by Mary Sykes Wylie
Psychiatrist Daniel Amen is a trim, elfin figure with a puckish smile and the staccato delivery of a stand-up comic. The winner of a Distinguished Fellow Award from the American Psychiatric Association, a clinical professor of psychiatry and human behavior at the University of California, Irvine School of Medicine, the author of 20 books and as many peer-reviewed papers, and a hugely popular public lecturer and workshop leader, he sounds, somewhat paradoxically given his own sum, a bit like a wiseacre underdog impudently challenging a reactionary establishment. He cheerfully rails against the self-satisfied stuffed shirts from the worlds of academic psychiatry who, in defiance of reason and good sense, don't accept his view that a brain-imaging method called SPECT is an invaluable tool for understanding and treating psychiatric disorders.
"I just don't get it. Why are we the only medical specialists who never look at the organ we treat?" he asks, his voice rising in exasperation before a jam-packed audience of 500 therapists drawn to a full-day workshop on his work. "Why is it controversial to get more information on people who suffer? The images are really easy to understand. What's the problem with having more data?"
And then the "piece de resistance". We're always being told that the brain is so terrifyingly, irreducibly complex that nobody except Nobel-caliber neuroscientists could ever begin to understand how it works. But Amen says, in effect, that it really isn't that hard for anybody--with a little training--to get a good sense of what all those brain modules are actually up to. "The images are really easy to understand--you don't need to make it any harder than it is," he says, as if explaining a new recipe to an insecure cooking student. "All SPECT does is measure three things--areas of the brain that work well, areas that are underactive, and areas that work too hard. Then you just gear the treatments to rebalance these areas."
So why not just take a look? What's the harm? His case is helped by the elegant, crisply articulated, brain images he shows that, in concert with his simple explanations, seem to luminously reveal what's actually going on upstairs.
Amen flashes two computer-reconstructed, three-dimensional, exquisitely tinted color scans, each of a different brain. One, a "healthy" brain, is a smooth ovoid shape, with some softly modulated rises and depressions; if it were a landscape, it would be a gently rolling pastoral scene. The other brain looks an awful mess. With its deep fissures, crevices, and "holes"--areas of severely low activity--it looks as if uneven chunks of it have been eaten away by a voracious rodent. This latter brain, Amen dramatically announces, is the brain of Kip Kinkel, the 15-year-old boy from Oregon who, in 1998, shot to death his mother and father and then drove to his high school, where he shot 24 more people, killing two.
Kinkel, Amen explains, had been seeing a psychotherapist and taking both Ritalin and Prozac, which only made him worse--more volatile and unreachable. His demoralized parents had taken him off his meds, after which he went on his murderous spree. "If a scan had been done on him before the killings, it would have shown an extraordinarily abnormal brain," says Amen. On the SPECT scan, he tells the audience, Kinkel's prefrontal lobe--associated with impulse control, judgment, and planning--exhibits extremely low activity. At the same time, his temporal lobe, controlling such functions as temper and mood stability, also showed abnormal patterns of blood flow, which can make a person more prone to aggression, emotional volatility, and violent suicidal and homicidal thoughts.
"If his therapists had actually seen his brain, they could have put him on mood stabilizers, and the odds are they'd have diminished his violent thinking dramatically." Amen pauses to let this sink in. "But because the current 'state of the art' in psychiatry is not to look at the brain, his doctors were simply throwing darts in the dark. Today you can try to kill yourself or kill other people, and nobody will look at your brain. But if your brain's not right, you won't be right."
Amen has a vast fund of salvation stories about people misdiagnosed and mismedicated, often for years, whose real problems are only finally revealed through the combination of intense clinical detective work--the kind any good therapist would do--and the nuclear magic of a SPECT camera, which, literally, casts light into the hidden recesses of the brain. "Giving a diagnosis of 'major depression' or 'ADD,' is like giving a diagnosis of 'chest pain,' or 'belly pain,'" says Amen with some asperity. "These are symptoms with many, many possible causes. And one treatment will not fit every person with similar symptoms. We need to start looking at the brain, to begin seeing the underlying physiology of what's going on. Scans aren't the answer, but they're certainly part of the answer. A psychiatric profession that doesn't look at the brain is archaic, dated, and stupid."
Amen now has the audience in the palm of his hand, laughing at his jokes, moved by his stories of troubled little kids whose lives were either saved or ruined, depending upon whether their underlying brain problems were discovered and treated. He seems to be as much on a personal crusade as a professional quest. But, periodically, a note of unabashed salesmanship and self-promotion intrudes--the repeated references to his "cool" books and their worldwide distribution; his bestseller, Change Your Brain, Change Your Life ; his column for Men's Health ; his media appearances on The Today Show, The Leeza Show, CNN ; his recent gig at the National Security Agency. For some in the audience, it's enough to induce emotional whiplash: are we hearing from a fearless pioneer dedicated to transforming the mental health field or a salesman whose most important product is himself?
To be sure, Amen has acquired a small, but growing, crowd of supporters and colleagues in psychiatry, psychology, and nuclear medicine--he says more than 1,000 professionals refer to him--who consider him a trailblazer and believe SPECT scans will revolutionize the practice of psychotherapy. "I think he's a real pioneer, making an enormous contribution to the field of psychiatry and helping to change the paradigm of how people think about the brain and psychiatric symptoms," says Joseph Wu, professor of psychiatry and clinical director of the brain imaging center at the University of California, Irvine. "Daniel Amen introduced me to a whole new universe of subcortical brain structures that we in nuclear medicine had only looked at casually before. He helped me realize that SPECT can be very useful for evaluating complex, difficult cases in which comorbidities are present," notes Dan Pavel, professor of radiology and nuclear medicine at the University of Illinois. "I came away from Amen's clinic convinced there is a place for SPECT in clinical psychiatry," writes AD/HD expert Edward M. Hallowell, coauthor with John J. Ratey of the bestselling Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. "It is obviously helpful to be able to look at the brain before you try to treat it. Perhaps SPECT will prove to be the most practical way for psychiatrists to do that."
But utter the name Daniel Amen to some of the leading members of the psychiatry and neuroscience research community and the reaction ranges from dismissal to derision and denunciation. "He's made a mountain of money doing scans [a two-scan evaluation at one of Amen's clinics costs $3,250, which also includes, a history, physician evaluation, and follow-up visit], but never, to my knowledge, published any data, or provided one shred of evidence that an independent investigator would be able to reproduce," says George Bush, psychiatry professor at Harvard Medical School and psychiatric neuroimaging researcher at the Martinos Center for Biomedical Imaging. "Amen is extremely successful, has many franchises and is a wickedly good salesman, but what he's doing isn't supported by scientific evidence. Where's his data? What does he know that all the other practitioners and researchers don't know?" asks Helen Mayberg, psychiatry and neurology professor and brain-imaging researcher at Emory University. In fact, so exercised is much of psychiatric officialdom by Amen's approach that, last January, the American Psychiatric Association's nine-member Council on Children, Adolescents and Their Families felt moved to issue an independent position paper opposing the use of SPECT in the clinical practice of child and adolescent psychiatry.
It seems strange that a person so disarming and apparently eager to please, who's clearly distressed by the uproar he's caused and seems like the last person who'd mount a Rambo challenge against entrenched power, would arouse such hostility. Or that his cause--the incorporation into psychotherapeutic and psychiatric practice of SPECT scans, a technology that's been around for decades--should be so contentious. So what is it about Daniel Amen and his mission to get therapists to use brain imaging, and SPECT in particular, as an aid to diagnosis and treatment that makes him such a lightning rod?
The Man Behind the Cause
Daniel Amen's personal and professional biography is a palimpsest of the odd and extraordinary, which may help explain why he's never found a home in the clubby atmosphere of the psychiatric and research establishments. His entrepreneurial success seems to particularly gall them--it adds insult to injury that he's not only doing something totally beyond the scientific pale, but making pots of money at it.
His talent for business seems almost foreordained by his background. His parents, the children of poor Lebanese immigrants, went to the West Coast during the 1940s. There, Amen pere began clerking in a relative's grocery store and then, embodying both the American dream and the ancient Phoenician talent for trade, worked his way up to become chairman of the board of Unified Grocers (a position he still holds), one of the largest wholesale grocery businesses in the country. Amen's family was large (five sisters, one brother), loving, but strict and Roman Catholic, headed by a tough, authoritarian paterfamilias. "I grew up with an extraordinarily successful father, who always expected the most from us," says Amen. "Our family honored work, and our lives were centered around work--I worked from the time I was 10. And nobody ever thought it was a bad thing to be successful."
Amen joined the Army at 18, partly because he had a low draft number, but also because his father told him not to. It was 1972, and the Vietnam War was in full swing, but Amen believed the recruiter who told him he'd be assigned as a vet's assistant. (He'd always loved animals and, as a teen, considered becoming a vet.) "I thought that the odds were good that nobody would be shooting at a vet's assistant." Instead, he ended up as a combat medic in Germany, where he got himself retrained as an X-ray technician, mainly so he could work in a nice, warm dispensary, rather than a chilly tent. But he became fascinated by X-ray technology and found that he loved studying the ghostly images of people's insides. "I looked at kidneys, lungs, skulls, thigh bones," he says now with remembered relish. "That's where the imaging story really begins."
Because of his religious background, Amen had seriously considered becoming a priest, but, as he says sardonically, "I couldn't stand the idea of being called 'Father Amen.'" He declined the priesthood, but certainly not religion. In Germany, he found himself drawn to the wholehearted, emotional expressiveness of Pentecostalism--shouting, praying in tongues, healing ceremonies, and all--so different from the restrained solemnity of the Roman Catholic mass. He was sufficiently moved by his new religious tack that, when he returned home, he got off the plane dressed in a "Jesus loves you" T-shirt and carrying a Bible, much to the consternation of his blindsided mother. By this time, 1975, he knew he wanted to go to a small school, and a religious one, so he finished his college education at Vanguard University, a small Christian college. Then, in 1978, he became a member of the first class of a newly opened medical school (since closed) at Oral Roberts University.
The nexus between capitalism and religion appears to have shaped Amen's life. In Healing the Hardware of the Soul, his book about the connection between a healthy brain and the capacity for morality, conscience, and faith, Amen writes that he felt "led by God to pursue this [SPECT] work." These days, he uses his training and skills as a kind of reverse mission to churches, in an effort to persuade Christians and Jews that much "sinful" behavior may be due to brain problems, rather than evil motives. Some of his critics haven't looked kindly on this sense of religious mission. "He's a true believer, and evangelical medicine is scary," says Mayberg.
After medical school, Amen took a residency in psychiatry at Walter Reed Army Medical Center. In 1987, the Army sent him to Fort Irwin, California, as the chief psychiatrist--the only psychiatrist in the middle of the desert for thousands of soldiers and their families--a population rife with drug abuse, depression, anxiety, domestic violence, psychosomatic ailments, and stress. This new gig would have been a daunting job for any psychiatrist, let alone a young, newly minted, and relatively untried one.
Serendipitously, in the old World War II building that housed his office, he found an antiquated biofeedback machine (an instrument that measures physiological responses, via electrodes or sensors attached to various parts of the body) left by his predecessor. He found that, even as a novice, he could use the machine to train people to warm their own hands by using their imaginations--thinking about burying their hands in hot sand, for example. He could also use it to help them reduce their anxiety or relieve their migraine headaches, while gaining a sense of self-control and personal mastery. Enthusiastic about his new toy, Amen convinced his dubious commander to pay $30,000 for an up-to-date model and send him for 10 days' training in biofeedback.
The biofeedback training program in San Francisco was, Amen remembers, a revelation: "The best, most exciting, training I'd ever had. I was just stunned by what I learned." It was the first major introduction he'd yet had to the powerful interaction of brain, body, and mind, and he was hooked. He discovered that people could learn how to control their own autonomic nervous system--relax their muscles, calm their breathing, reduce their sweat-gland activity, lower their blood pressure and heart rate--to relieve both physical tension and mental anxiety. Moreover, through neurofeedback (a form of biofeedback in which electrodes are attached to the scalp), they could learn to change their own brain-wave patterns, and thus their mental states. "I was so excited to have this cool new technology that I went back to Fort Erwin and started using it on everybody."
Amen was particularly anxious to try out this new brain-mind technique on kids with AD/HD. "Standard psychotherapy, as I'd been trained to do with AD/HD kids, made me crazy--they just never got any better," he recalls. Medications helped, but not nearly often enough, and there was no way to predict whether or not they would work. So Amen began using neurofeedback with his AD/HD patients to encourage more normal brain waves and reduce their symptoms. While not exactly the fast-track cure he'd have liked (it could take from one to two years to produce significant improvement), neurofeedback did work encouragingly well, with the side benefit of helping many kids avoid or lessen medications. In 1989, when he opened his private practice in northern California, he equipped it with his own biofeedback equipment.
Amen's clinic was an immediate success, no doubt partly because of the workaholic habits, business acumen, and marketing skills he says he inherited from his father; but also because he was the only child psychiatrist for 300,000 people in the county. During this period, he worked six- and seven-day weeks, building up his practice, directing the dual-diagnosis unit of a local hospital, lecturing in the local community, and writing a news column (he'd already published two self-help books on getting ahead in school and in work).
In March 1991, Amen attended a lecture on SPECT imaging at the hospital where he worked. If learning about neurofeedback had been a revelation to him, seeing SPECT scans was an epiphany. SPECT is the acronym for single photon emission computerized tomography, a nuclear-medicine imaging technique that measures an organ's blood flow or activity level--its function . An MRI, by contrast, looks at brain structure or anatomy, just as an ordinary X-ray does (but provides far more detailed images). A patient being SPECT-scanned is injected with a "radiopharmaceutical" and then lies on a table for about 15 minutes while a multiheaded camera rotates around his or her head picking up gamma rays (which are like pulses of light) from the radioactive material taken up by the brain cells. The data obtained by the camera are processed by a supercomputer to produce a series of two-dimensional cross sections of the brain. Different activity levels--relative blood flow--show up as shades of different colors or gray tones, depending on the color scale of the software program chosen by the imager.
These cross sections are then reconstructed into three-dimensional images. Notwithstanding Amen's suggestion that brain scans "aren't that hard to read," it's definitely not a simple process, requiring real skill and judgment to do well. To a lay viewer, the cross sections that first come out of the computer look like a meaningless kaleidoscope of colors and patterns. It takes an expert in reading, understanding, and manipulating the scans to tweak them into an accurate but elegant form--the dramatic, 3-D pictures of the kind Amen shows his audiences.
The Society for Nuclear Imaging officially recognizes only four common indicators for the clinical use of SPECT: to detect and evaluate strokes, brain trauma, and suspected dementia (a recent article says that brain scans like SPECT can predict Alzheimer's disease nine years before people have symptoms), or to locate focal points of epileptic-seizure activity. But SPECT has been used in a huge and highly eclectic number of research studies on almost every conceivable psychiatric and neurological condition, as well as some nonpsychiatric studies, like measuring the impact of meditation and prayer on blood flow to different brain areas.
The lecturer at Amen's hospital, a local nuclear physician named Jack Paldi, showed brain images of patients with depression, dementia, schizophrenia, and head trauma, comparing them with normal brains. Using these amazing images, Paldi tried to demonstrate that one could actually see the differences between brains that worked well and those that didn't, see how medications changed the way brains functioned and where those changes occurred. In this rush of graphically astonishing images, Amen thought he could begin, finally, to understand why some of his patients just couldn't seem to benefit from therapy or get their lives in order, no matter how hard they tried. It wasn't psychological resistance or personality type or deep-seated unconscious motives that kept them from getting better: it was simply that the software of their brains wasn't up to speed!
"I was absolutely blown away," remembers Amen, who took up Paldi's offer to do no-cost SPECTs on interested physicians and, six months later, got one himself. Shortly after the lecture, however, he ordered 10 scans on particularly difficult patients, which, according to Amen, resulted in "literally miraculous changes" in five of them. One patient was a 12-year-old boy with a nasty temper, a history of aggression, and school failure, who'd been hospitalized three times, prescribed assorted drugs (including Ritalin, which made him hallucinate), and treated with two years of psychoanalytic therapy. The scan showed low temporal-lobe function (associated, as in Kip Kinkel's case, with anger, violence, and mood swings), as well as frontal-lobe problems (which kept him from being able to concentrate in school). Amen placed him on mood stabilizers and a different stimulant, and voila! Within three weeks, he became milder tempered, began making friends, and, says Amen, "turned into the sweetest boy you'd ever want to meet." His school performance improved dramatically as well.
Another woman had been diagnosed with Alzheimer's after she'd nearly burned down her own home and lost her driver's license. Amen scanned her and found no signs of the characteristic abnormalities associated with dementia. But he did see that her deep limbic structures were "on fire" (a favorite bit of Amen-speak to describe brain areas of severe overactivity). This suggested depression, which can sometimes mimic Alzheimer's symptoms of memory loss, apathy, indifference, and disorientation. Amen prescribed Wellbutrin--an antidepressant and stimulant--and voila` again! Within weeks, she'd regained her memory, and her mood was much better. Within six months, she got her driver's license back.
"How many experiences does a psychiatrist have like these in a whole career?" Amen asks. "I had five of them in the space of a few weeks."
By Amen's lights, SPECT was not diagnosing new conditions. The scans didn't remotely correlate with DSM diagnostic categories, but they often revealed the inaccuracy of previous diagnoses and suggested functional anomalies that shed light on otherwise unexplained symptoms. Nor were his treatments miraculous, radical, or novel; they apparently just hit the target better than earlier interventions. In short order, he was a true believer in the modality. "I thought, 'How can I do psychiatry in good conscience without using scans when I don't really understand what is going on? How can I just continue to rely on guesswork when I have this tool at my disposal?'"
Between 1991 and 1995, he became something of a SPECTomaniac, reading everything he could find, attending meetings about SPECT, and ordering SPECT scans on hundreds of patients at the local hospital. He was asked to talk about SPECT at hospitals and at the University of Colorado medical school. He wrote a research paper comparing SPECT brain images of ADD children to those of normal children. He became an enthusiastic promoter of SPECT.
But there were signs of smoke from an impending firestorm almost from the beginning. In 1992, at a meeting of the American Psychiatric Association (APA), where he attended an all-day course on the use of SPECT in child psychiatry, he went to a lecture by National Institute of Mental Health child-psychiatry researcher Alan Zametkin. This would-be colleague used PET scans (a form of nuclear imaging with higher-quality resolution than SPECT, though more difficult and expensive to use) in a groundbreaking study of what ADD brains look like. Zametkin, says Amen, was one of his heroes, so he went up to him after the talk in the spirit of a fan approaching a star. "I told him that, partially based on his work, I was using SPECT in my own practice," remembers Amen.
But if he'd expected an avuncular smile of approval, he was mistaken. Zametkin angrily barked at Amen that these techniques were strictly for research and in no way intended for clinical use. In no uncertain terms, he told Amen, in effect, to cease and desist what he was doing.
"But why do you do these studies if you don't intend this technology to be used clinically?" Amen asked, baffled.
"I do them just to learn more; it's interesting basic science," Zametkin replied loftily.
This is an attitude foreign to Amen. "I really have no interest in science for science's sake," he admits. "I'm a clinician through and through--it's my reason for living. I get my juice from my practice, from relationships with patients, not from research."
Back home in California, the natives were also getting restless. A local pediatric neurologist, after calling three or four researchers around the country and hearing that SPECT wasn't ready for clinical prime-time, complained to hospital officials about Amen's heterodox behavior. "The neurologist told me that my reasons for ordering scans weren't empirically proven, and that I should quit doing them. He said, 'The brain is for neurologists, not psychiatrists,'" Amen recalls, even now incredulous. "I told him he was nuts." At a meeting of the hospital authorities, Amen was given permission to continue getting SPECT scans for his patients, but he was now required to have the medical director sign off on his requests.
In 1993, he was asked to help teach a brain-imaging course at the APA annual meeting, but when the program came out, a Dallas SPECT researcher wrote the APA program chairman demanding to know why such a controversial figure was included. The program committee chair sat in on the presentation and supported Amen's work, but many others were openly hostile to him, making a point of telling him he was a fraud and a mountebank and ought to be drummed out of the medical profession. It had gotten to be too much, so he decided to retreat from the public field, help his patients in the relative privacy of his clinical practice, and let other people do the research and fight the battles.
It's hard to imagine as restless and driven a figure as Amen ever really settling for a quiet, low-profile practice in suburban California, so he'd probably have taken up the gauntlet again sooner or later. But a crisis involving his 9-year-old nephew, Andrew, launched him back into the fray.
Amen's sister called him in tears one day early in 1995, telling him that her son--his nephew and godchild--had attacked a little girl on the baseball field for no reason. Over the preceding year, this friendly, active, outgoing little boy had become surly, angry, mean, and depressed, and had begun drawing pictures of himself shooting other children or hanging from a tree. Amen told his sister to bring the boy in the next day and, after a lengthy interview, personally took him to the hospital to be scanned. "When I looked at the image, I saw he had no left temporal lobe at all!" recalls Amen. This was, again, a part of the brain associated with violence, aggression, and suicidal and homicidal feelings. Andrew was almost immediately given an MRI scan, which showed a cyst about the size of a golf ball where his temporal lobe should have been.
But Amen couldn't find anybody willing to remove the cyst. Three pediatric neurologists--one at Harvard--told him that Andrew's behavior was probably not related to the cyst and that they wouldn't remove it until there were "real symptoms." Amen was beside himself. "Hearing this made me nearly psychotic, I was so angry." He remembers shouting, "What do you mean, 'real symptoms?' You don't think suicidal and homicidal thoughts and behaviors in a 9-year-old are real symptoms?" Real symptoms, the Harvard neurologist coolly informed him, meant seizures and speech problems. Period.
Finally, he located a pediatric neurosurgeon at UCLA who said he'd operated on three other children with the same problem--a temporal lobe cyst resulting in aggression. This doctor performed the operation on Andrew. When the boy finally woke up after the surgery, he smiled at his mother--the first smile from him she'd seen in more than a year. Shortly afterward, he became, once again, the youngster he'd been before his problems began.
This event changed Amen's life, he says. "From that moment on, I felt I could no longer be shy, or allow myself to be hurt by criticism, or fearful that people wouldn't like what I was doing. I just thought of all the kids who are in residential treatment facilities or end up in prison because they've done terrible things, and nobody ever even knows whether or not it's because they have something terribly wrong with their brains."
Now a newly energized Amen charged full-steam ahead. He completed the 1,000-hour training and supervision program to obtain the license in handling radioactive material that's necessary to do scans, bought SPECT equipment, and became, as far as he knows, the only psychiatrist in the world who had then incorporated brain imaging in his own practice. He once again took up the SPECT gospel and began spreading the word, and once again was met with virulent attacks.
In 1996, after Amen gave the State of the Art Lecture in Medicine at the Society of Development Pediatrics, a San Francisco pediatrician stood up and excoriated him for using brain imaging to justify giving drugs to children for AD/HD--in effect, accusing him of shilling for Big Pharma. Shortly after the meeting, he was anonymously reported to the California Medical Board for practicing outside the generally accepted standards of care. The state medical board began an investigation, which took a full year--of lawyers, interviews, questions, reviews of his articles, office visitations. "The worst year of my life," Amen calls it. Finally, after his work was sent to the departments of neurology and nuclear medicine at UCLA, he was exonerated and became an expert reviewer of psychiatry for the California Medical Board.
Amen and His Critics
Today, about eight years later, Amen has no doubt succeeded as a medical entrepreneur. He has two clinics in California, one in Washington State, and one in Reston, Virginia. By any measure, he's a huge success. Besides founding his clinics and cranking out books (another is on the way), he's produced a "Clinician's Toolbox" of brain-related materials for therapists, a brain-scan atlas, and assorted CDs and videos. He's given more than 100 presentations in the United States and abroad, written or been the subject of numerous articles in the popular press, appeared on scores of radio and television shows, testified at numerous trials, and developed a 12-week high school course on the brain to be piloted in 30 schools this fall. There are perhaps 15, mostly for-profit, psychiatrist-run clinics around the country that now use SPECT--a fair number of the proprietors trained by Amen himself. In addition, an indeterminate number of psychiatrists around the country quietly, but regularly, refer their own patients for brain scans.
Nevertheless, most of the research community and the psychiatric establishment remain deeply unimpressed. Indeed, there isn't anything about Amen or what he does that his critics do like. Following the back-and-forth between them and him is like watching a bunch of increasingly infuriated boxers all trying to knock down an inflatable punching doll--the harder they hit, the faster he bounces back. They argue that Amen isn't competent to use scans because he's not board certified in nuclear medicine, didn't train in radiology (his several hundred hours of imaging training don't count), and doesn't follow science-based methods of differential diagnosis (using appropriate tests to differentiate systematically between distinct diseases with similar symptoms). He counters that he has the proper licenses to do his studies, teaches SPECT at a major medical school, has written or cowritten chapters about SPECT in three professional textbooks, has produced nearly two dozen peer-reviewed papers, instructs nuclear-medicine doctors who come from far away to spend weeks at his clinic, has chaired workshops on SPECT at the APA annual meeting, and, finally, just a year ago, received a Distinguished Fellow Award from the APA. "I have more experience with SPECT than anybody else in the world, and there are mountains of scientific literature backing up my clinical work--1,500 such studies are on my website alone."
They argue that he sits on a proprietary stash of 27,000 scans, like a miser sitting on a pile of gold bullion, and won't give researchers access to his data because he's afraid an independent look will undermine his claims. He contends that researchers are perfectly welcome at his clinic, to talk to his doctors, see how they interpret scans, and look at his database. But one leading researcher he invited out to see his scans hasn't followed through, and no one else has ever asked to see them.
They say, to quote Harvard's George Bush, that "he's unethically subjecting people, including children, to potentially dangerous ionizing medication in a diagnostic test of no proven benefit." He cites Michael Devous, a leading nuclear-medicine expert, who writes that "there are no data that have ever demonstrated any harm to humans by radiation exposure at diagnostic imaging levels." The average radiation exposure for one SPECT scan, Amen points out, is similar to that of an abdominal X-ray, which is routinely ordered for common childhood medical conditions, including constipation.
They say, repeatedly and maddeningly in Amen's view, that he claims to diagnose psychiatric illnesses from the scans. He just as repeatedly insists that he never uses SPECT to "diagnose" anything, but looks at the scan within the context of the person's life and after a full psychiatric evaluation to get more information that might shed light on puzzling, difficult, or anomalous symptoms. "I've never said the image is 'the answer.' We use it when we don't know what's going on, when we think it might supply a piece of the puzzle--it's like radar that helps us better target the problem. The alternative to doing scans is blindly putting kids on meds or multiple meds without looking at their brains either before or afterward."
Finally, and most damagingly, they say that what Amen is doing is totally unsupported by the facts--that he hasn't remotely demonstrated the scientific validity or reliability of using scans as he does. They argue that it isn't yet possible to identify subtle distinctions in single subjects that reliably correlate with specific symptoms. "When a radiologist looks at a chest X-ray, he recognizes pneumonia, or an enlarged heart or liquid at the base of the lungs that correlate with disease because he's compared these abnormal scans to thousands of normals and other abnormals," says neuroscientist Bush. "Maybe in 50 years, when someone comes in looking as if he or she has a certain syndrome, we'll be able to refer them to a radiologist who'd be able to interpret that individual scan. But we're not yet, as a field, in a position to distinguish one brain scan from another. Right now, you can look at any individual scan and what you'll find is color blobs across a screen. What separates science from nonscience is the ability to pick out quantitative, statistically reliable, patterns [in those blobs] based on large numbers of scans--set certain criteria for a disorder, show it in 50 cases compared with 50 normals, for example. Amen isn't doing that. Essentially, all he's doing is 'blobology.'"
To this, Amen responds that factoring in the individual variability in each brain, rather than drawing general, statistical inferences from a large base of cases, is a strength of his method, not a weakness. Researchers look for signature features in a scan that will reliably correlate with specific DSM categories, which do not reflect the complexity and heterogeneity of psychiatric disorders as they're experienced by real people, Amen argues. " DSM diagnoses are artificially derived from symptom clusters," he says. "But they don't explain why people are having these symptoms--why one person's depression or anxiety or AD/HD may be entirely different from the same formal diagnosis in somebody else. Only by looking at each person's individual scan can you get some insight into the underlying physiological pattern in the brain, so we can target treatment specifically to what that person needs."
In addition, he says, researchers study "pure" cases--people with one supposed diagnosis without the confounding variables of comorbid conditions (i.e., drug addiction along with their depression, AD/HD symptoms along with their anxiety). This approach simply doesn't reflect the complexity, variability, and individuality of real people and real patients.
Finally, researchers compare people with a DSM diagnosis to presumed "normals," but Amen doubts that there's such an entity as a "normal" brain. Recruiting people for a database of normals, his office screened 1,500 people and found only 72, who met the criteria for "normal"--no signs of head injury, no history of substance abuse, no psychiatric illness, and no first-degree relative with a psychiatric illness. "'Normal' is a myth," he says flatly.
Whatever the specifics of his critics' objections to Amen's work, it's hard not to suspect that underlying the intensity of their response is their objection to Amen himself--his persona, his style, his modus operandi. Most scientists lead comparatively monastic, inconspicuous lives (though not necessarily impecunious--many act as paid consultants to pharmaceutical and medical-device companies). Even those few who achieve eminence do so largely within the circumscribed universe of their peers. How many people can name a recent Nobel laureate in any scientific field? They have their own worldview, and what they consider Amen's heavy-handed promotion of high-tech gimmickry is as far from it as earth is from Pluto.
"The nature of science is agnosticism," says Helen Mayberg in a passionate defense of the way researchers do things. "Our job is to ask questions, measure data, continue doing the research until we find out what's real, what isn't. I've devoted my entire professional life to using imagery to understand depression, and the more progress I make, the more complicated it gets. As a clinical neurologist, I see patients die all the time. I don't have to have anybody tell me how much people suffer. But no matter how much, as a doctor, I want some idea for a promising new treatment to be true, as a scientist, I have to remain an agnostic. We all know the system isn't as good as it should be, but it's the best we've got. We get accused of living in ivory towers, but we do what researchers do--we can't leapfrog over the process."
For researchers like Mayberg, Amen is anathema--a leap-frogger to the nth degree. His disregard for professional politesse can make even his friends and defenders cringe. Jerry Rodos, a psychiatrist in the Chicago area, who regularly refers difficult patients for scans, remembers taking a younger colleague to hear him lecture. "We walked into the conference room, my friend took one look at the Amen concession--tapes and books and CDs, advertisements for his clinics, posters, etc.--and was completely turned off before he even sat down. I think Dan has done a lot of neat work, and what he is saying is very valuable, but he's not a traditionalist and hasn't spent a lot of effort trying to get refereed journals to review his material. If you have something important to say, you submit it to peer-reviewed journals, rather than just run off and start four clinics and write popular books about it. Dan Amen is a big promoter of Dan Amen, and that offends many of his colleagues."
Partly in response to critiques like this, even from allies, Amen has hired a statistician-researcher and is preparing several studies, including one on predicting treatment response in AD/HD patients based on their different scan subtypes. But Amen doesn't believe his opponents will come to like him anytime soon, no matter what kind of studies he publishes. "A friend of mine told me I was like somebody under an old Romanian curse--doomed to know something that's true, but nobody believes him," he says gloomily.
The Client's Experience
Meanwhile, anathema or not, Amen's clinics do 400 to 500 scans a month, and, according to follow-up questionnaires given one month and six months after treatment, 85 percent of this patients think they received "significant benefit" from the process. According to therapy researcher Jay Lebow, however, this isn't unusually high--about 90 percent of psychotherapy users report being satisfied with their treatment, which can simply mean they liked the therapist and felt understood and cared for.
At least some of Amen's patients, however, clearly feel that the experience transformed them, even saved their lives. Whole families get scanned, and then refer their friends and acquaintances and fellow church-members. Some of Amen's most convinced champions are evangelical Christians, who believe that Amen is doing God's work and want to help him do it. Linda and Gaylen Bronson, a California couple who are committed Christians, were so delighted with Amen's treatment of their family that they started the Recovery Assistants Foundation, a tax-exempt, charitable organization that helps people who couldn't otherwise afford it to get and pay for SPECT scans, therapy, and medications.
To get some idea of how the Amen phenomena can build on itself, consider the Woodmansees--Jack, a retired general and businessman, and his wife Patty--who live in a suburb of Dallas. The Woodmansees heard about Amen a decade ago from a friend who felt the SPECT scan and his treatment had dramatically improved her life. Because the Woodmansees had a grandson diagnosed with AD/HD, who was doing very poorly on Ritalin, they sent for an Amen video about AD/HD. Watching it as a family, their adult son (the father of the AD/HD child) came to the conclusion that he probably had AD/HD, too. The senior Woodmansees made appointments for the son and grandson to get scanned, and then decided to take their granddaughter, who had behavioral problems. Eventually, three different branches of the family trooped out to California to be scanned.
Soon they were all talking about the temporal lobes, cingulate gyrus, prefrontal cortex and noting the interesting family resemblances in their brain-perfusion patterns. They also became advocates for Amen, sending along friends, neighbors, and members of their congregation, and even financing scans for people who couldn't afford them. They brought Amen to Dallas to give lectures, and have been trying to convince him to open a clinic there.
Two years ago, Richard and Sarah Mitchell took their 10-year-old daughter, Terry, in for a scan. Always a difficult child, Terry was now throwing herself on the floor in explosive temper tantrums, harassing her siblings, causing classroom disruptions, and failing in school. Diagnosed with AD/HD and oppositional defiant disorder, she'd been prescribed a stimulant, which she vociferously fought taking, and which only made her worse. After the scan, Amen prescribed an antidepressant, a mood stabilizer, and a handful of supplements. He also recommended several therapists. But not one of the three therapists worked out, and the drugs didn't help much, either.
So Amen shifted course. He took Terry off meds, cranked up the supplements, including large doses of over-the-counter omega-3 fatty acids, GABA, and other amino acids (believed to reduce anxiety), recommended a high-protein diet, and helped her parents learn some techniques for handling their daughter better. Now, about two years later, Terry still tends to be bossy and overbearing, has a hard time picking up on social cues, and is emotionally immature. But she's much better than she was--her grades are now high Bs, she likes school, and her mood has generally improved. "She isn't raging anywhere near as much," her mother reports, and she clearly feels more at peace with herself.
Terry's case points to a paradoxical and perhaps misunderstood aspect of Amen's approach. However radical the use of SPECT may seem, his treatment is unconventional only in that it's far more heterogeneous and informed by alternative-healing methods than the Johnny-one-note pharmaceutical orientation of most psychiatrists. While not shy about prescribing medications, often in twos and threes, he also recommends nutritional and herbal supplements, cognitive therapy, EMDR, biofeedback, parenting-skills training, diet, exercise, meditation, and abstinence from alcohol.
How does treatment with Amen compare with what another psychiatrist might recommend? Might not Terry, for example, have done just as well if she'd found a reasonably creative and open-minded therapist willing to try a variety of different approaches and hang in with the family for as long as it took? Of course. Did the SPECT scan speed up the process? Possibly. Does Terry's family believe that scans are magical keys to the kingdom of the inner brain and that Amen is the sorcerer who, essentially, saved their child? Completely. "Without Dr. Amen, she'd probably be in some military school now," says Terry's mother. "I feel blessed to have met him." Among the Amenophiles, this attitude isn't unusual.
For all that people say about what most mattered to them about their experience at one of Amen's clinics, it would be a mistake to underestimate the weight of the old saw that a picture is worth a thousand words. People believe they're seeing an actual picture of something empirically real, fundamentally true, and undeniably revealing about themselves. This apparently incontrovertible glimpse of reality can be unwelcome, even shocking, but it has to be taken seriously. Before the scan, Terry Mitchell had furiously refused to take medications, and felt her parents were disciplining her unfairly. When her scan was shown to her and explained, she looked at it quietly and somberly for a long time, and said, "I guess I really do need medications." It's easy to believe Amen when he talks about the power of these scans to convince even adolescents that the drugs they ingest really are hurting their brains--there's the evidence.
Critics might argue that this troubled child has been conscripted into a possibly false sense of her personal pathology by a misused and misleading test. But, paradoxically, scans that show something amiss can be oddly reassuring. "Do you know what people's biggest worry is about seeing their scan?" Amen asks. "That the scan will show nothing ; that it'll look normal, which means that they're suffering because they're weak or bad." After her scan, Terry felt relieved, her mother said, because the scan explained why she was having so much trouble and removed her sense of self-blame for not acting like a "normal" girl.
Brain and Soul
This peculiar, but almost universal, sleight of thought--"it's not me, it's my brain "--helps explain Amen's appeal and, for that matter, the appeal of all "biological psychiatry." Whether or not we're religious, spiritual seekers, or hard-nosed materialists, we feel intuitively that our real selves, our souls, if you will, aren't the same as the soft "hardware" of the brain. And unlike many drive-thru drug dispensers, as psychiatrists have too often become, Amen actually seems to care about the soul, perhaps even in some way believes he's doing his part to save souls, or at least free them from the malign influence of a sick brain. And clearly, Amen and his staff do everything they can to make the people who come to them feel like real people with basically whole souls, whatever is wrong with their neurophysiology.
Recently, Ted, a nonprofit administrator who'd seen Amen at the Networker Symposium, decided to get his own brain scanned in Amen's clinic in Reston, Virginia, which is directed by psychiatrist Charles Parker. Now in his mid-fifties, Ted says he's been depressed since his late thirties. He describes his emotional state not as sadness so much as apathy, lack of energy, zest, and motivation. "Nothing's wrong in my life. In fact, I think I have a great life. I just don't enjoy it very much," he says. He also has a hard time concentrating and, while he used to read a lot, now just zones out in front of the TV. He was in therapy many years ago, though not since becoming depressed, and has tried a number of medications--Prozac, Wellbutrin, Cymbalta, Paxil--and acupuncture, all to no avail.
Ted loved his whole experience at the Amen clinic. The staff seemed entirely made up of young, attractive, extraordinarily pleasant women with big smiles who, Ted was intrigued to see, all wore very high heels. "It was a little like the Stepford Wives, only they seemed genuinely nice." He filled out a 15-page questionnaire, went through a lengthy interview with the "historian," and then underwent a concentration scan. Two days later, he went in for his resting scan, and a day or two after that, Dr. Parker reviewed the scans with him.
Ted found Dr. Parker to be the nicest person of an amazingly nice staff, scoring about 110 on a 100-point friendliness scale. "The psychiatrist I go to for my meds checks is a nice enough guy, I guess, but he's like an iceberg compared to Dr. Parker, whom I liked much better. He really seemed to want to spend as much time with me as I needed."
As for the scans and what emerged from them, things get a little murky. The report was long, complicated, and somewhat confusing to Ted, who said that, as he listened, "after five minutes or so, I kind of glazed over." The scans showed less than normal perfusion in areas of the prefrontal cortex, temporal lobes, and parietal lobes; increased, or excessive, perfusion in the basal ganglia and limbic system; and "scalloping," or dehydration, on the outer surface. Altogether, all of this signifies . . . well, a lot of possibilities--including, but not limited to, short attention span, low motivation, memory problems, abnormal perception, impulsivity, disorganization, distractibility, anxiety, irritability, depression, and mood cycles.
In this somewhat jumbled mass of findings, what fascinated Ted the most was the pronounced indentation in his left prefrontal cortex, consistent, said Parker, with past brain injury. Amen contends that many psychiatric conditions may result from undiagnosed, and even apparently mild, brain trauma without unconsciousness, and he makes it a practice to ask his patients at least five times if they've ever experienced head injuries. Ted was also interested to learn that several of the patterns picked up on in the scan are often seen in people with AD/HD.
The upshot of all this was that, according to Parker and Amen (who read the scan), Ted had been taking the wrong medication--Cymbalta only exaggerates symptoms of AD/HD and concentration difficulties. He was to begin taking Effexor right away, and Adderall a few weeks down the line. Besides this, he should begin exercising and take various supplements. Ted was given a list of books and referrals to holistically trained MDs specializing in nutrition and brain-injury recovery, neurofeedback experts, and brain-health websites. He was also told to make a follow-up appointment. For a technique that's supposed to provide the focus for well-targeted, specific clinical interventions, Ted's SPECT scan seems to have resulted in something of a hodgepodge of generic recommendations.
But Ted came away from his adventure feeling elated--less like somebody who's had a high-tech medical procedure with no very clear prognosis, and more like somebody who'd won the lottery and been given a new lease on life. "I thoroughly loved the whole thing. I'm very glad I did it. It was uplifting and made me feel so hopeful." And the scans? "They're interesting to look at--very pretty. It's neat to have somebody show you what your brain looks like. And then to be shown this big indentation that's not supposed to be there; well, it's concrete evidence that something really did happen to you. I do think I understand my own brain a little bit better."
Whatever the outcome for Ted's case, or for Amen's crusade overall, it seems inevitable that his work, or some variant of it, represents a glimpse into the future. With the development of revolutionary new technologies permitting a direct look inside the brain, people will be increasingly dissatisfied with the clinical guesswork and serial medication trials that constitute so much of psychiatry today.
Nor will psychotherapists, the workhorses of the mental health industry, be content to wait until the last peer-reviewed, double-blinded study demonstrating SPECT's empirical validity and reliability has been published before making use of these technologies in their own practices. They've never been willing to delay using what seemed useful to their patients until they've gotten the okay from the higher orders of scientific inquiry. EMDR and many forms of body-oriented trauma therapies, as well as a host of other therapeutic methods, are still considered fringe by research psychologists, but that isn't stopping therapists from using them. Whether one considers Amen a devil or a new messiah, his use of SPECT visionary or voodoo, it seems likely that time is on his side.
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. Contact: email@example.com.
by Margaret Wehrenberg
"I don't think I want to live if I have to go on feeling like this." I hear this remark all too often from anxiety sufferers. They say it matter-of-factly or dramatically, but they all feel the same way: if anxiety symptoms are going to rule their lives, then their lives don't seem worth living.
What is it about anxiety that's so horrific that otherwise high-functioning people are frantic to escape it? The sensations of doom or dread or panic felt by sufferers are truly overwhelming--the very same sensations, in fact, that a person would feel if the worst really were happening. Too often, these, literally, dread-full, sickening sensations drive clients to the instant relief of medication, which is readily available and considered by many insurance companies to be the first line of treatment. And what good doctor would suggest skipping the meds when a suffering patient can get symptomatic relief quickly?
But what clients don't know when they start taking meds is the unacknowledged cost of relying solely on pills: they'll never learn some basic methods that can control or eliminate their symptoms without meds. They never develop the tools for managing the anxiety that, in all likelihood, will turn up again whenever they feel undue stress or go through significant life changes. What they should be told is that the right psychotherapy, which teaches them to control their own anxiety, will offer relief from anxiety in a matter of weeks--about the same amount of time it takes for an SSRI to become effective.
Of course, therapists know that eliminating symptomatology isn't the same as eliminating etiology. Underlying psychological causes or triggers for anxiety, such as those stemming from trauma, aren't the target of management techniques; they require longer-term psychotherapy. However, anxiety-management techniques can offer relief, and offer it very speedily.
The unpleasant symptoms most likely to be helped by medication are the very ones that the 10 best-ever anxiety-management techniques are intended to correct. They fall into three typical clusters:
- the physical arousal that constitutes the terror of panic;
- the "wired" feelings of tension that correlate with being "stressed out" and can include pit-of-the-stomach doom;
- the mental anguish of rumination--a brain that won't stop thinking distressing thoughts.
A therapist armed with methods for addressing these clusters can offer her anxious client the promise of relief for a lifetime, if she knows which of these "10 best" techniques work for which symptoms, and how to use them.
Panic is the physical arousal that sends many clients running for Xanax. Sympathetic arousal causes the heart-thumping, pulse-racing, dizzy, tingly, shortness-of-breath physical symptoms that can come from out of the blue, and are intolerable when not understood. Even high levels of acute anxiety that aren't as intense as outright panic attacks can constitute very painful states of arousal. Physical symptoms of anxiety include constant heightened physical tension in the jaw, neck, and back, as well as an emotional-somatic feeling of doom or dread in the pit of the stomach. The feeling of doom will always set off a mental search for what might be causing it.
Bad as these symptoms are, there are methods that, when followed regularly as lifelong habits, offer tremendous relief.
Method 1: Manage the Body.
Telling anxiety-prone clients to take care of their bodies by eating right, avoiding alcohol, nicotine, sugar, and caffeine, and exercising is a strikingly ordinary "prescription," but not doing these things can undermine the effectiveness of other antianxiety techniques. During the summer before Ellie went off to college, for example, she'd almost eliminated her anxiety by practicing deep, calm breathing and learning to stop her catastrophic thinking. She'd even been able to stop taking the antianxiety medication she'd used for years. But two months after starting college, her panic attacks came roaring back with a vengeance. She came back to see me, but quickly let me know that she was going to call her psychiatrist for another Xanax prescription. I suggested that, before she made the call, she spend a couple of weeks keeping a "panic profile"--a journal recording when and under what circumstances she suffered from panic attacks.
A couple of weeks later, she came to my office smiling broadly. "I figured it out," she said, grinning as she showed me her panic profile. She'd traced her panic attacks to days after she drank heavily and smoked cigarettes--neither of which had she done over the summer while living in her parents' house. Also, her caffeine use had risen dramatically while at school--to help her wake up for classes after partying at night--and her diet had devolved to pizza and doughnuts. She really didn't want to give up these habits, but keeping the journal had reminded her that her anxiety symptoms are physical, and that calming her body had defused her panic triggers once before. Taking care again to eliminate CATS (caffeine, alcohol, tobacco, sugar + Nutrasweet), Ellie got back on track without returning to meds. The simple rule--manage the body--must remain a first priority throughout treatment for anxiety. Ellie had a major relapse when she let go of routine self-care.
Therapists who remember that humans have bodies as well as minds are much likelier to inquire routinely about ongoing self-care, including sleep and exercise. They're also more willing to help clients overcome their reluctance to follow a self-care routine. A tip to remember for female clients who experience a resurgence of symptoms in spite of the fact that they're managing their body is to consider hormonal changes. Pregnancy, postpartum changes, hysterectomy, and interruptions in cycles may contribute to anxiety. The slow process of menopause, which may begin over a wide range of ages, is another factor to consider. Shifts in thyroid function also contribute to shifts in anxiety. They can occur at any age, and predominate in female clients. Therapists need to be particularly alert to what might be going on in the body when a client who was previously doing well starts having trouble.
Method 2: Breathe.
Ellie and I next reviewed her use of diaphragmatic breathing to ward off the panic. As it turned out, she'd forgotten how helpful breathing had been when we first started working together, and had quit doing it. Now, not only did she suffer again from panic, but she thought it was too powerful to be relieved merely by breathing deeply. She'd begun to panic just thinking about feeling panic. I've often found that when clients say that breathing "doesn't work," it's because they haven't learned to do it correctly. Or once having learned it, they've given it up when they felt better, believing that they no longer needed to do it. By the time they feel anxiety returning, they're convinced that something so simple can't possibly be really effective. Therefore, it's important for therapists to emphasize and reemphasize that breathing will slow down or stop the stress response, if the client will just do it.
The biggest block to making breathing truly helpful is the time it takes to practice it until it becomes an ingrained habit. Most relaxation books teach clients to practice breathing once a day for 10 minutes, but I've never found a client who actually learned how to do it from this one, daily, concentrated dose. I don't teach clients to breathe for lengthy periods until they've practiced it for very short periods many times a day. I ask them to do the conscious, deep breathing for about one minute at a time, 10 to 15 times per day, every time they find themselves waiting for something--the water to boil, the phone to ring, their doctor's appointment, the line to move at the bank. This will eventually help them associate breathing with all of their surroundings and activities. This way, they're more likely to actually remember to breathe when anxiety spikes. Ellie needed a review session in breathing to help her get back on track.
Method 3: Mindful Awareness.
Since the return of her panic attacks, Ellie had also begun to fear that she'd always be afraid. "After all," she said, "I thought I was cured when I went back to school, and now look at me! I'm constantly worried I'll have another panic attack." She'd started to give catastrophic interpretations to every small, physical sensation--essentially creating panic out of ephemeral and unimportant changes in her physical state. A slight chill or a momentary flutter in her stomach was all she needed to start hyperventilating in fear that panic was on its way, which, of course, brought it on. She needed to stop the catastrophic thinking and divert her attention away from her body.
Like most anxious people when they worry, Ellie was thinking about the future and wasn't in the moment. She felt controlled by her body, which required her to be on the lookout for signs of panic. She'd never considered that she could manage her body--and prevent panic--by controlling what she did or didn't pay attention to. But, in fact, by changing her focus, she could diminish the likelihood of another panic attack. A wonderful technique, this simple "mindful awareness" exercise has two simple steps, repeated several times.
1. Clients close their eyes and breathe, noticing the body, how the intake of air feels, how the heart beats, what sensations they have in the gut, etc.
2. With their eyes still closed, clients purposefully shift their awareness away from their bodies to everything they can hear or smell or feel through their skin.
By shifting awareness back and forth several times between what's going on in their bodies and what's going on around them, clients learn in a physical way that they can control what aspects of their world--internal or external--they'll notice. This gives them an internal locus of control, showing them, as Ellie learned, that when they can ignore physical sensations, they can stop making the catastrophic interpretations that actually bring on panic or worry. It's a simple technique, which allows them to feel more in control as they stay mindful of the present.
Many clients with generalized anxiety disorder (GAD) experience high levels of tension that are physically uncomfortable and compel them to search frantically for the reasons behind their anxiety. They hope they can "solve" whatever problem seems to be causing anxiety and thus relieve its symptoms. But since much of their heightened tension isn't about a real problem, they simply waste time running around their inner maze of self-perpetuating worry. And even if their tension does stem from psychological or neurobiological causes, there are ways to eliminate the symptoms of chronic worry before addressing those dimensions. The following methods are most helpful for diminishing chronic tension.
Method 4: Don't Listen When Worry Calls Your Name.
Colleen feared I'd think she was crazy when she said, "It's as if my anxiety has a voice. It calls to me, 'Worry now,' even when there's nothing on my mind. Then I have to go looking for what's wrong." And she was very good at finding something wrong to worry about. An executive who had a lot of irons in the fire, she had no shortage of projects that needed her supervision. On any day, she could worry about whether a report had been correct, or projected figures were accurate, or a contract would generate income for her firm. In describing the voice of worry, she was describing that physical, pit-of-the-stomach sense of doom that comes on for no reason, and then compels an explanation for why it's there. This feeling of dread and tension, experienced by most GAD clients, actually comprises a state of low-grade fear, which can also cause other physical symptoms, like headache, temporo-mandibular joint (TMJ) pain, and ulcers.
Few realize that the feeling of dread is just the emotional manifestation of physical tension. This "Don't Listen" method decreases this tension by combining a decision to ignore the voice of worry with a cue for the relaxation state. Early in treatment, GAD clients learn progressive muscle relaxation to get relief. I always teach them how to cue up relaxation several times throughout the day by drawing a breath and remembering how they feel at the end of the relaxation exercise. We usually pair that deeply relaxed state with a color, image, and word to strengthen associations with muscle relaxation and make it easier to cue the sensation at will.
We then use that ability to relax to counteract the voice of worry. Clients must first learn that worry is a habit with a neurobiological underpinning. Even when a person isn't particularly worried about anything, an anxiety-prone brain can create a sense of doom, which then causes hypervigilance as the person tries to figure out what's wrong. Colleen smiled with recognition when I said that, when she was in this state, it was as though her brain had gone into radar mode, scanning her horizons for problems to defend against. I asked her to pay attention to the order of events, and she quickly recognized that the dread occurred before she consciously had a worry. "But," she announced, "I always find something that could be causing the doom, so I guess I had a good reason to worry without realizing it."
She believed the doom/dread must have a legitimate cause, and was relieved to learn that her need to find the cause (when there really wasn't one) stemmed from a brain function. This cause-seeking part of her brain, triggered by changes in her physiology that made her feel dread, in effect, called out, "Worry now!"
To stop listening to that command to worry, I suggested that she say to herself, "It's just my anxious brain firing wrong." This would be the cue for her to begin relaxation breathing, which would stop the physical sensations of dread that trigger the radar.
Method 5: Knowing, Not Showing, Anger.
Anger can be so anxiety-provoking that a client may not allow himself to know he's angry. I often find that clients with GAD have an undetected fear of being angry. Bob was a case in point. He had such a tight grin that his smile was nearly a grimace, and his headaches, tight face muscles, and chronic TMJ problems all suggested he was biting back words that could get him into trouble. There were many arenas of his life in which he felt burdened, such as losing out on a promotion and his wife's chronic inability to spend within their budget, but he genuinely believed he was "putting a good face" on his problems. As with other anxious clients, the acute anxiety was compelling enough to command the therapy time, and it would have been possible to ignore the anger connection. However, as long as anger stays untreated, the anxious client's symptoms will stay in place.
When a client fears anger because of past experience--when she remembers the terrifying rage of a parent, or was severely condemned for showing any anger herself--the very feeling of anger, even though it remains unconscious, can produce anxiety. The key to relieving this kind of anxiety is to decrease the client's sense of tension and stress, while raising the consciousness of anger so that it can be dealt with in therapy. I've found that simply being able to feel and admit to anger in sessions, and to begin working on how to safely express it, diminishes anxiety. I tell clients, "To know you're angry doesn't require you to show you're angry."
The technique is simple. I instruct clients that the next time they're stricken with anxiety, they should immediately sit down and write as many answers as possible to this specific question, "If I were angry, what might I be angry about?"Â I tell them to restrict their answers to single words or brief phrases. The hypothetical nature of the question is a key feature, because it doesn't make them feel committed to the idea that they're angry. They may destroy the list or bring it in for discussion, but I ask them to at least tell me their reactions to writing this list. Without fail, this exercise has helped some of my anxious clients begin to get insight into the connection between their anger and their anxiety, which opens the door to deeper levels of psychotherapy that can resolve long-standing anger issues.
Method 6: Have a Little Fun.
Laughing is a great way to increase good feelings and discharge tension. The problem for anxious clients is that they take life so seriously that they stop creating fun in their lives, and theyÂ stop experiencing life's humorous moments. Everything becomes a potential problem, rather than a way to feel joy or delight.
Margaret was a witty woman, whose humor was self-deprecating. A high-level executive who typically worked 12- to 14-hour days, she'd stopped laughing or planning fun weekends about two promotions back. Her husband rarely saw her on weeknights, and on Saturday and Sunday, she typically told him she was just "going to run over to the office for a little while"--anywhere from 3 to 7 hours. When I asked her to make a list of what she did for fun, she was stymied. Other than having a drink with friends after work, her list of enjoyable activities was almost nonexistent.
Getting in touch with fun and play isn't easy for the serious, tense worrier. I've often found, however, that playing with a child will get a person laughing, so I asked her to spend some time with her young nieces. She agreed, and noticed that she felt more relaxed after being with them for an afternoon. Then I asked her to watch for any impulse to do something "just because," without any particular agenda in mind. When I saw her next, she seemed transformed. She said, "I had an impulse to stop for an ice-cream cone, so I just went out and got it. I don't know when the last time was that I felt like doing something and just did it--no worries about whether everyone else had a cone or whether I should wait till later. It was fun!" Over time, listening to her inner wishes helped Margaret feel that there was a reservoir of pleasure in life that she'd been denying herself, and she began to experiment with giving herself the time to find it.
But Margaret needed to rediscover what she liked after years of ignoring pleasure. For a time, our therapy goal was simply to relearn what she had fun doing. Fun-starved clients sometimes need a "prescription," like "Take two hours of comedy club and mix with a special friend, once a week" or "Plan one weekend out of town with your husband every two months." Not surprisingly, tightly wired workaholics initially need to make fun a serious goal of treatment, something to be pursued with some of the same doggedness they put into work.Â But once they actually find themselves laughing and enjoying themselves, they become less tightly wired, less dogged, and more carefree. Laughter itself is one of the best "medications" of all for tension and anxiety.
The final methods are those that deal with the difficult problem of a brain that won't stop thinking about distressing thoughts. Worries predominate in social phobia, GAD, and other kinds of anxiety, and continual rumination can create nausea and tension, destroying every good thing in life. A metaphor drawn from nature for this kind of worry would be kudzu, the nearly unkillable plant that proliferates wildly, suffocating every other form of life, just as continual worry suffocates clients' mental and emotional lives.
I don't believe rumination is caused by deep-seated conflict in the way anger-anxiety might be; I think it's almost entirely a neurobiologically driven feature of anxiety. What clients usually worry about--often ordinary, day-to-day concerns--is less important than the omnipresence of the worry. Their brains keep the worry humming along in the background, generating tension or sick feelings, destroying concentration, and diminishing the capacity to pay attention to the good things in life. Seeking reassurance or trying to solve the problem they're worrying about becomes their sole mental activity, obscuring the landscape of their lives. Nor can ruminators ever get enough reassurance to stop worrying altogether. If one worry is resolved, another pops right up--there's always a fresh "worry du jour."
Therapy with these clients shouldn't focus on any specific worry, but rather on the act of worrying itself. If a ruminating brain is like an engine stuck in gear and overheating, then slowing or stopping it gives it a chance to cool off. The more rumination is interrupted, the less likely it'll be to continue. The following methods are the most effective in eliminating rumination.
Method 7: Turning It Off.
Peter's rumination was the bane of his existence. A mile-a-minute supersalesman with remarkable drive, he had a capacity to fret that could wear out a less energetic person. His mind traveled from one possible problem to another like a pinball that never comes to rest. Ruminating worry preoccupied him so much that he couldn't enjoy being with his children or relax before going to sleep--his last conscious awareness at night was of worry.
In therapy, he had a hard time focusing on just one issue at a time; one worry just reminded him of another and another after that. Before addressing the psychological underpinnings of worry in his life, we needed to find a way for Peter to cool down his brain and halt the steady flow of rumination for a while.
From Eugene Gendlin's Focusing method, I've borrowed the concept of "clearing space" to turn off and quiet the ruminative mind. I ask the client to sit quietly with eyes closed and focus on an image of an open container ready to receive every issue on his or her mind. She's then instructed to see and name each issue or worry, and imagine putting it into the container. When no more issues come to mind, I suggest that the client mentally "put a lid" on the container and place it on a shelf or in some other out of the way place until she needs to go back to get something from it. Once the jar is on the shelf, the client invites into the space left in her mind whatever is the most important current thought or feeling. Perhaps she's at the office and needs to think about a work-related issue, or she needs to shop and should plan what she'll buy, or she's with friends and wants to focus on what they're saying. At night, right before sleep, the client is asked to invite a peaceful thought to focus on while drifting off.
Peter is a man who prefers tangible tools to metaphorical ones, so when he was at home, I suggested that instead of using imagery, he make a written list of the issues he couldn't turn off and put the list in a desk drawer to wait for him overnight, or even place it in his freezer to help him "chill out." Any tangible technique is fine, such as Al Anon's idea of a "God Box" to hold slips of paper, each with a worry written down that the client is turning over to God. The goal of "turning it off" is to give the ruminative mind a chance to rest and calm down.
Method 8: Persistent Interruption of Rumination.
Ruminative worry has a life of its own, consistently interfering with every other thought in your client's mind. Thought-stopping/ thought-replacing is the most effective cognitive-therapy technique for interrupting chronic rumination, but I find the key to making it work is persistence . Clients very quickly pick up on the technique itself, but they're always shocked by how rumination can subvert all their good efforts, and by how persistently they have to keep at it to succeed. I've had clients come back and say the technique didn't work, because they'd tried it 20 to 30 times in a day and they still were ruminating. I tell them that they must do it every time they catch themselves ruminating, even if it is 1,000 times a day or more! That's what I mean by persistence.
Darla is a good example. She was a self-described worrywart before she got cancer, but after her diagnosis, her anxiety zoomed out of control. Although treatment was successful and she'd been in remission for some time, she still had constant, negative, racing thoughts about whether her cancer would recur. A really hard worker in therapy, she did every method I suggested, and was ready to use thought-stopping to interrupt her ruminations about cancer. "Remember," I told her, "winning this game is about persistence. Do the thought-stopping exercise every single time you find yourself worrying, no matter how many times you have to do it."
At the next session, she reported her success--she really had radically cut back the amount of worrying she was doing. But it worked only because I'd warned her about how persistent she'd have to be. "When you told me I'd have to thought-stop every time, even if it was 1,000 times a day," she said, "I thought you were kidding. If you hadn't warned me, I'd have given up in despair after about 100 times, thinking it would never work for me. Since you said 1,000, I figured I'd better stay the course. After a couple of days, it got markedly better." Rumination is persistent, and the only way to beat it at its own game, so to speak, is to be even more persistent.
Method 9: Worry Well, But Only Once.
Some worries just have to be faced head-on, and worrying about them the right way can help eliminate secondary, unnecessary worrying. Connie knew that her next medical results were going to tell the story of whether she needed surgery. Although there's always a level of legitimate worry about any medical problem, some medical conditions, like high thyroid, create anxiety symptomatology. Connie's medical problems weren't causing the anxiety symptoms, but her anxiety about her condition was getting in the way of her medical recovery. She called the doctor's office repeatedly, until the doctor said she'd fire Connie if she got one more phone call before the test results came in.
Connie was out of control with worry, so we tried out a method that actually had her worry, but worry well--and only once. Here's how that works. The client must: (1) worry through all the issues; (2) do anything that must be done at the present time; (3) set a time when it'll be necessary to think about the worry again; (4) write that time on a calendar; and (5) whenever the thought pops up again, say, "Stop! I already worried!" and divert her thoughts as quickly as possible to another activity.
Connie and I set a 10-minute time limit on our worry session, and then together thought through all the possible ramifications of a positive test result. She covered things such as "Who'll watch the cat while I'm in the hospital?" "Will I have to miss too many days of work?" "Will I need a ride home?" We covered everything from the mundane to the serious, if unlikely, "What if I die while in surgery?"
It's critical to this method to cover all the bases, but 10 minutes, surprisingly, is an adequate amount of time in which to do that. At the end of the worry period, Connie agreed that she had no other worries related to the surgery, so we set a time at which she thought she'd need to think about the problem again. We agreed that the next time she should let the possibility of surgery cross her mind was when the doctor's office called. Until that moment, any thought would be counterproductive. She wrote in her PDA that she could worry again at 4 p.m. on Tuesday afternoon, by which time the results would be in and the doctor had promised to call. If she hadn't heard at that point, then she could start worrying and call the doctor's office.
Having worried well, we moved to the "Only Once" part of the method. She then practiced, "Stop It! I already worried!" and we made a list she could carry around with her that enumerated some distractions to use. While this may sound trite, her brain believed her when she said she'd already worried, because it was true.
Method 10: Learn to Plan Instead of Worry.
A big difference between planning and worrying is that a good plan doesn't need constant review. An anxious brain, however, will reconsider a plan over and over to be sure it's the right plan. This is all just ruminating worry disguising itself as making a plan.
Clients who ruminate about a worry always try to get rid of it by seeking the reassurance that it's unfounded. They believe that if they get the right kind of solution to their problem--the right piece of information or the best reassurance--they'll then be rid of the worry once and for all. They want to be absolutely sure, for example, that a minor mistake they made at work won't result in their being fired. In reality, however, a ruminating brain will simply find some flaw in the most fail-safe reassurance and set the client off on the track of seeking an even better one.
One good way to get out of the reassurance trap is to use the fundamentals of planning. This simple but often overlooked skill can make a big difference in calming a ruminative mind. I teach people how to replace worrying with planning. For most, this includes: (1) concretely identifying a problem; (2) listing the problem-solving options; (3) picking one of the options; and (4) writing out a plan of action. To be successful with this approach, clients must also have learned to apply the thought-stopping/thought-replacing tools, or they'll turn planning into endless cycles of replanning.
After they make a plan, ruminating clients will feel better for a few minutes and then start "reviewing the plan"--a standard mental trick of their anxiety disorder. The rumination makes them feel overwhelmed, which triggers their desire for reassurance. But when they've actually made the plan, they can use the fact that they have the plan as a concrete reassurance to prevent the round-robin of ruminative replanning. The plan becomes part of the thought-stopping statement, "Stop! I have a plan!" It also helps stop endless reassurance-seeking, because it provides written solutions even to problems the ruminator considered hopelessly complex.
For example, if Connie, who'd worried well about surgery, found out she did have to have the surgery, she could write out the plan to get ready. The new plan would cover all the issues she'd identified in her worry session, from finding a catsitter to writing a living will. She'd put completion dates in for each step and cross off the items as she did them until the day of the surgery. Then, each time she needed reassurance, the concrete evidence that she had a good plan would enable her to go on to some other thought or activity.
While these techniques aren't complicated or technically difficult to teach, they do require patience and determination from both therapist and client. For best results, they also demand clinical knowledge of how and why they work, and with what sorts of issues; they can't simply be used as all-purpose applications, good for anybody in any circumstance.
But the rewards of teaching people how to use these deceptively simple, undramatic, and ungimmicky methods are great. While clients in this culture have been indoctrinated to want and expect instantaneous relief from their discomfort at the pop of a pill, we can show them we have something better to offer. We can give people a lasting sense of their own power and competence by helping them learn to work actively with their own symptoms, to conquer anxiety through their own efforts--and do this in a nonmanipulative, respectful, engaging way. People like learning that they have some control over their feelings; it gives them more self-confidence to know they're not the slaves of physiological arousal or runaway mental patterns. And what we teach them is like playing the piano or riding a bicycle: they own it for life; it becomes a part of their human repertoire. What medication can make that claim?
Margaret Wehrenberg, Psy.D., has been in private practice as a psychologist and addictions counselor for more than 20 years. She also specializes in trauma and anxiety, working with adolescents and adults. She's the cofounder of the Reflex Delay Institute, and the author of Stress Solutions: Effective Strategies to Eliminate Your Stress. Contact: firstname.lastname@example.org. Letters to the Editor about this article may be e-mailed to email@example.com.