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

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

Broadman’s brain areas

M R Diffusion Tensor Imaging – Tractography

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)

Senior Research Scientist National Institute of Mental health (I) Triune theory Senior Research Scientist National Institute of Mental health 1913 - 2007

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

Triune Theory

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

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

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

Triune Theory

Triune Theory

TRIUNE BRAIN

TRIUNE BRAIN

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

(1) Triune Brain: Triune Intelligence (?)

(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

(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.

(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

(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

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

Variations of the Tri-dimensional Intelligence:

(2) Better diagnostic criteria of Autism

(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

(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

(2) Better diagnostic criteria of Autism

(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

(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

(3) Better clinical assessment of autism

(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

(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

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

(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)

(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

(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

(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 (?)

(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)

(4) Better Understanding of Aetiology of ASD

(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

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

(5) Schizophrenia and Autism

(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

(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)

(5) Schizophrenia and Autism

(5) Schizophrenia and Autism

(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

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