Salerian Brain Laws #1 and #2 (SBL1 and SBL2):

Frontal Cortex Function and Dopamine Govern Mood and Executive Function

By Alen J. Salerian, MD

I am excited to share two of my discoveries of brain function and dysfunction, two novel theories I advance about the essence of all neuropsychiatric disorders.  Region specific dysfunction and abnormal neurotransmission regulated by thermoregulation laws govern all neuropsychiatric disorders.

The precise scientific details of my theories are going to be published in peer-reviewed journals by the end of 2009, yet my wish to help people with serious neuropsychiatric disorders prompted me to immediately reveal my findings.

Salerian Brain Law #1 suggests two factors govern all neuropsychiatric disorders:  region-specific brain dysfunction and abnormal neurotransmission mediated by thermodynamic laws.  In essence, Salerian Brain Law #1 proposes that the laws which govern neurological disorders also govern neuropsychiatric illnesses as diverse as schizophrenia, bipolar disorder, depression, post-traumatic stress disorder, addictions.  Thus, Salerian Brain Law suggests the majority of neuropsychiatric disorders are biological in origin, the presenting symptoms, the severity and the course of the disorder defined by a specific region of the brain influenced by the specific neurotransmitters responsible in regulating the neuropsychiatric function of that particular brain region.

The second Salerian Law of the Brain suggests that the prefrontal cortex dictates human mood and executive function, consistent with its evolutionary neurobiological supremacy over the rest of the brain.  Thus, only when the prefrontal cortex function is less than perfect or only when the prefrontal cortex function is dysfunctional that a Homo sapien brain exhibits any mood or executive dysfunction.

In essence, the prefrontal cortex is the king with full authority over a chemical cocktail of complex neurobiological homeostasis, and hence, no mood or executive dysfunction can develop in the presence of a robust and functional prefrontal cortex.

The above-mentioned interactions frequent occur in lower species, yet they are not as profound for the extraordinary superiority of the prefrontal cortex to perceive, process, mediate and master the sensory input from other parts of the brain as they are in Homo sapien brain function.  This is precisely why, for any clinical entity with diminished executive function, compromised initiative and lowered energy, motivation, mood and self-confidence to develop, there must always be some disturbance or dysfunction of prefrontal cortex function.

As to the notion of complexity of brain function, mental state and the countless factors that may influence neurobiology, hence the prefrontal cortex, one can merely state that the final outcome remains the same; to use a common if not so scientific language that the bottom line does not change the evolutionary superiority of the prefrontal cortex over the rest of the brain.

The use of the Salerian Laws or any section of this paper without the written consent of Alen J. Salerian, MD and Washington Center for Psychiatry is prohibited.

The high point of my graduation from medical school was a dinner celebration on Princess Island off the coast of Istanbul as cheers and toasts were finally fading. I was surrounded by happy faces and watery eyes in all directions when my cousin Joe, a skinny, tall man known to us as “Nervous Joe,” spoke loudly on a Friday evening some 25-plus years ago. “Come on Alen, now that you are a real doctor, tell me, what can you do for my hands?” with both of his hands and arms extended, over half-filled wine glasses, we all stared at his red, chapped hands.

Hmm! What help could I offer? There were too many possibilities. “Hey, Joe, you need a dermatologist!” I offered.

A phone call, a visit, and a few weeks later, cousin Joe shared with me his diagnosis: Compulsive hand washing secondary to obsessive-compulsive disorder (OCD).

There was a time not many centuries ago when OCD was viewed as a satanic possession treatable with exorcism. Not until the mid 1980s did we discover that OCD was not a rare disease. The Epidemiologic Catchment Area Study that the National Institute of Mental Health sponsored identified a lifetime prevalence rate of OCD in about 2.5% of the general population, greater than the rate of panic disorder or schizophrenia.

Increasingly, the profession is recognizing that for most patients OCD is a lifelong illness. Approximately 65% of patients develop OCD before age 25 and less than 15% of patients will develop the disorder after age 36.

Postulated Causes

The past century has witnessed a gradual transformation of the theories explaining the underlying causes of OCD. No longer can Freudian psychodynamic explanations of OCD survive scientific scrutiny. Still, the exact causes of OCD are not known. Yet, there seems to be increasing evidence that biological factors play an important role and that genetic and environmental factors may contribute to particular symptoms.

Serotonergic dysregulation has been proposed as the basis of OCD. And not surprisingly, the most efficacious agents for OCD have been SSRIs or medications that have potent effects on selective serotonin reuptake inhibition such as clomipramine. A number of studies suggest a genetic link to OCD. Some report that about 25% of OCD patients have a first-degree relative with OCD.

Comorbidity

Statistics strongly suggest that patients with OCD may present with other psychiatric disorders. At the time of OCD diagnosis, 31% of patients suffer from major depression, and the prevalence of depression in OCD patients ranges from 67% to 78%. Similarly, the lifetime prevalence of a core existing anxiety disorder is also high, ranging from 22% to 28% for simple phobias and 12% to 15% for panic disorder.

Treatment Strategies

During the past several decades, various treatment strategies including pharmacotherapy, behavior therapy, and psychosurgery emerged as somewhat effective in treating OCD.

Pharmacotherapy

Approximately 65% to 75% of patients with OCD report moderate improvements with serotonergic agents. In spite of the relatively dirty effect profile (i.e., dizziness, weight gain, constipation, somnolence and dry mouth), many clinicians still view clomipramine (Anafranil) as the gold standard of OCD treatment. Understandably, because of their more favorable side effect profiles, SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine) should be considered first.

Two factors, inadequate dosage and inadequate duration of treatment, have often been linked to treatment failures. A 12-week trial with dosages up to 300 mg of clomipramine, 200 mg with sertraline, 80 mg with fluoxetine, 300 mg with fluvoxamine, and 60 mg with paroxetine are necessary prior to a realistic evaluation of medication efficacy. In spite of early disappointing results with various psychological treatments such as psychoanalytic psychotherapy, relaxation therapy, hypnosis, and biofeedback, the past decade also witnessed the positive outcome of behavior therapy for patients with OCD.

Electroconvulsive Treatment

How about electroconvulsive treatment (ECT) or augmentation strategies? To date, there has not been any convincing evidence to support using ECT for OCD patients. And unlike treatment-resistant depressed patients who may respond favorably to adjunct lithium, liothyronine, methylphenidate or buspirone, the current psychiatric literature remains, at best, controversial about the efficacy of augmenting agents for OCD when monotherapy fails.

Psychosurgery

What about psychosurgery? Ever since its introduction, psychosurgery has offered hope and triggered apprehension for patients with OCD. And rarely has a medical approach been vilified as much as psychosurgery has. Yet, few people know much about the recent reports indicative of moderate success for treatment-resistant patients with OCD.

Even though using very conservative outcome criteria, different studies suggest a 41% to 56% moderate improvement; the current psychiatric consensus remains unchanged. Consider psychosurgery only for severely incapacitated patients for whom all other treatments failed.

More on OCD from DSM-IV

According to the DSM-IV, OCD is classified as one of the anxiety disorders. OCD may be diagnosed if the patient demonstrates obsessions or compulsions that cause marked distress, are time consuming (generally an hour or more per day), or significantly interfere with social or role functioning.

Obsessions are defined by:
-Recurrent and persistent thoughts, impulses or images that are experienced, at some point during the disturbance, as intrusive and inappropriate, and cause marked anxiety or distress.
-The thoughts, impulses, or images are not simply excessive worries about real-life problems.
-The person attempts to ignore or suppress such thoughts or impulses or neutralizes them with some other thought or action.
-The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions are defined by:
-Repetitive behaviors (e.g., handwashing, ordering, or checking) or mental acts (e.g., praying, counting or repeating words silently) that are performed in response to an obsession, or according to rules that might be applied rigidly.
-The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

The Nevada State Athletic Commission delivered a stinging blow that hurt Mike Tyson badly when it denied him a boxing license Jan. 29.

Yet no one seems willing to extend a helping hand to rescue the powerful fighter from the demons of the mind that pound him with greater force than any opponent.

For years, people have called Tyson crazy, out of control, a wild man, even an animal. He’s been fined, imprisoned, barred from the ring and shunned. Yet in all of his glorious years of ear biting, brawling, lawbreaking and serving time in prison, Tyson has never once been forced to seek and finish psychiatric treatment. Tyson needs mandatory psychiatric care. And as a psychiatrist who for 25 years has worked with terribly troubled people, I have patiently waited for some sporting or legal authority to force Tyson to get the help he so desperately needs.

It seems, however, that there’s a stigma attached to mental health disorders that prevents the authorities from treating them like any other health issue.

I’m sure if Tyson were suffering from a concussion, the boxing authorities would allow him to fight only after a medical expert deemed him healthy. Why isn’t the same help given to those with mental health disorders?

Maybe Tyson’s race and educational background have influenced why he hasn’t been given help. How long would it take us to commit Andre Agassi if he jumped across the net and bit the ear or thigh of competitors like Pete Sampras or Lleyton Hewitt? Probably faster than a three-minute round in the ring.

I find it interesting that the same people who vilify Tyson for his actions could not find enough praise for the courage and spirit of Professor John Nash for his triumph over his psychological demons, as chronicled in the film and book “A Beautiful Mind.” Nash was violent and dangerous like Tyson, and got better only after treatment was forced on him.

It’s sad that the United States is one of the few civilized countries that consistently does not require treatment for severely handicapped people.

Our recent history is filled with brutally painful lessons of the dark consequences of unrecognized psychiatric disorders. There’s evidence that President Franklin Delano Roosevelt was psychologically impaired by depression in 1944 when he let Stalin steal Eastern Europe at Yalta, and that President Ronald Reagan’s Alzheimer’s disease began while he was still at the White House.

And what about the FBI’s top counterintelligence officer, Robert Hanssen, who sold our nuclear secrets to Russia? For 20 years, Hanssen confessed his spying and his deep psychological problems to his Catholic priest, but all he received was advice to pray.

What kind of advice are we giving Tyson? I wonder how many people have said to him: “Don’t worry about the Nevada boxing license–there are so many other states we haven’t tried yet,” instead of just having him committed.

It was less than four years ago that the Nevada commissioners rejected another of Tyson’s licensing bids, naming lack of continued treatment for his erratic behavior as their main reason.

It doesn’t particularly matter to me whether Tyson ever fights in the ring again. But as a psychiatrist–and someone who wants to feel safe with people like Tyson roaming the streets–it does matter to me that he receives help, even if we have to force it on him.

We don’t have to accept Tyson’s outrageous acts. For society’s sake, and for Tyson’s own sake, we must open our eyes to the perils of untreated mental disorders. Instead of continuing to attack this sick man, we need to help him get well.