Apr 08 2008
Phrenology was a 19th century pseudoscience that claimed to associate brain areas with specific personality traits. It was based on palpating bumps on the skull and was totally bogus. New brain imaging procedures are giving us real insights into brain function in health and disease. They are still blunt instruments, and it is easy and tempting to over-interpret what we are seeing. In his book The New Phrenology William Uttal warns that “the excitement of these new research tools can lead to a neuroreductionist wild goose chase” and that we must be careful not to succumb to new versions of the old phrenology.
The Amen Clinics, founded by Daniel G. Amen, MD, offer SPECT (single photon emission computed tomography) scans to help diagnose and manage conditions such as attention deficit disorders (ADD), mood disorders, anxiety and panic disorders, autistic spectrum disorders, obsessive compulsive disorder (OCD), substance abuse, toxic exposure, brain trauma, memory problems, temper problems, and relationship and marital struggles.
The scans generate colored pictures of the brain that show “areas of your brain that work well, areas that work too hard, and areas that do not work enough.” They do not actually provide a diagnosis, but “must be placed in the context of a person’s life, including their personal history and mental state.” “The goal of treatment is to balance brain function, such as calm the overactive areas and enhance the underactive ones.”
SPECT depicts blood flow or chemical reactions in different areas of the brain. It is invasive and potentially harmful: it requires the injection of a radioactive tracer. Areas of low blood flow show up as apparent “holes” on colored pictures of the brain, giving a moth-eaten appearance. Amen says that when patients improve clinically, the appearance of their follow-up scan typically improves. Patients using marijuana had areas of low activity in the temporal lobes compared to patients not using the drug. Dr. Amen says he can literally show his patients “this is what your brain looks like on drugs.”
In a typical patient with attention deficit disorder, obsessive thinking, anger outbursts, and depression, Amen found demonstrable defects on the initial scan which were visibly improved after three years of clomipramine therapy. He says that this kind of graphic demonstration can help persuade patients that their problem is physical or physiological and might be helped with medication or other treatments. I’m not convinced. Doctors regularly diagnose and treat depression on the basis of clinical symptoms, and both doctors and patients can recognize symptomatic improvement. Do SPECT scans really add anything significant to this process?
Insurance companies consider SPECT scans for diagnosis of psychiatric disorders to be a research tool, an experimental procedure not yet ready for prime time. In my opinion, Amen has jumped the gun by using SPECT scanning clinically before research has validated his methods. He thinks he is helping patients; but without proper controlled studies, he can’t really know for sure. The FDA would never have approved a new medication on the basis of the kind of evidence Amen is going by. We don’t know (1) whether the scans really improve accuracy of diagnosis, (2) whether the defects we see represent causes or results of the illness, (3) what the progressive changes from scan to scan really mean, (4) whether seeing a picture of their brain actually improves patients’ understanding of their disease, (5) whether it improves their compliance with treatment, or (6) whether Amen’s whole process actually improves patient-oriented outcome compared to optimal treatment without scans. Amen is convinced his methods work, because his patients improve, and because they give him grateful feedback and reinforcement. He may be right, or he may be wrong. Quacks all have patients who improve and give them reinforcement too, even for the most nonsensical remedies that can only act as placebos.
The charge is $3250 up front, and most insurance companies will not provide reimbursement because they consider it experimental. There is a 10% discount for testing additional family members. The testing procedure takes four days. The Amen Clinic’s informed consent form is misleading: it does not divulge that the American Psychiatric Association has spoken out against SPECT scanning for these purposes and has warned of potential harm – especially to children, who are more susceptible to the effects of radiation.
Desperate patients will grasp at any straw. There is an argument for offering unproven treatments as a last resort that “might” help. There are also arguments for limiting treatment to closely monitored research settings until the truth is known. There is no excuse for misrepresenting an unproven treatment as a treatment that has been proven effective. And there is no excuse for concealing essential information from patients, or for creating false hopes by implying a promise of more than they can really deliver.
In 2005 I wrote an article for Quackwatch critiquing the Amen Clinic. Amen and his lawyers protested. Dr. Stephen Barrett and I posed specific questions and they attempted to answer them, but we didn’t find their answers satisfactory. Their answers and my comments can be seen at this link.
In one of his books Amen suggests that “Mother Teresa and Mahatma Gandhi had optimal brain function” whereas “Adolph Hitler and other brutal dictators had faulty brain wiring.” The fact that he can make these historical diagnoses without SPECT scans argues against the need for SPECT scanning in his patients. I saw a TV documentary where a teenager was being shown his scan results and was told one area showed that he had difficulty controlling impulses. Why would you need a scan to tell that?
Amen’s website has lots of testimonials from satisfied patients; but he doesn’t tell you about the patients who were dissatisfied, who felt their money was wasted. In one case “nothing that was written or diagnosed actually came from the SPECT image, but from a history taken orally from the family.” A relative of a patient sent me the glossy Amen Clinic brochure that is being handed out at her son’s school. The sender was particularly amused by a set of brain pictures of an “overfocused wife” and an “underfocused husband.” Yes, Amen is using SPECT scans for marital counseling!
Some of the treatments he offers are even more disturbing. Once the pretty pictures have guided him to a diagnosis, Amen recommends a number of questionable treatments, some of which have been tested and found not to work, and many of which are not recommended by science-based medical doctors – such as Eye Movement Desensitization and Reprocessing (EMDR), hyperbaric oxygen therapy, and oral GABA, which is not likely to help with any problems in the brain since it can’t get there: it doesn’t even cross the blood-brain barrier. For “temporal lobe issues” he prescribes phosphatidyl serine, gingko biloba, vitamin E, and ibuprofen. He has his own line of vitamins and diet supplements which are available for purchase on his website. He also sells books and videos, lectures, and has developed his ideas into a big business.
It’s nice to have pretty pictures, and I’m sure they do serve as a visual aid to help doctors engage their patients in appropriate treatment programs. But do they really need those pictures, or is it just something “nice to have” like those ultrasound pictures of fetuses taken with no medical indication, just because parents want to “see” their unborn child? Can Amen really justify what he is doing? Desperate patients are being sold hope at these clinics, at a high price, at a small but real risk, and without any scientific evidence that SPECT improves patient outcome over those who receive optimum treatment without SPECT.
When William Withering wrote his book on foxglove in 1785, he described all his failures along with his successes, and he humbly suggested that “if” his observations were confirmed by others, foxglove “might” become a useful part of standard medical practice. That was the voice of a critical thinker and a true scientist.
There is no suggestion of that kind of caution on Amen’s website. He seems very certain he is right – but lots of people have been equally certain of other things that turned out to be wrong. Humans are very good at fooling themselves, and the only corrective is the scientific method properly applied.
Dr. Amen was recently in the news for advocating SPECT scans for all the presidential candidates. I don’t think I need to explain why that’s a very bad idea.
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