Abnormal behavior is the common denominator of a great variety of neuropsychiatric disorders. Bipolar and obsessive and compulsive disorders, attention deficit hyperactivity disorder (ADHD), anxiety, and depression are just some of the myriad conditions of behavior dysfunction that can disrupt a person’s life. Fortunately, modern physicians who evaluate such patients today have access to new technologies that provide functional images of the brain. These images provide new insight into the nature of their disorders, and contribute to the decisions leading to appropriate treatment.
Brain SPECT (single photon emission computed tomography) is one such technique. It is a functional brain imaging procedure which generates a color 3-D representation of the brain, displayed in a variety of formats (slices, volumes, surfaces). The colors are proportional to the amount of blood-flow to that area of the brain, which generally is proportional to the level of functional activity in that region.
Functional imaging provides a way to infer how the brain works. The information it provides helps identify areas of abnormally high or low function in the cerebral cortex, subcortical structures, brainstem, and cerebellum. This information gives insight into the biological nature of various symptoms and can contribute to the formulation of a treatment strategy. This is especially true when a patient suffers from not just one, but multiple coexisting disorders.
There are many clear examples of the relationship between psychiatric disorders and behavior. Coexisting disorders can interact with each other, and frequently result in a vicious cycle of negative reinforcement. Consider the effects of depression, which has a negative influence on many other behaviors. Depressed girls often suffer from anxiety disorders, and depressed boys are more likely to have disruptive behavior disorders.
It is well known that all abnormal behavior has consequences. The difficulty resides in the fact that while some of these consequences are obvious, other ones are less so. Guilt, shame, and other feelings can be hidden from others, yet still have profound effects. Such feelings can bring on depression, and it comes as no surprise that people with behavior disorders are prone to depression.
It is important to note that while medication is often indispensable, at least until some re-equilibration occurs within the central nervous system, there are additional approaches available. Neurofeedback, noninvasive brain stimulation, physical exercise, kinesitherapy, and cognitive rehabilitation therapy (CRT) are just some of the techniques shown to be useful in treating behavioral abnormalities.
Cognitive rehabilitation therapy involves physical movement of the major muscle groups, combined with multisensory stimulation, development of visual coordination, balance exercises, and cognitive processing exercises. CRT is thought to result in the development of new dendritic connections in the brain. These steps can be expected to favorably influence brain function and implicitly affect behavior, mood, motivation, and possibly cognition. These practices can have a therapeutic effect and, perhaps most importantly, a preventative effect, especially if started early enough in life.
Behavioral abnormalities are a consequence of multiple and often complex conditions. The difficulties of evaluating such patients and prescribing appropriate treatments are well known. Brain SPECT adds information to the clinical data and help in decision-making. In the case of the 10-year-old girl with multiple disorders (see below), the additional information provided by SPECT left no doubt that antiepileptic medication needed to be pursued. With the availability of sophisticated new brain-imaging techniques like SPECT, physicians can more effectively diagnose and treat complex behavioral disorders, and thus help their patients to better lives.
The following is an example of the way Brain SPECT can be of help in the workup of complex cases with coexisting symptoms.
These images are from a 10-year-old girl, adopted at birth. Her birth mother was thought to be bipolar and on antidepressant medication (Prozac) during her pregnancy.
The child was referred to our center as a case of ADHD with comorbidity (continuing behavioral problems). She had major impulse-control difficulties, mood swings, learning disabilities, anxiety, and attention difficulties. She was forced to leave school and began home schooling. In public and during our examination, she appeared meek, but at home she was aggressive with her four siblings. She had rage episodes, was often maniacal and sometimes injurious to herself, shredding her long hair. Yet, she was on no medication, and her previous EEG was normal.
Her SPECT found evidence of extreme hyperperfusion in the left frontal pole and anterior cingulate gyrus and multiple additional abnormal features. This contributed to the final impression of limbic epilepsy, likely associated with early onset bipolar disorder. The many areas of extreme and marked hyperfunctioning reinforced the need for a mood stabilizer/antiepileptic medication. This was indeed prescribed and subsequently an antipsychotic treatment and neurofeedback treatment were added. In four months, she was able to go back to school.