On Friday, October 22, 2004, Dr. William C. Klindt addressed attendees at the SCV-CAMFT luncheon on the subject of brain scanning technology. Klindt shared numerous images of brains from his library, and spoke about what we can learn from brain imaging. He showed a series of pictures of normal brains, as well as providing images of brains damaged by stroke or injury, brains altered by substance abuse or chemical exposure, and brains of patients with a variety of psychiatric and behavioral disorders.
Fundamentally, with brain scanning technology, we now can know what "normal" looks like at various ages and stages of brain development. We can also see what's working properly inside the brain, and more importantly for us as clinicians, what's not working.
Because human brains are all basically similar, the library of images on file gives us a baseline for comparison. And because each brain has its unique variations, we can see them through brain imaging, and know pretty well what those shadows on the screen mean. A given area that, for example, is calm and quiet in a normal brain, may show excessive activity (appearing "hot") in a disturbed individual. That overactivity correlates to the behavioral manifestations that correspond to an anxiety disorder. A different area that would normally show moderate activity may be "cold" (underactive). The behavior of the individual will resemble that of persons who have suffered injury to that particular area of the brain. In both situations, proper diagnosis and treatment is made much easier because the scan shows clearly what needs to be treated.
It can be advantageous to use brain SPECT imaging when one sees or anticipates:
- mild to severe brain trauma
- dementia (including Alzheimer's, Pick's, and vascular dementias)
- cognitive decline
- seizure activity, including temporal lobe epilepsy
- atypical psychiatric disorders
- cerebral vascular disorders
- aggressive or violent behavior
- substance abuse
- exposure to toxic substances
SPECT imaging is also an extremely useful tool in situations where a forensic/legal evaluation is required. The procedure takes only about 10 minutes. The patient lies still on a bed, radioactive dyes are injected, and then the bed is moved so the patient's head is inserted into a cylindrical scanner. The scanner rotates around patient's head, taking successive "slices" of image. The radiation dosage is approximately equivalent to having a chest X-ray, and is 400 times less than the amount of radioactivity designated as "perfectly safe" by U.S. government agencies. Health insurance coverage of this procedure is mixed: PPOs often reimburse for it, while HMOs usually do not. MediCal may cover it in certain limited circumstances. The out-of-pocket cost is $1,100 for a single scan. Klindt prefers to do two scans, for a total cost of $2,200. Procedures other than SPECT, i.e. PET scans and MRIs, are much more costly. For patients without insurance, and without the financial resources to pay for scans, the Recovery Assistance Foundation in Southern California may grant funding.
Klindt shared numerous slides from his library of clinical images. There are several ways of "looking" at the brain. There are sectional views: horizontal (top-down view, in a sequence of images "stacked" one upon the other), sagittal (vertical front-to-back slices, in a sequence moving right to left), and coronal (vertical slices as viewed from the front). The isocontour view shows surface views of both the top and bottom surfaces of the brain. Color coding, such as depicted in Talairach space, indicates patterns and amounts of blood flow in various areas of the brain.
Using these images, we can see areas of the brain that are quiet and calm, and normally active areas, as well as under- or overactive regions. (Perhaps surprisingly, the cerebellum is usually the most active area.) In certain cases, a patient may need to stop taking medication before having a scan. The question of whether to go off meds, and if so, for how long, is answered depending on the patient's condition. This evaluation must be made by the physician in consultation with the individual patient.
The SPECT scan is already proving useful in diagnosing Alzheimer's Disease. In addition, Dr. Daniel Amen, working with Dr. Schenkel, at University of California, Irvine, has been developing newer techniques and better scans, allowing earlier diagnosis and treatment of Alzheimer's disease.
Through SPECT scans, we can see the effects of psychiatric disorders, substances, or prescription medications on the brain. The scans are especially valuable when working with ADD teens, because they can see it is really an issue relating to brain function, not an issue of them being "bad" or "stupid."
Visible overactivity in a given area corresponds with the behavioral and emotional manifestations of a particular disorder. For example, anxiety, depression, and bipolar disorder all have distinctive "footprints" in the brain. In a case where there is a brain infection or tumor, that disease will show clearly in the brain imagery. The physician can therefore make much better decisions about what treatment and/or prescription medication might be most effective. One of the significant advantages of SPECT scanning is that, when a patient can see that there is something wrong inside the brain, the patient is much more likely to comply with treatment. Thus, a SPECT scan can successfully cut through denial in substance abuse clients, leading to better progress toward recovery.
Substance abuse clients, after seeing the real picture of "this is your brain on drugs" are (appropriately) concerned, and frequently ask how their brain will look after they clean up. In other words, can the brain recover and return to normal? Yes, the brain can recover to some extent, if the individual gets clean, but there is a permanent long-term effect. Additionally, the brain will be much more vulnerable to further damage because of the prior abuse it suffered. One relapse will promptly return the brain to its pre-recovery state, and it will usually take 6 to 12 months to get the brain back to its "new normal" condition.
In certain conditions, in addition to improved nutrition, hyperbaric oxygen treatment can be helpful in restoring better brain function. Oxygen therapy can also be valuable in treating patients after a stroke. When should a therapist refer a client for a brain scan? When repeated prescription medications and talk therapy do not work, when diagnostic detail is desired, and whenever there is any history of brain trauma, a referral is highly appropriate. It is worth noting that a dose of caffeine initially stimulates the brain. However, after three to four hours, caffeine acts as a powerful vasoconstrictor, which results in decreased blood flow to the brain, and hence, foggy-mindedness. Klindt offered the names of the following local physicians who will refer patients for a brain scan:
- Bruce Wermuth, M.D., Psychiatrist, Los Gatos
- Sharadha Raghavan, M.D., San Jose
- Saad Shakir, M.D., San Jose
- Matthew Stubblefield, M.D., Palo Alto
Review by: Melissa Miller, MFT
