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Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian Psychiatry.
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My name is Ed Miller, and I'm the trainee editor of Australasian Psychiatry.
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Joining me today are deputy editors of Australasian Psychiatry, Fiona Wilkes and Andrew Amos, Editorial Committee member Michael Waiteman, and psychoanalytic psychotherapist Stephen Yates.
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Welcome, everyone.
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Thanks, Ed.
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Hi Ed.
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Hello.
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So this is the first part of two parts to this podcast, where we will be discussing a paper that we have all written together, which is currently undergoing peer review for publication.
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And the paper provides a conceptual overview of neuropsychoanalytic and neuropsychiatric principles, which we think could help to inform a basic neuroscientific curriculum for psychiatry trainees.
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We will touch on topics such as the common origins of both neuropsychoanalysis and neuropsychiatry in psychoanalysis, neurology, and early psychiatry, philosophy of mind, psychoanalysis, consciousness, and affective neuroscience for neuropsychoanalysis, and discussing the importance of hierarchical brain network function and scope of disorders and treatments for neuropsychiatry.
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We will also describe case vignettes and demonstrate how these concepts could be used to better understand specific psychiatric presentations.
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Ultimately, we hope to champion psychiatrists as expert psychotherapists, as well as provide clinical neuroscience knowledge for psychiatry, which could be used in lecture material, online teaching modules, bedside teaching, psychotherapy training for psychiatrists, and case formulation and discussion.
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So, since the 1990s, there has been an explosion of neuroscientific and philosophical advances in our understanding of brain and mind, with major implications for psychiatry.
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Psychiatry is increasingly considered to be a clinical neuroscience discipline, meaning that it deals with disorders that stem from disrupted brain networks and systems caused by underlying genetic, developmental, and environmental influences.
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However, the developments in neuroscience are technically complex and are occurring at a rapid pace.
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This makes them difficult to contextualize with other psychiatry curriculum elements that often do not progress as quickly, such as mental health legislation, some ethical principles, diagnostic criteria and nostology, and psychotherapy training.
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This makes developing and refining a robust clinical neuroscience curriculum for psychiatry a difficult task.
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Consequently, the development of a clinical neuroscience curriculum for psychiatry training lags behind the neuroscientific progress, with many training programs having no such component or there being a wide variation in content when it is taught.
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So, neuropsychoanalysis and neuropsychiatry are two fields that are closely related to psychiatry, which have already incorporated neuroscience into their regular practice and theory.
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It makes sense then that highlighting key concepts from these fields would greatly enhance the development of a clinical neuroscience curriculum for basic psychiatry training.
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Moreover, discoveries from neuropsychoanalysis and neuropsychiatry could help equip psychiatrists to become expert psychotherapists by leveraging their unique training in both contemporary mind and brain science.
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I'll hand over to Stephen, who will now talk a little bit about neuropsychoanalysis.
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The term neuropsychoanalysis was coined by Mark Sommes, now Professor Mark Sommes from the University of Cape Town, who's a clinical neuropsychologist.
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Who, in work with brain injured patients, was initially, I think, a bit dissatisfied with conventional psychological training's perspective on subjectivity, on what it means to be a subject, have an inner life.
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And contemporaneous work with stroke patients, um, various types of brain injuries.
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Professor Solmes began to explore how psychoanalytic phenomena manifest in those patients with demonstrable brain deficit.
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And what he found was a set of patterns and uh made a series of comments and arguments that attempted to re-integrate a the substrate of the brain into a psychoanalytic understanding or as they relate to psychoanalytic phenomena.
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The bridge that finally allowed um a much fuller integration of the two disciplines was actually the work of Yach Pangset in affective neuroscience that happened through the Nazis and early cousins.
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That by demonstrating the seven networks of the emotion networks with their unique irreducible affect states, Solms made a series of reinterpretations, essentially of Freudian drive theory that later feeds into an object relations theory that tries to do what Freud had wanted to happen in a project for a scientific psychology, which is to reintegrate the natural sciences into psychology.
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So in this sense, they are, as you say, an attempt to integrate psychoanalysis into the neurosciences.
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This rather naturally leads to a deeper exploration of the fundamental experience of consciousness.
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So if you think of psychoanalysis as being essentially a study of the subject, and there are other studies of of subjectivity and religion and art, but from the perspective of science, uh psychoanalysis is a fairly comprehensive idea about what it means to be a subject.
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The neuroscientific picture has always been a bit complicated because the brain is both subject and object.
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You know, as one could put it as that neuroscience and psychoanalysis have been viewed as two perspectives of the same unknowable thing in nature.
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You know, the reality behind the subjective mind and the objective brain, which we should not necessarily try and solve but to straddle.
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So there's quite a lot of potential for neuropsychoanalysis to bridge the theoretical gaps in theory, uh particularly in psychoanalytic theory, but probably more broadly in psychological theory, uh, which have tended to, for you know, reasons a bit beyond the ri this discussion, become siloed and remain separate.
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So the chances there for psychoanalytic theory to come together with the brain, and this is a very exciting prospect.
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The philosophical backbone of neuropsychoanalysis is Bruce Spinoza's dual aspect monism, which is Spinoza's philosophy, which he articulated in the 1600s in ethics, presaged the modern neuroscientific investigation of essentially feelings, affects, and emotions, which is the field I referred to earlier in ethic neuroscience, which did influence Freud.
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So formulated by Spinoza in dual aspect monism is response to dualism, to Descartes' dualism.
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If Descartes postulated that mind and brain are separate entities, which accorded with religious dogma at the time and notions of the soul, the Spinoza's position is is counterposed to that.
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For Descartes, the soul resides in the pineal gland, which was its interface to the body, but both were fundamentally different, and therefore the soul was theoretically able to persist beyond death, so you can accommodate for religious ideas within this.
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Spinoza, though, in ethics described the mind and brain as being forms of a third property, which he called substance.
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And a position referred to as dual aspect monism because the substance monism has two dual aspects.
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The mind and brain are neither completely representative or ephenomenal to the other, but occupy opposite and interrelating aspects.
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But dual aspect monism was suppressed in deference to the religious utility of Cartesian dualism and only recently re-entered modern vocabulary.
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Emergentism and transcendental materialism are outgrowths of dual aspect monism which accept that mind can be a property, an emergent property of the brain with the potential for immaterial properties that are not reducible to physical matter.
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So our article provides an overview of the main mind-brain philosophies relevant to clinical neuroscience curriculum.
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And there's also an adjacent, fairly persuasive argument raised by Psalms that attempt to solve the hard problem of consciousness using neuropsychoanalytic understanding in The Hidden Spring.
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But I'll stop there.
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Thanks, Stephen.
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So I might move across to introducing some of the key conceptual areas of neuropsychoanalysis.
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And I'll start by talking about a few examples of how neuroscience has been used to help explain unconscious mental processes.
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So one really good example of this comes from the work of neuropsychiatrist Eric Candle, who suggested that there could be a link between some of Freud's theories, such as his topographic and structural models, and memory systems.
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And he thought this would be a fruitful area for collaboration between psychoanalysis, biology, and neuroscience.
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So, for example, he thought that different layers of the unconscious, including the pre-conscious, unconscious and the unconscious proper, might be linked to different memory systems and corresponding brain regions and networks, such as the prefrontal cortex.
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Another example comes from the work of Mark Solms, Jack Panshep, and others in this area who suggested that Tolvig's concepts of anoetic, noetic, and autonoetic consciousness might correspond to procedural, semantic, and episodic memory systems.
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Again, another example, dream psychology and dream physiology, have also got thorough neuroscientific descriptions, which can be linked back to Freud's dream theory as well.
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An example of this is Solmes' demonstration that dream imagery is instantiated in the medial, prefrontal and parietal areas rather than brainstem nuclei.
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Mark Solms also suggested that neuroscientific processes can help us test, update and refine Freudian theory.
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For example, there is some recent neuroscientific evidence that suggests that an inverted topographic model of the mind may actually be closer to reality, as the psychoanalytic ego, which is the part of the psychoanalytic self which is most conscious, might in fact be brainstem generated rather than cortical, whereas affects and drives may be more cortically placed than originally thought.
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So there's a huge potential for the use of neuroimaging methods to help unmask unconscious processes in other psychoanalytic concepts such as mourning or psychoanalytic perspectives on confabulation.
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That's a really exciting area of research.
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Another core insight that arises from linking the psychoanalytic unconscious to neuroscience is the free energy principle.
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So the free energy principle has been described as the new royal road in the dialogue between neuroscience and psychoanalysis, the bridge between the mind and the brain.
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This free energy principle was introduced by Carl Fristen in the 1990s in his brain imaging work.
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The free energy principle analogizes the mind-brain system to any other biological system that requires adaptation to its environment to survive.
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It considers the brain as a hierarchically constructed inferential machine containing many interconnected large-scale networks.
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These hierarchical networks optimise the prediction, representation, and construction of increasingly complex lower order mental and sensory information to more accurately interpret and predict the meaning of both the internal and external environments.
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So the way this works is that it minimises the amount of free energy, which can be thought of statistical uncertainty or surprise.
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It minimises the amount of that available in the mind and brain, thus reducing prediction error, which can also be understood as reducing the statistical complexity of the information contained in the brain.
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This means that the mind-brain can never know the world directly, but only perceive it by predicting what it could be like and then testing it against new information.
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The mind brain always tries to predict reality as accurately as possible, which is important for survival.
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Sufficiently poor predictions could result in psychopathology like hallucinations.
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Another way to put it would be that the mind-brain tries to continuously learn about the world to feel safe, to adapt, and to survive.
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This basic model, intriguingly, is similar to Freud's original topographic model of primary and secondary processes.
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The primary process generates unconscious fantasies, wishes, and desires generated by the id, which is an example of bottom-up processing, and these are countered by the top-down ego's affinity for contrasting these impulses against the incoming sensory information and the reality of the external world.
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According to Jim Hopkins, a psychoanalyst, the free energy principle overlaps with psychoanalysis in understanding emotional conflict and trauma, understanding the function of memory consolidation and reconsolidation in dreaming, and identifying the role played by the mind-brain's tendency to predict reality in order to reduce statistical complexity and buffer against excessive statistical surprise in the origins of a range of mental disorders such as schizophrenia.
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Thanks, Michael.
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I'm now going to talk about the neurobiology of infancy development and affective neuroscience.
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So the neuroscientific investigation of memory, sleep, and dreaming and consciousness can also be linked to the psychoanalytic focus on early life development.
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Both Freudian and Bionian descriptions of mind elucidate a developmental process that explains how the registration of bodily sensory and affective experience creates, shapes, and is represented in thought.
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This longitudinal buildup of unconscious representations of visceral states and their representations in thought has been linked to activity in the posterior and middle insula and the default mode network.
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Candel discussed this buildup in terms of psychological determinacy, causality and development, including the role of early life experience and predisposition in the development of psychopathology, and linked this to Freudian constructs like signal anxiety.
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Johannes Letonen suggested that neurobiological and protopsychological processes during the perinatal period can be linked to psychoanalysis.
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So, for example, the impact of early attachment and caregiving relationships can be mapped to specific biochemical processes and the molecular genetic mechanisms of neuronal synapse formation.
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So these processes are formative for the early organization of the mind and also create preconditions for non-verbal, unconscious communication and therapeutic interplay.
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Furthermore, neuroscientific evidence also suggests that the psychoanalytic concept of the ego may be present from birth, which provides an example of how neuroscience can help to answer key psychoanalytic questions.
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Pankschep described nested brain-mind hierarchies where primary process emotion systems, genetically endowed affects in the deep subcortical regions of the brain, become shaped and moulded by learning and conditioning in the midbrain, before being represented in symbolic and tertiary level thought in the neocortex.
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So, this bottom-up process is then regulated by top-down neocortex inputs in what is referred to as a two-way or circular causation process of representation and learning.
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Bangshep argues that the seat of consciousness, the self, as it relates to and intertwines with affect and drives, is now increasingly established to be subcortical rather than cortical.
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Neuropsychoanalysis uniquely integrates clinical and technical psychoanalytic concepts with neuroscience research, providing novel explanations for how psychotherapy works, uncovering additional neuroscience findings that may relate to clinical practice and helping clinicians develop deeper formulations.
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Multiple studies have researched the neuroscience of psychoanalytic concepts, including transference and countertransference, defense systems, free association and dreaming and trauma.
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Indeed, transference and countertransference are regarded as cornerstones of psychoanalytic and psychodemic psychotherapies, as well as having broad applicability across a range of psychotherapeutic modalities.
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Transference in particular has been defined as a tendency in which representational aspects of important and formative relationships, such as with parents and siblings, can be both consciously experienced and or unconsciously ascribed to other relationships.
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In the context of a psychoanalysis, this is a spontaneous development of representation of in behavior and in unconsciously determined utterance of early life experience.
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In this sense, transference relates to the implicit relational schema and dynamic pattern matching of a patient invoked in therapy based on a priori learning and memory formation.
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Activation of these a priori emotional processes in therapy is key to psychic change, part of which involves activation and remodeling of declarative and procedural memory networks with associated neural correlates in the superior and inferior frontal gyra and in the putamin.
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In other words, transference is a premature automatization of which interpretation helps to render into working memory.
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Understanding the neuroscience of similar therapeutic processes such as automatic mirroring and reflective functioning helps to explain clinical phenomena such as therapeutic alliance and change, since the neural motor networks of psychotherapy patients may automatically mirror the motor movements of the therapist, which then may impart effects on the neuronal systems in the brain of the patient, including through the function of the motor neurons.
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Researching the effects of psychotherapy on patients with known neurological disorders may further elucidate its neuroscientific basis.
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Psychoanalysts themselves could be used as research subjects for individual case studies by being given different neuropeptides and being asked to psychoanalytically interpret the changes to their own phenomenology.
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This approach could be used in areas such as psychedelic assisted psychotherapy, whereby small doses of psychedelic medication are administered to a patient to assist with a psychotherapeutic process.
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Reviews suggest that psychotherapy has measurable effects on brain structures.
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One mechanism of action for this may be that psychotherapy causes changes to the serotonin-driven neuronal networks in the brain of subjects with depression.
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Jeremy Holmes hypothesizes that some psychotherapeutic interventions, such as analytic psychotherapy and mentalization-based treatments, work because of their propensity to bind free energy.
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That is, reduce unpredictability or minimize prediction error, which in turn enhances Bayesian inference and allow experience and feeling states to be metabolized and assimilated.
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I'm now going to look at some critiques for and against neuropsychoanalysis.
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So despite these advances in collaboration between psychoanalysis and neuroscience, some are concerned that neuroscience and neuropsychoanalysis have abandoned dual aspect monism, particularly the need to bridge the gap between mind and brain by becoming biologically reductionistic.
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A valid neuropsychoanalysis requires a balance between subjective and objective factors in psychoanalysis and neuroscience.
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It risks becoming a token appropriation of neuroscience.
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Another concern is that psychotherapists who incorporate neuroscience may unconsciously use biological models when they encounter resistance.
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A simple example is the issue of whether or not to tell a patient that from a neuroscientific perspective the recollection of birth trauma memory is impossible.
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Should the analyst focus on the symbolic meaning for the patient or should they use the knowledge of neuroscience to directly challenge a false claim?
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Similarly, the prescription of psychotropic medication could be made as a counter-transferential defense against the anxiety of resistance, or it could treat that anxiety directly through a biological mechanism.
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And I was just wondering, uh Stephen, could you talk a little bit about your personal experience with this issue, I guess?
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So, as a medically trained, you know, psychoanalytic psychotherapist, how do you or do you employ neuroscience in your psychoanalytic practice?
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This is a really interesting question.
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There is an intuition that a neuropsychoanalytic formulation in a clinical case leads to a better outcome.
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What exactly those outcomes are are very much open to questions.
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There's I know of a PhD student who's researching this.
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I know that there are plans to do studies which could address this question, but it's it's far, far from being answered.
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My experience as an analyst with offering neuropsychoanalytic understandings comes, I think, in in several forms.
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Firstly, there is a specific supervision technique developed by Soms to understand what is the main feeling that the patient is suffering from.
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And so you can understand through the content of the analytics session what is it that's the main problem for this particular person.
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And these relate to the seven affective systems that described in affective neuroscience.
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So, you know, panic, grief, care, rage, lust, fear, seeking, and so on.
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By establishing this is actually quite a big deviation from other ways of supervising a case psychoanalytically.
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In my experience, what needs to happen in an in an analytic encounter is to sort of make contact with something, with the patient and turn it from You know, an undigested affective experience into thought.
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This is very much a sort of Biononian idea that it moves through a process of sort of phylogenetic development into something more sophisticated, which of course takes a lot of time.
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And this requires affective contact between the analyst and the patient.
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Neuropsychoanalysis or the discoveries introduced from neuropsychoanalysis, I think, give you a firmer grounding for what exactly it is that you're doing.
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You're involved in an affective experience with the patient for the purposes of thinking something new, i.e., rendering it into working memory and developing understanding.
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Well, can I ask one follow-up question, Stephen?
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Is a challenge that's generated by a neuroscientific understanding any different from a challenge generated by any other aspect of experience?
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I suppose it's only the risk that to be with a patient requires you to engage with your subjectivity.
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I guess if if you if you look at I think it's Anne Alvarez thought that part of what's developed in an analysis is sort of observing yourself whilst being yourself.
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I call it sort of one foot in the river and one foot on the bank.
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And that and this is not solved.
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You don't ultimately become more in the river or more on the bank.
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The whole process of psychic maturation is to have an emotional experience whilst being able to observe it without being unduly dissociated from the feeling.
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This is different in the sense this is the authority of science, and people are often very confronted by a science because they know that they don't understand it.
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So it might be more confronting, but I think the dynamics probably are very similar.
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When you challenge someone with an idea that their parent hates them, for example, you often you probably wouldn't do that with a very fragile patient, but they then need to process that and experience that, learn to deal with that, as you say, while observing themselves.
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I think the authority of science is different, but that the dynamic of processing that response is the same.
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I've I've probably only been able to address this by by metaphor or reasoning by analogy.
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I'm sure that neuropsychoanalysis will lead to the design of better psychotherapies in the same way that flight and the science of flight and the science of aerodynamics leads to the design of better planes.
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I don't think we're at all clear on in what way it improves the performance of the pilot.
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You know, that that that is I love the idea that there are going to be many plane crashes in the development of neural psychoanalysis.
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But we refined the science of uh of how it's understood, you know, and vernoulli and so on.
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And I think pilots I mean, I had a little bit of experience flying light planes, not not heaps, but it is a lot of it is about feel, and there is something analogous to an analytic development of yourself as an individual because you are two subjects coming together.
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I think neuro the neuropsychoanalytic understanding has this sort of mental presence that I am still engaged in a scientific experience.
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There's something scientific about it without reducing the fact that it might be exceedingly meaningful to both people and of course oriented towards the development in the patient.
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That's how that's how I put it.
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I I I think probably other people are going to put it much better than that in the fullness of time.
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But one thing that I've sort of very briefly reflected on that issue is that neuroscience might not help to make the way forward clear for psychoanalysis, but it can tell you when you're going really off track.
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Yes.
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Potentially.
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So so it can you can have one simple kind of study or neuroscientific solution to let you know, okay, it's definitely not down that way.
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And so you can potentially reduce harm or make something relatively straightforward, but the way forward still isn't necessarily clear.
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It's a very good point.
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That was really well demonstrated with um some of the theoretical assertions that Francis Tusten made around autistic spectrum disorders that were had to do with early memory, uh, and neuroscience sort of answered the question, you know, about that.
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And uh I I think that's a I think that's a really good point.
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Like analysing people with schizophrenia, for example, like a schizophrenic mother or something, whereas we know it's much more complicated than that.
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We don't know what it is exactly, but we know it's not just that one kind of simple explanation.
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Yeah, yeah.
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I agree.
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I agree.
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Other authors also highlight that neuropsychoanalysis often ignores other psychoanalytic theories, such as Lacanian, in favour of Freudian theory, despite the development of multitudinous psychoanalytic schools that either extend or diverge from Freud's original work.
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This concern is symbolically reflected in the choice of neuropsychoanalysis as the name of the discipline.
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Gaugert has highlighted a view that neuropsychoanalysis does not truly represent psychoanalysis, because psychoanalysis is the study of persons, not so-called mind brains, and is primarily interested in meanings, including symbolic, pre-symbolic, and unconscious, which are argued to have little relevance to neuroscience.
00:27:26.640 --> 00:27:37.680
Blass and Carmelli argue that the central task of psychoanalysis is the hermeneutic investigation of the unconscious, as opposed to superficial neuroscientific investigations.
00:27:38.000 --> 00:27:53.359
However, some have argued that this attitude stems from the fact that many analytic institutes have become siloed and dogmatic, with a reluctance to collaborate with other research groups or engage in interdisciplinary study, and that this is an outdated epistemological position.
00:27:53.599 --> 00:28:03.680
Psychiatric practitioners are also in a truly unique position to integrate clinical neuroscience with the psychotherapies, including traditional psychoanalytic psychotherapy.
00:28:03.920 --> 00:28:16.240
This is because a good clinical neuroscience curriculum still has the opportunity to address the more subjective elements of human experience, such as affects, emotions, and their phenomenology and experience.
00:28:16.559 --> 00:28:25.920
These concepts could then be linked to learning processes, theory of change, and eventually in relation to the clinical practice of psychotherapy or psychoanalysis.
00:28:26.160 --> 00:28:34.559
Moreover, as scientific knowledge about the brain is acquired, fundamental psychotherapy skills become increasingly important for psychiatrists.
00:28:34.799 --> 00:28:49.680
Skills such as being with, as opposed to doing to, tolerating and bearing uncertainty, and the acknowledgement of psychic reality and subjectivity when utilizing interpersonal processes such as reflective function and mentalization.
00:28:50.000 --> 00:29:02.079
Similarly, key psychoanalytic clinical and technical principles such as free association, transference, and counter-transference can be further aligned with neuroscience research and emotional experience.
00:29:02.319 --> 00:29:17.039
In this vein, within a psychiatric clinical neuroscience curriculum, there are calls for a parallel focus on humanistic psychiatry as a fundamental aspect of any psychotherapeutic process, which includes existential and ontological perspectives.
00:29:17.279 --> 00:29:35.920
These include acknowledging the differences between psychological constructs or theories and lived human experience, and that knowledge is enhanced through double descriptions, scientific and humanistic, in the same way that three-dimensional vision is produced by comparing differing information streams from the two eyes.
00:29:36.400 --> 00:29:40.799
That brings us on nicely to talking a bit more about neuropsychiatry.
00:29:41.119 --> 00:29:49.039
The Russian psychologist Alexander Laria made some key advances in brain science here, underpinning the emergence of neuropsychiatry.
00:29:49.279 --> 00:29:58.640
Laria began his career in the 1920s with a deep interest in psychoanalysis, entering into correspondence with Freud in 1922 and founding a psychoanalytic society.
00:29:58.960 --> 00:30:15.839
But by the end of his career in the late 1970s, he'd formulated mind and brain as hierarchical functions with a complex structure and genesis and subserving overlying psychological functions which, unlike neurology, could not be precisely localized except for some key elementary components.
00:30:16.160 --> 00:30:26.880
Laria's interest in psychoanalysis influenced him to link personal experience and development with mind and brain function, leading to the emergence of the field of neuropsychiatry in the 1980s.
00:30:27.200 --> 00:30:42.480
A 1985 symposium in Paris, marking the hundredth anniversary of Guy de la Tourette syndrome, is cited as a turning point in the acceptance that a disorder could have both biological and psychological components, rather than being exclusively either neuroanatomical or functional.
00:30:42.640 --> 00:30:54.960
With increased recognition of neurological etiologies of psychiatric conditions, the British Neuropsychiatry Association was established in 1987, and the American Neuropsychiatric Association was established in 1989.
00:30:55.119 --> 00:31:00.960
Neuropsychiatry is now often classified as a hybrid discipline on the border between psychiatry and neurology.
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It's sometimes seen as the psychiatry of brain disorders, i.e., that neuropsychiatrists work with mental disorders, which in most cases originate from a brain malfunction.
00:31:11.279 --> 00:31:18.880
Broadly, it's said to emphasize cognitive functions such as episodic memory, visual attention, executive control, and visually guided action.
00:31:19.359 --> 00:31:33.920
This parallels an interest in neuroimaging and the omics: genomics, proteomics, metabolomics, lipidomics, epigenomics, transgotomics, and neuronomics, particularly regarding their association with potential endophenotypes and biomarkers for disease.
00:31:34.240 --> 00:31:45.039
Neuropsychiatry remains at present a subspecialty of psychiatry, and unlike neuropsychoanalysis, has its own training and qualification pathway in many psychiatric postgraduate colleges.
00:31:45.920 --> 00:31:49.680
It's a systemic slash dynamic specialty.
00:31:49.920 --> 00:31:59.359
Given neuropsychiatry is focused on broad cognitive domains, Georg Nortoff suggests that neuropsychiatry should focus on a systemic dynamic localization.
00:31:59.599 --> 00:32:10.640
This means that phenotypic function is attributed to a network of hierarchical interconnections, which contribute to pluripotential functional or phenotypic systems rather than to just anatomy.
00:32:10.880 --> 00:32:16.720
This network may incorporate resonator oscillator circuits associated with a degree of neuronal integration.
00:32:16.960 --> 00:32:25.039
An example is the association between subphalonic beta band activity and Parkinson's disease, which we worked out a few years ago now.
00:32:25.359 --> 00:32:37.359
Nortoff describes neuronal integration as the coordination and adjustment of neuronal activity across multiple brain regions, which is considered necessary for a complex function to occur, such as emotion or cognition.
00:32:37.599 --> 00:32:55.519
Similarly, Friston and Price have distinguished between functional connectivity, the outcome of remote neurophysiological events, including the way these are mediated by other factors, and effective connectivity, which describes the direct influence that one neural system exerts over another, either at a synaptic or population level.
00:32:55.759 --> 00:33:01.680
On a micro scale, connectivity may be impacted by the number of synapses, dendrites, or neurotransmitter factors.
00:33:02.480 --> 00:33:11.519
While on a mesoscale, there may be columns of local connections, and on a macro scale, there may be links between neuronal populations by pathways from different regions of the brain.
00:33:11.759 --> 00:33:17.279
Combinations and degrees of interaction between all three levels can then give rise to their respective functional connectivity.
00:33:17.599 --> 00:33:34.319
Nortov has described how these processes may relate to traditional psychiatric and neuropsychiatric disorders, such as top-down modulation and its role in post-traumatic stress disorder, reciprocal modulation and depression, modulation by reversal and phobias, and modulation by functional unity and catatonia.
00:33:34.559 --> 00:33:41.920
Neuropsychiatry addresses multiple disorders where cognitive, behavioral, or affective disturbances result directly from brain changes.
00:33:42.160 --> 00:33:53.039
It is a reasonably well-defined set of treatments, including neurostimulation, neuromodulation, neuropsychiatric rehabilitation, including measures to enhance neuroplasticity, which is really cool, and pharmacotherapy.
00:33:53.200 --> 00:34:03.359
Electroconvulsive therapy remains the main neurostimulation modality, but has been joined by vagus nerve stimulation, transcranial direct current stimulation, and transcranial magnetic stimulation.
00:34:03.599 --> 00:34:15.440
Deep brain stimulation is another important modality of treatment for neuropsychiatric conditions, particularly for Tourette's syndrome, obsessive compulsive disorder, and depression, much more commonly in other countries than in Australia.
00:34:15.920 --> 00:34:24.880
In the future, other psychiatric treatments such as gene therapy, stem cell use, and brain implants may involve direct brain intervention and could be regarded as neuropsychiatric.
00:34:25.119 --> 00:34:40.800
Neuropsychiatric rehabilitation is a relatively new field that originated in the treatment of traumatic brain injury, but is being researched to treat a range of disorders with neurocognitive effects, such as the dementias and schizophrenia, by addressing dysfunctions of neuroplasticity and neurogenesis.
00:34:40.960 --> 00:34:50.880
Similarly, cognitive stimulation and training, such as executive exercises and memory training, have been researched as a means to improve cognitive function, particularly in the prevention of dementia.
00:34:51.119 --> 00:34:58.639
Moreover, a large focus of neuropsychiatric research is in the field of biomarkers and other omics discoveries mentioned earlier.
00:34:58.960 --> 00:35:24.400
Much of this work involves researching endophenotypes as intermediaries of underlying biological causes rather than relying on clinical phenotypes or syndromes, with an example being mismatch negativity, which is a test of how a brain responds to an unexpected stimulus in a repetitive sequence as an intermediary marker in schizophrenia through relating glutamate and NMDAR receptor dysfunction and auditory hallucinations.
00:35:25.039 --> 00:35:29.199
So that's all the time we have for part one of this podcast.
00:35:29.360 --> 00:35:31.920
So we'll bring part one to a close.
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Part two of this podcast will cover a range of different case vignettes, which will hopefully highlight the range of perspectives and topics discussed here in the clinical context, which will hopefully sort of bring them to life a little bit more and make them a little bit more practical and have some clinical utility.
00:35:51.119 --> 00:35:57.679
I'd like to thank Andrew, Fiona, Michael, and Stephen for coming on today and having such a rich and interesting discussion.
00:35:57.840 --> 00:35:58.400
Thanks to you all.
00:35:58.719 --> 00:35:59.199
Thanks, Ed.
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Thanks, Ed.
00:36:00.480 --> 00:36:01.119
It was fascinating.
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We'd also like to acknowledge David Bill and Nishta Kuma from the college who give us so much support in producing and editing the show.
00:36:08.639 --> 00:36:17.760
We are also thankful to Australasian Psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shady Day for our music.
00:36:18.000 --> 00:36:25.920
We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors.
00:36:26.320 --> 00:36:33.119
We always love getting feedback or suggestions for further episodes, including volunteers interested in being a guest.
00:36:33.360 --> 00:36:39.920
Please get in touch by email at thethoughtbroadcast.podcast at ranzcp.org.
00:36:40.239 --> 00:36:41.039
That's all for now.
00:36:41.119 --> 00:36:42.320
My name is Ed Miller.
00:36:42.480 --> 00:36:44.800
Thanks for listening, and we'll catch you next time.
00:00:03.040 --> 00:00:08.480
Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian Psychiatry.
00:00:08.640 --> 00:00:13.039
My name is Ed Miller, and I'm the trainee editor of Australasian Psychiatry.
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Joining me today are deputy editors of Australasian Psychiatry, Fiona Wilkes and Andrew Amos, Editorial Committee member Michael Waiteman, and psychoanalytic psychotherapist Stephen Yates.
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Welcome, everyone.
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Thanks, Ed.
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Hi Ed.
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Hello.
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So this is the first part of two parts to this podcast, where we will be discussing a paper that we have all written together, which is currently undergoing peer review for publication.
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And the paper provides a conceptual overview of neuropsychoanalytic and neuropsychiatric principles, which we think could help to inform a basic neuroscientific curriculum for psychiatry trainees.
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We will touch on topics such as the common origins of both neuropsychoanalysis and neuropsychiatry in psychoanalysis, neurology, and early psychiatry, philosophy of mind, psychoanalysis, consciousness, and affective neuroscience for neuropsychoanalysis, and discussing the importance of hierarchical brain network function and scope of disorders and treatments for neuropsychiatry.
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We will also describe case vignettes and demonstrate how these concepts could be used to better understand specific psychiatric presentations.
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Ultimately, we hope to champion psychiatrists as expert psychotherapists, as well as provide clinical neuroscience knowledge for psychiatry, which could be used in lecture material, online teaching modules, bedside teaching, psychotherapy training for psychiatrists, and case formulation and discussion.
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So, since the 1990s, there has been an explosion of neuroscientific and philosophical advances in our understanding of brain and mind, with major implications for psychiatry.
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Psychiatry is increasingly considered to be a clinical neuroscience discipline, meaning that it deals with disorders that stem from disrupted brain networks and systems caused by underlying genetic, developmental, and environmental influences.
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However, the developments in neuroscience are technically complex and are occurring at a rapid pace.
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This makes them difficult to contextualize with other psychiatry curriculum elements that often do not progress as quickly, such as mental health legislation, some ethical principles, diagnostic criteria and nostology, and psychotherapy training.
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This makes developing and refining a robust clinical neuroscience curriculum for psychiatry a difficult task.
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Consequently, the development of a clinical neuroscience curriculum for psychiatry training lags behind the neuroscientific progress, with many training programs having no such component or there being a wide variation in content when it is taught.
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So, neuropsychoanalysis and neuropsychiatry are two fields that are closely related to psychiatry, which have already incorporated neuroscience into their regular practice and theory.
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It makes sense then that highlighting key concepts from these fields would greatly enhance the development of a clinical neuroscience curriculum for basic psychiatry training.
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Moreover, discoveries from neuropsychoanalysis and neuropsychiatry could help equip psychiatrists to become expert psychotherapists by leveraging their unique training in both contemporary mind and brain science.
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I'll hand over to Stephen, who will now talk a little bit about neuropsychoanalysis.
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The term neuropsychoanalysis was coined by Mark Sommes, now Professor Mark Sommes from the University of Cape Town, who's a clinical neuropsychologist.
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Who, in work with brain injured patients, was initially, I think, a bit dissatisfied with conventional psychological training's perspective on subjectivity, on what it means to be a subject, have an inner life.
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And contemporaneous work with stroke patients, um, various types of brain injuries.
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Professor Solmes began to explore how psychoanalytic phenomena manifest in those patients with demonstrable brain deficit.
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And what he found was a set of patterns and uh made a series of comments and arguments that attempted to re-integrate a the substrate of the brain into a psychoanalytic understanding or as they relate to psychoanalytic phenomena.
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The bridge that finally allowed um a much fuller integration of the two disciplines was actually the work of Yach Pangset in affective neuroscience that happened through the Nazis and early cousins.
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That by demonstrating the seven networks of the emotion networks with their unique irreducible affect states, Solms made a series of reinterpretations, essentially of Freudian drive theory that later feeds into an object relations theory that tries to do what Freud had wanted to happen in a project for a scientific psychology, which is to reintegrate the natural sciences into psychology.
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So in this sense, they are, as you say, an attempt to integrate psychoanalysis into the neurosciences.
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This rather naturally leads to a deeper exploration of the fundamental experience of consciousness.
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So if you think of psychoanalysis as being essentially a study of the subject, and there are other studies of of subjectivity and religion and art, but from the perspective of science, uh psychoanalysis is a fairly comprehensive idea about what it means to be a subject.
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The neuroscientific picture has always been a bit complicated because the brain is both subject and object.
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You know, as one could put it as that neuroscience and psychoanalysis have been viewed as two perspectives of the same unknowable thing in nature.
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You know, the reality behind the subjective mind and the objective brain, which we should not necessarily try and solve but to straddle.
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So there's quite a lot of potential for neuropsychoanalysis to bridge the theoretical gaps in theory, uh particularly in psychoanalytic theory, but probably more broadly in psychological theory, uh, which have tended to, for you know, reasons a bit beyond the ri this discussion, become siloed and remain separate.
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So the chances there for psychoanalytic theory to come together with the brain, and this is a very exciting prospect.
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The philosophical backbone of neuropsychoanalysis is Bruce Spinoza's dual aspect monism, which is Spinoza's philosophy, which he articulated in the 1600s in ethics, presaged the modern neuroscientific investigation of essentially feelings, affects, and emotions, which is the field I referred to earlier in ethic neuroscience, which did influence Freud.
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So formulated by Spinoza in dual aspect monism is response to dualism, to Descartes' dualism.
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If Descartes postulated that mind and brain are separate entities, which accorded with religious dogma at the time and notions of the soul, the Spinoza's position is is counterposed to that.
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For Descartes, the soul resides in the pineal gland, which was its interface to the body, but both were fundamentally different, and therefore the soul was theoretically able to persist beyond death, so you can accommodate for religious ideas within this.
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Spinoza, though, in ethics described the mind and brain as being forms of a third property, which he called substance.
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And a position referred to as dual aspect monism because the substance monism has two dual aspects.
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The mind and brain are neither completely representative or ephenomenal to the other, but occupy opposite and interrelating aspects.
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But dual aspect monism was suppressed in deference to the religious utility of Cartesian dualism and only recently re-entered modern vocabulary.
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Emergentism and transcendental materialism are outgrowths of dual aspect monism which accept that mind can be a property, an emergent property of the brain with the potential for immaterial properties that are not reducible to physical matter.
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So our article provides an overview of the main mind-brain philosophies relevant to clinical neuroscience curriculum.
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And there's also an adjacent, fairly persuasive argument raised by Psalms that attempt to solve the hard problem of consciousness using neuropsychoanalytic understanding in The Hidden Spring.
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But I'll stop there.
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Thanks, Stephen.
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So I might move across to introducing some of the key conceptual areas of neuropsychoanalysis.
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And I'll start by talking about a few examples of how neuroscience has been used to help explain unconscious mental processes.
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So one really good example of this comes from the work of neuropsychiatrist Eric Candle, who suggested that there could be a link between some of Freud's theories, such as his topographic and structural models, and memory systems.
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And he thought this would be a fruitful area for collaboration between psychoanalysis, biology, and neuroscience.
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So, for example, he thought that different layers of the unconscious, including the pre-conscious, unconscious and the unconscious proper, might be linked to different memory systems and corresponding brain regions and networks, such as the prefrontal cortex.
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Another example comes from the work of Mark Solms, Jack Panshep, and others in this area who suggested that Tolvig's concepts of anoetic, noetic, and autonoetic consciousness might correspond to procedural, semantic, and episodic memory systems.
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Again, another example, dream psychology and dream physiology, have also got thorough neuroscientific descriptions, which can be linked back to Freud's dream theory as well.
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An example of this is Solmes' demonstration that dream imagery is instantiated in the medial, prefrontal and parietal areas rather than brainstem nuclei.
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Mark Solms also suggested that neuroscientific processes can help us test, update and refine Freudian theory.
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For example, there is some recent neuroscientific evidence that suggests that an inverted topographic model of the mind may actually be closer to reality, as the psychoanalytic ego, which is the part of the psychoanalytic self which is most conscious, might in fact be brainstem generated rather than cortical, whereas affects and drives may be more cortically placed than originally thought.
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So there's a huge potential for the use of neuroimaging methods to help unmask unconscious processes in other psychoanalytic concepts such as mourning or psychoanalytic perspectives on confabulation.
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That's a really exciting area of research.
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Another core insight that arises from linking the psychoanalytic unconscious to neuroscience is the free energy principle.
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So the free energy principle has been described as the new royal road in the dialogue between neuroscience and psychoanalysis, the bridge between the mind and the brain.
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This free energy principle was introduced by Carl Fristen in the 1990s in his brain imaging work.
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The free energy principle analogizes the mind-brain system to any other biological system that requires adaptation to its environment to survive.
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It considers the brain as a hierarchically constructed inferential machine containing many interconnected large-scale networks.
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These hierarchical networks optimise the prediction, representation, and construction of increasingly complex lower order mental and sensory information to more accurately interpret and predict the meaning of both the internal and external environments.
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So the way this works is that it minimises the amount of free energy, which can be thought of statistical uncertainty or surprise.
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It minimises the amount of that available in the mind and brain, thus reducing prediction error, which can also be understood as reducing the statistical complexity of the information contained in the brain.
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This means that the mind-brain can never know the world directly, but only perceive it by predicting what it could be like and then testing it against new information.
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The mind brain always tries to predict reality as accurately as possible, which is important for survival.
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Sufficiently poor predictions could result in psychopathology like hallucinations.
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Another way to put it would be that the mind-brain tries to continuously learn about the world to feel safe, to adapt, and to survive.
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This basic model, intriguingly, is similar to Freud's original topographic model of primary and secondary processes.
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The primary process generates unconscious fantasies, wishes, and desires generated by the id, which is an example of bottom-up processing, and these are countered by the top-down ego's affinity for contrasting these impulses against the incoming sensory information and the reality of the external world.
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According to Jim Hopkins, a psychoanalyst, the free energy principle overlaps with psychoanalysis in understanding emotional conflict and trauma, understanding the function of memory consolidation and reconsolidation in dreaming, and identifying the role played by the mind-brain's tendency to predict reality in order to reduce statistical complexity and buffer against excessive statistical surprise in the origins of a range of mental disorders such as schizophrenia.
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Thanks, Michael.
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I'm now going to talk about the neurobiology of infancy development and affective neuroscience.
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So the neuroscientific investigation of memory, sleep, and dreaming and consciousness can also be linked to the psychoanalytic focus on early life development.
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Both Freudian and Bionian descriptions of mind elucidate a developmental process that explains how the registration of bodily sensory and affective experience creates, shapes, and is represented in thought.
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This longitudinal buildup of unconscious representations of visceral states and their representations in thought has been linked to activity in the posterior and middle insula and the default mode network.
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Candel discussed this buildup in terms of psychological determinacy, causality and development, including the role of early life experience and predisposition in the development of psychopathology, and linked this to Freudian constructs like signal anxiety.
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Johannes Letonen suggested that neurobiological and protopsychological processes during the perinatal period can be linked to psychoanalysis.
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So, for example, the impact of early attachment and caregiving relationships can be mapped to specific biochemical processes and the molecular genetic mechanisms of neuronal synapse formation.
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So these processes are formative for the early organization of the mind and also create preconditions for non-verbal, unconscious communication and therapeutic interplay.
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Furthermore, neuroscientific evidence also suggests that the psychoanalytic concept of the ego may be present from birth, which provides an example of how neuroscience can help to answer key psychoanalytic questions.
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Pankschep described nested brain-mind hierarchies where primary process emotion systems, genetically endowed affects in the deep subcortical regions of the brain, become shaped and moulded by learning and conditioning in the midbrain, before being represented in symbolic and tertiary level thought in the neocortex.
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So, this bottom-up process is then regulated by top-down neocortex inputs in what is referred to as a two-way or circular causation process of representation and learning.
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Bangshep argues that the seat of consciousness, the self, as it relates to and intertwines with affect and drives, is now increasingly established to be subcortical rather than cortical.
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Neuropsychoanalysis uniquely integrates clinical and technical psychoanalytic concepts with neuroscience research, providing novel explanations for how psychotherapy works, uncovering additional neuroscience findings that may relate to clinical practice and helping clinicians develop deeper formulations.
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Multiple studies have researched the neuroscience of psychoanalytic concepts, including transference and countertransference, defense systems, free association and dreaming and trauma.
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Indeed, transference and countertransference are regarded as cornerstones of psychoanalytic and psychodemic psychotherapies, as well as having broad applicability across a range of psychotherapeutic modalities.
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Transference in particular has been defined as a tendency in which representational aspects of important and formative relationships, such as with parents and siblings, can be both consciously experienced and or unconsciously ascribed to other relationships.
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In the context of a psychoanalysis, this is a spontaneous development of representation of in behavior and in unconsciously determined utterance of early life experience.
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In this sense, transference relates to the implicit relational schema and dynamic pattern matching of a patient invoked in therapy based on a priori learning and memory formation.
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Activation of these a priori emotional processes in therapy is key to psychic change, part of which involves activation and remodeling of declarative and procedural memory networks with associated neural correlates in the superior and inferior frontal gyra and in the putamin.
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In other words, transference is a premature automatization of which interpretation helps to render into working memory.
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Understanding the neuroscience of similar therapeutic processes such as automatic mirroring and reflective functioning helps to explain clinical phenomena such as therapeutic alliance and change, since the neural motor networks of psychotherapy patients may automatically mirror the motor movements of the therapist, which then may impart effects on the neuronal systems in the brain of the patient, including through the function of the motor neurons.
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Researching the effects of psychotherapy on patients with known neurological disorders may further elucidate its neuroscientific basis.
00:17:55.920 --> 00:18:07.519
Psychoanalysts themselves could be used as research subjects for individual case studies by being given different neuropeptides and being asked to psychoanalytically interpret the changes to their own phenomenology.
00:18:07.680 --> 00:18:18.880
This approach could be used in areas such as psychedelic assisted psychotherapy, whereby small doses of psychedelic medication are administered to a patient to assist with a psychotherapeutic process.
00:18:19.200 --> 00:18:23.680
Reviews suggest that psychotherapy has measurable effects on brain structures.
00:18:23.839 --> 00:18:34.000
One mechanism of action for this may be that psychotherapy causes changes to the serotonin-driven neuronal networks in the brain of subjects with depression.
00:18:34.319 --> 00:18:48.240
Jeremy Holmes hypothesizes that some psychotherapeutic interventions, such as analytic psychotherapy and mentalization-based treatments, work because of their propensity to bind free energy.
00:18:48.480 --> 00:19:02.160
That is, reduce unpredictability or minimize prediction error, which in turn enhances Bayesian inference and allow experience and feeling states to be metabolized and assimilated.
00:19:03.759 --> 00:19:08.880
I'm now going to look at some critiques for and against neuropsychoanalysis.
00:19:09.119 --> 00:19:26.799
So despite these advances in collaboration between psychoanalysis and neuroscience, some are concerned that neuroscience and neuropsychoanalysis have abandoned dual aspect monism, particularly the need to bridge the gap between mind and brain by becoming biologically reductionistic.
00:19:27.039 --> 00:19:34.240
A valid neuropsychoanalysis requires a balance between subjective and objective factors in psychoanalysis and neuroscience.
00:19:34.400 --> 00:19:37.759
It risks becoming a token appropriation of neuroscience.
00:19:38.240 --> 00:19:46.960
Another concern is that psychotherapists who incorporate neuroscience may unconsciously use biological models when they encounter resistance.
00:19:47.200 --> 00:19:57.200
A simple example is the issue of whether or not to tell a patient that from a neuroscientific perspective the recollection of birth trauma memory is impossible.
00:19:57.599 --> 00:20:05.759
Should the analyst focus on the symbolic meaning for the patient or should they use the knowledge of neuroscience to directly challenge a false claim?
00:20:06.079 --> 00:20:18.640
Similarly, the prescription of psychotropic medication could be made as a counter-transferential defense against the anxiety of resistance, or it could treat that anxiety directly through a biological mechanism.
00:20:18.960 --> 00:20:24.960
And I was just wondering, uh Stephen, could you talk a little bit about your personal experience with this issue, I guess?
00:20:25.039 --> 00:20:34.720
So, as a medically trained, you know, psychoanalytic psychotherapist, how do you or do you employ neuroscience in your psychoanalytic practice?
00:20:35.279 --> 00:20:37.039
This is a really interesting question.
00:20:37.440 --> 00:20:46.160
There is an intuition that a neuropsychoanalytic formulation in a clinical case leads to a better outcome.
00:20:46.319 --> 00:20:50.480
What exactly those outcomes are are very much open to questions.
00:20:50.640 --> 00:20:54.000
There's I know of a PhD student who's researching this.
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I know that there are plans to do studies which could address this question, but it's it's far, far from being answered.
00:21:02.240 --> 00:21:09.759
My experience as an analyst with offering neuropsychoanalytic understandings comes, I think, in in several forms.
00:21:10.000 --> 00:21:20.400
Firstly, there is a specific supervision technique developed by Soms to understand what is the main feeling that the patient is suffering from.
00:21:20.799 --> 00:21:28.960
And so you can understand through the content of the analytics session what is it that's the main problem for this particular person.
00:21:29.200 --> 00:21:34.720
And these relate to the seven affective systems that described in affective neuroscience.
00:21:34.880 --> 00:21:40.240
So, you know, panic, grief, care, rage, lust, fear, seeking, and so on.
00:21:40.640 --> 00:21:47.680
By establishing this is actually quite a big deviation from other ways of supervising a case psychoanalytically.
00:21:48.720 --> 00:22:04.880
In my experience, what needs to happen in an in an analytic encounter is to sort of make contact with something, with the patient and turn it from You know, an undigested affective experience into thought.
00:22:05.119 --> 00:22:15.599
This is very much a sort of Biononian idea that it moves through a process of sort of phylogenetic development into something more sophisticated, which of course takes a lot of time.
00:22:15.680 --> 00:22:20.559
And this requires affective contact between the analyst and the patient.
00:22:20.960 --> 00:22:31.039
Neuropsychoanalysis or the discoveries introduced from neuropsychoanalysis, I think, give you a firmer grounding for what exactly it is that you're doing.
00:22:31.279 --> 00:22:42.000
You're involved in an affective experience with the patient for the purposes of thinking something new, i.e., rendering it into working memory and developing understanding.
00:22:42.400 --> 00:22:44.480
Well, can I ask one follow-up question, Stephen?
00:22:44.799 --> 00:22:52.480
Is a challenge that's generated by a neuroscientific understanding any different from a challenge generated by any other aspect of experience?
00:22:52.960 --> 00:22:59.759
I suppose it's only the risk that to be with a patient requires you to engage with your subjectivity.
00:23:00.079 --> 00:23:09.839
I guess if if you if you look at I think it's Anne Alvarez thought that part of what's developed in an analysis is sort of observing yourself whilst being yourself.
00:23:10.000 --> 00:23:13.039
I call it sort of one foot in the river and one foot on the bank.
00:23:13.279 --> 00:23:15.519
And that and this is not solved.
00:23:15.680 --> 00:23:18.960
You don't ultimately become more in the river or more on the bank.
00:23:19.119 --> 00:23:28.720
The whole process of psychic maturation is to have an emotional experience whilst being able to observe it without being unduly dissociated from the feeling.
00:23:35.839 --> 00:23:44.079
This is different in the sense this is the authority of science, and people are often very confronted by a science because they know that they don't understand it.
00:23:44.240 --> 00:23:48.160
So it might be more confronting, but I think the dynamics probably are very similar.
00:23:48.319 --> 00:24:01.440
When you challenge someone with an idea that their parent hates them, for example, you often you probably wouldn't do that with a very fragile patient, but they then need to process that and experience that, learn to deal with that, as you say, while observing themselves.
00:24:01.680 --> 00:24:09.359
I think the authority of science is different, but that the dynamic of processing that response is the same.
00:24:09.759 --> 00:24:16.240
I've I've probably only been able to address this by by metaphor or reasoning by analogy.
00:24:16.799 --> 00:24:32.799
I'm sure that neuropsychoanalysis will lead to the design of better psychotherapies in the same way that flight and the science of flight and the science of aerodynamics leads to the design of better planes.
00:24:33.039 --> 00:24:38.799
I don't think we're at all clear on in what way it improves the performance of the pilot.
00:24:39.039 --> 00:24:46.240
You know, that that that is I love the idea that there are going to be many plane crashes in the development of neural psychoanalysis.
00:24:51.359 --> 00:24:57.200
But we refined the science of uh of how it's understood, you know, and vernoulli and so on.
00:24:57.440 --> 00:25:12.480
And I think pilots I mean, I had a little bit of experience flying light planes, not not heaps, but it is a lot of it is about feel, and there is something analogous to an analytic development of yourself as an individual because you are two subjects coming together.
00:25:12.799 --> 00:25:22.000
I think neuro the neuropsychoanalytic understanding has this sort of mental presence that I am still engaged in a scientific experience.
00:25:22.240 --> 00:25:32.079
There's something scientific about it without reducing the fact that it might be exceedingly meaningful to both people and of course oriented towards the development in the patient.
00:25:32.799 --> 00:25:34.079
That's how that's how I put it.
00:25:34.160 --> 00:25:38.160
I I I think probably other people are going to put it much better than that in the fullness of time.
00:25:38.240 --> 00:25:51.440
But one thing that I've sort of very briefly reflected on that issue is that neuroscience might not help to make the way forward clear for psychoanalysis, but it can tell you when you're going really off track.
00:25:51.680 --> 00:25:52.079
Yes.
00:25:52.400 --> 00:25:52.960
Potentially.
00:25:53.119 --> 00:26:00.799
So so it can you can have one simple kind of study or neuroscientific solution to let you know, okay, it's definitely not down that way.
00:26:01.039 --> 00:26:08.000
And so you can potentially reduce harm or make something relatively straightforward, but the way forward still isn't necessarily clear.
00:26:08.480 --> 00:26:09.359
It's a very good point.
00:26:09.440 --> 00:26:25.839
That was really well demonstrated with um some of the theoretical assertions that Francis Tusten made around autistic spectrum disorders that were had to do with early memory, uh, and neuroscience sort of answered the question, you know, about that.
00:26:26.000 --> 00:26:28.880
And uh I I think that's a I think that's a really good point.
00:26:29.440 --> 00:26:36.880
Like analysing people with schizophrenia, for example, like a schizophrenic mother or something, whereas we know it's much more complicated than that.
00:26:37.039 --> 00:26:42.240
We don't know what it is exactly, but we know it's not just that one kind of simple explanation.
00:26:42.799 --> 00:26:43.200
Yeah, yeah.
00:26:43.440 --> 00:26:44.000
I agree.
00:26:44.160 --> 00:26:44.640
I agree.
00:26:45.039 --> 00:27:00.160
Other authors also highlight that neuropsychoanalysis often ignores other psychoanalytic theories, such as Lacanian, in favour of Freudian theory, despite the development of multitudinous psychoanalytic schools that either extend or diverge from Freud's original work.
00:27:00.559 --> 00:27:06.880
This concern is symbolically reflected in the choice of neuropsychoanalysis as the name of the discipline.
00:27:07.200 --> 00:27:26.400
Gaugert has highlighted a view that neuropsychoanalysis does not truly represent psychoanalysis, because psychoanalysis is the study of persons, not so-called mind brains, and is primarily interested in meanings, including symbolic, pre-symbolic, and unconscious, which are argued to have little relevance to neuroscience.
00:27:26.640 --> 00:27:37.680
Blass and Carmelli argue that the central task of psychoanalysis is the hermeneutic investigation of the unconscious, as opposed to superficial neuroscientific investigations.
00:27:38.000 --> 00:27:53.359
However, some have argued that this attitude stems from the fact that many analytic institutes have become siloed and dogmatic, with a reluctance to collaborate with other research groups or engage in interdisciplinary study, and that this is an outdated epistemological position.
00:27:53.599 --> 00:28:03.680
Psychiatric practitioners are also in a truly unique position to integrate clinical neuroscience with the psychotherapies, including traditional psychoanalytic psychotherapy.
00:28:03.920 --> 00:28:16.240
This is because a good clinical neuroscience curriculum still has the opportunity to address the more subjective elements of human experience, such as affects, emotions, and their phenomenology and experience.
00:28:16.559 --> 00:28:25.920
These concepts could then be linked to learning processes, theory of change, and eventually in relation to the clinical practice of psychotherapy or psychoanalysis.
00:28:26.160 --> 00:28:34.559
Moreover, as scientific knowledge about the brain is acquired, fundamental psychotherapy skills become increasingly important for psychiatrists.
00:28:34.799 --> 00:28:49.680
Skills such as being with, as opposed to doing to, tolerating and bearing uncertainty, and the acknowledgement of psychic reality and subjectivity when utilizing interpersonal processes such as reflective function and mentalization.
00:28:50.000 --> 00:29:02.079
Similarly, key psychoanalytic clinical and technical principles such as free association, transference, and counter-transference can be further aligned with neuroscience research and emotional experience.
00:29:02.319 --> 00:29:17.039
In this vein, within a psychiatric clinical neuroscience curriculum, there are calls for a parallel focus on humanistic psychiatry as a fundamental aspect of any psychotherapeutic process, which includes existential and ontological perspectives.
00:29:17.279 --> 00:29:35.920
These include acknowledging the differences between psychological constructs or theories and lived human experience, and that knowledge is enhanced through double descriptions, scientific and humanistic, in the same way that three-dimensional vision is produced by comparing differing information streams from the two eyes.
00:29:36.400 --> 00:29:40.799
That brings us on nicely to talking a bit more about neuropsychiatry.
00:29:41.119 --> 00:29:49.039
The Russian psychologist Alexander Laria made some key advances in brain science here, underpinning the emergence of neuropsychiatry.
00:29:49.279 --> 00:29:58.640
Laria began his career in the 1920s with a deep interest in psychoanalysis, entering into correspondence with Freud in 1922 and founding a psychoanalytic society.
00:29:58.960 --> 00:30:15.839
But by the end of his career in the late 1970s, he'd formulated mind and brain as hierarchical functions with a complex structure and genesis and subserving overlying psychological functions which, unlike neurology, could not be precisely localized except for some key elementary components.
00:30:16.160 --> 00:30:26.880
Laria's interest in psychoanalysis influenced him to link personal experience and development with mind and brain function, leading to the emergence of the field of neuropsychiatry in the 1980s.
00:30:27.200 --> 00:30:42.480
A 1985 symposium in Paris, marking the hundredth anniversary of Guy de la Tourette syndrome, is cited as a turning point in the acceptance that a disorder could have both biological and psychological components, rather than being exclusively either neuroanatomical or functional.
00:30:42.640 --> 00:30:54.960
With increased recognition of neurological etiologies of psychiatric conditions, the British Neuropsychiatry Association was established in 1987, and the American Neuropsychiatric Association was established in 1989.
00:30:55.119 --> 00:31:00.960
Neuropsychiatry is now often classified as a hybrid discipline on the border between psychiatry and neurology.
00:31:01.359 --> 00:31:11.039
It's sometimes seen as the psychiatry of brain disorders, i.e., that neuropsychiatrists work with mental disorders, which in most cases originate from a brain malfunction.
00:31:11.279 --> 00:31:18.880
Broadly, it's said to emphasize cognitive functions such as episodic memory, visual attention, executive control, and visually guided action.
00:31:19.359 --> 00:31:33.920
This parallels an interest in neuroimaging and the omics: genomics, proteomics, metabolomics, lipidomics, epigenomics, transgotomics, and neuronomics, particularly regarding their association with potential endophenotypes and biomarkers for disease.
00:31:34.240 --> 00:31:45.039
Neuropsychiatry remains at present a subspecialty of psychiatry, and unlike neuropsychoanalysis, has its own training and qualification pathway in many psychiatric postgraduate colleges.
00:31:45.920 --> 00:31:49.680
It's a systemic slash dynamic specialty.
00:31:49.920 --> 00:31:59.359
Given neuropsychiatry is focused on broad cognitive domains, Georg Nortoff suggests that neuropsychiatry should focus on a systemic dynamic localization.
00:31:59.599 --> 00:32:10.640
This means that phenotypic function is attributed to a network of hierarchical interconnections, which contribute to pluripotential functional or phenotypic systems rather than to just anatomy.
00:32:10.880 --> 00:32:16.720
This network may incorporate resonator oscillator circuits associated with a degree of neuronal integration.
00:32:16.960 --> 00:32:25.039
An example is the association between subphalonic beta band activity and Parkinson's disease, which we worked out a few years ago now.
00:32:25.359 --> 00:32:37.359
Nortoff describes neuronal integration as the coordination and adjustment of neuronal activity across multiple brain regions, which is considered necessary for a complex function to occur, such as emotion or cognition.
00:32:37.599 --> 00:32:55.519
Similarly, Friston and Price have distinguished between functional connectivity, the outcome of remote neurophysiological events, including the way these are mediated by other factors, and effective connectivity, which describes the direct influence that one neural system exerts over another, either at a synaptic or population level.
00:32:55.759 --> 00:33:01.680
On a micro scale, connectivity may be impacted by the number of synapses, dendrites, or neurotransmitter factors.
00:33:02.480 --> 00:33:11.519
While on a mesoscale, there may be columns of local connections, and on a macro scale, there may be links between neuronal populations by pathways from different regions of the brain.
00:33:11.759 --> 00:33:17.279
Combinations and degrees of interaction between all three levels can then give rise to their respective functional connectivity.
00:33:17.599 --> 00:33:34.319
Nortov has described how these processes may relate to traditional psychiatric and neuropsychiatric disorders, such as top-down modulation and its role in post-traumatic stress disorder, reciprocal modulation and depression, modulation by reversal and phobias, and modulation by functional unity and catatonia.
00:33:34.559 --> 00:33:41.920
Neuropsychiatry addresses multiple disorders where cognitive, behavioral, or affective disturbances result directly from brain changes.
00:33:42.160 --> 00:33:53.039
It is a reasonably well-defined set of treatments, including neurostimulation, neuromodulation, neuropsychiatric rehabilitation, including measures to enhance neuroplasticity, which is really cool, and pharmacotherapy.
00:33:53.200 --> 00:34:03.359
Electroconvulsive therapy remains the main neurostimulation modality, but has been joined by vagus nerve stimulation, transcranial direct current stimulation, and transcranial magnetic stimulation.
00:34:03.599 --> 00:34:15.440
Deep brain stimulation is another important modality of treatment for neuropsychiatric conditions, particularly for Tourette's syndrome, obsessive compulsive disorder, and depression, much more commonly in other countries than in Australia.
00:34:15.920 --> 00:34:24.880
In the future, other psychiatric treatments such as gene therapy, stem cell use, and brain implants may involve direct brain intervention and could be regarded as neuropsychiatric.
00:34:25.119 --> 00:34:40.800
Neuropsychiatric rehabilitation is a relatively new field that originated in the treatment of traumatic brain injury, but is being researched to treat a range of disorders with neurocognitive effects, such as the dementias and schizophrenia, by addressing dysfunctions of neuroplasticity and neurogenesis.
00:34:40.960 --> 00:34:50.880
Similarly, cognitive stimulation and training, such as executive exercises and memory training, have been researched as a means to improve cognitive function, particularly in the prevention of dementia.
00:34:51.119 --> 00:34:58.639
Moreover, a large focus of neuropsychiatric research is in the field of biomarkers and other omics discoveries mentioned earlier.
00:34:58.960 --> 00:35:24.400
Much of this work involves researching endophenotypes as intermediaries of underlying biological causes rather than relying on clinical phenotypes or syndromes, with an example being mismatch negativity, which is a test of how a brain responds to an unexpected stimulus in a repetitive sequence as an intermediary marker in schizophrenia through relating glutamate and NMDAR receptor dysfunction and auditory hallucinations.
00:35:25.039 --> 00:35:29.199
So that's all the time we have for part one of this podcast.
00:35:29.360 --> 00:35:31.920
So we'll bring part one to a close.
00:35:32.159 --> 00:35:50.719
Part two of this podcast will cover a range of different case vignettes, which will hopefully highlight the range of perspectives and topics discussed here in the clinical context, which will hopefully sort of bring them to life a little bit more and make them a little bit more practical and have some clinical utility.
00:35:51.119 --> 00:35:57.679
I'd like to thank Andrew, Fiona, Michael, and Stephen for coming on today and having such a rich and interesting discussion.
00:35:57.840 --> 00:35:58.400
Thanks to you all.
00:35:58.719 --> 00:35:59.199
Thanks, Ed.
00:35:59.840 --> 00:36:00.320
Thanks, Ed.
00:36:00.480 --> 00:36:01.119
It was fascinating.
00:36:01.440 --> 00:36:08.400
We'd also like to acknowledge David Bill and Nishta Kuma from the college who give us so much support in producing and editing the show.
00:36:08.639 --> 00:36:17.760
We are also thankful to Australasian Psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shady Day for our music.
00:36:18.000 --> 00:36:25.920
We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors.
00:36:26.320 --> 00:36:33.119
We always love getting feedback or suggestions for further episodes, including volunteers interested in being a guest.
00:36:33.360 --> 00:36:39.920
Please get in touch by email at thethoughtbroadcast.podcast at ranzcp.org.
00:36:40.239 --> 00:36:41.039
That's all for now.
00:36:41.119 --> 00:36:42.320
My name is Ed Miller.
00:36:42.480 --> 00:36:44.800
Thanks for listening, and we'll catch you next time.
