Will it be possible to integrate psychoanalysis and clinical research in the future?

INVITED EDITORIAL

Will it be possible to integrate psychoanalysis and clinical research in the future?

Glen Gabbard

MD. Chair of Psychoanalysis, Brown Foundation, Houston, TX, USA. Professor of Psychiatry, Baylor College of Medicine, Houston, TX, USA

I was invited to write this editorial to address a crucial question for the future of psychiatry: is it possible to integrate psychoanalytic thinking and clinical neuroscience research? The answer is simple: it is not only possible, but essential. Psychiatry as a medical specialty is unique in that it embraces a holistic perspective to a far greater extent than other specialties. To define psychiatry in its simplest terms, we might say that it is the study of the person in the context of biopsychosocial forces. The worst possible outcome for psychiatry would be to fragment into a brain and a mind that are not joined – a Cartesian dualism that misleads our patients into thinking that the two are not inextricably bound together. Other false dichotomies include genes/environment and biological/psychosocial.¹

Our task is to insist on an integrative understanding of the human being. In a recent commentary in the Journal of the American Medical Association, Thomas Insel, the Director of the National Institute of Mental Health, and his co–author, Remi Quirion, made the following observation: "Psychiatry presents to the rest of medicine a unique blend of interpersonal skills and behavioral expertise that will be increasingly needed in this era of care dominated by technology. The challenge will be to incorporate neuroscience without losing the discipline's sophisticated understanding of behavior and emotion" (p. 2221).²

We live in an era where all societies are enamored of technology. We have decoded the genome. We have positron emission tomography (PET) scans, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans at our disposal. However, if we are looking for the self, i.e., the "soul" of the person, we will not find it in the DNA. We will not discover it in a dark room gazing at an illuminated MRI scan. The complexities of the unique and the idiosyncratic in each of us cannot be reduced to genes, chemicals and brain structures. We need two languages – one more suited for biology and one derived from psychology. Kendler³ has designated this mode of thinking as explanatory dualism. In brief, this brand of dualism does not separate mind and brain like Cartesian dualism. It merely notes that there are two different ways of knowing and understanding that require two different levels of explanation, both equally useful.

Indeed, there is a synergism of neuroscience and psychoanalytic thought. Many of the tenets of psychoanalytic theory are being fleshed out and confirmed by neuroscience research. For example, all psychoanalytic theories emphasize the importance of development in their formulations. What happens when one is a child shapes the adult. We now know enough about gene–environment interactions to begin to understand these mechanisms. Early childhood experience appears to shut down some genes while turning on others. Antisocial personality disorder is a good example. In a prospective study from Dunedin, New Zealand, Caspi et al.⁴ followed a birth cohort of 1,037 children at regular intervals. Almost all were still in the study sample at the age of 26. Between the age of 3 and 11, 8% experienced severe maltreatment, 28% experienced probable maltreatment, and 64% experienced no maltreatment. The investigators determined that a functional polymorphism in the gene responsible for the neurotransmitter metabolizing enzyme monoamine oxidase–A (MAO–A) was found to moderate the effect of maltreatment. Males with low MAO–A activity genotype who were maltreated in childhood had elevated antisocial scores. Males with high MAO–A activity did not have elevated antisocial scores, even when they had experienced childhood maltreatment. Of males with both low MAO–A activity genotype and severe maltreatment, 85% developed antisocial behavior. Neither genes nor environment alone were sufficient – the two had to interact with one another to produce antisocial behavior.

In this model of genetic vulnerability acted on by psychosocial stressor, psychoanalytic thinking has an additional contribution to make. This one is in the realm of meaning. Traumatic events may or may not leave a mark on the individual depending on their meaning to that individual. For example, Kendler et al.⁵ demonstrated that life events trigger depressive episodes in those with genetic vulnerability. However, life events with particular meanings to the individual may be more closely linked with the onset of major depression. In their research, events with a combination of humiliation (because of a separation initiated by a significant other) and loss were more depressogenic than pure loss events such as death. Humiliating events that directly devalue the individual in a core role were strongly linked to a risk for depressive episodes. Hence clinicians must explore meanings of traumas rather than merely note their presence.

In addition, neuroscience research in recent years has supported Freud's notion that most of mental life is unconscious⁶ and has begun to use functional imaging to demonstrate defense mechanisms such as repression.⁷ As we enter this new era of cutting–edge science, we must preserve what we know about what it means to be human. Reductionism into a purely psychoanalytic or purely biological explanation of human events is tempting. We like things simple. But we do our patients a disservice when we fail to recognize their complexity.

References

1. Gabbard GO. Mind, brain, and personality disorders. Am J Psychiatry. 2005;162(4):648–55.

2. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA. 2005;294(17):2221–4.

3. Kendler KS. A psychiatric dialogue on the mind–body problem. Am J Psychiatry. 2001;158(7):989–1000.

4. Caspi A, McClay J, Moffitt TE, Mill J, Martin J, Craig IW, et al. Role of genotype in the cycle of violence in maltreated children. Science. 2002;297(5582):851–4.

5. Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA. Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Arch Gen Psychiatry. 2003;60(8):789–96.

6. Westen D. The scientific status of unconscious processes: is Freud really dead? J Am Psychoanal Assoc. 1999;47(4):1061–106.

7. Anderson MC, Ochsner KN, Kuhl B, Cooper J, Robertson E, Gabrieli SW, et al. Neural systems underlying the suppression of unwanted memories. Science. 2004;303(5655):232–5.

Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007