“A Person-Centered Approach to Diagnosis and Treatment”

Lukasz M. Konopka AM, PhD, ECNS, June 13 23, 2017

Spectrum Center for Integrative Neuroscience McHenry, IL Spectrumin.com

Financial disclosure

• I do not have any financial interest or relationship with the manufacturer of any commercial product(s) or service(s) discussed as part of my presentation

Objectives

• Identify various, subjective and objective tools for patient assessment

• Recognize the presented objective assessment tools and identify the clinical utility of these tools

• Identify patients who may benefit from the “brain to behavior approach”

• Describe how to use the “brain to behavior approach” when developing personalized treatments

• Person-centered medicine is dedicated to the promotion of health as a state of physical, mental, socio-cultural and spiritual wellbeing as well as to the reduction of disease, and founded on mutual respect for the dignity and responsibility of each individual person.

“In usual practice settings, 42% of patients who begin antidepressant treatment discontinue the medication within 30 days of treatment”

Warden D, Trivedi MH, Wisniewski SR, Davis L, Nierenberg M, Gaynes BN, et al. Predictors of attrition during initial (citalopram) treatment for depression: a STAR’D report. Am J Psychiatry 2007, 164: 1189-1197.

Evidence-Based Approach

Asking a question that can be answered

Finding the evidence

Clinically evaluating this evidence

Applying this evidence to clinical problem

Evaluating the outcome

Reevaluating the process

Paradigm Change

From the couch to the laboratory and clinic: Redefining the paradigm

Current Paradigm:

• The “trained professional” focuses on the clinical presentation. The Data are gathered.

• Based on soft guidelines, a formulation is made by matching the current clinical presentation and history to a soft standard such as the DSM. The diagnosis is given. The Hypothesis is generated

• Therapeutic intervention is initiated. The Experiment begins.

• Evaluation of treatment efficacy continues… Outcomes are evaluated measured?

What are the types of data?

Bio- the physical patient/client in its wholeness; includes the genetics, as well as central, peripheral, endocrine and metabolic systems. (measured with objective tools; based on the normal databases) Psycho- the construct focusing on behaviors that relies upon biological substrates. (measured by the interaction with the patient, based on the ability to develope a patient rapport , motivation, willingness, and ability) Social- the interaction of the patient/client with the environment in the contexts of interpersonal and intrapersonal relations (systems approach). (measured by observation and interaction with the patient) Spiritual- higher order functions (measured by observation and interaction with the patient)

BioPsychoSocialSpiritual (BPSS) Model

Intake

Psychological Developmental Family Systems

Psychiatric Symptoms

Neurobiological Genetics

Neuroimaging Neurobehavioral

Converging Data

Case Conceptualization

Converging Data

Objective Tools

• Genetic Mapping

Objective Tools

• Structural and functional imaging tools

Structural Neuroimaging

Modalities

• X-ray • Computed Axial Tomography (CT) • Magnetic Resonance Imaging

(MRI)

qMRI measuring hippocampus volume

Bremner, J. D., Randall, P., Vermetten, E., Staib, L., Bronen, R. A., Mazure, C., ... & Charney, D. S. (1997). Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse—a preliminary report. Biological psychiatry, 41(1), 23-32.

“Preliminary Evidence for Sensitive Periods in the Effect of Childhood Sexual Abuse on

Regional Brain Development”

J Neuropsychiatry Clin Neurosci. 2008 ; 20(3): 292–301

Based on 26 abused and 17 healthy women

Functional Neuro-imaging Modalities Readily available clinically

• Magnetoencephalography (MEG) • Quantitative electroencephalography (EEG) • Low resolution brain electromagnetic tomography (LORETA) • Evoked Potentials (EP) • Positron Emission Tomography (PET) • Single Photon Computed Tomography (SPECT) • Functional Magnetic Resonance Imaging (fMRI) • Magnetic Resonance Spectroscopy (MRS)

Auditory Evoked Potential Current Density projected on T1-MRI

Assessment that results in therapy

EEG 10-20 International System

EEG

Foreground Background

Cognitive Evoked Potentials P-300

• We present neutral auditory and visual stimuli to the patients.

• We evaluate the brain response to the frequent and infrequent stimuli

Auditory P-300

Visual P-300

Integrated Visual and Auditory Continuous Performance Task (IVA)

• IVA provides objective data about a person’s ability to concentrate and avoid making impulsive errors.

• Prudence- ability to inhibit impulsivity

• Consistency- accuracy of response times

• Stamina- maintain speed

• Vigilance- error of omission • Focus- response time variability • Speed- delay for correct

responses

Quantitative Assessment: Physiology and Behavior

qEEG depends on the statistical evaluation

Z-statistics

Functional Neuroimaging Modalities

• Quantitative electroencephalography (EEG) • Evoked Potentials (EP)

• Quantitative Positron Emission Tomography

(PET)

• Quantitative Single Photon Computed Tomography (SPECT)

Neurobehavioral Assesment

Neurobehavioral Assessment

• 1) Paper and pencil tests (RBANS) • 2) Computer administered test (CANTAB) • 3) Self report measures: a) Dissociation Scale;

b) Limbic Irritability Scale c) Sleep Quality Scale

• 4) Clinical interview that results in a narrative for potential emotional activation

• 5) Evaluation of EKG for heart rate variability (activation or hyper-supresion)

Repeatable Battery for the Assessment of Neuropsychological Status,

Form A (RBANS-A or B)

• RBANS is a brief measure of broad neuro-cognitive function, administered face-to-face with indices of:

• Immediate and Delayed Memory, • Attention, Language Performance • Visuospatial abilities. • (The data are compared to same-age peers)

Cambridge Neuropsychological Test Automated Battery (CANTAB):

• CANTAB was a comprehensive computerized battery measuring overall cognitive functioning across six indices:

• 1) Induction, • 2) Visual Memory, • 3) Executive Function, • 4) Attention, • 5) Semantic-Verbal Memory, • 6) Response Control and Decision-Making,

Behavioral Objective Measure Profile of Mood State (POMS):

• 30-item, self-report scale, 5-point scale

ranging from “not-at-all” to “extremely”.

• Affective states: Fatigue-Inertia, Anger-Hostility, Vigor-Activity, Confusion-Bewilderment, Depression-Rejection, and Tension-Anxiety

Dissociative Experiences Scale, 2nd Edition (DES-II):

• The DES is a brief self-report inventory rated on a percentile scale ranging from 0 to 100 summarizing the frequency of dissociative experiences.

McLean Hospital Limbic System Check List-33 Rating Scale (LSCL-33)

• The LSCL is a self-report, 33-item checklist, identifying symptoms related to somatic and sensory experiences and behavioral and memory functions. The scale measures symptoms including hallucinations, somatic disturbances, automatisms, and dissociative tendencies. The scores range from 0-99.

Pittsburgh Sleep Quality Index (PSQI):

• The PSQI is a self-rated questionnaire that assesses sleep quality and disturbances within the span of one month. This measure includes assessment of seven components of sleep including:

• 1) subjective sleep quality • 2) sleep latency • 3) sleep duration • 4) habitual sleep efficiency • 5) sleep disturbances • 6) use of sleep medication • 7) daytime dysfunction

Converging Data

Cases

In collaboration with: David Hamilton MD-Neuropsychiatry

Jesse Viner MD-Psychiatry Midwest Advanced Radiology Center Dr. Parvez Shirazi-Nuclear Medicine

Dr. Elizabeth M. Zimmerman- Psychology Christian J. Konopka PhD/MD Student

Betty Wolff, Art Therapist Kimberly Thurston, Art Therapy Intern

Integrated qEEG-PET and MRI Case-1

20-year-old female with complex psychiatric presentation including suicide attempts, childhood trauma. Frontal lobe seizures. Unable to complete sentences when emotionally activated.

qEEG Results Pre- and Post-Treatment Case 2

27-year-old male with a complex psychiatric history of isolation, social withdrawal, self injury, suicidal attempts.

Acute Oral Medication Challenge with 20mg Methylphenidate

and Emotional Activation

“Incidental Finding” Case 3

26-year-old woman with a significant history of soothing difficulties as a child, learning problems throughout her schooling, stimulant abuse, stimulant seeking. High level of anxiety and depression. OCD symptoms. Cognitive impairment CANTAB and RBANS. Legal problems.

Arts and Science

How studying the performing arts effects patients who are deaf.

Marlee Matlin: Marlee got her start with ICODA’s Children’s Theater at the age of seven. She went on to win the 1987 Best Actress Academy Award for her work as Sarah in Children of a Lesser God. Since then Marlee starred for two seasons on Reasonable Doubts was twice nominated for Emmy Wards for her guest appearances on NBC’s Seinfeld and CBS’s Picket Fences. Most recently Marlee has appeared on Desperate Housewives, Extreme Home Makeover, Home Edition, My Name is Earl, The L Word, Dancing With the Stars.

Thanks!