Why Should We Understand the Brain and Not Just the Mind for Successful Psychiatric Treatment?

Often, we wonder if an individual’s behavioral problems stem from an unwillingness or inability to change. We also want to know if appropriate medications can improve their condition.  Let’s look at these two issues.

The brain directs our behaviors, which stem not simply from reflexive patterns but from complex internal processes.  Reflexes respond to specific stimuli and always generate the same response, e.g., after tapping a knee, the leg extends.  Although reflexes are simple behaviors involving a two-neuron circuit within the spinal cord–one neuron providing the input and the other providing the output–they are also part of the central nervous system, which includes the brain.

When we consider our behaviors, we do not think about tracing a series of reflexes.  Rather, we talk about complex decision-making involving many neurons and how our decisions help us plan our day or initiate an uncomfortable conversation with our boss.  As we prepare ourselves for these activities, we make actionable decisions based on how we interpret our past experience and our hopes for the immediate and distant future. When we make decisions, we access our memories and use them to interpret our current situation with an eye for possible positive or negative outcomes. Furthermore, our feelings of self-worth, our confidence, and unrelated external stressors, such as relational difficulties or a family illness, may influence our mood and thoughts and complicate our decision-making. For example, one’s mood may influence when one decides to confront one’s employer. To make an appropriate decision, we must assimilate many brain networks and evaluate the brain’s available data.  Many psychiatric patients struggle with engaging the brain’s decision-making networks; they may get caught at one or more decision points and end up behaviorally stuck, unable to progress.

So, how can we help find and untangle behavioral paralysis? Despite a patient’s critical willingness to change, it is often insufficient for a cure, and although psychotherapeutic approaches are numerous, when used exclusively, they have limited clinical effect.

If we understand brain function, we can treat difficult behaviors because today’s new neuroimaging technology gives us the tools.  We know the brain is composed of 100 billion neurons. Each single neuron continuously receives from 10-50 thousand inputs that form very complex networks for processing information and updating memories. Even during sleep, the brain is hard at work; the brain is on the job 24 hours a day, seven days a week. When a network is injured or chronically overloaded by stress, sleeplessness, or the abuse of psychoactive substances, the brain’s efficiency suffers, and the brain malfunctions. Often, observably aberrant behaviors such as aggression, repetitive thoughts and actions, the inability to concentrate, form memories, manage impulses, motivate,  or organize are the ultimate outcomes.

New imaging techniques let us look at a living brain without risking the patient’s health or interfering with ongoing brain processes. Now, we can evaluate a brain, its architecture, and connections through magnetic resonance imaging, MRI. During specific tasks such as resting, reading, listening, and experiencing emotions, functional brain studies can tell us how the brain is using its brain-fuels, oxygen and glucose.  Functional MRI evaluates oxygen consumption, and nuclear medicine techniques, such as positron emotion tomography (PET), assess glucose and oxygen.  Single photon emission tomography (SPECT) considers the brain’s blood flow, while PET and SPECT help us visualize specific, important, and unique proteins that influence brain function.  In addition, we can see how the brain works in real-time using techniques such as quantitative electroencephalography (qEEG) and magneto encephalography (MEG) that evaluate synchronized neuronal activity’s electrical and magnetic signals for the expected normal processes and functions. If we observe the abnormal patterns related to a person’s symptoms, we can begin to develop therapeutic interventions targeting to these anomalies.

Where do medications fit into the therapeutic schema? Unfortunately, today, no medications are specific enough to selectively and exclusively target an identified brain network. So when we decide to use medications, we not only treat the whole brain, but also the whole body. Not only does medication target abnormal brain networks but all the body systems. For example, a medication may reduce one’s perception of anxiety and muscle tension, but at the same time, it may also decrease one’s cognitive ability and decrease blood pressure.

New, emerging techniques, such as guided imaging neurofeedback and current and/or magnetic indirect and direct brain stimulation, are being developed to more precisely target and rewire offending networks and eliminate symptoms. Clearly, no one therapy will work for all patients, so developing a person-centered approach is the key. Recent evidence suggests that multimodal brain therapies are the most effective. Thus, at the end of a patient’s therapy, because brain imaging techniques are quantitative and reproducible, we can re-evaluate the patient to see whether the targeted brain systems are back on-line and whether the patient‘s symptoms are in-check. When analyzed, these data allow us to better understand which therapies work and how we can develop more appropriate, effective treatments.