Healing ADD

Its first edition came out from Putnam in 2001. The subtitle of that edition spoke of six types of ADHD. In the revised edition from Berkley in 2013, the number of types rose to seven. What is mostly available today is this second edition.

Daniel G. Amen is a psychiatrist. He is the founder of a chain of clinics bearing his own name in the US and the author of many bestsellers. The distinguishing feature of his clinics is that they routinely use a brain imaging method called SPECT in psychiatric evaluation.

Many of Amen's books have been translated into Turkish by Pegasus Yayınları; on his author page at Kitapyurdu there are about a dozen titles. But among them I could not see a verified Turkish edition of Healing ADD. So I write it under its English title.

I described my view of ADHD books on this site in a separate article; if you have read it, you can guess which of the patterns there this book touches. Still, I tried to read the book fairly, because there are things in it that really do work.

The book's promise

The subtitle states the promise clearly: seeing the types of ADHD and healing them.

The book's central claim is this. ADHD consists of several separate types corresponding to different brain patterns. These types can be seen on SPECT images. Identifying the right type is the key to choosing the right treatment. A treatment given for the wrong type, for example a stimulant medication, does not work in some people or makes the picture worse.

In the first edition Amen said he reached this conclusion based on thousands of brain scans and more than ten thousand patient evaluations. The revised edition cites a larger imaging database.

Seven types

The seven types in the revised edition are roughly these:

Classic type. Inattention, hyperactivity and impulsivity together.

Inattentive type. Distractibility but no restlessness; sluggishness, low energy.

Over-focused type. Getting stuck on a thought or topic, difficulty with flexibility, argumentativeness, worry loops.

Temporal lobe type. Anger outbursts and quick flare-ups.

Limbic type. Pessimism, low mood, withdrawal.

"Ring of fire" type. Intense restlessness, sensory oversensitivity, aggression.

Anxious type. The seventh type, added in the 2013 edition. Tension, expecting bad outcomes, bodily stress symptoms such as headaches and digestive problems.

The book offers separate recommendations for each type: medication, supplements, diet, exercise, neurofeedback, thought work, parenting and school strategies. It also offers the reader a questionnaire for determining their type. But the idea that the real definitive result will come from a scan permeates the whole book.

What SPECT shows

SPECT is a method that images blood flow in different regions of the brain with the help of a radioactive tracer injected into a vein. It has real uses in nuclear medicine, such as the evaluation of certain neurological diseases.

In Amen's approach the person is scanned both at rest and during a task that demands attention, and the type is determined by looking at the patterns in the two images.

The problem here is not the method itself but the meaning loaded onto it. That blood flow in a brain region differs from the average does not on its own show that the difference corresponds to a psychiatric diagnosis or to a particular treatment. To show that, blinded studies are needed: can the person reading the scan find the right type without knowing the person's diagnosis, and does the treatment chosen by type give better results than the standard approach?

The field's objection

The answers to these questions, according to most of the field, still do not exist.

In 2010 Bryon Adinoff and Michael Devous wrote in a letter published in the American Journal of Psychiatry that there is no empirical data supporting the claim that many psychiatric conditions can be recognized with resting SPECT images and their treatment chosen accordingly. The same letter reported that the brain imaging council of the Society of Nuclear Medicine had proposed that Amen test his method with blinded scans, and that this proposal was not accepted. Amen replied to these criticisms in the same journal; the debate went both ways.

The detailed assessment of Amen written by the Office for Science and Society at McGill University lists similar points: there is no randomized, blinded study testing the method; the types Amen describes are categories with no counterpart in the DSM; the American Psychiatric Association, the National Institute of Mental Health and the Society of Nuclear Medicine and Molecular Imaging do not endorse the use of SPECT for this purpose.

The same assessment draws attention to two more practical points. The radiation load of an initial pair of scans is at a level comparable to a computed tomography scan. The cost of the initial evaluation is a few thousand dollars. And there is a dietary supplement company under the same roof as the clinics.

This last point is the one that made me think most. That the same institution sells both the diagnostic method a book recommends and the supplements it recommends does not automatically show that the content is wrong. But it requires the reader to look at every recommendation once more.

Where today's understanding of diagnosis stands

DSM-5 describes ADHD through three presentations: predominantly inattentive, predominantly hyperactive-impulsive and combined. These presentations are based on behavioral symptoms and may change over time. There is no validated brain imaging test in use today for making the diagnosis.

On the heritability side too the picture is clear: the 2019 review by Faraone and Larsson, based on twin studies, puts heritability at about 74 percent. This heritability comes from a large number of genes, each carrying a small effect. There is no natural fit between this picture and the idea of a few separate brain types that are easily told apart on a scan.

For this reason some of the types in the book felt to me less like subtypes of ADHD and more like descriptions of other conditions that often occur together with ADHD. The anxious type looks very much like an anxiety disorder, the limbic type like depression, the over-focused type like obsessive thought patterns. The temporal lobe type is close to a description of anger and emotional dysregulation.

The intuition the book is right about

Here I want to give the book its due.

People with ADHD really are not alike. Of two people who have received the same diagnosis, one is in constant motion and the other cannot get out of bed in the morning. In one anger comes to the fore, in the other anxiety. Co-occurring conditions are very common and really do affect the choice of treatment. In ADHD that runs together with anxiety or depression, doctors have to think differently.

Amen said this variety loudly and as early as 2001. He took the reader's question, "why doesn't my ADHD match the description in the books," seriously. Reading the type descriptions, instead of one single "my ADHD" I had to look separately at the different parts inside it, and that was useful.

Another plus of the book is that it is not against medication. Unlike many alternative-treatment books, it discusses stimulant medications and the other options. But the medication recommendations tied to type determination are also not supported by the evidence that standard clinical guidelines rest on. The decision on medication and dose is made with the doctor who examines you; a type description in a book cannot be the basis of that decision.

Lifestyle suggestions such as exercise, sleep, cutting down alcohol and regular eating are also generally reasonable. Some of them have a limited ADHD-specific effect, but they do no harm to general health.

Supplements and neurofeedback

More caution is needed here.

The book recommends different supplements by type, and among the general recommendations there are supplements such as fish oil. On omega-3 the research picture is mixed and the effects, where found, are small. I covered the details in the article does omega-3 help ADHD. For many of the other supplement recommendations in the book I could not see solid randomized evidence specific to ADHD.

Neurofeedback is also among the methods recommended in the book. The 2016 meta-analysis by Cortese and colleagues found no significant effect in measures where the assessors did not know which group received which treatment. Before putting this method at the base of a treatment plan, you need to know this finding.

Supplements can interact with medications. You need to tell your doctor before you start using them, and the book asks less attention from the reader on this than it should.

The book's language

The text is fluent and self-assured. There are case stories, scan images are described, and a tone that gives the reader hope prevails.

The problem is exactly here. There are very few sentences in the book saying what is contested. Instead of marking something unknown as unknown, the author's own clinical experience is put in place of evidence. As a reader it is hard to tell which claim rests on independent research and which on the clinic's own data.

In a review I read of the book, it said the book at times resembles a long advertisement for SPECT. This is a bit harsh but not entirely unfair. The idea that the best way of determining type is a scan is repeated all through the book.

Why it is read so much

It is also important to understand why a book with such clear criticisms is still read this much.

The first reason is the promise of personalization. Many people diagnosed with ADHD cannot fit themselves exactly into the standard description. The sentence "this is your type, this works for you" gives a feeling of being recognized that a general guideline cannot give.

The second reason is the visual element. A brain image creates a sense of concreteness that a questionnaire or a clinical interview cannot. For someone who spent years hearing "it's all in your head," seeing a photograph of their brain can be a powerful experience. I do not want to belittle this feeling. But that an image is convincing does not show that the conclusion drawn from it is right.

The third reason is hope. The book opens seven different doors to the reader, and behind each door there is a plan. Things that can be started the next day.

The site's three questions

In the article ADHD books that don't help I had proposed three questions for judging a book in five minutes. Applied to this book, the picture looks like this.

Does it give sources? Partly. But the type system at the center of the claims rests largely on the data of the author's own clinic and has not been verified by independent researchers.

Does it state its limits? Very little. I did not come across sections that tell the reader openly that the method is contested.

What does it say about medication? Here the book is better off than anti-medication books. It does not reject medication. But it ties the choice of medication to an unverified type system.

One of the three questions is partly positive, two are negative. This result did not surprise me.

If you are going to read it

If you are going to read it, read it knowing how to read it.

Use the type descriptions as a checklist showing which aspects of your own picture you should look at more carefully. Do not put them in place of a diagnostic system. If anxiety, low mood, anger or getting stuck is prominent in you, treat that as the possibility of a co-occurring condition to talk over with your doctor.

Before taking the scan recommendations seriously, read the criticisms above. If you are thinking of paying for a scan, know that it is not part of today's diagnostic and treatment guidelines.

Do not turn the supplement sections into a shopping list.

I would not recommend this book as a first book to someone newly diagnosed and confused. It is more suitable for someone who, after laying a solid ground on diagnosis and treatment, wants to get to know a contested corner of the field. The book's real value also emerges when it is read together with that ground.