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Grawe (2007) in his book Neuropsychotherapy provides important insights into the neuroscience of specific disorders giving therapists an opportunity to target disorder-specific therapy:

Depression

Depression therapy can relapse. This is because the memory content is ingrained based on the violated control and attachment needs early on in life. This refers to stress, emotion regulation, automatic perceptual tendencies, automated relationship regulation, avoidance reactions all of which are stored implicitly. When we are working with implicit (unconscious) memory then we need to work with motivational approach goals connected with basic needs, instincts. Basic old-wave CBT approaches are limited. This is because even after CBT the attachment styles will remain. Grawe (2007) states it is not unusual for depression therapy to relapse. If an insecure attached client has strong avoidance schemas connected with an attachment need then inconsistency will stay in place. It will continue to manifest in their relationships and interpersonal problems as well as other symptomology. In this case the therapist needs to explore the direct consequences of past attachment need violations in the early years of life. They may have a reduced stress tolerance, poor emotion regulation, decreased self-efficacy expectancies and reduced self-esteem. Therefore effective goal-attainment scaling is needed. The Bern Inventory of Therapy Goals identifies five areas for goal setting:

1. Problem-Mastery and Symptom Reduction
2. Interpersonal Goals
3. Well-being
4. Orientation and Meaning
5. Self-actualisation and self-esteem

A copy of the assessment can be found here:

http://wsmitraining.weebly.com/uploads/1/3/9/3/13934314/bern_inventory_of_treatment_goals.pdf

The purpose is to increase attachment needs and styles, addressing avoidance motivational schemas, increasing stress tolerance, increasing emotion regulation, unfavourable consistency-securing mechanisms, increasing self-esteem and basic needs.

Depression can often result from violations of control need which deactivates the ACC responsible for goal-orientations in the environment. Basically the client gives up. From this a loss of desire to control is manifested and thus the avoidance system is activated placing the client in defensive/protective state. They no longer want any new experiences or new feelings which all require the activation of the ACC. Regions of the brain that are more activated in this situation are the amygdala and right ventromedial PFC where negative emotions are activated, increasing depression. A shrunken hippocampus reflects the damaging result of stress hormones.

Depressed clients often reported parents who restricted/controlled and were less caring/affectionate. They could not explore their environment freely or experience positive control situations, had reduced self-esteem, increased anxiety, increased depression and increased neuroticism in adulthood. People with increased internal control beliefs reported increased life satisfaction, greater well-being, self-confidence and resistance to stress. When clients can control situations we become happier, more stress-resistant, resilient and healthier. The therapist needs to focus on developing these experiences in the session and between sessions to help develop the client’s motivational approach goals and needs, creating positive memories of control and positive relationship attachment.

Stress

Neural activation during stress can spread across the whole brain activating multiple hormones including adrenaline, corticotrophic releasing factors (CRF), vasopressin and cortisol. However, repeated confrontation with stress can trigger a new neural connection to react more positively such a cognitive or behavioural reaction. This will obviously have the result of reducing the tension/stress. Repeated confrontation with the same trigger will actually strengthen the positive response. Challenging situations can increase the volume of the cortex, better formed blood vessels in the brain, increased number of glia cells, enhanced branching of pyramidal neurones, increased density of cortisol synapses, i.e. a better formed more efficient brain. Incongruent and stressful situations can have the result of developing neural structures rather than weakening them. Tolerance, endurance and resilience increases. Therefore, some stress is beneficial to brain development.

Stress increases HPA and glucocorticoids which bind to the glucocorticoid receptors of the neurones and glia cells triggering negative feedback loops down-regulating the release of stress hormone. Prolonged triggering of this process due to a stressful environment results in the non-functioning of noradrenergic reaction, that is, no fight and flight response is activated. Glucocorticoids harm the activated glutamate synapses and pyramidal cells in the hippocampus which have a high density of glucocorticoid receptors. Noradrenergic axons and neural terminals in the cortex are sensitive to cortisol and begin to degenerate. Behaviourally, excessive glucorticoids lead to erasure of previously acquired behavioural patterns. Sometime clients will be emotion-focused rather then problem-focused because the emotions are so intense and dysregulated. Strategies to reduce this is essential before working on new motivational approach goals. In the meantime the clients avoidance goals are activated even where there is no real threat. Anxiety is thus triggered. The anxiety is anticipatory with reduced attention and motor behaviour, increased scanning and hypervigilance of the environment and preparation for fight, flight, freeze and fawn trauma responses.

PTSD

PTSD changes the brain structure and therefore how it functions. There is a stronger hormonal response to stress after PTSD. Having a smaller hippocampus at birth is also a risk for developing PTSD but PTSD isn’t necessarily a causative factor in reducing the size of the hippocampus. Anxiety reactions may be more prolonged. Trauma is stored in the implicit memory and therefore the symptoms of PTSD emerge as result of dissociation between the implicit and explicit memory. Since the hippocampus is responsible for explicit memory the smaller it is the greater the PTSD symptoms. Memory therefore becomes more engraved in the amygdala which conditions the five senses. This explains why PTSD sufferers experience amplification in their senses – sounds, smells, tastes, touch, sights are heightened and more sensitive – hence the overwhelming experiences of memories and flashback. This heightened memory recall cannot be extinguished but can be inhibited in the orbitofrontal cortex (OFC) which is connected to the hippocampus. PTSD sufferers find it enormously difficult to recall events because they are stored implicitly and not explicitly. This impaired memory is caused by an impaired hippocampus, impaired memory due to excessive high levels of stress hormones and the client’s avoidance of processing the past traumas, understandably. People with PTSD cannot process traumatic events in the hippocampus into logical explicit memory narratives. Instead the amygdala forms implicit memory in the form of bodily states, sense-specific cues (smells, sounds, pictures/images). They are disjointed memories that are intended to protect the client from re-traumatisation. However, narrative therapy helps the client process old memories  into logical and accurate memories considering essential facts and details that can help alleviate perceptions of guilt and blame and lead to reduced anxiety and trauma reactions. Narrative therapy helps move the implicit memories in the amygdala towards the hippocampus, PFC and language centres all parts of bringing memories from the implicit level to the explicit one. The hippocampus, PFC and language centres all work towards inhibiting the nature of the amygdala and thus move the client out of PTSD into more healthy mental and emotional states.

GAD – Generalised Anxiety Disorder

Anxiety is an unsuccessful form of emotion regulation manifesting during experiences that are actually not threatening. GAD symptoms include: hyper-vigilance, avoidance, worrying, cognitive avoidance, intense anticipatory anxiety, overactive threat/avoidance system, hyper-arousal, inability to feel safe even in safe situations. Anxiety is heightened arousal and elevated activity of the sympathetic nervous system. The parasympathetic nervous system is compromised and fails to inhibit inappropriate anxiety. Heart rate indicates anxiety regulation. These structures are also involved in anxiety – ACC, insular and orbitofrontal cortex, amygdala and anterior executive region (AER) and the vagus nerve which inhibits the heart rate. GAD also dysregulates the central autonomic network (CAN) which results in compromising the vagus nerve and increases the heart rate caused by excessive worrying.

Panic Disorder

Panic disorder is heart-related and increases activation of the right frontal lobe leading to activation of avoidance system. In panic disorder avoidance tendencies are more easily triggered with corresponding negative emotions and avoidance reactions. Therapy provides opportunities to inhibit these responses of panic, avoidance and cultivate calming and soothing strategies. Panksepp & Biven (2005) also relate panic disorder to one of their emotional systems – PANIC-GRIEF – the fear of abandonment/aloneness. It is also related to attachment theory and early experiences of insecure attachment with primary caregivers where control and needs were violated. These separation distress symptoms are also close to the pain systems and regions of the brain and may be co-experienced with anxiety. Panic can be triggered neuro-chemically (hyper secretions) such as glutomate and corticotropin and thus calmed by oxytocin and prolactin that are secreted in comforting, reassuring, loving and protective experiences such as hugging with a safe attachment figure or reassurance and the core conditions from a supportive therapist.

Obsessive Compulsive Disorder (OCD)

OCD is related to a neural circuit linking and activating the orbito-frontal cortex, basal ganglia and thalamus. OCD affects completely different regions of the brain compared to other anxiety disorders. There are three symptom factors:

1. Obsessive thoughts with aggressive content and control obsessions
2. Obsessive orderliness and repetitions
3. Fear of contamination and compulsive cleaning

OCD behaviours can affect social behaviours like aggression, hygiene and sexuality and are therefore triggered/activated inappropriately and hyperactively. They are difficult to stop. Inhibitory processes are too weak to suppress or stop the impulse/impetus. Therapy consists of addressing and inhibiting the negative emotions, facilitating positive goal-oriented activity, strengthening inhibitory processes and exposure with response prevention (ERP).

© Martin Handy 2022