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Psychodynamic therapy in patients with somatic symptom disorder
Psychodynamic therapy in patients with somatic symptom disorder
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Patrick Luyten1,2, Celine De Meulemeester1 and Peter Fonagy2 1 Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium, 2 Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
People with persisting somatic complaints comprise a large subset of patients across the different tiers of healthcare. A recent meta-analysis based on 32 studies in 24 countries (total N 5 70,085 patients) estimated that up to 50% of patients in primary care present with at least one somatic complaint that cannot be readily explained by medical causes, with approximately 30% of patients fulfilling criteria for somatic symptom disorder (Haller, Cramer, Lauche, & Dobos, 2015). In tertiary care, up to 9% of patients present with more than one type of somatic symptom disorder (Bass & May, 2002). There is a wide variety of functional somatic symptoms affecting the different body systems. Almost every medical specialty has defined syndromes in which patients present with a particular set of symptoms (see Table 13.1) (Wessely & White, 2004). Evidence is amassing that functional somatic disorders (FSDs) are part of a spectrum of functional somatic syndromes with common genetic, pathophysiological, and psychological mechanisms. Studies have suggested high levels of comorbidity and familial coaggregation among the syndromes (Aggarwal, McBeth, Zakrzewska, Lunt, & Macfarlane, 2006). Furthermore, their high comorbidity with depression and anxiety and similarities in terms of stress response have led to the assumption that they are part of a spectrum of affective disorders (Hudson et al., 2003). This chapter first provides a contemporary attachment perspective to understanding patients with FSDs and empirical evidence supporting this perspective. Next, it discusses how this understanding can be translated into a systematic treatment approach. We provide a clinical example of the systematic treatment approach and end with a discussion of future areas for research and clinical practice.
Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00013-1 © 2019 Elsevier Inc. All rights reserved.
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Table 13.1 Examples of functional somatic symptoms in different medical specialties. Type of functional somatic symptoms
Medical specialty
Chronic fatigue syndrome Fibromyalgia, chronic widespread pain, back pain Irritable bowel syndrome, dyspepsia Chronic pelvic pain Noncardiac chest pain, functional palpitations Hyperventilation syndrome Tension headache, migraine, functional neurological disorder, conversion disorder, somatosensory disorder Urethral syndrome, interstitial cystitis Dermatitis, inflammatory dermatosis Laryngospasm, pharyngospasm, temporomandibular syndrome, bruxism Multiple chemical sensitivity
Internal medicine Rheumatology Gastroenterology Gynecology Cardiology Respiratory medicine Neurology Urology Dermatology Otolaryngology Allergy/immunology
An attachment and mentalizing approach to FSDs Assessment and heterogeneity of FSDs Patients with FSDs are very heterogeneous in terms of the role of both psychological and biological factors in their symptoms. Hence, any generalization about the role of biological and psychological factors in these patients is clinically unproductive. We have learned to refrain from trying to provide such answers, which are always based on group research. Indeed, in any given case it is often quite difficult, if not impossible, to gauge the respective role of these factors, particularly as the clinician’s knowledge of the patient and his or her condition is typically very limited at the start of any treatment. As treatment progresses, the picture typically becomes clearer, and then this question may be—and typically is—revisited. In this respect, it is always wise to make sure the patient has undergone thorough medical screening. Similarly, for most patients a detailed psychological assessment is indicated, focusing on possible problems related to attachment issues; (embodied) mentalizing, that is, the capacity to reflect on their own (embodied) self and others; and epistemic trust, the capacity to trust others as a source of knowledge, including the knowledge that the clinician offers concerning the patient’s own presenting problems. This assessment determines to a large extent the therapeutic options for the patient and the subsequent focus of treatment.
Attachment and emotion regulation in FSDs Impairments in stress and emotion regulation, typically resulting from complex interactions among biological and environmental factors, are a key feature in FSDs (Tak & Rosmalen, 2010). Many FSD patients have experienced chronic
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overburdening of the stress system as a result of physical and/or psychological stress and conflict, leading to a state of allostatic load (McEwen, 2007) that disrupts the dynamic equilibrium (allostasis) typical of the stress regulation system and neurobiological systems associated with the stress response. These systems mainly include the immune and pain-regulating systems and associated biomediators. Physical and psychological stressors are often closely intertwined, as is demonstrated by the finding that many patients with FSDs show a pattern of overactivity, which chronically overburdens the stress system (Luyten, Van Houdenhove, Lemma, Target, & Fonagy, 2013; Van Houdenhove & Luyten, 2008). The emergence of pain and fatigue-related complaints leads to additional stress and conflict, not least because these patients often encounter invalidating responses from others. This leads in turn to the patients experiencing feelings of inferiority and being a failure. A vicious cycle ensues, characterized by increasing emotional distress and conflict; the individual begins to function in a constant state of fight-or-flight. This is why any understanding of the origins of FSDs that does not take into consideration the roles and function of the attachment system is, in our view, problematic. The attachment system is a biobehavioral system that is activated in response to distress and thus plays a key role in restoring allostasis, the dynamic equilibrium that characterizes biological functioning (McEwen, 2007). In normative development, activation of the attachment system leads the individual to seek proximity to attachment figures. When attachment figures are available and responsive, this typically leads to effective downregulation of distress (see Fig. 13.1). This experience is gradually generalized, leading to feelings of agency and efficacy in the face of adversity based on the underlying belief that others will be there to provide support, care, and validation in times of need. Normative stress regulation thus always involves a process of coregulation in relation to attachment figures (Diamond, Stovall-McClough, Clarkin, & Levy, 2003; Sbarra & Hazan, 2008). The neurobiology of the process of coregulation is increasingly understood; it mainly involves the mesocorticolimbic dopaminergic reward system, which underlies the attachment system. This system is responsible not (A) Downregulation of distress via the normally functioning attachment system
(B) Hyperactivation of the attachment system in the context of FSD
Distress/ fear
Distress/ fear
Exposure to threat –
Activation of attachment
–
Adverse emotional experience
Activation of attachment
Downregulation of emotions Proximity seeking
Proximity seeking
Figure 13.1 The relationship between the attachment and stress regulation systems.
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only for the rewarding nature of attachment relationships, but also for the downregulation of neuroendocrine stress regulation systems, including the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system (Luyten & Fonagy, 2018). Persistent somatic complaints make the normative downregulation of distress effectively impossible, as there simply is no (or very little) relief possible from these conditions. This typically leads to a breakdown of the normative stress regulation process, even in individuals who were securely attached before the onset of their complaints. The patient is forced to shift to the use of so-called secondary attachment strategies, that is, affect regulation strategies that are used when the primary or normative stress regulation strategy fails (Mikulincer & Shaver, 2007). There are two main secondary attachment strategies. The first involves hyperactivation of the attachment system. This involves anxious efforts to find understanding, support, and relief and is expressed in increasingly demanding, clinging, and claiming behavior (Waller & Scheidt, 2006). The second involves deactivation of the attachment system; attachment needs are denied, and the patient resorts to a stance emphasizing autonomy, independence, and strength (Cassidy & Kobak, 1988; Mikulincer & Shaver, 2007). This strategy is often expressed in high levels of self-critical perfectionism, persistence, overactivity, and all-or-nothing behavior (Luyten et al., 2011). Although secondary attachment strategies may bring some temporary relief, they are associated with high interpersonal and metabolic costs. Becoming increasingly demanding characteristically leads to frustration with and often rejection by others, confirming the patient’s fear that others will abandon or reject him or her. This self-fulfilling prophecy may have a disastrous impact both on the patient’s intimate relationships and on relationships with health professionals. As a result, allostatic load further increases, which further increases these patients’ tendency to cling on to others in an attempt to find support, relief, and understanding from them (Maunder & Hunter, 2008). Hyperactivation of the attachment system ensues. Presenting oneself as completely self-reliant and invulnerable, as is typical of patients who excessively use attachment-deactivating strategies, increasingly leads to feelings of isolation and loneliness (Mikulincer & Shaver, 2007). Suppressing emotional distress leads to increasing allostatic load, which may lead to a complete “biopsychosocial crash” of the stress system as a result of the “wear and tear” caused by chronic stress. At this point, attachment-deactivating strategies typically fail, and the patient becomes highly anxious, needy, and/or depressed (Mikulincer, Dolev, & Shaver, 2004). It is important to recognize that for many FSD patients, attachment issues are not necessarily present before the onset of their condition but may emerge as a consequence of the persistent somatic complaints and continuing allostatic load, leading to the breakdown of the normative coregulation of stress and overreliance on the secondary attachment strategies outlined above (see Fig. 13.2). Of course, some patients do have a history of disrupted attachment before the onset of their complaints. Studies in animals and humans have demonstrated an association between early adversity and vulnerability to stress-related symptoms. For patients
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Predisposing factors
Environmental
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Biological
Stress and allostatic load
Precipitating factors
Secondary attachment strategies
Mentalizing impairments
Perpetuating factors Perpetuating behaviors
Figure 13.2 Contemporary psychodynamic understanding of individuals with functional somatic disorders.
who fall into this subgroup, existing attachment issues may be aggravated by the experience of FSD. This has important implications for the treatment of these patients (Luyten, Mayes, Target, & Fonagy, 2012; Luyten & Van Houdenhove, 2013).
Mentalizing in FSDs Disruptions in stress regulation and the excessive use of secondary attachment strategies typically lead to a serious disruption in the capacity for mentalizing, that is, the capacity to interpret the self and others in terms of intentional mental states (feelings, wishes, desires, goals, etc.) and, in particular, in the capacity for embodied mentalizing. Embodied mentalizing refers to the ability to interpret the body as the seat of emotional life and as being intrinsically part of one’s own self-definition and self-image. Chronic somatic complaints typically impair and distort this capacity; somatic symptoms are often experienced as an “attack” from within on the patient’s capacity to reflect. Patients with chronic illness have been described as
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experiencing their illness as an “internal object” that is constantly threatening them and that needs to be negotiated with and soothed (Schattner, Shahar, & Abu-Shakra, 2008). In regard to the reflective capacities of FSD patients, earlier formulations of FSD have focused on alexithymia, that is, a general lack of emotional awareness and the inability to describe emotional states. However, only a subset of FSD patients (15% 22%) were found to have clinical levels of alexithymia (Pedrosa Gil, Scheidt, Hoeger, & Nickel, 2008; Pedrosa Gil, Weigl, et al., 2008; Waller & Scheidt, 2006). Alexithymia is not specific to FSD but is also found in other disorders, and it reflects the effects of childhood trauma more generally; only a subset of patients with FSD have such a history. Moreover, evidence suggests that, rather than exhibiting a global deficit in emotional awareness, patients with FSDs have more specific difficulties in embodied mentalizing. For instance, many of these patients are unable to link their emotional states to their own body. They are also less accurate in describing their own physical sensations (Bogaerts et al., 2010). Furthermore, patients with FSDs tend to have negative beliefs about expressing their own emotions (Hambrook et al., 2011). FSD patients’ impairments in mentalizing typically are evident as an oscillation between excessive mentalizing (hypermentalizing), expressed in apparently highly sophisticated narratives about mental states that lack any grounding in subjective experience, and hypomentalizing, that is, the almost complete denial of the importance of inner mental states. In the face of pervasive and persistent somatic complaints, three so-called nonmentalizing modes that are characteristic of earlier developmental stages may reemerge, perpetuating the patient’s symptoms and relationship difficulties (see Box 13.1).
Epistemic distrust and FSDs FSD patients are often considered to be difficult to treat (Fischhoff & Wessely, 2003), but this notion is neither accurate nor helpful. In addition to being overwhelmed by the continuing distress of their somatic symptoms, FSD patients are often confronted with disbelief and skepticism from others. Furthermore, health professionals often use unhelpful diagnostic labels and obsolete models of FSDs, offer pessimistic prognoses, and frequently underestimate patients’ need for validation. As a result, many FSD patients feel severely misunderstood, invalidated, and bitter (Blom et al., 2012). The concept of epistemic trust is helpful in this context. Epistemic trust is, in essence, the capacity to trust others as a reliable source of knowledge about the world (including one’s condition) and to see others as being able to convey knowledge that is personally relevant and that can be generalized. This capacity first develops in the context of early attachment relationships and is dependent upon the quality of those relationships. Epistemic distrust is particularly prevalent among individuals with dismissive and disorganized attachment styles, as are commonly
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Box 13.1 Three nonmentalizing modes in patients with functional somatic disorders Psychic equivalence mode G
G
G
Patients equate inner (mental) states with outer reality; the internal has the same power as the external. Intolerance of alternative perspectives, leading to concrete understanding. Managed in therapy by the therapist avoiding being drawn into nonmentalizing discourse. The therapist validates the patient’s thoughts and feelings but suggests alternative perspectives.
Teleological mode G
G
G
Extreme exterior focus. Patients cannot accept anything other than an obvious, observable change or action as a true indicator of one’s intentions. Managed in therapy by validation, then switching focus to how this makes the patient feel and how these feelings are connected with current (interpersonal) problems.
Pretend mode G
G
G
Ideas form no bridge between inner and outer reality; the patient’s thoughts and feelings are decoupled from the external world. In extreme, may manifest as dissociation of thought (hypermentalizing or pseudomentalizing). Managed in therapy by interrupting nonmentalizing processes and “rewinding” to when the patient was still mentalizing.
found in patients with FSDs (Waller & Scheidt, 2006). Individuals who have severe difficulties with epistemic trust may oscillate between being overtrustful of others and being extremely distrustful, so-called epistemic hypervigilance. The individual is constantly on his or her guard, questioning the motives underlying others’ advice and opinions. Problems with epistemic trust can make it difficult for patients to accept help from others, including health professionals, and may possibly lead to such professionals’ attempts to help the patient causing iatrogenic effects (Luyten & Abbass, 2013). Unsurprisingly, the relationships of these patients with health professionals are often turbulent, characterized, for instance, by cycles of idealization and devaluation. The patient may start out by clinging to a health professional as the patient’s “last resort,” soon followed by disappointment and reproach when the symptoms persist, which, in turn, often induces rejection by the health professional. Although many patients with FSD may have premorbid problems with epistemic trust, repeated experiences of invalidation (e.g., “There is nothing wrong with you, it’s all in your mind”) may further erode epistemic trust.
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Treatment approach A variety of psychodynamic treatment approaches for patients with FSDs have been developed and empirically validated over the past decades (Abbass, 2015; Guthrie & Moghavemi, 2013; Koelen et al., 2014; Luyten, van Houdenhove, Lemma, Target, & Fonagy, 2012; Sattel et al., 2012). These approaches include brief and longer-term individual outpatient treatments and both brief and longerterm more extensive, often multidisciplinary, multicomponent, psychodynamically oriented treatment programs for the most severely affected patients. There is also emerging evidence that psychodynamic treatments for patients influence the neurobiological circuits that are thought to be centrally involved in FSDs, such as the stress, reward, and mentalizing systems (Abbass, Nowoweiski, Bernier, Tarzwell, & Beutel, 2014). Consistent with our theoretical approach outlined above, our own treatment approach, dynamic interpersonal therapy for FSD (DIT-FSD), focuses on the core features of patients with FSD: their overreliance on secondary attachment strategies, problems with (embodied) mentalizing, and difficulties with epistemic trust. DIT-FSD is based on the general principles of dynamic interpersonal therapy (DIT), a manualized, integrative psychodynamic treatment approach (Lemma, Target, & Fonagy, 2010) that has been empirically validated in both controlled trials (Fonagy et al., 2018; Lemma, Target, & Fonagy, 2011) and routine clinical practice (Department of Health, 2012). Because of its integrative nature, DIT-FSD has much in common with other contemporary psychodynamic treatment approaches for patients with FSDs. DIT has two key foci in treatment. On the one hand, there is a constant focus on fostering the process of mentalizing. On the other hand, there is a focus on the content of the patient’s dynamics, through the joint formulation between the therapist and patient of what is termed an interpersonal affective focus (IPAF)—a recurring and often unconscious pattern of relating to the self and others that is a factor in the onset and perpetuation of complaints. The focus on the process of mentalizing and on current rather than past problems—particularly in the early phases of treatment and in more severely affected patients—is deliberate, because reflecting on connections between presenting symptoms and interpersonal issues (particularly those that happened in the past, as in the case of complex trauma) typically exceeds patients’ mentalizing capacities. Of course, the patient’s past is discussed in DIT, but primarily in relation to its influence on current presenting and interpersonal problems and only once the patient has developed the necessary mentalizing skills to reflect on such connections. DIT can be offered in a 16-session format, although some patients need considerably fewer sessions, or, for more severely affected patients, there is a 28-session format. Here, we will describe the core phases and principles of the 16-session format, which consists of three phases. The first phase (Sessions 1 4) typically involves engagement of the patient and formulation of a treatment focus (the IPAF). Engaging the patient in treatment is the first focus of the initial phase. As was mentioned earlier, many of these patients
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resist psychological explanations for their condition and have a history of negative experiences with health professionals. Many (although not all) patients with FSD therefore present with severe epistemic distrust. The only way for the therapist to counter these feelings is by strong and empathic validation of the patient’s feelings of invalidation, in combination with recognizing the reality of their suffering. In addition, many of these patients’ core anxieties are mobilized by the start of therapy, including anxieties related to their attachment history. Strong expectations of being rejected, abandoned, or criticized are typically activated, because any therapeutic relationship activates the attachment system and thus “old” templates concerning these issues. Explicit discussion and exploration of these issues, and of what might “go wrong” in relation to the therapist and therapy more generally, may prevent early dropout and other avoidance behaviors. In DIT-FSD there is always a focus on the potential for therapeutic interventions to become iatrogenic; premature interpretations or even more general but equally premature attempts to convey a particular model of illness to these patients may lead dropout or difficult and stormy transference countertransference issues (e.g., idealization denigration cycles, regressive dependency, sadomasochistic transferences) (Luyten & Abbass, 2013). It is preferable to try to arrive, through consensus rather than conflict, at a common (implicit or explicit) illness theory that recognizes the patient’s subjective experience and the complexity of FSDs. In DIT-FSD this is partly achieved by the therapist and patient jointly deciding on an IPAF during the first four sessions. Formulating the IPAF with the patient is the second core focus of the initial phase of DIT-FSD. An IPAF refers to a recurrent cognitive affective relational or attachment pattern that is associated with the onset and perpetuation of the patient’s symptoms. The IPAF consists of four elements: a specific, often nonconscious, representation of the self; the same for others; affects linking the two; and the defensive function of this constellation. The defensive function refers to the fact that the IPAF, like an attachment strategy, is seen as an adaptive strategy that is used with the aim of finding a balance in life, however distorted this may be. For example, the self in patients with FSDs is often depicted as caring and concerned for others (i.e., “compulsive caregiving”), while others are experienced as aloof, indifferent, and uncaring. Feelings of sadness, helplessness, and hopelessness are often associated with this self other pattern. However, the frustration and aggression that these patients harbor against others, because others have never cared for the patients in the way they care for others, is defended against. The IPAF is formulated on the basis of the interpersonal narratives of the patient and material that emerges in the here-and-now of the therapeutic session. Hence the formulation of a clear and explicit focus for treatment in collaboration with the patient, based on material that emerges in the session (rather than based on what therapist believes and suggests is “wrong” with the patient), plays an important role in countering epistemic distrust and fosters mentalizing. Indeed, the formulation of the IPAF empowers the patient to begin to recognize this pattern himself or herself in the patient’s daily life between sessions. This recognition typically marks the beginning of the second phase.
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The second phase of DIT (Sessions 5 12) consists of working through the IPAF and consolidating therapeutic progress. These aims are achieved by a joint process whereby the patient is helped to recognize his or her typical interpersonal attachment pattern in daily life, with a focus on the patient’s capacity to reflect on the impact of this pattern on the embodied self, others, and self-in-relation-to-others. The patient becomes increasingly able to recognize this pattern and understand its developmental origins and its advantages and disadvantages (i.e., the emotional cost). This is achieved by the therapist accepting and validating the patient’s pattern as understandable given the context and subsequently pointing out the emotional and physical costs associated with this pattern. For instance patients who primarily rely on attachment-deactivating strategies, because of the unavailability of their attachment figures, have learned to adopt a stance marked by compulsive autonomy: They have to be able to face any challenge or obstacle on their own and cannot ask for help or express distress. They often function in a hyperrationalized mode and consider their own body as a largely disembodied “machine.” A major focus in the treatment of these patients is to foster embodied mentalizing so that, for instance, they can begin to realize that feeling “tense” or “nervous” may actually mean that they feel sad and angry because they think that no one really cares for them or cares what it is they are trying to achieve. This entails identifying bodily states as reflecting emotions (affect recognition) and realizing that a presumably undifferentiated bodily state (e.g., “I feel tense”) may actually involve several emotional states that are linked to each other and with the IPAF (e.g., “I actually felt very sad and rejected when she said that, and then I started to feel really angry, but also ashamed and guilty, so I did not mention it to her, and simply carried on”). Increasingly, the patients begin to realize the high personal, interpersonal, and (often) metabolic costs of their repetitive pattern of relating to themselves and others. This is the driving force behind the motivation to change. In DIT the therapist actively encourages and supports change. In the middle phase the therapist uses the full spectrum of psychodynamic interventions: (1) supportive interventions (reassurance, support, and empathy); (2) interventions that foster mentalizing; (3) expressive interventions such as interpretation, which include a limited focus on the transference relationship when appropriate (e.g., when the link between what happens in the therapeutic relationship and the IPAF is so obvious that it needs only little interpretative effort to clarify this link) or when needed (e.g., when the transference relationship becomes overly negative); and (4) directive techniques (e.g., encouraging the patient to change the way in which he or she interacts with others). The final phase (Sessions 13 16) focuses on empowering the patient to continue the process of therapeutic change on his or her own. This is initiated by sharing a draft “goodbye” letter written by the therapist. This letter provides an overview of (1) the presenting problems, (2) the IPAF, (3) what has been achieved in terms of change, and (4) what has not yet been achieved. This letter frequently provokes very strong emotional reactions in the patient. In our experience, the extent to which the IPAF is reactivated in response to this letter and the extent to which the patient realizes this are good indicators of the nature of therapeutic change.
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Hence the final sessions typically focus on empowering the patient to continue the process that has started during therapy. This is particularly important in the context of treating patients with FSD, many of whom have a long history of somatic, psychological, and/or relational problems.
Clinical illustration Michelle was referred to me (PL) because of a general state of exhaustion after years of struggling with various somatic complaints, including fatigue, headache, back pain, and neurological symptoms with no clear biological cause (e.g., numbness in her fingers, vision difficulties). Michelle is in her forties and has worked as a nurse in a large university hospital for more than 10 years. She is married and has two daughters. Although she finds her husband generally supportive of her and feels that her relationship with her daughters is generally good, she mentions in the first session that she has always had the feeling that, deep down, her husband and children do not really love her. When asked why she has this feeling, she says that they must think of her as someone who has never accomplished anything significant in life, that she is basically a “grey mouse” who cannot compete with other women who have accomplished much more in life. “Other women,” she says, “can do it all: They have children, they have a career, they have hobbies. I’m nothing basically, I get home tired, try my best to take care of my husband and children, but they never show any appreciation.” Michelle says that she has never had any psychological problems but was rather shy and timid as a child. She describes her parents as “good parents . . . they gave me everything I needed.” When asked to provide an example of her “good parents,” another picture emerges. She says that although her parents did their best, she never had the feeling that they encouraged her to achieve anything important in life or supported her in her life ambitions. They always treated her as a “little shy girl” and were happy that she finally managed to get a job as a nurse and started a family soon after she graduated. According to Michelle, however, she fell in love with “the first decent man I could get hold of. I needed someone, always have, and I wanted to have children as soon as possible, and would do things differently as a mom.” Now, however, she feels increasingly distant from her husband and children, as if they push her away: “They seem to have their own life. Where am I in all this?” She has very few friends and has the same feeling in relation to them, as if they all have their own lives and are not interested in her. This makes her feel sad, helpless, and as if she is alone in the world. Her somatic problems began when she started working again soon after the birth of her second daughter. She had long and varying shifts at work and increasingly began to feel exhausted. She developed severe back pain and other somatic symptoms (e.g., numbness in her fingers), and one evening, when she was looking at the computer screen at work in the hospital, the text on the screen became blurred—something she has repeatedly experienced since.
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When she was asked what was happening in her life and relationship at that time, her expression suddenly changed. Up until that point, she had spoken in a timid, fatigued, and depressed manner (almost like a shy little girl); now her voice lifted, she leaned toward me, arms outstretched, and in a desperate yet forceful tone said that the feeling of being left alone, of being unimportant, became very strong around that time. Her husband became less and less interested in her, her daughters seemed to be doing fine without her (e.g., in day care), and even her patients seemed not to need her any more. While caring for patients had been a major source of fulfillment for her up to that point, she increasingly had the feeling that her patients disliked her and preferred other nurses (an example of psychic equivalence). She exclaimed, “How is this possible? Why does everyone reject me?” As soon as she had said this, she almost physically collapsed and started crying, saying, “I feel so tired, I feel so alone.” This was the first time she ever had the feeling that her physical symptoms might be connected to what was going on in her life. This is a crucial feature of DIT-FSD, as it opens up the so-called epistemic superhighway that characterizes epistemic trust. This connection is not suggested by anyone else; it is the patient who experiences the connection in the here-andnow of the session, which leads to increasing curiosity about what else might surface in treatment and what else there might be in the therapist’s mind. In the third session we jointly arrived at the IPAF as a focus for the treatment. Michelle’s self-representation involved extremely negative views of the self as worthless, “a grey mouse,” and even the feeling that she was “nothing.” Others were seen as uninterested in her, not supportive, and unavailable. This made her feel alone, sad, abandoned, helpless, and fatigued, a proto-emotion that covered up all other emotions (see below), particularly the frustration and anger that she felt toward her husband, her children, her parents, her colleagues, and even her patients for “not being there for her.” These feelings, however, were strongly defended against by a feeling of helplessness, fatigue, emotion, often even physical paralysis, and guilt. While initially she responded to these feelings with a hyperactivation of the attachment system and (in teleological mode) hoped that caring for others would lead to those others providing her with love and support, this strategy began to fail as her pattern of compulsive caregiving increasingly strained her physical and emotional capacities. A “biopsychosocial crash” ensued, and one evening she fainted at work and was taken to the emergency room and subsequently referred to specialist psychiatric treatment. During the second phase of treatment, Michelle gradually came to recognize how this pattern of compulsive caregiving had completely controlled her life. She realized how, desperate for love, support, and recognition, she had been continuously focused on “being there for someone else; it became almost an obsession, I had to take care of others, I could not let go any longer.” She increasingly began to realize in the sessions and between sessions how this pattern was related to her physical complaints: “Once you start paying attention to it, you suddenly realize how exhausting it is to always want to take care of others, to constantly think what others will think of you.” She also began to notice how angry this made her and
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how her sadness and anger made her feel exhausted. Hence as her capacity for (embodied) mentalizing improved, she also became aware of the high physical and emotional costs of her lifelong pattern. This was a major turning point in the treatment, as she started wondering how she should do things differently. We started thinking together about first taking small steps, as this stable pattern was most likely not going to change overnight. Michelle’s relationship with her husband and children began to change dramatically; instead of being focused on what she thought they needed, she became very interested in how they had felt. She was astonished by the fact that they had been extremely worried about her all the time and how afraid they had been that they might lose her, particularly when she had fainted at the hospital. For the first time she had the feeling that her husband and children truly loved her. At work she asked for a transfer to a physically and emotionally less demanding unit, and slowly, as her mood lifted, her somatic problems also began to improve, particularly when she began to realize how much anger there always had been in her. When I handed Michelle the goodbye letter in Session 13, she was extremely nervous. She began sweating and almost fainted when she started to read the letter. As a result, it took her a long time to read the letter, and although she agreed with almost everything in it, she added, quite ashamed, “But I am still nothing.” Hence there was a strong reactivation of the IPAF in response to the goodbye letter, which she quickly realized when I suggested this possibility to her. However, for much of the session her mentalizing capacities fluctuated strongly, and she was torn between her “old” self-representation of being unworthy (and her belief that I was uninterested in her) and her “new” stronger image of herself. In the next session we were able to look back at this reactivation of her “old” pattern and to link it to the many challenges that still lay ahead. Indeed, if this old pattern was so readily reactivated in treatment, it could also be easily reactivated outside the consulting room. The remainder of the sessions therefore focused on consolidating changes and further supporting her in finding new ways of thinking and feeling about herself and others with regard to what had happened in the past and what was happening in the present and may happen in the future. By this time her somatic symptoms had almost completely disappeared.
Conclusions This chapter has presented a broad, evidence-based psychodynamic approach to the conceptualization and treatment of patients with persistent somatic complaints. This approach helps us to understand the connections between the patient’s presenting problems, his or her subjective responses to these problems, and his or her developmental history. These formulations have clear implications for the treatment of these patients regardless of the specific treatment approach used. We have argued for the importance of recognizing these patients’ impairments in attachment,
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mentalizing, and epistemic trust, as these problems may make it more difficult to establish a therapeutic alliance and create the potential for iatrogenic treatment effects. Health professionals, in particular psychodynamic therapists, should be keenly aware of these dynamics and should distinguish the patient’s premorbid vulnerability from his or her response to persistent somatic complaints.
References Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press. Abbass, A. A., Nowoweiski, S. J., Bernier, D., Tarzwell, R., & Beutel, M. E. (2014). Review of psychodynamic psychotherapy neuroimaging studies. Psychotherapy and Psychosomatics, 83, 142 147. Available from https://doi.org/10.1159/000358841. Aggarwal, V. R., McBeth, J., Zakrzewska, J. M., Lunt, M., & Macfarlane, G. J. (2006). The epidemiology of chronic syndromes that are frequently unexplained: Do they have common associated factors? International Journal of Epidemiology, 35, 468 476. Available from https://doi.org/10.1093/ije/dyi265. Bass, C., & May, S. (2002). Chronic multiple functional somatic symptoms. British Medical Journal, 325, 323 326. Available from https://doi.org/10.1136/bmj.325.7359.323. Blom, D., Thomaes, S., Kool, M. B., van Middendorp, H., Lumley, M. A., Bijlsma, J. W., & Geenen, R. (2012). A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with FM. Rheumatology (Oxford), 51, 347 353. Available from https://doi.org/10.1093/rheumatology/ker342. Bogaerts, K., Van Eylen, L., Li, W., Bresseleers, J., Van Diest, I., De Peuter, S., . . . den Bergh, O. (2010). Distorted symptom perception in patients with medically unexplained symptoms. Journal of Abnormal Psychology, 119, 226 234. Available from https://doi.org/10.1037/a0017780. Cassidy, J., & Kobak, R. R. (1988). Avoidance and its relation to other defensive processes. In J. Belsky, & T. Nezworski (Eds.), Clinical implications of attachment (pp. 300 323). London, UK: Routledge. Department of Health. (2012). IAPT three-year report. The first million patients. London, UK: Department of Health. Available from http://webarchive.nationalarchives.gov.uk/ 20160302155226/http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf. Diamond, D., Stovall-McClough, C., Clarkin, J. F., & Levy, K. N. (2003). Patient-therapist attachment in the treatment of borderline personality disorder. Bulletin of the Menninger Clinic, 67, 227 259. Available from https://doi.org/10.1521/bumc.67.3.227.23433. Fischhoff, B., & Wessely, S. (2003). Managing patients with inexplicable health problems. British Medical Journal, 326, 595 597. Available from https://doi.org/10.1136/ bmj.326.7389.595. Fonagy, P., Lemma, A., Target, M., O’Keeffe, S., Constantinou, M., Ventura Wurman, T., Pilling, S. (2018). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Manuscript in review. Guthrie, E., & Moghavemi, A. (2013). Psychodynamic-interpersonal therapy: An overview of the treatment approach and evidence base. Psychodynamic Psychiatry, 41, 619 635. Available from https://doi.org/10.1521/pdps.2013.41.4.619.
Psychodynamic therapy in patients with somatic symptom disorder
205
Haller, H., Cramer, H., Lauche, R., & Dobos, G. (2015). Somatoform disorders and medically unexplained symptoms in primary care. Deutsches A¨rzteblatt International, 112, 279 287. Available from https://doi.org/10.3238/arztebl.2015.0279. Hambrook, D., Oldershaw, A., Rimes, K., Schmidt, U., Tchanturia, K., Treasure, J., . . . Chalder, T. (2011). Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome. British Journal of Clinical Psychology, 50, 310 325. Available from https://doi.org/10.1348/014466510X519215. Hudson, J. I., Mangweth, B., Pope, H. G., Jr., De Col, C., Hausmann, A., Gutweniger, S., . . . Tsuang, M. T. (2003). Family study of affective spectrum disorder. Archives of General Psychiatry, 60, 170 177. Available from https://doi.org/10.1001/archpsyc.60.2.170. Koelen, J. A., Houtveen, J. H., Abbass, A., Luyten, P., Eurelings-Bontekoe, E. H., Van Broeckhuysen-Kloth, S. A., . . . Geenen, R. (2014). Effectiveness of psychotherapy for severe somatoform disorder: Meta-analysis. British Journal of Psychiatry, 204, 12 19. Available from https://doi.org/10.1192/bjp.bp.112.121830. Lemma, A., Target, M., & Fonagy, P. (2010). The development of a brief psychodynamic protocol for depression: Dynamic interpersonal therapy (DIT). Psychoanalytic Psychotherapy, 24, 329 346. Available from https://doi.org/10.1080/02668734. 2010.513547. Lemma, A., Target, M., & Fonagy, P. (2011). The development of a brief psychodynamic intervention (dynamic interpersonal therapy) and its application to depression: A pilot study. Psychiatry: Interpersonal and Biological Processes, 74, 41 48. Available from https://doi.org/10.1521/psyc.2011.74.1.41. Luyten, P., & Abbass, A. (2013). What is the evidence for specific factors in the psychotherapeutic treatment of fibromyalgia? Comment on ‘Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial’. General Hospital Psychiatry, 35, 675 676. Available from https://doi.org/10.1016/j.genhosppsych.2013.07.007. Luyten, P., & Fonagy, P. (2018). The stress-reward-mentalizing model of depression: An integrative developmental cascade approach to child and adolescent depressive disorder based on the Research Domain Criteria (RDoC) approach. Clinical Psychology Review, 64, 87 98. Available from https://doi.org/10.1016/j.cpr.2017.09.008. Luyten, P., & Van Houdenhove, B. (2013). Common and specific factors in the psychotherapeutic treatment of patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy Integration, 23, 14 27. Available from https://doi.org/10.1037/ a0030269. Luyten, P., Kempke, S., Van Wambeke, P., Claes, S., 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, 21 30. Available from https://doi.org/ 10.1521/psyc.2011.74.1.21. Luyten, P., Mayes, L. C., Target, M., & Fonagy, P. (2012). Developmental research. In G. O. Gabbard, B. Litowitz, & P. Williams (Eds.), Textbook of psychoanalysis (2nd ed., pp. 423 442). Washington, DC: American Psychiatric Press. Luyten, P., van Houdenhove, B., Lemma, A., Target, M., & Fonagy, P. (2012). A mentalization-based approach to the understanding and treatment of functional somatic disorders. Psychoanalytic Psychotherapy, 26, 121 140. Available from https://doi.org/ 10.1080/02668734.2012.678061.
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Luyten, P., van Houdenhove, B., Lemma, A., Target, M., & Fonagy, P. (2013). Vulnerability for functional somatic disorders: A contemporary psychodynamic approach. Journal of Psychotherapy Integration, 23, 250 262. Available from https://doi.org/10.1037/ a0032360. Maunder, R. G., & Hunter, J. J. (2008). Attachment relationships as determinants of physical health. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 11 32. Available from https://doi.org/10.1521/jaap.2008.36.1.11. McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87, 873 904. Available from https://doi.org/10.1152/ physrev.00041.2006. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics and change. New York, NY: Guilford Press. Mikulincer, M., Dolev, T., & Shaver, P. R. (2004). Attachment-related strategies during thought suppression: Ironic rebounds and vulnerable self-representations. Journal of Personality and Social Psychology, 87, 940 956. Available from https://doi.org/ 10.1037/0022-3514.87.6.940. Pedrosa Gil, F., Scheidt, C. E., Hoeger, D., & Nickel, M. (2008). Relationship between attachment style, parental bonding and alexithymia in adults with somatoform disorders. International Journal of Psychiatry in Medicine, 38, 437 451. Available from https:// doi.org/10.2190/PM.38.4.d. Pedrosa Gil, F., Weigl, M., Wessels, T., Irnich, D., Baumuller, E., & Winkelmann, A. (2008). Parental bonding and alexithymia in adults with fibromyalgia. Psychosomatics, 49, 115 122. Available from https://doi.org/10.1176/appi.psy.49.2.115. Sattel, H., Lahmann, C., Gundel, H., Guthrie, E., Kruse, J., Noll-Hussong, M., . . . Henningsen, P. (2012). Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: Randomised controlled trial. British Journal of Psychiatry, 200, 60 67. Available from https://doi.org/10.1192/bjp.bp.111.093526. Sbarra, D. A., & Hazan, C. (2008). Coregulation, dysregulation, self-regulation: An integrative analysis and empirical agenda for understanding adult attachment, separation, loss, and recovery. Personality and Social Psychology Review, 12, 141 167. Available from https://doi.org/10.1177/1088868308315702. Schattner, E., Shahar, G., & Abu-Shakra, M. (2008). I used to dream of lupus as some sort of creature’: Chronic illness as an internal object. American Journal of Orthopsychiatry, 78, 466 472. Available from https://doi.org/10.1037/a0014392. Tak, L. M., & Rosmalen, J. G. M. (2010). Dysfunction of stress responsive systems as a risk factor for functional somatic syndromes. Journal of Psychosomatic Research, 68, 461 468. Available from https://doi.org/10.1016/j.jpsychores.2009.12.004. Van Houdenhove, B., & Luyten, P. (2008). Customizing treatment of chronic fatigue syndrome and fibromyalgia: The role of perpetuating factors. Psychosomatics, 49, 470 477. Available from https://doi.org/10.1176/appi.psy.49.6.470. Waller, E., & Scheidt, C. E. (2006). Somatoform disorders as disorders of affect regulation: A development perspective. International Review of Psychiatry, 18, 13 24. Available from https://doi.org/10.1080/09540260500466774. Wessely, S., & White, P. D. (2004). There is only one functional somatic syndrome. British Journal of Psychiatry, 185, 95 96. Available from https://doi.org/10.1192/bjp.185.2.95.
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Patrick Luyten1,2, Celine De Meulemeester1 and Peter Fonagy2 1 Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium, 2 Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
People with persisting somatic complaints comprise a large subset of patients across the different tiers of healthcare. A recent meta-analysis based on 32 studies in 24 countries (total N 5 70,085 patients) estimated that up to 50% of patients in primary care present with at least one somatic complaint that cannot be readily explained by medical causes, with approximately 30% of patients fulfilling criteria for somatic symptom disorder (Haller, Cramer, Lauche, & Dobos, 2015). In tertiary care, up to 9% of patients present with more than one type of somatic symptom disorder (Bass & May, 2002). There is a wide variety of functional somatic symptoms affecting the different body systems. Almost every medical specialty has defined syndromes in which patients present with a particular set of symptoms (see Table 13.1) (Wessely & White, 2004). Evidence is amassing that functional somatic disorders (FSDs) are part of a spectrum of functional somatic syndromes with common genetic, pathophysiological, and psychological mechanisms. Studies have suggested high levels of comorbidity and familial coaggregation among the syndromes (Aggarwal, McBeth, Zakrzewska, Lunt, & Macfarlane, 2006). Furthermore, their high comorbidity with depression and anxiety and similarities in terms of stress response have led to the assumption that they are part of a spectrum of affective disorders (Hudson et al., 2003). This chapter first provides a contemporary attachment perspective to understanding patients with FSDs and empirical evidence supporting this perspective. Next, it discusses how this understanding can be translated into a systematic treatment approach. We provide a clinical example of the systematic treatment approach and end with a discussion of future areas for research and clinical practice.
Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00013-1 © 2019 Elsevier Inc. All rights reserved.
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Table 13.1 Examples of functional somatic symptoms in different medical specialties. Type of functional somatic symptoms
Medical specialty
Chronic fatigue syndrome Fibromyalgia, chronic widespread pain, back pain Irritable bowel syndrome, dyspepsia Chronic pelvic pain Noncardiac chest pain, functional palpitations Hyperventilation syndrome Tension headache, migraine, functional neurological disorder, conversion disorder, somatosensory disorder Urethral syndrome, interstitial cystitis Dermatitis, inflammatory dermatosis Laryngospasm, pharyngospasm, temporomandibular syndrome, bruxism Multiple chemical sensitivity
Internal medicine Rheumatology Gastroenterology Gynecology Cardiology Respiratory medicine Neurology Urology Dermatology Otolaryngology Allergy/immunology
An attachment and mentalizing approach to FSDs Assessment and heterogeneity of FSDs Patients with FSDs are very heterogeneous in terms of the role of both psychological and biological factors in their symptoms. Hence, any generalization about the role of biological and psychological factors in these patients is clinically unproductive. We have learned to refrain from trying to provide such answers, which are always based on group research. Indeed, in any given case it is often quite difficult, if not impossible, to gauge the respective role of these factors, particularly as the clinician’s knowledge of the patient and his or her condition is typically very limited at the start of any treatment. As treatment progresses, the picture typically becomes clearer, and then this question may be—and typically is—revisited. In this respect, it is always wise to make sure the patient has undergone thorough medical screening. Similarly, for most patients a detailed psychological assessment is indicated, focusing on possible problems related to attachment issues; (embodied) mentalizing, that is, the capacity to reflect on their own (embodied) self and others; and epistemic trust, the capacity to trust others as a source of knowledge, including the knowledge that the clinician offers concerning the patient’s own presenting problems. This assessment determines to a large extent the therapeutic options for the patient and the subsequent focus of treatment.
Attachment and emotion regulation in FSDs Impairments in stress and emotion regulation, typically resulting from complex interactions among biological and environmental factors, are a key feature in FSDs (Tak & Rosmalen, 2010). Many FSD patients have experienced chronic
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overburdening of the stress system as a result of physical and/or psychological stress and conflict, leading to a state of allostatic load (McEwen, 2007) that disrupts the dynamic equilibrium (allostasis) typical of the stress regulation system and neurobiological systems associated with the stress response. These systems mainly include the immune and pain-regulating systems and associated biomediators. Physical and psychological stressors are often closely intertwined, as is demonstrated by the finding that many patients with FSDs show a pattern of overactivity, which chronically overburdens the stress system (Luyten, Van Houdenhove, Lemma, Target, & Fonagy, 2013; Van Houdenhove & Luyten, 2008). The emergence of pain and fatigue-related complaints leads to additional stress and conflict, not least because these patients often encounter invalidating responses from others. This leads in turn to the patients experiencing feelings of inferiority and being a failure. A vicious cycle ensues, characterized by increasing emotional distress and conflict; the individual begins to function in a constant state of fight-or-flight. This is why any understanding of the origins of FSDs that does not take into consideration the roles and function of the attachment system is, in our view, problematic. The attachment system is a biobehavioral system that is activated in response to distress and thus plays a key role in restoring allostasis, the dynamic equilibrium that characterizes biological functioning (McEwen, 2007). In normative development, activation of the attachment system leads the individual to seek proximity to attachment figures. When attachment figures are available and responsive, this typically leads to effective downregulation of distress (see Fig. 13.1). This experience is gradually generalized, leading to feelings of agency and efficacy in the face of adversity based on the underlying belief that others will be there to provide support, care, and validation in times of need. Normative stress regulation thus always involves a process of coregulation in relation to attachment figures (Diamond, Stovall-McClough, Clarkin, & Levy, 2003; Sbarra & Hazan, 2008). The neurobiology of the process of coregulation is increasingly understood; it mainly involves the mesocorticolimbic dopaminergic reward system, which underlies the attachment system. This system is responsible not (A) Downregulation of distress via the normally functioning attachment system
(B) Hyperactivation of the attachment system in the context of FSD
Distress/ fear
Distress/ fear
Exposure to threat –
Activation of attachment
–
Adverse emotional experience
Activation of attachment
Downregulation of emotions Proximity seeking
Proximity seeking
Figure 13.1 The relationship between the attachment and stress regulation systems.
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only for the rewarding nature of attachment relationships, but also for the downregulation of neuroendocrine stress regulation systems, including the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system (Luyten & Fonagy, 2018). Persistent somatic complaints make the normative downregulation of distress effectively impossible, as there simply is no (or very little) relief possible from these conditions. This typically leads to a breakdown of the normative stress regulation process, even in individuals who were securely attached before the onset of their complaints. The patient is forced to shift to the use of so-called secondary attachment strategies, that is, affect regulation strategies that are used when the primary or normative stress regulation strategy fails (Mikulincer & Shaver, 2007). There are two main secondary attachment strategies. The first involves hyperactivation of the attachment system. This involves anxious efforts to find understanding, support, and relief and is expressed in increasingly demanding, clinging, and claiming behavior (Waller & Scheidt, 2006). The second involves deactivation of the attachment system; attachment needs are denied, and the patient resorts to a stance emphasizing autonomy, independence, and strength (Cassidy & Kobak, 1988; Mikulincer & Shaver, 2007). This strategy is often expressed in high levels of self-critical perfectionism, persistence, overactivity, and all-or-nothing behavior (Luyten et al., 2011). Although secondary attachment strategies may bring some temporary relief, they are associated with high interpersonal and metabolic costs. Becoming increasingly demanding characteristically leads to frustration with and often rejection by others, confirming the patient’s fear that others will abandon or reject him or her. This self-fulfilling prophecy may have a disastrous impact both on the patient’s intimate relationships and on relationships with health professionals. As a result, allostatic load further increases, which further increases these patients’ tendency to cling on to others in an attempt to find support, relief, and understanding from them (Maunder & Hunter, 2008). Hyperactivation of the attachment system ensues. Presenting oneself as completely self-reliant and invulnerable, as is typical of patients who excessively use attachment-deactivating strategies, increasingly leads to feelings of isolation and loneliness (Mikulincer & Shaver, 2007). Suppressing emotional distress leads to increasing allostatic load, which may lead to a complete “biopsychosocial crash” of the stress system as a result of the “wear and tear” caused by chronic stress. At this point, attachment-deactivating strategies typically fail, and the patient becomes highly anxious, needy, and/or depressed (Mikulincer, Dolev, & Shaver, 2004). It is important to recognize that for many FSD patients, attachment issues are not necessarily present before the onset of their condition but may emerge as a consequence of the persistent somatic complaints and continuing allostatic load, leading to the breakdown of the normative coregulation of stress and overreliance on the secondary attachment strategies outlined above (see Fig. 13.2). Of course, some patients do have a history of disrupted attachment before the onset of their complaints. Studies in animals and humans have demonstrated an association between early adversity and vulnerability to stress-related symptoms. For patients
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Predisposing factors
Environmental
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Biological
Stress and allostatic load
Precipitating factors
Secondary attachment strategies
Mentalizing impairments
Perpetuating factors Perpetuating behaviors
Figure 13.2 Contemporary psychodynamic understanding of individuals with functional somatic disorders.
who fall into this subgroup, existing attachment issues may be aggravated by the experience of FSD. This has important implications for the treatment of these patients (Luyten, Mayes, Target, & Fonagy, 2012; Luyten & Van Houdenhove, 2013).
Mentalizing in FSDs Disruptions in stress regulation and the excessive use of secondary attachment strategies typically lead to a serious disruption in the capacity for mentalizing, that is, the capacity to interpret the self and others in terms of intentional mental states (feelings, wishes, desires, goals, etc.) and, in particular, in the capacity for embodied mentalizing. Embodied mentalizing refers to the ability to interpret the body as the seat of emotional life and as being intrinsically part of one’s own self-definition and self-image. Chronic somatic complaints typically impair and distort this capacity; somatic symptoms are often experienced as an “attack” from within on the patient’s capacity to reflect. Patients with chronic illness have been described as
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experiencing their illness as an “internal object” that is constantly threatening them and that needs to be negotiated with and soothed (Schattner, Shahar, & Abu-Shakra, 2008). In regard to the reflective capacities of FSD patients, earlier formulations of FSD have focused on alexithymia, that is, a general lack of emotional awareness and the inability to describe emotional states. However, only a subset of FSD patients (15% 22%) were found to have clinical levels of alexithymia (Pedrosa Gil, Scheidt, Hoeger, & Nickel, 2008; Pedrosa Gil, Weigl, et al., 2008; Waller & Scheidt, 2006). Alexithymia is not specific to FSD but is also found in other disorders, and it reflects the effects of childhood trauma more generally; only a subset of patients with FSD have such a history. Moreover, evidence suggests that, rather than exhibiting a global deficit in emotional awareness, patients with FSDs have more specific difficulties in embodied mentalizing. For instance, many of these patients are unable to link their emotional states to their own body. They are also less accurate in describing their own physical sensations (Bogaerts et al., 2010). Furthermore, patients with FSDs tend to have negative beliefs about expressing their own emotions (Hambrook et al., 2011). FSD patients’ impairments in mentalizing typically are evident as an oscillation between excessive mentalizing (hypermentalizing), expressed in apparently highly sophisticated narratives about mental states that lack any grounding in subjective experience, and hypomentalizing, that is, the almost complete denial of the importance of inner mental states. In the face of pervasive and persistent somatic complaints, three so-called nonmentalizing modes that are characteristic of earlier developmental stages may reemerge, perpetuating the patient’s symptoms and relationship difficulties (see Box 13.1).
Epistemic distrust and FSDs FSD patients are often considered to be difficult to treat (Fischhoff & Wessely, 2003), but this notion is neither accurate nor helpful. In addition to being overwhelmed by the continuing distress of their somatic symptoms, FSD patients are often confronted with disbelief and skepticism from others. Furthermore, health professionals often use unhelpful diagnostic labels and obsolete models of FSDs, offer pessimistic prognoses, and frequently underestimate patients’ need for validation. As a result, many FSD patients feel severely misunderstood, invalidated, and bitter (Blom et al., 2012). The concept of epistemic trust is helpful in this context. Epistemic trust is, in essence, the capacity to trust others as a reliable source of knowledge about the world (including one’s condition) and to see others as being able to convey knowledge that is personally relevant and that can be generalized. This capacity first develops in the context of early attachment relationships and is dependent upon the quality of those relationships. Epistemic distrust is particularly prevalent among individuals with dismissive and disorganized attachment styles, as are commonly
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Box 13.1 Three nonmentalizing modes in patients with functional somatic disorders Psychic equivalence mode G
G
G
Patients equate inner (mental) states with outer reality; the internal has the same power as the external. Intolerance of alternative perspectives, leading to concrete understanding. Managed in therapy by the therapist avoiding being drawn into nonmentalizing discourse. The therapist validates the patient’s thoughts and feelings but suggests alternative perspectives.
Teleological mode G
G
G
Extreme exterior focus. Patients cannot accept anything other than an obvious, observable change or action as a true indicator of one’s intentions. Managed in therapy by validation, then switching focus to how this makes the patient feel and how these feelings are connected with current (interpersonal) problems.
Pretend mode G
G
G
Ideas form no bridge between inner and outer reality; the patient’s thoughts and feelings are decoupled from the external world. In extreme, may manifest as dissociation of thought (hypermentalizing or pseudomentalizing). Managed in therapy by interrupting nonmentalizing processes and “rewinding” to when the patient was still mentalizing.
found in patients with FSDs (Waller & Scheidt, 2006). Individuals who have severe difficulties with epistemic trust may oscillate between being overtrustful of others and being extremely distrustful, so-called epistemic hypervigilance. The individual is constantly on his or her guard, questioning the motives underlying others’ advice and opinions. Problems with epistemic trust can make it difficult for patients to accept help from others, including health professionals, and may possibly lead to such professionals’ attempts to help the patient causing iatrogenic effects (Luyten & Abbass, 2013). Unsurprisingly, the relationships of these patients with health professionals are often turbulent, characterized, for instance, by cycles of idealization and devaluation. The patient may start out by clinging to a health professional as the patient’s “last resort,” soon followed by disappointment and reproach when the symptoms persist, which, in turn, often induces rejection by the health professional. Although many patients with FSD may have premorbid problems with epistemic trust, repeated experiences of invalidation (e.g., “There is nothing wrong with you, it’s all in your mind”) may further erode epistemic trust.
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Treatment approach A variety of psychodynamic treatment approaches for patients with FSDs have been developed and empirically validated over the past decades (Abbass, 2015; Guthrie & Moghavemi, 2013; Koelen et al., 2014; Luyten, van Houdenhove, Lemma, Target, & Fonagy, 2012; Sattel et al., 2012). These approaches include brief and longer-term individual outpatient treatments and both brief and longerterm more extensive, often multidisciplinary, multicomponent, psychodynamically oriented treatment programs for the most severely affected patients. There is also emerging evidence that psychodynamic treatments for patients influence the neurobiological circuits that are thought to be centrally involved in FSDs, such as the stress, reward, and mentalizing systems (Abbass, Nowoweiski, Bernier, Tarzwell, & Beutel, 2014). Consistent with our theoretical approach outlined above, our own treatment approach, dynamic interpersonal therapy for FSD (DIT-FSD), focuses on the core features of patients with FSD: their overreliance on secondary attachment strategies, problems with (embodied) mentalizing, and difficulties with epistemic trust. DIT-FSD is based on the general principles of dynamic interpersonal therapy (DIT), a manualized, integrative psychodynamic treatment approach (Lemma, Target, & Fonagy, 2010) that has been empirically validated in both controlled trials (Fonagy et al., 2018; Lemma, Target, & Fonagy, 2011) and routine clinical practice (Department of Health, 2012). Because of its integrative nature, DIT-FSD has much in common with other contemporary psychodynamic treatment approaches for patients with FSDs. DIT has two key foci in treatment. On the one hand, there is a constant focus on fostering the process of mentalizing. On the other hand, there is a focus on the content of the patient’s dynamics, through the joint formulation between the therapist and patient of what is termed an interpersonal affective focus (IPAF)—a recurring and often unconscious pattern of relating to the self and others that is a factor in the onset and perpetuation of complaints. The focus on the process of mentalizing and on current rather than past problems—particularly in the early phases of treatment and in more severely affected patients—is deliberate, because reflecting on connections between presenting symptoms and interpersonal issues (particularly those that happened in the past, as in the case of complex trauma) typically exceeds patients’ mentalizing capacities. Of course, the patient’s past is discussed in DIT, but primarily in relation to its influence on current presenting and interpersonal problems and only once the patient has developed the necessary mentalizing skills to reflect on such connections. DIT can be offered in a 16-session format, although some patients need considerably fewer sessions, or, for more severely affected patients, there is a 28-session format. Here, we will describe the core phases and principles of the 16-session format, which consists of three phases. The first phase (Sessions 1 4) typically involves engagement of the patient and formulation of a treatment focus (the IPAF). Engaging the patient in treatment is the first focus of the initial phase. As was mentioned earlier, many of these patients
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resist psychological explanations for their condition and have a history of negative experiences with health professionals. Many (although not all) patients with FSD therefore present with severe epistemic distrust. The only way for the therapist to counter these feelings is by strong and empathic validation of the patient’s feelings of invalidation, in combination with recognizing the reality of their suffering. In addition, many of these patients’ core anxieties are mobilized by the start of therapy, including anxieties related to their attachment history. Strong expectations of being rejected, abandoned, or criticized are typically activated, because any therapeutic relationship activates the attachment system and thus “old” templates concerning these issues. Explicit discussion and exploration of these issues, and of what might “go wrong” in relation to the therapist and therapy more generally, may prevent early dropout and other avoidance behaviors. In DIT-FSD there is always a focus on the potential for therapeutic interventions to become iatrogenic; premature interpretations or even more general but equally premature attempts to convey a particular model of illness to these patients may lead dropout or difficult and stormy transference countertransference issues (e.g., idealization denigration cycles, regressive dependency, sadomasochistic transferences) (Luyten & Abbass, 2013). It is preferable to try to arrive, through consensus rather than conflict, at a common (implicit or explicit) illness theory that recognizes the patient’s subjective experience and the complexity of FSDs. In DIT-FSD this is partly achieved by the therapist and patient jointly deciding on an IPAF during the first four sessions. Formulating the IPAF with the patient is the second core focus of the initial phase of DIT-FSD. An IPAF refers to a recurrent cognitive affective relational or attachment pattern that is associated with the onset and perpetuation of the patient’s symptoms. The IPAF consists of four elements: a specific, often nonconscious, representation of the self; the same for others; affects linking the two; and the defensive function of this constellation. The defensive function refers to the fact that the IPAF, like an attachment strategy, is seen as an adaptive strategy that is used with the aim of finding a balance in life, however distorted this may be. For example, the self in patients with FSDs is often depicted as caring and concerned for others (i.e., “compulsive caregiving”), while others are experienced as aloof, indifferent, and uncaring. Feelings of sadness, helplessness, and hopelessness are often associated with this self other pattern. However, the frustration and aggression that these patients harbor against others, because others have never cared for the patients in the way they care for others, is defended against. The IPAF is formulated on the basis of the interpersonal narratives of the patient and material that emerges in the here-and-now of the therapeutic session. Hence the formulation of a clear and explicit focus for treatment in collaboration with the patient, based on material that emerges in the session (rather than based on what therapist believes and suggests is “wrong” with the patient), plays an important role in countering epistemic distrust and fosters mentalizing. Indeed, the formulation of the IPAF empowers the patient to begin to recognize this pattern himself or herself in the patient’s daily life between sessions. This recognition typically marks the beginning of the second phase.
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The second phase of DIT (Sessions 5 12) consists of working through the IPAF and consolidating therapeutic progress. These aims are achieved by a joint process whereby the patient is helped to recognize his or her typical interpersonal attachment pattern in daily life, with a focus on the patient’s capacity to reflect on the impact of this pattern on the embodied self, others, and self-in-relation-to-others. The patient becomes increasingly able to recognize this pattern and understand its developmental origins and its advantages and disadvantages (i.e., the emotional cost). This is achieved by the therapist accepting and validating the patient’s pattern as understandable given the context and subsequently pointing out the emotional and physical costs associated with this pattern. For instance patients who primarily rely on attachment-deactivating strategies, because of the unavailability of their attachment figures, have learned to adopt a stance marked by compulsive autonomy: They have to be able to face any challenge or obstacle on their own and cannot ask for help or express distress. They often function in a hyperrationalized mode and consider their own body as a largely disembodied “machine.” A major focus in the treatment of these patients is to foster embodied mentalizing so that, for instance, they can begin to realize that feeling “tense” or “nervous” may actually mean that they feel sad and angry because they think that no one really cares for them or cares what it is they are trying to achieve. This entails identifying bodily states as reflecting emotions (affect recognition) and realizing that a presumably undifferentiated bodily state (e.g., “I feel tense”) may actually involve several emotional states that are linked to each other and with the IPAF (e.g., “I actually felt very sad and rejected when she said that, and then I started to feel really angry, but also ashamed and guilty, so I did not mention it to her, and simply carried on”). Increasingly, the patients begin to realize the high personal, interpersonal, and (often) metabolic costs of their repetitive pattern of relating to themselves and others. This is the driving force behind the motivation to change. In DIT the therapist actively encourages and supports change. In the middle phase the therapist uses the full spectrum of psychodynamic interventions: (1) supportive interventions (reassurance, support, and empathy); (2) interventions that foster mentalizing; (3) expressive interventions such as interpretation, which include a limited focus on the transference relationship when appropriate (e.g., when the link between what happens in the therapeutic relationship and the IPAF is so obvious that it needs only little interpretative effort to clarify this link) or when needed (e.g., when the transference relationship becomes overly negative); and (4) directive techniques (e.g., encouraging the patient to change the way in which he or she interacts with others). The final phase (Sessions 13 16) focuses on empowering the patient to continue the process of therapeutic change on his or her own. This is initiated by sharing a draft “goodbye” letter written by the therapist. This letter provides an overview of (1) the presenting problems, (2) the IPAF, (3) what has been achieved in terms of change, and (4) what has not yet been achieved. This letter frequently provokes very strong emotional reactions in the patient. In our experience, the extent to which the IPAF is reactivated in response to this letter and the extent to which the patient realizes this are good indicators of the nature of therapeutic change.
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Hence the final sessions typically focus on empowering the patient to continue the process that has started during therapy. This is particularly important in the context of treating patients with FSD, many of whom have a long history of somatic, psychological, and/or relational problems.
Clinical illustration Michelle was referred to me (PL) because of a general state of exhaustion after years of struggling with various somatic complaints, including fatigue, headache, back pain, and neurological symptoms with no clear biological cause (e.g., numbness in her fingers, vision difficulties). Michelle is in her forties and has worked as a nurse in a large university hospital for more than 10 years. She is married and has two daughters. Although she finds her husband generally supportive of her and feels that her relationship with her daughters is generally good, she mentions in the first session that she has always had the feeling that, deep down, her husband and children do not really love her. When asked why she has this feeling, she says that they must think of her as someone who has never accomplished anything significant in life, that she is basically a “grey mouse” who cannot compete with other women who have accomplished much more in life. “Other women,” she says, “can do it all: They have children, they have a career, they have hobbies. I’m nothing basically, I get home tired, try my best to take care of my husband and children, but they never show any appreciation.” Michelle says that she has never had any psychological problems but was rather shy and timid as a child. She describes her parents as “good parents . . . they gave me everything I needed.” When asked to provide an example of her “good parents,” another picture emerges. She says that although her parents did their best, she never had the feeling that they encouraged her to achieve anything important in life or supported her in her life ambitions. They always treated her as a “little shy girl” and were happy that she finally managed to get a job as a nurse and started a family soon after she graduated. According to Michelle, however, she fell in love with “the first decent man I could get hold of. I needed someone, always have, and I wanted to have children as soon as possible, and would do things differently as a mom.” Now, however, she feels increasingly distant from her husband and children, as if they push her away: “They seem to have their own life. Where am I in all this?” She has very few friends and has the same feeling in relation to them, as if they all have their own lives and are not interested in her. This makes her feel sad, helpless, and as if she is alone in the world. Her somatic problems began when she started working again soon after the birth of her second daughter. She had long and varying shifts at work and increasingly began to feel exhausted. She developed severe back pain and other somatic symptoms (e.g., numbness in her fingers), and one evening, when she was looking at the computer screen at work in the hospital, the text on the screen became blurred—something she has repeatedly experienced since.
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When she was asked what was happening in her life and relationship at that time, her expression suddenly changed. Up until that point, she had spoken in a timid, fatigued, and depressed manner (almost like a shy little girl); now her voice lifted, she leaned toward me, arms outstretched, and in a desperate yet forceful tone said that the feeling of being left alone, of being unimportant, became very strong around that time. Her husband became less and less interested in her, her daughters seemed to be doing fine without her (e.g., in day care), and even her patients seemed not to need her any more. While caring for patients had been a major source of fulfillment for her up to that point, she increasingly had the feeling that her patients disliked her and preferred other nurses (an example of psychic equivalence). She exclaimed, “How is this possible? Why does everyone reject me?” As soon as she had said this, she almost physically collapsed and started crying, saying, “I feel so tired, I feel so alone.” This was the first time she ever had the feeling that her physical symptoms might be connected to what was going on in her life. This is a crucial feature of DIT-FSD, as it opens up the so-called epistemic superhighway that characterizes epistemic trust. This connection is not suggested by anyone else; it is the patient who experiences the connection in the here-andnow of the session, which leads to increasing curiosity about what else might surface in treatment and what else there might be in the therapist’s mind. In the third session we jointly arrived at the IPAF as a focus for the treatment. Michelle’s self-representation involved extremely negative views of the self as worthless, “a grey mouse,” and even the feeling that she was “nothing.” Others were seen as uninterested in her, not supportive, and unavailable. This made her feel alone, sad, abandoned, helpless, and fatigued, a proto-emotion that covered up all other emotions (see below), particularly the frustration and anger that she felt toward her husband, her children, her parents, her colleagues, and even her patients for “not being there for her.” These feelings, however, were strongly defended against by a feeling of helplessness, fatigue, emotion, often even physical paralysis, and guilt. While initially she responded to these feelings with a hyperactivation of the attachment system and (in teleological mode) hoped that caring for others would lead to those others providing her with love and support, this strategy began to fail as her pattern of compulsive caregiving increasingly strained her physical and emotional capacities. A “biopsychosocial crash” ensued, and one evening she fainted at work and was taken to the emergency room and subsequently referred to specialist psychiatric treatment. During the second phase of treatment, Michelle gradually came to recognize how this pattern of compulsive caregiving had completely controlled her life. She realized how, desperate for love, support, and recognition, she had been continuously focused on “being there for someone else; it became almost an obsession, I had to take care of others, I could not let go any longer.” She increasingly began to realize in the sessions and between sessions how this pattern was related to her physical complaints: “Once you start paying attention to it, you suddenly realize how exhausting it is to always want to take care of others, to constantly think what others will think of you.” She also began to notice how angry this made her and
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how her sadness and anger made her feel exhausted. Hence as her capacity for (embodied) mentalizing improved, she also became aware of the high physical and emotional costs of her lifelong pattern. This was a major turning point in the treatment, as she started wondering how she should do things differently. We started thinking together about first taking small steps, as this stable pattern was most likely not going to change overnight. Michelle’s relationship with her husband and children began to change dramatically; instead of being focused on what she thought they needed, she became very interested in how they had felt. She was astonished by the fact that they had been extremely worried about her all the time and how afraid they had been that they might lose her, particularly when she had fainted at the hospital. For the first time she had the feeling that her husband and children truly loved her. At work she asked for a transfer to a physically and emotionally less demanding unit, and slowly, as her mood lifted, her somatic problems also began to improve, particularly when she began to realize how much anger there always had been in her. When I handed Michelle the goodbye letter in Session 13, she was extremely nervous. She began sweating and almost fainted when she started to read the letter. As a result, it took her a long time to read the letter, and although she agreed with almost everything in it, she added, quite ashamed, “But I am still nothing.” Hence there was a strong reactivation of the IPAF in response to the goodbye letter, which she quickly realized when I suggested this possibility to her. However, for much of the session her mentalizing capacities fluctuated strongly, and she was torn between her “old” self-representation of being unworthy (and her belief that I was uninterested in her) and her “new” stronger image of herself. In the next session we were able to look back at this reactivation of her “old” pattern and to link it to the many challenges that still lay ahead. Indeed, if this old pattern was so readily reactivated in treatment, it could also be easily reactivated outside the consulting room. The remainder of the sessions therefore focused on consolidating changes and further supporting her in finding new ways of thinking and feeling about herself and others with regard to what had happened in the past and what was happening in the present and may happen in the future. By this time her somatic symptoms had almost completely disappeared.
Conclusions This chapter has presented a broad, evidence-based psychodynamic approach to the conceptualization and treatment of patients with persistent somatic complaints. This approach helps us to understand the connections between the patient’s presenting problems, his or her subjective responses to these problems, and his or her developmental history. These formulations have clear implications for the treatment of these patients regardless of the specific treatment approach used. We have argued for the importance of recognizing these patients’ impairments in attachment,
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mentalizing, and epistemic trust, as these problems may make it more difficult to establish a therapeutic alliance and create the potential for iatrogenic treatment effects. Health professionals, in particular psychodynamic therapists, should be keenly aware of these dynamics and should distinguish the patient’s premorbid vulnerability from his or her response to persistent somatic complaints.
References Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press. Abbass, A. A., Nowoweiski, S. J., Bernier, D., Tarzwell, R., & Beutel, M. E. (2014). Review of psychodynamic psychotherapy neuroimaging studies. Psychotherapy and Psychosomatics, 83, 142 147. Available from https://doi.org/10.1159/000358841. Aggarwal, V. R., McBeth, J., Zakrzewska, J. M., Lunt, M., & Macfarlane, G. J. (2006). The epidemiology of chronic syndromes that are frequently unexplained: Do they have common associated factors? International Journal of Epidemiology, 35, 468 476. Available from https://doi.org/10.1093/ije/dyi265. Bass, C., & May, S. (2002). Chronic multiple functional somatic symptoms. British Medical Journal, 325, 323 326. Available from https://doi.org/10.1136/bmj.325.7359.323. Blom, D., Thomaes, S., Kool, M. B., van Middendorp, H., Lumley, M. A., Bijlsma, J. W., & Geenen, R. (2012). A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with FM. Rheumatology (Oxford), 51, 347 353. Available from https://doi.org/10.1093/rheumatology/ker342. Bogaerts, K., Van Eylen, L., Li, W., Bresseleers, J., Van Diest, I., De Peuter, S., . . . den Bergh, O. (2010). Distorted symptom perception in patients with medically unexplained symptoms. Journal of Abnormal Psychology, 119, 226 234. Available from https://doi.org/10.1037/a0017780. Cassidy, J., & Kobak, R. R. (1988). Avoidance and its relation to other defensive processes. In J. Belsky, & T. Nezworski (Eds.), Clinical implications of attachment (pp. 300 323). London, UK: Routledge. Department of Health. (2012). IAPT three-year report. The first million patients. London, UK: Department of Health. Available from http://webarchive.nationalarchives.gov.uk/ 20160302155226/http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf. Diamond, D., Stovall-McClough, C., Clarkin, J. F., & Levy, K. N. (2003). Patient-therapist attachment in the treatment of borderline personality disorder. Bulletin of the Menninger Clinic, 67, 227 259. Available from https://doi.org/10.1521/bumc.67.3.227.23433. Fischhoff, B., & Wessely, S. (2003). Managing patients with inexplicable health problems. British Medical Journal, 326, 595 597. Available from https://doi.org/10.1136/ bmj.326.7389.595. Fonagy, P., Lemma, A., Target, M., O’Keeffe, S., Constantinou, M., Ventura Wurman, T., Pilling, S. (2018). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Manuscript in review. Guthrie, E., & Moghavemi, A. (2013). Psychodynamic-interpersonal therapy: An overview of the treatment approach and evidence base. Psychodynamic Psychiatry, 41, 619 635. Available from https://doi.org/10.1521/pdps.2013.41.4.619.
Psychodynamic therapy in patients with somatic symptom disorder
205
Haller, H., Cramer, H., Lauche, R., & Dobos, G. (2015). Somatoform disorders and medically unexplained symptoms in primary care. Deutsches A¨rzteblatt International, 112, 279 287. Available from https://doi.org/10.3238/arztebl.2015.0279. Hambrook, D., Oldershaw, A., Rimes, K., Schmidt, U., Tchanturia, K., Treasure, J., . . . Chalder, T. (2011). Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome. British Journal of Clinical Psychology, 50, 310 325. Available from https://doi.org/10.1348/014466510X519215. Hudson, J. I., Mangweth, B., Pope, H. G., Jr., De Col, C., Hausmann, A., Gutweniger, S., . . . Tsuang, M. T. (2003). Family study of affective spectrum disorder. Archives of General Psychiatry, 60, 170 177. Available from https://doi.org/10.1001/archpsyc.60.2.170. Koelen, J. A., Houtveen, J. H., Abbass, A., Luyten, P., Eurelings-Bontekoe, E. H., Van Broeckhuysen-Kloth, S. A., . . . Geenen, R. (2014). Effectiveness of psychotherapy for severe somatoform disorder: Meta-analysis. British Journal of Psychiatry, 204, 12 19. Available from https://doi.org/10.1192/bjp.bp.112.121830. Lemma, A., Target, M., & Fonagy, P. (2010). The development of a brief psychodynamic protocol for depression: Dynamic interpersonal therapy (DIT). Psychoanalytic Psychotherapy, 24, 329 346. Available from https://doi.org/10.1080/02668734. 2010.513547. Lemma, A., Target, M., & Fonagy, P. (2011). The development of a brief psychodynamic intervention (dynamic interpersonal therapy) and its application to depression: A pilot study. Psychiatry: Interpersonal and Biological Processes, 74, 41 48. Available from https://doi.org/10.1521/psyc.2011.74.1.41. Luyten, P., & Abbass, A. (2013). What is the evidence for specific factors in the psychotherapeutic treatment of fibromyalgia? Comment on ‘Is brief psychodynamic psychotherapy in primary fibromyalgia syndrome with concurrent depression an effective treatment? A randomized controlled trial’. General Hospital Psychiatry, 35, 675 676. Available from https://doi.org/10.1016/j.genhosppsych.2013.07.007. Luyten, P., & Fonagy, P. (2018). The stress-reward-mentalizing model of depression: An integrative developmental cascade approach to child and adolescent depressive disorder based on the Research Domain Criteria (RDoC) approach. Clinical Psychology Review, 64, 87 98. Available from https://doi.org/10.1016/j.cpr.2017.09.008. Luyten, P., & Van Houdenhove, B. (2013). Common and specific factors in the psychotherapeutic treatment of patients suffering from chronic fatigue and pain disorders. Journal of Psychotherapy Integration, 23, 14 27. Available from https://doi.org/10.1037/ a0030269. Luyten, P., Kempke, S., Van Wambeke, P., Claes, S., 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, 21 30. Available from https://doi.org/ 10.1521/psyc.2011.74.1.21. Luyten, P., Mayes, L. C., Target, M., & Fonagy, P. (2012). Developmental research. In G. O. Gabbard, B. Litowitz, & P. Williams (Eds.), Textbook of psychoanalysis (2nd ed., pp. 423 442). Washington, DC: American Psychiatric Press. Luyten, P., van Houdenhove, B., Lemma, A., Target, M., & Fonagy, P. (2012). A mentalization-based approach to the understanding and treatment of functional somatic disorders. Psychoanalytic Psychotherapy, 26, 121 140. Available from https://doi.org/ 10.1080/02668734.2012.678061.
206
Contemporary Psychodynamic Psychotherapy
Luyten, P., van Houdenhove, B., Lemma, A., Target, M., & Fonagy, P. (2013). Vulnerability for functional somatic disorders: A contemporary psychodynamic approach. Journal of Psychotherapy Integration, 23, 250 262. Available from https://doi.org/10.1037/ a0032360. Maunder, R. G., & Hunter, J. J. (2008). Attachment relationships as determinants of physical health. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 11 32. Available from https://doi.org/10.1521/jaap.2008.36.1.11. McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87, 873 904. Available from https://doi.org/10.1152/ physrev.00041.2006. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics and change. New York, NY: Guilford Press. Mikulincer, M., Dolev, T., & Shaver, P. R. (2004). Attachment-related strategies during thought suppression: Ironic rebounds and vulnerable self-representations. Journal of Personality and Social Psychology, 87, 940 956. Available from https://doi.org/ 10.1037/0022-3514.87.6.940. Pedrosa Gil, F., Scheidt, C. E., Hoeger, D., & Nickel, M. (2008). Relationship between attachment style, parental bonding and alexithymia in adults with somatoform disorders. International Journal of Psychiatry in Medicine, 38, 437 451. Available from https:// doi.org/10.2190/PM.38.4.d. Pedrosa Gil, F., Weigl, M., Wessels, T., Irnich, D., Baumuller, E., & Winkelmann, A. (2008). Parental bonding and alexithymia in adults with fibromyalgia. Psychosomatics, 49, 115 122. Available from https://doi.org/10.1176/appi.psy.49.2.115. Sattel, H., Lahmann, C., Gundel, H., Guthrie, E., Kruse, J., Noll-Hussong, M., . . . Henningsen, P. (2012). Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: Randomised controlled trial. British Journal of Psychiatry, 200, 60 67. Available from https://doi.org/10.1192/bjp.bp.111.093526. Sbarra, D. A., & Hazan, C. (2008). Coregulation, dysregulation, self-regulation: An integrative analysis and empirical agenda for understanding adult attachment, separation, loss, and recovery. Personality and Social Psychology Review, 12, 141 167. Available from https://doi.org/10.1177/1088868308315702. Schattner, E., Shahar, G., & Abu-Shakra, M. (2008). I used to dream of lupus as some sort of creature’: Chronic illness as an internal object. American Journal of Orthopsychiatry, 78, 466 472. Available from https://doi.org/10.1037/a0014392. Tak, L. M., & Rosmalen, J. G. M. (2010). Dysfunction of stress responsive systems as a risk factor for functional somatic syndromes. Journal of Psychosomatic Research, 68, 461 468. Available from https://doi.org/10.1016/j.jpsychores.2009.12.004. Van Houdenhove, B., & Luyten, P. (2008). Customizing treatment of chronic fatigue syndrome and fibromyalgia: The role of perpetuating factors. Psychosomatics, 49, 470 477. Available from https://doi.org/10.1176/appi.psy.49.6.470. Waller, E., & Scheidt, C. E. (2006). Somatoform disorders as disorders of affect regulation: A development perspective. International Review of Psychiatry, 18, 13 24. Available from https://doi.org/10.1080/09540260500466774. Wessely, S., & White, P. D. (2004). There is only one functional somatic syndrome. British Journal of Psychiatry, 185, 95 96. Available from https://doi.org/10.1192/bjp.185.2.95.