Present at the Future

by Ira Flatow

  Clive does not recognize his wife, though, when she walks by. But he does remember her “sound.”

  “He recognizes her footsteps. He recognizes her voice. He recognizes her gestures, her approach. And above all he recognizes her kisses. So he recognizes sort of physical and auditory contact with his wife.”

  Sacks says Clive has retained other small vestiges of normality. He is able to dress himself “very nattily and to talk fluently and to walk around” and perform all sorts of various skills. But it’s Clive’s preserved musical powers that very much interest Sacks.

  “People sometimes use a different term and call this procedural memory. But whether this rather narrow-sounding term can be expanded to include all of his musical powers, I don’t know.”

  Sacks says he is interested in other memory-musical phenomena such as musical hallucinations, “where sometimes relatively unmusical people will hear something in great detail, a detail they never knew that they knew. Typically in musical hallucinations, the music hallucinated is usually music from early life, sometimes very, very early life. I begin to get the impression that musical memory can be extremely exact and faithful in pitch, in time, and all the subtleties in almost everybody.”

  Sacks says that while most of Clive’s musical skills were learned before his brain was injured—“it’s more a preservation of skills and knowledge, musical knowledge, than any enlargement of them”—he thinks that Clive and some other people with amnesia can continue to learn.

  “Some years ago, in my Anthropologist on Mars book, I’d described an amnesic young man musically inclined called Greg and how on one occasion I took him along to the Grateful Dead. He’d been a Deadhead in the 1960s. He sang along with the earlier songs. He was very puzzled by the later songs. He said it’s like the music of the future, which in a way it was for him. Later he had no recollection of having been to Madison Square Garden, but he did have some recollection of the new music. And so I think that new music can be learned by the amnesic.”

  Sacks has known about Clive since the mid-1980s. Most of the research about Clive’s unique musical abilities involve merely observing him as he goes about his life. But Sacks believes just watching him and taking notes is not scientific enough.

  “He also needs other sorts of studies like brain imagery to show exactly what is going on in his brain when he perceives music, when he recollects music, when he plays music. The techniques like this weren’t available twenty years ago.”

  Sacks uses techniques common to studying brains today—brain scanners—which can observe the parts of the brain as they become activated by music. He’s found that music is widely infused throughout the brain.

  “So many parts of the brain light up when music is being played or imagined or hallucinated or recollected. It’s not only in many areas of the cortex on both sides.” He noticed that the music energizes the cerebellum and the basal ganglia—near the brain stem—which, he says, may be involved in the sense of rhythm and timing, “which, for example, is knocked out in Parkinson’s disease, which is why music is so important for people like that.”

  Whether there’s any sort of final music area, the way there is a language area, people are not certain. But there may be one in one of the temporal lobes.

  As a clinician, Sacks continues to study the surprising effects that music has on the brain. He has met people in whom seizures have been elicited by music.

  “I saw a lady who was originally found unconscious with a bitten tongue by the radio. The last thing she could remember was that there had been Neapolitan songs on the radio. No attention was paid to this but then when this occurred again and again, it became clear that Neapolitan songs—and no other music—were a specific trigger for her, and again this must tell one something about the brain.

  “I did recently write about a patient, a woman, who had become aphasic—who had lost language—but had not lost her musical abilities and how sometimes she could get the words of a song, not only the music of a song but also the words of a song. This at least pleased her very much because it showed that the language was there somewhere, whether or not it could be disembedded from the song.”

  MUSIC THERAPY

  If music has the power to evoke such hidden talents in brain-damaged people, perhaps it has healing powers too. Many physicians, says Sacks, use music as therapy.

  “In 1973, when a documentary of Awakenings was made, when the film director came to our hospital, he said, ‘Can I meet the music therapist? She seems to be the most important person around here.’ At one of the hospitals where I work, we have an institute for music and neurological function. And I think music therapists are very important, both in practice and as researchers and opening doors, and I have great respect for them.”

  One region ripe for research, says Sacks, are the brain’s frontal lobes, the creative, inquisitive part of the brain. Music may offer a window inside. We are only just beginning to study creativity and what goes on in the brain, says Sacks. “Certainly the improvising musician is the nicest, and, in a way, simplest and most accessible example of creativity at work, and I agree it would be lovely to do such studies.

  “So I think of music as an unexpected way of getting into the mind and brain, in all sorts of ways, in all sorts of directions. And it’s relatively new. If you look at a neurology or neuroscience book of twenty, twenty-five years ago, you don’t find any reference to music.”

  Yet music, says Sacks, is “as rich as language. I think we are a musical species, no less than a language species,” but the musical side of our species has been ignored, he says, “or treated anecdotally” because we don’t think it’s important to survival of the species.

  “Certainly, Steven Pinker [cognitive psychologist at Harvard] has referred to music as auditory cheesecake—or just something which happens. And I suspect, as some others do, that the origins of music and speech go together, and the two of them coevolved. There’s certainly no culture in which music isn’t important, whether as a means of expression or communication or ritual or enjoyment.”

  CHAPTER FOUR

  PATHWAYS OF ADDICTION

  He raised his eyes languidly from the old black-letter volume which he had opened. “It is cocaine,” he said, “a seven-per-cent solution. Would you care to try it?”

  —SHERLOCK HOLMES,

  The Sign of the Four

  If you look back in history, whenever we didn’t understand a disease or an illness, our response to people who got sick was always the same: We blamed the person with the illness. There was a time when people who had cancer were stigmatized. No one would dare say the c-word out loud. The same was true, and still is, to a certain extent, for mental illness, such as depression.

  But as we become more enlightened about disease and disease processes, we have come to understand that cancer or mental illness is not a moral failure or a character weakness but a disease. The same can be said about our attitudes toward addiction. Only now are we beginning to understand that addiction is a disease—that there are real biophysical changes that occur in the brain that can make some people vulnerable to becoming addicted and make it nearly impossible for them to quit; time after time, they relapse.

  “There is no question that addiction is a disease,” says Dr. Nora Volkow, director of the National Institute on Drug Abuse, part of the National Institutes of Health. “Research has shown that it affects the brain in very specific ways that can help us understand why, through this damage, the person loses control of his or her action, as it relates to taking drugs. Despite this, it is still not accepted as a disease by most people.”

  Even physicians, at times, have trouble. “Unfortunately, yes, indeed, even physicians do not recognize that sometimes it’s a disease.” One of the problems is understanding when a habit becomes an addiction, when it crosses the line from just being an annoying trait to a life-threatening one. “We have a number of things that we look for, in terms of when we begin to call something an addiction,” says
Dr. Shelly Greenfield, associate professor of psychiatry at Harvard Medical School and associate clinical director of the McLean Hospital Alcohol and Drug Abuse Treatment Program, in Boston. “We’re really looking for adverse consequences in the person’s life, such as a person spending more time using the substance, or using it in greater quantities than they want to, giving up activities because they’re using the substance or recovering from it. They continue to use something in spite of the fact that they know it jeopardizes their physical or their mental health.”

  SPOTTING THE SIGNS

  But how easy is it for physicians, nurses, and other health care providers to spot signs of substance abuse and addiction? Greenfield says physicians and nurses are often not trained well enough to see evidence that might be right in front of them.

  “In fact drug and alcohol addiction are among the largest, most prevalent problems that we have; they present a major public health problem in addition to an individual and family problem. And at almost every health care setting, whether it’s a physical health care setting or mental health care setting, patients present themselves for other types of disorders and they also have a co-occurring substance use disorder.” This presents an opportunity for physicians and nurses to actually engage and screen patients. Are they using alcohol or drugs in a harmful way? Have they already become addicted or dependent on these substances? “A doctor can actually catch a patient, where something is moving forward into becoming a major abuse or dependence problem, and can help by educating a patient and referring them to treatment, to intervening earlier on in the course of the disease process. Of course, in every area of medicine, what we try to do is intervene as early as possible. But often doctors and nurses haven’t had adequate clinical training to screen and diagnose and to understand what the treatment processes are.”

  In many cases, says Volkow, doctors in emergency departments are afraid to ask patients if they are addicted to drugs. “Why don’t they ask the question? Because drug addicts are stigmatized and doctors feel uncomfortable asking the patients do they drink, do they take cocaine. And they don’t even know how to ask that question sometimes—and certainly they don’t recognize it.” And even if they do know to ask the right questions, they may not know how to follow them up. “Unfortunately, there is no parity for the treatment of drug addiction. So as a result of that, many medical insurances will not cover the cost of doing an evaluation for drug addiction and proper referral. A patient that is addicted when they have a job or they are referred by their physician is very different from the situation of a person that is homeless, that doesn’t have a job, that doesn’t have a family, that ends up in the emergency room, and you are actually hand-tied in terms of what you can offer.”

  And many times, people with addiction problems may never show up in a physician’s office or emergency department. Though they appear in countless television and film plots, the people who continually show up in clinics for treatment represent just the tip of the iceberg, says Greenfield. “In fact, the vast majority of folks who have substance abuse disorder problems, many are working every day. They are taking care of various kinds of responsibilities out in the world, and they are actually having problems with addiction. Sometimes those things manifest themselves at home rather than at work. Sometimes they may not show up in an emergency room, but they may show up, maybe, in a mental health care clinic or a physical health care clinic.

  “So this is not just in the emergency room with someone who’s coming in acutely, multiple times, but it’s much more generalizable to all sorts of health care settings where we, as medical professionals, can do a much, much, much better job at diagnosing early and referring for treatment many, many individuals who could actually benefit from all the available treatments that do exist and are actually effective.”

  “THIS IS YOUR BRAIN ON DRUGS…”

  Remember that commercial? Really an anticommercial, about the dangers of drugs? The frying pan, the burned egg? It sent a clear message that addiction is not just a bad habit but is also a complex chemical interaction in your brain. And one of the breakthroughs in the addiction field was the realization, says Dr. Rob Malenka, professor in psychiatry and behavioral sciences at Stanford University, that whether it’s nicotine or alcohol or cocaine or heroin, they all work on the brain’s reward circuitry.

  “Through evolution, the brain has evolved to tell us what feels really good, what is rewarding, what is important for our survival. And we now know that all these different drugs of abuse act on this specific circuit in these specific brain areas.” One of the key chemical messengers in the brain circuits is a substance called dopamine. “It’s a substance we term a neurotransmitter, and it turns out that all these different addictive substances increase the actions or the release of dopamine.” And while the effects and actions of dopamine are just now being understood, the release of dopamine in certain brain structures tells the person that this substance is reinforcing or rewarding.

  “And then, for certain genetically vulnerable individuals, there are long-lasting changes in these circuits that lead the person to believe that the pursuit of this substance is the most important thing in their life.” These long-lasting changes occur in the connections between nerve cells, called synapses. “So the communication between individual nerve cells that are part of this circuit starts to change. There are molecular changes in these cells that are part of these circuits. We’re beginning to learn a reasonable amount about what are these changes in specific connections between nerve cells. And that’s the first step towards trying to understand how to reverse those changes.”

  Because reversal is the key to drug addiction. As Mark Twain once said about his own addiction, “I don’t have much trouble giving up smoking. I’ve done it a hundred times.” In many cases it’s possible to stop the addiction, give up the cigarettes or cocaine. But what happens is that people go back to smoking or snorting. They can’t stay away. Once those chemical and neurological changes take place in the brain, reversing them is not very easy. The addiction has rewired the brain and, very importantly, brought into that rewiring the part of the brain that encodes memories, so that a relapse may occur without the person even being exposed to the addictive substance but simply to the memory of that exposure.

  “It’s extraordinarily important,” says Volkow, “in the terms of why it’s so difficult to treat addiction and why people, despite the fact that they face catastrophic consequences—not negative, catastrophic—and they don’t want to take the drug anymore, they relapse. It’s almost like a reflex.” Volkow is very clear and determined on this important point. She wants to make sure you understand just how difficult it is for someone to not relapse when exposed to that memory. It’s almost like uncontrolled salivating when you think about a great dessert.

  “Inside your brain, there is a release of dopamine when the person that’s addicted sees stimuli associated with the drug that activates the motivational circuit almost in a reflexlike way. And that drives him or her to do that behavior. And that’s evidently one of the mechanisms why relapse occurs and it’s so difficult to ‘kick the habit.’”

  So finding a way to erase that emotional circuitry is one of the great challenges. “Indeed, that’s one of the strategies that we’re now trying to encourage investigators to look at: the development of medications that can either erase those memories associated with the drug or, alternatively—very important—can create stronger memories that can overcome those learned responses. So that your behavior is not driven by what we call conditioning, but by these new learned experiences.”

  There is ongoing research to erase those neurological pathways, but so far only in lab animals. “But there are some real interesting positive results that suggest that this strategy may, in fact, prove beneficial in helping people through the therapeutic process.”

  But what about other addictions that do not start out with well-known street drugs such as nicotine or alcohol but instead with addictive behavior a
bout activities such as gambling, eating, or playing video games. Is the brain laying down the same kind of new pathways? Malenka says the general consensus among scientists is that “yes, a lot of these other kinds of compulsive, especially rewarding behaviors, or reinforcing behaviors like gambling, like overeating, like perhaps even video game playing, certainly effect these so-called reinforcement reward circuits, they do effect the release of this chemical messenger dopamine. Work done by Volkow and others has shown that it’s not only the release of dopamine but also how much is released and how fast it’s released that is important.

  “And it turns out, the highly addicting substances, like cocaine, can really cause a much more rapid, stronger increase in this chemical messenger than, for instance, what I do all the time, which is eat doughnuts, or eat a quart of Häagen-Dazs ice cream, which is highly rewarding for me. But I can kick the habit when I choose to.”

  WATCHING THE CRAVING IN THE BRAIN

  Volkow agrees. She says it’s a “very interesting question that has started to intrigue many of the scientists; certainly, it has intrigued me for many years.” Using brain imaging, Volkow and her colleagues at the Brookhaven National Laboratory in Upton, New York, have watched the brain in action as it reacts to different stimuli, “specifically in pathological eating in obesity, versus those that we see in addiction.” And what she sees are both similarities and differences. The similarities: there is a marked disruption of the functioning of the dopamine system, which is directly affected by drugs, “but it’s also the one that motivates our behavior vis-à-vis natural activities like eating or doing social interactions or engaging in procreation—sexual behaviors.”

  The dopamine system becomes dysfunctional, she says, in both addiction and overeating. The dopamine is not released in as great a quantity as it was before, so that it does not produce that terrific sense of well-being—the high—as it used to. “And it is believed that one of the reasons why there is a motivation to either continue taking the drug or to compulsively eat is that it’s a mechanism to compensate for this deficit.” In other words, you eat more or take more drugs to stimulate more dopamine release. It takes more to achieve the “high.”