Tuesday, 31 December 2013

Is this punding? You decide

While I appreciate that starting any blog with the word Wagner is usually enough to have readers abandoning the page like lemmings, you might want to stick around for this one. Trust me, it will make sense -- well, inasmuch as anything I write makes sense.

Because dear reader, and you may already be in the singular rather than plural, I want to tell you how the music of Richard Wagner has alerted me to possible new developments in my Parkinson's. And no, despite the man's overwhelming sense of self-importance, not even he claimed to be a neurologist. Pretty much everything besides -- musician, composer, poet, political activist, author and general philanderer. But not a neurologist.

Let me backtrack a little.

As many of you who know me would be the first to acknowledge, I like music. And my tastes are catholic, albeit with a few gaping holes. I can't imagine the day dawning when I will buy my first Eminem record for instance. And Lady Gaga should probably not rely on me to bolster sales in the post-Christmas lull. But other than a few egregious examples, I like most music. And some music, I absolutely adore. Many of you will already be hearing the possible direction this is taking. But bear with me.

Anyway, to cut a long story short (and when have I ever), I discovered that, over some 30 years of purchasing, I have amassed just over 3500 classical CDs. Leaving aside the fact that this amounts to a cash outlay of somewhere in the region of a year's salary, it also represents a substantial listening time commitment. People often ask me how I find time to listen to them all. Well, the answer is of course that I don't. Assuming a conservative estimate of 60 minutes per disc, and an average listening day of say 10 hours (just to make the mathematics easy), I could start at Albinoni at 9 AM on January 1, 2014 and only reach the closing bars of Zemlinsky's Sinfonietta at around supper time on 14 December.

I would have put Beethoven behind me in late February, before hearing Delius's 'First Cuckoo in Spring' appropriately enough in mid-March. April would be spent wading through the deep waters of Elgar oratorios before summer marched in around June with Mahler's hymn to nature, the mighty 3rd Symphony. By August, we are humming 'O Mio Babbino Caro' and ''Nessun Dorma' with a glass of Barolo in hand, before Sibelius's Tapiola accompanies a distinct nip in the September air. As we rummage for jumpers in October, Stravinsky's Rite of Spring seems a world away. Slippers by the fireside in November can only mean the whoop of Valkyries, before Walton invites us to Belshazar's Feast, just as the office Christmas bashes gets underway.

I f I took an hour off for lunch each day, we would be into 2015 before I had popped the cork on Strauss's Champagne Gallop. And if I allowed myself music free weekends, we would be surrounded by Sugar Plum fairies until well after Easter 2015. And if the restriction was a mere one hour per day (and I have to concede that there are some people out there who listen to as little Wagner as this), we would have changed presidents not once but twice during the course of my classical record collection. In fact it's not beyond the realms of possibility that, by the time Wagner reaches the end of the world in Gotterdammerung, the world could actually have ended. Now that would be a production worth seeing ...

Of course these calculations make the assumption that I do not buy a single CD between now and the election of Obama's successor's successor (or the end of the world, whichever comes first). And let's face it, that's not going to happen.

For many of you, the prospect of listening to my record collection for the next decade would be about as popular as eight years of Republican government. And probably about as productive.

Okay, enough of these diversions. Let's get down to the serious business of what I have to say. Amusing though the above may be (I hope it made you laugh), the very detail of it reveals the number of important aspects of Parkinson's. How a record collection can be indicative of symptom progression is something that many of you may find puzzling. But in amongst all those fripperies, are some key facts.

1) I have an abnormally large number of CDs.

2) I have expended significant time and energy counting them

3) I have arranged them in alphabetical order

4) I have performed several unnecessary (if amusing) calculations on these CDs.

From a neurological stance, these activities are evidently pointless. It really doesn't matter how many CDs I have nor the length of time the music would play for. Not one of these mental exercises has the slightest value. These are essentially repetitive and unproductive behaviour elements. And there is a word for this behaviour.

It's called punding.

Punding is essentially the unproductive repetition of small behavioural components, to the exclusion of other behaviours. Typical examples might be the collection and sorting of objects according to size or shape for instance. Taking things to pieces and reassembling them might be another example, particularly amongst men. Women will often repeatedly sort through their handbags or tidy continuously. Many people with Parkinson's who exhibit punding find it comforting, rewarding or in some way enjoyable and are frustrated when diverted from the activity. Most who pund retain insight into their behaviour.

On the face of it, and in the absence of any other information, you would reasonably suppose that I was showing signs of punding. Collecting and sorting are hallmarks of punding. So, were I to present myself to an uninitiated neurologist -- a trainee for instance -- they might draw that conclusion and treat accordingly.

We know that this is a dopaminergic behaviour as it was first observed in amphetamine and cocaine users, both of which drugs release dopamine in the brain. A recent paper (Fasano & Petrovic, 2010) appeared to implicate the dopamine agonists in general and those with actions on D1 and D2 receptors particularly.

But am I actually punding? If the hypothetical neurologist trainee knew me a little better, might they draw a different conclusion?

The key thing here is the premorbid personality. What was the patient (me) like before I had Parkinson's? Is this apparent punding a new behaviour, entirely out of character, or is it merely an exaggeration of the behaviour I exhibited before Parkinson's? Is it even exaggeration at all?

So, to help answer this question, let me take you back more than 40 years. A 10-year-old Jon has a bedroom at the end of a long corridor. Sharing his bedroom are 4 floor-to-ceiling industrial shelf units. And covering (literally covering) every inch of space are model aeroplanes of every shape or form. More than 200 as I recall, and here memory fails me. And these planes were divided up thematically. Two shelves were occupied by First World War aircraft -- Sopwiths, Fokkers, Spads and so on, surrounding the pride of my collection, a Handley Page bomber. And so it went on, each shelf organised according to nationality or time period (e.g. Second World War American bombers). On those four shelves was an entire Airfix airforce. Were these planes real, they would have amounted to a significant strategic deterrent.

So my point is this. The 10-year-old Jon did not have Parkinson's and did not take any medication beyond the usual aspirin or paracetamol. Juvenile Jon was nonetheless of a rather obsessive persuasion and although I did not wash my hands hundreds of times a day, I always avoided the cracks in pavements.

I would submit, your honour, that what at first sight looks like an open and shut case of punding is rather more complex. I don't rule punding out but I do believe that it is important to take into account the patient's own personality, however quirky!

Finally, before I subject my case to you for scrutiny, I should just like to respond to each of the points I enumerated above:

1) 3500 CDs is not unique. David Mellor has more.

2) It’s only a ballpark figure, accurate to ~50 or so.

3) Well, since they occupy 8 metres of shelf space, how would you find any CD otherwise

4) Actually only once - for the amusement of readers of this blog.

Over to you -- am I punding?
Fasano A, Petrovic I (2010) Insights into pathophysiology of punding reveal possible treatment strategies. Mol Psychiatry. 15: 560-73.

Tuesday, 24 December 2013

Come dine with me...

About a year ago I received a letter inviting me if I would like to participate in a program called "Come Dine with Me" on Channel 4 as I recall. There was a paragraph or two explaining the nature of the show -- basically five contestants she take it in turns to cook for the others. Then, at the end of it all, everyone votes to decide who cooked the best meal. The show is also punctuated by brief interviews with each contestant in which they say what they liked and disliked.

Sounds innocuous enough I thought and mentioned it to Alice.

"You should definitely do it Dad" she said "the contestants cook awful food and say bitchy and sarcastic things about each other. You'd be perfect".

I think she intended it as a kind of complement.

But if I had ever entertained even the briefest flicker of interest in participating, Alice's rather overcandid appraisal of my suitability pretty much snuffed it out.

I pretended to be hurt.

After all, if the principal pre-requisite for the show is to be sarcastic and cook dreadful food, it's rather unsettling that, in Alice's eyes, I have both bases already covered.

She's probably right about the corrosive tongue. Despite repeatedly being told, as a child, that it was neither big nor clever, I've always found sarcasm to be both. You only have to look at the number of nations without an equivalent of this rapier-sharp linguistic weapon to acknowledge its power. It is something peculiarly British. Our language, with nearly 3 times as many words as others, is particularly conducive to sarcasm.

I'm probably also bang to rights on the food. Nobody who has ever experienced my lentil and bean sprout clafoutis would query my ability to create something inedible from normally promising ingredients, to somehow snatch culinary defeat from the jaws of gastronomic victory. My family lose track of the occasions where I have somehow managed to turn say eggs, milk and flour into a sort of chilled-omelette-sorbet-thing rather than the classic hot soufflé they were perhaps anticipating. My explanation about the spiritual value of walking the path less travelled is brushed aside as swiftly as the food itself.

But even with my impeccable qualifications for the show, it quickly becomes clear that the participants are infinitely worse, taking the word 'scathing' to dizzying new heights. It transpires that, in addition to passing judgement on the food, the guests are expected to wander around their host''s dwelling, treating the viewing public to their thoughts on the contents of sock drawers, wardrobes and wine cellars. Every nook, cranny and crevice is poked, prodded and probed. All is laid bare -- whether you buy your clothes at Top Man or at Gieves and Hawkes, all is fair game to the perfidious vipers who participate in the show.

By any standards, it's grim viewing. To be stuck in a room with one self opinionated narcissist is purgatory. Take five, all with volume control issues, and it's as near to hell as I can imagine. One minute the guests are oozing fulsome praise for the host and for his adventurous sprout terrine with a cabbage jus, only to then liken it, for the benefit of the cameras, it to a luminous green cowpat,

The whole notion of the show is, in any case, a ridiculous contrivance. If you put Tarquin Chinless-Wonder, Gazza and Betty Boop around the same table, it's a fair bet that conversation will be, at best, stilted. Betty will know as little about plover's eggs as Tarquin does about pink feather boas. But then of course, if they all got on like a house on fire, there would be no television programme.

I remember Castaway a decade or so ago, ostensibly a social experiment on the concept of community, where a group of people were abandoned on the island of Tarantsay. As a social experiment it was a success. For the most part, the people got on reasonably well. As a piece of prime-time television however, it was pretty lame. Until the producers hit upon the idea that the islanders needed to relax and also to find more of their own food. Their solution to this two-pronged conundrum was to supply the islanders with alcohol and guns respectively. Suddenly the program had an edge. Although, for the most part, still resolved through a series of civil verbal exchanges, there was now the possibility, however remote, that differences of opinion might instead find themselves subject to an armed response.

Castaway at least had some kind of sociological or scientific pretensions. But a situation as contrived as Come Dine with Me does not even have that. It's is more unreality than reality TV. With regard to scientific merit, it is rather like stamping on woodlice to see if they can support the weight of a human being.

But the show has served one useful purpose. I'm satisfied that no matter how sarcastic I become and no matter how badly I cook, I will never appear on the programme.

Well, maybe if there were guns...

Thursday, 19 December 2013

Cascais near Lisbon

A couple of weeks or so back I found myself in Cascais, 20 miles west of Lisbon, for a conference. I say 'I found myself' probably conveys the wrong impression. Rather like saying, after a stag night, that 'I found myself' naked in a roadside skip near Arbroath, handcuffed to a Puerto Rican stripagram girl and with the word Dolores tattooed across my chest. We've all been there.

No, this time I actually chose to be there. In Cascais not Arbroath. You knew that.

So why Cascais, a well-known and wealthy seaside resort, the Monte Carlo of Portugal indeed, adjacent to Estoril where the yachted aristocracy of Europe would meet for the Portuguese Grand Prix? Not, you might think, a particularly representational venue for an academic conference. And in that you would be right. Since the legislation on pharma-funded conferences tightened, these have been dour, grey affairs so unattractive that there would be no chance of mistaking them for any pharmaceutical jolly. No indeed. These conferences are calls of duty rather than freebies. Food is grey and uninteresting, served by staff of the same ilk. And should you ask for a second helping of anything, you are greeted like a latterday Oliver Twist. Believe me, short of conducting proceedings in a Turkish prison, it's hard to see how they could be less incentivised.

Dissatisfied even with these austerity measures, at least one drug company is rumoured to be terminating all paid relationships with physicians. That includes sponsorship for doctors to attend conferences and honoraria for work on advisory boards. Now call me an old cynic (and many do) but I don't see this working. Okay, there may be those amongst the company who feel that this amounts to a strong occupation of the moral high ground. They may even be right. In a utopian society, doctors might well work for free and give up their annual leave for the greater good, even spend the money set aside for the family holiday in order to attend a conference.

No, really.

Meanwhile, back in reality, I suspect the truth is rather more predictable. Given the choice between unpaid work for a drug company and a round of golf with friends, I think we know who is holding all the clubs. To believe in altruism on this scale you would need to have a strong faith in porcine aviation. The simple reality is that doctors will seek sponsorship from other sources. That means other drug companies. Rival drug companies. The moral high ground can be a pretty lonely place sometimes.

It reminds me of the old Soviet Cold War joke:

Q: what's the definition of a string quartet in Russia?

A: a symphony orchestra after a tour of the West.

Don't get me wrong -- I'm not advocating a return to the gravy train days of old where influential physicians were (allegedly) kept sweet with all sorts of nonsensical and inappropriate inducements. Stories of paid 'fact-finding' trips to the Bahamas, although probably apocryphal, helped create the perception of widespread abuses by an industry grown cynical. Austerity was seen as the only reasonable antidote. And predictably, as so often with regulatory measures, the pendulum swung dramatically. Conference venues, instead of being upmarket hotels were suddenly gulags.

But of course if the pharmaceutical industry is not covering the bar bill, none of the above restrictions apply. And without lavishing speakers with carriage clocks, laptops, iPads and other sundry electronics, it is still possible to make the conference experience more enjoyable. Cascais, where you can walk along the beach at dawn before the scientific sessions, is just such an experience. A place you want to return to and people you want to work with again.

Do I feel sullied by such comparative opulence? Do I feel corrupted by such generous hospitality? Do I believe that my opinions have been in some way bought? No, not in the least. It's just nice to have a conference in an environment that is conducive to productive work and not an attempt to faithfully recreate the film set of Midnight Express.

Obrigado Cascais. Obrigado.