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ARTICLES: Heike Schmolck, Diane Mosnik, and Paul Schulz Rating the approachability of faces in ALS Neurology 2007; 69: 2232-2235 [Abstract] [Full text] [PDF]

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Rating the approachability of faces in ALS

Marc Gotkine   (25 February 2008)

Reply from the authors

Heike Schmolck, Paul Schulz   (25 February 2008)

Rating the approachability of faces in ALS 25 February 2008
Marc Gotkine, Department of Neurology, Hadassah University Hospital Medical School of the Hebrew University, Jerusalem, Israel Send Correspondence to journal: Re: Rating the approachability of faces in ALS marc{at}gotkine.com Marc Gotkine	I read the paper by Schmolck et al. with great interest. [1] The authors demonstrate the trusting nature of patients with ALS when confronted with threatening-looking individuals in a potentially dangerous situation. Responses to the particular question used in the study reflect a combination of threat perception as well as a willingness to subject oneself to the perceived risk (attack by the threatening individual) in order to achieve the perceived benefit (receipt of directions resulting in a swift return to familiar surroundings). Although this abnormal response may, as the authors postulate, indicate bilateral amygdala dysfunction, perhaps the differences observed between the ALS group and the combined control group are the product of alternative factors: 1) Decreased perceived risk of attack due to the external stigma of disability in patients with ALS. 2) A "braver" perspective in people with ALS when facing situations non-ALS patients may find intimidating. While this could reflect neurodegeneration-related dysfunction of the amygdala it may be argued that this is a psychologically mediated shift of perspective similar to that which occurs in populations living in hostile conditions under fear of terrorism. [2] 3) A skew in the perceived risk/benefit ratio in patients with ALS due to the impact their prognosis has on their expectations for the future. From a utilitarian standpoint, the probability of fatal attack multiplied by the expected loss of quality-adjusted life years, may be outweighed by the benefit of getting home quickly in the ALS group, but not in the control group. References 1. Schmolck H, Mosnik D, Schulz P. Rating the approachability of faces in ALS. Neurology 2007;69:2232-2235 2. Pat-Horenczyk R, Peled O, Miron T, Brom D, Villa Y, Chemtob CM. Risk-taking behaviors among Israeli adolescents exposed to recurrent terrorism: provoking danger under continuous threat? Am J Psychiatry 2007;164:66-72. Disclosure: The author reports no conflicts of interest.
Reply from the authors 25 February 2008
Heike Schmolck, Mercy Ruan Neurology Clinic 1111 6th Street Suite A100 Des Moines IA 50314, Paul Schulz Send Correspondence to journal: Re: Reply from the authors hschmolck{at}mercydesmoines.org Heike Schmolck, et al.	We thank Dr. Gotkine for his interesting comments. Looking at our paradigm on the basis of a risk-benefit analysis might add significantly to the understanding of patient behavior. Dr. Gotkine suggested that there might be decreased perceived risk of attack due to the external stigma of disability in patients with ALS. However, only a subset of our participants did, in fact, have obvious disability. Moreover, the time since disease onset did not correlate with behavior but with disability. Second, it is suggested that people with ALS might have a “braver” perspective facing intimidating situations akin to populations living under hostile conditions. We tried to address the problem of a life-threatening disease process causing this shift in perspective by recruiting a control group that faced a similar prognosis with significant physical limitations. We used severe heart failure. Behavior in this disease control group was not significantly different from the healthy control group suggesting that it is not the prognosis that alters ALS behavior, but the areas of brain affected by the disorder. The suggested skew in the perceived risk/benefit ratio for ALS patients as described should also apply to the heart failure group, although significantly fewer heart failure patients exhibited the “fearless” behavior seen in several ALS patients. Finally, it could be hypothesized that the psychologically mediated shift of perspective regarding risk taking Dr. Gotkine has described in populations living in hostile conditions under fear of terrorism is an adaptive biological phenomenon mediated by down-regulation of the amygdala.[2] This would then be a mechanism opposite to what is observed in anxiety disorders, where an increase in amygdala activity is implicated as the neuro-biological basis of disease. In summary, Dr. Gotkine’s comments are very interesting and warrant further investigation. However, regarding the “braver perspective” question, it appears that the areas of brain altered by ALS, and not a reaction to the prognosis, alters ALS behavior on the Faces Task. Disclosure: The authors report no conflicts of interest.