Neuropsychoanalysis: A Contemporary Introduction by GeorgeNorthoff. Published by Routledge, Abingdon, 2023; 168 pp, £19.99 paperback.

Georg Northoff is a philosopher, psychiatrist and neuroscientist working at the University of Ottawa in Canada. This, his most recent book, contributes to the now two-decade-old interdisciplinary attempt called neuropsychoanalysis to understand how neural activity in the brain transforms into psychic activity. Divided into nine chapters with titles inherently intriguing to psychoanalytic thinking such as ‘Self and narcissism’, ‘Dreams, depression and schizophrenia’, ‘Attachment and trauma’, and ‘Conscious and unconscious’, the book's main takeaway is that while it is true that certain parts of the brain certainly underpin specific functions (e.g., the occipital lobe for vision, the amygdala for fear), there is another dynamic, global aspect to brain function which depends on unique patterns of different kinds of brain wave activity. You could say his aim in this book is to introduce another dimension to understanding the brain, so that space (i.e., where in the brain a function seems to reside) is augmented with an understanding of how the dynamics of time operate as an energetic and essential dimension of brain function as well. He is calling this lens through which he is looking spatiotemporal neuroscience, and each chapter explores how this new way of seeing can allow us to explore familiar concepts in a new way. What he means by ‘spatial’ is how spontaneous activity in the brain occurs topographically through various interacting networks like the default-mode network, salience network, and central executive network, whose relationships seem to be modulated by the brain's global activity. The ‘temporal’ part refers to the brain's fluctuations or oscillations in various frequency ranges (in size order, largest to smallest, these are: gamma, alpha, beta, theta and delta waves) which, together, provide a certain temporal dynamic structure to different brain functions. In his first chapter, ‘Self and narcissism’, Northoff draws on a concept of self he developed over a decade ago in which he argued that there are three layers of self, a bodily interoceptive self, an affective extero-proprioceptive self, and a cognitive, mental self. The interoceptive self is the most basic layer of the self. It is responsible for processing interoceptive stimuli from our own bodies and forms that part of which is known as the salience network, involving different areas of the brain. The next layer, the proprioceptive self, takes account of the environment and processes stimuli such as facial expression and tone of voice, as well as integrating the different sensory modalities, some of which filter up from the interoceptive self. The final layer is the cognitive self, which is largely underpinned by cortical regions forming the default mode network and the central executive network. This enables us to represent our own self in mental states—you could call it the self-reflective self. Northoff makes the point that all these selves are constituted in a spatially nested hierarchy, much like a house needs foundations (the interoceptive self) to hold up walls (the proprioceptive self), which in turn are together needed to hold up the roof (the cognitive self ). And what of the temporal aspect? Well, Northoff argues that the brain's spontaneous neural activity can be characterized by different waves, where power is strongest in the infra-slow range and decreases across the slow, fast and ultrafast ranges following a power law distribution. Together, the different frequencies and their distinct degrees of power constitute a complex temporal structure in the brain's spontaneous activity. The longer and more powerful slower frequencies nest and contain the shorter and less powerful faster frequencies and this amounts to long-range temporal correlation (LRTC), which operates across different time scales or frequencies. Now this gets a bit technical for me, but I think essentially what Northoff is saying is that LRTC amounts to a form of memory that is not defined by specific contents that are encoded, stored, and recalled or retrieved. Instead, memory refers here to the temporal structure of the neural activity across distinct time points. Being temporal and dynamic, LRTC provides not only temporal stability through correlation of different timescales, that is, temporal continuity, but also temporal memory, that is, temporal stability, through connecting past, future and present time points. One could thus speak of temporal or dynamic memory that, as process- and structure-based memory, must be distinguished from the more content-based cognitive memory in the traditional sense. The LRTC thus operates at a deeper layer of the brain, just as psychoanalysis assumed that certain events remain unconscious or non-conscious in the depth of our mind. However, the degree to which that temporal structure, the LRTC of self, is developed strongly shapes the kinds of contents we can recall and remember in our consciousness. For instance, stronger power in slower frequencies (with high LRTC) biases us towards sad contents in our memory, as it is typical of depression, while stronger power in the faster frequencies favours happy and joyful contents, resulting in mania in the most extreme cases. Hence, the deep layer of temporal memory seems to shape the contents of our cognitive memory. How might this be implicated in Narcissism? Northoff cites studies showing that highly narcissistic subjects yielded significantly lower degrees of activity changes during an empathy task (compared with non-empathy tasks), especially in the right anterior insula, when compared with low narcissism subjects. This is of interest as the right anterior insula is the region that nests and connects the three distinct layers of self. Hence, decreased activity in the right anterior insula may indicate decreased degrees of connection and nestedness among the three layers of self in highly narcissistic subjects. Dynamic brain scans of people suffering from early relational trauma (who would likely have disorganized attachment patterns oscillating between dissociative states and impulsive emotionally labile states) show changes in various cortical and subcortical brain regions that belong to the limbic system, including the insula and the orbitofrontal cortex (Schore, 2003). Interestingly, these regions strongly overlap with those recruited during the most basic layer of the interoceptive self in the nested neural hierarchy. As psychotherapists, we spend our days sitting with people whose early experiences with caregivers have given them brains adapted to relating unhappily. It is exciting to me that the science is starting to understand how and what gets sculpted in the brain by aberrant care-giving. Northoff uses his following chapters to describe how a temporo-spatial neuroscience perspective can add interesting new dimensions to familiar psychoanalytic topics, discussing for example how dissociation can be understood as the cognitive self separating from its nesting neural layers below where the default mode network's dynamics dissociate from the slow-fast dynamics of the regions mediating the interoceptive and proprio-exteroceptive layers of the self. He has some interesting ideas about defence mechanisms, for example, arguing their ‘location’ at the interface of self and environment make them intra-psychic and inter-personal at the same time. Thus, defence mechanisms establish the highways between self/ego and environment/object. If, for instance, the lower layer of self, the interoceptive self, is disrupted and reorganized by Adverse Childhood Experiences (see Felitti et al., 1998), the consequences reverberate throughout both the exteroceptive and mental/cognitive self in a manner which resembles more pervasive defence mechanisms such as projection and introjection, underpinning psychosis and depressive disorders. If, in contrast, the mental/cognitive layer of self reorganizes itself due to object relation difficulties occurring later on in development, defence mechanisms producing neurotic symptoms such as reaction formation will predominate, while the intero- and exteroceptive layers remain more or less intact. Neuropsychoanalysis has been enriched in recent years by Karl Friston's application of the Free Energy Principle to understand the brain (see my review of Jeremy Holmes’ book in the August 2021 issue of this Journal). Northoff explores this dimension in Chapter 4 on ‘Cathexis and free energy’. He cites recent studies combining ECoG/electrophysiology and fMRI which demonstrate a direct relationship of fMRI-based global brain activity as measured by the global signal (GS) with electrophysiological measures; these findings suggest that GS is not merely non-neuronal noise but also an important source of neuronal activity itself, responsible for modulating neuronal activity on both the cortical and subcortical levels. He explains that there is a correlation between GS and long-cycle durations of the infraslow and very fast frequencies which underpin how different brain networks sync up together. To support this idea, Northoff describes studies of anaesthesia which show that the brain's GS is strongly reduced, if not absent in these states. Thus, the level of GS may correspond to the level of arousal as the most basic dimension of consciousness. He shows how different sleep stages and dreams exhibit different GS topography from each other, which also distinguishes them from anaesthesia. Interestingly, the dream state includes strong concentration of the global brain activity along the cortical mid-line axis of the default-mode network and visual network regions. He uses the concept of GS to explain how depression or mania come about, arguing that the more the global dynamic is present in, for instance, the default-mode network (DMN), the more energy is invested in internally oriented cognition (like self-reference and mental time travel). In cases of depression, he observes increases in both global DMN activity and self-referentiality (i.e., rumination), while in mania, increased global dynamic can be observed in the motor cortex which, behaviourally, is manifest in psychomotor agitation, which psychodynamically may be associated with an increase in external objects. In this review I hope I have whetted your appetite to read Northoff's book in its entirety as I believe his spatiotemporal neuroscience is an interesting new perspective in the neuropsychoanalysis debate. How it will translate into clinical applications remains to be seen. The NHS has yet to advocate TCMS (trans cranial magnetic stimulation) as effective, though there are increasing numbers of practitioners offering these services in the United States. Perhaps as they become more targeted and better able to manipulate our brain waves, they will have an important place in our therapeutic endeavours. A brain jelly cap wired up to a computer where we sculpt our patients’ brain wave patterns as they free associate may yet become an indispensable addition to our consulting rooms! If I had one criticism, it would be the title of Northoff's book, which is called a ‘contemporary introduction’. I think an introduction should be possible to pick up without prior knowledge of neuropsychoanalysis, but I don't think this book would feel entirely accessible to a reader with no brain topography at their fingertips. I have been following neuropsychoanalysis for over two decades now and there were moments where I struggled to follow. I think for those readers unfamiliar, Peter Afford's helpful and very accessible work, Therapy in the Age of Neuroscience (Routledge, 2020) is a good place to start.

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