Can you please elaborate on the statement you made at the 2011 U.S.

Psychiatric and
Mental Health Congress

that psychotherapy can literally change the brain?

Jon W. Draud, MD, MS: This is a great question and points out the flaw
in the old dichotomy that psychotherapy is for psychological disorders
whereas medication is reserved for biological disorders. Of course this is
incorrect and there has been much research on plastic brain changes. The
advent of functional magnetic resonance imaging, single-photon emission
computed tomography, and positron emission tomography has truly advanced this area
of study over the last decade.

Nearly 20 studies have been published on brain changes after psychotherapy for
depression, anxiety disorders, and borderline personality disorders. Examining the
various studies, the overall conclusion is that cognitive therapy, behavior therapy,
psychodynamic psychotherapy, and interpersonal therapy alter brain functions in
patients suffering with major depressive disorder (MDD), obsessive-compulsive
disorder (OCD), panic disorder, social anxiety disorder, borderline personality disorder
(BPD), specific phobias, and post-traumatic stress disorder.1-14

Most studies show similar changes after medication and psychotherapy, but some recent
studies show differences. Goldapple et al.3 found increased metabolism at dorsal
cingulate and hippocampus and decreased flow to medial frontal cortex as well as dorsal
and ventral frontal areas in cognitive-behavioral therapy (CBT) applied to patients with
MDD. This is different from medication metabolic changes, which typically show
increases in prefrontal cortex and decreases at hippocampus and subgenual anterior
circulate. There have also been some differences in patterns of metabolism with short-
term psychodynamic therapy and fluoxetine among patients with MDD.15

Many psychotherapies are aimed at enhancing patients abilities to problem solve,

regulate affect, and change their negative views of themselves. Brain areas that are
involved tend to be the dorsolateral, ventrolateral, and medial prefrontal cortices, the
anterior cingulate, the posterior cingulate/precuneus, and the insular cortices.16 Beutel et
al.8 demonstrated a frontal deactivation and amygdala hyper-activation in symptomatic
patients with panic disorder. The prevailing theory of how CBT works is via top
down regulation of hyper-excitable links with formations by prefrontal cortical areas.
Similarly, Schnell and Herpertz13 showed that after dialectical behavior therapy there is
decreased activity in areas that were previously hyperaroused in patients with BPD.

These findings are, of course, interesting and lead us to the notion that all good
clinicians are already aware of: a good therapeutic alliance that combines psychotherapy
and incorporates medications is almost always superior to either modality used alone.

Jon W. Draud, MD, MS