Inside the mind of Dr Harold Shipman
In order to understand some of the terms in this article some basic details are explained. There are several parts of neurons or nerve cells. These are
1. The synapses.
2. The dendrites.
3. The cell body.
4. The axon.
Click here for a diagram of a neuron or nerve cell. There are about 100 billion nerve cells in the brain.
It is recommended that you watch this short video before reading this article as it may improve the understanding of the article.
The tree model of brain disease – video
Dendrites are fibres which receive information from other neurons.The dendrites are tree-shaped. Dendron means “tree” in Ancient Greek. Dendrites have protruberances on their surface called dendritic spines rather like leaves on a tree. Dendritic spines have receptors or synapses on their surface. Synapse means “connection” in Ancient Greek.
Synapses receive chemicals or neurotransmitters from other nerve cells.The axon is a single fibre which transmits information to other neurons. Axon means “to go or to travel” in Ancient Greek.
In a recent study Professor John Armstrong found that changes in spine or leaf density and length precede changes in synaptic strength and number. This confirms the importance of the spines or leaves in being required for synapse development. Generally speaking the more dendritic spines there are on a dendrite the more electrical activity and firing of electrical signals or “firing rates” there are. However many questions remain unanswered.
In most psychiatric diseases there are changes in the shape of neurons and in particular the dendritic spines. The dendritic spines or leaves are generally reduced in number and density. This may be compared to the reduction of the leaves on a tree which occurs from summer into winter.
These abnormalities are associated with immune system activation. The immune system seems to be regulated by white cells called regulatory T-cells or TREGS. (For more information check out “Mechanism of Disease: Evolving Role of Regulatory T Cell in Atherosclerosis: TREGs in Human Autoimmune Disorders on medscape.com) The immune system in the brain is abnormal in most psychiatric disorders and may be associated with abnormal TREG cell activity. This suggests that the changes in dendritic spines are inflammatory in nature.
Genetic abnormalities are also increasingly being discovered in psychiatric disease which explains why identical twins often both have the same psychiatric disorder.
The inflamed dendrites are called “dendritis”, as in Medicine, inflammation of a structure is proceeded by the suffix “itis”. It is noted that dendritis precedes nerve cell death or apoptosis and that in most psychiatric disorders the nerve cells are still alive but not functioning normally due to the inflammation.
Synapse numbers are also affected and this may be described as “synapsitis.” However as Professor Armstrong`s research confirms the dendritic spines seem to determine the synapse numbers rather than vice-versa.
It is important to realise that up to 70% of the brain`s synapses on these spines change every day as described by Professor Travis. The spines or leaves can decrease in number over hours in response to stress as described by Professor Baram.
And so to the clinical features of psychiatric disorders and how they relate to reduced dendritic spine or leaf numbers. In psychiatric disorders the reduction in spine or leaf numbers is predominantly in the frontal lobes or front of the brain.
Reduced numbers of dendritic spines result in reduced firing rates or electrical activity of the dendrites. This is correlated with the development of increased sensitivity to excessive feelbad or negative thoughts and feelings of
1. Resentment i.e. hatred.
2. Self-pity i.e. “depression”.
3. Fear i.e. “anxiety”.
4. Dishonesty i.e. criminality.
There is often associated obsessive-compulsive behaviour when dendritic spine numbers are reduced in the frontal lobes.
If the memory centre of the brain or hippocampus` dendritic spines or leaves are affected short-term memory and later long-term memory will be decreased. This is referred to as “hippocampitis”.
It was thought that in some disorders of the brain an accumulation of material from disordered metabolism was the reason why the brain malfunctioned. However recent studies have confirmed that there just wasn’t volume of the debris to account for the abnormal brain function e.g. Alzheimer`s disease and Parkinson`s disease.Reduction in spine or leaf numbers are now being noted in many brain disorders such as migraine and epilepsy (see Novel Therapeutic Approach for epilepsy: Dendritic Abnormalities in Epilepsy on medscape.com).
In summary most psychiatric diseases and neurological diseases are associated with reduction in size and numbers of dendritic spines. The spines may be compared to the leaves on a tree. The proposed comparison to the reduction of leaves on a tree from summer into winter may be easier to understand than the current chemical model where patients are informed that their brain chemicals i.e. serotonin or dopamine are too low.
The DSM IV diagnosis of dependency is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect
(b) Markedly diminished effect with continued use of the same amount of the substance.
2. Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for the substance
(b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
3. The substance is often taken in larger amounts or over a longer period than intended.
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of substance use.
7. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Dependency results in an obsession-compulsion to use a substance.
The Tree Model Of Brain Disease As Applied To Dependency
People with dependency often have the following characteristics
1. Family history of dependency
2. Feeling different or disconnected – often feeling superior or inferior
3. Feeling threatened by intimacy
4. Feeling either a perfectionist or a failure
5. Feeling time is passing too quickly or slowly
6. Being sensitive when younger e.g. greatly feeling the sense of loss
7. Feeling normal with the first use of a substance
8. Needing more of the substance to achieve feelings of normality in association with obsession-compulsion to use the substance
9. Eventually the substance results in feeling worse
10. Losses due to the behavior related to using the substance.
In the tree model, dendritic spine or leaf numbers/density are low before substance use. The patient often has negative feelings and is sensitive to these feelings. Initial use results in increased dendritic spine growth and improvement in feelings towards normality. With continued use the substance results in reduced dendritic spine growth related to increased immunological activity and the development of bad feelings. However the brain, perhaps related to hippocampitis and memory impairment, increases the use of the substance in an attempt to reproduce the good feelings.
Eventually losses result. Initially the person stops loving themselves and then develops psychiatric symptoms e.g. depression-anxiety eventually followed by physical ill-health.
The tree model describes how people, places or things have the same effect on dendritic spine numbers/density as substances. This may be mediated by stress hormones e.g. CRF which reduce dendritic spine numbers and also increases immunological activity.
The Strange Case Of Dr Jekyll And Mr Hyde
This novel by Robert Louis Stevenson, who himself may have been cocaine-dependent, shows the progression of dependency.
This is an excerpt from Wikipedia: The Strange Case of Dr Jekylland Mr Hyde
“His ability to change back from Hyde into Jekyll slowly vanished. Jekyll writes that even as he composes his letter he knows that he will soon become Hyde permanently, and he wonders if Hyde will face execution for his crimes or choose to kill himself. Jekyll notes that, in either case, the end of his letter marks the end of the life of Dr Jekyll. With these words, both the document and the novel come to a close.”
The Case Of Dr Harold Shipman
Some significant events
His mother Vera was influential – possibly dependent herself?
Born in council estate but high achiever and went to medical school to become a doctor – perhaps as a result of perfectionism. Had to re-sit the entrance examination suggesting his stubbornness.
Tended to isolate. The family may have felt superior to the neighbours.
As a child he wore a tie when siblings wore casual clothes making him feel different.
17 years old – Losing his mother to cancer. This would have caused great sense of loss to which he was highly sensitive. The loss would have reduced dendritic spine densities and caused brain inflammation with subsequent resentment. There is a saying “resentment kills” – usually this applies to the sufferer but in this case it resulted in the sufferer killing others.
Seeing the doctor giving his mother the narcotic drug called pethidine which relieved her physical and emotional pain. This gave him the idea that narcotics would relieve emotional pain.
28 years old – blackouts due to narcotics.
29 years old – becoming dependent on the narcotic pethidine and losing his job because of forging prescriptions. He may have commenced murdering at this age. However even with the potential loss of his career he failed to develop insight and continues to use narcotics as the obsession-compulsion is overwhelming. Admitted to Rehabilitation Unit and closely avoided being erased from the Medical Register.
31 years old – resumes General Practice. Noted to be empathic i.e. hypersensitive to his patient`s feelings but also act in superior manner towards his patients.
31-46 years old – at same time as committing murders he develops an interest in supporting local schools and St John`s Ambulance. This may represent the residual goodness in him which was gradually disappearinng or it may be been motivated by dishonesty in order to provide good cover.
46 years old – leaves Group Practice and has possibly committed tax fraud representing greed and dishonesty.
46 years old – become solo General Practitioner. This may have been related to difficulty working with others because of difficulties connecting and feeling either superior or inferior.
52 years old – discovered to have very high cremation certificate rate to cover up his murders.
He then forged a will in order to gain financially from one of the patients he murdered. Wikipedia comments that the author Brian Masters reports two theories
1. He wanted to be caught because his life was out of control.
2. He planned to retire at fifty-five and leave the country.
His life seems to parallel that of Dr Jekyll. However with advances in neuroscience one can now try to understand why he behaved the way he did.
He seemed to have several of the features of dependency using the tree model
1. Family history of dependency
3. Difficulties with connecting with others related to feelings of superiority or inferiority..
4. Hypersensitivity to feelings.
5. Early feel-bad feelings – resentment, self-pity, fear, dishonesty.
6. Relief of feel-bad feelings with narcotics. Perhaps the early murders made him feel as though he was helping others who were suffering i.e. he thought he was behaving altruistically.
7. Increasing use of narcotics with opposite effect. His murders escalated as though he was dependent on murder in order to achieve the earlier good feelings which would never return. The obsession-compulsion to murder just made the bad feelings of guilt, remorse and shame worse.
8. Losses due to use. Initially he lost his self, then his mental health (depression/anxiety) and finally his physical health (blackouts possible epilepsy) . Losses are usually in this order.
He eventually reached the end-point of severe dependency known as the “jumping-off place” where he didn`t want to live but was afraid of dying.
Murdering another human is the most dishonest act a human can perform. It may well have been that at the end of his murdering spree the act of murder replaced the narcotics as the “substance of choice” instead of a manifestation of dishonesty. This is termed “dependency (to narcotics in this case) coming out sideways”.
It seems that if dependency is related to progressive brain inflammation and reduction in dendritic spine density/numbers especially in the frontal lobes then it anticipated that Dr Harold Shipman`s brain would show severe reduction in dendritic spine density in the frontal lobes and his neuro-inflammatory markers would be significantly elevated e.g. TNF.
It would be interesting to know if the brain is available for dendritic spine analysis particularly of the frontal lobes and if any of the fluid or CSF surrounding his brain was preserved in order to measure inflammatory markers.
Sources of Dr Harold Shipman`s life:
Famous Serial Killers: Dr Harold Shipman
Harold Shipman: an account of the murderous GP of Hyde