Catching up on my continued medical education, an article in the February 2018 American Journal of Psychiatry stimulated interest. It is entitled “The Neurodevelopmental Basis of Early Childhood Behavior: Irritable and Callous Phenotypes as Exemplars.”
Authored by Lauren Wakschlag, Ph.D. and colleagues, the article identifies that “disruptive behavior… is one of the earliest-onset psychopathologies…that is expressed in some manner before age 5.” The authors cite Herbert Jasper’s article entitled “Electroencephalographic Analyses of Behavior Problem Children”. The article emphasizes that EEG shows brain abnormalities in children with “childhood behavioral disorders.”
There is also published baseline, unmedicated EEG and QEEG data in patients across diverse psychiatric syndromes.A persistent baseline EEG abnormality makes the case for neuropathology, not psychopathology. Averring a psychiatric illness without adequate physical data on each patient violates the medical model and perpetuates semantic confusion caused by the misuse of words. Why does the psychiatric establishment continue to avoid this epistemological truth?
After all, Herbert Jasper’s article, “Electroencephalographic Analysis of Behavior Problem Children” was published by the American Journal of Psychiatry in November 1938.
Response to “Will Neuroimaging Produce a Clinical Tool for Psychiatry?”
To: Satrajit S. Ghosh PhD. ,Justin T. Baker MD, PhD.
I read your scholarly article, “Will Neuroimaging Produce a Clinical Tool for Psychiatry?” in the May 2019 issue of Psychiatric Annals. Since 1986, I have evolved and utilize a comprehensive medical approach, using individual mental status, cognitive performance and any variant physical findings as well as their baseline EEG and QEEG data in the diagnosis and treatment of patients across the spectrum of psychiatric and substance abuse syndromes. The goal of treatment is homeostasis.
Below are pertinent citations regarding my work:
- Emory H, Mizrahi N. Glycaemic control by monoamine oxidase inhibition in a patient with type 1 diabetes; Diabetes and Vascular Disease Research 2017,Vol. 14(2) 163-1652.
- Emory H, Mizrahi N. Monoamine Oxidase Inhibition in a Patient with Type I Diabetes &Depression; J Diabetes Sci Technol. 1-2, Mar 8, 2016
- Emory H, Wells C and Mizrahi N. Quantitative EEG and Current Source Density Analysis of Combined Anti-epileptic Drugs and Dopaminergic Agents in Genetic Epilepsy: Two Case Studies. Clinical EEG and Neuroscience1-7; published online Oct. 17, 2014.
- Suffin, SC and Emory, WH, Schiller, MJ and Kling, A. A QEEG Database Method for Predicting Pharmacotherapeutic Outcome in Refractory Major Depressive Disorder. Journal of American Physicians and Surgeons. 2007; 12(4).
- Suffin, SC and Emory WH, Schiller, MJ and Kling A. QEEG Database Method for Predicting Pharmacotherapeutic Outcome in Refractory Major Depressive Disorder. J of American Physicians and Surgeons. 2007; 12(4).
- Suffin, SC and Emory, WH. Neurometric Subgroups in Attentional and Affective Disorders and Their Associations with Pharmacotherapeutic Outcome. J of Clinical EEG 1995; 26:76-83.
- Contribution: Use of Referenced –EEG (rEEG) in assisting medication selection for the treatment of depression. DeBattista C, et.al., Journal of Psychiatric Research. 45 (2011) 64-75.
If you have any interest in my EEG/QEEG based approach, I will be pleased to dialogue with you.
Hamlin Emory MD
Science Daily Blog Response by W. Hamlin Emory, MD:
National trial: EEG brain tests help patients overcome depression
Date of Article: May 15, 2018
Source: UT Southwestern Medical Center
Summary: “A new study found that measuring electrical activity in the brain can help predict a patient’s response to an antidepressant.”
Response: Dr. Trivedi points out in this article that EEG may be helpful in identifying patients who are not likely to respond to one of the selective serotonin reuptake inhibitors (SSRI’s), the current recommended initial medical treatment that most doctors prescribe for patients with a depressive syndrome.
Recently, Dr. Trivedi has embarked on a 10-year study to identify individual EEG/QEEG measures in persons with mood disorders. The goal is to introduce objectivity in psychiatric prescribing by identifying patients who are unlikely to improve with an SSRI, the customary psychiatric approach.
EEG/QEEG medication response studies in patients across a range of psychiatric syndromes appeared in 1995. The first paper was “Neurometric Subgroups in Attentional and Affective Disorders and Their Association with Pharmacotherapeutic Outcome.” Since then, this neurophysiologic approach was validated and published by five US medical centers in 2010. The article is entitled “The use of referenced-EEG (rEEG) in assisting medication selection for the treatment of depression.”
As a psychiatrist with over twenty-five years’ experience using this approach, I agree that a comprehensive medical approach and baseline EEG/QEEG data reduces trial-and-error medical prescribing and patient suffering. A comprehensive physical exam and application of individual EEG/QEEG measures provides a way that medical doctors can learn from experience and improve individual patient outcomes.
Hamlin Emory MD
Science Daily Blog Response by W. Hamlin Emory, MD:
Psychiatric diagnosis ‘scientifically meaningless’
Date of Article: July 8, 2019
Source: University of Liverpool
Summary: “A new study has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders.”
Response: Today, there is confusion about medical diagnosis in psychiatric practice. A medical diagnosis requires identification of a physical or physiologic variance of such magnitude or duration that a medical treatment is justified. The University of Liverpool authors – through their research – point out that psychiatric labels use different decision-making rules, and “clinical diagnoses “tell us little about individual patients and what treatment they need. The explanation for this predicament is semantic confusion that is perpetuated by the misuse of words.
Psychiatric disorders as currently specified ignore the mixed and multiple neurophysiologic differences that occur in patients across the broad spectrum of mental and substance abuse disorders.
In fact, “clinical diagnoses” in psychiatry violate the medical model and are only a behavioral sorting system. Psychiatrists who only employ the DSM’s behavioral sorting system are not making medical diagnoses.
The medical model requires individual physical measures, so it follows that patients with mental disorders and/or substance abuse warrant a procedure to identify the presence of variant neurophysiology that may be causing distress.
There is a growing body of research that shows how visual EEG and quantitative EEG (QEEG) is employed to subtype patients by their neurophysiologic differences and – if indicated – guide the selection of a neuroactive medical regimen to improve individual brain activity. The goal of this treatment is homeostasis.
The authors of this University of Liverpool research study are correct, in not only pointing out the flaws in psychiatric categories, but also in the additional omission of individual brain imaging by EEG/QEEG which happens to be the best technology for studying brain function as it’s the only current technology that works at the speed at which the brain works.
As Professor John Reed, University of East London said in the article, “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or what kind of help we need when distressed.” I couldn’t agree more with this statement, and EEG/QEEG is the least invasive, most inexpensive and accurate marker of whether a patient may benefit from a neuro-active medication and its type.
I am alarmed by the increasing number of ads that specifically target persons with a mental disorder and/or chemical dependency. This tragedy in clinical medicine has put “…the cart before the horse.”
A person’s behavior is not a medical diagnosis. It is merely a description. What is needed is a comprehensive assessment of each person’s automatic brain and bodily physiology.
Basic neuroscience has shown that most of the brain’s energy is expended by a person’s unconscious, automatic circuits. These are the circuits that should be monitored and measured in each patient before a treatment can be logically – and individually – reasoned.
Psychiatric and chemical dependency treatment violate the rule: “Physiological measurement before physiologic treatment.”
Hamlin Emory MD
Are any psychiatrists or other medical doctors interested in learning how to assess, measure and improve each patient’s neurophysiology?
Before I send any patient for psychotherapy, I am ethically obligated to rule out any inherited variance that may be causing a person’s distress. My method of assessing psychiatric or substance abuse issues is to review the physical systems (ROS), do a physical exam that includes resting state vital signs and a cognitive exam, and then monitor any physiologic variance to assure its validity.
Then, I conduct a baseline, unmedicated visual EEG and quantitative EEG (QEEG) to compare each patient’s numerical QEEG data – about a thousand numbers – with age-average, asymptomatic norms. Any variance is an objective evidence of neuropathology, which should be improved or resolved before committing a person to psycho-analytic treatment.
Rather than using psychological concepts, a medical treatment should be physiologically reasoned. Sorting patients by their baseline, unmedicated EEG/QEEG data is currently the only way a doctor can accurately prescribe medication. This process is analogical reasoning, the primary technique used in clinical medicine.
One would think that medical schools and medical associations worldwide would want to adopt and teach such an individualized, non-invasive scientific approach to treating inherited neurophysiologic variations.
Hamlin Emory MD
To the Editor of the New Yorker and Rachel Aviv
Thank you for your well-written piece The Challenge of Going off Psychiatric Drugs in the April 1, 2019 New Yorker. Your depiction of what is still considered best practice in psychiatry – an approach to brain changing medications based on subjective symptoms and DSM classification – is in effect a best guess. Evidence that psychiatric prescribing is guessing was published in JAMA, September 7, 2014. Entitled “Emergency Department Visits by Adults for Psychiatric Medication Adverse Events,” more than 89,000 such events were recorded annually in U.S. emergency rooms between 2009 and 2011.
We view Ms. Laura Delano through two lenses. While she became a victim off the multiple medications she was prescribed, she also demonstrated that she is heroic. Her voice and experience are evidence that people seeking care are unwittingly victimized by a profession that takes an oath to do no harm yet violates medical epistemology.
Inherited chemical-electric measures of brain activity are generally ignored, not only in psychiatry, but across medical specialties. The brain is primarily a homeostatic organ and easily changes when a particular naturopathic or allopathic agent exerts a salutary effect; in fact, basic neuroscience has shown a majority of brain metabolism is devoted to these automatic circuits. They keep us alive and adapting to changing circumstances 24/7. Consider that you are obligated to sit or stand for a long duration of time with no or minimal movement – in a theater, at a lecture, for a family photograph with perpetually moving grandchildren or waiting in a long line. You will eventually sense an increasing visceral need to shift your position, yet you don’t allow yourself to move. That is what it’s like to have a brain-based variance in the automatic circuits!
We use comprehensive data from each patient to treat, or rather to optimize their brain and bodily physiology. We collect a patient’s vital signs and apply individual EEG data in clinical practice. Our clinical experience has taught us that persons with a brain-based mental disorder are trying to achieve relief from an abnormal neurobiology. Persistent substance abuse, bingeing, purging, restricting food, obsessions, compulsions, self-mutilation, suicide and/or violence, etc. are behaviors that change neurophysiology and provide transitory relief. Although such stigmatizing behaviors seem maladaptive, they are adaptive attempts that fail. With an EEG/QEEG guided, patient centered approach and homeostatic treatment, most patients can achieve and maintain physical health and mental wellbeing.
As with Ms. Delano, humanity deserves medical care that is up to date, based on objective data and surpasses a best guess approach.
Hamlin Emory, MD Mark Shatsky, DO