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Healing Anxiety and Depression
By Daniel G. Amen
Berkley Publishing GroupCopyright © 2004 Daniel G. Amen
All right reserved.
Chapter OneSeeing Anxiety and Depression:
Brain SPECT Imaging
Sean was one of the cutest, brightest ten-year-old boys with blond hair and big blue eyes we had ever seen. He came into our clinic clutching Dr. Amen's book Change Your Brain, Change Your Life, which his mother had given to him and which he had actually read from cover to cover. Based on what he had read in the book he predicted that he would have problems in his deep limbic system and left temporal lobe. When we asked him how he knew this, he said that he had periods of really bad depression, a very bad temper, and that he had tried to kill himself the year before when he was feeling really sad. He also said that sometimes he saw shadows and bugs crawling on walls when there were none. As part of Sean's evaluation we did a brain SPECT series. When we reviewed the scans with Sean it became clear that he had perfectly predicted his own SPECT results. He had excessive activity in the brain's emotional center (the deep limbic system) and decreased activity in the left temporal lobe. As he and his parents looked at the images on the computer screen, tears rolled down Sean's and his mother's cheeks. "I never wanted to feel bad or be so mad," he said. "I always wanted to be good. I guess I know why I had those problems." On the right treatment, guided by the scans, his history, and our clinical observations, Sean's mood and temper stabilized and he thrived in school and at home.
A picture can be invaluable. Once we started our imaging work we could clearly see that these diseases were in fact brain problems. From the first month performing scans, more than twelve years ago, imaging has changed the way we look at patients. Before we were able to perform brain scans, our approach to diagnosis and treatment was based on patient interviews and symptom checklists, such as those found in the DSM (Diagnostic and Statistical Manual) published by the American Psychiatric Association. The DSM, now in its fifth version, is considered by many to be the bible for diagnosing psychiatric illness. Unfortunately, psychiatric diagnoses in the DSM are still based on symptom clusters and have little or nothing to do with underlying brain dysfunction.
Shortly after starting the imaging work, we learned to use the scan images like radar to help us target treatment toward the specific brain regions that were abnormal. The greatest aspect of our work was observing that effective treatment causes a patient's brain to actually start healing. We could change brain patterns, see it on a follow-up scan, optimize brain function, and subsequently help people heal from the inside out.
Using brain imaging to help diagnose psychiatric illness was not part of our training, even though we trained at some of the most respected institutions in the country. Dr. Amen trained at the Walter Reed Army Medical Center in Washington, D.C., and Dr. Routh at the Mayo Clinic in Rochester, Minnesota, and Timberlawn Hospital in Dallas, Texas. Brain imaging is usually not a significant part of the curriculum in most psychiatric training programs. Although most psychiatric illnesses are strongly brain-based, psychiatrists don't look at brain function because:
* imaging is usually not a part of psychiatric training programs;
* imaging is not a part of psychiatric tradition;
* most psychiatrists do not know how to read brain scans or what the results mean;
* most psychiatrists are not sure how to use information from brain scans to help with diagnosis and guide treatment;
* many psychiatrists believe it is hard to get brain imaging studies approved by insurance companies in the age of managed care; * most psychiatrists still perceive brain imaging tools as experimental;
* many psychiatrists are uncomfortable with technology.
We have argued for more than twelve years that it is crucial for psychiatrists to look at the brain on a day-to-day clinical basis. The field is changing, although much more slowly than we would like. We are actively involved in teaching the imaging techniques in this book to psychiatric residents and other physicians around the country.
Physicians have a number of different ways to look at the brain. MRI and CT scans are examples of anatomical studies. They tell us what the brain looks like, but not what it is doing and therefore are rarely helpful as diagnostic aids for neuropsychiatric and behavioral problems. Using a car engine analogy, the problem is usually with how the engine works, not how it looks. A car engine may look beautiful in a photograph, yet it may not start. Can you imagine how long a service center would remain in business if the mechanic's standard reply to a car owner's complaint was, "Well, it looks just fine"? Yet this is exactly what the vast majority of people who have brain dysfunction hear from the medical community after their EEG, MRI, or CT results come in. We have no doubt that in most cases these brains "look just fine" because the problem is not with "looks" but rather with how the brains work.
Currently, there are five ways to evaluate brain function:
Electroencephalogram (EEG), a technology that is seventy years old, uses electrodes to record electrical activity from the scalp and infer information about brain function. It has poor resolution and is rarely helpful for psychiatric purposes.
Quantitative EEG studies (QEEG) is a more sophisticated version of EEG that uses computers to enhance electrical signals, but still relies on inferring data about the brain through the scalp, skull, and coverings of the brain. Dr. Amen used QEEG before he switched to SPECT in 1991.
Positron emission tomography (PET) is a nuclear medicine study utilizing minute doses of radioisotopes to look at living brain blood flow and metabolism. PET studies provide elegant views of brain function, but the equipment tends to be available in research centers and cannot be accessed by large numbers of patients.
Single photon emission computed tomography (SPECT) is also a nuclear medicine study that evaluates cerebral blood flow. SPECT is the study we perform at the Amen Clinics. We find it the most practical and cost effective, and it provides amazing pictures of brain function.
Functional MRI, or fMRI, a newer study, is taking over much of the research in psychiatry. fMRI's advantages include no radiation, as opposed to PET and SPECT, but it is in the early stages of use with little clinical application to psychiatry at this point.
SPECT: A Window into Anxiety and Depression
Before we go further, it is important to understand SPECT technology. SPECT stands for single photon emission computer tomography. It is a sophisticated nuclear medicine study that allows us to visualize brain blood flow and metabolism. In this study, a radioactive isotope is attached to a substance (Ceretec) that is easily taken up by the cells in the brain. A small amount of this compound is injected into a patient's vein, travels through the bloodstream, and locks into brain cells. As the isotope breaks down it releases energy in the form of gamma rays. The gamma rays are like beacons of light that signal where the compound is in the brain. People do not have allergic reactions to SPECT studies. Special crystals in the SPECT "gamma" camera detect these beacons of light as the camera rotates around the patient's head for about fifteen minutes. About 10 million gamma rays strike the crystals during a typical scan, and a supercomputer then translates this information into sophisticated blood flow/metabolism maps and three-dimensional images of the brain. Physicians and researchers use these maps to identify patterns of brain activity that correlate to healthy brain function and those that are associated with psychiatric and neurological illnesses.
SPECT imaging belongs to a branch of medicine called nuclear medicine. Nuclear medicine studies measure the physiological functioning of the body. They are used to diagnose a multitude of medical conditions: heart disease, certain forms of infection, the spread of cancer, and bone and thyroid diseases. Brain SPECT studies help in the diagnosis of brain trauma, dementia, atypical or unresponsive mood disorders, strokes, seizures, the impact of drug abuse on brain function, complex forms of Attention Deficit Disorder, and atypical or aggressive behaviors.
Brain SPECT studies were initially used in the late 1960s and early to mid-1970s. CT and the more sophisticated MRI anatomical studies replaced SPECT studies in the late 1970s and 1980s. At the time, the resolution (image clarity) of those studies was superior to SPECT for seeing tumors, cysts, and blood clots. Yet, despite their clarity, CT scans and MRIs could offer images of only a static brain and its anatomy; they gave no information about the activity of a working brain. In the last decade it has become increasingly recognized that many neurological and psychiatric disorders are not disorders of the brain's anatomy, but are problems of brain function.
Two technological advancements have once again encouraged the use of SPECT studies. The early SPECT cameras were called single-headed cameras because they used only one imaging device and took as long as one hour to rotate around a person's brain. People had trouble holding still for that long, the images were fuzzy and hard to read (earning nuclear medicine the nickname "unclear medicine"), and they did not give much information about the activity levels of the deep brain structures. Then multi-headed cameras were developed with special filters that imaged the brain faster with enhanced resolution. Advancements in computer technology allowed for improved data acquisition. The brain SPECT studies of today, with their markedly improved resolution, can see deeper into the inner workings of the brain with far greater clarity.
We typically do two scans when we evaluate a patient's brain. We do a baseline scan during which the patient is asked to let his mind wander, and a concentration scan during which we challenge the brain with a computerized test that measures attention span and impulse control. We have found it most helpful to have both scans to see how the brain activates with or without concentration and to have a baseline scan for comparison.
We look for three things when we evaluate a SPECT study: areas of the brain that work well, areas of the brain that work too hard, and areas of the brain that do not work hard enough.
The images in this book represent two kinds of three-dimensional (3D) images of the brain. The first is a 3D surface image, which captures the top 45 percent of brain activity. It shows blood flow of the brain's cortical, or outside, surface. These images are helpful for visualizing areas of healthy blood flow and activity as well as seeing areas with diminished perfusion and activity. They are helpful in looking at strokes, brain trauma, and the effects from drug abuse. A healthy 3D surface scan shows good, full, symmetrical activity across the brain's cortical surface on page 19.
The second type of SPECT images we look at are 3D active brain images comparing average brain activity to the hottest 15 percent of activity. These images are helpful in visualizing overactive brain areas, as seen in active seizures, and many types of anxiety and depression, among other irregularities. A healthy 3D active scan shows increased activity, seen by the light color in the active scans below, in the back of the brain, the cerebellum, and visual, or occipital, cortex, and average activity everywhere else, shown by the background grid on page 20.
It is important to note that everyone's brain looks different. Brains are like faces and there is variation among them. From an aesthetic standpoint, on scans some brains are beautiful, while others are a bit misshapen and funny looking. Beautiful or not, from looking at more than 17,000 brain SPECT studies it is clear to us that a healthy brain shows good, full, even, symmetrical activity. A healthy brain has all of its major parts intact and they work together in a relatively harmonious fashion. While there are normal age variations, the brain scans of children and teenagers reveal more activity than the brain scans of adults; even an elderly brain, if properly cared for during life, looks full, symmetrical, and healthy.
When we first started studying anxiety and depression we thought we would discover evidence of brain patterns that would clearly define the two illnesses. We thought we would see signature patterns for each illness. We were wrong. There was not one brain pattern for anxiety and one for depression; there were many different patterns. Of course, once we thought through the problem it was foolish to think that one pattern would fit all people with depression or anxiety. After all, everyone who is anxious or depressed does not respond to the same medication or the same form of psychotherapy. As we studied the different patterns we made some other exciting discoveries. We noticed that certain brain patterns responded to specific treatments, while other brain patterns were made worse by traditional treatments. We started to use the scan information like radar to guide us in our treatment choices, and in doing so we saw our patients improve from the more precise treatment. Over time, we grouped the patterns for anxiety and depression into seven different categories and developed treatment protocols for each one.
Excerpted from Healing Anxiety and Depression by Daniel G. Amen Copyright © 2004 by Daniel G. Amen. Excerpted by permission.
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