The Talking Cure and chimney sweeping were terms Bertha Pappenheim, known in case studies by the alias Anna O., used for the verbal therapy given to her by Josef Breuer. They were first published in Studies on Hysteria (1895).
As Ernest Jones put it, “On one occasion she related the details of the first appearance of a particular symptom and, to Breuer’s great astonishment, this resulted in its complete disappearance,” or in Lacan‘s words, “the more Anna provided signifiers, the more she chattered on, the better it went”.
Breuer found that Pappenheim’s symptoms – headaches, excitement, curious vision disturbances, partial paralyses, and loss of sensation, which had no organic origin and are now called somatoform disorders – improved once the subject expressed her repressed trauma and related emotions, a process later called catharsis. Peter Gay considered that, “Breuer rightly claimed a quarter of a century later that his treatment of Bertha Pappenheim contained ‘the germ cell of the whole of psychoanalysis’.”
Sigmund Freud later adopted the term talking cure to describe the fundamental work of psychoanalysis. He himself referenced Breuer and Anna O. in his Lectures on Psychoanalysis at Clark University, Worcester, MA, in September 1909: “The patient herself, who, strange to say, could at this time only speak and understand English, christened this novel kind of treatment the ‘talking cure’ or used to refer to it jokingly as ‘chimney-sweeping’.”
Locus Classicus
There are currently three English translations of Studies on Hysteria, the first by A. A. Brill (1937), the second by James Strachey (1955), included in the Standard Edition, and the third by Nicola Luckhurst (2004). The following samples come from Breuer’s case study on “Anna O…” where the concept of talking cure appears for the first time and illustrate how the translations differ:
Edition
Outline
1937
In the country, where I could not see the patient daily, the situation developed in the following manner: I came in the evening when I knew that she was in a state of hypnosis, and I took away from her the whole supply of fantasms which she had collected since my last visit. In order to obtain good results this had to be accomplished very thoroughly. Following this, she was quite tranquil and the next day she was very pleasant, docile, industrious and cheerful. The following day she was always more moody, peevish, and unpleasant; all of which became more marked on the third day. In this state of mind it was not always easy even in hypnosis to induce her to express herself, for which procedure she invented the good and serious name of “talking-cure,” and humorously referred to it as “chimney-sweeping.” She knew that after expressing herself, she would lose all her peevishness and “energy,” yet whenever (after a long pause) she was in an angry mood she refused to talk, so that I had to extort it from her through urging and begging, as well as through some tricks, such as reciting to her a stereotyped introductory formula of her stories. But she never spoke until after she had carefully touched my hands and had become convinced of my identity. During the nights when rest could not be obtained through expression, one had to make use of chloral. I tried this a number of times before, but I had to give her 5 grams per dose, and sleep was preceded by a sort of intoxication, which lasted an hour. In my presence she was cheerful, but when I was away, there appeared a most uncomfortable, anxious state of excitement (incidentally, the deep intoxication just mentioned made no change in the contractures). I could have omitted the narcotic because the talking, if it did not bring sleep, at least produced calm. In the country, however, the nights were so intolerable between the hypnotic alleviations, that we had to resort to chloral. Gradually, however, she did not need so much of it.
1955
While she was in the country, when I was unable to pay her daily visits, the situation developed as follows. I used to visit her in the evening, when I knew I should find her in her hypnosis, and I then relieved her of the whole stock of imaginative products which she had accumulated since my last visit. It was essential that this should be effected completely if good results were to follow. When this was done she became perfectly calm, and next day she would be agreeable, easy to manage, industrious and even cheerful; but on the second day she would be increasingly moody, contrary and unpleasant, and this would become still more marked on the third day. When she was like this it was not always easy to get her to talk, even in her hypnosis. She aptly described this procedure, speaking seriously, as a ‘talking cure’, while she referred to it jokingly as ‘chimney-sweeping’.[1] She knew that after she had given utterance to her hallucinations she would lose all her obstinacy and what she described as her ‘energy’; and when, after some comparatively long interval, she was in a bad temper, she would refuse to talk, and I was obliged to overcome her unwillingness by urging and pleading and using devices such as repeating a formula with which she was in the habit of introducing her stories. But she would never begin to talk until she had satisfied herself of my identity by carefully feeling my hands. On those nights on which she had not been calmed by verbal utterance it was necessary to fall back upon chloral. I had tried it on a few earlier occasions, but I was obliged to give her 5 grammes, and sleep was preceded by a state of intoxication which lasted for some hours. When I was present this state was euphoric, but in my absence it was highly disagreeable and characterized by anxiety as well as excitement. (It may be remarked incidentally that this severe state of intoxication made no difference to her contractures.) I had been able to avoid the use of narcotics, since the verbal utterance of her hallucinations calmed her even though it might not induce sleep; but when she was in the country the nights on which she had not obtained hypnotic relief were so unbearable that in spite of everything it was necessary to have recourse to chloral. But it became possible gradually to reduce the dose. ————————— [1] These two phrases are in English in the original.
2004
While the patient was in the country, where I was unable to visit her every day, the situation developed as follows. I came in the evening, when I knew that she would be in her hypnosis, and removed the entire stock of phantasms that she had amassed since my last visit. For this to be successful, there could be no omissions. Then she would become quite calm and on the following day was agreeable, obedient, industrious, and even in good spirits. But on the second day she was increasingly moody, contrary and disagreeable, and this worsened on the third. Once she was in this temper it was not always easy, even in her hypnosis, to get her to talk things through, a procedure for which she had found two names in English, the apt and serious ‘talking cure’ and the humorous ‘chimney-sweeping’. She knew that having spoken out she would lose all her contrariness and ‘energy’. If, after a comparatively long break, she was already in a bad mood, she would refuse to talk, and I had to wrest it from her, with demands, pleas and a few tricks such as reciting one of the phrases with which she would typically begin her stories. But she would never speak until she had made sure of my identity by carefully feeling my hands. During those nights when talking things through had not calmed her, it was necessary to resort to chloral. I had tried this on a few previous occasions, but found it necessary to give her 5 grams, and sleep was then preceded by a state of intoxication lasting several hours. Whenever I was present, this state was bright and cheerful, but, in my absence, it took the form of an anxious and extremely unpleasant excitement. (The contracture was completely unaffected by this state of severe intoxication.) I had been able to avoid the narcotic, because the talking through at the very least calmed her down, even if it did not also allow her to sleep. But while she was living in the country the nights between those in which she was relieved by hypnosis were so unbearable that it was necessary to resort to chloral; gradually, however, she needed to take less of it.
Current Sstatus
Mental health professionals now use the term talking cure more widely to mean any of a variety of talking therapies. Some consider that after a century of employment the talking cure has finally led to the writing cure.
The Talking Cure: The science behind psychotherapy is also the name of a book published by Holt and authored by Susan C. Vaughan MD in 1997. It explores the way in which psychotherapy reshapes the through incorporating neuroscience research with psychotherapy research and research on development. It contains clinical vignettes of the “talking cure” in action from real psychotherapies.
Celebrity Endorsement
The actress Diane Keaton attributes her recovery from bulimia to the talking cure: “All those disjointed words and half-sentences, all those complaining, awkward phrases…made the difference. It was the talking cure; the talking cure that gave me a way out of addiction; the damn talking cure.”
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Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.
The therapy’s primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful. The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings.
Patients come to therapy because of either symptoms or interpersonal difficulties. Symptoms include traditional psychological problems like anxiety and depression, but they also include physical symptoms without medically identifiable cause, such as headache, shortness of breath, diarrhoea, or sudden weakness. The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness. Within psychiatry, these phenomena are classified as “Somatoform Disorders” in DSM-IV-TR.
The therapy itself was developed during the 1960s to 1990s by Habib Davanloo, a psychiatrist and psychoanalyst from Montreal. He video recorded patient sessions and watched the recordings in minute detail to determine as precisely as possible what sorts of interventions were most effective in overcoming resistance, which he believed was acting to keep painful or frightening feelings out of awareness and prevent interpersonal closeness.
ISTDP is taught by Habib Davanloo at McGill University, as well as in other University and post-graduate settings around the world. The ISTDP Institute offers on-line ISTDP training materials, including introductory videos and skill-building exercises.
Origins and Theoretical Foundation
In 1895, Josef Breuer and Sigmund Freud published their Studies on Hysteria, which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as “Anna O” who suffered headaches, partial paralysis, loss of sensation, and visual disturbances. These symptoms did not conform to known patterns of neurological disease, and neurologists were thus unable to account for symptoms in purely anatomical or physiological terms. Breuer’s breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives. Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis, and the experiencing of the previously forbidden or painful emotion was abreaction.
Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association, interpretation of resistance, and dream interpretation. With each step, therapy became longer. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his 1937 paper “Analysis Terminable and Interminable.”
From the 1930s through the 1950s, a number of analysts were researching methods of shortening the course of therapy without sacrificing therapeutic effectiveness. These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo. One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these “rapid responders” were able to recover quickly with therapy because they were the least traumatised and therefore had the smallest burden of repressed emotion, and so were least resistant to experiencing the emotions related to trauma. However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.
A number of psychiatrists began directing their psychotherapeutic research into methods of overcoming resistance. Dr. David Malan popularised a model of resistance, known as the Triangle of Conflict, which had first been proposed by Henry Ezriel. At the bottom of the triangle are the patient’s true, impulse-laden feelings, outside of conscious awareness. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.
The emotions at the bottom of Malan’s Triangle of Conflict originate in the patient’s past, and Malan’s second triangle, the Triangle of Persons, originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist. The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory. Independent empirical support came from Bowlby’s newly arising field of Attachment Theory.
Bowlby and Attachment Trauma
John Bowlby, a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures (usually the mother, but often the father and others) in early life. He concluded, in opposition to received psychoanalytic dogma of the day, that childhood experience was far more important than unconscious fantasy. He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother. For instance, a child taken out of its mother’s arms cries loudly in protest, and it is only quieted by being restored to its mother’s arms. Bowlby observed that the innate attachment system would be activated by loss of proximity to the mother, and that long-lasting trauma to the child could result from attachment interruption. Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.
Bowlby conducted numerous studies and noted strong correlations between adverse early-life circumstances – primarily the lack of a consistent and nurturing relationship with the mother – as the source of numerous difficulties, including persistent depression, anxiety, or delinquency in adulthood. Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties. Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.
Davanloo’s Discovery of the Unconscious Consequences of Attachment Trauma
In the 1960s, while Bowlby was observing children directly, Davanloo was beginning his work with symptomatic and character-disturbed adults. As he began his video-recording work and became progressively successful against higher levels of resistance, he noted that particular themes reappeared with striking consistency in patient after patient.
First, the therapist’s efforts to get to know the patient’s true feelings often aroused a simultaneous mixed feeling in the patient, composed of deep appreciation for the therapist’s relentless efforts to get to know the patient deeply, combined with equally deep irritation at the therapist for challenging the patient to abandon long-held resistances which could thwart the therapeutic effort.
Davanloo noted, in concert with Malan’s Triangle of Conflict, that patients would unconsciously resist the therapist’s efforts to get to the root of their difficulties. He also observed, from his videotaped sessions, that patients would simultaneously send off signals of their unconscious anxiety. Davanloo carefully monitored these signals of anxiety and saw that they represented the rise of complex mixed feelings with the therapist. The mix represented that part of the patient seeking relief from painful symptoms but also an active desire to avoid painful, repressed feelings.
As Davanloo became more skilled at unlocking the patient’s true unconscious feelings, he noted an often very predictable sequence of feelings. The sequence was by no means invariable, but it occurred frequently enough to allow the therapist to hypothesise its existence in a majority of cases.
First, after a high rise of mixed feeling with the therapist, manifested as signals of intense anxiety (tension in skeletal muscle, often manifested as wringing of the hands, accompanied with deep, sighing respirations), there would often be a breakthrough of rage, accompanied by an immediate drop in anxiety. This rage, Davanloo discovered, is intensely felt. It often has a violent impulse associated with it, sometimes even a murderous impulse. Once patients feel this rage, they are able to describe vividly detailed fantasies of what the rage would do if it were to take on a life of its own.
The rage is a product of thwarted efforts to attach from the past. Those thwarted efforts to love and be loved yield pain, in the form of what Bowlby described as protest. The pain yields a reactive rage at the loved person who thwarted attachment efforts.
Complete experiencing of the rageful impulse is typically accompanied by a tremendous relief at finally getting something out which has yearned for release. However, the relief is typically short lived.
Next, Davanloo almost invariably noted that patients then experience a tremendous wave of guilt about the rage. The guilt is a product of the fact that the old rageful feelings were with a person who was also loved. It is this guilt, Davanloo discovered, which is the key ingredient in symptom formation and character difficulties. Symptoms and interpersonal difficulties (usually unconscious efforts to ward off intimacy and closeness) are the product of guilt, which turns the rage back on the self. For instance, the rage of a two-year-old toward a mother who dies may be experienced in the present as suicidal feelings (self-directed murderous rage).
Beneath the guilty feelings from the past, Davanloo almost invariably noted painful feelings about thwarted efforts at emotional closeness to parents and others in childhood. Finally, at the deepest layer of feelings are the still powerful yearnings for closeness, attachment, and love.
The goal of the ISTDP therapist is, as rapidly as possible, to help the patient overcome resistance, and then experience all the waves of mixed, genuine feeling, previously unconscious, triggered by the intense therapeutic process. Those feelings are traced back to their origins in the past, and then both therapist and patient come to understand how the patient came to be the “consciously confused, unconsciously driven” person in the present. Old pockets of emotion are drained, the patient has a clearer self-narrative, and self-destructive symptoms and defences are renounced. The understanding gained is not just cognitive, but goes to the fundamental, emotional core. The influence of Freud’s early trauma theory is evident.
Specific Therapeutic Interventions
Davanloo discovered the layers of the dynamic unconscious through a process of developing specific interventions which allow the therapist to reach those layers. Those interventions, applied in a specific fashion at specific times in the therapeutic process, are all calculated to overcome the patient’s resistance as quickly and completely as possible, to allow the earliest and fullest experience of true feelings about the present and past as quickly as possible. Those interventions are known as pressure, challenge, and head-on collision.
I. Pressure: Therapeutic Encouragement and Reaching through to the Patient
Pressure is the principal ingredient of ISTDP, and it takes many forms. Initially, pressure takes the form of encouraging the patient to describe symptoms and interpersonal difficulties as specifically as possible, so both patient and therapist get the clearest picture possible of the precise difficulties. It starts from the moment the patient walks into the room, in the form of the question, “Are there some difficulties you are experiencing which you would like us to have a look at?”
The primary form of pressure is pressure toward feeling. Again, this is exerted mainly in the form of questions, such as, “How did you feel toward your boss for humiliating you in front of your staff? We see that you got anxious and depressed, but how did you feel?”
Pressure can be toward the patient’s will: “Can we look to your feelings? Do you want us to look to your feelings?”
Pressure is also exerted toward the therapeutic task: “Our goal here, if you want, is to get to the root, the engine, driving your difficulties. So, can we look at a specific time when you experienced anxiety? This will give us a clear picture of the problem which we can use to get to the engine.”
In its essence, pressure is encouragement from the therapist to the patient. It is encouragement to renounce defences, tolerate anxiety, and walk, with the therapist, into those places which have previously been off-limits. It is a way of saying, “There’s nothing in there we cannot face together, and we do so in your service, to relieve you of painful difficulties.”
Patients with low resistance are often quite responsive to pressure alone. However, as explained above, those are the patients who are healthiest to begin with. For patients with higher levels of resistance, usually the product of a more traumatised early phase of life, pressure quickly leads to the patient erecting barriers with the therapist. Those barriers are the patient’s habitual defences against avoided feelings. The combination of intentional (conscious) and unintentional (unconscious) defences is called the resistance. The therapist is constantly monitoring for both the rise in anxiety and the appearance of resistance. When resistance does make its appearance, new interventions, in addition to pressure, are called for.
II. Challenge: Pointing Out and Interrupting Defences in Concert with the Patient
Challenge is a two-stage process. The first stage is clarification, which is the therapist’s effort to confirm that resistance is operating, and also to acquaint the patient with the specific defence being deployed. Patients are often quite unaware of their own defences. Clarification takes the form of a question, meant to clarify the defence to both patient and therapist: “Do you notice that when you speak of being angry with your boss that you smile and giggle? Is a smile something you sometimes do to cover up a deeper feeling?”
When a defence is properly clarified, both patient and therapist can work together against it, because it represents an obstacle to the therapeutic task of getting to the patient’s true feelings. A defence which has not been clarified is still invisible to the patient. It is also important to note that in childhood, defences can be a useful tool in emotionally overwhelming or traumatic situations. According to Los Angeles-based psychiatrist Katherine Watkins, M.D.:
“defenses such as dissociation and repression can shield us from intense feelings that we are developmentally unprepared to experience and process. However as we grow up, this shielding cuts us off from our full range of feelings, even when we are now emotionally able to handle the feelings.”
Challenge to the defences represents an exhortation to the patient to abandon the defence: “Again you smile when I ask you about feelings in relation to being humiliated by your husband. If you don’t smile, how were you truly feeling?” This particular intervention is a very powerful one in the therapist’s arsenal. As with all powerful interventions, if it is misapplied, the consequences can be severe: rapid misalliance with the therapist, worsening of symptoms, and treatment dropout. This is because the patient perceives a premature challenge, applied when a defence has not been clarified, as a criticism or a personal attack.
A common misunderstanding of ISTDP is that the therapist’s role is to badger the patient through the use of Challenge. However, the proper use of challenge is as an aid or enhancement to the therapeutic alliance by removing an obstacle to the rise in complex feelings with the therapist. If challenge originates as a product of frustration in the therapist or as a misunderstanding of the unconscious, then stalemate is virtually assured.
The main purpose of challenge is to remove any obstacles in the way of the mutually agreed upon task of getting to the engine of the patient’s present difficulties: warded-off, complex feelings in relation to traumatising experiences with important attachment figures in the past.
The majority of patients are able to experience their true mixed feelings with a combination of Pressure and properly clarified Challenge. However, a sizable minority of patients erect a massive wall of resistance with the therapist. This wall is erected automatically and is an over-learned, habitual response, used to avoid emotional intimacy, both with the therapist and with other important figures in the patient’s personal orbit. When the therapist observes that the patient’s resistance has fully crystallised, it is time to deploy the ultimate intervention.
III. Head-On Collision: Pointing Out the Reality of the Defences and Encouragement to Overcome Them
The Head-on Collision is an intervention aimed not at any single defence but rather aimed at the entire defensive structure being deployed by the patient. It is an urgent appeal to the patient to exert maximal effort to overcome the resistance, and it takes the form of a summary statement to the patient which explains the consequences of continuing to resist:
Let’s take a look at what’s happening here. You have come on your own free will, because you are experiencing a problem which causes you pain. We have set out to get to the root of your difficulties, but every time we attempt to move toward it, you put up this massive wall. The wall keeps me out, and it keeps you from knowing your own true feelings. If you keep me out, you keep me useless. Is that what you want? Because, as you see, you are certainly capable of keeping me useless to you. My first question is, why would you want me to be useless? You see, the consequences of this would be that I would be unable to help you. I’d like to, but the nature of this work is that I can’t help everyone. Sometimes I fail. However, can you afford to fail? How much longer do you want to carry this burden?
This complex intervention is simultaneously aimed at the patient’s will, is a reminder of the task, and is a wake-up call to the therapeutic alliance to exert maximal effort against the resistance. It is a reminder, in stark terms, that the therapeutic task is in jeopardy and may well fail. Finally, it is a reminder to the patient of the consequences of failure, as well as an implied reminder that success is also possible.
The interventions of Pressure, Challenge, and Head-on Collision, all aimed at helping the patient experience true feelings in relation to the present and past, allowed Davanloo to expand the scope of patients who can be helped by short-term psychodynamic psychotherapy. A model which initially worked only with highly motivated patients able to describe a clearly problematic area can now be applied to patients whose difficulties are diffuse and whose motivation is also initially quite diffuse. The results are deep, lasting changes in areas of both symptomatic and interpersonal disturbances.
It is also worth stressing that ISTDP, unlike traditional psychodynamic therapies, assiduously avoids interpretation until such time as the unconscious is open. The use of trial interpretations is explicitly avoided. The phase of interpretation only commences once it is clear to both therapist and patient that there has been a passage of previously unconscious emotion. Quite often, it is then the patient who takes the lead in interpreting:
“The incredible rage I felt toward you when you refused to let me off the hook regarding my feelings is exactly the same rage that I felt toward my father when I was five years old and found out he had been killed in the war and wasn’t coming home. I buried the rage that day because I felt so guilty about it. That’s the day I became depressed.”
Evidence Base
Davanloo’s initial research was published in the form of a qualitative case series of approximately 200 patients. He maintains a large video library of treated cases which he uses for teaching conferences, though this has not yet been made available for other psychotherapy researchers to independently verify and quantify Davanloo’s claims. Recent studies however, support the efficacy of the ISTDP technique, as described below. He claims efficacy with psychological symptoms, medically unexplained symptoms (so-called functional or somatoform disorders), and characterological disturbances (referred to as Personality Disorders in DSM).
Empirical research into the efficacy of ISTDP, and other brief psychodynamic psychotherapies is active. There are now over 60 published outcome studies in ISTDP including 40 randomised controlled trials for depression, anxiety, personality, somatic symptom and substance use disorders. There are also over 20 studies showing the cost effectiveness of the method through reducing doctor visits, medication costs, hospital costs and disability costs. Summary of cost effectiveness studies to 2018
ISTDP has been investigated for:
Personality Disorders.
Depression and Treatment Resistant Depression.
Anxiety Disorders.
Functional Neurological Disorders.
Somatic Symptom Disorders: at least 20 studies as of October 2019.
Summary of ISTDP Somatic Condition Studies:
Cost effectiveness studies: at least 22 studies as of October 2019.
As an Adjunct to Care in Severe Mental Disorders.
Substance Use Disorders.
A Cochrane systematic review examined the efficacy of short-term psychodynamic psychotherapies for common mental disorders such as depression, anxiety and personality disorders. Without distinguishing between different forms of STDP from Davanloo’s ISTDP, modest to large short-term gains were reported for a broad range of people experiencing common mental disorders. Further research is required to determine the effectiveness and long term benefits of psychodynamic psychotherapies for common mental disorders. Neuroscientist and Nobel Prize winner, Eric Kandel refers to Davanloo’s technique and its effectiveness in providing relief from emotional disturbances.
Relationship to Cognitive Therapy
Cognitive therapy (CT), developed by Aaron T. Beck, focuses on illogical thoughts as the main driver of emotional difficulties. These beliefs, such as, “Everything I attempt inevitably fails,” are postulated to cause emotional states like depression or hopelessness. The therapist collaborates with the patient to determine which faulty cognitions are currently accepted by the patient as true. Together, the patient and therapist discover these cognitions and collaboratively explore the evidence for and against them. Relief of symptoms comes from replacing unfounded cognitions with more reality-based thoughts. CBT has been shown effective in numerous trials[citation needed], particularly for depression and anxiety disorders.
While ISTDP accepts the presence of faulty cognitions, the causality is thought to be reversed. The ISTDP therapist would posit that unconscious emotions lead to unconscious anxiety, which is managed by unconscious defences. These defences can certainly include hopeless, helpless, or self-deprecating cognitions. Rather than examining evidence for and against a thought like, “I am unable to know my own true feelings,” an ISTDP therapist might say, “If you adopt that position, which is essentially a position of helplessness, we will not get to the engine driving your difficulties. If you renounce this helpless position, how are you truly feeling right now?”
Both the CT and ISTDP therapist call the thought into question, with the goal of ultimately liberating the patient. The difference is that the ISTDP therapist sees the faulty cognition as preventing access to the true, buried feelings, while the CT therapist sees the faulty cognition as the cause of the painful emotions leading to the painful psychological state. It may well be the case that causality flows in both directions, dependent on the individual, the emotions, and the cognitions involved. As of this writing, though both CT and ISTDP show good evidence of clinical efficacy, the theoretical question of whether feelings drive thoughts or thoughts drive feelings remains unresolved; it could well be the case that thought and feeling are inextricably bound, and that we have not yet developed adequate psychological or neuroscientific concepts and tools to frame these sorts of questions properly.
Body dysmorphic disorder (BDD), occasionally still called dysmorphophobia, is a mental disorder characterized by the obsessive idea that some aspect of one’s own body part or appearance is severely flawed and therefore warrants exceptional measures to hide or fix it.
A cartoon of a patient with body dysmorphia looking in a mirror, seeing a distorted image of himself.
In BDD’s delusional variant, the flaw is imagined. If the flaw is actual, its importance is severely exaggerated. Either way, thoughts about it are pervasive and intrusive, and may occupy several hours a day, causing severe distress and impairing one’s otherwise normal activities. BDD is classified as a somatoform disorder, and the DSM-5 categorises BDD in the obsessive-compulsive spectrum, and distinguishes it from anorexia nervosa.
BDD is estimated to affect from 0.7% to 2.4% of the population. It usually starts during adolescence and affects both men and women. The BDD subtype muscle dysmorphia, perceiving the body as too small, affects mostly males. Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it. Fearing the stigma of vanity, one usually hides the preoccupation. Commonly unsuspected even by psychiatrists, BDD has been underdiagnosed. Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD has high rates of suicidal thoughts and attempts at suicide.
Brief History
In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia, which described the disorder as a feeling of being ugly even though there does not appear to be anything wrong with the person’s appearance. In 1980, the American Psychiatric Association recognised the disorder, while categorising it as an atypical somatoform disorder, in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM). Classifying it as a distinct somatoform disorder, the DSM-III’s 1987 revision switched the term to body dysmorphic disorder.
Published in 1994, DSM-IV defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing social or occupational dysfunction, and not better explained as another disorder, such as anorexia nervosa. Published in 2013, the DSM-5 shifts BDD to a new category (obsessive-compulsive spectrum), adds operational criteria (such as repetitive behaviours or intrusive thoughts), and notes the subtype muscle dysmorphia (preoccupation that one’s body is too small or insufficiently muscular or lean).
Signs and Symptoms
Dislike of one’s appearance is common, but individuals who suffer from BDD have extreme misperceptions about their physical appearance. Whereas vanity involves a quest to aggrandise the appearance, BDD is experienced as a quest to normalise the appearance merely. Although delusional in about one of three cases, the appearance concern is usually non-delusional, an overvalued idea.
The bodily area of focus can be nearly any and is commonly face, hair, and skin. In addition, multiple areas can be focused on simultaneously. A subtype of body dysmorphic disorder is bigorexia (anorexia reverse or muscle dysphoria). In muscular dysphoria, patients perceive their body as excessively thin despite being muscular and trained. Many seek dermatological treatment or cosmetic surgery, which typically do not resolve the distress. On the other hand, attempts at self-treatment, as by skin picking, can create lesions where none previously existed.
BDD is an obsessive-compulsive disorder but involves more depression and social avoidance despite DOC. BDD often associates with social anxiety disorder. Some experience delusions that others are covertly pointing out their flaws. Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyper-arousal.
Most generally, one experiencing BDD ruminates over the perceived bodily defect several hours daily or longer, uses either social avoidance or camouflaging with cosmetics or apparel, repetitively checks the appearance, compares it to that of other people, and might often seek verbal reassurances. One might sometimes avoid mirrors, repetitively change outfits, groom excessively, or restrict eating.
BDD’s severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods. Social impairment is usually greatest, sometimes approaching avoidance of all social activities. Poor concentration and motivation impair academic and occupational performance. The distress of BDD tends to exceed that of either major depressive disorder or diabetes, and rates of suicidal ideation and attempts are especially high.
Causal Factors
As with most mental disorders, BDD’s cause is likely intricate, altogether biopsychosocial, through an interaction of multiple factors, including genetic, developmental, psychological, social, and cultural. BDD usually develops during early adolescence, although many patients note earlier trauma, abuse, neglect, teasing, or bullying. In many cases, social anxiety earlier in life precedes BDD. Though twin studies on BDD are few, one estimated its heritability at 43%. Yet other factors may be introversion, negative body image, perfectionism, heightened aesthetic sensitivity, and childhood abuse and neglect.
Social Media
Constant use of social media and “selfie taking” may translate into low self-esteem and body dysmorphic tendencies. The sociocultural theory of self-esteem states that the messages given by media and peers about the importance of appearance are internalised by individuals who adopt others’ standards of beauty as their own. Due to excessive social media use and selfie taking, individuals may become preoccupied about presenting an ideal photograph for the public. Specifically, females’ mental health has been the most affected by persistent exposure to social media. Girls with BDD present symptoms of low self-esteem and negative self-evaluation. Researchers in Istanbul Bilgi University and Bogazici University in Turkey found that individuals who have low self-esteem participate more often in trends of taking selfies along with using social media to mediate their interpersonal interaction in order to fulfil their self-esteem needs. The self-verification theory, explains how individuals use selfies to gain verification from others through likes and comments. Social media may therefore trigger one’s misconception about their physical look. Similar to those with body dysmorphic tendencies, such behaviour may lead to constant seeking of approval, self-evaluation and even depression.
In 2019 systematic review using Web of Science, PsycINFO, and PubMed databases was used to identify social networking site patterns. In particular appearance focused social media use was found to be significantly associated with greater body image dissatisfaction. It is highlighted that comparisons appear between body image dissatisfaction and BDD symptomatology. They concluded that heavy social media use may mediate the onset of sub-threshold BDD.
Individuals with BDD tend to engage in heavy plastic surgery use. Mayank Vats from Rashid Hospital in the UAE, indicated that selfies may be the reason why young people seek plastic surgery with a 10% increase in nose jobs, a 7% increase in hair transplants and a 6% increase in eyelid surgery in 2013. In 2018, the term “Snapchat Dysmorphia” was brought to life after several plastic surgeons reported that some of their patients were seeking plastic surgeries to mimic “filtered” pictures. Filtered photos, such as those on Instagram and Snapchat, often present unrealistic and unattainable looks that may be a causal factor in triggering BDD.
Diagnosis
Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting. In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, having been historically unrecognised, only making its first appearance in the DSM in 1987, but clinicians’ knowledge of it, especially among general practitioners, is constricted. Meanwhile, shame about having the bodily concern, and fear of the stigma of vanity, makes many hide even having the concern.
Via shared symptoms, BDD is commonly misdiagnosed as social anxiety disorder, obsessive-compulsive disorder, major depressive disorder, or social phobia. Social anxiety disorder and BDD are highly comorbid (within those with BDD, 12-68.8% also have SAD; within those with SAD, 4.8-12% also have BDD), developing similarly in patients -BDD is even classified as a subset of SAD by some researchers. Correct diagnosis can depend on specialized questioning and correlation with emotional distress or social dysfunction. Estimates place the Body Dysmorphic Disorder Questionnaire’s sensitivity at 100% (0% false negatives) and specificity at 92.5% (7.5% false positives). BDD is also comorbid with eating disorders, up to 12% comorbidity in one study. Both eating and body dysmorphic disorders are concerned with physical appearance, but eating disorders tend to focus more on weight rather than one’s general appearance.
BDD is classified as an obsessive-compulsive disorder in DSM-5. It is important to treat people suffering from BDD as soon as possible because the person may have already been suffering for an extended period of time and as BDD has a high suicide rate, at 2-12 times higher than the national average.
Treatment
Medication and Psychotherapy
Antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs), and cognitive-behavioural therapy (CBT) are considered effective. SSRIs can help relieve obsessive-compulsive and delusional traits, while CBT can help patients recognise faulty thought patterns. Before treatment, it can help to provide psychoeducation, as with self-help books and support websites.
Self-Improvement
For many people with BDD cosmetic surgery does not work to alleviate the symptoms of BDD as their opinion of their appearance is not grounded in reality. It is recommended that cosmetic surgeons and psychiatrists work together in order to screen surgery patients to see if they suffer from BDD, as the results of the surgery could be harmful for them.
Are somatoform disorders ‘mental disorders’? A contribution to the current debate.
Background
During the last 2 years, a debate has started over whether the somatoform symptoms/medically unexplained symptoms are wrongly placed under the category of mental disorders (section F in International classification of diseases-10 and in Diagnostic and statistical manual for mental disorders-IV).
Recent Findings
Most experts on medically unexplained symptoms agree that there is a substantial need for revision of the diagnoses of somatoform disorders. While some authors suggest moving the somatoform disorders from axis I to axis III, others suggest improving the classification of these syndromes on axis I, such as by using empirically derived criteria and by introducing psychological descriptors which justify the categorisation as a mental disorder.
In contrast to the situation when the last version of Diagnostic and statistical manual for mental disorders was published, new empirical data has shown some psychological and behavioural characteristics of patients with somatoform symptoms. These and other empirically founded approaches can be landmarks for the revision of this section in Diagnostic and statistical manual for mental disorders-V and International classification of diseases-11.
Summary
The classification of somatoform disorders as ‘mental disorders’ could be justified if empirically founded psychological and behavioural characteristics are included into the classification process.
Attention focusing, symptom catastrophising, and symptom expectation are outlined as possible examples of involved psychological processes.
Reference
Rief, W. & Isaac, M. (2020) Are somatoform disorders ‘mental disorders’? A contribution to the current debate. Current Opinion in Psychiatry. 20(2), pp.143-146. doi: 10.1097/YCO.0b013e3280346999.
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