How Psychotherapy Changes the Brain Understanding the Mechanisms

Ronald Pies, MD, a Clinical Professor of Psychiatry at Tufts University and Lecturer on Psychiatry at Harvard Medical School tells researchers in Finland, "Very nice update in an area of promising "mind-brain" integration!" The researchers begin by telling us:

Psychotherapy outcomes and the mechanisms of change that are related to its effects have traditionally been investigated on the psychological and social levels, by measuring changes in symptoms, psychological abilities, personality, or social functioning. Many psychiatrists have also held the unfortunate dichotomized position that psychotherapy is a treatment for “psychologically based” disorders, while medication is for “biologically based” disorders.1 During the past several decades, it has become clear that all mental processes derive from mechanisms of the brain.2 This means that any change in our psychological processes is reflected by changes in the functions or structures of the brain. Straightforward reductionistic stances, however, are unfounded because there is clear evidence that our subjective experiences affect the brain.1

Plastic changes in the brain have been difficult to study in humans, but there has been more success in animal studies. Changes in the brain in relation to experience have been detected at the cellular and molecular levels in animals using different experimental approaches. The advent of functional neuroimaging, including single photon emission CT (SPECT), positron emission tomography (PET), and functional MRI, has made it possible to study changes at the brain systems level (by measuring changes in brain blood flow or metabolisms) and, increasingly, also on the molecular level using SPECT and PET in the living human brain. http://webcache.googleusercontent.co...&ct=clnk&gl=us (Hopefully this link will work. Registration otherwise is required to read the article.)

Brain system level studies on the effects of psychotherapy

So far, nearly 20 studies on brain changes after psychotherapy for depression, anxiety disorders, and borderline personality disorder have been published (Table). The first study was published nearly 20 years ago, in 1992. In this study, the researchers compared behavior therapy with fluoxetine(Drug information on fluoxetine) treatment. Both treatment modalities demonstrated similar changes in the brain—especially in the caudate nucleus.

Drawn together, these system level studies suggest that cognitive-behavioral therapy (CBT), dialectic behavior therapy (DBT), psychodynamic psychotherapy, and interpersonal psychotherapy alter brain function in patients suffering from major depressive disorder (MDD), obsessive-compulsive disorder, panic disorder, social anxiety disorder, specific phobias, posttraumatic stress disorder, and borderline personality disorder (BPD).3-16

The majority of these studies have reported similar brain changes after psychotherapy and medication. However, some recent studies have also shown clear differences among these treatment modalities. In the study by Goldapple and colleagues,5 treatment response for CBT in patients with MDD was associated with increases in metabolism in the hippocampus and dorsal cingulate and decreases in the dorsal, ventral, and medial frontal cortex. This pattern was clearly distinct from the pattern caused by paroxetine(Drug information on paroxetine), which included increases in metabolism in the prefrontal areas and decreases in the hippocampus and subgenual cingulate. In the recent study by Karlsson and colleagues,17 clear differences emerged between short-term psychodynamic psychotherapy and fluoxetine among patients with MDD.

From brain changes to mechanisms of psychotherapy

In addition to just reporting the findings on brain changes as a result of psychotherapy, some of these studies have made it possible to construct models that explain the mechanisms behind the changes that result from the different psychotherapies. These models can then be compared with the psychological theories of these psychotherapies.

Many psychotherapies attempt to enhance patients’ problem-solving capacities, self-representation, and regulation of affective states. The brain areas that play a role in these functions include the dorsolateral prefrontal cortex, ventral anterior cingulate cortex, dorsal anterior cingulate cortex, ventral and dorsal subregions of the medial prefrontal cortex, posterior cingulate cortex, precuneus, insular cortex, amygdala, and ventrolateral prefrontal cortex. (For a review, see Frewen et al.18)

For example, the mechanism behind the effectiveness of cognitive therapy for patients with MDD could be through an increase in prefrontal function, which is involved in cognitive control, while antidepressant medications operate more directly on the amygdala, which is involved in the generation of negative emotion.19

Because one of the major hypotheses regarding the effect of CBT on brain functioning concerns a more effective (“top-down”) regulation of hyperexcitable limbic structures by prefrontal control systems, it seems that psychodynamic psychotherapy may also function, at least in part, via these mechanisms. The findings from a study by Beutel and colleagues10 are in line with this hypothesis and demonstrate both a frontal deactivation and an amygdala-hippocampal hyperactivation seen in symptomatic patients with panic disorder. When their panic symptoms and anxiety levels were reduced following treatment, the frontal deactivation and amygdala-hippocampus hyperactivation were normalized.

Affective hyperarousal is the hallmark of BPD and the main target for DBT. This would mean that DBT leads to a decrease in the activity in relation to emotional stimuli in the brain areas that serve these functions. This was indeed found in the study by Schnell and Herpertz,15 whose findings suggest that after DBT, there is a decrease in hemodynamic response to negative stimuli in the right-sided anterior cingulate, the temporal and posterior cingulate cortices, and the left insula.

The researchers conclude:

Although still preliminary, the studies using neuroimaging for measuring change caused by psychotherapy will in the long run lead to a more refined understanding of how different psychotherapies work. This may lead to a development in which specific modes of psychotherapy can be designed to target specific brain circuits.1 In addition, neurobiological research may help refine psychological theories about the change processes.

What is significant for me and the comment made by Dr. Pies is this statement: "Straightforward reductionistic stances, however, are unfounded because there is clear evidence that our subjective experiences affect the brain.1" Efficacious treatment of illnesses requires more than simply focusing on chemical imbalances.

simply put, byz, to your comment-amen to that.

Thanks for this post on neuroplasty, a subject which is hardly discussed on this forum. Why not? Neuroplasty is an exciting field of science of great benefit to those of us who are biochemically compromised. I, for one, have been greatly helped by medication, namely Citalopram, AND therapy which is helping me rebuild pathways through attachment theory. Let's hear more about neuroplasty!! SQ

This is a really good article and I'm so glad to see it!

I have always thought that the brain changes/rewires itself. I've seen those with acquired brain injury etc. who have had to relearn some of the basics, be very successful in doing so. Or how many times do we so those who have spinal cord injuries that learn how to walk again or use their arms/hands again when they were told it would never happen? The only way that was possible was to rewire how the brain thinks/perceives the information and how it responds. There was no reason for me to believe that it would be different for those of us with mental illnesses as well. Every single time we learn something, our brain changes and learns how to store that information for retrieval.

How might psych meds interfer with that process I wonder. I know that since I gave in to meds there has been a noticable and continuous decline of my cognitive abilities. Learning something new is way outside of my reality. Remembering my name or how to spell 'the' or find the ? on my keyboard is enough of a chore. Finding my way to and from the store I have been to a zillion times. I would like to think my brain is capable of storing information but hey what happened to the information that was already stored in there?

I probably took your comment in the wrong direction but the questioned jumped at me when I read the post.

That's a good question snowgoose. I wish I had an answer for you. I would imagine that they could interfere, but I think that's a question for your doctor(s). I'm sorry that it's so difficult for you. Have you received any help from a brain injury foundation at all?

It is interesting to read about this kind of research and the new learning it presents. I guess I just feel sorry for myself because these 'elite' treatments will never be available to me no matter how effective they are.

I can't even access psycho therapy for lack of resources. Well and good for the 99% but not something that will likely trickle down to me anytime soon if ever.

There is a program that does the rotation on PBS now and then. It is titled something with the brain. Bald guy who shows how the brain works and how it regenerates. He shows this through those MRI's or whatever they are called. It was really interesting but still I thought it would never be available to me but great for those who can afford it. I am happy for them.

Thanks Sabby. I wish I had a doctor who could answer these questions. MY GP needs the internet to find answers to my most basic questions about my dx or the meds. I know more about the illness and treatment then he does. The wait for a pdoc is minimum 3 months and 8 weeks between visits if you are even given that option.

Because of the shortages and the mobility of pdocs each time I was sent to one of them I would walk out with a new dx (or at least some additions to the list that keeps growing... what is up with that!!) and a new set of recommended meds.

Get this one..... the last pdoc gave me a prescription for anxiety. I told her my fear of abusing meds so we agreed she would only prescibe 10 at a time and provide refills for 6 months.

I held on to that script for a few months now but things have been so bad that I thought I would give the med a try. Turns out there are no refills ordered and that 2 1/2 months needed to pass before I could get a refill.

Abilify... I think that is what it is called. Anyways I didn't take the script. Been here before. They prescribe something and for one reason or another I can't get a refill without jumping through hoops.

My anxiety just mounted as the girl tried to explain things to me. It was too much. I just had to walk away mid sentence while she said something about a refund. I told I would be back another day but I couldn't deal for another minute while I bolted to my car and cried until I could help myself settle things down.

Sorry.... did not mean to sound so defeated but sometimes it is easy to accept things as they are and go about taking care of myself and not looking outside of me for help. The let downs are much harder for me to deal with.

i just love these articles, even tho i can barely hold their content in my head. you see, i was one of those with a brain injury from an "allergic" reaction to many strong meds, and left with an IQ of about 60, talk of institutionalization, etc. so i know a little about neuroplasty. i have regained, by dint of self-rehabilitation, about 55 IQ points. a great deal of the last leg of rehab has been using Holosync, a binaural auditory technology sold by CenterPointe.com. it is a long term therapy, lasting about 7 yrs.

what i really liked, fortunately for me, was at the very end of the article:

"What is significant for me and the comment made by Dr. Pies is this statement: "Straightforward reductionistic stances, however, are unfounded because there is clear evidence that our subjective experiences affect the brain.1" Efficacious treatment of illnesses requires more than simply focusing on chemical imbalances."

it was my determination, perseverance, independent self-direction, and unrelenting search for new ways to restart or rebuild the brain's functions that made my recovery possible. i believe these to be the very foundations of recovery. no matter which model, method, or path one feels suits them, it is an individual journey, and we can only encourage one another by kindness, sharing, and acceptance. no misery need apply~ :P ,, best wishes to you all,,, Gus

like you gus, i suffered from severe damage due to reactions from medication related side effects. i lost about a year of my life due to them. memory loss, falls resulting in blood clots, shoulder injuries, dwi's (which thankfully resulted in no charges), spasms from meds, difficulty swallowing, losing the ability to read, difficulty in ability to follow thru on plans etc.

it was horrible. before this all happened i would read all the time...tons of books..my house was full of books..i wrote a novel..now it is a challenge for me to read a magazine article. i find it difficult to cook or follow thru on projects..or some simple tasks like cooking or even taking medicines at times. i find my entire thought process has changed to a more visual one...now when i need to think of a word i almost picture the image of it first & then the word comes to me...which was not the way it was before.

all of this is as a result of the time i was over medicated..i can not even tell you the medicines i was one. i live alone & have no family so it was up to me to fight the battle alone basically to stop the treatment & dig my way out of the fog. it was a nightmare.

but i can see how the brain has rewired somewhat...altho there is still some work to be done...i get frustrated because as someone who never studied in college & graduated with a 3.something gpa now i find reading difficult. it makes me angry...angry that i can not make dinner at times...or remember to pay a bill or take a pill...or other simple things...there is a blockage or a missed gap/synapse someplace.

i was telling my t this last week..if i knew where the damage was or what it was then i would feel better..i could understand it...or if someone would even admit there was damage..other than me saying i can't figure out how to do things....it feels as tho i have worked my way back from a brain injury..much is improeved but yet it isn't perfect.

frustrating....& all from medicines.

Snowgoose,
I think you are talking about the series with Dr. Amen. Without going for the expensive treatments, he has books available: Change Your Brain, Change Your Body and others, which are available in bookstores or online that can be helpful for further insight into what he discusses on that series and at a much lower cost. Perhaps this will help if interested.

((((stumpy)))))

I am so sorry that you experienced such a terrible reaction to medications. And it is totally understandable that you would want to know how your brain was effected and how to work on recovery with an understanding of what was effected.

We live in a world that is so full of medications to treat different illnesses and relieve uncomfortable symptoms, but we forget that every medication we take effects our brains. We often just trust a physician that hands us a prescription as just someone who is treating us and knows what is best to allow us to heal. But often that physician doesn't always know all the side effects and has been marketed by a salesman that respresents a pharmacutical company, so he too may be blind to a certain extent.

I often wonder about how many young women go on birth control, just thinking about controling pregnancy or even ways to remove that uncomfortable bothersome cycle that naturally takes place in her body every month. And what every woman doesn't realize is that she is truely playing around with her whole body chemistry that does effect the health of the brain as well.

I experienced a terrible reaction to a drug called Lupron that was administered to me in an implant in my arm to stop my period so I could heal after lazor surgery to lazor out endometriosis that itself was reaking havoc in my body and disabling me more and more. I ended up suddenly falling apart and experienced a completely disabling depression where I could not function psychologically. I went to see my gynocologist, thankfully I went to the right place to seek help. My gyno never told me it was the Lupron, he just told me that I had no estrogen count in my blood and that he would help me recover and not to worry. So I was treated with estrogen replacement and Zoloft. I slowly felt the fog lifting, very slowly one day at a time and it took a few months.

Now after I felt better, I slowly weaned myself off of the Zoloft because the side effects were getting to me. After I did that, I later slowly weaned myself off of the estrogen replacement pills. But what did happen to me was that Lupron sent me into early menopaus. And for a quite a few years I was always afraid that at any time I might be presented with and onset of depression that might cripple me. So I basically, quietly lived in a secret fear.

It wasn't for a long time that I learned about the side effects of Lupron and was able to trace my severe depression to taking that drug. And the problem was that the pharmacutical company did know that was happening and so they also warned the doctor but it had not gone public until many cases of that side effect were presented.
And as that happened, it was finally made public.

I don't think it is fair that someone not be informed about the real source of their reaction to a drug and what damage was caused in the brain. And it is obvious to me that there is often not full disclosure to drug dangers until way after the side effects are presented by many so that the information has to be disclosed.

I am very concerned about many mediations that are presented to young women for birth control. And other medications that can do much more harm than good.

It is much better to understand what therapy is truely treating and why, rather than wander around in the dark. I do believe that with therapy and direction we can learn ways to heal and overcome different challenges in our brains. But as has been proven in therapy after a brain trama a certain direction in therapy can present ways for the brain to overcome many different kinds of damage and often rewire and access and make new pathways to allow a patient to access recovery for losses. So, the growing study and understanding of brain pathology is truely paramont and the more we know as patients what has been possibly damaged or weakened, we can feel more hope and a sense of "I can recover" as we make efforts in therapy.

Open Eyes

Neuroplasticity is an area of research I'm very interested in and already have taken a few research-based courses in but I feel like I've only just scratched the surface of it. The brain can, "re-wire" but only in certain areas. The hippocampus functions in consolidating short-term memory and working memory to long-term memory, retrieving long-term memory storage and spatial navigation. It does not re-wire (or if it does to no great extent) partly due to the fact it uses pyramidial neurons, whereas many other brain areas do not. Likewise, the amygdala also uses pyramidial neurons.

Some of the research I focused on in other courses dealt with analyzing the structural differences at the level of the synapse. In other words, analyzing changes in interneuron communication. The issue with neuro-imaging studies, such as fMRI, is they indicate changes in structural size and activation, however, they cannot indicate whether the activation is inhibitory or excitatory. Normally this can be determined based on known information of the brain region but when a completely different brain area activates that did not prior to psychotherapeutic treatment, it can be difficult to determine whether it is inhibitory or excitatory.

I'm not a doctor so I may not be able to give a clear answer. Using the computer model of the brain, there are several sites at which information stored in long-term memory can be lost or disrupted. First, it cannot be retrieved because the memory has degraded. Second, the memory is indeed retrieved but it is drastically altered, so your expectations of the memory do not coincide with the content of the memory. Third, the memory is retrieved and fully intact, however, other brain areas are affected preventing the memory from being "read". Fourth, there are several very similar memories that have been integrated into one, so key details that you may want have been omitted. This fourth possible cause occurs in everyone. A great example is when you went to school, you learned math (just to keep things simple I'm only picking 1 academic subject). You learned how to add, subtract, multiply and divide, as well as geometry, calculus, algebra, etc... . The problem is, you are very unlikely to remember in which grade you learned each of these topics because that fine detail has been omitted. All four of these are normally attributed to the memory degraded as a result of time, however, in your case I would say the medications. As for why and how, that becomes a complex biochemical discussion that probably is not yet fully uncovered by research. Why your memory has been drastically affected whereas others who took the same medication were not isn't something that can be answered in any great detail. It would partially come down to genetics, although that answer has to wait until the Human Genome Project is fully complete.

I don't want to sound too ghoulish but your doctor probably isn't the person to turn to for your answers. Clinicians are rarely taught or know the in-depth mechanisms of how medications work in the body and brain. Obviously he/she can tell you the medication crosses the blood-brain barrier via receptor-mediated transport and is designed to target ___ receptors. Beyond that, you probably would get more detailed answers from a researcher in pharmacology specializing in pharmacodynamics. Clinicians are limited by what they're told the medication does in a summarized and simplified form. When talking to their patients, they further summarize and simplify the information.

Thanks everyone for your input regarding meds and pathway building. My anxiety (GAD/OCD/PTSD) got so high by the time I was 62 that I was ready to begin Citalopram (generic Celexa). Previous to age 62 I had refused all "drugs" whether street or medical. Gads, what a difference Citalopram made: wish I had taken it sooner. Could have saved me (and my family) many years of suffering, not to mention the self-abuse I was doing to my own body by pumping a steady stream of cortisol into my system.

There is medical evidence that SSRIs calm the brain's limbic system. Here's how: when the amgdala (fear center) is less activated, the hippocampus begins to "unshrink" as the cortisol levels drop. A healthy, full size hippocampus supports better memory recall. A shrunken hippocampus is NOT the aging person's friend because it greatly ups the chances of early-onset dementia and/or Alzheimer's disease. The stats on these two diseases for those having chronic PTSD is 50-70%.

In the past, I found that counseling appointments prior to medication created an endless cycle of pain without enough grain. How many times can I go over the abusive past? Doing so made me constantly nervous. Because of recent scientific break throughs, I know now what was happening--the amgdala is damaged and needed relief from the gore.

I currently go to a therapist who specializes in attachment disorder as well as anxiety-related disorders. She has shown me the childhood developmental stage that was neglected, thus the pruned or broken pathway. We build it forward. I have healthy people in my life. No longer do I subject myself to the core abusive family who have not sought help. The work I do with my therapist is productive; many pathways have been rebuilt, which gives me better function in my daily life. However, some empathic reasoning seems impossible: I simple have no fond memories of my abusive dad. We never bonded then and because he is dead, there is no chance to re-create that dynamic. I am 64, so there is no dad figure in my life to practice with. I accept that fully and get on with the pathways I can do more successfully.

This is the best holiday season I've ever had in my life. Our grown children have seen a change in me and those kids who have symptoms similar to mine have placed themselves on meds and/or therapy. We are connected in a healthy, forward looking way. We laugh and have fun! Depression is gone. My meds have settled me down and have given me a chance to practice cognitive behavorial therapy tools. Life is truly worth living.

What helped me along the way was reading Dr. Daniel Siegel's easy to understand book on brain pathway development. One is called Mindset. Also Dr. Bruce Perry's books called The Boy Who Was Raised by Dogs was awesomely helpful, as was Born for Love. Those two books put therapy in a rightful place. I also studied Boundaries through Dr. Henry Cloud and Dr. John Townsend's books. Also, learning to speak in I-statements helped me to own my own stuff without blaming the past for everything.

Hoping this post from a senior citizen, diagnosed late in life, is encouraging to somebody who might need it. Getting help while you are young makes for a better life. Susan Quinn

[quote=snowgoose;2139837]It is interesting to read about this kind of research and the new learning it presents. I guess I just feel sorry for myself because these 'elite' treatments will never be available to me no matter how effective they are.

I can't even access psycho therapy for lack of resources. Well and good for the 99% but not something that will likely trickle down to me anytime soon if ever.

Have you tried your local NAMI organization? I have found it to be very helpful in every conceivable way (good education on mental disorders, meds, caregiving, and personal and family support groups) and it's free. Also, those attending are a wellspring of resource information. Susan Quinn

Thanks Susan. I don't live in the US but we do have a similar organization in my country. I do tap into it for information but my story is so common because of shortages there isn't much they can do. Our health care system is near explosion.

I did turn to our local mental health centre but they can only provide crisis support. No long term counselling available. I guess it is out there somewhere but I live on $800 a month disability pension with $500 of that going to housing. There is no money to pay for therapy once the 3 visit limit is reached.

I do use alternative sources for support and guidence so I am not totally without support. I should also say that I often look for barriers to allow me to resist what makes me uncomfortable.

I'm guessing it is the Charlie Rose brain series with Eric Kandel.

Coincidentally, I just took a class at school on neurobiology, and neuroplasticity was our buzzword. I wrote a paper for class on "the neurobiology of psychotherapy" so I've been reading some of those papers mentioned by TheByzantine. I think it's totally cool that science is now figuring out why and how psychotherapy helps people. It also will allow more and more the therapist to choose the right directions in therapy based on the person's brain deficits.

I guess there are ways they could interfere, but also ways they can help, just like therapy. In my reading, I found numerous studies about brain circuit remodeling that are promoted by medication. For example, SSRIs promote growth of new hippocampal neurons. It's a fascinating field. I'm not trying to minimize the negative experiences some have had with medication, as seen in the stories told by several on this thread. Unfortunately, the knowledge to help everyone automatically with the right med or the right therapy is just not there yet (which pill? which therapy exercises?). A big challenge now is the diagnostics--how does one know what treatment a person's brain needs? It can be a lot more challenging to figure that out than just looking for a rather primitive symptom cluster in a person (low mood + insomnia + hopelessness, etc.). Right now it's hit or miss, not to mention the genetic component. For some individuals, medications may allow them to respond to psychotherapy, so a combination can help where neither alone gives much traction.

I don't think a lot of therapists know about the brain work. I checked in the therapist training program at my school and they don't have any classes on neurobiology or the brain. Maybe they learn brain-based therapies in their classes on individual, group, and family therapy but it is not apparent to me that content is included from looking at course titles and descriptions.

Here are two general audience books about neuroplasticity for those who want to learn more. The Siegel book focuses on psychotherapy, the Doidge book has some on talk therapy but also contains information on other therapies for brain healing.
The Brain That Changes Itself by Norman Doidge
Mindsight by Daniel Siegel

Yes that is it. I knew it had 'brain' in there somewhere. Thanks for figuring out what I was talking about. I would encourage people to check it out. He makes it easy to understand and gives evidence that is pretty impressive.

Thanks pachyderm. Fresia has it right. I didn't remember the doctors name but the book is the title I was trying to pull out of my head. Once I say it I knew it was the right one.