Possible Applications of Triune Brain Theory in Developmental Disorders Dr Khalid Mansour Locum...

Possible Applications of Possible Applications of Triune Brain Theory in Triune Brain Theory in

Developmental DisordersDevelopmental Disorders

Dr Khalid MansourDr Khalid MansourLocum Consultant Forensic Psychiatrist Locum Consultant Forensic Psychiatrist

in Learning Disabilitiesin Learning DisabilitiesEric Shepherd Unit Eric Shepherd Unit

How does the brain work?How does the brain work? Main functional structure of the brain?Main functional structure of the brain? Brain centres (Phrenology) (too simple)Brain centres (Phrenology) (too simple) Brain circuits (e.g. Papez circuit – FLS vs Brain circuits (e.g. Papez circuit – FLS vs

OPD – M R diffusion tensor imaging – OPD – M R diffusion tensor imaging – Tractography) (vague, little clinical Tractography) (vague, little clinical applications)applications)

Evolutional/developmental approach (Triune Evolutional/developmental approach (Triune Theory):Theory): Strong scientific evidenceStrong scientific evidence More comprehensive theory of brain functioning More comprehensive theory of brain functioning High clinical potential High clinical potential

Broadman’s brain areas Broadman’s brain areas

M R Diffusion Tensor Imaging – M R Diffusion Tensor Imaging – TractographyTractography

Triune TheoryTriune Theory ““The most influential idea in The most influential idea in

neuroscience since World War II” neuroscience since World War II” (Durant in Harrington 1992)(Durant in Harrington 1992)

MacLean’s Triune Brain Concept has MacLean’s Triune Brain Concept has had limited acceptance or been had limited acceptance or been largely ignored by professional largely ignored by professional neurobiologist (Science Journal 1990 neurobiologist (Science Journal 1990 & American Scientist journals 1992) & American Scientist journals 1992) (Cory in Cory & Gardner 2002) (Cory in Cory & Gardner 2002)

(I) Triune theory(I) Triune theory

Senior Research ScientistSenior Research ScientistNational Institute of Mental healthNational Institute of Mental health

1913 - 20071913 - 2007

Triune TheoryTriune TheoryVertebrates can be divided from evolutionary Vertebrates can be divided from evolutionary point of view into three main categories:point of view into three main categories:

1.1. Animal with brains made mainly of Animal with brains made mainly of spinal cord, spinal cord, brain stem, basal ganglia and cerebellumbrain stem, basal ganglia and cerebellum ((reptilian brainreptilian brain, the , the R-ComplexR-Complex or the or the Striatal Striatal ComplexComplex): e.g. ): e.g. ReptilesReptiles, birds & fish, birds & fish

2.2. Animals which brain is mainly made from the Animals which brain is mainly made from the R-R-Complex + the limbic LobeComplex + the limbic Lobe (diencephalons, (diencephalons, Amygdala, septum, Mammillary body, Fornix, Amygdala, septum, Mammillary body, Fornix, limbic cortex: Broca’s area, cingulated cortex, limbic cortex: Broca’s area, cingulated cortex, hippocampus & others): e.g. Rats, cats , dogs hippocampus & others): e.g. Rats, cats , dogs and monkeys and monkeys

3.3. Animals which brain is mainly made of: Animals which brain is mainly made of: R-R-Complex + Limbic System + the NeocortexComplex + Limbic System + the Neocortex: : e.g. e.g. Apes and humansApes and humans

Triune TheoryTriune Theory

Triune TheoryTriune Theory(I) (I)

Animal with brains made mainly of Animal with brains made mainly of Reptilian Reptilian brainbrain ((R-ComplexR-Complex))

1.1. Mainly Mainly ReptilesReptiles, birds & fish, birds & fish

2.2. Evolutionary functions:Evolutionary functions:

a)a) Motor behaviour including motor Motor behaviour including motor routines, motor subroutine, motor routines, motor subroutine, motor memory and motor (non-verbal) memory and motor (non-verbal) communicationscommunications

b)b) Primitive emotions: rage, fear & Primitive emotions: rage, fear & submissiveness submissiveness

c)c) Copulation Copulation

Triune TheoryTriune Theory(II) (II)

Animals which brain is mainly made from Animals which brain is mainly made from the the reptilian brains + the limbic Lobe:reptilian brains + the limbic Lobe:

Lower mammals e.g. Rats, cats , dogs Lower mammals e.g. Rats, cats , dogs and monkeys and monkeys

Evolutionary functions: (beginning of Evolutionary functions: (beginning of family)family) Nursing of the offspring (parental Nursing of the offspring (parental

care)care) Vocalisation (audio-vocal Vocalisation (audio-vocal

communication)communication) PlayPlay


(III) (III) Animals which brain is mainly made of: Animals which brain is mainly made of: R-R-Complex + Limbic System + the Neocortex:Complex + Limbic System + the Neocortex:

1.1. Higher mammals e.g. Apes and humansHigher mammals e.g. Apes and humans

2.2. Evolutionary functions: (beginning of Evolutionary functions: (beginning of cultures)cultures)

Problem solving skills (Mentation) Problem solving skills (Mentation) LearningLearning Detailed memoryDetailed memory Verbal communication Verbal communication Preservation of ideasPreservation of ideas

TRIUNE BRAINTRIUNE BRAIN

Clinical Applications of the Clinical Applications of the Triune Theory in Developmental Triune Theory in Developmental

Disorders:Disorders:

1.1. Triune Brain > Triune “Intelligence”Triune Brain > Triune “Intelligence”

2.2. Better clinical assessment and Better clinical assessment and diagnosis of autism diagnosis of autism

3.3. Better diagnostic criteria of AutismBetter diagnostic criteria of Autism

4.4. Better understanding of aetiology Better understanding of aetiology of ASDof ASD

5.5. Schizophrenia and Autism Schizophrenia and Autism

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

(1)(1) Triune Brain: Triune Triune Brain: Triune IntelligenceIntelligence

R-Complex: processing object related data R-Complex: processing object related data > Object-Related Skills / Intelligence> Object-Related Skills / Intelligence

Limbic System: processing emotional data Limbic System: processing emotional data > Emotional Skills / Intelligence> Emotional Skills / Intelligence

Neocortex: processing social data> Social Neocortex: processing social data> Social Skills / IntelligenceSkills / Intelligence

We could have : We could have : Object related intelligence (general intelligence Object related intelligence (general intelligence

- IQ), - IQ), Emotional Intelligence & Emotional Intelligence & Social intelligence Social intelligence


Object Related IntelligenceObject Related Intelligence (general (general intelligence - IQ): managing physical intelligence - IQ): managing physical environment (not emotionalised – not environment (not emotionalised – not socialised) e.g. budgeting and socialised) e.g. budgeting and travelling travelling

Emotional Intelligence:Emotional Intelligence: managing managing emotional/personalised environment emotional/personalised environment e.g. emotional bonding, insight and e.g. emotional bonding, insight and empathy.empathy.

Social Intelligence:Social Intelligence: managing social managing social environment e.g. functioning in social environment e.g. functioning in social groups and social appropriateness.groups and social appropriateness.


Why Three-Dimensional Intelligence? Why Three-Dimensional Intelligence? Clinical Evidence:Clinical Evidence: Emotional Intelligence Emotional Intelligence

and Social Intelligence, are used in every and Social Intelligence, are used in every day clinical workday clinical work Emotional intelligence: (Leuner,1966; Emotional intelligence: (Leuner,1966;

Payne, 1985; Greenspan, 1989; Salovey Payne, 1985; Greenspan, 1989; Salovey and Mayer,1990; Goleman, 1995). and Mayer,1990; Goleman, 1995).

Social Intelligence: (Cohen, 2000; Social Intelligence: (Cohen, 2000; Goleman, 2006) Goleman, 2006)

ASD:ASD: a good example of the separation of a good example of the separation of Object Related Intelligence from Emotional Object Related Intelligence from Emotional Intelligence and Social IntelligenceIntelligence and Social Intelligence


Potential applications of triune intelligence:Potential applications of triune intelligence: Explains variations in development of Explains variations in development of

intelligenceintelligence One step towards more use of IQ formatOne step towards more use of IQ format

Object related intelligence (General intelligence) IQObject related intelligence (General intelligence) IQ Emotional intelligence IQEmotional intelligence IQ Social Intelligence IQ Social Intelligence IQ

End of categorical classification of ASDEnd of categorical classification of ASD

Variations of the Tri-dimensional Variations of the Tri-dimensional Intelligence:Intelligence:

(2) Better diagnostic (2) Better diagnostic criteria of Autismcriteria of Autism

(2) Better diagnostic criteria of (2) Better diagnostic criteria of AutismAutism

Current Diagnostic Criteria DSM-IVCurrent Diagnostic Criteria DSM-IV(I) (I) A total of six (or more) items from (a), (b), and (c), A total of six (or more) items from (a), (b), and (c),

with at least two from (a), and one each from (b) and with at least two from (a), and one each from (b) and (c)(c)

(A) (A) qualitative impairment in social interaction:qualitative impairment in social interaction: impairments in nonverbal behaviors such as eye-to-eye gazeimpairments in nonverbal behaviors such as eye-to-eye gaze failure to develop peer relationships failure to develop peer relationships lack of spontaneous seeking to share enjoyment, interests, or lack of spontaneous seeking to share enjoyment, interests, or

achievements achievements lack of social or emotional reciprocity lack of social or emotional reciprocity

(B)(B) qualitative impairments in communication: qualitative impairments in communication: delay in the development of spoken languagedelay in the development of spoken language marked impairment in sustain a conversation marked impairment in sustain a conversation idiosyncratic languageidiosyncratic language lack of social imitative playlack of social imitative play


Current Diagnostic Criteria DSM-IV Current Diagnostic Criteria DSM-IV (cont)(cont)

(C)(C) Restricted repetitive and stereotyped patterns of Restricted repetitive and stereotyped patterns of behavior, interests and activities:behavior, interests and activities: stereotyped and restricted patterns of intereststereotyped and restricted patterns of interest inflexible nonfunctional routines or ritualsinflexible nonfunctional routines or rituals stereotyped and repetitive motor mannerismsstereotyped and repetitive motor mannerisms preoccupation with parts of objectspreoccupation with parts of objects

(II) Delays with onset prior to age 3 years:(II) Delays with onset prior to age 3 years:

(III) The disturbance is not better accounted for by (III) The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative DisorderRett's Disorder or Childhood Disintegrative Disorder


Proposed Diagnostic CriteriaProposed Diagnostic Criteria(1) Essential features:(1) Essential features:

Poor development of social intelligence/skillsPoor development of social intelligence/skills Lack of social reciprocity Lack of social reciprocity dysfunctional social aspects of play dysfunctional social aspects of play dysfunctional social aspects of communication dysfunctional social aspects of communication Social awkwardnessSocial awkwardness failure to develop peer relationshipsfailure to develop peer relationships

Poor development of emotional Poor development of emotional intelligence/skills : intelligence/skills :

Self-centredness with poor self awarenessSelf-centredness with poor self awareness lacking empathy (dysfunctional theory of mind) lacking empathy (dysfunctional theory of mind) Lack of emotional reciprocity Lack of emotional reciprocity Poor appreciation of emotional expressionsPoor appreciation of emotional expressions Emotional awkwardnessEmotional awkwardness Poor emotional aspects of playPoor emotional aspects of play Poor emotional aspects of communication Poor emotional aspects of communication


Proposed Diagnostic Criteria (Cont)Proposed Diagnostic Criteria (Cont)(2) Compensatory Features:(2) Compensatory Features: ((Try to feel less overwhelmed, more in control and more secure):

Restricting environment Restricting environment Restricting interestRestricting interest Islets of exceptional interests Islets of exceptional interests tendency to keep rigid control over environment tendency to keep rigid control over environment Rigid routines or ritualsRigid routines or rituals

(3) Associated features:(3) Associated features: Existential (not stress related) anxietyExistential (not stress related) anxiety Pathological habits (dysfunctional routines)Pathological habits (dysfunctional routines) Poor development of speechPoor development of speech Poor eye to eye contactPoor eye to eye contact OCD like symptoms and rituals OCD like symptoms and rituals Motor mannerisms Motor mannerisms Preoccupations with parts of objects Preoccupations with parts of objects

(3) Better clinical (3) Better clinical assessment of autismassessment of autism

(3) Better clinical assessment of (3) Better clinical assessment of AutismAutism

Autism is primarily a disorder of emotional and social Autism is primarily a disorder of emotional and social development which could be due to developmental development which could be due to developmental abnormalities in both limbic system and neocortex. R-Complex abnormalities in both limbic system and neocortex. R-Complex could be intact or affected too.could be intact or affected too.

All affected brain functions could take different forms: All affected brain functions could take different forms: lost functions (like in ablation studies) lost functions (like in ablation studies) exaggerated functions (irritation or excitation studies)exaggerated functions (irritation or excitation studies) partially lost or partially exaggeratedpartially lost or partially exaggerated

Assessment of each neurological part Assessment of each neurological part separately:separately: Assessment of R-ComplexAssessment of R-Complex Assessment of Limbic SystemAssessment of Limbic System Assessment of Neocortical System Assessment of Neocortical System


General assessment of R-complexGeneral assessment of R-complex

1.1. General functioning General functioning Deals mainly with objects related dataDeals mainly with objects related data Function: survival in physical worldFunction: survival in physical world Produce behavioural routines Produce behavioural routines

2.2. Specific functioning Specific functioning Routines (skills), Routines (skills), Habits, Habits, Motor Communication, Motor Communication, Repetitions (OCD like symptoms) Repetitions (OCD like symptoms)

3.3. Assessment of the subsystemAssessment of the subsystem Arousal or motivation assessment (e.g. rocking, Arousal or motivation assessment (e.g. rocking,

ADHD)ADHD) Involuntary muscular movementsInvoluntary muscular movements

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


R-Complex Specific FunctioningR-Complex Specific Functioning Object related Routines: functional motor Object related Routines: functional motor

routines routines Primitive e.g., territorial behaviour Primitive e.g., territorial behaviour Advanced e.g. tidying one’s roomAdvanced e.g. tidying one’s room

Object-related Habits (Pathological) : not Object-related Habits (Pathological) : not functional motor routines e.g. pica, functional motor routines e.g. pica, addiction, fire setting addiction, fire setting

Object-related Checking (repetitive) Object-related Checking (repetitive) behaviour: e.g. behaviour: e.g. Exaggerated routines (e.g. hoarding) Exaggerated routines (e.g. hoarding) Failed to execute routines (repetitive behaviour Failed to execute routines (repetitive behaviour

or OCD like symptoms)or OCD like symptoms)


General assessment of Limbic SystemGeneral assessment of Limbic System1.1. General functioningGeneral functioning

deals mainly with emotional (individual-related) datadeals mainly with emotional (individual-related) data Function: survival in the physical world Function: survival in the physical world as an as an

individualindividual Not normally functional in autismNot normally functional in autism

2.2. Specific functioning (emotional routines and Specific functioning (emotional routines and habits) habits)

PlayPlay audio-vocal communicationaudio-vocal communication Attachment with othersAttachment with others Theory of mind Theory of mind

3.3. Assessment of the subsystem Assessment of the subsystem Attachment disorders Attachment disorders


Limbic System Specific functioning:Limbic System Specific functioning:

New emotional routines: not well developed New emotional routines: not well developed in ASDin ASD e.g. e.g. Self centerednessSelf centeredness Hostile dependence on safe relations Hostile dependence on safe relations Increased anger or increased blaming behaviour,Increased anger or increased blaming behaviour, Dysfunctional empathy Dysfunctional empathy

Pathological emotional habitsPathological emotional habits e.g. e.g. deviated sexual interests (paedophilia) deviated sexual interests (paedophilia)

Dysfunctional emotional communicationDysfunctional emotional communication e.g.e.g. ““one way communication” “talking at you not to you” one way communication” “talking at you not to you”

Existential anxietyExistential anxiety


General assessment of Neocortical General assessment of Neocortical systemsystem

1.1. General functioning of Neocortex General functioning of Neocortex Deals mainly with social (group) dataDeals mainly with social (group) data Function: survival in the Function: survival in the physical worldphysical world

as as anan individual individual who is in the same time who is in the same time a a member of a bigger social groupmember of a bigger social group

2.2. Specific functioning Specific functioning Social Routines (skills) Social Routines (skills) Social Habits (pathological) Social Habits (pathological) Social CommunicationSocial Communication

3.3. Assessment of the subsystemAssessment of the subsystem Imagination / Fantasy disorders (?)Imagination / Fantasy disorders (?)


Neocortical System Specific functioning:Neocortical System Specific functioning: Social routines: how undevelopedSocial routines: how undeveloped

Failure of functions: social isolation, social Failure of functions: social isolation, social awkwardness awkwardness

Exaggerated functions: paranoid social attitudes Exaggerated functions: paranoid social attitudes (Nicky Reilly Syndrome)(Nicky Reilly Syndrome)

Pathological habits: Pathological habits: Drug-misuse-to-fit-in syndrome, Drug-misuse-to-fit-in syndrome, hoax phone calls, hoax phone calls, Pyromania Pyromania

Social communication disorderSocial communication disorder Poor appreciation of danger (naivety Poor appreciation of danger (naivety

syndrome) syndrome)

(4) Better Understanding of (4) Better Understanding of Aetiology of ASDAetiology of ASD

(4) Better understanding of (4) Better understanding of aetiology of ASDaetiology of ASD

No single aetiology for ASDNo single aetiology for ASD Pathway of aetiologies Pathway of aetiologies

Upward connections from R-Complex to Upward connections from R-Complex to LS and/or to neocortexLS and/or to neocortex

Downward connection from Neocortex Downward connection from Neocortex and/or LS to R-complex and/or LS to R-complex

Each connection can be disturbed by Each connection can be disturbed by different mechanisms different mechanisms

(4) Better understanding of (4) Better understanding of aetiology of ASDaetiology of ASD

Autism is not a one thing: multiple Autism is not a one thing: multiple aetiologies.aetiologies.

(5) Schizophrenia and (5) Schizophrenia and AutismAutism


Similarities:Similarities: Schizophrenia > disturbance of processing Schizophrenia > disturbance of processing

of social (neocortical system) and of social (neocortical system) and emotional (limbic system) dataemotional (limbic system) data

Late stages Schizophrenia (deficit Late stages Schizophrenia (deficit syndrome)> syndrome)> ^ autistic features ^ autistic features

Differences: Differences: Schizophrenia: acquired, adulthood illness, Schizophrenia: acquired, adulthood illness,

disintegrative (regressive) disintegrative (regressive) Autism: developmental, childhood Autism: developmental, childhood

disorder, progressive disorder, progressive


Can autistics develop schizophrenia ?Can autistics develop schizophrenia ? Autistics can mimic delusional patients Autistics can mimic delusional patients

on the ward. They can also be genuinely on the ward. They can also be genuinely paranoid and make erroneous paranoid and make erroneous judgments but still not delusionaljudgments but still not delusional

Having hallucinations and delusions Having hallucinations and delusions does not mean Schizophrenia (autism does not mean Schizophrenia (autism with psychotic symptoms is not a with psychotic symptoms is not a schizophrenia like Dementia with schizophrenia like Dementia with psychotic symptoms is not a psychotic symptoms is not a schizophrenia) schizophrenia)


How to treat autistics with psychotic How to treat autistics with psychotic features?features? Autistics with psychotic features develop Autistics with psychotic features develop

further while incorporating the psychotic further while incorporating the psychotic features in their development (e.g. build self-features in their development (e.g. build self-esteem based on delusions of grandiosity)esteem based on delusions of grandiosity)

psychosis becomes part of the foundation of psychosis becomes part of the foundation of the personality > “functional psychosis”the personality > “functional psychosis”

If treated > more disturbance If treated > more disturbance Only treatment is; replacement therapy (not only Only treatment is; replacement therapy (not only

removal therapy)removal therapy) Antipsychotic medications are not usually very Antipsychotic medications are not usually very

effectiveeffective Behavioural and environmental therapies more Behavioural and environmental therapies more

effective effective

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