Short-term Psychodynamic Therapies for Soma5c Symptom ...al2898/columbia_psychosomatics...Short-term...

Short-termPsychodynamicTherapiesforSoma5cSymptomDisorders

AllanAbbassMD,FRCPCProfessor&ProgramDirector

CentreforEmo:onsandHealthwww.istdp.caDalhousieUniversity,Halifax,Canada

Allan Abbass MD 2017 1

Reference Materials n  Reaching through Resistance.

Detailed manual on ISTDP psychodiagnosis and treatment with case examples

n  www.reachingthroughresistance.com Available on Amazon:

http://a.co/3UGMWx0 n  Graded Format article on

capacity building: http://bit.ly/2gVT7iB Article on Resistance http://reachingthroughresistance.com/wp-content/uploads/2015/02/PsychodynamicPsychiatry2016.pdf

2

n  Hidden from View: A clinician’s guide to Psychophysiological Disorders

n  Written with a Mindbody expert internist Howard Schubiner and written for doctors

n  How to educate, provide first and second line treatments and basic ISTDP methods.

n  Coming out end of 2017-early 2018

n  www.unlearnyourpain.com

Allan Abbass MD 2017

n Evidence

n 5diagnosablemechanismsofSoma:cSymptomForma:on

n Treatmentpathways

Allan Abbass MD 2017 3

Direct Assessment and Treatment of Emotional Factors in Psychosomatic Conditions: Dr. Allan Abbass Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Canada Allan is a leading teacher and researcher in the area of Short-Term Psychotherapy, and author of Reaching through Resistance: Advanced Psychotherapy Techniques, 2015. Thursday, December 7th, 2017 8:30 am – 5:00 pm Breakfast and Lunch is Provided  Helen Wood Hall Auditorium School of Nursing Auditorium 1W-304 255 Crittenden Blvd., Rochester, NY 14620 Online Registration and Additional CME Course Information http://www.cvent.com/d/jtq885

Allan Abbass MD 2017 4

Meta-analysisofShortTermPsychodynamicPsychotherapyforSoma7cDisorders

Abbass,Kisely&Kroenke,2009

23Studies:broadrangeofcondi:onsn MediumtoLargeEffectSizesvscontrolsincreasedover:me

n  Emo:onalExperiencingmoreeffec:vethanInsightfocusedmodels(ES:0.60to1.31)

n Weareprocessofupda:ngthisreview:expect40+studiesAllan Abbass MD 2017 5

IntensiveShort-termDynamicPsychotherapy:Davanloo(+Malan)

n  Withinthecontextofformingtherapeu:caXachmentàunprocessedfeelingsaboutpreviousaXachmentsareac:vated

n  Thisallowsonetodirectlydiagnoseunconsciousemo:onalcontributorstosoma:csymptomsstemmingfromaXachmenttrauma

n  Treatment:handlingavoidantresponses,buildingreflec:vecapacityandenablingthesoma:cexperienceofunprocessedfeelingsaboutaXachmenttrauma.

Allan Abbass MD 2017 6

IntensiveShort-termDynamicPsychotherapyinSoma7cSymptomDis.

n  15publishedoutcomestudiesn  7RandomizedControlledTrials8CaseSeriesn  Costreduc:on>>>treatmentcostn  UrethralSyndrome/PelvicPain,BackPain,Func:onal

MovementDisorders,ChronicHeadache,Pseudoseizures,ChronicPain(3RCTs)IrritableBowelSyndrome,MixedMUS(2studies),AtopicDerma::s,Bruxism,Func:onalNeurologicaldisorders

n  Effectsaremediumtolargeandsustainedinfollow-up(TownandDriessen2013)

n  OutperformedMindfulness-basedStressReduc:onforChronicPain

7 Allan Abbass MD 2017

ISTDPvsMindfulnessbasedStressReduc7onforChronicPainChavooshietal,2015

Allan Abbass MD 2017 8

TotalDoctorandHospitalCosts/pa7ent:N=890

$0.00

$2,000.00

$4,000.00

$6,000.00

$8,000.00

$10,000.00

$12,000.00

$14,000.00

1 yr Pre 1 yr Post 2 yr Post 3 yr Post

Case

Control

NormalPopula:onCosts

17Xcostoffset

Abbass,etal2015,JPsychiatricResearch Allan Abbass MD 2017 9

PseudoseizuresN=28,3.6sessionsofISTDPRusselletal,2016

0

5000

10000

15000

20000

25000

1 yr pre 1 yr post 2 yr post 3 yr post 4 yr post

ISTDP

0

200

400

600

800

1000

1200

1 yr pre 1 yr post 2 yr post 3 yr post 4 yr post

ISTDPHospital Costs Doctor Costs

Normal Population

Allan Abbass MD 2017 10

BOND With

Parents

Allan Abbass MD 2017 11

BOND With

Parents PAIN FEAR

Allan Abbass MD 2017 12

BOND With

Parents PAIN FEAR

Rage, Guilt about the Rage

Allan Abbass MD 2017 13

BOND With

Parents PAIN FEAR

Rage, Remorse about the Rage

Diffuse Symptoms Character disorder

Allan Abbass MD 2017 14

Currentperson

Therapist/Doctor

Pastperson

Allan Abbass MD 2017 15

UnconsciousAnxiety

UnconsciousDefense

UnconsciousFeelings

Allan Abbass MD 2017 16

UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings

1.FocusonFeelingsorDefenses

2.Monitorresponses

Allan Abbass MD 2017 17

MainpaVernsandtreatment

n  Voluntarymusclestenseup,defendanddetachn HELPTOSOMATICALLYEXPERIENCETHEFEELINGS

n  Goflatwithsmoothmuscleanxietyn  Goflatwithmotorconversionn  Goflatwithcogni:veperceptualdisrup:on

n  BUILDCAPACITYTHEFEELTHEFEELINGS:anxietyshiKstovoluntarymuscles

n  THENEXPERIENCETHEFEELINGSAllan Abbass MD 2017 18

1.StriatedMuscleUnconsciousAnxiety

n  HandsClenchn  Arms,Shoulders,Neckn  Intercostal:Sighn  Abdomen,backn  LegsandFeet

àFibromyalgia,tremor,:cs,headache,chestpain,abdominalwallpainn  SeewithIntellectualiza:onaboutfeelingsAllan Abbass MD 2017 19

2.SmoothMuscleUnconsciousAnxiety

n Gastrointes:naln  BloodVesselsn  Airwaysn  Bladderà AbdominalPain,IrritableBowelSyndrome,Dyspepsia,Migraine

à AbsenceofStriatedmuscleanxietyà Mediatedby(unconscious)Repressionoffeelings

Allan Abbass MD 2017 20

3.Cogni7ve-perceptualDisrup7on

n  Dissocia:on,losingtrackofthoughts,poormemory,fain:ng

n  Visualblurring,blindnessn  Dysfunc:onofothersensesn  Hallucina:onsinall5senses:CanperceivePain

n àNeurologicalpresenta:onsn  SeenwithProjec:onoffeelingsandimpulses

Allan Abbass MD 2017 21

4.MotorConversion

n Muscleweaknessn àNeurologyConsulta:onandEmergencyDepartments

n  SeenwithRepression

Allan Abbass MD 2017 22

UnconsciousAnxiety

StriatedMuscleAnxietyIsola:onofAffect

SevereRepression

ModerateRepression

MildRepression

ConsciousFeelings Threshold to experiencing impulse/feelings

Allan Abbass MD 2017 23

UnconsciousAnxiety

StriatedMuscleAnxietyIsola:onofAffect

ConsciousFeelings

1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect

1

3 2

3 2

1

Allan Abbass MD 2017 24

5.Sympathysymptomsn  Guiltaboutragecausesthesamesymptomsasapersonunconsciouslywantedtoinduceinanother.

n  CommonExamples:n  StranglingàChokingn Headdamageàheadache

n  Greaterthan1000videotapecaseexamples

Allan Abbass MD 2017 25

Soma7cpathwaysofimpulsesandfeelings

n  Love:warmthinchestandurgetoembracen  Grief:tearsandthoughtsoflossn  Rage:upwardheatandenergytochestthenhandsthenneckandhead:urgetodoviolence

n  Guilt:dis:nctwavesofpainfulfeelingwithupperbodypainandthoughtsofremorse

Allan Abbass MD 2017 26

Inhibitory Forces Go Down

Somatic Rage Goes up same system

AMA Atlas online Allan Abbass MD 2017 27

Conclusionn  AXachmenteffortsmobilizefeelingsaboutoldaXachments

n  Theseunprocessedfeelingscanac:vateaspectrumofsoma:csymptoms

n  Thisprocesscanbediagnoseddirectlyn  Experiencingthefeelingscanreduceorremovethesymptomsandneedtosuffer(characterchange)

n  Diagnos:candtreatmentimplica:onsforpsychosoma:cdisturbances

Allan Abbass MD 2017 28