Psychoanalytical dream theory and brain mechanisms
Solms, M. (2001) Dreaming and REM sleep are controlled by different brain mechanisms.’ Behavioral and Brain Sciences, 83, 843-850.
The equation of dreaming and REM sleep has massive implications for the credibility of psychoanalytic dream theory, for the reason that the brain mechanisms of REM sleep are automatic and “motivationally neutral” (Hobson). This equation was established in humans in the 1950s, but the elucidation of its brain mechanisms was performed mainly in rats and cats, where there is no possibility of monitoring the concomitant effects of REM manipulations on dreaming.
This study represents the first systematic attempt to characterise the effects of localised brain lesions on human dreaming (N=361). The results were dramatic: firstly it was found that lesions which obliterate REM sleep do not obliterate dreaming; secondly it was found that lesions which obliterate dreaming do not obliterate REM sleep; and thirdly it was found that lesions which obliterate dreaming are located in forebrain structures responsible for higher cognitive and motivational functions, namely visuospatial perception (parioto-occipital cortex) and reward (mesocortical-mesolimbic dopamine system).
Researchers at the Sigmund Freud Institute (Frankfurt) and University of Cape Town are using the above-identified patients (non-dreamers with focal brain lesions) to establish the biological function of dreaming as opposed to REM sleep. Freud’s hypothesis that dreams protect sleep is being tested, along with other competing hypotheses.
University of Cape Town
Sigmund Freud Institute
Serotonin-transporter (SERT) densities in dynamic psychotherapy of depression
Joensuu M, Lehto S, Tolmunen T, Saarinen P, Valkonen-Korhonen M, Vanninen R, Ahola P, Tiihonen J, Kuikka J, Pesonen U, Lehtonen J. 5-HTTLPR polymorphism and serotonin transporter binding in drug-naïve patients with major depression. Psychiatry and Clinical Neurosciences 64:387-393, 2010.
Lehtonen J, Tiihonen J, Joensuu M, Lehto SM, Ahola P, Saarinen PI, Valkonen-Korhonen M, Tolmunen T, Kuikka J. (2012) Toward molecular psychotherapy of Depression? Pp. 219-232. In: Levy, R., Ablon, S., Kächele, H. (Eds.) Psychodynamic Psychotherapy Research.Practice-Based Evidence and Evidence-Based Practice (pp. 219-232). Totoja NJ, Humana Press.
Lehtonen J. (2012a) At the crossroads of psychoanalysis and neuroscience. Scandinavian Psychoanalytic Review, 35, 9-20.
We found in two case-reports (Viinamäki et al. 1998, Saarinen et al. 2005) that lowered SERT in patients with major depression was normalised during dynamic psychotherapy, and we also found that SERT densities were elevated in mixed mania (Tolmunen et al. 2004). We then collected a naturalistic sample of patients with major depression and followed their Hamilton scores and SERT densities for psychotherapy of six months. It was found that the relationship between Hamilton score decrease and SERT increase during psychotherapy followed an inverted U-curve, thus suggesting two different types of responses (Laasonen-Balk et al. 2004).
We thereafter collected a sample of drug-naïve first-episode patients with major depression (intention to treat analysis n=33) and randomised them to two groups, one being treated immediately after baseline measurements and the other after waiting six months for dynamic psychotherapy. The baseline findings revealed significant SERT reduction at the level of midbrain (MB) (Joensuu et al. 2007), and moreover an association was discovered between the SERT SS-allele genotype and SERT reduction in medial prefrontal cortex (MPC)(Joensuu et al. 2010).
The patients in both groups received a one-year treatment twice a week with dynamic psychotherapy. The SERT changes did not differ between the groups which were consequently pooled together. It was found that in patients with atypical symptoms SERT densities changed towards normal, but not in patients with Hamilton scores typical for major depression (Lehto et al. 2008a). In the same sample dopamine transporter (DAT) densities showed an association with the length of depression (Lehto et al. 2008b).
When the whole sample, with a significant baseline SERT reduction, was not selected according to the type of symptoms, it was found that after one-year of treatment patients with high severity of symptoms (above median) at the baseline showed significant SERT normalisation during the one-year therapy whereas patients with low severity (under median symptom burden) did not show changes in SERT densities. However, both groups showed equal reduction in Hamilton scores. (Joensuu et al. 2014, submitted).
We conclude that SERT normalisation during dynamic psychotherapy is likely to be related to the reduction of symptom severity and that patients with less symptom burden do not respond to psychotherapy with a change in their lowered SERT levels.
Moreover, our findings on the SERT genotype at baseline is suggestive that different SERT genotypes may have a differential effect on the behaviour of SERT densities in depression.
An overview of our findings until 2012 has been presented in Lehtonen et al. 2012. The conceptual body-mind philosophy problems in connecting psychodynamic understanding with brain state variables has been published in Lehtonen 2012a and 2012b.
Prof. Johanes Lehtonen
University of Eastern Finland and the University Hospital of Kuopio
Departments of Psychiatry, Clinical Physiology and Forensic Psychiatry, Niuvanniemi Hospital
Institute of Health and Welfare, Helsinki
Gen environment relations in depression: Chilean Millennium Nucleus: “Psychological intervention and change in depression”
Nuevo, R., Leighton, C., Dunn, G., Dowrick, C., Lehtinen, V., Dalgard, O. S., Ayuso-Mateos, J. L. (2010). Impact of severity and type of depression on quality of life in cases identified in the community. Psychological Medicine, 40(12), 2069-2077. doi: 10.1017/s0033291710000164
Gen environment relations in the origin of depression and well being
Genetically our differences are small, so it can be assumed, that the relation with the unique environment that each person suffers since conceived plays an important role in creating our uniqueness. Depression constitutes a recurrent, frequently chronic condition requiring long-term clinical management (Angst, 1997). Both genetic and environmental factors have been implicated in developmental pathways to depression (Saveanu & Nemeroff, 2012; Sullivan, Neale, & Kendler, 2000).
With regard to depression, much research has focused on interactions between environmental factors and polymorphisms, since the leading study of Caspi and colleagues (Caspi et al., 2003) demonstrating that individuals with one or two copies of the short allele of the serotonin transporter gene promoter region exhibited more depressive symptoms, diagnosable depression, and suicidality in relation to stressful life events than individuals homozygous for the long allele. This has led to a renewed focus on stress (Hammen, 2005) and early and later adversity in particular in explaining vulnerability for depression, especially among genetically predisposed individuals (Heim & Nemeroff, 2001; Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; Risch et al., 2009).
Research in this area has mainly focused on studying the moderation of negative environment from a diathesis- stress perspective. In recent years, studies began to include positive variables such as preventive interventions, positive parenting styles, or even no trauma, it was noted that in some cases, the same alleles that were more sensitive to negative events, were also more sensitive to positive events. Hence, the model began to shift from a model of diathesis to stress or vulnerable phenotype to the model of differentiated sensitivity to the environment or social susceptibility (Bakermans-Kranenburg & van Ijzendoorn, 2011; Bakermans-Kranenburg, Van, Pijlman, Mesman, & Juffer, 2008; Belsky & Pluess, 2009; Boyce & Ellis, 2005; Cicchetti & Rogosch, 2012; Ellis & Boyce, 2008; Ellis, Boyce, Belsky, Bakermans-Kranenburg, & Van Ijzendoorn, 2011; Ellis, Essex, & Boyce, 2005; Oreland, Nilsson, Damberg, & Hallman, 2007; Pluess, Belsky, Way, & Taylor, 2010; Roisman et al., 2012; Sheese, Voelker, Rothbart, & Posner, 2007), which contends that more susceptible individuals in a positive environment will show more favourable outcomes but if they experience negative environments will show more negative results. This model argues that certain genes make us more sensitive or reactive to the environment "for better or for worse”, leading to the notion of plasticity or malleability genes. The importance of including recent and positive events in the interaction of gene and environment studies is that maybe transforming the environment in a positive one by psychotherapy or promoting social positive policies, could have a positive and effective outcome, especially in more sensitive people. Noticing the importance and power of social context to modify risky vulnerabilities.
Two systematic reviews are taking place in this field:
(1) DIFFERENTIAL SUSCEPTIBILITY GENES; A SYSTEMATIC REVIEW OF GXE and (2) GENETIC POLYMORPHISMS, OXYTOCIN AND DEPRESSION
The aim of these review, therefore is to provide a critical review of research on GxE. Specifically, provide a systematic qualitative review of research on various genes that have been investigated in GxE research and the genetic contribution of oxtytonergic system polymorphisms in the pathophysiology of depression with the aim to address gaps in our knowledge and formulate a number of recommendations for future research.
Design and method
For this reviews, empirical studies published in peer-reviewed journals in English, between January 2002 to April 2014, were retrieved using several search engines (PubMed, PsycINFO, and Google Scholar). Finally, references of retrieved papers were hand searched. After two of the authors (AB y CL) screened for these inclusion criteria, 241 studies were recruited for the first review and 11 studies were identified for the oxytonergic review,
Changes in brain functions in chronic depressed patients after long-term psychoanalytic compared with cognitive behavioural treatments: Frankfurt fMRI / EEG Depression Study (FRED)
Fischmann T, Russ M.O. and Leuzinger-Bohleber M. (2013): Trauma, dream and psychic change in psychoanalyses: a dialogue between psychoanalysis and the neurosciences. Frontiers in Human Neuroscience, 7, 877. doi: 10.3389/fnhum.2013.00877.
Fischmann, T., Leuzinger-Bohleber, M., Kächele, H. (2012): Traumforschung in der Psychoanalyse: Klinische Studien, Traumserien, extraklinische Forschung im Labor. Psyche -. Zeitschrift für Psychoanalyse, 66, 833-861.
Leuzinger-Bohleber, M., Fischmann, T. (2014): Transgenerationelle Weitergabe von Trauma und Depression: Psychoanalytische und epigenetische Überlegungen. In: V. Lux & T. Richter (Hrsg.): Kulturen der Epigenetik: Vererbt, codiert, übertragen (S. 69-88). Berlin: DeGruyter.
The FRED started in 2007 and is a still ongoing study conducted at the Sigmund-Freud-Institut in cooperation with the research team of the LAC-depression study, the Brain Imaging Center (BIC) and the Max-Planck-Institute for brain research (MPIH) in Frankfurt, the Hanse Neuro-Psychoanalysis study (HNPS) and the sleep-somnological centre of the hospital Hofheim. The research is funded by the Neuro-Psychoanalysis Society – HOPE and the Research Advisory Board of the IPA.
Depression from a brain physiological angle may be related to a neurotransmitter disorder, or a frontal lobe dysfunction (Belaker & Agam, 2008; Caspi et al., 2003; Risch et al., 2009). It may also be the result of a disturbed “reward system” (Northoff & Hayes, 2011). But despite these findings no distinct brain physiological marker for depression has been found so far.
The FRED study aims at researching whether changes in the course of therapy have brain physiological correlates looking at some of these areas. Assuming that psychotherapy working on memory and recurring dysfunctional behaviors and experiences has precipitations within in the brain like synapse configuration, priming and axonal budding the hypotheses for FRED are (1) psychotherapy is a process of change in encoding conditions of memory, and (2) elements of memory can be depicted in fMRI by a recognition experiment of memories related to an underlying conflict. Another aspect of change relevant for the FRED study is that of clinical change found in dreams in the course of psychotherapy. Hence changes of dreams in the course of therapy are investigated as well and related to the neurophysiological findings.
Seventeen chronically depressed patients were recruited from the pool of the LAC-depression study and participated in a naturalistic observational design. In a first diagnostic phase an operationalized diagnostics (OPD) interview concentrating on axis II (relational) and a dream interview was conducted. From these two interviews the stimuli for the fMRI scanning were created individually for each patient. For one, one, dream words were taken from a significant dream elicited in the dream interview and for the other confrontational sentences taken from the OPD interview were formulated. Brain activation patterns resulting from these stimuli in the fMRI serve as dependent variables. Measurements are taken at three different time points – each one minimum 8 months apart – revealing changes in activation patterns occurring in the course of therapy.
First results of the dream experiments revealed that patients confronted with dream words in contrast to so-called neutral words (taken from an all-purpose story) showed differential activation of the precuneus, the ventro-lateral pre-frontal cortex (VLPF), and the anterior cingulate gyrus, among others. These three brain areas are known to be involved in self processing operations (experience of self agency), generation of basic causal explanations, and regulating emotions (see also below), where the ACC is also known for its conflict monitoring feature. In the course of therapy it could be shown that the recognition or rather re-sounding of initially significant dream content at the beginning of therapy activated specifically the precuneus and the left parietal lobe, which did not substantiate after one year of therapy. The disappearance of these areas—which are involved in attention processes but are also significant to emotional processing by the self—at T2 allude to the supposition that possibly the dream content has lost its special importance and is experienced now in the same manner as the neutral story.
As for the OPD part of FRED, it consists of three conditions in the fMRI scanner, which are repeated six times each. In condition 1 four subjectively confrontational (conflict-oriented) statements extracted from the previously conducted OPD interview (relational axis II) are presented consecutively in the fMRI scanner on a screen. In condition 2 subjects see four statements of an all-purpose situation presented in the same manner, and finally condition 3 is composed of four relaxation statements. Analysis of the fMRI brain scans contrasting the different conditions (dysfunctional sentences > traffic + relaxation) revealed specific activation patterns again in the precuneus, and above that of the posterior and anterior cingulate gyrus, medial prefrontal cortex (MFC), occipital cortex and the left hippocampus for condition 1 (dysfunctional sentences). The occipital cortex and precuneus are important brain structures for primary visual processes (occipital c.) and visual-spatial imagery (precuneus). But besides this the precuneus is also known to be an important brain area for episodic memory retrieval and self-processing operations, i.e., for first person perspective taking and experience of agency. The cingulate gyrus being an important part of the limbic system helps regulate emotions and pain and constitutes an important feature of memory just like the hippocampus, which is aligned for memory formation, specifically long-term memory (episodical biographic). The MFC is postulated to serve as an online detector of information processing conflict (Botvinick, Cohen & Carter, 2004) but also has a regulative control function of affective signals (Critchley, 2003; Matsumoto, Suzuki & Tanaka, 2003; Posner & DiGirolamo, 1998; Roelofs, van Turennout & Coles, 2006; Stuphorn & Schall, 2006). In a single case study it could also be shown that MFC activation could no longer be detected after one year of psychotherapy, suggesting that the conflict impact has diminished in the course of therapy
While it is the first study of its kind, the study has its limitations. The sample size is relatively small, which is due for one to the longitudinal design of the study and for the other to the fact that investigating in an fMRI environment limits possible candidates. The strength of the study is the naturalistic design. The study scientifically follows chronically depressed patients in the course of their long-term psychoanalytical therapy, where changes in brain functions are investigated on ‘real’ patients undergoing psychotherapies realized in the offices of ‘real’ psychotherapists associated with a high external validity of the findings. A comparison to a non-depressive control-group is still lacking.
Neuroimaging and attachment with “children-at-risk”
Leuzinger-Bohleber, M., Fischmann, T., Neubert, V., Hartmann, L.K., Läzer, K.L., Pfenning-Meerkötter, N., Schreiber, M., Ackermann, P. (2014): Project Eva: Evaluation of two prevention programs with high-risk children in kindergarten. Journal of the American Psychoanalytic Association, 62(3), NP29-NP31.
Ekman, M., Derrfuss, J., Tittgemeyer, M., & Fiebach, C. J. (2012). Predicting errors from reconfiguration patterns in human brain networks. Proceedings of the National Academy of Sciences, 109, 16714-16719
Fiebach, C. J., Rissman, J., & D’Esposito, M. (2006). Modulation of inferotemporal cortex during verbal working memory maintenance. Neuron, 51, 251-261.
The neuroimaging study on attachment with “children-at-risk” will start in 2015 and will be conducted at the Sigmund-Freud-Institute in cooperation with the Institute for Neurocognitive Psychology of the Goethe University (fiebachlab). The Research is funded by the Deutsche Forschungsgemeinschaft (DFG: FI 2065/1-1).
The integration of children-at-risk is one of the most pressing societal tasks. Moreover there is a growing risk of social disintegration of at-risk children. Social disintegration, low educational success, violence, psychosomatic and emotional disturbances as well as increased drug consumption especially in adolescents are attributable – among others – to emotional neglect respectively to severe traumatization in early childhood. In recent years a vast amount of studies from the field of empirical attachment research illuminated factors which influence cognitive-affective and social development of children. They investigated among others the development of attachment patterns of children in their first years of life.
In this study this thread will be taken up by investigating children with an insecure-disorganized attachment with respect to neuronal correlates of emotional reaction to attachment-relevant stimuli. Since disorganized attached children in elementary school age show an increasing amount of psycho-social and aggressive problems, a further hypothesis is tested, whether those children will have a more intensive reaction on social ostracism than securely attached children.
This interdisciplinary study investigates disorganized attached children in comparison to securely attached children with respect to structural and functional neurobiological conspicuities by means of structural and functional magnetic resonance imaging (sMRI/fMRI). The research aims at investigating relationships of early childhood experiences, individual attachment patterns and neurobiological correlates.
A literature review revealed that differences in attachment styles lead to differential modulation of different neuronal systems. Most of these findings stem from investigations on rodents. The few studies on humans on neurophysiological correlates of attachment were mainly conducted with adults and therefore don’t permit a distinct linkage between early childhood experience and neurophysiological correlates. Early childhood experiences are most probably reshaped by a variety of experiences in adolescents and adulthood. Therefore this research appears to be most valid despite the heightened difficulties to recruit children with reliably determined problematic attachment-type for neurocognitive studies.
Buchheim A, Labek K, Taubner S, Kessler H, Pokorny D, Kächele H, Cierpka M, Roth G, Pogarell O & Karch S (2018) Modulation of gamma band activity and late positive potential in patients with chronic depression after psychodynamic psychotherapy. Psychotherapy and Psychosomatics DOI: 10.1159/000488090:
Buchheim A, Erk S, George C, Kächele H, Martius P, Pokorny D, Spitzer M & Walter H (2016). Neural response during the activation of the attachment system in patients with borderline personality disorder: An fMRI study. Frontiers of Human Neuroscience. doi: http://dx.doi.org/10.3389/fnhum.2016.00389
Buchheim A, Viviani R, Wiswede D, Kessler H, Kächele H, Cierpka M, Roth G, Münte T, Erhard P, George C, Kernberg O, Taubner S (2012) Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS ONE, 7: e33745. doi:10.1371/journal.pone.0033745..
Taubner, S., Buchheim, A., Rudyk, R., Kächele, H., Bruns, G. (2012). How does neurobiological research influence psychoanalytic treatments. The American Journal of Psychoanalysis 72: 269-286.
In recent years, human neuroscience has become interested in the investigation of brain changes when patients are under psychotherapy. As this is a complex process that cannot be adequately captured with standard experimental paradigms from neuroscience, new approaches and the inclusion of the subjective, individual perspective have to be applied.
Previous studies examining the functional neuroanatomy of psychotherapy in depressed patients have mostly studied interpersonal therapy or cognitive behavioral therapy. The present research from the Hanse-Neuro-Psychoanalysis Study reports on the first fMRI study with recurrently depressed patients treated with long-term psychoanalytic therapy (Buchheim et al. 2008).
Our study design differed from that of previous studies in the following respects.
1) Neuroimaging studies have examined the effects of short time psychotherapy (e.g. 12-20 weeks), applying cognitive-behavioral or interpersonal therapy in depressed patients. We examined depressed patients during psychoanalytic treatment providing a longer observation window (15 months of therapy).
2) Most studies used more unspecific and non-personal stimuli (e.g. International Affective Picture System or the Ekman faces) to induce certain moods to assess neural changes during therapy. Our research group developed two different fMRI paradigms with an individualized research approach in order to operationalize processes relevant for depression and therapeutic change on different levels:
(a) Adult Attachment Projective Picture System to assess representations of significant attachment experiences (e.g. separation, loss etc) and relationships (Part I),
b) Operationalized Psychodynamic Diagnosis (OPD-2) as a valid tool to investigate the participant’s dysfunctional interpersonal relationship patterns (see Part II).
The OPD paradigm is also applied in the Frankfurter-fMRI/EEG-Depressionsstudie (FRED) (PI: PD Dr. T. Fischmann) in the context of a collaborative study.
In an attempt to bridge the gap between science and clinical practice, a clinical research project was initiated together with the participating psychoanalysts. It investigated the influence of the neuroscientific study on the therapeutic process by regular group meetings of the psychoanalysts, case reflections and self-report data from patients (Taubner et al. 2012).
Prof. A. Buchheim
Institut für Psychologie Universität Innsbruck
Neural changes in prefrontal-limbic function in chronically depressed patients after 15 months of psychoanalytic therapy using the Adult Attachment Projective Picture System (AAP) as an individualized paradigm
Buchheim, A., Viviani, R., Kessler, H., Kächele, H., Cierpka, M., Roth, G., George, C., Kernberg, O.F., Bruns, G., Taubner, S. (2012). Changes in prefrontal-limbic function in major depression after 15 months of long-term psychotherapy. PLoS ONE 7(3): e33745. doi: 10.1371/journal.pone.0033745
Buchheim, A., & George, C. (2012). Using the AAP in neurobiology research. In: C. George & M. West, M. (Eds.), The Adult Attachment Projective Picture System (pp. 253-274). New York: Guilford Press..
We investigated recurrently depressed (DSM-IV) unmedicated outpatients (N=16) and healthy control participants matched for sex, age, and education (N=17) before and after 15 months of psychoanalytic therapy. The stimulus materials were attachment-related pictures from the Adult Attachment Projective Picture System (AAP), an interview measure for assessing attachment representations that has been shown to be feasible for using in an fMRI environment (Buchheim & George 2012). These pictures are designed to elicit mental engagement with attachment-related experiences such as separation, illness, danger, and loss. To increase the capacity of the signal to elicit a response related to the emotional processes of each individual, material was here prepared using personalized content derived from AAP interviews with each participant. In the personally relevant condition the AAP attachment scenes were accompanied by individually tailored descriptions containing core sentences from the patient’s own narrative previously elicited by each picture. The same series of attachment scenes accompanied by a standard factual, non-emotional description for all participants was used as control condition. Participants were scanned at two time points (at the beginning of therapy and after 15 months). Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy.
In the fMRI study signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. The pattern of changes in prefrontal areas found in the present study may be associated with mechanisms of emotional appraisal and control, suggesting reduced recourse to styles characterized by suppression and avoidance after long-term therapy. This interpretation outlines a possible mechanism for the understanding of emotional appraisal and regulation in the psychodynamic psychotherapy of depression.
The same sample was also examined in an EEG setting. At the beginning of treatment, patients confronted with the attachment paradigm showed a sustained gamma-band activity and a significant higher late positive potential (LPP) at fronto-central sites compared to the healthy controls. After 15 months of treatment, gamma band responses to personalized stimuli were significantly decreased in patients. This effect was not observed in the control group. In addition, the LPP amplitudes of the patients decreased and equalized to the amplitudes of the healthy controls. A smaller LPP as well as gamma band response after 15 months of treatment may indicate reduced emotional responses e.g. due to enhanced emotion regulation strategies. (Buchheim et al. 2014).
Univ. Prof. Dr. Anna Buchheim
Institute of Psychology, University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria,
Neural correlates of therapeutic changes in chronically depressed patients in psychoanalytic psychotherapy with the Operationalized Psychodynamic Diagnosis (OPD)
Kessler, H., Taubner, S., Buchheim, A, Münte, T.F., Stasch, M., et al. (2011). Individualized and clinically derived stimuli activate limbic structures in depression: An fMRI Study. PLoS ONE 6(1): e15712.
Kessler, H., Stasch, M., & Cierpka, M. (2013). Operationalized psychodynamic diagnosis as an instrument to transfer psychodynamic constructs into neuroscience. Frontiers in Human Neuroscience 7:718.
Taubner, S., Kessler, H. & Wiswede, D (2013). Neural activity in relation to empirically derived personality syndroms of depression using a psychodynamic fMRI paradigm. Frontiers in Human Neuroscience 7:812. DOI:10.3389/fnhum.2013.00812
Wiswede, D., Taubner, S., Buchheim, A., Münte, T.F., Stasch, M., et al. (2014) Tracking functional brain changes in patients with depression under psychodynamic psychotherapy using individualized stimuli. PLoS ONE 9(10): e109037.
Operationalized Psychodynamic Diagnosis (OPD-2) served as a tool to investigate complex intrapsychic processes in a reliable way by constructing core conflict formulations that were presented to the patients in the scanner. Kessler et al. (2013) provides the foundation and rationale of this procedure.
18 unmedicated patients with recurrent major depressive disorder were confronted with individualized and clinically derived stimuli in a functional MRI experiment before (T1) and after eight months (T2) of psychodynamic therapy. A control group of 17 healthy subjects was also tested twice without intervention. The experimental stimuli were sentences describing each participant’s dysfunctional interpersonal relationship patterns derived from clinical interviews based on OPD (Kessler et al., 2011; Wiswede et al., 2014).
At T1 patients showed enhanced activation compared to controls in several limbic and subcortical regions, including amygdala and basal ganglia, when confronted with OPD sentences. At T2 the differences in brain activity between patients and controls were no longer apparent. Concurrently, patients had improved significantly in depression scores. Using ecologically valid stimuli, this study supports the model of limbic hyperactivity in depression that normalizes after treatment. Additionally, this study provides empirical evidence that the application of individualized stimuli is a powerful method to investigate complex intrapsychic processes as well as deepen our understanding of depression and its neural correlates.
Taubner et al. (2013) studied subgroups within the sample of chronically depressed patients. Using empirically derived personality syndroms with the Shedler-Westen-Assessment-Procedure, two personality factors could be distinguished: depressive or emotional-hostile-externalizing personality respectively. The degree to which patients score on the second correlated with relatively higher activity in three key areas involved in emotion processing, evaluation of reward/ punishment, negative cognitions, and social knowledge.
Dr. Henrik Kessler
Department of Psychosomatic Medicine and Psychotherapy, LWL University Clinic Bochum, University Hospital of the Ruhr University of Bochum, Alexandrinenstrasse 1–3, D-44791 Bochum, Germany
Prof. Dr. Svenja Taubner
Institut für Psychosziale Prävention, Universittof Heidelberg
FMRI-Monitoring of an ongoing psychoanalysis
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 23(7): 677, doi: 10.3389/fnhum.2013.00677.
For the first time the Ulm-Innsbruck study group explored the feasibility of single case research approach of an ongoing psychoanalysis using repeated fMRI measurements. We pursued the integration of clinical presentation, of operationalized formal instruments to describe the individual psychotherapeutic process (PQS), and of neuroimaging techniques to monitor the psychotherapeutic process on both the clinical and the neural levels. In the fMRI scans, the individualized attachment paradigm was used again (see also Buchheim et al. 2012).
Clinically, this patient presented defense mechanisms that influenced the relationship with the therapist and that was characterized by fluctuations of mood that lasted whole days, following a pattern that remained stable during the year of the study. The two modes of functioning associated with the mood shifts strongly affected the interaction with the therapist, whose quality varied accordingly (‘easy’ and ‘difficult’ hours).
In the fMRI data, the modes of functioning visible in the therapy hours were significantly associated with modulation of the signal elicited by personalized attachment-related scenes in the posterior cingulate. This region has been associated in previous studies to self-distancing from negatively valenced interactions presented during the scan.
This pilot study may provide indications of the possible involvement of this brain area in spontaneously enacted self-distancing defensive strategies, which may be of relevance in resistant patient reactions in the course of a specific phase in psychoanalytic psychotherapy (Buchheim et al. 2013).
Univ. Prof. Dr. Anna Buchheim
Institute of Psychology, University of Innsbruck, Innrain 52, 6020 Innsbruck, Austria
Zurich Depression Study
Boeker, H., Richter, A., Himmighoffen, H., Ernst, J., Bohleber, L., Hofmann, E., Vetter J., & Northoff, G. (2013). Essentials of psychoanalytic process and change: how can we investigate the neural effects of psychodynamic psychotherapy in individualized neuro-imaging? Frontiers in Human Neuroscience, 7, 355.
The Zurich Psychotherapy Neuroimaging Study
This ongoing study investigates changes in hemodynamic activation patterns using fMRI (functional magnetic resonance imaging) in depressed patients during psychodynamic psychotherapy. An individualized research paradigm is employed which reflects specificities of every patient’s single case and focuses on feelings associated to maladaptive interpersonal behaviour patterns. The fMRI findings of this individual research paradigm are set in relation to clinical findings generated from a large set of psychodiagnostic assessments.
Treatment groups include psychodynamic psychotherapy (PPT) (n=20), cognitive behavioural psychotherapy (n=20), body-centered psychotherapy (n=20) with a control group of matched healthy participants (n=20). Testing will take place before and after psychotherapy (max. after six months), with controls being tested within the same time frame. Apart from the fMRI examinations, participants will pass psychological testing including an OPD-2 interview, a standardised clinical diagnostic interview (mini DIPS, Diagnostisches Kurz-Interview bei Psychischen Störungen [Diagnostic short interview for mental disorders], Margraf, 1994) and a series of questionnaires. Primary outcome measures will be hemodynamic activation differences between conditions during fMRI examination with group and time as well as changes on psychodynamic dimensions, particularly in those related to interpersonal relations (OPD-2, OPD-SF, MIPQS, IIP-D, IMI, FKBS).
This study adopts an individualized neuroimaging approach to track neurobiological changes underlying psychodynamic psychotherapy. The strength of the study design resides in the use of an innovative fMRI paradigm along with a large set of psychological and psychodynamic measures. Also, collaboration with other psychotherapeutic institutes enabled the inclusion of different treatment groups (cognitive behavioural psychotherapy and body-centred psychotherapy). Limitations of the study design include methodological challenges of using an individualized neuroimaging approach. Furthermore, variability in the different treatment groups was only controlled to a certain extend.
Prof. Dr. med. Heinz Böker
Psychiatrische Universitätsklinik Zürich
Neural Predictors of Successful Brief Psychodynamic Psychotherapy for Persistent Depression
Roffman, J.L. Witte, J.M., Alexandra S. Tanner, A.S., Ghaznavi, S. Abernethy, R.S., Crain, L.D., Giulino, P.U., Lable, I., Levy, R. A., Dougherty D.D:, Evan, K.C., Fava , M.(2014): Neural Predictors of Successful Brief Psychodynamic Psychotherapy for Persistent Depression, Psychother Psychosom 83: 364–370.
Psychodynamic psychotherapy has been used to treat depression for more than a century. However, not all patients respond equally well, and there are few reliable predictors of treatment outcome.
We used resting 18 F-fluorodeoxyglucose positron emission tomography ( 18 FDG-PET) scans immediately before and after a structured, open trial of brief psychodynamic psychotherapy (n = 16) in conjunction with therapy process ratings and clinical outcome measures to identify neural correlates of treatment response.
Pretreatment glucose metabolism within the right posterior insula correlated with depression severity. Reductions in depression scores correlated with a pre- to posttreatment reduction in right insular metabolism, which in turn correlated with higher objective measures of patient insight obtained from videotaped therapy sessions. Pretreatment metabolism in the right precuneus was significantly higher in patients who completed treatment and correlated with psychological mindedness.
Resting brain metabolism predicted both clinical course and relevant psychotherapeutic process during short-term psychodynamic psychotherapy for depression.
Joshua L. Roffman, MD, MMSc
Massachusetts General Hospital
Room 2606, 149 13th Street
Charlestown, MA 02129 (USA)