Financial Disclosures

None

Ann Tilton, MD

Professor of Neurology and Pediatrics

LSUHSC New Orleans

The Power of Belief

Mystery/History

• How our beliefs impact

our lives and those we

touch

• Lens—

– Neurology of Voodoo

– History of Salem Witch

Trials

• Teach us about our

civilized world

Blurred Boundaries

Religious-Social-Biologic

Pain

Placebo/Nocebo

Sudden and Inevitable Death

Possession

Mass Hysteria

Distinctive Characteristic of a

Society is it’s World View

• “Primitive”

–All part of the

universe

–No separation

of spirits,

religion and

magic

• “Civilized”

–Forces are under

our control

–Little interest

Voodoo (based on West African Beliefs)

• Fate is predetermined

– Western culture-Tarot cards

– Difference---it can be altered

• To counteract the evil forces

– One needs a priest or medicine man

• One is not at the mercy of evil

– System to combat evil

Supreme

Being

Deities

Gods /Loas

Ancestor

Spirits

Priests/Intermediary

Social Groups

Slave Trade-New World

1619-1861

Slave Trade-New World

1619-1861

• New world was hostile

• Accepted new gods

– Serpent deity Da - Saint Patrick

– Leyba Guardian of entrances - Saint

Peter

– Continued to use talisman

• Integrated into Catholicism

Marie Laveau –

Voodoo Queen

• 1794-1881 (1915)

• Commercial

venture

• Added saints/

prayers/ candles

and holy water

• Powerful - For

good or ill

• Immortal?

Voodoo Today

In New Orleans--open practice

Voodoo Lives On–

Gris-Gris

• A mixture of black

and white magic

– Juju, mojo

• Powerful - For

good or ill

• Potion worn

– Pepper, brick, hair,

animal skin

• Resurgence…

Can Voodoo alleviate pain?

• A 40 yr old woman consults a priest

for severe back pain

• The priest invokes an incantation for

the help of a loa and applies a

tingling salve

• The pain completely resolves by the

next morning

Why did the Voodoo Work?

Mechanisms of Response to

Pain Therapy

Any medical treatment has

two components

• The specific effects of treatment

• The perception that the therapy is

being administered

Modulation of Nociceptive

System

• Central and peripheral mechanisms

can increase or decrease pain

perception

• Placebo• Psychological

• Biological

Placebo and Nocebo

• Placebo is latin for “I shall please”

• Nocebo is latin for “I shall harm”– 1 in 20 treated with placebo withdraw due to

adverse effects

• Calls attention to use of a sham drug

– What matters is not the “drug” but the

changes in the brain

Psychological explanation

• Classical conditioning- Pavlov

– “Clinical” setting has an effect

• Nocebo–

– nausea - where chemotherapy took place

• Placebo–

– Protocol - conditioning with a placebo analgesic

cream

– The conditioned group believed the cream

would work- resulted in less pain

Placebo Response

• If the subject believes in the healer or

treatment - Improvement will occur

• Placebo effect (DBPC) up to 50%

– Triptan study

• 20-40%

What influences the Placebo

Effect?• Pill size

– Color, number, and capsule (cost?)

• Mode of administration

– IM > pill, IV > IM

– Seen > hidden

• (blocked by naloxone)

– Surgery

• Sham surgery

(An Evaluation of Internal-Mammary-Artery Ligation by a Double-Blind TechnicN Engl J Med 1959)

What influences the Placebo

Effect?

• Doctor-patient interaction

• Expectations

• Time spent

• Enthusiasm

• White coats

• Stethoscope

• Emergency room setting

Pain

• Chemical substrate for placebo

– Secretion of endogenous

opioids ( 2x beta endorphins)

• Reversed by naloxone

– Cholecystokinin (CCK)

• Inhibition

– Act on 5-HT system

Brain imaging

• PET first showed

the area activated

during opioid or

placebo induced

analgesia largely

overlapped

– Rostral anterior

cingulate cortex

– Orbital frontal

cortex and

periaqueducatal

gray

Activation of μ-opioid receptors

Parkinson’s Disease

• Increased dopamine

release-dorsal

striatum

• Fetal transplant

study

– QOL improved

depending on the

“believed “group of

assignment

Psychological Factors?

• Stress aggravate pain or trigger

• Strong emotion may blunt pain

– Soldiers / accidents

– Sociocultural (Reversed with naloxone)

• Voodoo removes pain

• “Fear of pain may be worse

than pain itself”

– CCK activated

Peripheral Factors?

• Gate control theory

– Stimulation of large

diameter afferents inhibit

small afferent fibers (substantia gelatinosa)

• Counter irritation

– Pain in a separate area

Clinical Trials

• DBPC Trials

– Importance of a placebo

– Comparing two active medications

• Headache and pain trials– Ketorolac, merperidine & placebo -- equal

• Open-Hidden protocols

– Reduced debate on placebo-ethics

– If there is a large difference open vs

hidden = placebo like

VoodooWhy did it work?

• Natural remission

• Placebo-BIG PILL

• Expectations

• Peripheral stimuli

• Effective treatment

Sudden and Inevitable

Death

• Usually in

ceremonies

• High stimulation

• Selected by the

sorcerer

– Individual falls over

dead

• A 23 year old woman presented on her

birthday to the emergency room stating

that she was going to die

• She and her sisters had been cursed

– Her sisters had died at 21 and 22 yrs of age as

the curse had stated

• She was admitted for observation

• She was found dead the next morning

Sudden Death

• 1942 Cannon published “Voodoo Death”

• Cases from all over the world

• REAL phenomenon

• What was in common?

– Absolute belief that an external force cause one’s demise

– The victim has no power to alter the course• Hopelessness and overwhelming

Can that really happen?

• Application to our world?– Patient says “I am going to die”

– Operating room -”poor guy-no hope”

– Omaha Beach

– Assault with death and only minor injuries

• A view of Neuro-Visceral Disease

– Sudden and Inevitable

How does it affect our care?

• In the context of neurological disease:

– ECG changes consistent with ischemia • aneurisms, SAH, coma, stroke

– The pathology – no ischemia

– With brain death the ECG findings reverse

• Is it rare?

– Series of 100 stroke patients• 90% of stroke patients

Mechanism of Neurogenic

Heart Disease

• Myofibrillar degeneration • The ultrastructural changes in almost every cell

• The changes are less at a distance from the

intracardiac nerves

• Distinctive?

– Myofibrils die hypercontracted (MI are atonic)

– Changes visible within minutes

– Subendocardial predominantly

» Serious Arrhythmia

(Prevented by sympathetic blockade)

Animal Models

• Capture or transfer

• Death from fright and restraint

– Autonomic hyperactivity

– Not blocked by adrenalectomy and with

normal serum catecholamines

– Evidence of direct neural connection to

the heart

What about stress?

– It can produce the same lesions

– 15 victims of physical assault-died of

the assault without internal injuries

• 11 of 15 had the myofibrillar degeneration

• Stress

– Takotsubo (octopus trapping pot)

• Left ventricular dysfunction in the apex

• Predominantly women after emotional

stress

• Time of natural disasters-earthquakes

The heart pathology is seen in:• Animals and people with acute

neurologic or psychiatric catastrophes

–Thought to have a role in death

associated with:

• SUDEP- up to 17%

• Drug abuse, asthma, grief, war

The Inevitable Voodoo Death

• Previously well woman developed severe

abdominal pain

– Surgery normal

• She became isolated, progressively weak

and died

• Buried outskirts of the cemetery

• Diagnosis- She had been cursed

• Folk medicine has two forms

– Natural

– Unnatural from hexes

• Contagious magic

– Once physically connected –cannot be separated

– Hair or fingernail – hex – illness

– Voodoo dolls-(extension of the person)

Does Inevitable Death

Happen?

• Premise:

– Cursed by another -- hopelessness

– Community / family withdraw support

– The individual is an outsider - fatigues,

stops eating

Examples: Churches, exorcisms

Are there similarities between

being cursed and fatal illness?

– Power-Medical authority predicts death

– The patient and family believe the doctor

– Patient has no control and may withdraw

– Physicians “withdraw”

– Family withdraws and patient dies prior to

biologic expectation

Examples

• Voodoo

–Hexed

–Slowly withdraws

–Family withdraws

• Western

–Surgery-no hope

–Loss of will to live

–Team withdraws

–Birthday death

–After natural

disaster

Possession?

• 24 yr fell to floor

convulsing while at his

uncle’s funeral

• Dx: Possessed by a

protective loa of his

uncle

• Treatment

– 6 years by a priest

• 27 yr fell into a fire

during a ceremony

• Dx: Possessed by

Mainette a bad loa– Who is related to fire

Possessions

• “ To be seized by spirits”

• Religion and epilepsy

– Greeks - visitation by the gods

– Christians - demonic possessions

• Voodoo is based on religion and

being possessed by spirits– Divine favor

The Voodoo Priest was not successful

– Why in their eyes?

• Noncompliant patient- clearly not following

instructions

• Did not believe

• Pseudo-event

• Too strong of an evil Loa

• Last--Wrong diagnosis – not a possession

– It was a seizure

• Often patients pursue both treatments

The Salem Witch Trials

Related Concern

• Eight girls in a small town begin to

have unusual movements

• The entire town became involved

• There is a great deal of attention

directed at the cases

• Original concern was a contagious cause

• But it was determined to be witch craft

begun by a worshiper of Voodoo

• By December 1691…8 girls were

“afflicted” with an unknown distemper

• Diagnosis – bewitched

• Treatment

– Fasting and prayer

– Witch cakes

Salem Witch Trials

Court allowed spectral evidence

and critical touch

Salem Witch Trials

• June-September 1692

–20 witches were convicted

–No confessions

–19 hanged and 1 stoned

• Stopped with a new Governor

–Reprieved 150 in spring 1693

What Caused This

Tragedy??

Ergotism• Claviceps purpurea grows on cereals

– Cold winters, wet springs and low lands

• Mycelia - 2-3 cm growth

• 1% ergot alkaloid

– Potent• 40 alkaloids

• Lysergic acid (LSD)

• Histamine, tyramine and

acetylcholine

Alternative

Conceptualization

• Mass “hysteria”

• Fraud

• Social cues– Goal directed enactment to sustain “bewitched”

– Goal directed does not imply fake

– Bewitched was confirmed by community leaders

– Role can not be terminated

Mass Psychogenic Illness

• 1952- 165 members of a cheerleading

squad in Monroe, LA accidently came on

the field and ultimately fainted

• 2002- 10 students (5 cheerleaders) in

North Carolina had nonepileptic seizures

and fainting

• 100s of cases per year in US

• Most cases resolve quickly

–If there is reassurance

• Environment is ok

• Not an extensive work-up

Le Roy New York

• Unusual combination of conversion

disorder and mass psychogenic

illness

– Began with cheerleaders

– Spread: 18 girls, 1 boy, and a 36 yr

woman

Le Roy Environmental

Issues

• Waste from closed company

• Train derailment and corroding

barrels

– EPA stated no chance-then hazmat

suits

• Erin Brockovich sent “testers”

Theories

• Environmental

• Pandas (pediatric autoimmune

neuropsychiatric disorder associated with

streptococcus)

– If you get better without pills –you were

faking

• Biopsychosocial

• Stress

Treatment

• Antibiotics

• Cognitive behavioral therapy

– Discuss the continuum of stress related

disorders

Brain Origin?

• Possibly amygdala

– Locus of startle and fear

– Overactive in conversion disorder

– Instead of psychological stress some

cases - involuntary movements (Hallett)

• Mirror neurons-when we witness

actions

Our Culture

• Originally thought to be contagious

– Then group hysteria

– Marginal social status

• Adopt a sick or possessed role

– Decrease job/school stress

– Sympathetic attention from others

Salem and Our Culture

• Social advantage

– Solace and sympathy as a victim

– Advance from little influence to one of

power

– Center of attention

– Command (fearful) respect

Brain is directly

influenced

through social,

psychological,

and biological

means

PLACEBO

NOCEBO

PAIN

SUDDEN DEATH

POSSESSION

PSYCHOGENIC

Have your beliefs changed?

• Belief systems hope to offer control

over what is seen as uncontrollable

• Be careful what you think is primitive

“The problem is not with what you see- the problem is with

what you recognize” -- Sherlock Holmes

THANK YOU !

Individual spells for you

Zombies

• Western world became aware of

Zombification in the occupation

of Haiti (1915-1934)

• Up to 1000 new cases per year

• Haitian penal code (246)

–Considers it murder

Zombification

• Body, mind, and spirit

– Physical body

– Awareness and memory

• The awareness and memory is kept in a

fastened bottle - (zombie astral)

• The body remains without will as a

slave

– Beatings

– Poison

Characteristics

• A young person is suddenly ill

• Recognized as dead and placed

in a tomb

• Stolen by a bokor (sorcerer)

• Secretly returned to life and

activity but not full awareness

Zombie Recipe

• One freshly, almost dead, person

• Some human bone and flesh

• Several varieties of exotic plants

• A few reptiles

• One type of worm

• A centipede

• A special type of spider

• One puffer fish

Zombie Escape

• Bottle breaks

• Bokor inadvertently feeds salt

• Bokor dies

• Released by divine intervention

• Release does not change the symptoms

Fear is reserved for the possibility of being Zombified oneself

Possibilities

• Neurotoxins

– Tetrodotoxin

(puffer fish)

• Apparent temporary

death

– Datura to revive or

control the zombie

• Produces extreme

passivity

Possibilities

• Neurotoxins

• Psychiatric

• Mental deficiency

• Mind control

Clairvius Narcisse

• Zombie for 2 years

• Wandered away

when his master died

• Found by his family

16 years later

Cases

• 30 yr woman died

• Seen 3 yrs later

• Tomb opened

• Help with daily

needs

• Recognized as a

zombie

• Dx: catatonic

schizophrenia

• 18 yr died

• 19 mo later recognized his father

• Uncle arrested and convicted

• Interview- ill and a zombie

• Dx: organic brain syndrome and SZ

Real ??

• Malevolent voodoo priests (Bokor) do

engage in Poisons and Neuroleptics

– Plants

• Anticholinergic

• Skin irritants

• Shaking and tremor

– Animals

• Cardioactive steroids

• Catecholamines

• Psychoactive agents

Mental Illness

• It is supernatural-a spell

• Psychotic break is a curse

• So the patient is not ashamed-not

their fault

– Laws protect – cannot divorce

• Depression is due to a medical

condition

– Presents with headache, backache