How important is the role brain scans can play in treating substance use disorders? In a recent presentation as part of the Williamsburg Place Lecture Series, psychiatrist Lantie Elisabeth Jorandby gave an overview of how one type of brain scan— single-photon emission computed tomography (SPECT)—can support the diagnosis and treatment of addictions and co-occurring mental disorders.
Dr. Jorandby is board certified in general psychiatry by the American Board of Psychiatry and Neurology and is board certified in addiction medicine. She is a fellow of the American Psychiatric Association and a member of the American Academy of Addiction Psychiatry. At Amen Clinics, she applies brain imaging science to help people who struggle with mood disorders, addictions, weight control, and anger-management issues.
Anatomy of the Brain
The brain is a wonderfully complex organ. It consists of approximately 100 billion neurons that use 20–30 percent of the body’s calorie intake. The brain’s neurons are capable of an estimated quadrillion connections—that’s a 1 followed by 15 zeros. This biological supercomputer consists of soft material and thus is vulnerable to impact injuries. Fortunately, it is contained in a fairly robust skull. In the presentation, Jorandby takes the audience through various areas of the brain and their functions relevant to substance use disorders and their underlying mental health conditions.
- Prefrontal cortex (impulse control, empathy, and insight)
- Cingulate gyrus (memory integration, thought shifting)
- Basal ganglia (anxiety modulation)
- Temporal lobes (language, memory, reading, spiritual experiences)
- Deep limbic system or thalamus (emotional tone, bonding, libido)
- Parietal lobes (spatial processing, creating maps)
- Cerebellum (fine motor skills)
Dr. Jorandby explains how SPECT imaging done at Amen provides an oft-neglected tool in psychiatry. “How do you know unless you look?” she asked. SPECT goes beyond taking a picture of anatomical structures. The functional imaging of a SPECT scan monitors biological activity at each place in the region analyzed. “SPECT doesn’t give you the diagnosis,” cautions Jorandby citing Harvard psychiatrist Harold Bursztajn. “But it allows you to ask better questions” about the psychiatric condition of the patient.
A Football Player with an Alcohol Problem
To illustrate the efficacy of SPECT imaging, Dr. Jorandby provides a case study. E.J. is a 58-year-old businessman and former college football player. His main concern when entering treatment was that his marriage was falling apart. He had been involved in a severe motor vehicle accident and his alcohol use had escalated to 2–3 bottles of wine per day. He reported irritable moods and suicidal thoughts.
Medically, E.J. presented with an enlarged liver, hypertension, obesity, and trouble sleeping. E.J. has a genetic disposition for alcoholism on his mother’s side of the family and drug addiction on the father’s side. His primary care physician diagnosed a depressive disorder and E.J. had a history of impulsive behavior. His mood was described as “pretty down.”
How can SPECT imaging help a patient like E.J.? The scans can “visualize the problem and reduce diagnostic and treatment errors,” explains Jorandby. When shown to patients, the scans tend to improve compliance. “Patients tell me they don’t want a brain that looks like that,” says Jorandby. People with substance use disorders are more motivated to stay sober. The images also decrease stigma. Family members are frequently fed up with the behavior of their loved one, but when they see the images they can often only say “wow.” It makes it easier for them to feel empathy for the addicted person.
The Brain on Marijuana
SPECT imaging provides convincing visual evidence that “marijuana is not a health food,” as Dr. Jorandby puts it. “Most of the country is getting carried away with trying to medicalize cannabis,” she explains. “Unfortunately, the message we’re sending to young people is that marijuana is safe.” SPECT scans reveal that regular cannabis use—especially with high THC concentrations—has a negative impact on the prefrontal cortex and the temporal lobes. In many cases Jorandby can tell from the scan alone which patient is using marijuana which one isn’t, because the changes in brain activity are so distinct. Other substances like alcohol or heroin cause similar tell-tale changes in brain activity.
Patterns of addiction
- Jorandby can link particular SPECT scans not only to specific substance misuse but also to specific mental health conditions. Recognizing six specific types allows for better individualized treatment plans.
- Compulsive (worried/over-focused) - increased anterior cingulate activity
- Impulsive (bored/impulsive) - low prefrontal cortex activity
- Compulsive/Impulsive - combination of types 1 & 2
- Sad/Emotional - high limbic with low prefrontal cortex activity
- Anxious (nervous/predicts the worst) - high basal ganglia activity
- Anger Issues (Mood instability) - abnormal temporal lobes
“It’s very important to identify these co-occurring disorders,” says Jorandby. “If you miss these in addiction treatment, patients will not be able to move forward with their recovery.”
Combining all available diagnostic tools, including SPECT, patient EJ received a comprehensive treatment plan:
- Identified: traumatic brain injury, sleep apnea, alcohol use disorder, hypothyroidism
- Treatment: naltrexone, mood stabilizer, dopamine agonist, CBT, 12-Step program
- Comprehensive: diet, exercise, medications, supplements, therapy, hyperbaric oxygen (to heal brain injury)
After nine months of treatment, E.J.’s SPECT showed improvement, and it was “nice for E.J. to have visual evidence that his recovery was working,” says Dr. Jorandby.