Transcript BIOLOGICAL CORRELATES OF PSYCHOTERAPY

FUNDACION CASTILLA DEL PINO
ABORDAJES PSICOTERAPEUTICO
DE LOS
TRASTORNOS PSIQUIATRICOS
Cordoba, Marzo 2009
INVESTIGACION EN PSICOTERAPIA
DINAMICA BREVE
Manuel Trujillo, M.D.
Professor of Psychiatry
New York University
BIOLOGICAL CORRELATES OF PSYCHOTHERAPY
FIGURE I
-3
-2
-1
0
1
2
Average (no treatment)
control effect size
Average Minimal
Treatment
(placebo) effect size
(.42)
Adapted from Lambert, et al. 1993
3
Average
psychotherapy
effect size (.82)
TABLE I
META-ANALYTIC REVIEWS OF
OUTCOME WITH DEPRESSION
Researchers
Patient Diag/
Treatment
Dobson (1989)
Depression/
Cognitive therapy
10
2.15
Nietzel, et al. (1987)
28
.71
Q.A. Project (1983)
Unipolar
Depression
Depression
10
.65
Robinson, et al. (1990)
Depression
29
.84
Steinbrueck, et al (1983) Depression
56
1.22
* Adapted from Lambert, et al. (1994)
No. of Effect
Studies Size
TABLE II
META-ANALYTIC REVIEWS OF
OUTCOME WITH ANXIETY
DISORDERS
Researchers
Allen, Hunter &
oDonahue (1989)
Patient Diag/
Treatment
No. of Effect
Studies Size
Public speaking
anxiety
97
.51
Clum (1989)
Panic,
283
agoraphobia/Behavior
therapy
70%*
Mattick, Andrews,
et al. (1990)
Agoraphobia
1.62**
* Percent improved , ** Pretest/Posttest measure
Modified from Lambert (1994)
51
TABLE III
META-ANALYTIC REVIEWS OF
OUTCOME WITH ANXIETY
DISORDERS
Researchers
Patient Diag/
Treatment
Q.A. Project
(1985a)
Christensen,
et al. (1987)
Anxiety
OCD/
Exposure
Treatment
Mattick, et al. Agoraphobia
(1990)
Trull, et al.
Agoraphobia
(1988)
* Percent improved , ** Pretest/Posttest measure
No. of
Studies
Effect Size
81
.98
5
1.38
51
1.62**
19
2.10*
Modified from Lambert (1994)
SUMMARY OF EFFECT OF STDP
EFFECT SIZES
Domain
STDP
Term/F-U
USUAL WAIT-LIST
TX
Term/F-U
Term/F-U
Target
Problems
1.39 – 1.57
0.55 – 0.84
0.27 – NA
Symptoms
0.90 – 0.95
0.22 – 0.24
0.12 – NA
Leichsenring F ( 2004)
Criteria for Admission to the
Study
Inclusion Criteria
• Age between 18 and 60
• Evidence of at least one close personal relationship
• No evidence of psychosis, organic brain syndrome or
mental retardation
• Absence of active Axis III medical diagnosis
• No evidence of substance abuse
• Not actively suicidal
• No history of violence or destructive impulse control
problem
• No recent psychotropic medication such as
neuroleptics, antidepressants, Lithium, etc.
Patient Demographics By
Group
BAP
STDP
CONTROL
N = 17
N = 15
N = 17
Age
39.6
38.5
38.4
Sex
F=11 (64.7%)
M= 6 (35.3%)
F=12 (80%)
M= 3 (20%)
F= 3 (18.8%)
M=13 (81.3%)
7 (41.2%)
7 (46.7%)
5 (29.4%)
10 (66.7%0
12 (80%)
13 (76.4%)
Married
College
Graduate
Assessment Instruments
•
•
•
•
•
Social History
Target Complaints
Symptom Checklist (SCL-90)
Social Adjustment Scale - SR
Personality Diagnostic Questionnaire
(PDQ)
Therapist Characteristics
Sex
BAP Group
(n=9)
5 Female; 4 Male
X=38 Years
Range=31-55
X=13 Years
Years Experience
Range=4-28
5 M.D.’s
Professional Degree
3 Ph.D.’s
1 M.S.W.
All
Theoretical Orientation
Psychodynamic
4=Yes
Analytic Training
5=No
5=Yes
Additional Other Training
4=No
Resolved Personal Analysis 5=Yes
4=No
5=Yes
Received Personal
4=No
Psychotherapy
Age
STDP Group
(n=9)
3
Female;
6
Male
X=43 Years
Range=30-56
X=13 Years
Range=5-31
7 M.D.’s
1 Ph.D.
1 M.S.W.
All
Psychodynamic
4=Yes
5=No
3=Yes
6=No
5=Yes
4=No
4=Yes
5=No
Reliability of Six Combination Variables
Process Coding of Videotaped Psychotherapy
Sessions
Variable
Three Judges Pooled
Transference Interpretation
followed by affect
.93
Transference Interpretation
followed by defense
.75
Non-transference Interpretation
followed by affect
.84
Non-transference Interpretation
followed by defense
.67
Clarification Interpretation
followed by affect
.62
Clarification Interpretation
followed by defense
.63
Admission & Termination Means and
Effect Sizes* for Significant
Findings on the SCL-90 and SAS
Subscales Across Groups
BAP
STDP
CONTROLS
ANCOVA
CL-90 Anxiety
Admission
39.91
44.31
45.50
F=4.39
Termination
27.55
36.23
41.00
p=.02
.92
.60
.33
SCL-90 Phobic Anxiety
Admission
37.45
32.92
35.56
F=3.67
Termination
18.36
28.01
37.00
p=.035
.97
.25
-.07
SD=19.78
Effect Size
Effect Size
SD=13.50
*Effect size was computed by subtracting the termination score from the admission
score and dividing by the standard deviation of the combined control and
experimental groups
Admission & Termination Means
and Effect Sizes for Global
Outcomes Across Groups
BAP
STDP
CONTROLS
ANCOVA
Target Complaint 1
Admission
Termination
Effect Size
10.47
6.67
1.23
10.08
5.91
1.35
11.69
10.25
.46
F=12.46
p=.0001
SD=3.10
SCL-90 Global Score
Admission
Termination
Effect Size
44.55
36.27
1.11
43.77
36.62
.96
47.38
44.06
.45
F=4.84
p=.01
SD=7.45
2.06
1.74
.70
2.13
1.76
.80
2.15
2.18
-.07
F=6.86
p=.003
SD=.46
Social Adjustment Scale
Admission
Termination
Effect Size
Subscales with STDP showing
significant differences over BAP
and controls
BAP
SCL-90 Depression
Admission
43.18
Termination
39.64
Effect Size
.46
STDP
CONTROLS
ANCOVA
46.46
35.46
1.47
50.69
47.94
.36
F=5.36
p=.0009
SD=7.67
SCL-90 Psychoticism
Admission
41.64
Termination
37.27
Effect Size
.41
37.62
28.23
.87
43.75
44.44
-.06
P=8.77
p=.0009
SD=10.77
SAS Social and Leisure
Admission
2.06
Termination
2.01
Effect Size
.09
2.13
1.76
.63
2.15
2.18
-.05
F=8.77
p=.035
SD=.59
Average Frequencies of Occurrence and
Comparative Percentages Per Session of
Therapist Behaviors in the Two Treatment Groups
Questions and Cognitive Probes
BAP
STDP
22.75 (21.9%) 27.4 (13.0%)
Affective and Nonverbal Probes
5.85 ( 5.5%) 24.4 (11.9%)
Clarification
16.50 (15.8%) 27.0 (13.5%)
Confrontation
13.75 (13.2%) 31.9 (15.5%)
Addressing Defensive Behavior
13.75 (13.0%) 36.2 (17.5%)
Addressing Anxiety
3.25 ( 3.0%)
3.8 (2.0%)
Addressing Warded -Off Impulses
4.75 ( 4.5%) 12.8 (6.0%)
Transference Relationship
8.25 ( 8.0%) 13.4 (6.5%)
Current and Past Relationships
Advice/Support
11.50 (12.0%) 26.0 (12.5%)
11.50 ( 2.9%)
TOTAL ACTIVITY OF THERAPIST 104.00
3.8 (1.8%)
206.00
Stepwise Regression For Affect and
Defense Variables On Composite
Outcome Score
Variables
Coefficient
T-test
df
Signficance Unique
Variance
Transference
followed by affect
.37
2.8
12
.01
.22
All Interventions
followed by
defense
-.42
-3.0
12
.02
25
All interventions
followed by affect
.13
.80
12
.44
.02
Multiple R Squared = .66
(F Value=7.71; df=3 and 12)
Partial Correlations of Affect
Variables & Outcome
(with Defensive Responding
Partialed Out
Composite Outcome
Clarification followed by Affect
.09
Nontransference Interpretation followed by Affect
.44
Transference Interpretation followed by Affect
.73
All Interventions followed by Affect
.58
BEST/WORST OUTCOMES
BEST OUTCOME
WORST OUTCOME
STDP
2-Obsessional
1- Histrionic
1 - Mixed
BAP
1- Histrionic
1- Mixed
2- Obsessional
BIOLOGICAL CORRELATES OF
PSYCHOTERAPY
PSYCHOTHERAPY CHANGE AGENTS
• Affective experiencing
• Cognitive mastery
• Behavioral regulation
BIOLOGICAL CORRELATES OF
PSYCHOTHERAPY
AFFECTIVE EXPERIENCE
• Implosion therapy
• Gestalt therapy
• Psychodrama
• STDP
Flooding
Emotional
Experience
Role playing
Impulse/Feelings
Experiencing
BIOLOGICAL CORRELATES OF
PSYCHOTHERAPY
COGNITIVE MASTERY
• Psychoan. therapy
Interpretation
• Supportive
Clarification,
support
Modification of
beliefs
• Cognitive
BIOLOGICAL CORRELATES OF
PSYCHOTHERAPY
BEHAVIORAL REGULATION
• Behavior therapy
Conditioning
• Assertiveness
therapy
Skills develop.
• Token economy
Modification of
rewards system
PSYCHOTHERAPY AND NEUROBIOLOGY
Cortex
Pre Frontal Cortex
+
Stimulus
Thalamus
Amygdala
Hippocampus
PSYCHOTHERAPY AND
NEUROBIOLOGY
Moderate
duration
stress
CA3
Stress
Glucocorticoids
Glutamate
Reversible atrophy
and loss of
dendritic spines
* Adapted from Kandel, 1999
Severe and
prolonged
stress
Neuronal
death
THE MIRROR NEURON SYSTEM
Rizzollati 1995
• Subset of multimodal neurons
(Simultaneous activation by different
sensory modalities)
• F5 in monkeys
• Broca 44, 45 in humans
(Prefrontal Cortex)
THE MIRROR NEURON SYSTEM
Activated by:
• Observing a meaningful action
• Performing the same action
• Basis for primitive
learning/communicating with others
THE MIRROR NEURON SYSTEM
Plays a role in:
• Affect resonance
• Empathy
• Group behaviors: hunting, dancing
• Language development