Psychiatry & Psychotherapy Podcast - Frontal Lobe Damage: Treating Patients through Grief, Acceptance and Growth

Episode Date: July 25, 2019

In this episode of the podcast, I interview Steven, one of my patients who had a rare form of a stroke—in the right orbital frontal cortex. He participated in a psychiatric program that I run. He tells his story of how his function and emotions changed, and how he dealt with it. At the end of the episode, I talk more with Jaeger Ackerman (a 4th year medical student) about the science and neurology of his case so other mental health professionals can have a basis for how to think about approaching brain injury with these psychiatric specifics. Steven was a former hotel executive, actor and certified professional accountant (CPA). By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel

Hello and welcome to the psychiatry and psychotherapy podcast, with over 32,000 mental health professionals listening every episode. Why? Because we need to stick together to survive the mental off field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. So before we start this episode, in this episode, we are going to go through someone's story. I actually have someone on the podcast with me, Stephen Prince, and he is going to be telling his story. And we're going to be looking at all the psychological changes, some of the medication changes, and changes in brain function. And then at the end of this episode, which is about 38 minutes, 40 minutes into the episode,

I will then come on and talk about some of the neurological aspects of this case, some of the details on his stroke and what kind of stroke it was and why he had to. some of the symptoms he did have, and we'll be looking into also broader types of issues that are similar. And so hopefully it's a great case to learn a lot about a particular individual, but then also to learn about some of the pathology that follows. All right, so welcome back to the podcast. I'm here with one of my patients who has consented to come on, and he is a former hotel executive actor, CPA. who had five strokes, really bad tinnitus,

and would spend hours a day, Googling, trying to figure out how to solve his medical issues. His anxiety eventually led him to have a heart attack, end up in the hospital, and eventually got referred to me as a psychiatrist. And so he's going to come on today to talk about his journey of recovery. And I think it's an important story to tell,

because all too often we don't see the longitudinal story of someone going through the steps necessary to recover. And so I'm really excited to have you on. Thank you. So let's start off. Tell me what was going on before you first came in to see me. Now, the first time you saw me was January 23, 2018. Right. Tell me what were some of the things that were leading you up to our first visit?

Well, I had been, I had five strokes over the last, since May of 2014, and the strokes really played havoc with me. I was suffering from anxiety, depression, fear, grief. I had all this emotion running around in me. And then in November of 2018, I suddenly got a ringing in my left ear, and it was driving me. and it was driving me absolutely up a wall. And I went to see my doctor. And while I was in the doctor's room, actually, while he was diagnosing me,

he gave me an EKG, and I had a heart attack right there. And in doctor's office, he called the ambulance. And they took me away to the hospital. I was there for three days. Luckily, it was a minor heart attack, and I was fine. But the ringing did not go away, and it was absolutely put me over the edge as far as this dark state.

I was in, I was so stressed about it, I was researching the internet constantly. I mean, at first I heard that there were drugs that were called autotoxic, which could be bad for your ears. And I would look up each one. I looked up the, I was on about five or six drugs at the time. I was looking them all up. I was driving my general practitioner absolutely crazy because I was emailing him every other day. I said, hey, can we cut down on this one? I read that it was autotoxic. And this one is a side. substitute. You know, I was trying every which way to get, get this ringing out of my head. It was making me absolutely, it got so bad I actually have guns in my house and I locked them up. Okay. Yeah. And so on top of the,

what I had already been suffering with from my strokes, adding the tinnitus, I said, I have to get psychiatric help. I mean, I was taking Xanax like M&Ms to be quite honest, just to, just to, just to, take the edge off of the anxiety I had. And that's when I found you. And I'm sure glad I did because it's been an amazing change ever since. So you came in, you know, from the first visit in my notes, I have that you had decreased interest. You no longer were going to movies.

You were doing a lot less. And then you were obsessed about your health. You spent hours a day on WebMD and other Googling of other, different types of things. Absolutely. I'm sure the number of hits on Google have dropped tremendously. You know, and you talked about how,

you know, you had been tried on a couple different medications. Yes. You would get these, like, flooded sensations. Yeah. Talk to me about those a little bit. You know, what would happen, and as I realize, it's kind of a result of having traumatic brain injury from the strokes I had,

I would have this sensory sensitivity. And if I was subjected to loud sounds, bright lights, it would cause my brain to be overstimulated, and I would just shut down. And what would happen is I would have to go to a dark place, I mean, dark no lights, I'd have to go to a quiet place. Usually I would end up going into my bedroom and getting under the covers.

And these episodes would last anywhere from two hours to 24 hours. And it was really scary because when your brain gets flooded, you just kind of shut down. I already was suffering from residual weakness in my left leg, which causes me to have balance issues when I walk. And when I got flooded, I couldn't walk. I had trouble walking. and you're in this terrifying place of, oh, my God, what if I don't get out of this?

What if this is the way it's going to be? So it's quite scary. So I've learned actually, I wear colored lenses now, which helped me to shade out, particularly for fluorescent lighting. If I'm subjected to fluorescent lighting for a long period of time, it starts to happen. It's why I don't go to the movies. I still don't. I still don't go to concerts. Places where loud noise over a prolonged period of time

subject me to brain flooding. Yeah. And how else did your personality change from before the strokes to after the strokes? Well, one thing was, I think there was a... Well, first of, I guess I was grieving because what I really felt was the loss of my former self. You know, I felt that the person who I was,

I mean, I had a successful, career. I was active in a lot of things. I used to play sports, you know, and I was socially active. And then once I had all the strokes, I almost became reclusive because first of, I couldn't physically do a lot of things I used to do. And I noticed a lot of my cognizant skills weren't quite the same. My memory wasn't quite the same. I noticed that I had, I could not recognize my former self. That was one thing. I was also very angry because I felt why did this happen to me? I felt kind of disconnected from my old self. And I also felt I was always, I became afraid to travel, which was a major thing being retired. Well, the strokes actually promulgated my retirement.

But I was afraid to travel because I was always afraid I would have another stroke. I live with that thought that, oh my God, what if I'm on an airplane? I'm not near my doctors. I'm near my hospital, and that caused me to have a lot of fear, which I had never had before. Yeah. And it seemed like before you were very analytical, before the stroke, and then afterwards, it's like your emotions were like so much more prevalent. Yes. Would you say that? Yeah, that's very true.

And the stroke was on your right side of your brain. Correct. And so you had left-sided weakness. Yeah, it was actually my ACA. anterior cerebral artery. Okay. Which only about,

as it was explained to me, one to three percent of strokes occur there. So initially, we talked about getting you into a day treatment program that I run.

Right. We had started you on Prozac. Yes. And we had decreased the boost bar. Yes. We started you

on 10 milligrams of Prozac. And then you came back a month later. And the weather MD searching had gone down a little bit, just from the first appointment. Yeah, it was a little decrease. A little decrease.

But your anxiety was still high. So then you started this program. And what were some of the initial impressions of starting a program like this? Oh, wow. Well, I was very nervous, number one. Number two, I was kind of scared. And I went into the room and I think there were five or six other people.

I looked around the room and go, I can't relate to these people. You know, there were people in different socioeconomic backgrounds and different demographics. I said, gee, I'll never fit in here. And then I remember we went around the room to introduce ourselves. And the analyst, Sean, who was fabulous, he said, introduced yourself. So, of course, not only he started with me. Thank you. And I introduced myself in the first way I introduced myself was,

my name and my medical background, the strokes and the other stuff I've had over the last five years. I've spent 40 days in the hospital since May of 2014. And then he stops everybody. And he goes, okay, do you realize you just all introduced yourself through your illness? And he said, aren't you people? Aren't you human beings or are you an illness? And that was the first kind of wake-up call that I got was I had seen myself through the lens of my limitations from my illness. Yes.

And that was the first major, whoa, this is different. That's really good. I mean, that kind of hits you over the head, right? Yeah, totally. And then he had, did you have you reintroduce yourself without any illness? Yes. And what did you say? I just said my name.

Hi, my name is Stephen Prince. and I'm here because I've got some issues that I'm having trouble dealing with and that was basically it. You know, I was thinking about like how, like if I were to introduce you at this point. Oh, wow. You know, now I'm scared.

I did give your job stuff, you know, and, you know, what were the initial problems that brought you in. But I think I would say, this is Stephen Prince. Like if he is probably one of the most grateful people that I've met, Wow.

Thank you. He's a loving husband, and he's sacrificial and taking care of grandkids at times, right? Thank you. Yes, that's true. And he's finding ways to help other people. That's absolutely true. In fact, that's one of my life missions now is to bring a message of hope and encouragement to other people who suffer from chronic illness.

Yeah. Yeah. And I want to get to there, but I kind of want to tell the story, so let's not jump ahead too far. Sorry. Okay. So what would you say were some of the big aha moments? Wow. Well, first let me say the men program was transformational.

In fact, my wife just told me this morning that she said it was life-changing. And I came to grips with things that went well beyond what the limitations of my men's challenges were. I mean, I came to grips with some things that, some recessed, repressed anger that I needed to empty out. And I came to, I'll give you an example. Like, for example, I had lost, I didn't realize it, but I had lost my assertiveness through my strokes because of my limitation. and what Sean did was he would put on the music in the room. And what it would start to annoy me, and what I would say is, hey, you know, that's a little bit loud.

And he would wait for me to say, could you turn off the music, please? It's disturbing me. And I finally, it took me a while to get there. But, I mean, it's a pretty small example of the fact that I had somehow, And this was a major thing, is my assertiveness, I was no longer assertive, not that I was ever a, you know, bully or whatever, but being handicapped kind of made me feel a little bit less than. And I noticed it in my relationship with my wife and my relationship with other people that I was not, that I had somehow forgotten how to assert myself and ask for what I wanted or how I felt. or different things of that nature.

That was a very big aha moment for me. Yeah. And that's very common. A common experience that I've seen is people kind of, as they move towards a place of mental health, they find a voice and they find an ability to express their needs, and they value that their needs are good needs. So for those of you who are unaware,

the MEND program is a partial program that, helps people with chronic medical illnesses and psychiatric illnesses. So we see patients, you know, who have all sorts of different medical issues and their psychological manifestations of them. And one of the things that if you, you know, don't live anywhere near where I live in California, L.A. area is, you know, there are these partial programs, these day treatment programs all across the country. And they're really intensive psychotherapy.

like you are there for hours a day and at first it is anxiety provoking it's difficult I often will intervene very early on in the first week or so and say hey can you hang on can you give it a week or two

and usually after a week or two people feel more connected to the group and it's a little bit easier to express themselves did you feel something like that as you got into the group absolutely you know

within a couple of meetings all of a sudden I related in some way to everybody else in the room and in fact, you know, became close, very, very close with some of the people. In fact, we still have occasionally text each other. Hey, how you doing you? Okay, I'm praying for you. And it's amazing how when you get away from personalities and just get to know people's heart how you find so much commonality with other people, particularly we're going

through the same challenging path of dealing with a chronic illness. So in my note on February 26, 2018, I wrote, started to learn he is not his medical issue. Yes. How did you come to that realization? You told the first story, but were there any other big things that led you to start to see that you're different than your medical issues?

Yeah. I think, and I love the men program. I have to tell you that. I'm not blowing smoke up. You're behind. But it's a fabulous program, and I'm so grateful to you for referring me to it. I think that as I got more comfortable with where I was at,

it was okay for me to be me, who also happens to have some physical and brain-related limitations. And I think as I be, I learned that I am acceptable for who I am because of who I am versus let me, when I used to meet people, the first thing I would do is say, yeah, my name is Stephen Prince,

and I've had five strokes, yada, yada, almost like verbal diarrhea on them. And my wife, you say to me, go, you know, tell that to everybody. Now I hardly tell it to people unless people will ask me, why do you stumble a lot? or why can't you listen to loud music or go to concerts?

And then I'll just say, well, I have some issues. But it's not, it's, it's, I learned to accept it. I think that's the biggest, one of the biggest things that the men program did for me is I moved from a place of battling this place of, with a chronic illness, to by the end of the program, I had moved to a place of acceptance of where I was at. And that was, for me, one of the biggest transformational things. I also found that I was more self-confident. And my wife actually noticed this.

She's told me that numerous times as my confidence came back. Yeah. And the tinnitus used to stress you out quite a bit. Yes. Is it gone? No, I have it. In fact, I just went to a doctor

who just told me it was permanent, but I've habituated to it. I've learned to live with it. I learned that it's going to be there, and I just need to learn to live with it and move on. And not only that, you know, it's funny, you know, I never heard of it before. And now it seems that everyone I ran until,

oh, yeah, I got onitis. You know, I just met an Air Force guy that said, oh, yeah, I've had tonitis since I was in the Vietnam War. He said, yeah, you learned to live with it after a while. So it's really, it doesn't bother me at all. At night, when it's quiet, you know, it'll be an irritant and, you know, I needed some help being able to sleep through night and you've helped me out with that. So it's not the issue that it was. And through our work, you also were

able to get off Xanax. Yes. I have, I think it was April 13, 2018, that I have a document that you were able to get off Xanax completely. We went down slowly. And I think you had increased clarity or like you weren't as confused or you had more a clear mind. I don't know if you are conscious of that. Yeah, I'm not that conscious of it other than I know that I have this issue when I'm when I'm bombarded by a lot of facts, figures and different details like that. I kind of get my brain gets, I call it brain fog. And I don't have it as much. Let's put that way. Yeah, so you were able to handle more inputs coming into your brain. That's correct.

And you're able to kind of not feel that fogginess from it. Yeah, that's correct, because I'm not responding to everything in an emotional way. The other thing I noted down on that same day is that you had more internal locus of control, meaning that you felt like you could make changes in your life and not be a victim or not the external environment is not influencing all of your emotions that you could influence your own emotions. Do you remember how that took place or anything about that other than it took place? Kind of, it was more like it finally took place.

You know, a lot of the work that I feel that we did in the program had a subconscious way of working itself into your being. and I think that would be the best way to describe it because I suddenly didn't feel, I never had victimitis, so to speak, but I did allow others outside of myself sometimes to control my emotions or what I was doing or where I was at

or how I felt. And I noticed just as I just did the program, I mean, I worked it, I did everything was asked of me, I did all the written work that we did, all the drawing work that we did. I was a horrible artist, by the way. But I noticed that things just seem to,

it's kind of like an onion peel. It's kind of just peeled away. One thing that we do in the program that's probably specific to this program is we do a lot of artwork and we do a lot of writing and of course the talking. But what we're trying to accomplish

is to get people to be convinced, in all three of those spaces. And by congruent, first of all, how would you define congruency? And which one was the hardest for you to become congruent in? Congruency really is having who you are in the outside match who you are on the inside. And I was not congruent. You know, I mean, because quite often I would have this facade. Not that was phony, but, you know, I would kind of.

hide who I really was quite often. In fact, one of the things that Sean used to call, he used to call me the entertainer. I used to be an actor and, you know, I always like to be, you know, the funny guy out there and, you know, life of the party and all that lot. And, and I thought that was a great way to be popular and be acceptable. And then Sean said, hey, you know, do you realize you do that? And it was almost like it was part of my personality. And, you know, and that kind of changed. You know, I still can, you know, tell funny stories and all that lot, but I'm comfortable now just being.

Okay. So somewhere in the midst of that journey, you found that if you could take off this sort of funny entertainer, you could become more congruent to your inner. experience. That's exactly correct. And which one came first? The writing, the talking, or the artwork. Oh, wow. For me, it was the writing. The writing came first. Yes, absolutely. Being able to write, as I was writing, I could touch those parts of me that brought up different emotions. And what was interesting is quite often, Sean would confront me in a loving way.

You know, he won't let me hide out. It won't let me get away with something. I mean, he would, if he saw that I wrote something that he knew that I was not being congruent with, he had an innate way of calling me out or calling the other people out on it in a loving way. Okay. Yeah. So the writing came first. Yes.

And then did the verbal come next or did the artwork? The verbal. And you know, there was another thing, actually, that was really intense. We went outside and first we drew different pictures on this large canvas. And on the canvas we put things that we did not like about ourselves, things that made us angry, things that we were pissed off about. And I was no holds barred. And then we went outside and Sean brought a bucket of ice

and it was on a dumpster or something. And we got to actually display our anger and throw ice and just almost destroying those things that we were, those people we were angry at, or those emotions we were angry at or those things or circumstances. And it was very liberating. It was kind of, it was a great release. Yeah.

It really was a fabulous release. That's great. Sean is moving up to Seattle, and he's going to be a therapist up there. Oh, wow. Starting this summer. Oh, wow. And I keep telling him he needs to. get on the podcast with me to talk about psychogenic seizures and different stuff that he's an expert in.

So a little plug for Sean in Seattle. If you get this, send me a DM and I'll give you his contact info or I'll put it on the link in the blog or something. He's been a good guy to work with. Okay. So then you kind of had this artistic expression where you're able to be congruent with your art with what you say. and one thing I think that's really important to state there is being funny and being someone who can entertain, that's incredibly adaptive in my mind. Like that's helped you get through a lot of tough situations. It's helped you connect with people. But you can now choose to turn that on or turn it off.

That's correct. So when we talk about making changes and becoming more congruent, you want to become congruent in spaces that the person's not going to shame you or the person's not going to, you know, reject you. So we're kind of changing into a little bit of the family therapy. Did your wife come in at all? Did you learn how to become congruent together? Yeah. One of the things that the program does is it encourages significant other spouse to come in and be part of the actual meeting. And so my wife did so that she could see what we do. And there was another time that she came in and we met privately with Sean. And it really was wonderful that we did that because this way it brought her into the circle of what was going on for me

because she was as affected by my behavior and my physical challenges as much as I was. because it was a life change. It was a life change for her as well. Yeah. So do you feel like your ability to be congruent with your experience in how you talk to your wife? Do you feel like that changed? Absolutely.

I think I've become much more passive over the last five years. And now I think I've become more assertive where if I disagree with something, I'll voice that if something irritates me or I don't like something. And my wife is great. We have a fabulous marriage. But in any marriage, you know, you have situations that, you know,

bring up different emotions and I'm much more able to discuss them now or to display them than I was before. Okay. And when you used to come in here, you know, you balance. You still have some balance issues, but it was very, very difficult to walk. You were very weak physically. I hope you don't mind you saying that. No, that's okay.

That's okay. And one thing we talked about was you starting to squat, starting to exercise. How has that been helpful to you? Well, let me just say I don't have a gym or anything like that. So I did start walking. I started walking with my, I have a walker, and I walk about a mile a day. And then about two weeks ago, I started on this program of doing planks to strengthen my core because you've been great about egging me on to do something.

And I've noticed, you know, improvement there. I'm feeling better as a result of doing more physical things. That's great. And so you started a group. Yes. And so after you graduated from, the program. You've continued to see me as an outpatient. We see each other about once a month and we check in and I've had the pleasure of hearing your sort of journey in starting your own

support group. So tell me a little bit about how that is. Well, that's been awesome. After the last time I was hospitalized for strokes in 2015, they had a support group and kind of the stroke ward and I said, wow, this is a great way because, you know, you don't feel alone. You know, one of the things that happens when you have an issue like chronic illness is this feeling of, Jesus, I'm the only person who's ever had this. And, you know, in a group, when you hear other people who are experiencing the same issues, it's encouraging. And I wanted to find a support group where I lived and I couldn't.

And then kind of midway through the men program, I said, you know what, I'm going to stop my own group. And originally I was going to do it just for a stroke. victims, but I said, now I'm going to do it for all people with chronic illness. And I actually started it where I live. We have a couple of community Facebook pages. And it's been incredible. We've now been doing it for a year and a half. I even am able to get medical or health professionals. In fact, Sean came to address the group last fall. He was fabulous. We've had a number of people. we've had a a druggist,

which is, you know, having a drugist at our meeting is like, you know, fishing in an aquarium and everybody who's on some kind of drug or not. But we have 15 to about 15 people on average who attend the meeting.

It's once a month. And it's been a great, I've gotten fabulous feedback from the people who attend regularly about encouragement and hope. And it's now my life mission. I want to, to bring hope and encouragement to people who have chronic illness. And I guess as a PS to this,

now I was never, I was never a very sympathetic or empathetic person before. And now I really feel compassion. My wife tells me this now. This is one of the biggest change she's seen in me over the last year is I've become much more sympathetic, empathetic, and, you know, And I know a lot of it, first off to my Lord's Savior, Jesus Christ, who actually encouraged me to become a minister. I actually was walking and praying one day, and I felt like this thing nagging at me that I need to become a minister. And so I went, you know, I didn't do Google, but I did Google it. And so I found I could become ordained online. So now I'm an ordained minister.

I can do weddings and what have you. but I don't know where this is leading me to, but I just trust the Lord that he's got me on a path and I just need to follow it. But the group has been a blessing, and I'm grateful for it. You know, since you're talking about the spiritual, I'm just curious how in the past two years,

or since I've known you, how has your spirituality changed or approved? Wow. Well, that's a great question. Thank you. I've been a Christian since July of 1990 when I gave my life to Jesus Christ. And that has been a tough walk. I've had a lot of backsliding, moving forward, backsliding, and different things like that.

But in the last year, particularly since the men program, I mean, I'm now, I listen to daily devotionals. I'm listening to different sermons every day when I walk, whether day. David Jeremiah or Greg Laurie or what have you. And I feel that I'm probably the closest I've ever felt to the Lord right now. Okay. Yes, we talk about emotional health, has improved, spiritual health, physical health. You're walking more, more exercise, and relational health, you know, like your connection with your wife and being able to be congruent.

Yeah, are there any other things that come to your mind that you would like to mention about this journey. You know, I'm reminded of the famous quote, you know, that life is 10% what happens to you and 90% how you deal with it. And I think that the, that's been a major change that's occurred because of the work that we've done because whereas before,

it was all the things that happened to me overpowered me. Now I have the power to overcome those issues around me because before it was 90-10 the other way. Whereas now I feel like, okay, that happened to me, that happened to me, but I have the ability to change how I respond to whether it be stimuli,

how I respond to other people, how I respond to the world around me, what I want to create, what path I'm on. And it's made my life a whole lot better, even though I still have the physical limitations and other issues related from the strokes, they're not running my life. That's good.

Wow. Yeah. Yeah. No, I think that's powerful. I think it's... I never thought of it that way before, actually. So thanks for asking the question. What was the epiphany?

The epitriony was the 90-10. Yeah. I never kind of viewed it in that way before, and it just suddenly hit me. So thank you. That's beautiful. Yeah, no, I think that's really good. Of course, I talk about that in one episode on Logo Therapy with Victor Frankl, Man Search for Meaning, you know, you can be in the midst of a concentration camp,

and you can still decide how you're going to interpret things. Wow. You can still have meaning. You can still choose. You know, between the environment attacking us at times, right, and our decision on how we're going to deal with it, you know, we can choose to make some changes in how we view things, the meaning we put to things.

So you've changed your meanings. You're not, you're no longer putting the meaning of I am illness. I am, you know, the bad things that have happened to me. You know, it's more distant. The bad, you know, the environment is distant. has some distance between you and who you are, right? I am, you know, Stephen Prince. I am, you know, a loving husband.

I am a grandfather. I am, you know, someone who is an ordained minister. I am serving my community. You know, that's who you are, right? That's your identity. Yes. And even probably deeper than that is I, you know, I'm someone with empathy and sympathy.

I'm someone with gratitude, you know, so that's probably even more core and your spirituality in that as well. So, wow, it's been so good having you on. Thank you. And, of course, if you have any thoughts, questions, there'll be links in the show notes. Maybe I'll put a link to your Facebook group so that if anyone is in the L.A. area and would like to benefit from that, they can find that. and I will put different links in the show notes that you can follow and learn more. So thank you so much for coming on. Thank you for having me.

So for a little bit now we're going to reflect on some of the things that we're going on in this case from a scientific perspective. So a lot of the time when I speak to patients, I use very sort of common phrases, common names of things. And I'm going to take a break from that a little bit and talk about some of the details. neurology, pathophysiology that was going on, and talk also into broader terms about stroke, post-stroke, frontal lobe injury. And I have Jagger Ackerman. He is a fourth-year medical student who has been working with me on rotation with me. And so we are going to be sort of talking through some of the things that we found in the literature. And we're going to be explaining some of the symptoms that Stephen Prince had and also some of the changes and what might have led to some of

those changes. You know, it's interesting, in this particular case, there were some things that were a little bit confusing to me early on. One thing was his flooding. He would have these sort of flooding sensations, whether it was visual, bright lights, discoes. Anytime there was multiple bright lights, flashing lights, that would really bother him. That would send him into a desire to sort of isolate for two hours to like 48 hours. And then there was also lots of sounds, lots of stimulus coming in, lots of bombardment with auditory stuff so we couldn't go to concerts anymore. And then he also explained to me that he couldn't handle when there was multiple conversations going on at the same time, when they were in a crowded room, very

loud so sometimes he would have to sort of move away from that as well and so that was a that was a puzzling symptom for me and um so I called a neurology friend dr. Losey works at Loma Linda and I asked him about that and um he said well the ACA is in the frontal lobe it's in the executive function and and then I talked to dr. Timothy Lee a consulate liaison psychiatrist and um he really hadn't heard about that specific constellation of symptoms frequently sort of happening as an episodic thing. But he said some of this stuff has to do with executive function and maybe inhibitory control. And so we were looking at this, me and Jagger, we're looking at this the last couple days. And so we're going to kind of break down some of our thoughts. We'll start a little bit more broad and then kind of zoom in and talk about

these unique symptoms. So Jagger, tell me a little bit about the right-sided ACA stroke. Yeah, so in this case, he had a right-side ACA stroke. Most common types of strokes is actually in the MCA, so the middle cerebral artery. His being in the anterior cerebral artery is going to be much less common, accounting for about 0.3 to 4.4% of stroke cases overall. It's more predominant in males, typically occurring between the ages of 59 and 75. And the ACA strokes, when they do occur, actually happen more on the left than the right. in our case here, him having a right-sided ACA stroke is actually quite rare.

Yeah, and he had this right-sided ACA stroke, and then he had actually, it was hard for them to diagnosis at first because it's a little bit more hard on MRI to pick this up. And he had a subsequent one, which kind of reinforced it. And so the first one occurred for him, May 2014, the second one, May 2015. And after that is when he started having the vision issues, the hearing issues. He had a little depth and peripheral issues in his vision and he was told not to drive. And then in May 2015, he started to have more of the sensory issues, the sounds, the bright

lights, especially the disco balls, police lights, fluorescent lights. And he also had the left-sided leg weakness. So tell me a little bit about why he would have left-sided leg weakness, but not sensory issues. Right. So again, with the ACA stroke, the most common presentation is going to have these motor deficits, usually involving the opposite side, lower extremity. So because he had a right-sided stroke, he presented, as you would expect, with left-sided lower extremity weakness. He complained of having weakness in his left leg. The reason for it being more motor deficits rather than sensory is because it's affecting, there's two different kind of quadrants of the brain, one focusing more on motor and one more on sensory. And the farther you go forward in the brain, it's a more,

like the more anterior region is a more motor focused region. And so this is actually something that we would expect to see in him is motor deficits without sensory deficits. Okay, so tell me a little bit about what other motor disorders might occur in an ACA stroke? So again, the ACA, just the distribution of the brain that it's involving, you're more likely to have lower extremity deficits. So you're going to see symptoms of weakness in the legs. You'll often see bladder issues as well. A lot of patients will have difficulties with incontinence, not being able to hold their urine, going to the bathroom quite frequently. Other symptoms that they might have is a slowing of the gate or actually like a staggered gate.

Sometimes they can present with a Parkinsonian gate so that's shuffling along the floor, almost as if your feet are glued to the floor. And then tremors are quite common as well. Yeah. And then one of the interesting things is ebulia. Am I saying that right? Yeah, we think it's abulia. So that's the A-B-U-L-I-E.

Yeah. And that has to do with low willpower and assertiveness. And so one of the interesting things you may remember about what he said in his story was that early on in the group therapy, he was not very assertive. Do you remember what the therapist did? The therapist would turn up the music and then wait for him to tell him directly to turn it off. And it reminded me of this book I read,

which talked about how the brain can basically regrow pathways, you know? And it takes practice and repetition to regrow pathways, to regrow abilities. And so even though this part was damaged, which normally would decrease assertiveness, decrease willpower, for him, he really has improved in this area. and it's practice and time, right? And I've seen the same thing happen for many people who lack assertiveness. Is that with training, with practice, it can improve.

Right. And what's him, which was especially interesting is it's not as if he weren't assertive throughout his whole life. This lack of assertiveness happened after the stroke itself. Yeah. Yeah. Some of the other commonalities in the ACA infarcs that we did, didn't see was agitation, motor perseveration, memory impairment. Sometimes there's emotional lability, which he felt more emotion, but it didn't seem like he had the emotional

lability that I've seen sometime with people when they go up and down and up and down. Any other symptoms that you found reported in ACA infarx? So anosognosia is another symptom that can appear in ACA infarx. And that's, that I think is when you don't know what you've lost. Anasagnosia is a lack of insight. And that is sometimes seen in people with ACA strokes. But it seemed like he had actually pretty good insight. So I didn't think he had that symptom in particular.

Sometimes people have altered consciousness or speech disorders. Why do you think he didn't have a speech disorder? So again, it's really going back to what areas of the brain are being affected by the stroke. MCA stroke, so the middle cerebral artery, is going to be the most common type of stroke that's going to present with speech disorders. What side, left or right? It's going to be on the left side, because that's where it's called Broca's area and Warnocki's area. So Broca's area is going to be kind of the part of the brain that's responsible for motor speech. so people who have an affected broca area,

they're going to have difficulty producing language at all. Whereas in Wernickees, that's going to be more receptive speech. Those are going to be the types of patients who will be rambling on, not making any sense whatsoever, but they're not even able to perceive that what they're saying doesn't make sense anymore. And again, both of those areas are supplied by the middle cerebral artery. So our patient, having an ACA stroke like he did, it's going to be more those lower extremity symptoms with sparing of any speech deficits.

Yeah, that's right. So Warniky's aphasia, it's like they're not bringing in the knowledge of speech. And so when they speak, it doesn't make sense like a normal person, but it's not like Broca's. We're Brocas. They have a hard time getting the words out. Right. So, yeah, because he has.

had the damage on the left side, he didn't have any speech issues. And then the altered consciousness, I see that as more of like a delirium. And delirium sometimes comes from stroke. And the bigger the stroke, the more likely that you'll have delirium. And so that would be, I think, more of the altered consciousness, which he did not have in his history. Okay, let's talk a little bit about the prefrontal cortex in general. Okay. So the ACA stroke, front of the brain prefrontal cortex. So in general, what does the prefrontal cortex tell me about it? So just from a purely anatomical definition, the prefrontal cortex is defined as the part of the cerebral cortex that receives projections from the medial dorsal nucleus of the thalamus.

So it's that part of the brain, the part of the cortex that's receiving those projections from the thalamus and then relaying kind of those pathways throughout the rest of the body for really the purpose of action. The prefrontal region of the brain as a subset of the frontal cortex is really the action cortex of the brain. Yeah, so action. Like doing either doing things like reasoning,

so things that don't have physical action, but they have mental action, and also action as in movement. And so the prefrontal cortex in humans makes up 29% of the brain, whereas in chimps, 17%, and in dogs, 7%, and in cats, a lowly 3.5%. So, you know, you still have in cats the predatory aggression and that kind of thing, but they don't have the reason and the ability to create beautiful operas and literature,

and that kind of thing that comes from the frontal lobe. Okay, so let's go into some of the categories of what the prefrontal cortex does. And then we'll zoom in to his case in particular. So there's the temporal organization, executive memory, executive attention, which includes working memory, preparatory set, inhibitory interference control. So let's start with temporal organization. So temporal organization, it's considered the most general and characteristic of all the prefrontal functions in primates. The idea of this temporal organization is it's what gives us, as higher primates, the ability to execute new, acquired, and elaborate behaviors. It's what allows us

to have speech fluency, and it's what gives us the capacity for higher reasoning and creative activity, really all clustered around this idea of being able to understand ourselves and others in space and time. And this is really the lateral prefrontal cortex. So this is the sort of the outside edges, which the ACA is in the middle. Correct. And so I think for him, this was spared. We didn't see this as much of a factor in him. Yeah. And so how about executive memory?

Tell me a little bit about what executive memory is and how that is related. So executive memory is this idea of taking formed prior experiences and utilizing these experiences for the acquisition of further executive memory, organization of behavior, reasoning, and language in the future. So it's this idea of taking structures that are occurring in the present or in the past and organizing them in such a way that serve us for the future. We can think of this as planning and decision making that humans do. Yeah. So humans are reasoning, they're planning, they're structuring things to serve them in the future. And the frontal lobe is really very important in that, in that sort of executive memory.

memory and that executive function. So we think about like being the executive of a company is planning and thinking and hopefully organizing the company so that it thrives. So there's a part of all of our brains that are doing that. And by the way, all of these parts of the brain can improve with practice. Just like an athlete can improve muscle strength. These parts of the brain can improve with practice. Tell me a little bit about, let's go to executive attention, and there's three aspects of it, and there's the working memory, and so tell me about the first aspect of executive attention, working memory. So working memory, it can be considered similar to short-term memory or an active memory, and this is really taking that temporal activation of long-term memory

and organizing it in a way that can be used in the immediate term. Really, we can understand this active memory or this working memory as sustained attention on an internal representation, which Miller and Cohen call cognitive control. So it's really taking this focus, taking this attention, and applying it to the immediate here and now. Yeah, so it's taking these kind of chunks of information and moving them around, these are like internal representations.

And one way of thinking about this is like if you're playing chess, you know, you have a memory of how the chess pieces move, right? And so as you're looking at a board, a beginner is thinking like, okay, I can move my pawn up two or I can move it up one, right? And so these are the chunks of information that a beginner is playing with. And as they get more advanced, they are thinking maybe how multiple moves are going to be combined together. Because they've seen so many chessboards and so many games played out,

it's like the chunks of information that they're moving around are bigger. Okay. And so this is what it means to have like a working memory. And how many, how big are these chunks? Depends on, you know, are you an expert at this? So for like, in psychiatry, you know, if you're thinking, small pieces, you might be thinking of a particular side effect of a particular medication. I'm thinking big pieces, you might be thinking about, you know, how do all these meds work together

and in concert or in a bad way. Right. Okay. Let's go on to the second aspect of executive attention, preparatory set. Yeah, so the preparatory set is the readdying or priming of sensory and motor structures for action. It's getting everything geared up ready to go, kind of thinking of a runner taking the running stance before the start of a race. And it's that part of the brain that's reconciling these sensory cues or reactive vated memories. So it's your brain taking in cues from the environment that are occurring now, coordinating them with past memories of events that have happened before, and then preparing your body for action and response.

to how it's coordinating all these things together at once. That's really good. So it's like, okay, in the chessboard analogy, you're now picking up the piece and moving it. You're moving that into action into motor. It's like motor attention. In archery, it would be pulling the bow back and letting the arrow go.

Okay, the third aspect is inhibitory interference control. Yeah, and this one is really interesting in general and in the case of our patient especially. So inhibition plays the role of enhancing and providing contrast to excitatory functions. When you have all this information that's coming at you at once, your brain does an incredible job of filtering out what it needs in the immediate and is able to kind of dampen down everything else in order to focus its attention on what needs to be achieved. in the immediate moment. So selective attention that we talked about earlier is accompanied by inhibition of whatever cognitive or emotional contents or operations would interfere with this attention. And just to take a step back and apply it to our patient, he had all these complaints of kind of sensory overload. And I think this can be viewed in the context of this lack of

inhibitory interference control. Yeah. And we actually found a really good good article on it called the inhibition of the right inferior frontal cortex by Aaron Robbins in 2004 and in this article they go through the right inferior frontal cortex and inhibitory control and I'll put a link in the in the blog that will accompany this and it really does go through a way to make sense of why the right ACA damaged caused him

to lose that ability to selectively inhibit lots of sounds lots of visual stuff coming in yeah that's really incredible and I've seen this also with people with ADHD

untreated ADHD sometimes they'll come in and they'll say like I'm sitting in the test and I hear everything I hear everyone else's pencils I hear the clock I hear the fan, okay? I also hear this in some patients with schizophrenia at times.

Sometimes they'll say something like they can't shut down all of the stimulus coming to them. They feel flooded with it. So when I learned about this, all of a sudden it really made sense to me, like why he was having this symptom. And so that really goes to another sort of component of like, well, why did I choose to do what I did, for example, with the Xanax? Because I tapered him off the Xanax slowly, mindfully, because Xanax is a benzodiazepine. It is something that lowers global brain function.

And so it's given for anxiety, but because it tunes down all of the brain at once, and especially the frontal lobe, in the same way that alcohol kind of tunes down the frontal lobe. So if you really want to optimize someone's sensorium, you really want them to have no anticholinergic medications, no benzodiazepines, no barbiturates. And so as someone who's really into psychosomatic medicine,

it's something that I pay attention to. And so I think getting off of this medication helped them little bit, right? Regan some of the function. Right. If you've, if you already have a decreased frontal lobe, just secondary to the nature of the stroke itself, having anything else on board that's going to dampen on top of that, that's a no-go.

Yep. And so this is, this is going to lead into a little bit on frontal lobe damage in general. And, you know, he had a stroke that led to some frontal lobe damage, but there's other ways that people develop frontal lobe damage. TBIs, frontal temporal lobe dementia. And there's some symptoms that are common in this. And what I really want to present is the optimization of sensorium. That's kind of like why I care about sensorium.

And this is why, okay? All right. So let's just briefly talk about these different types. So stroke? Yeah, so stroke, traumatic. brain injury and frontal temporal lobe dementia are really three-brage categories. And we have instructive cases from discrete trauma that have occurred from war injuries, frontal lobe tumors, lobectomies that have been done in the past as methods for trying

to alter different types of psychoses and even vascular, infectious, or degenerative processes. And those processes in particular have been informative. because it's a progression. So we've been able to actually see through the data extensions of the disease process. Yeah, and I really want to emphasize that in his story, you could see that he was regaining function that was lost. And the brain can change itself, right? And so just like physical therapy can regain physical function, Okay, and this is why like nowadays, when someone has a stroke, we don't just do physical therapy once a week.

We do it like five days a week. And we want them, you know, if their right hand is working fine, we put a midden on it that forces them to use their left hand. We want someone to use those areas that have deficits and we want them to use it repetitively. And so that's why in the, in any partial program or any like daytrimed program, like the men program, with repetitive use, okay? You can start to regain function that maybe there wasn't there before. Wow.

Okay. So let me talk a little bit about Phineas Gage because Phineas Gage was like the first person with frontal lobe injury. This was an 1848, New England. He was a construction foreman. He was about five foot, six. He was athletic.

And back then, they would blast the stone to make Pathmore level for railroads. And so, you know, before his injury, he was described by his bosses as efficient and capable by others as having temperate habits. He was described with considerable energy of character. And so they would drill this hole. They would put in the gunpowder about one halfway. They would insert a fuse. And then they would put some sand.

And they would tamp the sand with an iron rod. And then they would light the fuse. Okay. So this is how they kind of like made these explosions, which made the Pathmore levels that could lay the railroad. So what happened in his event is that he basically, the powder was put in the gunpowder, the fuse was put in. And then Gage asked co-workers to cover it with sand. He turns away for a little bit. And before the person puts in the sand, he taps the powder with his iron.

bar. And there was an explosion that sent the iron bar up through his left cheek and it pierces the base of his skull. It transverses the front part of his brain and exits on the top part of his head and lands 100 feet away. And so he is stunned but awake. And in a Boston medical article, It documented that immediately after the explosion. The patient was thrown onto his back. He had a few convulsive motions of his extremities. But he got in this cart himself and with little assistance from men. And so there was this young doctor, Edward Williams, who arrived and later quoted saying

that he talked so rationally and was so willing to answer questions. his physician, John Harlow, without antibiotics, treated his wound with vigorous cleaning, placing the patient so that it could easily be drained. And he ended up overcoming high fevers and an abscess. And Harlow was quoted saying, I dressed him and God healed him. Well, the story goes on that Dr. Harlow documented that his limbs worked. only his left eye was blind. He had this

the equilibrium or balance, so to speak, between his intellectual faculty and his animal propensities were gone. And so this was a really bad frontal lobe injury in which he was fitful, irreverent, indulging at times in the grossest profanities,

which was not previously his custom. And he ended up totally having his personality change. And so, you know, this was like a complete frontal lobe damage, like a large amount of his frontal lobe, okay? And what I think about this case when I hear it is that when I heard this, it was very mind-blowing to me that someone's personality could change from brain injury. Right. And so drastically. So drastically and so quickly. Of course, our patient, he didn't have severe fits of rage, he didn't have all that sort of, you know, he didn't have worsening of his moral behavior because the frontal lobe damage was small

and it was in the right inferior part. But he did have that some of his, some of his change in his assertiveness and a change in his ability to filter sounds. Okay. So other symptoms that sometimes come from frontal lobe injuries are apathy. Do you want to say anything about that? Yeah, so from a couple studies, they found that the lateral prefrontal convexity was especially associated with this apathy.

The author is Paradiso in a paper in 1999 and Cummings in 1993, both reported these levels of apathy and reported indifference and attitude towards others. Yeah, this is more of the lateral part, and that's really important to specify here. Also, depression has been found in these injuries, especially the anterior and the lateral lobes. Left-sided lesions were more likely to lead to depression than right-sided lesions. And in post-mortem neuropathology of depressed patients indicated a general prefrontal, like, shrinking. Right, and that's especially interesting to consider. of you have these patients who have trauma or damage to the brain that leads to depressive symptoms,

but on the contrary, you also have depressed patients who are showing reduction in sizes of the brain. So it's this really interesting interplay going on in neuropathology. When someone's depressed, we want to always treat them and we want to get them out of the depression, if at all possible. Because we know that there's a progression of the disease. There's a progression of things in a bad way. Some people have euphoria. And they have sporadic or recurrent euphoria.

It resembles the affect of a hypomanic state. They can be nervous, irritable, sometimes paranoid. They can sometimes be accompanied by compulsive, shallow, childlike humor. distractibility or hyperactivity, kind of like ADHD. Anything else you want to mention about that symptom in particular? One area that was interesting was just this perseveration. You see these patients who continue to repeat odd patterns of behavior, really continuing to act out these same behaviors without changing them.

Some patients will have this hyper-oract. they'll continue to just eat and eat and eat. Patients who wouldn't smoke at all before, who are now smoking every single day. And these increases in hypersexuality, patients who used to have a normal appropriate sex drive, who are now becoming promiscuous, cheating on spouses,

and going out and really just engaging in behavior that's entirely different from the person that they used to be. Yeah, and I think once again we're talking broadly about very large frontal lobe dysfunction that can happen from TBIs or frontal temporal dementia. There can also be empathy issues. And interestingly, Stephen Prince described he had increased empathy, and I truly believe that, from watching him from the beginning to the end. And I think some of that empathy can be learned, it can be improved.

And I think there's nothing like going through therapy or group therapy that can improve your empathy and learning how to be congruent with your emotions. But if there are large lesions of the orbital frontal ventral medial cortex, it can improve affective empathy, which is the ability to feel other people's emotional content. Affective empathy is lower in psychopaths, primary psychopathy, and not impaired in autism. They have normal affective empathy. empathy. They have more issues with cognitive empathy, which is the ability to put it into words. And they also can develop issues with interpreting and responding to facial expressions and

emotional voice. So tell me a little bit about some of the changes in social behavior. So in these social behaviors, it's these really. really drastic changes that can be quite scary to friends and family of the individual who's exhibiting these changes. It's been documented of this insatiable hunger. Patients who have had severe frontal lobe damage who now just have this excessive drive to eat put on incredible amounts of weight in a very short time. And interestingly, there was also a case reported by herb in 1989 talking about bulimia. So this patient with no prior history of any mood disorders, no prior history of anorexia or bulimia after having this frontal lobe damage suddenly becoming

bulimic to the point where they were throwing up pretty much every day. I mentioned earlier this increased sex drive, becoming promiscuous and impulsive anger as well. And again, these can be quite frightening to the friends and family of the individual. The person themselves who's experiencing these changes often isn't aware of how these changes are being perceived by others, but can be quite distressing for spouses and family. Yeah, and once again, these are, this severity of symptoms and these exact symptoms, were not what we saw with Stephen Prince, but I think it's important to kind of like think through like okay if you if you have lateral side of the frontal lobe how does that show up if you have

general frontal lobe damage from traumatic brain injuries or from frontal temporal dementia how does that show up this really leads into kind of my big pitch on sensorium so i sensorium is defined as total brain function. It's the ability to make sense of, you know, and to, you know, rationally move through the world and with, you need the total brain to do that. And so everyone has fluctuations of their sensorium. So, you know, everyone's a little bit sharper in the morning unless they're still kind of waking up to a bendadryl that they took the following night that knocked them out. and everyone may be at around three or four is a little bit lower sensorium and some people are unique and different and sensorium so it fluctuates

and also you know you can imagine if you didn't eat if you were isolated if you were chronically stressed out your sensorium would be lower and so sensorium fluctuates and everyone has a certain level of capacity and when someone has had either a head injury or a stroke or a TBI, their sensorium is a little bit more precarious, meaning like dips in their sensorium can affect them more. And so when I take someone's history who has a history of any of these issues, I look at what do they like when there's certain sororiums at their peak

and what is it like at their worse? And so that's why I asked them some questions in the, history about like, okay, when were you having these issues, what time of the day? Because I was trying to judge, like, were these fluctuating with his sensorium or not. In general, how I optimize sensorium is, number one, chronic stress. So how do you alleviate any chronic stress? So therapy was a big piece for that. So how do I help someone no longer, you know, have these sort of ongoing conflicts, which are really, you know, just very exhausting to be in every day. You know, whether it's chronic anger that they're living with, how do I help them get through

that? Or how do I help them connect with their, you know, the people that they live with better? Okay. That's sort of the stress, the chronic stress. Other things are exercise. So trying to get people to squat, to deadlift. And, you know, the stronger you are, the more sensorium you're and a half. And so there's been a lot of studies, and I talk about these in my, um, uh, sensory I think part two or three when I go through exercise. I talk about how actually strength training can slow down the decline of the brain. So, you know, as we get older, our brain slowly loses mass a little bit. And if we exercise, it actually slows that process. And then the, the next thing is a diet, you know,

know. So they found Mediterranean diet is actually healthy for the brain. So we look at that. Sleep. So how do we optimize sleep? How do we get someone sleeping, you know, eight hours a night or however amount, whatever the amount that gives them that peak sensorium, right? Or if they have obstructive sleep apnea, how do we help them get through their obstructive sleep apnea? So for him, having a sleeping medication was very helpful. He didn't have a obstructive sleep apnea. so those parts were taken care of. And the final piece, which was very interesting to me in part four in my Sensorium series,

I go into this in depth, but they've actually found that having a sense of agency and internal locus of control actually improves your Sensoria. It improves frontal lobe function, right? So if you believe that you have the ability to change, if you believe that you have the ability to influence the world,

then your sensorium will improve. So when he talks about meaning, when he talks about purpose, when he talks about having a group, having a faith, all of these things are optimizing his sensorium. Yeah, he's empowered. He's empowered.

Yeah. And he's like moving into that, like the final stages of the Ericksonian stages of generativity. You know, where he's like, how do I make, like I was talking to him today on the phone. You were there with me. Right, right. And he was, you know, I was telling him, hey, we're getting this ready. We're thinking about having the discussion about this at the end. And I said, you know, I think this is going to help a lot of doctors in the future really understand, write ACA and, you know, understand the pathology and maybe be able to

help other people better. And when I said that, do you remember what happened? He was so excited about it. He wanted to know how he could be a part of it. He was just overjoyed. He was overjoyed. Yeah. And he is in a place of generativity. You know, how do I help others? And, you know, how do I connect my story to help other people improve their lot, improve their lives?

And, you know, providers improve their ability to diagnose and treat effectively, you know. you know and i have a very similar passion i really hope from listening to this today that someone out there catches a couple of these over the course of your life you know and that by catching maybe some of these some of these symptoms you know you're able to better help these people you're better able to help think through okay you know we can improve brain function through repetition through practice through connection through people through um you know walking with people and And we can optimize aspects of the sensorium. We can get people off of medications that are anticholunduric or benzodiazepines.

We can get people, we can help empower people to know that exercise, diet changes, improving their sleep. All of those things are going to improve their long-term ability to thrive. And so that's what I get passionate about. And I know when I was talking about that today, you were like, okay, I get it. Yeah, it's been so much fun just being a part of it and seeing your passion for it. I know it's rubbing off on me as well. Yeah, so we're bringing this to an end.

If this was at all helpful in the show notes, you can follow it. We'll have kind of a blog or write-up that will go with this. We'll have a bunch of these studies cited so you can look at this in more detail. I know this was a lot of information at the end, but we're going to put this all in the blog. and in the, so you can, um, you can dig into it and digest it further. Um, but thank you so much to Stephen Prince for coming on. It was, um, it's been great working with him. He is once again, a loving, grateful person and it's been such a joy to see him overcome. And, um, I look forward to continuing to walk with him and enjoy connecting with him and his family. So until next time.