'Brain Energy' by Chris Palmer, MD (review)

Mental disorders are metabolic disorders.

‘Brain Energy’ by Chris Palmer, MD is a critique of the standard approaches to diagnosis and treatment of mental illness as codified in the Diagnostic & Statistical Manual-5 (DSM-5) published by the American Psychiatric Association (APA).

Introduction

The brain is the single most metabolically demanding organ in the body. It uses about 30% of all the caloric energy consumed by the body.

Imagine that for a minute.

If about one third of our metabolism is dedicated just to powering our thoughts, does it make sense that thinking can make us tired? Or that we can’t think as well when we’re hungry or fatigued? Or that metabolic stimulants (e.g., caffeine, sugar) have powerful cognitive effects?

It makes sense to me.

And it’s the principal thesis behind Dr. Chris Palmer’s book Brain Energy (Palmer 2022), in which he provides a critique of the standard approach to diagnosis and treatment of mental disorders as it has been codified in the Diagnostic & Statistical Manual-5 (DSM-5). As an alternative, Palmer advocates for a metabolic approach to diagnosis and treatment of causes he claims that underlie symptoms associated with a constellation of mental health issues including anxiety, depression, and post-traumatic stress disorders.

Critique & contributions

Palmer is not the first to criticize the DSM-5 as hopelessly confusing and ineffective. For example, in Complex PTSD: From Surviving to Thriving, Pete Walker wrote “I once heard renowned traumatoligist John Briere quip that if complex post-traumatic stress disorder were even given its due, the DSM used by all mental health professionals would shrink from its dictionary-like size to the size of a thin pamphlet” (Walker 2013, p8). However, while Walker brushes aside the DSM, Palmer undertakes a more systematic critique of its overlapping diagnostic criteria that fail to result in reliable prognoses or treatments.

Neither is Palmer, by his own admission, the first to suggest that metabolism is critical to mental health. Palmer claims that his unique contribution is assembling different “pieces of the puzzle together to reveal one coherent theory” (Palmer 2022, p5).

I think Palmer overreaches in his claim. In science, the measure of a theory is the extent to which it generates informative, falsifiable hypotheses. Palmer offers us none.

His principal contribution is his critique, not his creation. For example, Palmer overlooks an enormous body of literature on somatic approaches to mental health exemplified by Bessel van der Kolk, MD (e.g., The Body Keeps the Score 2014) and Peter Levine, PhD (In An Unspoken Voice 2010), as well as Walker’s work on the origins of mental health disorders in chronic, inescapable childhood trauma that rewires the young, neuroplastic brain. Palmer also overlooks work by Daniel Amen, MD (e.g., The End of Mental Illness 2020), who pioneered the use of SPECT brain imaging to replace self-reported symptoms as a basis for diagnosis and treatment.

Where Palmer might have connected his metabolic approach to others who have successfully worked outside the ambiguity of the DSM is to point out that the work of somatic approaches is energetically exhausting. For example, in my article The Trauma Benefits of Trembling, I described how shivering can help reset the autonomic nervous system to reduce the risk of emotional flashbacks and post-traumatic stress disorder (PTSD). What I took for granted is the energetic expenditure required. Similarly, the cognitive reframing and thought interruption prescribed by Walker must require an enormous energetic effort, given the metabolic demands of thought.

Palmer might have hypothesized that effective mental health therapies increase demands on brain metabolism, and that strengthening the metabolism to meet those demands might facilitate or accelerate those therapies. Given that Palmer’s experience treating mental health disorders as a practicing psychiatrist is in a traditional clinical setting primarily using talk therapy, it may be that improvements he attributes to metabolic interventions are really cases in which the metabolic fixes support other therapies, rather than replaces them. In fact, this combination of metabolic support (e.g., nutritional supplements) for other therapies is characteristic of Amen’s approach.

Nonetheless, for people frustrated with the futility of the DSM, Palmer offers more than solace. He offers new possibilities based in metabolism.

Review

For my readers considering Palmer’s book as an aid to their own efforts to either recover from trauma and redesign their lives, I’ve copied below the text of the Brain Energy review I posted on Amazon:

While the pithy, dust-jacket Editorial Reviews from academics and clinicians describing 'Brain Energy' are accurate, they might not speak to the average reader who is struggling with low mood, depression, or unresolved trauma.

In this regard, Brain Energy can help.

Part 1 deconstructs the DSM-5 and describes the way that current practices in psychiatry and psychology result in a confusing myriad of overlapping diagnoses that often leave patients feeling neglected, misdiagnosed, and overlooked. The metaphor of 'mental illness' suggests that maladies of the mind can be treated as if they were infectious diseases -- e.g., with pills. If you're a patient with a DSM-5 diagnosis, you may have experienced years of changing diagnosis, misdiagnosis, and unsuccessful medications that left you feeling increasingly hopeless and misunderstood. Dr. Palmer suggests that the reason so many of the DSM-5 mental disorders are so similar is that they all have a common foundational cause in the metabolism of the brain. While he is careful to acknowledge that schizophrenia, anorexia, and Alzheimer's are different diseases (for example), by the end of Part 1 you will understand that mental disorders are often accompanied by physiological comorbidities relating to metabolism. The implication is that there can be multiple expressions the same energetic dysfunctions.

Part 2 builds a convincing case that disorders of brain metabolism are the critical, overlooked risk factor in mental (or psychiatric) disorders. By itself, this is not a novel assertion. For example, we have known for decades that a ketogenic diet will control epileptic seizures. However, ketosis (or exogenous ketone supplement ingestion) has an undeserved reputation as some kind of dangerous, radical fringe diet adopted by only by 'biohackers' and conspiracy theorists. Dr. Palmer advocacy for ketogenesis from his position at Harvard University (notorious for advancing now discredited theories of diet and nutrition such as the cholesterol-heart hypothesis) may in fact be regarded as revolutionary at his home institution. Originally popularized by Dr. Robert Atkins as an effective strategy for weight loss, Dr. Palmer (a practicing psychiatrist) accidentally discovered improvements in mood among patients who adopted keto to treat obesity.

Although the discover was accidental, the mechanisms of action are not. When the body ingests more carbs than it burns, two things happen: 1) fat gain, and 2) insulin resistance. The later is a condition in which insulin in the bloodstream -- responsible for shuttling glucose across the cell membrane -- becomes increasingly less effective. That is, the cells resist the action of insulin, resulting in higher concentrations of glucose (sugar) in the blood. Although the evolutionary reasons for insulin resistance are unknown, it may be that lower concentrations of glucose within the cell walls give the mitochondria inside more time to process the carbohydrate without production of excess reactive oxygen species. Overworked mitochondria can be more prone to damage by ROS, and damaged mitochondria in the brain are less effective for powering essential cognitive processes.

Ketosis is a proven remedy for insulin resistance, and may rejuvenate the mitochondria throughout the body, including the brain. When your brain's mitochondria function better, you will feel a boost to both your mood and your mental energy. For example, ketosis has been shown to have an anxiolytic effect (which means it reduces anxiety) and consequently it has been used with some success in the resolution of anorexia nervosa.

Part 3 expands the description of 'metabolism' beyond diet to include sleep, light exposure, exercise, drugs, and alcohol. The implication here is that the brain and body act as a complex system, and consequently systemic approaches to health will be more effective than focused strategies. While this is true, the unfortunate outcome for some readers, already discouraged, maybe to conclude that it is all impossibly complex, difficult, and too ambitious to fix.

That's not true.

The most important critique of Dr. Palmer's otherwise fine text is that the prescriptive section 'Developing Your Metabolic Treatment Plan' is too general. It lacks specificity and actionable recommendations that readers can implement immediately on their own. Instead, it funnels readers towards professional clinicians -- despite the fact that by Dr. Palmer's own description the vast majority of his colleagues are unwilling or unqualified to act on the type of science 'Brain Energy' describes.

Thus, readers reaching the end of the book may be disappointed or confused about where to begin their 'Brain Energy' healing journey.

An outstanding companion to 'Brain Energy' is Ben Bikman, PhD's book on insulin resistance called 'Why We Get Sick.' Professor Bikman explains insulin resistance in greater detail in a way that will help readers understand how to reduce their risk of heart disease, Type 2 diabetes, and cancer, as well as improve mental health.

My own advice is to begin by eliminating refined sugar and flour (e.g., bread, pasta, rice) from your diet. Bikman gives some suggestions (e.g., stevia) for sweeteners that will not spike your blood sugar. And Dr. Paul Saladino is well-known for advocating for honey and maple syrup as healthy sweeteners. Dr. Palmer doesn't mention these sweeteners specifically, but there's nothing in his 'Brain Energy' book that contradicts or is inconsistent with the Bikman & Saladino recommendations.

More difficult is the elimination of seed oils. Called "vegetable oils" by the industry that invented them, these are cooking oils extracted from soybeans, corn, cotton, peanut, and other seeds. Unlike fruit oils (olive, avocado, coconut) the seed oils contain a type of fat that interferes with the proper function of cell membranes, and can result in insulin resistance. It's more difficult to eliminate them because they are cheap and ubiquitous. But you can reduce their intake by avoiding margarine, Crisco, soybean oil (e.g., in salad dressings) and fried foods.

Finally, it sounds crazy to most people, but deliberate cold exposure (e.g., ice baths) is a proven method for increasing insulin sensitivity and resolving metabolic disorders. The cold will clear glucose from your bloodstream and recruit brown fat that helps modulate your thyroid function. As a bonus, winter swimming and ice baths have been shown to stimulate production of dopamine, which makes it impossible to stay in a low mood.

In summary, Dr. Palmer's 'Brain Energy' book presents a convincing case that metabolic syndrome is a critical disorder that impinges upon mental health. Because this fact is overlooked by most, if not all, mental health professionals, it's easy to see why rates of recovery associated with mood-stabilizing pharmaceuticals and talk therapy are so low. Without fixing your metabolism, your efforts to fix your mental health will be challenged by a brain that is working without the energy it needs to perform demanding tasks like cognitive reframing and the executive functions necessary for mental well-being.

However, once you and your mental health professional are convinced by Dr. Palmer that metabolism is at the core of your dissatisfaction, you will likely need to seek other sources to develop a successful metabolic treatment program.

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Additional Reading