Defense of the DSM-5: New diagnoses for picking, bingeing, and tantrums. - Slate Magazine

Several new diagnoses appear in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, released later this month, and critics are attacking with claws extended. Controversy surrounds whether several of these new disorders should be included, and many experts question their validity.

Even Allen Frances, psychiatry professor emeritus at Duke University, who chaired the task force for the previous edition, the DSM-IV, called the day on which the DSM-5 was approved "a sad day for psychiatry." Of greatest concern is the new manual's potential to over-pathologize human behavior.

One of the most controversial new diagnoses, which Slate has covered before, is Disruptive Mood Dysregulation Disorder. It is intended to describe children between 6 and 18 years of age who show some signs of potential childhood-onset bipolar disorder. The category's hallmark criteria are "temper outbursts that are grossly out of proportion in intensity or duration to the situation." Yes, that's right. It sounds like temper tantrums.

Another controversy has erupted around Binge Eating Disorder. Bingeing, or eating a large quantity of food in a shorter period of time than is typical, is a disordered behavior according to theDSM-5. An individual who has eaten excessively at least 12 times in a period of three months meets criteria for Binge Eating Disorder. Frances calls Binge Eating Disorder one of the "top 10 changes to be ignored," noting that bingeing is "no longer just a manifestation of gluttony and the easy availability of really great tasting food.DSM has instead turned it into a psychiatric illness." (In fairness, bingeing is not a novel concept. It was previously listed as one of a number of potential symptoms used to diagnose a range of eating disorders, or it could be identified on its own as falling into the category Eating Disorder Not Otherwise Specified.)

It's unclear what the new diagnostic criteria mean for most people. It could mean that children with temper tantrums (that would be most kids, right?) could potentially be evaluated and/or treated for a psychiatric illness. Tantrums may become more than tantrums, but rather potential symptoms of mental illness. Anyone who eats like it's Thanksgiving a few too many times within a few months may be considered mentally ill.

However, there's more to this than simply saying our culture is moving toward pathologizing normal behavior. The DSM-5's heart is in the right place. In many cases the authors of the new manual have added categories to keep people from being wrongly labeled with a more severe disorder. Having the category Disruptive Mood Dysregulation Disorder may deter clinicians from prematurely diagnosing bipolar disorder, a serious mental illness with associated stigma that is often treated with medications that carry a host of potentially significant adverse effects.

The DSM-5 also adds skin picking (Excoriation Disorder) to its list of new diagnoses, which is characterized by repetitive skin picking that results in lesions, accompanied by recurrent unsuccessful attempts to cease the behavior. Critics have asserted that everyone picks their skin as a normal part of grooming behavior and turning such a behavior into a psychiatric illness will result in the inappropriate diagnosis of many normal individuals with normal behaviors. But skin picking is more than popping a few pimples. Yes, everyone picks at his or her skin at some point; however, skin picking as a disorder extends to picking, scraping, or gouging that results in scarring or disfigurement.

I see patients who struggle with skin picking, and they are seeking therapy because it has started to interfere with their ability to have a normal life.  It's important to remember that the DSM-5 is written for clinicians who are seeing patients with a set of troublesome symptoms. It's not a catalog for the general public to browse through in order to identify problems in themselves or others. Binge Eating Disorder has been included for the benefit of a therapist seeing a patient who worries about his binge eating and its negative impact on his life, not to pathologize everyone at an all-you-can-eat restaurant.

Many of the critiques coming from nonprofessionals treat the DSM-5 as the be-all and end-all tool for evaluating mental health and charging for mental health care. Actually, though, it isn't. Health care providers are tied to a different manual for billing and coding purposes, theInternational Classification of Diseases, Ninth Revision. It is actually this manual that diagnoses call home. Without it, insurance companies will not process claims for payment. The ICD-9 codes are largely consistent with those of DSM-IV, but with the release of DSM-5, there is likely to be confusion and billing issues. Incidentally, ICD-10 will not be released until 2014. Some frustrated clinicians are contemplating whether they will pay any attention to theDSM-5's release and, instead, may continue to use the DSM-IV/ICD-9 coding system. This may be merely their own disgruntled resistance to change.

The revolt against the DSM-5 has culminated in a bold, yet not unexpected, statement by Thomas Insel, the director of the National Institute of Mental Health. Insel's Director's Blog entry on April 29 expressed his displeasure with not only DSM-5 and its unwelcome additions, but also the DSM's symptom-based categorical approach as a whole.  He noted that the long-standing goal of the DSM as a diagnostic tool is to provide clinicians with a common language for psychopathology, and it continues to meet that goal. However, in an era of dramatic advancements in neuroscience and genetics, the DSM's approach to diagnosis has become outdated, relying on clusters of observable symptoms rather than lab tests. He asserts that as medical diagnosis has advanced, the growth and maturation of psychiatric diagnosis has been stunted.  In fact, of the DSM-5, Insel writes, "It is, at best, a dictionary, creating a set of labels and defining each," noting that although the DSM's common language creates a certain "reliability," "[t]he weakness is its lack of validity." 

Although Insel's statement came as a surprise to some, the NIMH has been working for several years to develop a set of criteria for the development of a new system for classifying mental illness. It just so happens that this may be a convenient time to gain support and momentum for NIMH's newly launched Research Domain Criteria project. Its goal will be "to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."  What does this really mean? It means that NIMH will no longer be adhering to specific sets of diagnostic criteria for inclusion in its studies and will be relying more heavily on "hard science" data for the identification of specific psychiatric illnesses.  It will be "re-orienting its research away from DSM categories." 

Ask clinicians how long the DSM-5 was in the works, and they are likely to joke about the painstaking wait for this lackluster manual. The project started in 1999 and involved 28 Task Force members, 13 Work Groups, 160 health care professionals, and more than 300 outside advisers.

Saying that it took many more years than anticipated would be a vast understatement.  However, it's difficult to even fathom the probable wait that the mental health field has to endure for the Research Domain Criteria's labor to come to fruition. I hope I am alive to see it. And I hope it's worth the wait.  For now, I'm still hovering over the purchase button toorder my new DSM-5.

http://www.slate.com/articles/health_and_science/medical_examiner/2013/05/defense_of_the_dsm_5_new_diagnoses_for_picking_bingeing_and_tantrums.single.html

A Data Trove Now Guides Drug Company Pitches - NYTimes

In the old days, sales representatives from drug companies would chat up local pharmacists to learn what drugs doctors were prescribing. Now such shoulder-rubbing is becoming a quaint memory — thanks to vast databases of patient and doctor information being used by pharmaceutical companies to market drugs.

The information allows drug makers to know which drugs a doctor is prescribing and how that compares to a colleague across town. They know whether patients are filling their prescriptions — and refilling them on time. They know details of patients' medical conditions and lab tests, and sometimes even their age, income and ethnic backgrounds.

The result, said one marketing consultant, is what would happen if Arthur Miller's Willy Loman met up with the data whizzes of Michael Lewis's "Moneyball." "There's a group of geeks, if you will, who are running the numbers and helping the sales guys be much more efficient," said Chris Wright, managing director of ZS Associates, which conducts such analyses for pharmaceutical companies.

Drug makers say they are putting the information to good use, by helping a doctor improve the chances that their patients take their medications as prescribed, or making sure they are prescribing the right drug to the right patients.

Some doctors, however, expressed discomfort with the idea of sensitive data being used to sell drugs, even though federal law requires that any personally identifiable information be removed. "I think the doctors tend not to be aware of the depths to which they are being analyzed and studied by people trying to sell them drugs and other medical products," said Dr. Jerry Avorn, a professor of medicine at Harvard Medical School and a pioneer of programs for doctors aimed at counteracting the marketing efforts of drug makers. "Almost by definition, a lot of this stuff happens under the radar — there may be a sales pitch, but the doctor may not know that sales pitch is being informed by their own prescribing patterns."

The research firm IMS Health has tracked information about which drugs doctors prescribe since the 1990s, and over the last decade, the list of available information has expanded to include insurance claims data, which yields a trove of intelligence about patients' medical diagnoses and insurance coverage. Additional details about patients, including income, education and ethnicity, can also be available.

One company, SDI Health, promises to provide clients with "actionable analysis" by tracking people — on an anonymous basis — as they move through the "patient experience." That includes, according to their Web site, filling prescriptions at a pharmacy, visiting a doctor, being admitted to the hospital and undergoing lab tests.

"Through our unique and proprietary patient-linking technology, we connect all aspects of a patient's behavior," the company's Web site states. IMS Health acquired SDI in 2011.

"The sales representative theoretically has the ability to understand not only the doctor's behavior, and which other physicians are key opinion leaders that the doctor listens to, but also the behavior of that doctor's patients," said Jerry Maynor, the director of marketing for North America at Cegedim Strategic Data, one of the companies that performs data analyses.

Some said that tracking physicians' behavior was no different from techniques other industries use to sell products, including following a consumer's Internet activity. But David Orentlicher, a law professor at Indiana University who writes on medical ethics issues, said the pharmaceutical companies' use of data has become more invasive. "A lot of the information comes out of the doctor-patient encounter," he said.

Privacy advocates also pointed to research showing that people in anonymous databases can sometimes be re-identified. "It just seems like it skirts the edge of the laws that do exist," said Adriane Fugh-Berman, an associate professor at Georgetown University Medical Center who is a critic of pharmaceutical marketing tactics.

Doctors who object to the use of their prescribing data by pharmaceutical companies can opt out through a program set up by the American Medical Association in 2006. But doctors cannot block the use of their insurance claims and other data, and some doctors complain that few know the program exists. About 31,650 of the nation's more than 767,000 practicing physicians, roughly 4 percent, have enrolled in the opt-out program since it was created, according to the A.M.A., which also sells information about doctors to companies like IMS.

Drug makers and their consultants say their techniques can help doctors by providing information that is customized to their needs. To sell the respiratory drug Spiriva, for instance, the German drug maker Boehringer Ingelheim uses insurance and prescribing data to focus on doctors with patients who have chronic obstructive pulmonary disease but who are not frequently prescribing long-acting drugs like Spiriva, which have been shown to reduce sudden attacks of severe complications in people with the disease, compared to shorter-acting drugs.

"You start analyzing what they're doing and you can find out if, through a combination of factors, you can intervene," said Paul Fonteyne, the president and chief executive of Boehringer Ingelheim USA.

Some pharmaceutical companies and consultants said the industry mainly used the data to market to big decision-makers like insurers, by demonstrating that their drugs are more cost-effective or show better outcomes for patients. Boehringer Ingelheim and the insurance company Humana, for example, recently announced a partnership aimed at improving the health and reducing costs for people with C.O.P.D. and other chronic diseases.

"At the end of the day, calling on doctors in terms of a personal selling model is a lot less important to selling your drug," said Andrew Kress, a senior vice president at IMS. "You can read a dark side to any of this, but the reality is that most manufacturers that IMS does research for are really trying to engage in a much more productive dialogue with the health care providers."

Companies are refining their pitches to doctors in part because it is getting harder to market to them. Studies show physicians are less willing to speak to sales representatives, either because they are opposed to such pitches, or because they are under pressure to see more patients. At the same time, the industry has laid off thousands of sales representatives in an effort to save money as once best-selling drugs have lost their patent protection.

"The industry is now having a harder time getting direct access to physicians," said Edward Rhoads, a managing partner and principal at the New England Consulting Group. As a result, he said, drug companies are asking, "How can we get the information into the community in a different way? There's a big emphasis in understanding how physicians influence each other."

This field, called influence-mapping, seeks to put a high-tech twist on the old idea that nothing sells a product better than word of mouth. One company, Activate Networks, applies technology licensed from Harvard University to draw connections between physicians with patients in common, then uses those ties to accelerate the adoption of newly introduced drugs.

"You can tell a lot about a physician's behavior by looking at what the people they have relationship with are doing," said Peter DeWan, the chief scientific officer at Activate Networks.

Mr. DeWan said his company assigned physicians a ranking based on how connected they were, which helped companies decide where to send a representative, or whom to invite to a talk about a drug.

But some doctors questioned whether these techniques were best for patients. Just because doctors are well connected doesn't mean they are prescribing the right drugs, said Dr. David C. May, a cardiologist who practices in a northern suburb of Dallas and is chairman of the board of governors for the American College of Cardiology.

"We have seen, in our particular part of Dallas, situations in which the physicians were aggressively marketed to and the drugs were perhaps inappropriately used early on," he said.

Dr. Larry Miller, the chief executive of Activate Networks, noted that the company also advised clients like insurance companies, which are using the same networks to persuade doctors to choose more inexpensive treatments. "You still have to be very careful," Dr. Miller said. "We all know our own networks and know who we respect."

http://www.nytimes.com/2013/05/17/business/a-data-trove-now-guides-drug-company-pitches.html?

My Medical Choice by Angelina Jolie - NYTimes.com

My mother fought cancer for almost a decade and died at 56. She held out long enough to meet the first of her grandchildren and to hold them in her arms. But my other children will never have the chance to know her and experience how loving and gracious she was.

We often speak of "Mommy's mommy," and I find myself trying to explain the illness that took her away from us. They have asked if the same could happen to me. I have always told them not to worry, but the truth is I carry a "faulty" gene, BRCA1, which sharply increases my risk of developing breast cancer and ovarian cancer.

My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman.

Only a fraction of breast cancers result from an inherited gene mutation. Those with a defect in BRCA1 have a 65 percent risk of getting it, on average.

Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much I could. I made a decision to have a preventive double mastectomy. I started with the breasts, as my risk of breast cancer is higher than my risk of ovarian cancer, and the surgery is more complex.

On April 27, I finished the three months of medical procedures that the mastectomies involved. During that time I have been able to keep this private and to carry on with my work.

But I am writing about it now because I hope that other women can benefit from my experience. Cancer is still a word that strikes fear into people's hearts, producing a deep sense of powerlessness. But today it is possible to find out through a blood test whether you are highly susceptible to breast and ovarian cancer, and then take action.

My own process began on Feb. 2 with a procedure known as a "nipple delay," which rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area. This causes some pain and a lot of bruising, but it increases the chance of saving the nipple.

Two weeks later I had the major surgery, where the breast tissue is removed and temporary fillers are put in place. The operation can take eight hours. You wake up with drain tubes and expanders in your breasts. It does feel like a scene out of a science-fiction film. But days after surgery you can be back to a normal life.

Nine weeks later, the final surgery is completed with the reconstruction of the breasts with an implant. There have been many advances in this procedure in the last few years, and the results can be beautiful.

I wanted to write this to tell other women that the decision to have a mastectomy was not easy. But it is one I am very happy that I made. My chances of developing breast cancer have dropped from 87 percent to under 5 percent. I can tell my children that they don't need to fear they will lose me to breast cancer.

It is reassuring that they see nothing that makes them uncomfortable. They can see my small scars and that's it. Everything else is just Mommy, the same as she always was. And they know that I love them and will do anything to be with them as long as I can. On a personal note, I do not feel any less of a woman. I feel empowered that I made a strong choice that in no way diminishes my femininity.

I am fortunate to have a partner, Brad Pitt, who is so loving and supportive. So to anyone who has a wife or girlfriend going through this, know that you are a very important part of the transition. Brad was at the Pink Lotus Breast Center, where I was treated, for every minute of the surgeries. We managed to find moments to laugh together. We knew this was the right thing to do for our family and that it would bring us closer. And it has.

For any woman reading this, I hope it helps you to know you have options. I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.

I acknowledge that there are many wonderful holistic doctors working on alternatives to surgery. My own regimen will be posted in due course on the Web site of the Pink Lotus Breast Center. I hope that this will be helpful to other women.

Breast cancer alone kills some 458,000 people each year, according to the World Health Organization, mainly in low- and middle-income countries. It has got to be a priority to ensure that more women can access gene testing and lifesaving preventive treatment, whatever their means and background, wherever they live. The cost of testing for BRCA1 and BRCA2, at more than $3,000 in the United States, remains an obstacle for many women.

I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.

Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of.

Angelina Jolie is an actress and director.

http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html?nl=todaysheadlines&emc=edit_th_20130514&_r=0&pagewanted=print

Doctors' Lucrative Industry Ties - NYTimes.com

Dr. Alfred J. Tria is the chief of orthopedic surgery at St. Peter's University Hospital, a 478-bed facility in New Brunswick, N.J., and to the medical technology company Smith & Nephew, his good word is worth a million bucks. Well, $940,857, to be precise.

That's how much the company paid Dr. Tria in fees for promoting its products and training doctors in Asia to use them from 2009 to 2011, according to disclosures required by the state of Massachusetts, where Dr. Tria is licensed. In 2010, Dr. Tria earned $421,905 from private industry — more than any other Massachusetts-licensed physician that year.

Dr. Tria may be an outlier, but gifts and payments to physicians from drug and medical device companies have been rampant in medicine for decades. Over a two-and-a-half-year period, device and drug companies shelled outover $76 million just to physicians licensed in Massachusetts, according to a study published online this month in The New England Journal of Medicine. That amount does not include outlays of less than $50, which are exempt from disclosure.

The companies treat doctors to dinner, pay them to attend lectures, and underwrite conferences and continuing medical education courses. Asked whether such payments could pose a conflict of interest for physicians, Dr. Tria said, "It's a legitimate concern."

A spokesman for St. Peter's said Dr. Tria had disclosed his financial relationships with industry to the hospital and refused to elaborate on the hospital's policy.

Information about these sorts of payments to physicians is available for the first time now in a handful of states that have passed laws requiring corporations to disclose payments to health providers. Next year, the data should be available nationwide when the federal Physician Payment Sunshine Act goes into effect. Corporations were supposed to start collecting the information last year.

"For many decades, we had no information — these were closely held industry secrets," said Susan Chimonas, of Columbia University, who has researched industry payments to physicians. "We are just starting to get a sense of how much money companies are spending on the marketing and consulting arrangements."

The data will be a treasure trove for researchers. For patients, the question is what to make of this information and whether to seek it out when choosing a physician or making an important medical decision. Orthopedic surgeons, cardiologists and psychiatrists received the most lucrative payments, the new study found. Primary care physicians — such as internists and pediatricians — were least likely to receive payments.

In Massachusetts, companies are required only to broadly categorize the purpose of the payments, and nearly 90 percent of them were described as "compensation for bona fide services." Dr. Aaron S. Kesselheim, an assistant professor at Harvard and the lead author of the new study, says that though the reported information can be vague, it can still be useful.

"It's another piece of data for patients to examine as they consider treatment options," he said. "If they go to an orthopedic surgeon who recommends a knee transplant, and they go to another who recommends watching and physical therapy, it might be interesting for the patient to wonder to what extent those two physicians have relationships with industry."

The question may also be appropriate if a physician changes a patient's prescription for no apparent reason, or prescribes a new or more expensive drug instead an older, tried-and-true alternative, said Dr. Joseph S. Ross, an internist and assistant professor of medicine at Yale.

"We know physicians are more likely to overprescribe or potentially prescribe inappropriately when they have a financial relationship with industry," Dr. Ross said. His own research has found that many physicians do not think there is anything inappropriate about industry gifts as long as they're not too lavish.

The size of the gift is not a determinant of its influence, experts say. Even a small gift can generate positive feelings and influence attitudes and behavior. "I don't think doctors ever set out to make decisions that are not in the best interest of their patients," said Dr. Deborah R. Korenstein, associate professor at Mount Sinai and a co-author of the study by Dr. Ross.

"But there are subconscious influences that people can't control, and that's why patients, and doctors, need to be concerned," she said.

A paper Dr. Korenstein published in 2011 found that more than a dozen expert panels that developed national clinical practice guidelines for managing diabetes and high cholesterol were dominated by physicians with financial conflicts of interest — that is, they were receiving payments from companies with an interest in how these diseases are managed.

Physicians often do not realize that they are being manipulated when drug companies offer to pay them consulting fees — for example, for listening to pharmaceutical representatives describe new medications and evaluating their performance. The real purpose "is just to get the doctor to listen to the reps over and over again," said Dr. Adriane Fugh-Berman, director ofPharmedOut, a project at Georgetown University Medical Center that focuses on the influence of drug company marketing.

Dr. Fugh-Berman advises patients to avoid physicians who see drug reps and dispense samples. "Ask, 'Could I have a tried-and-true drug?' 'Could I have a generic version?' "

Although many schools and hospitals have adopted new policies that guide interactions with industry, they exempt physicians who are not staff employees and do not restrict the doctors' income. Tufts University Medical Center adopted a policy in 2010 that required physicians to get approval and review if they were paid more than $25,000 in a year by a private company. But a Tufts associate professor, Dr. Yoav Golan, an infectious disease specialist, was paid $340,754 by drug companies in 2011, including $100,000 from Forest Laboratories, $73,918 from Merck and $42,109 from Pfizer, according to disclosures filed in Massachusetts.

A Tufts spokeswoman, Julie Jette, said the payments were approved by the university. "The policy wasn't intended to be a cap," she said. Dr. Golan did not respond to an e-mail requesting comment.

Dr. Chimonas said she would encourage physicians and their professional groups "to think about how all the information that is coming out is going to be interpreted or understood by the public."

"It's so important for patients to be able to trust their physicians," she said.

http://well.blogs.nytimes.com/2013/05/13/doctors-lucrative-industry-ties/

Brain science: Great articles about experimental neuroscience, conjoined brains, and everlasting consciousness. - Slate Magazine

Though many mysteries of the brain remain unsolved, advances in medicine and technology are bringing us closer to understanding exactly how it functions. Here are stories on brain breakthroughs, the scientists who made them, the patients who experienced them, and the ethics behind it all:

The Brain That Changed Everything
Luke Dittrich • Esquire • October 2010

When a neurosurgeon cut in to Henry Molaison's brain in 1953, his life changed forever. So would everything that science ever knew about memory.

"Brain surgery is an ancient craft — there is a four-thousand-year-old hieroglyphic text describing successful operations — and among my grandfather's most interesting artifacts was a collection of premodern and tribal neurosurgical instruments. As a kid, I found those picks and blades fascinating and terrible to contemplate. It wasn't just the age of the tools, it was the acts they were intended for. Brain surgery, whatever the era, always requires at least two frightening qualities in its practitioners: the will to make forcible entry into another man's skull, and the hubris to believe you can fix the problems inside."

Could Conjoined Twins Share a Mind?
Susan Dominus • New York Times Magazine • May 2011

On the shared life of Tatiana and Krista Hogan.

"Twins joined at the head—the medical term is craniopagus—are one in 2.5 million, of which only a fraction survive. The way the girls' brains formed beneath the surface of their fused skulls, however, makes them beyond rare: their neural anatomy is unique, at least in the annals of recorded scientific literature. Their brain images reveal what looks like an attenuated line stretching between the two organs, a piece of anatomy their neurosurgeon, Douglas Cochrane of British Columbia Children's Hospital, has called a thalamic bridge, because he believes it links the thalamus of one girl to the thalamus of her sister. The thalamus is a kind of switchboard, a two-lobed organ that filters most sensory input and has long been thought to be essential in the neural loops that create consciousness. Because the thalamus functions as a relay station, the girls' doctors believe it is entirely possible that the sensory input that one girl receives could somehow cross that bridge into the brain of the other. One girl drinks, another girl feels it"

The Itch
Atul Gawande • The New Yorker • June 2008

What the sensation of an uncontrollable itch can tell us about how the brain operates.

"Contemplating what it's like to hold your finger in a flame won't make your finger hurt. But simply writing about a tick crawling up the nape of one's neck is enough to start my neck itching. Then my scalp. And then this one little spot along my flank where I'm beginning to wonder whether I should check to see if there might be something there. In one study, a German professor of psychosomatics gave a lecture that included, in the first half, a series of what might be called itchy slides, showing fleas, lice, people scratching, and the like, and, in the second half, more benign slides, with pictures of soft down, baby skin, bathers. Video cameras recorded the audience. Sure enough, the frequency of scratching among people in the audience increased markedly during the first half and decreased during the second. Thoughts made them itch."

The Strange Neuroscience of Immortality
Evan R. Goldstein • The Chronicle of Higher Education • July 2012

How some scientists are turning to connectomes—maps of the brain's neural circuitry—to make the case for brain preservation, mind uploading, and eternal life.

"Among some connectomics scholars, there is a grand theory: We are our connectomes. Our unique selves—the way we think, act. Feel—is etched into the wiring of our brains. Unlike genomes, which can never change, connectomes are forever being molded and remolded by life experience. Sebastian Seung, a professor of computational neuroscience at the Massachusetts Institute of Technology and a prominent proponent of the grand theory, describes the connectome as the place where 'nature meets nurture.'

"Hayworth takes this theory a few steps further. He looks at the growth of connectomics—especially advances in brain preservation, tissue imaging, and computer simulations of neural networks—and sees something else: a cure for death.

The Brain on Trial
David Eagleman • Atlantic • July 2011

Should the discovery of a brain disease or disorder excuse a person from prosecution? How recent advancements in brain science are changing understandings of volition.

"As our understanding of the human brain improves, juries are increasingly challenged with these sorts of questions. When a criminal stands in front of the judge's bench today, the legal system wants to know whether he is blameworthy. Was it his fault, or his biology's fault?

"I submit that this is the wrong question to be asking. The choices we make are inseparably yoked to our neural circuitry, and therefore we have no meaningful way to tease the two apart. The more we learn, the more the seemingly simple concept of blameworthiness becomes complicated, and the more the foundations of our legal system are strained."

The Split Brain: A Tale of Two Halves
David Wolman • Nature • March 2012

How a radical surgery intended to separate the right hemisphere of the brain from the left impacted both researchers and patients.

"But what Vicki could never have known was that her surgery would turn her into an accidental superstar of neuroscience. She is one of fewer than a dozen 'split-brain' patients, whose brains and behaviours have been subject to countless hours of experiments, hundreds of scientific papers, and references in just about every psychology textbook of the past generation. And now their numbers are dwindling.

"Through studies of this group, neuroscientists now know that the healthy brain can look like two markedly different machines, cabled together and exchanging a torrent of data. But when the primary cable is severed, information — a word, an object, a picture — presented to one hemisphere goes unnoticed in the other."

As Good as Dead
Gary Greenberg • The New Yorker • August 2001

Is there really such a thing as brain death?

"When I spoke to Nick's parents, they still had trouble with the notion that, to become a donor, it was not enough for their son to die with his body more or less intact. He would have to have the right kind of death, with the systems in his body shutting down in a particular order. 'I'm so confused about this part of it,' his mother said. 'I don't understand why, if his heart stops beating, they can't put him back on a respirator." Rick, too, was confused about the moment at which "the plug will be pulled.' In reality, there is no moment when the plug is pulled; to keep the organs viable, the respirator is left operating—and the heart keeps beating—until the surgeon removes the organs.

"Confusion about the concept of brain death is not unusual, even among the transplant professionals, surgeons, neurologists, and bioethicists who grapple with it regularly. Brain death is confusing because it's an artificial distinction constructed, more than thirty years ago, on a conceptual foundation that is unsound. Recently, some physicians have begun to suggest that brain-dead patients aren't really dead at all—that the concept is just the medical profession's way of dodging ethical questions about a practice that saves more than fifteen thousand lives a year."

http://www.slate.com/articles/life/longform/2013/05/brain_science_great_articles_about_experimental_neuroscience_conjoined_brains.html?