Sunday, October 11, 2009

Dr. Amen and ADHD

Dr. Amen is a well known child and adult psychologist specializing in brain imaging science. He believes there are currently 6 types of ADHD not the 3 stated in the Diagnostic Manual.

The brain imaging that he works with is referred to as SPECT imaging (single photon emission computerized tomography). SPECT is a sophisticated nuclear medicine study that looks directly at cerebral blood flow and indirectly at brain activity (or metabolism). In this study, a radioactive isotope (which, as we will see, is akin to a myriad of beacons of energy or light) is bound to a substance that is readily taken up by the cells in the brain.

One kind is a 3D surface brain image, looking at the blood flow of the brain’s cortical surface. These images are helpful for picking up cortical surface areas of good activity as well as underactive areas. They are helpful to look at strokes, brain trauma, the effects from drug abuse, etc. A normal 3D surface scan shows good, full, symmetrical activity across the brain’s cortical surface.

The other kind is a 3D active brain image comparing average brain activity to the hottest 15% of activity. These images are helpful for picking up areas of overactivity, as seen in active seizures, obsessive compulsive disorder, anxiety problems, certain forms of depression, etc. A normal 3D active scan shows increased activity (seen by the light color) in the back of the brain (the cerebellum and visual or occipital cortex) and average activity everywhere else (shown by the background grid).

Physicians are usually alerted that something is wrong in one of three ways: (a) they see too much activity in a certain area; (b) they see too little activity in a certain area; or (c) they see asymmetrical areas of activity, which ought to be symmetrical.

These are "neurotypical" images of the brain.

1. Classic ADHD: Sufferers are inattentive, distractable, disorganized, hyperactive, restless and impulsive SPECT Brain imaging typically shows decreased activity in the basal ganglia and prefrontal cortex during a concentration task. Dr. Amen notes that this subtype of ADD typically responds best to psychostimulant medication.

2. AD/HD, primarily inattentive ADD subtype with symptoms of inattention and also chronic boredom, decreased motivation, internal preoccupation and low energy. Brain SPECT imaging typically shows decreased activity in the basal ganglia and dorsal lateral prefrontal cortex during a concentration task. This subtype of Inattentive ADD also typically responds best to psychostimulant medication.

3. Overfocused ADD, with symptoms of trouble shifting attention, cognitive inflexibility, difficulty with transitions, excessive worrying, and oppositional and argumentative behavior. There are often also symptoms of inattention and hyperactivity-impulsivity. Brain SPECT imaging typically shows increased activity in the anterior cingulate gyrus and decreased prefrontal cortex activity. This subtype of Overfocused ADD typically responds best to medications that enhance both serotonin and dopamine availability in the brain, such as venlafaxine or a combination of an SSRI (such as fluoxetine or sertraline) and a psychostimulant.

5. Limbic ADD, with symptoms of inattention and/or hyperactivity-impulsivity and negativity, depression, sleep problems, low energy, low self-esteem, social isolation, decreased motivation and irritability. Brain SPECT imaging typically shows increased central limbic system activity and decreased prefrontal cortex activity. This Limbic ADD subtype typically responds best to stimulating antidepressants such as buprion or imipramine, or venlafaxine if obsessive symptoms are present.

6. Ring of Fire ADD – many of the children and teenagers who present with symptoms of ADD have the "ring of fire" pattern on SPECT. They often do not respond to psychostimulant medication and in many cases are made worse by them. They tend to improve with either anticonvulsant medications, like Depakote or Neurontin, or the new, novel antipsychotic medications such as Risperdal or Zyprexa. The symptoms of this pattern tend to be severe oppositional behavior, distractibility, irritability and temper problems and mood swings. We think it may represent an early bipolar pattern.
The important thing to remember is that each individual should have a full diagnostic assessment of their condition. Interventions could include:
1. Diet
2. Exercise
3. Medication
4. Supplements
5. Behavioural Interventions - for person with ADHD and family (Neurofeedback)
If medication is given it is important to make sure that there is proper supervision, followthrough and evaluation of the child. You also need to find the right doctor who will spend time with the family to explain the use of the medication and alternatives.

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