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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
BIOLOGICAL CORRELATES OF PSYCHOTERAPY
FIGURE I
-3
-2
-1
0
1
2
Average (no treatment)
control effect size
Average Minimal
Treatment
(placebo) effect size
(.42)
Adapted from Lambert, et al. 1993
3
Average
psychotherapy
effect size (.82)
SUMMARY OF EFFECT OF STDP
EFFECT SIZES
Domain
STDP
Term/F-U
USUAL TX
Term/F-U
WAIT-LIST
Term/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 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
1.09-1.28
1.13-1.30
Overall
effectiveness
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
1.09-1.28
1.13-1.30
Overall
effectiveness
SUMMARY OF EFFECT OF LTDP
EFFECT SIZES
Domain
Pt’s with Multiple
Disorders
Term/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 Psychotherapy
Results- 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 SelfDisorders)
(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
PSYCHOTHERAPY AND NEUROBIOLOGY
Cortex
Pre Frontal Cortex
+
Stimulus
Thalamus
Amygdala
Hippocampus
Psychotherapy and
Neurobiology
DISORDER
TECHNIQUES
POST-TREATMENT FINDINGS
OCD – Social
Phobia
CBT/BT
Decrease metabolism in R
caudate nucleus
Uncoupling of cortico-striatothalamic activity
Decrease limbic metabolism
Decreased 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
Major
Depression
TECHNIQUES
IPT
POST-TREATMENT FINDINGS
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 SYSTEM
Rizzollati 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)