We live in an era of stigma regarding psychiatric illness, psychiatric patients and psychiatric treatments-an era in which a Supreme Court justice suggests in a minority-dissenting opinion that one would be better off talking to one's mother than to a psychotherapist.
Indeed, psychotherapy is often viewed as a form of hand-holding rather than a "real" treatment. This perspective persists despite the fact that there is overwhelming evidence that it is a highly effective intervention. In psychotherapy studies, the magnitude of the effect size is sufficient to justify interrupting clinical trials on the grounds that it would be unethical to withhold such a highly effective treatment (Ursano & Silberman, 1994).
Evidence and Imaging Techniques
With advances in the neurosciences, and especially in imaging techniques, we stand at the threshold of demonstrating that psychotherapy is a powerful intervention that affects the brain. While it has been intuitively obvious to most clinicians that psychotherapy must work by affecting the brain (how else could it work?), recent breakthroughs in technology have allowed us to begin demonstrating for the first time what kinds of changes occur with psychotherapy. Documentation of these changes may go a long way toward removing the stigma currently attached to psychotherapy.
While there was a time when psychotherapy was thought to be the appropriate treatment for "psychologically based" disorders, and medication was considered the treatment of choice for "biologically based" disorders, this distinction is now becoming increasingly specious (Gabbard, 1994; Gabbard and Goodwin, 1996).
In one study of obsessive-compulsive disorder, Baxter et al. (1992) looked at local cerebral metabolic rates for glucose using positron emission tomography scan methodology. They found that both behavior therapy and fluoxetine (Prozac) produced similar decreases in cerebral metabolic rates in the head of the right caudate nucleus, suggesting (but not proving) that this form of psychotherapy and fluoxetine have similar physiological effects at the level of the brain.
There is extensive evidence that cognitive-behavior therapy is an effective treatment for panic disorder. Panic attacks can be triggered by lactate infusion in those with panic disorder. At least one study (Shear et al., 1991) has demonstrated that lactate induction of panic can be effectively reversed through successful cognitive therapy. These findings suggest that psychological interventions can alter the response of the brain to biochemical factors.
Psychiatric researchers in Finland recently published a report showing that psychodynamic therapy may have a significant impact on the neurotransmitter serotonin (Viinamki et al., 1998). At the beginning of a one-year psychotherapy process, single photon emission computed tomography (SPECT) imaging was undertaken with a 25-year-old man suffering from personality disorder and depression. Another young man with similar problems also underwent imaging but did not receive psychotherapy or other treatment.
Initial SPECT imaging showed that both patients had markedly reduced serotonin uptake in the medial prefrontal area and the thalamus compared with 10 healthy control subjects. After one year of dynamic therapy, repeat SPECT imaging showed that the patient who received the psychotherapy had normal serotonin uptake while the control patient who did not receive psychotherapy continued to have markedly reduced serotonin uptake. This study suggests that dynamic psychotherapy may normalize serotonin metabolism.
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(The preceeding is a summary of Dr. Gabbard's presentation as the third annual Gene Usdin, M.D., Distinguished Visiting Lecturer in Psychiatry. Previous lecturers were Jerry M. Lewis, M.D., and Peter V. Rabins, M.D.-Ed.)