In this article Dr. Amen gives an overview of the most common brain problems and what to look for if you think that you, or someone you know, might have one.
I once had a phone call from a very close friend whom I hadn’t heard from in years. He sounded different. When we lived close together, he was energetic, positive, outgoing, funny and fascinated by the world around him. As I listened to him on the phone, however, his voice was flat and his thoughts were very negative. He told me his life had no meaning and he would much rather “see heaven” than struggle through any more days. My friend was sleeping a lot, had problems concentrating, and even lost interest in sex, which was a real change for him. He was suffering from a clinical depression. He was the last person in the world with whom I expected to be having that kind of conversation.
But, brain illnesses affecting emotion, behavior or learning are very common. A study sponsored by the National Institutes of Mental Health reported that 49% of the population will suffer from a mental illness (really brain illnesses) during some point in their life. Mood problems, anxiety disorders, alcohol or drug abuse and attention deficit disorders are the most common problems. Mental illnesses strike the rich and the poor, the successful and the not so successful. They devastate individuals and families, and they often go untreated because of the stigma our society attaches to them.
My friend had postponed calling me for over nine months. It was not until his wife threatened to divorce him that he called me. Many uninformed people have the erroneous idea that people with emotional illnesses are strange, scary or way out there. It is true that some people with mental illnesses have delusions or are violent, but the vast majority of people who suffer from anxiety, depression or drug use are more like you and me than they are different, but left untreated, these problems seriously undermine a person’s ability to be their best self.
Below is a brief synopsis of mood disorders, anxiety problems, substance abuse and attention deficit disorder. Whenever I evaluate a new patient I take a bio/psycho/social approach. That means I look at the biological, psychological and social causes that may be underlying the problem. In addition to the bio/psycho/social approach to diagnosis and treatment, the work at our clinics also subtypes brain illnesses based on scan findings. For example, we have seen seven different types of anxiety and depression and six different types of ADD. We work to target treatment to enhance the underlying brain systems that may be involved in the problem. See Healing Anxiety and Depression and Healing ADD for a full discussion of subtyping these illnesses.
Mood Disorders

• Depression

Janet, a 42 year old lawyer, wife and mother of three, was referred to me because she was tired all the time. Her family physician ruled out the physical causes of fatigue and thought she was overstressed. Additionally, she had trouble concentrating at work and experienced difficulty sleeping. Her sex drive was gone, her appetite was poor and she had no interest in doing things with her family. Janet would start to cry for no apparent reason and she even began to entertain desperate suicidal thoughts. Janet had a serious depressive illness.
Depression is a very common mental illness. Studies reveal that at any point in time, 3-6% of the population have a significant depression. Only 20-25% of these people ever seek help. This is unfortunate because depression is a very treatable problem.
The following is a list of symptoms commonly associated with depression:

• sad, blue or gloomy mood
• low energy, frequent fatigue
• lack of ability to feel pleasure in usually pleasurable activities
• irritability
• poor concentration, distractibility, poor memory
• suicidal thoughts, feelings of meaninglessness
• feelings of hopelessness, helplessness, guilt and worthlessness
• changes in sleep, either poor sleep with frequent awakenings or increased sleep
• changes in appetite, either marked decreased or increased
• social withdrawal
• low self-esteem

Here is an example of the bio/psycho/social approach to understanding depression.
There are several important biological factors to look for in depression:

• It’s important to look at the family history. We know there is often a genetic link to depression and it often runs in families where there has been alcohol abuse.
• It’s also important to evaluate patients from a medical point of view, as there are a number of illnesses that can cause depression. These include thyroid disease, infectious illnesses, cancer, and certain forms of anemia. A heart attack, stroke, or brain trauma can also leave a person vulnerable to depression.
• Periods of dramatic hormonal shifts (post-partum or menopausal) often precipitate problems with depression.
• Additionally, certain medications can cause depression. Most notable among these are birth control pills, certain blood pressure or cardiac medications, steroids, and chronic pain control medicines.
• In evaluating depression, it’s essential to take a good alcohol and drug abuse history. Chronic alcohol or marijuana use often causes depression, while amphetamine or cocaine withdrawal is often accompanied by serious suicidal thoughts.

The psychological factors to look for in depression include:

• major losses, such as the death of a loved one, break up of a romantic relationship, loss of a job, self-esteem, status, health or purpose.
• multiple childhood traumas, such as physical or sexual abuse.
• negative thinking that erodes self-esteem and drives mood down.
• learned helplessness, the belief that no matter what you do things won’t change. This comes from being exposed to environments where you are continually frustrated from reaching your goals.

The social factors or current life stresses to evaluate in depression include:

• marital problems,
• family dysfunction,
• financial difficulties and
• work-related problems.

In Janet’s case, her physical examination was normal, but her father had periods of depression and she had an uncle who killed himself. Psychologically, she had a very critical mother and subsequently she was extremely self-critical. Socially, her marriage had been difficult for the past several years and she was often fighting with her teenage son.
The best results in treating any emotional illness occur with a bio/psycho/social approach. Janet was placed on antidepressant medication and learned to be significantly less critical of herself. We also spent time working on her marriage and her relationship with her teenage son. In ten weeks she felt more energetic and was able to concentrate. Her mood was good. She slept well and her appetite returned. She also got along better at home with her husband and son.
Depression is a very treatable illness. Early detection and treatment from a bio/psycho/social perspective is important to a full and complete recovery. From a biological standpoint we think of medication or supplements and proper diet and exercise. Exercise has been found in some studies to be as effective as medication, but cheaper and with fewer side effects (most side effects of exercise are positive). Psychotherapy has also been found to be helpful in treating depression. The two best studied forms of psychotherapy for depression are cognitive therapy, which teaches patients to counteract the negative thoughts that invariably surface with depression, and interpersonal psychotherapy, which teaches patients to have more effective relationships.

• Bipolar Disorder

Another type of mood disorder is called bipolar disorder, where people cycle between two poles. There may be periods of depression that alternate with periods of high, manic, irritable or elated moods. Mania is categorized as a state distinct from one’s normal self, where he has greater energy, racing thoughts, more impulsivity, a decreased need for sleep, and a sense of grandiosity. It is often associated with periods of hypersexuality, hyperreligiosity, or spending sprees. Sometimes it is also associated with hallucinations or delusions. In treating the depressive part of the cycle, both pharmaceutical and supplement antidepressants have been known to stimulate manic episodes. It is important to vigorously treat this disorder, as it has been associated with marital problems, substance abuse, and suicide.
Here is a list of symptoms often associated with bipolar disorder:

• Periods of abnormally elevated, depressed, or anxious mood
• Periods of decreased need for sleep, feeling energetic on dramatically less sleep than usual
• Periods of grandiose notions, ideas or plans
• Periods of increased talking or pressured speech
• Periods of too many thoughts racing though the mind
• Periods of markedly increased energy
• Periods of poor judgment that leads to risk-taking behavior (separate from usual behavior)
• Periods of inappropriate social behavior
• Periods of irritability or aggression
• Periods of delusional or psychotic thinking

Bipolar is used to be called manic depressive illness and is thought to be the more classic form of this disorder. In recent years, a milder form of the disorder called Bipolar II has been described that is associated with depressive episodes and milder “hypomanic” issues.
The treatment for bipolar disorder, both I and II, is usually medication, such as lithium or anticonvulsants such as Depakote. In recent years there is literature to suggest that high doses of omega three fatty acids, found in fish or flax seed oil, can also be helpful.

• Anxiety Disorders

There are four common types of anxiety disorders that can affect people in a negative way: panic disorders, agoraphobia, obsessive compulsive disorders and post traumatic stress disorders. I’ll briefly discuss each of these and their treatments.
Panic Disorder
All of a sudden your heart starts to pound. You get this feeling of incredible dread. Your breathing rate goes faster. You start to sweat. Your muscles get tight, and your hands feel like ice. Your mind starts to race about every terrible thing that could possibly happen and you feel as though you’re going to lose your mind if you don’t get out of the current situation. You’ve just had a panic attack. Panic attacks are one of the most common brain disorders. It is estimated that 6-7% of adults will at some point in their lives suffer from recurrent panic attacks. They often begin in late adolescence or early adulthood but may spontaneously occur later in life. If a person has three attacks in a three week period doctors make a diagnosis of a panic disorder.
In a typical panic attack, a person has at least four of the following twelve symptoms: shortness of breath, heart pounding, chest pain, choking or smothering feelings, dizziness, tingling of hands or feet, feeling unreal, hot or cold flashes, sweating, faintness, trembling or shaking, and a fear of dying or going crazy. When the panic attacks first start many people end up in the emergency room because they think they’re having a heart attack. Some people even end up being admitted to the hospital.
Anticipation anxiety is one of the most difficult symptoms for a person who has a panic disorder. These people are often extremely skilled at predicting the worst in situations. In fact, it is often the anticipation of a bad event that brings on a panic attack. For example, you are in the grocery store and worry that you’re going to have an anxiety attack and pass out on the floor. Then, you predict, everyone in the store will look at you and laugh. Pretty quickly the symptoms begin. Sometimes a panic disorder can become so severe that a person begins to avoid almost any situation outside of their house – a condition called agoraphobia.
Panic attacks can occur for a variety of different reasons. Sometimes they are caused by medical illnesses, such as hyperthyroidism, which is why it’s always important to have a physical examination and screening blood work. Sometimes panic attacks can be brought on by excessive caffeine intake or alcohol withdrawal. Hormonal changes also seem to play a role. Panic attacks in women are seen more frequently at the end of their menstrual cycle, after having a baby, or during menopause. Traumatic events from the past that somehow get unconsciously triggered can also precipitate a series of attacks. Commonly, there is a family history of panic attacks, alcohol abuse or other mental illnesses.
On SPECT scans we often see hyperactivity in the basal ganglia, or sometimes temporal lobe problems. Psychotherapy is my preferred treatment for this disorder and in some studies has been shown to calm basal ganglia activity. Sometimes supplements or medications can also be helpful. Unfortunately the most helpful medications are also addictive, so care is needed.
Agoraphobia
The name agoraphobia comes from a Greek word that means “fear of the marketplace.” In behavioral terms it means the fear of being alone in public places. The underlying worry is that the person will lose control or become incapacitated and no one will be there to help. People afflicted with this phobia begin to avoid being in crowds, in stores, or on busy streets. They’re often afraid of being in tunnels, on bridges, in elevators, or on public transportation. They usually insist that a family member or a friend accompany them when they leave home. If the fear establishes a foothold in the person, it may affect his or her whole life. Normal activities become increasingly restricted as the fears or avoidance behaviors dominate their life.
Agoraphobic symptoms often begin in the late teen years or early twenties, but I’ve seen them start when a person is in their fifties or sixties. Often, without knowing what is wrong, people will try to medicate themselves with excessive amounts of alcohol or drugs. This illness occurs more frequently in women and many who have it experienced significant separation anxiety as children. Additionally, there may be a history of excessive anxiety, panic attacks, depression, or alcohol abuse in relatives.
Agoraphobia often evolves out of panic attacks that seem to occur “out of the blue,” for no apparent reason. These attacks are so frightening that the person begins to avoid any situation that may be in any way associated with the fear. I think these initial panic attacks are often triggered by unconscious events or anxieties from the past. For example, I once treated a patient who had been raped as a teenager in a park late at night. When she was 28, she had her first panic attack while walking late at night in a park with her husband. It was the park setting late at night that she associated with the fear of being raped and which triggered the panic attack. Agoraphobia is a very frightening illness to the patient and his or her family. With effective, early intervention, however, there is significant hope for recovery. The scan findings and treatment are similar to those for people with panic disorder. The one difference is that people with agoraphobia often have increased anterior cingulate gyrus activity and get stuck in their fear of having more panic attacks. Getting stuck in the fear often prevents them from leaving home. Using medications, such as Prozac and Lexapro, or supplements, such as 5-HTP and St. John’s Wort, to increase serotonin and calm this part of the brain is often helpful.
Obsessive Compulsive Disorder
The hallmarks of obsessive compulsive disorder (OCD) are recurrent thoughts that seem outside a person’s control, or compulsive behaviors that a person knows make no sense but he feels compelled to do anyway. The obsessive thoughts may involve violence (such as killing one’s child), contamination (such as becoming infected by shaking hands), or doubt (such as the worry of having hurt someone in a traffic accident, even though no such accident occurred). Many efforts are made to suppress or resist these thoughts, but the more a person tries to control them, the more powerful they can become.
The most common compulsions involve hand-washing, counting, checking, and touching. These behaviors are often performed according to certain rules in a very strict or rigid manner. For example, a person with a counting compulsion may feel the need to count every crack on the pavement on their way to work or school. What would be a 5 minute walk for most people could turn into a 3 or 4 hour trip for the person with OCD. They have an urgent sense of “I have to do it” inside. A part of the individual generally recognizes the senselessness of the behavior and doesn’t get pleasure from carrying it out, although doing it often provides a release of tension.
Over the years, I’ve treated many people with OCD, the youngest of whom was 5 years old. He had a checking compulsion and had to check the house locks at night as many as 20 – 30 times before he could fall asleep. The oldest person I treated with this disorder was 83. She had obsessive, sexual thoughts that made her feel dirty inside. It got to the point where she would lock all her doors, draw all the window shades, turn off the lights, take the phone off the hook and sit in the middle of a dark room trying to catch the abhorrent sexual thoughts as they came into her mind.
On SPECT studies we often see excessive activity in the basal ganglia and anterior cingulate gyrus. Behavior therapy can be helpful and has been shown to improve brain function. Using medications, such as Prozac and Lexapro, or supplements, such as 5-HTP and St. John’s Wort, to increase serotonin and calm these parts of the brain is often helpful.
Post Traumatic Stress Disorder
Joanne, a 34 year old travel agent, was held up in her office at gun point by two men. Four or five times during the robbery, one of the men held a gun to her head and said he was going to kill her. She graphically imagined her brain being splattered with blood against the wall. Near the end of this 15 minute ordeal they made her take off all her clothes. She pictured herself being brutally raped by them. They left without touching her, but locked her in a closet.
Since that time her life had been thrown into turmoil. She felt tense, and was plagued with flashbacks and nightmares of the robbery. Her stomach was in knots and she had a constant headache. Whenever she went out she felt panicky. She was frustrated that she could not calm her body: her heart raced, she was short of breath and her hands were constantly cold and sweaty. She hated how she felt and she was angry about how her nice life had turned into a nightmare. What was most upsetting to her were the ways that the robbery affected her marriage and her child. Her baby picked up the tension and was very fussy. Every time she tried to make love with her husband, she began to cry and get images of the men raping her.
Joanne had posttraumatic stress disorder (PTSD), a brain reaction to severe traumatic events such as a robbery, rape, car accident, earthquake, tornado, or even a volcanic eruption. Her symptoms are classic for PTSD, especially the flashbacks and nightmares of the event.
Perhaps the worst symptoms, however, come from the horrible thoughts about what never happened, such as seeing her brain splattered against the wall and being raped. These thoughts were registered in her subconscious as fact, and until she entered treatment she was not able to recognize how much damage they had been doing to her. For example, when she imagined that she was being raped, a part of her began to believe that she actually was raped. The first time she had her period after the robbery she began to cry because she was relieved she was not pregnant by robbers, even though they never touched her. A part of her even believed she was dead because she had so vividly pictured her own death. A significant portion of her treatment was geared to counteract these erroneous subconscious conclusions.
Without treatment, PTSD can literally ruin a person’s life. The most effective treatment is usually psychotherapy. One type of psychotherapy that I think works especially well for PTSD is called eye movement desensitization and reprocessing or EMDR. You can learn more about this technique in my book Healing Anxiety and Depression or visiting www.emdria.org. Depending on the severity of PTSD, certain types of medications and supplements can also be helpful.

• Drug And Alcohol Abuse

Many people use alcohol or drugs to medicate underlying brain systems that are misfiring. Downers, such as alcohol, marijuana, sedatives and pain killers, are used to calm hyperactive brain systems; while uppers, such as cocaine and methamphetamine, are used to stimulate underactive areas of the brain. The problem is that most of these substances are addictive and cause brain damage. Sometimes the damage is permanent. In addition, substance abuse has a serious negative impact on relationships, work, and health. In relationships, many people complain that their partner who is abusing these substances is emotional, erratic, selfish and unpredictable. Alcohol and drug abuse are common causes of relationship break ups. The list of health problems from alcohol and drugs fill volumes of books. The most common work place problems include erratic job performance, absenteeism, tardiness, work accidents, and decreased job performance. Denial is frequently strong in substance abusers. The person with the problem is usually the last one to recognize that a problem is present. Alcohol and drug-related problems are similar in many ways. I have chosen to lump these two groups together for simplicity.
Note: Alcohol means any beverage or medication that contains any alcohol – from beer to wine to hard liquor, or even some cough preparations; drugs mean any mind-altering substances that produce stimulant, depressant, or euphoric effects – amphetamines, barbiturates, marijuana, cocaine, heroin, PCP, and so on.
Go through the following list of symptoms of excessive alcohol or drug use and check off those that apply to you. This will give you an idea if this area is a problem for you or someone you know.

• Increasing consumption of alcohol or drugs, whether on a regular or sporadic basis, with frequent and perhaps unintended episodes of intoxication.
• Use of drugs or alcohol as a means of handling problems.
• Obvious preoccupation with alcohol or drugs and the expressed need to have them.
• Gulping of drinks or using large quantities of drugs.
• The need for increasing quantities of alcohol or the drug to obtain the same “buzz.”
• Tendency toward making alibis and weak excuses for drinking or drug use.
• Needing to have others cover for you, either at work or at home.
• Refusal to concede what is obviously excessive consumption and expressing annoyance when the subject is mentioned.
• Frequent absenteeism from the job, especially if occurring in a pattern, such as following weekends and holidays (Monday morning “flu”).
• Repeated changes in jobs, particularly if to successively lower levels, or employment in a capacity beneath ability, education, and background.
• Shabby appearance, poor hygiene, and behavior and social adjustment inconsistent with previous levels or expectations.
• Persistent vague body complaints without apparent cause, particularly those of trouble sleeping, abdominal problems, headaches, or loss of appetite.
• Multiple contacts with the health care system.
• Persistent marital problems, perhaps multiple marriages.
• History of arrests for intoxicated driving or disorderly conduct.
• Unusual anxiety or obvious moodiness.
• Withdrawal symptoms on stopping (tremors, feeling extremely anxious, craving drugs or alcohol, vomiting, etc.); an alcoholic or drug abuser has usually tried to stop many times but was unable to withstand the symptoms of withdrawal.
• Hearing voices or seeing things that aren’t there is not uncommon.
• Blackouts (times you cannot remember).
• Memory impairment.
• Drinking or using drugs alone; early morning use; secretive use.
• DENIAL in the face of an obvious problem.

My favorite definition of an alcoholic or drug addict is anyone who has gotten into trouble (legal, relational, or work-related) while drinking or using drugs, then continues to use them. They did not learn from the previous experience. A rational person would realize that he or she has trouble handling the alcohol or drugs and stay away from them. Unfortunately, many people with these problems have to experience repeated failures because of the substance use, and thus hit “rock bottom” before treatment is sought.
There has been a very helpful trend in medicine over the last ten years to classify alcoholism and excessive drug use as illnesses, instead of morally weak behavior. The American Medical Association, the World Health Organization, and many other professional groups regard these as specific disease entities.
Untreated, these diseases progress to serious physical complications that often lead to death. Here are some important facts you need to know about alcohol and drug abuse:

• These addictions often run in families. The more relatives a person has who are alcoholics or addicts, the more likely they are or will become dependent on these chemicals. As a rule of thumb: one parent = 25% chance; two parents or one parent and one sibling = 50% chance; three or more family members = 75%+ chance.
• Alcoholism or drug addiction shortens life expectancy by an estimated ten to fifteen years.
• Alcoholism and drug addictions occur in about fifteen million Americans. If this problem applies to you, you are not alone.
• There is no typical person with alcoholism or drug addictions. These diseases affect people in all socio-economic classes.
• Drunken driving or driving under the influence of drugs is responsible for well over fifty percent of the highway traffic fatalities.
• Alcoholism and drug addictions are treatable. Treatment for alcohol or drug abusers and their families is widely available today in all parts of the country.

In treating substance abuse, it is important to recognize and treat any underlying cause of the problem, such as unrecognized depression, bipolar disorder, anxiety disorders or ADD. New medications have been developed that have been found helpful in alleviating withdrawal symptoms and decreasing cravings for the substances. Psychotherapy and support groups are often helpful.

• Attention Deficit Disorder

Do you often feel restless? Have trouble concentrating? Have trouble with impulsiveness, either doing or saying things you wish you hadn’t? Do you fail to finish many projects you start? Are you easily bored or quick to anger? If the answer to most of these questions is yes, you might have attention deficit disorder (ADD).
ADD is the most common brain problem in children, affecting 5-10% of them in the U.S., and one of the most common problems in adults. The main symptoms of ADD are a short attention span, distractibility, disorganization, procrastination, and poor internal supervision. It is often, but not always, associated with impulsive behavior and hyperactivity or restlessness. Until recently, most people thought that children outgrew this disorder during their teenage years. For many, this is false. While it is true that the hyperactivity lessens over time, the other symptoms of impulsivity, distractibility and a short attention span remain for most sufferers into adulthood.
Current research shows that 60-80% of ADD children never fully outgrow this disorder. Over the years I have seen thousands of children who had attention deficit disorder. When I meet with their parents and take a good family history, I find that there is a about an 80% chance that at least one of the parents also had symptoms of ADD as a child and may, in fact, still be showing symptoms as an adult. Many of the parents were never diagnosed. Not infrequently I learn of ADD in adults when parents tell me that they have tried their child’s medication (not something I recommend) and that they found it very helpful. They report it helped them concentrate for longer periods of time, they became more organized, and were less impulsive.
Common symptoms of the adult form of ADD include: poor organization and planning, procrastination, trouble listening carefully to directions, and excessive traffic violations. Additionally, people with adult ADD are often late for appointments, frequently misplace things, may be quick to anger, and have poor follow through. There may also be frequent, impulsive job changes and poor financial management. Substance abuse, especially alcohol or amphetamines and cocaine, and low self-esteem are also common.
Many people do not recognize the seriousness of this disorder and just pass these kids and adults off lazy, defiant, or willful. Yet, ADD is a serious disorder. Left untreated, it affects a person’s self-esteem, social relationships, and ability to learn and work. Several studies have shown that ADD children use twice as many medical services as non-ADD kids, up to 35% of untreated ADD teens never finish high school, 52% of untreated adults abuse substances, teens and adults with ADD have more traffic accidents, and adults with ADD move four times more than others.
Many adults tell me that when they were children they were in trouble all the time and had a real sense that there was something very different about them. Even though many of the adults I treat with ADD are very bright, they are frequently frustrated by not living up to their potential.
From our research with SPECT scans, it is clear that ADD is a brain disorder, but not one simple disorder. I have described six different types of ADD. The most common feature of ADD is decreased activity in the prefrontal cortex with a concentration task. This means that the harder a person tries, the less brain activity they have to work with. Many people with ADD self medicate with stimulants, such as caffeine, nicotine, cocaine or methamphetamine, to increase activity in the PFC. They also tend to self medicate with conflict seeking behavior. If they can get someone upset, it helps to stimulate their brain. Of course, they have no idea they do this behavior. I call it unconscious, brain driven behavior. But, if you are around ADD people long enough, you will see and feel the conflict seeking behavior.
The best treatment for ADD depends on the type of ADD a person has. See my book Healing ADD for a complete description of types and treatments. In general, intense exercise helps, as does a higher protein, lower carbohydrate diet. Sometimes medications or supplements are helpful, but sometimes they can make things worse if they are not right. When correctly targeted, ADD is a highly treatable disorder in both children and adults.