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The Social Brain:The Social Brain:

Perspective of aPerspective of aPsychiatrist-in-Psychiatrist-in-

TrainingTrainingMorton SoslandMorton Sosland

Research CommitteeResearch Committee

Group for the Advancement of Psychiatry (GAP)Group for the Advancement of Psychiatry (GAP)Other committee members: Russell Gardner, Beverly Sutton, JohnOther committee members: Russell Gardner, Beverly Sutton, John

Beahrs, Jacob Kerbeshian, Fred Wamboldt, Alan Swann, JohanBeahrs, Jacob Kerbeshian, Fred Wamboldt, Alan Swann, JohanVerhulst, Michael Schwartz, Carlo Carandang, Doug Kramer, JohnVerhulst, Michael Schwartz, Carlo Carandang, Doug Kramer, John

LooneyLooney


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Copyright SLACK IncorporatedCopyright SLACK Incorporated

Used with PermissionUsed with Permission

Reprint web siteReprint web siteHttp://www.slackinc.com/reprintsHttp://www.slackinc.com/reprints

Morton D. Sosland, The SocialMorton D. Sosland, The SocialBrain and the Psychiatrist inBrain and the Psychiatrist in

Training,Training, Psychiatric Annals,Psychiatric Annals,

35:10, pp 854-866, 2005.35:10, pp 854-866, 2005.
http://www.slackinc.com/reprintshttp://www.slackinc.com/reprintshttp://www.slackinc.com/reprints


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The Psychiatry TraineesThe Psychiatry Trainees

DilemmaDilemma

MS: Child Psychiatry Fellow on committeeMS: Child Psychiatry Fellow on committee

for 2 yearsfor 2 years

Psychiatry divided in biological &Psychiatry divided in biological &

psychologicalpsychological

Each gives different explanation:Each gives different explanation: For why patients sufferFor why patients suffer

For treatment choicesFor treatment choices

Divides psychiatric facultyDivides psychiatric faculty

Psychiatry training affected in residency andPsychiatry training affected in residency and

fellowshipfellowship

Affects available future professionalAffects available future professionalopportunitiesopportunities


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T.M. Luhrmann wroteT.M. Luhrmann wrote

(in)(in)Of Two Minds: The Growing DisorderOf Two Minds: The Growing Disorder

in American Psychiatryin American PsychiatryYoung psychiatrists are supposed toYoung psychiatrists are supposed to

learn to be equally good at both talklearn to be equally good at both talk

therapy and drug therapy,therapy and drug therapy,

psychotherapy and biomedicalpsychotherapy and biomedical

psychiatry, and the Americanpsychiatry, and the American

Psychiatric Association thinks thatPsychiatric Association thinks that

this integration is what trainingthis integration is what trainingprograms in psychiatry teach.programs in psychiatry teach.

Psychiatrists are supposed toPsychiatrists are supposed to

understand these approaches asunderstand these approaches as


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T.M. LuhrmannT.M. LuhrmannOf Two MindsOf Two Minds

Yet they are taught as different tools,Yet they are taught as different tools,

based on different models, and usedbased on different models, and used

for different purposes. Somefor different purposes. Some

psychiatrists do integrate them topsychiatrists do integrate them to

some extent. But those who do havesome extent. But those who do have

to integrate two approaches that areto integrate two approaches that are

different from the outset that carrydifferent from the outset that carrywith them different models of thewith them different models of the

person, different models ofperson, different models of

causation, and different expectationscausation, and different expectations


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Problems for PatientsProblems for Patients

Psychiatrist division & confusion about thePsychiatrist division & confusion about thecause and treatment for illness so patientscause and treatment for illness so patientsfeel so equally or morefeel so equally or more Chemical imbalance or genetic in natureChemical imbalance or genetic in nature

(biological)?(biological)? Or social or psychological?Or social or psychological? If chemical or genetic in causation, why useIf chemical or genetic in causation, why use

psychotherapy?psychotherapy? If psychological/from family or upbringing, thenIf psychological/from family or upbringing, then

why medication?why medication? Social brain explanations clarifySocial brain explanations clarify

psychiatric illnesspsychiatric illness In my own mind,In my own mind,

In the minds of my patients,In the minds of my patients, And more effective treatment strate iesAnd more effective treatment strate ies


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Social Brain Definition ISocial Brain Definition I

The social brain framework helpsThe social brain framework helps

organize and explain allorganize and explain all

psychopathology.psychopathology.

A single gene-based disorder likeA single gene-based disorder like

Huntington disease is expressed to aHuntington disease is expressed to a

large extent as social dysfunction.large extent as social dysfunction.

Conversely, traumatic stress hasConversely, traumatic stress has

structural impact on the brain asstructural impact on the brain as

does the socially interactive processdoes the socially interactive process

of psychotherapy.of psychotherapy.


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Social Brain Definition IISocial Brain Definition II

The social brain concept suggestsThe social brain concept suggests

Unifying explanation for how brainsUnifying explanation for how brains

developeddeveloped

Why mental illness exists and how itWhy mental illness exists and how it

affects usaffects us

It offers hope for how to treat mentalIt offers hope for how to treat mentalillness more effectively using aillness more effectively using a

unified approach.unified approach.


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Social Brain Definition IIISocial Brain Definition III

Psychiatric disorders fundamentallyPsychiatric disorders fundamentally

entail social communicationentail social communication

problems for those afflictedproblems for those afflicted

Successful human interactionSuccessful human interaction

depends on communication withdepends on communication with

other peopleother people


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Social Brain Definition IVSocial Brain Definition IV

Attachment stems from collaborativeAttachment stems from collaborative

communication.communication.

Secure attachment involves contingentSecure attachment involves contingent

communication,communication, Signals from one person gain direct response bySignals from one person gain direct response by

the otherthe other

Children learn from parentsChildren learn from parents

Good, loving and functional patterns of behaviorGood, loving and functional patterns of behavior

oror

Dysfunctional behaviors, e.g.Dysfunctional behaviors, e.g. AggressionAggression

Poor responses to stress, orPoor responses to stress, or


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Social Brain IntegratesSocial Brain Integrates

When available and done in anWhen available and done in an

integrated manner, the teamintegrated manner, the team

approach worksapproach works

& all patients, even when no team& all patients, even when no team

involved,involved,

Benefit when viewed with 3 componentsBenefit when viewed with 3 components

combinedcombined

Doesnt replace BPS: social brainDoesnt replace BPS: social brain

idea extends itidea extends it


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Social Brain IntegratesSocial Brain Integrates

Brain involved in & resulted fromBrain involved in & resulted from

social interactions, thereforesocial interactions, therefore

Social brain defines a biological systemSocial brain defines a biological system

at the biological, psychological, andat the biological, psychological, andsocial intersectionsocial intersection

All thoughts and emotions stem fromAll thoughts and emotions stem from

neural connections andneural connections andneurotransmitters in the context ofneurotransmitters in the context of

social learningsocial learning


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Social Definition inSocial Definition in DSM-DSM-

IVIV Psychiatrys social componentPsychiatrys social component

critically figures in any DSM-IVcritically figures in any DSM-IV

diagnosisdiagnosis

Patients inability to function sociallyPatients inability to function socially

or occupationally (occupationsor occupationally (occupations

represent social functions) makes arepresent social functions) makes a

critical diagnostic distinction.critical diagnostic distinction.


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IVIVThroughoutThroughout DSM-IVDSM-IV, we read:, we read:

The symptoms cause clinically significantThe symptoms cause clinically significant

distress or impairment in social, occupational, ordistress or impairment in social, occupational, or

other important areas of functioning.other important areas of functioning. Helps diagnose Major Depressive Episode,Helps diagnose Major Depressive Episode,

Dementia, Generalized Anxiety Disorder,Dementia, Generalized Anxiety Disorder,

Personality Disorders & others.Personality Disorders & others.

Other specialties differOther specialties differ Cardiologists do not need social function to defineCardiologists do not need social function to define

MIMI

How one works does not help define diabetes inHow one works does not help define diabetes in

endocrinologyendocrinology


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IVIV Substance Abuse diagnosis includesSubstance Abuse diagnosis includes

the criterion of failure to fulfill majorthe criterion of failure to fulfill major

role obligations at work, school, orrole obligations at work, school, or

home.home.

Many childhood psychiatric disordersMany childhood psychiatric disorders

possess definitions partially based onpossess definitions partially based on

the childs poor social interactionsthe childs poor social interactions Pervasive developmental disordersPervasive developmental disorders

quintessentially defined by socialquintessentially defined by social

interactionsinteractions


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ADHD Selected ForADHD Selected For

Some have examined ancient human ancestorsSome have examined ancient human ancestors GAP Child Committee asked:GAP Child Committee asked:

Did social environment affect human brains inDid social environment affect human brains inevolutionary times?evolutionary times?

Through an evolutionary biological lens, someThrough an evolutionary biological lens, somemental disorders seem an adaptive response tomental disorders seem an adaptive response toearly pathogenic environmentsearly pathogenic environments

And/or they reflect the optimization of brainAnd/or they reflect the optimization of brainfunction to some environments at the cost offunction to some environments at the cost of

poorer response to the demands of otherpoorer response to the demands of otherenvironmentsenvironments

Given current estimated frequency of ADHD (3% toGiven current estimated frequency of ADHD (3% to5%):5%):

Seems likely such prevalence maintained by selectionSeems likely such prevalence maintained by selectionforcesforces


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Group MembershipGroup Membership

A neuroimaging study examined subjectsA neuroimaging study examined subjects

rejected by peers in a computer gamerejected by peers in a computer game

Brain reacted to social rejection as it reacted toBrain reacted to social rejection as it reacted to

painpain In same mannerIn same manner In same anterior cingulate cortex locationIn same anterior cingulate cortex location

Our brains wire us as social animals.Our brains wire us as social animals.

Anciently survival likely depended onAnciently survival likely depended ongroup-membership so thatgroup-membership so that

Pain of social rejectionPain of social rejection people to remain inpeople to remain in

social groupssocial groups


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Gene-Life StressorsGene-Life Stressors

Interact For DepressionInteract For Depression 5-HTT gene has a promoter region5-HTT gene has a promoter region

either short or long alleleeither short or long allele

Result: Depression more likely withResult: Depression more likely with

double or single copies of shortdouble or single copies of short

alleles (s/l or s/s)alleles (s/l or s/s)

Stressful life events = problems withStressful life events = problems with

employment, finances, housing,employment, finances, housing,

relationships and the social stress ofrelationships and the social stress of

physical health problemsphysical health problems


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Gene-Life StressorsGene-Life Stressors

Interact For DepressionInteract For Depression

More detal: if 4 or more stressful lifeMore detal: if 4 or more stressful life

events happen between the ages ofevents happen between the ages of

21 and 26,21 and 26,

33% of those with at least one short33% of those with at least one short

allele (s/s or s/l) became depressedallele (s/s or s/l) became depressed

compared to 17% of those with the l/lcompared to 17% of those with the l/l

genotype.genotype.The study also examinedThe study also examined

associations between childhoodassociations between childhood

maltreatment between ages 3 andmaltreatment between ages 3 and


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Verbal CommunicationVerbal Communication

Adaptation over evolutionary timeAdaptation over evolutionary timewired human brains forwired human brains forcommunication among peoplecommunication among people

Large brain proportion forLarge brain proportion forcommunicationcommunication

Cerebral cortex does verbal &Cerebral cortex does verbal &nonverbal messagingnonverbal messaging pattern recognition & pattern generationpattern recognition & pattern generation

for writingfor writing

facial recognitionfacial recognition

planning behaviorsplanning behaviors


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Learning Through SocialLearning Through Social

InteractionsInteractions Research on stress and genesResearch on stress and genes

indicatesindicates

Social interactionsSocial interactions neural connectionsneural connections

do not end in early development.do not end in early development.

Social interactions more influenceSocial interactions more influence

receptive brains earlyreceptive brains early

Neurons more plastic thenNeurons more plastic then But brains continue development throughoutBut brains continue development throughout

lifelife


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Learning Through SocialLearning Through Social

InteractionsInteractions Learning causes new connections inLearning causes new connections in

brainbrain

This happens through relationshipsThis happens through relationships

People learn new ways of handlingPeople learn new ways of handling

situationssituations

Such happens through psychotherapy.Such happens through psychotherapy.

Important learning with parents,Important learning with parents,

siblings, spouses, friends, children,siblings, spouses, friends, children,

workplace & communityworkplace & community


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BeliefsBeliefs

We frequently test beliefs andWe frequently test beliefs and

change themchange them

In isolation, belief change harderIn isolation, belief change harder

Versus discussing ideas with anotherVersus discussing ideas with another

whowho

Reinforces orReinforces or

Provides a new perspectiveProvides a new perspective

If a new perspective stems fromIf a new perspective stems from

another, one changes beliefs moreanother, one changes beliefs more

readilyreadily


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BeliefsBeliefs

Some stick to dysfunctionalSome stick to dysfunctional

relationship patternsrelationship patterns

Those thrive best if open to life-longThose thrive best if open to life-long

learninglearning

They work on improving relationshipsThey work on improving relationships

byby

Testing out old patterns of behaviorTesting out old patterns of behavior

Rejecting dysfunctional beliefsRejecting dysfunctional beliefs

Developing new beliefsDeveloping new beliefs

Evolving new approaches to lifeEvolving new approaches to life


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Social Learning TheorySocial Learning Theory

Rockland: Behavior, personal factors, andRockland: Behavior, personal factors, and

social forces all operate as interlockingsocial forces all operate as interlocking

determinants of one anotherdeterminants of one another

Behavior stems from the environmentBehavior stems from the environment People play roles in creating the social milieu &People play roles in creating the social milieu &

other circumstances that arise in their dailyother circumstances that arise in their daily

transactions.transactions.

Humans: advanced capacity forHumans: advanced capacity forobservational learningobservational learning

Enables them knowledge and skills expansionEnables them knowledge and skills expansion

From modeling influencesFrom modeling influences


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Two Memory SystemsTwo Memory Systems

Learning involves two memory systemsLearning involves two memory systems

used togetherused together

Declarative or explicit system andDeclarative or explicit system and

Procedural or implicit system involvesProcedural or implicit system involves Striatum mediate skills & habitsStriatum mediate skills & habits

Amygdalae (+ neocortex & cerebellum) mediateAmygdalae (+ neocortex & cerebellum) mediate

emotionsemotions

Unconscious physical & emotional memories work inUnconscious physical & emotional memories work in

thesethese

When something new learned, declarativeWhen something new learned, declarative

memory works 1memory works 1stst & procedural memory to variable extents& procedural memory to variable extents

Constant repetition moves declarative toConstant repetition moves declarative to


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Two Memory SystemsTwo Memory Systems

Experience of frightening situation orExperience of frightening situation or

traumatic eventtraumatic event declarative memories in hippocampus mixdeclarative memories in hippocampus mix

with emotional memories in amygdalawith emotional memories in amygdala Person may later feel depressed & anxiousPerson may later feel depressed & anxious

when emotional memories reactivatewhen emotional memories reactivate

Procedural and emotional memories in theProcedural and emotional memories in the

amgydalaamgydala MayMay bodys autonomic systembodys autonomic system

leading to fight or flight reactionsleading to fight or flight reactions

Faster breathing & heart rate with sweating skinFaster breathing & heart rate with sweating skin

Reactions = PTSD symptoms.Reactions = PTSD symptoms.


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Brain-Affected PatientsBrain-Affected Patients

Combined medication &Combined medication &

psychotherapy works better thanpsychotherapy works better than

either aloneeither alone

Even diagnoses viewed as primarilyEven diagnoses viewed as primarily

biological benefit frombiological benefit from

psychotherapypsychotherapy

Psychotherapy of course is notPsychotherapy of course is notunbiologicalunbiological


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ADHDADHD

ADHD exemplifies a disorder with a largeADHD exemplifies a disorder with a large

neurobiological & genetic componentneurobiological & genetic component

NIMH Collaborative Multisite MultimodalNIMH Collaborative Multisite Multimodal

Study of Children with Attention-Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA):Deficit/Hyperactivity Disorder (MTA):

Combined medication-behavior management =Combined medication-behavior management =

68% success68% success

Medical management only = 56% successMedical management only = 56% success Behavior therapy alone = 34% successBehavior therapy alone = 34% success

Combined improvement compared to othersCombined improvement compared to others

statistically significantstatistically significant


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Combined BipolarCombined Bipolar

Treatment BestTreatment Best Agreement: one with bipolar disorderAgreement: one with bipolar disorder

needs medicationneeds medication Yet psychotherapy makes a significantYet psychotherapy makes a significant

differencedifference

LamLam et alet al examined cognitive therapyexamined cognitive therapyadjunctivelyadjunctively 103 patients with bipolar disorder103 patients with bipolar disorder

Randomized designRandomized design

Cognitive tx group: 14 psychotherapyCognitive tx group: 14 psychotherapysessions in 1sessions in 1stst half year 2 booster sessionshalf year 2 booster sessionsduring 2during 2ndnd half yearhalf year

Relapse results over the year:Relapse results over the year:


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Combined Bipolar Tx: MoreCombined Bipolar Tx: More

ResultsResults Controls without cog tx:Controls without cog tx:

>3-fold more time in bipolar episodes (mean, 88>3-fold more time in bipolar episodes (mean, 88

days)days) Compared with cognitive therapy group (mean, 27Compared with cognitive therapy group (mean, 27

days).days). 33% without cog tx needed hospital adm for33% without cog tx needed hospital adm for

bipolar episodesbipolar episodes Compared to 15 % of patients with therapyCompared to 15 % of patients with therapy

Cognitive therapy: patients developedCognitive therapy: patients developedskills to monitor moodsskills to monitor moods

Plus any prodromal symptomsPlus any prodromal symptoms

Modified moods/behavior before prodrome full-Modified moods/behavior before prodrome full-

blownblown

C bi d S hi h iC bi d S hi h i


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Combined SchizophreniaCombined Schizophrenia

TxTx Psychotic beliefs blossom ifPsychotic beliefs blossom if

Isolation continuedIsolation continued

No opportunity nor desire to reality-testNo opportunity nor desire to reality-test

Cognitive Behavioral therapists encourage patientsCognitive Behavioral therapists encourage patients

To examine alternative explanationsTo examine alternative explanations With sometimes profound results, e.g.,With sometimes profound results, e.g.,

When auditory hallucinations become not outside forceWhen auditory hallucinations become not outside force

But strong thoughts in their heads.But strong thoughts in their heads.

Patient may also learn behavioral techniques thatPatient may also learn behavioral techniques that

stop voicesstop voices This reduces stress to internal voice with lessenedThis reduces stress to internal voice with lessened

reactionreaction

Changes in cells and molecules still result inChanges in cells and molecules still result inschizophrenia butschizophrenia but Isolation + lack of reality testingIsolation + lack of reality testing worsened illnessworsened illness


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MS Experience with OP TxMS Experience with OP Tx

of Schizophreniaof Schizophrenia

Co-led with M.W. Deibler group withCo-led with M.W. Deibler group with

schizophrenia.schizophrenia.

Several heard auditory hallucinations duringSeveral heard auditory hallucinations during

sessions.sessions. Focused on testing out behavioral strategies,Focused on testing out behavioral strategies,

such as humming or reading, to control auditorysuch as humming or reading, to control auditory

experienceexperience

Plus looked at alternative explanations forPlus looked at alternative explanations forvoicesvoices

Social form of group therapy provedSocial form of group therapy proved

helpful to severalhelpful to several

Isolative hallucination changed to controllableIsolative hallucination changed to controllable

ki f


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Turkington: OP Tx ofTurkington: OP Tx of

SchizophreniaSchizophrenia

Psychologic meanings help in psychotxPsychologic meanings help in psychotx

adjunctive to medicationadjunctive to medication

Beneath systematized delusions and derogatoryBeneath systematized delusions and derogatory

hallucinations lies a personalized meaning, or ahallucinations lies a personalized meaning, or aschema, that drives symptomsschema, that drives symptoms

A personal storylineA personal storyline

I am a bad person idea may foster aI am a bad person idea may foster a

voice that expresses itvoice that expresses it In response, patient forms beliefs about theIn response, patient forms beliefs about the

voice,voice,

e.g., devil speaks, or alien sources produce thee.g., devil speaks, or alien sources produce the

soundssounds

T ki t OP T fT ki t OP T f


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Turkington: OP Tx ofTurkington: OP Tx of

SchizophreniaSchizophrenia Frightening interpretations may triggerFrightening interpretations may trigger

anxiety & withdrawalanxiety & withdrawal This worsens more hallucinations & otherThis worsens more hallucinations & other

symptomssymptoms

Cognitive & behavioral interventionsCognitive & behavioral interventions Include alternative explanations for the voicesInclude alternative explanations for the voices

Relaxation training to reduce anxiety,Relaxation training to reduce anxiety,

Activity scheduling,Activity scheduling,

A voice diary to encourage patients to disputeA voice diary to encourage patients to disputethe content of the voicesthe content of the voices therefore to gain control over themtherefore to gain control over them

Plus other strategies for advanced copingPlus other strategies for advanced coping


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Split Treatment: ChallengeSplit Treatment: Challenge

So social brain thinking withSo social brain thinking with

implications meansimplications means

Psychotherapy & other socialPsychotherapy & other social

interventions should happen as well asinterventions should happen as well asmedicationmedication

Challenge: combined approachChallenge: combined approach

difficultdifficult In era of managed careIn era of managed care

Split model of psychiatrist-therapistSplit model of psychiatrist-therapist

Separate functions determined bySeparate functions determined by


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Many work where medicating =Many work where medicating =

responsibilityresponsibility

But patients social relationships helpBut patients social relationships help

understand recoveryunderstand recovery

Should enhance the placebo effect toShould enhance the placebo effect to

its fullestits fullest

Engage meaningfully with patientEngage meaningfully with patient

Inquire on complianceInquire on compliance

Including reasons for non-complianceIncluding reasons for non-compliance


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Many psychiatrists for various reasonsMany psychiatrists for various reasonschoose to focus more on the biologicalchoose to focus more on the biologicalside of psychiatry,side of psychiatry, They limit their model of diagnosis & treatmentThey limit their model of diagnosis & treatment

But error to omit recognition/appreciationBut error to omit recognition/appreciationof the social side of treatmentof the social side of treatment Incredibly importantIncredibly important

regardless of how intervention happensregardless of how intervention happens

Plus we need to assist patients in socialPlus we need to assist patients in socialinteractions in the community and withinteractions in the community and withtheir familiestheir families

Think of vocational training or continuingThink of vocational training or continuingeducationeducation


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Even with a newest antipsychotic orEven with a newest antipsychotic or

antidepressantantidepressant

Just sitting home alone boredJust sitting home alone bored

Patients more likely relapse into depression orPatients more likely relapse into depression orpsychosispsychosis

As one woman with schizoaffectiveAs one woman with schizoaffective

disorder saiddisorder said

An idle mind is the devils workshop.An idle mind is the devils workshop.

Vocational Training doesnt work in allVocational Training doesnt work in all

cases, butcases, but

When it does it gives a purpose in lifeWhen it does it gives a purpose in life

--

MS C l i fMS C l i f


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MS Conclusions forMS Conclusions for

Psychiatrist in TrainingPsychiatrist in Training

As a psychiatrist in training, I felt excitedAs a psychiatrist in training, I felt excited

About using various sociophysiologicalAbout using various sociophysiological

interventionsinterventions

Only with both communication & drugscan oneOnly with both communication & drugscan onemost effectively treatmost effectively treat

Psychiatric AnnalsPsychiatric Annals offered a past issue onoffered a past issue on

treatment resistant depressiontreatment resistant depression

ECT, adjunctive medication, & cognitiveECT, adjunctive medication, & cognitivebehavior therapy each possessed empiricalbehavior therapy each possessed empirical

supportsupport

To help patients bestTo help patients best

Patients need biological, psychological & socialPatients need biological, psychological & social

R fReferences


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ReferencesReferences Luhrmann TM.Luhrmann TM. Of Two Minds: The Growing Disorder in American Psychiatry.Of Two Minds: The Growing Disorder in American Psychiatry. NewNew

York, NY: Alfred A. Knopf; 2000. p. 7.York, NY: Alfred A. Knopf; 2000. p. 7. Jensen, PS, Mrazek D, Knapp PK, Steinberg, L, Pfeffer, C, Schowalter J, Shapiro, T.Jensen, PS, Mrazek D, Knapp PK, Steinberg, L, Pfeffer, C, Schowalter J, Shapiro, T.

Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation. J. AmEvolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation. J. AmAcad. Child Adolesc. Psychiatry 36:12, Dec 1997. 1672-1679.Acad. Child Adolesc. Psychiatry 36:12, Dec 1997. 1672-1679.

Eisenberger NI, Lieberman MD, Williams KD.Eisenberger NI, Lieberman MD, Williams KD. Does rejection hurt? An fMRI study ofDoes rejection hurt? An fMRI study ofsocial exclusion.social exclusion. Science.Science. 2003;302:290-292.2003;302:290-292.

Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, McClay J, Mill J, MartinCaspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, McClay J, Mill J, MartinJ, Braithwaite A, Poulton R. Influence of life stress on depression: moderation by aJ, Braithwaite A, Poulton R. Influence of life stress on depression: moderation by apolymorphism in the 5-HTT gene. Science. Vol 301, 18 July 2003, 386-389.polymorphism in the 5-HTT gene. Science. Vol 301, 18 July 2003, 386-389.

Hjelle, L.A. and Ziegler, DJ, Personality Theories: Basic Assumptions, Research, andHjelle, L.A. and Ziegler, DJ, Personality Theories: Basic Assumptions, Research, and

Applications, third edition. McGraw-Hill, Inc., USA, 1992 p 336.Applications, third edition. McGraw-Hill, Inc., USA, 1992 p 336. Rockland, LH. Supportive Therapy: A Psychodynamic Approach. Basic Books, (1989)Rockland, LH. Supportive Therapy: A Psychodynamic Approach. Basic Books, (1989)United States of America. pp. 250-251.United States of America. pp. 250-251.

Kandel, ER. Biology and the Future of Psychoanalysis: A new intellectual frameworkKandel, ER. Biology and the Future of Psychoanalysis: A new intellectual frameworkfor psychiatry revisited. Am J. Psychiatry 156:4. April 1999. 505-524.for psychiatry revisited. Am J. Psychiatry 156:4. April 1999. 505-524.

Swanson, JM. Clinical Relevance of the Primary Findings of the MTA: Success RatesSwanson, JM. Clinical Relevance of the Primary Findings of the MTA: Success RatesBased on Severity of ADHD and ODD Symptoms at the End of Treatment. J of ChildBased on Severity of ADHD and ODD Symptoms at the End of Treatment. J of Childand Adolescent Psychiatry. 40 (2), Feb 2001, pp 168-179.and Adolescent Psychiatry. 40 (2), Feb 2001, pp 168-179.

Lam DH, Watkins ER, Hayward P, Bright, J, Wright K, Kerr N, Parr-Davis G, Sham P. ALam DH, Watkins ER, Hayward P, Bright, J, Wright K, Kerr N, Parr-Davis G, Sham P. A

randomized controlled study of cognitive therapy for relapse prevention for bipolarrandomized controlled study of cognitive therapy for relapse prevention for bipolaraffective disorder. Arch Gen Psychiatry. Vol 60, Feb 2003. 145-152.affective disorder. Arch Gen Psychiatry. Vol 60, Feb 2003. 145-152.

Turkington, D. Psychologic Mechanisms of Psychosis. Johns Hopkins UniversityTurkington, D. Psychologic Mechanisms of Psychosis. Johns Hopkins UniversitySchool of Medicine Advanced Studies in Medicine. Vol 3, Sept. 2003. S773-S775.School of Medicine Advanced Studies in Medicine. Vol 3, Sept. 2003. S773-S775.

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