WEBVTT - Special Episode: Dr. Sara Manning Peskin & A Molecule Away from Madness 0:00:44.080 --> 0:00:47.479 Hi, I'm Aaron Welsh and this is this podcast Will 0:00:47.520 --> 0:00:50.640 Kill You. You are listening to the latest book Club 0:00:50.680 --> 0:00:53.600 episode of the season, a series where we get to 0:00:53.640 --> 0:00:58.120 interview authors about their books covering fascinating and important topics 0:00:58.160 --> 0:01:00.840 in science and medicine. If if this is your first 0:01:00.840 --> 0:01:04.320 time tuning in this season, welcome, thanks for joining us, 0:01:04.680 --> 0:01:08.440 and also be prepared to make room on your bookshelf 0:01:08.480 --> 0:01:11.720 and to read list. Last time we did this series, 0:01:11.800 --> 0:01:14.319 we just sort of released the episodes without giving you 0:01:14.360 --> 0:01:18.600 an opportunity to read beforehand, and this season, we decided, 0:01:18.800 --> 0:01:21.600 in the spirit of real life book clubs, to give 0:01:21.640 --> 0:01:23.800 those of you who want it a sneak peek of 0:01:23.840 --> 0:01:26.880 the books that we'll be chatting about this season. So 0:01:27.319 --> 0:01:29.440 if you are one of those wanting to read along 0:01:29.480 --> 0:01:32.440 with us, head over to our website This Podcast Will 0:01:32.480 --> 0:01:34.600 Kill You dot com, where you can find a link 0:01:34.720 --> 0:01:38.120 under extras to our bookshop dot Org affiliate page, which 0:01:38.160 --> 0:01:41.759 has our reading lists, including our book club list featuring 0:01:41.959 --> 0:01:44.640 all of the books we covered last season as well 0:01:44.680 --> 0:01:48.200 as the ones we'll be covering this season. It's a 0:01:48.400 --> 0:01:51.720 pretty incredible list, if I do say so myself, and 0:01:51.880 --> 0:01:54.520 I really can't wait to share all of these interviews 0:01:54.520 --> 0:01:58.320 with you all. I'm especially thrilled for today's conversation with 0:01:58.480 --> 0:02:01.840 doctor Sarah Manning Peskin, who is an assistant professor of 0:02:01.840 --> 0:02:05.720 Clinical Neurology at the University of Pennsylvania and author of 0:02:05.840 --> 0:02:09.720 A Molecule Away from Madness, Tales of the Hijacked Brain. 0:02:10.440 --> 0:02:15.600 In this captivating and heartrending book, doctor Peskin takes readers 0:02:15.600 --> 0:02:20.040 through stories of the brain gone awry, exploring the histories 0:02:20.120 --> 0:02:24.400 behind some of these neurological illnesses, and defintely explaining some 0:02:24.600 --> 0:02:29.640 incredibly complex concepts that frame our limited understanding of how 0:02:29.680 --> 0:02:33.160 the brain actually works. I want to ask you all 0:02:33.240 --> 0:02:36.680 to take a second to consider the human brain. What 0:02:36.800 --> 0:02:40.000 are you doing in this very moment besides listening to 0:02:40.040 --> 0:02:44.160 the podcast. Maybe you're cooking dinner. Maybe you're out walking 0:02:44.200 --> 0:02:48.080 your dog, maybe you're crocheting, Maybe you're driving home from work, 0:02:48.280 --> 0:02:51.079 or maybe you're just chilling on the couch. What did 0:02:51.120 --> 0:02:53.880 you do today? Took a shower and got ready for work, 0:02:54.440 --> 0:02:58.720 scrolled through Instagram memes for probably longer than you should have. Guilty, 0:02:59.520 --> 0:03:03.880 wrote a less emails, watch some reality TV? Also guilty. 0:03:04.600 --> 0:03:10.360 How do you feel exhausted? Content anxious, excited, curious, depressed. 0:03:10.960 --> 0:03:14.200 We are capable of doing so much and doing it 0:03:14.360 --> 0:03:17.920 all at the same time, of feeling so much, of 0:03:18.080 --> 0:03:22.640 creating and imagining, of thinking and overthinking, of holding a 0:03:22.760 --> 0:03:27.320 million different emotions, and to do lists and memories inside 0:03:27.320 --> 0:03:31.519 of ourselves, all while doing something as mundane as cooking dinner. 0:03:32.120 --> 0:03:35.320 And it's our brains, of course, that allow us to 0:03:35.440 --> 0:03:39.960 do this miraculous multitasking. I think it's easy for many 0:03:40.040 --> 0:03:43.080 of us to take our brains for granted, and maybe 0:03:43.120 --> 0:03:46.320 some of that comes from the expectation that every morning 0:03:46.360 --> 0:03:49.320 when we wake up, we assume our brains will be 0:03:49.400 --> 0:03:53.160 there just as they were yesterday, maybe a bit groggy, 0:03:53.320 --> 0:03:56.320 maybe in need of some caffeine, but ready to help 0:03:56.400 --> 0:03:59.040 us take on the day. But what happens when our 0:03:59.080 --> 0:04:02.040 brains don't findunction in the capacity we expect them to. 0:04:02.720 --> 0:04:06.720 What happens when our brains betray us. I don't think 0:04:06.760 --> 0:04:10.320 we always appreciate just how close our brains are to 0:04:10.440 --> 0:04:14.840 the edge, how something so small and seemingly insignificant as 0:04:14.880 --> 0:04:20.200 a stray protein, for instance, can profoundly disrupt everything about 0:04:20.200 --> 0:04:23.880 how our brain works. In a molecule away from madness, 0:04:24.000 --> 0:04:28.080 Doctor Peskin shares stories that reveal the vulnerabilities in our brains, 0:04:28.600 --> 0:04:31.760 using each story to teach readers what we know about 0:04:31.760 --> 0:04:35.520 the inner workings of our brains, to remind us how 0:04:35.600 --> 0:04:40.240 many mysteries remain, and to convey that with every story told, 0:04:40.440 --> 0:04:45.680 with every molecule or protein examined, people remain at the center. 0:04:46.800 --> 0:04:50.280 I really loved A Molecule Away from Madness, not just 0:04:50.360 --> 0:04:56.080 for the fascinating histories or thoughtful examinations of complex neurological concepts, 0:04:56.440 --> 0:04:59.880 but also for the way that doctor Peskin centers patients 0:05:00.120 --> 0:05:04.640 in the narratives of these illnesses, bringing so much compassion 0:05:04.720 --> 0:05:07.400 and empathy to a field where it can be too 0:05:07.560 --> 0:05:10.320 easy to lose sight of the whole person when your 0:05:10.360 --> 0:05:14.839 focus is on an individual protein. I am really excited 0:05:14.839 --> 0:05:17.640 to share my conversation with doctor Peskin with you all, 0:05:17.760 --> 0:05:43.880 so let's just get right into it. Sarah, thank you 0:05:44.160 --> 0:05:47.760 so very much for joining me today. I absolutely loved 0:05:47.760 --> 0:05:50.640 your book, A Molecule Away from Madness Tales from the 0:05:50.720 --> 0:05:55.520 Hijacked Brain, and I thought you beautifully blended clear and 0:05:55.560 --> 0:06:00.200 accessible medical information with such a strong sense of humanity 0:06:00.320 --> 0:06:03.800 and empathy, and it was such a great piece of 0:06:03.839 --> 0:06:07.400 scientific storytelling. And I know that you've often been compared 0:06:07.480 --> 0:06:10.279 to Oliver Sex, but hopefully you won't mind hearing that 0:06:10.360 --> 0:06:14.400 comparison one more time, because I really, yeah, I just 0:06:14.520 --> 0:06:17.480 I thought it was so amazing and I've been telling 0:06:17.520 --> 0:06:18.640 everyone I know about it. 0:06:18.839 --> 0:06:20.560 Oh, thank you so much. I was so excited to 0:06:20.600 --> 0:06:20.920 be on. 0:06:21.320 --> 0:06:24.039 So I wanted to start with, you know, asking you 0:06:24.160 --> 0:06:26.600 how you got this idea to write this book. What 0:06:26.839 --> 0:06:29.200 when did you decide I want to write a book, 0:06:29.200 --> 0:06:31.360 And when did you decide I want to write this book, 0:06:31.400 --> 0:06:32.839 and what was your process like? 0:06:33.880 --> 0:06:36.680 So I started. I came to writing pretty late. Initially 0:06:36.720 --> 0:06:38.719 I was going to become a scientist and I wanted 0:06:38.760 --> 0:06:42.320 to like have a lab. And then I actually I 0:06:42.360 --> 0:06:45.560 started an MDPHD combined program. I did like a year 0:06:45.600 --> 0:06:48.000 and a half of the PhD and was like, oh no, 0:06:48.080 --> 0:06:51.200 this is not right, this isn't the right fit, and 0:06:51.279 --> 0:06:55.560 so I quit the PhD program and I finished medical 0:06:55.560 --> 0:06:57.200 school and I was an intern and we had to 0:06:57.279 --> 0:06:59.680 do two months of night shift, and there were some 0:06:59.760 --> 0:07:01.880 nights that were wild and some nights where it's like 0:07:02.320 --> 0:07:05.480 nothing much happens and it's a little bit lonely. And 0:07:05.600 --> 0:07:08.520 so I started writing some memoir stuff, and then I 0:07:08.640 --> 0:07:11.600 essentially realized, like, my life is not that interesting, No 0:07:11.600 --> 0:07:13.640 one really wants to read about my life that much. 0:07:14.360 --> 0:07:17.600 But my work is fascinating and the patients I see 0:07:17.600 --> 0:07:20.760 are amazing, and the family dynamics that you witness are 0:07:21.480 --> 0:07:26.240 incredibly intricate and emotionally moving, and that stuff is interesting. 0:07:26.760 --> 0:07:28.400 And so then I sort of started to think about, 0:07:28.800 --> 0:07:30.880 you know, what are the most interesting stories. And the 0:07:30.920 --> 0:07:32.840 way that someone actually put it to the in terms 0:07:32.880 --> 0:07:34.120 of how you think about what you want to do 0:07:34.160 --> 0:07:36.920 in medicine, is when you open the clinic door, like 0:07:36.960 --> 0:07:38.520 who do you want to see on the exam table? 0:07:39.800 --> 0:07:41.560 And that's how I sort of started to shape the 0:07:41.960 --> 0:07:45.120 book itself, and I initially wrote. Initially the idea was 0:07:45.160 --> 0:07:46.840 to do sort of the traditional thing of like, oh, 0:07:46.880 --> 0:07:49.120 this patient shows up and they have these curious symptoms 0:07:49.480 --> 0:07:52.000 and then aha, this is the diagnosis and here's how 0:07:52.040 --> 0:07:55.640 the disease works, and you know, that's your package. But 0:07:55.680 --> 0:07:58.400 the more I wrote about it, I realized the actually, 0:07:58.400 --> 0:08:00.960 the more important thing is actually the history of the disease, 0:08:01.880 --> 0:08:04.640 because it's learning about a disease itself, and the mechanics 0:08:04.680 --> 0:08:07.200 is so dry, but learning about how we discovered the 0:08:07.200 --> 0:08:09.840 disease and what kinds of sort of wacky and outlandish 0:08:09.920 --> 0:08:13.240 characters were involved. That's actually exciting. The narrative part is 0:08:13.280 --> 0:08:14.280 what's exciting. 0:08:14.680 --> 0:08:17.160 Oh yeah, absolutely, I mean that's our bread and butter 0:08:17.200 --> 0:08:21.120 here on the podcast mine especially. I love medical history 0:08:21.320 --> 0:08:24.320 and sort of getting into that step one, step two, 0:08:24.400 --> 0:08:27.520 how do all the pieces fit together? So of course 0:08:27.560 --> 0:08:30.360 that's another reason why I loved your book. So who 0:08:30.440 --> 0:08:33.000 did you want to see on the exam table? Like 0:08:33.000 --> 0:08:36.160 how did you end up choosing neurology as your specialty. 0:08:36.960 --> 0:08:39.360 I ended up realizing that I thought the most interesting 0:08:39.360 --> 0:08:42.240 diseases were ones that change people's identities. And I think 0:08:42.600 --> 0:08:44.320 like we all sort of think about like, look, if 0:08:44.320 --> 0:08:46.240 I broke my leg, I would still be the same person. 0:08:46.840 --> 0:08:48.840 Or you know, I may go through this bad relationship, 0:08:48.840 --> 0:08:50.440 but I'll come out and you know, I'm still me 0:08:50.559 --> 0:08:54.040 and I'm learning things and I'm evolving. And yet the 0:08:54.120 --> 0:08:56.920 are these select diseases where there's a you know, there's 0:08:56.920 --> 0:09:00.160 a molecular problem and it actually sort of oh or 0:09:00.160 --> 0:09:02.959 hauls your identity and it actually makes you realize that 0:09:03.640 --> 0:09:05.800 the essence of what you think is yourself is actually 0:09:05.800 --> 0:09:09.200 not as protected as you think. And those are these 0:09:09.240 --> 0:09:11.360 is that I found to be sort of most fascinating, 0:09:11.400 --> 0:09:13.920 both in terms of the science of them, but also 0:09:13.960 --> 0:09:16.600 in terms of the social environment. So you know, what 0:09:16.640 --> 0:09:20.080 do you do when your partner suddenly is incredibly disinhibited 0:09:20.080 --> 0:09:22.640 and going up to strangers and having affairs. And it's 0:09:22.640 --> 0:09:26.160 not a sort of a moral failing, it's a molecular problem. 0:09:27.080 --> 0:09:29.280 Let's take a quick break, and when we get back, 0:09:29.360 --> 0:09:48.760 there's still so much to discuss. Welcome back everyone. I've 0:09:48.760 --> 0:09:51.760 been chatting with doctor Sarah Manning Peskin about her book 0:09:51.840 --> 0:09:55.400 A Molecule Away from Madness, Tales of the Hijacked Brain. 0:09:55.760 --> 0:09:59.120 Let's get back into things. And you get into a 0:09:59.160 --> 0:10:01.439 lot of this in your book, right, And there are 0:10:01.480 --> 0:10:06.160 so many different ways that the brain can change suddenly 0:10:06.200 --> 0:10:08.880 and change who you are, or there can be just 0:10:08.920 --> 0:10:13.199 like the tiniest little switch that flips. And so how 0:10:13.240 --> 0:10:16.880 did you decide which diseases and also which personal stories 0:10:16.880 --> 0:10:18.520 that you wanted to include in your book? 0:10:19.240 --> 0:10:20.800 I tried to think of a structure of like, what 0:10:20.840 --> 0:10:23.040 are the types of diseases that actually cause this type 0:10:23.040 --> 0:10:26.439 of thing? And there's not that many different categories. I 0:10:26.520 --> 0:10:30.200 basically described a sort of divided it into mutants, which 0:10:30.240 --> 0:10:34.920 are DNA mutations or DNA changes, rebels, which are problems 0:10:34.920 --> 0:10:36.640 with proteins. So if you think about DNAs, like the 0:10:36.679 --> 0:10:39.280 biggest molecule that we have in our body, proteins are 0:10:39.280 --> 0:10:42.160 pretty big, and proteins basically carry out They're the kind 0:10:42.200 --> 0:10:44.600 of the work horses, that's what really keeps ourselves alive. 0:10:44.640 --> 0:10:46.920 The DNA is really, for the most part, just a 0:10:47.080 --> 0:10:49.480 sort of instruction book. It's proteins that really do the work. 0:10:50.240 --> 0:10:52.599 And then there are small molecules. So there's things that 0:10:52.640 --> 0:10:56.080 are smaller than DNA, smaller than proteins, and they either 0:10:56.400 --> 0:10:59.320 cause a problem by being present. I called those invaders, 0:10:59.679 --> 0:11:02.319 or they have a cause a problem by being absent 0:11:02.520 --> 0:11:05.680 or not being there in enough quantities, and I called 0:11:05.679 --> 0:11:08.680 those evads. And a lot of the diseases that have 0:11:08.760 --> 0:11:12.040 a single molecular problem, and most of them fit into 0:11:12.080 --> 0:11:13.240 one of those categories. 0:11:13.960 --> 0:11:16.920 In terms of the personal stories, like are these all 0:11:17.360 --> 0:11:21.120 patients that you personally have treated or how yeah, how 0:11:21.160 --> 0:11:24.080 did that aspect come into play? 0:11:24.360 --> 0:11:26.199 So then, so only two of the patients are people 0:11:26.200 --> 0:11:28.080 that I treated, and when I interviewed them, they weren't 0:11:28.160 --> 0:11:29.960 under my care anymore, which make it also makes it 0:11:29.960 --> 0:11:33.600 easier so to think about being confident that asking them, 0:11:33.640 --> 0:11:35.640 you know, if I can interview them, isn't you know, 0:11:35.760 --> 0:11:37.720 causing them to worry that their care might suffer if 0:11:37.760 --> 0:11:40.440 they say no. But no. I essentially wrote down the 0:11:40.440 --> 0:11:42.400 different diseases and then I reached out to specialists of 0:11:42.440 --> 0:11:44.360 different feels and said, you know, do you have enough 0:11:44.360 --> 0:11:46.920 patients who you think might be interested? And it actually 0:11:46.920 --> 0:11:49.160 turned out when I went to interview patients it was 0:11:49.400 --> 0:11:51.320 I think it's actually more meaningful for people to be 0:11:51.400 --> 0:11:54.600 interviewed than I realized, because you when we develop diseases, 0:11:54.760 --> 0:11:56.240 you know, you go to a doctor and you say, 0:11:56.240 --> 0:11:58.440 like look up and feeling X y Z, and the 0:11:58.480 --> 0:12:00.400 doctor says, we want to get some tests, and then 0:12:00.480 --> 0:12:02.240 you come back and you get a little more information, 0:12:02.320 --> 0:12:05.080 and then maybe your symptoms change or you get more tests, 0:12:05.360 --> 0:12:07.600 and there's sort of an evolution of getting a diagnosis, 0:12:07.679 --> 0:12:10.880 and then the disease itself can evolve over time. And 0:12:11.000 --> 0:12:12.920 it's really uncommon for people to be able to sit 0:12:12.920 --> 0:12:15.480 down and say, you know, what has this entire road been, like, 0:12:15.960 --> 0:12:17.679 you know, what's the last six years of my life 0:12:18.000 --> 0:12:20.560 been like from the beginning changes to where I am now, 0:12:20.840 --> 0:12:22.960 and it's actually fulfilling for people to be able to 0:12:23.000 --> 0:12:26.560 actually walk through that with someone in sort of in 0:12:26.760 --> 0:12:30.160 slow motion. So I was actually sort of surprised that 0:12:30.280 --> 0:12:32.360 after interviews people be like, oh, that was actually that 0:12:32.400 --> 0:12:34.440 was a really wonderful experience. And I was sort of thinking, oh, 0:12:34.480 --> 0:12:35.840 my gosh, thank you so much for giving me so 0:12:35.880 --> 0:12:39.000 many hours of your time. But actually it was nice. 0:12:39.040 --> 0:12:41.360 It was sort of a mutually beneficial thing. 0:12:42.080 --> 0:12:44.360 Yeah, I can imagine it would be really sort of 0:12:44.400 --> 0:12:48.040 like cathartic and difficult, but also I think that the 0:12:48.120 --> 0:12:51.160 personal stories just adds so much because it kind of 0:12:51.200 --> 0:12:55.360 places it in a human context. It grounds these these diseases, 0:12:55.440 --> 0:12:57.679 these things, and you're like, these are people who are 0:12:57.880 --> 0:13:02.679 experiencing them. This is their story. It's not just lab charts, 0:13:02.720 --> 0:13:05.600 it's not just these results. It's not just this you know, 0:13:05.720 --> 0:13:08.280 list of symptoms. And so yeah, I felt like that 0:13:08.400 --> 0:13:12.720 was really impactful. Were there any stories that you didn't 0:13:12.800 --> 0:13:16.000 end up including, or any diseases that you initially thought 0:13:16.040 --> 0:13:17.719 that you were going to include as part of the 0:13:17.760 --> 0:13:20.360 book but didn't end up making the final cut. 0:13:21.040 --> 0:13:23.839 There were some that got cut there was I wanted 0:13:23.840 --> 0:13:27.199 to include a chapter around manganese poisoning because it can 0:13:27.240 --> 0:13:29.840 cause parkinsonism, so it can cause people to have movement changes. 0:13:30.120 --> 0:13:33.840 But it turned out it's really mired in legal issues 0:13:33.880 --> 0:13:36.880 because a lot of it was workplace exposure, and so 0:13:37.240 --> 0:13:39.040 I ended up I was like reaching out to lawyers 0:13:39.040 --> 0:13:41.520 saying like, are your clients interested in talking? And then 0:13:41.559 --> 0:13:42.800 it was sort of like, I think that I'm entering 0:13:42.840 --> 0:13:46.360 into a realm that I shouldn't go into, and so 0:13:46.360 --> 0:13:48.959 so that one got even though it's a fascinating story. 0:13:50.160 --> 0:13:52.840 And then there were some people. There's two people who 0:13:52.840 --> 0:13:55.920 are interviewed who were, you know, wonderful people and wonderful stories. 0:13:55.960 --> 0:13:58.120 And ultimately, when I finished with the structure of the book, 0:13:58.120 --> 0:14:02.000 they sort of felt kind of extraneous in terms of 0:14:02.040 --> 0:14:06.240 the stories themselves, but the people were wonderful, and so 0:14:06.280 --> 0:14:07.440 in the back of my head, I'm always like, oh, 0:14:07.760 --> 0:14:09.559 I'm some point I have to write up those stories. 0:14:09.880 --> 0:14:15.120 Yeah, next book. So when you're not writing, what are 0:14:15.160 --> 0:14:17.200 you doing on the day to day? I mean, I 0:14:17.240 --> 0:14:19.600 know you're probably still writing, but yeah, what do you 0:14:19.600 --> 0:14:21.000 do besides being an author? 0:14:21.960 --> 0:14:25.720 Yes? So I mean I watch TV, I do the 0:14:25.760 --> 0:14:30.040 normal things. But you know, I'm a cognitive neurologist, so 0:14:30.120 --> 0:14:33.160 two days a week I see patients, and it's it's 0:14:33.160 --> 0:14:34.880 mostly patients who are coming in and saying, you know, 0:14:34.960 --> 0:14:37.080 do I have dementia? What's going to happen in the future, 0:14:37.480 --> 0:14:40.080 And most of what we see is sort of atypical cases. 0:14:40.080 --> 0:14:43.560 So often it's people who are younger or people who 0:14:43.600 --> 0:14:46.200 have unusual symptoms. So someone who comes in and says, 0:14:46.800 --> 0:14:48.160 you know, look, I've been seeing people at the end 0:14:48.200 --> 0:14:49.520 of my bed and I know they're not there, but 0:14:49.640 --> 0:14:53.560 they really look clear to me, or you know, things 0:14:53.560 --> 0:14:55.080 like we had said fur some you know, my partner 0:14:55.120 --> 0:14:58.240 is acting strangely. He's totally apathetic and he used to 0:14:58.240 --> 0:15:00.800 be so warm, and he went out and bought a 0:15:00.800 --> 0:15:04.520 sports car and didn't tell me, or you know, people 0:15:04.520 --> 0:15:06.560 who say, you know, look, I'm having trouble using the 0:15:06.640 --> 0:15:08.320 right side of my body and it's gotten worse and 0:15:08.320 --> 0:15:11.960 worse over time. So these sort of really atypical cases 0:15:12.480 --> 0:15:15.000 where people have language problems, so they come in and 0:15:15.000 --> 0:15:17.200 they say, you know, I used to be a big 0:15:17.280 --> 0:15:20.120 gardener and you know, someone mentioned the word mulch before 0:15:20.160 --> 0:15:22.240 and I couldn't really figure out what it meant. And 0:15:22.320 --> 0:15:25.560 so it's a lot of these atypical sort of conditions 0:15:25.560 --> 0:15:28.280 that people walk around for years and they can tell 0:15:28.360 --> 0:15:31.880 something's up, but they go to neurologists, they go to psychiatrists, 0:15:31.920 --> 0:15:34.920 and they can't get a diagnosis. And so a lot 0:15:34.960 --> 0:15:36.600 of what we do is sort of seeing those cases 0:15:36.600 --> 0:15:38.360 and saying, you know, if you're not alone, this is 0:15:38.400 --> 0:15:40.080 a real disease. It's sort of in your head, but 0:15:40.160 --> 0:15:43.600 not in your head. And so that's what I do, 0:15:43.800 --> 0:15:45.640 you know, much of the time outside of writing. 0:15:46.480 --> 0:15:49.520 So I am a huge fan of medical history, as 0:15:49.560 --> 0:15:52.880 I mentioned, and as everyone who listens to the podcast knows, 0:15:52.920 --> 0:15:56.360 it's what I talk about. And so I really enjoyed 0:15:56.440 --> 0:15:59.200 all of the historical components that you put in your book, 0:16:00.040 --> 0:16:05.200 especially the story of Alzheimer and how Alzheimer's disease got 0:16:05.240 --> 0:16:08.880 its name, which of course involves this instance of Alzheimer 0:16:08.960 --> 0:16:12.360 himself standing up and presenting what he found at a 0:16:12.400 --> 0:16:16.880 scientific meeting where he was met with absolute silence. So 0:16:17.480 --> 0:16:21.040 can you place his findings in the context of dementia 0:16:21.080 --> 0:16:25.040 research at that time and maybe kind of speculate on 0:16:25.440 --> 0:16:27.880 why no one really seemed to care all that much 0:16:27.880 --> 0:16:31.200 about or recognize immediately the importance of his presentation. 0:16:32.440 --> 0:16:35.840 Yeah, so this story is sort of fascinating. So Alzheimer business, 0:16:37.040 --> 0:16:39.560 he was a sort of a very social guy, very smart. 0:16:40.000 --> 0:16:42.720 He'd gone to this top school and then he did 0:16:42.720 --> 0:16:45.360 a PhD on the cellular life of earwax and he'd 0:16:45.360 --> 0:16:48.000 gotten like a citation for disturbing the piece. So he 0:16:48.080 --> 0:16:49.880 was sort of a work hard, play hard kind of guy. 0:16:50.520 --> 0:16:54.160 And he goes into work when morning at the asylum 0:16:54.280 --> 0:16:57.200 for the insane and epileptic it was called in Frankfurt, 0:16:57.400 --> 0:17:00.400 and he meets this woman, August Dieter, who was a 0:17:00.480 --> 0:17:04.399 housewife and she's in her early fifties. She was fifty 0:17:04.440 --> 0:17:06.840 one when he met her, but in her forties even 0:17:06.880 --> 0:17:10.400 she started having difficulty. She would forget things in recipes, 0:17:10.480 --> 0:17:12.800 she was getting confused where she was going around the house. 0:17:13.560 --> 0:17:15.560 She became very suspicious that her husband was having an 0:17:15.560 --> 0:17:18.400 affair with a neighbor, even though there was no evidence, 0:17:18.680 --> 0:17:21.199 and her husband had taken her to the doctor and 0:17:21.200 --> 0:17:23.159 the doctor basically said, pack her clothes and drop her 0:17:23.160 --> 0:17:25.320 off with the asylum, and so that's what he did 0:17:25.720 --> 0:17:28.720 and she never got out, but he saw her the 0:17:28.800 --> 0:17:33.879 next day and he very quickly realized her case was unusual. 0:17:34.280 --> 0:17:37.919 And what he realized is that she was had a 0:17:38.080 --> 0:17:40.119 very a horrible short term memory. So he would come 0:17:40.160 --> 0:17:42.040 and he would show her a bunch of objects, and 0:17:42.080 --> 0:17:44.320 she could name them. She could do math, she could 0:17:44.320 --> 0:17:47.639 describe things like the color of soot, but as soon 0:17:47.680 --> 0:17:49.359 as he would take the objects away, she would have 0:17:49.520 --> 0:17:51.720 no idea that he had ever shown them to her. 0:17:52.400 --> 0:17:53.879 Or if he asked her to write her name, she 0:17:53.920 --> 0:17:55.880 would write, she wrote missus, and then she couldn't write 0:17:55.920 --> 0:17:57.760 the rest of her name. She sort of forgot the 0:17:57.800 --> 0:18:00.880 task or forgot how to do it. And he realizes 0:18:00.920 --> 0:18:03.800 the case is unusual, and so he treats her for 0:18:04.040 --> 0:18:07.520 all over but a year, and then he actually Alzheimer's 0:18:07.880 --> 0:18:10.640 own wife actually dies a very young and he's left 0:18:10.640 --> 0:18:13.119 with three kids, and he ends up moving to another city. 0:18:13.160 --> 0:18:15.760 But he basically calls DIBs on her brain, which was 0:18:15.760 --> 0:18:18.240 something you could do in that time. And so everyone 0:18:18.320 --> 0:18:20.199 knows that this asylum that when you know, when this 0:18:20.240 --> 0:18:22.280 woman dies, it's going to her brain's going to go 0:18:22.280 --> 0:18:25.120 to Alzheimer. And and sure enough, a few years later 0:18:25.160 --> 0:18:27.760 she passes away and an intern from the hospital and 0:18:27.800 --> 0:18:29.960 Frankfurt calls him up and is like, you know, do 0:18:30.000 --> 0:18:31.960 you want the brain still? And he's like, send it over, 0:18:32.480 --> 0:18:35.000 And so they fix the brain and formaldehyde and they 0:18:35.040 --> 0:18:37.480 send the whole brain and her entire medical record to 0:18:37.520 --> 0:18:41.159 Alzheimer's at this other hospital. There's no consenting there, you know, 0:18:41.359 --> 0:18:44.960 it's a totally different time. And he looks at her 0:18:45.000 --> 0:18:47.000 brain under a microscope and he sets built up of 0:18:47.040 --> 0:18:51.200 these two structures. One is what we call plaques, which 0:18:51.240 --> 0:18:54.000 basically look like a spot of spray paint in the brain. 0:18:54.760 --> 0:18:58.160 That obviously is microscopic, and then the other is called 0:18:58.200 --> 0:19:01.320 we call him tangles now, and they basically like spaghetti 0:19:01.359 --> 0:19:05.320 inside of neurons. And people had seen the structures before, 0:19:05.400 --> 0:19:08.280 but they had seen it essentially an older people where 0:19:08.280 --> 0:19:11.800 they thought the structures didn't really mean anything. And Alzheimer's 0:19:11.800 --> 0:19:14.600 big contribution was finding this woman and realizing she had 0:19:14.600 --> 0:19:19.080 an enormous, enormous burden of these plaques and tangles, and 0:19:19.160 --> 0:19:21.840 so what he did that was so sort of partly 0:19:21.880 --> 0:19:23.560 he was so good at microscopy and he was such 0:19:23.560 --> 0:19:25.800 an expert in the field, but also he was very 0:19:25.880 --> 0:19:29.360 quick to say, is this a different disease, and that 0:19:29.480 --> 0:19:31.199 was the key. It's that he said, you know, have 0:19:31.320 --> 0:19:34.199 I actually discovered something new? And so he goes to 0:19:34.240 --> 0:19:38.520 this conference and he presents his data, and just as 0:19:38.520 --> 0:19:41.399 you said, so he basically talks about the case. He 0:19:41.440 --> 0:19:46.240 shows pictures and slides, and at the end there's like 0:19:46.280 --> 0:19:50.080 total silence. The moderator basically says, well, it seems there's 0:19:50.080 --> 0:19:53.840 no desire for discussion, and please take a seat. And 0:19:53.880 --> 0:19:56.040 then and later in the day, actually the talk that 0:19:56.119 --> 0:19:59.400 garnered the most interest is to talk about excessive masturbation. 0:19:59.520 --> 0:20:01.480 That was the high light of the meeting, of course. Yeah, 0:20:01.840 --> 0:20:04.000 and so it's so, yeah, you were sort of left 0:20:04.000 --> 0:20:05.720 with this thing of oh my gosh, this is one 0:20:05.760 --> 0:20:07.400 of the most you know, it's one of the deadliest 0:20:07.400 --> 0:20:09.399 diseases in the world, it's one of the top causes 0:20:09.440 --> 0:20:13.720 of death, and yet at its discovery, nobody really sensed 0:20:13.720 --> 0:20:16.639 that it was important. And I think there's a few reasons, 0:20:16.680 --> 0:20:18.360 but I think a big thing is that he presented 0:20:18.359 --> 0:20:21.720 a single case. Yeah, and so there's you know, there's 0:20:21.920 --> 0:20:24.520 thousands of case reports that come out every day and 0:20:24.640 --> 0:20:27.359 it's hard to sift through, you know, which ones are 0:20:27.440 --> 0:20:30.280 actually meaningful, and you can sort of think about what 0:20:30.320 --> 0:20:32.840 about the next case of COVID. People probably didn't realize 0:20:32.880 --> 0:20:35.439 that that was anything unusual. It's only when it becomes 0:20:35.440 --> 0:20:38.040 more widespread that you realize, oh, in retrospect, that was 0:20:38.080 --> 0:20:40.600 a big deal. And so I think part of that 0:20:40.680 --> 0:20:43.320 was that it was it's a single case. And part 0:20:43.320 --> 0:20:46.959 of it is also that in that time it's harder 0:20:47.080 --> 0:20:51.080 to disseminate scientific information. So you can imagine anyone who's 0:20:51.080 --> 0:20:52.679 not at that meeting is not going to hear that. 0:20:53.480 --> 0:20:55.199 So it's not the same as today, where you publish 0:20:55.200 --> 0:20:56.920 a paper and then with a click of a button, 0:20:57.240 --> 0:20:59.800 the entire world has access to it. So I think 0:20:59.840 --> 0:21:02.240 that's another part of it. And part of it also 0:21:02.280 --> 0:21:04.680 is that he wasn't as far in his career as 0:21:05.119 --> 0:21:07.879 he eventually would get. So the way that Alzheimer's disease, 0:21:07.920 --> 0:21:11.359 the way the term eventually gets coined is his mentor 0:21:11.400 --> 0:21:14.679 actually publishes a revision of a textbook and mentions the 0:21:14.680 --> 0:21:17.800 case and mentions Alzheimer's disease, and so he basically is 0:21:17.800 --> 0:21:21.960 a little bit of who you know am, So that 0:21:22.000 --> 0:21:23.760 I think that those were sort of I think some 0:21:23.800 --> 0:21:26.520 of the main reasons why I didn't really get recognition 0:21:26.600 --> 0:21:27.280 at the beginning. 0:21:28.320 --> 0:21:30.520 Let's take a quick break here. We'll be back in 0:21:30.800 --> 0:21:49.879 just a few Welcome back, everyone, I'm here chatting with 0:21:49.920 --> 0:21:53.160 doctor Sarah Manning Peskin about her book, A Molecule Away 0:21:53.160 --> 0:21:57.800 from Madness. Let's get into some more questions. It's such 0:21:57.840 --> 0:22:01.800 a fascinating story. And another one that I found so 0:22:01.880 --> 0:22:05.880 interesting and I had no idea about was Abraham Lincoln 0:22:06.080 --> 0:22:10.760 and how he maybe was taking this medication that possibly 0:22:10.880 --> 0:22:14.080 was altering his personality. Can you share a bit about how, 0:22:14.160 --> 0:22:16.280 first of all, how you came across that story, and 0:22:16.280 --> 0:22:17.840 then what that story is. 0:22:18.840 --> 0:22:20.840 Yeah, so I was looking sort of at I wanted 0:22:20.880 --> 0:22:23.520 to do at least one chapter about, you know, toxins, 0:22:23.800 --> 0:22:26.920 and people have written books about toxins, so I sort 0:22:26.960 --> 0:22:28.600 of thought, you know, how do you choose which one 0:22:28.600 --> 0:22:31.560 to write about? Either it's a really, really unusual toxin 0:22:31.760 --> 0:22:36.159 or it's a sort of unusually salient case. And I figured, 0:22:36.240 --> 0:22:38.960 you know, everyone's heard of Abraham Lincoln. It's an interesting case. 0:22:38.960 --> 0:22:41.040 And also sort of the idea of, you know, how 0:22:41.040 --> 0:22:43.879 do you speculate on the medical issues of historical figures 0:22:43.880 --> 0:22:45.600 who have died where you can never really prove it. 0:22:46.160 --> 0:22:49.159 So it brings up all sorts of questions, and the 0:22:49.880 --> 0:22:53.879 guy who sort of unnersed the air treated the theory 0:22:54.680 --> 0:22:57.399 is a fascinating guy who's a he's an infectious disease 0:22:57.480 --> 0:23:03.280 doctor and who actually essentially pioneered oral rehydration therapy, so 0:23:03.320 --> 0:23:07.199 he's credited with saving thousands and thousands of people. But 0:23:07.240 --> 0:23:10.640 he's also a medical historian on the side. And he 0:23:10.760 --> 0:23:15.359 was reading Gorvidelle's book Lincoln, and he saw that it 0:23:15.400 --> 0:23:18.919 mentioned something about Lincoln taking a substance called blue mass, 0:23:19.480 --> 0:23:21.399 and so he went back to the primary literature and 0:23:21.400 --> 0:23:24.479 realized there's all these references Lincoln. There's no quote from 0:23:24.560 --> 0:23:27.760 Lincoln himself, but there are quotes from his closest confidants, 0:23:27.800 --> 0:23:30.880 basically saying Lincoln used to take blue mass, and then 0:23:30.920 --> 0:23:33.240 after he got elected, he realized it made him cross 0:23:33.359 --> 0:23:35.800 and so he stopped taking it. And it's kind of 0:23:35.800 --> 0:23:39.840 amazing to think about these incredible political figures having medication 0:23:39.960 --> 0:23:43.640 side effects and sort of thinking about what if he 0:23:43.880 --> 0:23:47.320 hadn't realized, you know, what would have happened then? And 0:23:47.359 --> 0:23:49.800 then is sort of the guy who created the theory 0:23:50.760 --> 0:23:53.000 in Norwo Herschard. He essentially went back and said, you know, look, 0:23:53.280 --> 0:23:56.280 there are actually these cases of Lincoln being really sort 0:23:56.320 --> 0:23:59.119 of actually sort of unhinged, and not that you know, 0:23:59.119 --> 0:24:02.400 we think of Lincoln as basically his emotions are basically 0:24:02.400 --> 0:24:05.320 like the statue. He's sort of sitting and thinking, and 0:24:05.359 --> 0:24:08.000 like we think of it, that's what he was always like. 0:24:08.080 --> 0:24:11.280 He was calm and measured, and yet there are these 0:24:11.359 --> 0:24:13.919 cases of him attacking a judge in the middle of 0:24:13.920 --> 0:24:17.480 a court case. In one of the Lincoln Douglas debates, 0:24:17.480 --> 0:24:20.440 he almost strangled a guy on stage. And so the 0:24:20.520 --> 0:24:23.000 question is you know where those medication side effects, and 0:24:23.040 --> 0:24:25.159 the foo line is we'll never be able to prove it. 0:24:25.200 --> 0:24:28.639 You have a thought is if he stopped using blue mass, 0:24:28.640 --> 0:24:30.720 which contains mercury, I should have said that that was 0:24:30.720 --> 0:24:34.920 the main toxic component. But if he stopped using mercury 0:24:35.359 --> 0:24:37.359 after right after he got elected, by the time he 0:24:37.400 --> 0:24:39.240 was assassinated, there wouldn't be any traces of it in 0:24:39.280 --> 0:24:41.520 his body. So there's no way to figure it out. 0:24:42.320 --> 0:24:45.080 On the podcast, we are pretty used to dealing with 0:24:45.200 --> 0:24:49.320 the gross and the gory and the weird, but even 0:24:49.400 --> 0:24:52.160 I was taken aback by the filth parties. The quote 0:24:52.240 --> 0:24:56.840 unquote filth parties held by Joseph Goldberger, So what was 0:24:56.880 --> 0:24:58.520 the deal with these parties. 0:24:59.480 --> 0:25:02.080 Yeah, it was it was from a time when it 0:25:02.119 --> 0:25:04.920 was very common to test things on yourself, and that's 0:25:04.960 --> 0:25:08.080 how scientists did their it did their work. So there 0:25:08.119 --> 0:25:12.439 was this disease called pilagra, which it caused diarrhea, It 0:25:12.480 --> 0:25:15.800 caused people to have a rash and sun exposed areas, 0:25:15.800 --> 0:25:17.600 so your face, your hands, you know, the top of 0:25:17.680 --> 0:25:22.640 your deck, and it caused a dementia and cognitive symptoms. 0:25:23.119 --> 0:25:25.600 And for a long time, people thought it just didn't 0:25:25.640 --> 0:25:28.520 exist in America, and then in the early nineteen hundreds 0:25:28.520 --> 0:25:30.880 it started cropping up in the southeast and it basically 0:25:30.880 --> 0:25:34.480 became this epidemic. It was, it became enormously common. People 0:25:34.520 --> 0:25:37.480 became extremely scared of it. It was often deadly, and 0:25:37.560 --> 0:25:40.919 so it was affecting primarily impoverished people. So it was 0:25:40.920 --> 0:25:45.560 affecting new orphans, it was affecting prisoners, it was affecting performers, 0:25:46.480 --> 0:25:48.720 and so at the beginning it didn't get that much attention. 0:25:48.800 --> 0:25:51.440 But then it started spreading and essentially you started getting 0:25:51.520 --> 0:25:54.280 national headlines saying that people are scared of this, you 0:25:54.280 --> 0:25:57.400 know disease. You people are scared of this killer, and 0:25:57.520 --> 0:26:02.520 so the predominant at the time was that either it 0:26:02.600 --> 0:26:06.719 was caused by a toxin and spoiled corn, or the 0:26:06.720 --> 0:26:08.719 theory that gained traction was that it was caused by 0:26:08.760 --> 0:26:12.520 a infection transmitted by flies. And the reason why that 0:26:12.560 --> 0:26:15.960 gained traction there was literally zero evidence. So there's zero 0:26:16.000 --> 0:26:19.920 evidence to show the guy who the guy who thought 0:26:19.920 --> 0:26:22.359 of the theory eventually went on to argue that cancer 0:26:22.440 --> 0:26:25.760 was caused by cockroaches. So there's zero proof that this 0:26:25.880 --> 0:26:28.000 is correct, but everyone wants to believe it because then 0:26:28.000 --> 0:26:30.640 you can basically say, you know, look, the diseases, it's 0:26:30.680 --> 0:26:32.600 their fault. It's the people who suffer from it. They're 0:26:32.640 --> 0:26:35.080 not clean and that's why they get this disease, and 0:26:35.119 --> 0:26:39.199 so we don't have any responsibility. And so even though 0:26:39.280 --> 0:26:41.720 so that theory starts, you know, taking hold, but there's 0:26:41.720 --> 0:26:44.119 no proof, and the disease is spreading, so people are scared, 0:26:44.760 --> 0:26:47.320 and so the Surgeon General calls on this guy, Joseph Goldberger. 0:26:48.040 --> 0:26:50.960 And Goldberger was a public health officer who was no 0:26:51.000 --> 0:26:54.520 stranger to contracting the diseases he was studying. So he'd 0:26:54.560 --> 0:26:59.159 gotten typhus, he'd gotten typhoid, and he'd actually exposed himself 0:26:59.200 --> 0:27:02.000 to skathies to prove about to try to like track 0:27:02.040 --> 0:27:06.280 that a epidetic was coming through mattresses. So he like 0:27:06.440 --> 0:27:08.760 very much is sort of roll your hands up and 0:27:08.800 --> 0:27:10.560 get it, roll your rest leaves up and get into 0:27:10.600 --> 0:27:14.000 it kind of guy. And he very quickly realized, like, look, 0:27:14.000 --> 0:27:16.080 this is not caused by an infection. It's caused by 0:27:16.119 --> 0:27:20.280 something in the diet. But nobody would believe him because 0:27:20.880 --> 0:27:23.639 the optics are totally different. Now if it's a and 0:27:23.680 --> 0:27:25.959 he actually really it's a dietary deficiency, it's not a 0:27:26.000 --> 0:27:28.320 toxin in the diet. It's that the diets of these 0:27:28.320 --> 0:27:32.480 people are missing a nutrient. And that's very problematic because 0:27:32.480 --> 0:27:34.440 now instead of saying, you know that these people are 0:27:34.440 --> 0:27:37.080 dirty and it's their fault, you're actually saying our country 0:27:37.119 --> 0:27:39.280 is literally starving its own people and now they're dying 0:27:39.320 --> 0:27:42.720 because of it. So the optics are totally different, and 0:27:43.359 --> 0:27:45.800 it's also more expensive to fix because now suddenly the 0:27:45.800 --> 0:27:49.080 solution is now you have to feed people. And so 0:27:49.119 --> 0:27:52.600 nobody really wants to believe him, and so he basically says, 0:27:52.600 --> 0:27:53.720 you know, like I'm going to prove to you that 0:27:53.760 --> 0:27:56.560 this is not an infectious disease, and so he starts 0:27:56.600 --> 0:27:58.399 off with him in a colleague and they take a 0:27:58.440 --> 0:28:01.920 sample of blood from a patient with LAGRA and they 0:28:02.400 --> 0:28:04.880 injected into their own shoulders and he talks about, how, 0:28:05.200 --> 0:28:06.919 you know, like we had some sore shoulders, but other 0:28:07.000 --> 0:28:09.400 than that, it was okay. And then he has more 0:28:09.440 --> 0:28:12.280 colleagues who are confident in him, and so they start 0:28:12.280 --> 0:28:15.040 getting a little bit more gruesome with the experiment. So 0:28:15.080 --> 0:28:19.880 they scrape the scales off of patients rashes, and they 0:28:20.080 --> 0:28:22.720 mix it in with their stool and their urine, and 0:28:22.760 --> 0:28:27.000 they actually swallow the pills. And actually even his wife 0:28:27.040 --> 0:28:29.320 wants to participate. They've had this sort of fraught marriage 0:28:29.320 --> 0:28:32.760 because he's always running off to these different states and 0:28:32.840 --> 0:28:36.560 other countries to get expose himself to these deadly diseases, 0:28:36.600 --> 0:28:39.000 and she's sort of like stuck at home managing all 0:28:39.040 --> 0:28:42.600 the children. But she decides she wants to participate, so 0:28:42.680 --> 0:28:44.720 she goes down to see him, and he doesn't let 0:28:44.720 --> 0:28:46.600 her eat stool or you know, or the urine. He 0:28:46.760 --> 0:28:48.760 but he does the blood one and he makes sure 0:28:48.800 --> 0:28:52.080 to take it from a female patient unless he should 0:28:52.080 --> 0:28:53.680 take you know, blood from a male patient and give 0:28:53.680 --> 0:28:56.840 it to his wife, but so she does participate also 0:28:56.840 --> 0:28:59.480 where they take an injection from a they take blood 0:28:59.480 --> 0:29:02.040 from a a woman with pologer and he injects it 0:29:02.080 --> 0:29:04.920 into his wife's abdomen. And at the end of it, 0:29:04.960 --> 0:29:06.840 they wait six months and he writes up the paper 0:29:06.840 --> 0:29:09.720 that basically says, you know, considering the amount of filth 0:29:09.720 --> 0:29:11.520 that we took in, it's pretty amazing that none of 0:29:11.600 --> 0:29:14.440 us got pillagra. And that's sort of the punchline. So 0:29:14.480 --> 0:29:15.920 we tried as hard as we could to get the 0:29:15.960 --> 0:29:19.040 disease and we still couldn't catch it. Yeah, And eventually 0:29:19.120 --> 0:29:21.840 he goes on actually to do this incredible work. Yeah, 0:29:21.880 --> 0:29:24.240 when he actually gets so close to getting to the 0:29:24.280 --> 0:29:27.360 answer of what nutrient is missing in pologra, and he 0:29:27.400 --> 0:29:29.760 figures out it's a B vitamin and then he dies 0:29:29.800 --> 0:29:33.480 pretty quickly, and he was nominated for a Nobel Prize 0:29:33.520 --> 0:29:35.760 multiple times that he dies before he ever gets one. 0:29:36.240 --> 0:29:39.400 And then other researchers sort of finish it and end 0:29:39.480 --> 0:29:42.240 up figuring out that it's a deficiency in nisin, which 0:29:42.600 --> 0:29:46.040 actually was available on the shelf the whole time in 0:29:46.480 --> 0:29:49.320 the office of the guy who coined the term vitamin. 0:29:49.360 --> 0:29:51.200 But he just didn't realize that that was the solution, 0:29:52.080 --> 0:29:54.880 so it actually was an incredibly cheap disease to treat. 0:29:55.640 --> 0:29:57.720 They just didn't know, so all these people, thousands and 0:29:57.720 --> 0:29:59.520 thousands of people died in the meantime. 0:30:00.400 --> 0:30:03.560 One of the themes that we frequently run into on 0:30:03.600 --> 0:30:07.000 the podcast is the shift that occurred in the late 0:30:07.040 --> 0:30:12.120 eighteen hundreds when medicine starts to become less personalized, focusing 0:30:12.320 --> 0:30:15.560 more on the disease, treating the disease rather than treating 0:30:15.600 --> 0:30:18.560 the patient. And it seems like that was largely due 0:30:18.600 --> 0:30:21.120 to things like, you know, germ theory being like, well, 0:30:21.160 --> 0:30:23.200 we can solve it this way, or it's this that's 0:30:23.240 --> 0:30:27.040 making you sick. The problem is external, not internal, as 0:30:27.040 --> 0:30:30.640 well as technological advancements in like medical measuring devices where 0:30:30.640 --> 0:30:35.320 we can translate your disease, your symptoms into numbers essentially. 0:30:36.360 --> 0:30:40.640 But it seems like these close personal relationships between August 0:30:40.760 --> 0:30:43.680 and Alzheimer and Anna and Pick that you talk about 0:30:43.720 --> 0:30:47.000 in your book kind of escaped that depersonalization. Do you 0:30:47.040 --> 0:30:50.000 think that they were unique at the time, or did 0:30:50.080 --> 0:30:54.960 neurology as a field kind of overall escape the depersonalization 0:30:55.000 --> 0:30:58.000 that was happening so broadly in most of medicine. 0:30:58.560 --> 0:31:00.560 So I don't think they were that unique at the time. 0:31:00.600 --> 0:31:02.640 I think so August Eater was that sort of the 0:31:02.680 --> 0:31:05.560 first case of Alzheimer's disease that he witnessed, and then 0:31:05.720 --> 0:31:08.120 Anna Jeronich was this case that Arnold Pick who was 0:31:08.160 --> 0:31:10.080 another researcher at the time and kind of a nemesis 0:31:10.120 --> 0:31:12.520 of Alzheimer's, but that was a case that that he 0:31:12.560 --> 0:31:15.720 wrote about, and they each wrote really extensively about these 0:31:15.760 --> 0:31:19.240 single patients. But I think the reason it's like that 0:31:19.360 --> 0:31:21.680 is just because they were they were the index patients 0:31:21.680 --> 0:31:24.680 of these new diseases. Or in Jern next, she was 0:31:24.960 --> 0:31:26.880 one of the first ten patients that he'd sort of 0:31:26.880 --> 0:31:29.520 seen like that. So I think it's more just that 0:31:30.080 --> 0:31:34.080 these are the seeds of new diseases. And at that 0:31:34.200 --> 0:31:37.360 level it is still personal because they're individual cases. And 0:31:37.440 --> 0:31:41.320 even now case reports are you do still get sort 0:31:41.320 --> 0:31:43.920 of this personal sense of people, even though they're you know, 0:31:44.000 --> 0:31:46.600 we don't include people's names anymore. We don't, you know, 0:31:47.440 --> 0:31:51.880 includes some of the offhand comments that people used years ago. 0:31:52.880 --> 0:31:55.240 But the index cases, I think are always they're always 0:31:55.240 --> 0:31:58.920 still individual cases and if anything, you know, as you said, 0:31:59.000 --> 0:32:00.600 it's a little bit funny now that so many of 0:32:00.640 --> 0:32:03.880 the biggest papers, it's like written by people who have 0:32:03.960 --> 0:32:05.640 never met people with the disease that they're studying, and 0:32:05.640 --> 0:32:07.840 they have to make these incredible contributions to the field, 0:32:08.120 --> 0:32:10.840 but there's actually no account of anyone with the disease. 0:32:10.840 --> 0:32:13.280 It's basically, you know, it starts off saying, you know, 0:32:13.320 --> 0:32:15.720 this is a meta analysis of x number of papers 0:32:15.720 --> 0:32:18.680 and x number of patients, and this disease is characterized 0:32:18.680 --> 0:32:20.920 by a blah and here's the statistics, and you could 0:32:20.960 --> 0:32:23.880 get through the entire paper, you could learn groundbreaking material, 0:32:24.240 --> 0:32:26.040 but literally have no idea what it's like to live 0:32:26.040 --> 0:32:26.680 with the disease. 0:32:27.520 --> 0:32:30.840 Yeah, I think that it's it's an interesting disconnect. And 0:32:31.440 --> 0:32:34.560 do you feel like that's something that in medical school 0:32:34.720 --> 0:32:37.800 or medical training today kind of is a field that 0:32:37.840 --> 0:32:40.960 could be improved upon, or like, how do you integrate 0:32:41.600 --> 0:32:45.880 witnessing these first hand experiences of what the disease is like? 0:32:47.000 --> 0:32:49.520 Is there a gap there that you think could or 0:32:49.560 --> 0:32:50.480 should be addressed. 0:32:51.640 --> 0:32:54.360 So there's a sort of emerging field of narrative medicine 0:32:54.360 --> 0:32:57.640 that's trying to address basically exactly that. If you look 0:32:57.720 --> 0:33:00.720 up most papers, it's all passive. It's sort of all 0:33:00.720 --> 0:33:03.400 passive language. It's essentially like you basically remove yourself from 0:33:03.440 --> 0:33:06.440 the experience. But the place where that's been sort of 0:33:06.520 --> 0:33:08.880 preserved or ideally is the first line place to preserve 0:33:08.960 --> 0:33:12.720 that sort of close, intimate narrative relationship is actually in 0:33:12.760 --> 0:33:15.880 the patient interaction, because really what you're doing when you 0:33:15.880 --> 0:33:18.560 sit down with a patient, what you're doing is actually 0:33:18.720 --> 0:33:20.720 you're trying to get a sense of their narrative. And 0:33:20.760 --> 0:33:22.880 when you write your note, what you're trying to do 0:33:23.000 --> 0:33:26.160 is basically say, look, here's their story, Here's how things 0:33:26.200 --> 0:33:28.200 evolve over time, Here's how they feel, Here's what it's 0:33:28.240 --> 0:33:30.800 like to be them. And you know, when you're telling 0:33:30.800 --> 0:33:33.400 your you know you're attending or whoever else about the story, 0:33:33.640 --> 0:33:35.800 you're trying to lead them to a conclusion. So you 0:33:35.840 --> 0:33:38.440 actually do need a narrative arc. So it actually is 0:33:38.440 --> 0:33:42.480 a very useful tool in medicine. And so part of 0:33:42.480 --> 0:33:44.600 what narrative medicine is trying to do is to say, 0:33:44.920 --> 0:33:47.960 you know, can we treat these patient interviews as intimate 0:33:48.000 --> 0:33:53.040 personal experiences where you actually extract not you know, numbers 0:33:53.120 --> 0:33:56.360 like lab results, but actually you're extracting an experience, and 0:33:56.360 --> 0:33:58.560 then you're trying to encapsulate that experience for someone else. 0:33:58.600 --> 0:34:01.640 You're actually using narrative to formulates, you know, what you've 0:34:01.680 --> 0:34:04.120 heard and to try to communicate to someone else, what 0:34:04.320 --> 0:34:07.680 is this patient's life actually like? Yeah, and that also 0:34:07.720 --> 0:34:11.279 allows you to create a more holistic plan. Yeah, so 0:34:11.360 --> 0:34:13.279 for us, it maybe you know, look, we'd like to 0:34:13.280 --> 0:34:15.799 start this medication, but also you know they're bored during 0:34:15.880 --> 0:34:17.920 the day and they're not engaged, and how can we 0:34:17.960 --> 0:34:20.160 find a way for them to be active during the day. 0:34:20.360 --> 0:34:21.960 So it allows you to think a lot more about 0:34:22.000 --> 0:34:25.000 a person's quality of life than just about whatever numbers 0:34:25.000 --> 0:34:25.960 get thrown up on the board. 0:34:26.960 --> 0:34:29.880 Several of the conditions that you discuss in your book, 0:34:30.080 --> 0:34:34.480 like Huntington's disease or Alzheimer's disease, for instance, are heritable, 0:34:34.719 --> 0:34:39.239 at least in part for the children of those diagnosed 0:34:39.360 --> 0:34:43.799 with these potentially heritable dementias, I feel like that can 0:34:43.840 --> 0:34:47.600 be doubly traumatic, right where you're watching your parents lose 0:34:47.640 --> 0:34:51.080 themselves or your grandparents lose themselves, and knowing that this 0:34:51.320 --> 0:34:55.319 likely awaits you. Can you talk about this experience and 0:34:55.440 --> 0:34:57.960 the complex ways that you've seen people deal with it. 0:34:59.160 --> 0:35:01.040 Yes, this is a This is a big part of 0:35:01.080 --> 0:35:02.880 what we do, partly because we see a lot of 0:35:02.920 --> 0:35:07.640 these atipoical cases. So, the woman who essentially pioneered the 0:35:07.680 --> 0:35:10.920 research that led to finding the gene that causes Huntingdon's disease, 0:35:11.600 --> 0:35:14.120 she was a woman who was highly educated. She'd done 0:35:14.160 --> 0:35:17.560 a Fulbright scholarship, and then her dad called her home 0:35:17.600 --> 0:35:21.320 and said, your mom's Huntingdon's disease and you have a 0:35:21.320 --> 0:35:24.040 fifty percent chance of getting the disease. And she basically 0:35:24.080 --> 0:35:26.799 overhauls her career, ends up focusing. She had taken I 0:35:26.800 --> 0:35:30.399 think either zero or one biology classes in her entire life, 0:35:31.120 --> 0:35:33.960 and she basically starts focusing on trying to find a cure. 0:35:34.200 --> 0:35:35.640 In order to find a cure, you have to find 0:35:35.640 --> 0:35:39.799 the cause. And so eventually she actually pioneers this work 0:35:39.840 --> 0:35:42.920 that leads to our current ability to test people for 0:35:43.000 --> 0:35:45.560 the gene that causes Huntington's disease. So you can now 0:35:45.560 --> 0:35:49.200 tell people who are totally asymptomatic that, look, you have 0:35:49.239 --> 0:35:52.600 this gene orban momorality that will likely cause Huntingdon's disease 0:35:52.640 --> 0:35:55.799 if you live long enough, and even though they have 0:35:55.800 --> 0:36:00.720 no symptoms, she actually never took the test, basically said, 0:36:00.880 --> 0:36:03.400 you know, look, I have a lot more to lose 0:36:03.520 --> 0:36:06.600 by taking the tests than I have to gain. She 0:36:06.680 --> 0:36:09.040 never took the test. She eventually developed symptoms of the disease, 0:36:09.040 --> 0:36:11.239 and now has sort of come in public saying that 0:36:11.360 --> 0:36:17.440 she's developed the disease and her sister didn't. And it's 0:36:17.440 --> 0:36:20.680 sort of this fascinating story. And so much of what 0:36:20.680 --> 0:36:23.200 we I deal with at work actually is diseases where 0:36:23.680 --> 0:36:26.000 you find out there's actually a single gene mutation or 0:36:26.040 --> 0:36:29.120 a single gene change that's causing the disease, and you 0:36:29.200 --> 0:36:30.680 sort of think it's a little bit strange. You know, 0:36:30.719 --> 0:36:32.680 you've had this DNA your whole life, and why is 0:36:32.719 --> 0:36:35.720 it suddenly causing you a problem in your your sixties 0:36:35.760 --> 0:36:38.880 even your seventies. And some of these diseases, you know, 0:36:38.960 --> 0:36:41.840 you can have the same gene change in one person, 0:36:41.880 --> 0:36:44.600 and you know multiple family members, and sometimes they all 0:36:44.640 --> 0:36:46.880 get the disease at the same time, and sometimes they 0:36:46.880 --> 0:36:48.920 get it at vastly different ages, or it doesn't even 0:36:48.920 --> 0:36:53.120 always cause the disease, And so the issues that arise 0:36:53.200 --> 0:36:57.360 are are incredibly emotionally complex. So the biggest thing that 0:36:57.400 --> 0:36:59.440 people think of is you know, do you want to know? 0:37:00.360 --> 0:37:01.520 You know, do you want to know if you have 0:37:01.600 --> 0:37:05.840 a mutation that causes a neurodegenerative you know, a deadly 0:37:05.840 --> 0:37:09.719 progressive disease that we have no cure for, And we 0:37:09.719 --> 0:37:11.799 couldn't tell you exactly when you'll get it. We can 0:37:11.840 --> 0:37:14.640 tell you the chances of getting it, but we can't 0:37:14.640 --> 0:37:17.040 tell you exactly when or that you'll definitely get it. 0:37:17.520 --> 0:37:20.320 And and do you want to know? And there's a 0:37:20.320 --> 0:37:22.560 few things I think about. So one is, you know, 0:37:22.600 --> 0:37:24.080 maybe you want to know because you want to enroll 0:37:24.120 --> 0:37:26.799 in a research study and uh, and maybe they'll be 0:37:26.880 --> 0:37:29.080 you know, you'll get a treating, you'll ever develop the disease. 0:37:30.440 --> 0:37:32.520 One of the big things is you know, do you 0:37:32.520 --> 0:37:34.279 want to know so you can plan? You know, so 0:37:34.280 --> 0:37:36.319 if you knew that you were going to get, you know, 0:37:36.320 --> 0:37:38.680 a nerd degenerate disease, and someone said, you know, look 0:37:38.719 --> 0:37:41.680 it's probably gonna it often starts in your fifties or sixties, 0:37:41.719 --> 0:37:45.719 would you change your career? Would you change your decisions 0:37:45.719 --> 0:37:48.520 about having kids? Would you change how much you travel? 0:37:48.520 --> 0:37:51.560 Would you change how much you spend? And the other 0:37:52.000 --> 0:37:55.600 really sort of most you know, the thing that I 0:37:55.600 --> 0:37:59.200 find most interesting is you also can have kids that 0:37:59.239 --> 0:38:02.240 don't have them meatation. So if you carry a mutation 0:38:02.520 --> 0:38:06.120 and you you don't want to have biological children that 0:38:06.160 --> 0:38:09.160 don't have it, you can do ivfs. Essentially, they take 0:38:09.600 --> 0:38:12.120 egg and sperm, they mix it together, you know, in 0:38:12.160 --> 0:38:14.360 a lab, and then they take the cell sort of 0:38:14.640 --> 0:38:17.440 grow and divide and grow and divide, and after a 0:38:17.480 --> 0:38:19.680 certain amount of time they take away one cell or 0:38:19.680 --> 0:38:21.239 they take I think it's more like four or five cells, 0:38:21.239 --> 0:38:23.759 So they take away a few cells and they look 0:38:23.800 --> 0:38:26.360 at the gene in those cells and they can say, okay, 0:38:26.400 --> 0:38:29.080 this is a normal version or not a normal version, 0:38:29.719 --> 0:38:32.200 and then they basically only use the embryos that have 0:38:32.400 --> 0:38:35.200 normal versions. They put it back in the uterus, you 0:38:35.239 --> 0:38:37.120 grow a kid, then the kid does not have the disease. 0:38:37.760 --> 0:38:40.799 So it's actually we have the technology to literally root 0:38:40.840 --> 0:38:45.239 out the mutations from family lineages, but only if you 0:38:45.280 --> 0:38:46.680 know that you have only if you know it you 0:38:46.719 --> 0:38:50.200 know to look. So it's really it's such a complex issue. 0:38:51.320 --> 0:38:55.399 And ultimately, there are normal people who decide to find out, 0:38:55.440 --> 0:38:57.560 and there are normal people who decide not to find out. 0:38:57.840 --> 0:39:01.000 And even within families, you know there'll be some siblings 0:39:00.960 --> 0:39:04.040 who do testing and some who don't, and it's it's 0:39:04.040 --> 0:39:06.719 one of the most fascinating issues that we deal with. 0:39:06.800 --> 0:39:08.560 The other big issue that comes up is basically, if 0:39:09.120 --> 0:39:11.640 you know, if a grandparent had the disease, a parent 0:39:11.680 --> 0:39:13.920 decides not to find out, but their child decides to 0:39:13.920 --> 0:39:16.520 get tested. If the child has the mutation, then the 0:39:16.520 --> 0:39:20.200 parent now knows. So it actually your people's decisions affect 0:39:20.200 --> 0:39:22.759 other people in the family. So it's just it's sort 0:39:22.760 --> 0:39:29.080 of scientifically fascinating and emotionally so fraught, but also actionable. 0:39:30.280 --> 0:39:33.120 Like with so much else in the history of medicine, 0:39:33.719 --> 0:39:37.520 broad categories of diseases end up being broken down into 0:39:37.520 --> 0:39:40.799 smaller clinical units as we grow to understand more and 0:39:40.840 --> 0:39:45.560 more about their pathologies, Like fever became many different things, 0:39:45.680 --> 0:39:50.560 Hysteria became endometriosis or MS or pcos or so many 0:39:50.560 --> 0:39:55.080 other things, and dementia in some ways was split similarly, 0:39:56.040 --> 0:39:58.879 in what ways do you think that the diseases that 0:39:58.920 --> 0:40:01.480 you talk about in your book or that you encounter 0:40:01.600 --> 0:40:04.960 in your work are still undergoing this type of revision. 0:40:06.520 --> 0:40:08.960 So the diseases, I mean, one of the big diseases 0:40:08.960 --> 0:40:12.000 that I see is front of temporal dementia, and even 0:40:12.000 --> 0:40:13.920 the name for that is like you're a little over 0:40:13.960 --> 0:40:17.840 twenty years old, So it's very much still an active 0:40:17.920 --> 0:40:21.520 field in that area in Partigo. So that's the disease 0:40:21.560 --> 0:40:23.799 where it has a few different variants. So it's been 0:40:23.840 --> 0:40:25.920 in the press a lot because Bruce Willis has now 0:40:25.960 --> 0:40:27.680 come out saying that he has or his family's come 0:40:27.719 --> 0:40:29.279 out saying that he has front or temporal dementia. So 0:40:29.320 --> 0:40:33.000 it's had a lot of coverage lately, and essentially some 0:40:33.120 --> 0:40:36.000 of it. Sometimes it can cause people to have these 0:40:36.040 --> 0:40:39.040 sort of really sort of antisocial behaviors, going up to strangers, 0:40:39.040 --> 0:40:43.480 saying in appropriate things, hypersexuality, eating non food things. Sometimes 0:40:43.480 --> 0:40:45.560 it can cause people to have language problems where they 0:40:46.040 --> 0:40:49.319 lose the connection between words and objects. So you know, 0:40:49.360 --> 0:40:51.319 you were taught when you were a kid that an 0:40:51.360 --> 0:40:54.799 apple is, you know, a green or red thing that's 0:40:54.840 --> 0:40:57.160 crunchy in the middle. But there's nothing inherent about an 0:40:57.160 --> 0:40:59.480 apple that sounds like apple. It's just that sound was 0:40:59.480 --> 0:41:02.680 attached to the word and you lose that connection, or 0:41:02.680 --> 0:41:05.240 some people start have having trouble with the motor programming 0:41:05.239 --> 0:41:07.319 of speech. So when you want to say a word, 0:41:07.400 --> 0:41:09.120 your mouth and your tongue has to move in a 0:41:09.120 --> 0:41:11.279 certain way to say it, and that's a message that 0:41:11.320 --> 0:41:13.600 goes from your brain to the muscles or in your mouth, 0:41:13.960 --> 0:41:17.239 and that connection gets lost. So in that disease, it 0:41:17.320 --> 0:41:19.960 essentially had like it had like ten different names, each 0:41:20.000 --> 0:41:22.600 of which had like the names themselves were like six 0:41:22.600 --> 0:41:25.520 different words put together, and people thought it was like 0:41:25.560 --> 0:41:28.319 multiple diseases, and then they finally figured out, actually it's 0:41:28.360 --> 0:41:30.320 the same disease, and it's sort of this aha moment, 0:41:30.440 --> 0:41:32.480 and then actually they go on and they realize when 0:41:32.480 --> 0:41:35.160 you look at under people's brains under a microscope, it's 0:41:35.200 --> 0:41:37.560 actually not the same disease. So it's sort of had 0:41:37.560 --> 0:41:39.840 this full evolution of like is this one disease? Is 0:41:39.880 --> 0:41:44.719 it multiple diseases? And ultimately we're not very good at 0:41:44.920 --> 0:41:47.680 for Alzheimer's disease. We actually have tests that we can 0:41:47.719 --> 0:41:49.560 do in living people and we can say, you know, look, 0:41:49.560 --> 0:41:52.520 we're essentially almost sure that that's what it is. With 0:41:52.560 --> 0:41:55.120 French of temporal dementia, you know, you can have two 0:41:55.120 --> 0:41:58.000 people who have exactly the same symptoms, their imaging looks similar, 0:41:58.640 --> 0:42:01.880 and yet under a microscope their brains look completely different. 0:42:01.920 --> 0:42:04.920 It's caused by a totally different protein in one person 0:42:04.920 --> 0:42:08.000 compared to another. Yeah, and so a lot of these 0:42:08.040 --> 0:42:12.120 fields are still, you know, very much evolving, and part 0:42:12.160 --> 0:42:14.839 of the issue is that difficulty in making the link 0:42:14.920 --> 0:42:18.680 between symptoms and imaging and testing and what's going on 0:42:18.760 --> 0:42:21.040 under a microscope because you can't access the brain. It's 0:42:21.040 --> 0:42:22.399 not like the lungs where you can take a piece 0:42:22.400 --> 0:42:24.920 out and you look at the molecules the brain. It's 0:42:24.920 --> 0:42:27.960 like we're using all these proxies and that's been you know, 0:42:28.160 --> 0:42:29.600 that's the big barrier. 0:42:30.719 --> 0:42:34.160 Speaking of frontotemporal dementia, in your chapter where you focused 0:42:34.160 --> 0:42:37.759 on that particular condition, you talk about the stigma and 0:42:37.800 --> 0:42:40.640 you mentioned some of these symptoms that are commonly seen 0:42:40.760 --> 0:42:45.719 with frontotemporal dementia and how they're maybe not what we 0:42:46.040 --> 0:42:50.160 typically think of when we think of dementia, and maybe 0:42:50.160 --> 0:42:52.840 that's because that's the way that dementia is portrayed in 0:42:52.960 --> 0:42:55.400 popular media. So there can be more of like a 0:42:55.440 --> 0:42:59.520 stigma maybe with these you know, atypical symptoms or symptoms 0:42:59.520 --> 0:43:01.719 that we persue to be a typical even though they're not. 0:43:02.200 --> 0:43:04.160 So can you talk a little bit about this this 0:43:04.239 --> 0:43:08.520 problem between the disconnect and how dementia is portrayed versus 0:43:08.760 --> 0:43:11.520 the actual like wide variety of ways that it can 0:43:11.600 --> 0:43:13.200 actually look in reality. 0:43:14.239 --> 0:43:16.719 Yeah, so I actually it's probably maybe two years ago. 0:43:16.719 --> 0:43:19.160 I actually give a class about dementia and the media, 0:43:19.239 --> 0:43:22.759 and there's some fascinating stuff out there, And it's also 0:43:22.800 --> 0:43:24.880 really a big topic of debate because one question is, 0:43:25.320 --> 0:43:27.239 you know, should you basically if you were writing a 0:43:27.239 --> 0:43:29.920 movie about someone with dementia, should your goal be to 0:43:29.920 --> 0:43:32.440 write about the typical cases so that people could learn 0:43:32.440 --> 0:43:34.440 about the disease and see what it usually looks like, 0:43:35.120 --> 0:43:37.600 or is your goal to write about whatever case is 0:43:37.680 --> 0:43:39.440 most interesting, whether it's rare or not. So if you 0:43:39.480 --> 0:43:44.640 think about the example of still Alice and she has 0:43:44.760 --> 0:43:48.040 it's a young it's a woman with Alzheimer's disease, so 0:43:48.040 --> 0:43:51.440 it's a very common disease, but it's young onset and 0:43:51.440 --> 0:43:52.680 in the I think it turns out to be a 0:43:52.880 --> 0:43:56.080 genetic cause, so it's really atypical. Those are like less 0:43:56.080 --> 0:43:58.880 than you know, one percent of cases. And so one 0:43:58.960 --> 0:44:02.160 question is is that a really useful movie, because you know, 0:44:02.200 --> 0:44:03.880 it was a big movie. It got lots of attention, 0:44:04.160 --> 0:44:06.479 so it got a lot of sort of light onto 0:44:06.480 --> 0:44:10.240 Alzheimer's disease. Is that really helpful or is it actually 0:44:10.280 --> 0:44:12.200 like you're making people think that it's all caused by 0:44:12.200 --> 0:44:13.960 a single gem and actually that's that was a really 0:44:14.000 --> 0:44:17.880 unusual case. Or if you're portraying, you know, people with 0:44:17.960 --> 0:44:21.920 dementia getting diagnoses, should you portray a compassionate doctor or 0:44:21.920 --> 0:44:24.480 should you portray what often gets portrayed, which is neurologist 0:44:24.520 --> 0:44:29.719 as being sort of aloof and sort of not emotionally engaged, 0:44:30.640 --> 0:44:34.239 and you know, how do you portray that interaction? And 0:44:34.320 --> 0:44:37.840 I think the bottom line is that it's complex and 0:44:39.200 --> 0:44:42.120 the most important thing from my perspective is really just 0:44:42.120 --> 0:44:44.799 portraying the humanity of the people with the diseases. The 0:44:44.880 --> 0:44:47.160 key is not talking about them when they're in the room, 0:44:47.760 --> 0:44:50.239 So portray them as you know, real people, and then 0:44:50.280 --> 0:44:53.200 you can drop clues in of like you know this, 0:44:53.400 --> 0:44:55.840 you know this is unusual, so you know this is 0:44:55.840 --> 0:44:57.840 a to atypical cakes or something like that, so you 0:44:57.880 --> 0:45:00.520 can get around that stuff. But the he really is 0:45:00.560 --> 0:45:04.560 to try to portray some sort of semblance of real 0:45:04.600 --> 0:45:06.800 life and you know, experience with these diseases. 0:45:08.040 --> 0:45:10.719 I want to take that class that sounds really interesting 0:45:12.880 --> 0:45:15.440 in your book. You also tell the story of a 0:45:15.480 --> 0:45:20.080 young woman who is diagnosed with NMDA receptor encephalitis, and 0:45:20.120 --> 0:45:23.080 I love how her mom was so integral and like 0:45:23.160 --> 0:45:25.719 pushing for no I think it's this and you know, 0:45:25.840 --> 0:45:30.360 just advocating, advocating, advocating, and how frustrating but also inspiring 0:45:30.400 --> 0:45:33.000 that part was. But one of the things that you 0:45:33.040 --> 0:45:36.560 point out is how different this person's experience might have 0:45:36.719 --> 0:45:39.000 been if she had gotten sick just a couple of 0:45:39.040 --> 0:45:43.240 decades ago, when the disease was largely unknown or completely unknown. 0:45:43.800 --> 0:45:46.760 And I know there's been some speculation of like historical cases, 0:45:46.880 --> 0:45:51.759 might the people accused of witchcraft actually had NMDA receptor encephalitis. 0:45:52.360 --> 0:45:55.200 So do you feel like there might be other fields 0:45:55.200 --> 0:45:59.320 in medicine or other conditions in medicine that might undergo 0:45:59.360 --> 0:46:01.560 a similar revolution in the future. 0:46:02.480 --> 0:46:06.480 Kind of DA receptor encephalitis is a wild disease that 0:46:06.560 --> 0:46:11.600 essentially works like PCP and now has been getting increasing attention, 0:46:12.480 --> 0:46:15.520 but it's it's still rare, and so the hope is that, 0:46:15.920 --> 0:46:17.279 you know, kind of we get there with the more 0:46:17.320 --> 0:46:21.439 common things like Alzheimer's disease, and so that's the that's 0:46:21.480 --> 0:46:24.200 the goal, And then the other question, which is to 0:46:24.239 --> 0:46:27.000 be honest, beyond my field of expertise, is you know, 0:46:27.040 --> 0:46:29.600 all these psychiatric diseases that we think of, you know, 0:46:30.120 --> 0:46:32.239 there's this schiz of them the late eighteen hundreds, and 0:46:32.520 --> 0:46:36.200 you know, psychiatry and neurology so suddenly split and dementia 0:46:36.239 --> 0:46:38.799 is kind of at the seams because it's you know, 0:46:38.840 --> 0:46:40.360 there may be a molecular cause, but a lot of 0:46:40.400 --> 0:46:43.879 the symptoms are sort of psychiatric in nature, and it's 0:46:43.920 --> 0:46:47.040 sort of gone along. It's gone along at the scenes 0:46:47.040 --> 0:46:49.920 of psychiatry and neurology. And one question is, you know, 0:46:50.000 --> 0:46:52.080 are we going to move that over more to psychiatry. 0:46:52.160 --> 0:46:54.839 So things like schizophrenia and other conditions that we think 0:46:54.880 --> 0:46:58.480 of as being really purely psychiatric, are those also going 0:46:58.520 --> 0:47:02.759 to end up having molecular causes over time? But I 0:47:02.760 --> 0:47:03.160 don't know. 0:47:04.239 --> 0:47:06.920 Even though dementia has been now sort of broken down 0:47:06.960 --> 0:47:10.680 into many different types where you can specify this versus that, 0:47:10.960 --> 0:47:14.239 and maybe the medications might be different, but is non 0:47:14.280 --> 0:47:19.000 pharmaceutical therapy or just care. Is are there similarities in 0:47:19.040 --> 0:47:21.319 the way that all of these different types of dementias 0:47:21.440 --> 0:47:22.160 are treated. 0:47:23.120 --> 0:47:26.520 Yeah, so there's a lot of similarities, and that comes 0:47:27.600 --> 0:47:29.760 that sort of becomes of importance because in some cases 0:47:29.800 --> 0:47:31.120 we say, you know, look, I could put you through 0:47:31.120 --> 0:47:33.560 this invasive test to try to figure out what's actually 0:47:33.600 --> 0:47:35.719 going on in your you know, at a molecular level 0:47:35.760 --> 0:47:37.560 in your brain, but it's not worth it because we're 0:47:37.560 --> 0:47:39.759 going to treat it the same. So that really comes 0:47:39.800 --> 0:47:44.759 to it's actually a clinically relevant question. And the bottom line, 0:47:44.840 --> 0:47:47.000 there's a few rules of some that really are very helpful. 0:47:47.040 --> 0:47:49.359 Things like, you know, people come in all the time 0:47:49.400 --> 0:47:52.160 and say, you know, when someone makes a mistakes, should 0:47:52.160 --> 0:47:54.080 I correct them or should I not correct them? And 0:47:54.120 --> 0:47:56.239 the bottom line for most of this stuff is essentially, 0:47:56.719 --> 0:47:59.000 if it's not unsafe, you don't need to correct them, 0:47:59.400 --> 0:48:01.840 and that, you know, having dementia oftentimes people are not 0:48:01.880 --> 0:48:03.319 aware of it, or if they're aware of it, it's 0:48:03.360 --> 0:48:06.520 painful for them to to think about. And so the 0:48:06.560 --> 0:48:09.279 general approach really is if it's not it's safe, you know, 0:48:09.360 --> 0:48:10.840 if they want to, you know, if they think that 0:48:10.880 --> 0:48:13.520 their dead father is coming for dinner, then by all means, 0:48:13.600 --> 0:48:16.040 let them set the table. That's okay. You know, it's 0:48:16.040 --> 0:48:17.680 not going to hurt if they are wearing their clothes 0:48:17.719 --> 0:48:22.960 inside out. Who cares and in the same way, you know, 0:48:23.000 --> 0:48:25.120 in public. One thing that we sort of talked to 0:48:25.200 --> 0:48:27.359 care Grave is about is, you know, if you're worried 0:48:27.360 --> 0:48:30.480 about them doing something socially inappropriate, you know, carry on 0:48:30.560 --> 0:48:32.200 business cards. I just say, you know, look, my loved 0:48:32.200 --> 0:48:35.279 one has this condition, Thanks for your understanding, and you 0:48:35.360 --> 0:48:37.080 just pass it to someone after it happens. And that 0:48:37.120 --> 0:48:40.279 way you're not having to like yell at your loved 0:48:40.280 --> 0:48:42.319 one in public, you're not having to explain it to 0:48:42.360 --> 0:48:45.440 someone else, and it actually spreads awareness and people realize that, 0:48:45.480 --> 0:48:48.560 you know, there's more than what meets the eye. So 0:48:48.600 --> 0:48:50.360 there's all sorts of things like that, and things like 0:48:50.719 --> 0:48:54.759 we talk a lot about sort of empathic lying and basically, 0:48:54.880 --> 0:48:58.439 you know, not if you need something to get done 0:48:58.760 --> 0:49:00.719 and trying to frame it in a way that has 0:49:00.760 --> 0:49:04.320 nothing to do with the person's cognitive status. So, you know, 0:49:04.360 --> 0:49:06.719 if you need someone to move to a facility, how 0:49:06.719 --> 0:49:09.080 do you figure out some explanation for that that doesn't 0:49:09.080 --> 0:49:12.440 completely involve their cognitive status? Because if you can imagine, 0:49:13.040 --> 0:49:16.080 oftentimes the example we give is like, you know, tell 0:49:16.120 --> 0:49:19.440 the normal cognitively normal care partner, like if I was 0:49:19.440 --> 0:49:20.719 going to try to convince you to move to a 0:49:20.800 --> 0:49:24.160 nursing home. What would I have to say? And it's 0:49:24.160 --> 0:49:27.000 tough to think about because with all these conditions, you're 0:49:27.080 --> 0:49:29.920 dealing with people who live in a different world in 0:49:29.960 --> 0:49:33.239 some ways, and so the tools, regardless of the type 0:49:33.239 --> 0:49:34.799 of dementia, a lot of the tools are the same. 0:49:34.800 --> 0:49:39.320 From that perspective, has the process of writing this book 0:49:39.520 --> 0:49:42.319 changed the way you practice medicine or the way that 0:49:42.400 --> 0:49:44.000 you interact with your patients. 0:49:45.560 --> 0:49:47.160 It had. I didn't expect it to. I think I 0:49:47.160 --> 0:49:50.840 thought of it initially as like two separate things, but 0:49:50.920 --> 0:49:52.960 I now when I get I mean a lot of 0:49:53.000 --> 0:49:57.560 what I do is give diagnoses of untreatable neurodegenerative progressive diseases, 0:49:58.040 --> 0:50:01.400 and I talk now a lot of the diagnoses. I 0:50:01.400 --> 0:50:03.200 talk a lot about the history of the diseases because 0:50:03.239 --> 0:50:05.759 it made me realize, like we all carry around these 0:50:05.800 --> 0:50:07.880 diagnoses and we have no clue where they came from. 0:50:07.960 --> 0:50:10.360 It's sort of as if like they were always around, 0:50:10.480 --> 0:50:12.600 but none of these diseases were known from the beginning 0:50:12.640 --> 0:50:17.080 of time. And talking to people about how these diseases 0:50:17.280 --> 0:50:20.319 were discovered, actually, first of all, it allows you to go 0:50:20.360 --> 0:50:22.160 back to the basics. So it allows you to communicate 0:50:22.160 --> 0:50:26.319 at a level that's actually more scientifically clear, and also 0:50:26.360 --> 0:50:28.480 it gives people a sense of you know, look, this 0:50:28.520 --> 0:50:30.279 is an evolving field, and our hope is to find 0:50:30.400 --> 0:50:32.520 cures for these things, and not that this is a 0:50:32.680 --> 0:50:35.320 static you know, it's not that Alzheimer's thease has always 0:50:35.320 --> 0:50:38.440 been around and we've never made any progress. It was 0:50:38.520 --> 0:50:40.520 discovered at a certain time and in factually made a 0:50:40.520 --> 0:50:42.759 lot of progress, and there is a lot of hope 0:50:42.800 --> 0:50:45.560 even though it's true we haven't found a cure, and 0:50:45.640 --> 0:50:48.040 so I try to couch the diagnoses and the sort 0:50:48.080 --> 0:50:51.640 of the history of the diseases now and I haven't 0:50:51.640 --> 0:50:54.400 gotten any negative feedback, so hopefully it works, Okay. 0:50:56.560 --> 0:51:01.560 I know. I love that you cover so many different 0:51:02.280 --> 0:51:05.560 diseases in your book, and they range from ones that 0:51:05.640 --> 0:51:09.520 are fairly well known, like Alzheimer's, so those that may 0:51:09.560 --> 0:51:13.440 not be on most people's radar, like an MDA receptor encephalitis. 0:51:13.440 --> 0:51:16.240 Even though it has got you gotten more press recently, 0:51:17.080 --> 0:51:21.600 do you find yourself more intrigued by one than the other, 0:51:21.800 --> 0:51:23.839 or do you find them all equally interesting, or are 0:51:23.880 --> 0:51:28.200 there aspects of these conditions that you find the most compelling. 0:51:28.800 --> 0:51:30.600 I think the cases that move me most are the 0:51:30.680 --> 0:51:33.640 ones where people have these atypical symptoms and they're walking 0:51:33.719 --> 0:51:37.319 around thinking that they're crazy. So people who have, you know, 0:51:37.320 --> 0:51:38.640 speech problems and they say, you know, look, for the 0:51:38.640 --> 0:51:40.479 past few years, I feel like people think I'm drunk 0:51:40.480 --> 0:51:42.520 every time I open my mouth because my words don't 0:51:42.560 --> 0:51:46.440 come up clearly. And it's very emotionally fulfilling to be 0:51:46.440 --> 0:51:49.000 able to say, you know, look, actually there's a name 0:51:49.040 --> 0:51:51.239 for this disease, and you're not crazy, and this is 0:51:51.239 --> 0:51:53.400 what's going on. And you know, if I had to 0:51:53.400 --> 0:51:55.279 put money down, this is the molecule that I think 0:51:55.360 --> 0:51:57.920 is going you know, hey, why are in your brain? 0:51:58.160 --> 0:52:00.680 And this is where we are in terms of trying 0:52:00.680 --> 0:52:04.080 to find treatments and here are research opportunities. That's sort 0:52:04.080 --> 0:52:06.680 of the most fulfilling is is these atypical cases where 0:52:07.080 --> 0:52:09.720 they've gone years without a diagnosis and you can say, 0:52:10.200 --> 0:52:13.040 you know, look, this is what's going on. I mean, 0:52:13.160 --> 0:52:15.160 the typical ones are also interesting, because you know, even 0:52:15.200 --> 0:52:19.560 typical cases bring up interesting family dynamics, But for me, 0:52:19.600 --> 0:52:21.160 it's sort of the I think it's sort of the 0:52:21.160 --> 0:52:23.760 atypic ones that are the most fulfillingent clinic. 0:52:24.880 --> 0:52:28.760 What is something you wish you had known before starting 0:52:28.880 --> 0:52:30.080 on your career journey. 0:52:31.080 --> 0:52:32.600 I guess this is part of my learned in the book. 0:52:32.600 --> 0:52:34.640 I guess I think the biggest thing was that I 0:52:34.680 --> 0:52:38.560 wish I knew more about communicating with patients. So much 0:52:38.600 --> 0:52:41.320 of medical school is like trying to cram an enormous 0:52:41.360 --> 0:52:44.120 amount of information in your brain, much of which if 0:52:44.160 --> 0:52:46.719 you become you know, a secialist or a subspecialist, you're 0:52:46.880 --> 0:52:51.399 literally never going to use. And so much of it 0:52:51.440 --> 0:52:55.399 is just this academic exercise and there's not as much 0:52:55.440 --> 0:52:57.920 emphasis on like how do you explain a disease to 0:52:57.960 --> 0:53:01.520 a patient who has no medical but background and variable 0:53:01.520 --> 0:53:06.200 health literacy? And that's I think In writing a book 0:53:06.239 --> 0:53:08.560 of for the lay public, I was in a writing 0:53:08.560 --> 0:53:10.839 group with lots of people, none of whom had any 0:53:10.880 --> 0:53:13.799 sort of medical background, and it was they were all 0:53:13.920 --> 0:53:16.680 very educated and there were I was like shocked. There 0:53:16.680 --> 0:53:18.040 were words that I would use and they would say like, 0:53:18.040 --> 0:53:19.880 that's that doesn't make sense to me. I don't understand 0:53:19.880 --> 0:53:22.440 that explanation, and I realized it was not them, it 0:53:22.520 --> 0:53:26.080 was my feeling. And I think I wish I was 0:53:26.080 --> 0:53:29.239 emphasized in medical school more. I mean, there's so much 0:53:29.239 --> 0:53:31.960 to learn, and there's like there's more to learn every day. 0:53:32.000 --> 0:53:33.840 So you only have four years and how are you 0:53:33.840 --> 0:53:35.520 going to learn all this material? So I know that 0:53:35.520 --> 0:53:39.040 it's sort of tight to fit in new stuff, but 0:53:39.080 --> 0:53:41.800 it's really something that's not covered much in medicine. 0:54:00.800 --> 0:54:04.640 What a fascinating conversation. I had such a great time 0:54:04.719 --> 0:54:07.800 chatting with you, Doctor Peskin. Thanks so much for taking 0:54:07.840 --> 0:54:11.080 the time and for writing such a wonderful book. If 0:54:11.120 --> 0:54:13.120 you all enjoyed this as much as I did and 0:54:13.160 --> 0:54:16.040 want to learn more, check out our website this podcast 0:54:16.120 --> 0:54:18.279 will kill You dot com. We're I'll post a link 0:54:18.320 --> 0:54:21.000 to where you can find a molecule away from Madness, 0:54:21.280 --> 0:54:24.120 as well as a link to doctor Peskin's website, and 0:54:24.200 --> 0:54:26.840 don't forget you can check out our website for all 0:54:26.880 --> 0:54:30.960 sorts of other cool things, including but not limited to, transcripts, 0:54:31.040 --> 0:54:35.000 Quarantini and Placebrita, recipes, show notes and references for all 0:54:35.040 --> 0:54:38.080 of our episodes, links to merch our bookshop dot Org, 0:54:38.120 --> 0:54:41.200 affiliate account, our Goodreads list, a first hand account form, 0:54:41.239 --> 0:54:44.719 and music by Bloodmobile. 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