The best part was obviously working with kids and their families. The worst part was insurance and billing and figuring out how you are going to help these people who are coming into your office today. I was very fortunate—once I moved to California and got into private practice, I had time to delve more into the writing that I wanted to do. And I thought, ‘40 is approaching swiftly on the horizon, why am I sitting around here waiting, thinking someday it would be fun to try to write a book? Let’s go for it. Let’s just try and put it out there.’ I connected with a great writing team. My first book, Reign Returned: The Felserpent Chronicles, Book 1, came out last year in 2022 and then the sequel, Blood Divided: The Felserpent Chronicles, Book 2, just came out October 3rd 2023. The final book in the trilogy has a publication date of October 2024. So, it’ll be three books in three years.

BrainWise: How did the first book come to life?

Keridan: That book started while I was still on the East Coast. I’d have these little moments where I knew these characters, I knew this was a story I wanted to tell and so in my spare time I would write little snippets. Sometimes the only writing I would do would be from 11 p.m. to midnight or midnight to 1 a.m. during the week because you’re working all day long and you have to find these bits of times to write when you can. The more I started doing it and letting that part of myself come out and breathe, the harder it was to keep putting it back into the box. Because the story started taking on a life of its own. So, it has been with me for a few years.

I really wasn’t sure what COVID would mean for the publishing industry at all. Thankfully with my first book coming out last year, I was fortunate that [Covid-related] shipping issues didn’t really affect it. Most of the worst had passed, bookstores were back to doing in-person events. [Once the book came out,] I had to figure out some changes. Was I going to pursue [writing]? Was I going to stick with what I had gone to college for, what I had decided was going to be my chosen career?

It was scary to make the transition, but it was incredibly exciting. Now that I’m at a point where I have two books out and I’m connecting with readers and starting to get feedback, it’s such a privilege to know that people enjoy the work and enjoy what I’m putting out there.

BrainWise: To what extent does neuropsychology play a role in your books?

Keridan: I try hard to include accurate mental health representations in my writing because that’s my background. And I would be remiss if I didn’t bring that into creating characters that I want readers to see. Anxiety doesn’t just have to look one way, depression doesn’t just have to look one way, trauma and processing, it doesn’t have to just look one way. And that’s been so incredibly rewarding.

We’re in a position in publishing right now where despite all of the really horrible things going on with book bans and libraries closing and school libraries closing, there’s never been a greater interest in accurate mental health representation. Ware getting a lot of own voices coming out and talking about their experiences—not just, ‘Here’s what happened to me,’ but instead, ‘Here’s what happened to me through the lens of this character that I created so that other people can better understand what it was like to go through this.’ Just as one example, my main character, Sebastian, was a victim of abuse as a child and I pulled directly from my own life experiences with that, having grown up in a very abusive, chaotic home. I wanted to show a character who thinks they’ve worked through this when they’re just ignoring it. Now that they’re in this new relationship with someone they love, they have to figure out what it means to be vulnerable? How do I open up about this trauma that I’ve experienced? What is my partner going to think if I have a nightmare and I wake up screaming? I’m just going to die of embarrassment. All these things that young adults go through, new relationships, big life changes—but experiencing that through characters who have a neurological or a neuropsychological diagnosis has been incredibly fun for me. And I love that I can reach so many more people than I could [as a neuropsychologist]. It is always a trade-off when you do cognitive testing with families, there’s a part of me that feels like I become part of that family, and they never leave me. The nice thing about writing a book is I can reach more people, the downside is it’s less personal than what I did before.

BrainWise: What was the most challenging aspect of leaving behind a career you had worked so hard to achieve?

Keridan: I have a Ph.D. That’s usually anywhere from five to seven years, then you do an internship. I did a two-year research fellowship. So, we’re talking into the double digits of [years of] schooling and commitment to [neuropsychology]. I think the biggest part was that I was more worried what other people were going to think of me for making this change. Thinking about looking around the room at my professional colleagues who have all these letters after their name and saying, ‘Hello, I’m going to be working on a YA fantasy novel.’ Just being able to believe in myself that I could do this and that I was not less-than for making a change—that was a challenge.

I’ve had some people ask, ‘Do you think you chose the wrong career? Do you think you went into the wrong field?’ Never. I love the education I got, I love the experiences I had, and the people that I connected with. Honestly, I don’t think I’d be writing the books that I am if I hadn’t had those experiences. We never know how things are going to play out ever. I’ve become so much better about trusting my instinct, listening to myself, and just going for it. I’m trying to be a little less of a Type-A Capricorn and a little more just go with the flow.

BrainWise: Can you please tell us a little about the series and what the enduring storylines are all about?

Keridan: In the first book, Reign Returned, we have an enemies-to-lovers story, because I’m a huge fan of [stories where] there’s all this conflict and we hate each other, [and then,] surprise, we’re actually going to fall in love. I’m a big fan of tropes in general. Some people will say they’re cheesy, I also say there’s a reason why they sell, and if it ain’t broke, don’t fix it. So, in the first book, we have a former king and queen who, before they die, bind their souls together and promise to return when it’s time to retake their kingdom and find one another. Centuries pass, they’re both reborn, but they come back with no knowledge of who they used to be, and they come back on warring sides. The first book is really about remembering the past in order to change the future. The second book comes around and my main characters have remembered their past, they know who they used to be, they know that they’re back and they’re ready to reunite the realms, but it’s not going to be that easy because…well, what would be the fun in that? So, they are back, and their arch enemy is back as well. This is really a story of found family, of figuring out who you are and who you want to be and gathering the support that you need in your life to make that happen.

BrainWise: Have you written the third book yet?

Keridan: Yes. The third book is currently undergoing proofreading. Without going into all the details here, with book three, I’m a huge fan of happily ever after, so I can tell you there is going to be a happily-ever-after. Our characters learn, they grow, family secrets are discovered, betrayals are survived. But in the end, as we always hope it does, good wins out and triumphs. [The book is scheduled to come out in October 2024.]

BrainWise: Now that your first series is behind you, what’s next?

Keridan: I’m working with an organization called The Novelry, because my next project is a middle grade book. This one is near and dear to my heart because my main character in this book is an 11-year-old girl with high-functioning autism. It’s a contemporary book, so it’s set in the present day, but there is a little bit of a dash of magic in there. I am incredibly excited. I’ve loved the young adult, YA, fantasy world, after three books, I needed a break because that’s a lot of plot lines and characters and layers to work through. I’m about three-fourths of the way done with this next book, and it will be for younger readers, which I’m really excited about.

[Another one] of the things I’m really excited about for 2024 and beyond is to have the opportunity to do more teaching. I am very fortunate that I have some fun events lined up for 2024, such as the San Diego Writers Festival. There’s a couple of different things that I can’t mention yet because they’re still potentially in the works. Writing is such a solitary activity. I mean, in the midst of it, it’s me with my laptop just sitting here with all these characters in my head. So, when I can get out in the real world and start connecting with readers and seeing people face-to-face, that’s so much fun. And I love that chance to interact and to hear something that they enjoyed about a book or a character.

BrainWise: To what extent are you keeping up with what’s happening in the world of neuropsychology?

Keridan: I could never fully disconnect from the brain community, no matter what. Even if I hit No. 1 on The New York Times Best Seller list, I will still be reading what’s happening with neuropsychology and especially pediatric neuropsychology. Any kind of breakthroughs involving kids, anything specifically related to oncology or autism or intellectually gifted kids who also have clusters of other things going on, I’m always paying attention to that and reading what I can because we need breakthroughs now more than ever. Especially since the pandemic, what kids have been facing from a mental health perspective, I don’t think we’ll fully even begin to understand it for years to come. But kids need services and support more than ever.

BrainWise: Do you ever see yourself going back into neuropsychology full-time?

Keridan: You just never know. I never thought I’d be sitting here doing this right now. But I will say I’m not actively seeing patients, I’m not actively taking on any cases or doing any neuropsychological testing at this point. Who knows? I would love to find a way to combine [writing and neuropsychology], whether it’s at a college-level class, to be able to talk about books and reading and brains and how this all goes together. Or it might just be a workshop that I put out. I’m going to think about that.

BrainWise: In conclusion, what advice can you offer others who are contemplating a career change, whatever their current careers might be?

Keridan: There comes a point where we have to decide, who are we living for? Are we living this life to make other people happy and do what we think they think we should do, or are we living this life for ourselves and figuring out how can we make the greatest contribution and connect with people? For me, growing up, books were an escape, they helped me stay sane. When I couldn’t leave the situation I was in, at least I could mentally check out and I had friends in books. That’s what I want to offer people today. Like saying, ‘Here’s a safe place where you can see someone, they might not be just like you, but there’ll be similarities and you can see yourself reflected on that page.’ We need more of that, it’s priceless.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

My experience treating depression with magnetic waves

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Editor’s note: Sandra Haney lives in Waynesboro, Virginia, and recently turned to Transcranial Magnetic Stimulation (TMS) to treat chronic depression. BrainWise Managing Editor Matt Villano wrote this story in her voice after an extensive interview with her about the experience. For more on the science of TMS, click here.

Depression is like an old friend at this point; I’m 41 years old, and I’ve been dealing with depressive episodes since I was about 15.

It was episodic early on. Things came and went. I had more prevalent anxiety than I did depression. Pretty severe panic attacks. Really frequent intrusive thoughts of death—not so much suicidal ideation but more thoughts about my eventual demise. Throughout my teens and twenties, I did therapy. I tried tons of different medications. Some worked a little. Most didn’t. There were a lot of side effects. I was about 28 when I found a combo of meds that worked: Paxil and Wellbutrin. I still had lots of side effects.

By the time I was 32, I said, “This is ridiculous.” I was tired all the time. I had gained about 30 pounds. Finally, I did a GeneSight test. It turned out I have a very rare triple copy of an enzyme called CYP2D6. That makes me an ultra-rapid metabolizer, which means roughly 80 percent of medications won’t work on me like they should. I metabolize them too quickly.

It’s not a great thing to have if you’re battling depression like I am.

When I learned about being an ultra-metabolizer, when I realized that meds basically weren’t going to work for me, I started thinking about Transcranial Magnetic Stimulation (TMS). From what providers had told me, this is a type of treatment that can work for people who can’t do meds—people like me. I didn’t know anybody who’d done it TMS. I did some research. I got a packet of literature. That was basically it—at the time, I was deeply depressed and could barely make it to my appointments, much less seriously consider something like that. So, I didn’t pursue it.

Fast-forward to 2022. I started sleeping extremely poorly. I was getting more and more depressed. I had a severe bout of anxiety that lasted for four months. As the anxiety subsided, I started experiencing suicidal ideation. It was becoming more and more severe. It reached a point where things were going south quickly. I talked to my psychiatrist. Together, we decided it was time to give TMS a try.

I started the treatment in August. I finished in October. All told, I did 37 sessions. And it helped. But more on that later.

Understanding the basics

When you get the treatment, a machine sends magnetic waves through your skull into your brain. The idea is to stimulate neurons to change the way they’ve handled things in the past—kind of like rewiring the brain. For more about the science behind it, check out the sidebar that BrainWise published in conjunction with my story.

My TMS sessions started out at 21 minutes long. By the end they were at 31 minutes. It’s kind of boring to sit there while the treatment is happening. The doctors told me I needed to stay fully conscious. They let me talk. There was a TV in the room so I could watch TV. They were clear that they wanted me to keep my brain active.

Every time I went it felt like an electric zap. Like a static shock. There was no sense of pain. It was like tapping against my head. This may just be my own imagination, but I could swear I felt it going through my skull. I know the brain has no pain receptors, so maybe that’s impossible.

During the sessions I didn’t really experience any kind of change in thought processes or perception. I also didn’t experience any emotional effects. Initially there were headaches and a sense of really deep fatigue. That lasted the first two weeks. After that the immediate effects were a little brightening. My mood improved a little bit each time. It wasn’t a long-term thing; I felt better for a little while, and as the day wanes, my mood dropped back down. For me, it was all about the cumulative effect.

Side effects

After 4 treatments I had some interesting effects occur. One night, after cooking an elaborate dinner, I was sitting on the couch and, suddenly, it felt like I could smell everything. It felt like my sense of smell had been dampened that whole time and, suddenly, it had come into focus. It was like until the TMS treatment, I was smelling things at about 25 percent of what they were. The super smell lasted for about an hour each time, and then things went back to baseline. They say a lot of your senses get dampened with depression. I now know that’s real.

Another thing that happened during treatment: I started experiencing these perception switches. I would go from one state of mind to another. The switches occurred every 15 to 30 minutes. The only way I can describe what it felt like was to compare it to when I did acid a few times and ate mushrooms as a kid. The perception shift you get when you’re under the influence of those chemicals—that’s what it felt like for me.

Later in the treatment cycle I started to get very irritable and very angry. I’d have these mini bouts of rage that would last for 30 seconds or so each time. That was disturbing. Everybody in the house was jumpy and avoiding me. The cats were like, “We’re out of here!” I was told by the lead TMS tech that that was a good sign, that my brain was creating new neural connections and that’s what was causing the irritation. Most people experience a depressive episode in the first three weeks, but some people experience anger. That was difficult to deal with.

The suicidal ideation faded in the first week and a half. It faded out quickly. I don’t know if that was what was happening in my brain—something the machine was doing—or if it was the fact that I was getting help and I was actively doing something to improve things. I was looking at living and improving my health and having hope instead of thinking about ending things. That alone was worth everything.

Charting progress

Over the course of my treatment, there were several markers I used to evaluate how it was going.

The first were the markers from the doctor’s notes. Every Friday I did one of the DSM questionnaires about depression and anxiety. The doctor kept those scores. Over the duration of the treatment, the doctor said my scores decreased depression-wise by about half and anxiety-wise by about a little more than half. The reduction in anxiety was the biggest thing I noticed. The other thing is that I found myself to be more motivated, more hopeful and a little more energized. The reduction in anxiety has been fantastic. Suicidal ideation disappearing has been fantastic. Depression has decreased, for sure. They said I would start sleeping better, but I didn’t. I’m a lifelong insomniac.

I have mixed emotions about this progress. I was hoping for more. At the same time, I know my expectations were unrealistically high and the whole time I fought to bring my expectations back to reality. I had to come to terms with the fact that this is something that will improve things so that I can further improve on my own. It’s like the treatment gave me a toehold so I could get moving in the right direction.

My doctor said things would continue to improve for about two months after the last treatment finished. I’ve also read that each TMS treatment cycle lasts about a year, and that after the year it really varies wildly. About a month later I’m still seeing improvement.

I also recognize that I’m lucky to have insurance. This treatment runs anywhere from $12,000 to $16,000. With my copay it was $980. This is what my specific insurance company and specific insurance plan required before approving TMS. I’m sure requirements are different from company to company, and even plan to plan within the same company.

After dealing with depression for most of my life, this feels like having a future. A lot of possibilities are now open that weren’t open before. My husband and I have been planning trips. We’re talking about going to Iceland and Finland. We talked about doing a bunch of different things. I feel much more excited and motivated to do that. I feel more excited to live.

Spreading the word

I kept a journal about my experiences. Once a week, I shared these journal entries with my friend list on Facebook. The entries were straightforward. Here’s what’s going on with me. Here’s what’s happening. Here’s what it’s been like. People were really interested. After my journal entries, I have been contacted by phone and through Facebook by people who are either interested in TMS for themselves or for loved ones.

I would recommend TMS. Even if TMS doesn’t work for someone at all, I encourage people to try something. Depression is not a way to live well, and it can end in your demise. For me, TMS felt like going to the moon, doing something totally unknown and super frightening.  At first, I felt like I was being a coward, but now I see the opposite is true. I can recognize it as being brave. The stigma around mental health is decreasing, which means more people are talking to each other about depression. Hopefully that means more and more people will start talking about TMS to help.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

Three decades of fighting for brain health

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U.S. Representative Bill Pascrell (D-N.J.) has established himself as a champion of brain health. The 86-year-old Army veteran has represented the Ninth Congressional District since 2013 and served in the House since 1997. During this time, he has leveraged his leadership in several ways to protect the brains of Americans. First, in October 2008, after the death of a young boy in his district who returned to playing football without having fully recovered from a concussion sustained earlier in the season, Pascrell introduced the Concussion Treatment and Care Tools Act (ConTACT), which has been endorsed by the National Football League, the National Football League Players Association, and the Brain Injury Association of America. ConTACT brings together a conference of experts to produce a guidelines for the treatment and care of concussions for middle- and high-school students. It also provides funding for schools’ adoption of baseline and post-injury neuropsychological testing technologies. Later in his tenure, in 2013, Rep. Pascrell introduced the Traumatic Brain Injury Reauthorization Act of 2013 (H.R. 1098; 113th Congress), a bill that reauthorized appropriations for Centers for Disease Control and Prevention (CDC) projects to reduce the incidence of traumatic brain injury and projects related to track and monitor traumatic brain injuries. The National Academy of Neuropsychology is honored to celebrate the leadership of Rep. Pascrell at its forthcoming annual conference in Philadelphia. In advance of that event, BrainWise Managing Editor Matt Villano spoke with Rep. Pascrell about his work and his commitment to brain health. What follows is a transcript of that exchange.

BrainWise: Why did you get into politics in the first place?

Rep. Bill Pascrell: A native son of New Jersey, I have built a life of public service around the principles I learned while growing up on the south side of Paterson. My parents and Italian-immigrant grandparents instilled the value of being a bridge builder: one who seeks to bring together the diverse peoples and neighborhoods in our communities to forge a better society. I was proud to serve in the New Jersey State Assembly in the 1980s and became mayor of my hometown Paterson in 1990. I entered Congress in 1997.

BrainWise: Since you became an elected official, you have been a champion of more than 6 million Americans who live with debilitating brain injuries. What sparked your interest in fighting for these issues, and how did you come to recognize this important group of citizens?

Rep. Pascrell: It bothered me that these Americans were too often being forgotten. Traumatic brain injury is a devastating debilitation that impacts not just its victims, but also their families and friends. I felt these Americans needed a champion in Washington and I have tried to be that champion. I founded the Congressional Brain Injury Task Force in 2001 to increase awareness of brain injury in the United States. [The organization also] supports research initiatives for rehabilitation and potential cures, and strives to address the effects such injuries have on families, children, education, and the workforce.

BrainWise: What inspired you to create this task force? What is the work of this group?

Rep. Pascrell: In 1998, I met a Clifton, New Jersey, constituent named Dennis Benigno, whose 15-year-old son had suffered a severe traumatic brain injury from an automobile accident that left him disabled. The Benigno family’s passion and dedication in finding a cure for their son and millions of others was my inspiration to act in Congress. Through the Task Force, I work on a bipartisan basis to raise public awareness of brain injuries among Americans of all stripes. We try to bring both federal support and public support to bear here. Public awareness is everything.

BrainWise: You co-chair the task force with Rep. Don Bacon, a Republican from Nebraska. At this time of such division in Congress it appears that you have been able to work across the aisle for this important cause. How?

Rep. Pascrell: On commonsense issues, compromise is not just possible but essential. When I speak with my Democratic and Republican colleagues on the need to raise awareness for brain injuries, they understand, and they are eager to get involved. Both parties working together has helped secure hundreds of millions of dollars to advance awareness and support those with traumatic brain injuries. We have passed legislation that recognizes the life-altering impact and supports researching into brain injuries that has affected millions of Americans.

BrainWise:  You have also been instrumental in bringing awareness to those who have experienced blast injuries; this resulted in The National Defense Authorization Act for Fiscal Year 2020. Why was that act so important, and why is it so important to help those who have suffered from these traumatic brain injuries?

Rep. Pascrell: This federal support has been critical to aid Traumatic Brain Injury victims. It is one thing to talk the talk and another to walk the walk. Politicians can speak a big game, but enacting actual federal aid is the key, and we have done that with these pieces of legislation we have gotten signed into law. That bill included language that I pushed for on blast exposure. Specifically, my language ensures blast exposure history will be recorded in medical records of servicemembers, requiring the enclosure of critical details including the date and duration of the incident. The National Academy of Medicine has concluded that servicemembers with blast exposure history are at increased risk of long-term health issues, including depression, Alzheimer’s-like symptoms, seizures, and problems with social functioning. Optimizing the readiness of servicemembers and recording blast exposure data is essential so that soldiers receive proper care for any service-connected medical issues that may arise later.

BrainWise: Finally, the issue of Chronic Traumatic Encephalopathy (CTE) is one we see grabbing a lot of headlines these days. Research into what causes this is ongoing, and early studies indicate CTE is not as connected to repeated head injuries as the mainstream media has portrayed. To what extent do you think our government should get involved in regulating activities that could potentially lead to CTE?

Rep. Pascrell: I think it starts with focusing a bright light on these problems. Congress can do that very well with hearings, public events, and public statements.  I have demanded answers from leading sporting organizations about how they are protecting athletes and students. Our kids and future generations are learning more and more about these harms, and we cannot treat them lightly.

Mourning of the inanimate

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It wasn’t the first time I had migrated from one parent’s house to the other’s. Eleven miles door-to-door and a world apart. “Something was wrong” with Mom, but a diagnosis was at arm’s length. As imperative as it was to address the jarring interruption to what I had previously understood her to be, getting an answer was paralleling the first page of what was expected to be a poignant new life chapter.

I hesitated to turn the page.

Having stretched the task over several weekends, I moved my belongings into Mom’s house. I was a broke thirty-something who had spent the totality of my savings a couple years prior on a six-and-a-half-month solo road trip around the United States. It was early September 2019, and I couldn’t afford to continue paying my dad the few hundred dollars a month he was charging me for rent. The bucket list travel had been a lived-out dream I’d repeat a thousand times over if I could, but after the trip I was back to substantiating paycheck to paycheck. With pride tucked between my legs, I went from low rent to no rent, accepting a humbling perk of familial cohabitation as an adult.

I recall placing my camera on a rocking chair in the front room of her house, a temporary placement among the boxes of knickknacks and clothes. It sat tucked inside an innocuous black bag, unbecoming of its gravity. My out-of-date smart phone had sufficed for documenting worldwide travels for years, but I had recently upgraded to point-and-shoot. To this day I am proud of all I had captured on the phone, but there’s an ego feeding self-assurance to finally owning “real” photography equipment.

Months after my previous birthday Dad casually offered to give me money toward a camera. (Originally, he opted to fund a hitch for my car, but after I did not take him up on the original offer, he concluded there was little interest in that specific generosity.) But I sure did perk up when he came across a springtime Target ad for a Canon Rebel bundle, a suitable starter kit for an amateur photographer looking to upgrade her equipment. Forty-five minutes after the proposal I was standing in the electronics department of the store waiting for the employee to unlock the glass display case. The heart palpitations confirmed that this was the gift for which I had been longing. Dad graciously understood the impact of the pivot when I returned home with the box clutched tightly in my hands and a giddy, beaming smile as matching accessory.

Mom always fed my hunger for creativity. With an appropriately supportive “Oh honey, that’s amazing” (or something of the like), she never failed to recognize each project regardless of its juvenile-handed craftmanship. My interest would wax and wane with varying mediums, but a few became woven into my being. I requested trips to the local craft or fabric store to garner beads for jewelry making, stamps and thick, velvety paper for homemade cards. These treasures would join the hoarded bins of paints and markers, journals, and dress-up clothes. Menus were made for special occasion meals that I crafted for hours; a home-room newspaper was fashioned with peers. To my dismay she riffled through bedroom drawers to read emotive poems about boys or depression, and embarrassingly, angsty notes directed toward her. It wasn’t lost to me that any good mother ought to express encouragement in their child’s interests, an obligation of love. As I got older, I understood this silent agreement between us that I would create and she would “Oooo” and “Ahhh,”but my ego luxuriated in it regardless.

In adulthood I narrowed my artistic efforts to writing, drawing, cooking, and later, photography. Honing them was continuous and boundless, a new-to-me definition of infinity. There was always more to make, lenses of perspectives to try on, skills to learn. Enter Alzheimer’s. Even as Mom faded, she was there for all of it. The more she leaned out of reality, the more I realized how precious her gift of support was. It’s intangible in the traditional sense, but it’s there in every production of my mind’s eye.

As of that move-in day, most of the photographs remained on the camera’s memory card. There was no urgency to upload and edit them at will. Their existence remained in the suspension of a plastic chip the size of a thumb, tucked in a cavity of the camera, hidden from the bright light of the living room by the protective barrier of a travel bag. A non-descript item amongst many, waiting to be unpacked into new shelves and drawers and wicker baskets for the guise of organization.

These were the tokens of the camera that I collected with gumption: Inky Joshua trees backlit with sorbet desert skies. Swirly rock striations of rust and cream, bookmarks of time. Brick walls swathed with city smog, fingertips, and speckled blood of unnamed revolutionaries assassinated by defunct reasonings. A sunrise more volcanic than its conical counterpart, igniting a landscape monument in the crook of its arch only in the brevity of time when light first reached it each morning. Tufa formations and earthy tears pooled into a lake more alien than Mars.

It wasn’t until weeks later, when I went to grab the camera to document an afternoon hike, that I realized it was missing. The longer it was out of sight, the more panic overtook me. Subsequently there were several occasions of feverishly looking in every space of the house to try and locate it. No, it wasn’t in any of the closets. Nor was it in the last of the moving boxes or under any furniture. The garage hadn’t gobbled it up.

Where the hell was it?

As revelations often are, a thought was born with certitude out of the nothingness of an ordinary day.

Again, I recalled bringing it into the house and gingerly setting it on the rocking chair to prevent it from getting jostled or knocked over. But this time I also remembered how Mom wanted to help with the move. In those earlier years she still maintained a compulsion to clean and organize, so she volunteered to pick up boxes and other nondescript packing materials as I unpacked. The human-sized black trash bag she held in my memory screamed at me. This was the first time I considered that Mom threw the camera—bag and all—away.

Was this truth? Or was I succumbing to the human urge to place blame on others for my own misplaced possessions? I didn’t care. The likelihood of the explanation seemed too obvious. I let the weepy, exasperated self-pity and tear-soaked hyperventilation take over. A still frame of the camera sitting mournfully in the garbage bin outside overtook my sanity. Of all the things she could have thrown away accidentally, why did it have to be that?

I can’t say for certain if I confronted her, but I have a feeling that I did. Not the shiniest reactionary decision to burden or shame my most consistent supporter when it was the disease, not her, that disposed of the camera.

Four years later, when I found mom a placement in a memory care facility and began moving out, the overwhelming suspicion was all but confirmed. Aside from the decluttering I had done during the pandemic and multiple wildfire evacuations, there were months upon months of preparation for the inevitable next step. The house needed to be renovated and staged to be sold. The profits were the only way to pay for Mom’s expenses as a soon-to-be resident of a place where others would care for her. I was both being set free from caregiving and saying goodbye to a version of us that we’d never meet again.

In my last hours at the house, I breathed in the bareness of each room. There was nowhere for a camera to hide. No corner or nook unexamined. Every possible resting place had been eliminated. It stung less than before, but I mourned it along with the swelling of so many goodbyes. Admittedly, that specific anguish had dulled when a stranger had gifted me the exact same camera bundle sometime in the last months before moving.

I had come across an online posting in a neighborhood group. The owner of the camera wanted to give it to someone who would use it with much more gumption and appreciation than she had. Close to a hundred people left comments of varying degrees, asking to procure the unusually high-value offering. My own comment thanked the woman for her generous act of kindness and briefly explained that my Alzheimer’s ridden mother had accidentally thrown mine away. It was the truth, but still felt slightly sticky to expose the transgression. I was sure that the camera would find its way into someone else’s hands, anyway. I had never seen so many responses to a post before.

Instead, this wayward camera became mine.

There is still disbelief when I see the device and its pack nonchalantly sitting in the room of my new home. It’s like the space in a book between the end of the last chapter and the beginning of the next. Definitive. Small, yet vast with meaning despite being nothingness sandwiched between the profound.

Sometimes I speak a quiet offering of gratitude to the woman, but also for my mother. It felt like everything had come full circle. Surely, somehow, Mom had a hand in that. 

For additional information about processing grief and loss as Alzheimer’s disease progresses, visit this Alzheimer’s Association page on the subject. Another good resource for families: The 36-Hour Day.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

Lauren Ahlgren is a writer and swim instructor in Bend, Oregon.

How today’s world is reshaping your brain

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Between the COVID-19 pandemic, climate change, constant mass shootings, social injustice, political turmoil, and 24/7 exposure to social media and misinformation, one thing’s for certain: We’re all going through a lot. New terms like “climate anxiety” and “solastalgia” are entering the lexicon to address what we’re experiencing—some even call these events “collective traumas.” If you’re feeling a general sense of stress and anxiety, that makes sense. You’re not alone.

If you’re also feeling a little numb, that makes sense, too. Our brains are powerful places—we know that we can neurally adapt in certain ways, desensitizing our brains to repeated stimuli. But studies also show that these collective traumas, despite their constancy, are taking a toll on us, with long-term consequences for our mental health.

Of course, neither numbness nor anxiety and trauma are ideal. When it comes to absorbing current events, what’s going on in our brains? And how can we healthily cope in today’s world?

Neural adaptation—your brain wants to be smart and efficient

Our brains love forming heuristics—shortcuts to making decisions and predicting patterns. This happens constantly, in both minor ways (is Simone Biles going to outperform Grace McCallum? (You’ve probably heard of Simone, so she’ll likely get your vote) and major ones (would you rather apply for a job at a workplace with one job opening or a dozen? Odds are the one with fewer openings seems more competitive and desirable).

In other words, our brains are always trying to save time and energy, down to the single-cell level, sometimes at the expense of logic—or even our senses. Heuristics, selective attention, going on “autopilot,” the list of ways our brains love efficiency goes on and on.

This energy-saving phenomenon can also be seen in the form of neural adaptation: the gradual decrease over time in responsiveness to a constant stimulus. For most neurotypical individuals, this can be seen nearly every second of every day—did you feel the texture of your chair the moment before you read this sentence? What about the background noise around you that you’re just now noticing? Your brain is making a good argument: If a stimulus keeps occurring and requires no response, why should it waste its time?

But what does the brain do with a near-constant bombardment of negative media exposure? From school shootings to misinformation to climate change, does the brain deem these incessant stimuli as worth less of a response over time? Do we grow numb to the data, or do we grow anxious and stressed? The short answer: As far as we know, it’s both.

Desensitization and stress

Neural adaptation to today’s constant barrage of negative events is a huge, nebulous topic. To demonstrate how it works, Krista Lisdahl, professor of psychology at UW–Milwaukee, starts us off with a narrower, more defined example: alcohol consumption.

“Over time, as the brain gets used to alcohol, receptors and neurotransmitters get downregulated, so they’re less available,” she explains.

With your natural baseline down—in this case, the brain’s GABA (gamma-aminobutyric acid) signaling, which reduces brain activity and provides a sense of calm—you wind up drinking more alcohol to achieve that same dopamine rush. That leads to a whole slew of negative side effects; desensitization, when gone too far, comes with repercussions.

Lisdahl points to a study that’s closer to the topic at hand, where children’s brains neurally adapted in response to adverse events like divorce, abuse, substance use, and natural disasters. At first, she explains, the children demonstrated an increased cortisol response through the hypothalamic-pituitary-adrenal axis (HPA) function—aka stress. Over time, that cortisol response blunted, and the brain’s neuronal structure changed. In this scenario, adaptation resulted in poor emotional control and reduced problem-solving skills.

“In the end,” says Lisdahl, “these things are bad for the brain.”

For more abstract stressors, such as media exposure to climate change and the Covid pandemic, we don’t have as much neural evidence, says Lisdahl—it’s a difficult study to do, never mind the unethical territory of ceaselessly bombarding individuals with triggering events. But a few topical studies do exist: One climate anxiety study found that a moderate level of media exposure was actually ideal, “encouraging people to rethink actions with negative ecological impacts.” Another study found that exposure to stressful information on climate change can be overwhelming, ultimately encouraging actions with negative ecological impacts.

Those sound contradictory, but what we know about stress tells us otherwise: In short, a moderate level of stress is good—it teaches and informs us, and we can eventually desensitize appropriately. We learn new coping strategies, explains Lisdahl, who brings up her 15-year-old learning how to drive. “When he first got behind the wheel, there was a lot of fear and hesitancy,” she says, until he was driving effortlessly on the highway two months later. “That stress increased adaptation and learning, and it was good for him.”

But go too far on either end—imagine a curve shaped like an upside-down U—and the brain either doesn’t mobilize the resources needed to meet a challenge, or it can’t regulate stress and ultimately can’t recover. If too much cortisol lives in your system, says Lisdahl, you might see increased inflammation and oxidative stress, sleep disruption, emotional regulation disruption, and maladaptive neuronal changes. Like we saw in the above children’s study, vital stress counter-regulatory systems can turn off entirely. (The same principle applies for adults, too.) These chronic stressors also have the power to hinder our cognition, with negative effects on critical cognitive functions such as memory and attention.

Clearly, desensitization and stress are a dangerous game, but there’s a wrench in this system: Some studies have found that, when it comes to things like media exposure to traumatic events, we don’t desensitize at all. Instead, we sensitize, a process with similar side effects—but one we have the power to stop.

Negative media exposure and sensitization

The Orlando shooting, the Colorado River disappearing—these are serious stories. What if our brains don’t desensitize to negative media exposure? That’s what E. Alison Holman, professor of nursing science and psychological science at the University of California–Irvine, sees in her research. Instead, negative media exposure initiates a dangerous cycle: Worrying about the future draws an individual to the media, which makes them worry about the future, which draws them to the media, and so on.

“Whether it be a hurricane or mass shooting or terrorist attacks,” Holman says, “people can develop post-traumatic stress-type symptoms, both early and across time.”

In one poignant example, Holman studied the degree of acute stress following the 2013 Boston Marathon bombings in two groups: those present at the event and those exposed through the media. On average, notes Holman, the people who were at the site reported less stress than the people who watched via the media. She attributes this in part to the media’s gravitational pull to the unnecessarily violent and dramatic: In the real world, people got to see the whole picture—an act of terrorism, yes, but also an act of the community coming together.

Holman adds that negative media exposure can compound—it doesn’t have to be one event or topic. In today’s world, from Charlottesville to Canadian wildfires to Ukraine, stressful events are coming clip after clip after clip, which can be overwhelming psychologically—your brain doesn’t get a break to relax and process. “It’s what we call ‘cascading or compounding collective events’,” she describes. “It’s those moments that work together to be very psychologically distressing for many people.”

She points to a study where individuals were given MRIs and exposed to different videos, some traumatic. The ventral occipital cortex (VOC), the part of the brain associated with the development of PTSD and other mental health issues, lit up upon viewing the violent content. Specifically, the study mentioned the VOC was associated with flashbacks, or the intrusive mental re-experiencing of traumatic events. “If we know that these things that we’re looking at are triggering,” she says, “it’s a really good idea for us to stop doing it.”

How to keep your brain healthy and engaged

Both Lisdahl and Holman independently remark that the media isn’t doing society any favors—the news gravitates toward sensational headlines and traumatic imagery to get your attention. It’s part of why the self-care movement is so huge; when it comes to the media, societal self-care doesn’t exist.

“Each person really needs to be very mindful and tuned in with their own mental health and their own stress,” says Lisdahl.

We all have different barometers for stress, and it’s important to stay in that Goldilocks zone of resiliency. Not everyone can be an activist—you have to stay engaged in a way that aligns with your values and with the time or resources that you have available.

Several NAN researchers noted the importance of caring for our physical bodies in how we mediate stress and build resiliency. Some peer-reviewed resources on those subjects are here, here, here, and here.

Holman notes that you can get a lot of knowledge from your body—if you pay attention to it. Notice your breathing, the tension you feel in your core; if you’re having a physiological response, cut it off.

“I wouldn’t even wait to that point,” she adds. “If you’re starting to feel like, ‘Oh my god, this is overwhelming,’ just turn it off.”

Both researchers suggest hard and fast limits on media exposure: 30 minutes or less per day. Both even suggest picking two neutral outlets—like the Associated Press or Reuters—and making your bite-sized news consumption routine. That also limits your exposure to misinformation, which, as other studies show, sways your emotions and opinions.

Lastly, Holman notes how important it is to connect with real people in your social world—to talk about these events, to get the support you need, to create social connections in your community.

“The way things have always been fixed or changed or made for the better,” she says, “is by people coming together and supporting each other. We can do that.”

For additional resources on dealing with climate anxiety, check out this Headspace feature, this book, and, of course, NAN’s brain health brochure.

This article has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

Music and the brain

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Sure, Dr. Eric A. Zillmer is the Carl R. Pacifico Professor of Neuropsychology at Drexel University. Yes, he serves as the school’s athletic director emeritus, and is the director of The Happiness Lab, a Drexel thinktank that investigates the meaning of happiness and its place in our culture. He’s a past president of the National Academy of Neuropsychology (NAN). He’s even a stroke survivor. Dr. Zillmer’s real passion is music. He is an accomplished musician and the current President of the Philadelphia Classical Guitar Society. He also spends much of his free time thinking about the intersection of music and the brain—how we as humans interact with and process music when we hear it. BrainWise Managing Editor Matt Villano recently sat down with Dr. Zillmer to discuss some of these topics. What follows is an edited transcript of their interview.

BrainWise: Generally speaking, what happens in our brains when we hear music?

Dr. Eric Zillmer: When you’re listening to music, it is relaxing, it lowers your blood pressure, it makes you feel good. There are very few things about music that are bad or wrong. If you think about it, [music] is almost a panacea to feeling well and happiness and creativity and just a lot of good things. If you look underneath the hood [of our brains], there’s a lot going on [when we hear music]. The brain contains billions of cells and neurons and an infinite number of possible connections among individual neurons that allow for this amazingly complex information exchange. Music locks you into the brain and into the moment, which is a beautiful, pleasant thing to do, very much like you would when you drive a car or when you engage in art or anything creative that requires you to be present. So that’s what happens.

I think a good way to frame all of this is that everything psychological, everything musical is essentially biological. When people say, ‘I trust my gut,’ or, ‘Let’s play it by ear,’ their behavior and thinking has a little to do with your ear and gut; it has to do with how your brain processes information. For me, as a teacher of how the brain works, I try to make how the brain works come alive, and I try to answer questions that seemingly look simple but may be complicated.

BrainWise: Can you elaborate?

Dr. Zillmer: If you think of the brain as a house that’s being remodeled and has many, many different rooms, there’s music everywhere. This analogy works well because we’ve had this reptilian brain, I would call it the basement, where sleep and breathing and heart rate [happen]. And then you have the first floor, which is the limbic system, the second floor is the cortex. And you have this new structure, this beautiful penthouse. Music enters the brain at the lowest level, we call it the brainstem. Which basically means we are hardwired for music.

From there, music is processed in many different areas of the brain. Even at the lowest level there is crossover. Almost everything that comes from the right side goes to the left side. There’s complexity right away when you’re dealing with music. If you’re a neuroscientist, you might say, ‘Wait a minute, this is interesting. What role does this play in evolution? What role does this play in humanity and making us feel humans?’ You don’t realize this when you put the stylus on the vinyl, you’re just listening to something. Then the brain starts processing. It manages information and then sorts it out and gives it meaning. In psychology, we talk about the difference between sensation, which is basically just realizing there is information out there, and then perception, which is, ‘Oh, this song sounds like Metallica.’

As we get a little bit more complicated, up in the evolutionary ladder of the brain to the first floor, we call that the limbic system, limbic meaning the border to the brain, and it includes several interesting structures that are well-defined. It’s like there’s certain rooms in this house that are well-defined, and one room is the cerebellum, which is an interesting structure in and of itself. Phrenologists thought this was where music was processed, so they would identify people’s skulls to see if they had a larger area in the back of their heads—where the cerebellum resides—and determine if someone might be musical. The cerebellum is a very complicated structure, it’s the brain’s organ of agility, it involves almost all cognitive functions related to music perception and music production. I think of it as a large filing cabinet. Everything gets sequenced there in terms of time and rhythm, and it’s being done automatically without you being aware of it.

So, you’re listening to music, and you don’t have any idea that this supercomputer, your cerebellum, is working all the time, just like when you turn on your car and the engine is running underneath the hood. And this cerebellum is a beautiful little piece of the puzzle because it requires the analysis of music. But when you play music, it also requires you to learn how to phrase a piece of music and then store it in the cerebellum.

BrainWise: The cerebellum plays a big part in how the brain engages with music. What other parts of the brain are important?

Dr. Zillmer: Another one is the hippocampus because it’s associated with memory and emotions. And anybody who thinks about music can relate to that because, if anything, music is emotional. And many times, when I was young, we would give music to a friend, a cassette deck, or we would make up a CD. And you’re thinking, ‘What am I actually giving them?’ Well, you’re giving them an emotion, and you’re presenting them with a potential memory. And that’s because music, as it works its way up to the penthouse, gets tagged emotionally, and then it also gets tagged with a memory. So, a lot of times it can’t be separated. Because it travels through this structure, which looks like a seahorse-shaped brain structure, and it processes conscious memories and explicit memories and implicit memories. There’s a lot going on even before you realize what you’re hearing.

There also is tremendous neuronal connectivity related to the processing of music. And many researchers think music came before language, so it makes sense that the brain has a lot of architecture that is related to understanding music, to identifying it, to appreciating it. (Language is much more localized in the smaller part of the brain.) There’s also a connection between our major sensory sense, which is vision, and this auditory information. In the visual cortex, we associate watching music and hearing music, so there’s a connection there between music and vision. Here one thinks about MTV or going to a Pink Floyd concert and seeing all the visuals and the artists standing in the shadows, or going to an opera and seeing all of this presentation.

Interestingly, in the brain there’s an area in the cortex [that controls] movement and feeling sensation. When music is being processed by your brain, it activates the motor strip and the motor cortex, and that’s why people dance, or they would like to dance to music or move to music. Even when I talk, I would say language is a form of music, [since] I use my hands. And so there is this integration and synchronization between motor behavior and auditory sounds.

There is a neurological reason that’s connected to the auditory processing system. Even when people sit still, there’s research that shows that the brain is activated in those areas, and there must be other areas in the brain that superimposed the inhibition of that activation, almost like you’re at war with yourself sitting still while listening to a rock concert, that’s why people want to get up and move. This idea of sitting quietly and processing music is somewhat incompatible with how the brain works. It’s much more compatible in terms of getting up and moving around.

BrainWise: You mentioned the ‘penthouse’ of the brain. What is that and what did you mean?

Dr. Zillmer: The penthouse of the brain is, of course, the frontal lobe, the most recently evolved structure. And it is so interesting because it allows free will, the idea that you can play music or that you can turn it off, and that you prefer different genres. Yet if you look at jazz and classical music and pop and R&B and electronic dance music, I do think the brain doesn’t differentiate between them. (See this article for more about this phenomenon.) What the brain kind of senses is beats per minute. If you’re a DJ, you know what that means because you’re locking into the synchronization of how your brain works.

The frontal lobe would allow you to make those kinds of selections. We have these genres, but I think you’re just dialing into the mood of how you want to consume this music. And that is interesting because most people want to listen to music to feel good or feel sad or feel reflective. And there’s these great mysteries why a minor chord would make people feel sad, and why a major chord would make them feel happy. But if you understand it within the idea that music is being traced through memories and through emotions, and then you can make that choice, it makes more sense.

BrainWise: A recent study out of New York University determined we can tell within the first five seconds of listening to a song whether it’s going to be a song that resonates with us. Why does this happen?

Dr. Zillmer: We are very good at reducing complex information into its units. Our brains are so good at sequencing information that we’re paying so much attention to the timing and synchronization of information that we don’t even think about. This leads to other mysteries. How is it possible that people who are blind, like Joaquín Rodrigo, a famous Spanish composer, can compose music? I bring him up because in the second movement of the Concierto de Aranjuez, he has three notes that Santana plays, Miles Davis plays, and probably 20 other artists have played them in pop culture. What is he tapping into? How is it possible that these three notes make so much sense?

BrainWise: Why and how do our brains affix music to certain memories?

Dr. Zillmer: Music is not that concrete, and it’s much more abstract. It’s almost like an inkblot test—an auditory inkblot. Almost everything we listen to is an ink blood test, it’s abstract, and we attach meaning to it because our frontal lobes are always on. I personally think it’s bad because we’re always trying to figure things out. We’re always on social media inside our own brains. I wish we would have a switch and we just turn it off, and we’re not trying to explain everything. Of course, then it becomes important to have the memory be filed away. But most of the time it is just an offer and a suggestion. That’s why music is played in bars, in food stores, in the elevator, and certainly when you’re performing gymnastics or figure skating. In these settings, music is evoking the potential, opening the door for a projection or a memory to occur. It might be an abstract memory, it could be it makes me feel sad, or it makes me feel good, or it makes me feel like being around people. But there’s a connection.

BrainWise: So why can we remember every word from a song we learned 30 years ago, while many of us can’t even remember what we ate for lunch yesterday?

Dr. Zillmer: Words are music, too. We rarely talk without intonation or rhythm, like the computer in ‘2001: A Space Odyssey.’ All this intonation and rhythm in speech is music. When you’re having auditory information coming into your brain, you are having a narrative that’s much deeper and complex because of the abstract nature. It has an opportunity to resonate in different ways, in different areas of the brain. Like I just said earlier, there are so many architectural geographical areas in the brain where music gets managed. It could be having a visual association, it could have a memory association, it could have no association. That is the beauty of it. More than half of all Nobel Peace Prize winners play an instrument, which means they’ve tapped into this conversation with themselves about creativity, opportunity, and hope. It’s much more complicated than language, and it also leaves the door open for growth and for self-actualization and creativity.

BrainWise: What is it about music that makes our brains—and bodies—react viscerally?

Dr. Zillmer: I’m a sports psychologist, and I’ve recently also worked with musicians because I really think of them as athletes. If you look at their personality profiles, the way they attack a problem and solve a problem, they’re very similar to athletes because it’s difficult to perform music. I think at the top of this food chain are vocalists. But if you think of a guitar solo like by David Gilmour or by Carlos Santana, they’re talking. And there are sections where they’re playing, and then there are sections where they are breathing, so to speak. It sounds like he’s talking, and I think that’s how they conceive music, they’re using, not their vocal cords, but they’re using the guitar. The most famous vocal groups like The Beatles and Crosby, Stills, Nash & Young, and the Bee Gees, have these incredible harmonies. And you could even argue that the Bee Gees have the best harmonies because they’re all from the same biological source because they’re brothers.

When you study the longest living people in the country, cultures, so for example, you go to Sardinia where the longest living men live, one out of 10 men live to the age of 90, healthy, you see a lot of different things. And, of course, people will focus on nutrition, but it’s also the lifestyle, how they eat and how they physically exercise. And that they do everything in moderation, including drinking, even though they make wine, and they make good wine. But something else they do is sing together. And really nobody talks about that. They look at the Mediterranean diet, but these people also sing together. And they have these beautiful groups of four men singing together in harmonies.

When we sing in harmony, we have a lot of neuronal circuitry that is dedicated to understanding the pitch and harmonies of a melody. When you’re singing like this with other performers, you’re simply activating more connections in your brain, thereby making it more interesting to listen to. And if it’s done well, and that’s what harmonies are, it must resonate with the architecture of the brain in the way we process information. The end effect is, ‘This is beautiful.’ You don’t even know what’s happening. You just think, ‘This is really pleasant and it’s really uplifting.’ What we also are learning from Sardinia is that also this idea that a culture does this suggests a form of socialization at the highest level, a form of bonding. There’s a connection not only between the music and the sounds, but also in terms of us humans doing this together that makes it very magical and special, makes those people happy, makes them feel like they’re connected. If you study happiness, the No. 1 key is social relationships. You’re doing something together, but you’re also doing something together that’s synchronized in a very complicated way by using your body as an instrument and having that come together in the auditory sense.

BrainWise: What happens in the brain when a musician engages in improvisation?

Dr. Zillmer: When you think of most of the music that we play, it’s concrete. The piano is like a typewriter, there are not that many keys. There are more keys than there are notes or on the guitar frets. But even on a guitar, there are 12 bars, six strings, and a bunch of frets. You can bend the string like some artists do to create a different kind of note. Even though it sounds infinitely difficult to understand music, especially in the Western hemisphere and the Western civilization, music has been very concrete. If you go to a normal orchestra concert, they play from a sheet of music and they’re playing something that was composed potentially 200, 300 years ago by, maybe Johann Sebastian Bach. The only modification is how they’re interpreting this piece of music. There’s no improv at all, it’s all being played from the source that the composer created. Most music is played like that.

Well, once musicians really work hard at what they’re doing, and like I already said earlier, they file everything into a filing cabinet, they must make everything automatic because the complexity of music is such that you can’t process and synthesize it at the same time. You must have it already stored. That’s why you need 10,000 hours of practice to become a professional musician. And if you are blessed with more talent and more perseverance and discipline, you become a virtuoso. These musicians look like they’re performing on the fly, as if they’re improvising. But if you think of what true improvisation would look like, it would look like randomness; it would be just random numbers, random notes. We don’t like that either, even improv needs to be within the context of the music.

What I’ve learned from the jazz guitar is, for example, that there’s quite a lot of structure within a jazz piece. The structure comes in key and chords. What jazz artists are very good at is changing the key with the chord, which is hard to do because you must have in your head all of the scales that go with a specific chord. You might change from A minor to E major within two beats, and you’re changing your solo, which jazz artists do. This sounds like improvisation. It’s very difficult and it’s very automatic, and it may even feel to them like improvisation, but they’re just playing scales. And so, I think there’s less improvisation to it than people might think, but I don’t think it takes anything away from it because it just looks like it.

BrainWise: Where will your research into music and the brain go next? What are the next big questions you plan to ask?

Dr. Zillmer: The first question is why is there music there to begin with? It’s also interesting to look at what makes music, music?  With AI everywhere these days, it seems like a computer could create this kind of pop song that could hit the Top 10. I mean, computers can beat humans in chess! But so far, no computer can compose music that we would consider novel and satisfactory or even celebrate. There are some other mysteries. One I already mentioned is this idea that music can sound sad, but also can sound happy. That is interesting—the connection between music and emotions. The moment you hear a piece in D major, it’s going to be uplifting and it has some hope. And then the movement changes to B minor and it’s all gloom and desperation, like the world is coming to an end. How’s that possible? That’s how composers composed it. Did they know this, or is this just something essentially how we live our lives?

Then there are interesting questions surrounding dancing to music. I don’t think we’ve really understood how that all happens there. There’s an interesting neuropsychological event that’s called synesthesia, which is where people hear music and sounds at the same time. Unfortunately, I don’t have that. I think I would love that. It’d be like a Pink Floyd concert in my head all day. How is that possible? The final question is what door does music open to our understanding of us as humans? That is ultimately the biggest question. When we send an object into space to represent humanity, I would send a piece of music. I think it captures us best and represents us as a people. There’s nothing to regret about ever putting on a record. It’s almost universally positive.

Editor’s note: Dr. Zillmer has contributed several panels about the intersection of music and brain science to an exhibit at the Paul Peck Gallery and Bossone Research Center at Drexel University in Philadelphia. The exhibit is titled, “Electrified: 50 Years of Electric Factory,” and will run through December 2023.

What happens when you treat depression with ketamine

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It was a Wednesday afternoon. March 27, 2019. The out-of-office notification popped up on the team calendar at my corporate job. I told everyone I had a “doctor’s appointment” – technically accurate, yet spiritually a lie. I wasn’t going to the doctor’s; I was going to space.

Okay, not actual space–a ketamine clinic just a block or so away from the University of Texas at Austin. I answered a few clipboards full of questions. They sat me in a chair, read my blood pressure, and asked me “What is your intention for today’s infusion?” I do not recall my answer.

Then the infusionist hooked me up to an EKG and poked a vein. The machine beeped and the bag began to drip. The next hour was the weirdest of my entire life–I was about to go into a K-hole to treat a depression I’d been battling for years.

Why I chose ketamine

I received my first official diagnosis of major depressive disorder in the spring of 2001. I was a freshman at Syracuse University, struggling with being a working-class kid from the Rust Belt at a prestigious private school that was a popular magnet for the types of kids we’d call “nepo-babies” in today’s parlance. I was not taking great care of myself. I exercised but forgot to eat. I made friends but not as quickly as I lost them. Occasionally, I even went to class. I got good grades but felt like a misfit.

For treatment, I tried Zoloft. I saw a social worker for counseling. I can’t say either worked. This began a years-long journey on therapists’ couches and doctors’ pills, trying to understand why I felt so sad, anxious, and broken – and, hopefully, feel better. My mental health waxed and waned, but in late 2018 I was low enough (and well-off enough) to try new alternatives.

When my counselor first suggested ketamine infusion therapy after my latest 90-day course of Lexapro yielded unremarkable results, I recoiled. I was never a fan of “drugs.” Too scary. Too much can go wrong. I saw kids put powdered ketamine up their noses in college, sink back in their chairs, and fall out of touch with reality. I thought to myself, “That looks like no fun at all and I’m never going to do that.”

Never say never, I guess. My counselor assured me I would be safe. “I can refer you. I’m good friends with the woman who runs the clinic and her husband’s the doctor there. They’ll take good care of you.” Eventually, I acquiesced. Weeks later, there I was in the chair: determined and pot-committed. I paid $500 to be there (and $3,000 for the initial course of treatment) and put my faith in this Y2K-era club drug. I had some good research on my side.

How ketamine works

Developed in 1962 as a dissociative anesthetic, chemists created the novel compound to be a safer and less hallucinogenic alternative to phencyclidine (PCP). At anesthetic doses, ketamine provides pain relief, sedation, and amnesia. Breathing function is preserved, your blood pressure rises, and your pulse ticks upward. It’s short-acting and quickly metabolized, providing relief within seconds and acute effects that last for an hour or less. It’s antidepressant potential was first noted in 1975.

Unlike conventional antidepressants, which target monoamines, ketamine acts upon the glutamate system of the brain as an N-methyl-d-aspartate (NMDA) receptor antagonist, mediating activity of GABA and glutamate neurotransmitters. Glutamate plays an important role in modulating responsive synaptic changes related to experiences associated with learning and memory.

If how ketamine works is unusual, how fast ketamine works is genuinely unprecedented. Recipients notice an improvement in mood within hours–improvements that can last over a week on their own and, when coupled with integrative therapies and proper care pre- and post-infusion, can last for months if not years.

Researchers at the University of British Columbia conclude, “[Ketamine’s] effects may ‘reset the system’ by counteracting the synaptic deficits, neuronal atrophy, and loss of connectivity in depression.” If you think of the brain as a computer–ketamine appears to perform a soft reboot, a quick start, a system restore, a hard-drive cleanup, and defragmentation all in one.

Ketamine’s ace in the hole is the way it appears to actually “rewire the brain” by increasing neuroplasticity. The brain can heal itself more easily by allowing new neural pathways to develop. Theodora Blanchfield, AMFT, a Los Angeles-based ketamine therapist posits that “the new neural pathways—think of them as new roads in your brain—allow you to create more positive thoughts and, therefore, behaviors. This is compared to traditional antidepressants, which only work as long as they are in your system.”

We can even observe this rewiring visually. In 2022, University of Pennsylvania researchers reported that ketamine switches off specific neurons involved in normal awake brain function and switches on an entirely different and previously inactive set of cells – believed to be a network of cells that enable “dreams, hypnosis, or some type of unconscious state”.

In an interview with Harvard Gazette, anesthesia researcher Fangyun Tian, Ph.D., summarized her own research by drilling down even further, reporting “high-frequency gamma oscillations in the prefrontal cortex and the hippocampus known to be involved in ketamine’s antidepressant effects from other studies.” Additionally, the researchers “found a three-hertz oscillation in the posteromedial cortex that another study showed might be related to ketamine’s dissociative effects.”

These gamma oscillations appear to promote the profound changes in cognition and perception that permeate the psychedelic experience–and also appear to aid in shaking the brain out of the “default mode network,” allowing people to more easily experience mental health breakthroughs and behavioral shifts.

Research into the potential applications yields buzzy headlines and buzzier results, suggesting ketamine-powered neuroplasticity improvements can aid in everything from OCD to PTSD to smoking cessation to alcohol use disorder to learning to tolerate tropical house music.

If this all sounds a bit bullish, it doesn’t come without risks or unknowns. While generally (and often exceptionally) safe, especially in short-term clinical settings, adverse side-effects among long-term clinical ketamine recipients include impairments in memory, executive functioning, self-awareness, and increases in emotional blunting and reward processing. Additionally, a 2022 review published in Frontiers in Neuroanatomy proposes that long-term recreational ketamine use was “associated with lower gray matter volume and less white matter integrity, lower functional thalamocortical and corticocortical connectivity.”

How a therapeutic K-Hole actually feels

My ketamine infusion treatment course consisted of six doses over three weeks. I received progressively increasing amounts, starting at 50mg and ending at 200mg. While no two infusions were alike, they were similar enough to be able to speak about them in broad strokes. Each infusion took about an hour. They started slowly, gradually warmed up, peaked, then waxed and waned in their cognitive distortions until the last drop. The emotional whiplash was sudden, frequent, random, and severe. I laughed, cried, and screamed – sometimes all at once. All the while, I felt a warm glow, a genuine sense of awe-struck wonder, and a slight tinge of dread that this could all go very wrong at any given moment.

Immediately after each dose, I journaled my thoughts in an attempt to remember as much of what I had just experienced as I could. I described the infusions as a “solo space flight,” the Antoine de Saint-Exupéry novella “La Petit Prince,” a journey into “the operating system” of reality to modify the UI and UX, “a wafer-thin atmosphere buffering a sort of meta-reality, enveloped by a dark abyss of nothingness, monitored by scientists in lab coats,” the “minus world” video game glitch in the original Super Mario Bros., and “the flume ride in the Mexico installation at Disney’s EPCOT theme park.” By the final infusion, I started coining terms like “soul meridian” and comparing myself to Simba from The Lion King and the Manchurian Candidate.

Other common ketamine experiences for me included: speaking in perfect French with my dead Papa as a young man at a Parisian cafe, faceless people performing heavy industrial work, feeling as though I’m hanging from the ceiling, feeling watched by MK Ultra-era government medical observers, staring in the direction of a precipice that never quite arrives, and a procession of formless deep blues and greens that wash into each other.

One frequent recurring experience was what I call the “coffin moment.” Approximately two-thirds of the way through most of the infusions, the chair in which I was sitting in folded into a coffin that rose from below the floor and onto a stage where people passed and pay respects. Then I levitated and floated toward a bright light on a well-lit path (think: Rainbow Road from Super Mario Kart). My life fast-forwarded like the climax of a montage that ended in silence and white stillness. I walked to a white door. That was when I heard a voice whisper “not yet,” and I dropped back into my body. I didn’t always make it all the way through that progression–sometimes I ended at the rising coffin–but the moment always played out the same: I was dead and I shouldn’t have been. Then the ketamine subsided.

For as insane as “pretend death” sounds, it’s not uncommon in a psychedelic context. In fact, ketamine is so adept at simulating near-death experiences that there’s peer-reviewed literature detailing the phenomenon. People taking clinical doses of ketamine report experiencing these sensations with uncanny levels of accuracy and consistency.

Not all of my ketamine infusions were pleasant; on two occasions out of the roughly 40 (including boosters) I’ve received, my hallucinations were so painful and intense that I had to cut the infusion short. On a handful of other occasions, my blood pressure spiked to levels that caused clinicians to draw the same dosage out over 75 or even 90 minutes instead of 60.

Still, at doses that cause full dissociation–approaching anesthesia–I progressed through states of curiosity, childlike immersion, omniscient appraisal of life and reality, existential dread, death, rebirth, and newfound confidence. Just about always in that order.

How it feels when it works (and when it doesn’t)

In my experience, there’s been no correlation between how an infusion feels and how successful it is. I’ve had profoundly meaningful and pleasant infusions that did next to nothing; I’ve had frightening and elegiac infusions that changed me in lasting ways.

Post-infusion care and integration are every bit as vital to neural rewiring as the ketamine itself.

My gameplan for what I call the “afterburn” (the 24 hours post-infusion) is to drink plenty of water, eat plenty of food, get plenty of sleep, and avoid all of the following: calls, work, driving, decision-making, the news, deep thought, stress, alcohol, and tobacco.

While most infusions register some improvement, a handful have not–usually due to something sabotaging the post-infusion window. Booze. Bad sleep. Dehydration. Stress. The Buffalo Bills losing to the Kansas City Chiefs in the playoffs.

When ketamine works–and I was usually able to tell by day No. 2, if not sooner–it was obvious. I started incorporating healthier habits. I felt myself become kinder and more empathetic, clearer in thought and morality, more courageous and self-assured, more compassionate toward myself, and less reactive to slights or mistakes. I laughed often and more easily.

Most noticeably, I became more curious. Ketamine may not be a wonder drug, per se, but my elementary understanding of neuronal function and limited experience with other psychotropic medication has convinced me to believe that there may be no other substance that sparks wonder so subtly or effectively.

It’s the curiosity and wonder that have led me to believe that this is the “rewiring” in action. I was often reminded of the Overview Effect–a cognitive shift experienced by astronauts upon seeing the Earth in full from space for the first time. When they return from orbit, they report increased feelings of cooperation and collectivism and a kind of self-transcendence. They become more appreciative, empathetic, and kind. They change the way they show up.

So … does it work?

It’s been four years since I first explored ketamine treatment for my depression. Since then, we’ve endured a deadly global pandemic and a distressing decline in our social and political climates. There’s not enough ketamine in the world to cure what ails us collectively. There’s so much of that noise in the data – plus unrelated work, home, and life stressors – that I can’t tell you whether I’m “still depressed” or if the infusions were worth it.

In short, I think it was worth trying, but it also was no magic bullet.

What I can tell you is this: Ketamine made me a marginally better person. Clearer, kinder, more curious, and occasionally happier. At the same time, I recognized that ketamine is just one part of a bigger picture. Improving your mood requires diligent self-care and self-inquiry, the absence of significant personal and systemic challenges, robust relationships with people close to you, and the curiosity and enthusiasm required to keep learning and growing. Ketamine helps facilitate that final piece and only that final piece.

If that feels like an underwhelming appraisal of something that repeatedly simulates near-death experiences for $500 per hour, let me close with this anecdote. In 2019, I collected my ketamine notes into a 10,000-word essay I published on Medium. It became my most popular and critically lauded written work and earned me enough money and professional and public service opportunities – including writing this very article – to radically change my life. It wasn’t the chemical that changed me; it was what I did with the opportunity it granted me that did. I’ve learned, grown, changed, and evolved – maybe that’s all we can do. Maybe that’s the best we can do. I’ll take it.