By: Lisa Lukianoff, Psy.D.

Discoveries in science promote advancements in fields of study. Case-in-point the psychological sciences field is inextricably linked with discoveries in neuroscience.

Neuropsychoanalysis, the clinical practice, and study of neuroscience and psychoanalysis, is an emerging field propelling research in the neuropsychoanalytic study of psychological states from a brain science perspective.

To study the neural patterns of psychodynamic conflict, scientists Kehyayan, Best, Schmeing, Axmacher, & Kessler (2013) used fMRI  scans to measure internal states. The scans revealed psychodynamic conflict in the anterior cingulate cortex and in the emotion-processing regions of the brain.

The concept of “neuropsychoanalysis” joins together psychoanalysis and neuroscience to allow for psychoanalytically informed neuroscience. “…if a theme comprised in the subject’s conflict is touched in a real-life situation, reactions on the behavioral, cognitive, and physiological level should be expected, that call for the regulation of cognitions, impulses and, most importantly, emotions”, (2013).

​Scientists Panksepp & Solms (2012) state that the study and idea of neuropsychoanalysis, which began in the 1990’s, arose from a clinical need to reconcile psychoanalytic and neuroscientific perspectives on emerging discoveries. The overarching goal was to better understand the neurobiological origins of emotions and psychiatric dysfunction. The focus is on brain functions, “Neuropsychoanalysis is especially interested in brain functions that govern instinctual life, in particular, those that are foundational for understanding subjectivity, agency, and intentionality”, (p. 1, 2012).

Ideally, the synthesis of these fields will produce a greater understanding of the neurological brain affective networks involved in psychological states and an understanding of higher cognitive functions.

“Researchers in this field assimilate the best conceptual tools and clinical observations from the pre-neuroscientific era that sought to understand the complexities of human mentation in their own right, and encourage their integrated use with all the new and old neuroscience techniques needed for a fuller understanding of mind than academic psychology and neuroscience has yet achieved”, (Panksepp & Solms, p. 3, 2012).

Based on these findings psychodynamic conflicts viewed by corresponding fMRI studies provide an investigative technique to analyze conflict processing with neuroimaging.

References
Kehyayan, A., Best, K., Schmeing, J. B., Axmacher, N., & Kessler, H. (2013). Neural activity during free association to conflict–related sentences. Frontiers in human neuroscience. Volume 7(705). Doi: 10.3389/fnhum.2013.00705.
http://journal.frontiersin.org/Journal/10.3389/fnhum.2013.00705/abstract

Panksepp, J. & Solms, M. (2012). What is neuropsychoanalysis? Clinically relevant studies of the minded brain. Trends in cognitive sciences. Volume 16(1): pp. 6-8. Doi:10.1016/j.tics.2011.11.005.
http://www.frontiersin.org/publications/22153583

The process of psychotherapy and re-transcribing past traumatic events invoke our procedural memory, making them explicit and conscious. This process allows for re-transcription of these implicit memories: synthesis realization and integration​. A supple brain, elasticity in the brain and the possibilities and limitations of neuroplasticity and neurogenesis, in the context of psychotherapy are examined.

How can clinicians implement neuroscience findings in a way that benefits clients? This brief overview highlights some aspects of neuroplasticity, illuminating the significance of working clinically with the plasticity potential of a brain.

Key neuroscientific discoveries
Our brains are capable of neurogenesis, growing new neurons, and neuroplasticity, creating new neural connections and pathways.
Learning is vital for the process of neurogenesis and neuroplasticity. The hippocampus is a region of more neurogenesis than other regions, a significant departure from previous thought. Early traumatic experiences interfere with the normal growth and development of the hippocampus in the limbic region, an area important for memories and emotional regulation.

Psychotherapy is a mechanism used to examine past traumatic events and a process of learning about oneself. Neuroplasticity occurs when the nervous system responds to experiences, thus experience-dependent. Experiences create a stimulus that ignites neural firing patterns in the brain to imprint or re-transcribe an experience, or to reorganize the infrastructure of previous experiences via new neural pathways. This process can occur during psychotherapy.

​Antidepressants have been discovered to increase neurogenesis in the hippocampus (Malberg, J., Eisch, A., Nestler, E., & Duman, R., 2000). This creates the possibility of healing a previously damaged area which affects behaviors. A combination of psychotherapy and antidepressants can profoundly improve a persons mental state.

Novel experiences and life-long learning facilitate both neurogenesis and neuroplasticity. Learning is more important than relying on already established skills and established neural pathways. Our brains grow new neurons and pathways from birth until death.

Neuroplasticity converges with psychology
Research about neuroplasticity brings scientific evidence to the foreground from a clinical use perspective. This collective research expands the field of neuroscience, of neural patterns and the process of neuroplasticity and neurogenesis. Understanding the principles of neurogenesis and neuroplasticity can positively impact clinical work with clients, on a neuron level. Neurons that fire together, wire together. 

In his book titled The Brain That Changes Itself Doidge (2007) introduces readers to multi-disciplinary scientists, physicians, psychiatrists and neuroscientist, whose collective research demonstrate the plasticity of the brain and introduces the idea that the brain changes based on new information. Norman Doidge, M.D. (2007) conducted research and interviews with many “neuroplasticians” which firmly coined the phrase neuroplasticity.

These advancements in neuroscience inextricably link psychological science with neuroscience. Doidge (2007) cites the research of Eric Kandel, a physician, psychiatrist and 2000 Nobel Prize winner who stated: “there is no longer any doubt that psychotherapy can result in detectable changes in the brain”.  Kandel continues to research the hippocampus and the plasticity of implicit and explicit memory. Other citations include that of neuropsychologist Mark Solms and neuroscientist Oliver Turnbull who state that “the aim of the talking cure…from the neurobiological point of view is to extend the functional sphere of influence of the prefrontal lobes”. These discoveries provide evidence of the significance of the intersubjective experience between a clinical practitioner and a client. 

Giving scientific weight to the function of neuroplasticity in the context of personal exploration in therapy, e.g. a talking cure, psychotherapy, Doidge (2007) discusses the neurological process of analysis. The benefit of a client talking about past traumatic experiences facilitates the unconscious procedural memory to integrate past trauma with a better understanding. This can produce a calming effect from a neurological perspective. "In the process, they plastically re-transcribe these procedural memories, so that they can become conscious explicit memories...” This allows a person to remember without reliving the emotions of painful past experiences. 

In their research Garland, E. & Howard, M. (2009) provide further support for the neuroplasticity growth in response to learning and therapy.  “Investigations of neuroplasticity demonstrate that the adult brain can continue to form novel neural connections and grow new neurons in response to learning or training even into old age”. Novel experiences create these new neural connections throughout the lifespan.

Not all of the discoveries lead to enhanced psychological states. While neuroplasticity shows how thoughts and actions can change the brain to create new structures and functions, thus new ways of understanding, we are also introduced to the rigidity of well-established neural networks, also a product of neuroplasticity (Doidge, 2007). Doidge refers to this as the “plastic paradox” whereby the same neuroplasticity that allows our brains to change can also keep us constrained and “stuck” by well-established neural patterns.

Debunking previously held thoughts about Localization
Mainstream psychological science and medicine held the collective belief that the brain was hard-wired and that cells continued to die off. Localizationist’s we more popular and believed that the neuroanatomical structure of the brain was a machine-like device with specific areas for specific functions. Neuroscience has demonstrated that multiple areas of the brain are involved in similar functions and can also rewire to compensate for a damaged area. The research shows that many areas of the brain can be used for multiple functions. Localization of the brain has been re-defined.

Multi-disciplinary 
Among the neuroscientists Doidge (2007) interviewed was Paul Bach-y-Rita. In 1969 Paul Bach-y-Rita published an article in a European science journal citing his research using a machine that sent signals to the damaged area of a brain that ultimately cured retinal damage in some cases. Bach-y-Rita’s research demonstrated that our brains were capable of neuroplasticity and using other area’s to restructure and create new neural growth. The research publication and its avant-garde nature caused isolation from some of his peers.          

Bach-y-Rita had a multi-disciplinary background and approach and tended to follow ideas as they evolved. As a neuroscientist, he had expertise in medicine, psychopharmacology, ocular neurophysiology, visual neurophysiology, and bio-medical engineering. Doidge (2007) asserts that Paul Bach-y-Rita stated “we see with our brains” and that if one area is damaged, another area can take over. He referred to this process as “sensory substitution”.   

Psychotherapy changes the brain
It was Eric Kandel who “was the first to show that as we learn, our individual neurons alter their structure and strengthen the synaptic connections between them…” Doidge explained that Kandel’s work demonstrated that learning produces new neurons in the brain that influence our genes and that psychotherapy changes people’s brain structure, “it presumably does so through learning, by producing changes in gene expression that alter the anatomical pattern of interconnections between nerve cells”. 

Further support of these brain changes, researchers Liggan & Kay (1999) discuss the neural mechanisms of memory in the context of psychotherapy and reveal that the brain does change, “…neural mechanisms of memory is based on discoveries that training or differential experience leads to significant changes in brain neurochemistry, anatomy, and electrophysiology. Consequently, it is generally accepted that psychotherapy is a powerful intervention that directly affects and changes the brain”.

Liggan & Kay (1999) also demonstrate how psychotherapy affects cerebral metabolic rates, serotonin metabolism, the thyroid axis, and stimulates processes akin to brain plasticity.

References

1. Bach-y-Rita, P. (1990). Brain plasticity as a basis for recovery of function in humans. Neuropsychologia, Brain Research 908. Volume 28(6); pp. 547-554.
2. Bach-y-Rita, P., & W Kercel, S. (2003). Sensory substitution and the human–machine interface. Trends in cognitive sciences. Volume 7(12); pp. 541-546. doi:10.1016/j.tics.2003.10.013
3. Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York: Viking.
4. Garland, E. & Howard, M. (2009). Neuroplasticity, Psychosocial Genomics, and the Biopsychosocial Paradigm in the 21st Century. Oxford Journal, Health Social Work. Volume 34 (3): pp. 191-199.doi: 10.1093/hsw/34.3.191
5. Kandel, E. R. (2005). Psychiatry, psychoanalysis, and the new biology of mind. Washington, DC: American Psychiatric Pub.
6. Liggan, D. & Kay, J. (1999). Some Neurobiological Aspects of Psychotherapy: A Review. Journal of Psychotherapy Practice Research. Volume 8(2): pp. 103–114. PMCID: PMC3330538.
7. Malberg, J., Eisch, A., Nestler, E., & Duman, R. (2000). Chronic Antidepressant Treatment Increases Neurogenesis in Adult Rat Hippocampus. The Journal of Neuroscience. Volume 20(24): pp. 9104–9110. PMID: 11124987.

How do you evaluate clients level of resilience and "stress inoculation"? A client may have better-coping mechanisms & an HPA-axis that regulates hormones more efficiently because they've been through tough times. Has your client handled unexpected stressful events throughout the course of their life and come out the other side a little stronger? 

The idea behind the “stress inoculation” effect is based on the hypothesis that exposure to moderate amounts of stress over a prolonged period of time helps an individual develop better-coping mechanisms, better resilience. Potentially.

Scientific researchers Russo, Murrough, Han, Charney & Nestler (2012) have studied the adaptive biopsychology of resilience in terms of an active behavioral, neural, molecular, and a hormonal basis.

These researchers state that the phenomenon of resilience has remained a mystery, biopsychologically speaking. Yet remarkably a high percentage of people exposed to intense levels of trauma and stress manage to maintain a relatively normal psychological homeostasis, (p. 1). “Within the general population, between 50–60% experience a severe trauma, yet the prevalence of illness is estimated to be only 7.8%. Children in particular display remarkable resilience across a range of negative environmental stressors”, (p. 6). Could this be an example of stress inoculation? Interestingly, "..."Stress resilience is enhanced in specific populations, such as military personnel and rescue workers, through controlled exposure to stress–related stimuli". Here is a population whose primary work exposes them. What biological factors allow for this?

To explore the underpinnings of this phenomenon, they examined the role of the neuroendocrine system as the neurobiological coping mechanism. Basically, the neuroendocrine system is the “house” that regulates the hypothalamus and other mechanisms involved in the maintenance of a person’s overall homeostasis. This includes a person’s regulatory systems like metabolism, hunger, energy output and blood pressure levels. Research shows the neurobiology of resilience is mediated by the presence of unique molecular adaptations in the neuroendocrine system: the hypothalamic-pituitary-adrenal (HPA) axis, production of Dehydroepiandrosterone (DHEA) and Testosterone. 

The HPA axis is the main mediator of the initial impact of stress on the brain. It regulates hormonal, neurochemical, and physiological changes. “Glucocorticoids, released from the adrenal cortex as a consequence of HPA axis activation, interact with steroid receptors expressed throughout the brain that functions primarily as transcription factors to regulate cellular function beyond the time scale of acute stress effects”, (pp. 2-3). This whole process drives the behavioral response a person experiences. However, the exact effect of this relationship between HPA and resilience is unclear. 

In the same area, Dehydroepiandrosterone (DHEA) is released, along with cortisol, in response to stress. Russo, Murrough, Han, Charney & Nestler (2012) propose that current research about DHEA suggests that it counter’s the negative effects by producing an anti-inflammatory response, (p. 1476). “It has been reported that DHEA responses to adrenocorticotropic hormone (ACTH) were elevated in PTSD and negatively correlated with the severity of symptoms, suggesting that DHEA release during stress may buffer the severity of PTSD”, (p. 3). Oddly, the hormone DHEA released during stress can actually help alleviate the negative response.

Testosterone is released in response to stress is considered to serve as a pro-resilience hormone creating a positive mood and connectedness, and important among sports team members. Interestingly, after the experience of a stress event, testosterone levels decrease for a period of time. "...Early studies in men suggest that testosterone may be effective in treatment–resistant depression and as an adjunct to SSRI treatment..."  (p. 3).

“it seems clear that moderate degrees of stress exposures during early life, adolescence, and adulthood can shift an individual’s stress…by increasing the range of tolerable stress for the organism”, (p. 7). These early exposures possibly prime the HPA axis to function more efficiently; producing moderate levels of hormones released thus allowing for less impact and more recovery. These findings and further research outcomes can have significant clinical implications for future treatments. "...far more insight is needed into the genetic, epigenetic,neurobiological, and neuroendocrine basis of sex differences in stress susceptibility vs. resilience. Finally, we need to better define how just the right type and level of stress inoculation, through this complex interplay of mechanisms, can promote resilience..."

References
Russo, S. J., Murrough, J. W., Han, M. H., Charney, D. S., & Nestler, E. J. (2012). Neurobiology of resilience. Nature neuroscience. Volume 15(11); pp. 1475-1484. Doi:10.1038/nn.3234.

Found online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580862/
Link to article: .http://www.nature.com/neuro/journal/v15/n11/abs/nn.3234.html

fMRI studies show neurological changes & activity in patient's receiving psychotherapy treatment. Implicit in these findings are both neurogenesis and neuroplasticity, a byproduct of treatment.

Researchers Buchheim, Labek, Walter & Viviani (2013) designed an empirical research study to investigate the outcome of long-term psychotherapy from a neurobiological perspective. “In the present study, we attempted to integrate a clinical description of the psychoanalytic process with two empirical instruments…brain activity based on a functional neuroimaging probe”, (p. 9).

They wanted to create a study that would allow us to “see” the effects of psychotherapy on the brain. To accomplish this, the design included using clinical data, a standardized instrument of the psychotherapeutic process (Psychotherapy process Q-Set, PQS), and functional neuroimaging (fMRI). fMRI scans were administered after therapy sessions while the patient viewed the Adult Attachment Projective Picture System (AAP). This was done for 12-months.

In their research findings Buchheim, Viviani, Kessler, Kachele, Cierpka, Roth, George, Kernberg, Bruns, & Taubner (2012) show improvements in depressive symptoms and neural activity in regions of the brain. "This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy". These scans showed neurological changes and activity in both patients receiving psychotherapy treatment.

In particular, the fMRI’s scans showed changes in the hippocampus, amygdala , subgenual cingulate, and medial prefrontal cortex after psychotherapy treatment. These findings documented neurobiological changes and a reduction of emotional reactivity after long-term psychotherapy. “The significant association of the changes in the subgenual cingulate and medial prefrontal cortex with symptom improvement supported the hypothesis of their relevance to the changes intervened during therapy”, (p. 5). 

They conducted a single-case study of a 42-year-old woman who received psychotherapy treatments for one year. The patient was described as having a disorganized attachment style with narcissistic traits, characterized by chronic fluctuating moods and self-esteem. The fMRI scans revealed neural activation in the ventrolateral and dorsolateral prefrontal cortex. This area is associated with controlling one’s focus and attention, and depression.

Other neural activation revealed from the fMRI scans included the pregenual portion of the medial prefrontal cortex, the posterior cingulate and precuneus, the middle temporal gyrus, and the anterior tip of the inferior temporal gyrus, and the occipital calcarine cortex. Buchheim, Labek, Walter & Viviani (2013) felt that these areas were most significant to this study because “The medial prefrontal cortex may also be associated with changes after the therapy of affective disorders…” (p. 9). They believe that observable neurological changes from therapy will be most visible in these brain regions.

The neurological response to psychotherapy allowed them to track this patient’s defensive characteristic via neural activity viewed in the scans. “Using functional neuroimaging, we were able to objectify the defensive structure of this patient during this phase of psychoanalytic treatment and the occurrence of difficult sessions”, (p. 11). 

While these research findings may not answer many important questions, they do show a distinct correlation between psychotherapy treatments and neurological activity. More research is needed in this area. “The relevance of these finding for future studies rests in the possibility of documenting specific mechanisms of action of depression therapy by systematically collating results from different studies and comparing different psychotherapeutic approaches…”, (p. 6). 

References
Buchheim A, Labek K, Walter S, & Viviani R. (2013). A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging. Frontiers in Human Neuroscience. Volume 7(677); pp. 1-13. Doi: 10.3389/fnhum.2013.00677.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805951/

Current research supports cardiovascular exercise, like running and cycling, enhances neuroplasticity (the creation of new neural pathways) in regions of the brain that improve cognitive function.  This study was conducted on aging adults.

These finding suggest that adhering to a cardiovascular exercise regime may reduce cognitive and neural decline in aging adults and slow age-related decline in the hippocampus, a region in the brain that processes short-term memory to long-term memory and processes spatial navigating. This is also the first region in the brain to be damaged by Alzheimer’s disease, (Hayes, Hayes, Cadden, & Verfaellie, 2013).

Research in a previous article (http://www.brainfacts.org/Across-the-Lifespan/Diet-and-Exercise/Articles/2013/Physical-Exercise-Beefs-Up-the-Brain ) showed that the hippocampus is an area known for neurogenesis (the growth of new cells) as a previous study shows that running and exercise also increases this new cell growth.

This cumulative research shows that cardiovascular exercise increases both neuroplasticity and neurogenesis, which is overall great for your brain.

Hayes, S., Hayes, J., Cadden, M., & Verfaellie, M. (2013). A review of cardiorespiratory fitness-related neuroplasticity in the aging brain. Frontiers in Aging Neuroscience. Volume 5(31). DOI: 10.3389/fnagi.2013.00031 PMCID: PMC3709413.

Oxytocin is a neuromodulator (which is a physiological process that sends neurons to several different neurotransmitters in the CNS) in the brain and is activated in intimate situations. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3055728/)

Current preliminary research findings show how oxytocin plays a role in prolonged anxiety and stress from traumatic, or unpleasant, memories via the lateral septum (http://www.psypost.org/2013/07/the-love-hormone-is-2-faced-oxytocin-strengthens-bad-memories-19149).