1. Locum Consultant Forensic Psychiatrist in Learning Disabilities
Possible Applications of Triune Brain Theory in Developmental Disorders
Dr Khalid Mansour
Locum Consultant Forensic Psychiatrist in Learning Disabilities
Eric Shepherd Unit

2. How does the brain work? Main functional structure of the brain?
Brain centres (Phrenology) (too simple)
Brain circuits (e.g. Papez circuit – FLS vs OPD – M R diffusion tensor imaging – Tractography) (vague, little clinical applications)
Evolutional/developmental approach (Triune Theory):
Strong scientific evidence
More comprehensive theory of brain functioning
High clinical potential

3. Broadman’s brain areas

4. M R Diffusion Tensor Imaging – Tractography

5. Triune Theory
“The most influential idea in neuroscience since World War II” (Durant in Harrington 1992)
MacLean’s Triune Brain Concept has had limited acceptance or been largely ignored by professional neurobiologist (Science Journal 1990 & American Scientist journals 1992) (Cory in Cory & Gardner 2002)

6. Senior Research Scientist National Institute of Mental health
(I) Triune theory
Senior Research Scientist
National Institute of Mental health

8. Triune Theory
Vertebrates can be divided from evolutionary point of view into three main categories:
Animal with brains made mainly of spinal cord, brain stem, basal ganglia and cerebellum (reptilian brain, the R-Complex or the Striatal Complex): e.g. Reptiles, birds & fish
Animals which brain is mainly made from the R-Complex + the limbic Lobe (diencephalons, Amygdala, septum, Mammillary body, Fornix, limbic cortex: Broca’s area, cingulated cortex, hippocampus & others): e.g. Rats, cats , dogs and monkeys
Animals which brain is mainly made of: R-Complex + Limbic System + the Neocortex: e.g. Apes and humans

9. Triune Theory

10. Triune Theory
(I)
Animal with brains made mainly of Reptilian brain (R-Complex)
Mainly Reptiles, birds & fish
Evolutionary functions:
Motor behaviour including motor routines, motor subroutine, motor memory and motor (non-verbal) communications
Primitive emotions: rage, fear & submissiveness
Copulation

11. Triune Theory
(II)
Animals which brain is mainly made from the reptilian brains + the limbic Lobe:
Lower mammals e.g. Rats, cats , dogs and monkeys
Evolutionary functions: (beginning of family)
Nursing of the offspring (parental care)
Vocalisation (audio-vocal communication)
Play

12. Triune Theory
(III)
Animals which brain is mainly made of: R-Complex + Limbic System + the Neocortex:
Higher mammals e.g. Apes and humans
Evolutionary functions: (beginning of cultures)
Problem solving skills (Mentation)
Learning
Detailed memory
Verbal communication
Preservation of ideas

13. Triune Theory

14. Triune Theory

15. TRIUNE BRAIN

16. TRIUNE BRAIN

17. Clinical Applications of the Triune Theory in Developmental Disorders:
Triune Brain > Triune “Intelligence”
Better clinical assessment and diagnosis of autism
Better diagnostic criteria of Autism
Better understanding of aetiology of ASD
Schizophrenia and Autism

18. (1) Triune Brain: Triune Intelligence (?)

19. (1) Triune Brain: Triune Intelligence
R-Complex: processing object related data > Object-Related Skills / Intelligence
Limbic System: processing emotional data > Emotional Skills / Intelligence
Neocortex: processing social data> Social Skills / Intelligence
We could have :
Object related intelligence (general intelligence - IQ),
Emotional Intelligence &
Social intelligence

20. (1) Triune Brain: Triune Intelligence
Object Related Intelligence (general intelligence - IQ): managing physical environment (not emotionalised – not socialised) e.g. budgeting and travelling
Emotional Intelligence: managing emotional/personalised environment e.g. emotional bonding, insight and empathy.
Social Intelligence: managing social environment e.g. functioning in social groups and social appropriateness.

21. (1) Triune Brain: Triune Intelligence
Why Three-Dimensional Intelligence?
Clinical Evidence: Emotional Intelligence and Social Intelligence, are used in every day clinical work
Emotional intelligence: (Leuner,1966; Payne, 1985; Greenspan, 1989; Salovey and Mayer,1990; Goleman, 1995).
Social Intelligence: (Cohen, 2000; Goleman, 2006)
ASD: a good example of the separation of Object Related Intelligence from Emotional Intelligence and Social Intelligence

22. (1) Triune Brain: Triune Intelligence
Potential applications of triune intelligence:
Explains variations in development of intelligence
One step towards more use of IQ format
Object related intelligence (General intelligence) IQ
Emotional intelligence IQ
Social Intelligence IQ
End of categorical classification of ASD

23. Variations of the Tri-dimensional Intelligence:

24. Variations of the Tri-dimensional Intelligence:

25. Variations of the Tri-dimensional Intelligence:

26. Variations of the Tri-dimensional Intelligence:

27. Variations of the Tri-dimensional Intelligence:

28. Variations of the Tri-dimensional Intelligence:

29. Variations of the Tri-dimensional Intelligence:

30. Variations of the Tri-dimensional Intelligence:

31. Variations of the Tri-dimensional Intelligence:

32. Variations of the Tri-dimensional Intelligence:

33. Variations of the Tri-dimensional Intelligence:

34. (2) Better diagnostic criteria of Autism

35. (2) Better diagnostic criteria of Autism
Current Diagnostic Criteria DSM-IV
(I) A total of six (or more) items from (a), (b), and (c), with at least two from (a), and one each from (b) and (c)
(A) qualitative impairment in social interaction:
impairments in nonverbal behaviors such as eye-to-eye gaze
failure to develop peer relationships
lack of spontaneous seeking to share enjoyment, interests, or achievements
lack of social or emotional reciprocity
(B) qualitative impairments in communication:
delay in the development of spoken language
marked impairment in sustain a conversation
idiosyncratic language
lack of social imitative play

36. (2) Better diagnostic criteria of Autism
Current Diagnostic Criteria DSM-IV (cont)
(C) Restricted repetitive and stereotyped patterns of behavior, interests and activities:
stereotyped and restricted patterns of interest
inflexible nonfunctional routines or rituals
stereotyped and repetitive motor mannerisms
preoccupation with parts of objects
(II) Delays with onset prior to age 3 years:
(III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

37. (2) Better diagnostic criteria of Autism

38. (2) Better diagnostic criteria of Autism
Proposed Diagnostic Criteria
(1) Essential features:
Poor development of social intelligence/skills
Lack of social reciprocity
dysfunctional social aspects of play
dysfunctional social aspects of communication
Social awkwardness
failure to develop peer relationships
Poor development of emotional intelligence/skills :
Self-centredness with poor self awareness
lacking empathy (dysfunctional theory of mind)
Lack of emotional reciprocity
Poor appreciation of emotional expressions
Emotional awkwardness
Poor emotional aspects of play
Poor emotional aspects of communication

39. (2) Better diagnostic criteria of Autism
Proposed Diagnostic Criteria (Cont)
(2) Compensatory Features:
(Try to feel less overwhelmed, more in control and more secure):
Restricting environment
Restricting interest
Islets of exceptional interests
tendency to keep rigid control over environment
Rigid routines or rituals
(3) Associated features:
Existential (not stress related) anxiety
Pathological habits (dysfunctional routines)
Poor development of speech
Poor eye to eye contact
OCD like symptoms and rituals
Motor mannerisms
Preoccupations with parts of objects

40. (3) Better clinical assessment of autism

41. (3) Better clinical assessment of Autism
Autism is primarily a disorder of emotional and social development which could be due to developmental abnormalities in both limbic system and neocortex. R-Complex could be intact or affected too.
All affected brain functions could take different forms:
lost functions (like in ablation studies)
exaggerated functions (irritation or excitation studies)
partially lost or partially exaggerated
Assessment of each neurological part separately:
Assessment of R-Complex
Assessment of Limbic System
Assessment of Neocortical System

42. (3) Better clinical assessment of Autism
General assessment of R-complex
General functioning
Deals mainly with objects related data
Function: survival in physical world
Produce behavioural routines
Specific functioning
Routines (skills),
Habits,
Motor Communication,
Repetitions (OCD like symptoms)
Assessment of the subsystem
Arousal or motivation assessment (e.g. rocking, ADHD)
Involuntary muscular movements

43. (3) Better clinical assessment of Autism Development of motor routines

44. (3) Better clinical assessment of Autism
R-Complex Specific Functioning
Object related Routines: functional motor routines
Primitive e.g., territorial behaviour
Advanced e.g. tidying one’s room
Object-related Habits (Pathological) : not functional motor routines e.g. pica, addiction, fire setting
Object-related Checking (repetitive) behaviour: e.g.
Exaggerated routines (e.g. hoarding)
Failed to execute routines (repetitive behaviour or OCD like symptoms)

45. (3) Better clinical assessment of Autism
General assessment of Limbic System
General functioning
deals mainly with emotional (individual-related) data
Function: survival in the physical world as an individual
Not normally functional in autism
Specific functioning (emotional routines and habits)
Play
audio-vocal communication
Attachment with others
Theory of mind
Assessment of the subsystem
Attachment disorders

46. (3) Better clinical assessment of Autism
Limbic System Specific functioning:
New emotional routines: not well developed in ASD e.g.
Self centeredness
Hostile dependence on safe relations
Increased anger or increased blaming behaviour,
Dysfunctional empathy
Pathological emotional habits e.g.
deviated sexual interests (paedophilia)
Dysfunctional emotional communication e.g.
“one way communication” “talking at you not to you”
Existential anxiety

47. (3) Better clinical assessment of Autism
General assessment of Neocortical system
General functioning of Neocortex
Deals mainly with social (group) data
Function: survival in the physical world as an individual who is in the same time a member of a bigger social group
Specific functioning
Social Routines (skills)
Social Habits (pathological)
Social Communication
Assessment of the subsystem
Imagination / Fantasy disorders (?)

48. (3) Better clinical assessment of Autism
Neocortical System Specific functioning:
Social routines: how undeveloped
Failure of functions: social isolation, social awkwardness
Exaggerated functions: paranoid social attitudes (Nicky Reilly Syndrome)
Pathological habits:
Drug-misuse-to-fit-in syndrome,
hoax phone calls,
Pyromania
Social communication disorder
Poor appreciation of danger (naivety syndrome)

49. (4) Better Understanding of Aetiology of ASD

50. (4) Better understanding of aetiology of ASD
No single aetiology for ASD
Pathway of aetiologies
Upward connections from R-Complex to LS and/or to neocortex
Downward connection from Neocortex and/or LS to R-complex
Each connection can be disturbed by different mechanisms

51. (4) Better understanding of aetiology of ASD
Autism is not a one thing: multiple aetiologies.

52. (5) Schizophrenia and Autism

53. (5) Schizophrenia and Autism
Similarities:
Schizophrenia > disturbance of processing of social (neocortical system) and emotional (limbic system) data
Late stages Schizophrenia (deficit syndrome)>
^ autistic features
Differences:
Schizophrenia: acquired, adulthood illness, disintegrative (regressive)
Autism: developmental, childhood disorder, progressive

54. (5) Schizophrenia and Autism
Can autistics develop schizophrenia ?
Autistics can mimic delusional patients on the ward. They can also be genuinely paranoid and make erroneous judgments but still not delusional
Having hallucinations and delusions does not mean Schizophrenia (autism with psychotic symptoms is not a schizophrenia like Dementia with psychotic symptoms is not a schizophrenia)

55. (5) Schizophrenia and Autism

56. (5) Schizophrenia and Autism

57. (5) Schizophrenia and Autism
How to treat autistics with psychotic features?
Autistics with psychotic features develop further while incorporating the psychotic features in their development (e.g. build self-esteem based on delusions of grandiosity)
psychosis becomes part of the foundation of the personality > “functional psychosis”
If treated > more disturbance
Only treatment is; replacement therapy (not only removal therapy)
Antipsychotic medications are not usually very effective
Behavioural and environmental therapies more effective

58. Comments