How is a brain SPECT relevant to the mental health field?

Dr. Amen outlines common SPECT imaging patterns that are clinically relevant after analyzing thousands of brain SPECT scans. According to his article, “Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based Underutilized Tool”, 2021, there are 6 clinically useful general patterns that can be observed in patients. Let’s go over each one of them:

1-    Overall Decreased Perfusion, or “Scalloping”: This pattern is most commonly observed in individuals who have been exposed to toxins, certain illnesses (such as Lyme disease, meningitis anemia, ect), or other insults to the brain. This is common among individuals who struggle with substance abuse, who are taking certain medications, who are exposed to toxins in their environment, and even exposure to general anesthesia. The figure below shows an example of a patient who had been misdiagnosed with two mixed personality disorders. The pattern shown in his brain is from his constant exposure to toxins at his job.

Image from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839.

2-    Traumatic Brain Injury (TBI) Pattern: many people might forget that they suffered a brain injury and might fail to report it to their physician. TBI can cause several different psychiatric symptoms as well as changes in cognition, and mood. Depending on the type of brain injury someone has, SPECT can help identify if a trauma is present. Dr Amen listed common findings in trauma on SPECT as “focal decreased near sight of injury and/or opposite side (contra coup), asymmetrical hypoperfusion in the prefrontal, temporal, parietal or occipital lobes; flattening of the prefrontal pole, decreased anterior temporal poles, and decreased contralateral cerebellar perfusion”. The following image shows the brain of a patient with severe impulsivity and depression, who had denied he suffered a brain injury 10 times. In his scan, there was evidence of “hypoperfusion, consistent with trauma in the left frontal-temporal lobe region”. When he was asked again, he remembered a motorcycle accident he had been in.

(Image from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839.)

3-    Cognitive Decline Patterns: SPECT is normally used to assess cognitive decline in dementia disorders and to distinguish between the different types of dementia. The brain scan pattern associated with Alzheimer's Disease (AD) for example, is a decrease in the posterior cingulate gyrus, parietal and medial temporal lobes; Frontal Lobe Dementia includes frontal and temporal love deficits; Vascular Dementia includes decreased activity in multiple areas. For more details on other dementia and cognitive decline, please visit “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149839/”

4-    Negative Emotionality and Hyperfrontality: can be seen in psychiatric disorders that have “cognitive inflexibility or getting stuck on negative thoughts or behaviors […], patients who struggle with being rigid, inflexible and oppositional […]”, which can include disorders such as OCD, Autism Spectrum Disorder, PTSD, and other mood and anxiety disorders. Identifying this brain activation pattern is particularly important for identifying individuals who can benefit from serotonergic medication for depression (1-5) and OCD (6,7), to predicting a good response to sleep deprivation (8,9), and repetitive transcranial magnetic stimulation (10) for depression. These are just some of the examples that brain SPECT can help by providing more specific routes of diagnosis and even treatment. Below are examples of active scans showing hyperfrontality compared to a healthy scan. As seen in the healthy scan, the more active regions in the brain are in the cerebellum.

Image showing hyperfrontality from: Amen DG, Trujillo M, Newberg A, Willeumier K, Tarzwell R, Wu JC, Chaitin B. Brain SPECT Imaging in Complex Psychiatric Cases: An Evidence-Based, Underutilized Tool. Open Neuroimag J. 2011;5:40-8. doi: 10.2174/1874440001105010040. Epub 2011 Jul 28. PMID: 21863144; PMCID: PMC3149839.

5-    Behavioral Problems and Hypofrontality: Hypofrontality or the lack of activation of the prefrontal cortex is associated with “a negative response to serotonergic medication in depression and clozapine in schizophrenia as well as with predicting relapse in alcoholics, improved response to acetylcholine- esterase inhibitors for memory and behavior in AD, predicting poor response to ketamine in fibromyalgia patients and improved response to stimulants in patients with ADHD symptoms during a concentration challenge” (Amen, 2011). The list goes on. It is important to note the variability of psychopathologies that hypofrontality is associated with. Nevertheless, it can be used to focus on specific symptoms and narrow down on specific diagnoses.

6-  Mood Instability, Memory Problems, and Temporal Lobe Abnormalities: Temporal lobe abnormalities in brain scans can be common among people with memory problems, mood instability, aggressive behavior, and language. Temporal Lobe Epilepsy (TLE) is a common that is associated with depressed/euphoric mood, anxiety, anergia, fear, atypical pain, irritability, and insomnia. Without a brain scan, such symptom clusters could lead to a personality disorder diagnosis and bipolar disorder. Epilepsy can be detected by EEG, however, EEG can also miss certain abnormalities that can be detected by SPECT. EEG can be used in combination with SPECT to identify TLE more accurately. SPECT can be useful in identifying other abnormalities that are not necessarily related to epilepsy disorders. Dr Amen recommends the use of anticonvulsants as a first-line treatment for people with mood instability or anger/aggression problems and who have either high or low perfusion in the temporal lobes. This is one example of how SPECT could lead to more accurate treatments for patients.

For more information and details visit these two articles by Dr. Amen that go into more depth about each brain scan pattern:

1-    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702964/

2-    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149839/

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