FUNDACION CASTILLA DEL PINO ABORDAJES PSICOTERAPEUTICO DE LOS

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 separationindividuation 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 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

PSYCHOTHERAPY AND NEUROBIOLOGY Cortex Pre Frontal Cortex - + Stimulus Thalamus Amygdala Hippocampus

Psychotherapy and Neurobiology DISORDER OCD – Social Phobia Major Depression TECHNIQUES CBT/BT CBT POST-TREATMENT FINDINGS Decrease metabolism in R caudate nucleus Uncoupling of cortico-striato-thalamic activity Decrease limbic metabolism Decreased thalamic metabolism 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) • F 5 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)