in first few slide we have tried to explain briefly about psychotherapy and its type,later we have explained about the microbiological basis of psychotherapy

1. Neurobiology of
Psychotherapy
Presented by- Dr kamran chisty.
Moderator- Dr Dilshana N.B
Department of psychiatry,Yenepoya
medical college,Mangalore,India.
E mail-kamranchisty@gmail.com

2. Very special Thanks to
• Dr. Dilshana N.B
Thank you for all pictures.
• Dr.Nishad PMA (PG)
• Dr. Anshul
• Dr. Antony
• Dr. Anaswarashree
• Dr Mohammed Imran M.D(ortho), M.C.H
Consultant N.M.C hospital,Abu
Dhabi,UAE.
2

3. Introduction
• Psychotherapy, or talk
therapy.
• Psychotherapy can
help eliminate or
control troubling
symptoms so a
person can function
better and can
increase well-being
and healing.
3

4. Definition
• (wolberg)
• It’s a treatment by physiological means of an
emotional nature in which a trained person
deliberately establishes a professional
relationship with the patient with an objective
of 1.removing modifying or retarding existing
symptoms.
2.of mediating disturbed patterns of behavior
3. and of promoting positive personality
growth and development.
4

5. DURATION OF
PSYCHOTHERPAHY
• Psychotherapy can be short-term (a few
sessions)-dealing with immediate issues
( or)
Long-term (months or years), dealing with
longstanding and complex issues.
5

6. Psychotherapy and Medication
• Psychotherapy is often used in
combination with medication to treat
mental health conditions.
• Psychotherapy has been shown to
improve emotions and behaviors and to be
linked with positive changes in the brain
and body.
• About 75 percent of people who enter
psychotherapy show some benefit from it.
6

7. Types of Psychotherapy
Cognitive behavior therapy (CBT)
Interpersonal psychotherapy (IPT)
Dialectical behavior therapy (DBT)
Psychodynamic therapy-
Psychoanalysis
Additional therapies -
-Animal-assisted therapy.
- Creative arts therapy .
-Play therapy
-Group therapy
7

8. Cognitive behavioral theraphy
THOUGHT
EMOTION BEHAVIOUR
8

9. Cognitive behavioral theraphy
contd..
• Cognitive behavioral therapy (CBT)-helps
people identify and change thinking and
behavior patterns that are harmful or
ineffective, replacing them with more
accurate thoughts and functional behaviors.
• Utilizes the cognitive model, operant
conditioning and classical conditioning to
conceptualize and treat a patient’s problems
• The therapist takes an active, problem
oriented, directive stance
9

10. Cognitive behavioral theraphy
contd..
• Used in wide range mental health problems:
depression, anxiety disorders, bulimia, anger
management, adjustment to physical health
problems, phobias, chronic pain.
• Panic Disorder (anxiety disorder)
• CBT – 16 sessions as effective as medication
management, better tolerated and more durable
in response.
• Obsessive Compulsive Disorder (anxiety disorder)
• CBT (cue exposure and response prevention) as
effective as medication management.
10

11. Dialectical behavior therapy
• IT is a specific type of
CBT that helps
regulate emotion.
• Bpd, bulimia nervosa,
dissociative identity
disorder.
11

12. Interpersonal therapy (IPT)-
12

13. Interpersonal therapy (IPT)-
• It helps patients understand underlying interpersonal
issues that are troublesome, like unresolved grief,
changes in social or work roles, conflicts with
significant others, and problems relating to others.
• Time-limited treatment for major depressive disorder
• Assumes connection between onset mood disorder
and interpersonal context in which they occur
• Used for variety depressed populations: geriatric,
adolescent, HIV-infected, marital discord
• Can be combined with medication
• Duration: 12 – 16 weeks.
• When MDD patients 6 weeks of IPT shows similar
changes of that of medications
13

14. • Couples’ therapy -Designed to modify
interactions of persons in conflict.
Restructures couples’ interaction.
• Indicated when individual therapy fails to
resolve relationship difficulty
• Family therapy -Intervention to alter
interactions among family members and
improve function.
• Interrupt rigid patters that cause distress.
14

15. Psychodynamic therapy-
• Psychodynamic therapy-
based on the idea that
behavior and mental well-
being are influenced by
childhood experiences and
inappropriate repetitive
thoughts or feelings that are
unconscious .
• Psychoanalysis- is a more
intensive form of
psychodynamic therapy.
Sessions are typically
conducted three or more
times a week
PAST FUTURE
15

16. Types of Psychotherapy
• Additional therapies -
-Animal-assisted therapy.
-Play therapy.
- Creative arts therapy .
-Group therapy.
16

17. Supportive therapy-
• uses guidance and
encouragement to
help patients develop
their own resources.
• Used-
Depression,phobias,o
cd, dysfunctional
thinking,panic attcaks.
17

18. Animal-assisted therapy.
• Animal-assisted
therapy – working
with dogs, horses or
other animals to bring
comfort, help with
communication and
help cope with
trauma.
18

19. Play therapy
• To help children
identify and talk about
their emotions and
feelings.
• Childrens-Dramatic
play with
dolls,puppets,
drawing,painting.
• Adolsecnets-creative
writing.
19

20. Creative arts therapy
• Creative arts therapy
– use of art, dance,
drama, music and
poetry therapies.
20

21. Group therapy
• Group therapy offers
opportunities for the
clinician to model and
facilitate practice of
important skills.
• Substance abuse and
eating disorders.
21

22. Neurobiology basis of
psychotherapy
• Early studies focused on hypthalamic pitutary
axis(HPA) activity,like increase salivary cortisol or
serum cortisol levels as physiological expression
of anxiety.
• Experiments determine psychotherapeutic
intervention reduces cortisol level.
• Study IPT was carried in depressed patient
showed different EEG sleep measures for
responders vs non responders.
• Recent study showed increased serum levels of
Nerve growth factor patients of anxiety following
treatment with CBT.
22

23. Neurobiology basis of
psychotherapy contd..
• No specific neurobiological basis of
psychotherapy.
• How ever various studies have shown
changes in brain while carrying out various
neuro imaging studies.
• How ever further research is required to
understand the exact mechanism of
psychotherapy.
23

24. CBT VS PAROXETINE in
Depression
• Method-14 drug-free patients (initially 17 but 3 did
not complete) scanned before and after treatment
with CBT.
• Imaging modality -fluorine-18 labelled
deoxyglucouse PET scan was done before and
after treatment.
• Between scans- 15–20 individualized session of
CBT by a trained therapist .
• Comparison to an independent group of 13 ,6-
week paroxetine-treatment responders carried out
to examine specificity of identified CBT effects
before and after treatment.
24

25. CBT VS PAROXETINE in
Depression contd..
• Clinical findings-Nine patients met the criteria (at least 50%reduction
in depression ratings) for a full response. Remaining five showed
35% reduction in depression ratings.
• Neural changes –CBT-Increased metabolism in the hippocampus
and decreased metabolism in the frontal and parietal cortices .
• paroxetine-treatment The reverse pattern seen i.e. decrease in the
hippocampus and increases in the frontal and parietal regions.
• Additional unique changes seen with each.
CBT group: increased metabolism in the anterior cingulate and
decreased metabolism in the medial frontal, orbital frontal and
posterior cingulate
• Peroxetine group: Increased metabolism in brain in stem and
cerebellum and decreased metabolism ventral subgenual cingulate
with paroxetine- treatment.
• Common to both groups: decreased metabolism in the ventral lateral
prefrontal cortex 25

26. Changes in regional glucose metabolism (fluorine-18-labeled deoxyglucose
positron emission tomography) in cognitive behavior therapy (CBT) responders
(top) and paroxetine responders (bottom) following treatment
26

27. IPT vs Paroxitine in Depression
Method-24 patients and 16 healthy
controls
• Imaging modality - PET scan was done
twice with 12 weeks of interval.
• All subjects drug-free at the time of initial
scan.
• Between scans, 10 patients (5 M, 5 F)
received paroxetine.
• 14 patients (8 M, 6 F) received IPT.
27

28. IPT vs Paroxitine in Depression
contd..
• Clinical findings- Both treatments produced
clinical improvement but this was greater in
the drug treated group.
• NEURAL CHANGES-Decreases in prefrontal
cortex and left anterior cingulate and
increases in left temporal lobe metabolism in
both paroxetine-and IPT-treated patient
groups.
• These changes were not seen in the healthy
control group except for an increase in the
right inferior temporal metabolism
28

29. IPT vs Paroxitine in Depression
contd
29

30. IPT vs Venlaffaxine hydrochloride
in Depression
• Method- 28 patients patients drug-free (6
months),13 pateints(4M,9F).
• Imaging modality-SPECT, twice (at baseline
and then post-treatment). All patients drug-
free at the time.
• Between scans, 13 patients (4 M, 9 F)
allocated to receive IPT weekly 1 session for
6 weeks and
• 15 patients (4 M, 11 F) to receive venlafaxine
hydrochloride for 6 weeks.
30

31. IPT vs Venlaffaxine
hydrochloride
• Clinical findings- Both treatments
produced significant clinical improvement
with somewhat greater improvement in the
drug-treated group.
• NEURAL CHANGES -Both treatments
produced increased blood flow in the right
basal ganglia.
• Limbic blood flow increased with IPT only.
31

32. Interpersonal psychotherapy
patinets
Patients receiving venlafaxine
hydrochloride.
32

33. CBT VS ANTIDEPRESSANTS IN
Panic disorder
• Method-Total-12 patients , six patients (3
M, 3 F) randomly assigned to receive CBT
and six patients (3M, 3F) to receive anti-
depressant medication (2 citalopram,2
sertraline, 2 venlafaxine) for 3 months.
• Imaging modality-PET scan
• Between scans 6 weeks of CBT(three
group sessions)
33

34. CBT VS ANTIDEPRESSANTS IN
Panic disorder contd..
• Clinical findings-Both groups showed clinical
improvement.
• CBT-treated group appeared to show a more
rapid change.
• Neural changes-Both treatments increased
uptake in the left hemisphere in the
prefrontal, temporoparietal and occipital
regions and, in the right hemisphere,posterior
cingulum and decreased uptake in the in the
left hemisphere in the frontal,temporal and
parietal regions.
34

35. CBT in Phobia
• Method-12 drug-free women with spider phobia
scanned before and after effective CBT and 13
healthy women scanned once.
• Imaging modality –fMRI scanned before and after
effective CBT and 13 healthy women scanned
once.
• Experiment-Activation paradigm. Within a single
experiment, subjects were exposed to five 30-s
blocks of film excerpts of living spiders in captivity
(activation condition), alternating with five 30-s
blocks of emotionally neutral film excerpts
displaying butterflies in nature (control
condition).Activation and control blocks separated
by 15-s blank blue screen.
35

36. CBT in Phobia contd..
• Clinical findings-All phobic subjects responded
well to CBT.The pre-selected criteria for a
response was defined as being able to touch the
entire series of pictures showing spiders,the
television screen showing the spiders and the real
spiders without reporting fear reactions
• Neural changes-Before CBT, fMRI activity in the
dorsolateral prefrontal cortex and the para-
hippocampal gyrus correlated with transient fear
during the viewing of phobogenic the stimuli in
phobic subjects. These brain responses were
absent in healthy controls and in phobic subjects
after they improved clinically with CBT.
36

37. CBT in Phobia contd..
37

38. CBT VS FLUOXETINE IN OCD
• Method-18 OCD patients. All patients drug-
free at the time of initial scan. nine patients (3
M, 6 F) received treatment with fluoxetine
hydrochloride and nine patients (4 M, 5 F)
received CBT over 8–12 weeks Allocation to
treatment type based on patient preference.
Four healthy controls (2 M, 2 F) .
• Imaging modality-PET done before sessions
of CBT. Healthy controls were scanned at
between 8-12 weeks interval.
38

39. CBT VS FLUOXETINE IN OCD
contd..
• Psychotheraphy details-Once or twice a week
met with their therapist for approximately 1 h
for review of assignments for individualized
exposure and response prevention exercises
which subjects did as homework and self-
monitored with graphs/diaries. Many patients
also attended CBT group for patients.
• Neural changes-Six patients met the pre-
established criterion (at least 30% reduction
in symptom scores) for a clinical response
39

40. CBT VS FLUOXETINE IN OCD
contd..
• Neural effects-Right caudate nucleus
metabolism, divided by ipsilateral
hemisphere metabolism (Cd/hem)
deceased after treatment in both CBT and
drug treated groups. These changes were
not detected in the healthy control group at
re-scanning.
40

41. CBT VS FLUOXETINE IN OCD
contd..
41

42. CBT in OCD
• Method- Nine drug-free patients (2 M, 7 F)
scanned twice before and after 8–12 weeks
of CBT. Further,nine drug-free patients from a
previous study
• (18) included in analysis
• Imaging modality-pet scan scanned twice
before and after 8–12 weeks of CBT.
Further,nine drug-free patients from a
previous study.
• Similar procedures as described for Baxter et42

43. CBT in OCD contd…
Clinical findings-New sample: six patients
met the pre established criterion for a clinical
response.
Remaining three were poor or non-
responders. Total sample: 12 (out of 18)
patients met the criterion for a clinical
response.
• Neural change-Bilateral (more robustly on the
right side) decreases in caudate nucleus
metabolism,divided by ipsilateral hemisphere
metabolism (Cd/hem) occurred in treatment
responders vs.non-responders
43

44. CBT in OCD contd…
44

45. DBT IN BPD
• Method-12 female patients,6f Bpd and 6 normal controls
• Imaging modality- five sequential fMRI scans over a 12-week DBT
in-patient treatment program. (days 0,7, 35, 63 and 91)
• Clinical findings-successful response to treatment interms of
reduction of self-harming behavior, decrement of aversive mood
swings, improvement of interpersonal functioning, i.e., reduction of
conflicts, angry outbursts etc.
• Neural change-Prior to DBT-treatment (t2) BPDpatients
displayed greater activation mainly in dorsolateral and dorsomedial
frontal areas of both hemispheres including the left caudal anterior
cingulate gyrus – and in the left superior temporal gyrus.
• DBT-treatment revealed fewer areas of increased activation in
patients.
45

46. DBT IN BPD
46

47. CBT in IBS
• Method-Six medication-free female patients
scanned twice (before and after therapy) and five
healthy female controls scanned once
• Imaging modality-PET before and after theraphy.
• Psychotheraphy details-10 weekly sessions
conducted in small groups of 3–6 patients.
Cognitive interventional protocol involved self-
monitoring, cognitive re-appraisal, worry control
and problem solving training following a treatment
manual developed by Blanchard (95).
47

48. CBT in IBS contd…
• Clinical findings-patients, meaningful changes
observed after cognitive therapy on measures of
somatic complaints (pain severity, bowel
dysfunction, |defecation, urge) and psychological
distress (anxiety, defecation, urge distress, pain
unpleasantness, worry, etc.).
• Neural changes -Reduced blood flow in the
parahippocampal gyrus, amygdala and inferior and
posterioranterior cingulate cortex after treatment
relative to pre-treatment levels in patients.Controls
showed activation in the above regions that were
intermediate between pre- post-treatment IBS
patients
48

49. conclusion
• First, it appears evident that psychotherapy is
effective in treating a wide variety of clinical
conditions, with results often equal to those
for drug-based treatments.
• Second, the affinity between patient and
therapist (the so-called therapeutic alliance)
may be a key factor in effective therapy.
• Third, although therapist skill is important in
establishing this relationship, experience is
not critical.
49

50. conclusion
• Fourth, level of functioning and the ability
to form a therapeutic alliance are better
predictors of outcome than diagnosis.
• Fifth, evidence suggests that common
factors and not specific techniques are
crucial in therapy.
50

51. Take home points:
• All psychotherapies have common features
• Psychotherapy is effective in treating a wide
variety of psychiatric diagnoses
• Psychotherapy-related changes in brain
activity are strikingly similar in specific
psychiatric diagnoses
• There are many schools of thought in
psychotherapy and there is no one “right”
approach
• You must consider multiple “patient factors”
when recommending psychotherapy
51

52. References
• Brody AL, Saxena S, Stoessel P et al. Regional brain
metabolic changes in patients with major depression
treated with either paroxetine or interpersonal therapy
Arch Gen Psychiatry 2001;58:631–640.
• Martin SD, Martin E, Rai SS, Richardson MA, Royall
R. Brain blood flow changes in depressed patients
treated with interpersonal psychotherapy or
venlafaxine hydrochloride: preliminary findings. Arch
Gen Psychiatry 2001;58:641–648.
• Goldapple K, Segal Z, Garson C et al. Modulation of
cortical-limbic pathways in major depression:
treatment specific effects of cognitive behavior therapy
Arch Gen Psychiatry 2004;61 (1):34–41.
52

53. References
• Fredrikson M, Wik G, Greitz T et al. Regional
cerebral blood flow during experimental phobic
fear.Psychophysiology 1993;30:126–130
• Paquette V, Levesque J, Mensour B et al. ‘Change
themind and you change the brain’: effects of
cognitivecbehavioral therapy on the neural
correlates of spider phobia.Neuroimage 2003;18
(2):401–419.
• Baxter lr JR, Schwartz JM, Bergman KS et
al.Caudate glucose metabolic rate changes with
both drug and behavior therapy for obsessive-
compulsive disorder. Arch Gen Psychiatry 1992;49
(9):681–689. 53

54. References
• American Psychological Association.
Understanding psychotherapy and how it
works Wiswede D, et al. 2014.
• Functional Brain Changes in Patients with
Depression under Psychodynamic
Psychotherapy Using Individualized
Stimuli. PLoS ONE. 2014. 2016.
• Karlsson, H. How Psychotherapy changes
the Brain. Psychiatric Times. 2011.
54

55. References
• Schwartz JM, Stoessel PW, Baxter LR
JR,Martin KM, Phelps ME. Systematic
changes in cerebral glucose metabolic
rate after successful behavior.
• Schnell K, Herpertz SC. Effects of
dialectic-behavioral-therapy on the neural
correlates of affective hyperarousal in
borderline personality disorder. Journal of
Psychiatric Research. 2007 Nov
1;41(10):837-47.
55

56. References
• Tasman A, Kay J, Lieberman JA, First MB, Riba
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