22584430_6479f1c7d2.thumbnail.jpg"Brains are like assholes" one of my mentors used to say. "Just 'cause we're all born with one doesn't mean we know how to use 'em."

What my mentor sought to convey is the odd fact that most prescriptions for psychiatric meds are written by non-psychiatrists. Although many of these non-psychiatrist clinicians know as much about brain function as any biologically oriented shrink knows, many others prescribing the meds clearly lack that information. For the patients seeing the latter group, the result is often missed diagnoses, inappropriate treatment, tremendous suffering, and - in the worst cases - catastrophic outcomes.

So what does all this talk of missed diagnoses, catastrophic outcomes, brains and assholes have to do with Senator McCain?

When prescribing meds for a patient - or selecting a leader for a nation - we can avoid a whole lotta suffering and death simply by incorporating well-known biology into our decision making.

We all like to think we're special. And we are - we're all unique individuals. So we all believe our brains and even our assholes are special. On the individual level, our brains and assholes are indeed special - and disease that affects my brain (or my asshole) will affect me in a unique and special way. Yet as biological organisms, we humans are pretty similar to one one another. As a species, our brains appear to share the same stucture and function - and the same is true of our anii.

Every politician - even Dan Quayle - has a brain. Senator McCain has a brain, too. And Senator McCain would take his brain along with the rest of him to the Oval Office were he to win election (or 5 votes from the Supremes).

What do we know about how Sen McCain's brain could be expected to function from 2009 through 2013 - or 2009 through 2017?

Well, the simple facts of brain biology can tell us a lot.

From my body's point of view, my brain's a selfish squishy diva who pitches a fit whenever the body won't give it what it needs. Among other demands, my brain wants about one-seventh of the blood my heart pumps through my lungs and out into the rest of the of my body. Greedy brain - that's about one-seventh of my total cardiac output. My greedy brain also has an incurable sweet tooth - it runs on the sugar known as glucose. The harder my little brain cells work, the more glucose they suck up. Lucky for me my brain doesn't have teeth - think of the cavities!

Lucky for you, too. Your brain - like Sen McCain's - requires about 15% of the blood your heart pumps. Your brain - like mine - requires a constant, steady diet of glucose.

And your brain - like mine and Sen McCain's - is a diva. Deprive the brain of its accustomed portion of the liquid feast the heart pumps out and - boom - the brain will take over the whole dining room. The brain does this by getting as close to the ground as possible, so all that yummy oxygenated blood will just flow downhill into the brain's greedy vessels.

From the outside, we call this "fainting".

Any good diva knows how to pitch a fit. When our diva brains don't get the glucose they want, we get all agitated - pale, sweaty, pacing, trembling. Our diva brains do this to get us to get up and get something to eat. If we don't feed our brains - or if our bodies can't make the glucose the brain requires - our diva brains will dial the performance up a notch. Our brains will direct the body to have fullblown seizures...long known by lay folk as "fits".

So what does all this have to do with assholes, catastrophic results, and Sen. McCain's brain?

Well, we clever monkeys known as humans share the same biological architecture (within our species). And we clever, self-absorbed monkeys have been trying to understand that architecture - and what that architecture means for us - at least since we started writing.

That long history of observation is the basis for actuarial tables: the grim lines of numbers that predict - for a given set of biological variables - how likely the humans who share those variables are to drop over dead or get nasty diseases.

The most obvious biological variables in humans are our gender (at birth) and the number of years we've been knocking about - and hence knocked about - on the planet. Exposure to toxins (smoking, occupation) are other biological variables. Opportunity to choose good food/housing, select safe occupations, and learn how to protect our bodies (all correlates of wealth) are other variables.

As I don't have gobs of money with which to bribe "support" Senatorial candidates, I've never met a Senator. Though I trained in a VA hospital and treated many vets (WWII, Korea, Vietnam) with PTSD, I never saw any Congressmen there - we were in Southern California...and irrespective of location, the veterans in Congress overwhelmingly choose red-carpet treatment at military (and academic) med centers over care in dilapidated VA facilities. Though I completed fellowship PTSD training at a major academic med center, I don't ever recall seeing a politician show up in the mental health waiting area.

So WTF could a doc who never saw any Senators - much less their brain - possibly learn about Sen McCain's brain?

Well, the Creationists will be surprised to hear it, but evolution is amazingly conservative. Because we're all humans and share the same biological architecture, knowing about a person's life history allows a doc to know a whole lot about that person's biology - even if the doc's never seen (much less bribed) the person.

What do we know about the person who walks around with Sen McCain's brain inside his body?

Well, we know gender. Sen McCain's a male (this week's NYT has more details).

We know age. At 71, Sen McCain is just beginning his eight decade. Were he to gain office, he'd end a first term at 76. Were he to serve out a second term, he'd have started his ninth decade before leaving office.

We know medical history: Sen McCain was diagnosed with melanoma in 1993. After treatment for the intial diagnosis, the melanoma returned two more times (2000 and 2002). Fortunately for the Senator, he (and his colleagues) all enjoy access to excellent medical care. So we also know Sen McCain has undergone three bouts of treatment for melanoma.

We know some aspects of occupational history. As a naval aviator, Sen McCain was regularly exposed to neurotoxic solvents and fuels. As a POW, Sen McCain was the victim of torture. Sen McCain has constant functional limitations from the torture (he cannot lift his arms above his head). According to his publicly released medical records, Sen McCain also has chronic pain resulting from numerous fractures; his captors when he was a POW did not provide adequate care, and the fractures did not heal properly.

The last two aspects of Sen McCain's documented medical history mean that Sen McCain's body and therefore his mind are confronted by reminders of his imprisonment and torture at least daily - and very possibly several times daily.

Like all Prez candidates, Sen McCain gets a lot of atttention. Multiple published observations describe Sen McCain as possessing/demonstrating:

  • a) affective lability (medicalese for widely varying moods)
  • b) poor impulse control (medicalese for adults with a penchant for throwing tanturms/provoking altercations/dropping trou)
  • c) repeated intrusive traumatic ideation (often refers to POW experience - describes same in [understandably] strong emotional terms.)
  • d) impaired attention/concentration (reports scant comprehension of US economy despite six years in House and sixteen years in Senate).
  • e) impaired judgment ( Keating Five; Vicki Iseman; early naval aviation career).
  • f) frequent irritability (medicalese for "acting like an asshole")

OK - so what does all this have to do with McCain and McCain's brain?

All the above tell us about the biology of the organism we know as Senator John McCain - and therefore tell us about his brain's biology.

First question: How long might Sen McCain's body live?

Senators have the best health care in the US - but even their docs haven't figured to a way to keep the Senators' brains going when their bodies give out. The presence of a functioning body being a prerequisite for healthy brain function, what do we know about how long the Senator's bod will be around?

Well, according to the Social Security's 2007 Life Table, the average 72 year old male has a life expectancy of 11.74 years. This means that - of the 66,000 72 year-old men in the SSA's data base - the average man of Sen McCain's age next January would be around almost twelve more years.

Second question: Does Senator McCain have an average body?

Nope. Because he's a Senator, he has access to health care most laypeople have never heard of - and most docs could only dream of providing. So the Senator's 72 year-old body will be far better cared for than the average 72 year old.

So that's the good news for the Senator. The not-so good news?

Even a casual Wiki reading reveals the Senator's body has seen some pretty rough times. He was a boxer despite the fact he lacked skills and as he stated "didn't have a reverse gear". He's a cancer survivor - and a survivor of two recurrences. By his own admission, he was pretty hard on that body: "I generally misused my health and youth". As a young man and officer, his reputation for hard partying and hard living was prodgious: "being on liberty with John McCain was like being in a train wreck."

Third question: Does Senator McCain Have an Average Brain?

Sadly, what may be desirable in young naval aviators doth not make for brain health. Repeated head injuries in boxing (especially in non-proficient boxers) predispose these boxers to brain disease later in life. Binge drinking and chronic heavy alcohol use also decrease brain function in later life. Depending on the treatment regimen, both chemo and radiation used to treat cancer may also lead to permanent cognitive impairment.

And - sadly - torture can also predispose victims to brain disease. The resulting impairments can take the form of psychiatric disease (especially PTSD), cognitive impairments, or both. The experience of being a POW has - in WWII POW's - also been shown to be associated with neuropsychiatric impairment (although the same study found the difference between POWs and non-POW's from the same combat theatre was realtively small).

Among 15 broad categories of diagnosis, differences were confined to gastrointestinal disorders (POWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (POWs 76% vs non-POWs 60%, P = .011), and cognitive disorders (excluding head injury, dementia, and stroke) (POWs 31% vs non-POWs 15%, P = .006). Of the 36 signs in the neurology of aging examination, POWs had a significantly higher proportion of seven extrapyramidal signs and six signs relating to ataxia.

J Am Geriatr Soc. 1999 Jan;47(1):60-4.

Sadly but not unexpectedly, after his release from captivity Sen McCain reported the recturrent intrusive memories which are essential symptoms in PTSD:

According to the records, McCain has said that immediately after his release from military prison in Hanoi there were "times when very realistic or frightening memories" came back to him. But McCain "can successfully put these memories out of his mind," the medical records said.

Sadly for Sen McCain and all veterans who were traumatized, the fact that traumatic symptoms fade after POW's release does not protect them against PTSD. A four year study of WWII and Korean War vets published in 2001 found:

symptoms were highest shortly after the war, declined for several decades, and increased within the past two decades. [snip] CONCLUSIONS: Both longitudinal and retrospective data support a PTSD symptom pattern of immediate onset and gradual decline, followed by increasing PTSD symptom levels among older survivors of remote trauma. Am J Psychiatry. 2001 Sep;158(9):1474-9

And just what makes the diagnosis of PTSD? Here are the current diagnostic criteria:

A. The person has been exposed to a traumatic event in which both of the following have been present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Am I saying that Sen McCain meets diagnostic criteria for PTSD? I'm not, because I honestly don't know - some of the diagnostic criteris require direct knowledge of the Senator's direct inner experience.

What I am saying in this post is that Sen McCain's life history indicates that his brain is at greater than average risk of dysfunction and impairment in the following areas:

- capacity to learn, recall, and reason with complex new information

- judgement and impulse control

- capacity to devote sustained attention.

Sen McCain - like all victims of trauma and torture - is entitled to absolute privacy regardiing his personal medical history. We as American citizens, however, are entitled to all possible information about the men and women who choose to ask act us to select them as president.

At the very least, Sen McCain's history raises many questions about the presence of objectively determinable disruption in neuropsychiatric function. He and his camapign have been forthcoming with his medical records in the past; his brain history strongly suggests that obtaining and releasing the results of current neuropsychiatric testing, imaging studies (perhaps including functional MRI and or auditory evoked potential findings) and other relevant assessments would be required in order to conclude that Sen McCain would bring to the Oval Office a brain functioning sufficiently well to serve as the second President of the 21st Century.