CHAPTER 8 - IMAGES OF BIPOLAR DISORDER AND SCHIZOPHRENIA
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Bipolar disorder has been characterized by increased activity across the cerebral cortex.
Clinically, during the manic phase the scans often look hyperactive, especially in the
lateral frontal cortex, lateral parietal lobes and lateral temporal lobes, focal increased
uptake in the limbic system has also been noted. Differentiating the initial onset of
bipolar disorder from schizophrenia is often a difficult task in an acutely psychotic
individual. In schizophrenia SPECT findings have frequently reported decreased activity,
especially in the prefrontal cortex. SPECT studies may provide helpful information in the
differential diagnoses of these disorders. In addition, SPECT can provide useful
information to patients to significantly improve compliance in disorders where compliance
is a frequent serious problem. Here are several examples.
Bipolar Disorder
Sarah was fifty-three years old when she was admitted to the hospital under my care. Just
the month before her family had her committed to another psychiatric hospital for
delusional thinking and bizarre behavior -- she had actually ripped out all the electrical
wiring in her home because she heard voices coming from the walls. In addition to the
above symptoms, she was barely getting any sleep, her thoughts raced wildly, and she was
irritable. In the previous hospital her doctor had diagnosed her with manic-depressive
disorder (a cyclical mood disorder). He had placed her on lithium (an anti-manic
medication) and an anti-anxiety medication. After responding well, she was sent home. But
Sarah, like Leigh Anne, did not want to believe that anything was wrong with her and she
stopped taking both medications. Her position was actually fortified by some members of
her family who openly told her she didn't need pills, that doctors only prescribe them
to force patients into numerous follow-up visits. Yet their advice was ill advised, for
within weeks of stopping the treatment, Sarah's bizarre behavior returned. This was
when her family brought her to the hospital where I worked. When I first saw Sarah, she
was extremely paranoid. Believing that everyone was trying to hurt her, she was always
looking for ways to escape the hospital. Again her thoughts were delusional, she believed
she had special powers and that others were trying to take them from her. At times, she
also appeared very "spacey." In an attempt to understand what was going on with
her for myself, and to convince her that her problems were biological, I ordered a SPECT
study.
Carrying this out did not prove easy. Our clinic tried to scan her on three separate
occasions. The first two times she ripped out the intravenous line saying we were trying
to poison her. The third time was a success because her sister went with her and calmed
her down by talking her through the experience. While the study revealed an overall
increase in activity in the deep limbic system, I found more intensity on the left side of
her scan (focal increased deep limbic uptake) and a marked patchy uptake across the
cortex. In other words, some areas showed increased activity and some showed decreased. My
experience told me that cyclic mood disorders often correlate with focal areas of
increased activity in the deep limbic system specifically as well as a patchy uptake
across the surface of the brain in general.
For Sarah's family, this was powerful evidence that her problems were biological, so
that when she still refused medication, they were now willing to encourage her to go back
on it. After she took their advice, her behavior normalized again and once I knew she was
feeling better, more in control, I showed her the brain studies. Through a better
understanding of the problem she was able to agree to follow-up visits and to stay on her
medication until both she and I concurred that she could stop.
Sometimes I'll rescan a patient several months after the first time to see what
difference the medication has made on the physiology of his or her brain. Although
Sarah's new study showed a vast improvement from her earlier one, I still noticed an
area of increased activity in the left temporal lobe, and Sarah was still complaining of
symptoms of spaciness. I changed her medication to Depakote, which is primarily used as an
anti-seizure medication, but has also been used for manic-depressive disorder. Not only
did her psychotic symptoms remain in remission but the spaciness disappeared as well. Five
years later only a small dose of Depakote has given Sarah a normal life.
top-down active view
note patchy uptake throughout the cortex
Sarah's case illustrates one of the most clinically significant problems in people
diagnosed with manic-depressive illness. This disorder is usually quite responsive to
medication. The problem is that when people afflicted by the disorder improve, they feel
so normal they do not believe they ever had a chronic problem to begin with. It is
difficult for people to accept that they have to keep taking medication when they think
they no longer have a problem. Yet, as we have seen, prematurely stopping medication
actually increases their chances for relapse. Through the use of these brain studies I
have been able to decrease the relapse rate of my patients by demonstrating graphically
the biological nature of their disorders and the need to treat them as such. It has been a
great asset to me in getting patients to cooperate in their own healing process. In
addition to that, it has helped me with one other important thing: convince patient's
to stop blaming themselves for their symptoms. Here are two more sets of images of Bipolar
patients taken during the manic phase of the illness.
Ryan was a 20-year-old male who presented with symptoms of grandiosity, racing thoughts,
decreased sleep, irritability and agitation. His parents reported there was a family
history of Bipolar Disorder in his grandfather.
Carrie was a second year college student when she first began having problems. She would
go days without sleeping. She began having trouble concentrating in school and stopped
going to classes. She started having sexual relationships with 4 different men and she
spent all of the money she had for the school year in three months. When her parents
discovered the problems they brought her in for evaluation. Carrie did not feel that
anything was wrong. She felt that she had just made several poor decisions, like anyone
her age. Her parents felt things were not the same. She had always been a thoughtful,
responsible person prior to the last several months. A scan was ordered to help evaluate
the clinical situation. It revealed marked patchy uptake throughout the cortex. Lithium
was very helpful for Carrie and she was able to return to school the next semester.
3D top-down active view
patchy increased uptake across the cortical surface
Schizophrenia
A 35-year-old man who had been living on the street was brought for evaluation by his
mother. He had previously been diagnosed on many occassions with paranoid schizophrenia,
but refused medication. His SPECT study revealed marked overall decreased activity
throughout the cerebral cortex. Being able to see his own brain activity, represented by
the 3D surface SPECT study, was helpful for him. He agreed to take his medication under
his mother's supervision. One month later, after significant clinical improvement on 4
mg of risperidone a repeat SPECT study was performed which showed improved overall
cerebral perfusion. Being able to see the before and after SPECT studies side by side on
the imaging computer monitor again was very encouraging to the patient and helped
significantly with compliance.
Paranoid Schizophrenia, before and after treatment with risperidone
(top-down and underside surface views)
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Before Treatment
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After Treatment
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marked decreased activity
throughout the cerebral cortex
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marked overall improvement
throughout the cerebral cortex
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SPECT BRAIN SCAN IMAGES
SPECT Images of Human Behavior - Table of Contents
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