February, 1999

Symposium: Child Psychiatry, Cognitive Neuroscience and Psychotherapy

William Swift, MD Chair

AACAP Annual Meeting Chicago October 1999.

Review Abstract

THE NEUROBIOLOGY OF PSYCHOSTRUCTURAL AND PSYCHOTHERAPEUTIC CHANGE: CONFLICT, DEFENSE, AND TRANSFORMATION.

Recent advances in our understanding of brain function through imaging associated with cognition, affect, and memory, have led to new insights into the impact of experience in the individual processing of emotions, memory, motivations and dreams. The concept of mental conflict derived from problematic affective and interpersonal experiences is at the core of the psychodynamic perspective in psychiatry. Complexity and diversity of individual experiences contribute to the autobiographical narrative and neurobiological structure of personality. Persisting mental conflict (psychoneuroses) originates through the encoding of developmental conflictual experiences in representational schemata that are repetitively evoked resulting in nonadaptive, non error correcting responses to the demands of the self system, interpersonal function and the material world. In the psychotherapeutic encounter the foregoing appear in psychological defense, resistance, transference, phenomena, salient dreams and enactments in the course of treatment. These are the patterns that are the objects and focus of psychotherapy.

The amygdaloid complex has a selective role in learning and memory processing, and its activation during emotional experiences may be related to the long-term conscious recall of these experiences. It appears to modulate memory storage during periods of emotionally influenced conscious recall. The significance of heightened emotion in the consolidation of cognitive data is a complex matter. Freud and later investigators such as David Rappoport, were inspired by their clinical observations to view a substantial part of psychological defenses and reaction patterns to be determined by the complex relationship between emotions and memory.

In the caudate nucleus of the basal ganglia, feeding components involve consummatory behavior, aphagia/hyperphagia, food seeking and reactions to the visualization of food. This motor behavior with feeding is in contrast to appetite satiety regulation in the hypothalamus. Many of the obsessional and ritual behaviors in eating disorders that resist modification and attempts at therapeutic intervention may be driven by the foregoing neurobiologic mechanisms. A developmental psychopathology of the eating disorder is gradually emerging from observation and research into the developmental stages of feeding, attachment and separation, and the psychobiology of appetite regulation and food selection.

Specific brain regions may be involved in recognition of emotion in the external world. The emotional recognition deficit in depression resembles deficits found in persons with focal right hemisphere brain damage. The neurobiologic deficit may initiate and amplify both intrapsychic and interpersonal conflict during a depressive episode.

The activation of the visual association cortex is seen in generalized anxiety disorder, obsessive compulsive disorder, and panic, and suggests hypervigilance as a common characteristic associated with fear and anxiety.

Visual and limbic areas operate actively during dreaming sleep (REM) functionally as a closed system that is disconnected from the frontal lobes. This dissociation may explain many experiential dream features such as the heightened emotionality, uncritical acceptance of bizarre content, parallel thoughts and images, temporal distortions, and the absence of reflective awareness. The "primary process" mental functioning in dreams suggested by Freud is certainly elicited. The interpretation of dreams may be of more significance for clues to affective states (anxiety, panic, depression, and aggression) than for more elaborate cognitive meanings. The significance of "dream work" in problem solving, transference, and complex psychological defenses will need reinvestigation and reinterpretation in psychotherapy. The role of dreams is clearly multidetermined and may have both a communication/disclosure function and a neurobiologic consolidation outcome that aids in processing experience.

Psychotherapy that indicates changes in behavior may do so by producing alterations in gene expression that produce new structural changes in the brain. Both pharmacological intervention and psychotherapy in the treatment of "neuroses" should if successful produce functional and structural change. Pharmacotherapy and psychotherapy may be synergistic for change by promoting consolidation of the biological substrate of their individual and combined effects. Variations such as length and frequency of sessions, use of participation and arousal techniques, and awareness of stereotyped resistances in cognitive set and behavior, may be linked to a rational neurobiologic understanding. Naturalistic observations of psychopathology extended and amplified by neurobiologic studies and the knowledge gained are now given a new meaning, with the hope for greater understanding and possibilities for transformations by newly enlightened treatments.

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