Neuroscience & Psychotherapy

10/28/2013

No Longer Strange Bedfellows?

“Advances in neuroscience provide guidance for the NEUROSCIENCE & PSYCHOTHERAPY: development of psychological conceptualizations of mental illness and treatment that go beyond a reductionistic NO LONGER STRANGE BEDFELLOWS biological etiology.”* TPA 2013: PART 2 NEUROSCIENCE IN THERAPY Timothy A. Urbin, PhD., MBA, HSP • “Reductionist”?: trying to “reduce human nature and suf- fering to biochemical malfunctions”* Clinical Psychologist/Neuropsychologist

Asst. Professor/Department of Family Medicine • Reductionism IS still alive but progress in genomics is Quillen College of Medicine showing it is the wrong path!

• * N. Cappas et.al. (2005). What psychotherapists can begin to learn from neuroscience: Seven principles of a brain-based Psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 42, 3, 374-383.

Useful to psychotherapy? Important to understand?

• “neuroscience can be useful to psychotherapy in at least • “Affective processes appear to lie at the core of the self, two ways”: and due to the intrinsic psychobiological nature of these 1. validation of existing psychotherapeutic theories and bodily-based phenomena recent models of human interventions development, from infancy throughout the lifespan, are 2. suggesting directions to enhance current clinical moving towards brain-mind-body conceptualizations.” practices • Schore, A. (2003). Affect Regulation and the Repair of the Self.

• “After three decades of the dominance of cognitive approaches, motivational and emotional processes have roared back into the limelight.”

* N. Cappas et.al. (2005). What psychotherapists can begin to learn from neuroscience: • Ryan (2007) Motivation and Emotion Seven principles of a brain-based Psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 42, 3, 374-383.

Clark & Beck (2010): Modified CBT

• “The power of psychotherapy to change the brain rests in • “Empirical evidence consistent with this model… indicates our ability to recognize and alter unintegrated or the effectiveness of cognitive therapy could be associated with reduced activation of the amygdalohippocampal dysregulated neural networks.” (p.340*) subcortical regions implicated in the generation of • *Cozolino, L. (2010) The Neuroscience of Psychotherapy: Healing the negative emotion and increased activation of higher-order Social Brain (2nd ed). New York: WW Norton & Co. frontal regions involved in cognitive control of negative emotion.” • Our human capacity to recognize problems also • “Deactivation of hypervalent dysfunctional schemas and improved access to more reflective, adaptive modes of allows us to change our brain processes! thought and behavior are considered crucial to symptom • “Thinking” allows us to meta-analyze our selves amelioration” • Clark, D.A. & Beck, A.T. (2010). Cognitive theory and therapy of anxiety and depression: Convergence with neurobiological findings. Trends in Cognitive Sciences 14 (2010) 418–424

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Neuroscience & Psychotherapy Term #1: Self-directed Neuroplasticity

“There is no longer any doubt that psychotherapy • Term #1: ‘self-directed neuroplasticity’ to serve as a can result in detectable changes in the brain.” general description of the principle that focused training and effort can systematically alter cerebral function in a predictable and potentially therapeutic manner” • Etkin, Pittenger, Polan, & Kandel (2005) J. of Neuropsychiatry & Clinical Neurosciences • Schwartz, J.M. & Begley, S. (2002) The Mind and the Brain: Neuroplasticity and the Power of Mental Force. New York: Harper Collins • Neuroplasticity: Primary principles • Use it or lose it • What fires together, wires together

Term #2: Relationship Neuroscience Findings: Early Neurodevelopment

• Rapidly expanding field of knowledge • Relationships are key to outcomes of early stages • Definition: “any work that uses neuroscience methods to understand close relationship processes or uses • Critical “bonding” network develops in infancy and relationship-relevant processes to advance knowledge of into 2nd year of life the brain.” • New module forms in right orbital-frontal cortex by • Healthy human connections: key to healthy brain! 2 ½ (parallels to Broca’s area in Left frontal lobe) • Interdisciplinary work involving experts in neuroscience, psychology, and biology- including biomarkers • Critical to self-regulation of emotion as well as • E.g. stress (cortisol) and bonding (oxytocin) hormones emotional interpretation of environment! • See: • Integral to “autoregulation” and “interactive regulation” • Adams, Glenn. III. Kunkel, Adrianne D., Editors (2012) Relationship science : integrating evolutionary, neuroscience, and sociocultural approaches . Washington, D.C.: American Psychological Association

Effect of Early Neurodevelopment 2 Effect of Early Neurodevelopment 3

• Outcome of this early stage is critical and long lasting • Responds in msec to changes in either environment • … “the most significant consequence of the stressor of • Internal & External environments early relational trauma is the lack of capacity for emotional • Verbal centers lag behind in assessing environment self-regulation” (Schore, 2002) • Typically follows the “lead” of the limbic system: • Becomes the source of our nonverbal (aka unconscious) • “Why do I feel this way? It must be because of …” sense of who we are and how we think about the world • NOTE: For adults, psychotherapy tries to help individual • Forms implicit memories: recognize these emotional reactions and underlying • “those things that you can’t quite put your finger on” implicit assumptions that are affecting their lives • CBT attempts to shift “control” to “rational” centers • System is always monitoring internal and external environments • Thinking taking charge of the override system! • Expanded models of CBT are developing- e.g. schema therapy • When you think “I don’t trust you…” or “Something’s • Better long term stability/relapse prevention wrong”, this system is already on!

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Progressive Developmental Goals Goal: Cognitive-Affective Balance (based on Neuroscience) KEY: Not the overall balance that matters, • Facilitate a healthy approach to emotional regulation it is the flexibility to shift when needed! • Approaches vary by age group

Start: Environmental management (young child)

To: Increased self-regulation (older child/teen)

To: Increased self-efficacy (teen/adult) Early Adolescence Early Adulthood To: Healthy, emotionally balanced Adult Ideally!

Managing Early Childhood Core childhood needs • Safety: “Stable Base,” Predictability • most influential Primary caregiver is • Love, Nurturing & Attention • Close face to face interaction is important due to infant’s • Acceptance & Praise limited vision (synchronized interaction) • Empathy • Tone of voice and facial expression are critical • Guidance & Protection • Imitating baby’s sounds is important for sense of social • Validation of Feelings & Needs connection • See Gottman & Gottman (2013) Emotion Coaching

• (NOTE: When treating children: focus on • When unmet, distress increases environment, quality of caregiver relationships, and • If not successfully met, maladaptive long term emotional-self regulation) schemas form

Early Stress 5 elements of emotion coaching Unmet Core Needs

Memory systems 1. Being aware of child’s emotions 2. Recognizing the emotion as an opportunity for intimacy TOXIC STRESS and teaching. 3. Listening empathically and validating the child’s feelings Hyper-responsive Chronic “fight or 4. Helping the child verbally label emotions stress response; flight;” cortisol / 5. Setting limits while helping the child problem solve calm/coping norepinephrine • Outcome research: “coached" children grew up to become "emotionally intelligent” CHILDHOOD STRESS Changes in Brain Gottman J. (1998) Raising an Emotionally Intelligent Child Architecture Gottman, J. & Gottman, J. (2013) Emotion Coaching. NY: Guilford Press

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“Emotionally Intelligent”? It is easier to build • able to regulate their emotional states • better at soothing themselves when they are upset strong children • can calm down their hearts faster after an upsetting incident than to repair • better at focusing attention • relate better to other people, even in tough situations like broken men. getting teased in middle school • better at understanding people • have better friendships with other children • better in school situations that require academic performance Frederick Douglass

Maladaptive Coping Styles What is a “Schema”?

• The ways in which a child adapts to a distressing childhood • “A schema is an extremely stable, enduring pattern that environment (survival): develops during childhood or adolescence and is 1. Schema surrender (freeze) elaborated throughout an individual’s life.” Limbic System 2. Schema avoidance (flight) • Important beliefs & feelings about oneself and the world Amygdala 3. Schema overcompensation (fight) • Individual “accepts” schema without question • Many specific, individual coping responses, derived from • Not necessarily “conscious”! these three broad styles • Typically maintained by right hemisphere and limbic system • Long term: leads to behavior with self-fulfilling prophecies • Self-perpetuating and very resistant to change. • The world is viewed through our schemas • Rose, Neutral, or Gray colored glasses!

Schema Therapy General Schema Therapy Guidance

• An integrative, unifying theory & treatment 1. Identify patterns in behavior • Consistent with current neuroscience studies a) Look beyond current identified triggers • Problems are assumed to have significant origins in b) Link pattern of problems to life history and early origins childhood & adolescent development 2. Educate them about pattern: “Reinventing Your Life” • Designed to treat a variety of long-standing emotional 3. Acknowledge benefit of the behavioral responses in the past (survival) difficulties, with individuals & couples 4. Increase awareness that responses are an impediment in • Combines cognitive, behavioral, attachment, object the present and likely in the future relations, and experiential approaches 5. Enhance self-efficacy by encouraging active awareness of “self-theory” (“hypotheses”= self-talk) • Specific “schema therapy” pioneered by Jeffrey Young 6. Encourage “corrective experiences” (Perry) to test these • Also expanded in CBT by Aaron Beck & Judith Beck “hypotheses”

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Differences from “standard” CBT Remember: Monitor YOUR nonverbals!

1. Greater emphasis on the therapeutic relationship • Nonverbals are primary triggers for “override system” • Identifying reactions in session is helpful 2. More emphasis on affective display during discussions and variations in mood states • Potential priming of implicit memory system: • Proxemics: proximity to another person 3. More exploration & discussion of childhood origins and • Nonverbal: distance developmental processes • Kinesics: bodily movements of another person 4. More emphasis on patterns/lifelong coping styles (e.g., • Nonverbal: Body posture, arm positions & movements avoidance and overcompensation) • Paralanguage: how messages are delivered 5. More emphasis on entrenched core themes/schemas • Nonverbal: Tone of voice, facial expressions, … suggested by behavioral patterns

Adolescents: Why DO they do the things they do? Critical Point for Psychotherapy

• “The "autobiographical memories" that tell the story of our lives are always undergoing revision precisely because our sense of self is too. We are continually extracting new information from old experiences and filling in gaps in ways that serve some current demand. Consciously or not, we use imagination to reinvent our past, and with it, our present and future.” (p. 66)

• GARRY, M., & POLASCHEK, D. (1999). Reinventing yourself: Who you are is limited only by your imagination. Psychology Today, 32(6), 65-69. • NOTE: This article is readily understood by everyone. However, there are MANY empirical research studies that have produced this now accepted conclusion.

Teenagers Adulthood

• Behaviors are primarily emotionally driven • Early Adulthood: • Amygdala: “Maximize pleasure, Minimize pain” • 18-25: Struggle between emotional and rational systems • Insight oriented approaches less effective: • Tendency to ignore “facts” that don’t fit “what they want” • Not “Why did you do that?” • Affects decision-making: school, career, relationships,… • Frequently produces “Rationalizing” behavior • 25-30: Integrated emotional and rational systems • Future focus may be more beneficial: • Time when “The lights come on!” • “The next time you are in this situation, what things can you do to prevent this problem from occurring?” • May struggle with decisions that have been made • “Where do you want to be in five years?” What are your dreams for • If significant emotional issues and maladaptive coping the future?” “What do you imagine your life will be like?” “What styles remain when entering this stage, result may be a things can you do now to make it more likely to happen?” “What psychological crisis things are you doing now that may interfere with these goals?”

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The integrated brain at 25-30 y/o? General Therapy Guidance

• Jimi Hendrix: died September 18, 1970, age 27 1. Reduce impact of current crisis/presenting problem • overdose barbiturates and alcohol . Goal: Initially reduce intensity of symptoms then reduce • Janis Joplin: died October 4, 1970, age 26 frequency of occurrence (stabilize override system) • “official cause of death was an overdose of heroin, possibly a. Use specific CBT approaches for depression, anxiety, etc. combined with the effects of alcohol” b. Possible Medication as short term adjunct to psychotherapy • Amy Winehouse: died July 23, 2011, age 26 2. Increase skills needed to stabilize & prevent relapse • alcohol poisoning • Goal: Reduce activation of “override” & Increase • Heath Ledger: died January 22, 2008, age 28 “thinking”(cognition) • “accidental intoxication from prescription drugs” a. Develop Relaxation/Mindfulness skills to slow reactions • Kurt Cobain: died April 8, 1994, age 27 b. Improve self-care/wellness (sleep, nutrition, exercise) • “officially ruled a suicide by a self-inflicted shotgun wound c. Enhance skills in Communication, Problem solving… • Jim Morrison: died July 3, 1971, age 27 d. Identify patterns in behavior to aid prevention • “alleged to have died of a heroin overdose”

Cautions for psychotherapists General Therapy Guidance 2

• “Although informative, eliciting accounts of disability and 3. Reinforce awareness of successes (using MI if possible) distress from patients may exacerbate negative . Goal: Enhance Self-Efficacy perceptions of self.” (Cappas et.al., 2005) . e.g. “You really did better… last time you… so this a positive change” . Begin delaying “fight, flight, or freeze” response . Assess perceived current “failures” to identify specific factors that • Talking about trauma can reduce or exacerbate emotional may have affected actual outcome or perception of outcome responses depending on the context used! • Problem solving & reframing 4. Enhance ability to predict situations that trigger relapse • Verbalize to client/patient that exploring these issues: . Goal: Enhance Self-Efficacy 1. is important for your understanding of possible triggers . Increase sense of control/improve future orientation 2. will not be an ongoing verbal focus of treatment (!) . Expand exposure to situations that will “change the brain”! . Enhance involvement of “Thinking” areas 3. Keeping a focus on traumatic events impairs healing

Activate “Corrective” Experiences: Increased Sense of Stress Event Negative Vulnerability Schemas • Talking is NOT enough! TOXIC STRESS Sympathetic • “Parts of the brain cannot be changed if they are Activation not activated” (verbalize to client) • “The client must have opportunities for new Hyper-responsive Chronic “fight or experiences that will allow the brain either to stress response; flight;” cortisol / break false associations or to decrease the calm/coping norepinephrine overgeneralization of trauma-related associations (corrective responses)” Changes in Brain Architecture • (Perry, ChildTraumaAcademy.org) “What Fires Together, Wires Together!”

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Stress Event Increased self-efficacy Increased Resilience Early Maladaptive Schemas

RelaxationTOXIC STRESS Skills • A broad, pervasive theme or pattern • Comprised of memories, bodily sensations, emotions & Parasympathetic cognitions Activation “Time to Think”: Implement • Basis of beliefs about oneself and one's relationships with Healthy Adult response Decrease “fight or others Relaxation response; flight”: cortisol / • Developed during childhood or adolescence calm/coping norepinephrine • Enhanced/reinforced throughout one's lifetime • Dysfunctional to a significant degree Changes in Brain • Affects relationships, life satisfaction, career stability Architecture “Use it or lose it”

The 18 Early Maladaptive Schemas Disconnection & Rejection Impaired Limits Schema perpetuation • Emotional Deprivation • Entitlement • Routine processes by which schemas function and • Abandonment • Insufficient Self-Control perpetuate themselves. • Mistrust/Abuse Other-Directedness • Accomplished by cognitive distortions, self-defeating • Subjugation behavior patterns and schema coping styles • Social Isolation • Self-Sacrifice • Schema will: • Defectiveness • Approval Seeking • highlight or exaggerate information that confirms the Impaired Autonomy Overvigilance & Inhibition schema and • Failure • Emotional Inhibition • will minimize or deny information that contradicts it • Dependence • Unrelenting Standards • Unhealthy behavior patterns will perpetuate the schema's existence • Vulnerability • Negativity/Pessimism • Therapist needs to clarify all of the above! • Punitiveness

Example: MDD Schema Change/Healing in Therapy • Evidence: “minimize or deny information that contradicts” • Point out when patient’s schemas seem to be triggered in • Johnstone, T., van Reekum, C.M., Urry, H.L., Kalin, N.H. and Davidson, R. J. a session or in recent events (2007) Failure to Regulate: Counterproductive Recruitment of Top-Down Prefrontal-Subcortical Circuitry in Major Depression. The Journal of Neuroscience, 27(33): 8877–8884 • Ask patient for trigger event, emotions & cognitions

• Finding: In Major Depression, frontal activity intensifies • Test validity of patient’s reaction: distinguish accurate rather than suppresses responses within amygdala perceptions from schema-driven overreactions • Rumination & Frequent verbal discussions with others • Link event in session with situations outside therapy

• Therapist tries to be aware when his/her own schemas are being triggered to clarify interpersonal processes

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How does that make you feel? Where has the DSM failed us?

• “The results indicated that affect labeling, relative to other • DSM V: intended to incorporate more neuroscience forms of encoding, diminished the response of the knowledge amygdala and other limbic regions to negative emotional • DSM: Reinforces reductionist approaches images.” • E.g. matching medications to diagnosis • Lieberman, M.D., Eisenberger, N.I., Crockett, M.J., Tom, S.M., Pfeifer, J.H., & Way, B.M. (2007) Putting Feelings Into Words : Affect Labeling Disrupts • Neuroscience research showing failure of this approach: Amygdala Activity in Response to Affective Stimuli. Psychological Science • “Lumps” together heterogenous groups under single label 2007 18: 421-428 • Creates artificial distinction between disorders with similar

neurobiological underpinnings

• “effective management of depression requires an individualized approach that is tailored to the specific symptom footprint of the presenting individual” • Sharpley 2013

DSM Example: Depression Can Neuroscience Help?

• “although usually reported as a unitary diagnosis, major • See Sharpley et.al. (2013) propose: depressive episode is composed of a range of different • 4 Depression Types suggested based on DSM dx criteria: symptoms that can occur in nearly 1500 possible • Clinical content subtypes: combinations to fulfill the required diagnostic criterion” • 1: depressed mood • Sharpley & Bitsikab (2013). Differences in neurobiological pathways of four "clinical content" subtypes of depression. Behavioural Brain Research, 256, 368-376 • 2: anhedonic depression Author identified “Highlights”: • 3: cognitive depression • Depressive behavior is heterogenous. • 4: somatic depression • Four "subtypes" of depression were identified from symptoms.

• Each subtype has different behaviors and neurological pathways. • Effective individualized treatment requires attention to these Different underlying neurobiological mechanisms = differences. Different treatment approaches

Subtype 1: depressed mood Subtype 2: anhedonic depression

• “most easily recognized and familiar of the two key • See Sharpley et.al. (2013) criteria” • “less well-known than depressed mood” to public • “early life experiences establish the ways in which future • “second of the two key symptoms” events are perceived and how they affect adult mental • “hypothesized to result from imbalance in catecholaminergic health” systems, principally dopamine (DA)” • “That learning has neurobiological mechanisms including • “characterized by a lack of interest in previously valued changes to prefrontal cortex, hippocampal, and amygdala rewards” functions induced by elevated HPA axis function and • “loss of “'desiring' factor for hedonic rewards” elevated serum cortisol which accompany prolonged • “find it difficult to expend effort to obtain the rewards” stress and anxiety. In addition, prolonged psychosocial • “overestimation of future costs and an underestimation of future stress reduces serotonin release and uptake” benefits” • “…use of treatments that re-establish serotonergic • Increase Dopamine? (buproprion) function if required” • Behavior Activation (Nike: “Just do it!”)

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Subtype 3: cognitive depression Subtype 3: cognitive depression

• See Sharpley et.al. (2013) • “Pharmacological treatments for cognitive deficits that • “deficits in executive functioning (EF), particularly in young enhance sleep quality and normalize circadian rhythm adults may be beneficial” • “selective attention, processing speed, vigilance, short-term memory and working memory” • “behavioral activation - may have some benefit” • “Difficulty… seeing the world from an alternative (non- • Increase activities with others depressing) perspective, the inability to shift mental set has been described as the most prominent EF impairment” • Decrease time “ruminating” & talking about depression • “deficits in processing information, and a bias toward negative • Sleep hygiene interpretation of information”

• “concentration difficulties… appear to include only the individual's ability to focus upon positive stimuli and emotions” • “difficulties when in unstructured situations (such as being alone, ruminating)”

Subtype 4: somatic depression Take Home Summary Points

• See Sharpley et.al. (2013) • We ARE trying to change the brain! • “either hyper- or hypo-activated, implying that it is this • “Change your brain, change your life” imbalance in physiological activity” • Rapid changes are unlikely to be sustained • “higher overall prevalence of depression among women is • Change takes time & persistence of therapist and patient due to somatic symptoms of MDE alone (appetite, sleep, • Therapeutic relationship is essential to positive changes fatigue) and not depressed mood, anhedonia or cognitive symptoms” • Patient needs to understand goals and process • • “Insomnia is one of the most common prodromal features” Understand the individual patient not the diagnostic label! • • “focusing upon the underlying physiological bases for Identify current behavior patterns and underlying schemas them such as diet, sleep and exercise” • Plan treatment based on this understanding • “may reduce MDE somatic symptoms with only marginal • Slow down “override” while enhancing “thinking” reference to the other (emotional, cognitive) symptoms” • Thinking should “lead” in the adult, not follow!