ADD Update: From the Top

by Dr Charles Parker on January 23, 2007 · 4 comments

Brief Biederman Report: ADD Medications and Scan Research

Last night spent a delightful evening with Joseph Biederman, MD, Director of Research at Mass General for Child Psychopharmacology and Professor as Harvard, clearly one of the most influential researchers in child psychiatry today. His presentation included numerous scan reports, specifically more fMRI, and demonstrated repeatedly what we have been talking about in previous posts regarding our findings with SPECT at Amen, DC. In a word, regarding scans and neurophysiology, we register considerable findings of agreement. Additional note: Biederman is one of the lead investigators who identified Bipolar Disorder in children, and has suggested specific treatment strategies.

His presentation affirmed that stimulant meds are the treatment of choice for ADD, and that not using meds appropriately is one of the most serious issues present in our current practice. He affirmed with scan evidence that stimulants clearly improve prefrontal cortical functioning.

Further, as an aside, he affirmed his own opinion that long acting stimulant meds deserve to be downgraded from the control of Schedule 2. I have heard from some friends in Washington that the FDA is considering changes in that regard. Dr Biederman made it clear that he didn’t feel he could tell the FDA what to do, but agreed with my own position that some changes should be made in regards to the controls on stimulants.

Biederman made it clear, as many in academia have, that he thinks Daniel Amen uses scans without sufficient evidence, and hates Amen’s use of the term “ring of fire” for bipolar evidence in scans. I think the term he used regarding Amen was “charlatan.” Biederman wants nuclear medicine psychiatrists to wait until researchers agree amongst themselves about specific scan findings. I wondered later if he feels the same way about the SPECT shop in UCLA that recently opened with much fanfare, almost like they were first!

I discussed my three years of experience with Amen in some detail, having seen personally about 1000-1200 patients and reviewed >1000 more, that scans are useful clinically and predictable. Scans make significant differences in treatment strategies and show excellent documentation of comorbid conditions. Our discussion was engaging and positive, though clear differences continue.

I agreed with his point regarding Amen’s consistent and pervasive use of the term “Ring of Fire,” and never used it on any of my own reports, as it is less scientific, more evocative, and does nothing to endear the scientific naysayers who loom in the periphery. “Ring of Fire” becomes an easy target, and does nothing to encourage effective discussion. My choice for that same finding: diffuse cortical hyperperfusion. This term is already in use with nuclear med docs.

It was a privilege to spend an evening with Dr Biederman, and will keep you posted as our conversation develops. I don’t think I will be able to get Biederman together with Amen soon, but hope to facilitate continued discussions with these divergent views.

ADD Update: From the Top

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Tagged as: ADD, Bipolar Disorder, children, Co-morbid Conditions, Daniel Amen, Diffuse Cortical Hyperfusion, FDA, fMRI, joseph biederman, Massachusetts General Hospital, Mental health, Neurophysiology, Prefrontal Cortex, Psychiatry, Psychopharmacology, ring of fire, SPECT, Treatment Strategy, UCLA

  • Ted Budzichowski

    Good point on the “Ring of Fire” term.

    It’s a real shame to see Amen selling branded nutritional supplements as this only damages his credibility – especially among professional colleagues.

    I also wonder if people will blindly accept diagnoses that feature functional imaging as evidence. Just like a radiologist can misread an x-ray, I can envision lesser psychiatrists using functional imagining while still pill-pushing – still ignoring the larger clinical picture – ignoring evidence of subtle physiological problems or brain injury etc. Unfortunately still labeling.

    Thanks for all the information you post. Looking forward to your book. We need more blogs like yours.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Ted,
      You caught the Amen issues completely – except for one point: No problem, in my book, selling branded supplements – the only problem is using them as a shotgun practice based upon the generalities of scans alone. New laboratory testing can help us be more precise in assessing specific metabolic and nutritional needs, and no problem if they are branded… just don’t, e.g., cookie cut the GABA supplements for “Ring of Fire,” – therein is the imprecision and the inappropriate use of findings. That one finding does not necessarily lead to the other conclusion. “Ring of Fire” may exist downstream from gluten sensitivity, and the real issue would be overlooked whilst offering treatment for superficial macro appearances. Not a far cry from the current challenge with diagnostics in the first place.
      cp

  • http://www.corepsychblog.com Dr Charles Parker

    Gina,
    Part of any new perspective is a new vocabulary, a new map for the newly discovered territory – so I certainly understand the usefulness of one aspect of Amen’s descriptive, metaphoric language: bringing along the public.

    The public has for years been ignored regarding the new science, relying almost entirely on journalists and their interpretations. “Ring of fire” does make good copy!

    But evocative new language creates a problem for SPECT innovators with traditional nuclear investigators in the process of paradigm transitions. To include the traditionalists, to include the work already on the table, it is best to soften the blow by using already agreed upon language, their own mapping system.

    Then we can say in discussion, offhandedly to the public, “This is a hot brain, looks almost like a ring of fire.” – but our reports should connect with our colleagues in the field – diffuse cortical hyperperfusion.

    Soon everyone will think they discovered it anyway, but I doubt “ring of fire” will serve as a scientific touchstone.

    Thanks for your thoughtful observations!
    cp

  • http://www.ginapera.com Gina Pera

    Ha! And here’s another difference between the halls of science and the real world. :-)

    I’ve known MANY people for whom the term “ring of fire” immediately resonated–because that is what the behavior feels like when you come up against it in yourself or a loved one.

    Yes, I know Amen coined the term from the scan image, but it also describes the behavior.

    Yes, we need all the double-blind, peer-reviewed studies. But we cannot forget the important Reality Test, too.

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