Brain-Based Therapy

Brain-Based Therapy - Interpersonal

Neurobiology

Brain-based concepts and techniques for managing stress, anxiety, depression and PTSD Symptoms. Interpersonal Neurobiology is a field and approach developed by Dan Siegel, MD. This approach emphasizes how awareness can shape the connections in the brain toward integration. With the knowledge of how interpersonal relationships shape our brains throughout the lifespan, we can actively “inspire each other to rewire” our internal and interpersonal lives toward integration. Through his writing and teaching, Dr. Siegel devotes his life to synthesizing and translating the latest scientific concepts so that they may be accessible and useful to as many people as possible in their personal and professional lives. Some neuroscience concepts that are relevant to the psychotherapy process are reviewed below:

I. Neuroplasticity of the brain.

∙ Neuroplasticity means the brain is malleable; i.e. that change is possible and the brain can be “rewired” for positive improvement!

∙ Hebb’s Law – “Neurons that fire together, wire together.” By engaging focus and attention neuronal firing increases, new neural networks grow, habits can be changed and patterns can be modified.

∙ Rather than thinking in terms of nature versus nurture, think of the approach here as nurtured nature. There are many elements of the brain that are soft-wired rather than hard-wired, including memory and emotional learning.

Basic Brain structure/primary regions and significant structures:

∙ The brain has 3 main parts and has been labeled the “triune brain” by neuroscientist Paul MacLean: (1) the cerebrum or neocortex, (2) the mammalian or limbic brain, and (3) the reptilian brain. The reptilian brain is the oldest part of the brain and includes the cerebellum and brain stem. The limbic (paleo-mammalian) brain evolved with humans and other mammals and is associated primarily with memory and emotion. Main structures of the limbic system include the hypothalamus, amygdala, and hippocampus. The cerebrum is the most advanced part of the brain and is associated with creativity, intelligence, language, and consciousness.

∙ There are four cerebral lobes – frontal, parietal (middle), temporal (side), occipital (posterior).

∙ The prefrontal cortex (PFC) – at the forefront of the frontal lobe associated with executive function and most complex cognitive, behavioral and emotional capacities. The dorsolateral prefrontal cortex (DLPFC) is associated with higher order thought, attention and short-term memory and the last part of the brain to fully develop. It maintains rich connections with the hippocampus. The orbitofrontal cortex (OFC) is known as the “social brain” and is associated with interpersonal bonding and emotion regulation.

∙ The cingulate cortex contains a high concentration of spindle cells, neurons that act as an interface between thoughts and emotions. The anterior cingulate cortex (ACC) in particular is associated with sustained attention, control, and emotion regulation.

∙ The amygdala, Latin for “almond,” is an almond shaped structure and part of the limbic system. The amygdala is associated with intense emotional states, especially fear and is referred to as the panic button or alarm center of the brain. It is also associated with memory and modulates memories associated with strong emotions. The alarm system of the brain is automatic. There are two pathways involving activation of the amygdala – the low road and the high road or the slow track and the fast track:

∙ The “low road” or “fast track” to amygdala activation: Input (visual or otherwise) that signals danger travels immediately from the hypothalamus to the amygdala without engaging the cortex. The freeze/fight/flight response is activated without conscious awareness. In the high road or slow track, the cortex is able to evaluate the input before the fight/flight/freeze response engages. The fight/flight response ensues as follows: the amygdala signals the hypothalamus by releasing norepinephrine and corticotropin-releasing factor (CRF). The hypothalamus in turn signals the pituitary gland which signals the adrenal glands to release adrenaline and then cortisol. Cortisol triggers the liver to make more glucose available in the bloodstream while blocking insulin receptors in nonessential organs and tissues. This process is referred to as the hypothalamic-pituitary-adrenal axis (HPA axis). With long-term stress, increased cortisol and glutamate leads to atrophy of the hippocampus and increased sensitization of the amygdala!

Chronic stress during early development can lead to disruption of normal function of the HPA Axis and to low levels of cortisol (hypocortisolemia). Chronic stress in adulthood generally leads to elevated cortisol levels (hypercortisolemia). The central nucleus of the amygdala is responsible for linking nonthreatening stimuli with stimuli that is perceived to be threatening, e.g. associating a bridge or a ladder with a fatal fall. Another part of the amygdala - the basal nucleus stria terminalis (BNST) - circumvents the central nucleus. The BNST is an action pathway. By taking action, we activate the left frontal lobe and the BNST in order to circumvent the dysfunctional linking of nonthreatening stimuli with legitimate stimuli, and thereby to decrease the overall reactivity of the amygdala. Even the use of detached attention or mindful awareness is action-oriented and helps us activate the left frontal lobe and to engage the BNST in order to calm the amygdala!

∙ The hippocampus, “sea horse” in Greek, is associated with memory and especially with the formation of new memories. Women show greater neuronal density in temporal lobe and activation of left hippocampus than in men, reflecting verbal advantage. Men show greater activity in the right hippocampus reflecting greater visual and spatial skills.

∙ Implicit memory – Implicit memory is essentially unconscious memory. Even without the narrative of conscious memory, implicit memory reacts to the emotional intensity of events and situations. The fight-flight response is activated by the perception of danger which may be associated with implicit as well as explicit memory and therefore may be an unconscious response, leaving a person confused as to why they are experiencing symptoms.

∙ Explicit memory is conscious, narrative or autobiographical memory.

∙ The major neurotransmitters: Glutamate: an excitatory neurotransmitter; it stirs activity. Gamma-aminobutyric acid (GABA): an inhibitory neurotransmitter; quiets down activity. The neuromodulators: serotonin, norepinephrine, dopamine. Serotonin plays a role in emotional tone, regulating the sensitivity of receptors. Low serotonin levels are associated with anxiety, depression and OCD. Norepinephrine activates attention. Norepinephrine also activates the sympathetic nervous system which activates the adrenal glands leading to a fight/flight response. Dopamine sharpens and focuses attention and has also been associated with reward, movement, and learning. Dopamine also activates the nucleus accumbens, the pleasure center of the brain. Endorphins are endogenous opioid neuropeptides that produce oblivion or euphoria that masks pain. Oxytocin is a hormone associated with social bonding and interpersonal trust. Serotonin, dopamine, oxytocin and endorphins are sometimes called the brain’s “happy chemicals.”

∙ The vagus nerve and Polyvagal theory. The vagus nerve is a major cranial nerve that serves a major function in the autonomic nervous system. There are two distinct branches of the vagus nerve, both of which originate in the medulla. However, as identified by Stephen Porges who developed Polyvagal theory, each branch is associated with a different adaptive behavioral strategy. The more evolutionarily primitive branch is the dorsal vagus or “vegetative vagus,” which is associated with passive reflexive regulation of visceral functions: peristalsis of the GI tract, sweating, the heart, lungs, diaphragm, and stomach. The dorsal vagus is responsible for heart rate, dilation of blood vessels and blood pressure. The output from the dorsal motor nucleus does not convey a respiratory rhythm. The most primitive function of the dorsal vagal complex is the “freeze” response and it is likely associated with dissocation following trauma. The ventral vagus, also called the “smart vagus” is more advanced and, unlike the dorsal vagus, it is myelinated. The ventral vagus is involved in the regulation of the somatic muscles of speech and eating: the larynx, pharynx, and esophagus. It is also associated with attention, motion, emotion and communication. With regard to the heart, the ventral vagus is part of a common neuronal network that produces a cardiorespiratory rhythm and that regulates the heart and the bronchi to promote calm and self-soothing states.

According to the Polyvagal Theory the growth of the autonomic nervous system evolves through three stages: 1) Freeze - First a primitive unmyelinated visceral vagus that fosters digestion and responds to threat by depressing metabolic activity. 2) Flight/Fight – Defensive mobilization or flight/flight is dependent on the functioning of the sympathetic nervous system; increasing metabolic output and inhibiting the visceral vagus so as to foster mobilization behaviors necessary for fight or flight. 3) Communication - The mammalian myelinated ventral vagus can rapidly regulate cardiac output to align with the environment and is associated with cranial nerves that regulate sociability via facial expression and vocalization. Porges notes that there is a phylogenetic (based on evolution) hierarchy of response to challenge: "The hierarchy emphasizes that the newer "circuits" inhibit the older ones. We use the newest circuit to promote calm states, to self-soothe and to engage. When this doesn't work, we use the sympathetic-adrenal system to mobilize for flight and flight behaviors. And when that doesn't work, we use a very old vagal system, the freeze or shutdown system." Porges suggests that we use our higher cognitive processes to calm the stress response and establish effective connections with others by using our facial muscles, making eye contact, modulating our voice and listening to others. In this way we increase the influence of the newer myelinated ventral vagus, which calms us and turns off the stress response and makes us more metabolically efficient. He says the social neural circuit supports our health through its calming influences on the heart and lungs and its reduction of HPA axis activation.

Anxiety and PTSD

Anxiety and posttraumatic stress disorder often do not respond to logical reasoning. Why?

The amygdala hijacks the brain. Sudden panic attacks and acute fear may stem from an unconsciously triggered amygdala pathway in the brain – the “low road” or “shortcut” fear response. However not all anxiety begins with the amygdala-mediated limbic brain. Anticipatory anxiety may be fed via the cortex. "Fear is a condition in search of content."

Two Pathways to Anxiety

∙ The brain is wired in such a way that you can respond to a threatening situation before you can think with the “low road” shortcut pathway, also known as the “amygdala hijack.”

∙ The immediate stress response, upon which the anxiety response is based, is triggered by the amygdala.

∙ The cortex, the thinking part of the brain, responds more slowly.

∙ Understanding the different parts of your brain that contribute to anxiety can help you learn ways to reduce anxiety effectively.

∙ Information from our senses is routed to the thalamus, and the thalamus sends that information to different parts of the brain to be processed.

The amygdala receives information very quickly, and can initiate a quick response…

∙ And the cortex responds more slowly (but still requiring less than a second) to provide the amygdala with more detailed information.

The Amygdala Pathway

∙ The amygdala processes the visual or other sensory information independently and more quickly than the cortex.

∙ The amygdala is also wired to be able to quickly activate the Sympathetic Nervous System and cause adrenaline/cortisol to be released, increasing the heart rate, widening the pupils, and preparing for freeze, fight or flight.

∙ The amygdala doesn’t have the ability to provide the detailed information and analysis that we can get from the cortex.

∙ The amygdala can respond in error, of course, but it seems to operate on the idea that it is safer to respond in error than to take the risk of delaying a protective response.

The Cortex Pathway

∙ The cortex allows us to process sensory information in detail, and interpret this information.

∙ It also has access to a great deal of stored information and memories to use in interpreting what is experienced.

∙ Sometimes this means a more accurate interpretation of the information. If the snake in the above diagram turned out to be a harmless garden snake and not a rattlesnake, the cortex would recognize this and tame the initial startle/fear response.

∙ But the cortex is also capable of interpreting information in a way that can needlessly increase anxiety.

∙ Therefore, the cortex pathway can also be a source of anxiety-provoking thoughts.

Posttraumatic Stress Disorder – “The Body Remembers”

The experience of PTSD is often difficult to verbalize because the executive functioning cortex becomes disengaged. Traumatic memory is mediated by the limbic brain and when triggered, associated amygdala response is also activated. Language and narrative memory are a function of the cortex so it becomes difficult to talk about the trauma experience or understand why it has been triggered.

Techniques or approaches designed to "tame the amygdala", to increase ventral vagal response, and to thereby reduce fear and anxiety:

1. Use the breath: By making an executive decision to focus on the breath you shift breathing from an automatic reptilian brain response to a conscious prefrontal cortex response. If this seems too difficult to do while in a fight or flight or panicked state of mind, parse the lips and slowly blow out – a slow, longer outbreath stimulates the ventral vagal nerve, activating the parasympathetic nervous system thereby calming the nervous system. The in-breath will then occur automatically and it is easier to focus on the out-breath. Engaging the breath is the quickest way to slow down the heart rate, to lower blood pressure and to return normal blood flow to the brain.

∙ Practice deep abdominal or diaphragmatic breathing while not in an anxious state makes it easier to breathe more deeply when under stress and reverse shallow breathing with the chest only.

Another useful breathing exercise for increasing the out-breath is the “2-4-6-8-10” method of breathing: (1) Inhale to the count of 2, (2) Exhale to the count of 2, (3) Inhale to the count of 2, (4) Exhale to the count of 4, (5) Inhale to the count of 2, (6) Exhale to the count of 6, (7) Inhale to the count of 2, (8) Exhale to the count of 8, (9) Inhale to the count of 2 (10) Exhale to the count of 10.

∙ From yoga, comes the Ujjayi or “Ocean Sounding Breath.” The Ujjayi breath focuses the mind and generates internal heat. In Ujjayi breathing, the glottis is partially closed. The glottis is that part in the throat area that closes when you swallow, but which is open when you breathe. When you partially close the glottis while breathing, you can hear a sound resonate from within, as well as feel a flow of air on the palate. A slightly different sound is heard on inhalation and exhalation. During inhalation, tighten the abdominal muscles very slightly, and during exhalation the abdominal muscles are used to exhale completely. The technique is as follows: a) Come into a comfortable seated position with your spine erect, or lie down on your back. Begin taking long, slow, and deep breaths through the nostrils. b) Allow the breath to be gentle and relaxed as you slightly contract the back of your throat creating a steady hissing sound as you breathe in and out. The sound need not be forced, but it should be loud enough so that if someone came close to you they would hear it.

c) Lengthen the inhalation and the exhalation as much as possible without creating tension anywhere in your body, and allow the sound of the breath to be continuous and smooth.

d) To help create the proper “ah” sound, hold your hand up to your mouth and exhale as if trying to fog a mirror. Inhale the same way. Notice how you constrict the back of the throat to create the fog effect. Now close your mouth and do the same thing while breathing through the nose.

2. Bilateral stimulation: Stimulating both sides of the brain can be surprisingly effective at reducing anxiety. Find two points and move the eyes back and forth horizontally for 24 sets. Or cross your arms and tap opposite arms 24 times each side. Another option is to hold a ball and pass it back and forth between your right and left hand, being sure to cross your center line. Bilateral stimulation increases coherence between the limbic brain and the neocortex and, like deep breathing, activates parasympathetic response.

3. Heart coherence: From the work of the HeartMath Institute, heart rate variability is associated with health and relaxation as well as brain coherence. The heart sends information to the brain through electromagnetic waves, through the pulse, through a blood pressure wave, and through the release of an atrial peptide, a hormone that inhibits other stress hormones. Bring awareness to your heart and begin to imagine breathing deeply in and out from the heart, keeping your hand over the heart to help you maintain your awareness on the heart as you breathe.

4. Mindfulness - cultivating a witnessing awareness: Negative emotion often begin at a level below conscious awareness. Neuroception is the term for the brain’s hard-wired process of continuously scanning the environment for signs of danger. When the perception of danger is present, the amygdala sounds the alarm leading to the sympathetic arousal already discussed. Victor Frankl wrote that “between the stimulus and the response, there is a space, and in that space is our power and our freedom.” Mindfully becoming aware of the cascading responses of the body and of events that trigger such responses and then restoring attention to the bigger context and perspective helps to calm the fear response. The orienting response is the term used when a mammal reorients to its environment following a dangerous event that triggered a freeze/fight/flight response. Increasing observational awareness not only internally but also externally to one’s visual field activates the orienting response. John Arden, PhD recommends a helpful acronym for using mindfulness and action to “rewire the brain.” The acronym is FEED:

• Focus

• Effort

• Effortlessness

• Determination

Focus and attention activates the PFC – ensuring other parts of the brain are engaged. An intention is established and attention is given to the intention. Effort shifts attention from perception to action which activates the brain to establish new synaptic connections. Effortlessness is a sign that a new habit has formed, that the brain is using less energy and new neuronal connections have been established. Determination means maintaining the intention to remain in practice.