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Functional somatic disorders
and (embodied) mentalization:
A mentalization-based
approach to the understanding
and treatment of functional
somatic complaints
Patrick Luyten, PhD
University of Leuven, Belgium
University College London, UK
Overview
• Functional Somatic Syndromes (FSS)
• Causation of FSS
▫ Biological
▫ Psychosocial
Personality
Embodied mentalization
• Implications for treatment
▫ Implications for body and mind in therapy
▫ New treatment: DIT-FSD
=> Building on basic research concerning the emergence of the embodied mind
Research Team
University of Leuven (Belgium): Boudewijn Van Houdenhove, Stefan Kempke, Nicole Vliegen
University College London and the Anna Freud Center (UK): Peter Fonagy, Alessandra Lemma, Mary Target
Tavistock Clinic, London: Brian Rock
Yale University (USA): Linda Mayes, Sidney J. Blatt, Michael Crowley
Functional Somatic Disorders (FSS)
• Spectrum of disorders
▫ High comorbidity
▫ High familial co-aggregation
• Pain- and fatigue-related conditions
▫ Chronic Fatigue Syndrome
▫ Fibromyalgia
▫ Irritable Bowel Syndrome
▫ Temporomandibular Pain Syndrome
Depression
Addiction and Anxiety Disorders
Irritable Bowel Syndrome
Cardio- vascular Disease
Fibromyalgia and Chronic
Fatigue Syndrome
Stress and Emotional Reactivity
Part of Spectrum of Stress-Related
Disorders?
1. Heim C, et al. Arch Gen Psychiatry 2006; 63:1258-66. 2. Imbierowicz K, et al. Eur J Pain. 2003;7:113-9. 3. Dong M, et al. Circulation. 2004;110:1761-6. 4. Drossman DA, et al. Ann Intern Med. 1990;113:828-33. 5. McCauley J, et al. JAMA. 1997;277:1362-8.
Example
Chronic Fatigue Syndrome (CFS)
• Medically unexplained fatigue for at least six months that does not improve with rest
• Other symptoms
▫ Muscle pain
▫ Sore throat
▫ Headaches
▫ Tender glands
▫ Unrefreshing sleep
▫ Impaired memory or concentration
▫ Post-exertional malaise
Causation • Precise causation remains elusive
• However
▫ Biological abnormalities have been identified
HPA axis (stress system)
Immunological systems
Neurotransmitter systems
▫ Psychological factors have been shown to influence the onset and course of CFS
Personality
(embodied) Mentalization
Early childhood adversity/attachment disruptions
Van Houdenhove, B., & Luyten, P. (2011). Listen to the story. CFS patients don’t live in a vacuum. Psychotherapy and
Psychosomatics, 80(2), 113-115.
Early life stress (ELS) and morning cortisol
in CFS patients and normal controls
Heim, C et al. Arch Gen Psychiatry 2009; 66: 72-80.
LN
(S
AL
IVA
RY
CO
RT
ISO
L [
g/d
l])
Minutes after Awakening
CON/No ELS (n=82)
CON/ELS (n=26)
CFS/No ELS (n=30)
CFS/ELS (n=51)
0 15 30 45 60
0.30
0.35
0.40
0.45
0.50
0.55
LN
(S
AL
IVA
RY
CO
RT
ISO
L [
g/d
l])
Minutes after Awakening
CON/No ELS (n=82)
CON/ELS (n=26)
CFS/No ELS (n=30)
CFS/ELS (n=51)
0 15 30 45 60
0.30
0.35
0.40
0.45
0.50
0.55
Early Adversity and Inflammation
Danese A, et al. Proc Natl Acad Sci USA 2007;104:1319-24.
Treatment
• Controversies about treatment
▫ Treatment effects of “evidence-based” treatments are relatively limited
▫ Often known as “difficult” patients: major transference-countertransference problems
Luyten, P., Kempke, S., & Van Houdenhove, B. (2009). Treatment of Chronic Fatigue Syndrome: Findings, Principles and
Strategies. Psychiatry Investigation, 5(4), 209-212.
Luyten, P., & Van Houdenhove, B. (in press). Common versus specific factors in the psychotherapeutic treatment of
patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy Integration
Van Houdenhove, B., & Luyten, P. (2008). Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of
perpetuating factors. Psychosomatics, 49(6), 470-477.
Working model • „Switch' of the stress system from a state of
'overdrive' to 'under-drive‟ as a result of prolonged physical and/or psychological stress
• Often triggered by physical/emotional event
• Leading to persisting impairments in the stress response involving disturbances in:
▫ Disturbed balance between glucocorticoid and inflammatory signaling pathways
▫ Pathological cytokine-induced sickness response effort/stress intolerance and pain hypersensitivity
▫ (embodied) mentalization
Luyten, P., & Van Houdenhove, B. (in press). Common versus specific factors in the psychotherapeutic treatment of
patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy Integration.
Van Houdenhove, B., & Luyten, P. (2011). Listen to the story. CFS patients don’t live in a vacuum. Psychotherapy and
Psychosomatics, 80(2), 113-115.
Working model
• Several of these factors are more likely to be consequence, rather than cause of FSS!!
(e.g., “alexithymia”, interpersonal features)
▫ CFS as “internal object” that threatens the self from within (Schattner, Shahar, & Abu-Shakra, 2008)
• Research program aimed at studying various factors involved and their interaction
• Focus today is on
▫ attachment and (embodied) mentalization
Luyten, P., & Van Houdenhove, B. (in press). Common versus specific factors in the psychotherapeutic treatment of
patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy Integration.
Van Houdenhove, B., & Luyten, P. (2011). Listen to the story. CFS patients don’t live in a vacuum. Psychotherapy and
Psychosomatics, 80(2), 113-115.
Attachment, personality, and
(embodied) mentalization in FSS
Attachment Deactivating,
Self-Critical Perfectionistic (SCP)
features
• FSS patients often described as hard-working, overactive, over-achieving
• High personal standards + high self-criticism
• Assert autonomy and independence as defense against underlying attachment needs (wish to be cared for, loved, recognized)
• Typical attachment deactivating strategy
Luyten, P., & Blatt, S. J. (2011). Integrating theory-driven and empirically-derived models of personality development and
psychopathology: A proposal for DSM-V. Clinical Psychology Review, 31, 52-68.
Van Houdenhove, B., & Luyten, P. (2009). Central Sensitivity Syndromes: Stress System Failure May Explain the Whole
Picture. Seminars in Arthritis and Rheumatism, 39(3), 218-219.
selfself
Intensity of emotional
investment
Most involved
Least involved
Mother
Partner
DaughterTeacher
Best friend
Colleague
Figure 3. Hierarchy of relationships associated with attachment avoidance in self-critical/autonomous
depressed individuals
Attachment Deactivating,
Self-Critical Perfectionism
• Developmental origins: high parental demands and/or a (defensive) reaction against harsh parenting
• “dominant-goal oriented”: overactivity as overcompensation, effort to affirm the self and soothe negative introjects by an often excessive focus on achievements
• May in part and in interaction with other (genetic) vulnerabilities explain “biopsychosocial crash”
• Associated with dysfunctional interpersonal transactional cycles
-> Interpersonal Affective Foci (IPAF)
▫ Self-fulfilling prophecies
▫ Contribute to active stress-generation
▫ Also recur in the transference-countertransference
▫ Bring specific needs and expectations into treatment
IPAF dimensions
Object Representation
Self Representation
Affect
1. A self-representation (eg. Demanding but neglected,
misunderstood, unloved)
2. An object representation (eg. Rejecting others)
3. An affect linking the two (eg. Helplessness)
4. The defensive function of this configuration
(eg. avoidance of own aggression)
SCP features and CFS
• SCP features are associated with CFS in both cross-sectional and longitudinal studies*
• Is clearly distinct from adaptive perfectionism**
• SCP is associated with low self-esteem, which explains higher levels of depression***
*Luyten, P., Van Houdenhove, B., Cosyns, N., & Van den Broeck, A. (2006). Are patients with Chronic Fatigue
Syndrome perfectionistic – or were they? A case-control study. Personality and Individual Differences, 40, 1473-
1483.
**Kempke, S., Van Houdenhove, B., Luyten, P., Goossens, L., Bekaert, P., & Van Wambeke, P. (in press).
Unraveling the role of perfectionism in chronic fatigue syndrome: Is there a distinction between adaptive and
maladaptive perfectionism? Psychiatry Research.
***Kempke, S., Luyten, P., et al. (in press). Self-esteem mediates the relationship between maladaptive
perfectionism and depression in chronic fatigue syndrome. Clinical Rheumatology.
SCP features and CFS
• SCP is associated with stress generation in the daily flow of life, leading to exacerbation of symptoms*
• SCP mediates the relationship between early adversity and stress reactivity in the daily flow of life**
• SCP is negatively associated with treatment outcome***
*Luyten, P., Kempke, S., Van Wambeke, P., Claes, S. J., Blatt, S. J., & Van Houdenhove, B. (2011). Self-critical
Perfectionism, Stress Generation and Stress Sensitivity in Patients with Chronic Fatigue Syndrome: Relationship with
Severity of Depression. Psychiatry: Interpersonal and Biological Processes, 74(1), 21-30.
** Kempke, Luyten et al. (2011). Early adversity in patients with Chronic Fatigue Syndrome: prevalence and effects
on daily symptoms. Manuscript submitted for publication.
*** Kempke, Luyten et al. (2011). Self-critical perfectionism, but not interpersonal dependency, predicts treatment
response in patients with chronic pain. Manuscript submitted for publication.
(Embodied) Mentalizing and FSS
• Dissociation between stress channels?
▫ Typically associated with attachment deactivating strategies
• Paradox: hypo- and hypermentalizing in FSS patients -> “hyperembodiment”-”disembodiment”
▫ Hypomentalizing:
Prementalizing modes of experiencing subjectivity
Importance of “somatic markers” in patients with FSS
▫ Hypermentalizing: “mentalization on the loose”
Luyten, P., Mayes, L. C., Fonagy, P., & van Houdenhove, B. (2010). The interpersonal regulation of stress: A
developmental framework. Manuscript submitted for publication.
Four polarities
• Automatic – controlled
• Internal – external
• Self – other
• Cognitive - affective
Luyten, P., Fonagy, P., Mayes, L., & Vermote, R., Lowyck, B., Bateman, A., & Target (2009). Broadening the scope of the mentalization based approach to psychopathology. Submitted. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381. Fonagy, P., Luyten, P., & Strathearn, L. (in press). The roots of borderline personality disorder in
infancy: A review of evidence from the standpoint of the mentalization based approach.
Infant Mental Health Journal.
Dissociation between stress
channels
• Stress response to experimental stress in CFS
(Trier Social Stress Test; TSST and personalized stress test: Sinha) ▫ T1: Baseline
▫ T2: pre-test (10min)
▫ T3: post-test
▫ T4: +10min
▫ T5: +10min
▫ T6: +10 min
▫ T7: +15min
▫ T8: +45min
Kempke, Luyten, Van Houdenhove, Claes et al. (2011).
Lupien et al., 2009
Psychological
Self:
2nd Order
Representations
Physical Self:
Primary
Representations
Representation
of self-state:
Internalization
of object’s image
Constitutional self
in state of arousal
Expression
Reflection
Resonance
Infant CAREGIVER
symbolic organisation
of internal state
Affect & Self Regulation Through
Mirroring
With apologies to Gergely & Watson (1996) Fonagy, Gergely, Jurist & Target (2002)
Re-emergence of non-mentalizing
modes under increasing arousal
= maladaptive attempts at affect
regulation
• Teleological mode
• Psychic equivalence mode
• Extreme pretend mode
Psychic equivalence mode
• What is thought is felt as real
• Everything becomes too real (e.g., thoughts, feelings)
• Decoupling of Mz or de-symbolization (concreteness of thought): Rejection literally hurts (Eisenberger et al., 2003)
• No room for “pretend”, “play”, symbolization, or inner security of mental exploration
• Particularly in traumatized patients
Psychic equivalence mode • Very painful feelings of shame, sadness,
emptiness, badness, which threaten to disintegrate the self -> evacuation by means of projection, projective identification, dissociation, self-harm
• psychological pain means bodily pain, worries feel like a painful weight on one‟s shoulders, and depressive thoughts literally “de-press” the self
• “hyperembodiment” => de-symbolization
• Risk of fundamental “mis-understanding”, that can be interpreted as unresponsive, rejecting, but also as a re-traumatization, and wilful misunderstanding by a cruel, sadistic therapist
“Somatic markers” of inner mental
states* • Hand clenching, tension, sighing, transpiration,
cramps, head ache, dizziness, pseudoseizures, fainting, throwing up
• Face, Voice (inflections, speech-like vocalizations, …)
• Moving away or towards (e.g., moving head away, closing eyes, mouth, sitting back)
• Little or no awareness of link with inner mental states and interpersonal relationships
*Abbass, A., Campbell, S., Magee, K., & Tarzwell, R. (2009). Intensive short-term dynamic psychotherapy to reduce
rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence
from a pre-post intervention study. Canadian Journal of Emergency Medicine, 11, 529-534.
Psychological
Self:
2nd Order
Representations
Physical Self:
Primary
Representations
Representation
of self-state:
Internalization
of object’s image
Constitutional self
in state of arousal
Expression
Reflection
Resonance
Infant CAREGIVER
symbolic organisation
of internal state
Affect & Self Regulation Through
Mirroring
With apologies to Gergely & Watson (1996) Fonagy, Gergely, Jurist & Target (2002)
Teleological mode
• Behavior and thoughts are equated
• Primacy of the physical/observable
• “I only believe it when I see it”
▫ Only what you see is real
▫ Strong belief in biological causes of disorder (“somatic attributions”)
Extreme pretend mode and
intellectualisation • Cognitive hypermentalization and
intellectualization/rationalisation
▫ Mentalization severed from reality
(“the educated neurotic”, “canned language”)
▫ May lead to wrong impression of therapeutic work and progress
• Affective hypermentalization
▫ Elaborate, overwhelming, confusing narratives (e.g., on TAT, Rorschach)
• Dissociation/”driving oneself crazy”
• “Hypomentalizers”: Sometimes derogation of mental life as such (“alexithymic”)
• Sometimes “hypermentalizers”: may look as highly sophisticated, insightful on first impression, but this often reflects cognitive hypermentalization
= collapses under increasing stress, leading to resurgence of symbiotic needs and negative self-views that are defended against
*Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the
psychodynamic approach to personality. Journal of Research in Personality, 39, 22-45.
Luyten, P., & Van Houdenhove, B. (in press). Common versus specific factors in the psychotherapeutic
treatment of patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy
Integration.
Hypo-hypermentalizing in FSS
A biobehavioral switch model of the relationship
between stress and controlled versus automatic
mentalization (Based on Mayes, 2000)
Attachment - Arousal/Stress
Evidence for hypomentalizing • Alexithymia*
▫ Only small subsample, mainly traumatized/ patients with attachment disorganization
▫ In others patients more likely to be a consequence rather than cause under high arousal conditions
• Subic-Wrana et al.**: reduced theory of mind assessed with a computer animation task in 30 hospitalized SFD patients compared to 30 healthy controls
*Pedrosa Gil, F., Weigl, M., Wessels, T., Irnich, D., Baumuller, E., & Winkelmann, A. (2008). Parental bonding and
alexithymia in adults with fibromyalgia. Psychosomatics, 49(2), 115-122.
Pedrosa Gil, F., Scheidt, C. E., Hoeger, D., & Nickel, M. (2008). Relationship between attachment style, parental bonding
and alexithymia in adults with somatoform disorders. Int J Psychiatry Med, 38(4), 437-451.
**Subic-Wrana, C., Beutel, M. E., Knebel, A., & Lane, R. D. (2010). Theory of Mind and Emotional Awareness Deficits in
Patients With Somatoform Disorders. Psychosomatic Medicine, 72(4), 404-411.
Evidence for hypomentalizing
• Leithner-Dziubas et al. (2010):*
▫ low RF (M=2.3)
▫ But chronic pelvic pain patients, with high rates of Axis I and axs II comorbidity (54.5% and 36.4% respectively), and high rates of affectionless and neglectful parenting
*Leithner-Dziubas, K., Blüml, V., Naderer, A., Tmej, A., & FIsher-Kern, M. (2010). Mentalisierungsfähighkeit und Bindung
bei Patientinnen met chronischen Unterbauchschmerzen: Eine Pilotstudie. Zeitschrift für Psychosomatik und Medische
Psychotherapie, 56, 179-190.
Figure 2. SCORS Dimension of Understanding of Social
Causality as Moderated by the Level of Personality
Organization
Koelen, J., Eurelings-Bontekoe, E. H., Veselka, L., Snellen, W., Bühring, M. E. F., & Luyten,
P. (2011). Social Cognition and Level of Personality Organization in Patients with
Somatoform Disorders: A case control study Manuscript submitted for publication.
Figure 1. SCORS Dimension of Complexity of Representations of
Others in Both Groups by the Level of Personality Organization
Koelen, J., Eurelings-Bontekoe, E. H., Veselka, L., Snellen, W., Bühring, M. E. F., & Luyten,
P. (2011). Social Cognition and Level of Personality Organization in Patients with
Somatoform Disorders: A case control study Manuscript submitted for publication.
hypomentalizing
• Rudimentary insight into social interactions based on stimulus-response causality logic
• Extreme difficulty in describing other people in terms of inner mental states, or character dispositions
• Instead generally „stick‟ to external attributes
Figure 3. SCORS Dimension of Emotional Investment in
Relationships by Level of Personality Organization
Investment in social relationships
• SFD patients are preoccupied with their own need-fulfilment in relationships, and are unable to hold conflicts and discrepancies in mind
Figure 4. SCORS Dimension of Affective Quality of Interactions
as Moderated by the Level of Personality Organization
Affective quality
• Scores for the SFD patients approached normality, in that their expectations from others and relationships are relatively neutral, as opposed to hostile and malevolent
Hypomentalizing with regard to self?
• Oldershaw et al. (2011)
• 45 patients with chronic fatigue syndrome (CFS), 50 healthy controls
• CFS patients had no impairments in different ToM tasks, but did have impairments with regard to social cognition pertaining to the self (levels of emotional awareness) = more complex social cognition
• No impairments in mentalizing outside interpersonal relationships (eg. music emotion test)
• These impairments were associated with lower ability to establish interpersonal relationships
Hypomentalizing with regard to self?
• CFS patients are less likely to interpret physical sensations as emotions (Dendy et al., 2001)
• Have negative beliefs about emotions, and the control and expression of emotions which are highly correlated with SCP (r=.59) (Rimes & Chalder, 2010; Maher et al., in press)
• Associated with socially compliant attitude with underlying hostility (Hambrook et al., 2010)
• Changes in CBT in beliefs about emotions are correlated with decreases in SCP (Rimes & Chalder, 2010)
Hypomentalizing with regard to self?
• consistent with general findings concerning MUS patients in that these are less interoceptively accurate in a symptom-related context (Bogaerts et al.,2008, 2010)
Hypermentalizing?
• Dziobek et al. (in press)
▫ Fibromyalgia participants did not differ from controls on overall theory of mind as measured by the Movie for the Assessment of Social Cognition (MASC)
▫ But did have higher scores on one subscale which taps into overly elaborated/interpreted social cognition (so called „exceeding theory of mind‟).
Developmental roots?
• Attachment trauma, and particularly emotional neglect, is associated with mentalizing impairments
• In FSS?
▫ High levels of insecure attachment and emotional neglect in particular
▫ Only emotional neglect predicted attachment deactivating strategies in CFS patients which in turn predicted worse clinical functioning
▫ Poor “mind-reading” in parents of adolescents with CFS
Conclusions
• Impairments in (embodied) mentalizing related to combination of
▫ Early adversity (poor mirroring/emotional neglect)
▫ Use of attachment deactivating strategies
▫ High arousal (as a consequence of disorder and current interpersonal relationships) further impairs mentalizing
▫ Impairments in self versus other mentalizing
▫ Impairments in cognitive versus affective mentalizing
Four polarities
• Automatic – controlled
• Internal – external
• Self – other
• Cognitive - affective
Luyten, P., Fonagy, P., Mayes, L., & Vermote, R., Lowyck, B., Bateman, A., & Target (2009). Broadening the scope of the mentalization based approach to psychopathology. Submitted. Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381. Fonagy, P., Luyten, P., & Strathearn, L. (in press). The roots of borderline personality disorder in
infancy: A review of evidence from the standpoint of the mentalization based approach.
Infant Mental Health Journal.
Shared neural circuits for mentalizing about the
self and others (Lombardo et al., 2009; J. Cog.
Neurosc.)
Self mental state
Other mental state
Overlapping for
Self and Other
Implications for Treatment
Luyten, P., & Van Houdenhove, B. (in press). Common versus specific factors in the
psychotherapeutic treatment of patients suffering from chronic fatigue and pain
disorders. Journal of Psychotherapy Integration.
Dynamic Interpersonal Theory - FSD
• Builds on insights into the development of the embodied mind
• DIT-FSD assumptions:
▫ Symptoms are related to threats to attachment system
▫ Reflect impairments in stress/affect regulation associated with secondary attachment strategies and resulting mentalizing impairments
Lemma, A., Target, M., & Fonagy, P. (2009). Dynamic Interpersonal Therapy. London:
Oxford University Press.
Lemma, A., Target, M., & Fonagy, P. (in press). The development of a brief
psychodynamic intervention (Dynamic Interpersonal Therapy) and its application to
depression: A pilot study. Psychiatry: Interpersonal and Biological Processes.
DIT-FSD
• Basic principles:
▫ Define and work through typical Interpersonal Affective Focus (IPAF)
▫ Starting from symptoms, “somatic markers” and often feeling of not being recognized/accepted/understood
• “Dangers” in SCP patients:
▫ Denial of role of psychological factors
▫ Pseudomentalization (“pseudoprofessional”)
▫ “pseudo-engagement”
Early Phase • Validation
▫ Validation of negative experiences resulting from the illness and response by others (“understanding lack of understanding”)
▫ Support the patient in seeking help for complaints • Inquisitive, mentalizing stance
▫ Immediate interest in mental states concerning self and others, and the link between both
▫ Modeling curiosity about mental states ▫ Using own experience as example ▫ Focus on “somatic markers” of emotions ▫ Linking emotions to interpersonal relationships
• Modesty ▫ Apologizing for mistakes ▫ Being modest about therapeutic aims
Defended Emotion
Figure. Triangle of Conflict
Defense Anxiety
Early Phase
• Aims:
▫ Engagement of patient
▫ Recovery of mentalizing, mainly through focus on symptoms and relationships-> sense of control and meaning
▫ Defining IPAF as focus of treatment
• Spectrum of interventions
▫ Supportive/empathic
▫ Simple mentalizing interventions focusing of affect: emotion recognition, emotion differentiation
▫ Linking inner mental states to symptoms and relationships
▫ Mentalizing the transference
▫ Directive
• Key role of IPAF
▫ Linking symptoms/mental states to relationships
▫ Identifying representation of self and other and linking affects and defensive strategy
Conclusions • Impairments in (embodied) mentalization may
play a role in onset and particularly course of FSS
• Has important implications for treatment, regardless of theoretical orientation
• May provide important insights into the origin of the embodied mind
• Current studies focus on
▫ Relationship with stress system (HPA axis), genetic polymorphisms, neural systems
▫ Intergenerational transmission
▫ Treatment development: process and outcome of DIT-FSD
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