The psychodynamic psychiatrist eschews reductionism. Recognizing that mental life and psychiatric symptoms are both overdetermined and multiply caused, psychodynamic clinicians are always interested in the interface between the biological and the psychosocial. Psychodynamic psychiatry is not antibiological. The psychodynamic psychiatrist is the integrator par excellence. Avoiding Cartesian dualism, the mind is seen as the expression of the activity of the brain. (13> Subjective experience affects the brain just as mental phenomena arise from the brain. Every treatment intervention is seen as being biopsychosocial in nature. Medications have psychological effects. Psychotherapeutic interpretations affect the brain. Moreover, psychodynamic psychotherapy and medications may work synergistically to provide better outcomes for patients. For example, a patient with a bipolar disorder who is denying that he has an illness and refusing to take lithium may ultimately have better compliance with the medication if the clinician explores the meaning of his denial and his reluctance to consider himself as someone requiring treatment.
The comprehensive mind-brain strategy of the contemporary psychodynamic psychiatrist fits well with our growing knowledge of the interaction between genes and the environment. In an inspired series of experiments with the marine snail Aplysia, Kandel(1. ,.!5) has demonstrated that synaptic connections are strengthened and permanently altered through regulation of gene expression connected with learning from the environment. In Aplysia the number of synapses actually double or triple as a result of learning. Kandel has suggested that psychotherapy might make similar neuroanatomical changes in the synapses. He argues that just as representations of self and others are malleable, the brain itself is a dynamic and plastic structure. He postulates that psychotherapy is a form of learning that produces alteration of gene expression and thereby alters the strength of synaptic connections. While the template function or the sequence of the gene is not affected by environmental experience, the transcriptional function of the gene (namely the ability of a given gene to direct the manufacture of specific proteins) is highly regulated and responsive to environmental factors.
There is also evidence in mammalian species that the brain is plastic and influenced by environmental factors. Rats raised in a social environment that requires complex learning to survive have significantly greater numbers of synapses per neurone compared to rats raised in isolation. (1.6) Environmentally derived activity appears to drive the development of dendrites so that they conform to cognitive schemes for the construction of mental representations. The brain is not a blank screen, and the individual's genetic endowment will constrain the impact of environmental factors. Nevertheless, neural connections between the limbic system, the cortex, and the autonomic nervous system become connected into circuits in accordance with specific experiences of the developing organism. This developmental pattern may be summarized as follows: 'Neurons that fire together, wire together'.(!7)
Primate research suggests that specific types of relatedness may serve to overcome genetic vulnerability. For example, Suomi(18) identified a cohort of infants comprising about 20 per cent of the Rhesus monkey colony in his laboratory who appeared to have an inborn vulnerability on a genetic basis. These infant monkeys reacted to brief separations with depressive reactions, increased cortisol and ACTH levels, and exaggerated noradrenaline turnover. He then placed these infants with unusually nurturant mothers within the monkey colony that he referred to as 'supermothers'. He observed that inborn vulnerability to separation anxiety and depressive reactions was overcome when the infants were allowed to have round-the-clock access to these extraordinarily nurturing mothers. Indeed, the interaction led these infant monkeys to become leaders in the social hierarchy. One can speculate that with a special type of nurturing relationship, the heightened sensitivity characteristic of these monkeys on a genetic basis was transformed into a highly adaptive means of relating to their peers in the social context.
Primate research is also serving to confirm certain psychoanalytical developmental notions. In a study of milder trauma, (B infant monkeys were randomly assigned either to normal mothers or to mothers temporarily made anxious by an unpredictable feeding schedule. Those with anxious mothers became socially subordinate and showed diminished capacity for normal social interaction. However, these social changes did not appear until adolescence, confirming the psychoanalytical notion that disturbances at early phases of development can produce delayed psychopathological changes in adolescence and adulthood. These behavioural changes were accompanied by serotonergic and noradrenergic alterations, indicating that the mild trauma of having a mother made anxious about how she will obtain sufficient food also produces brain changes.
The research summarized here points to the dynamic interplay between genetic expression and the environment. Gene expression cannot be considered static. It is a dynamic phenomenon that interacts with and reacts to environmental experiences. Heritable characteristics of children actually shape their relationships with their parents and siblings.(20) In turn, the response of family members to the child affect the genetic expression. Hence genetic influences on some types of psychopathology may be dependent on the mediation of social processes. A child's genetic endowment will influence the way parents relate to a child, and the way the parents treat the child will then influence that child's developing brain. Biological and psychosocial processes are constantly intertwined, and neither is prior.
In many major psychiatric disorders, such as depression, genetic factors appear to influence whether a stressor produces an episode of illness. (2!* From a psychodynamic perspective, the meaning of stressors must also be incorporated. Some stressors that may seem mild to one individual are overwhelming to another because of their idiosyncratic conscious or unconscious meaning. In addition, the presence of biologically generated symptoms in no way diminishes the importance of meaning. Pre-existing psychodynamic conflicts may attach themselves to biologically driven symptoms, and the symptoms then function as a vehicle for the expression of the conflicts/22,* Auditory hallucinations are generated by alterations in neurotransmitters in persons with schizophrenia, but the content of the hallucination often has specific meanings based on the patient's psychodynamic conflicts. Hence a patient who is being told that he is a failure and should kill himself by a hallucinated voice may be tormented by a sense that his life is shattered by his illness and that he no longer has any purpose in living.
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