Tuesday, November 16, 2010

A Brush with Madness

I'm giving myself ten minutes to do this. To write whatever storms into my mind then hit post.

I think the archaic revival might run into some barriers. Like starvation, no communication, and other electrical difficulties if it embraces the Abbey-esque Luddite philosophy entirely.

As much as I want to get onto that other boat I think I will just slip between the hulls and end up swimming by myself among the sea-monsters, bullets whizzing past my head with bubbles trailing behind in dark water.

What will this same attempt look like when I'm able to just think the text into existence without the trouble of commanding my fingers. We're almost there.

Have I done this before?

What were some of the ideas I was having earlier today? I was going to write a post entitled "a brush with madness" and I even logged into research blogging several times with the intention of creating HTML tags for the citations I found via pubmed search about psychotic manifestations in patients with the blood related disease - porphyria.

You see, I had a most jarring experience a few days before Halloween this year. It's ironic I went to the "Rally to Restore Sanity" the weekend after this experience.  I speak of a secondary encounter with real madness at a free public lecture fellow graduate student Nick Clark and I presented at the Park Hill library in Denver on October 26th, 2010. Our talk took place downstairs in the community room at the library. It felt like the community room at Saint Peter and Paul Church in Jamestown New York; the one where my parents met in choir - threadbare carpet and the dank smell of stale coffee. It was in the basement and it felt like a basement. We were presenting our lecture "The Biochemistry of Halloween" as a fun science-out-reach type event. After a successful presentation last year we were asked for an encore lecture by the CSU alumni association. Nick and I showed up about an hour and a half early to make sure we had a functional projector and helped set up seats. When we finished setting up a young woman with curly black hair entered the otherwise empty room and excitedly asked us

"Are you the guys talking about VAMPIRES?"

"Indeed we are, but the talk does not start for another 45 minutes." I replied

"Oh that's OK I'll just wait here." She said and sat giddily waiting it the front row.

We had decent turn out for an event in the basement of a public library held at 5:30 on a weekday. About 35 people showed up to hear about the "Biochemistry of Halloween" and there was really positive audience participation and several intelligent questions. All ages were represented.

At the end of the lecture the excited patron was the first to run up to Nick and I . She quickly asked for all our references linking dementia and porphyria. We took her e-mail address and said no problem. The woman then went on to explain that she was particularly interested in the topic as her ex-boyfriend was afflicted with porhyria. She knew the specific form - coproporphyria. Nick and I both immediately felt bad and responded by saying that we did not want to offend anyone by implying that patients with porphyria were actually vampires. Her reaction to this was most shocking. She said she was fascinated by the idea that historical cases of porphyria might explain the origin of vampire myths because her ex-boyfriend was in fact presently in jail because he went "nuts" and tried to cut her head off with a knife!

Well, that just hit me like a ton of bricks! Here we are trying to be super politically correct by not offending anyone connected with any of these diseases we were talking about and here was a real world case where a patient with porphyria was acting deranged. This rose a significant ethical dilemma in my mind. Current treatment of porphyria is diet control and injections of properly formed heme - analogous to diabetes patients receiving insulin as treatment - replacing the body's missing thing. But in the case of porphyria it is not just replacement of the problem chemical that needs to be addressed. The mal-formed chemicals stay in the blood stream and cause problems in the brain of the patient; hallucinations, dementia, and severe anxiety to name a few. To entirely alleviate the affects of the disease those "bad" molecules need to be removed as well. This is probably not an option as it would require the patient to be on constant dialysis.

The question then arises. If a patient experiences mental disturbances including psychopathic behavior because of a disease is that patient responsible for his/her actions? Can a patient plead insanity in this instance? What extent should the public help this individual manage their psychological problems to protect its members? I had heard of this type of scenario in ethical thought experiments before but this was the first time a case like this was staring me in the face. She said that she thought her ex was crazy and hoped he rotted in prison. But how much of his bad behavior was of his own free will and how much was due to biochemistry? Could his attempted murder have been prevented if medicine was able to safely remove the detrimental chemicals from his blood? This is much different that a badly behaving drug addict - in that case an individual is choosing to put the delusion -inducing chemicals in their blood while in the case of porphyria the patient has no choice. What if the patient was simultaneously abusing drugs?  To what degree is that self-medication attributed to the disease? Are patients in this situation doomed to the fate of this guy? How does society deal with this situation?

In looking for answers to some of the clinical aspects of these questions I stumbled on a surprising medical speculation.  Some scholars have attributed the bouts of madness experienced by the great impressionist painter Vincent Van Gogh to acute intermittent porphyria!  His self mutilation, delirium, agitation, paranoia and sporatic timing of his attacks may all be explained by him having this disease. Exacerbated by poor diet and subsnace abuse - especially absinthe - may have pushed him over the edge.  Though he had produced some of the world's most stimulating paintings on July 29th, 1890 in a northwestern suburb of Paris Vincent took his own life by shooting himself in the chest. 

This medical scenario begs the question.  If Van Gogh were to be born today with the advent of contemporary medicine and diagnosis would his paintings scream with such beauty?


Sedel F, Baumann N, Turpin JC, Lyon-Caen O, Saudubray JM, & Cohen D (2007). Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. Journal of inherited metabolic disease, 30 (5), 631-41 PMID: 17694356  

Rose FC (2006). Van Gogh's madness. International review of neurobiology, 74, 253-69 PMID: 16730519  

Altintoprak AE, Ersel M, & Bayrakci A (2009). An unusual suicide attempt: a case with psychosis during an acute porphyric attack. European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 16 (2), 106-8 PMID: 19262206  

Mandoki MW, & Sumner GS (1994). Psychiatric manifestations of hereditary coproporphyria in a child. The Journal of nervous and mental disease, 182 (2), 117-8 PMID: 8308532


ceilingcat said...

"The question then arises. If a patient experiences mental disturbances including psychopathic behavior because of a disease is that patient responsible for his/her actions?"

New Scientist had an article about a sex offender who is now attempting to have his name removed from the sex offenders register because his offenses were caused by disease.

"The sudden and uncontrollable paedophilia exhibited by a 40-year-old man was caused by an egg-sized brain tumour, his doctors have told a scientific conference. And once the tumour had been removed, his sex-obsession disappeared."

In this case the man's "insanity" had an obvious physical cause. I frequently wonder whether some "criminals" have a behaviour-affecting disease which lacks the obviousness of the sex offender mentioned above.

Anonymous said...

"If a patient experiences mental disturbances including psychopathic behavior because of a disease is that patient responsible for his/her actions? Can a patient plead insanity in this instance?"

Surely yes. This is the very definition of "mentally ill" - that's the whole point. The question of whether or not their loss of control, over their faculties means that they were not criminally responsible for their actions is - of course - a case-by-case thing for the court to decide, but the principle applies.

Richard S. Russell said...

"But how much of his bad behavior was of his own free will and how much was due to biochemistry?"

100% of EVERYBODY'S behavior is due to biochemistry, including the part of your own behavior which causes you to assign value judgments like "good" and "bad" to other people's behavior.

= = = = = =
I behave as if I have free will because what choice do I have?

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