Neuroplasticity Of Psychotherapy?

By Wasim Kakroo 

OUTCOMES of psychotherapy and the way it brings change in a person’s attitude and behavior have historically been studied on the psychological and social levels, by assessing changes in symptoms, psychological functioning, personality, or social functioning. Many clinicians have also held the problematic view that psychotherapy is a treatment for “psychologically based” issues while medication is a treatment for “biologically based” issues. It has been evident over the past few decades that the brain’s neural networks are the source of all mental functions. In other words, any alteration to our psychological processes will reflect itself in the ways that the brain’s architecture or functions change. However, there is ample evidence that our subjective experiences have an impact on the brain, contradicting simple reductionistic positions that many of the clinicians hold.

Though, it has been very difficult to study human neuroplasticity that I discussed in the previous week’s article on neuroplasticity, (i.e., how brain changes its structure based on life experiences), however, animal studies have yielded better results to understand the concept. Various experimental appraoches have been used on animals to detect changes in the brain in response to various experience at the cellular and molecular levels. It is now possible to study changes at the brain systems level (by measuring changes in brain blood flow or metabolisms) and, increasingly, on the molecular level using SPECT and PET in the living human brain thanks to the development of functional neuroimaging, which includes single photon emission CT (SPECT), positron emission tomography (PET), and functional MRI.

What research studies say about the impact of psychotherapy at the brain system level?

The brain changes following psychotherapy for depression, anxiety disorders, and borderline personality disorder have been the subject of innumerous studies to date in the past few decades and the data has been published in various top scientific journals. The first study was released in 1992. In this study, the researchers contrasted fluoxetine treatment with behaviour therapy. Similar changes in the brain were seen with both treatment regimens, particularly in the caudate nucleus, a part of brain responsible for various functions such as planning the execution of movement, learning, memory, reward, motivation, emotion, and romantic interaction.

When these system level studies are combined, they suggest that patients with major depressive disorder (MDD), obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder, specific phobias, posttraumatic stress disorder (PTSD), and borderline personality disorder (BPD) may experience changes in brain function as a result of various psychotherapy modalities such as cognitive-behavioral therapy (CBT), dialectic behaviour therapy (DBT), psychodynamic psychotherapy, and interpersonal psychotherapy.

Similar brain changes following psychotherapy and medication have been documented in the majority of these studies. However, some recent investigations have also demonstrated considerable variations between various therapy approaches. In the study by Goldapple and colleagues, the response to CBT treatment in patients with MDD was linked to increases in metabolism in the various areas of the brain such as hippocampus and dorsal cingulate and decreases in the other areas of brain such as dorsal, ventral, and medial frontal cortex. This pattern was notably different from the paroxetine (an SSRI, used to treat depression and other emotional disorders)-induced pattern, which involved metabolic increases in the prefrontal regions and decreases in the hippocampus and subgenual cingulate. In one study by Karlsson and colleagues, notable differences between short-term psychodynamic psychotherapy and fluoxetine among individuals with Major Depressive Disorder was found.

How mechanisms of psychotherapy lead to alterations in the brain?

Some of these research studies have made it feasible to build models that explain the mechanics behind the changes that result from the various psychotherapies, in addition to just reporting the findings on brain alterations as a result of psychotherapy.

Various psychotherapies aim to improve patient’s capacity for problem-solving, self-representation, and emotional control. The dorsolateral prefrontal cortex, ventral anterior cingulate cortex, dorsal anterior cingulate cortex, ventral and dorsal subregions of the medial prefrontal cortex, posterior cingulate cortex, precuneus, insular cortex, amygdala, and ventrolateral prefrontal cortex are the brain regions that contribute to these functions and it can be deduced from this correlation that psychotherapy affects these brain regions in a positive way.

For instance, the effectiveness of cognitive therapy for individuals with Major Depressive Disorder may be due to an increase in the function of prefrontal cortex, which is involved in reflective and rational thinking, whereas antidepressant medicines work more directly on the amygdala, which is involved in regulation of various emotions.

It seems that psychodynamic psychotherapy (one of the types of psychotherapy) may also work, at least partially, via similar mechanisms as is proponded regarding the impact of CBT on brain functioning and that includes a more effective (“top-down”) regulation of hyperexcitable limbic regions by prefrontal control systems. This concept is supported by the results of a study by Beutel and colleagues, which show that symptomatic patients with panic disorder have both a frontal deactivation and an amygdala-hippocampal hyperactivation. Following psychotherapy treatment, the amygdala-hippocampus hyperactivity and frontal inactivation returned to normal and their panic attacks and anxiety levels decreased.

Borderline Personality Disorder (BPD) is characterised by affective hyperarousal, which is also the core focus of Dialectical Behavior Therapy (DBT). This would imply that DBT helps the brain regions involved in affective hyperarousal to become less active in response to emotional stimuli. In fact, Schnell and Herpertz’s investigation confirmed this conclusion, indicating that DBT reduces the hemodynamic response to negative stimuli in the brain regions such as left insula, temporal and posterior cingulate cortices, and right anterior cingulate.

How psychotherapy helps to bring changes at molecular levels?

Studies were done to study the effect of psychotherapy at molecular level and they found that learning from the experience could influence gene expression by altering the strength of synaptic connections between nerve cells and thus causing morphological changes in neurons (causing neuroplasticity).

Patients with Major Depressive Disorder (MDD) were randomised to receive either short-term psychodynamic psychotherapy or fluoxetine (an antidepressant) in a Finnish study. The patients underwent a PET brain scan before therapy and again four months later. In the two publications that were published, the researchers reported that, according to standard symptom ratings, the clinical outcomes in both therapy groups (i.e., psychotherapy as well as pharmacotherapy group) were comparable, implying that both the treatment approaches were almost equally potent.

In conclusion, I intend to bring it to the attention of my readers that psychotherapy as a treatment option has been tested through hard science and thus should be accepted as seriously as they accept medication as a treatment option and that combining both the treatment options together can give them better and long lasting results with lesser rates of relapse.

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