jueves, 28 de junio de 2012

Psychodynamic Psychopharmacology

Psychiatric Times. Vol. 28 No. 9

Psychodynamic Psychopharmacology
By David Mintz, MD |September 9, 2011
Dr Mintz is Director of Psychiatric Education at the Austen Riggs Center in Stockbridge, Mass. The author reports no conflicts of interest concerning the subject matter of this article.
During the past 2 decades, psychiatry has benefited from an increasingly evidence-based perspective and a proliferation of safer, more tolerable, and perhaps more effective treatments. Despite these advances, however, treatment outcomes are not substantially better than they were a quarter of a century ago.1 Treatment resistance remains a serious problem across psychiatric diagnoses.2 One likely reason that outcomes have not improved substantially is that as the pendulum has swung from a psychodynamic framework to a biological one, the impact of meaning (i.e., the role of psychosocial factors in treatment-refractory illness) has been relatively neglected, and psychiatrists have lost some potent tools for working with the most troubled patients.
Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment.3 This approach recognizes that many of the core discoveries of psychoanalysis (the unconscious, conflict, resistance, transference, defense) are powerful factors in the complex relationships between the patient, the illness, the doctor, and the medications. In many cases, these factors are largely concordant with treatment and do not need to be addressed in order for treatment to be effective. However, in patients who are treatment-resistant, it is likely that psychodynamic factors (that may well be unconscious) are deeply at odds with therapeutic goals.

Dynamic factors in psychopharmacology
There is currently a small but impressive evidence base that shows that psychological and interpersonal factors play a pivotal role in pharmacological treatment responsiveness.
An analysis of the data from a large, NIMH-funded, multicenter, placebo-controlled trial of the treatment of depression found a provocative treater x medication effect.4 While the most effective prescribers who provided active drug (antidepressant) had the best results, it was also true that the most effective one-third of prescribers had better outcomes with placebos than the least effective one-third of prescribers had with active drug. This suggests that how the doctor prescribes is actually more important than what the doctor prescribes!
A series of meta-analyses of FDA databases (examining an unbiased sample, including negative, unpublished studies) shows that although antidepressant medications are effective, the placebo effect accounts for between 76% and 81% of treatment effectiveness.5-7 Placebo does not mean imaginary or untrue. Placebos produce real, clinically significant, and objectively measurable improvements in a wide range of conditions, including psychiatric disorders.8,9 And, placebo responses produce measurable changes in brain activity that largely overlap medication-induced improvements.10 The patient’s desire to change and a positive transference to the doctor and his or her medications can mobilize profound self-healing capacities—capacities that appear to be even more potent than the medication’s active ingredient.
Although most of our patients ask us for help, many are conflicted about getting well if their illness has created some conscious or unconscious benefit. If a patient is not “ready to change,” it is unlikely that a medication, however potent, will produce a therapeutic effect. Beitman and colleagues11 found, in a placebo-controlled trial, that patients who received a benzodiazepine for anxiety and who were highly motivated to change had the most robust response. However, placebo recipients who were highly motivated to change had a greater reduction in anxiety than patients who took the active drug but were less ready to change. Readiness to change was found to be the single most powerful determinant of treatment effectiveness—even more potent than type of therapy (i.e., active vs. placebo).
In 1912, Freud12 noted that the unobjectionable positive transference (consisting of such things as the patient’s belief in the doctor’s salutary intentions, the wish to use the doctor to get better, and the desire to win the doctor’s love or esteem by genuinely trying to get better) was a key factor in the patient’s ability to overcome symptoms. This unobjectionable positive transference, i.e., the therapeutic alliance, is one of the most potent ingredients of treatment.12,13 In a large, placebo-controlled, multicenter trial of treatments of depression, Krupnick and colleagues14 showed that patients were most likely to respond when they received the active drug and had a strong therapeutic alliance. Those least likely to respond when given placebo had a poor therapeutic alliance. Patients who received placebo and who had a strong treatment alliance had a significantly more robust therapeutic response than patients who received an antidepressant but had a poor therapeutic alliance. Taken together, these studies examining the relative effectiveness of biologically and symbolically active aspects of the medication suggest that meaning effects in psychopharmacology are more potent than biological effects.4-7,11,13,14 
Just as positive transferences to the doctor or drug lead to positive responses, negative transferences are likely to lead to negative responses. Patients who have been abused or neglected by caregivers in the past or those who otherwise feel vulnerable to authority figures (either because of social disadvantage or a propensity to acquiesce) are prone to nocebo responses.15,16 The obverse of the placebo response, nocebo responses occur when patients expect (either consciously or unconsciously) to be harmed. Many patients who experience intolerable adverse effects to medications are nocebo responders. It comes as no surprise that these patients are likely to become treatment-resistant.

Pharmacological treatment resistance
From a psychodynamic perspective, patients may be seen as resistant to medication or resistant from medication. These 2 broad categories of pharmacological treatment resistance tend to have different underlying dynamics and may require different kinds of interventions.
Patients who are resistant to medications have conscious or unconscious factors that interfere with the desired effect of medications. Often, resistance in this category takes the form of nonadherence but also includes patients who repeatedly experience adverse responses to medications (i.e., nocebo responders).
In contrast, patients who are resistant from medications more typically are eager to receive the medication or some benefit that the patient ascribes to the medication. For such patients, pills may appear to relieve symptoms, but they do not contribute to an improvement in the patient’s quality of life. Resistance to medications and resistance from medications are not mutually exclusive, and some patients present with both dynamics.
In 1905, Freud17 described the psychodynamic concept of resistance and concluded that many patients were unconsciously reluctant to relinquish their symptoms or were unwittingly driven, for transference reasons, to resist the doctor. These same dynamics may apply in pharmacotherapy. Although suffering greatly, patients may find good uses for their symptoms. Patients who derive significant secondary gains from their symptoms (e.g., they are relieved from various burdens, or they receive care rather than neglect as a result of their illness) can be deeply conflicted about getting better, which may manifest as treatment resistance.
Patients who need their symptoms to communicate something that they cannot put into words will be similarly ambivalent.2 When symptoms constitute an important defense mechanism, patients are also likely to resist medication effects until they have developed more mature defenses or more effective ways of coping.3
 Patients who are not resistant to symptom reduction may nonetheless be motivated to resist the doctor on the basis of a transference experience of the doctor as untrustworthy or even dangerous. Such patients often painstakingly negotiate the medication, dosing, and timing of medications (so as not to feel under the control of the malevolently experienced doctor) or surreptitiously manage their own regimen (by taking more or less than the prescribed dose). Needless to say, if they are not taking a therapeutic dose, they lessen their chances of a therapeutic response. As noted, if these patients cannot resist the doctor’s orders, then their bodies may unconsciously do the resisting for them, which leads to nocebo effects.
Patients who are treatment-resistant from medication typically present as hungry for medications. Although they take the medications and may report symptom reduction, these patients do not function better with pharmacotherapy; in fact, some seem to get worse. A psychodynamic psychopharmacologist is mindful that there are countless ways these medications may serve countertherapeutic and/or defensive aims.
Patients may use pills defensively to disavow responsibility for their feelings and actions.18 This commonly occurs in the case of primitively organized and character-disordered patients who rely on splitting and projective dynamics. Such patients tend to see things strictly in black and white and frequently defend against feeling intolerably and completely bad by displacing all of the “badness” onto the “other” in a relationship.
After receiving a prescription for mood stabilizers for bipolar disorder, a patient prone to splitting as a defense will often experience an immediate reduction in dysphoria. A psychopharmacologist who is inclined to think both psychodynamically and biologically will recognize that the reduction in dysphoria may be occurring not because of the medication but because it allows the patient to create a stable split within which he can remain good while all badness is located in “my bipolar.”
While patients may feel better, they actually do worse. No longer feeling personally responsible for symptomatic behavior, they give their worst instincts free rein, exacerbating personal and interpersonal chaos. It is important not to collude unwittingly with these legally competent patients whose treatment resistance relates to defensive use of medications. Rather, it is crucial to empathically help them understand that although they are ill, they remain responsible for their choices.
Medications can be used defensively in myriad ways. Patients who experience people as dangerous and unreliable may attempt to replace people with pills. Still other patients may feel that any “negative” feeling is pathological and should be extinguished. If accepted at face value, this can lead a well-meaning psychiatrist toward an ever more complex and burdensome medication regimen that actually contravenes healthy developmental aims.
When pills are used to manage developmentally appropriate feelings, such as loneliness, disappointment, sadness, frustration, or anger, patients lose important opportunities that might lead to improved internal controls and increased affective or interpersonal competence. Patienthood may be reinforced.

Elements of psychodynamic psychopharmacology
Psychodynamic psychopharmacology represents an integration of biological psychiatry and psychodynamic insights and techniques. Psychodynamic psychopharmacology provides little guidance about what to prescribe; instead, it helps prescribers know how to prescribe to improve outcomes.
There are 6 principles for psychodynamically informed pharmacological practice with treatment-resistant patients3:
• Avoid a mind-body split
• Know your patient
• Attend to the patient’s ambivalence about the loss of symptoms
• Address negative transferences and resistance to medications
• Be aware of countertherapeutic uses of medications (resistance from medications)
• Identify and contain countertransference involving prescribing19
Avoid a mind-body split. A psychodynamic psychopharmacologist recognizes that a rigid mind-body dualism is a fantasy. Experiences, feelings, ideas, and relationships change the structure and function of the brain just as the state of the brain influences experience. A psychodynamic psychopharmacologist considers that a positive or negative medication response may be a direct action of the pill or may be mediated by the meanings the patient attaches to the pill.

Mind-body integration also means that psychotherapy and psychopharmacology will need to be well-integrated so that psychopharmacological interventions facilitate the psychotherapy and so that the therapy helps the patient become conscious of psychological sources of pharmacological treatment resistance. Effective psychopharmacological interventions to treatment nonresponse might include an increase in frequency of appointments rather than an increase in medication dosage.20

Know your patient. Sir William Osler, the father of modern medicine, remarked that “it is much more important to know what sort of patient has a disease than to know what sort of disease a patient has.” This is a central tenet of psychodynamic psychopharmacology. Practically, this means that the pharmacologist should get a thorough developmental and social history to make reasonable hypotheses about the psychosocial origins of the patient’s treatment resistance. The prescriber should also directly assess the patient’s attitudes about medications (fears of dependency, worries about being “turned into a zombie,” and so on). This not only helps assess potential sources of resistance, but it also lets the patient know the prescriber is interested in him as a person, which may enhance the alliance.

Attend to ambivalence about loss of symptoms. Identify potential sources of ambivalence about symptoms, such as secondary gains, and communicative or defensive value of symptoms. It may be helpful at the point of intake to ask the patient what he would stand to lose if treatment was successful. (The same question posed in the middle of a treatment may be colored by the doctor’s frustration and is more likely to produce a negative response.)

Address negative transferences and resistance to medications. Once potential sources of resistance to the medication or the doctor are understood, they must be addressed. If they are clear at the outset, they must be addressed preemptively. In this way, an alliance is made with the patient before massive resistance is sparked. Negative transferences must be identified and worked through. Empathic interpretation of nocebo responses can resolve adverse effects.21

Be aware of countertherapeutic uses of medications (resistance from medications). Countertherapeutic uses of medications should also be interpreted. As a prescriber, you might tolerate some irrational use of medications if the patient is working through an issue that interferes with a healthier use of those medications. There comes a time, however, when discontinuation of a countertherapeutic medication may become a condition of continued pharmacological treatment.

Identify and contain countertransference in prescribing. When patients struggle with overwhelming dysphoric affects, they often evoke corresponding effects in their prescribers.2 It seems likely that a medication regimen made up of, for example, 3 antidepressants, 4 mood stabilizers, 3 antipsychotics, and 1 or 2 anxiolytics, has in part been shaped by countertransference. Such a regimen is unlikely to be effective and is perhaps aimed at treating the doctor’s anxiety rather than the patient’s; the patient is not the only source of treatment resistance. A psychodynamic psychopharmacologist recognizes that the psychiatric relationship is an encounter between a big mess and an even bigger mess. An attitude of humility along with periodic consultation about difficult cases helps manage irrational prescribing.


There are many sources of pharmacological treatment resistance. When treatment resistance arises from the level of meaning, interventions are not likely to be successful unless they address problems at the level of meaning. Psychiatric care providers who operate from either a dogmatic psychotherapeutic paradigm or a psychopharmacological paradigm are hobbled by having access to only half the patient. Psychodynamic psychopharmacology combines rational prescribing with tools to identify and address irrational interferences with healthy and effective use of medications. We should not neglect psychodynamic contributions that enhance the integration of meaning and biology. It is the capacity to integrate and understand complex situations that more than anything else lends its particular power to our discipline and gives us skills for working with particularly troubled patients. 

1. Kessler RC, Berglund P, Demler O, et al; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003; 289:3095-3105.
2. Plakun EM. A view from Riggs—treatment resistance and patient authority: I. A psychodynamic perspective. J Am Acad Psychoanal Dyn Psychiatry. 2006; 34:349-366.
3. Mintz D, Belnap B. A view from Riggs: treatment resistance and patient authority—III. What is psychodynamic psychopharmacology? An approach to pharmacologic treatment resistance. J Am Acad Psychoanal Dyn Psychiatry. 2006; 34:581-601.
4. McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect Disord. 2006; 92:287-290.
5. Kirsch I, Sapirstein G. Listening to Prozac but hearing placebo: a meta-analysis of antidepressant medication. June 26, 1998. http://psycnet.apa.org/?fa=main.doiLanding&doi=10.1037/1522-3736.1.1.12a. Accessed June 24, 2009.
6. Khan A, Warner HA, Brown WA. Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry. 2000; 57:311-317.
7. Kirsch I, Moore TJ, Scoboria A, Nicholls SS. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment 5, Article 23. 2002. http://www.journals.apa.org/prevention/volume5/pre0050023a.html.
8. Brody H. Placebos and the Philosophy of Medicine. Chicago: University of Chicago Press; 1977.
9. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med. 2002; 136:471-476.
10. Mayberg HS, Silva JA, Brannan SK, et al. The functional neuroanatomy of the placebo effect. Am J Psychiatry. 2002; 159:728-737.
11. Beitman BD, Beck NC, Deuser WE, et al. Patient Stage of Change predicts outcome in a panic disorder medication trial. Anxiety. 1994; 1:64-69.
12. Freud S. The dynamics of transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 12. London: Hogarth Press; 1912/1958.
13. Blatt SJ, Zuroff DC. Empirical evaluation of the assumptions in identifying evidence-based treatments in mental health. Clin Psychol Rev. 2005; 25:459-486.
14. Krupnick JL, Sotsky SM, Simmens S, et al. The role of therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 1996; 64:532-539.
15. Hahn RA. The nocebo phenomenon: scope and foundations. In: Harrington A, ed. The Placebo Effect: An Interdisciplinary Exploration. Cambridge, MA: Harvard University Press; 1997.
16. McNair DM, Fisher S, Kahn RJ, Droppleman LF. Drug-personality interaction in intensive outpatient treatment. Arch Gen Psychiatry. 1970; 22:128-135.
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18. Gibbons FX, Wright RA. Motivational biases in causal attributions of arousal. J Pers Soc Psychol. 1981; 40:588-600.
19. Kayatekin MS, Plakun EM. A view from Riggs: treatment resistance and patient authority, Paper X: from acting out to enactment in treatment resistant disorders. J Am Acad Psychoanal Dyn Psychiatry. 2009; 37:365-382.
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A continuación se incluye el comentario del Dr. Romulo Lander, Psicoanalista de la Asociacion Psicoanalitica de Venezuela, así como también la opinión de la Dra. Elsa Paz, Psicoanalista en formación de la Asociación Psicoanalítica Mexicana

Me encantó el artículo sobre psicofarmacología psicodinámica porque es la primera vez en la formación que leo un material donde está integrada la psiquiatría con el psicoanálisis. Yo tengo pacientes enviados por psicoanalistas o psicoterapeutas para tratarlos farmacológicamente y he visto, efectivamente, que es muy importante saber que una vez tratado el trastorno psiquiátrico, la sintomatología caracterológica y los mecanismos de defensa se acentúan. Y por ésto es muy importante estar en comunicación con ellos (los psicoanalistas o psicoterapeutas) y además evitar caer en la invitación del paciente a que te conviertas en su segundo psicoterapeuta, por supuesto, sin descuidar los factores psicodinámicos que corresponden al rol del psiquiatra.
Yo tengo, como el Dr. Mintz, una paciente con un trastorno bipolar tipo II con una estructura psicótica en la que el principal mecanismo de defensa es la escisión. Me fue enviada por una psicoanalista. Una vez que la hipomanía cesó, el funcionamiento psicótico de su estructura y la escisión se acentuaron, además que su vida se complicó al no tener la ganacia secundaria de la hipomanía (no poder llegar a meta en sus actividades). Ahora la paciente no llega a meta en sus actividades por una reacción evitativa. La paciente dice "estar peor", pues como dice el Dr. Mintz "Todo su mal se localizaba en "su bipolaridad". He tenido que trabajar con ella, haciéndole ver que el caos personal y sus temores tienen que ver más bien con su estructura de personalidad y que esto lo tiene que tratar con su psicoterapeuta, porque ahora la paciente está intentando escindir su psicoterapia al tratar de convertir la consulta psiquiátrica en una sesión psicoterapéutica.
¡Muy buen artículo! ¡Me gustó!

Respuesta del Dr. Rómulo Lander al trabajo enviado sobre psicofarmacología
Apreciada Elsa y demás colegas:
He recibido el correo de Elsa con sus comentarios en relación a la psiquiatría farmacológica y la psicoterapia psicoanalítica. Entiendo que Elsa es psiquiatra y psicoanalista. Yo también fui psiquiatra de adultos y luego fui psiquiatría infantil. De eso hace muchos años. Ahora desde  hace cuarenta y dos años me dedico en exclusiva al psicoanálisis. Como seguramente saben existen psicoanalistas que consideran útil combinar el análisis con los psicofármacos. Existen otros que no lo consideran útil, ni indicado. En lo personal me inclino hacia este segundo grupo.
Sin embargo entiendo que la Psiquiatría de emergencia con presencia de pacientes agudos, melancólicos, agitados y algunos violentos, requieren de fuertes y modernos antipsicóticos y tranquilizantes, para poder acceder luego a algún tipo de psicoterapia. Ese punto es aceptado por casi todos los analistas y no está en discusión. El problema es con los pacientes ambulatorios con síntomas variados y que están interesados en mejorar su vida. Medicar estos pacientes puede ser contraindicado. La medicación tiene efectos colaterales indeseables. Allí es donde está el problema de salud pública. Allí es donde se centra el debate. Como psicoanalista tengo una opinión y me permito enviártela. Escribí este mini texto hace un mes. Aquí se lo envío a todos para incendiar la discusión. Creo que discutir todo esto es sano para todos nosotros. Discutir ayuda a argumentar y a aclarar contradicciones, permitiendo que surja el sentido común. Sin embargo me preocupa que esto se encuentre fuera del tema del seminario actual dedicado específicamente a la transferencia. Pero el texto enviado por Elsa requiere de argumentación en contrario.
1.      He encontrado que los Post-Grados de Psiquiatría Clínica actuales se dividen en dos tipos. Unos son aquellos Post-Grados que mantienen en su enseñanza las ideas de la llamada Psiquiatría Dinámica, la cual se fundamenta en la existencia de los procesos mentales inconscientes. Son psiquiatras dinámicos que escuchan y hacen psicoterapia psicoanalítica con sus pacientes. Los otros Post-Grados llamados de psiquiatría biológica son aquellos que rechazan la propuesta dinámica y fundamentan su práctica psiquiátrica en la teoría de la consciencia y en la causalidad que ejercen los trastornos neuroquímicos en el sistema nervioso central  y donde el ejercicio de la psicoterapia no es recomendado y lo consideran algo de muy poca utilidad. Este último tipo de Post-Grado ha producido un nuevo Paradigma psiquiátrico.
2.      Por otra parte esta clínica psiquiátrica biológica se interesa muy poco por la historia de vida del paciente y muy poco por la historia de la familia del paciente. Para este tipo de psiquiatras biológicos lo novedoso es el estudio de los valores sanguíneos de los diversos neurotransmisores que están presentes en ese momento en la sangre del paciente. Toda esta información ayuda para poder clasificar y ubicar en la taxonomía psiquiátrica la patología en cuestión que luego va a determinar el psicofármaco correcto a indicar.
 3.      El nuevo paradigma de trabajo psiquiátrico biológico establece que la enfermedad mental es causada por un desbalance de los neurotransmisores que operan en las sinapsis cerebrales. Por lo tanto la salud mental se evalúa según el estado de los neurotransmisores medidos en sangre. La ayuda para normalizar estos neurotransmisores ofrecidos por el psiquiatra biológico es fundamentalmente de tipo farmacológico. No es de tipo psicoterapéutico. Podemos admitir que esta ayuda farmacológica es parcialmente efectiva pero tiene sus inconvenientes. Tiene sus grandes limitaciones y sus efectos indeseables. Muchos investigadores se preguntan por el desequilibrio mental causado por el uso excesivo de fármacos psicoactivos que afectan el equilibrio natural de los neurotransmisores en el cerebro. 
4.      La verdadera realidad es que lamentablemente esta ayuda psicofarmacológica no produce conocimiento ni produce desarrollo mental. La persona no descubre las causas de sus problemas, ni el origen de su sufrimiento. Así pues este tipo de ayuda inevitablemente y en el mejor de los casos es simplemente paliativo. Se trata de ofrecer un alivio transitorio sintomático a los estados de angustia o depresión. Tiene el beneficio de que es accesible a las masas necesitadas de ayuda. No requiere de un esfuerzo personal de introspección, ni de reflexión sobre sí mismo, ya que solo basta con ingerir por vía oral o vía parenteral un medicamento. Otro aspecto negativo de este tipo de ayuda es que el alivio producido por el medicamento no es sostenible a lo largo del tiempo. Sin embargo es lo único disponible en muchos casos y eso lo hace útil desde el punto de vista de política sanitaria. Es bueno saber la presencia inevitable de serios efectos colaterales indeseables.
5.      Existe otro punto que nos obliga a una reflexión adicional. Es necesario agregar que existe una diferencia profunda entre la clínica psiquiátrica y la psicoanalítica. Esta diferencia está en la forma como se entienden las causas o llamada también etiología de las enfermedades mentales. Es decir el problema de la causalidad de las estructuras. La clínica psiquiátrica actual moderna se apoya en el Manual de Diagnostico Estadístico. Ese manual diagnostico define los requisitos mínimos [los síntomas] para catalogar correctamente las entidades nosológicas. Estos requisitos se refieren principalmente al tipo de síntomas presentes en las diferentes patologías. Se han utilizado recursos estadísticos epidemiológicos computarizados para lograr una mayor precisión estadística de los síntomas. Es importante señalar que estos manuales nosológicos no toman y no pueden tomar en cuenta la causa de las enfermedades para el diagnóstico. 
6.      Como ya he mencionado, un nuevo paradigma psiquiátrico se ha impuesto en la práctica clínica psiquiátrica en los últimos veinte años. Este paradigma o modelo de trabajo se impuso por su conveniencia y facilidad de administración dando origen al tratamiento psiquiátrico psicofarmacológico. Esto ocurre al establecerse una relación invariable y fija llamada unívoca entre el diagnóstico psiquiátrico y los neurotransmisores. Estas variaciones de los neurotransmisores son cuantificables en la sangre. Ambos aspectos quedan así unidos artificialmente en forma específica unívoca. Los neurotransmisores pasan a ser considerados erróneamente la causa última de los trastornos mentales. Como todos sabemos esto se encuentra abierto a un intenso debate científico teórico y clínico. Sin embargo, a pesar de la insistencia de la psiquiatría biológica de mantener este paradigma podemos decir que no existe una causa psiquiátrica convincente para esos trastornos neuroquímicos. La propuesta de la psiquiatría biológica dice que a cada entidad nosológica le corresponde una alteración neuroquímica particular, la cual es corregida por un psicofármaco específico.
7.      Esta forma de pensar que está presente en este nuevo paradigma es lo que se debate intensamente, ya que tiene consecuencias en las decisiones terapéuticas y en el destino de las personas. La clínica psicoanalítica como ya he explicado en otro texto, utiliza el concepto teórico de las estructuras psíquicas inconscientes e incluye una propuesta diferente de causalidad para las estructuras mentales. Aparece una nueva propuesta psicoanalítica llamada el Paradigma Psicoanalítico, el cual plantea que existen tres formas de instalarse una patología en la psique: por vía de un trauma psíquico, por vía de un conflicto psíquico, o por vía de un déficit estructural o también llamado defecto estructural, el cual es adquirido temprano en la vida.
8.      El debate sobre los neurotransmisores se centra en lo siguiente: ¿Son los neurotransmisores alterados los que causan los síntomas mentales? o es a la inversa: ¿Son los síntomas de la mente los que luego causan la alteración de los neurotransmisores en sangre? El psicoanálisis propone y argumenta a favor de la segunda alternativa. Un ejemplo: El miedo como respuesta emocional a algún peligro se caracteriza por la presencia de cambios neurofisiológicos tales como taquicardia, erección pilosa, dilatación de pupila, diuresis, sequedad de la boca, etc. Estos cambios neurofisiológicos son producidos por la nor-epinefrina llamada también adrenalina, la cual es un neurotransmisor muy conocido y potente. Sin embargo la adrenalina es producida por una orden involuntaria de la corteza cerebral a través del eje: corteza, sub-corteza, hipotálamo, hipófisis, tiroides y suprarrenales. Es decir que la cantidad de la adrenalina en sangre depende de la presencia de un estimulo psíquico emocional y no a la inversa.

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