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When It’s Not Clear If a Disorder Is From the Brain or the Mind…

Neurologist Andrew Knox explains to Robert J. Marks that some psychological problems appear as if they were brain problems — yet there’s nothing wrong with the brain

In the podcast released last Thursday, Walter Bradley Center director Robert J. Marks interviewed pediatric neurologist Dr. Andrew Knox from the University of Wisconsin School of Medicine and Public Health on “Ways the brain can break” (#220, January 5, 2023).

What follows is Part 4 of the discussion, “When it’s not clear if a disorder is from the brain or the mind…” Here are Part 1: How our brains are — and aren’t — like computers, Part 2: What is happening when children have strokes or dementia signs?, and Part 3: How do strokes, dementia offer insight into how the brain works?

This portion begins at roughly 25:15 min. A partial transcript and notes, and Additional Resources follow.

Epileptic vs. non-epileptic seizures

Robert J. Marks: You also talked about something called non-epileptic seizures. What is a non-epileptic seizure? …

Andrew Knox: This is a great example of the interface between neurology and psychiatry. A patient who has non-epileptic seizures experiences all the symptoms of a seizure. So from their perspective, they might notice involuntary movements of their body, and then they might lose consciousness and then wake up later, similar to a patient who has an epileptic seizure.

The difference is that if you were recording their brain waves, you wouldn’t see any sort of change in the brain wave pattern. It’s thought that those sorts of seizures come not out of dysfunction of particular neurons, but of certain thought processes or certain thoughts that potentially lie in the subconscious.

Andrew Knox, MD

Let me develop that a little further … taking a step back and just talking about what is an epileptic seizure? What we think happens during an epileptic seizure, usually, is, you have your neurons firing off at their appropriate times, working on their particular tasks. The analogy I like to use with patients is you can think of it like a city full of people. The people are all going about doing their particular jobs, or things that they’re doing. During an epileptic seizure, for a variety of different reasons, neurons usually wind up firing off together all at the same time in a way that’s not helpful.

You can think of it as a group of people in the city start to riot. They’re all upset about something — enough that they gather together, they all go to the center of the town, and are yelling at people to change things. That riot goes on for a while, and then eventually, people go their separate ways and the city goes back to functioning like normal.

You see evidence of that sort of a change in neuronal behavior if you’re recording brain waves. During an epileptic seizure, you see spikes in the brainwave patterns that happen a couple of times a second, or even many times a second.

Andrew Knox: Okay, yeah. The contrast, for a non-epileptic seizure, is that you don’t have that same change — people are all coming together to the center of the city and rioting. You don’t see those regular discharges on the EEG when you look at the brainwave patterns. In fact, if you look at an EEG during a non-epileptic seizure, the brainwave patterns are unchanged. So they look the same as at any other time. But the patient is still experiencing all the symptoms of a seizure, and again, that happens because some part of how the brain is working to process what’s happening is dysfunctional; usually in the patient’s subconscious.

This can happen for a variety of different reasons. The classic illustration that I give patients is patients who witness a terrible, traumatic event that they can’t process might wind up developing symptoms later that express the trauma that they just experienced. Non-epileptic seizures are one example of a functional neurologic disorder.

Blindness as an emotional response

Andrew Knox: Another example might be, let’s say someone witnessed the brutal murder of their spouse, and then two or three days later, suddenly, they are blind; they can no longer see. The neurologist does the exam, they see the pupils seem to respond normally, the eyes even seem to track in ways that you would expect, and yet, the person is unable to see. The brain hardware, the pathways that process visual information, are intact, but there’s something about that trauma that they witnessed that is preventing them from processing visual information and interpreting it the way they usually do. Does that make sense?

Understanding the causes of seizures, epileptic or otherwise

Robert J. Marks: As an engineer, I would say that an epileptic seizure, it’s a difference between coherence and non-coherence; coherence and a kind of chaos, if you will, in the brain.

Andrew Knox: But again, the way I like to describe this to patients, that comes out of my computer engineering background, is that epileptic seizures are like a hardware problem. You can see a change in the way that individual neurons are firing off. Whereas non-epileptic seizures are more like a software problem. The hardware is working, but the way the brain is processing the information is not working correctly during that time. Patients seem able to identify with that pretty well.

Everyone can think of [a time] when they’ve loaded or tried to run too many apps on their phone at the same time. The thing eventually just locks up, and then you have to restart it. And then it goes back to normal function. That’s probably a good analogy for what happens during non-epileptic seizures.

What role does our subconscious mind play in brain disorders?

Robert J. Marks: You mentioned things happening in the subconscious. Do we have access to measure activity in the subconscious in any way?

Andrew Knox: The answer to that question is not straightforward. There are probably people who could answer it better than I could, but I think there’s probably not a good way to objectively access what’s happening in the subconscious.

Most insight into what is happening in the subconscious is going to come through the individuals themselves, and it’ll come over time. Part of the whole idea of psychotherapy is to spend time getting more access to some of those things that are happening in the subconscious that may affect or cause some of the problems that you’re having in a disorder like psychogenic, non-epileptic seizures…

Functional gait disorders

Robert J. Marks: So tell me about functional gait disorders and how that relates to the way that the brain breaks.

Andrew Knox: Yeah. Those are really just another example of a functional disorder, similar to a non-epileptic seizure or functional blindness that we talked about. Really, any sort of functional disorders that are rooted in disordered thought processes can wind up manifesting as a whole variety of different symptoms. So there’s some patients who, because of their functional disorder, wake up, and one day discover, “I can’t walk normally anymore. I’m just not able to walk.”

There’s some really interesting tricks that can help some of those patients … if a patient is unable to walk normally forward, they may still be able to walk normally backward. Identifying things like that are helpful for the treatment of the disorder.

Usually, those disorders, you treat sort of along two different lines. One part of the treatment is cognitive behavioral therapy — working with a psychologist to identify the thought patterns that are causing this particular symptom in the first place. The other line is by usually doing therapies. That needs to be targeted to what the particular problem is. For someone who can’t walk anymore, they’re going to work with a physical therapist to rebuild that ability to walk.

Andrew Knox: Discovering something like, “Huh, I can’t walk forward, but I can walk backward,” gives you a good sort of jumping-off point for then relearning how to walk forward again.

You may also wish to read: Part 1: How our brains are — and aren’t — like computers. Pediatric neurologist Andrew Knox looks at the topic with computer engineer Robert J. Marks. The conversation drifts to strokes — one of the ways that the brain can “break,” even in children.

And Part 2: What is happening when children have strokes or dementia signs? Many children who would have died 40 years ago can live a relatively full life today but they are at risk of stroke or dementia. Neuroplasticity, the ability of the brain to rewire neurons to provide lost functions to at least some extent offers hope for rehabilitation.

Part 3: How do strokes, dementia offer insight into how the brain works? Neurologist Andrew Knox thinks the brain may store memories is an associative scheme, where previous memories are used to build up new ones. Some episodes of loss of consciousness are not seizures or stroke; syncope, caused by low blood pressure, can turn out to be harmless.

Additional Resources

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When It’s Not Clear If a Disorder Is From the Brain or the Mind…