About PSYCHOTHERAPIES

PSYCHOTHERAPIES

There is compelling evidence that psychotherapies can be helpful in treating many

psychiatric disorders. Psychotherapeutic efficacy likely depends on many factors,

including the personality and skills of the therapist and the specific type of therapy.

Deciphering how various components of psychotherapy play a role in clinical benefits

is in some ways parallel to analyzing the similarities and differences of various

classes of antidepressants. Available data support the idea that clinical improvement

resulting from psychotherapies, medications, or combinations of both is associated

with changes in the function of specific brain systems. Based on observed changes in

regional metabolism in frontal cortex and the hippocampus,it appears that antidepressant

medications, ECT, and cognitive behavioral therapy (CBT) have distinct

effects on the circuitry of depression. Medications appear to increase metabolism in

frontal cortex while diminishing activity in hippocampus. CBT has the opposite effects,

decreasing metabolism in frontal cortex and increasing activity in the hippocampus,

while ECT diminishes metabolism in both regions. These intriguing observations

suggest that there are distinct, but possibly complementary, ways to reset the neural

systems involved in psychiatric illnesses.Interestingly,the enhanced hippocampal

metabolism observed with CBT may reflect the learning associated with this form of

treatment, while the enhanced metabolism in frontal cortex seen with medications

may give clues about the role of monoamines in modulating cortical function, perhaps

affecting attention and working memory. Similarly,it is important to disentangle

which effects on neural circuitry contribute to clinical benefits, which are therapeutically

neutral, and which result in side effects.

In prior sections, we noted the nonspecificity of pharmacologic and device mediated

treatments.It is also important to note that many psychotherapies are also

nonspecific in their clinical utility. For example, CBT,the most intensely studied of the

psychotherapies, can benefit a wide range of conditions,including mood disorders,

anxiety disorders, chronic insomnia, chronic pain, and possibly schizophrenia, at

the minimum. To us this highlights the rehabilitative nature of psychotherapy and

the power that it may have when combined with pharmacologic or brain-stimulation

approaches.

It is increasingly being recognized that using neuroscientific methods to study effectiveness and underlying mechanisms of psychotherapies is important. The same

scientific rigor that is applied to pharmacologic interventions and device-mediated

interventions can be applied to all psychotherapies.In recent years, clinicians skilled

in psychotherapeutic interventions have become increasingly interested in studying

how psychotherapies affect brain function, and clinicians specializing in somatic

interventions are increasingly interested in understanding the effects of psychotherapy

on brain systems. The tension between psychotherapy and somatic therapy camps

has been a significant and misguided part of psychiatry's past, but it is unlikely to play

as noticeable a role in psychiatry's future as the two camps converge on understanding

neural mechanisms in illnesses and their treatments.

LIFESTYLE INTERVENTIONS

Certain lifestyle activities can have significant beneficial effects health,including mental health. Routine exercise, sleep hygiene,learning, interactions, balanced diets, weight control, and avoidance of tobacco alcohol all appear to promote well-being. How these lifestyle factors aid in the treatment of psychiatric symptoms is not yet understood, of action are likely to be diverse. Although these "interventions" specific than the treatments discussed previously,they can and should For example,the effects of exercise and weight loss can be investigated effects on overall health and brain function using both human studies models. At the present time,it suffices to emphasize that heart-healthy coupled with appropriate social interactions are,in general, good for specificity and mechanisms of these effects are exciting areas for future work. 

REHABILITATIVE VERSUS ETIOLOGIC THERAPIES

In considering the beneficial effects of talk therapy, Samuel Guze suggested various psychotherapies represent forms of medical rehabilitation.In other psychotherapies can help patients function at higher levels even in the ongoing symptoms; however,these treatments are not curative and their is independent of the etiology of the symptoms. At the time he championed

this concept, Guze sought to refute the notion that psychodynamic therapy corrects the cause of symptoms.Importantly,treatments do not have directed at the mechanisms underlying an illness in order to be effective; psychotropic medications are good examples of this fact. The rehabilitation is based on the observation that physical, occupational, and speech patients regain function following strokes or other brain injuries. not address the cause of the brain damage and do little to repair dead they help patients learn methods of adapting to the damage and find

to accomplish tasks such as walking,talking, and activities of daily living. This

approach to treatment is different from ones like the use of antibiotics to treat infections.

With the correct antibiotic,the actual cause of the illness is eradicated. use of a combination of syndromic/symptom-based treatments and rehabilitative

strategies is not unique to psychiatry; it is the norm in the management of most

common illnesses in medicine.

We would extend Guze's concepts and suggest that there is likely to be a continuum

between rehabilitative therapies and etiologic therapies Wトen applied to the treatment

of neuropsychiatric illnesses. Some aspects of psychotherapies are truly rehabilitative

in that resulting changes in behavior may have little to do with the mechanisms

underlying the symptoms. Thus, people may begin to feel better after they start to

exercise or just become more active, and this "feeling better" may counteract some

of the low mood that an underlying depression is causing. This is the essence of the

"behavioral" component of CBT for depression. Certain therapies, however, may

target brain systems that are directly involved in the underlying disorder. People phobias,for example, can be successfully treated with exposure and desensitization

therapy. Repeated controlled exposure to spiders may allow a person to become less

fearful of spiders, and gradual exposure to heights may help a person to control of heights.In fact,recent research suggests that administering a drug such as

D-cycloserine, an agent that improves learning and enhances the function of glutamate

synapses via effects on NMDA receptors, speeds the rate of improvement with

exposure/desensitization therapies. This new learning may correct the abnormal

function of fear circuits driving the phobia. Given advances in understanding how

specific forms of learning are processed in the brain,it is possible that certain could be designed to target neural systems involved in the genesis certain symptoms, even though they do not alter molecular or synaptic defects.

We believe that psychotherapies can be considered as falling at different along a rehabilitative-etiologic continuum depending on the therapy and the disorder.

Most psychotherapies are rehabilitative, while other psychotherapies may target etiology or at least target specific brain systems relevant to the etiology.

Studying psychotherapies from this perspective offers hope of devising even more

effective approaches going forward. The work with D-cycloserine is an early proof-of-

concept that targeting the synaptic machinery of learning and memory may be a

way to enhance the effectiveness of certain psychotherapies. However, we would

strongly caution against drawing conclusions about the mechanisms underlying any

illness based on the effects of any psychotherapy. Psychiatry has pursued this the past,resulting in scientifically naive statements about the "causes" of illnesses

based on the effects of a therapy or the theory underlying a therapy. The more that

psychotherapy research is rooted in modern brain science,including sophisticated

neuroimaging,the higher the likelihood that treatments can be devised to influence

aberrant circuitry.

What about psychotropic medications? Again, while these agents may have both

direct and indirect effects on the ICNs that underlie illness,itis unlikely that targetthe molecular etiologies of symptoms. Naturally, different medications

maybe more or less specific in terms of addressing actual causality. The of benzodiazepines may directly affect stress pathways that are on overdrive an anxiety-producing situation. Although they do not prevent the stimuli with the stress response,they are effective in blocking or dampening Antidepressants and antipsychotics are likely to have direct and indirect the ICNs that underlie mood and psychotic symptoms, but these agents are to have any effect on the primary cause of the disorders. Thus,these drugs midway on the rehabilitative-etiologic spectrum.

Cholinesterase inhibitors may improve some pathways that are harmed brain destruction associated with DAT. Although they don't reverse etiology,drugs do directly influence specific pathways and can delay progression symptoms for 6 to 12 months. Medications are being developed that are block the formation of beta-amyloid,the putative causative toxic protein in DAT. These types of agents may be closer to drugs that interfere actual etiology of an illness. Similarly, antibody therapies designed eliminate toxic accumulations of amyloid may target a process that is to the etiology of the disorder. The key point is that the etiology of a be understood before it is possible to define etiology-based therapies.to be seen how well etiology-based therapies reverse symptoms after an developed. It is possible, perhaps even likely,that once an illness has wide-ranging degenerative and plastic changes in the brain will effectiveness of even highly specific etiology-based treatments.Indeed,suggest that amyloid deposition has both local and longer-range effects function.In this case, a combination of etiology-based treatment and strategies may be required for optimal clinical outcomes.

What about ECT? Although it is one of the most effective treatments and perhaps all of medicine,its effects persist for only a limited time last treatment in an acute course. The efficacy of ECT suggests that it influences pathways but does not eliminate the cause. Furthermore,its ability to involved in illness is only temporary. It is not clear why the beneficial are time-limited, although the need for ongoing maintenance treatment is to ECT and is found with psychotropic medications and other brain-stimulation

methods. Interestingly, effective evidence-based psychotherapy may result in of the more enduring therapeutic effects in psychiatry, perhaps reflecting of learning on the human brain.

It is important to realize that no matter where treatments fall along etiologic spectrum,they can be very helpful. Physical rehabilitation a stroke or injury is often the most effective way to restore function completely. Similarly,the rehabilitative effects of exercise on mood well-being may be as helpful as, or perhaps even more helpful than, medications

for mild depression. Changing the behaviors of caregivers of patients can be more beneficial to the patient than a cholinesterase inhibitor, of both cholinesterase inhibitors and educational intervention may work synergistically.

THE ROLE OF THE PATIENT AND OTHERS IN TREATMENT

As is true for many common illnesses,treatment of psychiatric illnesses can benefit

from the involvement of family,friends, and support systems. We address this topic

in our prior book Demystifying Psychiatry. When considering rehabilitative strategies

in psychiatry,it is important to consider the role of social networks in determining

clinical outcomes.Isolation and loneliness are unhealthy and bad for brain function.

The rehabilitative role of social ties is visible in most aspects of life. Support from

social networks such as small groups for alcoholics (Alcoholics Anonymous), clubhouse

models of assisting persons with illnesses such as schizophrenia, and cancer

support groups can be very effective at helping people feel that others care,that they

are not alone, and that they have self-worth. For many disorders, support systems

that address the family's needs as well as those of the patient can be very valuable. example,the Alzheimer's Association provides many support services for caregivers,

who can easily become stressed and depressed. Their tiered level of support can highly effective in providing the psychological and physical resources to help keep the patient at home instead of moving him or her to a nursing home. Similar

approaches are found in Al-Anon for families of alcoholics and in the National

Alliance on Mental Illness for families struggling with other mental disorders.

Although we have focused on the neuroscience of psychiatric illness in this we do not believe that neuroscience will provide all the answers going forward. the other hand,ignoring neuroscience will greatly delay progress in addressing causes of these disorders and in developing new and innovative ways to manage psychiatric

disorders. Once we understand molecular and synaptic causes and the ways

these causes lead to phenotypic presentation via neural network changes, we will better able to develop treatments that are targeted to specific aspects of aberrant function. Even when we understand much more about the brain mechanisms underlying

psychiatric disorders,it is likely that rehabilitative and social support remain important in clinical practice. This is not unique to psychiatry;it is true treatment of almost all common chronic disorders in medicine and neurology.