FUNDACION CASTILLA DEL PINO

ABORDAJES PSICOTERAPEUTICO DE LOS

TRASTORNOS PSIQUIATRICOS

Cordoba, Marzo 2009

PRESENTE Y FUTURO DE LAS PSICOTERAPIAS DINAMICAS

SYMPOSIUM EN HONOR DE AARON T. BECK , M.D.

Manuel Trujillo, M.D. Professor of Psychiatry

New York University

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BIOLOGICAL CORRELATES OF PSYCHOTERAPY

FIGURE I

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Average (no treatment) control effect size

Average psychotherapy effect size (.82)

Average Minimal Treatment(placebo) effect size (.42)

Adapted from Lambert, et al. 1993

SUMMARY OF EFFECT OF STDP EFFECT SIZES

Domain STDPTerm/F-U

USUAL TXTerm/F-U

WAIT-LISTTerm/F-U

Target Problems

1.39 – 1.57 0.55 – 0.84 0.27 – NA

Symptoms 0.90 – 0.95 0.22 – 0.24 0.12 – NA

Leichsenring F ( 2004)

SUMMARY OF EFFECT OF LTDP EFFECTS SIZES

DOMAIN LTDP-PTS withMultiple Disorders

Term/F-U

PTS with complex

Anxiety/DepresTerm/F-U

Target Problems

1.62 – 1.84 1.82-1.94

Symptoms 0.98 – 1,18 1.02-1.32

Overall effectiveness

1.09-1.28 1.13-1.30

SUMMARY OF EFFECT OF LTDP EFFECTS SIZES

DOMAIN LTDP-PTS with

Multiple Disorders

Term/F-U

PTS with complex Anxiety/Depres

Term/F-U

Target Problems

1.62 – 1.84 1.82-1.94

Symptoms 0.98 – 1,18 1.02-1.32

Overalleffectiveness

1.09-1.28 1.13-1.30

SUMMARY OF EFFECT OF LTDPEFFECT SIZES

Domain Pt’s with MultipleDisordersTerm/F-U

Pt’s with Complex

Anx/Depr.Term/F-U

Personality Function

0.96-1.43 – 1.57 0.97-1.79

Social Functioning

0.94-1.01 1.02-0.99

Leichsenring F , JAMA ( 2008)

Core features of the LTDP

• Development of insight• Identification and interpretation of

transference and resistance• Integration of Cognitive and Affective

components

New Models of STDP Panic-Focused ( B.

Milford)• Panic symptoms carry psychological

meanings the aim is to un-cover such unconscious meanings, and

• To work through conflicts related to separation-individuation and abandonment

• To work through conscious or unconscious anger

Panic- Focused PsychotherapyResults- RCC

• Twice as many experimental psychotherapy patients met response criteria at termination than controls

• 73% of PFPP patients vs 39% of the controls met the response criteria for panic (40% red. in scale score).

• PFPP patients also achieved > control reduction in functional impairment.

New Models • Transference-Focused P. for Borderlines (Clarkin, Kernberg)• STDP for Narcissistic P.D and Self-

Disorders) (Trujillo)• Affect-Focused STDP (Fosha)• Impulse-Focused P. for Borderlines

(Complutense Group)

Psychotherapy and Neurobiology

• The growth of neural science in general, and of cognitive neuroscience and neuropsychology , affords contemporary psychoanalysis a second chance to anchor classical meta-psychology in a newly evolving neural science.

Psychotherapy and Neurobiology

Pathways include:• the modulation of basic neurophysiological brain

functions (Shear et al)• altering serotonergic function (Viinamäki, Baxter)• modifying synaptic plasticity and gene expression

( Kandel, Brody)• changes in the function of the anterior cingulate

cortex (Saxena), various limbic structures, the prefrontal cortex and other brain centers which play key roles in the processing of key emotions and views of self and others

Cortex

Stimulus Thalamus Amygdala Hippocampus

Pre Frontal Cortex

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PSYCHOTHERAPY AND NEUROBIOLOGY

Psychotherapy and Neurobiology

DISORDER TECHNIQUES POST-TREATMENT FINDINGS

OCD – Social Phobia

CBT/BT Decrease metabolism in R caudate nucleus

Uncoupling of cortico-striato-thalamic activity

Decrease limbic metabolismDecreased thalamic metabolism

Major Depression CBT Decrease activation in dorsolateral prefrontal cortex

Decrease activation in parahipocampal gyrus

Increase activation in limbic regions

Psychotherapy and Neurobiology

DISORDER TECHNIQUES POST-TREATMENT FINDINGS

Major Depression IPT Increase activation in right basal ganglia

Increase activation in right posterior cingulate

Decrease metabolism in prefrontal cortex, which correlates with symptom improvement

THE MIRROR NEURON SYSTEMRizzollati 1995

• Subset of multimodal neurons (Simultaneous activation by

different sensory modalities)•F5 in monkeys•Broca 44, 45 in humans (Prefrontal Cortex)

THE MIRROR NEURON SYSTEM

Activated by:•Observing a meaningful action•Performing the same action•Basis for primitive

learning/communicating with others

THE MIRROR NEURON SYSTEM

Plays a role in:•Affect resonance•Empathy•Group behaviors: hunting, dancing•Language development

Psychotherapy and Neurobiology Towards an Integration

The models links

• GENETICS, with• ADVERSE DEVELOPMENT• Altered NEUROPHYSIOLOGY• Dysfunctional COGNITIONS• Stressful TRIGGER• DEPRESSION

Links and Steps • Genetics : 5 HTTPLR s/l alleles• Reactive amygdala- Cognitive biases• Exaggeration of stressful events (HPA

act.)• Dominance of limbic over PFC• Deficient Reappraisal of (-) Cognitions• DEPRESSION

PSYCHOTHERAPY AND NEUROBIOLOGY

“We must recollect that all of our provisional ideas in psychology will presumably one day be based on an organic structure.”

Sigmund Freud, “On Narcissism” (1914)

PSYCHOTERAPY AND NEUROBIOLOGY

“We may expect [physiology and chemistry] to give the most surprising information and we cannot guess what answers it will return in a few dozen years of questions we have to put to it. They may be a kind that will blow away the whole of our artificial structure of hypothesis.”

Sigmund Freud, “Beyond the Pleasure Principle” (1920)