Short-termPsychodynamicTherapiesforSoma5cSymptomDisorders

AllanAbbassMD,FRCPCProfessor&ProgramDirector

CentreforEmo:onsandHealthwww.istdp.caDalhousieUniversity,Halifax,Canada

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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

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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

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n Evidence

n 5diagnosablemechanismsofSoma:cSymptomForma:on

n Treatmentpathways

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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

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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.

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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

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ISTDPvsMindfulnessbasedStressReduc7onforChronicPainChavooshietal,2015

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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

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BOND With

Parents

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BOND With

Parents PAIN FEAR

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BOND With

Parents PAIN FEAR

Rage, Guilt about the Rage

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BOND With

Parents PAIN FEAR

Rage, Remorse about the Rage

Diffuse Symptoms Character disorder

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Currentperson

Therapist/Doctor

Pastperson

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UnconsciousAnxiety

UnconsciousDefense

UnconsciousFeelings

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UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings

1.FocusonFeelingsorDefenses

2.Monitorresponses

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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

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3.Cogni7ve-perceptualDisrup7on

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

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

n àNeurologicalpresenta:onsn  SeenwithProjec:onoffeelingsandimpulses

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4.MotorConversion

n Muscleweaknessn àNeurologyConsulta:onandEmergencyDepartments

n  SeenwithRepression

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UnconsciousAnxiety

StriatedMuscleAnxietyIsola:onofAffect

SevereRepression

ModerateRepression

MildRepression

ConsciousFeelings Threshold to experiencing impulse/feelings

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UnconsciousAnxiety

StriatedMuscleAnxietyIsola:onofAffect

ConsciousFeelings

1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect

1

3 2

3 2

1

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5.Sympathysymptomsn  Guiltaboutragecausesthesamesymptomsasapersonunconsciouslywantedtoinduceinanother.

n  CommonExamples:n  StranglingàChokingn Headdamageàheadache

n  Greaterthan1000videotapecaseexamples

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Soma7cpathwaysofimpulsesandfeelings

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

n  Guilt:dis:nctwavesofpainfulfeelingwithupperbodypainandthoughtsofremorse

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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

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