Neuroscience-based Cognitive Therapy

New Methods for Assessment, Treatment, and Self-Regulation

Tullio Scrimali

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781119943037
• Edition: 1
• Topic: Psychology
• Subtopic: Neuropsychology
• Index: Psychology

A pioneer of CBT explores recent advances in neuroscience, showing how they can be applied in practice to improve the effectiveness of cognitive therapy for clients with a wide range of diagnoses including mood disorders, anxiety disorders, eating disorders and schizophrenia

• Utilizes the latest advances in neuroscience to introduce tools that allow clinicians, for the first time, to directly 'measure' the effectiveness of cognitive therapy interventions
• Rigorously based in neuroscientific research, yet designed to be readable and jargon-free for a professional market of CBT practitioners
• Covers theory, assessment, and the treatment of a wide range of specific disorders including anxiety disorders, mood disorders, eating disorders, addictions and schizophrenia
• Written by a respected pioneer in the field

1

Neuroscience in Context

1

Neuroscience, Clinical Psychology, and Cognitive Therapy

Neuroscience constitutes one of the most important components in contemporary scientific development. Due to the introduction, on the one hand, of increasingly more sophisticated techniques and, on the other, of those that are progressively easier to learn and apply as well as more economic to acquire and utilize, neuroscience is no longer either the exclusive heuristic method for understanding the brain and comprehending the mind typically employed in costly professional research labs, or the tool of mental disorder clinics. The purpose of this book, and of the research and applications described in it, is to propose a series of methodologies that, though coming from neuroscience laboratories, still provide concrete clinical applications today.

At the outset, we must quickly tackle a problem that Paul Grobstein focused on in an interesting article, asking whether psychotherapists and clinicians of the mind were genuinely interested in neuroscience today, or whether they were inclined to consider it an annoying and intrusive approach (Grobstein, 2003). I myself have had to confront, in Italy and abroad, some spirited colleagues, clinical psychologists, and psychotherapists who were highly annoyed by neuroscience, often becoming openly hostile to it. In the minds of some clinicians, there must be a vision similar to that humorously represented in Figure 1.1.

Figure 1.1 How clinicians imagine the psychophysiological setting.

This book shows how neuroscience is now already available to clinical psychologists, not only as a valuable new brain and mind heuristics, but also as valid application methods with which I have personally worked for many years. To begin with, let's define exactly what neuroscience is and what it concerns.

The term “neuroscience” indicates a set of disciplines, both heuristic and applicational. The objectives of these studies range from structural, both macroscopic and microscopic, to functional aspects, examined from the biochemical, biophysical, and physiological viewpoint. Neuroscience also includes the study of the phylogenetic and ontogenetic development of the brain. From an applications viewpoint within the clinical setting, neuroscience predetermines the identification of etiologic pathogenetic processes of neurological and mental diseases and the development of new methodologies for the diagnosis and treatment of psychic distress.

The Society for Neuroscience was officially founded in 1969 but, from a strictly historical point of view, we can say that the macroscopic morphological study of the brain began in ancient Egypt. Until some years ago, neuroscience was considered largely as a biological branch of human knowledge, while more recently, due to the development of new disciplines such as cognitive psychology, neuropsychology, scientific philosophy, and theories of complexity, a very solid bridge to the human sciences has been created.

The most typical investigational methods in contemporary neuroscience are built on all those techniques that make possible a morphological, and above all functional, accurate, objective, and replicable, study of the central, peripheral, and autonomic nervous systems. In this book the concept of imaging is used broadly, referring to the development of a model or an understanding of the brain, rather than in the narrow sense of a visual image provided by brain imaging techniques such as CAT. Among these techniques of cerebral imaging, those relating to recording electroencephalographic (EEG) activity and studying electrodermal activity (EDA) are the most frequently employed today.

Methods of cerebral imaging that were developed in the last thirty years of the twentieth century, due to the advent of information systems technology methodologies, brought a series of important contributions to the comprehension of dysfunctional processes and structural alterations in the nervous system over the course of psychiatric disorders, particularly in the area of schizophrenia. Introduced into a clinical setting at the beginning of the 1970s, the first brain imaging technique was computerized axial tomography (CAT), which evolved into computed tomography with the development of brain analysis methodologies that allowed the study of various cross-sections in addition to the axial.

Godfrey Hounsfield, the English engineer who fine-tuned the technique, obtained the Nobel Prize in 1979 (Hounsfield, 1973). In the following decade, at the start of the 1980s, nuclear magnetic resonance was developed and introduced into the clinical setting, permitting better definition than computed tomography. In this case, the inventor and technique developer was a researcher of Armenian descent and a naturalized United States citizen, Rayon Damadian, who obtained the Nobel Prize in 2003 for this revolutionary invention (Mattson and Simon, 1996).

A real revolution in the area of brain imaging techniques took place with the development of new methodologies that were capable not just of identifying structural alterations in the cerebral mass but also of directly viewing in real time the biochemical modifications occurring in various parts of the brain as they are stimulated for action. We can say that, with the finalization of such methodologies, the age-old dream of having a tool for direct observation of brain activity in a living human being was finally realized. The principal techniques in functional brain imaging are single positron emission tomography (SPECT), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI).

The first two methodologies make it possible to view functional cerebral activation by highlighting blood flow. In particular, PET allows the dynamic study of cerebral metabolism, by viewing both regional blood flow and local consumption of glucose. Additionally, functional analysis of the different brain systems that utilize different neurotransmitters is possible.

From the 1990s, the technique that signaled a real leap in studies using dynamic functional viewing of the central nervous system (CNS) was fMRI. In particular, a specific fMRI method utilizes blood as a means of natural contrast based on the fact that hemoglobin is diamagnetic and oxyhemoglobin is paramagnetic. In functionally activated areas of the brain, an increase in oxygen consumption and oxygenated blood flow occurs, resulting in an increase of oxygenated hemoglobin and a reduction in deoxyhemoglobin. The fMRI thus allows us to view activated areas of the brain without the necessity of administering any other means of contrast. Therefore, the method is extremely manageable apart from the need to have the patient enter the MRI tunnel.

Morphological and functional imaging techniques applied to the CNS remain, for now, confined to the laboratory, even though a recent development looks promising for application in the clinical setting in the near future. In the United States, BIOPAC has recently marketed a new functional analysis system limited to the frontal lobe that no longer requires the patient to enter the MRI tunnel lying down, but can be used simply by applying small sensors to the patient's forehead (BIOPAC, 2009). Via a screen placed in front of the patient, this system is also able to activate the cognitive and executive functions typical of the frontal lobes and record the internal functional correlates of nerve activity patterns under both normal and pathological conditions, all in a quasi-clinical setting with the patient comfortably seated and minimally disturbed. The system cost of about €30,000 (about US$42,600) is quite accessible, making it, at least on paper, a tool that can promote the development of research in clinical psychology founded on analysis of functional modification in the frontal lobes.

This new technology is called functional optical brain imaging, or functional near-infrared (NIR) based optical brain imaging (fNIR). Like fMRI, it is based on the potential for analyzing in real time the metabolic changes relative to neuron activity by quantifying regional levels of oxyhemoglobin and deoxyhemoglobin. Analysis is based not on a methodology related to the magnetic behavior of hemoglobin molecules but on the application of spectral techniques. Since only a cap with 16 integrated sensors is needed, the fNIR appears truly revolutionary and boasts great potential for the study of cognitive processes. Due to the fact that it predominantly analyzes the functional activity of the frontal lobes, it appears quite promising for research in mental disorders, specifically autism and schizophrenia (McCarthy et al., 1997).

Some medical specialties, such as neurology, neurosurgery, and neuropathology, have already established strong links with neuroscience, applying new methods for diagnosis and treatment (Waxman, 2004).

In psychiatry (the discipline to which the subject matter of this book is most closely related), many exchanges with the field of neuroscience have been developed and concerning a range of disorders such as schizophrenia, depression, and anxiety (Lepage et al., 2011; Berlim et al., 2010; Killgore et al., 2011; Gabbard, 2005). Some branches of neuroscience seem to be closer to cognitive therapy (CT), such as behavioral neuroscience (Breedlove, Rosenzweig, and Watson, 2007), cognitive neuroscience (Holyoak and Morrison, 2005), and developmental neuroscience (Nadarajah et al., 2003). Furthermore, if we consider my own complex approach to CT then social neuroscience (Harmon-Jones and Beer, 2009) and Systems Neuroscience (Hemmen and Sejnowski, 2006) must also be considered.

The aim of this book is to create a new branch of science that can be a link between neuroscience and CT. But what are the actual applications that we can transfer from the neuroscience lab to the clinical psychology setting, and what use do they have? I maintain that there are primarily two applications: complex psychological diagnosis and psychotherapy. Both are discussed in subsequent chapters, and both are based on my research and applications experience.

In neuroscience, the discipline that bridges the laboratory and the clinical setting is known as clinical psychophysiology. This discipline involves methods and procedures that constitute a true interface system between the brain, the mind, and their relational context. In the clinical context, it thus deals with implementing objective analysis methodologies of the functioning of the central, neurovegetative, and autonomic nervous systems. As we will see later, the techniques that are now more readily available in the clinical setting are computerized EEG and digital analysis of EDA.

As I describe, the idea of utilizing psychophysiological techniques in the clinical psychology setting is in the same vein as the most recent positions documented in psychotherapy and contemporary neuroscience, such as that of Nobel Prize winner Erik Kandel, who sees the clinic, and particularly clinical psychology, psychiatry, and psychotherapy, as more and more closely flanking the lab. Scholars such as Cozolino and Siegel propose a neurobiology of psychotherapy and relational processes, including the crucial one of reciprocity and attachment (Kandel, 1998; Cozolino, 2002; Siegel, 1999; 2007). Before moving on to describe the range of applications in clinical psychology, it is important to focus, even if briefly, on a series of conceptual and theoretical topics that form the basis for the rational and consistent clinical use of the techniques coming out of the neuroscience laboratories.

2

The Mind–Brain Problem

The relationship of the mind to the brain, or mind–brain problem, constitutes a question that has been debated for centuries and which was confronted organically for the first time in the modern age by René Descartes, who proposed a dualistic solution. To the great French philosopher, the mind was an extracorporeal entity (res cogitans or mental substance) structured by a spiritual reality, not a material one. The brain, on the other hand, belonged to the physical dimension (res extensa or corporeal substance). The two entities interacted via the pineal gland's role as mediator, which represented the critical interface between the immaterial world of the mind and the physical world of the brain (Descartes, 1984–1991).

The mind–brain problem is, however, quite a bit older, and reflection on this theme began with the birth of western thought. In Greece, within the brief course of the fifth and fourth centuries BCE, there was a profound philosophical development focused on the human psyche that formed the conceptual foundation for all further development in theories concerning the mind–brain problem. The three key positions in the conception of the problem are clearly identifiable in the reflections of Greek philosophers such as Democritus, Plato, and Aristotle. These ideas then travel through twenty-five hundred years of history to resurface today with the same strong impact. We can only be impressed by the incredible modernity of ancient Greek philosophical content which still forms a solid epistemological foundation for modern thought in the western world.

Democritus may be considered the founder of the materialist-substantialist concept of the human psyche. He considered that both spirit and body constitute entities in the same way as do atoms, even though those entities forming the psyche would be more dynamic and ethereal. Therefore, the body is material and the mind is material; however, both are rather transitory, as they require the energy that respiration supplies. To Democritus, with the cessation of breathing and death, both the body and psyche decompose and decay, following an inexorable course of increasing entropy, as we would term it today. To the great philosopher, even cognition occurred through material channels, via interaction between the atoms the material emits and the sensory organs (Diels and Kranz, 1976). We can ultimately identify in Democritus the true originator of the biologist-physicalist-reductionist tradition, one that is clearly present in contemporary neuroscience conceptualizations today.

Some years later, Plato firmly opposed Democritus’ view, asserting that the psyche, though also endowed with substantive properties, was made up of different material from that of the body. To the great Athenian philosopher, the psyche was in fact an entity alien to the body, residing there as prisoner yet always aspiring to transcend it. To Plato, the human spirit is also immortal and survives the death of the body. Souls receive reward and punishment in the afterlife according to their behavior during earthly existence, as described in the Phaedo (Reale and Antiseri, 1997). Therefore, Plato may be considered the real originator of substantialist theories of the mind and the soul, which find full recognition within the framework of many religious doctrines such as Christianity, Islam, and Buddhism. In addition to this substantialist view on which modern religions were founded, Plato offered a description of the human psyche as made up of three different entities, well represented in the very beautiful metaphor of the charioteer on the chariot pulled by two horses, one black, ugly, angry, and unfaithful, the other white, intelligent, and gentle. To get the chariot to move, the charioteer must mediate between the two very different animals and, more than that, master the black horse, which represents the carnal, emotional, and impulsive part of the mind as opposed to the intellectual part, or the metaphorical white steed.

A truly critical scientific revolution occurred some years later when Aristotle became the first to introduce a functionalist-dualist yet non-substantialist view of the mind–brain connection (Ackrill, 1972–3). Aristotle considered the mind not as an ontological entity distinct from the biological entity of the brain but rather as a function of the latter. Aristotle thus proposed a functionalist approach to the study of the mind that differed profoundly from that of his master Plato, who had arrived, as we saw, at deeming the mind a real substance, distinct from the body and capable of autonomous existence (Plato, 1900–1907).

Aristotle then discerned three components in the human psyche but did so with impressive modernity in referring to biological concepts. In fact, he discussed a vegetative mind tied to basic biological functions, a sensitive mind connected to the perception of reality, and an intellectual or rational mind (Reale and Antiseri, 1997). The extraordinary acui...