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 demonstrate what kinds of changes occur with psychotherapy.
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.
Effects of Psychological Factors
Cancer research has shown positive effects of group psychotherapy, and by inference, a powerful effect on the brain and the body. Spiegel et al. (1989) conducted a controlled study in which metastatic breast cancer patients were randomly assigned to group psychotherapy or a control condition. Those in group psychotherapy lived an average of 18 months longer than controls. In a study of malignant melanoma patients, Fawzy et al. (1993) placed patients in either a support group or a control condition. They found that patients in the support group have more favorable death rates and more lengthy remissions than the controls. Most remarkable, this effect appeared to occur even though the support group lasted only six weeks.
A group of Pittsburgh investigators (Thase et al. 1998) studied 78 unmedicated patients with mild major depressive episodes. They were examined for sleep architecture changes before and after six weeks of cognitive-behavior therapy. The psychotherapy affected the neurobiological sleep variables in the same way as antidepressant medications.
While all of these studies are preliminary and require replication and further research, there can be little doubt that we are entering a new frontier in the mind-brain specialty known as psychiatry.
We now know that the brain is characterized by considerable plasticity and that genes are not static but responsive to environmental factors which we are only beginning to understand. Kandel (1998) has suggested that by producing changes in gene expression, psychotherapy may alter the strength of synaptic connections. Biological and psychosocial factors appear to have equal weight in development. There is a reciprocal effect of gene expression on environment and environment on gene expression in every family system. We can no longer afford a reductionism in either a biological or psychosocial direction.
All this evidence of the impact of psychotherapy on the brain opens up new lines of investigation to enhance our understanding of psychopathology and treatment: a) the mechanisms of action of psychotherapy, b) the interrelationships of the mechanisms of action of medication and psychotherapy, and c) a clearer understanding of pathogenesis itself and the malleability of some components of the pathogenetic mechanisms of major psychiatric disorders.
Baxter LR, Schwartz JM, Bergman KS et al. (1992), Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Arch Gen Psychiatry 49(9):681-689.
Fawzy FI, Hyun CS, Fawzy NW et al. (1993), Malignant melanoma effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 50(9):681-689.
Gabbard GO (1994), Mind and brain in psychiatric treatment. Monograph. In: The Institute of Pennsylvania Hospital Strecker Award Monograph Series XXXI, November.
Gabbard GO, Goodwin F (1996), Clinical psychiatry in transition: Integrating biological and psychosocial perspectives. In: Review of Psychiatry, American Psychiatric Press, pp 527-548.
Kandel ER (1998), A new intellectual framework for psychiatry. Am J Psychiatry 155(4):457-469.
Shear MK, Fyer AJ, Ball G et al. (1991), Vulnerability to sodium lactate in panic disorder patients given cognitive-behavioral therapy. Am J Psychiatry 148(6):795-797.
Spiegel D, Bloom J, Kraemer HC, Gottheil E (1989), Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2(8668):888-891.
Thase ME, Fasiczka AL, Berman SR et al. (1998), Electroencephalographic sleep profiles before and after cognitive-behavior therapy of depression. Arch Gen Psychiatry 55(2):138-144.
Ursano R, Silberman EK (1994), Psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy. In: The American Psychiatric Press Textbook of Psychiatry, 2nd ed. Hales E, Yudofsky SC, Talbott, eds. Washington, D.C.: American Psychiatric Press.
ViinamÃ¤ki H, Kuikka J, Tiihonen J, Lehtonen J (1998), Change in monoamine transporter density related to clinical recovery: A case-control study. Nord J Psychiatry 52:39-44.
(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.)