The Medial Prefrontal Cortex and the Amygdala

The Medial Prefrontal Cortex and the Amygdala

This is another topic which is primarily for patients. Like the section on the Threat Response what follows is just my method of teaching these concepts to patients. I hope some of these ideas can be helpful to you as you educate your patients. I believe strongly that psycho-education is a powerful tool in our work with patients. Of course, we modify the teaching depending on who we are seeing but straightforward education is one of the best ways to reduce a patient’s anxiety about themselves, increase confidence and self-worth, and continues to make the therapy a more collaborative process.

Most of our patients are somewhat aware of the amygdala and how it plays a role in our response to stress. I focus the teaching on aspects that are related to practical ways they can use this knowledge. I first draw a very primitive schematic of the brain from a lateral view which shows the presence of the temporal lobe. I cannot really draw. I mean, I really can’t draw. So, anything you come up has got to be better than mine. I then make a very large, filled in circle taking up most of the front of the temporal lobe. I tell them the amygdala has several functions but the one we look at is its function as the alarm center of the brain, firing off when there is a threat. For those of us old enough to see the TV show, Lost in Space, or younger, but seen in syndication, the robot is their amygdala with “Danger Will Robinson, Danger!” I tell them the amygdala fires off to alert the entire self to be prepared to handle any threat. I also tell them that the greater the threat the faster it fires, the intensity of the firing increases and the time frame of the firing lengthens. Although this is not fully physiologically accurate, I find it a good model for teaching.

Since alarm and all the accompanying symptoms are the characteristic experience of PTSD, I tell them one thing we must learn is to “dampen” this response. If we can decrease the speed, intensity, and length of amygdala firing, we can then reduce the PTSD symptoms which feel so out of our control. Patients are then very interested in both learning the ways and become dedicated to put them into practice.

The first we all know and is the basis of the others, is the breath. What surprises me is how much our patients do not know how to breathe properly when anxious, even though they may have been taught by several therapists. The first thing I hear is, “I’ve tried that before, it doesn’t work”. This is where we need to be both sympathetic and gentle. My first reaction tends to be something like, “Of course it didn’t work. You didn’t do it right!” I have found that doesn’t tend to go over very well. Go figure. It works better when I acknowledge how difficult it is to learn and practice. I also tell them that until they learn it well, the breathing will be of no use when they are super anxious or panicking so don’t expect to work. It won’t. It must be learned and practiced several times per day when we are not anxious. I do ask them to show me how they are trying to breathe. Many think they are diaphragmatic breathing when they are not. Telling them that though does not help. What I find works better is acknowledging they basically have it right and ask if they are open to learning how to improve what they already are doing. We know that placing our hand on our belly and feeling the outward expansion is crucial. They don’t know though. So, we practice with them.

For the longest time I did not know that was not enough. We can be belly breathing yet our intercostal rib muscles remain tight and we are still in a restrictive breathing pattern. We need the feedback simultaneously from the abdomen and the chest so one hand goes on the abdomen, the other on the heart. Both need to be expanding outward. I noticed for a while that my abdomen expanded but my chest still raised up and not out. So, when it comes to the breathing, if they are having trouble or not doing it at home it is useful to do a little bit of practice and observation each session.

The next good way to “dampen” down the amygdala is not easy for many of our patients. We are both predators and prey animals. As prey, we are herd animals, and are biologically wired to have the amygdala tone down by rejoining the herd. For our patients though, the problem is, “What herd?” “There’s no group I know of, and even if I did I can’t (or wont) go”. “You’re expecting me to do something impossible” And they are correct. Most of them can’t. We tell them to think and tell us one person they feel fairly safe with. If there is no one, we as the therapist, might be that one person. Two people is still a small herd.

But what do we need to do? When weather permits, just a daily walk with that person, outside weather permitting. If they have no one then we walk outside each visit with them. Outside is important as they can begin to feel safety cues outside of their usual safe zone. One rule though. On the walk itself they cannot talk about their anxiety, their depression, or anything that’s going wrong in their lives. They can with their friend or family member about problems at other times, But not on the walk itself. So, what do they talk about? One or more “anchors” we have already identified from the Resource Assignment. In inclement weather instead of a walk, then tea time or coffee time or hot chocolate time indoors. It is critical though that during that time only talk about anchors is permitted. After tea time when they go in another room together then any talk positive or negative is fine.

The third way I teach to “dampen” the amygdala is the most effective both in the short term and continually throughout their lives. This where the medial prefrontal cortex comes in. Again, I use a schematic of the brain and the medial prefrontal cortex which is much simpler than the actual complete anatomy or physiology, but what I teach is close enough, and is easy to grasp. The medial prefrontal cortex is actually two. We have one on each side of the brain. I will refer to it as one just as we refer to the vagal nerves usually as the vagus. It is medial, meaning it sits in the middle of the brain but it is prefrontal so it also sits in the very front of the brain. If we put our finger in the middle of our forehead it sits right behind the skull there. One way to look at the medial prefrontal cortex is as the “mindful brain”. It is the part of our brain that allows us to stand back and look at ourselves. Another way to see it is as the “noticing brain”. We use it to mindfully notice things about ourselves and the environment. The really fascinating part to me is there are a massive number of connections from the medial prefrontal cortex to the amygdala that are inhibitory fibers. The mindful or noticing brain tells the amygdala to “Calm down”. So, the more we use our noticing or mindful brain we get better at “reigning in” a runaway amygdala. When the patients learn about this the begin to understand why we are always harping on “mindfulness, mindfulness, mindfulness” and they also don’t get so irritated with us.

Now, for us as therapists, how do we use this knowledge ourselves to help our patients? We try to make sure that many of our questions of the patient “force” mindful answers. My two favorites are “What is (or was) that like for you?” and, “What do (or did) you notice? There are others you can use or already use but these are the ones I like the most. Sometimes, when I am very tired getting up in the morning, I jokingly ask my wife to go in for me. She is not a therapist so asks me what could she do or say. I tell her all she needs is these two questions and that will probably carry her through most all of the sessions.

So, breathing, joining the small herd (one or two), and training the mindful brain are the best ways our patients can learn to “dampen” down the amygdala.