The Impact of Psychotherapy on the Brain
by Glen O. Gabbard, M.D.
September 1998, Vol. XV, Issue 9
Psychiatric Times
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We live in an era of stigma regarding psychiatric illness, psychiatric
patients and psychiatric treatments-an era in which a Supreme Court
justice suggests in a minority-dissenting opinion that one would be
better off talking to one's mother than to a psychotherapist.
Indeed, psychotherapy is often viewed as a form of hand-holding
rather than a "real" treatment. This perspective persists
despite the fact that there is overwhelming evidence that it is a highly
effective intervention. In psychotherapy studies, the magnitude of the
effect size is sufficient to justify interrupting clinical trials on
the grounds that it would be unethical to withhold such a highly effective
treatment (Ursano & Silberman, 1994).
Evidence and Imaging Techniques
With advances in the neurosciences, and especially in
imaging techniques, we stand at the threshold of demonstrating that
psychotherapy is a powerful intervention that affects the brain. While
it has been intuitively obvious to most clinicians that psychotherapy
must work by affecting the brain (how else could it work?), recent breakthroughs
in technology have allowed us to begin demonstrating for the first time
what kinds of changes occur with psychotherapy. Documentation of these
changes may go a long way toward removing the stigma currently attached
to psychotherapy.
While there was a time when psychotherapy was thought
to be the appropriate treatment for "psychologically based"
disorders, and medication was considered the treatment of choice for
"biologically based" disorders, this distinction is now becoming
increasingly specious (Gabbard, 1994; Gabbard and Goodwin, 1996).
In one study of obsessive-compulsive disorder, Baxter
et al. (1992) looked at local cerebral metabolic rates for glucose using
positron emission tomography scan methodology. They found that both
behavior therapy and fluoxetine (Prozac) produced similar decreases
in cerebral metabolic rates in the head of the right caudate nucleus,
suggesting (but not proving) that this form of psychotherapy and fluoxetine
have similar physiological effects at the level of the brain.
There is extensive evidence that cognitive-behavior therapy
is an effective treatment for panic disorder. Panic attacks can be triggered
by lactate infusion in those with panic disorder. At least one study
(Shear et al., 1991) has demonstrated that lactate induction of panic
can be effectively reversed through successful cognitive therapy. These
findings suggest that psychological interventions can alter the response
of the brain to biochemical factors. Psychiatric researchers in Finland
recently published a report showing that psychodynamic therapy may have
a significant impact on the neurotransmitter serotonin (Viinamýki
et al., 1998). At the beginning of a one-year psychotherapy process,
single photon emission computed tomography (SPECT) imaging was undertaken
with a 25-year-old man suffering from personality disorder and depression.
Another young man with similar problems also underwent imaging but did
not receive psychotherapy or other treatment.
Initial SPECT imaging showed that both patients had markedly
reduced serotonin uptake in the medial prefrontal area and the thalamus
compared with 10 healthy control subjects. After one year of dynamic
therapy, repeat SPECT imaging showed that the patient who received the
psychotherapy had normal serotonin uptake while the control patient
who did not receive psychotherapy continued to have markedly reduced
serotonin uptake. This study suggests that dynamic psychotherapy may
normalize serotonin metabolism.
Effects of Psychological Factors
Cancer research has shown positive effects of group psychotherapy,
and by inference, a powerful effect on the brain and the body. Spiegel
et al. (1989) conducted a controlled study in which metastatic breast
cancer patients were randomly assigned to group psychotherapy or a control
condition. Those in group psychotherapy lived an average of 18 months
longer than controls. In a study of malignant melanoma patients, Fawzy
et al. (1993) placed patients in either a support group or a control
condition. They found that patients in the support group have more favorable
death rates and more lengthy remissions than the controls. Most remarkable,
this effect appeared to occur even though the support group lasted only
six weeks.
A group of Pittsburgh investigators (Thase et al. 1998)
studied 78 unmedicated patients with mild major depressive episodes.
They were examined for sleep architecture changes before and after six
weeks of cognitive-behavior therapy. The psychotherapy affected the
neurobiological sleep variables in the same way as antidepressant medications.
While all of these studies are preliminary and require
replication and further research, there can be little doubt that we
are entering a new frontier in the mind-brain specialty known as psychiatry.
We now know that the brain is characterized by considerable
plasticity and that genes are not static but responsive to environmental
factors which we are only beginning to understand. Kandel (1998) has
suggested that by producing changes in gene expression, psychotherapy
may alter the strength of synaptic connections. Biological and psychosocial
factors appear to have equal weight in development. There is a reciprocal
effect of gene expression on environment and environment on gene expression
in every family system. We can no longer afford a reductionism in either
a biological or psychosocial direction.
All this evidence of the impact of psychotherapy on the
brain opens up new lines of investigation to enhance our understanding
of psychopathology and treatment: a) the mechanisms of action of psychotherapy,
b) the interrelationships of the mechanisms of action of medication
and psychotherapy, and c) a clearer understanding of pathogenesis itself
and the malleability of some components of the pathogenetic mechanisms
of major psychiatric disorders.
Dr. Gabbard is the Bessie Walker Callaway Distinguished
Professor of Education and Psychoanalysis at the Menninger Clinic and
Karl Menninger School of Psychiatry and Mental Health Sciences.
References
Baxter LR, Schwartz JM, Bergman KS et al. (1992), Caudate
glucose metabolic rate changes with both drug and behavior therapy for
obsessive-compulsive disorder. Arch Gen Psychiatry 49(9):681-689.
Fawzy FI, Hyun CS, Fawzy NW et al. (1993), Malignant melanoma
effects of an early structured psychiatric intervention, coping, and
affective state on recurrence and survival 6 years later. Arch Gen Psychiatry
50(9):681-689.
Gabbard GO (1994), Mind and brain in psychiatric treatment.
Monograph. In: The Institute of Pennsylvania Hospital Strecker Award
Monograph Series XXXI, November.
Gabbard GO, Goodwin F (1996), Clinical psychiatry in transition:
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Psychiatry, American Psychiatric Press, pp 527-548.
Kandel ER (1998), A new intellectual framework for psychiatry.
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Shear MK, Fyer AJ, Ball G et al. (1991), Vulnerability
to sodium lactate in panic disorder patients given cognitive-behavioral
therapy. Am J Psychiatry 148(6):795-797.
Spiegel D, Bloom J, Kraemer HC, Gottheil E (1989), Effect
of psychosocial treatment on survival of patients with metastatic breast
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Thase ME, Fasiczka AL, Berman SR et al. (1998), Electroencephalographic
sleep profiles before and after cognitive-behavior therapy of depression.
Arch Gen Psychiatry 55(2):138-144.
Ursano R, Silberman EK (1994), Psychoanalysis, psychoanalytic
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Press Textbook of Psychiatry, 2nd ed. Hales E, Yudofsky SC, Talbott,
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Viinamýki H, Kuikka J, Tiihonen J, Lehtonen J (1998),
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A case-control study. Nord J Psychiatry 52:39-44.
(The preceeding is a summary of Dr. Gabbard's presentation
as the third annual Gene Usdin, M.D., Distinguished Visiting Lecturer
in Psychiatry. Previous lecturers were Jerry M. Lewis, M.D., and Peter
V. Rabins, M.D.-Ed.)
Reference
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