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Neurological Changes During Psychotherapy: Do we need drugs to change the brain?
In our diverse society, it is necessary to understand that the same treatments may not work for everyone. For diseases that are thought to be caused by differences in brain chemistry, the variety in brain chemistry (as well as the variety in what is felt as "normal" or "baseline") means that certain treatments may not work in the same ways for everyone. Currently the medical community seeks to treat depression and obsessive compulsive disorder in two main ways: psychoactive drugs or cognitive behavioral therapy. However, both of these treatments are not fully understood, nor their efficacy verified. Due to the intensely individual experiences with these "diseases" (see Paul Grobstein, "Exploring Depression"), we sought to explore the differing mechanisms that may be behind these treatments.
As a brief background, obsessive compulsive disorder (OCD) causes people to be plagued with persistent, unwelcome thoughts or images or by the urgent need to engage in certain rituals, such as hand washing (2). It is hypothesized that this may be caused by abnormalities in the neurotransmitter serotonin or hyperactivity in a brain region called the caudate nucleus (4). Depression is characterized by long-term feelings of sadness and hopelessness, as well as a loss of interest in what used to be pleasurable activities (1)., and may be caused by serotonin or norepinephrine differences.
Pharmacological therapy seeks to treat these hypothesized underlying chemical imbalances. Drugs such as Paxil and Effexor seek to increase the amount of serotonin or norepinephrine that is available between connections in the brain in an attempt to alter brain chemistry back to that which made the individual feel more like they are hoping to. Cognitive behavioral therapy, on the other hand, tries to help patients become aware of their own behaviors and replace them with more beneficial behaviors, changing patterns of thinking (4). Over a period of intensive therapy (usually 10 weeks or so) the client and therapist work together to develop steps that will change the thinking of the client. Instead of washing their hands immediately, they may slowly build up to progressively longer wait times while learning to think things like "this dirt is ok, it will not cause me harm." When indeed no negative event occurs, the patient slowly alters the restrictive compulsive behaviors that they seek to eliminate.
These two types of treatment seem to have some similar impacts on the brain, however. For OCD, both drug treatment and CBT have been shown to both decrease activity in the caudate nuclei that correlated with patients reporting a decrease in OCD behaviors (4). In depressed patients, both therapy and antidepressants cause increases in the basal ganglia, though patients who used therapy (in this case, it was interpersonal therapy) also showed activation of the cingulate gyrus (4).
The differences in these treatments seem to stem from a top down verses bottom up treatment. With cognitive behavioral therapy, brain changes occur in regions of the brain that were later to evolve, those that deal with cognition, memory, and planning, such as the hippocampus and frontal cortices (3, 5, 8). However, pharmacological treatment appears to alter more fundamental brain regions such as the brainstem and cerebellum, which are associated with basic functioning like breathing and gross motor control (3, 5, 8). However, there seems to be a "same effect, different mechanisms" process occurring, as these different mechanisms are causing similarly felt changes in behavior and mood.
Guest speaker Dr. Elna Yadin, a psychologist that performs CBT in her practice, talked about how she sees to use the natural plasticity of the brain to fix a "glitch" in your brain. She saw this treatment as using the brain's own mechanisms to fix a problem instead of using drugs. The brain is a plastic organ and learning can change structures that may be functioning in an undesired way (7)
The central questions that discussion focused around were what the pros and cons were of each type of treatment. If each seem to have a similar effect in some people, what is causing the differences and what can we do to benefit the most people? Furthermore, for what reasons is one treatment used over another? What do these research studies mean for future treatment methods or even for our model of what disease is? Finally, why do 100% of people not feel a return to baseline, and what is baseline anyways?
Class and forum discussion topics focus on a few distinct areas. One main topic was the idea of individual differences and the ways that cognitive behavioral therapy can be tailored to each person. If perhaps depression (or even CBT) give individual benefits, as some people mentioned, then each individual should have their own type of treatment. Many people noted that "individuals vary quite a lot in terms of responsiveness to treatment" (ehinchel "Individuality", Felicia, "Psychotherapy") and that they "doubt if any two people ever have the exact same dysfunction going on in their brains" (krosania, "Individual Differences"). The benefit seen with CBT is that it "is tailored to the individual" (Andrea G. "Individualizing treatment") and seen as more flexible (Danielle "Neurological Changes..."). It seems there was a consensus that individual differences DO exist and must be taken into account when deciding upon treatment methods. "Variability of therapeutic response [must be taken] seriously" (Paul Grobstein, "Depression and exuberance") and lead us to try to understand what is behind these differences and "disorders."
Another topic was the question of possible self-selection for talk therapy, that the people who chose to take this route are already in a particular mindset that makes them best able to benefit from this form of treatment. To receive CBT it is necessary to that you "consider yourself to have a 'disorder'" (ehinchel "Individuality") and be "highly motivated" (Krosania "Along this line of thought...). However, it was brought up that you have to do the same thing when getting a prescription (Andrea G "Individualizing Treatment"). The question of whether "patients [are] more satisfied with a quicker result or...fixing your mental glitch with your own machinery" (K. Smythe, "Psychotherapy and the brain"). Futhermore, does talk therapy have to be with a licensed therapist, or can it could be with a friend or other acquaintance? Can you "confide in a trusted friend about a crisis" (Rebecca W., "Combining Therapeutic Strategies") and still reap the same benefits as working with a practitioner of CBT?
It is also very interesting to think on this subject in terms of our past discussions about diversity. If these disorders are just "another form of diversity" (Danielle "Neurological changes...") then it makes me wonder why we are treating them at all, as opposed to looking for ways that these conditions can benefit the individual and a diverse society as a whole.
Drugs were seen often as a "quick fix" alternative to therapy. "Drugs are so much easier...CBT may seem to be more and more of a hassle" (ehinchel "Individuality"). However one person mentioned our society's movement towards natural treatments and away from psychopharmacology (ebitler, Psychotherapy thoughts...) and suggested that these changes would lead to CBT and other forms of therapy being more utilized. However, there were also people saw the opposite as more beneficial, with talk therapy "start[ing] with very local change...while psychotherapy target[ing] the whole brain at once" {Rebecca W., "Combining Therapeutic Strategies"). Perhaps they could be used in adjunct with therapy, to "enhance talk therapy" (Rebecca W, "Combining Therapeutic Strategies") or to motivate someone more (krosania, "Along this line of thought").
Many people commented on our guest speaker Dr. Yadin's idea that the brain can be used to fix itself. There seemed to be a trend to want to "use the brain to fix/heal itself-as a first line of treatment...maybe then considering employing drugs" (Stephanie, "Psychotherapy), "we should use the brain itself for fixes first...and drugs second" (ehinchel "Individuality") but the interesting point was brought up in that same post that we cannot force people to try CBT first. However, there was a feeling that this was a better or more natural form of treatment (JaymElaine, "Psychotherapy and the Brain) and should be utilized when possible.
There were also comments made about the side effects associated with each type of treatment. It was brought up multiple times that there is so much that we do not know about other effects and why there may be time delays between treatment and effects. Perhaps the differing changes that appear to occur with each type of treatment are occurring via connections that we are not aware of, as many people suggested that our research methods currently in use are not as clear cut as desired. There was a sense of wanting to look more at "what other molecules, chemicals, and pathways these [therapeutic] drugs that attempt to 'target one molecule' are affecting" (Stephanie, "Psychotherapy) . While a lot of people thought about these chemical effects of drugs, it was brought up by many posters that we should also look at the "downstream changes in the psychotherapy model" and attempt to elucidate exactly what is occurring when these drugs or therapies are utilized (ebitler "Psychotherapy thoughts", also see Elliot Rabinowitz "More on psychotherapy," aamen, "I also thought this was an").
Where do we go from here? We do not fully understand why for some brain differences either pharmacological treatment or cognitive behavioral therapy both work for some people, with one or the other, or both, or neither, having an effect on particular individuals. What will future treatment look like? CBT or drug treatment alone improve depression in about half of patients, but when these therapies are combined, almost 3/4 improve (Keller et al. 2000). What can be done differently to help 100% of people who desire a change in the way that feel achieve that? Do the unknown effects and downstream treatments of each type of therapy (both talk and drug) make either of them too risky to use? How do natural differences and changes in the brain over time come into play in these treatments and "disorders?" These questions and more remain unanswered at this time but are vitally important to keep in mind when evaluating and developing ways to bring a person back to baseline.
Further research and exploration is necessary to understand how currently limited resources and treatment options can best be utilized to work with individual responses and experiences. If we continue to ignore diversity within the disease spectrum we will not be able to help a large number of people who may unresponsive to current treatment paradigms. We need a better comprehension of the mechanisms involved in obsessive compulsive disorder and depression as well as the downstream effects of pharmacological treatment and talk therapy. I hope that awareness of these as-yet unanswered questions will lead to better treatments in the future.
All forum comments can be found at /exchange/node/2144. Accessed April 2008.
(1) (2008). "What is Depression?" National Institute of Mental Health. Updated 3 April 2008. Accessed April 2008.
http://www.nimh.nih.gov/health/topics/depression/index.shtml
(2) (2008). "What is Obsessive-Compulsive Disorder?" National Institute of Mental Health Updated 2 April 2008. Accessed April 2008. http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
(3) Bender E (2004 May 7). "Brain Data reveal why psychotherapy works." Psychiatric News 39(9): 34. Accessed Feb 2008. http://pn.psychiatryonline.org/cgi/content/full/39/9/34
(4) Friedman RA (2002 Aug 27). "Like Drugs, Talk Therapy can Change Brain Chemistry." Forensic Psychiatry and Medicine. Accessed Feb 2008. http://www.forensic-psych.com/articles/artNYTTalkTherapy8.27.02.html
(5) Goldapple K et al. (2004). "Modulation of Cortical-Limbic Pathways in Major Depression." Archives of General Psychiatry 61: 34-41. http://archpsyc.ama-assn.org/cgi/content/full/61/1/34
(6) Keller MB et al. (2000). "A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression." New England Journal of Medicine 342: 1462-1470. http://content.nejm.org/cgi/content/abstract/342/20/1462
(7) Liggan DY and Kay J (1999). "Some neurobiological aspects of psychotherapy." Journal of Psychotherapy Practice and Research 8(2): 103-114. jppr.psychiatryonline.org/cgi/content/full/8/2/103
(8) Linden DEJ (2006). "How psychotherapy changes the brain-the contribution of functional neuroimaging." Molecular Psychiatry11: 528-538. www.nature.com/mp/journal/v11/n6/full/4001816a.html
As a brief background, obsessive compulsive disorder (OCD) causes people to be plagued with persistent, unwelcome thoughts or images or by the urgent need to engage in certain rituals, such as hand washing (2). It is hypothesized that this may be caused by abnormalities in the neurotransmitter serotonin or hyperactivity in a brain region called the caudate nucleus (4). Depression is characterized by long-term feelings of sadness and hopelessness, as well as a loss of interest in what used to be pleasurable activities (1)., and may be caused by serotonin or norepinephrine differences.
Pharmacological therapy seeks to treat these hypothesized underlying chemical imbalances. Drugs such as Paxil and Effexor seek to increase the amount of serotonin or norepinephrine that is available between connections in the brain in an attempt to alter brain chemistry back to that which made the individual feel more like they are hoping to. Cognitive behavioral therapy, on the other hand, tries to help patients become aware of their own behaviors and replace them with more beneficial behaviors, changing patterns of thinking (4). Over a period of intensive therapy (usually 10 weeks or so) the client and therapist work together to develop steps that will change the thinking of the client. Instead of washing their hands immediately, they may slowly build up to progressively longer wait times while learning to think things like "this dirt is ok, it will not cause me harm." When indeed no negative event occurs, the patient slowly alters the restrictive compulsive behaviors that they seek to eliminate.
These two types of treatment seem to have some similar impacts on the brain, however. For OCD, both drug treatment and CBT have been shown to both decrease activity in the caudate nuclei that correlated with patients reporting a decrease in OCD behaviors (4). In depressed patients, both therapy and antidepressants cause increases in the basal ganglia, though patients who used therapy (in this case, it was interpersonal therapy) also showed activation of the cingulate gyrus (4).
The differences in these treatments seem to stem from a top down verses bottom up treatment. With cognitive behavioral therapy, brain changes occur in regions of the brain that were later to evolve, those that deal with cognition, memory, and planning, such as the hippocampus and frontal cortices (3, 5, 8). However, pharmacological treatment appears to alter more fundamental brain regions such as the brainstem and cerebellum, which are associated with basic functioning like breathing and gross motor control (3, 5, 8). However, there seems to be a "same effect, different mechanisms" process occurring, as these different mechanisms are causing similarly felt changes in behavior and mood.
Guest speaker Dr. Elna Yadin, a psychologist that performs CBT in her practice, talked about how she sees to use the natural plasticity of the brain to fix a "glitch" in your brain. She saw this treatment as using the brain's own mechanisms to fix a problem instead of using drugs. The brain is a plastic organ and learning can change structures that may be functioning in an undesired way (7)
The central questions that discussion focused around were what the pros and cons were of each type of treatment. If each seem to have a similar effect in some people, what is causing the differences and what can we do to benefit the most people? Furthermore, for what reasons is one treatment used over another? What do these research studies mean for future treatment methods or even for our model of what disease is? Finally, why do 100% of people not feel a return to baseline, and what is baseline anyways?
Class and forum discussion topics focus on a few distinct areas. One main topic was the idea of individual differences and the ways that cognitive behavioral therapy can be tailored to each person. If perhaps depression (or even CBT) give individual benefits, as some people mentioned, then each individual should have their own type of treatment. Many people noted that "individuals vary quite a lot in terms of responsiveness to treatment" (ehinchel "Individuality", Felicia, "Psychotherapy") and that they "doubt if any two people ever have the exact same dysfunction going on in their brains" (krosania, "Individual Differences"). The benefit seen with CBT is that it "is tailored to the individual" (Andrea G. "Individualizing treatment") and seen as more flexible (Danielle "Neurological Changes..."). It seems there was a consensus that individual differences DO exist and must be taken into account when deciding upon treatment methods. "Variability of therapeutic response [must be taken] seriously" (Paul Grobstein, "Depression and exuberance") and lead us to try to understand what is behind these differences and "disorders."
Another topic was the question of possible self-selection for talk therapy, that the people who chose to take this route are already in a particular mindset that makes them best able to benefit from this form of treatment. To receive CBT it is necessary to that you "consider yourself to have a 'disorder'" (ehinchel "Individuality") and be "highly motivated" (Krosania "Along this line of thought...). However, it was brought up that you have to do the same thing when getting a prescription (Andrea G "Individualizing Treatment"). The question of whether "patients [are] more satisfied with a quicker result or...fixing your mental glitch with your own machinery" (K. Smythe, "Psychotherapy and the brain"). Futhermore, does talk therapy have to be with a licensed therapist, or can it could be with a friend or other acquaintance? Can you "confide in a trusted friend about a crisis" (Rebecca W., "Combining Therapeutic Strategies") and still reap the same benefits as working with a practitioner of CBT?
It is also very interesting to think on this subject in terms of our past discussions about diversity. If these disorders are just "another form of diversity" (Danielle "Neurological changes...") then it makes me wonder why we are treating them at all, as opposed to looking for ways that these conditions can benefit the individual and a diverse society as a whole.
Drugs were seen often as a "quick fix" alternative to therapy. "Drugs are so much easier...CBT may seem to be more and more of a hassle" (ehinchel "Individuality"). However one person mentioned our society's movement towards natural treatments and away from psychopharmacology (ebitler, Psychotherapy thoughts...) and suggested that these changes would lead to CBT and other forms of therapy being more utilized. However, there were also people saw the opposite as more beneficial, with talk therapy "start[ing] with very local change...while psychotherapy target[ing] the whole brain at once" {Rebecca W., "Combining Therapeutic Strategies"). Perhaps they could be used in adjunct with therapy, to "enhance talk therapy" (Rebecca W, "Combining Therapeutic Strategies") or to motivate someone more (krosania, "Along this line of thought").
Many people commented on our guest speaker Dr. Yadin's idea that the brain can be used to fix itself. There seemed to be a trend to want to "use the brain to fix/heal itself-as a first line of treatment...maybe then considering employing drugs" (Stephanie, "Psychotherapy), "we should use the brain itself for fixes first...and drugs second" (ehinchel "Individuality") but the interesting point was brought up in that same post that we cannot force people to try CBT first. However, there was a feeling that this was a better or more natural form of treatment (JaymElaine, "Psychotherapy and the Brain) and should be utilized when possible.
There were also comments made about the side effects associated with each type of treatment. It was brought up multiple times that there is so much that we do not know about other effects and why there may be time delays between treatment and effects. Perhaps the differing changes that appear to occur with each type of treatment are occurring via connections that we are not aware of, as many people suggested that our research methods currently in use are not as clear cut as desired. There was a sense of wanting to look more at "what other molecules, chemicals, and pathways these [therapeutic] drugs that attempt to 'target one molecule' are affecting" (Stephanie, "Psychotherapy) . While a lot of people thought about these chemical effects of drugs, it was brought up by many posters that we should also look at the "downstream changes in the psychotherapy model" and attempt to elucidate exactly what is occurring when these drugs or therapies are utilized (ebitler "Psychotherapy thoughts", also see Elliot Rabinowitz "More on psychotherapy," aamen, "I also thought this was an").
Where do we go from here? We do not fully understand why for some brain differences either pharmacological treatment or cognitive behavioral therapy both work for some people, with one or the other, or both, or neither, having an effect on particular individuals. What will future treatment look like? CBT or drug treatment alone improve depression in about half of patients, but when these therapies are combined, almost 3/4 improve (Keller et al. 2000). What can be done differently to help 100% of people who desire a change in the way that feel achieve that? Do the unknown effects and downstream treatments of each type of therapy (both talk and drug) make either of them too risky to use? How do natural differences and changes in the brain over time come into play in these treatments and "disorders?" These questions and more remain unanswered at this time but are vitally important to keep in mind when evaluating and developing ways to bring a person back to baseline.
Further research and exploration is necessary to understand how currently limited resources and treatment options can best be utilized to work with individual responses and experiences. If we continue to ignore diversity within the disease spectrum we will not be able to help a large number of people who may unresponsive to current treatment paradigms. We need a better comprehension of the mechanisms involved in obsessive compulsive disorder and depression as well as the downstream effects of pharmacological treatment and talk therapy. I hope that awareness of these as-yet unanswered questions will lead to better treatments in the future.
All forum comments can be found at /exchange/node/2144. Accessed April 2008.
(1) (2008). "What is Depression?" National Institute of Mental Health. Updated 3 April 2008. Accessed April 2008.
http://www.nimh.nih.gov/health/topics/depression/index.shtml
(2) (2008). "What is Obsessive-Compulsive Disorder?" National Institute of Mental Health Updated 2 April 2008. Accessed April 2008. http://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
(3) Bender E (2004 May 7). "Brain Data reveal why psychotherapy works." Psychiatric News 39(9): 34. Accessed Feb 2008. http://pn.psychiatryonline.org/cgi/content/full/39/9/34
(4) Friedman RA (2002 Aug 27). "Like Drugs, Talk Therapy can Change Brain Chemistry." Forensic Psychiatry and Medicine. Accessed Feb 2008. http://www.forensic-psych.com/articles/artNYTTalkTherapy8.27.02.html
(5) Goldapple K et al. (2004). "Modulation of Cortical-Limbic Pathways in Major Depression." Archives of General Psychiatry 61: 34-41. http://archpsyc.ama-assn.org/cgi/content/full/61/1/34
(6) Keller MB et al. (2000). "A Comparison of Nefazodone, the Cognitive Behavioral-Analysis System of Psychotherapy, and Their Combination for the Treatment of Chronic Depression." New England Journal of Medicine 342: 1462-1470. http://content.nejm.org/cgi/content/abstract/342/20/1462
(7) Liggan DY and Kay J (1999). "Some neurobiological aspects of psychotherapy." Journal of Psychotherapy Practice and Research 8(2): 103-114. jppr.psychiatryonline.org/cgi/content/full/8/2/103
(8) Linden DEJ (2006). "How psychotherapy changes the brain-the contribution of functional neuroimaging." Molecular Psychiatry11: 528-538. www.nature.com/mp/journal/v11/n6/full/4001816a.html
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Comments
Interesting
That is an interesting topic to be considered. Virtual reality devices could also help in cognitive rehabilitation for persons with complex brain disorders, helping them to identify and correct patterns of conscious and unconscious thought. I’m currently studying cognitive therapy and, while doing some research on the Internet, I came across some very interesting articles and publications written by Dr Maurice Prout. They have been helping me a lot in developing my research papers.
Diversity, mental health, and beyond
Yep. See An Updated Approach to Mental Health, Depression and Exuberance and Exploring Depression. And maybe also
and
as per Diversity and Productivity and Brain and Education ?