Financial Disclosures · Marie Laveau – Voodoo Queen • ... good or ill •Immortal? Voodoo...
Transcript of Financial Disclosures · Marie Laveau – Voodoo Queen • ... good or ill •Immortal? Voodoo...
Financial Disclosures
None
Ann Tilton, MD
Professor of Neurology and Pediatrics
LSUHSC New Orleans
The Power of Belief
Mystery/History
• How our beliefs impact
our lives and those we
touch
• Lens—
– Neurology of Voodoo
– History of Salem Witch
Trials
• Teach us about our
civilized world
Blurred Boundaries
Religious-Social-Biologic
Pain
Placebo/Nocebo
Sudden and Inevitable Death
Possession
Mass Hysteria
Distinctive Characteristic of a
Society is it’s World View
• “Primitive”
–All part of the
universe
–No separation
of spirits,
religion and
magic
• “Civilized”
–Forces are under
our control
–Little interest
Voodoo (based on West African Beliefs)
• Fate is predetermined
– Western culture-Tarot cards
– Difference---it can be altered
• To counteract the evil forces
– One needs a priest or medicine man
• One is not at the mercy of evil
– System to combat evil
Supreme
Being
Deities
Gods /Loas
Ancestor
Spirits
Priests/Intermediary
Social Groups
Slave Trade-New World
1619-1861
Slave Trade-New World
1619-1861
• New world was hostile
• Accepted new gods
– Serpent deity Da - Saint Patrick
– Leyba Guardian of entrances - Saint
Peter
– Continued to use talisman
• Integrated into Catholicism
Marie Laveau –
Voodoo Queen
• 1794-1881 (1915)
• Commercial
venture
• Added saints/
prayers/ candles
and holy water
• Powerful - For
good or ill
• Immortal?
Voodoo Today
In New Orleans--open practice
Voodoo Lives On–
Gris-Gris
• A mixture of black
and white magic
– Juju, mojo
• Powerful - For
good or ill
• Potion worn
– Pepper, brick, hair,
animal skin
• Resurgence…
Can Voodoo alleviate pain?
• A 40 yr old woman consults a priest
for severe back pain
• The priest invokes an incantation for
the help of a loa and applies a
tingling salve
• The pain completely resolves by the
next morning
Why did the Voodoo Work?
Mechanisms of Response to
Pain Therapy
Any medical treatment has
two components
• The specific effects of treatment
• The perception that the therapy is
being administered
Modulation of Nociceptive
System
• Central and peripheral mechanisms
can increase or decrease pain
perception
• Placebo• Psychological
• Biological
Placebo and Nocebo
• Placebo is latin for “I shall please”
• Nocebo is latin for “I shall harm”– 1 in 20 treated with placebo withdraw due to
adverse effects
• Calls attention to use of a sham drug
– What matters is not the “drug” but the
changes in the brain
Psychological explanation
• Classical conditioning- Pavlov
– “Clinical” setting has an effect
• Nocebo–
– nausea - where chemotherapy took place
• Placebo–
– Protocol - conditioning with a placebo analgesic
cream
– The conditioned group believed the cream
would work- resulted in less pain
Placebo Response
• If the subject believes in the healer or
treatment - Improvement will occur
• Placebo effect (DBPC) up to 50%
– Triptan study
• 20-40%
What influences the Placebo
Effect?• Pill size
– Color, number, and capsule (cost?)
• Mode of administration
– IM > pill, IV > IM
– Seen > hidden
• (blocked by naloxone)
– Surgery
• Sham surgery
(An Evaluation of Internal-Mammary-Artery Ligation by a Double-Blind TechnicN Engl J Med 1959)
What influences the Placebo
Effect?
• Doctor-patient interaction
• Expectations
• Time spent
• Enthusiasm
• White coats
• Stethoscope
• Emergency room setting
Pain
• Chemical substrate for placebo
– Secretion of endogenous
opioids ( 2x beta endorphins)
• Reversed by naloxone
– Cholecystokinin (CCK)
• Inhibition
– Act on 5-HT system
Brain imaging
• PET first showed
the area activated
during opioid or
placebo induced
analgesia largely
overlapped
– Rostral anterior
cingulate cortex
– Orbital frontal
cortex and
periaqueducatal
gray
Activation of μ-opioid receptors
Parkinson’s Disease
• Increased dopamine
release-dorsal
striatum
• Fetal transplant
study
– QOL improved
depending on the
“believed “group of
assignment
Psychological Factors?
• Stress aggravate pain or trigger
• Strong emotion may blunt pain
– Soldiers / accidents
– Sociocultural (Reversed with naloxone)
• Voodoo removes pain
• “Fear of pain may be worse
than pain itself”
– CCK activated
Peripheral Factors?
• Gate control theory
– Stimulation of large
diameter afferents inhibit
small afferent fibers (substantia gelatinosa)
• Counter irritation
– Pain in a separate area
Clinical Trials
• DBPC Trials
– Importance of a placebo
– Comparing two active medications
• Headache and pain trials– Ketorolac, merperidine & placebo -- equal
• Open-Hidden protocols
– Reduced debate on placebo-ethics
– If there is a large difference open vs
hidden = placebo like
VoodooWhy did it work?
• Natural remission
• Placebo-BIG PILL
• Expectations
• Peripheral stimuli
• Effective treatment
Sudden and Inevitable
Death
• Usually in
ceremonies
• High stimulation
• Selected by the
sorcerer
– Individual falls over
dead
• A 23 year old woman presented on her
birthday to the emergency room stating
that she was going to die
• She and her sisters had been cursed
– Her sisters had died at 21 and 22 yrs of age as
the curse had stated
• She was admitted for observation
• She was found dead the next morning
Sudden Death
• 1942 Cannon published “Voodoo Death”
• Cases from all over the world
• REAL phenomenon
• What was in common?
– Absolute belief that an external force cause one’s demise
– The victim has no power to alter the course• Hopelessness and overwhelming
Can that really happen?
• Application to our world?– Patient says “I am going to die”
– Operating room -”poor guy-no hope”
– Omaha Beach
– Assault with death and only minor injuries
• A view of Neuro-Visceral Disease
– Sudden and Inevitable
How does it affect our care?
• In the context of neurological disease:
– ECG changes consistent with ischemia • aneurisms, SAH, coma, stroke
– The pathology – no ischemia
– With brain death the ECG findings reverse
• Is it rare?
– Series of 100 stroke patients• 90% of stroke patients
Mechanism of Neurogenic
Heart Disease
• Myofibrillar degeneration • The ultrastructural changes in almost every cell
• The changes are less at a distance from the
intracardiac nerves
• Distinctive?
– Myofibrils die hypercontracted (MI are atonic)
– Changes visible within minutes
– Subendocardial predominantly
» Serious Arrhythmia
(Prevented by sympathetic blockade)
Animal Models
• Capture or transfer
• Death from fright and restraint
– Autonomic hyperactivity
– Not blocked by adrenalectomy and with
normal serum catecholamines
– Evidence of direct neural connection to
the heart
What about stress?
– It can produce the same lesions
– 15 victims of physical assault-died of
the assault without internal injuries
• 11 of 15 had the myofibrillar degeneration
• Stress
– Takotsubo (octopus trapping pot)
• Left ventricular dysfunction in the apex
• Predominantly women after emotional
stress
• Time of natural disasters-earthquakes
The heart pathology is seen in:• Animals and people with acute
neurologic or psychiatric catastrophes
–Thought to have a role in death
associated with:
• SUDEP- up to 17%
• Drug abuse, asthma, grief, war
The Inevitable Voodoo Death
• Previously well woman developed severe
abdominal pain
– Surgery normal
• She became isolated, progressively weak
and died
• Buried outskirts of the cemetery
• Diagnosis- She had been cursed
• Folk medicine has two forms
– Natural
– Unnatural from hexes
• Contagious magic
– Once physically connected –cannot be separated
– Hair or fingernail – hex – illness
– Voodoo dolls-(extension of the person)
Does Inevitable Death
Happen?
• Premise:
– Cursed by another -- hopelessness
– Community / family withdraw support
– The individual is an outsider - fatigues,
stops eating
Examples: Churches, exorcisms
Are there similarities between
being cursed and fatal illness?
– Power-Medical authority predicts death
– The patient and family believe the doctor
– Patient has no control and may withdraw
– Physicians “withdraw”
– Family withdraws and patient dies prior to
biologic expectation
Examples
• Voodoo
–Hexed
–Slowly withdraws
–Family withdraws
• Western
–Surgery-no hope
–Loss of will to live
–Team withdraws
–Birthday death
–After natural
disaster
Possession?
• 24 yr fell to floor
convulsing while at his
uncle’s funeral
• Dx: Possessed by a
protective loa of his
uncle
• Treatment
– 6 years by a priest
• 27 yr fell into a fire
during a ceremony
• Dx: Possessed by
Mainette a bad loa– Who is related to fire
Possessions
• “ To be seized by spirits”
• Religion and epilepsy
– Greeks - visitation by the gods
– Christians - demonic possessions
• Voodoo is based on religion and
being possessed by spirits– Divine favor
The Voodoo Priest was not successful
– Why in their eyes?
• Noncompliant patient- clearly not following
instructions
• Did not believe
• Pseudo-event
• Too strong of an evil Loa
• Last--Wrong diagnosis – not a possession
– It was a seizure
• Often patients pursue both treatments
The Salem Witch Trials
Related Concern
• Eight girls in a small town begin to
have unusual movements
• The entire town became involved
• There is a great deal of attention
directed at the cases
• Original concern was a contagious cause
• But it was determined to be witch craft
begun by a worshiper of Voodoo
• By December 1691…8 girls were
“afflicted” with an unknown distemper
• Diagnosis – bewitched
• Treatment
– Fasting and prayer
– Witch cakes
Salem Witch Trials
Court allowed spectral evidence
and critical touch
Salem Witch Trials
• June-September 1692
–20 witches were convicted
–No confessions
–19 hanged and 1 stoned
• Stopped with a new Governor
–Reprieved 150 in spring 1693
What Caused This
Tragedy??
Ergotism• Claviceps purpurea grows on cereals
– Cold winters, wet springs and low lands
• Mycelia - 2-3 cm growth
• 1% ergot alkaloid
– Potent• 40 alkaloids
• Lysergic acid (LSD)
• Histamine, tyramine and
acetylcholine
Alternative
Conceptualization
• Mass “hysteria”
• Fraud
• Social cues– Goal directed enactment to sustain “bewitched”
– Goal directed does not imply fake
– Bewitched was confirmed by community leaders
– Role can not be terminated
Mass Psychogenic Illness
• 1952- 165 members of a cheerleading
squad in Monroe, LA accidently came on
the field and ultimately fainted
• 2002- 10 students (5 cheerleaders) in
North Carolina had nonepileptic seizures
and fainting
• 100s of cases per year in US
• Most cases resolve quickly
–If there is reassurance
• Environment is ok
• Not an extensive work-up
Le Roy New York
• Unusual combination of conversion
disorder and mass psychogenic
illness
– Began with cheerleaders
– Spread: 18 girls, 1 boy, and a 36 yr
woman
Le Roy Environmental
Issues
• Waste from closed company
• Train derailment and corroding
barrels
– EPA stated no chance-then hazmat
suits
• Erin Brockovich sent “testers”
Theories
• Environmental
• Pandas (pediatric autoimmune
neuropsychiatric disorder associated with
streptococcus)
– If you get better without pills –you were
faking
• Biopsychosocial
• Stress
Treatment
• Antibiotics
• Cognitive behavioral therapy
– Discuss the continuum of stress related
disorders
Brain Origin?
• Possibly amygdala
– Locus of startle and fear
– Overactive in conversion disorder
– Instead of psychological stress some
cases - involuntary movements (Hallett)
• Mirror neurons-when we witness
actions
Our Culture
• Originally thought to be contagious
– Then group hysteria
– Marginal social status
• Adopt a sick or possessed role
– Decrease job/school stress
– Sympathetic attention from others
Salem and Our Culture
• Social advantage
– Solace and sympathy as a victim
– Advance from little influence to one of
power
– Center of attention
– Command (fearful) respect
Brain is directly
influenced
through social,
psychological,
and biological
means
PLACEBO
NOCEBO
PAIN
SUDDEN DEATH
POSSESSION
PSYCHOGENIC
Have your beliefs changed?
• Belief systems hope to offer control
over what is seen as uncontrollable
• Be careful what you think is primitive
“The problem is not with what you see- the problem is with
what you recognize” -- Sherlock Holmes
THANK YOU !
Individual spells for you
Zombies
• Western world became aware of
Zombification in the occupation
of Haiti (1915-1934)
• Up to 1000 new cases per year
• Haitian penal code (246)
–Considers it murder
Zombification
• Body, mind, and spirit
– Physical body
– Awareness and memory
• The awareness and memory is kept in a
fastened bottle - (zombie astral)
• The body remains without will as a
slave
– Beatings
– Poison
Characteristics
• A young person is suddenly ill
• Recognized as dead and placed
in a tomb
• Stolen by a bokor (sorcerer)
• Secretly returned to life and
activity but not full awareness
Zombie Recipe
• One freshly, almost dead, person
• Some human bone and flesh
• Several varieties of exotic plants
• A few reptiles
• One type of worm
• A centipede
• A special type of spider
• One puffer fish
Zombie Escape
• Bottle breaks
• Bokor inadvertently feeds salt
• Bokor dies
• Released by divine intervention
• Release does not change the symptoms
Fear is reserved for the possibility of being Zombified oneself
Possibilities
• Neurotoxins
– Tetrodotoxin
(puffer fish)
• Apparent temporary
death
– Datura to revive or
control the zombie
• Produces extreme
passivity
Possibilities
• Neurotoxins
• Psychiatric
• Mental deficiency
• Mind control
Clairvius Narcisse
• Zombie for 2 years
• Wandered away
when his master died
• Found by his family
16 years later
Cases
• 30 yr woman died
• Seen 3 yrs later
• Tomb opened
• Help with daily
needs
• Recognized as a
zombie
• Dx: catatonic
schizophrenia
• 18 yr died
• 19 mo later recognized his father
• Uncle arrested and convicted
• Interview- ill and a zombie
• Dx: organic brain syndrome and SZ
Real ??
• Malevolent voodoo priests (Bokor) do
engage in Poisons and Neuroleptics
– Plants
• Anticholinergic
• Skin irritants
• Shaking and tremor
– Animals
• Cardioactive steroids
• Catecholamines
• Psychoactive agents
Mental Illness
• It is supernatural-a spell
• Psychotic break is a curse
• So the patient is not ashamed-not
their fault
– Laws protect – cannot divorce
• Depression is due to a medical
condition
– Presents with headache, backache