How Neuroscience Can Influence Mental Health Practice NOW

Daniel G. Amen, MD

Introduction

When you do individual psychotherapy you are interacting with and impacting the brains of your clients.  When you perform psychological testing you are interacting with, challenging and testing the brains of your clients.  When you are consulted by families or organizations you interact with and influence many brains within the systems.  Whether you are a psychologist, psychiatrist, marriage and family counselor, clinical social worker, drug treatment counselor, pastoral counselor or psychiatric nurse the organ you influence and change is the brain.

Why then does neuroscience take a back seat in the education of mental health professionals?  Why is basic neuroscience not required for the majority of mental health professional degrees?  Why do most mental health professionals remain stuck with Sigmund Freud in 1895 when he wrote in the Project for Scientific Discovery, “The brain science of my time is not up to the task of explaining patients’ symptoms”?  I have argued for nearly two decades that it is time for mental health professionals to arm themselves with the knowledge of brain science to enhance mental health evaluations and treatment.

Over the past 17 years the Amen Clinics have performed nearly 50,000 brain SPECT studies for psychiatric indications.  Looking at the brain has been one of the most informative and stimulating adventures of my life.  In the past few years I have been able to distill our work into 9 very simple principles.  I share them here to try to encourage you to consider brain science in all you do with your clients.

Nine Amen Clinic Principles

1. Your brain is involved with everything you do. How you think, how you feel, how you act, and how well you get along with other people has to do with the moment-by-moment functioning of your brain.  After looking at thousands of brain scans I have come to realize that how your brain functions influences the kind of therapist you are, the effectiveness of your mothering skill, and how well you do in business.  Are you the kind of therapist that is on time, listens, and is generally helpful? Likely, your frontal lobes work right.  Or, are you the type of therapist that is often late, interrupts clients, and has trouble completing reports in a timely fashion.  It may be that you had a frontal lobe injury playing football in high school.

2. When the brain works right, you work right.  When the brain is troubled, you generally experience trouble in your relationships, work, or within yourself. Since the brain is recognized as the organ of behavior, it makes sense that brain problems, such as Alzheimer’s disease, attention deficit disorder, schizophrenia or brain trauma is likely to decrease a person’s effectiveness in life.  Your success in life is associated with how well your brain works.
This principle leads to an important paradigmatic shift: if you see someone who is “not right” then it may not be “his choice” or “his personality,” it may not even be his upbringing or environment (directly) but a matter of his brain not working properly.  WHY it’s not working properly is a question not easily answered by saying he or she has a personality disorder, but the paradigm shift comes when we at least consider not “what’s the matter with YOU?” but “What’s the matter with your BRAIN?” when someone is behaving poorly.

3. The brain is the most complicated organ in the universe. There is nothing as complex as the human brain.  Nothing.  It is estimated that we have 100 billion neurons or nerve cells and trillions of supportive brain cells called glial cells.  Each neuron is connected to other neurons by up to 10,000 individual connections between cells.  You have more connections in your brain than there are stars in the universe.  Also, even though your brain is only about two percent of your body’s weight, it uses twenty five to thirty percent of the calories you consume.  Your brain is the major energy consumer in the body.  Of the breakfast, lunch, dinner and snacks you had today, almost a third went to feed your brain.

4. I you believe the first three principles, this next one is critical and often the undiagnosed cause of many “behavioral, learning or emotional” problems.  Your brain is very soft, yet it is housed in a very hard skull that has many ridges.  Mild traumatic brain injuries can change people’s whole lives and virtually no one knows it, because mental health professionals never look at brain function. In fact, you do not have to lose consciousness to have a serious brain injury.

Phineas Gage, the most famous case in neurosurgery literature, clearly demonstrates this point. Gage was a railroad construction in 1848.  At the time he was described as a moral man of good character.  A freak job accident caused a three and a half foot iron rod to act like a missile, burning into the left side of his face and exiting the top of his left front skull, damaging his prefrontal cortex.  He never lost consciousness despite the severe accident that ultimately robbed Gage of his personality and good character.  John Harlowe, Gage’s physician, stated 11 years later that after the accident, “Gage was no longer Gage.”

When we understand that brain injuries matter, we become much more cautious about letting children hit soccer balls with their heads; snowboard without helmets or play tackle football.  As mental health professionals we need to take even mild traumatic brain injuries seriously.  Clinically, I have found that I have to ask patient at least 5 times whether or not they have had a serious brain injury. Often they forget, and therapists give them the diagnoses of personality disorders, when, in fact, they have brain damage from injuries or accidents.

5. Certain parts of the brain tend to do certain things. For many years, neuropsychiatrists and neuropsychologists have known that certain brain systems are involved with certain behaviors.  For example, the prefrontal cortex is involved with executive functions; the temporal lobes are involved with memory, auditory processing, word finding and emotional reactions; the anterior cingulate gyrus is involved with cognitive flexibility and shifting attention, etc.  Understanding psychobiology is critical to taking a new view of psychiatric illness.

6. Problems in certain brain areas are often associated with specific learning, behavioral or emotional problems. Understanding this principle allows clinicians to start listening for brain system problems, rather than just trying to fit people into DSM-IV diagnostic categories.  For example, if there are prefrontal cortex issues one would expect there to be executive function problems, such as short attention span, disorganization, poor planning and impulse control issues.  If there are temporal lobe problems it is likely people will exhibit struggles with memory, mood stability, word finding and temper control. If there are parietal lobe issues people may get lost easily.  Knowing about brain pathology allows clinicians to target treatments to brain areas rather than nebulous psychiatric diagnoses.  With this model, clinicians develop prefrontal cortex treatments, temporal lobe treatments, etc.

7. Most psychiatric illnesses are not single or simple disorders. Giving someone the diagnosis of major depression is akin to giving patients the diagnosis of chest pain.  Why don’t we give people the diagnosis of chest pain?  Because chest pain is a symptom with many potential causes, such as heart or lung disease, musculoskeletal problems, abdominal or back problems, as well as grief or panic attacks.  Unfortunately, in psychiatry we give people simple diagnoses, such as major depression, ADD, or bipolar disorder, that represent symptoms clusters without understanding the richness of the potential underlying causes.  This leads to overly simplistic treatments that make some better and many worse.  Our brain imaging work has classified 6 different types of ADD and 7 different types of anxiety and depression. Understanding the types helps us be better at targeting treatments to specific brain areas.

8. Imaging the brain helps mental health professionals be more effective, decreases stigma and increases compliance for patients. Imaging the brain teaches mental health professionals to ask more informed questions.  Why are psychiatrists (and I would argue or mental health professionals) the only medical professionals that never look at the organ they treat?  You can try to kill yourself today in Los Angeles and virtually no one outside of our clinics will look at the patient’s brain.  Cardiologists, orthopedists, gynecologist, gastroenterologists, and ophthalmologists all look at what they do before they do it.  It would be considered malpractice in almost all areas of medicine to treat patients solely based on history and clinical examination.  Yet, isn’t that what we do in mental health?

We have had great tools to look at brain function for two decades. So why don’t we look?  Several reasons: imaging the brain is not part of our training, experience or tradition.  UC, Irvine is the only psychiatric residency program that I am aware of that teaches residents how to use imaging tools clinically.  It is time to change.  The brain is our organ and we need more information to do the best job for our clients and stop guessing what might be the problem.

The study we do in our clinic is called brain SPECT imaging.  SPECT stands for single photon emission computed tomography and measures blood flow and activity patterns in the brain.  It basically tells us three things: 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.  Once we know how an individual patient’s brain works, the goal of treatment is to balance brain function, such as calm the overactive areas and enhance the underactive ones.

Withholding imaging in unclear or resistant cases does an injustice to our patients and in our clinical experience often harms them.  Ineffectively treated neuropsychiatric disorders are expensive, hurtful and demoralizing.  Here is an example:

A couple came for evaluation after their marital therapist told them she thought they should get divorced.  They had been treated by her for three years and spent nearly $20,000 in care.  In addition, each partner had had a psychiatric evaluation by an independent psychiatrist.  The husband was diagnosed as having a mixed personality disorder with narcissistic and antisocial features.  The recommendation for divorce upset the couple and their family physician referred them for a more thorough evaluation, including brain SPECT scans.  The husband’s scan had a toxic appearance (Image 1 shows a healthy scan, Image 2 is the husband’s scan), consistent with drug or alcohol use, but in the history the husband reported that he didn’t drink and had never used drugs.  This was also confirmed by his wife.  The scan results caused his physician to think through a completely different differential diagnosis than is typical in psychiatric medicine.  Problems consistent with a toxic appearance on SPECT include drug or alcohol use, a medication effect, a past near drowning event, severe hypothyroidism, anemia, AIDS dementia, or an environmental toxin.  It turned out that the husband worked in a furniture factory, finishing cabinets all day long.  Inhalants frequently show a toxic pattern on scans.  Even the best marital therapy is likely to fail until the husband’s brain function is improved.  Having this information dramatically changed the treatment plan and was instrumental in helping this couple’s marriage.

9. The brain can change! This is the headline for mental health in the new millennium!  When we do the right things for our clients, whether it is great psychotherapy, effective use of medication or supplements, or newer treatments such as transcranial magnetic stimulation or hyperbaric oxygen treatment we enhance brain function and enhance people’s lives.  My bestselling book, Change Your Brain, Change Your Life is centered on this principle.  We have seen it work for more than 17 years.  The brain is adaptive and influenced by what we do for it.  The opposite is also true, the brain can change in a negative way when we do the wrong things.  Yes, you can impair brain function with the wrong interventions.  We must have great respect for our interventions.  I argue that we need to look at the brain before we do things to it and also check ourselves periodically to see if we are making things better or worse.

AD is a retired NFL football player.  He retired at the age of 28 due to several concussions.  Years later he came for evaluation to prevent the cognitive problems he saw in other retired football players.  Image 17 shows clear evidence of brain damage.  Six months later on fish oil, gingko, and huperazine his brain looked much better and he said he felt more energetic and was better able to focus and remember.

Optimizing Brain Function

From our work as clinical neuroscientists, psychiatrists, and brain-imaging experts, our clinics have developed a simple 7 step program for optimizing brain function. Incorporate these steps into your own life and the lives of your clients to keep the brain healthy for as long as possible.

1. Protect Your Brain — Protecting the brain from injury, pollution, sleep deprivation, and stress is the first step to optimizing its function.  Wear your seatbelt when you’re in a car, and wear a helmet when you ride a bicycle, motorcycle, or go snowboarding.  Make sure children wear helmets. One head injury can ruin a life. Along the same lines, do not let children hit soccer balls with their heads. Soccer balls are heavy. Repeatedly slamming a child’s head against a soccer ball may cause minor repetitive trauma to the brain. At this time there are not enough studies to say heading soccer balls is safe. I encourage my children to play golf, baseball, and tennis, rather than football, soccer, or hockey.

Current brain imaging research has shown that many chemicals are toxic to brain function. Alcohol, drugs of abuse, nicotine, much caffeine, and many medications decrease blood flow to the brain. When blood flow is decreased the brain cannot work efficiently.  Avoid these toxic substances.  In a similar way, sleep deprivation also decreases brain activity and limits access to learning, memory, and concentration. A recent brain imaging study showed that people who consistently slept less than 7 hours had overall less brain activity. Getting enough sleep is essential to brain function.

Scientists have only recently discovered how stress negatively affects brain function. Stress hormones have been shown in animals to be directly toxic to memory centers. Brain cells can die with prolonged stress. Managing stress effectively is essential to good brain function.

2. Feed Your Brain — The fuel you feed the brain has a profound effect on how it functions. Lean protein, complex carbohydrates, and foods rich in omega 3 fatty acids (large cold water fish, such as tuna and salmon, walnuts, Brazil nuts, olive oil, and canola oil) are essential to brain function. Unfortunately, the great American diet is filled with simple sugars and simple carbohydrates, causing many people to feel emotional, sluggish, spacey, and distracted.
Balancing your diet is essential to brain health and longevity.  I also recommend taking a 100% vitamin and mineral supplement, along with extra Vitamin E and C for brain longevity.

3. Kill the ANTs That Invade Your Brain — The thoughts that go through your mind, moment by moment, have a significant impact on how your brain works. Research by Mark George, MD and colleagues at the National Institutes of Health demonstrated that happy, hopeful thoughts had an overall calming effect on the brain, while negative thoughts inflamed brain areas often involved with depression and anxiety. Your thoughts matter.  I often teach my patients how to metaphorically kill the ANTs that invade their minds. ANTs stand for Automatic Negative Thoughts. The ANTs are automatic. They just happen. But they can ruin your whole day, maybe even your life. For example, I once treated a college student who was ready to drop out of school. He thought he was stupid because didn’t do well on tests. When his IQ was tested, however, we discovered that he had an IQ of 135 (in the superior range). He just wasn’t a good test taker.  Whenever you feel sad, mad or nervous write out your automatic negative thoughts and talk back to them.  You do not have to believe every thought that goes through your head. It’s important to think about your thoughts to see if they help you or they hurt you. Develop an internal anteater to hunt down and devour the negative thoughts that are ruining your life.

4. Work Your Brain — Your brain is like a muscle. The more you use it, the more you can use it. Every time you learn something new your brain makes a new connection. Learning enhances blood flow and activity in the brain. If you go for long periods without learning something new you start to lose some of the connections in the brain and you begin to struggle more with memory and learning.  Anatomist Marian Diamond, PhD, from the University of California at Berkely studied aging in rats. Those rats who were allowed an easy life without any new challenges or learning had less brain weight than those rats who were challenged and forced to learn new information in order to be fed. New learning actually caused increased brain density and weight. Strive to learn something new everyday, even if it is just for a short period of time. Einstein said that if a person studies a subject for just 15 minutes a day in a year he will be an expert, and in five years he may be a national expert. Learning is good for your brain.

5. Exercise For Your Brain –  Regular physical exercise enhances brain function.  People who exercise on a regular basis have better memories with age, they have better blood flow to the brain and many cerebral processes are enhanced.  Physical exercise is the fountain of youth that many people seek.  Exercise protects you from illnesses of aging.  The best kind of exercise improves the pump force of your heart (cardiovascular exercise) and strengthens the muscles of your body (resistive exercise).

6. Develop A “Concert State” For Your Brain — Optimal performance is best achieved when a “concert state” exists in the brain. By “concert state” I mean “a relaxed body with a sharp, clear mind,” much as you would experience at an exhilarating symphony. Achieving this state requires the ability to relax and focus.  Deep breathing, prayer and meditation are excellent ways to achieve this state.  Studies on prayer and meditation have also shown brain changes that help people block out the external world but focus internally.  In Andrew Newberg’s book, Why Won’t God Go Away, he described a series of experiments with Tibetan Monks meditating and Catholic Nuns praying.  Both states enhanced brain function.  In the fall of 2003 I performed a study that demonstrated meditation had significant positive effects on brain function.  Work to develop a “concert state” by relaxing your body and developing mental clarity.

7. Treat Brain Problems Early — Many people sabotage themselves by denying they have brain problems until significant damage has been done to their lives. Most psychiatrists feel that there is a significant brain component to depression, anxiety problems, attention deficit disorder, obsessive compulsive disorder, substance abuse problems, and even violence. Unfortunately, the stigma associated with seeing a psychiatrist still prevents people from seeking help for obvious problems.  Clearly, the earlier people seek help for these problems the less negative impact they will have on their lives. If you struggle with any of these problems you are not alone. According to the National Institutes of Health 51% of Americans will have a psychiatric illness (depression, anxiety, ADD, OCD, substance abuse problems, etc.) at some point in their lives. Successful people have problems, they are smart enough to seek help. The earlier the better.

Understanding our patients and clients through the lens of brain science helps us be more effective and less judgmental.  It teaches us to focus on brain health as well as the psychodynamics that might be present.  This is a very exciting time to be a mental health professional.  We are on the verge of a radical new shift in our profession that will be more open to integrating the mind, body and the soul in mental health.

Daniel G. Amen, MD is a psychiatrist, brain imaging specialist, a Distinguished Fellow of the American Psychiatric Association and the CEO and medical director of Amen Clinics, Inc. (ACI) in Newport Beach and Fairfield, California, Tacoma, Washington and Reston, Virginia.  ACI has the world’s largest database of functional brain scans related to psychiatric medicine, now totaling nearly 50,000 scans, and the clinics have seen patients from 70 countries.  Dr. Amen is an Assistant Clinical Professor of Psychiatry and Human Behavior at the University of California, Irvine School of Medicine.  Dr. Amen is the author of 22 books, including the New York Times bestseller, Change Your Brain, Change Your Life.  He is also the author of Healing ADD, Healing The Hardware of the Soul, Making A Good Brain Great, Sex On The Brain, and the co-author of Healing Anxiety and Depression and Preventing Alzheimer’s.  His most recent book is Magnificent Mind At Any Age.  He also wrote and produced two recent shows for public television.