Basal Ganglia System

Basal Ganglia Functions

• integrates feeling and movement
• shifts and smoothes fine motor behavior
• suppression of unwanted motor behaviors
• sets the body’s idle or anxiety level
• enhances motivation
• pleasure/ecstasy

Associated Problems

• anxiety, nervousness
• panic attacks
• physical sensations of anxiety
• tendency to predict the worst
• conflict avoidance
• Gilles de la Tourette’s Syndrometics
• muscle tension, soreness
• tremors
• fine motor problems
• headaches
• low/excessive motivation
• chronic tension
• predicts the worst
• frequent physical complaints

Basal Ganglia Discussion with Abbreviated Case Studies

The basal ganglia are a set of large structures toward the center of the brain that surround the deep limbic system.  The basal ganglia are involved with integrating feelings, thoughts and movement, along with helping to shift and smooth motor behavior.  In our clinic we have noticed that the basal ganglia are involved with setting the body’s idle or anxiety level.  In addition, they help to modulate motivation and are likely involved with feelings of pleasure and ecstasy.  Let’s look at each of these functions in more depth.

The integration of feelings, thoughts and movement occur in the basal ganglia.  This is why you jump when you’re excited, tremble when you’re nervous, freeze when you are scared or get tongue-tied when the boss is chewing you out.  The basal ganglia allow for a smooth integration of emotions, thoughts and physical movement and when there is too much input they tend to lock up and do not allow a smooth transition.  A patient of mine was badly burned in a motorcycle accident in San Francisco.  As he lay burning on the ground, people stood nearby, frozen with fear, unable to move to help him.  For years he was frustrated by their actions.  Wondering why no one moved to help him.  “Didn’t they care.  Was he not worth trying to help?” he wondered.  For years, this man lived with both the physical pain from the accident along with the emotional pain of feeling others did not care enough to help him.  He was relieved to be able to gain a new perception of the situation.  The intensity of emotion caused by the fiery accident overwhelmed the onlookers’ basal ganglia and they became unable to move, even though most of them probably wanted to help.

When the basal ganglia are naturally overactive (as we have seen in the case of people with anxiety tendencies or disorders) people are more likely to be overwhelmed by stressful situations and have a tendency to freeze or become immobile (in thoughts or actions).  When the basal ganglia are naturally underactive (as we have seen in people who have attention deficit disorder or ADD) often a stressful situation moves a person to action.  Often people with ADD are the first ones on the scene of an accident and they respond to stressful situations without fear.  I know, for example, that one of my friends who has ADD is a lot quicker at responding to crises than I am (as mentioned in Chapter One, I have naturally overactive basal ganglia).  I remember one situation where we were leaving a restaurant paying the bill at the counter when the lady in front of us suddenly fell to the ground.  My friend quickly went to her aid while I stood there a bit frozen by the intensity of the situation.  And I had medical training, my friend did not.  I used to feel guilty about not moving quickly in those situations, but it has helped to learn that my brain just doesn’t work that way.  The activity in my basal ganglia make it a little harder to move quickly in anxious situations.

Shifting and smoothing fine motor behavior is another basal ganglia function and is essential to handwriting and motor coordination.  Again, let’s use the example of attention deficit disorder.  Many children and adults who have ADD, have very poor handwriting.  The act of handwriting is difficult and often stressful for them.  Their writing often looks choppy or sloppy.  In fact, many teens and adults with ADD print as opposed to writing in cursive.  They find printing easier, because it is not a smooth motor movement, but rather a start and stop motor activity.  Many people with ADD also complain they have trouble getting their thoughts out of their head and onto paper, a term called finger agnosia (where the fingers cannot tell what the brain is thinking).  We know that the medications that help ADD symptoms, such as the psychostimulants Ritalin, Dexedrine or Adderall, work by enhancing the production of the neurotransmitter dopamine in the basal ganglia.  It is often amazing how these medications improve handwriting and enhance a person’s ability to get their thoughts out on paper in an easier way.  In addition, many people with ADD say that their overall motor coordination is improved with these medications.  Here is an example from one of my patients.

Another clue about the motor control functions of the basal ganglia comes from the understanding two other illnesses, Parkinson’s Disease (PD) and Gilles de la Tourette’s Syndrome (TS).  PD is due to a deficiency of dopamine within the basal ganglia system.  It is characterized by a “pill rolling” hand tremor, muscle rigidity, cogwheeling (jerking, stop-and-start movements when trying to rotate a joint), loss of agility, loss of facial expression and slow movements.  Often, adding dopamine enhancing drugs, such as L-dopa, helps these symptoms significantly and people are able to have smoother motor movements.   The basal ganglia also are involved in suppressing unwanted motor activity.  When there are abnormalities in this part of the brain people are more at risk for Tourette’s Syndrome, which is a combination of both motor and vocal tics (more on this later in the chapter).

In doing our brain imaging work, we have seen that the basal ganglia must also be involved in setting the body’s idle or anxiety level.  When we see too much activity in the basal ganglia it is often associated with anxiety, tension, increased awareness and heightened fear.  When there is too little activity in this part of the brain, there are often problems with motivation, energy and get-up-and-go.

Of interest, however, some of the most highly motivated individuals we have scanned, such as CEOs of companies, also have significant increased activity in this part of the brain.  One of our theories is the excessive basal ganglia activity may be associated with heightened anxiety or it may be associated with increased motivation.  If you do not use the increased dopamine to get things done, you are more likely to feel anxiety and tension.  Some people can use this increased activity in the form of motivation to be the “movers” in our society.  My mother, for example, who like me has increased activity in this part of the brain, does tend to be a bit anxious, but she is a woman on the go.  She plays golf 4-5 times a week, raised seven children without appearing stressed and is always up “doing something” for other people.  Using the increased energy and drive from increased activity basal ganglia activity is likely essential to not feeling terribly anxious.

Another interesting finding about this part of the brain is that the basal ganglia is likely involved in the pleasure control loops of the brain.  One brain imaging study performed by Nora Volkow’s group at the Brookhaven National Laboratory in Upton, New York looked at where cocaine and Ritalin work in the brain.  Both cocaine and Ritalin were taken up mostly in the basal ganglia.  Cocaine is an addictive substance.  Ritalin, in doses prescribed for ADD, is not.  The study clearly showed why.  Cocaine is a powerful enhancer of dopamine availability in the brain and it has both very fast uptake and clearance from the brain.  It comes on strong in a powerful wave and then it’s gone.  The person gets a high high, then it’s gone so the person wants more.  In contrast, Ritalin also increases the availability of dopamine to the basal ganglia, but it is less powerful in its effects and it clears from the brain at a much slower rate.   Dr. Volkow’s group postulated that is activation by cocaine perpetuates the compulsive administration of the drug and is intensely desired by the cocaine abuser resulting in the loss of control over the drive to take more cocaine.  Ritalin, on the other hand, enhances motivation, focus and follow through but does not give users a high or an intense desire to use more (unless used at much higher doses than clinically prescribed).  In fact, one the biggest clinical problems I have with ADD teenagers is they forget to take their medication.

Intense romantic love can also have a cocaine-like effect on the brain, robustly releasing dopamine in the basal ganglia.  Love has real physical effects.  I had the opportunity to scan a close friend, Bill, shortly after he had met a new woman in his life.  He was “head-over-heels” for her.  After their third date, where they spent the day at the beach in each other’s arms, my friend came by my office to tell me about his new found love.  After talking with him for 10 minutes it was clear to me that he had very positive intense feelings of “new love” for her.  He was so happy it seemed almost like a high similar to the highs people get with drugs.  By coincidence, when Bill was in my office my nuclear technician came in to my office and told me we had an extra dose of the isotope to do another scan if I had someone who needed one.  Since I had a scan of Bill before, as part of our normal control group, I thought we’d scan him again and get a look at the brain of new love.  To my utter amazement, his brain looked like he had just taken a lot of cocaine.  The activity in both the right and left basal ganglia was very intense, almost to the point where it looked like he had seizure activity in this part of the brain.  Love has “real effects on the brain,” as powerful as addictive drugs. 

Anxiety, Nervousness, Panic Disorder

Excessive basal ganglia activity resets the body’s idle to a “revved up” level and people feel anxious, nervous, tense and tend to predict bad things.  Almost all of the patients we have treated with panic disorder whom we’ve scanned had heightened basal ganglia activity.  Here’s an example of a patient with a panic disorder.

Gary first came to see me about eight years ago.  He had first gone to his doctor complaining of back pain.  The doctor examined Gary’s back and found a tender spot over his kidneys.  He asked Gary to get a kidney X-ray.  In Gary’s mind as soon as the doctor asked him to get this X-ray his thoughts took off, “The doctor is going to find out I have cancer,” he thought. (Notice the little leap in logic!)  But his thoughts didn’t stop there.  “The doctor’s going to find out I have cancer.  I’m going to have to have chemotherapy.”  So he’s now in the treatment phase, 10 seconds into this.  “I’m going to vomit my guts out, lose all my hair, be in a tremendous amount of pain, and then I’m going to die!”  His mind did this all in a span of 30 seconds.  Then Gary had a panic attack.  His heart started to race out of his chest.  His hands became ice cold.  He started to hyperventilate.  And he started to sweat all over.  He turned to the doctor and he said, “I can’t have that X-ray.”

Bewildered, the doctor replied, “What do you mean?  You came to see me to get help.  I need this X- ray, so I can figure out…”

Gary said, “No, you don’t understand!  I can’t have the X-ray!”

So the doctor found my number, called me and said, “Daniel, please help me with this guy.”

As Gary told me this story, I knew that he had a lifelong panic disorder.  Gary was also an expert at predicting the worst, which was driving his panic symptoms.

In treating Gary, I taught him the “Basal Ganglia Prescriptions” given later in the book.  I even went with him to have the kidney X-rays because it was important to have it done quickly.  I hypnotized him enabling him to be calm through the procedure.  He did wonderfully; he had great thoughts!  He breathed in a relaxed way; and he went through the procedure without any problems until the X-ray technician came back into the room with a worried look on his face and asked Gary what side of his body was he having the pain.  Gary grabbed his chest and looked at me like, ‘You SOB!  I knew you were lying to me about this! I am going to die.’  I patted him on the leg and said,  “Look Gary, before you die, let me take a look at the X-ray” (psychiatrists are also medical doctors).  As I looked at his X-ray I could see that Gary had a big kidney stone, which can be terribly painful, but kidney stones usually don’t kill anybody!  Gary’s basal ganglia, which were working too hard, put him through tremendous emotional pain by causing him to predict the worst possible outcome to situations.

When there are basal ganglia problems, people have a tendency to predict the worst.  In addition, the basal ganglia anxiety made his pain worse.  As he became more anxious about his pain, the anxiety signals caused his muscles to contract and the smooth muscles in the ureter (the tubes from the kidneys to the bladder) contracted clamping down on the stone intensifying the pain.  The combination of psychotherapy, Nardil (an MAO inhibitor antidepressant with anti-panic qualities) and infrequent use of Valium helped Gary live a more normal life.

Anxiety provoking situations also cause many people with overactive basal ganglia to become frozen with fear unable to leave their homes.  Agoraphobia (fear of being in public) occurs when people fear having panic attacks and become so frozen, that they can’t even leave their own homes.  The fear keeps them frozen.  I have treated many people who have been housebound for years (one lady for 40 years) because of fear of having a panic attack.  She could not look past her disability, but became frozen by fear.

Marsha, a critical care nurse, was forced into treatment by her husband.  She was 36-years-old when she first began experiencing panic attacks.  She was in a grocery store when all of a sudden she felt dizzy, short of breath, with a racing heart and a terrible sense of impending doom.  She left her cart in the store and ran to her car where she cried for over an hour.  After her first episode, the panic attacks increased in frequency to the point where she stopped going out of her house, fearing that she’d have an attack and be unable to get help. She stopped working and made her husband take the children to and from school. Her subsequent symptoms typically included shortness of breath, heart palpitations, cold hands, a terrifying sense of impending doom, sweating and negative thinking.  She was opposed to any medication, because in the past her mother, in attempting to treat her own panic attacks, became addicted to Valium and was often quite mean to my patient Marsha.  She did not want to see herself as being in any way like her mother.  She believed that she “should” be able to control these attacks.  Her husband, seeing her dysfunction only worsen, made the appointment and physically brought her to see a family counselor.  The counselor taught her relaxation and how to talk back to negative thoughts, but it didn’t help her.  Her condition worsened and her husband brought her to see me.  Given her resistance to medication I decided to order a SPECT study to evaluate and then also be able to show her her own brain function.

Her SPECT study was abnormal.  It revealed marked increased focal activity in the right side of her basal ganglia.  This is a very common finding in patients who have a panic disorder.  Interestingly, patients who have active seizure activity also have focal areas of increased activity in their brains.  My colleagues and I wonder if the basal ganglia findings are the behavioral equivalent to seizures with the intense level of emotions associated with panic attacks.

The findings on her scan convinced Marsha to try medication.  I put her on Klonopin, an anti-anxiety medication that is also used for seizure control.  In a short period of time she became able to go out of her house, back to work and resume her life.  In addition to the medication, I taught her the group of “Basal Ganglia Prescriptions” (given later) including sophisticated biofeedback and relaxation techniques and worked with her on correcting the negative “fortune-telling thoughts.  Several years later she was able to completely stop her medication and has remained “panic free.”

A Case Of Post Traumatic Stress Disorder

Mark, a 50-year-old business executive, was admitted to the hospital shortly after he tried to kill himself.  His wife had just started divorce proceedings against him, and he felt as though his life was falling apart.  He was angry, hostile, frustrated, distrusting and chronically anxious.  His co-workers felt that he was “mad all the time.”  He also complained of a constant headache.  Mark was also a decorated Vietnam Veteran, an infantry soldier with over 100 kills.  He told me that he lost his humanity in Vietnam and that the experience made him “numb.” 

In the hospital, he said that he was tormented by the memories of the past.  Mark had post traumatic stress disorder (PTSD).  He felt that with his wife leaving him, he had no reason to live.  Due to the severity of his symptoms, along with a history of a head injury in Vietnam, I ordered a brain SPECT study.  It was abnormal, showing marked increased activity in the left basal ganglion.  It was the most intense activity in that part of the brain I had ever seen. 

Left-sided basal ganglion findings are often seen in people who are chronically irritable or angry.  Mood stabilizers, such as Lithium, Tegretol, or Depakote, are often helpful in decreasing the irritability and calming down focal “hot” areas in the brain. I placed Mark on Depakote.  Almost immediately, his headaches went away and he began to feel calmer.  The hospital staff noted how much calmer he was.  He stopped snapping at everyone and he became more able to do the psychological work of healing from his divorce and the wounds from Vietnam. 

In working with Mark, I often felt that his experiences in Vietnam had reset his basal ganglia to be constantly on the alert.  Nearly everyday for 13 months of the war, he had to be “on alert” in order to avoid being shot.  Through the years, he never had the chance to learn how to reset his brain back down to normal.  The medication and therapy allowed him to relax, and feel, for the first time in 25 years, that he had truly left the war zone.

Conflict Avoidance

Anxiety is, by definition, very uncomfortable.  Thus, people who are anxious tend to avoid any situations that make them uncomfortable, especially dealing with conflict.  People who have basal ganglia problems tend to be frozen by conflict and subsequently do what they can to avoid it.  Unfortunately, conflict avoidance can have a serious negative impact on your life. 

Loren, the owner of a neighborhood deli, hated conflict.  He also has problems with chronic feelings of tension and anxiety.  The problem caused him to not fire employees who were not good for his business, out of fear of confrontation.  This caused him to be overly nice to people who were negative to him, resulting in Loren resenting his lack of assertiveness.  It even caused marital problems.  For years Loren wouldn’t talk about the things in his marriage that made him unhappy.  He would just hold them in until he finally exploded.  Learning to deal with conflict was the centerpiece of his treatment. 

In a similar way, Betsy’s conflict avoidant tendencies were ruining her career.  She worked at a local oil company.  Being very bright, she advanced quickly in her career until she got to a certain position.  At that level, she had to deal with high-powered men who were competitive and very used to conflict and confrontation.  Betsy reacted to these men by becoming quiet and deferential.  She looked for ways to please these men to avoid the anxiety that she perceived would overwhelm her if open conflict were to occur.  Guess what happened?  Betsy stopped DEAD in her career.  She was unable to be assertive and express her own ideas if they differed from others. 

Betsy, initially came to see me for a severe panic disorder that prevented her from driving.  Her husband and friends had to drive her everywhere because she was afraid she’d have a panic attack. 

In treatment, I taught her how to deal with the conflict.  I taught her how to face these men and not run away from them.  Subsequently, she began to speak up in meetings, stand up for her positions in the company and the upper management began to pay attention to her in a positive way.

It’s very important to learn ways to soothe your basal ganglia. Otherwise, the anxiety and programming from the past will rule your life.

>Gilles de la Tourette’s Syndrome (TS)

TS is a very interesting disorder that provides the bridge between the basal ganglia and two seemingly opposite disorders, attention deficit disorder (ADD) and obsessive-compulsive disorder (OCD). TS is characterized by both motor and vocal tics lasting more than a year. Motor tics are involuntary physical movements such as eye blinking, head jerking, shoulder shrugging and arm or leg jerking. Vocal tics typically involve making involuntary noises such as coughing, puffing, blowing, barking and sometimes swearing (corprolalia). TS runs in families and there have been several genetic abnormalities found in the dopamine family of genes. SPECT studies, by my clinic and others, have found abnormalities in the basal ganglia of the brain. One of the most fascinating parts of TS is that there is a high association between TS and both ADD and OCD. It is estimated that 60% of people with TS have ADD and 50% of people with TS have OCD. On the surface it would appear that these are opposite disorders. People with ADD have trouble paying attention, while people with OCD pay too much attention to their negative thoughts (obsessions) or behaviors (compulsions). In looking further at both ADD and OCD patients clinically, I have found a high association of each disease in each other’s family histories. So, for example, people with ADD often have relatives with OCD-like features and people with OCD have people in their families with ADD. There is even a subtype of ADD that has been termed overfocused ADD of people who have both symptoms of inattention and overfocus.

A crash course in the neurotransmitters (chemical messengers which help the brain to function) dopamine and serotonin is necessary here. In the brain there tends to be a balancing mechanism between dopamine and serotonin. This balance tends to be tipped in the basal ganglia. Dopamine is involved with motor movements, motivation, attention span and setting the body’s idle. Serotonin is more involved with mood control, shifting attention and cognitive flexibility. When something is done to the brain to raise dopamine levels serotonin becomes less effective; and when serotonin levels are raised, dopamine becomes less effective. For example, when I give someone a psychostimulant to treat ADD, it works by effectively raising the availability of dopamine in the basal ganglia. This helps with focus, follow through and motivation. If I give them too much they may become obsessive, moody and inflexible (symptoms of too little serotonin). Likewise, if I give someone who has ADD a medication that enhances serotonin availability in the brain, such as Prozac (a selective serotonin reuptake inhibitor) their ADD symptoms are likely to become worse, and they won’t care they are worse (lowered motivation).

Since the basal ganglia is involved with dopamine production (low in ADD); shifting and suppressing motor movements (lack of smoothness or cogwheeling may result in tics); and has been found to be overactive in OCD (in conjunction with the cingulate gyrus) the basal ganglia are likely significantly involved in all three of these disorders.  Blocking dopamine, with certain antipsychotic medications, such as Haldol and Orap, helps to suppress tics but make ADD symptoms worse.  Psychostimulants, such as Ritalin, Dexedrine or Adderall, help ADD symptoms, but have a variable effect on tics (they may make them better or worse).  In addition, as mentioned, psychostimulants tend to exacerbate OCD symptoms and cause people to focus more on the thoughts or behaviors that bother them.  An interference mechanism in the basal ganglia is likely to be part of the picture, upsetting the dopamine-serotonin balance in the brain.

Fine Motor Problems

As discussed earlier, fine motor problems are often associated with basal ganglia abnormalities.  We discussed handwriting problems earlier in this chapter.  Another interesting connection probably related to basal ganglia activity is the development of fine motor tremors when we become anxious.  When the basal ganglia are overactive we are more at risk for increased muscle tone or tremors.  In my practice I have often prescribed the medication propranolol to calm the tremors musicians get during a performance.  Personally, when I lecture in front of an audience I do not hold papers in my hands because the paper may start to rattle or shake in response to any anxiety I might feel.

Increased muscle tension related to overactive basal ganglia activity is often associated with headaches.  I have noticed that a number of people with resistant headaches have intense focal areas of increased activity in the basal ganglia.  This seems to occur with both muscle contraction headaches (often described a pain in the back of the neck or as a tight band around the forehead) and migraines (usually one-sided pounding or throbbing headache which may be preceded by an aura or warning phenomena).   Interestingly, often anticonvulsant medication such as Depakote or Tegretol, which decrease areas of overactivity in the brain, has been found helpful in decreasing some types of headaches.

Low and High Motivation

As mentioned, motivation tends to be low in dopamine deficient states, such as ADD.  Interestingly, when serotonin levels are raised too high decreased motivation also becomes a problem.  Physicians know that when they overshoot the dose of serotonin enhancing antidepressants (such as Prozac, Zoloft, Paxil, Luvox) lowered motivation is often the result.  Many people have told me they stopped these medications because they stopped doing things that were important to their business or home life.  Once CEO told me he stopped taking Zoloft because he wasn’t keeping up with his paperwork and he really didn’t care.  “That’s not like me,” he said.

Heightened dopamine or basal ganglia states may cause anxiety as mentioned above, but it may also cause increased or even excessive motivation.  In our experience with many CEOs of corporations, they often have enhanced basal ganglia activity.  They also tend to work excessive hours.  In fact, weekends tend to be the hardest time for these people.  During the week, they charge through each day, getting things done.  On the weekend, during unstructured time they often complain of feeling restless, anxious and out-of-sorts.  Relaxation is foreign to them.  In fact, it is downright uncomfortable.  Workaholics may be made in the basal ganglia.  Their internal idle or energy level doesn’t allow them to rest.  Of course, there is a positive correlate. Many of the people in society who make things happen, are driven by a basal ganglia that keeps them working for long periods of time.  The most successful people I know do not work a standard work week.