Dementia Alliance International is closing the year with the December 2015 research wrap, written by Dr Shibley Rahman, an academic from the UK, and a DAI supporter and volunteer.
I hope DAI members and supporters find it interesting. Thank you for taking the time and putting in so much effort in writing it Shibley.
Can you have ‘too much’ behaviour?
A DAI “research roundup” on excessive religiosity
There seems to me something intrinsically blasphemous about writing a post about neuroscience and religion in the holy festive season? So please do forgive me.
I sometimes feel ashamed how little I questioned particular medical-isms of the neurology of dementia. These include a ‘hyperjocular’ state; when you’re a bit too jokey for someone else’s liking. And so it goes on: ‘hyperphagia’, ‘hypersexual’, ‘hyperoral’, etc. But I suppose they help to define the scope of syndromes – such as the Kluver-Bucy syndrome which can occur in dementia (key features being ‘hypersexual’ and ‘hyperoral’).
Referring to any behaviour in dementia by clinicians is mostly in the pejorative sense. I suppose therefore that referring to any excessive behaviour shows a wilful blindness to the lack of subjective level of agreement of what an acceptable behaviour is.
And then you go onto research these groups of people with a particular dementia diagnosis.
A major flaw in researching any diagnostic group of people with dementia is that you assume that the initial diagnosis is water-tight. This is far from true in many cases as has been demonstrated by post mortem pathological studies of series of people with an in vivo diagnosis of dementia (see Prof Seth Love’s seminal paper from 2005).
The diagnostic criteria are themselves a ‘sledgehammer’ approach. The dementias which are predominantly the temporal lobe variant of the frontotemporal dementia (the temporal lobe being the part of the brain near the brain) comprise, for example, semantic dementia and the primary progressive aphasias.
About these dementias, Dennis Chan and colleagues in Brain (2009) originally observed the following.
“The most prominent cognitive deficits were impairment of episodic memory and getting lost. Prosopagnosia* was a symptom in right temporal lobe atrophy patients. These patients also exhibited a variety of behavioural symptoms including social disinhibition, depression and aggressive behaviour. Nearly all behavioural disorders were more prevalent in the right temporal lobe atrophy patient group than the semantic dementia group. Symptoms particular to the right temporal lobe atrophy patient group included hyper-religiosity, visual hallucinations and cross-modal sensory experiences.”
But this paper didn’t really define the scope of the hyper-religiosity.
It is indeed a vague term.
What could it possibly mean? Praying to more than one God? Going to church 20 times a day? Buying 40 copies of the Holy Bible? Intense feelings pursuant to following a particular religion?
My own particular interest is in the behavioural variant of the frontotemporal dementia.
Here as Laura Hughes, Tim Rittman and colleagues correctly argue, the excessive behaviours have been interpreted as a failure of inhibition.
“Behavioural deficits are a common and challenging aspect of the behavioural variant of frontotemporal dementia (bvFTD). Disinhibition, impulsivity and socially inappropriate behaviour are core diagnostic features of this disorder, together with stereotypical or perseverative actions, hyperorality, loss of empathy, apathy, and executive dysfunction including cognitive inflexibility.”
Lessons can be learnt about hyperreligiosity from other disease processes affecting the temporal lobe other than dementia – epilepsy, for example. This year, Rocio Garcia-Santibanez and Harini Sarva published on “Isolated Hyperreligiosity in a Patient with Temporal Lobe Epilepsy.” But even here the emphasis in the discussion was on the mechanism of electrophysiology rather than the phenomenon of ‘hyperreligiosity’ itself, though the authors did offer some useful clues about what they felt were in scope.
“Hyperreligiosity may be an ictal, an interictal, or a postictal phenomenology. Ictal religiosity is a type of ecstatic seizure, such as feelings of joy or pleasure. Different examples of ictal religious experiences include intense emotions of God’s presence, hallucinations of God’s voice, clairvoyance, or even telepathy.”
But an answered question in the literature – conveniently ignored by all – is why excessive activity as evidenced by EEG might produce the same type of phenomenon of hyperreligiosity as a pathological process causing atrophy (decrease in volume) of the human brain?
Indeed, it’s almost as if the exact nature of the pathology is irrelevant too.
Two years ago, Kara O’Connell, Joanne Keaveney and Raymond Paul considered Geschwind syndrome (O’Donnell et al., 2013), which is relevant too to dementia (see emboldened sentence).
“Geschwind syndrome is an eponymous syndrome of interictal behaviour or personality disorder, which has been described in temporal lobe epilepsy.
It has also been described in frontotemporal dementia.
Clinical features of this syndrome include preoccupation with philosophical and religious concerns, anger, excessive emotionality, viscosity (noted especially in speech), circumstantiality, altered sexuality, and hypergraphia.”
But all of this preoccupation with identifying the ragbag of symptoms which cluster together make me wonder about the attitude of the medical profession towards dementia: whether medics get more of a kick out of diagnosing disease than promoting wellbeing of their patients.
The current state of affairs is described as follows:
“He is presently maintained on olanzapine, lithium, and valproic acid medications. The patient currently presents with long-standing hypergraphia, religious preoccupation, and hyposexuality. An example of these symptoms is the patient’s preoccupation with God, writing multiple pages daily stating, “God is good, God is good.””
But the most bizarre in this small series of papers I have seen was published in 5 November 2015. There, D. Erik Everhart, Eric M. Watson, Kelly Bickel and Alexandra Stephenson described, “Right Temporal Lobe Atrophy: A Case That Initially Presented as Excessive Piety”
Their description is as follows:
“His spouse also indicated that personality changes may have initiated years before. More specifically, the patient was moved to Pastor progressively smaller congregations over a period of 10 years, in part secondary to having interpersonal difficulty with managing a church body as well as the noteworthy increase in piety.”
But the paper never defines what this ‘noteworthy increase in piety’ actually is.
And not one is it questioned – what is a reasonable level of piety?
I do wonder how research academics and practitioners expect to make such judgments without being questioned by other members of their communities.
* Prosopagnosia is difficulty in perceiving faces.
Chan, D., Anderson, V., Pijnenburg, Y., Whitwell, J., Barnes, J., Scahill, R., Stevens, J.M., Barkhof, F., Scheltens, P., Rossor, M.N., Fox, N.C. The clinical profile of right temporal lobe atrophy. Brain. 2009 May;132(Pt 5):1287-98. doi: 10.1093/brain/awp037. Epub 2009 Mar 18.
Everhart, D.E., Watson, E.M., Bickel, K.L., Stephenson, A.J. Right temporal lobe atrophy: acase that initially presented as excessive piety. Clin Neuropsychol. 2015 Nov 5:1-15. [Epub ahead of print].
Garcia-Santibanez, R., Sarva, H. Isolated hyperreligiosity in a patient with temporal lobe epilepsy, Case Reports in Neurological Medicine, Volume 2015, Article ID 235856, 3 pages.
Hughes, L.E., Rittman, T., Regenthal, R., Robbins, T.W., Rowe, J.B. Improving response inhibition systems in frontotemporal dementia with citalopram. Brain. 2015 Jul;138(Pt 7):1961-75. doi: 10.1093/brain/awv133. Epub 2015 May 21.
O’Connell, K., Keaveney, J., Paul, R. Case report: a novel study of comorbidity between schizoaffective disorder and Geschwind Syndrome, Case Reports in Psychiatry Volume 2013, Article ID 486064, 3 pages.
Author: Dr Shibley Rahman © 2015
Editor: Kate Swaffer