Hello, Habr!
 
 
The past my articles were mainly devoted to pharmacology, but this is not really my theme, I'm still a clinical psychologist (recently), so today we will talk about conversational therapy in all its manifestations.
 
 
 
 
tl; dr : in a long and tedious article, the question of the effectiveness of psychotherapy is considered (
? yes, it is effective, within its limits of applicability, of course [/i] ), and also reflections on how this effectiveness is achieved (by implementing morphological and metabolic changes at the expense of neural plasticity of the brain [/i] ).
 
 
At the end of the bonus for fans of video format (if any): a presentation on the topic of this article: if you read lazily, you can see.
 
psychoanalysis up to modern behavioral and cognitive-behavioral approaches. Or, to put it more simply, about " " Chatting with a psychologist /psychotherapist "
 
 

Why it is needed when there are tablets

 
 
Indeed, we live in the XXI century, on the market every year come out more and more perfect psychiatric drugs , designed to treat a little less than all known mental disorders[3], and the relevance of psychological /psychotherapeutic influences is questioned by many.
 
 
Nevertheless, there are reasons for using colloquial (non-pharmacological) methods.
 
 
Firstly , they are in some cases as effective as treatment with drugs: in the case of depression [4,5], panic disorder , social phobia [5]and even psychosis [6].
 
 
Secondly , in some cases they are more effective than drugs: in the treatment of RK [5], some types of depression[8].
 
 
Thirdly, , often joint use of drugs and psychotherapeutic techniques is more effective than just drug treatment[6,7,45].
 
 
Fourthly , in a number of cases they give fewer side effects and[6]are easier to carry. .
 
 
 
Fig. 2 . Treatment by the method KPT and pharmacotherapy led to a significant decrease in tonsil activity in anxiety situations. Source:[45]
 
 
Of course, I would not want the reader to get the wrong impression about psychotherapy as a panacea: in some cases, some methods of colloquial action are not only not useful, but also harmful (for example, "unstructured" types of psychotherapy when dealing with patients suffering from borderline personality disorder )[9]. In the final analysis, the medical influence is determined by the doctor in each case .
 
 
An attentive reader may note that in this section we are talking about psychotherapy, but not about psychological counseling.
 
 
Indeed, the latter has been much worse studied, due to the insufficiently developed methodology of research (3-33-3788 how to evaluate the success of counseling in divorce-not by the number of preserved marriages? [/i] ), but also because the principles of "evidence" are much less prevalent.
 
 

What kind of psychotherapy is effective

 
 
There are a lot of types of psychotherapy[10]: cognitive , Behavioral , cognitive-behavioral , rational-emotionally-behavioral , narrative , psychodynamic , psychedelic , interpersonal , Gestalt therapy , logotherapy , d sensitization and processing by eye movement
 
 
 
Fig. 3 . From Freudian associations[первого уровня]to modern methods of therapy based on the principles of evidence.
 
 
And every school pretends to be considered effective. And in some areas there is a completely sane evidence base. In most cases, the explanations for this very efficiency are maintained through the constructions adopted within the framework of this approach, and nowhere outside these frameworks are not quoted.
 
 
For example, Logotherapists believe that they achieve positive results by helping the patient find the meaning of life[11], supporters of cognitive approach - due to work with negative automatic thoughts[12], representatives psychodynamic directions - due to work with the transfer, drives and object relations[13], supporters of psychedelic approach - due to work with perinatal matrices and systems of condensed experience[14]and etc.
 
 
At the same time, most of these explanations lose all credibility as soon as they are outside the context of the theory that generated them. So, for example, the cognitive postulate that thoughts affect the emotions of[12]is not accepted at all in the psychodynamic school, where a completely opposite view is used.
 
 
Contrary to the prevalent opinion in the domestic environment, the clinical effectiveness (
? to the extent consistent with the principles of evidence-based medicine , Which is generally possible for psychotherapy [/i] ) Is not only cognitive-behavioral, but also, for example, psychodynamic therapy[15,16,17]. Those. Different therapies based on completely different sets of axioms show comparable efficacy.
 
 
Modern authors note[10, стр. 7190], that all approaches to psychotherapy have a common basis, providing efficiency:
 
"The relationship between the therapist and the client, in which different roles carry a different set of expectations and responsibilities; impartial and unconditional acceptance of the client by the therapist; Union, whose goal is to work on common goals. "
 
However, these categories are too " hypothetical " And " psychological " (And therefore
? poorly formalized [/i] ), To be satisfied with them as an explanation for the effectiveness of "medical conversations."
 
 
One of the most interesting attempts to identify and describe the quantitatively universal basis of successful therapy is the study of the German authors[18], in which it was found that the predictor of the success of therapy is the difference in emotions that are displayed on the face of the therapist, and those that the client expresses during the narration.
 
 
In other words, if during the first session the client with a sad face talks about his pain (expressing " negative emotion "), And the therapist listens to him, showing interest and satisfaction (" satisfactory emotion "), Then therapy , is likely to be successful. If both express emotions of one orientation ("positive" /"negative"), then no.
 
 
The authors well formalized the testing procedure, making up a very limited "dictionary" of emotions and selecting only those expressions of persons that exactly corresponded to it. With regard to determining the success of therapy (also not an easy task), evaluations of the therapist, the patient and objective indicators of symptom reduction were used.
 
 
Their conclusions are quite different from the predictions and explanations provided by the therapists themselves: they talk about anything: motivational readiness, the radical personality of the client, the level of organization of this individual, the underlying schemes - but not about those emotions that they express their faces.
 
 
Such studies make us somewhat skeptical about the supposed mechanisms for realizing the useful changes that psychotherapists /psychologists talk about, and are pushing to find some more convincing ways of explaining the presence of these very changes.
 
 

Therapy and brain changes

 
 
Some time ago there was no way to objectively evaluate the effect of therapy on the brain, so therapists made the bold (and often incorrect) assumptions about the presence and nature of such influence.
 
 
Naturally, such a situation could not last indefinitely, and as soon as the researchers had available methods for visualizing the brain ( ? PET
? ? MRI
? [/i] ? fmrt
? [/i] ? SPECT
), studies were published with the aim of which determined the extent of the impact (or lack thereof) of conversational therapy on the physiological substrate of the brain.
 
 
The identification of this influence would solve several important tasks - from the proof that the colloquial therapy is generally works. , to an understanding of how it works, is there a difference between different types of therapy, etc.?
 
 
Below is my attempt to systematize data on visualization of changes caused in the brain by conversational therapy.
 
 
It does not pretend to be universal, but when I created it, I tried to include more or less sane research, and recheck the authors' conclusions.
 
 
 
Fig. 4 . The influence of conversational therapy on the brain. Sources:[10, 32, 33, 34]. Table Available in Google Docs .
 
 
What do we see in this table? First , which is striking, it is the fact that completely different types of therapy affect the same areas of the brain (for example, the caudate nucleus or tonsil).
 
 
The second is Is that in some studies the activity of certain areas increases (for example, the tonsils in the Ritchey study), while in others, with the same therapy, it decreases (the limbic system including the amygdala in the Goldapple study).
 
 
The third is - is that some studies are marked in gray font. These are the ones whose design caused me the greatest doubts. But since there are not so many such studies for today, I included them here.
 
 
What happens in the end? There is some inconsistency in the data. It is caused by the fact that, firstly, the brain is a complex and controversial thing (I, I think, has already talked about this), and secondly, because the studies had an entirely different methodology.
 
 
What is the value of this table, if it is impossible to compare directly the different methods of PT? In that you can be sure that the conversation therapy " Something does there with the brain ", And also that on its basis you can try to build some cautious guesses as to how this most conversational therapy works.
 
 
But first, let's try to highlight some of the patterns in these changes. To do this, let's not take a long look at the table, but use the data of ready meta-analyzes.
 
 

Assumptions regarding the influence of colloquial therapy

 
 
It is assumed that with depression KPT Strengthens cortical control from the side of the prefrontal cortex (in particular - its dorsolateral part), which inhibits (inhibits) impulses of subcortical structures[32, стр. 6].
 
 
What does it mean: impulses that rise " from the depths of the unconscious "(It's just a beautiful metaphor), they begin to be better controlled by structures more relevant to rational thinking.
 
 
If you recall how works. KPT - namely she tries to replace " automatic thoughts filled with cognitive distortions for more sober and rationalistic assessments of the situation ", Then we can trace some logic in this all.
 
 
Therapy aimed at activating the behavior of , presumably, leads to activation of of the striatum and the use of a remuneration system that includes the regions of the dorsolateral prefrontal and orbital frontal cortex[32, стр. 6]
 
 
What does this mean: again, the activation of " more conscious structures ", As well as the structures responsible for the behavior (as a set of motor, ie, physical actions).
 
 
Logically, we activated the behavior, the structures that are responsible for it were activated. Since this therapy is essentially behaviorism, it is not surprising that the structures responsible are included, incl. for reflexes and analysis of encouragement /punishment.
 
 
Overcoming the suppressed emotions and weakening unconscious guilt, which are important components of psychodynamic therapy , presumably, are associated with a decrease in the activity of the subgenual anterior cingulate cortex[32, стр. 6].
 
 
It's all very interesting, because this most subgenual PPC participates in t.ch. in overcoming the feelings of fear (here you can draw far-reaching conclusions that, perhaps, psychodynamics are right, and the displaced wine is therefore displaced, that the psyche is "afraid" of accepting it, but this will lead us to speculation).
 
 
It should be noted that these assumptions did not come from scratch, but on the basis of other studies (in[32]there are references on the corresponding pages).
 
 

A little bit about the brain

 
 
Before discussing the results of studies of the influence of conversational therapy on the brain, you need to talk a little about how it is arranged and consider some of its components directly related to the subject matter of the article, in order to understand what the researchers have accumulated there.
 
 
The main thing that can be said about the brain: it is complicated . There are only ways to consider it, there is so much that the unprepared person has a head around - all these column , departments , cortical card , functional blocks , Fields of Brodman etc.
 
 
 
Fig. 5 . The progress of psychiatry and neuroscience with the eyes of the man in the street.
 
 
We will not attempt here to consider the structure of the brain from all possible points of view, but only fragmentarily describe those parts of it that are relevant to the subject of this article.
 
 
It should be noted that the brain is a distributed system with a high degree of parallelism[21, стр. 132], therefore it would not be completely wrong to say that one or another part of it performs a specific limited function. That is why all phrases like " Amygdala is responsible for the reactions of fear " Should be taken as more or less successful analogies /metaphors, no more).
 
 
Nevertheless, to some extent its components are specialized, and we will try to consider this specialization in the context of interest to us.
 
 
 
Fig. 6 . Some components of the brain that are relevant to the subject of this article are[31, стр. 126].
 
 

Tonsil

 
 
Tonsil, it is also an almond-shaped body. It is located in temporal lobe (median temporal lobe)[19, стр. 232]. Since we have two hemispheres and temporal lobe, respectively, also two, then the amygdala is also "divided into two pieces".[19, стр. 211]. This, by the way, not only refers to the amygdala.
 
 
 
Fig. 7 . Tonsil and some of her connections.
 
 
Connecting with prefrontal and temporal bark , as well as with the spindle-shaped convoluted amygdala, plays a significant role in the social and emotional cognition of[10, стр. 240]and is considered the main center for processing emotional information[19, стр. 482].
 
 
No less important is the fact that the amygdala is connected to hippocampus [19, стр. 216], which is involved in remembering information (consolidating memory from short-term to long-term memory), processing it, and extracting[19, стр. 78]from memory. .
 
 
The amygdala is part of the so-called. limbic system. It is shown that the structures limbic system and contiguous nucleus participate in the "final calculation of remuneration", appropriating the characteristics of pleasure or displeasure experienced emotional experience, and the warning /excitation system uses reticular formation , thalamus, amygdala and cortex, to assign this experience the personal meaning and significance of[10, стр. 7186].
 
 
In studies it was shown that the amygdala responds to the emotional stimuli[19, стр. 297]and mediates the conditioned reflex reaction of fear[19, стр. 538].
 
Dynamic interactions between the amygdala and the medial prefrontal cortex (mPFC) are conceptualized as a system that allows us to automatically respond to biologically significant stimuli, and to regulate these responses when the situation requires this[20, стр. 113].
 
 
The amygdala has two "inputs" through which it receives sensory information. First, the data comes from the senses in thalamus , then - go on one of two independent paths: either directly into the amygdala, or first pass through prefrontal cortex , and then reach the amygdala through the front cingulate cortex [22, стр. 19]:
 
 
 
Fig. 8 . Two modes of activation of the amygdala.
 
 
The first way is "
? fast and dirty [/i] " - the amygdala receives information that some kind of tin is created in the outside world, and does not go into details of what exactly it was for the stimulus: it starts acting without wasting time on then, to understand the situation.
 
 
The second way is slower, but involves some analysis of incoming information. The data is processed in prefrontal cortex , which integrates sensory information from the sensory organs with information about the context of this stimulus obtained from the hippocampus, compares it with the experience stored in long-term memory, analyzes the previous similar situations and decides how real the danger is. This decision she sends to the amygdala, which in case of a positive response triggers the preparation of the body for the reaction of "flight or attack."
 
 
If the bark " " Recognized the stimulus as not dangerous ", The amygdala on the contrary inhibits the stress response[22, стр. 19].
 
 
For example, if an untrained person noticed a snake on his way, it is very likely that his tonsil will be activated by the thalamus without the involvement of the cortex. At the same time, if it is a herpentologist who understands that the snake is not dangerous, then it is quite possible that his reaction will follow the second scenario.
 
 
Showing[10, стр. 7184], that the activity of the amygdala is increased in depression and posttraumatic disorders . Even worse, if the increase in activity of the amygdala is combined with a decrease in the activity of the prefrontal cortex.
 
 
Those. it is advantageous for us to reduce the activity of the amygdala either directly or indirectly through increased activity in the prefrontal cortex (see above data on the corresponding changes in the result of psychotherapy).
 
 

The horsetail nucleus is

 
 
The horsetail nucleus (along with the shell shell, which together form [/i] ? neostriatum
) are part of basal ganglia , which are associated with afferent (sensory, "incoming") and efferent (motor, "outgoing") connections to the structures of the midbrain - black substance and subthalamic nucleus .
 
 
 
Fig. 9 . A hawkish kernel.
 
 
The horsetail nucleus functions as part of the "gates" in the basal ganglia, it is associated with frontal bark and therefore involved in high-order cognitive processes. The increased activity of the bark excites its cells (and the cells of the shell), which, in turn, relieve braking from the thalamus[23, стр. 514].
 
 
For our narrative, it is important that the tusk core contributes to the launch of the right action schemes and the selection of appropriate subgoals based on performance evaluation (ie participates in planning), because Both processes are fundamental to the successful targeted action of[24]. Thus, the caudate nucleus can be called " .3 feedback processor " W2w2w246.
 
 
The ability to perform targeted actions is something that often suffers from mental illness.
 
 
The horsetail nucleus plays an important role in the learning, speech and transmission of information about disturbing events between the thalamus and the orbitofrontal cortex.
 
 
The increased volume of the caudate nucleus (in comparison with the norm) correlates with violations of the spatial working memory[25].
 
 
Dysfunction of the caudate nucleus is associated with such phenomena as Tourette's syndrome and obsessive-compulsive disorder [38]. In some cases it makes sense to reduce its activity (more correctly, to return it under the control of the large hemispheres).
 
 

Thalamus

 
 
Thalamus (part of the intermediate brain) is the most important "neural hub", where almost all sensory signals (except smell) switch to the[19, стр. 85]cortex.
 
 
 
Fig. 10 . The thalamus.
 
 
The supposed function is the reception of information from sensors, its primary processing, input and storage of[19, стр. 201], transfer to the bark. In some cases, the thalamus increases the activity of the cortex, in others - it is blocked by[19, стр. 122]
 
 
The fact that olfactory signals go around the thalamus allows the adherents of perfumery and aromatherapy to talk about the importance of their activity with some degree of validity (they say, you can affect the emotional sphere with smells).
 
 
In studies on monkeys it was shown that the thalamus is associated with compulsive behavior and signs of anxiety[26]. It is believed that the behavior aimed at checking and rechecking, as well as constant cleaning, " , Sewed " In the thalamus[27].
 
 
Together with the temporal lobes, the thalamus inhibits excessive mood swings that arise in response to the daily complex stimuli[10, стр. 7185].
 
 
The thalamus is the central component for integrating memories of the perceptive, somatosensory and cognitive processes of[42].
 
 
In addition, the thalamus plays an important role in modulating the activity of the amygdala (see above).
 
 

Hippocampus

 
 
Hippocampus , as well as amygdala , is located inside each of the temporal lobes of the brain[19, стр. 211].
 
 
 
Fig. 11 . The hippocampus.
 
 
It plays an important role in the transfer of experimental information to long-term memory, as well as in the extraction of episodic memories, relates to the spatial orientation of[19, стр. 213].
 
 
Studies show that the hippocampus is an important part of the[28]consciousness mechanism. . The hippocampus is one of the few brain structures in which neurogenesis (the production of new neurons during life) is possible[19, стр. 216]
 
 
Together with the amygdala and the limbic cortex, the hippocampus forms limbic system [19, стр. 231]. These structures are closely related to the work of short-term memory (that is, memory of experiences under the control of consciousness)[19, стр. 232].
 
 
Other studies show that the hippocampus participates in unconscious memory processes, and that they (conscious and unconscious processes) are related to each other by[29]In addition, the hippocampus plays an important role in the processes of spatial imagination, the formation of memory and access to it[31, стр. 65]
 
 
The hippocampus (more precisely, its dysfunction) plays an important role in the pathogenesis of such mental illnesses as schizophrenia, autism, depression[10, стр. 227].
 
 

Anterior cingulate bark

 
 
 
Fig. 12 . Front waist cortex.
 
 
The front waist cortex is performs various functions, of which for us the most interesting are[10, стр. 7183]: conscious regulationemotions through rechecking negative emotions, suppressing excessive excitement and suppressing the activity of the amygdala.
 
 
Those. when we understand that " driving "In their fears, and we can deliberately refuse them, we must say thank you for our front cingulate cortex.
 
 

Prefrontal cortex

 
 
 
Fig. 13 . Prefrontal cortex.
 
 
Prefrontal cortical areas perform an important controlling function in the brain. These structures are necessary for arbitrary control. In addition, they participate in emotions and restrain involuntary impulsive reactions[19, стр. 93]. The prefrontal cortex is involved in the decision-making process related to morality issues[31, стр. 7],
 
 
A person's conscious feelings arise when the signals of the limbic system reach the areas of the prefrontal cortex that support the consciousness of[31, стр. 39].
 
 
The prefrontal cortex is the substrate for the basic functions of Ego [10, стр. 7184], together with the amygdala she manages a significant part of the emotional life of the person and provides adaptability. Violation of the work of this ligament can cause very acute emotional pain and marring human prudence.
 
 
The dorsomedial prefrontal cortex plays a central role in the implementation of downward cognitive modulation (that is, a person's ability to analyze his feelings, assess their " adequacy" and, if necessary, suppress them) fear and other emotions, answers - based on mentalization and empathy . It is also the physiological basis for object relations [10, стр. 7184].
 
 
While her activity is lowered, psychotherapy is not particularly effective[10, стр. 7184]It is interesting that psychoanalysts, back in those days when visualization technologies were not invented, said that for a successful therapy the patient needed time to "strengthen the Ego" (it later became clear that they had in mind an increase in the activity of the dorsomedial prefrontal cortex).
 
 
This was achieved through the creation of trust, supportive relationships, validation, etc. Proper nutrition, rest and moderate exercise are also considered (and are considered) useful. Now for these purposes apply in t.ch. antidepressants.
 
 
The signals of the prefrontal cortex can "block" the pain, and this can be either a conscious or an unconscious process[31, стр. 109]
 
 
Dorsolateral (not to be confused with the dorsomedial, one lateral, the other - the medial in spatial respect) the prefrontal cortex is a key component of the infrastructure providing executive functions of the psyche [10, стр. 7184]: it has to do with the processes of attention, concentration, control of effort, memory and emotional memory.
 
 
The interaction between the amygdala and the prefrontal cortex is extremely important for the regulation of the emotional response to stimuli of the environment.[32, стр. 6]It is believed that the medial prefrontal cortex regulates and controls the response of the amygdala to the incoming stimuli[20, стр. 115]
 
 

Orbito-frontal cortex

 
 
Technically, it is part of prefrontal cortex .
 
 
 
Fig. 14 . Orbitofrontal cortex.
 
 
Orbito-frontal cortex inhibits (or enhances, depending on its condition) impulsive activity in each specific situation in response to the impact of stimuli of a certain kind (
? sexual stimulation, risk, excitement ), And is also responsible for manifesting the personal characteristics of[10, стр. 7186]
 
 
Studies using visualization have shown that the euphoria associated with the use of certain substances correlates with an increase in metabolic activity in the orbitofrontal cortex and the reticular formation, while dysphoria , caused by abstinence , a decrease in activity in these zones[10, стр. 7186].
 
 
This area of ​​the brain is directly related to the decision-making[39]. According to the findings of[40]neuroscientist Antonio Damasio, in the decision-making process, people use not only the cognitive, but also the emotional sphere: facing too complex (contradictory, under the conditions of lack of data) choice, a person overloads his conjecture and it ceases to cope.
 
 
This is where the emotional sphere is connected, just to make at least some decision, and the orbitofrontal cortex serves as " hub ", Connecting the cognitive and emotional spheres.
 
 
Showing[35], that in patients suffering from OCD, the volume of the orbitofrontal cortex of the left hemisphere is less than in healthy people.
 
 

About mental diseases from the point of view of neurophysiology and biochemistry

 
 
Now we will briefly consider how the components of the brain examined (and some other) are connected with mental illness and the mental problems of healthy people. We will not consider here the whole nosology of mental illnesses (this is the topic of a separate large article), but we briefly go over the most famous of them.
 
 

Depression

 
 
With depression, the activity of the dorsolateral prefrontal cortex is reduced, which contributes to the experience of loneliness, social isolation and the establishment of low performance standards[10, стр. 7185]
 
 
Depression is associated with a decrease in the interaction between the almond and dorsal anterior cingulate cortex[32, стр. 6]
 
 
Studies using visualization methods have shown that the subgenual anterior cingulate cortex is overactive in depression, and some treatment methods, such as antidepressants, electroconvulsive therapy and transcarnival magnetic stimulation lead to a decrease in activity in this area[10, стр. 182].
 
 
Some evidence suggests that the volume of the hippocampus[50]decreases with depression. .
 
 

Schizophrenia

 
 
Concrete and unambiguous links between brain regions and schizophrenia have not been established so far, but at the moment this pathology is associated with changes in the hippocampus, the entorhinal cortex , multimodal associative cortex, limbic system, amygdala, cingulate cortex, thalamus and medial temporal lobe [10, стр. 239].
 
 

Obsessive-compulsive disorder

 
 
Currently, there are two main ways to explain the pathophysiology of OCD: through cortico-thalamo-cortical pathway and through the connection of the limbic system and bark[30].
 
 
Insel outputs the data[36], based on the analysis of studies using visualization, according to which the symptoms of OCD are explained by pathology in three regions of the brain: the orbitofrontal cortex, the cingulate cortex and (to a lesser extent) the caudate nucleus: excessive activity in the head part of the caudate nucleus suppresses transmission in the fibers of the white ball , which usually extinguishes the activity of the thalamus.
 
 
As a result, the thalamus increases the activity of the orbitofrontal cortex, which through the lobar cortex closes on the head part of the caudate nucleus, forming a cycle of positive feedback.
 
 

Early disadaptive schemes

 
 
Unlike the above nosological units, in themselves, early disadaptive regimens are not a mental illness: there is no such diagnosis.
 
 
However, it makes sense to include them in this article, because they are very widespread in healthy people and significantly interfere with them.
 
 
What is early disadaptive scheme (hereinafter simply "
? scheme [/i] ")? The scheme is such a psychic construction, which includes memories, thoughts, emotions and bodily sensations. And they do not just enter, but are cunningly interconnected and interdependent[48, стр. 41].
 
 
The scheme is formed somewhere in the early history of the life of the individual (usually in childhood, but maybe later) as a reaction to certain events or phenomena of relationships with people important to this person (that is, the father beat, my mother did not like [/i] ").
 
 
The amygdala stores in itself an unconscious information about a trauma /negative emotional experience.
 
 
When a person encounters stimuli reminiscent of events that led to the formation of a scheme, the amygdala triggers an unconscious process of activating those same emotions and physical sensations. It happens faster than a person has time to realize anything.
 
 
When the circuit is activated, the person is covered with a wave of emotions and bodily sensations. He is not always aware of the connection of experience with the original trauma.
 
 
Recognizable memories of trauma are stored in the hippocampus[48, стр. 41]and higher sections of the cortex. In fact, the emotional and cognitive aspects of traumatic experiences are stored in different parts of the brain.
 
 
An example of the scheme: a boy in his childhood climbed into his father's box with tools, his father severely beat. Many years passed, the boy grew up and presents a project to customers. Everything is good with him - he cope with anxiety, he thoroughly prepared, but then one of the listeners asks him a question
 
 
And the amygdala is activated (for example, from the tone or some characteristic word) by starting the circuit. The speaker disorientates this question, he begins to worry, forget details, feel incompetent, becomes covered with sweat, trembles, etc.
 
 
The task that is usually put in working with schemes is to strengthen the control of the prefrontal cortex over the amygdala.
 
 

The results of the research

 
 
Now that we have at least some understanding of how conversational therapy should affect the brain, and how this brain works, it's time to talk about the results of studies whose purpose was to evaluate the effect of psychotherapy on the morphological and biochemical characteristics of the brain.
 
 
In the meta-analysis,[32]a significant relationship was found between the effect of therapy on rostral the anterior cingulate cortex and the precentral furrow (increased activity), which more or less coincides with the initial assumptions.
 
 
Ventral-rostral the prefrontal cortex has extensive connections with regions of the brain responsible for the processing of emotions, in particular, with the amygdala. In addition, it participates in the decision-making process and the performance of the remuneration system.
 
 
In healthy people, the regulation of emotions is related to the suppression of tonsil activity by the rostral and dorsal cingulate and some regions of the anterior cingulate cortex. Those. "Fear coming from the depths" in response to a stimulus is intercepted at some point, analyzed and "canceled."
 
 
Characteristic of depression is stuck on negative thoughts can be explained by a decrease in the level of communication between the cingulate and tonsil. It looks like a constant samoyedstvo on themes " I'm a loser "," everything will be bad " etc.
 
 
Strengthening the activity of the rostral cingulate cortex as a result of the application of psychotherapy may reflect improvements in emotional regulation and be the possible basis of the mechanism. cognitive revaluation .
 
 
Cognitive revaluation - this is, in fact, one of the cornerstones of the CCP. It is that automatically arising negative thoughts should be caught and analyzed, and then replaced by more adequate ones (not containing cognitive distortions).
 
 
The intensification of the activity of the anterior cingulate cortex is manifested after the course of CPT, but, after a course of long-term psychodynamic therapy, this activity decreases[32, стр. 18].
 
 
However, the authors do not give any interpretations on this matter, and we will not invent any gibberish. Perhaps the point here is that in some studies the entire cortex is considered in its entirety, and in others, the subgenual part of it (the decrease in activity of which correlates with a decrease in guilt and oppression of suppressed emotions).
 
 
Long-term verbal therapy leads to a decrease in activity in the left precentral gyrus , which is usually associated with motor functions, but can be involved in the processes of cognitive functioning.
 
 
In a systematic study, weakened tonsil activity as a result of the use of CBT and psychodynamic therapy[32, стр. 19]. And since the amygdala is the "center of fear" (again, a very, very figurative analogy), a decrease in its activity should lead to a reduction in the severity of depressive and anxious symptoms.
 
 
In another systematic meta-study,[37]the authors concluded that the anomalies in the hippocampus, amygdala, lower frontal gyrus, hook , as well as in areas actively involved in the management of emotions (dorsolateral prefrontal cortex and anterior cingulate cortex) are the predictors of successful psychotherapeutic treatment of anxiety disorders.
 
 
Or, if you fantasize a little, then with some stretch you can say that with successful therapy of anxiety disorders will be obsledTo change in these areas.
 
 
In a study of the effects of psychotherapy in depression,[41]was shown. , that conversational therapy leads to a normalization of the connections between the limbic system and the cortex, especially in the anterior cingulate cortex. In the same study, the use of activity was suggested. islet part as a biomarker, which will help the doctor determine which method of treatment is best suited in this particular case - psycho- or pharmacotherapy.
 
 
In the meta-study[42]therapy by the method of desensitization and processing by eye movement (not entirely colloquial therapy, the essence of which is to recall traumatic memories and move your eyes back and forth, no matter how ridiculous this may sound), the change in the pattern of interaction between the hemispheres was shown.
 
 
It also contained data indicating an increase in the volume of the hippocampus, an increase in the activity of the anterior cingulate cortex, and the left frontal lobe. These and other data indicate that this therapy leads to increased control of the prefrontal cortex over the too active limbic system.
 
 
In the study of the effect of long-term psychodynamic psychotherapy, it was shown that as a result of this method of treatment, the activity of the amygdala /hippocampus, subgenual cortex and medial prefrontal cortex[44]decreases. . These changes correlated with a decrease in the symptoms of depression.
 
 

How psychotherapy affects the brain

 
 
Well, the research shows us quite convincingly that the brain changes under the influence of verbal therapy. But how exactly does he do it?
 
 
The answer lies in such a property as neuroplasticity. More precisely, not so: there is no direct evidence that psychotherapy improves brain neuroplasticity, but the commonplace is the notion that this very neuroplasticity is somehow involved in the process of psychotherapy[49].
 
 
Applied to the nervous system, neuroplasticity is the ability of nerve elements and regulatory molecules to adaptively rearrange under the influence of endogenous and exogenous effects[46, стр. 79].
 
 
Neuroplasticity is observed at different levels[47]- at the level of the brain as a whole, at the level of its individual components, at the level of neurons and even at the subcellular level.
 
 
The fundamental component of neuroplasticity is the plasticity of synaptic connections (ie, connections between neurons) that constantly disappear and reappear, and the balance of these opposing processes depends primarily on the activity of the neurons[47].
 
 
Dependence of synaptic plasticity on activity is one of the central points of the concept of neuroplasticity, as well as learning and memory theories, based on experience-induced changes in the structure and function of synapses.
 
 
Long-term plasticity is realized as a result of changes in the expression of genes triggered by signaling cascades, which in turn are modulated by various signaling molecules upon changes in neuronal activity.
 
 
A detailed examination of the molecular mechanisms of neuroplasticity is clearly beyond the scope of this article, so we will dwell on the fact that the ability of the brain to change under the influence of external influences is proven. And it is it that allows you to implement all the changes discussed above.
 
 

Other factors of the impact of psychotherapy

 
 
Here we will discuss some additional hypotheses as to how the therapy can influence the brain:
 
 
1. Perhaps psychotherapy affects the levels neurotransmitters, in particular, serotonin . In the review[49]It is shown that patients suffering bipolar affective disorder and depression, and who had a lowered serotonin level (compared to the control group) in the prefrontal cortex and thalamus prior to treatment, showed an increase in serotonin levels in these areas after an annual course of psychodynamic therapy. True, the study, on the basis of which this conclusion is drawn, has far from ideal design (small sample, lack of successful reproduction).
 
 
2. Perhaps therapy affects the operation of the thyroid axis . In the same review[49]a reference is made to a study in which it was shown that depressed patients who successfully responded to CPT achieved a decrease in T4 (thyroid hormone), while patients who did not respond to therapy had a rise in T4.
 
 
3. Perhaps, psychotherapy stimulates the processes related to brain neuroplasticity . As already mentioned above, there is no clear evidence that psychotherapy leads to an increase in brain neuroplasticity, but there is evidence obtained on animals, according to which training leads to it.
 
 
It is considered[49], that in psychotherapy occurs training through the study , which leads to an increase in the synaptic potentials of the neurons of the perforating path connecting the entorhinal cortex with the dentate gyrus of the hippocampal formation.
 
 
The same increase was demonstrated in animal models: rats who underwent spatial orientation training had a higher density of dendritic spines compared to the two control groups.
 
 
Since the length of the dendrites, like the structure of their branching, remained unchanged, conclusions were drawn about the formation of new synapses.
 
 
Of course, directly transferring data from animal models to humans, and even taking into account different activities (direct learning in one case and psychotherapy in the other) is not entirely correct, but some authors[49]consider the use of these data as an argument in favor of the hypothesis that psychotherapy changes the brain at the physical level.
 
 

Practical conclusions

 
 
Conversational therapy can lead to significant changes in the brain. Naturally, not only it - various mental exercises, meditation and general life experience, too, use neuroplasticity to form an appropriate connector.
 
 
However, studies show that with conversational therapy, these changes reach a higher level than when it is absent.
 
 
The question of whether it is possible to use neuroplasticity for self-therapy, I'll leave it unanswered: the article has already turned out to be too long.
 
 

The video version is

 
 
And here is the promised video version for those who prefer listen to all the garbage in the background on the accelerated reproduction of watch, not read:
 
 

 
 
Sorry for the quality of the broadcast, it's terrible, I know.
 
 

Literature

 
 
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