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The Applications of Brain Imaging to the Diagnosis and Treatment of Mental Illnesses
Ellen E. Harrell
Glen Allen High School
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Introduction
Brain imaging as a tool to diagnose and treat mental illness has become exceedingly
controversial. While psychiatrists in the later twentieth century expected to be able to fully rely
on imaging to address mental illness by now, today’s diagnosis and treatment process largely
still relies on the methods of the past. The current diagnosis process for mental illness is based
off of patients’ answers to subjective diagnostic questions. The criteria for diagnosing mental
disorders, like depression, are loose. Such criteria lead to an over-diagnosis of some disorders
and an under-diagnosis of others, like unipolar depression and bipolar disorder respectively.
When mental disorders are misdiagnosed, patients are mistreated. The treatment plan for
someone with one disorder, like depression, is much different than for someone with another
disorder, like bipolar disorder. This places immense an immense amount of importance on
having a correct diagnosis in the first place. The idea behind brain imaging as a diagnostic tool
for mental illness is that if researchers can identify specific brain features unique to different
mental disorders that are absent in the general population, society could more accurately treat
patients.
diagnosis process. The theory behind it is that imaging would enable a clear-cut diagnosis: one
based off of brain abnormalities rather than clusters of symptoms. It was expected that brain
imaging technology would have enabled faster diagnoses by present times. However, in 2005,
researchers had not come to a consensus about a tool that could be used for mental illness
evaluations (Carey, 2005). By this point, nearly three decades had already passed; the 1990’s had
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been dubbed the “Decade of the Brain” by scientists who hoped brain scans would “turn on the
lights in what had been a locked black box” (Carey, 2005). In the year 2005, nearly 500 imaging
studies were being published each year (Carey, 2005). Yet, the more imaging studies that were
conducted, the more obstacles were also discovered. Initially, it was thought that schizophrenia
could be identified by a loss of brain volume; studies demonstrated that those with schizophrenia
can “lose 5 to 10 percent of overall brain volume” over ten years (Carey, 2005). At the same
time, though, brain volume varies from person to person by “at least ten percent “(Carey, 2005).
Findings such as this one threaten the prospects of brain imaging as a diagnostic tool; there is
difficulty in distinguishing regular brain abnormalities from those that cause mental illness.
Other analyses and studies have supported this skepticism. While there are high hopes for
neuroimaging in mental illness diagnoses, there are problems associated with imaging itself that
make the process more difficult. In the meta-analysis “Addressing Reverse Interference in
Disorders,” different regions of the brain were mapped in 537 fMRI studies (Sprooten et al.,
2017). These studies were of patients with a wide variety of disorders: “schizophrenia, bipolar
disorder, major depressive disorder, anxiety disorders, and obsessive compulsive disorder
(Sprooten et al., 2017). After looking at 21,427 patients, they found different regions of the brain
and their levels of activation to be associated with different mental disorders (Sprooten et al.,
2017). This finding does support using brain imaging to study mental disorders. However, they
also emphasized that different types of studies, such as region-of-interest studies (ROI studies),
resulted in “the over-representation of the amygdala and the caudate nucleus,” which did not
occur in “whole-brain studies” (Sprooten, et al.). In these whole-brain studies, the thalamus and
parahippocampal gyrus have been thought to be involved with mental illness, yet the widespread
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attribution of mental illness to the amygdala has stifled the research of these regions (Sprooten et
al., 2017). This finding signifies that mental illness research needs to analyze more than just
particular biomarkers in the brain; it must analyze the whole, not just the sum of its parts.
Even though imaging might not be quite there yet, our current diagnostic process for
mental illness is arguably worse. Although the manual does get updated, the different versions of
the Diagnostic and Statistical Manual of Mental Disorders have proven themselves problematic.
bipolar disorder as depression. In Dr. Tanvir Singh and Dr. Muhammed Rajput’s publication
“Misdiagnosis of Bipolar Disorder,” the prevalence of bipolar disorder is placed in context with
the misdiagnosis. It is estimated that 1.4 to 6.4 percent of people worldwide have bipolar
disorder, placing them at a risk of suicide twenty times higher than the general population (Singh
& Rajput, 2006). In 1994, bipolar disorder was found to be widely misdiagnosed, and a study in
2000 found that the misdiagnosis crisis had not improved since (Singh & Rajput, 2006). In a
National Depressive and Manic-Depressive Association survey, it was found that “69 percent of
patients are misdiagnosed initially and more than one-third remain misdiagnosed for 10 years or
more” (Singh & Rajput, 2006). Disturbingly, two different studies in 1999 and 2000 revealed
that “almost 40 percent of bipolar patients are initially diagnosed with unipolar depression”
(Singh & Rajput, 2006). With this information in mind, bipolar disorder is mistaken for
depression frequently, which results in the wrong medical treatment. This is giving a huge
proportion of people who are at a severe risk of suicide the wrong treatment. Much of this can be
attributed to the flawed diagnostic criteria of the DSM-IV. In diagnosing bipolar II disorder, it is
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required that a patient experiences a hypomanic state for a four day duration, whereas many
experts believe that hypomanic states only last for 1-3 days on average (Singh & Rajput, 2006).
Such strict criteria prevents patients from getting individualized care, as mental disorders are
Where the DSM-IV criteria is failing to distinguish bipolar disorder and unipolar
depression, neuroimaging is showing promise. While these studies are in their earliest stages,
studies are aiming to identify different endophenotypic markers of bipolar disorder that would
distinguish it from unipolar depression (Keener & Phillips, 2009). These endophenotypic
markers could be linked to findings in MRI, positron emission tomography (PET), and diffusion
tensor imaging (DTI) studies (Keener & Phillips, 2009). If such markers were found, they would
allow individuals who are at risk for bipolar disorder to be diagnosed early prior to the illnesses’
onset (Keener & Phillips, 2009). In Dr. Matthew Keener and Dr. Mary Phillips’s “Neuroimaging
in Bipolar Disorder: A Critical Review of Findings,” it was found that adults with bipolar
disorder have enlarged amygdalae (Keener & Phillips, 2009). This differs with the finding that
adolescents with bipolar disorder have smaller amygdalae (Keener & Phillips, 2009). It also must
be noted that these studies specifically focused on bipolar I disorder, and studies on bipolar II
disorder are lagging behind (Keener & Phillips, 2009). The study concludes that neuroimaging is
useful in identifying the endophenotypic markers associated with bipolar disorder, and that
future studies should focus on neural systems associated with emotional regulation (Keener &
Phillips, 2009).
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developing biomarkers with depression. As in a publication by Drysdale et al., depression “is not
a unitary disease…” (Drysdale, et al., 2017). This disorder has been found to have four distinct
types (Drysdale, et al., 2017). According to this article, depression can be identified by its
pathways in the limbic system and in the frontostriatal circuits; in each different type of
depression, there is dysfunction (Drysdale, et al., 2017). Although symptoms overlap among the
four types, these different types have specific biomarkers in the brain (Drysdale, et al., 2017). In
these studies, it was found that “[c]lustering patients...enabled the development of diagnostic
classifiers (biomarkers) with high sensitivity and specificity…” meaning that depression can be
identified in this manner statistically (Drysdale, et al., 2017). If this is the case, depression can
more easily be differentiated from other disorders, like bipolar disorder, perhaps leading to better
diagnoses.
Conclusion
Seeing the flaws in the diagnosis process in context with the emerging results of
neuroimaging, it can best be inferred that neuroimaging should play a role in the future of mental
illness diagnoses. The questions of when and how of course lingers, but in this moment, the
focus needs to be on consolidating the research. More meta-analyses need to take place, and they
need to be applied to clinical practice, as Dr. Daniel Amen is doing. Clinical trials must take
place to see how accurate the studies are cumulatively. Most importantly, research must begin to
be added up, so that doctors can best understand their patients situation’s in a timely manner. The
DSM’s will only get so good from version to version, and it would be best if we could focus
most on imaging. Therefore, neuroimaging should not be immediately used to diagnose and treat
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mental illness, but seeing the stagnation of our current diagnostic system alongside the progress
References
Carey, B. (18 Oct. 2005). Can brain scans see depression? The New York Times.
Brain-scans-see-depression.html
Drysdale, A. T., Grosenick, L., Downar, J., Dunlop, K., Mansouri, F., Meng, Y., … Liston, C.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686113/
Sprooten E., Rasgon A., Goodman M., Carlin A., Leibu E, Lee W. H., & Frangou S. (2017).
brain activation in common mental disorders. Human Brain Mapping PMID: 28067006
Singh, T., & Rajput, M. (2006). Misdiagnosis of Bipolar Disorder. Psychiatry (Edgemont),