neuroscience-based cognitive therapy (new methods for assessment, treatment, and self-regulation) ||...

P1: SFN/XYZ P2: ABCJWST154-c01 JWST154-Scrimali January 19, 2012 8:18 Printer Name: Yet to Come

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Neuroscience in Context


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Neuroscience, Clinical Psychology,and Cognitive Therapy

Neuroscience constitutes one of the most important components in con-temporary scientific development. Due to the introduction, on the onehand, of increasingly more sophisticated techniques and, on the other, ofthose that are progressively easier to learn and apply as well as more eco-nomic to acquire and utilize, neuroscience is no longer either the exclusiveheuristic method for understanding the brain and comprehending the mindtypically employed in costly professional research labs, or the tool of mentaldisorder clinics. The purpose of this book, and of the research and applica-tions described in it, is to propose a series of methodologies that, thoughcoming from neuroscience laboratories, still provide concrete clinicalapplications today.

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

This book shows how neuroscience is now already available to clinicalpsychologists, not only as a valuable new brain and mind heuristics, butalso as valid application methods with which I have personally worked for

Neuroscience-based Cognitive Therapy: New Methods for Assessment, Treatment, and Self-Regulation,First Edition. Tullio Scrimali.C© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.


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Figure 1.1 How clinicians imagine the psychophysiological setting.

many years. To begin with, let’s define exactly what neuroscience is and whatit concerns.

The term “neuroscience” indicates a set of disciplines, both heuristic andapplicational. The objectives of these studies range from structural, bothmacroscopic and microscopic, to functional aspects, examined from thebiochemical, biophysical, and physiological viewpoint. Neuroscience alsoincludes the study of the phylogenetic and ontogenetic development of thebrain. From an applications viewpoint within the clinical setting, neuro-science predetermines the identification of etiologic pathogenetic processesof neurological and mental diseases and the development of new method-ologies for the diagnosis and treatment of psychic distress.

The Society for Neuroscience was officially founded in 1969 but, froma strictly historical point of view, we can say that the macroscopic mor-phological study of the brain began in ancient Egypt. Until some yearsago, neuroscience was considered largely as a biological branch of human


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knowledge, while more recently, due to the development of new disci-plines such as cognitive psychology, neuropsychology, scientific philosophy,and theories of complexity, a very solid bridge to the human sciences hasbeen created.

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

Methods of cerebral imaging that were developed in the last thirty yearsof the twentieth century, due to the advent of information systems tech-nology methodologies, brought a series of important contributions to thecomprehension of dysfunctional processes and structural alterations in thenervous system over the course of psychiatric disorders, particularly inthe area of schizophrenia. Introduced into a clinical setting at the begin-ning of the 1970s, the first brain imaging technique was computerized axialtomography (CAT), which evolved into computed tomography with the de-velopment of brain analysis methodologies that allowed the study of variouscross-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 followingdecade, at the start of the 1980s, nuclear magnetic resonance was devel-oped and introduced into the clinical setting, permitting better definitionthan computed tomography. In this case, the inventor and technique devel-oper was a researcher of Armenian descent and a naturalized United Statescitizen, Rayon Damadian, who obtained the Nobel Prize in 2003 for thisrevolutionary invention (Mattson and Simon, 1996).

A real revolution in the area of brain imaging techniques took placewith the development of new methodologies that were capable not just ofidentifying structural alterations in the cerebral mass but also of directlyviewing in real time the biochemical modifications occurring in variousparts of the brain as they are stimulated for action. We can say that, withthe finalization of such methodologies, the age-old dream of having a toolfor direct observation of brain activity in a living human being was finally



realized. The principal techniques in functional brain imaging are singlepositron emission tomography (SPECT), positron emission tomography(PET), and functional magnetic resonance imaging (fMRI).

The first two methodologies make it possible to view functional cerebralactivation by highlighting blood flow. In particular, PET allows the dynamicstudy of cerebral metabolism, by viewing both regional blood flow and localconsumption of glucose. Additionally, functional analysis of the differentbrain systems that utilize different neurotransmitters is possible.

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

Morphological and functional imaging techniques applied to the CNSremain, for now, confined to the laboratory, even though a recent devel-opment looks promising for application in the clinical setting in the nearfuture. In the United States, BIOPAC has recently marketed a new func-tional analysis system limited to the frontal lobe that no longer requiresthe patient to enter the MRI tunnel lying down, but can be used simplyby applying small sensors to the patient’s forehead (BIOPAC, 2009). Viaa screen placed in front of the patient, this system is also able to acti-vate the cognitive and executive functions typical of the frontal lobes andrecord the internal functional correlates of nerve activity patterns underboth normal and pathological conditions, all in a quasi-clinical settingwith the patient comfortably seated and minimally disturbed. The systemcost 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 inclinical psychology founded on analysis of functional modification in thefrontal lobes.

This new technology is called functional optical brain imaging, or func-tional near-infrared (NIR) based optical brain imaging (fNIR). Like fMRI,it is based on the potential for analyzing in real time the metabolic changesrelative to neuron activity by quantifying regional levels of oxyhemoglobin


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and deoxyhemoglobin. Analysis is based not on a methodology related tothe magnetic behavior of hemoglobin molecules but on the application ofspectral techniques. Since only a cap with 16 integrated sensors is needed,the fNIR appears truly revolutionary and boasts great potential for the studyof cognitive processes. Due to the fact that it predominantly analyzes thefunctional activity of the frontal lobes, it appears quite promising for re-search in mental disorders, specifically autism and schizophrenia (McCarthyet al., 1997).

Some medical specialties, such as neurology, neurosurgery, and neu-ropathology, have already established strong links with neuroscience, ap-plying new methods for diagnosis and treatment (Waxman, 2004).

In psychiatry (the discipline to which the subject matter of this book ismost closely related), many exchanges with the field of neuroscience havebeen 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 tocognitive therapy (CT), such as behavioral neuroscience (Breedlove, Rosen-zweig, and Watson, 2007), cognitive neuroscience (Holyoak and Morrison,2005), and developmental neuroscience (Nadarajah et al., 2003). Further-more, if we consider my own complex approach to CT then social neuro-science (Harmon-Jones and Beer, 2009) and Systems Neuroscience (Hem-men and Sejnowski, 2006) must also be considered.

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

In neuroscience, the discipline that bridges the laboratory and the clin-ical setting is known as clinical psychophysiology. This discipline involvesmethods and procedures that constitute a true interface system betweenthe brain, the mind, and their relational context. In the clinical context, itthus deals with implementing objective analysis methodologies of the func-tioning of the central, neurovegetative, and autonomic nervous systems. Aswe will see later, the techniques that are now more readily available in theclinical setting are computerized EEG and digital analysis of EDA.

As I describe, the idea of utilizing psychophysiological techniques in theclinical psychology setting is in the same vein as the most recent positions



documented in psychotherapy and contemporary neuroscience, such as thatof Nobel Prize winner Erik Kandel, who sees the clinic, and particularly clin-ical psychology, psychiatry, and psychotherapy, as more and more closelyflanking the lab. Scholars such as Cozolino and Siegel propose a neurobi-ology of psychotherapy and relational processes, including the crucial oneof reciprocity and attachment (Kandel, 1998; Cozolino, 2002; Siegel, 1999;2007). Before moving on to describe the range of applications in clinicalpsychology, it is important to focus, even if briefly, on a series of conceptualand theoretical topics that form the basis for the rational and consistentclinical use of the techniques coming out of the neuroscience laboratories.

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