Case Study: Emotional Trauma & Frontal Lobe Dysfunction
By Rishi Sood, MD, ABPN
Imagine waking up every morning feeling sad, exhausted and hopeless. You go to the doctor and after a brief visit, you are prescribed a medication that is intended to increase serotonin (the “happy” chemical). After 4 to 6 weeks you are told that you should see improvement, but your symptoms get worse. You return to the doctor and are told to discontinue the treatment and over the course of several years go through several medication trials and all sorts of psychotherapy, which do not help. More aggressive approaches are tried. However, Transcranial Magnetic Stimulation, ECT, and Ketamine (used in treatment-resistant cases) fail to provide relief. Over this time period, your marriage ends, you become unemployed and the only purpose to continue living is to see your children grow. Unfortunately, this had been Kevin’s journey when he arrived at the Amen Clinics New York in September of 2017.
When I met Kevin for an initial consultation, he shared that we were his last hope. We agreed that we needed to take a deeper look to determine what we were missing. We began by taking a detailed childhood developmental history.
It was evident that Kevin was exposed to early childhood trauma. His earliest memories were of his parents arguing with the quarrels turning violent when his father would drink alcohol. His older sister would intervene, while Kevin would avoid conflict altogether and use video games to escape reality. Kevin was described by peers and teachers as a shy, introverted, well-behaved boy, but what no one could see is how much Kevin struggled with focus. When teachers would lecture, he would zone out or, as he described it “my brain would shut down.” Completing homework took more than four hours when it should have taken one to two hours to complete. Kevin was able to get “average” grades but often felt inferior as his parents would compare him to Asian peers who were excelling in their tight-knit community. His mother would tell him to work harder and berate him for being lazy. During his adolescence, Kevin turned to marijuana to numb his feelings of inadequacy and decrease overall stress.
Hearing this, I began to think of Kevin’s poor brain. I had an idea of what could be going on but needed to actually look at his brain to really have a clear picture.
When we scanned his brain, several subcortical structures were much more active as compared to healthy controls for his age group. A “diamond pattern” was seen in both resting and concentration states. We often see this pattern in individuals who have experienced emotional trauma and suffer from Post-Traumatic Stress Disorder (PTSD). It was as if Kevin’s brain was on high alert ready to defend against any threat when there was no threat.
It was also evident that Kevin had frontal lobe dysfunction which worsened when he concentrated. The frontal lobe is the “Executive Center” of our brain and governs concentration and short-term memory. This explained Kevin’s struggles in school and in his marriage where he reported: “not being able to keep up with daily responsibilities which led to severe disaccord between me and my ex-wife.”
In order to effectively help Kevin, it was imperative that both systems (frontal lobe and subcortical) needed to be targeted. Upon review of prior treatment plans, both systems were in fact targeted but never together.
The first phase of treatment involved quieting the subcortical circuitry without causing further frontal lobe dysfunction. Our research has shown that a particular class of medications (SNRI-Selective Serotonin Norepinephrine Inhibitors) can drastically reduce depressive symptoms when dealing with these specific brain patterns. We started Venlafaxine (SNRI) and within six weeks Kevin began to report less obsessional thinking, and agitation and was no longer in a constant “fight or flight state.”
To help further decrease the high activity in the emotional trauma circuitry, Kevin completed several sessions of Eye Movement Desensitization Processing (EMDR). During the EMDR therapy, Kevin attended to emotionally disturbing material (i.e. witnessing his father physically abusing his mother). The EMDR therapy facilitated the accessing of his traumatic memory network so that information processing was enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. Kevin reported that the memories “no longer controlled me, it was as if I was free from the past.”
Despite his improvement, Kevin continued to report struggling with attention which made sense as we still had work to do on his frontal lobe. Kevin and I agreed to take more of a natural approach, before adding more medication. We started Omega 3 Power and L-Tyrosine to increase dopamine levels. Within two weeks Kevin reported improved concentration and within three months read a novel cover to cover for the first time in his life.
Kevin understood that taking the medication and supplementation provided the scaffolding to aid in recovery. To take his brain health to the next level he would need to do more. Now that the depression had lifted, he was motivated. Kevin began to exercise (High-Intensity Interval Training 3 times per week) and eliminated processed sugar from his diet. This further increased energy levels and enhanced sleep.
In just 6 months, Kevin’s condition had dramatically improved and he reported having a “new lease on life.”
As I reflect on Kevin’s case, I cannot help but wonder, “What would have happened to Kevin had we not looked at his brain?” I do not believe we would have been able to help Kevin. This case highlights how critical it is to understand the interplay of brain systems and how optimization in a specific sequence can lead to dramatic improvement.
We continue in our quest in helping others, with the hope that one day everyone will have the opportunity that Kevin had. When Kevin changed his brain by doing the things we recommended, he changed his life.
About the Author: Rishi Sood, MD, ABPN
Dr. Sood values working with adults and children across all age ranges. He is experienced in mood and anxiety disorders, addiction, ADD/ADHD, impulsive/disruptive behavior disorders, Autism Spectrum, psychotic disorders, OCD, and PTSD. He uses dynamic as well as cognitive-behavioral therapy, interpersonal psychotherapy, family psychotherapy and works to integrate pharmacotherapy and alternative therapies to optimize brain health and function. Behavioral change is a process and Dr. Sood incorporates a motivational interviewing approach into evaluations to support the client and meet them where they are at, offering client-centered care. He firmly believes that clients do well with continued support in their journey toward optimal brain health.
