情感調節與記憶重塑Affect Regulation & Memory Reconsolidation

周勵志

新光醫院精神科

台灣向日葵全人關懷協會

Email: jou.psyc@msa.hinet.net

關鍵字

• 情感 Affect• 依附 Attachment• 記憶 Memory• 心智化 Mentalization

“Biomedical" and “Psychosocial" define two discrete paradigms, and the division into these separate models has had a stagnating effect on the science of mental health.

Cloninger CRFeeling Good: The Science of Well-Being. Oxford, UK, Oxford University Press, 2004

Mind vs. Brain

The intention is to furnish a psychology that shall be a natural science. Sigmund Freud, 1895

一個科學心理學計劃Project for a Scientific Psychology

• We must recollect that all of our provisional ideas in psychology will presumably one day be based on an organic substructure.

Freud S,"On Narcissism“, 1914

http://www.flickr.com/photos/alyletteri/4724841560/

心理學的器質次結構

Neurology, Psychiatry, & Neuroscience (I)

• Since the 1960s the evolution in the understanding of neuropharmacology and the identification of neurotransmitters have led to the emergence of biological psychiatry.

• At first psychiatric research focused on measuring neurotransmitter levels in the brain, spinal fluid, or urine and identifying receptor modifications associated with disease.

Martin JBAm J Psychiatry 2002; 159:695-704

The Integration of Neurology, Psychiatry, and Neuroscience in the 21st Century

• Decade of the Brain, 1990 - 1999• neurologic and psychiatric research are

moving closer together in I. tools II. questionsIII. theoretical frameworks

Martin JBAm J Psychiatry 2002; 159:695-704

http://en.wikipedia.org/wiki/George_H._W._Bush

Figure 1. The Relationship of Neuroscience, Neurology, and Psychiatry and Their Subtopics to Mind and Brain

The Integration of Neurology, Psychiatry, and Neuroscience in the 21st Century

• Functional imaging techniquesI. magnetic resonance imaging, MRIII. positron emission tomography, PETIII. computerized tomography, CT

• Used byneurologistspsychiatristspsychologistscognitive neuroscientists

Martin JBAm J Psychiatry 2002; 159:695-704

Figure 1. Areas of Impaired Functioning Addressed by Psychiatry, Neurology, and Neuropsychiatry

Yudofsky SC, Hales RE Am J Psychiatry 2002 159; 8:1261-4

Eric R. KandelThe Nobel Prize in Physiology or Medicine 2000

A New Intellectual Framework for Psychiatry

• The great challenge for biology and psychiatry at this point is to delineate that relationship in terms that are satisfying to both the biologist of the brain and the psychiatrist of the mind....

Kandel ER Am J Psychiatry 1998; 155:457-469

Biology & the Future of Psychoanalysis

• Biology rewrites metapsychology on a scientific foundation

• Biological insights could serve as a stimulus for research, for testing specific ideas about how the mind works.

Kandel ERAm J Psychaitry 1999; 156:505-524

Biology & the Future of Psychoanalysis

• The century that is ending has been preoccupied with nucleic acids and proteins. The next one will concentrate on memory and desire.

Kandel ERAm J Psychaitry 1999; 156:505-524

A Common Framework for Psychiatry & The Neural Sciences

Principle 1. All mental processes, even the most complex psychological processes, derive from operations of the brain.

Principle 2. Genes and their protein productsare important determinants of the pattern of interconnections between neurons in the brain and the details of their functioning.

Kandel ERAm J Psychiatry 1998; 155:457-469

A Common Framework for Psychiatry & the Neural Sciences

Principle 3. Altered genes do not, by themselves, explain all of the variance of a given major mental illness. Social or developmental factors also contribute very importantly.

Principle 4. Alterations in gene expression induced by learning give rise to changes in patterns of neuronal connections.

Kandel ERAm J Psychiatry 1998; 155:457-469

A Common Framework for Psychiatry & the Neural Sciences

Principle 5. Insofar as psychotherapy or counseling is effective and produces long-term changes in behavior, it presumably does so through learning, by producing changes in gene expression that alter the strength of synaptic connections and structural changesthat alter the anatomical pattern of interconnections between nerve cells of the brain.

Kandel ERAm J Psychiatry 1998; 155:457-469

心理治療是一種

界(介)面科學

Brain & Mind

Necker cubeIs the red dot on the near or far corner?

www.healthyeyes.org.uk/index.php?id=144

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Hebb's TheoryNeurons Firing Together, Wiring Together

Self-organizing process

愛屋及烏

Brain as ANonlinear Dynamic System (I)

• Neurons firing together, wiring together. • The stronger the connectivity, the stronger

the constraints.Hebb DO, 1949The Organization of Behavior

1904 –1985 Canadian psychologist

記憶像冰山腳下的湖泊

http://www.51766.com/xianlu/11025/1102561599.html

Gerald M Edelman, MD , PhDNobel laureate, 1972

Brain as ANonlinear Dynamic System (II)

• Constraints change over time, & memories can be activated & then deactivated.

Peled & Geva：Brain Organization & PsychodynamicsJ Psychother Pract Res 1999; 8:24-39

• The brain is a self-tuning dynamical system.• “complex behavior” is erratic & extremely

sensitive to small changes in initial conditions.－Butterfly effect 蝴蝶效應

Globus & Arpaia：Psychiatry and the New DynamicsBiological Psychiatry 1994; 35:352-364

Brain as ANonlinear Dynamic System (III)

• Biological nets are chemically tunable moment to moment, leaving no trace, only a fluctuating atunement.

• The outside is not represented inside but participates on the inside as a constraint on a self-organizing process.

• Perception is where cognition & reality meet. ……cognition tunes & the “meeting” is an “interval” leading to “settlement.”Globus GG：Toward a Noncomputational Cognitive NeuroscienceJ Cognitive Neuroscience 1992; 4:299-310

Another Brain

• “ the self-organization of the developing brain occurs in the context of a relationshipwith another self, another brain.”

• the social experience-dependent maturation of the right brain in human infancy is equated with the early development of the self.

Schore ANPediatr Rev 2005;26:204-217

Mind & Brain (I)

• What we call 'mind' can be understood as the activity of the brain.

Andreasen, N D Science 1997; 275, 1586-1593

• Mental phenomena arise from the brain, but subjective experience also affects the brain.

Gabbard, Glen OBr J Psychiatry 2000; 177:117–122

Mind & Brain (II)

• Relational changes and the brain I. Preliminary evidence from other speciesindicates that social cues available in the

environment may influence the way in which a specific neurotransmitter affects theorganism.

Yeh et al.Science. 1996 Jan 19;271(5247):366-9

Crayfish

Mind & Brain (III)• Relational changes and the brain

II.Those with anxious mothers－ a. diminished capacity for normal social

interaction b. socially subordinate

－ did not manifest until adolescence－ psychoanalytic notion that

early developmental disturbances→ later psychopathological changes

Rosenblum LA & Andrews MWActa Paediatrica Suppl, 397, 57-63

Mind & Brain (IV)

• Environmental impact on gene expressionI. learning from the environment →

regulation of gene expression → Synaptic connections permanently altered andstrengthened

II. Psychotherapy may cause similar changes－ influence the structure and function of

the brainKandel, ER Am J Psychiatry 1998;155, 457-469

Mind & Brain (V)

III. Repeated sensory experiences →cortical reorganization－structural changes follows experiential changes

Holloway, 2003; Nelson, 2000IV. Chronic

negative emotional experiences → neuroatrophypositive emotional experiences → neurogenesis

Sapolsky, 2000; 2004

海蛞蝓Aplysia

Mind & Brain (VI)

• Windows in time early childhood (15 months to 4 years), late childhood (6-10 years), puberty & mid-adolescence

Ornitz, E MDevelopmental aspects of neurophysiology. In Child andAdolescent Psychiatry: A Comprehensive Textbook (2nd ed), 1996

Mind & Brain (VII)• Windows in time

I. Trauma → changes in neuromodulation &

physiological reactivity－ anxiety associated with a. traumatic expectations b. increased attention to external stimuli

to detect dangerPynoos, R A et al Issues in the developmental neurobiology of traumatic stress.In Psychobiology of Posttraumatic Stress Disorder (eds R.Yehuda & A C McFarland), 1997

Mind & Brain (VIII)

• Windows in time II. Early childhood trauma

→ alter midbrain, limbic and brainstem structures through a. extended alarm reactions b. use-dependent modification

III. Early neglect and deprivation → Retard cortical development→ limiting cortical modulation of limbic,

brainstem and midbrain responses to fear and danger

Perry, D B et al.Infant Mental Health Journal 1995; 16, 271-291

海蛞蝓 Aplysia

Gene & Environment (I)

• Mendelian patterns of inheritance do not apply to mental illness.

• Different forms of expression and incomplete penetrance are typical of the major disorders

• Environmental and developmental factorsGabbard, Glen OBr J Psychiatry 2000; 177:117–122

Gene & Environment (II)

• The sequence of a gene, or the template function, is not affected by environmental experience, but the transcriptional function of the gene -the ability of a gene to direct the manufacture of specific proteins - is certainly responsive to environmental factors and regulated by those influences.

Kandel, E R Am J Psychiatry 1998;155, 457-469

Gene & Environment (III)

• Conflictual and negative parental behaviour— 60% of variance in adolescent antisocial

behaviour— 37% of variance in depressive symptoms

• Non-shared family environment— parenting behaviour directed specifically

at one child

Reiss D et al.Arch Gen Psychiatry 1995 ;52:925-36

Gene & Environment (IV)

• Individual's genetic endowment influencesthe type of parenting

• Development input from parents and other figures in the environment may, in turn, influence the further read-out of the genome.

Reiss D et al.Arch Gen Psychiatry 1995 ;52:925-36

Gene & Environment (V)

• Genetic influences— individual differences in the liability to

show particular behaviors — strong and pervasive but rarely

determinativeRutter M Arch Gen Psychiatry 2002; 59:996–1000

• Psychosocial stressors— changing the functioning of the brain.

Gabbard GO Am J Psychiatry 2005;162:648-55

Gene & Environment (VI)

• Gene-environment interactions — reverberating 'hall of mirrors’

• Emotion and memory circuits—consistent patterns of connection— stimuli in the environment

Gabbard, Glen OBr J Psychiatry 2000; 177:117–122

www.nature.com/.../051215/438922a_f1.html

Neuroscientist & Neuropsychiatrist, 1938 ~

Linking Mind & Brain in the Study of Mental Illnesses

A Project for a Scientific Psychopathology

• Mental illnesses as disorders of mind arising in the brain.

• Neural mechanisms of mental illnesses －dysfunctions in specific neural circuits－ cognitive and pharmacological factors.

Andreasen NC Science 1997; 275:1586–1593

Neurobiology and Psychotherapy An Emerging Dialogue

• 精神疾病可以說是主體的(subjective)、神經生理的、環境的、及社會的等諸多因素之間不斷循環交互影響之後的產物；其中包括許多在主要症狀、感情、認知、和社會互動間所形成的負向反饋圈(negative feedback loops)。而這些迴路或反饋圈的功能或失能是會受到一些認知或藥理因素的影響或改變的。

Fuchs TCurr Opin Psychiatry 2004; 17:479–485.

Affect

Psychiatry1996;59(3):213-39

主題

http://archive.feedblitz.com/206439/~3917673

湧現(突現 )現象Emergence

• 複雜系統(complex system)中由次級組成單元間簡單的互動所造成的複雜現象。

• 為複雜系統重要的特性之一。

Affect, Memory, Attachment (I)

Affect： Survival & reproductive fitness (Darwin1872)a. Brainstem：neurotransmitter system, autonomic

function, motor nuclei for facial nerveb. Limbic system：endocrine system, learning &

memory system, social/emotional behaviorsc. Neocortex：complex cognitive tasks, experiential

awarenessAmini F et alPsychiatry1996;59(3):213-39

Shifting Focus from Cognition to Emotion

• Models have moved from Piagetian theories of cognitive development to psychobiological models of social-emotional development

• Emotions are the highest order direct expressions of bioregulation in complex organisms

• Maturation of the neural mechanisms involved in self-regulation is experience-dependent

Schore ANPediatr Rev 2005;26:204-217

http://www.fortsask.ca/Content_Files/Images/Baby.jpg

Affect Synchrony

• From birth onward—proto-attachment experiences—smell, taste, touch

• At around 8 weeks of age—mutual gaze—the mother makes herself contingent, easily predictable, and manipulatable by the infant

Schore ANPediatr Rev 2005;26:204-217

Affect Synchrony

• synchrony develops as a consequence of each partner’s learning the rhythmic structure of the other and modifying his or her behavior to fit that structure.

• the tempo of their engagement, disengagement, and reengagement is coordinated.

Lester BM, Hoffman J, Brazelton TBChild Develop 1985;56:15–27

• mutual regulatory systems of arousal.Schore ANPediatr Rev 2005;26:204-217

Contingent Responsivity

• The more the empathic mother tunes her activity level to the infant during periods of social engagement, the more she allows him or her to recover quietly in periods of disengagement.

• The more she attends to the child’s reinitiating cues for re-engagement, the more synchronized becomes their interaction.

Schore ANPediatr Rev 2005;26:204-217

Healthy Affective Development

• These interactively regulated, synchronized interactions promote the infant’s regulatory capacities and are fundamental to his or her healthy affective development.

Schore ANPediatr Rev 2005;26:204-217

Attachment

依附理論Attachment Theory

John Bowlby, 1907-1990

http://psychology.about.com/od/loveandattraction/ss/attachmentstyle.htm

www.geocities.com/.../meadows/3786/wolf.html

The wolf is a highly social animal, generally living within the same pack for most, if not all, of its life. Survivaldepends very much upon the pack.

Affect Attachment, Memory (II)

a. Social mammals are fundamentally incapable of maintaining basic neurophysiologic homeostasis on their own.

b. Attachment system is not only an organizing feature of basic neurophysiologic function but the central organizing system in the brain of higher mammals.

c. Human behaviors pertaining to relationships may not readily influenced by the more advanced cognitive structures

Field 1985; Hofer 1984; kraemer 1992; Reite & Capitanio 1985;Amini 1996

Attachment System (I)

• Psychoanalysis has long argued that the manner in which a mother and her infant interact creates within the child's mind the first internal representation not only of another person but of an interaction, of a relationship.

• This initial representation of people and of relationships is thought to be critical for the subsequent psychological development of the child.

• The interaction goes both ways.Kandel ERAm J Psychaitry 1999; 156:505-524

Attachment System (II)• The development of these internal

representations can only be induced during certain early and critical periods in the infant's life.

• During these critical periods, and only during these periods, the infant (and its developing brain) must interact with a responsive environment (an "average expectable" environment) if the development of the brain and of the personality is to proceed satisfactorily.

Kandel ERAm J Psychaitry 1999; 156:505-524

Attachment System (III)

• From an evolutionary point of view, the attachment system clearly enhances the infant's chances for survival by allowing the immature brain to use the parents' mature functions to organize its own life processes.

• The infant's attachment mechanism is mirrored in the parents' emotionally sensitive responses to the infant's signals.

Kandel ERAm J Psychaitry 1999; 156:505-524

Attachment Figures

• Provide protection, promote safe exploration of the environment and help the infant learn to regulate emotions in a pro-adaptive, effective way.

• 保護安全地探索環境

情感調節

Hruby R, Hasto J, Minarik PNeuro Endocrinol Lett 2011;32:111-20

內在運作模式Internal Working Model

• 在依附關係中除表現依附行為，也會形成一個對主要照顧者、自我及環境的內在運作模式。

• 對依附者所產生的感受、情緒、知覺會內化形成內在客體表徵，也會形成對自我、對他人、對環境的概念以及適應行為。

陳秉華，1996

http://www.thedigeratilife.com/blog/buy-cheap-eyeglasses-online/

Internal Working Model

• Schemas in an associative memory network(Hašto 2006; Shaver & Mikulincer 2009).

• Formed internal models a. tend to remain unchanged b. distinctively affect the formation of new

relations• Create essential neurobehavioral regulations

for individual survival• Affect regulation & emotional processing

Hruby R, Hasto J, Minarik PNeuro Endocrinol Lett 2011;32:111-20

Hruby R, Hasto J, Minarik PNeuro Endocrinol Lett 2011;32:111-20

Attachment throughout Life Span

• psychobiological attunement and the interactive mutual entrainment of physiologic rhythms are fundamental processes that mediate attachment.

• Throughout the life span, attachment is a primary mechanism for the regulation of biologic synchronicity within and between organisms.

Schore ANPediatr Rev 2005;26:204-217

Sociophysiology

• The art of the doctor-patient relationship, which involves the physician’s empathy and the capacity for responsive listening, “entails establishing the same kind of person-to-person attunement that is essential to the development of the newborn (Shore, 1994).”

Adler HMJ Gen Intern Med 2002; 17: 883–890

Memory

Kandel ER, 1999

Figure 2. The different stages of selection inthe theory of Neural Darwinism

www.mindcreators.com/NeuralDarwinism.htm

Self-organizing Actors OS, relying on perceptual data coming throughShort Term Memory, translated into system patterns. In turn, these patterns are subjects of meaning sharing and reasoning driven by system dynamics toward emergence of Self.

Therapy is just another way ofcreating synaptic potentiation in brain pathways that control the amygdala. …….. And the way we do this is by getting the cortex to control the amygdala.

LeDoux J, 1996

Creating Synaptic Potentiation

Role of Learning in the Conduct ofPsychotherapy

• Evidence indicated that activity-dependent short-term and long-term changes in strength of synaptic transmission are important for memory processes. ＊ long-term potentiation (LTP) & long-term depression (LTD) of excitatory postsynaptic potentials.(Cansino S & Williamson SJ, 1997; Davis M, 1992)

Liggan D & Kay JJ Psychother Pract Res. 1999 Spring;8(2):103-14

Learning & Psychotherapy

• Cortical maps are dynamic constructs －remodeled in detail by behaviorally

important experiences through lifeLiggan D & Kay JJ Psychother Pract Res 1999;8:103-14

Unconscious Mental Processes

• Constant repetition can transform declarative memory into a procedural type＊開車

Kandel ERAm J Psychaitry 1999; 156:505-524

Unconscious Mental Processes

• Procedural memory is itself a collection of processes :

I. priming, or recognition of recently encountered stimuli, is a function of sensory cortices;

II. the acquisition of various cued feeling states involves the amygdala;

III. formation of new motor (and perhaps cognitive) habits requires the neostriatum;

IV. learning new motor behavior or coordinated activities depends on the cerebellum

Kandel ERAm J Psychaitry 1999; 156:505-524

Memory & Psychotherapy• Human infants

－ functional memory system at birth－ more capable of implicit learning than

explicit learning at this stage • Information regarding affect－processing in the implicit system

• Implicit system is capable of －extracting and storing prototypes and rules

Amini F et al.Psychiatry 1996; 59:213-239

http://picbook-huichutai-huichutai.blogspot.tw/2007/12/blog-post_01.html

Memory & Psychotherapy

• Rules learned implicitly → self-perpetuating bias for interpreting later experience to consist with past experience, regardless of the appropriateness

• Information learned is not available for conscious processing and reflection, →guides behavior without impinging on

consciousness.

Amini F et al.Psychiatry 1996; 59:213-239

Memory & Psychotherapy

• Patterns of implicit rules are revealed and reflected upon in psychotherapy→ learning of new patterns explicitly repeated → new habit-based manner is engrained in the

implicit memory system.

Amini F et al.Psychiatry 1996; 59:213-239

何謂心理治療？Once Over: What is Psychotherapy?

一種去學習(unlearning)、學習(learning) 、再學習(relearning)的過程。病人必須學習如何去除適應不良的行為模式，發展更多新的、有效的適應機轉，然後一再重複，以增強這些新的行為模式。除了思考、感覺、行為模式的知識傳遞外，治療師更像是一位好老師—善於應用個人的影響力。

Bellak LJ Nerv Ment Dis 1977;165:295-299

Something More

• Intellectual－Insight 洞察

• Experiential－Doing 改變－Being 存在

Mentalization

Infant, Imitation

flickr.com/photos/seandreilinger/1009286871/

Infant Imitation

• 20 minutes (Kugiumtzakis,1985; Reissland,1988)• 42 minutes (Meltzoff & Moore, 1983)

• Mouth opening (Heimann & Schaller, 1985; Legerstee, 1991)

• Lip pursing, eye blinking (Kugiumtzakis,1985)• Head movements, cheek movements (Fontaine, 1984)• Hand Gestures (Meltzoff & Moore, 1989)

• Vocal sounds such as /m/, /a/, and /ang/ as early as 40 minutes after birth (Kugiumtzakis,1993)

Infant Imitation

Birth of the Agentive SelfAttachment figure “discovers” infant’s mind (subjectivity)

Representationof infant’smental state

Attachment figure

Core ofpsychologicalself

Infant internalizes caregiver’s representation to form psychological self

Internalization

Inference Infant

Bateman & Fonagy, 2004

98

Reflective Parenting &Development of Mentalization

• Mirroring Mentalizing“小屁屁濕了嗎？＂ “想要換尿布了喔?＂

“一個人站太久了嗎？＂ “想要抱抱嗎?＂

Having the person in mind.Bridge the focus on physical reality and

internally directed attention.

The Neural Correlates of Maternal & Romantic Love

• Both deactivated a common set of regions associated with negative emotions, social judgment and 'mentalizing', that is, the assessment of other people's intentions and emotions.

Bartels A, Zeki SNeuroimage 2004;21(3):1155-66

Love Makes Blind

Attachment & mentalisation

• Attachment and mentalisation are loosely coupled systems existing in a state of interactive but partial exclusivity.

Fonagy P. & Bateman ABr J Psychiatry 2006; 188: 1-3

Mechanisms of change in MBT

• A safe attachment context in which it is safe for the patient to explore the mind of the other.

• Encourage to mentalize, to experience and confront negative affect and to elaborate and review issues of morality＊.

＊ from the Latin moralitas "manner,character, proper behavior"

http://www.tc-of.org.uk/index.php?title=Recent_PD/Non-TC_Cartoons

Mentalization

•The term “mentalized affectivity” describes how affect regulation is transformed by mentalization.•Elements of mentalized affectivity：I. identifyingII. modulatingIII. expressing affects

Conclusion

Psychobiological Viewof Psychotherapy (I)

I. A physiological process capable ofa. regulating neurophysiologic process & b. altering underlying neural process.

II. Implicitly learned generalizations may not be easily influenced by explicitly acquired knowledge structures or by explanations regarding the learning task. (Berry & Broadbent 1984; Reber & Millard 1968)

Amini F et al. 1996

Psychobiological Viewof Psychotherapy (II)

III. An attachment relationship whose purpose is a. regulate affective homeostasis b. restructure attachment-related implicit

memory IV. The experientially based aspects of

psychotherapeutic relationship are more important.

Amini F et al. 1996

Psychobiological Viewof Psychotherapy (III)

V. The therapist has been invited to play in a. an affective-relational duetb. the patient’s attachment pattern will

provide the principle melody.VI. The therapist’s job is to allow the duet to

begin and to take up his/her place in the melody, so the piece can gradually be directed to a different ending.

Amini F et al. 1996

http://www.galeriaaniela.com.au/Regina%20Noakes%20Paintings.htm

System Approach To Psychotherapy (I)

I. The interpersonal relationship between therapist and client is the tool for creating the needed change.

II. Initially the relations with the therapist will repeat the same patterns of interpersonal relations that caused the distress.

Peled & Geva：Brain Organization & PsychodynamicsJ Psychother Pract Res 1999; 8:24-39

System Approach To Psychotherapy (II)

III. The skilled therapist a. identifies these patterns b. gradually changes the attitudes of the client

toward similar future situations. IV. Successively, this change continues both in

and outside of the therapeutic setting.

Peled & Geva：Brain Organization & PsychodynamicsJ Psychother Pract Res 1999; 8:24-39

“I know thatyou know that I know……”

相視而笑，莫逆於心

I and Thou (I)

• Psychotherapy as an example of “I-Thou” Relationship

• I. Mutuality, directness, presentness, intensity, & ineffability

• II. An important kind of healing occurs through “meeting” rather than through insight & analysis.

• III. Through “entering unto relation” men confirm each other, and each becomes a self with the other.

Buber M, 1965The Knowledge of Man： A philosophy of interhuman

I and Thou (II)• Psychotherapy as an example of “I-Thou”

Relationship• IV. By mutual confirmation, man knows

himself to be “made present in his uniqueness by the other……as just so & not otherwise in all his wholeness, unity & uniqueness.”

• V. One can only do this as a partner, requiring not empathy or intuitive perception but “a bold swinging into the other”.

Buber M, 1965The Knowledge of Man： A philosophy of interhuman

謝謝聆聽，

敬請指教！