CorePsychBlog

SPECT Functional Brain Imaging Is Not 'Mind Reading'

Image via WikipediaLet's Take the Woo Woo out of New Brain Science Discoveries
If you are interested in the science of brain imaging on any level you will be interested in just taking a moment over at CBS 60 Minutes from this past Sunday night.

In an interesting report on functional brain imaging Lesley Stahl graphically demonstrates [excellent video footage] some of the exciting progress with the actual brain 'pictures of thinking' - thinking about specific items: hammer, screwdriver etc. Dr Just at Carnegie Mellon is one of the interviewees - in this short report they put a 60 Minutes producer in the fMRI machine, took pictures of her brain activity, then demonstrated exactly what she was thinking whilst in the machine. Good Stuff!

With fMRI and SPECT the essential key word here is "functional" brain imaging - this MRI photo >> is simply an example of a static MRI picture, not functioning, not actually thinking in process, just anatomic structure. The 'brain action' is in the 'function.'

We have been talking about SPECT imaging here since we started, and posted on this controversy with SPECT imaging with Carlat and Amen in May '08. SPECT can be used very effectively in the context of good psychiatric practice.

In the comments that follow on the CBS site one can easily see how the 'Mind Reading' spin clearly terrified some folks, as the researchers indicated that we would soon have beams bouncing off our heads that would know our private thoughts. Not to worry, the benefit outweighs the risk - and the hype does a disservice to the message.

And if you are interested in SPECT applications in mental health office practice: Do sign up for notification of SPECT Training here at CorePsychBlog.

Take a look at 60 Minutes to see what's going on, and don't fret the hype.

101 Fascinating Brain Blogs: An Excellent Review

Image via Wikipedia

Brain information continues to mushroom:

Many excellent brain blogs keep all of us posted on these interesting neuroscience developments. Alisa Miller has reviewed and published an inclusive summary "101 Fascinating Brain Blogs" over at the Online Educational Database [OEDb] for our mutual use and Holiday reading. 

Included are some of my old friends from Furious Seasons, to Mind Hacks.

This superior list includes many of the blogs I have listed here at CorePsychBlog, and many new resources as well. It looks like Alisa's careful review will keep those of us interested in the evolution of brain science with many pages to read over into the next year!

Naturally I am happy to announce as a side bar that CorePsychBlog made the list, #73, but who's checking?

More this weekend on a recent peer-reviewed study that confirms very clearly what I have been writing about all along: Many are not asking the questions effectively in the office - the complexity of the mind finds little solace in the oversimplification that swims downstream from reductionistic labels.

More later - do pop over and take a look at this excellent review.

Gluten/Celiac, Migraine, & ADD/ADHD Connections 1

Migraine and ADD Clearly Connect with Brain Vascularity - Blood Flow
Image via Wikipedia
Blood Vessels Diminished in Function Contribute to Migraines and to ADD.
- One cause for all these problems, often over-looked, is gluten sensitivity. I have posted many notes here on this topic, but with the last post at CorePsychBlog added the migraine interest. Celiac Disease, 'CD' in some of these abstracts, is end stage gluten sensitivity.

When we do SPECT imaging at CorePsych we measure rCBF - regional cerebral blood flow, and there you can see the brain vascular problems often associated with migraines on the SPECT image.

These are some additional reference links you will appreciate on migraine, blood flow and gluten sensitivity:

1. Hadjivassiliou M, Gibson A, Davies-Jones GA, et al. Does cryptic gluten sensitivity play a part in neurological illness?. Lancet 1996;347:369–71.  "Our data suggest that gluten sensitivity is common in patients with neurological disease of unknown cause and may have aetiological [causal] significance."
2. Hadjivassiliou et al. Headache and CNS white matter abnormalities associated with gluten sensitivity Neurology 2001; 56: 385-388  "The authors describe 10 patients with gluten sensitivity and abnormal MRI. All experienced episodic headache, six had unsteadiness, and four had gait ataxia. MRI abnormalities varied from confluent areas of high signal throughout the white matter to foci of high signal scattered in both hemispheres. Symptomatic response to gluten-free diet was seen in nine patients."
3. This excellent link at Celiac.com has several references on migraines including one regarding migraines in children.
4. This link will take you to several articles at Celiac.com that address the ADD/Gluten connection.
5. Mirza M, et al Interictal SPECT with Tc-99m HMPAO studies in migraine patients, Acta Neurol Belg. 1998 Jun;98(2):190-4. "The SPECT images revealed clear interhemispheric asymmetry in the upper frontal and occipital parts of the brain in migraineurs. It is suggested that an impaired regional cerebral vascular autoregulation may exist even during headache-free intervals in patients suffering from migraine." [SPECT Imaging shows impaired vascular activity even when not having a migraine.]

I'll have some more soon - interesting how migraine and ADD can similarly impaired problems with cerebral blood flow

Brain Imaging and Innovation: "Iconoclast" is Must Read

Before we get started:
Please go over now and hook up to follow me as a friend on Twitter - there I can give you faster updates on all my many activities! http://twitter.com/drcharlesparker  - I am also planning to organize blog updates here at CorePsychBlog for postings with a specific schedule of topics [more later], and better connections for a variety of interesting activities including video blogs on a variety of topics we all find interesting.

I have always enjoyed developing teams, and anticipate that we can have some more fun with these different levels of staying posted. Very much going on here, and with the Tweets can keep you posted even more easily.

Important next step:                                          
-Strongly urge you to get this book- Iconoclast: A Neuroscientist Reveals How to Think Differently by Gregory Berns, MD PhD - as soon as I got half way through I added to my list of personal favorites at the CorePsych Books [It's down on the shelf of Parker Personal Favorites...]

Def: "Iconoclast: a person who does something others say can't be done." Now that I have your attention...

Why this book is so very cool:
Iconoclast discusses brain imaging evidence applied to the process of creative thinking... and more than that, creative application in groups. Berns actually takes out-of-the-box-creative-thinking and applies it to social networking!

You know how devoted I am to brain evidence in the context of the abundant medication madness , - and if you are a regular reader here, I know this one needs to become tops on your reading list. My partner, Jeff Schlichter, PhD, and I think Iconoclast is so significant we gave it as a gift to all of our outpatient team in Va Beach at Parker, Schlichter and Associates.

Some additional points that are quite memorable -

Impulsivity: Is it AD/HD or IED, Intermittent Explosive Disorder?

Intermittent Explosive Disorder [IED] can look like AD/HD - but it's more than that: Take a look at this material from the National Institute of Health that also differentiates IED from Bipolar:

Intermittent Explosive Disorder (IED) Affects up to 16 Million Americans in their lifetime

"A little-known mental disorder marked by episodes of unwarranted anger [-sounds like ADD/ADHD at first glance] is more common than previously thought, a study funded by the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH) has found. Depending upon how broadly it's defined, intermittent explosive disorder (IED) affects as many as 7.3 percent of adults — 11.5-16 million Americans — in their lifetimes. The study is based on data from the National Comorbidity Survey Replication, a nationally representative, face-to-face household survey of 9,282 U.S. adults, conducted in 2001-2003.

People with IED may attack others and their possessions, causing bodily injury and property damage. Typically beginning in the early teens, the disorder often precedes — and may predispose for — later depression, anxiety and substance abuse disorders. Nearly 82 percent of those with IED also had one of these other disorders, yet only 28.8 percent ever received treatment for their anger, report Ronald Kessler, Ph.D., Harvard Medical School, and colleagues. In the June, 2006 Archives of General Psychiatry, they suggest that treating anger early might prevent some of these co-occurring disorders from developing."

For the diagnostic criteria read on: 

Fixing the ADD Madness: The Diagnostic Mess

Right Targets Right Interventions
If you don't see the specific AD/HD target, if you don't have a specific objective, how can you hit anything no matter what technique you use? The debate about what to do for ADD treatment goes far beyond just the ADD medications I have repeatedly been reviewing here at CorePsychBlog: See this summary ADD Medication Details post.

Professionals Disagree
I'm out here with an amazing group of folks for a 4 day meeting in LA, some are child psychiatrists, some are psychologists, some are family counselors, and the offline debate is most interesting - each sees the ADD diamond from the lens of their experience and training. The good news is that a big shift is occurring as the most informed know they can't cover it all, myself included.

Excercise is helpful, nutrition is remarkably useful, breakfast and sleep are essential, ADD medicatons do help if they are used correctly, - but none of this works if they have an undiagnosed immune dysfunction [gluten sensitivity], a hormone dysregulation [PCOS], an addiction, brain injury, or psychological problems with a family member - to name but a few.

ADD is simply too complex a picture to just shoot the meds based upon a diagnostic manuel [DSM-IV]that is, quite simply, outdated. It's not wrong, it just isn't sufficient. Yes, it works if you want to talk to a teacher, but has limited value if you really work with those who suffer the complexity of ADD Spectrum Disorders.

Stay tuned will be doing more regular updates here, gotta run to the meeting this AM, driving down to the Westin at LAX from up North near Beverly Dr.

Quick Personal Note
It's been great fun staying with my LA family in West Hollywood, my son who works at Cedar Sinai as an anesthesiologist. my super daughter in law who works as a nurse there, and my grandson who smiles all day, from first blush in the AM until he starts to fade at night - and, at 9 mos old, only fusses if you don't get it - I guess it runs in the family.

It's still early out here, and the little guy isn't up, so I will get out on the road and will update you more when I find a moment with my machine.

ADD Context II: Physics, Reality, and Structure

ADD: A diagnosis over time - A diagnosis of context.

So what do I mean by "context?"

In the last post I told you about the physics professor with ADD - and you may very well have said: Impossible! His "management problem," that "group problem" he has, is not ADD, it is SAD, Social Anxiety Disorder.

Descriptively I agree, but functionally [from the point of view of brain function} it's more than that.

Yes, from one perspective, description and labels alone... he manifests his inability to function, his cognitive anxiety, with groups of people. There, in that people reality, symptoms of cognitive anxiety occur. Groups of people bring a change to his mathematically safe reality. People introduce an exposure to change, to unpredictable variables, and decreased structure unsettles his prefrontal cortex.

The pre-frontal cortex works vigorously to handle reality over time - its executive functions sets the brain and the person to keep in step with changing reality.

People are unpredictable for him, math is not. Groups of people present one context of reality - physics, mathematics is another reality. For him physics is more predictable. Different, less predictable realities significantly alter the process of thinking and acting with ADD.

No, ADD is not like a bacterial infection that remains present until the antibiotic works to kill all the offending bugs. It is a condition that is much more mercurial, often not categorically obvious, not present all day every day, - but exists in specific contexts of reality.

Some show no ADD in Jr High, but serious ADD arises as a freshman in High School - the context, the variables, the real structure has changed.

This simple observation is why so many have problems understanding and treating ADD - they don't get this problem of changing reality, and context. They think it appears categorically, like an infection, all or none - and if you are academically smart, all A's through several graduate schools, you couldn't possibly have that problem

Without understanding and correcting this simple point, we will continue to treat labels, categorical descriptions, and not the people where they live, in some context of changing reality.

AD/HD: Diagnosis and Treatment Often Miss the Mark

AD/HD, ADD, ADHD - The diagnosis is often missed - and since the diagnosis is missed, treatment objectives are missed even more frequently. - But why?

Let's take a moment to really look at clinical function - with one example of ADD from an unexpected source: a physics professor. This will be a short note on a very frequently observed problem:

Our diagnostic grid for ADD Spectrum Disorders [with multiple expressions of attention related issues] is almost purely descriptive - with the inevitable consequence that we most often treat labels, not people. The public is mad because, more frequently than not, our measurements simply don't consider their pain.

ADD involves much more than "hyperactive," "inattentive" and "combined!" And if you are smart, you must, obviously, be lazy...

In evaluations for ADD/ADHD we don't measure, we don't consider clinically, cognitive function in context - especially if you are really smart! If you are really smart with a bunch of degrees, you couldn't possibly suffer with ADD/ADHD, right?

I have repeatedly witnessed this frequent oversight for years - and that's why I think we should change our perspective, - and why I am busy writing my book. If you see enough brains with SPECT brain imaging, and compare those brains with clinical findings and results from the Conner's Continuous Performance Test [others agree], you will see how that test frequently misses the mark.

Read on...

SPECT Brain: NPH-Normal Pressure Hydrocephalus

SPECT: Single Photon Emission Computed Tomography putting the T in SPECT Brain Imaging.

The Tomographic View: The operational word for this post is Tomography... these slices make a difference for NPH: Normal Pressure Hydrocephalus - see the "TV Commercial" [showing the typical gait] at the bottom of this page and I'll tell you a brief story about the one, the NPH one, that almost got away.

This is a shot of what I saw on [many] tomographic views/slices provided by the patient for the second opinion. The surface 3-D renderings, like the ones in many of Amen's Books, looked actually quite good - but looking at the slices, the inside of the brain, there was another story.  Take a quick look at this brain sliced through the magic of SPECT imaging, and see if you see what immediately came to my attention:

Those blue areas in the center simply shouldn't look like this: these pictures are the blue holes of swollen ventricles, on multiple levels, multiple slices.

But let's start at the beginning: Chief Complaint in this 65 yo male: memory deterioration, long standing ADD symptoms recently worse, no head injury, and, yes, some clear metabolic problems... but the big finding in the tomographic slices - big holes in the center of the brain, where the ventricles have swollen and ballooned out. Those blue areas are the ventricles, filled with cerebral spinal fluid, pushing the brain out against the skull. And for the neurologists out there... no fixed gait, no incontinence - in fact he is "compulsive" about working out.

Interesting presentation...

AD/HD Office Updates: Home and Away

The operant word for this fall: Busy
It's been intense gang - home and away... this small picture gives you a little of the feel for the current activity level:  much of the travel is teaching/discussing aspects of the AD/ADHD experience - viewed by other ADD treatment docs, - and by some very interesting brain injury folk I'll tell you about in the next post:

Take note:
Changed the intro audio on the main page, only 1.5 min, and added

An AD/HD Problems with Medications Audio Outline: 17.25 min audio discussing in more detail the 10 Biggest Problems with ADD/ADHD Medications, - it goes with the 1200 word article available when you sign up for updates on the ADD book [also over there on the upper right of the post] - then, quite happily, notified the folks in my book database of the audio upgrade - another techno-hurdle.

First, an Apology -
In the last several weeks I've been in Greenville, SC, Tampa, FL, Bristol, TN, Jackson and Battle Creek, MI and some spots around VA, speaking with many [more than 200] of my medical colleagues about their experiences regularly treating AD/HD, thus the apology - I have been off my writing schedule here.

The AD/HD Philosophic Reception
The discussion about aspects of my new book has been, quite interestingly, uniformly positive. The theme in my medical presentations is simple, and often addressed here at CorePsychBlog -

• we often do not use precise parameters with our AD/HD treatment targets, - current diagnostic criteria are imprecise, superficial, amorphous and "move about" too much- does that cover it? If we don't see it how can we hit it?
• we don't appreciate the specific trajectories of the drugs we use, and thereby often miss the mark just because we don't adjust our sights correctly, but, rather, too often blast away. Are we shooting howitzers at wrens?
• we do regularly see drug interactions that are relevant, and come up frequently with generically available cheaper meds like Prozac and Paxil, secondary to the inappropriate pressures of managed care - said another way: those two cheap drugs are making the whole treatment scene much more difficult with stimulants - for the patients and the docs. Plumbing issues abound.
• the public and many professionals do not accept that AD/HD is a contextual diagnosis that appears in certain realities, and not in others - it's not like a bacterial infection - so the diagnosis is often completely missed... It's there, but the radar is not tuned to see that incoming.
• and these are but a few of the points that haunt thousands of patients and offices everyday... These experiences aren't odd, but rather pandemic in the trenches - thus the book.

Stay tuned for more reports from the front.