In the medical world of Nash Boutros, M.D., psychiatry is not just an abstract science of examining verbal cues and exploring a patient's emotions.
This psychiatrist believes there is an observable "method in the madness" via clues detectable using electroencephalography, or EEG.
EEG is usually a timed recording of electrical activity along the scalp, and measures voltage changes from ionic current flows within the neurons of the brain. The data is reported as brain waves, or "squiggly lines," said Dr. Boutros, professor of Psychiatry and Behavioral Neuroscience for the Wayne State University School of Medicine.
In general medicine, EEG is used to diagnose or observe epilepsy, coma and brain death. In psychiatry, however, the standard EEG (s-EEG), inspected by the naked eye of an expert, tends to show only less conspicuous changes that are in need of much more research to fully establish their clinical correlates. Occasionally, s-EEG may reveal an abnormality indicative of a neurological process like epilepsy or a space-occupying lesion. These situations are usually accompanied by clinical red flags.
Dr. Boutros has made it his life's work to bring the electrophysiological assessment of neuropsychiatric disorders to the forefront of respected medicine. The s-EEG is only a small part of the discipline of psychiatric electrophysiology, Dr. Boutros said. The major promise comes from the computer quantification of the EEG signal (QEEG), evoked brain responses (responses elicted by external or cognitive stimuli), sleep studies and magnetoencephalography. In fact, psychiatric electrophysiology is not limited to diagnostic methodologies but includes therapeutic techniques like electroconvulsive therapy, magnetic seizure therapy, transcranial magnetic stimulation, vagal nerve stimulation and deep brain stimulation.
Dr. Boutros is pushing for the Wayne State University School of Medicine to become a major training and testing site for psychiatric electrophysiology fellows in the not-so-distant future.
"What I'm hoping is we become one of the main centers," said Dr. Boutros, co-author of the book, "Standard Electroencephalography in Clinical Psychiatry."
He is currently working on developing an "Atlas of EEG Patterns Commonly Seen in Psychiatry Patients."
His review, "Advances in electrophysiology in the diagnosis of behavioral disorders," co-authored with the lab's Klevest Gjini, M.D., Ph.D., and Cynthia Arfken, Ph.D., was published in the September 2011 edition of the journal "Expert Opinion of Medical Diagnostics." The article details the boundaries of the field and the different clinical services to be provided.
He wants a major health system to recognize the work they're doing at WSU, leading to support for the now research-based science to transition to everyday use in clinical settings. Dr. Boutros is director of the School of Medicine's Psychiatric Clinical Electrophysiology and Transcranial Magnetic Stimulation, or TMS, laboratories, located within the University Psychiatric Center in Detroit. The associate chair for Research in the Department of Psychiatry and Behavioral Neurosciences has received a decidedly warm reception for his pioneering efforts.
"This is the future for clinical neuropsychiatry," said David Rosenberg, M.D., the Miriam L. Hamburger Endowed Chair of Child Psychiatry and professor and interim chair of Psychiatry and Behavioral Neurosciences at WSU. "We're very proud of this."
Dr. Boutros' lab, staffed by post-doctoral fellows, is home to state-of-the-art TMS, rTMS, electroencephalography and other equipment the staff uses in a variety of active, funded studies. They include the Bipolar-Schizophrenia Network on Intermediate Phenotypes study, or B-SNIP. The ongoing multi-center, large-scale study initially funded in 2007 by the National Institute of Mental Health focuses on understanding the genetic basis and brain changes in those with schizophrenia/schizoaffective and bipolar disorder using safe neuropsychological neuroimaging technology.
The Wayne State University School of Medicine and University Physician Group are accepting patients and control participants for this study, and others. Aside from the B-SNIP, studies include intracranial mapping of brain sensory habituation - the relationship between the brain's ability to habituate to repeating stimuli and the effects of racist stimuli on the cardiovascular system in African-Americans (a project in collaboration with WSU School of Nursing Associate Professor Rosalind Peters, Ph.D., R.N., F.A.A.N.), post-traumatic stress disorder in war refugees; rTMS in the treatment of cocaine dependence, the clinical relevance of isolated epileptic discharges in non-epileptic panic patients and electrophysiological characterization of deficit syndrome schizophrenia patients.
Dr. Boutros is a founding member of the Electroencephalography and Clinical Neuroscience Society, receiving the organization's Presidential Service Award in 2007. The society acts as the gatekeeper for the electrophysiology movement initially launched in the 1960s. He sees opportunity for private companies to invest in the future of developing technology.
"The field is being born. It's in the process, so it is 90 percent research, 10 percent clinical," he said. "It's new. We go preach, try to convert psychiatrists, and hopefully one day we'll become an integrated part of psychiatry."
The society, through peer-reviewed articles, abstracts and studies, extracts what's consistent and clinically useful. Among the useful is a series of "healthy" and "unhealthy" brain databases to compare and contrast EEGs to help diagnose attention deficit hyperactivity disorder and brain injuries. The next step is quantifying the EEG itself, transforming the "squiggly waves" into complete, useful brain maps. "That's the actual future of electrophysiology," Dr. Boutros said.
By identifying brains that are related and have a genetic tendency to bipolar and schizophrenia disorder, researchers may begin to understand how genetics translate into clinical presentation. The study could lead to the identification of genes associated with abnormal brain function in bipolar and schizophrenia.
For Dr. Boutros and his team, the brain is most certainly directly linked to behavior. Yet most psychiatry students are never exposed to using EEG in their clinical practice despite the fact that s-EEG abnormalities are not uncommon and can potentially influence treatment and diagnosis.
Only 100 years ago, neurology and psychiatry were in the same field - everyone was a "brain scientist," Dr. Boutros said. In the first half of the 20th century, that shifted. "Sigmund Freud was the leader of the shift away from evidence-based to abstract psychiatry. He died in 1939. His theories were espoused in the 20 years preceding that, but did not take a really strong hold of Psychiatry until about 20 years after his death."
But in the 1960s, Fred Gibbs, M.D., and his wife, Erna Gibbs, espoused their beliefs that EEG was telling physicians, including psychiatrists, something about psychiatric disorders. The idea was considered absurd at the time, Dr. Boutros said, and Dr. Gibbs was heckled and yelled at during a conference. He was subsequently forced to leave the American EEG Society he founded.
More than 40 years later, Dr. Rosenberg believes a future neurophysiology residency and Dr. Boutros' overall work is a "definitely plausible and very relevant new direction. It could also be very fundable, which is something our department needs to explore."
Volunteers are needed to participate in the B-SNIP study, including biological siblings, children or parents of a person diagnosed with schizophrenia or bipolar disorder, as well as healthy community members with no history of major mental illness or family history of schizophrenia/schizoaffective or bipolar disorder. WSU is among the six national sites seeking thousands of participants. Others include the Olin Neuropsychiatry Research Center in Hartford, Conn.; Yale School of Medicine in New Haven, Conn.; Johns Hopkins Medicine in Baltimore; Harvard Medical School in Boston; University of Texas Southwestern Medical School in Dallas; and the University of Illinois, Chicago Center for Cognitive Medicine.
All procedures are painless and include a clinical interview, simple tests of memory, attention and other brain processes, a blood test, a safe non-radioactive brain scan and a test of brain waves using a 64-channel EEG and recorded eye movement. Volunteers may earn up to $200 upon completion of the study.
In addition to the B-SNIP study, the Brain Research and Imaging Neurosciences Division seeks people for other studies, with compensation included. For more information, contact Mae Nordin at MNordin@med.wayne.edu or call 800-650-7837.