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        Articolo allegato al numero monografico (N. 11, anno VI, gennaio 2009) di Frenis Zero dal titolo "Autobiografie dell'inconscio".

 

 

  " LUTTO E MELANCONIA RIVISITATO: corrispondenze tra i principi della metapsicologia freudiana e le scoperte empiriche della neuropsichiatria"

 

 

 

 

 

 di Robin L. Carhart-Harris1  , Helen S. Mayberg2  , Andrea L. Malizia1  , David Nutt1

1Psychopharmacology Unit, University of Bristol, Bristol, UK

2Emory University School of Medicine, Atlanta, GA 30322, USA

 

 

Il presente articolo è la traduzione italiana di "Mourning and melancholia revisited: correspondences between principles of Freudian metapsychology and empirical findings in neuropsychiatry", uscito su "Annals of general Psychiatry" 2008, 7:9. Il testo contenuto in questa pagina corrisponde alla prima metà dell'articolo originale. L'articolo nella sua integralità verrà proposto in un prossimo libro, pubblicato dalle Edizioni Frenis Zero, dedicato al dialogo tra psicoanalisi e neuroscienze. La traduzione in italiano è di Giuseppe Leo.

Abstract

Freud began his career as a neurologist studying the anatomy and physiology of the nervous system, but it was his later work in psychology that would secure his place in history. This paper draws attention to consistencies between physiological processes identified by modern clinical research and psychological processes described by Freud, with a special emphasis on his famous paper on depression entitled 'Mourning and melancholia'. Inspired by neuroimaging findings in depression and deep brain stimulation for treatment resistant depression, some preliminary physiological correlates are proposed for a number of key psychoanalytic processes. Specifically, activation of the subgenual cingulate is discussed in relation to repression and the default mode network is discussed in relation to the ego. If these correlates are found to be reliable, this may have implications for the manner in which psychoanalysis is viewed by the wider psychological and psychiatric communities.

 

 


 

 

 

PREMESSA

<<Quando qualche idea nuova approda nella scienza, e viene salutata all'inizio come una scoperta e come tale viene di regola  anche messa in discussione, la ricerca obiettiva subito dopo rivela che dopo tutto in realtà non si trattava di una novità>>1   .

L'intenzione di questo articolo è quella di attirare l'attenzione sulle concordanze tra la metapsicologia freudiana e le recenti scoperte in neuropsichiatria, specialmente quelle riguardanti la depressione.  Sarà fatto un esempio di come le scoperte nelle tecniche di 'imaging' cerebrale ed in neurofisiologia possano fornire un contesto rinnovato per la maggior parte delle fondamentali teorie della psicoanalisi. Nel suo famoso scritto "Lutto e melanconia", Freud  operò un'elegante applicazione della teoria psicoanalitica alla malattia depressiva. E' compito del presente articolo creare dei parallelismi tra i processi psicologici descritti da Freud e quelli fisiologici identificati dalla moderna ricerca clinica al fine di fornire una più ampia comprensione dell'intero fenomeno.

tto la tutela di Meynert, Freud iniziò la sua carriera come neurologo studiando l'anatomia e la fisiologia del midollo spinale. Ispirato dalla tradizione di Helmholtz (1821-1894) e dal "parallelismo psico-fisico" reso affascinante da Hering (1838-1918), Sherrington (1857-1952) e Hughlings-Jackson (1835-1911), Freud cominciò a considerare più seriamente il modo in cui una scienza di movimenti energetici cerebrali potesse dar conto dei fenomeni psicologici2  . E' stato detto che Freud non ha mai veramente abbandonato le sue radici fisiologiche3-4  e che i suoi primi 'flirts' con il parallelismo psico-fisico abbiano continuato ad abitare <<l'intera serie dei [suoi] lavori teorici fino all'ultimo>>4   .

Questo nostro lavoro inizierà con una rassegna di alcuni concetti chiave della metapsicologia freudiana (libido, investimento, investimento oggettuale, Io, Super-Io, Es, inconscio, processo psichico primario e secondario, rimozione) e verrà fatto un tentativo di ipotizzare i loro correlati fisiologici. Farà seguito una sintesi di "Lutto e melanconia" ed un ampio sguardo alle scoperte più rilevanti della neuropsichiatria. Di particolare interesse sono quelle emergenti dalle tecniche di "neuroimaging" per quanto riguarda la depressione e l'umore depresso provocato, la stimolazione cerebrale profonda(DBS) di una prozione dell'area cingolata ("subgenual cingulate"- area di Brodmann 25/Cg25) per il trattamento della depressione resistente, la stimolazione elettrica delle regioni mediali del lobo temporale, e l'atrofia regionale e perdita gliale nel cervello di pazienti affetti da depressione maggiore.

Prima di iniziare, è importante fare pochi brevi commenti sul principale parallelismo psico-fisico. Tracciare delle connessioni tra fenomeni psicologici e biologici era un approccio verso cui Freud era sia critico:

<<Eviterò accuratamente la tentazione di determinare la localizzazione psichica in qualsiasi modalità anatomica>> [5]

<<Ogni tentativo di scoprire una localizzazione dei processi mentali... è fallito completamente. Lo stesso destino attenderà ogni teoria che tenti di riconoscere la posizione anatomica del sistema [di coscienza] - come presente a livello corticale, e di localizzare i processi inconsci nelle parti sottocorticali del cervello. C'è uno hiatus che al momento non può essere colmato, e nemmeno è questo uno dei compiti della psicologia da portare a compimento. La nostra topografia psichica allo stato attuale non ha nulla a che vedere con l'anatomia>>[6].

ma anche ricettivo:

<<Tutte le nostre idee provvisorie in psicologia si baseranno presumibilmente un giorno su una sottostruttura organica>> [7]

L'ambiguità nella posizione di Freud si può spiegare col suo essere critico nei confronti dell'approccio modulare o "segregazionista" [8] e con la sua preferenza per un modello più dinamico [9]. Essenzialmente, Freud era contrario a votare per le cause anatomiche dei fenomeni psicologici, ma non al tracciare dei paralleli tra processi psicologici e fisiologici:

<<E' probabile che la catena degli eventi fisiologici del sistema nervoso non stia in connessione causale con gli eventi psichici. Gli eventi fisiologici non cessano appena cominciano quelli psichici; al contrario, la catena fisiologica continua. Ciò che accade è semplicemente che, dopo un certo istante temporale, ognuno (o qualcuno) dei suoi collegamenti ha un fenomeno psichico corrispondente a se stesso. Di conseguenza, lo psichico è un processo parallelo al fisiologico - "un concomitante dipendente" [9].

Integrare la psicoanalisi con le moderne neuroscienze è uno sforzo difficile e controverso. Si dovrebbe chiarire sin dall'inizio ciò che crediamo possibile si possa ottenere con questo approccio. La psicoanalisi può essere vista su due livelli: un livello ermeneutico, interpretativo o basato sul significato; ed uno metapsicologico, basato sui processi mentali.  Il livello ermeneutico è di per se stesso soggettivo. La questione che spesso è stata sollevata è se sia possibile identificare delle coordinate spaziotemporali di significato soggettivo. A questa visione ha dato il suo contributo Paul McLean nel suo libro fondamentale "The triune brain in evolution" [10]:

<<Dato che il cervello soggettivo fa unicamente affidamento sulla derivazione dell'informazione immateriale, non si può mai stabilire un metro immutabile per se stesso... L'informazione è informazione, non materia o energia>> [10].

Sarebbe non corretto ascrivere questa posizione al dualismo. Il parallelismo psicofisico è un approccio materialista che riconosce che il significato emerge nl tempo tra le reti dei sistemi comunicativi. E' necessario affermare che l'evidenza citata in questo articolo non può logicamente convalidare la psicoanalisi a livello ermeneutico e neppure fornisce alcuna prova sull'efficacia della psicoanalisi come modalità di trattamento (si veda alla nota [11] per una rassegna). Ciò che crediamo si possa fare, comunque, è riunire linee convergenti di ricerca a supporto della topografia freudiana della mente. Le scoperte citate nel seguito di questo articolo descrivono cambiamenti nei processi fisiologici che sono paralleli a cambiamenti nei processi psicologici; comunque, le misurazioni oggettive non gettano nessuna luce sullo specifico contenuto o significato avuto all'interno di questi processi. Accanto all'interpretazione, molto del lavoro di Freud è stato dedicato alla teorizzazione dei processi psichici dinamici; le energie che fluiscono dentro e fuori dalle province mentali, l'energia investita, ostruita e scaricata nell'ambito della mente. E' questo livello metapsicologico della psicoanalisi che  crediamo sia il più accessibile all'integrazione con le moderne neuroscienze.

 
Un'introduzione a qualche termine chiave della metapsicologia freudiana
Libido

<<Libido significa in psicoanalisi in primo luogo la forza (che si pensa possa essere variabile e misurabile quantitativamente) delle pulsioni sessuali dirette verso un oggetto - "sessuale" nel senso esteso richiesto dalla teoria analitica >> [12].

A partire dal suo primissimo uso che sia mai stato registrato [13] il termine "libido" è stato utilizzato per denotare la principale energia del sistema nervoso. Freud differenziò la "libido" da una più generale "energia psichica":

<<Abbiamo definito il concetto di libido come una forza variabile in senso quantitativo che potrebbe servire come misura dei processi e delle trasformazioni che avvengono nel campo dell'eccitamento sessuale. Distinguiamo questa libido rispetto alla sua speciale origine dall'energia che si deve supporre sottenda i processi mentali in generale>> [14].

L'uso estensivo fatto da Freud del termine "sessuale" lo ha portato ad essere in conflitto con Jung, il quale ipotizzò che la principale energia del sistema nervoso non fosse di per se stessa sessuale [15]. Verosimilmente, le due prospettive non sono inconciliabili. Possiamo considerare la "libido" freudiana in connessione con il sistema pulsionale motivazionale (si veda oltre il paragrafo su l'Es) e con il ritiro e l'investimento dell'energia cerebrale (si veda oltre il paragrafo sull'Io). L'"energia psichica" di Jung può essere considerata in modo meno specifico come energia cerebrale in generale.

 
Investimento ("cathexis")

L'originale tedesco "Besetzung" si traduce letteralmente come "occupazione", "riempimento" o "investimento". Il neologismo "cathexis" non era particolarmente amato da Freud [16]. Freud per primo usò il termine su un livello esplicitamente fisiologico, riferendosi ai neuroni << "cathected" con una certa quantità di [energia] [2], sistemi <<caricati con una somma di eccitazione>> [17] e <<provvisti di una quota di affetto>> [18]. In breve, il termine "cathexis" significa "investimento libidico". E' un concetto importante in modo vitale per l'integrazione della metapsicologia freudiana con i principi delle moderne neuroscienze. In questo articolo, discutiamo i cambiamenti della risposta emodinamica e di altre misure neurofisiologiche in relazione al ritiro  e all'investimento della libido.

 
Investimento oggettuale ("Object cathexis")

Il concetto di "oggetto" è usato in un senso vasto in psicoanalisi per riferirsi ad oggetti letterali, astratti e simbolici. Persone, compiti, attività ed idee possono tutti servire da oggetti. Il processo dell'investimento oggettuale ("objet cathexis") può essere confrontato con il processo della conoscenza diretta verso un obiettivo, dato che entrambi richiedono investimento libidico. Sulla base dei dati di "neuroimaging" sulla depressione (si veda oltre nel paragrafo su "Scoperte neuropsichiatriche nella depressione correlate coi principi della metapsicologia freudiana"), proponiamo che l'attivazione della corteccia prefrontale dorsolaterale (DLPFC) si correli con l'investimento oggettuale, mentre una riduzione di tale attivazione sia correlata con un diminuito investimento oggettuale che si manifesta in depressione sotto forma di anedonia (si veda oltre il paragrafo sull'ipofrontalità). Come discusso in questa sessione, l'attivazione del DLPFC è accompagnata da una de-attivazione in una rete di regioni note come rete neuronale della modalità di funzionamento di base ("default-mode network" - DMN) [19]. Il DMN è altamente attivo in condizioni di riposo cognitivo. Le regioni coinvolte durante l'attivazione cognitiva vengono qui denominate rete orientata all'oggetto ("object-oriented network"- ON). Proponiamo che l'attivazione dell'ON e la de-attivazione del DMN si correlino col processo di investimento oggettuale.

 
L'io

L'originale tedesco "das Ich" traduce in modo letterale "l'Io". E' spiacevole che i termini di Freud non siano stati tradotti in modo più letterale dato che gli originali contengono un richiamo che si è perso nella traduzione.

Freud usava il concetto di io in una gran varietà di differenti modi; un modo utile di ottenere un significato di differenti applicazioni, consiste nel citare qualche esempio del suo uso:

1. Un referente del senso conscio del sé:

<<In ogni individuo c'è un'organizzazione coerente dei processi mentali; e questo lo chiamiamo il suo io. E' a questo io che la coscienza si attacca>> [1].

2. Una forza inconscia che mantiene la coesione del sé:

<<E' certo che gran parte dell'io è esso stesso inconscio e soprattutto quello che possiamo chiamare il suo nucleo; solo una piccola porzione di esso è coperta dal termine "preconscio">> [20].

3. Un nucleo di coesione somatica:

<<L'io è per prima cosa e principalmente un io corporeo>> [1].

4. Una riserva di libido:

<<Perciò ci formiamo l'idea che c'è un originario investimento libidico dell'io, da cui qualcosa viene in seguito destinato agli oggetti>> [7].

<<L'io è una vera ed originaria riserva di libido>> [20].

5. L'agente primario della rimozione:

<<L'io è la facoltà che mette in moto la rimozione>> [12].

Dato che ci sono molte differenti funzioni dell'io, sarebbe contro-intuitivo suggerire che esso abbia dimora in una data regione del cervello. Sulla base di un gran numero di studi di "neuroimaging", proponiamo che una rete altamente connessa di regioni, principalmente incorporate nella corteccia mediale prefrontale (mPFC), nella corteccia posteriore cingolata (PCC), nel lobulo parietale inferiore (IPL) e nelle regioni temporali mediali [19, 21-31], soddisfi molti dei criteri dell'io freudiano. Questa conglomerazione di attività è stata denominata la "rete della modalità di funzionamento base" ("default mode network") [19] (figura 1).

 

thumbnailFigura 1. Regioni positivamente correlate con il " default mode network" (in arancione), soprattutto la corteccia mediale prefrontale (mPFC), la   corteccia cingulata posteriore (PCC), il   lobulo  parietale inferiore e    le regioni temporali mediali. L'attività in queste regioni si è dimostrato che diminuisce  durante la prestazione cognitiva diretta verso un obiettivo. Le aree mostrate in blu sono  negativamente correlate con il "default mode network" (DMN) e possono essere descritte come una rete orientata verso l'oggetto "object-oriented network" (ON). L' ON è attivato in modo consistente durante i compiti cognitivi diretti verso un obiettivo, ma è relativamente inattivo in condizioni di riposo. Si ipotizza nel presente articolo che il  DMN sia funzionalmente coerente con l'io freudiano. L' immagine  è riprodotta col permesso di http://www.blackwellsynergy.com/ webcite[289].

 
Un'analisi recente in un ampio campione di volontari sani ha mostrato che la connettività all'interno del DMN subisce un marcato aumento con la maturazione dall'infanzia all'età adulta [31]. L'attività nel nodo mediale prefrontale del DMN è stato strettamente associato con l'auto-riflessione (si veda ad es., [22,24,27,32]) e recenti evidenze suggeriscono che la corteccia mediale prefrontale (mPFC)  eserciti la principale causalità all'interno di questa rete [33]. La corteccia posteriore cingolata (PCC) ed il lobulo parietale inferiore (IPL) sono stati associati con la propriocezione [34,35] mentre la corteccia posteriore cingolata (PCC) e le regioni temporali mediali sono state associate al recupero dei ricordi autobiografici [36-39]. Il DMN mostra un alto livello di connettività funzionale in condizioni di riposo [28,33]. L'attività in questa rete diminuisce in modo consistente durante l'impegno in compiti cognitivi diretti verso un obiettivo [28, 33, 40] e la connettività all'interno della rete neuronale  tende a diminuire durante gli stati di ridotta coscienza [41,42]. In termini freudiani, la cognitività diretta verso un obiettivo richiede uno spostamento di libido (energia) dalla riserva dell'io (il DMN) e del suo investimento negli oggetti (attivazione del DLPFC). Ci sono evidenze per cui questa funzione  venga ad essere compromessa in un gran numero di disturbi psichiatrici, compresa la depressione [43-48].

 

<<L'io è una grande riserva  da cui la libido, che è destinata agli oggetti, fluisce via ed a cui ritorna da quegli oggetti>> [49].

In aggiunta ai nodi del mPFC e del PCC nell'ambito del DMN e alla loro relazione con l'io, ipotizziamo sulla base dei dati di "neuroimaging" e delle scoperte provenienti dalla stimolazione cerebrale profonda ( si veda oltre il paragrafo sulle scoperte neuropsichiatriche nella depressione correlate coi principi della metapsicologia freudiana) che la corteccia mediale prefrontale (PFC) nella porzione ventromediale (vmPFC) eserciti una forte influenza inibitrice sui centri emozionali e motivazionali ("visceromotori") [50]. Questa forza inibitrice è la funzione più primitiva dell'io. Come viene  oltre elaborato questo punto, la corteccia prefrontale ventromediale (vmPFC) gioca un ruolo importante  nella patofisiologia della depressione. Ad esempio, si è trovato che l'inibizione della regione ventrale del ginocchio del corpo calloso, l'area cingolata Cg25, allevia la sintomatologia depressiva in pazienti affetti da depressione resistente (TRD) [51]. L'area Cg25 e la regione ad essa prossimale sembrano esercitare un'influenza modulatoria sui centri chiave "visceromotori" come l'amigdala, l'area tegmentale ventrale (VTA) ed il nucleus accumbens (NAc) [50, 52]. Si è visto che certi centri limbici (ad es., l'amigdala) sono patologicamente attivi nella depressione (si veda la voce bibliografica [50] per una rassegna).

 
 
 
(L'articolo continua su un prossimo libro delle Edizioni Frenis Zero)

       

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