Special Episode: Dr. Sara Manning Peskin & A Molecule Away from Madness

and to read list. Last time we did this series, we just sort of released the episodes without giving you an opportunity to read beforehand, and this season, we decided, in the spirit of real life book clubs, to give those of you who want it a sneak peek of

the books that we'll be chatting about this season. So if you are one of those wanting to read along with us, head over to our website This Podcast Will Kill You dot com, where you can find a link under extras to our bookshop dot Org affiliate page, which has our reading lists, including our book club list featuring all of the books we covered last season as well

as the ones we'll be covering this season. It's a pretty incredible list, if I do say so myself, and I really can't wait to share all of these interviews with you all. I'm especially thrilled for today's conversation with doctor Sarah Manning Peskin, who is an assistant professor of Clinical Neurology at the University of Pennsylvania and author of A Molecule Away from Madness, Tales of the Hijacked Brain.

In this captivating and heartrending book, doctor Peskin takes readers through stories of the brain gone awry, exploring the histories behind some of these neurological illnesses, and defintely explaining some incredibly complex concepts that frame our limited understanding of how the brain actually works. I want to ask you all to take a second to consider the human brain. What are you doing in this very moment besides listening to

the podcast. Maybe you're cooking dinner. Maybe you're out walking your dog, maybe you're crocheting, Maybe you're driving home from work, or maybe you're just chilling on the couch. What did you do today? Took a shower and got ready for work, scrolled through Instagram memes for probably longer than you should have. Guilty, wrote a less emails, watch some reality TV? Also guilty. How do you feel exhausted? Content anxious, excited, curious, depressed.

We are capable of doing so much and doing it all at the same time, of feeling so much, of creating and imagining, of thinking and overthinking, of holding a million different emotions, and to do lists and memories inside of ourselves, all while doing something as mundane as cooking dinner. And it's our brains, of course, that allow us to

do this miraculous multitasking. I think it's easy for many of us to take our brains for granted, and maybe some of that comes from the expectation that every morning when we wake up, we assume our brains will be there just as they were yesterday, maybe a bit groggy, maybe in need of some caffeine, but ready to help us take on the day. But what happens when our brains don't findunction in the capacity we expect them to.

What happens when our brains betray us. I don't think we always appreciate just how close our brains are to the edge, how something so small and seemingly insignificant as a stray protein, for instance, can profoundly disrupt everything about

how our brain works. In a molecule away from madness, Doctor Peskin shares stories that reveal the vulnerabilities in our brains, using each story to teach readers what we know about the inner workings of our brains, to remind us how many mysteries remain, and to convey that with every story told, with every molecule or protein examined, people remain at the center.

I really loved A Molecule Away from Madness, not just for the fascinating histories or thoughtful examinations of complex neurological concepts, but also for the way that doctor Peskin centers patients in the narratives of these illnesses, bringing so much compassion and empathy to a field where it can be too easy to lose sight of the whole person when your focus is on an individual protein. I am really excited to share my conversation with doctor Peskin with you all,

so let's just get right into it. Sarah, thank you so very much for joining me today. I absolutely loved your book, A Molecule Away from Madness Tales from the Hijacked Brain, and I thought you beautifully blended clear and accessible medical information with such a strong sense of humanity and empathy, and it was such a great piece of

scientific storytelling. And I know that you've often been compared to Oliver Sex, but hopefully you won't mind hearing that comparison one more time, because I really, yeah, I just I thought it was so amazing and I've been telling everyone I know about it.

nothing much happens and it's a little bit lonely. And so I started writing some memoir stuff, and then I essentially realized, like, my life is not that interesting, No one really wants to read about my life that much. But my work is fascinating and the patients I see are amazing, and the family dynamics that you witness are incredibly intricate and emotionally moving, and that stuff is interesting. And so then I sort of started to think about,

you know, what are the most interesting stories. And the way that someone actually put it to the in terms of how you think about what you want to do in medicine, is when you open the clinic door, like who do you want to see on the exam table? And that's how I sort of started to shape the

book itself, and I initially wrote. Initially the idea was to do sort of the traditional thing of like, oh, this patient shows up and they have these curious symptoms and then aha, this is the diagnosis and here's how

the disease works, and you know, that's your package. But the more I wrote about it, I realized the actually, the more important thing is actually the history of the disease, because it's learning about a disease itself, and the mechanics is so dry, but learning about how we discovered the disease and what kinds of sort of wacky and outlandish characters were involved. That's actually exciting. The narrative part is what's exciting.

and I'm learning things and I'm evolving. And yet the are these select diseases where there's a you know, there's a molecular problem and it actually sort of oh or hauls your identity and it actually makes you realize that the essence of what you think is yourself is actually not as protected as you think. And those are these is that I found to be sort of most fascinating, both in terms of the science of them, but also

in terms of the social environment. So you know, what do you do when your partner suddenly is incredibly disinhibited and going up to strangers and having affairs. And it's not a sort of a moral failing, it's a molecular problem.

like the tiniest little switch that flips. And so how did you decide which diseases and also which personal stories that you wanted to include in your book?

with proteins. So if you think about DNAs, like the biggest molecule that we have in our body, proteins are pretty big, and proteins basically carry out They're the kind of the work horses, that's what really keeps ourselves alive. The DNA is really, for the most part, just a sort of instruction book. It's proteins that really do the work. And then there are small molecules. So there's things that are smaller than DNA, smaller than proteins, and they either

cause a problem by being present. I called those invaders, or they have a cause a problem by being absent or not being there in enough quantities, and I called those evads. And a lot of the diseases that have a single molecular problem, and most of them fit into one of those categories.

patients who you think might be interested? And it actually turned out when I went to interview patients it was I think it's actually more meaningful for people to be interviewed than I realized, because you when we develop diseases, you know, you go to a doctor and you say, like look up and feeling X y Z, and the doctor says, we want to get some tests, and then you come back and you get a little more information, and then maybe your symptoms change or you get more tests,

and there's sort of an evolution of getting a diagnosis, and then the disease itself can evolve over time. And it's really uncommon for people to be able to sit down and say, you know, what has this entire road been, like, you know, what's the last six years of my life been like from the beginning changes to where I am now, and it's actually fulfilling for people to be able to actually walk through that with someone in sort of in

slow motion. So I was actually sort of surprised that after interviews people be like, oh, that was actually that was a really wonderful experience. And I was sort of thinking, oh, my gosh, thank you so much for giving me so many hours of your time. But actually it was nice. It was sort of a mutually beneficial thing.

was really impactful. Were there any stories that you didn't end up including, or any diseases that you initially thought that you were going to include as part of the book but didn't end up making the final cut.

saying like, are your clients interested in talking? And then it was sort of like, I think that I'm entering into a realm that I shouldn't go into, and so so that one got even though it's a fascinating story. And then there were some people. There's two people who are interviewed who were, you know, wonderful people and wonderful stories.

And ultimately, when I finished with the structure of the book, they sort of felt kind of extraneous in terms of the stories themselves, but the people were wonderful, and so in the back of my head, I'm always like, oh, I'm some point I have to write up those stories.

have unusual symptoms. So someone who comes in and says, you know, look, I've been seeing people at the end of my bed and I know they're not there, but they really look clear to me, or you know, things like we had said fur some you know, my partner

is acting strangely. He's totally apathetic and he used to be so warm, and he went out and bought a sports car and didn't tell me, or you know, people who say, you know, look, I'm having trouble using the right side of my body and it's gotten worse and worse over time. So these sort of really atypical cases where people have language problems, so they come in and they say, you know, I used to be a big gardener and you know, someone mentioned the word mulch before

and I couldn't really figure out what it meant. And so it's a lot of these atypical sort of conditions that people walk around for years and they can tell something's up, but they go to neurologists, they go to psychiatrists, and they can't get a diagnosis. And so a lot of what we do is sort of seeing those cases and saying, you know, if you're not alone, this is a real disease. It's sort of in your head, but

not in your head. And so that's what I do, you know, much of the time outside of writing.

scientific meeting where he was met with absolute silence. So can you place his findings in the context of dementia research at that time and maybe kind of speculate on why no one really seemed to care all that much about or recognize immediately the importance of his presentation.

housewife and she's in her early fifties. She was fifty one when he met her, but in her forties even she started having difficulty. She would forget things in recipes, she was getting confused where she was going around the house.

She became very suspicious that her husband was having an affair with a neighbor, even though there was no evidence, and her husband had taken her to the doctor and the doctor basically said, pack her clothes and drop her off with the asylum, and so that's what he did and she never got out, but he saw her the next day and he very quickly realized her case was unusual. And what he realized is that she was had a

very a horrible short term memory. So he would come and he would show her a bunch of objects, and she could name them. She could do math, she could describe things like the color of soot, but as soon as he would take the objects away, she would have no idea that he had ever shown them to her. Or if he asked her to write her name, she would write, she wrote missus, and then she couldn't write the rest of her name. She sort of forgot the

task or forgot how to do it. And he realizes the case is unusual, and so he treats her for all over but a year, and then he actually Alzheimer's own wife actually dies a very young and he's left with three kids, and he ends up moving to another city. But he basically calls DIBs on her brain, which was something you could do in that time. And so everyone knows that this asylum that when you know, when this woman dies, it's going to her brain's going to go

to Alzheimer. And and sure enough, a few years later she passes away and an intern from the hospital and Frankfurt calls him up and is like, you know, do you want the brain still? And he's like, send it over, And so they fix the brain and formaldehyde and they send the whole brain and her entire medical record to Alzheimer's at this other hospital. There's no consenting there, you know, it's a totally different time. And he looks at her brain under a microscope and he sets built up of

these two structures. One is what we call plaques, which basically look like a spot of spray paint in the brain. That obviously is microscopic, and then the other is called we call him tangles now, and they basically like spaghetti inside of neurons. And people had seen the structures before, but they had seen it essentially an older people where

they thought the structures didn't really mean anything. And Alzheimer's big contribution was finding this woman and realizing she had an enormous, enormous burden of these plaques and tangles, and so what he did that was so sort of partly he was so good at microscopy and he was such an expert in the field, but also he was very quick to say, is this a different disease, and that was the key. It's that he said, you know, have

I actually discovered something new? And so he goes to this conference and he presents his data, and just as you said, so he basically talks about the case. He shows pictures and slides, and at the end there's like total silence. The moderator basically says, well, it seems there's no desire for discussion, and please take a seat. And then and later in the day, actually the talk that garnered the most interest is to talk about excessive masturbation.

That was the high light of the meeting, of course. Yeah, and so it's so, yeah, you were sort of left with this thing of oh my gosh, this is one of the most you know, it's one of the deadliest diseases in the world, it's one of the top causes of death, and yet at its discovery, nobody really sensed that it was important. And I think there's a few reasons, but I think a big thing is that he presented

a single case. Yeah, and so there's you know, there's thousands of case reports that come out every day and it's hard to sift through, you know, which ones are actually meaningful, and you can sort of think about what about the next case of COVID. People probably didn't realize that that was anything unusual. It's only when it becomes more widespread that you realize, oh, in retrospect, that was a big deal. And so I think part of that

was that it was it's a single case. And part of it is also that in that time it's harder to disseminate scientific information. So you can imagine anyone who's not at that meeting is not going to hear that. So it's not the same as today, where you publish a paper and then with a click of a button, the entire world has access to it. So I think that's another part of it. And part of it also is that he wasn't as far in his career as

he eventually would get. So the way that Alzheimer's disease, the way the term eventually gets coined is his mentor actually publishes a revision of a textbook and mentions the case and mentions Alzheimer's disease, and so he basically is a little bit of who you know am, So that I think that those were sort of I think some of the main reasons why I didn't really get recognition at the beginning.

was altering his personality. Can you share a bit about how, first of all, how you came across that story, and then what that story is.

And also sort of the idea of, you know, how do you speculate on the medical issues of historical figures who have died where you can never really prove it. So it brings up all sorts of questions, and the guy who sort of unnersed the air treated the theory is a fascinating guy who's a he's an infectious disease doctor and who actually essentially pioneered oral rehydration therapy, so he's credited with saving thousands and thousands of people. But

he's also a medical historian on the side. And he was reading Gorvidelle's book Lincoln, and he saw that it mentioned something about Lincoln taking a substance called blue mass, and so he went back to the primary literature and realized there's all these references Lincoln. There's no quote from Lincoln himself, but there are quotes from his closest confidants, basically saying Lincoln used to take blue mass, and then after he got elected, he realized it made him cross

and so he stopped taking it. And it's kind of amazing to think about these incredible political figures having medication side effects and sort of thinking about what if he hadn't realized, you know, what would have happened then? And then is sort of the guy who created the theory

in Norwo Herschard. He essentially went back and said, you know, look, there are actually these cases of Lincoln being really sort of actually sort of unhinged, and not that you know, we think of Lincoln as basically his emotions are basically like the statue. He's sort of sitting and thinking, and like we think of it, that's what he was always like. He was calm and measured, and yet there are these cases of him attacking a judge in the middle of

a court case. In one of the Lincoln Douglas debates, he almost strangled a guy on stage. And so the question is you know where those medication side effects, and the foo line is we'll never be able to prove it. You have a thought is if he stopped using blue mass, which contains mercury, I should have said that that was the main toxic component. But if he stopped using mercury after right after he got elected, by the time he was assassinated, there wouldn't be any traces of it in

his body. So there's no way to figure it out.

And for a long time, people thought it just didn't exist in America, and then in the early nineteen hundreds it started cropping up in the southeast and it basically became this epidemic. It was, it became enormously common. People became extremely scared of it. It was often deadly, and so it was affecting primarily impoverished people. So it was affecting new orphans, it was affecting prisoners, it was affecting performers, and so at the beginning it didn't get that much attention.

But then it started spreading and essentially you started getting national headlines saying that people are scared of this, you know disease. You people are scared of this killer, and so the predominant at the time was that either it was caused by a toxin and spoiled corn, or the theory that gained traction was that it was caused by a infection transmitted by flies. And the reason why that

gained traction there was literally zero evidence. So there's zero evidence to show the guy who the guy who thought of the theory eventually went on to argue that cancer was caused by cockroaches. So there's zero proof that this is correct, but everyone wants to believe it because then you can basically say, you know, look, the diseases, it's their fault. It's the people who suffer from it. They're not clean and that's why they get this disease, and

so we don't have any responsibility. And so even though so that theory starts, you know, taking hold, but there's no proof, and the disease is spreading, so people are scared, and so the Surgeon General calls on this guy, Joseph Goldberger. And Goldberger was a public health officer who was no stranger to contracting the diseases he was studying. So he'd gotten typhus, he'd gotten typhoid, and he'd actually exposed himself to skathies to prove about to try to like track

that a epidetic was coming through mattresses. So he like very much is sort of roll your hands up and get it, roll your rest leaves up and get into it kind of guy. And he very quickly realized, like, look, this is not caused by an infection. It's caused by something in the diet. But nobody would believe him because the optics are totally different. Now if it's a and he actually really it's a dietary deficiency, it's not a toxin in the diet. It's that the diets of these

people are missing a nutrient. And that's very problematic because now instead of saying, you know that these people are dirty and it's their fault, you're actually saying our country is literally starving its own people and now they're dying because of it. So the optics are totally different, and it's also more expensive to fix because now suddenly the

solution is now you have to feed people. And so nobody really wants to believe him, and so he basically says, you know, like I'm going to prove to you that this is not an infectious disease, and so he starts off with him in a colleague and they take a sample of blood from a patient with LAGRA and they injected into their own shoulders and he talks about, how, you know, like we had some sore shoulders, but other

than that, it was okay. And then he has more colleagues who are confident in him, and so they start getting a little bit more gruesome with the experiment. So they scrape the scales off of patients rashes, and they mix it in with their stool and their urine, and they actually swallow the pills. And actually even his wife

wants to participate. They've had this sort of fraught marriage because he's always running off to these different states and other countries to get expose himself to these deadly diseases, and she's sort of like stuck at home managing all the children. But she decides she wants to participate, so she goes down to see him, and he doesn't let

her eat stool or you know, or the urine. He but he does the blood one and he makes sure to take it from a female patient unless he should take you know, blood from a male patient and give it to his wife, but so she does participate also where they take an injection from a they take blood from a a woman with pologer and he injects it

into his wife's abdomen. And at the end of it, they wait six months and he writes up the paper that basically says, you know, considering the amount of filth that we took in, it's pretty amazing that none of us got pillagra. And that's sort of the punchline. So we tried as hard as we could to get the disease and we still couldn't catch it. Yeah, And eventually

he goes on actually to do this incredible work. Yeah, when he actually gets so close to getting to the answer of what nutrient is missing in pologra, and he figures out it's a B vitamin and then he dies pretty quickly, and he was nominated for a Nobel Prize multiple times that he dies before he ever gets one.

And then other researchers sort of finish it and end up figuring out that it's a deficiency in nisin, which actually was available on the shelf the whole time in the office of the guy who coined the term vitamin. But he just didn't realize that that was the solution, so it actually was an incredibly cheap disease to treat. They just didn't know, so all these people, thousands and thousands of people died in the meantime.

making you sick. The problem is external, not internal, as well as technological advancements in like medical measuring devices where we can translate your disease, your symptoms into numbers essentially. But it seems like these close personal relationships between August and Alzheimer and Anna and Pick that you talk about

in your book kind of escaped that depersonalization. Do you think that they were unique at the time, or did neurology as a field kind of overall escape the depersonalization that was happening so broadly in most of medicine.

of these new diseases. Or in Jern next, she was one of the first ten patients that he'd sort of seen like that. So I think it's more just that these are the seeds of new diseases. And at that level it is still personal because they're individual cases. And even now case reports are you do still get sort of this personal sense of people, even though they're you know, we don't include people's names anymore. We don't, you know, includes some of the offhand comments that people used years ago.

But the index cases, I think are always they're always still individual cases and if anything, you know, as you said, it's a little bit funny now that so many of the biggest papers, it's like written by people who have never met people with the disease that they're studying, and they have to make these incredible contributions to the field, but there's actually no account of anyone with the disease.

It's basically, you know, it starts off saying, you know, this is a meta analysis of x number of papers and x number of patients, and this disease is characterized by a blah and here's the statistics, and you could get through the entire paper, you could learn groundbreaking material, but literally have no idea what it's like to live with the disease.

the experience. But the place where that's been sort of preserved or ideally is the first line place to preserve that sort of close, intimate narrative relationship is actually in the patient interaction, because really what you're doing when you sit down with a patient, what you're doing is actually

you're trying to get a sense of their narrative. And when you write your note, what you're trying to do is basically say, look, here's their story, Here's how things evolve over time, Here's how they feel, Here's what it's like to be them. And you know, when you're telling your you know you're attending or whoever else about the story, you're trying to lead them to a conclusion. So you actually do need a narrative arc. So it actually is

a very useful tool in medicine. And so part of what narrative medicine is trying to do is to say, you know, can we treat these patient interviews as intimate personal experiences where you actually extract not you know, numbers like lab results, but actually you're extracting an experience, and then you're trying to encapsulate that experience for someone else. You're actually using narrative to formulates, you know, what you've heard and to try to communicate to someone else, what

is this patient's life actually like? Yeah, and that also allows you to create a more holistic plan. Yeah, so for us, it maybe you know, look, we'd like to start this medication, but also you know they're bored during the day and they're not engaged, and how can we find a way for them to be active during the day. So it allows you to think a lot more about a person's quality of life than just about whatever numbers get thrown up on the board.

likely awaits you. Can you talk about this experience and the complex ways that you've seen people deal with it.

overhauls her career, ends up focusing. She had taken I think either zero or one biology classes in her entire life, and she basically starts focusing on trying to find a cure. In order to find a cure, you have to find the cause. And so eventually she actually pioneers this work that leads to our current ability to test people for

the gene that causes Huntington's disease. So you can now tell people who are totally asymptomatic that, look, you have this gene orban momorality that will likely cause Huntingdon's disease if you live long enough, and even though they have no symptoms, she actually never took the test, basically said, you know, look, I have a lot more to lose by taking the tests than I have to gain. She

never took the test. She eventually developed symptoms of the disease, and now has sort of come in public saying that she's developed the disease and her sister didn't. And it's sort of this fascinating story. And so much of what we I deal with at work actually is diseases where you find out there's actually a single gene mutation or a single gene change that's causing the disease, and you

sort of think it's a little bit strange. You know, you've had this DNA your whole life, and why is it suddenly causing you a problem in your your sixties even your seventies. And some of these diseases, you know, you can have the same gene change in one person, and you know multiple family members, and sometimes they all get the disease at the same time, and sometimes they get it at vastly different ages, or it doesn't even always cause the disease, And so the issues that arise

are are incredibly emotionally complex. So the biggest thing that people think of is you know, do you want to know? You know, do you want to know if you have a mutation that causes a neurodegenerative you know, a deadly progressive disease that we have no cure for, And we couldn't tell you exactly when you'll get it. We can tell you the chances of getting it, but we can't tell you exactly when or that you'll definitely get it. And and do you want to know? And there's a

few things I think about. So one is, you know, maybe you want to know because you want to enroll in a research study and uh, and maybe they'll be you know, you'll get a treating, you'll ever develop the disease. One of the big things is you know, do you want to know so you can plan? You know, so if you knew that you were going to get, you know, a nerd degenerate disease, and someone said, you know, look it's probably gonna it often starts in your fifties or sixties,

would you change your career? Would you change your decisions about having kids? Would you change how much you travel? Would you change how much you spend? And the other really sort of most you know, the thing that I find most interesting is you also can have kids that don't have them meatation. So if you carry a mutation and you you don't want to have biological children that

don't have it, you can do ivfs. Essentially, they take egg and sperm, they mix it together, you know, in a lab, and then they take the cell sort of grow and divide and grow and divide, and after a certain amount of time they take away one cell or they take I think it's more like four or five cells, So they take away a few cells and they look at the gene in those cells and they can say, okay, this is a normal version or not a normal version, and then they basically only use the embryos that have

normal versions. They put it back in the uterus, you grow a kid, then the kid does not have the disease. So it's actually we have the technology to literally root out the mutations from family lineages, but only if you know that you have only if you know it you know to look. So it's really it's such a complex issue. And ultimately, there are normal people who decide to find out, and there are normal people who decide not to find out.

And even within families, you know there'll be some siblings who do testing and some who don't, and it's it's one of the most fascinating issues that we deal with. The other big issue that comes up is basically, if you know, if a grandparent had the disease, a parent decides not to find out, but their child decides to get tested. If the child has the mutation, then the parent now knows. So it actually your people's decisions affect

other people in the family. So it's just it's sort of scientifically fascinating and emotionally so fraught, but also actionable.

in your work are still undergoing this type of revision.

out saying that he has front or temporal dementia. So it's had a lot of coverage lately, and essentially some of it. Sometimes it can cause people to have these sort of really sort of antisocial behaviors, going up to strangers, saying in appropriate things, hypersexuality, eating non food things. Sometimes it can cause people to have language problems where they

lose the connection between words and objects. So you know, you were taught when you were a kid that an apple is, you know, a green or red thing that's crunchy in the middle. But there's nothing inherent about an apple that sounds like apple. It's just that sound was attached to the word and you lose that connection, or some people start have having trouble with the motor programming

of speech. So when you want to say a word, your mouth and your tongue has to move in a certain way to say it, and that's a message that goes from your brain to the muscles or in your mouth,

and that connection gets lost. So in that disease, it essentially had like it had like ten different names, each of which had like the names themselves were like six different words put together, and people thought it was like multiple diseases, and then they finally figured out, actually it's the same disease, and it's sort of this aha moment, and then actually they go on and they realize when you look at under people's brains under a microscope, it's

actually not the same disease. So it's sort of had this full evolution of like is this one disease? Is it multiple diseases? And ultimately we're not very good at for Alzheimer's disease. We actually have tests that we can do in living people and we can say, you know, look,

we're essentially almost sure that that's what it is. With French of temporal dementia, you know, you can have two people who have exactly the same symptoms, their imaging looks similar, and yet under a microscope their brains look completely different. It's caused by a totally different protein in one person

compared to another. Yeah, and so a lot of these fields are still, you know, very much evolving, and part of the issue is that difficulty in making the link between symptoms and imaging and testing and what's going on under a microscope because you can't access the brain. It's not like the lungs where you can take a piece out and you look at the molecules the brain. It's like we're using all these proxies and that's been you know, that's the big barrier.

popular media. So there can be more of like a stigma maybe with these you know, atypical symptoms or symptoms that we persue to be a typical even though they're not. So can you talk a little bit about this this problem between the disconnect and how dementia is portrayed versus the actual like wide variety of ways that it can actually look in reality.

most interesting, whether it's rare or not. So if you think about the example of still Alice and she has it's a young it's a woman with Alzheimer's disease, so it's a very common disease, but it's young onset and in the I think it turns out to be a genetic cause, so it's really atypical. Those are like less than you know, one percent of cases. And so one question is is that a really useful movie, because you know,

it was a big movie. It got lots of attention, so it got a lot of sort of light onto Alzheimer's disease. Is that really helpful or is it actually like you're making people think that it's all caused by a single gem and actually that's that was a really

unusual case. Or if you're portraying, you know, people with dementia getting diagnoses, should you portray a compassionate doctor or should you portray what often gets portrayed, which is neurologist as being sort of aloof and sort of not emotionally engaged, and you know, how do you portray that interaction? And I think the bottom line is that it's complex and the most important thing from my perspective is really just

portraying the humanity of the people with the diseases. The key is not talking about them when they're in the room, So portray them as you know, real people, and then you can drop clues in of like you know this, you know this is unusual, so you know this is a to atypical cakes or something like that, so you can get around that stuff. But the he really is to try to portray some sort of semblance of real life and you know, experience with these diseases.

that part was. But one of the things that you point out is how different this person's experience might have been if she had gotten sick just a couple of decades ago, when the disease was largely unknown or completely unknown. And I know there's been some speculation of like historical cases, might the people accused of witchcraft actually had NMDA receptor encephalitis.

So do you feel like there might be other fields in medicine or other conditions in medicine that might undergo a similar revolution in the future.

there's this schiz of them the late eighteen hundreds, and you know, psychiatry and neurology so suddenly split and dementia is kind of at the seams because it's you know, there may be a molecular cause, but a lot of the symptoms are sort of psychiatric in nature, and it's sort of gone along. It's gone along at the scenes of psychiatry and neurology. And one question is, you know, are we going to move that over more to psychiatry.

So things like schizophrenia and other conditions that we think of as being really purely psychiatric, are those also going to end up having molecular causes over time? But I don't know.

Things like, you know, people come in all the time and say, you know, when someone makes a mistakes, should I correct them or should I not correct them? And the bottom line for most of this stuff is essentially, if it's not unsafe, you don't need to correct them, and that, you know, having dementia oftentimes people are not aware of it, or if they're aware of it, it's

painful for them to to think about. And so the general approach really is if it's not it's safe, you know, if they want to, you know, if they think that their dead father is coming for dinner, then by all means, let them set the table. That's okay. You know, it's not going to hurt if they are wearing their clothes inside out. Who cares and in the same way, you know,

in public. One thing that we sort of talked to care Grave is about is, you know, if you're worried about them doing something socially inappropriate, you know, carry on business cards. I just say, you know, look, my loved one has this condition, Thanks for your understanding, and you

just pass it to someone after it happens. And that way you're not having to like yell at your loved one in public, you're not having to explain it to someone else, and it actually spreads awareness and people realize that, you know, there's more than what meets the eye. So there's all sorts of things like that, and things like we talk a lot about sort of empathic lying and basically, you know, not if you need something to get done and trying to frame it in a way that has

nothing to do with the person's cognitive status. So, you know, if you need someone to move to a facility, how do you figure out some explanation for that that doesn't completely involve their cognitive status? Because if you can imagine, oftentimes the example we give is like, you know, tell the normal cognitively normal care partner, like if I was going to try to convince you to move to a

nursing home. What would I have to say? And it's tough to think about because with all these conditions, you're dealing with people who live in a different world in some ways, and so the tools, regardless of the type of dementia, a lot of the tools are the same.

It's sort of as if like they were always around, but none of these diseases were known from the beginning of time. And talking to people about how these diseases were discovered, actually, first of all, it allows you to go

back to the basics. So it allows you to communicate at a level that's actually more scientifically clear, and also it gives people a sense of you know, look, this is an evolving field, and our hope is to find cures for these things, and not that this is a static you know, it's not that Alzheimer's thease has always

been around and we've never made any progress. It was discovered at a certain time and in factually made a lot of progress, and there is a lot of hope even though it's true we haven't found a cure, and so I try to couch the diagnoses and the sort of the history of the diseases now and I haven't gotten any negative feedback, so hopefully it works, Okay.

what's going on. And you know, if I had to put money down, this is the molecule that I think is going you know, hey, why are in your brain? And this is where we are in terms of trying to find treatments and here are research opportunities. That's sort of the most fulfilling is is these atypical cases where they've gone years without a diagnosis and you can say,

you know, look, this is what's going on. I mean, the typical ones are also interesting, because you know, even typical cases bring up interesting family dynamics, But for me, it's sort of the I think it's sort of the atypic ones that are the most fulfillingent clinic.

literally never going to use. And so much of it is just this academic exercise and there's not as much emphasis on like how do you explain a disease to a patient who has no medical but background and variable health literacy? And that's I think In writing a book of for the lay public, I was in a writing group with lots of people, none of whom had any sort of medical background, and it was they were all

very educated and there were I was like shocked. There were words that I would use and they would say like, that's that doesn't make sense to me. I don't understand that explanation, and I realized it was not them, it was my feeling. And I think I wish I was emphasized in medical school more. I mean, there's so much to learn, and there's like there's more to learn every day. So you only have four years and how are you

going to learn all this material? So I know that it's sort of tight to fit in new stuff, but it's really something that's not covered much in medicine.

will kill You dot com. We're I'll post a link to where you can find a molecule away from Madness, as well as a link to doctor Peskin's website, and don't forget you can check out our website for all sorts of other cool things, including but not limited to, transcripts, Quarantini and Placebrita, recipes, show notes and references for all of our episodes, links to merch our bookshop dot Org, affiliate account, our Goodreads list, a first hand account form,

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