Compulsive Acts

A psychiatrist's tales of ritual and obsession.

The Biology of Psychotherapy

Therapy IS a biological treatment.

Some psychiatric medication enthusiasts are quick to dismiss therapy as a questionable intervention not necessarily more helpful or more transformative than talking to a good friend. With the great increase in psychopharmacology options over the last decade, and in the marketing resources promoting them, it has become de rigueur to think of therapy as ineffective, time-consuming and costly. As a result, many patients whose psychological problems might well benefit from therapy are not considering it. Yet growing evidence from brain imaging research suggests that the form of therapy known as cognitive behavioral therapy, or CBT, produces changes in the brain similar to those produced by medications when they work. This "proof" of how a person's brain can be transformed by therapy is giving credence to what therapists and many patients have long recognized: psychological interventions can profoundly change a person's symptoms.

Cognitive behavioral therapy emphasizes the role our thoughts play in how we feel. Even if stressful external situations don't change, changing how we think about them can prevent a negative emotional response such as depression. The therapist's role is to help patients be more rational in their assessment of such situations and not make unwarranted worst-case-scenario assumptions about them. It is a time-limited therapy that involves active collaboration between patient and therapist. Psychiatric conditions from depression to panic disorder may benefit from CBT, but it is research into its role in the treatment of obsessive-compulsive disorder that has yielded the most fascinating results.

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Obsessive-compulsive disorder (OCD) is characterized by anxiety-laden intrusive thoughts and accompanying repetitive behaviors that are meant to reduce the anxiety. About 60 percent of OCD patients respond to drugs in the Prozac family, or CBT, or a combination of both. The exact chemical basis for OCD remains poorly understood, but hyperactivity at the level of the neurons, or brain cells, is consistently seen in parts of the OCD brain. One way this hyperactivity is measured is through the increased rate of glucose metabolism seen in OCD patients on brain imaging, especially in a part of the brain called the caudate nucleus. On a more intriguing note, successful treatment with either Prozac-like medications or CBT seems to reverse that. In a study that compared CBT to Prozac, researchers used a brain-scanning technique called positron emission tomography (PET) to measure the rate of glucose metabolism in the OCD brain after Prozac treatment alone and after therapy treatment alone. The results were essentially identical: both interventions decreased the rate of glucose metabolism to levels seen in healthy people without OCD, and the rate of the decrease seemed proportional to the degree of improvement in their OCD symptoms. Studies like this make CBT look like a biological treatment similar to medications because it, too, can be seen to work on the brain in ways that are objective and measurable. And it's free of side effects.

It cannot be overemphasized, however, that for many patients with psychiatric illnesses medications remain absolutely essential, even life-saving - in many depression and panic cases, for example, psychiatrists have to prescribe medications if only to get patients to a point where they can make it to therapy appointments and engage in a meaningful therapy experience. Therapy is not about to replace medications, but, especially with the biological evidence coming out, the knee-jerk reaction against it looks as justified as a scientologist's knee-jerk reaction against Prozac.

(Dr. Elias Aboujaoude runs the Impulse Control Disorders Clinic at Stanford University. He is the author of "Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession.")

Dr. Aboujaoude is a psychiatrist and author based at Stanford University. His most recent book is Virtually You: The Dangerous Powers of the E-Personality.

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