Post on 11-May-2019
IntensiveShort-termDynamicPsychotherapy:Detec6ngandtrea6ng
soma6csymptomdisordersAllanAbbassMD,FRCPC
Professor&ProgramDirectorCentreforEmo:onsandHealth
DalhousieUniversity,Halifax,Canadaallan.abbass@dal.cawww.allanabbass.com
Allan Abbass MD 2017
ReferenceMaterialsn ReachingthroughResistance.
DetailedmanualonISTDPpsychodiagnosisandtreatmentwithcaseexamples
n www.reachingthroughresistance.comAvailableonAmazon:
hLp://a.co/3UGMWx0n GradedFormatar:cleorcapacity
assessmentandbuilding:hLp://bit.ly/2gVT7iBAr:cleonResistancehLp://reachingthroughresistance.com/wp-content/uploads/2015/02/PsychodynamicPsychiatry2016.pdf
n HiddenfromView:Aclinician’sguidetoPsychophysiologicalDisorders
n WriLenwithaMindbodyexpertinternistHowardSchubinerandwriLenfordoctors
n Howtoeducate,providefirstandsecondlinetreatmentsandbasicISTDPmethods.
n Comingoutendof2017-early2018
n www.unlearnyourpain.comAllan Abbass MD 2017
CentralPointsn Thepresenceofemo:onalfactorscanbedirectlydetected
n TherearespecificpaLernsofunconsciousanxietyanddefensewhichoccurtogether
n Theactualsoma:cexperienceofunprocessedrage,guiltandgriefcanovercomesoma:za:on
Allan Abbass MD 2017
BOND With
Parents PAIN FEAR
Rage, Remorse about the Rage
Character Disorder + Symptoms
Allan Abbass MD 2017
Whattodo?
n Handlebarrierstoengagementn Trytoformtherapeu:caLachmentn Focusonunderlyingavoidedfeelingsn Thisac:vatesalltheunresolvedcomplexfeelingsn Thisac:vatestheanxietyanddefensesn Buildanxietytoleranceasneededn Helpexperiencetheavoidedfeelingsn Linkeverythingtogether
Allan Abbass MD 2017
UnconsciousAnxiety
UnconsciousDefense
UnconsciousImpulses&Feelings
1.PressureonFeelingsorDefenses
2.MonitorAnxiety&Defenseresponses
Allan Abbass MD 2017
3paCernswewillstudy
n 1.Tenseupmusclesandintellectualize,usecharacterdefensesordetach
n 2.GoFlatwithrepressiontosmoothmuscleanxiety,conversionordepression
n 3.GoFlatwithcogni:veperceptualdisrup:onorprimi:vedefenses
n 4.Noresponse
Allan Abbass MD 2017
StriatedMuscleUnconsciousAnxietyn HandsClenchn Arms,Shoulders,Neckn Intercostal:Sighn Abdomen,backn LegsandFeet
àHyperven:la:on,Fibromyalgia,headache,chestpain,abdominalwallpain,tremor,:csn SeewithIsola:onofAffect:intellectualiza:on
Allan Abbass MD 2017
SmoothMuscleUnconsciousAnxietyn Gastrointes:naln Vascular,CoronaryArteriesn Bronchin Bladder
n AbdominalPain,IrritableBowelSyndrome,Dyspepsia,Migraine,PelvicPain
n Mediatedby(unconscious)Repressionoffeelings
Allan Abbass MD 2017
Cogni:ve-perceptualDisrup:onn Dissocia:on,losingtrackofthoughts,poormemory,fain:ng
n Visualblurring,blindnessn Dysfunc:onofothersensesn Hallucina:onsinall5senses
n SeenwithPrimi:vedefensesincludingProjec:onoffeelingsandimpulses
Allan Abbass MD 2017
MotorConversion:Muscleweakness
n àNeurologyConsulta:onandEmergencyDepartments
n SeenwithRepressionn Nostriatedanxietywhenconversionisac:ve
Allan Abbass MD 2017
Sympathysymptomsn Guiltaboutragecausesthesamesymptomsasapersonunconsciouslywantedtoinduceinanother.
n CommonExamples:n StranglingàChokingn Headdamageàheadachen Chestdamageàchestpainn Tearing/rippingsensa:onsàPrimi:verage
n Management:pressuretofeelguiltabouttheragetoremoveorreducepain
Allan Abbass MD 2017
SpectrumofPsychoneuro6cDisorders
Low Resistant
Highly Resistant
Moderate Resistant Mild Severe/
Borderline Moderate
SmoothMuscle/Conversion+Repression
Cogni:ve-PerceptualDisrup:on+Primi:veDefenses
SpectrumofPa:entswithFragileCharacterStructure
StriatedMuscle+Isola:onofAffect
Allan Abbass MD 2017
SpectrumofPsychoneuro6cDisorders
Low Resistant
Highly Resistant
Moderate Resistant Mild Severe/
Borderline Moderate
ViolentRage
MurderousRage
Primi:veMurderousRage
SpectrumofPa:entswithFragileCharacterStructure
Primi:veTorturousRage
Grief
Allan Abbass MD 2017
ComplexTransferenceFeelings(CTF)
n Mixedfeelingsintherapylinkedtothepastbond,trauma,pain,rageandguiltaboutrage.
n Includesapprecia:onandirrita:ontowardthetherapistbecauseofthechallengetodefenses
Allan Abbass MD 2017
UnconsciousTherapeu6cAlliance(UTA)
n Thisistheunconscioushealingforceinthepa:ent
n UTAismobilizedinpropor:ontothedegreeofmobiliza:onoftheCTF
n Bringsmentalimagesandclearlinkagestotrauma
n “UnconsciousMobilized”meansmobiliza:onoftheUTA
Allan Abbass MD 2017
SpectrumofUTA
R>>UTAWhispersfromtheUTA
R<<UTAImagesTransferGuiltandRageR<UTA
GriefandClearLinks
R>>UTANega:on&Dreams
After Davanloo, 2001. Abbass, 2012 Allan Abbass MD 2017
Pressure ModerateResistance
Striatedmuscleanxietyplusfeelcomplextransferencefeelings
HighResistance
Depression,smoothmuscleanxietyormotorconversion
HighResistancewithRepression
Cogni:ve-perceptualdisrup:onorprimi:vedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxiety
CapacityBuildingFormats
Repeatedunlocking,workingthrough,termina:on
Striatedmuscleanxietyplusfeelcomplex
transferenceFeelings
Breakthroughofgriefaboutloss
LowResistance
Completetreatmentin1or2sessions
Inquiry
ResistanceRises
Resistancecrystallizesinthetransference
Clarify,Challenge,
HeadonCollision
Allan Abbass MD 2017
Pressure ModerateResistance
Striatedmuscleanxietyplusfeelcomplextransferencefeelings
HighResistance
Depression,smoothmuscleanxietyormotorconversion
HighResistancewithRepression
Cogni:ve-perceptualdisrup:onorprimi:vedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxiety
CapacityBuildingFormats
Repeatedunlocking,workingthrough,termina:on
Striatedmuscleanxietyplusfeelcomplex
transferenceFeelings
Breakthroughofgriefaboutloss
LowResistance
Completetreatmentin1or2sessions
Inquiry
ResistanceRises
Resistancecrystallizesinthetransference
Clarify,Challenge,
HeadonCollision
Allan Abbass MD 2017
Pressure ModerateResistance
Striatedmuscleanxietyplusfeelcomplextransferencefeelings
HighResistance
Depression,smoothmuscleanxietyormotorconversion
HighResistancewithRepression
Cogni:ve-perceptualdisrup:onorprimi:vedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxiety
CapacityBuildingFormats
Repeatedunlocking,workingthrough,termina:on
Striatedmuscleanxietyplusfeelcomplex
transferenceFeelings
ResistanceRises
Resistancecrystallizesinthetransference
Clarify,Challenge,
HeadonCollision
Allan Abbass MD 2017
Moderateresistantpa6ents
n Buriedmurderousrageandguiltandgriefn Anxietyisallstriatedn Maindefenseisisola:onofaffectandintellectualiza:on
n Pressuretoseeunderlyingfeelingsmobilizestheunconscioustherapeu:calliance
n Ifdefensescrystallizeintheroom,clarifyandchallengethem
Allan Abbass MD 2017
PressureDavanloo1999
n Themainstayinterven:onofISTDPn Encouragingthepa:enttoconnecttohistruefeelingsandbeopenwiththetherapistaboutthesefeelings.
n =Reachingthroughresistancetothepersonunderneath
n àPsychodiagnosisandTreatmentRoadmap
n PressureincreasesComplexTransferenceFeeelings,UTAandResistance
Allan Abbass MD 2017
ChallengeDavanloo1999
n Thisisdoneonlywhentheresistancesarecrystallizinginthetherapeu:crela:onship(transference),whentheyareanobstruc:ontothetherapeuHcbondandtask
n First,clarifythedefenceswiththePa:entn Thenpressure:encouragethepa:enttoovercometheresistanceswithyou
n Finally,challengethedefencesinconcertwiththepa:ent.
Allan Abbass MD 2017
Unconscioustherapeu:calliance
ComplexTransferencefeelings
“Unlocked”
Resistance
Lowrise:inquiryandpressure
Midrise:Resistance
crystallizingintransference.ClarifyandChallenge,
Maintainpressure
Allan Abbass MD 2017
Therapist Pa:ent
Therapist Pa:ent
Therapist Pa:ent
Lowrise
Highrise
Midrise
=DefenseAllan Abbass MD 2017
Unconscioustherapeu:calliance
ComplexTransferencefeelings
“Unlocked”
Resistance
Midrise:Resistance
crystallizingintransference.ClarifyandChallenge,
Maintainpressure
UTA, CTF AND RESISTANCE ARE RISING
Allan Abbass MD 2017
Unconscioustherapeu:calliance
ComplexTransferencefeelings
“Unlocked”
Resistance Highrise:Resistanceintransference.Challenge,
Maintainpressure,Headoncollide
UTA, CTF AND RESISTANCE ARE ALL AT VERY HIGH LEVELS
Allan Abbass MD 2017
StriatedMuscleAnxietyGoesDownBody
NeurobiologicalPathwayofRagegoesupSamesystem:Displacingsoma:za:on
AMAAtlasonlineAllan Abbass MD 2017
§ Firstbreakthrough:somepassageofgriefwithlinkagetopastorrecentperson
§ Par:alUnlocking:soma:cpathwayoflove,rage,guiltandgriefareexperiencedtosmalldegree:vividlinktopastperson.
Unlocking
Allan Abbass MD 2017
StriatedMuscleAnxietyGoesDownBody
NeurobiologicalPathwayofRage:goesupsamesystemdisplacingsoma:za:on
AMAAtlasonlineAllan Abbass MD 2017
Pressure
Depression,smoothmuscleanxietyormotorconversion
HighResistancewithRepression
Cogni:ve-perceptualdisrup:onorprimi:vedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxiety
CapacityBuildingFormats
Inquiry
ResistanceRises
Allan Abbass MD 2017
UnconsciousAnxiety
StriatedMuscleAnxietyIsola:onofAffect
SevereRepression
ModerateRepression
MildRepression
ConsciousFeelings Threshold to experiencing impulse/feelings
Allan Abbass MD 2017
UnconsciousAnxiety
StriatedMuscleAnxietyIsola:onofAffect
ConsciousFeelings
1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect
1
3 2
3 2
1
Allan Abbass MD 2017
HowtoReduceAnxiety
n Talkn Lettheclient/pa:enttalkn ChangeSta:onsCàTorTàCorCàCn Focusonbodilycuesn RecapitulateonwhathappenedP-C-TandI/F-Anxiety-Defence
n Stayofffeelingsforamoment
Allan Abbass MD 2017
WhentoResumePressure
n Whentensionisbackinstriatedmusclesn Whenpa:entisac:velyisola:ngaffectn Whenthepa:entsuggestsweexplorethismoreorexpressescuriosityabout“whythathappens”
n Whenheexpressesthatheisreadyformorepressure”canyouaskmethatonemore:me?
Allan Abbass MD 2017
Portraying
n Imageryofwhatanurgewantstodon Ameanstoholdawarenessandisolatetheaffect:desensi:ze
n CanbeusedwithliLletonoexperienceoftherage.n Increasesisola:onofaffectandbringsanxietytostriatedmuscles
n Raisesthresholdthathecanusethesedefencesandtolerateanxiety.
Allan Abbass MD 2017
UnconsciousAnxiety
StriatedMuscleAnxietyIsola:onofAffect
ConsciousFeelings
1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect
1
3 2
3 2
1
Allan Abbass MD 2017
UnconsciousAnxiety
StriatedMuscleAnxietyIsola:onofAffect
ConsciousFeelings
1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect
CTF UTA RESISTANCE
Allan Abbass MD 2017
Pressure
Cogni:ve-perceptualdisrup:onorprimi:vedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxiety
CapacityBuildingFormats
Inquiry
ResistanceRises
Allan Abbass MD 2017
FragileCharacterStructurePa6ents
n Dissociate,losevision,losehearing,hallucinaten Projec:on,splimngprojec:veiden:fica:onn Needcapacitybuildingn Preandpost:structuralchangesàStriatedmuscletensionandisola:onofaffect
n Theregularbreakthroughofunderlyingfeelings,workingthroughandtermina:on
n Treatment20-150sessionsdependingonseverity
Allan Abbass MD 2017
WEAK BOND
PAIN FEAR
Rage, Remorse about the Rage, Craving Bond Severe Character
Disorder + Symptoms
Allan Abbass MD 2017
Isola:onofaffectStriatedmuscle
Mildfragile
Moderatefragile
Severefragile,borderline
Threshold
toCPDorp
rimi:vede
fenses
Therapeu:
cwindow
1
3
2 12
3
1. Pressure 2. Rise in CTF 3. Recap
Unconsciousanxietyanddefense
Consciousfeelings
Allan Abbass MD 2017
Cogni:ve
Perceptual
Disrup:on
Repression
SmoothMuscle
Isola:onofaffectStriatedMuscle
MildFragileModerateFragileSevereFragileBorderline
Allan Abbass MD 2017
ResultsofCapacityBuildingPhase
n Anxietyinstriatedmusclen Abilitytoselfreflectn Abilitytoreduceownanxietyn Understandingofthetrauman Reduc:onofparanoia/projec:onandgriefaboutit
n Emergingempathyforfamily
Allan Abbass MD 2017
UTAinRepeatedUnlocking
n Spontaneousunlockingsinweekn Imagerypopsinheadn Deadbodiesn Sensa:onsinbodyn Dreamsthatarebreakthroughsn Vividcontentallowstrongguilttobefeltn SenseofPresence:UTA
Allan Abbass MD 2017
Resultsofrepeatedunlockingphase
n Nexttonosignsoffragilityn Emo:onsareseparated:de-fusedn Compassionforselfn Empathyandloveforothers:survivorguiltn Griefaboutpsychopathologyn Func:onalgainsn Growingmasteryofpsychodynamicsn Altruism:wishtogivetoothers
Allan Abbass MD 2017
WorkingThroughPhase
n Mobiliza:onofgriefandselfcompassionasguiltisremoved
n Defusionofpuni:vesuperegofromselfn DrivesforaLachmentn Healthyac:vityinlifen Returntofunc:onn Pocketsofrageandguilts:llemergen Griefisdominantn Empathy/loveforfamilymembers
Allan Abbass MD 2017
CourseofIntensive“Long-term”DP
Start End
Capacity Building
Repeated Unlocking
Working Through Termination
Allan Abbass MD 2017
UsewhenbelowthresholdsEvokefeelingsAc:vatesoma:cpathwayofrageDevelopimagesFirelimbicareasincludingamygdala
UsewhenabovethresholdsSelf-reflectLinkphenomenaObservethebodyObservethoughtsFirebrainself-reflec:vecenters
Reflection: Recap
Pressure
Usetoop:mizerisewithoutbeingoverthresholdCombinebothself-reflec:onandpressureTrainbraintofirebothfunc:onalregionstogether
BRACING
Abbass, Reaching Through Resistance, 2015 Allan Abbass MD 2017
Cogni:ve
Perceptual
Disrup:on
Repression
SmoothMuscle
Isola:onofaffectStriatedMuscle
MildFragileModerateFragileSevereFragileBorderline
Allan Abbass MD 2017
UnconsciousAnxiety
StriatedMuscleAnxietyIsola:onofAffect
ConsciousFeelings
1.Pressuretorage2.Risetoabovethreshold3.PresstoGuiltandregulatedownanxietyasneeded4.ExtensiveRecapping
1
3
2
3
2
1
Immersive Approach to Building Capacity
Allan Abbass MD 2017
Adjunc6veISTDPforPsycho6cDisorders
n Forresidualanxiety,depressionandinterpersonalproblemsandsomepsychotogeniccycles
n N=38,Mean13sessionsn Sigreduc:oninselfreportParanoididea:on,Anxiety,Obsessive
Compulsive,andGlobalsymptomra:ng(BSI)
0
5000
10000
15000
20000
25000
30000
1 yr Pre 1 yr Post 2 yr Post 3 yr Post 4 yr Post
Hospital Costs
0
200
400
600
800
1000
1200
1 yr Pre 1 yr Post 2 yr Post 3 yr Post 4 yr Post
Doctor Billings
Abbass, et al, 2015 Allan Abbass MD 2017