ADD/ADHD Contents In this document, you will find answers to ADD/ADHD, options for treatment and additional resources, including our top 10 tips for treating ADD and more, including: The Problem How Amen Clinics Can Help You Resources Available Clinical Evaluations How SPECT Can Help Amen Clinics, Inc. The Problem Left Untreated ADD Ruins Lives Attention deficit disorder (ADD), often referred to as ADHD or attention deficit hyperactivity disorder, is the most common psychiatric disorder in children, and one of the most common problems in adults, affecting between 5-10% of the population. ADD is characterized by persistent short attention span, distractibility, disorganization, procrastination and often problems with hyperactivity or restlessness, forethought, judgment and impulse control. Having "untreated" ADD affects nearly every aspect of a person's life and has been associated with school underachievement, family conflict, drug abuse, legal difficulties and poor work performance. ADD is involved with low self-esteem, chronic stress, failure and even suicide. The standard treatment for ADD in both children and adults is stimulant medications, such as Ritalin or Adderall. These medications are helpful for many people, but they also make many others with typical ADD worse. Sometimes negative reactions to these medications can be extreme, such as hallucinations, violent outbursts, volatile temperaments, psychosis and suicidal behavior. Shortly after Dr. Amen began the brain SPECT imaging work began in 1991, he realized that ADD was not a single or simple disorder. Just as there are many different causes of chest pain, there were different brain SPECT patterns in his ADD patients. Over the subsequent 6 years, he described 6 different types of ADD that required individual treatments. One treatment did not fit everyone. Below, is an explanation for 6 different ADD types, along with an example of a patient s brain before and after treatment, how we use brain SPECT imaging scans, and additional resources. Note there is greater detail in his book Healing ADD. 1
6 Types of ADD/ADHD Here are 6 different types of ADD/ADHD, each with different brain function issues and treatment protocols. Type 1: Classic ADD Symptoms: Primary ADD symptoms (short attention span, distractibility, disorganization) plus hyperactivity, restlessness, and impulsivity SPECT: Usually low prefrontal cortex and cerebellar activity with concentration Supplements: Multi-vitamin, fish oil and supplements to boost dopamine, such as L- tyrosine, green tea, rhodiola, ginseng Medications: Stimulant medications, such as Adderall, Concerta, Ritalin, or Vyvanse Type 2: Inattentive ADD Symptoms: Primary ADD symptoms plus low energy and motivation, spacey, and internally preoccupied. Type 2 tends to be diagnosed later that Type 1, if at all. It is more common in girls. These are quiet kids and adults, often labeled as lazy, unmotivated or not that smart. SPECT: Usually low prefrontal cortex and cerebellar activity with concentration. We are working hard to see how these two types differ in the brain. Supplements: Multi-vitamin, fish oil and supplements to boost dopamine, such as L- tyrosine, green tea, rhodiola, ginseng Medications: Stimulant medications, such as Adderall, Concerta, Ritalin, or Vyvanse Type 3: Overfocused ADD Symptoms: Primary ADD symptoms plus cognitive inflexibility, trouble shifting attention, stuck on negative thoughts or behaviors, worrying, holding grudges, argumentative, oppositional, and a need for sameness. It is often seen in families with addiction problems or obsessive-compulsive tendencies. SPECT: Usually high anterior cingulate activity plus low prefrontal cortex with concentration Supplements: Multi-vitamin, fish oil, plus supplements to boost both serotonin (5HTP, inositol, saffron, L-tryptophan or St. John s Wort) and dopamine (L-tyrosine, green tea, rhodiola, ginseng) 2
Medications: Antidepressant Effexor, or a combination of an SSRI, like Prozac, and a stimulant Type 4: Temporal Lobe ADD Symptoms: Primary ADD symptoms plus a short fuse, misinterprets comments, periods of anxiety, headaches or abdominal pain, history of head injury, family history of rages, dark thoughts, memory problems, and struggles with reading; it s often seen in families with learning or temper problems. SPECT: Usually low temporal lobe activity plus low prefrontal cortex with concentration Supplements: Multi-vitamin, fish oil, GABA for irritability or gingko, vinpocetine, huperzine A and acetyl-l-carnitine to boost acetylcholine for memory issues. Medications: Stimulants, by themselves, usually make people with this type more irritable. It is effectively treated with a combination of anti-seizure medications (such as Neurontin) and stimulants. Type 5: Limbic ADD Symptoms: Primary ADD symptoms plus chronic mild sadness, negativity, low energy, low self-esteem, irritability, social isolation, and poor appetite and sleep patterns. Stimulants, by themselves, usually cause problems with rebound or cause depressive symptoms. SPECT: Usually high deep limbic activity plus low prefrontal cortex at rest and with concentration Supplements: Multi-vitamin, fish oil, SAMe or DL-phenylalanine Medications: Stimulating antidepressants, such as Wellbutrin. Type 6: Ring of Fire ADD Symptoms: Primary ADD symptoms plus moodiness, anger outbursts, oppositional, inflexibility, fast thoughts, excessive talking, and very sensitive to sounds and lights. Dr. Amen named it Ring of Fire after the intense ring of over-activity he saw in the brains of those affected. This type is usually made much worse by stimulants. SPECT: Marked overall increased activity across the cortex, may or may not have low prefrontal cortex activity 3
Supplements: Multi-vitamin, fish oil, and a combination of 5HTP, GABA and L-tyrosine Medications: Anticonvulsants (such as Neurontin) and SSRI medication, or the use of the novel antipsychotic medications such as Risperdal or Zyprexa. How Amen Clinics Help Detailed clinical histories + Brain SPECT imaging and appropriate lab studies = more targeted treatment + lifestyle changes = high levels of success. At Amen Clinics, Inc. (ACI) we are dedicated to improving the lives of every patient and family we serve through education, the latest advances in neuroimaging, laboratory testing, and individualized treatment plans. We use the least toxic, most effective treatments for our patients, and use a wide variety of interventions from natural supplements, medications, dietary interventions and targeted forms of psychotherapy. Resources Available Amen Clinics, Inc. provides personalized diagnoses, counseling from one of many accomplished doctors, as well as a brain-directed products and education, proven to enhance your brain and overall health. For more information, go to www.amenclinics.com. Clinical Evaluations As part of our evaluation process we use brain SPECT imaging, in addition to clinical interviews, diagnostic checklists and laboratory studies when appropriate. Our recommendations may include natural supplements, medications, targeted forms of psychotherapy, and alternative methods such as neurofeedback or hyperbaric oxygen therapy. How SPECT Can Help Below is a brain SPECT (single photon emission computed tomography) scan of Joan, a woman who suffered from severe ADD and dyslexia her whole life. The image on the left is her brain when we first scanned her at age 62. Notice the potholes and irregularities, which show low blood flow to her brain. After a few days of being on a brain-healthy program, see how her brain, on the right, had improved. You can literally, change your brain and change your life, and with a better brain for Joan came a much better life, no matter what your age. 4
Before treatment After treatment At the Amen Clinics, we have been using brain SPECT imaging as an aide in making diagnoses and individualizing treatment plans since 1991. Brain SPECT helps us gain a deeper understanding of the biological underpinnings of our patients problems and then helps us formulate the biological part of our patients treatment plans. For example, SPECT helps us understand if an underlying head injury or toxic exposure may be contributing to our patients problems. If a patient has an overactive brain, SPECT helps us make recommendations to calm the brain, where if a patient has an underactive brain I am more likely to make recommendations to help stimulate it. Always, the SPECT data needs to be correlated with the clinical information. SPECT looks at blood flow and activity patterns. SPECT is different than CAT scans and MRIs, those are anatomy scans. They show what the brain actually, physically looks like. SPECT looks at how the brain functions. SPECT is a nuclear medicine study that uses small doses of isotopes as tracking devices to look at living brain tissue. The radiation exposure from one SPECT study is 1/3th the level of radiation from an abdominal CAT scans, a very common procedure in medicine. SPECT gives a three dimensional view of brain activity. Basically, SPECT measures three things: areas of the brain that work well, areas of the brain that are low in activity and areas of the brain that are high in activity. By the early 1990s when Dr. Amen first started ordering scans there were already hundreds of functional imaging studies (SPECT and PET) on Alzheimer s disease, head injuries, seizures, strokes, ADD, depression, substance abuse and schizophrenia. Knowing the type of depression, ADD, autism or bipolar disorder that you have is critical to getting the right help so that your treatment doesn t make you worse. 5
Research Based Since 1993 Dr. Amen and his research team have published 49 scientific articles, including papers on his work with NFL athletes, suicide, ADHD, predicting treatment response with stimulants, marijuana, aggression, murder, criminal recidivism, brain injury, EMDR and posttraumatic stress disorder, oppositional defiant disorder, before and after treatment response with clomipramine and Subtyping ADHD. In addition to our own research, we list over 2,500 scientific abstracts on a wide variety of neuropsychiatric conditions on our website at www.amenclinics.com (under The Science) so that clinicians and researchers can see the incredible depth of scientific knowledge underlying the application of the imaging work we do. For physicians and mental health clinicians a SPECT scan can show: The underlying cerebral blood flow and consequently metabolic activity patterns of the brain. Specific areas of the brain that are implicated with specific clinical problems, such as the prefrontal cortex with executive function and the medial temporal lobes with memory (2). unexpected findings that may be contributing to the presenting problem(s), such as toxicity, potential areas of seizure activity, brain trauma, or brain pathology. Underlying potential seizure activity that may be contributing to the problem, more accurately seen by SPECT than standard EEG, especially in the areas of the medial temporal lobe. Specific target areas for treatment, such as an overactive basal ganglia, anterior cingulate gyrus (seen on anxiety and OCD spectrum disorders) or an underactive temporal lobe (seen in seizure disorders and other disorders such as brain trauma). The specific effect of medication on the brain, and subsequently how to adjust medication dosages. Often patients report that SSRIs are helpful but also cause demotivation or memory problems. SPECT studies can show when SSRIs are causing excessive decreased prefrontal or temporal lobe activity that clinical evaluation only hints at. How the brain actually functions on the specific medical treatment. See the many before and after scans at www.amenclinics.com. A SPECT scan s image occurs (as opposed to PET or fmri) while the patient is sitting upright in an injection room, not while he or she is lying in the camera. Within 2 minutes of injecting the medicine for SPECT it locks in the brain where it stays fixed and measurable for up to 6 hours. Thus the SPECT image occurs in a more normal state (in the injection room), rather than while a person is lying in an MRI tube listening to what 6
sounds like machine gun fire (MRI tubes are noisy and can be frightening) or a PET scanning device. Furthermore, PET images occur as isotope is slowly assimilated over a 30 45 minutes window of time. This is very different from a SPECT scan that locks in within a window of 2 minutes post injection. Because the image occurs at the time of injection outside the imaging camera, it gives SPECT several significant advantages. Most notably, we are able to sedate people after they have been injected so that they can lie still for the scan and not affect the images. Often hyperactive or autistic children or demented adults have difficulty lying still for the scan, which is essential for a high quality scan (motion artifact ruins the scan in all of these imaging techniques). Furthermore, with the six hour half-life of the SPECT isotope, if we find motion artifact we can easily redo the study without additional injection of the isotope. A SPECT scan helps provide real, demonstrable answers to refractory symptoms and, in addition, helps clinicians ask better and more targeted questions about toxic exposure, brain injuries, anoxia, inflammation, or infection, that patients may have initially denied or forgotten. A SPECT scan helps clinicians prevent mistakes that hurt patients by prescribing the wrong treatments, such as unnecessarily stimulating an already overactive brain or, on the other hand, unnecessarily calming an underactive one. A SPECT scan can help evaluate those who may be at risk for dementia the brain often shows changes years before people have clinical symptoms of dementia. One study reported that there has to be a loss of 30% in the hippocampus before symptoms occur. Using autopsy data in 54 patients Bonte reported that brain SPECT had a positive predictive value for Alzheimer s disease of 92%. SPECT scans can also help to differentiate between types of dementia (Alzheimer s disease, frontal temporal lobe dementia, Lewy body dementia, and multi-infarct dementia), early in the disease each have their own patterns. SPECT scans help clinicians understand why they use certain medications such as anticonvulsants to stabilize temporal lobe function or calm focal areas of marked hyperactivity, or stimulants to enhance decreased prefrontal perfusion, or SSRIs to calm basal ganglia and anterior cingulate hyperactivity. A SPECT scan can identify specific areas of the brain hurt by trauma to better target treatment and help deal with insurance, legal and rehabilitation issues. A SPECT scan can often demonstrate a specific brain malfunction that may contribute to relapse behaviors of recovering alcoholics, drug addicts, eating disordered or sexual addicts. For example: the patient may have suffered an injury in the prefrontal cortex or temporal lobes, or have overactivity in basal ganglia, limbic system, or prefrontal cortex, each of which could contribute to their relapse behaviors. 7
A SPECT scan is also useful to determine if further adjustment of medication is needed. SPECT scans of patients already on medication can reveal areas of the brain that need to be further addressed for overactivity or underactivity. For patients and their families: A SPECT scan can help take modern psychopharmacology and treatment with nutritional supplements from mystery and unknown consequences to reality and more predictable outcomes. A SPECT scan allows patients to have a specific physical representation of their problems that is accurate and reliable. A SPECT scan helps develop a deeper understanding of the problem and leads to decreased shame, guilt, stigma and self loathing. Scans can increase self forgiveness. Patients can see that their problems are, in part, a medical problem. A SPECT scan helps to increase compliance. Pictures are powerful. Scans can provide a very powerful influence in enhancing the willingness and ability to accept and adhere to a treatment program. Patients often realize that not taking their treatment for anxiety, depression, rage, ADD, etc. is similar to not wearing the right glasses for their eyes. Treatment becomes less an experiment and more scientific. A SPECT scan helps families understand when specific symptoms may not get better, such as having permanent brain damage from an injury. Such an understanding allows patients and families to accept the condition and work effectively with the measurable handicap. A SPECT scan helps substance abusers decrease denial and become motivated for treatment by seeing the damage they have done to their own specific brain. A SPECT scan can help motivate recovering alcoholics and addicts continue in sobriety as it becomes clear to patients that further use will cause increased brain scalloping and further damage. A SPECT scan physically shows patients how treatments have impacted (improved or worsened) brain function. A SPECT scan helps motivate verbally and physically abusive spouses to follow medication protocols by seeing they have a physical abnormality that may be contributing to their problems. A SPECT scan is useful for the patient that is post cancer chemotherapy and is suffering with a chemotherapy toxic brain. It gives them insight into their cognitive struggles and may also help their doctors see the physical results of chemotherapy 8
problems as differentiated from the emotional, traumatic consequences of dealing with cancer. A SPECT scan allows patients to understand why specific treatments are indicated, which medications or supplements are helpful, and why certain medical interventions are chosen. As Clinicians at Amen Clinics: We use SPECT in a clinical environment to observe patterns of activity, to guide us in re-balancing a brain whose activity patterns are clearly abnormal. Biology drives our recommendations. A SPECT scan can guide us in the application of specific medications or other treatments such as supplements, neurofeedback, and hyperbaric oxygen therapy. SPECT is never the complete or final answer. It is part of the answer that when used with a good clinical history and examination gives clinicians and patients more information for diagnosis and to tailor treatments to the specific patient. What SPECT Scans Cannot Do Give a diagnosis in the absence of clinical information Give the date of a head injury Give the date of an infection or toxic exposure Assess or evaluate IQ Assess or evaluate the guilt, innocence, motivation or sanity of a criminal defendant References Camargo, EE: Brain SPECT in neurology and psychiatry. J Nucl Med. 2001 Apr;42(4):611-23. Holman BL, Devous MD Sr. Functional brain SPECT: the emergence of a powerful clinical method. J Nucl Med. 1992 Oct;33(10):1888-904. Krausz Y, Bonne O, Marciano R, Yaffe S, Lerer B, Chisin R. Brain SPECT imaging of neuropsychiatric disorders. Eur J Radiol. 1996 Feb;21(3):183-7. 9
Amen Clinic Research Papers: http://www.amenclinics.net/brain-science/spectresearch/amen-clinics-research/ How Brain SPECT Imaging Can Help with ADD With clinical history, SPECT scans can help decide whether or not you have ADD Help determine your type of ADD to direct treatment See if the treatment is working at an optimal level See if there are other co-occurring conditions that need to be treated Decrease the emotional pain of stigma and increase compliance Help families see the biological nature of ADD to better understand the illness Top 10 Tips for Treating ADD for All Types 1. Take a 100% multi-vitamin every day. Studies have reported that they help people with learning and help prevent chronic illness. 2. Adults, take 2,000-4,000mg of high quality fish oil a day (1,000-2,000mg for children). 3. Eliminate caffeine from your diet. It interferes from sleep and helping the other treatments work. 4. Intense aerobic exercise daily for 30-45 minutes. For kids, if you cannot find a safe exercise (no brain injuries please), take them on long, fast walks. 5. Turn off the television and video games, or limit them to no more than 30 minutes a day. This may be hard for kids and teens, but it can make a huge difference. 6. Food is a drug. Most people with ADD do best with a higher protein, lower simple carbohydrate diet. 7. Many people with ADD are conflict or excitement seeking, as a means of stimulation. They can be masters at making other people mad or angry. Do not lose your tempers with them. If they get you to explode their unconscious, low energy prefrontal cortex lights up and likes it. Never let you anger be their medication. They can get addicted to it. 1 0
8. Test ADD kids and adults for learning disabilities. They occur in up to 60% of people with ADD. The local schools are often set up to do this for school age children. 9. Apply for appropriate school or work accommodations. 10. Never give up seeking help. Get Help with ADHD/ADD from Amen Clinics, Inc. Amen Clinics, Inc. specializes in brain health, innovative neuroscience research, diagnosis and treatment for a wide variety of neuropsychiatric, behavioral and learning problems in children, teenagers and adults. Established in 1989 by Daniel Amen, M.D., the center has an international reputation for utilizing brain SPECT scan imaging for a wide variety of neuropsychiatric problems, including ADD, anxiety, depression, autism and memory problems. Our philosophy at the Amen Clinics is simple: Change your brain, Change your life. For more information about ADD/ADHD and our treatment plans, please call the Amen Clinics at 1-888-564-2700 or schedule an appointment at www.amenclinics.com. 1 1