Christopher M. Palmer’s Brain Energy
BenBella Books Inc., Dallas TX; 2022, 320 pages
Review By Barry Blackwell
Christopher M Palmer is an Assistant Professor of Psychiatry at Harvard Medical School and Director of Postgraduate and Continuing Education at McClain Hospital.
The Book’s subtitle is “A Revolutionary Breakthrough in Understanding Mental Health--and Improving Treatment for Anxiety, Depression, OCD, PTSD, and More” and is dedicated “To my mother and my futile attempts to save you from the ravages of mental illness that lit a fire in me that burns to this day.”
The volume is 320 pages and 22 chapters long with 20 pages of Notes & References as well as an Introduction.
The introduction unveils the key to understanding the genesis of this compelling book. The author explains, “When I began my career, for more than 25 years, when my patients asked me about the causes of mental illness, I would give long answers that made me sound educated and competent. I’d talk about neurotransmitters, hormones, genetics and stress. After a few years of this I began to feel like a fraud… people often weren’t getting better. Treatments would work for a few months, or even a year or two, but the symptoms would come back. I began telling people the simple truth: “No one knows what causes mental illness.”
That changed in 2016:
“Tom was a 33-year-old man with schizoaffective disorder. He had suffered from hallucinations, delusions, and mental anguish every day of his life. Over 13 years he was troubled by his illness. He had 17 different medications, but none worked. They sedated him which reduced his anxiety and agitation, but they didn’t stop his hallucinations or delusions. What’s more they caused him to gain over 100 pounds which added to his low self- esteem. Maybe losing weight could help him gain a sense of control. After experimenting with several approaches without success we decided to try a ketogenic diet- low in carbohydrates, moderate in protein, and high in fat. Within weeks Tom not only lost weight but I began to notice remarkable and dramatic changes in his psychiatric symptoms. He was less depressed and sedated. He began making eye contact and I saw a presence and spark I had never seen before. After 2 months he told me his hallucinations were receding and he was rethinking his paranoid theories; to realize they weren’t true and probably never had been. Tom went on to lose 150 pounds, moved out of his father’s home and completed a certificate program. He was even able to perform improv in front of a live audience. I was flabbergasted, had never seen anything like this in my entire career; this man had a psychotic disorder that had resisted a decade of treatment.
“I began digging into the medical literature and discovered the ketogenic diet is a long standing, evidence-based treatment for epilepsy and can stop seizures even when medications fail. Along with its use in epilepsy the ketogenic diet is used in treating obesity and diabetes and even being pursued in Alzheimer’s disease. Why would one treatment work for all these disorders, if only in some people?
“This question forced me to uncover the connections and integrate this with everything I knew as a neuroscientist and psychiatrist. When I finally put all the pieces together, I realized I had stumbled on something beyond my wildest dreams. I had developed a unifying theory for the cause of all mental illnesses. I call this the theory of brain energy.
“This book is not about the ketogenic diet or solely concerned with serious mental illness. The scientific insights apply to mild disorders as well. It may change the way you think about all human emotions and experiences. I am not offering a simple cure-all or advocating any single treatment. The unexpected effectiveness of one particular treatment was only the first clue that started me on a path to a new understanding of mental illness. This book shares that understanding, taking you on a journey I hope will transform the way you think about mental illness and mental health.”
This is a truly innovative and timely volume. Timely because it comes not only when Palmer expresses his own dissatisfaction with contemporary treatments and diagnosis but that it is becoming the coin of the realm marked by the unravelling of psychopharmacology, the diagnoses we make and drugs we prescribe. So, not surprisingly, preceding the text is “Praise for Brain Energy” comprised of comments by 15 leading international scientists, clinicians and educators extolling the books virtues.
Contents of the Book
PART1: (Chapters 1-4) “Connecting the Dots”
PART 2: (Chapter 5-8) “Brain Energy”
PART 3: (Chapter 9-21) “Causes & Solutions”
Part 1 begins by documenting that contemporary mental health is not working citing the WHO 2017 estimates that 800 million people (10% of the world population) suffer from a disorder. When substance abuse is added it rises to 190 million and 13%. The rates are higher in the US, reaching 20%. Lifetime prevalence rises to half the population - 50% - and continues to rise, across the diagnostic spectrum, approaching a pandemic, including ADHD and depression in children with work related burnout in adults. Covid 19 has imposed an additional burden. Mental illness is costly ($2.5 million in 2010 and rising) as well as imposing misery and despair and sometimes violence.
This chapter also notes that “many patients are frustrated by the ineffectiveness of mental health treatments… its simply because our treatments don’t work all that well.”
The chapter ends with the words of Tom Insell the Director of the NIMH at the time of his retirement in 2017: “I spent 13 years at NIMH pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded in getting lots of really cool papers by cool scientists at fairly large costs – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”
To make real progress we must be able to answer the question, “What causes mental illness?” Up until now we have failed.
Part 1 continues in Chapter 2 with “What causes Mental illness and what does it matter?” After describing Engel’s Biopsychosocial model, Palmer focuses on major depression to discuss and identify shortcomings in the “chemical imbalance” theory. But this diligent search for a cause ends with the conclusion that, “The same set of symptoms continues to come up over and over again across categories, regardless of risk factors or perceived causes, whether biological, psychological, social, or some combination. This is at the heart of the difficulty we have in making progress in mental health care. Without a clear cause, we end up treating symptoms as opposed to disorders. Most of our treatments are symptomatic.”
The chapter ends with a definitive suggestion: “To develop a scientific theory of what might be happening in the body or brain from beginning to end - the cascade of events that leads to mental illness. Once established researchers can study people exposed to different risk factors and look for evidence of this cascade. This research has already taken place; the evidence has been gathered. That’s what this book is about.”
Chapter 3 is “Searching for a common pathway.” This title invites a discussion of contemporary efforts, an evaluation of The Diagnostic and Statistical Manual of Mental Disorders, updated in 2022 as DSM-5-TR.
The premise of the DSM is that there are distinct disorders with clear criteria separate from each other. These have “tremendous importance, they are required for clinical care and reimbursement as well as funding for research.”
However, there are no objective tests to confirm any disorder and we are committed to checklists of symptoms and criteria. Even then no two people with a particular disorder are exactly alike due to heterogeneity and comorbidity. Different symptoms, severity and levels of impact on function vary while about half the people have more than one diagnosis.
These dilemmas lead the author to propose “A Deeper Look.” He compares three psychotic disorders, schizophrenia, schizoaffective disorder and bipolar disorder. The NIMH funded a multisite study of more than 2,400 people with these disorders examining key biological and behavioral measures including brain scans, genetic testing, EEGs, blood parameters, inflammation levels and performance on a variety of cognitive tests. The population was different from normal people but not between the three disorders. Treatments were also the same, including mood stabilizers and antidepressants. Palmer speculates whether these distinct disorders develop from a common pathway just as diverse infections share the same symptoms even when caused by different bacterial or viral agents.
This leads further to speculate if this is the common pathway for all mental disorders, supported by the bidirectional relationship between all of them. Multiple examples are cited including a 2019 Danish health registry study of six million citizens over 17 years that found that if you had any mental disorder, you were two to 30 times more likely to be diagnosed with another one.
The chapter ends with reference to another study. In 2018 Avshalom Caspi and Terrie Moffit used a mathematical model to analyze correlations between all mental disorders and found a p-factor (general psychopathology) that predicted a person’s liability to develop a mental disorder. This factor was common to all mental disorders, the liability to have more than one disorder and even to predict the severity of symptoms.
Chapter 4, “Could It All Be Related?” goes a step further noting that mental health disorders also have a strong bidirectional relationship with many metabolic and neurological disorders. The author selects three metabolic disorders (obesity, diabetes, cardiovascular disease) and two neurological disorders (Alzheimer’s disease and epilepsy) on which to focus. All five are commonly associated with depression, anxiety, insomnia and even psychosis. Palmer cites convincing studies in all these conditions to support a common pathway. The chapter ends with “Hiding in Plain Sight.”
He confronts the fact that all mental and metabolic disorders “have been skyrocketing over the last fifty years. Why is that and how have we ignored it?” Candidates to blame include the stress of modern life, artificial ingredients and processed food or “is this an epidemic of laziness?” People confronted with changing their exercise and health behaviors often excuse themselves saying, “I don’t have enough energy” or “It’s too hard.”
It’s not a motivational problem. It’s a metabolic one! We’ve been missing the elephant in the room!
Part 11: Brain Energy
Chapter 5, “Mental Disorders are Metabolic Disorders,” opens with a metaphor made in 1938 by Albert Einstein and Leopold Infeld about the requisites for a novel theory:
“Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. But the point from which we started out still exists and can be seen, although it appears smaller and forms a tiny part of our broad view gained by the mastery of obstacles on our adventurous way up.”
For any new theory to be taken seriously, it must incorporate what we already know to be true. It can’t just replace it; it must tie together our existing knowledge and experience into a broader understanding – one that will widen our perspective and offer new insights. The new insight that mental disorders are metabolic does not discount the benefit obtained from medications, psychotherapy and social interventions. It ties together practitioners and disciplines many think are unrelated: psychiatry, neurology, cardiology and endocrinology.
The material in Part 11 shows the following:
- Metabolic abnormalities {obesity, diabetes, cardiovascular disease) consistently occur in mental disorders.
- Biological, psychological and social risk factors are common to both mental and metabolic disorders.
- Every one of these risk factors is tied to metabolism.
- All symptoms of mental disorders can be tied to metabolism, more specifically to mitochondria, the master regulators of metabolism.
- All effective biopsychosocial treatments in the mental health field work by affecting metabolism.
Having set these criteria Palmer acknowledges that “when it comes to metabolism nothing is simple.” He deals with this in two ways, he provides details of his treatment of Mark, his original patient and he provides a more detailed explanation of Metabolism and Energy.
Briefly stated “metabolism is how our body creates and uses energy.”
Chapter 6, Mental States and Mental Disorders, distinguishes between the two conditions. The former are adaptive reactions to adversity, the latter represent brain malfunction. The link occurs when the stress response evokes changes in four domains:
- The hypothalamic-adrenal (SAM) axis, releasing cortisol.
- The sympathetic-adrenal (SAM) axis, releasing adrenalin.
- Inflammation
- Changes in gene expression, especially in the hippocampus.
All these changes effect metabolism in both body and brain often provoked by adverse childhood experiences (ACE’s). One study of 17,000 people found that six or more of these take 20 years off a person’s life.
When a person is stressed, metabolic resources are diverted to deal with it, depriving the brain of energy, leading to metabolic and mental symptoms and causing cell failure (autography).
This rationale results in “setting aside DSM-5 diagnostic labels and focusing instead on symptoms.” This is already recognized by NIH, recommending instead Research Domain Criteria (RDoc). These are function, cognition and behavior or motivation. This also leads to a new, simplified definition of mental illness:
- The brain is not working properly.
- This results in mental symptoms.
- Malfunction appears over time.
- The symptoms cause suffering or impairment.
Chapter 7, “Magnificent Mitochondria,” explores how these intracellular structures are “powerhouses of the cell” and create energy by converting food and oxygen to ATP. Without them life wouldn’t exist.
The author traces their evolutionary development going back billions of years. Today there are about 1,500 mitochondria genes in DNA. “Mitochondria and human cells are now 100% committed to each other.” Neither can survive without the other. Each human cell has between three to four hundred mitochondria. Some are stationary, others mobile, but always to where events in the cell occur, sucking up ADP and converting it into ATP, all the energy the cell needs to perform its functions, “releasing a neurotransmitter or hormone, or doing something else. Mitochondria are also directly involved in controlling calcium levels, essential to the cell’s functions.” They also control how genes turn on or off (epigenetics) by transporting nuclear protein H1.
Not surprisingly, “the greater the number of healthy mitochondria, the healthier the cell.” The numbers decline with age and disease.
Finally, mitochondria eliminate old and damaged cells. Everyday about 10 billion cells in the human body die, some suddenly (necrosis), others programmed to be replaced by new cells (apoptosis).
The author suggests mitochondria are “Like little robotic workers”, longtime loyal servants to human cells. When they aren’t working neither is the human body or brain.”
Chapter 8, “A Brain Energy Imbalance,” reviews how the diseases and illnesses associated with impaired mitochondrial function include all the psychiatric, neurological and metabolic disorders discussed but also include medical disorders such as many cancers and Parkinson’s disease.
This is not new evidence. In 1928 Dr. Raymond Pearl suggested that longevity and aging were metabolic diseases. In 1972 Dr. Denham Harman proposed the mitochondrial theory of aging. In 2017 Dr. Douglas Wallace, founder of mitochondrial genetics published an article in JAMA Psychiatry claiming, “all psychiatric disorders are the result of mitochondrial dysfunction.”
PART 111 Causes and Solutions
This final part consists of 21 chapters. Two of these chapters are particularly informative – Chapters 9 and 20.
Chapter 9, “What’s causing the Problem and what can we do?” offers the following:
- Treatment that corrects metabolic imbalance only – neurotransmitter or hormonal; often stopping medication.
- Treatments to overcome or reduce causes of dysregulation of mitochondria or metabolism such as diet, sleep, substance abuse, medication or psychosocial distress.
- Specific treatments for improving metabolism or mitochondrial function.
- Mitochondrial biogenesis
- Mitography – getting rid of defective mitochondria, replacing them with healthy ones.
- Autography – Repairing structural damage.
Chapter 20, “Putting it all together. Developing your treatment plan,” presents a “Success Story: Beth: Over medicated and still sick.”
“Diagnosed with ADHD at age 9, prescribed stimulants that relieved some cognitive symptoms but still impulsive and she didn’t have many friends, often felt criticized and rejected with low self-esteem. In High School she had chronic depression, was suicidal and began cutting herself. By the time she was in College she had been hospitalized several times.
“Christopher met her at age 21, diagnosed with chronic depression, panic disorder, borderline personality, premenstrual dysphoric disorder and ADHD. She was on 5 medications without benefit.
“They began with prolonged attempts to wean her off medication and begin dialectical behavior therapy. It took several years to wean her from medication, but she was able to finish college and hold a job. She started to exercise, joined Weight Watchers, lost weight and her psychiatric symptoms were all gone, treatment stopped, and she became an accomplished athlete, competing in ultramarathons. She married and got a full-time job.
“Some of the medications he failed to benefit from impair metabolism and mitochondrial function. She also lost weight and found love and a job with self-respect. These all played a role in her remarkable recovery.”
Remainder of Part 111
Ch. 10 Genetics & Epigenetics
Ch. 11 Chemical Imbalance, Neurotransmitters & Medication
Ch. 12 Hormones & Metabolic Regulators
Ch. 13 Inflammation
Ch. 14 Sleep, Light. Circadian Rhythms
Ch. 15 Food, Fasting and your Gut
Ch. 16 Drugs & Alcohol
Ch. 17 Physical Activity
Ch. 18 Love, Adversity & Purpose in Life
Ch. 19 Why do Current Treatments work?
Ch. 21 A New Day for Metabolic Health
The last chapter (21) is addressed to the reader with an appeal to participate in helping spread and implement the understandings of this new model of mental illness due to “Metabolism & Mitochondria” in a manner free from stigma and full of hope for people “suffering from mental illness alone and in silence, begging for more effective treatments and better lives.”
References:
Caspi A, Moffitt TE. All for One and One for All: Mental Disorders in One Dimension. Am J Psychiatry 2018;175(9):831-844.
Harman D. Free radical theory of aging: Consequences of mitochondrial aging. AGE 1983;6:86-94.
Pearl R. On the Pathological Relations Between Cancer and Tuberculosis. Proceedings of the Society for Experimental Biology and Medicine 1928;26(1):73-75.
Wallace DC. A Mitochondrial Etiology of Neuropsychiatric Disorders. JAMA Psychiatry 2017;74(9):863-4.
March 2, 2023