Abstract
Opinions vary on the relevance of neuroscience to psychotherapy. Some make the case that there is no relationship between the two disciplines. After all psychotherapists, particularly psychodynamic therapists, work with interpersonally constructed meaning in the present moment. Even if it is the case that this is all transacted in the brain, neuroscience can have little or nothing of relevance to say about that interpersonal dynamic. Others talk about neuroscience as though it offers the hope of biological validation for their models of psychotherapeutic work. This is of particular importance to psychoanalysis, which, being difficult to falsify, has over recent decades lost a degree of credibility in wider scientific debate. Neuroscientists would call the former view a ‘dualist perspective’ meaning that even if all neural processes associated with an aspect of conscious experience were identified the association between neural events and subjective events can only be correlative not causative. In neuroscientific terms the latter view would be seen as ‘materialistic monism’, following the assumption that mental life can be seen as the product of, or can be reduced to, innumerable neural interactions. Further to this it could be argued that neuroscience has proceeded well enough without the psychotherapeutic perspective and vice versa so what do these two disciplines have to offer each other?
Introduction
Opinions vary on the relevance of neuroscience to psychotherapy. Some make the case that there is no relationship between the two disciplines. After all psychotherapists, particularly psychodynamic therapists, work with interpersonally constructed meaning in the present moment. Even if it is the case that this is all transacted in the brain, neuroscience can have little or nothing of relevance to say about that interpersonal dynamic. Others talk about neuroscience as though it offers the hope of biological validation for their models of psychotherapeutic work. This is of particular importance to psychoanalysis, which, being difficult to falsify, has over recent decades lost a degree of credibility in wider scientific debate. Neuroscientists would call the former view a ‘dualist perspective’ meaning that even if all neural processes associated with an aspect of conscious experience were identified the association between neural events and subjective events can only be correlative not causative. In neuroscientific terms the latter view would be seen as ‘materialistic monism’, following the assumption that mental life can be seen as the product of, or can be reduced to, innumerable neural interactions. Further to this it could be argued that neuroscience has proceeded well enough without the psychotherapeutic perspective and vice versa so what do these two disciplines have to offer each other?
Another philosophical and neuroscientific position ‘dual aspect monism’ makes the case that psychoanalytic practice and neuroscience provide two perspectives, namely subjective and objective, on the brain. Psychoanalysis provides perhaps the most detailed and in-depth account of intrapsychic life and the interpersonal mind as it is perceived by the subject, where as neuroscience is the objective study of the structure and function of the brain as a bodily organ. It is this binocular view which offers new metapsychological understanding of clinical phenomena and refines research questions for neuroscientists. For this reason, it is important that psychotherapists and psychotherapeutically interested psychiatrists understand recent developments in neuroscience and are able to think about their implications for clinical work and research. To this end this chapter aims to describe those developments in psychodynamic neuroscience most relevant to psychotherapists and psychiatrists.
The indivisibility of brain and mind and consequent indivisibility of biological and psychotherapeutic psychiatry are well expressed in Kandel’s new intellectual framework for psychiatry [1]. Eric Kandel won a Nobel prize for his research on the physiological basis of memory that described the unique domain psychiatry occupied in academic medicine in analysing the interaction between the social and biological. He refers to Freud’s own starting point as a neurologist leading to the publication of his Project for a Scientific Psychology [2] in which he linked psychological hypotheses with neurophysiological processes. Freud abandoned his project because neuroscience had not progressed to a point that his theories could be tested, not because the endeavour itself was flawed. Kandel argued that during the 1950s and 60s when psychoanalysis dominated academic psychiatry in the USA the discipline was largely unconcerned with the brain as an organ of mental activity. Subsequently biological psychiatry may be in danger of becoming unconcerned with mind as the subject of mental activity. The importance of this extends beyond understanding our patients as people who experience illness which is otherwise defined in biological terms. Kandel makes the case that of greater importance still is maintaining a perspective on both brain and mind with potential to reinvigorate the intellectual life of psychiatry. Box 27.1 sets out the principles of his proposed intellectual framework.
Box 27.1 Kandel’s ‘New Intellectual Framework for Psychiatry’
Principle 1. All mental processes, even the most complex psychological processes, derive from operations of the brain, even where the causes of the disturbances are clearly environmental.
Principle 2. Genes and their protein products are important determinants of the interconnections between neurons in the rain, their functioning exerting a significant control over behavior.
Principle 3. Genes do not, by themselves, explain all of the variance of a given major mental illness, b ehaviour and social factors act on the brain by modifying the expression of genes and function of nerve cells. Thus “nurture” is ultimately expressed as “nature.”
Principle 4. Alterations in gene expression induced by learning give rise to changes in neuronal connections. These form the basis of individuality as well as initiating and maintaining abnormalities of behavior induced by social contingencies.
Principle 5. If psychotherapy is effective in bringing about lo ng-term changes in behavior, it p resumably does so through learning, changing gene expression, altering the strength of synaptic connections and bringing about structural changes.
Over the past two decades neuroscience developments have generated renewed clinical and scientific interest in this area. Among other developments a new scientific discipline Neuropsychoanalysis has emerged. This has been led by Professor Mark Solms a psychoanalyst and neuropsychologist promoting interdisciplinary dialogue and research at this interface. Research developments include investigations of the unconscious and memory, the neural mechanisms of drives, dreams, primary and secondary processes and defence mechanisms. What follows is only a small corner of a rapidly evolving field. The areas covered have been chosen on the basis of their relationship with psychoanalytic theory and their relevance to clinicians.
These include:
Instinct, drive and affect
Interoception, exteroception and the embodied self
Self, other and the drive to relate
Generating an internal model of the world: fantasy and reality
The role of dreaming in mental life
Instinct, Drive and Affect
Instinct and drive are fundamental concepts in Freud’s metapsychology. Instinct in Freud’s terminology refers to innate preconceptions about the world linked to unconditioned stereotyped responses such as the rooting reflex. He defined drive, (‘Triebe’ in the original German text) as ‘a measure of the demand made upon the mind for work in consequence of its connection with the body’ [3]. When the body deviates from its homeostatic set point this deviation makes demands upon the brain to respond to restore the balance. It may do so by either acting to meet the drive demand or by inhibiting the demand itself. More recent neuroscience findings indicate that these drive demands are associated with qualities of experience or qualia. For example, when blood glucose drops there may be a physical sensation such as feeling faint but there is also a felt mental quality of the experience of hunger and the urgency of the need to find food. These qualities of experience are affects. Affects are defined as distinct from but related to emotional feelings.
The relationship between affect and homeostatic need is a relatively recent neuroscientific idea. Ideas about the nature, origin and classification of affect have been evolving for over a century. One of the earliest, the James-Lange theory (1884) proposed that emotion did not originate in the brain at all [4]. As an example physiological autonomic arousal on perceiving something frightening such as an oncoming train was thought to give rise to the emotional experience of fear. More recently Silvan Tomkins identified nine primary affects, including shame and disgust, each characterised by particular intensity and physiological expression [5]. This and Eckman’s classification were based on the social expression of emotion rather than their neurobiological basis [6]. Joseph LeDoux adopted a neuroscientific approach to the study of emotion. Like many researchers he was interested in the amygdala, thought to process memory and mediate emotional responses. His research on fear conditioning identified two pathways to the amygdala – a fast subcortical pathway transmitting rapid behavioural responses to threats (‘Pavlovian threat conditioning’) and a slow pathway providing highly processed cortical information responsible for the feeling of fear [7]. His research improved understanding of how the brain responds to threats and how fearful memories are stored which has relevance to exposure therapy. However, LeDoux proposed the brain detects feelings but does not create them. Jaak Panksepp, a professor of veterinary medicine, investigated subcortical networks mediating affect in mammals. He identified subcortical systems with discrete neurochemistries and anatomical distribution each with distinct affective qualities and behavioural correlates. He proposed affects are intrinsic to the brain and stereotypical [8]. The importance of Panksepp’s findings cannot be underestimated. Before his research contribution neuroscience research had focussed on cognition and those forms of behaviour which were available to direct observation. Emotion was considered subjective and therefore not amenable to study through empirical methods. As a consequence of Panksepp’s findings affect could be studied objectively leading to the development of a new scientific discipline affective neuroscience.
Affective Neuroscience
Jaak Panksepp’s primary research in animals identified seven anatomically and functionally distinct subcortical Basic Emotion Command Systems (BECS). These systems are usually described by capitalising their names. They are SEEKING, PANIC, FEAR, RAGE, LUST, CARE and rough and tumble PLAY. These systems, are located between the brainstem and limbic system, parts of the brain which have homologous structures in all mammals, including humans. Their function is to provide information to higher centres in the cerebral cortex about the state of the interior of the body in relation to the external world and to motivate behaviour to meet inner homeostatic and survival needs. In this way the BECS coordinate the multitude of hormonal and neural signals arising from the body into categories with pleasant and unpleasant qualia (affect). The quality of the pleasant/unpleasant affect engendered is particular to each individual affect command system. For example, for the PANIC system the pleasant qualia would be the comfort of closeness with an attachment figure and the unpleasant would be the separation distress. BECS have both a perceptual function in receiving such bodily states and asigning qualia to them but also a function in motivating specific categories of behaviour directed towards meeting basic survival imperatives, the pleasant/unpleasant qualia providing the affective motivation for the behaviour. Table 27.1 illustrates these functions for four of the seven BECS.
Table 27.1 Function, anatomy and neurochemistry of four BECS
| BECS | Function | Anatomy | Neurotransmitters |
|---|---|---|---|
| SEEKING |
|
|
|
| PANIC |
| PAG–bed nucleus of the stria terminalis (BNST)–pre-optic area–dorsomedial thalamus–anterior cingulate gyrus |
|
| FEAR |
| Dorsal PAG–medial hypothalamus–central and lateral amygdala |
|
| RAGE | Behavioural: three distinct aggressive circuits
Psychological: anger stimulated by threat, restricted freedom of movement, irritation to body surfaces or obstructed access to resources | PAG–BNST–medial and fornical hypothalamic nuclei–medial amygdala |
|
SEEKING and PANIC
Examining the SEEKING and PANIC systems in greater detail will clarify the role of BECS and the link between these biological systems and psychotherapeutic concepts such as libido and attachment. The SEEKING system motivates behaviour to locate resources in the environment which will satisfy appetite. It is not itself oriented towards a particular goal but is activated in response to hunger, thirst or sexual desire. If you are thirsty SEEKING provides the motivational drive to look for ‘something’. The hypothalamus identifies what you are looking for, that is, water. The SEEKING system is tonically active underpinning the activity of all the other BECS. From Table 27.1 it will be apparent that neuroanatomically it is the dopaminergic mesolimbic, mesocortical pathway which is causally implicated in the major psychiatric disorders. It may become overactive through use of stimulants or as a consequence of mental illness in mania and schizophrenia. It is thought SEEKING may also become active as a consequence of failure of top-down regulation or failure of regulatory mechanisms between the BECS [9]. SEEKING not only motivates behavioural activation but also mental activity. When SEEKING is overactive it is thought to increase the tendency towards making spurious connections between cause and effect and the development of delusional ideas.
The PANIC system motivates proximity seeking behaviour in both infants and adults. As described earlier the qualia associated with the PANIC system are the comfort of emotional and physical closeness and the pain and anxiety associated with separation and loss. It has been suggested that there is an apparent correspondence between the SEEKING system and Freud’s concept of a libidinal drive which is blind to its object. In contrast the PANIC system mediates attachment behaviour providing the biological basis for Bowlby’s attachment theory [10].
Panksepp identified two systems responsible for different forms of anxiety. The PANIC system being associated with the depressive affect and anxiety associated with social loss and the FEAR system associated with environmental threat. It would seem that the systems underpinning separation anxiety and persecutory anxiety are distinct from one another. The psychopharmacology of these systems appears to correspond with these findings. Benzodiazepines may be effective in moderating the GABA receptors in the FEAR system, tricyclics antidepressants and opiates acting upon the PANIC system. On the basis of Panksepp’s findings Yovell undertook a randomised controlled trial which demonstrated the efficacy of short-term low-dose buprenorphine in the treatment of depression and suicidal ideation [11]. For psychotherapists the idea that the therapeutic relationship has its effects at both psychological and neurobiological levels is perhaps surprising and could change our way of thinking about how psychological/biological change happens.
Affective Consciousness and Representations of the Body in the Brain
BECS are also thought to mediate what is described as core affective consciousness. This refers to both the quantitative attribute of wakefulness and the qualitative attributes already described arising from the BECS. Core affective consciousness comprises awareness of the homeostatic status of the interior of the body arising from two systems, the humoral (hormonal) system and the autonomic nervous system. These are the two mechanisms by which the brain perceives the interior of the body (interoception) and this interoceptive mode of perception is core affective consciousness. In this way the body is represented in two ways in the brain. The external surface of the body, perceived objectively through exteroceptive senses and through motor activity, is represented in body maps on the cortical surface. The interior of the body is perceived through interoception and is represented in deep brain regions including the hypothalamus, ventral tegmental area, parabrachial nuclei, nucleus locus coerulus, reticular formation and periaqueductal grey. Somatotopic maps exist in both brain regions. The interior of the body gives rise to both affective consciousness providing the basis for the core quality of subjective being [12]. The two forms of consciousness arising from these two representations of the body differ. Where consciousness of the external world and the objective body is specific to each sensory modality, affective consciousness perceives both the state of the interior of the body and the response of the subject to external events. Antonio Damasio, whose research demonstrated the central role of emotion in social cognition and decision-making, proposed core consciousness is fundamentally dependent on the response of the protoself, which is represented in the brainstem and defined in these bodily terms, and environment [13].
Panksepp’s BECS sitting at the interface between brain and body do not mediate emotional feelings in the way we usually experience them. He proposed affects were elaborated in more sophisticated ways at higher levels in the brain through nested hierarchies. Figure 27.1 illustrates the ‘bottom-up’ relationship between basic affects and ‘cognised’ affects and top-down affect regulation.
Related posts:
Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
Chapter 9 – Systemic Family Therapy
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 15 – Personality Disorder
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 17 – Psychological Approaches to Medically Unexplained Symptoms
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