An Outcome of Psychodynamic Psychotherapy: A Case Study of the Change in Serotonin Transporter Binding and the Activation of the Dream Screen
Saarinen, Pirjo Irmeli, Lehtonen, Johannes, Joensuu, Mikko, Tolmunen, Tommi, et al., American Journal of Psychotherapy
We explored the outcome of psychodynamic psychotherapy of a female patient with major depression using clinical evaluation and serotonin transporter (SERT) binding assessed with [^sup 123^I]nor-β-CIT SPECT. The psychotherapy process was analyzed with special emphasis on the change that was recognized in the dreaming process. The activation of the dream screen in transference seemed to form a turning point during the psychotherapy. Normalization of SERT binding at the midbrain level was found on 12-month follow-up. Major alleviation of depressive symptoms assessed by rating scales was evident only six months after SERT normalization.
There is evidence that serotonin transporter densities are altered in depression. The findings of Malison et al. (1998) suggested the first reductions in the density of brain serotonin transporter (SERT) binding sites in living depressed patients. Single-photon emission computed tomography (SPECT) is useful and sensitive in imaging neurochemical systems in vivo, but has been less frequently applied in studying affective disorders than, for example, schizophrenia (Grasby, 1999).
A decreased serotonin transporter level associated with depression and its normalization during the course of psychodynamic psychotherapy has been reported in a case-control study using SPECT imaging (Viinamaki, Kuikka, Tiihonen, & Lehtonen, 1998). It has also been suggested that the learning about oneself which occurs in psychotherapy may in itself influence the structure and function of the brain (Kandel, 1998). Furthermore, Gabbard expressed an opinion that psychotherapy may produce lasting improvements and alter brain functioning (Gabbard, 2001).
Traditionally, it has been assumed that significant psychotherapeutic interaction is reflected in the dreams of the patient. An important part of dreaming occurs during REM sleep. According to Reiser (1997), the neurons in the visual cortex are just as active during REM sleep as when the subject is looking at an outside scene while awake. The capacity for dreaming seems to depend on the early relationship between the mother and her child, with implications for both the psychology and neurophysiology of the infant-mother relationship (Lehtonen, 1997, 2002, 2003).
The "dream screen", also called a dream matrix, can be seen as the basic organization of dream elements (Lehtonen, 1997). The concept was first introduced by Lewin in 1946 (Lewin, 1953), for whom the screen represented the breast during sleep. Later, he concluded that the dream screen is not only a simple projection screen for the dream picture; it is also an integral wish-fulfilling element in the dream. In actual dreaming, the dream screen can exist in the form of a landscape, a mountain or a hill that is able to connect different visual symbols, so the dream can be shaped into a holistic entity. The activation of the dream screen in adult transference during psychoanalysis (Lehtonen, 1997; Rycroft, 1951; Boyer, 1960) and psychotherapy (Saarinen, 2003) signifies a turning point during the psychotherapy process. During a psychoanalytic/psychotherapeutic process the dream screen is able to support a double cathexis, a narcissistic one and an object-related real-person cathexis, which makes the dream screen a bridge from a narcissistic orientation to object relations (Boyer, 1960).
AIM OF THE STUDY
In order to explore the outcome of psychodynamic psychotherapy of a patient with major depression, we analyzed serotonin transporter binding of the brain at baseline and on twelve-month follow-up. The severity of depression was assessed by depression rating scales at baseline and on follow-up after twelve and eighteen months. We also analyzed the psycho-therapy process, placing special emphasis on dreams implying activation of the dream screen. We aimed to clarify by means of our case-report how these two different domains, biological and psychodynamic, might be connected in a real clinical setting. …