The Importance of Dopamine in Creative Expression: By Dr. De Leon

“We of the craft are all crazy. Some affected by gaiety others by melancholy but all are more or less touched.” ~Lord Byron

As you all know, I have had some major health issues setbacks lately which have curtailed my involvement in various activities including my bi-monthly blog writings. Main reason for this has been lack of creativity along with a lack of mental drive to get anything done. Of course having blood pressures fluctuate in a drop of a hat from 95/60 laying down to 200/95 sitting and even higher standing or mild activity such as dressing or bathing causing blindness a couple of times along with a TIA (mini stroke) did not help much either, which scared the living daylights out of me being a neurologist and all.

As I laid around mindlessly watching T.V. trying to stay calm and avoid any major excitement (difficult in my life at times it seems like), I caught some scenes of the movie -“A Beautiful Mind” perhaps many of you will remember this movie which won many awards for Russell Crowe’s portrayal of a brilliant mathematician (John Forbes Nash Jr.) who struggled with lifelong mental illness in the form of schizophrenia.

Following a stream of semi-consciousness, I began thinking about my own patients with mental illness over the years including those with Parkinson’s disease and the apparent connection of great intelligence, creativity and mental disease.  From ancient times of the Greeks important people like Aristotle thought that creativity came from the gods and the muses (the 9 daughters of Zeus). These were the mythical personifications of the arts and sciences.Image result for pietà michelangelo

One thing is clear to me and to many others who have studied this subject is the direct correlation of dopamine and intelligence. After all we know that this is the chemical responsible for learning and reward system. A study by psychologist J. Phillippe Rushton discovered that creativity was highly correlated with a high intelligence and traits of abnormal personality – schizotypal. Those who had a condition with known dopamine involvement particularly those with excess dopamine such as bipolar or schizophrenia (like Nash) were found in literature to be extremely brilliant and creative individuals. In my experience this has also been true, all of whom hated being on “treatment” which suppressed their dopamine because it ‘stifled’ their creativity and their originality causing them more often than not to go off their meds time and time again. We have example after example of great literary minds and artist who had significant neurological deficits who were quite prolific despite their disease. I believe, that this is greatly in part to the excess of dopamine circulating in their brains. People like Earnest Hemingway, Michelangelo, Virginia Wolf, Sylvia Plath, even Robin Williams.The Old Man and the Sea

Pondering about the subject of creativity it dawn on me that since I had stopped intake of my Rytary (Levodopa replacement), I had lost my spunk, mental acuity, including writing creativity, and worst again stopped bring interested in reading my favorite novels which everyone in my family noticed…this I believe is due to fact that reading a novel with complex story line requires a great deal of concentration and recollection which use up large amounts of dopamine.

Incidentally, as an aside reading is what I needed the most to regulate my blood pressure because studies have shown that simply emerging oneself in a favorite fictional book especially if already read and enjoyed can quiet the heart rate and lower blood pressure several points within a few minutes- so take out those favorite fictional novels out to Keep your brain and heart healthy!

However, since I began to feel the effect of lack of dopamine in my body after more than a week without it, I took my first dose again last night and behold I woke up with a brain full of ideas and ready to tackle the world once more, read, write and be creative. ( I won’t be going off my levodopa anytime soon again) Confirming that dopamine is the key substance needed to thrive in life and be creative. So in reality, this question of artistic expression in Parkinson is truly a simple one. Parkinson’s appears to be responsible for our new talents indirectly just as those with frontal lobe dementia due to excess of dopamine either by design of disease itself as in the case of FTD or by external supplementation in PD. Perhaps some of us have already been gifted with latent artistic talents that have been dormant for years unexpressed due to insufficient stimulation of our own muse. This would explain why people who undergo DBS no longer have the same creative expression as seen before the procedure because by design the operation is meant to reduce amounts of external dopamine required so people no longer have that boost to surpass the threshold into the creative realm.

Since a study of more than one million people in Sweden found a direct correlation between creative occupations and mental illnesses. This may be an area for further development as a way of doing vocational rehab for those of us with Parkinson’s disease who were forced to abandon our previous occupations. Something to ponder. As I continue to regain my own mental stability –recalling the day I first took levodopa, as a day when everything came completely into complete mental focus.

This weekend I will be relaxing with some dark chocolate curled up to a good book, maybe even enjoy some poetry!

 

Sources:

https://en.m.wikipedia.org/wiki/Creativity_and_mental_illness

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041074/

 

 

Tardive Syndromes- Tardive dystonia, Parkinsonism, and Other Movement Disorders: By Dr. De Leon

What is a Tardive (late) Dyskinesia?

This is a persistent, at times irreversible, abnormal involuntary movement disorder appearing after a prolonged (usually 1-2 years) or extensive intake of dopamine antagonist (blockers) such as old traditional neuroleptics. Prior to onset of atypical antipsychotics like Seroquel, there was a slew of elder patients in nursing homes and mental facilities with tardive dyskinesias mainly due to antipsychotics like Haldol (usually referred as Vitamin H among health professionals). They can develop in the course of treatment (at least 3 months), after dose reduction, or even after the causative drug has been withdrawn. Stopping or decreasing dopamine blockers causes tardive dyskinesias in about 40% of people previously asymptomatic.

These movements usually present as hyperkinesias (excessive movement) involving the trunk, limbs and orofacial muscles. Exposure to these drugs can reproduce any of the involuntary movements that are hyperkinetic inn nature such as chorea, dystonia, myoclonus, tics, and tremors. Tardive dyskinesias is a generic form used to refer to all these syndromes. But a more restrictive syndrome of involuntary movement of face and mouth (buccolingual masticatory syndrome) also seen in older patients with maladjusted /poor fitting dentition-was the first type of tardive dyskinesia ever written about. Patients look like they are constantly chewing or ruminating. This involves the tongue twisting, persistent protrusion of tongue with lip smacking, puckering and chewing motions. Sometimes may be accompanied by trunk swaying, rocking movements and pelvic trusts. while standing in place these individuals tend to pace or march in place or shift their weight from one leg to another. in addition these patients exhibit moaning and grunting as well as abnormal breathing patterns causing frequent referral to pulmonary and cardiac specialists. They often have respiratory dyskinesias (arrhythmic breathing, deep inspirations and fast breathing).

An unusual clinical manifestation of tardive dyskinesia is a painful sensation in the oral and genital region.

Drug Induced Dyskinesias:

  • Lithium-Parkinsonism
  • Dilantin (phenytoin-with high or normal levels)- disappear with dose reduction or withdrawal- causes chorea, other movements are dystonia, ballismus, tremor, asterixis, and myoclonus.
  • Tegretol (carbamazepine)-tics (vocal and motor)in children and dystonia in brain damaged children.
  • Tricyclic antidepressants ( Elavil, imipramine)- either acute intoxication or after chronic use. 1) Acute abnormal movements are tremors, myoclonus, choreathetosis.2) Chronic use leads to chorea. Symptoms stop with drug cessation.
  • Fluoxetine-myoclonus
  • B-adrenergic drugs used for respiratory disease ( like albuterol, terbutaline) cause tremors.
  • oral contraceptives– can cause chorea
  • calcium channel blockers- (e.g. verapamil, Norvasc)- can cause parkinsonism, and acute dystonia
  • reserpine- parkinsonism
  • tetrabenazine-parkinsonism
  • Antiemetics-metoclopramide, Phenergan-parkinsonism, chorea, dystonia.

Risk factors:

  1. old age
  2. female gender
  3. mentally impaired
  4. duration of illness
  5. length of drug exposure
  6. cumulative drug exposure
  7. history of mood disorder
  8. diabetes (2x greater risk)
  9. structural brain abnormalities
  10. history of electroconvulsive therapy
  11. early side effects like parkinsonism

Risk factors for acute dystonia:

  • male gender (2:1)
  • younger than 30
  • high dose of neuroleptic
  • potency of drug
  • underlying psychiatric disorder like schizophrenia
  • family predisposition

Akathisia (restlessness-feelings of inner tension causing patients to shift positions continuously); frequently misdiagnosed as anxiety. Caused by prolonged exposure to dopamine blockers.

Treatment:

  • reserpine
  • tetrabenazine
  • clozapine
  • tardive dystonias requires a combined approach with levodopa and anticholinergics; clonazepam (klonopin)

If you are on any of these medications and have movement disorder follow up with an MDS or if your current symptoms have worsen and are on one of these meds make sure you follow up immediately.

 

 

 

Parkinson’s disease and The Work Place: By Dr. De Leon

lucile ball

This is a classic picture of one of my all time favorite comediennes with a well known skit. Every time life comes at us fast, this is what I am reminded of.  Sometimes no matter how hard we try, we have to swallow some of the stuff coming our way in order to keep moving forward. As I have been having more recent medical complications due to my Parkinson’s disease and medication side effects, I again was reminded of Lucille Ball. I like her initially was thinking in the last few months that perhaps I was on the other side and I could handle going back to working as a physician despite my PD (easy- peeze-no problem). However, as life demands have increased followed by  one thing, another and another, I have begun to feel like things are speeding up on my own conveyor belt causing a big pile up, making the juggling and keeping up a bit more hectic and demanding. This does not mean I am giving up on practicing neurology again or stop my advocacy.

But, I have begun to think more about those of us who live with chronic illness and have a job, trying to maintain one, or are looking for ways to earn a living with a different career after PD diagnosis.

As many of us have learned, it is not always possible to keep working at previous capacity or even at any capacity when illness strikes particularly in the face of continuous fluctuations especially if sudden or unpredictable, as mine has been lately, or as we approach advanced stages and begin experiencing motor fluctuations such as dyskenesias.

According to a British study of 308 Parkinson’s patients, 82% had ceased to work after 10 years of disease, 57% retired early like me due to disease.

We all know life with a chronic disease like Parkinson’s is a constant juggling act. We have to learn to balance our health along with family, social, and work responsibilities. This can be a feat for many.

When we first get diagnosed after the initial shock wears off and reality sets in, we have to consider our financial resources to be able to continue providing not just for those who depend on us; but more importantly for the increasing financial needs that come with being chronically ill.

So as you contemplate your future financial stability, you must start making concessions for a time when you are no longer able to carry out your present job duties or perform any standard job. Think of the worst scenario and build from there but without going to panic mode or being paralyzed by anxiety and fear.

I am sure you will begin to wonder if you should share your diagnosis with your boss or fellow employees.

First, I have to say candidly and with all due respect-it is no body’s business unless you want it to be. If your job is unaffected – may not need to disclose. But if you are having to take off more, or performance no longer the same as it was prior to symptoms of PD, this maybe an indication of the need to discuss diagnosis sooner rather than later. If you are self-employed of course you have more autonomy. You have more flexibility of decreasing hours; keeping in mind as someone who knows first-hand about running a business when boss is ill productivity and quality inevitably begins to decline unless there is someone else with vested interest to maintain. Also when you are the boss, your responsibility to those you employ supersede your take home, this means that when earnings decrease only person affected is you ( particularly at the beginning unless you curtail number of employees and/ or shut business down).

Second, take care of yourself and your health by eliminating undue stress by asking employer for things to make your life easier. Taking more breaks, coming in late once a week, having the appropriate tools to make job easier, higher chairs, work from home, etc. of course the better the worker and more indispensable you are. Subsequently, the more likely to have leverage and demands (needs) met.

Third, prepare yourself mentally about the possibility of losing your job due to PD. Few ways to be prepared for future is to continuously learn new skills (I have become a writer), update your resume, look for jobs that allow you independence, flexible hours, work from home such as telecommunications. The key is to find a new passion. We all know that when we are actively pursuing what makes us happy we infuse joy to others and work is no longer so stressful. After all you have the keys of your destiny to make the right accommodations to help with your disease.

But just because its fun it does not mean it will necessarily be easy. After all work is work and can exert a toll on our bodies. for instance, even though I very much enjoy traveling and speaking, this requires a lot more dopamine than when I am just relaxing at home.

Fourth, ask yourself truthful questions like does my irritability make it difficult for others to work with me? Could my cognitive slowness cause a serious problem at work?, do my tremors get in the way of performing daily activities at work? If you answer yes to any of these questions, you may need to talk to your employer about finding ways to avoid or diminish these symptoms so you won’t lose your job. Perhaps, it may be wise to think about career rehab or alternate jobs, as I mentioned earlier especially within your place of employment. Does your boss need meticulous work behind the scenes? PD patients have been found to be more capable of performing these types of tasks especially if repetitive.

Fifth, do not underestimate your mood- particularly for us women with PD it was discovered in similar study as above that women are more prone to leave the work force earlier due to depression, anxiety, and overall general poor quality of life. We as women also have to recall that we have more stressors such as being caregivers to elderly parents, children, grandchildren, and many times have less financial resources available to us. remember to enlist help of a team of professionals to help planning for future. these include social workers, estate planning lawyers and financial planners.

Finally, You may require to plan for both long and short-‘term costs of medication, home adaptations, insurance and other health care related needs’. This also includes planning or at least thinking weather or not you might apply for social security disability or early social security which can affect retirement plans.

For more information go to :PDF  link below to find financial and legal advice/support.

 

Sources:

http://www.pdf.org/en/science_news/release/pr_1415296989

http://www.pdf.org/fin_legal_work

http://www.pdf.org/en/fall05_employment

When to disclose illness at work

http://www.ncbi.nlm.nih.gov/pubmed/16941456

 

 

 

Hospital Adventures of a Parkinson’s Diva: By Maria De Leon

Last week after having a very successful trip to Baton Rouge for their 5th PD conference, I was suddenly struck with neurological symptoms resembling a TIA (transient ischemic attack) like all good…

Source: Hospital Adventures of a Parkinson’s Diva: By Maria De Leon